Geriatric Pertinent Points from History
Syndrome
o Confirm etiology of dementia:
DEMENTIA ! Domains affected? Trajectory
of cognitive decline?
! Duration of cognitive
impairment?
! Always EXCLUDE delirium and
depression!
! Are there reversible causes of
dementia? [DEMENTIA]:
• D – Drugs / Delirium
• E – Endocrine [Thyroid]
• M – Metabolic
[Hypercalcemia]
• E – Ethanol, Emotional
[Depression]
• N – Normal Pressure
Hydrocephalus [Gait
Apraxia + Urinary
incontinence + Dementia]
• T – Tumor / Trauma
• I – Infection [Neurosyphilis]
• A – Anemia [B12
deficiency]
o Severity:
! AMT? [Age and Education]
! cMMSE? [Age and Education] "
Should be performed if AMT
UNIMPAIRED but there is hx of
cognitive impairment
! Global Deterioration Scale
! DSM-IIIr
! Functional Assessment Staging
Tool
! ADLs + Behaviors [including
depression / sleep problems] +
Cognition
o Complications i.e. BPSD: “Baseline
behavior?”
! Causes of agitation in patients
with dementia [PRISMMMM]:
• P – Pain + other unmet
needs
• R – Retention of urine
• I – Impacted faeces, Itch,
Iatrogenic [Restraints,
Tubes, Catheters]
• S – Sleep deprivation +
Social [Carer stress, Carer
Pertinent Physical Relevant Investigations /
Examination
o Focus on neurological o Dementia bloods
exam: o Brain imaging
! To characterize
dementia subtype
• Neuro deficits "
stroke disease
• PD/EPSE
features " DLB
• Gait – apraxia "
stroke, NPH
• Frontal release
signs " FTD
! To rule out reversible
causes of dementia
! To look for
complications of
treatment
• EPSE "
antipsychotics
Management Plan
Med Review
o Treat delirium / depression / reversible causes of cognitive
impairment
o Med review [remove offending drugs that worsen cognition]
o Confirm diagnosis if not formally diagnosed: Etiology,
severity, BPSDs, carer stress?
o Primary treatment goals for dementia:
! Maintain QOL
! Maximize function
o Non-pharmacological mx:
! Behavioral chart in ward:
• A - Antecedent trigger / circumstances
• B – Behavior
• C – Consequences
! OT for cognitive stimulation / behavioral strategies
! PT for function
o Pharmacological mx:
! Cognitive enhancers – to give or not to give???
• Need to explain modest benefits, side effects and
cost to family
! Meds for BPSD:
• Failed non-pharmacological
• Risk of self harm or harm to others
• If still cannot treat dangerous / stressful BPSD
symptoms, consider refer to PsychoG
o Caring for the caregiver:
! Dementia counseling – diagnosis, natural course,
prognosis, possible associated behavioral problems,
coping strategies, patient safety
! Behavioral strategies for BPSD [caregiver education,
home based interventions]
! Home safety – fall prevention, wandering prevention,
medication supervision, driving issues, fire prevention
! Caregiver support groups +/- respite
o Person-centered care:
! LPA
! ACP
! Care and safety issues – meds, cooking, wandering,
driving?
o Discharge planning:
! Community support services – Dementia day care or
day rehab? ADA Home Intervention Program? H2H?
GDH? Home help services?
 abuse]
• M – Medical illness [Sick]
• M – Medications
• M – High / Low
• M – Mad [Psychosis]

! Exclude delirium in the ward!

o Carer stress:
! Dementia counseling? [for newly
dx cases]
! Behavioral strategies?
! Known to services to support
patient and carer?

o If dementia already diagnosed by

reliable source:
! No need detailed cognitive hx
! Current functional status most
important
! Current behavior and BPSD
! Any coping difficulty and carer
stress

