Geriatric assessment Prof Mollentze / Dr. D. Greyling.
-
Upload
bertha-alexander -
Category
Documents
-
view
243 -
download
0
Transcript of Geriatric assessment Prof Mollentze / Dr. D. Greyling.
![Page 1: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/1.jpg)
Geriatric assessment
Prof Mollentze / Dr . D. Greyling
![Page 2: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/2.jpg)
Questionnaire
• 1. Continue this sequence in a logical way:
• M T W T • 2.Correct this formula with a single stroke:
• 5 + 5 + 5 = 550
![Page 3: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/3.jpg)
Questionnaire
• 3. Please write anything here:
•
• 4. Draw a rectangle with 3 lines:
![Page 4: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/4.jpg)
General
• Definition of aging: a Progressive , universal decline first in functional reserve and then in function over time.
• Old age is not a disease, but the risk of developing disease is increased.
![Page 5: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/5.jpg)
Presentation of disease in older people
• Factors that influence recognition of disease in older people:
• 1. Acceptance of ill health and seeking medical advice.
• 2. Atypical presentation of disease processes
![Page 6: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/6.jpg)
Background
• Between 2000 and 2030 , the number of older adults is expected to increase from 420 to 974 million people.
• 59 % of older adults are living in the developing countries of Africa, Asia, Latin America and the developing world have the largest increase in older adults because of the AIDS epidemic and because of better health services and lifestyle.
![Page 7: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/7.jpg)
Geriatric giants
• Immobility , instability and /or falls• Intellectual impairment• Sleep disorders• Confusion• Impaired senses – hearing , vision, proprioseption• Incontinence• Heart disease• Syncope/ Dizziness• Stroke• Malignancies
![Page 8: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/8.jpg)
Definition of frailty
• Frailty is a clinical syndrome : 3/> of the following:
• 1.- Unintentional weight loss of > 4,5 kg in the past year
• 2.-Feeling exhausted• 3.-Weakness( poor grip strength)• 4.-Slow walking speed• 5.-Low physical activity
![Page 9: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/9.jpg)
Frailty
• Associated with a high risk of falls , disability and death.
• Frailty is part of a single or multiple clinical syndromes
![Page 10: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/10.jpg)
Approach to the geriatric patient
• Functional status is the best indicator of prognosis and longevity.
• Functional status: defined as the ability of a person to provide in his/her own daily needs.
![Page 11: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/11.jpg)
The comprehensive geriatric assessment
• Focus on the evaluation of:• 1. Physical health• 2. Mental health• 3. Functional status• 4. Social functioning• 5. Environment
• A multidisciplinary team approach – Social worker , Dedicated nursing staff, Occupational and physiotherapist , Podiatrist , Biokinetician
![Page 12: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/12.jpg)
Medication
Mobility
Mentation
Activities of DailyLiving
Social Support
Advance directives
Hearing
Vision
Incontinence
VisionDepression
Domain Approach
![Page 13: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/13.jpg)
When is a multidisciplinary approach necessary
• The number of medical and surgical and neurological/mental problems
• The number of prescription medications
• Functional limitations in two or more activities of daily living
![Page 14: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/14.jpg)
History taking
• “ Don’t talk about patients , talk with them”• Introduction, purpose• First impression give clues to disease/present problem• Eye contact• Handshake• What is your name?• Don’t rush• Permission needed for collaborate history• Collateral information: Family, Caregiver , Environment• Ask about aids – hearing, spectacles, walking and wheelchair
![Page 15: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/15.jpg)
History to be emphasized• 1. The patient profile: Current residence• Care giver• Employment history• 2. History of the present illness• 3. Medication review: Drug side effects• Dosage adjustment ; Calculate creatinine
clearance ( Cockroft Gold formula )• Over the counter medications• Indications• Compliance • Drug interactions• Correct dose• Protein levels and nutritional status • Attention to anticholinergic , psychotropic's and drugs with a
narrow therapeutic index •
![Page 16: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/16.jpg)
Adjustment dosage in renal impairment
• Calculate creatinine clearance:
[140-age(y)] x weight (kg)CCr (GFR) = (males)
S-Cr (μmol/L) x 1.23
[140-age(y)] x weight (kg)CCr (GFR) = (females)
S-Cr (μmol/L) x 1.04
![Page 17: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/17.jpg)
History continue.• 4. Family history : Dementia , Early Parkinson's , atherosclerotic
disease ,diabetes mellitus , hypertension and cancer.
