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, mobilityActivities 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

IncontinenceThere 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