! !
 Geriatric Pertinent Points from History
Syndrome
o Determine phenotype of delirium:
DELIRIUM Hypoactive, hyperactive or mixed
o Predisposing causes of delirium:
! Advanced age
! Dementia
! History of delirium
! Dependency in ADLs
! Medical comorbidities
! History of alcohol abuse
! Male
! Diminished hearing / vision
o Look for precipitating causes of
delirium: [DELIRIUM]:
! D – Drugs [including Alcohol!]
! E – Electrolytes + Endocrine
[Hyper/Hypo-thyroidism,
Hyper/Hypo-glycemia]
! L – Lack of Drugs [Withdrawal,
Inadequate Pain Control]
! I – Infection
! R – Reduced sensory input [Lack
of visual / hearing aids]
! I – Intracranial [Infection,
Hemorrhage, Stroke, Tumor]
! U – Urinary retention + Fecal
impaction
! M – Myocardial + Pulmonary
issues
! S – Surgery
o Determine if any disruptive or
hazardous behavior e.g. aggression
or self harm
! !
Pertinent Physical
Examination
o CAM assessment: [1+2+
either 3 or 4]
! Acute onset +
fluctuating course
! Inattention: Days of the
week backwards
! Disorganised thinking
! Altered level of
consciousness
o Look / Ask for easily found
causes of delirium:
! Vitals
! Hydration
! Pain – joints
! Fecal impaction and
urinary retention
! Focal neurological
deficit
Relevant Investigations /
Med Review
o Look for causes of delirium
o Brain scan if:
! Hx of falls / HI
! New focal neuro deficis
! Fever or AMS
suggestive of
intracranial infections
! No other identifiable
etiology of delirium
o Med review!
! Anticholinergics
! Anticonvulsants
! Antidepressants
! Antihistamines
! Anti-inflammatory e.g.
Prednisolone
! AntiPD drugs
! Antipsychotics
! BZD
! H2 antagonists
! Opiods
o Exclude alcohol or nicotine
withdrawal!
Management Plan
o Aim for PREVENTION rather than management once
delirium has occurred!
o Multi-factorial approach [because multiple factors contribute
to delirium]:
! Identify and treat reversible contributors:
• Meds, infections, fluid balance disorders, hypoxia,
pain, sensory deprivation, elimination problems
• Minimize parameters / drains and tubes
! Maintain behavioral control:
• Behavior chart!
• Behavioral interventions
• Pharmacological interventions
! Anticipate and prevent / manage complications:
• Urinary incontinence
• Immobility and falls
• Pressure ulcers
• Sleep disturbances
• Feeding disorders
! Restore function in delirious patients:
• Hospital environment
• Cognitive reconditioning
• Functional rehab – match performance to ability as
delirium clears
• Family education / support
o Caregiver:
! Education and management strategies
o Discharge planning:
Supportive management in community if delirium not
fully cleared on discharge – GDH??
 Geriatric Pertinent Points from History
Syndrome
o Symptoms of depression [≥5 of
DEPRESSION following for ≥2/52]:
! S – Sleep disturbance [Insomnia
/ Hypersomnia]
! I – Interest lost [Anhedonia] ***
! G – Guilt
! E – Energy levels low /
Exhaustion
! C – Concentration impaired
! A – Appetite change
! P – Psychomotor agitation /
retardation
! S – Suicidal ideation
! Low mood ***
o Evaluation of suicidal risk [SAD
PERSONS – Admit if >4]:
! S – Sex [Male]
! A – Age [Elderly]
! D – Depression [esp with
hopelessness]
! P – Previous attempt
! E – Ethanol abuse
! R – Rational thinking loss [e.g.
command hallucinations]
! S – Social support deficit
! O – Organised plan
! N – No spouse
! S – Sickness [esp if chronic and
debilitating]
! !
Pertinent Physical
Examination
o Quick bedside screen – first
2 questions of PHQ 9:
! Anhedonia?
! Low mood?
Relevant Investigations /
Med Review
o Geriatric Depression Scale
[screening]
Management Plan
o Exclude ddx of medical illness / dementia / psychotic
depression
o Non-pharmacological mx:
! Psy-OT for engagement, psychotherapy [if cognitively
okay]
! Exercise
! ECT: If serious risk of suicide, life threatening poor
intake due to MDD
o Pharmacological mx:
! Management principles:
