Geriatric Health Assessment Flashcards Preview

Health Assessment > Geriatric Health Assessment > Flashcards

Flashcards in Geriatric Health Assessment Deck (63):
1

Five areas to focus on function

  • Physical
  • Social
  • Psychological
  • Cognitive
  • Environment

2

Challenges to Geriatric Health Assessment

 

  • Communication
  • Underreporting of symptoms: afraid of hospital, nursing homes, not being able to care for selves anymore à minimize
  • Vague or non-specific complaints: “More tired than normally am” - ? is it normal aging or HF?
  • Atypical presentation of common clinical problems: e.g. her pt that had unilateral weakness, neuro symptoms, didn’t want interventions e.g. CT/MRI. Looked around and found UTI. Treated her and all neuro Sx subsided.
  • Multiple coexisting illnesses
  • Cognitive impairment: family member helpful

3

IZs

Influenza, Pneumococcus, Herpes zoster, Td

4

lab to review at every visit

calculated creatinine clearnance - esp if on a lot of meds!

5

Good resource for meds in geriatric population

http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2012

Beer's Criteria

6

General symptoms may indicate treatable underlying disease

 

  • Fatigue
  • Anorexia
  • Weight loss
  • Insomnia
  • Continence
  • Mood
  • Memory
  • Pain
  • Mobility problems
  • Recent change in functional status
  • Falls: big one – all the sudden falling, often an underlying issue

7

Common physical findings: vital signs

Elevated BP
Postural changes in BP
Irregular Pulse
Tachypnea
Weight changes

8

ADLs

(personal needs)

FEED
TOILET
DRESS
GROOM (hair, nails, makeup, shaving, oral care, clothing))
TRANSFER
AMBULATE (walk inside; outside)
BATHE OR SHOWER
climb stairs
maintain posture

 


change position in bed/chair
climb stairs
sleep
communicate
sex

9

IADLs

(household needs) "Instrumental ADLs"

USE TELEPHONE (summon help in an emergency)
SHOP (groceries, supplies)
PREPARE FOOD
HOUSEKEEPING (cleaning, garbage disposal)
LAUNDRY
TRANSPORTATION
TAKE MEDICINES
MANAGE MONEY
pet care
home maintenance (repairs, lawn care, snow removal)
self-care: medical needs

 

10

loss in ADLs vs IADLs

IADLs tend to go first. Loss of  ADLs really concerns us

11

Assessing gait speed

  • Measure a standard distance (e.g., 20 feet) and place markers at the start and finish.
    • Start the patient 5 feet in front of the mark and have the patient walk 5 feet past the finish mark.
    • Begin the stopwatch as soon as the person’s foot crosses the start line and stop recording when the person’s second foot crosses the finish line.
    • Have the person perform 3 repetitions of each condition and calculate the average time
  • Ask the patient to walk at his/her preferred walking speed. Instruct the patient to continue walking 5 feet beyond the finish line.
  • Ask the patient to walk as quickly as possible, but safely. Instruct the patient to continue walking 5 feet beyond the finish line.
  • <1.9 ft./sec = would benefit from PT eval and possible treatment

12

Assessing mobility

Timed Up and Go:

  • Arms folded across chest
  • Rise from chair
  • (use cane or walker if needed)
  • Walk 10 feet, turn, walk back, sit down
  • Normal : < 10 sec; Further assessment: > 20 sec

13

Comprehensive functional assessment

  • Performance oriented mobility assessment (Tinetti Gait and Balance Scale)
  • http://www.hospitalmedicine.org/geriresource/toolbox/pdfs/poma.pdf
  • Full musculoskeletal and neurological examination

14

What would lead you to perform a comprehensive nutritional assessement?

