Geriatric Assessment and Care Quiz

Adult and Geriatric Medicine - AGM 1

• This course is an introduction to Adult and Geriatric Medicine (AGM).
• The course is taught by Laura Wylie, MPAS, PA-C.
• The course instructor's email is [email protected].

Course Content

• Adult Medicine is the general rule.
• Geriatrics is the exception.
• A major challenge of geriatric care is understanding the rule before learning the exceptions.
• Caregivers often deal with more complex situations, such as multiple co-morbid disorders and polypharmacy.

Unique Aspects of Elder Care

• Care of the elderly involves various settings, such as ambulatory, home, and institutional care.
• Curative and palliative care may need to be considered.
• Multiple co-morbid disorders are commonplace in the elderly.
• Patient safety is an important aspect of elder care.
• Polypharmacy and pharmacokinetics are vital topics to consider in the elderly.

Where are the Elderly?

• 2010 data suggests elderly living in community dwelling vs. institutions
  • 65-75: 95-99% community dwelling, 1% in institutions.

  • 85: 85% community dwelling, 15% in institutions.

Case Scenarios

• A 45-year-old male presents with a leg wound from a fall, a week prior.
  • Problem list includes: 1 week ago fall; possible infection; tetanus status.
  • Questions to ask include: How did the fall occur?; Are there any medications?; Does it hurt?; Remainder of 7 dimensions
• A 75-year-old male presents with a leg wound from a fall
  • Problem list includes: 1 week ago fall; possible infection; tetanus status; 75-year-old
  • Questions to ask include: How did the fall occur?; Are there any medications?; Does it hurt?; 7 Dimensions included (Where were you able to get up on your own?; Do you use an assistive device?; Have you fallen in the last year?)

Comprehensive Geriatric Assessment (CGA)

• CGA is used to manage the specific needs of the geriatric population.
• Six components of CGA: data collection; team discussion; treatment plan development; treatment plan implementation; medications; referrals; monitoring.
• Requires an interdisciplinary approach.
• Each stage of the CGA process is completed with data gathering, team discussion and development of the treatment plan.

The More Data Collected, The Easier The Assessment

• Past medical history (extending back as far as possible).
• Medications (include Beers Criteria, multiple provider input).
• Social history (occupation, finances).
• Depression screening (PHQ-2, PHQ-9, GDS).
• Activities of Daily Living (ADLs).
• Instrumental Activities of Daily Living (IADLs).
• Falls and Gait.
• Incontinence.
• Nutritional status.
• Vitals.
• Cognition.
• Get Up-And-Go Test.
• Advanced care planning.
• Review USPSTF recommendations.

Medications

• Match medications to problem list.
• Utilize a "brown bag" approach.
• Multiple provider input.
• Include Beers Criteria, allergies, and side effects.

In Geriatrics, Function is Primary

• Activities of Daily Living (ADLs): personal care, continence, mobility, feeding.
• Instrumental Activities of Daily Living (IADLs): shopping, finances, telephone, driving, cooking, housekeeping.

Multiple Screening Tools for the Elderly

• Tools help screen for Geriatric Syndromes
• Focus areas: Nutrition, Frailty, Pressure Ulcers, Incontinence, Syncope, Falls, Dizziness/Vertigo, Delirium, Sleep Disorders, Abuse
• Common Tools in CGA:
  • Cognitive Status (MMSE, MOCA, Mini-Cog)
  • Affective Status (Geriatric Depression Scale - GDS)
  • Mobility-Gait & Balance (Tinetti Performance-Oriented Mobility Assessment - POMA)
  • Functional Status-Activities of Daily Living (Katz ADL, Lawton IADLs)
  • Nutritional Adequacy (Mini Nutritional Assessment - MNA)

Falls

• Leading cause of injury/death in the elderly.
• Many falls are unreported.
• In 2014, falls resulted in 7 million injuries.
• Significant economic burden on Medicare.
• 50% of deaths from falls are attributed to traumatic brain injuries

Falls Assessment is Crucial

• Essential for effective treatment plan development.
• Risk factors: history of falls; lower extremity weakness; age; female gender; cognitive impairment; balance problems; psychotropic drugs; arthritis; orthostatic hypotension; anemia; hearing loss; visual impairment; increased number of chronic diseases.
• Assessments: Timed Get Up and Go; Physical Exam (orthostatic HTN, appropriate vision correction, hearing, extremities, neuro); Diagnostics (CBC, vitamin D, cardiac studies)
• Interventions- falls prevention using multidisciplinary teams

Patient Incontinence

• Patients rarely discuss incontinence unless asked directly.
• Consider the following phrasing: “In the past year, have you ever lost your urine or gotten wet?”; “Have you ever not been able to make it to the bathroom in time?”

Malnutrition

• Malnutrition is often a hidden cause of falls and decline among the elderly.

Vitals

• Significant weight changes over time
• Orthostatic blood pressure
• Irregular heart rate and palpitations
• Undiagnosed conditions revealed by blood oxygen saturation levels.

Cognitive Impairment

• MMSE, MOCA, Mini-Cog.
• (Neurology will provide more detail)

Capacity vs Competency

• Capacity: An individual's ability to make informed decisions (medical).
• Competency: A legal state of mental soundness to make decisions.

Advanced Care Planning.

• Essential part of discussion with patients about end-of-life options.
• DNR/DNI
• Advanced Directives (Who, When, Exceptions)
• POA (more than one; alternate; anyone to avoid)
• Patients' Priorities, Joy, and Future Goals

Other Diagnostic Tests

• Labs: Baseline ECG, Chest X-ray, complete blood count (CBC), vitamin D levels, drug levels, RPR, albumin, pre-albumin, homocysteine, B12, Vitamin D

Case Studies (Examples):

• Case studies are included to illustrate application of principles,
• Example Scenarios presented involve patient refusal of flu vaccine, or a patient with dementia wanting bank access.

Patient Quality of Life

• Assessment should focus on the goals, concerns, and priorities of each patient.
• Discuss patient and family desires.
• Goals should include function, independence, and comfort.
• Document a negotiated plan
• Shared decision making is important

USPSTF Screening Guidelines

• Guidelines are to prevent major illnesses before symptoms manifest.
• Provides a systematic tool for clinicians to identify appropriate preventive services for patient characteristics.

Cancer

• The biggest risk factor for cancer is age, with 60% of new cases and 70% of deaths occurring.
• A variety of theories are used to describe cancer risk and its origin.

Initial Presentation of Illness

• Initial symptoms of illness are often assumed to be simple aging processes
• A variety of symptom examples are shown in a table, to highlight this phenomenon

Review the Components of the CGA

• Past medical history; medications; social history; depression screening (PHQ-2, PHQ-9, GDS); ADLs; IADLs; falls; incontinence; nutritional status, vitals, cognitive function (Get-up and Go Test); patient-specific USPTF recommendations; advanced care planning considerations are reviewed