Evaluating and Caring for the Geriatric Patient

Question 1

how is the geriatric assessment effective?

Answer 1

Effective in keeping patients in the community and reducing mortality

Question 2

what approach provides better chronic disease management and informed medical decision making

Answer 2

Teach-back approach

Question 3

how can we Ensure awareness and sensitivity to cultural differences with regards to patient preferences and personal aging goals

Answer 3

Make every attempt to provide information in patients native language and offer interpreters

Question 4

why be conscientious of a patient’s health literacy level and how to achieve this?

Answer 4

1. Often feel less empowered when interacting with health care providers
2. Assess what the patient already knows or understands
3. Slow speech and avoid medical terminology
4. Use pictures if ready literacy is low
5. Literacy appropriate written instructions help to improve chronic disease management
   - 5th grade or lower, clear heading, bright contrasting colors, large font size (14 or larger)

Question 5

7 Components of a Geriatric Assessment

Answer 5

• Comprehensive H&P Exam
• Functional assessment
• Social assessment
• Environmental assessment
• Nutritional assessment
• Psychological assessment
• Patient goals

Question 6

challenges with geriatric assessments

Answer 6

1. communication
2. underreporting of sx
3. vague sx
4. multiple complaints

Question 7

PMHx should include?

Answer 7

1. Previous surgical procedures
2. Major illnesses and hospitalizations
   - Previous transfusions
3. Immunization status
   - Influenza
   - pneumococcus
   - Td
   - Zoster
   - Covid
4. Preventive health measures
   - Mammography
   - Pap smear
   - Colon cancer screening
   - Antimicrobial prophylaxis
   - Estrogen replacement
5. Tuberculosis history and testing

Question 8

what should be included in medication hx?

Answer 8

“Brown bag” technique
Knowledge of current medication regimen
Compliance
Perceived beneficial or adverse drug effects
Previous allergies

Question 9

A strong social support network can be the determining factor of whether the patient can ____ or needs placement in an ______.

Answer 9

remain at home
institution

Question 10

how can social assessments be helpful?

Answer 10

1. Determine who would be available to help if your patient becomes ill.
2. Early identification of social support problems can help with planning and timely development of resource referrals.
3. For patients with functional impairment, ascertain who can help your patient with ADLs and IADLs.

Question 11

areas of high importance in PE

Answer 11

1. Visual and auditory acuity
2. Gait and ambulation
3. Abdomen – aortic dilation
4. Mental status and cognitive function
   - MMSE
   - MoCA - Montreal Cognitive Assessment

Pathologic findings can be superimposed on age-related physical changes

Question 12

more sensitive in detecting milder forms of cognitive impairment compared to MMSE
comes in multiple languages, versions for audiovisual impairments and lower literacy
what is this assessment?

Answer 12

MoCA - Montreal Cognitive Assessment

Question 13

causes of postural changes in blood pressure for geriatric assessment vitals

Answer 13

May be asx and occur in the absence of volume depletion
Aging changes, deconditioning, and drugs may play a role
Can be exaggerated after meals
Can be worsened and become symptomatic with antihypertensive,vasodilator, and TCA

Question 14

Poor personal grooming and hygiene can be signs of what?

Answer 14

poor overall function, caregiver’s neglect, and/or depression; often indicates a need for intervention

Question 15

Slow thought processes and speech usually represents what?

Answer 15

Usually represents an aging change; Parkinson disease and depression can also cause these signs

Question 16

Diminished turgor often results from ?

Answer 16

• atrophy of subcutaneous tissues rather than volume depletion
• when dehydration suspected, skin turgor over chest and abdomen most reliable

Question 17

with decreased visual acuity, what is often overlooked?

Answer 17

Hemianopsia is easily overlooked and can usually be ruled out by simple confrontation testing

Question 18

an irregular pulse could indicate what?

Answer 18

Arrhythmias

relatively common in otherwise asx elderly; seldom need specific evaluation or treatment

Question 19

what types of ulcerations are common in geriatric assessments?

Answer 19

Lower extremity vascular and neuropathic ulcers

Pressure ulcers common and easily overlooked in immobile patients may indicate a lack of adequate patient care

Question 20

what diminished hearing is common? what can be helpful with these assessments?

Answer 20

High-frequency hearing

pts with difficulty hearing normal conversation or a whispered phrase next to the ear should be evaluated further

Portable audioscopes - helpful in screening for impairment

Question 21

what is the common site for early sign of malignancies

Answer 21

Area under the tongue

Question 22

what abnormal lung sounds can be heard in geriatric assessments?

Answer 22

Crackles can be heard in the absence of pulmonary dz and HF

often indicate atelectasis

Question 23

systolic murmurs are common and most often ____; clinical history and bedside maneuvers can help to differentiate those needing further evaluation
Carotid bruits may need further evaluation

Answer 23

benign

Question 24

Prominent aortic pulsation is suspicious of ?

Answer 24

abdominal aneurysms

Question 25

what are the MC lesions seen in geriatric assessments?

Answer 25

**AKs, BCC** *most others are benign*

Question 26

what genitourinary things can be seen in a geriatric assessment?

