1. A (hopefully) Practical Approach to the Geriatric Complete Physical in Family Medicine. Dr. C Hoggard R1’s of 2016

2. Disclosure No disclosures I have borrowed heavily from many different doctor’s presentations None of the pictures used are mine (except 1)

3. My Goals for this talk Introduce the Complete Geriatric Assessment (GCA) Introduce the Geriatric Syndromes aka Geriatric Giants How do you screen for these syndromes in the office Focusing on aspects of Geriatrics that we are never taught Billing Bring it all together with a couple of cases

4. Geriatrics

5. Why is Geriatrics Important?: Case Gwendolyn Ricci is new to your practice and arrives with her family for an initial assessment. Her family does most of the talking for her and Gwendolyn often looks at them for assistance in answering your questions. You note she has a shuffling wide based gait, and turns on block. She even has a fall in the office! She exit seeks and is incontinent of bladder and bowels. Her family seems to think this is normal. What action do you take?

6. Why is Geriatrics Important? Case answer Nothing! Gwendolyn is 1 year old. Like pediatrics, geriatrics deals with a special population requiring a specialized set of skills. They are not merely “older adults”.

7. What is the Geriatric Assessment? Brace Yourself

8. Components of a Geriatric Assessment Vision Hearing Cognition Depression Falls/mobility Cardiovascular risk factors, symptoms etc Respiratory-COPD Endocrine-thyroid, diabetes GI-bowels GU-incontinence, sexual function Neuro- Strokes etc MSK –osteoporosis, arthritis Skin Medications Immunizations POA/PD/AD Smoking and alcohol ADL, IADLS, Living situation Driving Abuse and Care-giver burnout Capacity

10. The Complete Geriatric Assessment

11. What should we be doing? Functional Assessment –Collateral is nice Geriatric Syndrome screening Quarterbacking (ie Case Managing: What we are trained to do but never taught) – Legal Paperwork/awkward conversations – Standard Regular screening/ Preventative Medicine

12. Functional Assessment

13. Activities of Daily LivingInstrumental Activities of Daily Living EatingMedication TransferCooking GroomingCleaning/ Laundry DressingFinances ToiletingShopping BathingTelephone Use/ Computer Driving*

14. Functional Assessment iADLsHistory to Illicit MedicationsBlister packing, can they walk you through their medications, BankingWhat do they pay? Missed bills, problem with PINS, Automatic banking, know where their money comes from? CookingHave they changed what they eat? Different tasting, frozen meals, weight loss ShoppingList generation, find what they want CleaningChange in the living condition *Telephone/ Computer use Can they work their new _____? *DrivingGet lost? The finger? Others concerned? accidents? Grandchild test?

15. Screen for the Geriatric Syndromes Cognition/ Delirium/ Depression Polypharmacy Incontinence Falls Osteoporosis Orthostatic Hypotension FTT Abuse **Driving

16. Screen for the Geriatric Syndromes Cognition/ Delirium/ Depression Polypharmacy Incontinence Falls Osteoporosis Orthostatic Hypotension FTT Abuse **Driving

17. The 3 D’s of Geriatrics Depression, Dementia and Delirium – look the same, smell the same, mimic each other and are often in combination.

18. Dementia Routine screening not recommended This will come to you in three ways 1.Family is worried 2.Functional Change 3.Hospital Admission

19. Dementia There must be a FUNCTIONAL DECLINE Activities of Daily LivingInstrumental Activities of Daily Living EatingMedication TransferCooking GroomingCleaning/ Laundry DressingFinances ToiletingShopping BathingTelephone Use/ Computer Driving*

20. Testing for Dementia SIMARD is not validated MOCA – for executive functioning and mild cognitive impairment MMSE – for more severe impairment, language based, needed to assess supports Clock Drawing Rudas The “head turning sign”

21. Dementia

23. Depression Do you feel sad/depressed? Do you feel hopeless? Do you feel life is not worth living? GDS 15 >5 is worrisome for Depression

24. Depression The Geriatric Depression Scale (GDS)

25. Delirium Fluctuating Behavioral Change Hyperactive/ Hypoactive What is your name? Where are you? What is the date? 1/3 of patients >70 yo in hospital are delirious and it can take up to 3 months to resolve!