  • lost more than 10 lbs. in the past 6 months without trying to do so?
  • Is Body Mass Index < 20?
  • Yes to either

15

nutritional assessment tools

  • Mini Nutritional Assessment:
  • http://consultgerirn.org/uploads/File/trythis/issue_9.pdf
  • Nutritional Screening Initiative: DETERMINE
    • http://www.hospitalmedicine.org/geriresource/toolbox/pdfs/determine.pdf
  • 24-hour recall or food diary
  • Albumin/prealbumin

16

cognitive assessment tools

  • Mini-Cog
  • http://consultgerirn.org/uploads/File/trythis/issue03.pdf
  • 3-item recall
    • If unable to remember all 3 after one minute, more comprehensive testing
  • Name as many four legged animals as possible in one minute (> 8 –10)
  • Clock drawing
  • Ask common knowledge questions
    • Major events, i.e. election, 9/11

17

Mental status assessments

folstein MMSE, SLUMS

consider educational level or other confounding factors!

18

Geriatric Assessment: Depression Screening

  • Ask:
    • “Do you often feel sad or depressed?”
  • Geriatric Depression Scale –short form [GDS-15]
    • http://www.stanford.edu/~yesavage/GDS.html
  • SIG-E-CAPS
    • Change in Sleep or sexual activity
    • Decreased Interest in activities
    • Increased feelings of Guilt or remorse
    • Decreased Energy
    • Difficulty Concentrating
    • Change in Appetite
    • Psychomotor increase or decrease
    • Thoughts of Suicide
  • Helplessness or hopelessness
  • Apathy or self-neglect
  • Irritability

19

Advanced Directives

  • Living Will
  • Healthcare proxy
  • “Five Wishes”  10 page legal document – what you want at end of life
    • http://www.agingwithdignity.org/5wishes.html
  • Ongoing discussion

20

actinic purpura

purple patches or macules on skin that fade over time. Come from blood that has leaked through poorly supported capillaries and spread wi/in the dermis

21

Assessing vision & hearing

included in 10-minute geriatric screener

eye chart, asking about hearing loss + whisper voice test if necessary

22

When to screen

take into acct years left & whether diagnosis would prolong or improve life

23

Frailty screening

3 of 5 central components ID'd in CV Health Study

  • unitentional weight loss,
  • slow walking speed,
  • self-reported exhaustion,
  • low energy ependiture,
  • weakness

24

ETHNIC(S) pneumonic

escape pitfalls of group labeling / provide more culturally relevant assessments:

  • E Explanation (How do you explain your illness?)
    T Treatment (What treatment have you tried?)
    H Healers (Have you sought any advice from folk healers?)
    N Negotiate (mutually acceptable options)
    I (Agree on) Intervention
    C Collaboration (with patient, family, and healers)

(S Spirituality)

may miss important info about cultural identity, social supports, views about health care

25

Experts recommend letting patients establish their cultural identity by probing 4 key areas during patient interview: 

  • individual's cultural identity 
  • cultural explanations of the individual's illness,
  • cultural factors related to psychosocial environment and levels of function,
  • cultural elements in clinicial patient relationship

26

Ethnogeriatric IQ

Can be assessed at Stanfor Geriatrics Education Center Web site

27

screening for colorectal cancer

through 75yo

recommends against 76-85yo

28

PSA screen, USPTF

insufficient evidence to balance benefits & harms for <75yo

Recommends against for >75yo

29

skin & lung ca, USPTF

insufficient to recommend for or against whole body skin exams or screenings for lung ca

30

age-related cognitive decline 

suggested by mild forgetfulness, difficulty rememering names, mildly reduced concentration. Sporadic & do not affect function

31

Mild cognitive impairment (MCI)

evidence of memory impairment w/o cognitive deficits or functional decline. AD develops at higher frequency in MCI pts

32

Alzheimer's Dz

  • normal alterness but progressive global deterioration of cognition in multiple domains, including short-term memory, but with sparing of memory for remote events.
  • Subtle language errors, visuospatial perceptual difficulties; and changes in executive function, or ability to perform sequential tasks such as IADLs. 
  • later progresses to aphasia, apraxia, left-right hand confusion, psychosis, agitation

33

The 6th vital sign

functional status

e.g., w/10-minute geriatric screener

34

10 minute geriatric screener

covers 3 areas: cognitive, psychosocial, physical function

includes vision, hearing, questions about urinary incontinence.

