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Lesson7 Geriatric Assessment

Lesson7 Geriatric Assessment

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Published by: Dennis Nabor Muñoz, RN,RM on May 24, 2010
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GERIATRIC ASSESSMENT CLASS #4, LESSON #7 Selected Web sites or link sites: http://www.mayo.

edu/geriatrics-rst/PFA.html http://www.med.upenn.edu/aging/link/shtml Introduction • • • • • • • • • • “Old age isn’t so bad when you consider the alternative.” Maurice Chevalier, actor “If I had known I was going to live this long, I would have taken better care of myself.” Eubie Blake (composer who lived to 100) “It’s not how old I am, it’s how I am old.” Groucho Marks, comedian People do not die from “old age.” People die from consequences of disease or accident. The aging effect is universal, progressive & intrinsic for all people Age related changes make the elderly more vulnerable to certain health problems, but do not cause disease 5% of geriatric population is estimated to be abused or neglected Majority of older adults live active, independent lives in the community 12% over 65 continue to work 25% are self employed, in comparison to 10% in general population

Demographics: The “Graying of America” • • • • • • • • Percentage of Americans 65 & older has tripled from 1900 (4.19%) to 1990 (12.6%) By 2030, with baby boomers aging, approximately 22% of US population will be over 65 Number of older persons living into 80’s & 90’s has increased Maximum life span (110 years) has not increased 85 years & older group: fastest growing population in US In 1986, 77% of older men were married & 52% of older women were widowed 15% of older men & 40% of older women live alone Elderly women outnumber elderly men 1.5:1 overall & 3:1 after 95

Aging Cohorts • • • 65 – 75 = Young Old 75 – 85 = Old 85+ = Old Old or Frail Elderly

Health Care Implications American Association of Retired Persons, Administration on Aging, US Census • More hospitalizations for elders • Average length of stay longer: 8.9 days vs 5.3 days for younger • 5% of elderly over 65 live in nursing homes: • 1% in 65 – 74 age group • 25% in 85 year-olds & older • 32% of health dollars is spent on geriatric population (12% of total population • Significant “out-of-pocket” health care expenses are incurred by elderly Major Chronic Conditions in Older Adults Arthritis Orthopedic impairments Hypertension Sinusitis Hearing Impairments Diabetes 1

Heart Disease Cataracts

Visual impairments Varicose veins

Common Disorders of Aging Minorities • African American: Higher incidence of strokes, obesity, cancer, glaucoma, diabetes & hypertension than nonminority. Higher rates of chronic disease, functional impairment & risk factors, such as unemployment, poverty & lack of adequate health care American Indians: Ten times more likely t have diabetes than Caucasians. Alcohol is a leading cause of health problems, including accidents, liver cirrhosis, suicide & homicide Asian Americans & Pacific Islanders: Tuberculosis is a major concern High incidence of cancer: Japanese Americans: stomach cancer Hawaiians: lung & breast cancer Chinese American Women: pancreatic cancer Latin Americans: Higher rates of hypertension, cancer, diabetes, arthritis & high cholesterol. High rate of chronic ailments & limitation in ADL. Have more days per year in bed due to illness

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GENERAL ISSUES TO CONSIDER • Altered presentation of disease: “General” rather than “classic” symptoms of younger adult. Examples: • Myocardial infarction (except in diabetic) classically presents with chest, but in the elderly may present with mental confusion, a fall, or nausea & vomiting or palpitations. • Hyperthyroidism, classically presents with tachycardia, sweats or anxiety, but in the elderly may present as depression or apathy • Appendicitis may not present with abdominal pain • Pneumonia may not present with shortness of breath, fever or chills, but with confusion Nonspecific presentation of disease: When ill, the elderly may not want to eat, have only nonspecific complaints & remain in bed. Relatives may report, “hasn’t gotten out of bed.” Underreporting of illness: May be due to a number of factors, such as: • Decreased awareness of symptoms (sensory, cognition) • Denial of symptoms or uncertainty of perceptions • May believe symptoms are normal for “old age” • May believe nothing can be done, so don’t mention it

Multiple pathological conditions: One condition may mask symptoms of another, or medications for one condition may adversely affect another condition. For example: A person with COPD may not be active enough to bring on symptoms of angina in presence of severe ischemic heart disease Polypharmacy: (3 or more medications) Instruct patient to being all prescription & OTC medications for review: 2

