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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

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Heart Disease Visual impairments
Cataracts 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

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:

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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 & time-
consuming & 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

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• 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

• 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

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

Score Count the number of capitalized Yes/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

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Money management Home maintenance

ASSESSMENT OF ADL & IADL

• 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

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

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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

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

NUTRITIONAL ASSESSMENT

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

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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

HAIR
• Graying & decrease in growth: scalp, axillary, public
• Course hair: eyebrow, nostril ear & some women develop increase in facial hair

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NAILS
• 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

• 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

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

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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

MUSCULOSKELETAL

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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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