35

DIAPERS

mnemonic for elucidating causes of incontinence

  • Delirium
  • Infection
  • Atrophic urethritis/vaginitis
  • Pharmaceuticals
  • Excess urine output from conditions like hyperglycemia or HF
  • Restricted mobility
  • Stool impaction

36

DDRRIIPP

elucidate causes of incontinence

  • Delirium
  • Drug side effects
  • Retention of feces
  • Restricted mobility
  • Infection of urine
  • Inflammation
  • Polyuria
  • Psychogenic

37

Fall reduction strategies

  • gait, balane, strength training
  • Vit D supplementation 700-100IU/daily
  • minimization or w/drawal of psychoactive or other meds

38

Initial screen for fall risk

  • 2+ falls in past 12 mths
  • presents w/acute fall
  • difficulty w/walking or balance

yes to any of above

39

increased cup to disc ratio suggests

open angle glaucoma

3-4x higher in AAs than in general population

40

COMMON AGE CHANGES: Cardiovascular

  • Atrophy of muscle fibers that line the endocardium
  • Atherosclerosis of vessels
  • Increased systolic blood pressure
  • Decreased compliance of the left ventricle
  • Decreased number of pacemaker cells
  • Decreased sensitivity of baroreceptors

41

IMPLICATIONS OF CHANGES: cardiovascular

  • Increased blood pressure
  • Increased emphasis on atrial contraction with an S4 heard
  • Increased arrhythmias
  • Increased risk of hypotension with positional change
  • Valsalva maneuver may cause a drop in blood pressure
  • Decreased exercise tolerance

42

COMMON AGE CHANGES: Neurologic

  • Decreased number of neurons and increase in size and number of neurological cells
  • Decline in nerves and nerve fibers
  • Atrophy of the brain and increase in cranial dead space
  • Thickened leptomeninges in spinal cord

43

IMPLICATIONS OF CHANGES: Neurologic

  • Increased risk for neurological problems: cerebrovascular accident
  • Parkinsonism
  • Slow conduction of fibers across the synapses
  • Modest decline in short-term memory
  • Alterations in gait pattern: wide based, shorter stepped, and flexed forward
  • Increased risk of hemorrhage before symptoms are apparent

44

COMMON AGE CHANGES: Respiratory

  • Decreased lung tissue elasticity
  • Thoracic wall calcification
  • Cilia atrophy
  • Decreased respiratory muscle strength
  • Decreased partial pressure of arterial oxygen

45

IMPLICATIONS OF CHANGES: Respiratory

  • Decreased efficiency of ventilatory exchange
  • Increased susceptibility to infection and atelectasis
  • Increased risk of aspiration
  • Decreased ventilatory response to hypoxia and hypercapnia
  • Increased sensitivity to narcotics

46

COMMON AGE CHANGES: Integumentary

  • Loss of dermal and epidermal thickness
  • Flattening of papillae
  • Atrophy of sweat glands
  • Decreased vascularity
  • Collagen cross-linking
  • Elastin regression
  • Loss of subcutaneous fat
  • Decreased melanocytes
  • Decrease in fibroblast proliferation

47

IMPLICATIONS OF CHANGES: Integumentary

  • Thinning of the skin and increased susceptibility to tearing
  • Dryness and pruritis
  • Decreased sweating and ability to regulate body heat
  • Increased wrinkling and laxity of the skin
  • Loss of fatty pads protecting bone and resulting in pain
  • Increased need for protection from the sun
  • Increased time for healing of wounds

48

COMMON AGE CHANGES: GI

  • Decreased liver size
  • Less efficient cholesterol stabilization and absorption
  • Fibrosis and atrophy of salivary glands
  • Decreased muscle tone in bowel
  • Atrophy of and decrease in number of taste buds
  • Slowing in esophageal emptying
  • Decreased hydrochloric acid secretion
  • Atrophy of mucosal lining
  • Decreased absorption of calcium

49

IMPLICATIONS OF CHANGES: GI

  • Change in intake caused by decreased appetite
  • Discomfort after eating related to slow passage of food
  • Decreased absorption of calcium and iron
  • Alteration of drug effectiveness
  • Increased risk of constipation, esophageal spasm, and diverticular disease