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Elderly over 65 use 25% of prescription medications consumed in US Average geriatric patient uses 4.5 medications Nursing home residents average 8 medications 7% of nursing home residents are taking 3 or more psychotropics Chief Complaint: Many have several conditions. Symptoms may be vague & not seem to relate directly to the system involved. Expectations: May be more emphasis on improvement of function (prolonging optimum physical, mental & social activity) than on diagnosis & cure Accumulated life history: Intelligence does not decline with age. Older adults are generally reliable historians & should be treated with respect for their intelligence, wisdom & accumulated life experiences. If there is a long history of medical problems, assessment may be complex & timeconsuming & patient may need to be screened for an interdisciplinary Comprehensive Geriatric Assessment (CGA) or re-scheduled for additional, shorter visits. Patients most likely to benefit from a CGA include: • Over age 75 • Have mild to moderate disabilities • May be at risk for nursing home placement • May have a poor social network

“GERIATRIC SYNDROMES: Conditions (not diseases) that place the patient at risk for functional decline, morbidity & mortality: Falls, incontinence, delirum, inappropriate medication use, mental status & mood impairment, functional impairment & poor nutrition.

GENERAL GUIDELINES FOR ASSESSMENT • • • Provide a private, safe, comfortable, warm environment that is well lighted & has minimal visual and noise distractions Provide for modesty, as patient may be sensitive regarding body changes Before beginning history assess for use of assistive devices & for impairment of 3 major functions: Vision, hearing & cognition

ASSESSMENT OF MENTAL STATUS & MOOD IMPAIRMENT • Cognitive Function • Dementia • Delirium • Depression • GENERAL COGNITIVE FUNCTIONING IN OLDER ADULTS (Miller, 1995) • Age related changes: may show some declines, but most capable of cognitive growth & intellectual development • Negative functional consequences: short term memory decreases, long term does not; no decline in crystallized intelligence (wisdom, creativity, common sense, breadth of knowledge), slight decline in fluid intelligence (abstraction, calculation, spatial orientation, inductive reasoning) & slower processing of information • Risk factors: Impaired sensory functioning, alcohol, medications, physical disorders, psychosocial influences, environmental distractions, lack of motivation & lack of stimulation 3

DEMENTIA: A gradual decline in memory & intellectual functioning. • Most common cause: Alzheimer’s disease (neuron loss & decrease in chemical transmitters) • Other causes: multiple strokes, alcohol abuse, Parkinson’s disease, Huntington’s disease & acquired immunodeficiency disease • Assessment of Cognitive Function: Do a simple 3-object recall screen. If patient is unable to recall 3 objects after 1 minute or if history suggests cognitive deficits, the MMSE & Clock Drawing Test may be administered: • Folstein Mini Mental Status Examination: MMSE, (30 points, total score). A score of less than 24 or recent decline in function, indicates further assessment Bates text, p. 120 Swartz text, pp. 649-650 Barkauskas, et al text, pp. 526-527 Clock Drawing Screening Test for Dementia, (4 points, total score) A score below 4 indicates further assessment Bates text, p. 119 DSM IV DEMENTIA CRITERIA A. Multiple cognitive deficits, including: 1. Memory impairment 2. One or more of the following: a. Aphasia (speech difficulty) b. Apraxia (movement, coordination, sensation difficulty) c. Agnosia (visual, auditory, recognition difficulty) d. Disturbance in executive function B. No.1 & No.2 must significantly impair occupational or social Functioning

DELIRIUM: Acute change in mental status, usually occurs during an acute medical illness or due to medications. Studies have reported that 5% to 36% of hospitalized elderly develop delirium during hospitalization • • • • • • DSM IV DELIRIUM CRITERIA Reduced attention Impaired sensorium Fluctuating course Disorganized thinking Subacute onset

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DEPRESSION: The most common mood disorder in late life, a syndrome that includes physiological, affective & mental symptoms. Some depression symptoms, such as weight loss, sleep disturbances & fatigue may be associated with other conditions. Geriatric Depression Scales (GDS) can be used to screen depression: • Yesavage Geriatric Depression Scale (30 points) Swartz text, p. 648 • Short form GBS (15 points) Included in following text


Ask patient “do you feed sad, blue, or depressed much of the time?” Older white men are at the highest risk for suicide of any age group.

