1. Geriatric Assessment
Brian Lavery, MD, FACP

2. Goals Focus on key areas in history and exam taking in older adults
Learn some basics of some key geriatric syndromes and how it pertains to history taking and exam skills

3. Aging of the Population
2000
2030
Topic
Slide 3

4. If only 12% of the population is > 65yo, then what percentage of adults in the hospital are >65yo?

5. Prevalence of Self-Reported Chronic Conditions
Percentage of adults 65 yr
Topic
Slide 5

6. White, non-Hispanic (%) Black, non-Hispanic (%)
Perceived Health
White, non-Hispanic (%)
Black, non-Hispanic (%)
Hispanic (%)
65–74
75–84
85+
Men
Good to excellent
80.9
75.3
68.2
67.9
57.8
54.0
67.0
60.8
54.9
Fair or poor
19.1
24.7
31.8
32.8
42.3
46.0
33.0
39.3
45.1
Women
82.7
76.7
70.7
66.7
55.9
54.3
64.4
59.0
49.9
17.3
23.4
29.9
33.3
44.1
45.7
35.6
40.8
50.2
Topic
Slide 6

7. Frequently, I hear health care professionals ask, why are we doing this, she’s How much longer do you think an 85yo female will live?

8. Life Expectancy in US (2009 data)
White
Black
All
Male
Female
At birth
78.8
76.4
81.2
74.5
71.1
77.6
Age 65
19.1
17.7
20.4
17.8
15.8
19.3
Age 85
6.6
5.8
7.0
6.8
5.9
7.2
Topic
Slide 8

9. Effective Communication Strategies with Older Adults
Use a well-lit room
Avoid backlighting
Minimize extraneous noise
Minimize interruptions
Topic

10. Effective Communication Strategies with Older Adults
Introduce yourself
Address the patient by last name
Face the patient directly
Sit at eye level
Speak slowly
Ask open-ended questions: “What would you like me to do for you?”
Topic

11. Effective Communication Strategies with Older Adults
Inquire about hearing deficits; raise voice volume accordingly
If necessary, write questions in large print
Allow ample time for patient to answer
Topic

12. Who Should We Take the History From?

13. Complete physical assessment includes:
Functional status
Nutrition
Vision
Hearing
Cognition

14. Functional Status
ADLs and IADLs

15. Activities of Daily Living
Bathing and showering
Personal hygiene and grooming
Dressing
Toileting
Transferring
Feeding
These are the things many people do when they get up in the morning and get ready to go out of the house: get out of bed, go to the toilet, bathe, dress, groom, and eat.

16. Instrumental Activities of Daily Living (IADLs)
using telephone
preparing meals
managing finances
taking medications
doing laundry
doing housework
shopping
managing transportation

17. Rapid Functional Status Screen
Rapid screen
Functional status
Answers “Yes” to one or more of the following: Because of a health or physical problem, do you need help to:
Shop?
Do light housework?
Walk across a room?
Take a bath or shower?
Manage the household finances?
Topic

18. Objective Assessment of Functional Status
Gait speed: Strongest predictor of future disability and death
A gait speed of 0.8 meters/second allows for independent community ambulation; a speed of 0.6meters/sec allows for community activity without a wheelchair.
These norms indicate that patients who can walk 50 feet in an office hallway in ≤ 20 seconds should be able to walk independently in normal activities.

19. Objective Assessment of Functional Status
Timed Get Up and Go test: Qualitative & timed; assesses gait, balance, and transfers
The tasks of rising from the chair, walking 10 feet (3 meters), turning around and returning to the chair, turning, and then sitting back down in the chair make up the “Timed Get Up and Go” test.
Most adults can complete in 10 seconds. Most frail older adults can complete in sec. > 14 sec is associated with increased falls risk. >20 sec should trigger a comprehensive evaluation. Results are strongly associated with functional independence in ADL’s.

20. Falls
Epidemiology: Between 30-40% of community dwelling people over the age of 65yo fall each year.
Almost 60% of those with a fall in the previous year will have a subsequent fall.
1% of falls in the elderly lead to hip fracture.

21. Falls
Screen by asking about any falls in the past year. Ask about dizziness
Exam should focus on:
vital signs/orthostatics
visual acuity
whisper test
cardiac
extremities (sensory/deformities)
neurologic exam including cognition
muscle strength
get up and go test

22. Measuring Orthostatic Vital Signs
1. Have the patient lie down for 5 minutes.
2. Measure blood pressure and pulse rate.
3. Have the patient stand.
4. Repeat blood pressure and pulse rate measurements after standing 1 and 3 minutes.
A drop in systolic BP of ≥20 mm Hg, or in diastolic BP of ≥10 mm Hg, or experiencing lightheadedness or dizziness is considered abnormal.

23. Assess Nutritional Status
Poor nutrition may reflect medical illness (cancer, depression), functional losses, financial hardship, access to food
Screen for malnutrition: Measure height, weight, BMI
BMI = weight (kg) / height (m2)
Watch for low BMI (<20 kg/m2)
Watch for unintended weight loss ≥ 5% in 6 months
Topic

24. Assess Nutritional Status
Unintentional Weight Loss: ≥2% decrease in one month, ≥5% in 3mos, or ≥10% in 6mos To meet criteria for malnutrition, you need 2 of the following: ●Insufficient energy intake ●Weight loss ●Loss of muscle mass ●Loss of subcutaneous fat ●Localized or generalized fluid accumulation that may mask weight loss ●Diminished functional status as measured by handgrip strength

25. Consequences of Malnutrition
reduced muscle and tissue mass, reduced bone mass (osteoporosis)
decreased mobility and stamina as a result of muscle wasting
breathing difficulties, and an increased risk of lung infections/resp failure
impaired wound healing
delayed recovery from illnesses
impaired immune system
difficulty staying warm: higher risk of hypothermia
poor libido (sex drive) and fertility problems.