• Acute phase: Antidepressants to achieve
remission
• Continuation phase: Continue on antidepressants
for at least 6/12 once remission achieved
• Maintenance phase: Remains on antidepressants
on therapeutic doses to prevent recurrences –
duration of maintenance therapy should be based
on the frequency and severity of previous
depressive episodes
o Choice of antidepressant depends on:
! Indications + spectrum of activity
! Side effects
! Patient factors [cost, tolerability, compliance]
 Geriatric Pertinent Points from History Pertinent Physical
Syndrome Examination
o ≥2 falls in the past 1 year? o Look / Ask for causes of
FALLS falls:
o Complications of fall ! Cognitive impairment
! Red flags: Long lie, inability to ! Cataracts
WB post fall ! Focal neurology +
dysmetria / pronator
o Precipitating factors for current fall drift + proprioception
+ peripheral
o Predisposing factors for falls [Big neuropathy
BMW COE FU]: ! Parkinsonism
! Big – Balance [Vision, Hearing, ! Joints
Cerebellar, Proprioception, ! Feet and footwear
Peripheral neuropathy] ! Walking aids!
! Cardiac arrhythmias
! B – BP [Postural BP]
! M – Medications [Sedatives, ! STANDING balance!
Psychotropics] and KIV semi tandem
Polypharmacy ! GAIT!
! W – Weakness [Prox or distal?
Unilateral or bilateral? UL or LL?] o Expectations of a “basic
falls assessment”:
! C – Cognition ! Details of falls
! O – Others [Pain? Footwear?] ! Mobility status
! E – Environment [Lighting,
Flooring, Steps] ! PBP
! Neuro exam – full
! F – Fear of falling works including
! U – Urinary incontinence sensation and
proprioception
o Hx of osteoporosis ! Exam of joints and feet
o If yes, any treatment? ! Gait assessment
! Vision assessment
! Cognitive assessment
! Urinary incontinence
! Med review
! If syncope or dizziness
" further workup of
etiology
Relevant Investigations / Management Plan
Med Review
o Causes of falls: o Complete workup for falls
! Postural BP
! Investigations to rule o For community-dwelling [AGS / BGS]:
out sepsis / o Multi-factorial fall risk assessment!
hypoglycemia,
medical issues, o Direct interventions tailored to identified risk factors +
metabolic causes appropriate exercise program: [TAILOR TO YOUR
[B12, folate] PATIENT!]
! PT for strength and balance exercise + gait training /
! ECG – arrhythmias Tai Chi " either home based or group exercises are
! KIV 2DE / Holter effective
! CT brain – if suspected ! OT for home assessment and modification [esp in
stroke or ICH those with visual impairment and recurrent falls in the
home]
! Med review!
• Anticholinergics ! Vit D >800 IU/day for proven / suspected Vit D
• Anticonvulsants deficiency, or those at high risk for falls
• Antidepressants ! Med review – minimize or stop psychotropics
• Antihistamines ! Manage polypharmacy
• AntiHTN,
Diuretics ! First cataract surgery
• Antipsychotics ! Advised not to wear multifocals while walking, esp on
• BZD stairs
• Insulin and
! Dual chamber PPM for cardioinhibitory carotid sinus
OHGA
hypersensitivity
• Opioids
! Manage postural hypotension:
• Systemic
• Non-pharmacological
glucocorticoids
• Pharmacological
o Complications of falls:
! Manage foot problems and footwear + use of walking
! X-rays / CT brain –
aids!
complications of falls
o For institutionalized [AGS / BGS]:
o Bone health:
! Vit D supplements at least 800 IU/day with:
! BMD, FRAX
! Vitamin D levels • Proven or suspected Vit D insufficiency
• Abnormal gait and balance
• High fall risk
o For cognitively-impaired [AGS / BGS]:
! Insufficient evidence to recommend for or against
multifactorial or single interventions to prevent falls in
older persons with known dementia in community or
institutions
o Bone health:
! Decide if will benefit from anti-resorptives – indications
vs risks
! Check CrCl and look for CI to antiresorptives
! BMD, FRAX
o Caregiver:
! Education on fall prevention and falls recovery