26. Screen for the Geriatric Syndromes Cognition/ Delirium/ Depression Polypharmacy Incontinence Falls Osteoporosis Orthostatic Hypotension FTT Abuse **Driving

27. Polypharmacy

28. Have your pharmacist do a medication review – 03.01NM (communication with pharmacy if pharmacy initiated) Watch for prescription cascades Watch for errors of omission Watch for inappropriate medications Ativan

29. Polypharmacy DiseaseWhat are they on?What should they be on? What should they avoid HTNRamipril 2.5mgAntihypertensiveNSAIDS DIABETESMetformin 1000mg BID Glucose lowering agent, ?ASA, ?Statin, ?Renal protection Hypoglycemic agents ArthritisIbuprofenDiclofenac Gel, Tylenol, Injections Narcotics? Braces? Ativan

30. Screen for the Geriatric Syndromes Cognition/ Delirium/ Depression Polypharmacy Incontinence Falls Osteoporosis Orthostatic Hypotension FTT Abuse **Driving

31. Incontinence

32. Do you have trouble with urine leaking? Do you have difficulty controlling your bowels or bladder? Have you ever not made it to the toilet? Are you afraid to leave the house if there is no bathroom easily accessible?

33. Screen for the Geriatric Syndromes Cognition/ Delirium/ Depression Polypharmacy Incontinence Falls Osteoporosis Orthostatic Hypotension FTT Abuse **Driving

35. Falls Have you fallen in the last year? Chair Raises The timed up and go test aka “TUG” Test – <10 sec is normal – <20sec can go out alone – > 20sec is a fall risk

36. Screen for the Geriatric Syndromes Cognition/ Delirium/ Depression Polypharmacy Incontinence Falls Osteoporosis Orthostatic Hypotension FTT Abuse **Driving

37. Osteoporosis

38. Are you shorter? Do your pants or skirts seem longer/hit the floor? Have you ever broken a bone? Have you had prolonged unusual back pain?

39. Osteoporosis TUG > 3cm (men) 2 cm (women) height loss in a year Wall to occiput Bone Mineral Density

40. Osteoporosis BMD can’t do it alone! – FRAX – CAROC A fragility fracture is OP. Your diagnosis is made! No BMD needed!

41. Screen for the Geriatric Syndromes Cognition/ Delirium/ Depression Polypharmacy Incontinence Falls Osteoporosis Orthostatic Hypotension FTT Abuse **Driving

42. Orthostatic Hypotension Just do it Systolic goal 150 >80 yo or Frail

43. Screen for the Geriatric Syndromes Cognition/ Delirium/ Depression Polypharmacy Incontinence Falls Osteoporosis Orthostatic Hypotension FTT Abuse **Driving

44. Failure to Thrive Has your weight changed? Look at their clothes Have you been buying new clothes? Are you driving? Any accidents in the last 5 years?

45. Nutrition Weigh your patients at every visit – Unintentional weight loss – 10% in the last 3-6 months Under-nutrition is often overlooked. Ask: – Have you lost weight? – What is your usual weight? – Have you had to buy new clothes, how are your clothes fitting? – How are your dentures fitting? – Who makes the meals?

46. Nutrition Causes: “normal aging physiology”, depression, dementia, delirium, isolation, medication, $, mobility, dental care…..etc Quick Fixes: Tx dx and change meds, meals on wheels, aids, companions, supplementation, presentation

47. Social issues Etoh/drugs Isolation

48. Screen for the Geriatric Syndromes Cognition/ Delirium/ Depression Polypharmacy Incontinence Falls Osteoporosis Orthostatic Hypotension FTT Abuse **Driving

49. Abuse – Verbal/emotional – Financial (home?) – Physical – Computer scams Is anyone making life difficult for you? Is there someone in your life that you think does not have your best interests in mind? Are you afraid of someone?

