Geriatric Functional Assessment:

The Geriatric Review of Systems

Mary B. Preston MD FACP
Associate Clinical Professor of
Geriatrics
University of Virginia

Objectives
Understanding of basic differences in organ
systems in the elderly
Knowledge of functional geriatric
assessment
With emphasis on mental status, mobility and
medication

Different metabolism/function
Cells and tissues
Increased fat to lean (even in skinny people)
Heat production falls (the older, the colder)
Connective tissue has decreased elasticity
Example: lungs and skin

Cardiovascular
More sensitive to volume changes
Stroke volume, resting cardiac output
decreases 1% per year
More ischemia therefore more myocardial
infarction and more congestive heart failure
More problems with cardiac rhythm
Tendency to have orthostatic hypotension

Respiratory
Decreased forced expiratory volume in 1 sec
(FEV1)
Decreased vital capacity
Arterial oxygen is less: the formula which
adjusts for age is
PaO2 = 100.10 - 0 .323 x age
example, 60 yo average pa02 is about 82

GI
Diverticulosis occurs in over 1/2 of people
over the age of 60
Decreased esophageal motility
Decreased saliva (by 2/3)
Less ability of liver to detoxify

Renal
Nephron loss
Blood supply to kidneys decreases
Decreased creatinine clearance

Musculo-skeletal
Decreased muscle strength and mass
Cartilage deteriorates with narrowing of
joint spaces
Bone mass decreased (osteoporosis)

Neurology
Parkinsons disease seen in 10% of this
population
Memory loss is NOT part of normal aging
Retention of new information decreases
with aging
There is a slower processing time with
aging

Sensory
Vision: trouble with glare and dim light;
increased farsightedness, cataracts
Hearing: decreased universally by age 85;
high frequency sounds harder to hear
Taste buds: are non-functional
Smell decreased
Decreased proprioception

NOT normal aging

Fatigue is not part of normal aging

Anemia is not part of normal aging
Incontinence is not part of normal aging
Depression is not part of normal aging

DESPITE what patients themselves tell

you I guess I am just getting old

Interviewing skills
Speak to the patient, not the caregiver
Speak distinctly and where the person can
see your lips
Take your time
Avoid age-ist remarks, EVEN if the patient
themselves makes them; dont agree
Older patients tend to be more conservative
in their dress and expect you to be also

Examination skills
Deafness: speak in front of the patient, not
to the side or behind them; do not shout
Attend to their comfort realizing that they
may have arthritis
Warm your hands
Realize that they may respond slower; this
does not indicate dementia

Covering the geriatric issues: The

screening geriatric assessment

Medication, mentation, mobility

Activities of daily living
Social Support
Advance directives
Hearing and Vision
Incontinence
Nutrition
Depression

CANDY TIME
Todays mneumonic: You will be quizzed on this
at the end of the hour! MMM

MEDICATION
MENTATION
MOBILITY

Medication

The list is NOT enough

Do they need each medication ?
Are there any medications that interact?
What is their renal function?
What drugs are potentially inappropriate in the
elderly?
What is the average number of medications taken
by an elderly person at home, in the nursing
home?

Medications - #2
The list: must include over the counter,
doses, as needed (prn), how often taken
Major interactions: Software programs help
Renal function: if you are a 90 yo man with
a creatinine of 1.0 (normal), a weight of
72 kg, your clearance is--------?
Average number of meds: 4.5 for
community dwelling, 7-9 for nursing homes

Medications #3
Clearance is 50cc/hr (nearly half normal)
Potentially inappropriate medications

Anti-cholinergics
Benzodiazepines
Tricyclics (ex: anti-depressants, muscle relaxers)
Quinolones
Meperidine
Indomethacin

Mentation
Common sense approach: look at the patients dress,
observe way questions are answered
Need a baseline: from records or family
Tests confirm your common sense and allow you to not
be fooled by the socially adept but demented patient
Prevalence of dementia is about 50% in those over the
age of 85

Mentation #2
You must distinguish between dementia,
delirium and depression
Dementia: gradual onset, progressive
Delirium: acute onset, fluctuation, patient is
inattentive
Depression: sad affect, sees future as no
better or even worse than the present

Tests for dementia

MMSE: developed 1975; educationally
dependent; poor specificity and sensitivity
but extensively used for screening
Questions: Orientation, Registration,
Attention, Recall, Language
How to score: no half credit for being close
Traditionally, less than 24 = cognitive
impairment

Tips for doing MMSE

Use spelling WORLD backwards rather than
serial 7s: easier for patient and for you
Overcoming resistance (yours and theirs)
I do these tests on ALL over age 65
Some of the questions may seem silly - just bear
with me
If patient upset by not doing well, skip to the
easier items

Other tests
Animal naming: Name all the animals you can in
one minute
Lab: Thyroid stimulating hormone (TSH), B12,
(VDRL only with appropriate history), CBC,
Chemistry (renal and hepatic function). It is rare
that a lab test shows you a problem that is
responsible for the dementia.
X-ray: one time MRI or CT scan - especially to
check for subdural hematoma

Mobility
Why might this be a problem?

Arthritis
Muscle atrophy (remember more fat than lean)
Sedentary life style
May contribute to incontinence
May contribute to depression

Exam for mobility/balance

The Get Up and Go test : person sitting in chair,
gets up, walks 10 feet, turns and walks back to
chair and sits down
The Functional Reach: standing, not moving legs,
reach with outstretched hand about 6 inches
One leg balance: should be able to stand a few
seconds on each leg independently

Activities of daily living

This is part of the geriatric history
ADLs versus IADLs
ADLs are basic, I =Independent or Instrumental
like using public transportation, using a phone

Mneumonic for ADLs: DEATH

Dressing, eating, ambulating, toileting, hygeine

Social Support
This is a variation of the social history
that you have been doing
Ask who would be able to help if the patient
became sick
Ask where the children live; do not assume
that if they live next door they help out

Advance Directives
ASK what the patient wants
Difference between the living will and the
durable power of attorney for health care
Offer the patient some concrete scenarios
Listen
Document

Hearing/Vision
Whisper test: Boxcar or several numbers,
or finger rubbing
20/40 is functional vision (glasses on); it is
the equivalent of newspaper print

Incontinence
There are 2 main types of incontinence
Stress: the history question here is Do you
pass urine if you cough or sneeze, or other
times involuntarily?
Urge: Do you have to rush to get to the
bathroom?

Nutrition
Ask if they have lost more than 10 pounds in the
last 6 months
The cause is likely to be not a disease, but a
situation

Medications
Depression/Loneliness
Finances
If a disease, hyperthyroidism, cancer

Depression
Single question approach;
How do you see your future?
Are you often sad or depressed?
What do you do for fun?

Depression #2
Distinguish between grief, minor depression and
major depression
Depression in the elderly CAN be treated
successfully
Grief: look at it functionally not in terms of time
Major depression: the janitor can recognize; the
excellent clinician can recognize minor
depression and greatly benefit their patient

MMM - what are they?

Medication
Mentation
Mobility

Conclusion
You are now ready to do an excellent history and
physical with your elderly patient
You know that it takes a different knowledge base,
a different set of skills, and above all, a non-ageist
attitude
If you remember nothing else, remember THE
THREE M approach