Answer 26

1. _atrophy_ - Testicular atrophy normal - atrophic vaginal tissue - possible dyspareunia and dysuria --- tx may be beneficial 2. _Pelvic prolapse (cystocele, rectocele)_ - Common - may be unrelated to sx - gynecologic evaluation helpful if pt has bothersome, potentially-related sx

Question 27

limited ROM is often caused by ?

Answer 27

pain resulting from active inflammation, scarring from old injury, or neurological disease if limitations impair function, a rehabilitation therapist could be consulted

Question 28

Arm drift may be the only sign of ?

Answer 28

residual weakness from a stroke

Question 29

Determining appropriate lab assessment is based upon ? what are the managements?

Answer 29

life expectancy Life expectancy is >10 years no change in recommendation on management of disease Life expectancy is <10 years (and especially when it is much less) order labs only if it will improve the patient's prognosis and quality of life

Question 30

Misinterpretation of abnormal lab values in geriatrics leads to ?

Answer 30

underdiagnosis and undertreatment

Question 31

Laboratory parameters unchanged by aging (10)

Answer 31

1. Hemoglobin and hematocrit 2. WBC 3. Platelet count 4. Electrolytes (sodium, potassium, chloride, bicarbonate) 5. BUN 6. LFT (transaminases, bilirubin, prothrombin time) 7. Free thyroxine index 8. TSH 9. Ca 10. Phosphorus

Question 32

Common abnormal laboratory parameters

Answer 32

1. Sedimentation rate - age-related change 2. Glucose - elevated during illnesses 3. creatinine - elevated values may indicate reduced renal function 4. albumin - decline indicate undernutrition 5. alkaline phosphatase - mild asx elevations common; liver and Paget disease if elevated 6. Serum iron, iron-binding capacity, ferritin - _decrease is NOT an aging change_ - undernutrition and/or GI bleed 7. Prostate-specific antigen - elevated with BPH, consider prostate cancer 8. Urinalysis - asx pyuria and bacteriuria MC, hematuria abnormal 9. Chest radiographs - Interstitial changes are a common age-related finding 10. ECG - ST-segment and T-wave changes, atrial and ventricular arrhythmias, and blocks _MC in asx and may not need specific evaluation/tx_

Question 33

An evaluation of how a patient’s health conditions impact their physical and psychosocial function _Central focus of geriatric care_

Answer 33

Functional Assessment

Question 34

Functional decline is multifactorial, what are they?

Answer 34

Medical (physical) Psychological Social Environmental

Question 35

Activities that people need to be able to do to take care of themselves ex: Ambulation, bathing, dressing, eating, transferring, continence, toileting what is this functional assessment?

Answer 35

ADLs

Question 36

Activities that allow an individual to live independently in the community ex: Transportation, shopping, cooking, using the telephone, managing money, taking medications, cleaning, laundry what is this functional assessment?

Answer 36

IADLs

Question 37

If possible, it is important to distinguish whether an ADL/IADL impairment primarily due to ?

Answer 37

cognitive decline physical disability cultural / family customs

Question 38

how often should functional assessments be preformed?

Answer 38

1. Assess during first comprehensive exam and periodically - Always assess after hospitalization, severe illness, or the loss of a spouse or caregiver 2. Loss of ADL or IADL function often signals a worsening disease - Look for reversible causes - No identifiable cause perform an environmental assessment

Question 39

An evaluation of a patient in their living space to provide more independence – allows patient to remain at home

Answer 39

Environmental Assessment

Question 40

Environmental Assessment is best if performed by who?

Answer 40

PT, OT, or speech therapist

Question 41

Environmental recommendations after geriatric assessments

Answer 41

- _Physical tools_: Ramps, grab bars, elevated toilet seats, shower chairs, walkers, bedside toilets - _Special services_: Meals on wheels, homehealth - _Increased social contact_: Friendly visits, telephone reassurance, participation in recreational activities Provision of critical elements: Food, money

Question 42

what nutritional assessment findings are common in older adults? why does this happen?

Answer 42

1. wt loss and malnutrition are common in older adults 2. A general decline in caloric need happens as we age - Slower metabolism - Reduced physical activity

Question 43

what is the trend with body weight in geriatrics?

Answer 43

increases from age 30 – 60 plateaus for ~10 years then declines

Question 44

when does nutritional assessment findings need to be evaluated further?

Answer 44

low BMI (< 20) unintentional wt loss > 10 pounds in 6 months

Question 45

Risk factors for malnutrition

Answer 45

1. Drugs altering appetite (digoxin, chemo, chronic steroid use) 2. Chronic dz (CHF, COPD, renal insufficiency, chronic GI dz) 3. Depression 4. Dental and periodontal disease 5. Decreased taste and smell 6. Low socioeconomic level 7. Physical weakness 8. Isolation 9. Food fads

Question 46

Reasons to use the Mini Nutritional Assessment? scoring?

