Flashcards in Assessment and Health Maintenance Deck (61):
T/F: Given the promotion of minority need care in medicine, including geriatrics, there has been a proven increase in the amount of geriatricians since 2000.
False, there has been a decrease since 2000
Goals of Comprehensive Geriatric Assessment
1. Provide an all-around evaluation
2. Establish appropriate management for medical problems
3. Improve the QoL for frail elders
4. Delay or prevent disability
5. Delay or prevent institutionalization
This is a multidisciplinary evaluation in which the multiple problems of older persons are uncovered, described, and explained if possible, and in which resources and strength of the person are catalogued, need for services assessed, and a coordinated care plan developed to focus on interventions on the person's problems.
Comprehensive Geriatric Assessment (CGA)
Why is the CGA important?
Increases Life Expectancy
What does the CGA allow you to screen for?
- Age-related increase in morbidity
- Age-related increase in use of medications
- Age-related decline in physical function
- Age-related decline in mental function
What are target conditions of geriatric patients?
- Dementia or delirium
- EOL care
- Falls or Mobility Disorders
- Pressure Ulcers
- Urinary Incontinence
This is a term describing more common concerns in vulnerable older patients rather than the general adult population.
How do we approach the comprehensive eval?
1. Target appropriate patients
2. Assess patients and developing recommendations
3. Implementing Recommendation
What does it mean to be "too sick to benefit" when targeting the appropriate audience?
- Critically ill or medically unstable
- Terminally Ill
- Disorders with no effective treatment
What does it mean to be "too well to benefit" when targeting the appropriate audience?
- One or a few medical conditions
- Needing prevention measures only
What does it mean to be "appropriate and will benefit" when targeting the appropriate audience?
- Multiple interacting bio-psychological problems that are amenable to treatment
- Disorders that required rehabilitation therapy
Components of the CGA?
1. Medical (medical problems, Rx, OTC)
2. Functional/Physical (ADLs, IADLs, Mobility)
5. Nutritional Assessment
6. Other Geriatric Syndromes (Urinary Incontinence, Falls, Frailty, Sleep Disorders)
7. Access to care and other facilities (Transportation, Finances)
8. Safety and Security
Investigating Medical Problems
- Prevention of Complication
- Control of Symptoms and prevention of side effects of medications
- Improve functional status
- Assess/Analyze the risk-benefit ratio of treatment
- Get detailed list of Rx, non-Rx, OTC, non-daily medications, ointments, creams, gels.
Beer's Criteria in relation to Medications
- Medications generally considered inappropriate when given to elderly people.
- Medications listed tend to cause effects due to the physiological changes of aging
- Criteria were created through consensus of panel of experts and were originally published in 1991 in the Archives of Internal Medicine. Updated in 2012
Assessing Functional Status
- Mobility, Strength, Vision
- Transferring from Bed to Chair
- Use of the telephone
- Meal Preparation
- House work
- Medication Management
- Management of Finances
Assessing Visual Impairment
1. Check for Functional Blindness:
- 1% age 71-74
- 17% 90+ yo
- 17% NH patients
2. Prevalence of Functional Visual Impairment
- 7% age 71-74
- 39% age 90+
- 19% NH Patients
- Annual Eye Exam
- Screening Test
Assessing Hearing Impairment
- Age 65-74 = 24%
- Age 75+ = 40%
- Whisper Test (1-2 feet behind patient, say three words)
This is the term for the purposeful movement from one place to another independently.
Important items in mobility evaluation include:
- Muscle Strength
- Gait Speed
Speed required to safely cross a traffic light
How do you Assess Mobility Balance?
- Tandem Walk
- Berg Balance Scale (may take longer)
How do you Assess Mobility Muscle Strength?
1. Observe if the patient is able to stand up from a sitting position without the support of his/her arms.
2a. If they are able to stand up, ask patient to:
- Sit in a chair with back straight and arms over the chest
- Stand up from sitting position as many times as possible in 30 seconds
2b. If they are not able to stand up (from 1.) Then you betta STOP!
How do you Assess Mobility Gait Time?