50

COMMON AGE CHANGES: Urinary

  • Reduced renal mass
  • Loss of glomeruli
  • Decline in number of functioning nephrons
  • Changes in small vessel walls
  • Decreased bladder muscle tone

51

IMPLICATIONS OF CHANGES: Urinary

  • Decreased GFR
  • Decreased sodium-conserving ability
  • Decreased creatinine clearance
  • Increased BUN
  • Decreased renal blood flow
  • Altered drug clearance
  • Decreased ability to dilute urine
  • Decreased bladder capacity and increased residual urine
  • Increased urgency

52

COMMON AGE CHANGES: Reproductive

  • Atrophy and fibrosis of cervical and uterine walls
  • Decreased vaginal elasticity and lubrication
  • Decreased hormones and reduced oocytes
  • Decreased seminiferous tubules
  • Proliferation of stromal and glandular tissue

53

IMPLICATIONS OF CHANGES: Reproductive

  • Vaginal dryness and burning and pain with intercourse
  • Decreased seminal fluid volume and force of ejaculation
  • Reduced elevation of the testes
  • Prostatic hypertrophy
  • Connective breast tissue is replaced by adipose tissue, making breast examination easier

54

COMMON AGE CHANGES: Musculoskeletal

  • Decreased muscle mass
  • Decreased myosin adenosine triphosphate activity
  • Deterioration and drying of joint cartilage
  • Decreased bone mass and osteoblast activity

55

IMPLICATIONS OF CHANGES: Musculoskeletal

  • Decreased muscle strength
  • Decreased bone density
  • Loss of height
  • Joint pain and stiffness
  • Increased risk of fracture
  • Alterations in gait and posture

56

COMMON AGE CHANGES: Sensory-Vision

  • Decreased rod and cone function
  • Pigment accumulation
  • Decreased speed of eye movements
  • Increased intraocular pressure
  • Ciliary muscle atrophy
  • Increased lens size and yellowing of the lens
  • Decreased tear secretion

57

IMPLICATIONS OF CHANGES: Sensory-vision

  • Decreased visual acuity, visual fields, and light/dark adaptation
  • Increased sensitivity to glare
  • Increased incidence of glaucoma
  • Distorted depth perception with increased falls
  • Less able to differentiate blues, greens, and violets
  • Increased eye dryness and irritation

58

COMMON AGE CHANGES: Sensory-Hearing

  • Loss of auditory neurons
  • Loss of hearing from high to low frequency
  • Increased cerumen
  • Angiosclerosis of ear

59

IMPLICATIONS OF CHANGES: Sensory-Hearing

  • Decreased hearing acuity and isolation (specifically, decreased ability to hear consonants)
  • Difficulty hearing, especially when there is background noise, or when speech is rapid
  • Cerumen impaction may cause hearing loss

60

COMMON AGE CHANGES: Sensory-smell/taste/touch

  • Decreased number of olfactory fibers
  • Altered ability to taste sweet and salty foods; bitter and sour tastes remain
  • Decreased sensation

61

IMPLICATIONS OF CHANGES: Sensory-smell/taste/touch

  • Inability to smell noxious odors
  • Decreased food intake
  • Safety risk with regard to recognizing dangers in the environment: hot water, fire alarms, or small objects that result in tripping

62

COMMON AGE CHANGES: Endocrine

  • Decreased testosterone, GH, insulin, adrenal androgens, aldosterone, and thyroid hormone
  • Decreased thermoregulation
  • Decreased febrile response
  • Increased nodularity and fibrosis of thyroid
  • Decreased basal metabolic rate

63

IMPLICATIONS OF CHANGES: Endocrine

  • Decreased ability to tolerate stressors such as surgery
  • Decreased sweating and shivering and temperature regulation
  • Lower baseline temperature; infection may not cause an elevation in temperature
  • Decreased insulin response; glucose tolerance
  • Decreased sensitivity of renal tubules to antidiuretic hormone
  • Weight gain
  • Increased incidence of thyroid disease