Geriatric Pertinent Points from History
Syndrome
o Hx of osteoporosis
OSTEOPOROSIS o If yes, any treatment?
! Any previous complications
with treatment?
! Any treatment failure?
• ≥2 incident FRAGILITY
fractures
• 1 incident FRAGILITY
fracture + either one of:
o Elevated bone
turnover markers
with no significant
reduction during
treatment OR
o A significant
decease in BMD
• BOTH no significant
decrease in bone
turnover markers AND a
significant decrease in
BMD
o Listen for secondary causes of
osteoporosis!
! RA and chronic inflammatory
disorders
! Endocrine: T1 DM,
hyperthyroidism,
hyperparathyroidism, Cushing’s,
Hypogonadism
! Chronic liver disease
! Chronic malnutrition /
malabsorption
! Drugs: Steroid use, anti-
androgen drugs, DM drugs, PPI,
antipsychotics, anticonvulsants
o Recurrent falls? Gait and balance
disorder?
! !
! CGT
o Discharge planning:
! Safe alone or not? – need carer or not?
! Need maintenance rehab or not?
Pertinent Physical Relevant Investigations / Management Plan
Examination Med Review
o Look for fall risk factors! o RP [CrCl], LFT, TFT, Ca / Alb o Complete workup for osteoporosis!
o Vit D ! Screen BMD if:
o Dental exam • Women >65yo
o Kyphosis o BMD • Men >50yo with risk factors for osteoporosis or
o Strength o FRAX who have common causes of secondary
o Gait and balance o XR L-spine to look for occult osteoporosis
vertebral # ! FRAX for 10 year probability of major osteoporotic # and
hip #
o Non-pharmacological mx:
! Increase weight bearing exercise
! Stop smoking; Cut alcohol
! Reduce fall risk – multi-factorial falls assessment!
! Diet: Sufficient protein intake
! Adequate Ca2+ [700-1200mg/day]
! Adequate Vit D [800 IU/day]
o Pharmacological mx:
o Decision-making:
! Treat or not?
• Indication?
• Absolute contraindications? E.g. severe renal
impairment
• Benefits – expected benefit of treatment [which
includes time to benefit] vs estimated life
expectancy and QOL
• Risks – side effects
! If treating, which one to use?
• Contraindications?
• Spectrum of anti-fracture effects across
skeletal sites
• Side effects of each drug
• Cost
• Patient tolerability and acceptance
o Dental clearance before starting bisphosphonates or
Denosumab!
 Geriatric Pertinent Points from History Pertinent Physical Relevant Investigations / Management Plan
Syndrome Examination Med Review
o Risk factors for postural o Sustained reduction of SBP o Med review! o Goal of management directed towards:
POSTURAL hypotension: ≥20mmHg or DBP ! Alpha blockers ! Improvement of symptoms
HYPOTENSION ! Older age ≥10mmHg within 3mins of ! Diuretics ! Improving functional status
! Men > Women standing or head-up tilt to at ! Vasodilators ! Reducing risk of syncope and falls
! Institutionalization least 60 degree on a tilt table ! Dopamine agonists
! Number of prescribed ! Most sensitive measure ! Venodilators o Treat reversible causes of postural hypotension
medications, esp early in AM [also ! TCA
antihypertensives usually more o Remove offending meds
! Multiple comorbidities symptomatic] o Autonomic function tests –
o Look at concomitant HR – for diagnosis of neurogenic o Non-pharmacological mx:
o Causes of postural hypotension absence of compensatory OH by assessing the ! Calf and ankle pumps prior to standing
[HANDI]: HR [<20beats per min] autonomic reflex arcs ! Prescribe pressure stockings [beware of PVD!]
! H – Hypovolemia; typical of neurogenic OH ! Moving from supine to standing in gradual stages
Hypopituitarism ! Adequate salt and water consumption
! A – Addison’s o Look for causes of postural
! N – Neuropathy [autonomic] e.g. hypotension: o Pharmacological mx: [CI in severe HTN, CHF, hypokalemia]
DM, PD, MSA or primary ! Hypovolemia ! Midodrine 2.5-10mg TDS [4hrs apart]
autonomic failure ! Sepsis • Alpha-adrenergic agonist – short acting pressor
! D – Drugs [antiHTN, diuretics, ! Deconditioning agent
antipsychotics, antiPD] ! Other autonomic • Side effects: Supine HTN [avoid evening doses]
! I – Idiopathic signs: Urinary ! Fludrocortisone 0.1-0.3mg/day
retention, severe • Synthetic mineralocorticoid – volume expander
o Associated complications – Postural constipation, decreased • Side effects: Supine HTN, heart failure, hypoK
hypotension is risk factor for: sweating, erectile ! Pyridostigmine 60mg
! Syncope dysfunction • Cholinesterase inhibitor that facilitates
! Falls ! Peripheral neuropathy cholinergic neurotransmission at the level of the
! Incident coronary heart disease, ! Neuro exam: autonomic ganglia " increases BP preferentially
stroke, heart failure Parkinson’s disease, on standing, when residual sympathetic tone is
! Mortality MSA, DLB increases
• But less effective in severe form of neurogenic
OH
• Side effects: N&V, loose stools, urinary
urgency, frequency and abdominal cramping