26. Vision
If unable to read a newspaper headline and sentence while reading with corrective lenses, test each eye with Snellen chart
Cataracts, glaucoma, macular degeneration, and abnormalities of accommodation worsen with age
Ask about everyday tasks: driving, watching TV, reading

27. Hearing
Hearing loss is common among older adults: affects 25%–40% of adults ≥65 years old in the United States.
Age-associated hearing loss is insidious and is often not reported by patients until it is moderate or severe
Impaired hearing can lead to: depression, social withdrawal, dementia
Hearing loss usually bilateral and in high-frequency range
What should we start with in our exam?
Topic

28. Hearing Assess first for cerumen impaction
Refer for formal audiometry testing if:
Acknowledges hearing loss when questioned
Unable to perceive letter/number combination whispered at a distance of 2 feet

29. Cognitive Impairment
Delirium vs. Dementia

30. Cognitive Impairment Normal Aging Mild Neurocognitive Disorder
Major Neurocognitive Disorder

31. Dementia
Major neurocognitive disorder: an acquired syndrome of decline in memory and other cognitive functions sufficient to affect daily life in an alert patient.
6-8% of people 65+ have AD, nearly 30% of 85+ have AD
Incidence doubles every 5 yr after age 65
Mainly occurs in adults > 65yo, so as longevity increases, dementia increases

32. Dementia Most people with dementia do not complain of memory loss
Cognitively impaired older persons are at increased risk for accidents, delirium, medical nonadherence, and disability
How do we screen for dementia?

33. Mini-Cog
The advantages of the Mini-Cog include high sensitivity for predicting dementia status, short testing time relative to the MMSE, ease of administration, and diagnostic value not limited by the subject's education or language

34. Mini-Cog Scoring
Borson S. The mini-cog: a cognitive “vitals signs” measure for dementia screening in multi-lingual elderly
Int J Geriatr Psychiatry 2000; 15(11):1021.

35. Depression
Consider depression if: 1. Mood or somatic symptoms out of proportion to what’s expected 2. Poor response to standard medical treatment 3. Poor motivation to participate in treatment 4. Lack of engagement with health care providers or family 5. Social regression or incapacity Differential Diagnosis: Medical illnesses and medication side effects can mimic depression.

36. Screening Tool for Depression
PHQ-2 (Patient Health Questionnaire 2):
“Have you ever had a time when you felt sad, blue, depressed, or down for most of the time for at least two weeks?”
“Have you ever had a time, lasting at least two weeks, when you didn't care about the things that you usually cared about or when you didn't enjoy the things that you usually enjoyed?”
97% sensitive, 67% specific
Validated only in outpatients

37. Constipation
Prevalence in older adults is 24-50%. Laxatives used daily in 10-18% of community dwelling older adults
Functional constipation is defined as any two of the following:
straining
lumpy hard stools
sensation of incomplete evacuation
use of digital maneuvers
sensation of anorectal obstruction or blockage w/ 25% of BMs
decrease in bowel frequency (less than 3 BMs/week).

38. Constipation Exam should focus on
Abdominal exam: bowel sounds, distention, tenderness, masses
Rectal exam: tone, fecal impaction, blood

39. Urinary Incontinence
Prevalence: 25-50% in women (any leakage once over past year). Weekly leakage in 10%. How common in men?
Major impact on quality of life
Associated with UTI’s, skin integrity/cellulitis, falls, nursing home placement, sleep deprivation, depression, social withdrawal
NEED TO SCREEN: You need to initiate the discussion

40. Urinary Incontinence Exam should focus on:
-Abdominal exam (bladder distention, masses)
-Cardiovascular (edema, heart failure)
-Rectal exam (mass, tone, sensation, prostate nodules, fecal load)
-Vaginal exam (mucosa, prolapse, volitional squeeze)
-Musculoskeletal (mobility and dexterity)

41. Polypharmacy
81% of older adults on at least one. 50% of Medicare patients is on 5 or more. 40% also took at least one OTC. 2/3 are on dietary supplement (herbs and vitamins).
“Brown Bag” method: Review all patient’s medications (it’s best if the patient brings their medications to the visit): meds from other providers, OTC meds, supplements, vitamins
Screen for medication adherence (nonadherence among older adults may be as high as 50%)

42. Polypharmacy
Inquire about difficulties taking medication and adverse events.
Ask patients to review which medications they are taking and how they are taking them (in a nonjudgmental manner) and compare to medication bottles’ directions.
Review refill history.
Ask caregivers about medication adherence.
Assess the patient’s ability to understand and comply with the medication regimen.

43. Social Assessment Ethnic, spiritual, and cultural background
Availability of a personal support system
Caregiver burden
Economic well-being
Safety of the home environment
Elder mistreatment
Advance directives
Topic

44. Thanks to: Annette Medina-Walpole, MD Thomas M. Gill, MD
AGS: American Geriatric Society

45. Questions?