Evaluation of The Elder Patient

David V. Espino, M.D.

Vice Chair & Director, Div. Of Community Geriatrics
Dept. of Family & Community Medicine
University of Texas Health Science Cntr-San Antonio
Elder Evaluation
 Introduction
 Evaluation
 Review
 Summary
Aging
 Is Not A Disease
 Occurs at Different Rates
• Among Individuals
• Within Individuals
 Increases Susceptibility to Specific
Conditions
Characteristics of Geriatric Medical
Conditions
 Chronic with
Superimposed Acute
Illness
 Multiple and
Coexisting
Iatrogenesis
 Medication Misuse
 Hospitalization
• Falls, Delirium,
Immobility
 Diagnostic/
Therapeutic
Procedures
Presentation of Geriatric Patient
 Typically “Atypical”
 Nonspecific
 “Cascade
Phenomenon”
Goals of Geriatric Care
 Care vs. Cure
• Iatrogenesis
 Function
 Quality of Life
 Prevention
 Palliation
Geriatric “Money Balls”
 Small Changes In
Function = Big QOL
Gains
 Taking Things Away QuickTime™ and a
Can Make Things TIFF (Uncompressed) decompressor
are needed to see this picture.

Really Better or Really

Worse!
Elder Evaluation
 Introduction
 Evaluation
 Orientation
 Summary
Geriatric Evaluation
 Geriatric H&P  Continence
 Functional  Eyes/Ears
 Cognitive/Affective  ETOH/Tobacco/Sex
 Medications  EnviroSocial
 Nutritional  Capacity
 Bone Integrity/Falls
 Strength/Sarcopenia
History:
{Communication & Rapport}
 Impaired Communication?
 Eye Contact, Physical Contact
 Use Last Name
 Speak Directly to Elder
• Establish Decision Maker
 Address CC
 Make Only One Change/Visit
Geriatric History
 Avoid Open Ended
Questions
 Focus On Current
Medical Problems
 Address Families
Concerns
 Focus On Medications
Physical Exam: Blood Pressure
 Blood Pressure
• 24% of Elders have
Orthostasis
 Pseudohypertension
 Trial of
Hypertensives?
• 25% Normotensive
Physical Exam: Height/Weight/Skin
 Serial Heights
 Serial Weights Essential
 Skin
• Senile Lentigines, Skin Tags
• Physical Abuse Signs?
• Decubs?
• Examine at Annual Exam
Physical Exam
 Areas to Focus On
• Cardiovascular
• Musculoskeletal
• Neurological
• Thyroid?
Functional Evaluation
 Instrumental Activities of Daily Living
• (IADL’s)
 Activities of Daily Living
• (ADL’s)
 Executive Functioning
 Gait & Balance
Gait & Balance
 Get Up and Go !
 Tinetti Gait &
Balance
Cognitive/Affective Status
 Folstein’s MiniMental State Exam
• (MMSE)
 Clock Drawing
 Geriatric Depression Scale
• (GDS)
Mini Mental State Exam
[ General Information ]

 Developed by Marshall Folstein in 1975

 Estimate Severity of Cognitive Impairment
 NOT Designed To Make Specific
Diagnoses
MMSE
[Cognitive Domains]

 Orientation/Time 5 points
 Orientation/Place 5 points
 Registration 3 points
 Attention/Calculation 5 points
 Recall of Three Words 3 points
 Language 8 points
 Visual Construction 1 point
MMSE
[Scoring / Cutoffs]
 Total Number of Correct Answers

 24-30 Correct No Cognitive Imp.

 18-23 Correct Mild Cognitive Imp.
 0-17 Correct Severe Cog. Imp.
MMSE
[Influences]
 Educational Level
 Race / Ethnicity
 Socioeconomic Status?
Clock Drawing Test
 Different Versions
 4 Point Scale Most
Useful
• 1 Point- Circle
• 1 Point-Numbers
• 1 Point-Hands/Arrows
• 1 Point-Right Time
Geriatric Depression Scale
[ General Information ]

 Total Number of Questions

 Long Version = 30
 Short Version = 15
 Administered in about 5 Minutes
 Count the Missed Questions
Geriatric Depression Scale
[ Error Cut-Offs ]
 Long Version
• < 11 Not Depressed
• 11-14 Possible Depression
• ≥14 Depression
 Short Version
• <11 Not Depressed
• ≥11 Probable Depression
Geriatric Depression Scale
[ Clinical Utility ]
 Use As Screener Only
 Utilize Suggested Cut-Offs
 Recognized Ethnicity or Language
Influence GDS Interpretation
Medications
 Only Use When Life,
Function or Comfort
Threatened
 Medications Must Be
Reviewed On Each
Visit
Medication Review
 Prescription
• Shared
 OTC
 OTB
 Alternative
Nutritional Status
 Often Overlooked
 Oral Screening
• Poor Dentures?
 “Weigh All Of The
Elders, All Of The
Time”
 BMI
Bone Integrity
 Risk Factors
 DEXA
 Falls Risk
Strength/Sarcopenia
 Strength Decreased
 Immobility Issues
Continence
 Major Cause of
Morbidity
 Urinary & Fecal
Incontinence
Eyes/Ears
 Eyeglasses
• Screen With
Snellen Chart
 Hearing Aids
• Ask About Hearing
 Alternative Aids
• $55 Radio Shack
ETOH/Tobacco/Sex
 Alcohol and Smoking
Common
• CAGE?
• Smoking Cessation
 Sex Also Common
• Major QOL
Enviro-Social Status
 Does The Elder Live
Alone?
 Who Functionally
Assists?
 Home Assessment, If
Necessary
Enviro-Social Status
 Social Activity,
Relationships and
Resources
 Caregiver Burden
 Quality Of Life Issues
 Advance Directives
 Capacity
Determining Capacity
 Describe Illness and
Course
 Explain Proposed
QuickTime™ and a

Treatment TIFF (Uncompressed) decompressor

are needed to see this picture.

 Understand Treatment
Consequences
 Understand Risks and
Benefits
Develop Plan
 Set Goals
• Realistic, Measurable,
Achievable
 Discuss With Family,
If Appropriate
 Develop Stepwise
Approach
Approach To Evaluation
 Visit 1
• Address CC, Initial Hx
 Visit 2
• PX and Labs
 Visit 3
• Cognitive/Functional
Eval
 Visit 4
• Social, QOL, and Plan
Elder Evaluation
 Introduction
 Evaluation
 Orientation
 Summary
Geriatrics Clinic
 South Module-FHC
 Both Frail Elder &
CDC
 Be Prompt
• 8:AM
• 1:PM
 Unexcused Absences
Process
 White Board
 Put Initials
 See Patient
 Present Patient
 Fill Out Orders
 Finish Note
Other Required Activities
 Keep Problem List
Current
 Keep Meds List
Current
 Fill Out Prescriptions
 Check Out before you
leave
Final Points
 Learning and
Knowledge Content
Are Different Things

 Just Because You

Complete A Task
Does Not Imply That
You Completed It
Well
SUMMARY
 Chronic Problems With Acute Events
Interspersed
 Communication Essential
 Expect the Unexpected
 Iatrogenesis Rules!