! OH in the hypertensive patient:

• AntiHTN meds should not be stopped in patients
with OH:
o Higher risk of falls with uncontrolled HTN
and OH
o Uncontrolled HTN also can worsen OH by
pressure diuresis
• Use antiHTN judiciously – ACE-I or ARB may
improve BP regulation and cerebral blood flow
in elderly patients and prevent OH

! OH in supine HTN:
• Avoid supine position in daytime
• Raise head of bed by 6-9 inches at night
• Short-acting antiHTN at bedtime

o Caregiver:
! Management strategies
 ! Fall prevention education
! Teaching PBP monitoring at home

o Mneumonic: [ABCDEF]
! A – Abdominal compression – abdominal binder when
out of bed
! B – Bed up / Bolus of water [cold water prior to
prolonged standing]
! C – Countermaneuvres
! D – Drugs [Midodrine, Fludocortisone, Pyridostigmine]
! E – Education / Exercise
! F – Fluids and salt

! !
 Geriatric Pertinent Points from History
Syndrome
o Duration of functional decline
FUNCTIONAL o Onset + Trajectory
DECLINE AND
IMMOBILITY o Cause of functional decline:
! Strokes? – cognitive decline at
same time as functional decline?
! If acute functional decline, make
sure assess for acute medical
causes
o Complications of immobility [RIP,
4Ds (Die Die Die Die!)]:
! R – Retention of urine, UTI
! I – Impacted feces
! P – Pneumonia
! D – DVT
! D – Deconditioning
! D – Decubitus ulcers
! D – Depression
o History of swallowing difficulty?
DYSPHAGIA
o Possible causes:
! Oral ulcer / dentures
! Structural causes of dysphagia
! Functional causes of dysphagia
Pertinent Physical
Examination
o Look / Ask for causes of
functional decline:
! Neuro exam – stroke?
PD?
! Gait and balance
! Pain and joint
assessment
! Vision and hearing
! Cognitive assessment –
delirium or dementia?
! Med review
! Environmental
assessment
o Look / Ask for complications
of immobility:
! PR for impacted feces
! PVRU for high RU /
IDC?
! Pressure ulcers
! DEPRESSION!!!!!
o Bedside swallow
assessment!
o Look for possible causes of
dysphagia:
! Oral exam
! Neuro exam – strokes,
PD, dementia,
delirium?
! Malignancy?
o Look for complications:
! Dehydrated?
o Weigh patient
Relevant Investigations /
Med Review
o Med review!
o RP to look at hydration
o If feeding via new NGT for
e.g. look for refeeding
bloods [Mg, K, PO4]
Management Plan
o Treat reversible causes of functional decline
o Remove offending meds
o Functional optimization:
! Social engagement – to pre-empt / manage low mood
associated with immobility
! ADL and ambulation: PTOT
! Continence: Wean off diapers, regular potting, bowel
regime
! Swallowing / speech: ST
o Nutritional optimization:
! Adequate protein
o MDM assessment:
! If have rehab potential:
• Set appropriate goals
• Refer to appropriate setting [inpatient ward,
subacute, comm hosp, outpatient rehab]
! If NO rehab potential:
• Need for long-term carer?
• Walking aids / home equipment?
• Home modification needed?
o Caregiver education and support:
! CGT for ADL / ambulation / tubes and feeding / care of
pressure areas + coping strategies
! Fall prevention advice
! Home modification – EASE
! Home equipment
o Discharge planning:
! Community support resources? – Day rehab? Outpatient
PT? GDH?? H2H? Home help services?
o Decide on most appropriate mode of feeding + type of diet and
fluid consistency
o Ref ST
o Ref dietician for supplements
o Review meds and determine if need to be crushed
o If for NGT, to review regularly to see if can wean off
o Determine causes of, and treat reversible causes of
dysphagia
o Caregiver education and support:
! Education on diet texture and fluid consistency
! CGT on feeding techniques
 Geriatric Pertinent Points from History Pertinent Physical Relevant Investigations / Management Plan
Syndrome Examination Med Review
o Is urinary incontinence bothersome? o Look / Ask for causes of o Look at bladder chart if o Need to classify the type and likely etiology of urinary
URINARY ! QOL urinary incontinence: available incontinence before treatment!
INCONTINENCE ! Fall risk ! PV for atrophic vaginitis o UFEME TRO UTI
/ UV prolapse? o PVRU o Treat if bothersome
o What kind of incontinence? ! PR for fecal impaction / o KUB imaging [if significant o Treat reversible causes
! Storage symptoms: Frequency, BPH / cauda equina? renal impairment, o Remove offending meds!
urgency, nocturia, incontinence ! PVRU? Palpable recurrent/persistent UTI or
! Voiding symptoms: Hesitancy, bladder? hematuria] o Non-pharmacological mx:
straining, dribbling, intermittency, ! Stress [cognitively INTACT]:
incomplete emptying o If palpable bladder, look for o Look for complications of • Pelvic muscle exercises
! Others: Dysuria, hematuria, obvious causes of palpable overflow incontinence: • Toilet regime - Prompted voiding
polyuria, nocturnal polyuria bladder: ! Renal impairment • Continence aids
! Strokes? ! US kidneys with • Weight loss
o Transient or Permanent? ! Spinal pathology? hydronephrosis, • Treat causes of cough
! Fecal impaction? BPH? bladder diverticulum
o Transient causes of urinary UV prolapse? ! UTI? ! Urge [cognitively INTACT]:
Incontinence [DIAPPERS]: • Bladder training
! D – Delirium o IDC / IMC? • Pelvic muscle exercises
! I – Infection [symptomatic]
• Toilet regime – Prompted voiding
! A – Atrophic vaginitis o Med review!
• Fluid and caffeine management
! P – Pharmacological [Sedatives, ! Anticholinergics
Diuretics, Cholinergics] ! Antidepressants
! Urge [and cognitively impaired]:
! P – Psychological [Depression] ! Antipsychotics
! E – Endocrine [Hyperglycemia, ! Diuretics • Timed voiding
Hypercalcemia] ! CCB • Fluid and caffeine management
! R – Restricted mobility ! ACE-I
! S – Stool impaction [Overflow ! Alpha agonists ! Overflow:
incontinence] ! Alpha blockers • Double-voiding
! CAFFEINE • Toilet regime
o Permanent causes of urinary • May need IDC / IMC
incontinence – 4 main types:
! Stress [impaired pelvic support, ! Functional:
failure of urethral closure] • Toilet regime
• Improve mobility / function
! Urge [detrusor overactivity from • Home modifications
bladder irritation or from strokes;
detrusor hyperactivity with o Pharmacological mx:
impaired contractility] ! Urge incontinence:
• Antimuscarinics [Oxybutynin, Tolteridine,
! Overflow – BOO [BPH, urethral Solifenacin] – anticholinergic class effects
stricture, UV prolapse] • Mirabegron – HTN; Cannot use with
antimuscarinics
! Overflow – detrusor • Premarin cream, if applicable
underactivity [peripheral
neuropathy, spinal nerve ! Stress incontinence:
damage, detrusor fibrosis] • Premarin cream, if applicable

! Mixed?? ! Overflow incontinence [BPH]:

• Alpha-blockers [Terazosin, Tamsulosin, Alfuzosin]
o Red flags: • 5 alpha reductase inhibitors [Finasteride,
! Hematuria – bladder Ca? Dutasteride]
Stones? • Combination [Duodart]
! Persistent / recurrent UTI
 ! Constitutional symptoms – o Surgical mx:
malignancy? ! Stress:
! High RU despite double • Retropubic suspension
voiding • Sling procedure
! Suspected neuro insults – • Periurethral bulking agent
spinal cord lesions
! Pelvic / prostate mass – ! Urge:
possible tumor • Sacral neuromodulation
• Intravesical botox

o Caregiver:
! Education and support
! Behavioral and home modification strategies: Night time
urinal / bedside commode

o IMC regime:
! Start with IMC BD:
• If post-void IMC >400ml: IMC QDS or insert IDC
• If PV IMC 300-400ml: IMC TDS
• If PV IMC 200-300ml: IMC BD
• If PV IMC 100-200ml: IMC OM
• If PV IMC <100 for 2 consecutive IMCs: Wean off

