Geriatric assessment

Prof Mollentze / Dr . D. Greyling

Questionnaire

• 1. Continue this sequence in a logical way:

• M T W T • 2.Correct this formula with a single stroke:

• 5 + 5 + 5 = 550

Questionnaire

• 3. Please write anything here:

•

• 4. Draw a rectangle with 3 lines:

General

• Definition of aging: a Progressive , universal decline first in functional reserve and then in function over time.

• Old age is not a disease, but the risk of developing disease is increased.

Presentation of disease in older people

• Factors that influence recognition of disease in older people:

• 1. Acceptance of ill health and seeking medical advice.

• 2. Atypical presentation of disease processes

Background

• Between 2000 and 2030 , the number of older adults is expected to increase from 420 to 974 million people.

• 59 % of older adults are living in the developing countries of Africa, Asia, Latin America and the developing world have the largest increase in older adults because of the AIDS epidemic and because of better health services and lifestyle.

Geriatric giants• Immobility , instability and /or falls• Intellectual impairment• Sleep disorders• Confusion• Impaired senses – hearing , vision, proprioseption• Incontinence• Heart disease• Syncope/ Dizziness• Stroke• Malignancies

Definition of frailty

• Frailty is a clinical syndrome : 3/> of the following:

• 1.- Unintentional weight loss of > 4,5 kg in the past year

• 2.-Feeling exhausted• 3.-Weakness( poor grip strength)• 4.-Slow walking speed• 5.-Low physical activity

Frailty

• Associated with a high risk of falls , disability and death.

• Frailty is part of a single or multiple clinical syndromes

Approach to the geriatric patient

• Functional status is the best indicator of prognosis and longevity.

• Functional status: defined as the ability of a person to provide in his/her own daily needs.

The comprehensive geriatric assessment

• Focus on the evaluation of:• 1. Physical health• 2. Mental health• 3. Functional status• 4. Social functioning• 5. Environment

• A multidisciplinary team approach – Social worker , Dedicated nursing staff, Occupational and physiotherapist , Podiatrist , Biokinetician

Medication

Mobility

Mentation

Activities of DailyLiving

Social Support

Advance directives

Hearing

Vision

Incontinence

VisionDepression

Domain Approach

When is a multidisciplinary approach necessary

• The number of medical and surgical and neurological/mental problems

• The number of prescription medications

• Functional limitations in two or more activities of daily living

History taking• “ Don’t talk about patients , talk with them”• Introduction, purpose• First impression give clues to disease/present problem• Eye contact• Handshake• What is your name?• Don’t rush• Permission needed for collaborate history• Collateral information: Family, Caregiver , Environment• Ask about aids – hearing, spectacles, walking and wheelchair

History to be emphasized• 1. The patient profile: Current residence• Care giver• Employment history• 2. History of the present illness• 3. Medication review: Drug side effects• Dosage adjustment ; Calculate creatinine

clearance ( Cockroft Gold formula )• Over the counter medications• Indications• Compliance • Drug interactions• Correct dose• Protein levels and nutritional status • Attention to anticholinergic , psychotropic's and drugs with a narrow

therapeutic index •

Adjustment dosage in renal impairment

• Calculate creatinine clearance:

[140-age(y)] x weight (kg)CCr (GFR) = (males)

S-Cr (μmol/L) x 1.23

[140-age(y)] x weight (kg)CCr (GFR) = (females)

S-Cr (μmol/L) x 1.04

History continue.• 4. Family history : Dementia , Early Parkinson's , atherosclerotic

disease ,diabetes mellitus , hypertension and cancer.

• 5. Extended social history: • Alcohol , smoking and drug use.• Sexual history.• Home : Stairs , Bathrooms , Support , Medical emergency care , Health

aides.• • 6. Past history: surgical ,major illnesses and hospitalizations

• 7. Review all systems / old notes and results

History continues• 8. Collateral history

• 9. Social support systems

• 10. Advanced directives • - Specific wishes when dying• - Living will• - Advanced directives• - Health proxy

• 11. Nutrition

• 12. Mood , Depression question are

Physical examination• Emphasis on:• 1. The vital signs : Pulse , Respiratory rate , Blood pressure , General signs,

Height and weight• 2. Skin : Careful examination• 3. Eyes : Vision , Fundoscopy• 4. Ears• 5. Mouth and teeth• 6. Cardiovascular : pulses and rhythm, murmurs , aorta and bruits• 7. Breast examination• 8. Pelvic and rectal examination : Incontinence• 9. Muscle and joints• 10. Gait and balance• 11. Nervous system

Functional assessment

• Functional impairment should not be accepted as “ just part of getting old”.