DSM IV MAJOR DEPRESSION CRITERIA Presence of 5 or more of the following: • Depressed mood • Diminished interest or pleasure • Weight loss or gain • Insomnia or hypersomnia • Pschomotor agitation or retardation • Fatigue or loss of energy • Feelings of worthlessness or guilt • Diminished energy to think or concentrate • Recurrent thoughts of death, suicidal ideation

GERIATRIC DEPRESSION SCALE (GBS) – short form 1. Do you often feel downhearted & blue? 2. Have you dropped many of your activities & interests? 3. Do you feel life is empty? 4. Do you often get bored? 5. Are you in good spirits most of the time? 6. Are you afraid that something bad is going to happen to you? 7. Do you feel happy most of the time? 8. Do you often feel helpless? 9. Do you prefer to stay at home, rather than going out & doing new things? 10. Do you feel you have more problems with memory than most? 11. Do you think it is wonderful to be alive? 12. Do you feel worthless the way you are now? 13. Do you feel full of energy? 14. Do you feel that your situation is hopeless? 15. Do you think that most people are better off than you are? Score Count the number of capitalized Yes/No

Yes no Yes no Yes no Yes no yes No Yes no yes No Yes no Yes Yes Yes Yes Yes Yes Yes no no No no No no no

0-5 = normal, 6-10 = mild depression, 11-15 severe depression FUNCTIONAL ASSESSMENT: ADL & IADL • Activities of Daily Living (ADL) Dressing Bowel control Transferring Bladder control Feeding Walking Bathing Climbing stairs Toileting Grooming Instrumental Activities of Daily Living (IADL) Telephoning Shopping Reading Meal preparation Leisure Laundering Medication management Housekeeping 5

Money management ASSESSMENT OF ADL & IADL • •

Home maintenance

Includes patient & proxy reports as well as observation of patient’s functional ability & functional level A number of functional assessment tools & questionnaires are available: Barkauskas, et al text, chapter 27: Selected examples: • • Katz ADL Index: general measure of self care & limited measure of mobility: Bathing, dressing, using toilet, transfer, continence, feeding PULSES profile: designed for rehabilitation & function independence assessment: P = Physical condition U = Upper limb functioning L = Lower limb functioning S = Sensory components E = Excretory function S = Support factors Barthel Index: a weighted index for assessing dependence in slef-care, mobility & continence Instrumental ADL Scale: measures more cognitively & less physically oriented functions Physical Self-Maintenance Scale (PSMS): includes 6 items of self-care & mobility Functional Activities Questionnaire (FAQ): measures 10 items necessary for independent living Rapid Disability Rating Scale: global disability scale Functional Status Rating Scale: Measures assistance needed in self-care & mobility & amount of social & cognitive impairment Functional Independence Measure (FIM) & Functional Assessment Measures (FAM): Comprehensive tools likely to be used in long-term care rehabilitation programs

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ASSESSMENT OF MOBILITY, GAIT & BALANCE Adapted from Rein Tideiksaar, Geriatrics, Vol 51 No.2 Feb. 1996 & Mayo Clinic Web sit • • • • • • • Sit & rise from a chair: Ability to sit & rise in a smooth controlled movement without balance loss or use of armrests. Poor performance indicate slower extremity dysfunction Stand in place for 10 – 15 seconds after rising from chair: Ability to stand steady unassisted without balance loss or dizziness. Poor performance indicates postural hypotension or vestibular dysfunction Stand with eyes closed, arms at sides & feet 3 inches apart: Ability to stand without support & without sway or balance loss. Poor performance indicates proprioceptive loss Maintain balance when receiving sternal nudge: Normal reaction is to stretch arms forward & away from body & take a step or two backward to regain balance. Poor performance indicates postural instability. A nudge in the lower back may be used to stimulate a righting reflex. Modified Romberg: a test for gait & ambulation: response to positional stress, loss of visual input & displacement, with eyes open – closed, various gait positions & sternal displacement nudges (mayo clinic web site) Bend down & reach, to pick up an object: Ability to maintain balance. Poor performance indicates altered balance & risk for fall with hard-to-reach activities 6

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Balance assessment with functional reach test: ability to stand with shoulder against wall & move extended arm & fist forward 6 inches without losing stability. Lesser distances indicate risk for falling (mayo clinic web site) Walk in straight line, turn around & walk back: Ability to walk & turn around without hesitation, excessive deviation from side to side, or feet scraping the floor. Poor performance indicates gait/balance dysfunction. Get up from floor: Ability to get up either unassisted or with help of chair for support. Poor performance indicates lower extremity dysfunction Shoulder function: Ability to put both hands behind head & also behind back of waist. Poor performance indicates limitation of shoulder mobility or pain

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ASSESSMENT OF URINARY INCONTINENCE • • • 15% - 30% of older adults living at home & up to 50% of nursing home residents have incontinence. Ask if patient has problems with loss of urine If answer is “yes,” consider common causes of incontinence: urinary tract infection, medication side effects, obstruction, stool impaction, delirium or dementia, polyuria/diabetes, restricted mobility, Parkinson’s disease, bladder nerve injury, relaxation of pelvic floor muscles, prostatic hypertrophy