Geriatric Pertinent Points from History Pertinent Physical Relevant Investigations / Management Plan
Syndrome Examination Med Review
o Risk factors for pressure ulcers: o Assess size and stage of o Albumin o Prevention of pressure ulcers:
PRESSURE ! Age >70yo pressure ulcer o HbA1c ! Skin care:
ULCERS ! Poor nutritional state o Complications? E.g. cellulitis • Clean and moisturize
! Urinary and fecal incontinence • Avoid contact with sweat / urine or fecal matter
• Barrier creams if wearing diapers
! Optimise nutrition:
• Weak evidence for supplements
! Minimise mechanical loading
! Encourage mobility
! Air mattress

o Management of pressure ulcers:

! Wound dressings:
• Wound cleansing and regular dressing change
! Surgical repair may be indicated for stage III and IV
ulcers

o Caregiver:
! CGT

o Person-centered care:
! ACP

o Discharge planning:
! HNF? H2H?

! !
 Geriatric Pertinent Points from History
Syndrome
o Manifestations of frailty [SWELL]:
FRAILTY ! S – Slow gait speed
! W – Weakness
! E – Exhaustion
! L – Loss of weight
! L – Low physical activity
o Clinical Frailty Scale [CFS]:
! CFS 1: Very fit
! CFS 2: Well
! CFS 3: Medical problems but
managing well
! CFS 4: Vulnerable. Slow but no
need help from others
! CFS 5: Mildly frail. IADLs need
help
! CFS 6: Moderately frail. Need
help with all outside activities.
BADLs need assistance
! CFS 7: Severely frail. All BADLS
dependent but stable, not actively
dying
! CFS 8: Very severely frail.
Approaching end of life [not
surprised if die in 6/12]
! CFS 9: Terminally ill
o History needed to determine CFS:
! BADL
! IADL
! Medical history
! Medications
o Premorbid frailty status " should be
reflection of patient’s overall health at
least 2/52 prior to acute illness
and/or functional decline
! !
Pertinent Physical Relevant Investigations / Management Plan
Examination Med Review
o Gait speed o Vit D levels o Comprehensive Geriatric Assessment!
o Strength o Albumin
o Look at nutritional status o Hb, Vit B12, TFT o Management approach:
o Look for depression! o GDS for depression 1. Exclude any modifiable precipitating causes of frailty esp
o Look for iatrogenic those that are treatable or environmental:
complications! o Meds review! o Screen for causes of fatigue " anemia, Vit B12
! IV lines deficiency, hypothyroidism, depression, postural
! IDC hypotension, sleep apnea!
! Drains o Screen for causes of weight loss " consider dietician
! CRIB for nutritional support or speech therapist for
swallowing impairment if present
o Screen for polypharmacy and review meds!
o Screen for and treat Vit D deficiency
2. Improve the clinical manifestations of frailty:
o Low physical activity " resistance exercise!
o Weakness " resistance exercise!
o Poor exercise tolerance " resistance exercise!
o Nutrition " high protein diet, Vit D!
3. Minimize consequences of vulnerability of frail elderly, by
compensatory strategies to buffer up support against
stressors:
o MINIMIZE IATROGENESIS!
! Prolonged bedrest
! Physical restraints
! Excessive hypocount / parameter monitoring
! Unnecessary tethering equipment e.g. IDC / IV
lines
o Falls prevention " strength and balance exercise!
o Nutritional support
o Social support e.g. Meals on Wheels, check on
medications etc
4. Educate family and patient on risks of developing
disability based on frailty status " to aid incorporating
patient’s goals and preferences into management plan
5. Explore Advanced Care Planning for all patients with
severe frailty [CFS ≥7]
o Person-centered care:
! ACP
! Prognostication!!!
 Geriatric Pertinent Points from History Pertinent Physical Relevant Investigations / Management Plan
Syndrome Examination Med Review
o Involuntary weight loss >5% of usual o Monitor weight o Treat reversible causes of poor intake / weight loss,
NUTRITION AND body weight over 6-12 months o Vit D levels including ST TRO dysphagia as cause
WEIGHT o Albumin o Remove offending meds!
o Causes of Impaired Feeding [MSG]:
! M – Motivation [Malignancy, o Med review: o Non-pharmacological mx:
Mood, Medication, Medical ! Anorexia: ! Ref dietician for supplements
illness, Mental (Severe • Digoxin ! Encourage careful feeding Q2H
dementia)] • Phenytoin ! Encourage home cooked food, make food more
! S – Swallowing [Oral ulcer / • SSRIs appealing
dentures, Structural causes of • CCB
dysphagia, Functional causes of • H2 blockers o Pharmacological mx:
dysphagia] • PPI ! Avoid using prescription appetite stimulants – no
! G – Get Food [Difficulty getting • Opioids evidence
food – buying / cooking / feeding ! Off-label meds:
• Furosemide
/ money] • Mirtazepine [caution in renal or hepatic
• K+ supplements
insufficiency]
• Ipratropium
• Theophylline o Caregiver:
! CGT for feeding / swallowing
! Affects taste and ! Education on causes of poor intake and strategies
smell:
• Metformin o Person-centered care:
• Captopril ! Prognostication!!!
• Klacid • Excess loss of lean body mass associated with
poor wound healing, infections, pressure
! Causes xerostomia: sores, functional decline, mortality ACP:
• Antihistamines ! ACP:
• Antidepressants • NGT in advanced dementia?
• Antipsychotics o Cochrane review: Insufficient evidence to
• Diuretics support the benefits of tube feeding in
advanced dementia in terms of survival,
QOL, nutrition, functional status, the
prevention of aspiration, or the
prevention and healing of pressure ulcers