"Get Up and Go" Test
- Simple Test to evaluate lower extremity strength, balance, and walking speed
- Can be done during a clinic visit
How do you do the "Get Up and Go Test?"
1. Ask patient to stand up from a sitting position
2. Walk 10 ft (3 meters)
3. Turn around and walk back to the chair
4. Sit down in chair
Time rating for the "Get up and go" test
< 20 seconds:Mostly independent
20-29 seconds: Variable Mobility
> 29 seconds: Impaired Mobility
Knowledge about Dementia (Cognition)
Increased risk for functional decline, delirium, falls, and caregiver stress.
Prevalence: 30% in community swelling patients 85+ yo
Alzheimer's Dz and Vascular Dementia: 80%+ of cases
Assessing for Dementia (Cognition)
Mini Cognitive Test
- 2 items delayed recall to assess memory
- Clock Drawing Test: Assesses executive function
How to perform the Mini-Cognitive Test?
- Ask patient to repeat 3 unrelated words and remember the words
- Show the patient a piece of paper with a pre-drawn circle of approximately 10 cm in diameter
- Tell the patient that the circle represents the face of a clock
- Ask the patient to put in the numbers so that it looks like a clock.
- Ask the patient to add arms so that the clock indicates at "10 minutes after 11" (No time limit)
- After patient finishes the clock test, ask the patient to tell you the 3 works that you had asked him/her to remember.
Scoring the Mini-Cognitive Test
0 Recall = Abnormal Result
1-2 Recall, Abnormal Clock Test = Abnormal Result
1-2 Recall, Normal Clock = Normal results
T/F: The Mini-Mental State Test is suitable for making a diagnosis.
Con of Mini-Mental State Exam
- Doesn't detect subtle memory losses, particularly in well-educated patients
- People from different cultural groups or of low intelligence or education may score poorly on this exam in absence of cognitive impairment, or will appear cognitively okay even if subtle impairment is available
- Does not test long term memory
What does the Folstein Mini-Mental State Exam test?
- Orientation to time and place (What is the year/session/date/day/month) (Where are we state/county/town/hospital/floor)?
- Registration: the ability to repeat named prompts (Name 3 object: 1 second to say each, then ask the patient all 3 after you said them)
- Attention Space and Arithmetic (Begin with 100 and count backward by 7, or spell WORLD backwards)
- Memory and Recall going back to the named objects in the registration section. (Ask for all 3 objects repeated above)
- Language asked to repeat a phrase (Show a pencil and a watch and ask the patient to name them)
Mini Mental State Test Scoring
- 25-30 out of 30 are considered normal
- 21-24 is considered mild
- 10-20 as moderate
- <10 as severe impairment
Common Scoring of Most People
- 28 >85 y/o and >12yrs education
- 29 70-74 y/o and >12yrs education
- 22 65-69 y/o and 0-4 yrs education
Why do we assess mood?
- 10% of 65+ yo with depressive symptoms
- 1% with major depressive disorder
Assc. physical decline of community-dwelling adults and hospitalized patients
- Hx of unintentional weight loss (10 lbs in 1 year, 5 lbs in 6 months)
- Current Body Mass Index
- Number of meals per day
- Accessibility of food items
- Problem with chewing and Swallowing
How are unintentional weight loss and death related?
Higher amount of unintentional weight loss, the higher the chance of death.
Other Geriatric Syndromes to Investigate
- Urinary Incontinence
- Fecal Incontinence
- Sleep-Wake Problems
- Access to Care and Other Facilities
- Elder Safety and Security
Falls in the elderly
- Slowed Reaction Time
- Impaired Protective Responses
- Comorbid Diseases
- Fractures occur in 3% of falls overall
- 87% of all fractures in elderly = falls
- 95% of hip fractures are due to falls
- Second leading cause of brain and spinal cord injury in older adults.
Consequences of Falls:
- Broken Bones
- 20% of restricted activity days (more than any other condition)
- Nursing Home Placement
Household Safety Techniques
- Handrails on both sides of any stairway
- Well lit stairways
- No-slip backing on rugs
- Hand bars in bath/shower
Sleep-Wake Patterns in the Elderly
- 50% of community dwelling geriatric patients complain of some sort of sleep disorder.