50. Safety Environmental assessment: Personal safety – Wandering bracelets, fall detectors Home hazards (think Rourke) – Guns, water temp, smoke detector, seat belts – Rugs, lighting, rails, bathing chair Care giver burn out – Respite (over night and daytime) – Counseling – Support services (Kirby center, early dementia case worker, HC)

51. Screen for the Geriatric Syndromes Cognition/ Delirium/ Depression Polypharmacy Incontinence Falls Osteoporosis Orthostatic Hypotension FTT Abuse **Driving

52. Driving

53. Don’t Miss Dr. DeFina’s Amazing Talk!!

54. Screen for the Geriatric Syndromes Geriatric SyndromeQuick Screen 3 D’sFunctional Assessment Maybe a MMSE/MoCA/Clock PolypharmacyCascades/ drug interactions Errors of omission Pharmacy involvement ? Incontinence4 questions Falls1 question Chair raise/ TUG Orthostatic BPNurse? FTTNurse? 2 questions Abuse3 very important questions Driving2 question

56. Recap Functional assessment Geriatric Syndromes

58. Quarterbacking This is the “stuff” every talk glosses over BUT is perhaps the most beneficial to your patients. This is where WE, the family doctor, make a difference. WE do what no other physician can do. This is OUR “specialty”.

59. Quarterback’s Check List  Goals of Care talk  Paperwork (PD/EPOA/Will)  Immunizations  Screening  Safety (Abuse, Injury prevention)  Driving  Nutrition  Social (Drinking, supports, ADLs/iADLs)  HOME CARE!

60. Goals of Care It is not a legal document 3% of all-comers survive resuscitation and ½ will have “significant impairment” We don’t all have the same values and beliefs Special populations Discussions with the family (especially the Agent)

61. Goals of Care What phrases have you heard? Keep the goals of care on the fridge, EMS is trained to look for it there.

62. Goals of Care R1R2R3M1M2C1C2 “Full resuscitation” “No Chest Compressions ” “No machines” “No ICU”“No surgery unless for symptoms control” No hospital transfer Palliative Everything we could possibly do for them. CPR 3% unwitnessed in healthy adults Go to ICUGo to ICU for medications and post surgery People would do surgery and chemo. Active screening with these ppl Will go to hospital only if it improves symptoms For facility patients really Can go for things like fracture. Dying or terminal illness

63. Personal Directives Just do it

64. Personal Directives Must have decisional capacity to make a personal directive Often done with a Lawyer but can just Google “Alberta Personal Directive” Name an “Agent” and hopefully an alternate – caution with spouses. Watch for abuse. The “Agent” can not be the witness

65. Personal Directive 2 Types of PDs – one that names whom can deem them incapable and one that deems them by two healthcare workers

66. Personal Directives Schedule 1 A person can name a person to deem them incapable If no person is chosen the default is a doctor or psychologist or designated capacity assessor

67. Personal Directives 03.04N is the code for enacting a PD (ie deeming someone incapable in one or more domains of decisional capacity) You should cover this in your talk on capacity Do not skip this day

68. Enduring Power of Attorney Usually done with a Lawyer Two types of EPOAs Immediate Clause Springing Clause

69. A Will Deals with someone’s ESTATE after they DIE Usually if this is up to date so is the EPOA

70. PD/EPOA/Will Do this as part of your regular physical or swear I will haunt you until the end of your practice….

71. Immunizations for Seniors Influenza – annually Pneumococcal – – PCV13 (Prevnar) once if immunocomprimized – PSV 23 once or twice q 5 year apart (may have gotten it before 65 with resp disease or smoking) – Space PCV13 and PSV23 apart by 1 year Tetanus-diptheria – q10 years Shingles – once after 50 yo (60’s optimal?)