! !
 Geriatric Pertinent Points from History Pertinent Physical Relevant Investigations / Management Plan
Syndrome Examination Med Review
o Med review! o Principles of Prescribing [5Rs]:
POLYPHARMACY ! E.g. of meds ! R – Restrain [Avoid prescribing if possible]
appropriate for de- ! R – Replace [With cost-effective alternatives / those with
prescribing: less side effects]
• Antihistamines ! R – Reduce:
• PPIs and H2 • Reduce Meds
blockers • Reduce Dose [Start low, Go slow]
• Iron • Reduce Frequency [Easy dosing]
• Memantine ! R – Reactions [Adverse reaction, Interactions]
• Antipsychotics ! R – Review, Review, Review
• Antidepressants
• Bisphosphonates o Get complete medication hx [including TCMs, OTCs]
! Including indications / side effects / interactions /
monitoring

o Decision making when considering new meds:

! Indications?
! If indicated, consider patient’s baseline prognosis
[how long will meds take to be useful? Is life expectancy
expected to be beyond this period?]
! Benefits
! Side effects
! Patient’s tolerability and compliance [practical dosing
regimen? cost?]

o Start low and go slow – attempt to reach therapeutic dose

before switching / adding on another med
o Caregiver and patient education
o Review, review, review!

o Consider appropriate de-prescribing:

! No indication anymore
! Not effective
! Harm > benefits
! Non compliant

o Monitor for flare ups or underlying condition / withdrawal

reactions

! !
 Geriatric Pertinent Points from History Pertinent Physical Relevant Investigations / Management Plan
Syndrome Examination Med Review
o Definition of chronic pain: o Evaluation of severity: o Appropriate imaging if red o Determine etiology and mechanism of pain
PAIN ! Pain which has persisted beyond ! Communicative: flags present
normal tissue healing time, in the • Verbal descriptor o If functionally impaired due to pain " ref to PTOT
absence of other criteria, taken to scale
be 3 months • Numerical rating o Analgesia:
scale ! Stepwise analgesic ladder:
o Pain history: ! Non-communicative: • Consider side effects, drug interactions, drug-
! Severity • Behavioral pain disease interactions [e.g. gabapentin resulting in
! Characteristics rating scale ataxia in high fall risk]
! Aggravating / relieving factors [checklist for non- ! Reassess pain severity, mood and function after starting
verbal pain new analgesia
! Impact of pain on physical indicators] ! If mechanical pain, pre-medicate with analgesia before
function, psychological • Pain activities
wellbeing and social Assessment in
Advanced o For uncommunicative patients who have pain behaviors
! Red flags: Dementia Scale without movement:
• Constitutional symptoms [PAINAD scale] ! Check if they:
• Hx of Ca – Breathing, • Had been fed in the last 2 hours?
• Hx of chronic infection Negative • Had lips and mouth moistened?
• Non-mechanical pain vocalization, • Have any skin eruptions?
• Worsening neurological Facial ! If persistent behaviors " consider trial of analgesia!
signs expression, Body
• Recent trauma Language,
Consolability
! Analgesia history and
response [including TCM] o Focused exam on:
! Site of pain
o Determine mechanism of pain: ! MSK
! Nociceptive ! Neuro exam
! Neuropathic
! Mixed
! Unknown
! Psychogenic
! !
 Geriatric Pertinent Points from History
Syndrome
o How to prognosticate?
PROGNOSTICATION ! Clinical judgement: “Would you
be surprised if this patient dies in
the next 6 months? 1 year?”
! Age-based averages or life
tables " show median survival
for age
! Referencing published studies:
• CASCADE study: NH
residents with advanced
dementia " median
survival 1.3 years; most
common complications are
eating problems, infections,
pneumonia
Pertinent Physical Relevant Investigations / Management Plan
Examination Med Review
o Consider:
! Prognosis
! Lag time to benefit
o Life expectancy = LtB " preferences should determine
recommendations
o Life expectancy > LtB " consider recommending
o Expected lag time to benefit of common clinical decisions:
! SSRI for depression: 1-2 months
! 5-alpha reductase inhibitor for BPH: 3-6 months
! Statins / bisphosphonates / BMD: 1-2 years
! Strict BP and lipid control for prevention of
macrovascular complications in DM: 2-3 years
! Strict BP control to <140/90 to improve cardiovascular
outcomes: 2-3 years