Answer 46

1. Declining food intake over the past 3 months 2. wt loss during the last 3 months 3. Mobility 4. Psychological stress or acute disease in past 3 months 5. Evidence of dementia/depression 6. BMI 7. Calf Circumference 12-14: Normal 8-11: At risk 0-7: Malnourished

Question 47

Micronutrients (vitamins and minerals) recommendations

Answer 47

1. Ca - Increases to 1200 mg/day --- Age 50 for F --- Age 70 for M 2. Vit D - Increase to 800 IU at age 70 3. Most OTC multivitamins meet remaining micronutrient needs

Question 48

Macronutrients (proteins, carbohydrates, fats) recommendations

Answer 48

_No change recommended_ - Omega 3 & Omega 6 fatty acids are not made, so _must be consumed_ - Fat intake <30% of total calories consumed - carbs should make up 55% of total calorie intake

Question 49

Managing Undernourishment and Malnutrition

Answer 49

1. Eat w/ family/friends and increase social support 2. Control pain 3. Increase physical activity 4. tx depression: preferably with Rx that has appetite stimulate 5. Caloric liquid or powder supplements 1 hr before meals - Not as a replacement - unless pt refuses to eat - Powder formulation can be mixed with food 6. Artificial tube feeding - temporary vs permanent: consider patient overall goal

Question 50

How to improve geriatric obesity

Answer 50

1. Healthy well-balanced diet 2. Exercise regimen - Must be feasible and detailed - Provide specific short-term goals - Exercise should include aerobic and resistance training 3. Pharmacologic agents have not been adequately investigated in the geriatric population

Question 51

Factors that can interfere with functional status on psychological assessment

Answer 51

1. Bereavement: Intervene Early 2. Widowhood - One of the most stressful transitions in later life - Better outcomes if patient has previous history of independence - Encourage volunteering and social engagement 3. Medical condition with a poor prognosis 4. Financial burden 5. Caregiver neglect 6. Depression - sx often atypical - Often deny dysphoric mood - Common sx include: --- Fatigue, weakness, anorexia, wt loss --- Anxiety, insomnia --- “Pain all over” --- Apathy --- Feelings of guilt --- Lack of concentration

Question 52

screening tools used for psych assessment? scoring?

Answer 52

1. Geriatric Depression Scale 2. PHQ-9 Patient Depression Questionnaire - score > 5 - suggestive of depression and should warrant f/u interview - Scores > 10 - depression

Question 53

for patient goals, Identify patient values and preferences such as:

Answer 53

Maintaining independence Symptom relief Prolonging survival

Question 54

Intentional or neglectful acts by a caregiver or trusted individual that led to or may lead to harm of a vulnerable older adult

Answer 54

elder abuse Affects _2% to 10%_ of elders despite being underreported _pt w/ cognitive impairment_ are at highest risk

Question 55

Five types of abuse

Answer 55

Physical Sexual Psychological / emotional Financial Neglect 

Question 56

1. Pattern of bruising or burns - Areas not likely to bruise during routine activity - abd, neck, posterior legs - Bruises that encircle elder person’s arms, legs, or torso - Burns in the shape of an object 2. Unexplained fractures, sprains, dislocations, internal injuries 3. Open wounds or cuts 4. Untreated injuries what type of elder abuse?

Answer 56

physical History – often self reported

Question 57

Unusual sexual behavior Unusual or inappropriate relationship between pt and abuser Bruises on or around the genital area/breasts Unexplained sexually transmitted or genital infections Unexplained vaginal or anal bleeding Torn, stained, or bloody underwear Pain with walking or sitting what type of elder abuse?

Answer 57

sexual Patient’s report of sexual abuse, assault, or rape

Question 58

hx shows Depression, Anxiety, Agitation, Excessive fears, Sleep changes, Change in appetite PE shows Passiveness, Evasive, Fear—possibly in presence of abuser, Confusion, Agitation, Significant wt changes, Sudden worsening medical conditions what are type of abuse are you suspecting

Answer 58

Psychological/Emotional abuse

Question 59

what can be seen in financial abuse?

Answer 59

Ambiguity of financial status Inability to pay bills, buy food or medications Sudden changes in legal documents (will, power of attorney, health care agent) Excessive concern regarding expenses necessary for patient’s care by the possible abuser Living excessively below the patient’s means Discomfort/evasiveness when discussing finances

Question 60

s/s of neglect

Answer 60

1. Absence of Hearing devices, Eyeglasses, Dentures, Assisted walking devices 2. Sudden changes or decline in health 3. Malnutrition, Dehydration, Poor hygiene, Inadequate or inappropriate clothing, Decubitus ulcers/bedsores, Recurrent infections

Question 61

what screenings can be done for potential elder abuse? scoring?

Answer 61

1. Elder Abuse Suspicion Index (EASI) - a “yes” answer to questions 2, 3, 4, 5, or 6 should raise a red flag for abuse Patient should be interviewed _alone_ to avoid intimidation

Question 62

Elder Abuse – Intervention and Management

Answer 62

1. Requires a comprehensive geriatric assessment 2. Ensure immediate safety of the patient - Admit to hospital if patient is unable to return to home safely - Contact local law enforcement if necessary 3. Contact Adult Protective Services (APS)