• Documentation of the patients baseline function is essential so that changes can be identified and addressed.

Geriatric assessment instruments Domain Time( minutes) for

performing testsInstrument

Dementia 9 Folstein Mini mental

Delirium <5 Confusion assessment

Hearing <0,5 Whisper test , Rinne and Weber test , Audiometric

Nutrition <2 Weight < 4,5 kg / 6 months

Gait and Balance <1 ( < 20 sec for test) Timed get up and go test , timed gait speed, One leg

Basic activity of daily living( ADLs)

• - Dressing• - Eating• - Ambulating• - Toileting• - Hygiene• ( DEATH )

Independent DALs

• Shopping• Housekeeping• Accounting• Food preparation• Using Transport• Using the telephone• (SHAFT)

Other dimensions of geriatric assessment

• Dental health• Nutrition• Driving ability• Social functioning• Recreational activities

Cognition

• Screening : 3 Item recall test

• Minimental Questionnaire

• Other questionnaires : TYM

Get up and go test

• Observed and time to rise from a chair and walk 3 meters , turn around and return to sit down in a chair.

• Normal : 10 seconds.• Impairment is associated with increased fall

risk.

Vision testing

• Schnellen Chart – impairment <20/40 line• Test near vision• Postural stability is father determined by

depth perception , Binocular vision and contrast sensitivity.

Whisper test

• Cover the opposite ear of the patient, exhale completely and whisper an easily answered question at 60 cm from the ear being tested.

Assess nutrition

• 1.Involuntary weight loss > 4,5 kg over 6 months.• 2. Abnormal body mass index ( kg/m²): < 22 or

>27• 3. Hypoalbuminemia• 4. Hypocholesterolemia• 5. Consider specific vitamin deficiencies –

Vitamin B12 , Folate ,Niacin, Thiamine.• Nutrition screening questionnaire

Dentition

• Dental problems like loose dentures , missing teeth or oral pathology might interfere with eating.

• Poor dental hygiene is a risk for bacteraemia and pneumonia or infective endocarditic.

• Many medical conditions in the elderly interfere with absorption, digestion, increased nutritional needs or require dietary restrictions .

Depression

• Common due to chronic disease ,chronic pain, isolation, loss of spouse and peers

• Financial stressors• Old age home placement• Being alone – most important cause• Self esteem diminished due to loss of

independence

Depression

Driving

• Predictors of poor driving events:• 1. Vision impairment• 2. Hearing impairment• 3. Minimental impairment• 4. Fewer blocks walked• 5. Foot abnormalities

Incontinence• Urinary incontinence: 30 % community• 50% nursing home • Up to 80 years : Female 2 x > Male• “ DRIIIPP”• D- Delirium• R-Restricted mobility• I : Infection( UTI); Inflammation(Atrophic vaginitis );

Impaction of faces• P-Pharmaceuticals • P-Post prostatectomy/ post bladder surgery

Pressure sores

Pressure ulcers/sores

• Risk factors for development of pressure ulcers:• 1. Alterations in sensation or response to

discomfort: • Degenerative neurological disease, CVA’s, CNS

injury ,Depression , Drugs that affect alertness• 2. Alteration in mobility: • -2.1. Neurological diseases • -2.2. Fractures, Pain , Restraints

Pressure ulcers cont.

• 3. Change in weight the past 6 months: Protein calorie under nutrition , Edema

• 4. Incontinence: Bowel or Bladder

Summary

• DEEP MIC N:• D- Depression, Dementia, Delirium , Dental, Dermis.• E- Eyes• E- Ears• P-Polypharmacia• M-Malignancies, Metabolic• I- Incontinence• C – Cardiac failure and coronary artery disease• N – Nutritional state

References

• Brown JS; Ann Intern Med 144: 715, 2006• Cassel CK; Geriatric Medicine, 4th ed,2003• Reuben DB; Geriatrics at your finger tips:2007;

8th ed.• Geriatric secrets ; 3 rd ed.• Hazzards: Geriatric Medicine • and Gerontology ; 6 th ed. • Davidson ‘s