! Prognostic indices: ! Tight glycemic control for prevention of microvascular

• Mortality indices complications in DM: 8-10 years
incorporating age, ! Colon, breast, prostate Ca screening: 10 years
comorbid conditions, and
functional status more o Person-centered care:
accurate than age alone ! ACP
• May be non-disease
specific, or disease specific

• Dementia:
o Advanced Dementia
Prognostic Tool
[ADEPT]:
• Predicts 6
month survival
among nursing
home residents
with advanced
dementia
o Hospice Guidelines
for estimating
survival of <6/12 in
dementia:
• 1. At or beyond
FAST Stage 7c
[and have all
the features up
till 7c]
• 2. Have at least
1 of the
following:
infection /
pneumonia /
eating
problems
 Geriatric Pertinent Points from History Pertinent Physical Relevant Investigations / Management Plan
Syndrome Examination Med Review
o Common symptoms to identify: o Orifices: o Communication:
PALLIATION ! SOB ! Oral cavity – oral ! Explore patient’s premorbid values and wishes
! Secretions and terminal rattling hygiene ! Take into account input from family
! Nausea and vomiting ! Mucous membranes – ! Validate emotions
! Pain in minimally communicative hydration status ! Identify:
patients ! Eyes – discharge • Need for supportive counseling?
Agitation / restlessness / terminal ! Bowels – constipation • Any financial issues?
delirium ! Bladder – urinary • Carers or family not coping well " may need post
retention bereavement follow up

o Organ system: o Patient-centered care:

! Skin – dryness, ! ACP
pruritus, integrity
o Management:
! Review and minimize unnecessary interventions:
• Investigations and blood taking – can stop?
• Parameters – reduce paras and focus on comfort
• Medications:
o Still beneficial? [given estimated life
expectancy]
o Antibiotics
o Inotropes
o Supplements and non-essential meds – for
“wellness”
o Route of administration – convert to S/C if
cannot take orally
o Renal and hepatic adjustments

• Ref pall book for details on common palliative

meds

o Caregiver:
! Education
! Counseling and support

o Discharge planning:
! Home hospice, inpatient hospice, NH with hospice
service
! Hospice day care

! !
 Geriatric Pertinent Points from History
Syndrome
o Factors that affect decision to offer
PREVENTION preventive measures:
! Remaining life expectancy
! Comorbidities
! Cognitive and functional status
! Risk of disease
! Preferences
! Screening not indicated if
natural history of disease
longer than expected
remaining life span!
Pertinent Physical Relevant Investigations / Management Plan
Examination Med Review
o Criteria that should generally be met for disease
screening:
! Disease to be screened must be serious enough, and
prevalent enough
! Disease should have an asymptomatic phase that can
be detected by screening
! There must be treatment that results in better
prognosis when treated early, vs after symptoms
develop
! Screening must be safe, sensitive and specific
! Screening costs should be acceptable
! Ideally, screening should have been found to be
effective in RCT
o Commonly offered preventive measures:
! Cancer screening:
• Mammogram – if at least >10 years remaining
• PSA – discuss pros and cons if life expectancy
>10 years
• Colonoscopy – may stop at age 75
! Other screening:
• BMD – if at least >5 years life expectancy
• Glucose and lipid screen – if at least >10 years
remaining, and if results would affect
cardiovascular disease
! Immunizations:
• Influenza [annual] – offer till end of life
• Pneumococcus PPSV23 and PCV13 [once after
age 65] – offer till end of life
o PPSV23 more for invasive pneumococcal
infections
o PCV13 more for pneumonia
o PCV13 first then PPSV23 after 6-12
months
o If PPSV23 given before 65yo:
• PCV13 at least 1 year after last dose
of PPSV23
• Then administer PPSV23 6-12 months
after PCV13 [and at least 5 years after
the most recent dose of PPSV23]
o If PPSV23 given after 65yo:
• PCV13 at least 1 year after last
PPSV23 dose
o If PCV13 given before 65yo:
• Administer PSV23 6-12 months after
PCV13
 • Herpes zoster live vaccine [once after age 60] –
offer till end of life [regardless whether have
herpes zoster before]
o Mainly to reduce post herpetic neuralgia
by 2/3
o CI in immunodeficiency / immunosuppressed
o Not included in subsidy

! Chemoprevention:
• Calcium – not recommended for primary
prevention
• Vit D – consider >800 IU/day in older adults
• Aspirin:
o Men 45-79yo: When benefit from MI
reduction > risks of bleed
o Women 55-79yo: When benefit from stroke
reduction > risks of bleed
o >80 yo: Insufficient data for recommendation