ASSESSMENT FOR FALLS • • • • • • • • • • Falls are frequent: up to 1/3rd of older adults living at home fall each year Falls increase to 50% by age 80 Risk factors: Sensory impairments: visual, vestibular, proprioceptive Neurological impairments: gait for mental status Musculoskeletal conditions: strength & mobility Cardiovascular conditions: orthostatic hypotension Medications: Situational factors: acute illness, unfamiliar environment Ask about falls in past 6 months & ability to get up from falls

ASSESSMENT FOR MEDICATION USE • • • Risk factors: multiple diseases & health care providers, sharing or rationing medications, limited financial resources & age related physiologic changes Age related changes: Absorption: > gastric pH; < absorptive surface, splanchnic (visceral) flow, GI motility, active transport, gastric secretions • Distribution: > cardiac output, total body water, lean body mass: > body fat • Metabolism: > hepatic mass, enzyme activity, hepatic blood flow • Excretion: > renal blood flow, glomerular filtration rate, tubular secretion General guideline: Assess for cumulative effect of medications & consider lower dosages Adverse side effects categories: Gastrointestinal irritation Sedation Anticholinergic effects Hypotension, postural hypotension Evaluation: Examine all medications, determine usage & dosage schedules

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NUTRITIONAL ASSESSMENT • Decreased BMR: Older adult needs fewer calories, so type of food becomes more important to endure adequate nutrition 7

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Weight & Height: Unintentional weight loss/gain in past 6 months Significant weight loss: 5% or more of prior body weight in 1 month, 7.5% in 3 months, or 10% in 6 month History: • Special diets • Food preparation & eating habits: 3-day diet history • Clinical symptoms: sore mouth, chewing or swallowing difficulty; Fractures; mood; mental status; & medications Laboratory Screening: albumin level & serum cholesterol Checklist to DETERMINE Nutritional Health D = Disease, Chronic or Acute E = Eating Problems/Habits T = Tooth loss E = Economic Hardship R = Reduced Social Contact M = Multiple Medications I = Involuntary Weight Gain or Loss N = Needed Assistance with Self Care E = 80 Years or Older

ASSESSMENT OF SELECTED SYSTEMS • Height, Weight, Vital Signs: Observe for orthostatic & hypothermic conditions

SKIN • • • • Thinning skin: due to atrophy of epidermis, hair follicles, sebaceous glands & reduction of subcutaneous fat (, with dryness, wrinkling, reduced turgor/elasticity & fragile vessels Photoaging: sun exposure contributes to hypopigmentation or hyperpigmentation Assess for: malignant changes, pressure sores, pruritis, ecchymosis Lesions: • Seborrheic (senile.solar) keratosis: beneign, raised, warty-type, scaly lesions, yellow-tan to dark brown • Skin tags: beneign, flesh colored • Senile lentigenes: “liver spots”, beneign, 1-2 cm brown pimented, in sun exposed areas • Vascular: beneign; telaniectasias or spider angiomas, cherry angiomas, senile purpura • Sebaceous gland hypertrophy: 1-3 mm, nose & forehead areas, yellowish • Actinic keratosis: beneign to pre-cancerous: red, dry, scaly lesions in sun exposed areas: Distinguish from skin cancer: • Basal cell: small nodules/bumps, pearly-translucent border with central ulcerated depression (red-brown-black): sun exposed areas • Squamous cell: red, scaly patches with central crusting that may ulcerate or bleed: sun exposed areas • Melanoma: sun protected areas: A-B-C-D Graying & decrease in growth: scalp, axillary, public Course hair: eyebrow, nostril ear & some women develop increase in facial hair


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Growth slows: may yellow, lack luster, develop ridges Finger nails: may be thin & split Toenails may thicken

HEAD, EYES, EARS, NOSE, THROAT & NECK • • Evaluate for head trauma Patients who complain of headaches, visual symptoms &/or polymyalgia symptoms should be evaluated for polymyalgia or temporal arteritis

EYES • • • • • • • • “Dry eye syndrome”: decreased mucous tears (may predispose to corneal ulcers, exposure keratitis) Fat loss from orbit: eyes have sunken appearance Lids: decreased strength/laxity: senile ptosis Ectropian or entropian: lower lids turning outward or inward Arcus senilis: calcium & cholesterol salt deposits at limbus of eye form grayish-white arc or halo Yellow pigment in lens: alters color perceptioin Presbyopia: loss of lens elasticity & accommodation for close vision: check near vision Floaters: degenerative changes in iris, vitreous humor & retina impair vision