72. Screening To screen or not to screen

73. Screening Depends on the patient’s goals Depends on the patient’s life expectancy – No survival benefit if the life expectancy is <5 years No real evidence in this population for screening

75. Screening Don’t Forget: Vision, Hearing and Dental Environmental assessment

76. Screening: Vision Vision: – Visual impairment is <20/40 (20% of 75+ seniors) and blindness is <20/200 (2% of the 75+seniors). – Ask: "has your vision changed??". – Snellen Chart = ocular vitals Screening: Glaucoma - >50yo q 1-2 years. DM2 q 1-2years,

77. Screening: Hearing Hearing: presbycusis is the high frequencies loss first and difficulty with background noise. – Ask: Do other’s complain about the TV or Radio being too loud? Is conversation difficult with background noise? – Look for social isolation (humm is it depression or dementia?), misinterpretation of what you are saying. – Review medications for lasix, salicylates, vancomycin and gentamicin.

78. Hearing: Tricks Tricks for talking to someone with poor hearing are: – Look directly at them – Speak slowly (don't shout and use sentences so it is easier to lip read) – Write things down – Reduce background noise – Have the patient repeat what they have heard back to you

79. Hearing Aids: – Hearing aids. There should be feedback when they turn on. Red in Right ear and Blue in Left ear. – Don’t refer for a hearing aid if they won’t wear it as they cost $600-900!! At least do the 30day trial – Personal amplifiers – Telephone for the deaf/ – Texting/ emails

80. YES! YOU CAN REALLY DO THIS!!

81. Dr. Hoggard’s Geriatric Physical Template HistoryPhysicalPlan At today’s visit: Issues: 1. 2… Function: Independent in iADLs Screening: Pap, Mammogram, BMD, CRC, DRE Diet: Recommended Vit D, 3 servings of dairy Exercise: Sleep: Geriatric Syndromes: Cognition: NC Mood: NC Incontinence: NC OP: NC Falls: NC Polypharmacy: Reviewed Driving: Driving, NC PD/EPOA: Both completed GOC: M1 Vaccinations: UTD Orthostatic Vitals: _____/_______ Height: Weight: HEENT – Vision Hearing Dental: Up to date CVS – S1s2 GAEB Abdo – def MSK – TUG < 10sec -No Edema -Good shoes, no aids MoCA/ MMSE – “nurse to perform” GDS – “nurse to perform” Labs ordered: F/u 1 year Nurse to perform GDS and MoCA ?? Driving assessment? Home Care? Pharmacy Review? Physio?

82. Show me the money!!!!

83. Billing: Office Practice ServiceCodeAmount Regular office visit03.03A35.91 (or 43.09 if >75 yo) Time modifierCMGP01-06 (15min units)15.70 Complete Physical03.04A + modifier88.90 Complex Care Plan (can be billed with complete physical) 03.04J + 03.04A + time modifier 213.80 + 88.90 = >302.70! Psychiatric Code (290)08.19G/ 08.19D (family member) 45ish/50ish Drivers Medical >74.5yo03.05H76.90 Geriatric Assessment03.04K300.00 Anticoagulation Management 03.01N16.95 Phone Call Nursing/ pharmacy 03.01ng/03.01NM16.95 Phone Call Patient/ family03.05JR/ 03.05JP18.88/ ?50

84. Billing:LTC ServiceCodeAmount Regular once weekly visit03.03E27.17 Admission to LTC03.04D105.50 Team Conference03.05JD (per 5 min unit!!)13.09 Formal Medication Review03.05JE27.29

85. Billing: Supportive Living ServiceCodeAmount Regular once weekly visit03.03NA (first visit onsite)/ 03.03NB (subsequent visits) 84.61 + CMPG Team Conference03.05JD (per 5 min unit!!)13.09 Formal Medication Review03.05JE27.29 Enacting a PD03.04N$100 ish