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

• Parkinson’s 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: ½ 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; don’t 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

• Today’s 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 patient’s 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