Common eye problems occurring more frequently in elderly: • Cataract formation: lens opacity, decreased visual acuity & sensitivity to glare from lights • Glaucoma: open-angle most common in older adult: measure intraocular pressure • Senile macular degeneration • Retinal hemorrhage

EARS • • • Outer ear: decrease in cerumen, dryness & hair increase in external can lead to cerumen impactions Middle ear: otosclerosis may produce conductive hearing loss Inner ear: Prebycusis (age related hearing loss), due to degeneration of organ Corti, leads to inability to hear high frequency sounds (speech degeneration from decrease in cochlear neurons may also occur) Background noise may be problematic Dizziness: may result from loss of hairs in semicircular canals

NOSE & THROAT • • • • MOUTH • • Atrophic changes in salivary glands cause dryness of mouth (xerostomia) & may lead to decrease in taste & dental caries: (encourage tooth brushing & discourage sweets) Gingival recession: problems with dentures & malalignment of bite 9 Decrease in smell: may affect appetite & taste or ability to detect smoke/gas… Decrease in mucous & gag predispose to upper respiratory infections Loss of elasticity in laryngeal muscles may produce tremulous or high-pitched voice Check for bruits & enlarged thyroid

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Loss of teeth: from caries or periodontal disease (check under dentures for ulcerations) Poorly fitting dentures may lead to eating & chewing problems & weight loss Examine tongue for malignancies

RESPIRATORY & CHEST • • • Kyphosis, increased A:P diameter & less compliant chest wall Loss of elasticity, reduction in vital capacity, degeneration of bronchial epithelium & mucous secretions increases susceptibility to infections Increase in morbidity for COPD, pneumonia, lung cancer, TB

CARDIOVASCULAR • • • Reduced elasticity & lumen of vessels, increased peripheral resistance (hypertension & widened pulse pressure) Isolated systolic hypertension & orthostatic hypotension (20 mm Hg drop with standing) BP lying & standing or sitting & standing, both arms Valves become sclerotic, especially aortic (55% have systolic murmur)

GASTROINTESTINAL • • • • • • Atrophy of gastrointestinal mucosa, with altered secretion, motility & absorption Changes in elastic tissue & colonic pressures may result in diverticulosis, which can lead to diverticulitis Atrophic changes in pancreas Decrease in hepatic mass, blood flow & microsomal enzyme activity lead to increased half-life of lipid-soluble drugs Increase in disease: GERD, ulcers, malnutrition, constipation, gall stones Examine for abdominal mass, hernias, blood in stool, enlarged prostate

GENITOURINARY & RENAL • • • • • Decrease in number of glomeruli, renal capacity, blood flow & urine concentration Decrease in bladder capacity & urinary incontinence Increase in UTI Male: Testosterone decreases: testes & penis decrease in size, testes lower in scrotum, libido unchanged; increase in BPH Female: Decline in estrogen induces menopause; ovaries, uterus & cervix decrease in size; vagina narrows & shortens & mucosa atrophies (vaginal estrogen creams may relieve dryness), libido unchanged: breast tissue less firm, less glandular with more fat tissue; increase in aatrophic vaginitis, osteoporosis, incontinence & UTI

ENDOCRINE • • • Decreased thyroid gland activity Decreased pancreatic function (hyperglycemia) Other hormonal changes may lead to alterations in fluid & electrolyte balance


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Atrophy of muscles (more commonly in distal extremities) Thinning of intervertebral disks & loss of height Osteoporosis, & increased risk of fractures Osteoarthritis: joint stiffness & decreased range of motion, pain Hand arthritic changes: Heberden’s & Bouchard’s nodes Increased risk of falls (gait changes or orthostatic hypotension) Assess gait: decreased stride length, anteroflexion of upper torso, flexion of arms & knees & Diminished arm swing may contribute to postural unsteadiness

NERVOUS SYSTEM • • • • • • • • Assess mental status Vibratory sensation decreases Reflexes commonly reduced Gag reflex may be reduced/absent Achilles tendon reflex often symmetrically reduced/absent Vascular changes of atherosclerosis can result in muliplte infarcts or transient ischemic attacks Cogwheel rigidity is suggestive of Parkinson’s disese Perform Romberg’s test & evaluate gait

HEALTH PROMOTION & SUCCESSFUL AGING • • • • • • • • • • Safety Smoking cessation Nutrition Weight control Medication management Alcohol & other drugs Exercise Stress management Social support Attitudes toward health

“Unless we can create a world which offers the possibility of aging with grace, honor & meaninglness, no one can look forward to the future.” S. Halleck


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