- Tend to take longer to fall asleep
- Lower sleep efficiency
- More night time Awakenings
- Wake up earlier
What causes the sleep-wake problems? (Multifactorial)
- Circadian Rhythm Changes
- Sleep Apnea
- Medical Illness
- Multiple Medications
- Psychiatric Illness
- Poor Sleep Hygiene
This is the term for a collection of symptoms, signs, or findings that are commonly found among older adults and predict adverse outcomes which includes:
- Increased Mortality
Markers for Frailty
- Slow walking speed
- Decreased Muscle Strength
- Decreases Energy Expenditure
- Unintentional Weight Loss
Assessing Access to Care and other Facilities
- Ask about transport
- Financial Factors
- Economic Factors may impact nutritional status, medication availability, etc.
What type of mistreatment do elderly patients come across?
- Physical Abuse
- Fianncial or Material Abuse
*3.2% of individuals 65+ yo have been victims
Criteria for Evaluating Preventive Services in the Elderly
Generally Accepted Criteria for Decision-Making
1. The condition must have a significant effect on health
2. Acceptable methods of preventive intervention must be available for the condition
3. The intervention must be effective in preserving health for primary prevention (counseling, chemo prevention, immunizations).
4. For other preventive services or interventions:
a. Must be period before patient is aware of the condition (seriousness or implications) during which it can be detected.
b. Tests must be available
c. Preventive services/treatment must have greater effectiveness than after condition is delayed.
5. The benefits of preventive service or treatment must outweigh any negative effects.
6. A comparison of the cost and benefits must be conducted.
CV and Cerebrovascular Dz Risk Factors:
- Screening Questions suggestive of TIAs/Angina should be considered
Recommendations of CV and Cerebrovascular Dz
1. Smoking cessation should be stressed
- Responsible for up to 30% of MIs and CVAs
- Stopping smoking reduces CV mortality within 1 year
2. Regular exercise should be recommended
- Assc. with reduced CV mortality
- Positive CV effects include reduced BP, lipids, obesity, and DM
3. Postmenopausal estrogen assc with CAD and a 50% reduction in risk of death in women
4. ASA 81 mg on a daily basis is recommended in absence of contraindications for stroke and CV risk reduction.
5. Reduced fat intake (with exception of olive oil, fatty fish, many types of nuts) appears to have protective effects.
6. Avoiding excess EtOH consumption may prevent HTN. Moderate amounts appear to reduce events.
What is the second leading cause of death in the elderly?
Recommendations for Breast Cancer
- Incidence increased with age (more aggressive forms in younger).
- Treatment with Lumpectomy and Tamoxifen well-tolerated and effective.
- The USPSTF concludes that current evidence is insufficient to assess additional benefits/harms of screening mammography in women >75.
Recommendations for Cervical Cancer
- Comparatively rare in the elderly.
- USPSTF recommends that patients with a hx of normal PAP smears do not PAP screening beyond 65 yo.
- Those without previous screening should have 2 normal PAPs before discontinuing
Recommendations for Colon Cancer
- Risk of CC increases with age.
- DREs and FOBTs alone are not effective as screens.
- Regular use of ASA associated with reduced cancer risk.
- USPSTF recommends against routine screening for colorectal cancer in adults age 76 to 85 years. - - There may be considerations that support colorectal cancer screening in an individual patient.
- USPSTF recommends against screening for colorectal cancer in adults older than age 85 years.
Recommendations for Prostate Cancer
- Common in older men and often asymptomatic
- USPSTF recommends against screening for prostate cancer in men age 75+ yo
Recommendations for Oral Cancer
- USPSTF concludes that the evidence is insufficient to recommend for or against routinely screening adults for oral cancer
- Oral cancer tx at an early stage improves outcomes
- Tobacco and EtOH increase risk
Recommendations for Skin Cancer
- USPSTF concludes that there is insufficient evidence to assess the balance of benefits/harms of using a whole-body skin examination by a primary care clinician or patient skin self-examination for the early detection of cutaneous melanoma, basal cell cancer, or squamous cell skin cancer in the adult general population.
- BCC and SCC are common and treatable.
- Recommend use of sunscreens.