• 5. Extended social history: • Alcohol , smoking and drug use.• Sexual history.• Home : Stairs , Bathrooms , Support , Medical emergency care ,
Health aides.• • 6. Past history: surgical ,major illnesses and hospitalizations
• 7. Review all systems / old notes and results
![Page 18: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/18.jpg)
History continues• 8. Collateral history
• 9. Social support systems
• 10. Advanced directives • - Specific wishes when dying• - Living will• - Advanced directives• - Health proxy
• 11. Nutrition
• 12. Mood , Depression question are
![Page 19: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/19.jpg)
Physical examination• Emphasis on:• 1. The vital signs : Pulse , Respiratory rate , Blood pressure , General signs,
Height and weight• 2. Skin : Careful examination• 3. Eyes : Vision , Fundoscopy• 4. Ears• 5. Mouth and teeth• 6. Cardiovascular : pulses and rhythm, murmurs , aorta and bruits• 7. Breast examination• 8. Pelvic and rectal examination : Incontinence• 9. Muscle and joints• 10. Gait and balance• 11. Nervous system
![Page 20: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/20.jpg)
Functional assessment
• Functional impairment should not be accepted as “ just part of getting old”.
• Documentation of the patients baseline function is essential so that changes can be identified and addressed.
![Page 21: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/21.jpg)
Geriatric assessment instruments Domain Time( minutes) for
performing testsInstrument
Dementia 9 Folstein Mini mental
Delirium <5 Confusion assessment
Hearing <0,5 Whisper test , Rinne and Weber test , Audiometric
Nutrition <2 Weight < 4,5 kg / 6 months
Gait and Balance <1 ( < 20 sec for test) Timed get up and go test , timed gait speed, One leg
![Page 22: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/22.jpg)
Basic activity of daily living( ADLs)
• - Dressing• - Eating• - Ambulating• - Toileting• - Hygiene• ( DEATH )
![Page 23: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/23.jpg)
Independent DALs
• Shopping• Housekeeping• Accounting• Food preparation• Using Transport• Using the telephone• (SHAFT)
![Page 24: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/24.jpg)
Other dimensions of geriatric assessment
• Dental health• Nutrition• Driving ability• Social functioning• Recreational activities
![Page 25: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/25.jpg)
Cognition
• Screening : 3 Item recall test
• Minimental Questionnaire
• Other questionnaires : TYM
![Page 26: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/26.jpg)
Get up and go test
• Observed and time to rise from a chair and walk 3 meters , turn around and return to sit down in a chair.
• Normal : 10 seconds.• Impairment is associated with increased fall
risk.
![Page 27: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/27.jpg)
Vision testing
• Schnellen Chart – impairment <20/40 line• Test near vision• Postural stability is father determined by
depth perception , Binocular vision and contrast sensitivity.
![Page 28: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/28.jpg)
Whisper test
• Cover the opposite ear of the patient, exhale completely and whisper an easily answered question at 60 cm from the ear being tested.
![Page 29: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/29.jpg)
Assess nutrition
• 1.Involuntary weight loss > 4,5 kg over 6 months.
• 2. Abnormal body mass index ( kg/m²): < 22 or >27
• 3. Hypoalbuminemia• 4. Hypocholesterolemia• 5. Consider specific vitamin deficiencies –
Vitamin B12 , Folate ,Niacin, Thiamine.• Nutrition screening questionnaire
![Page 30: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/30.jpg)
![Page 31: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/31.jpg)
Dentition
• Dental problems like loose dentures , missing teeth or oral pathology might interfere with eating.
• Poor dental hygiene is a risk for bacteraemia and pneumonia or infective endocarditic.
• Many medical conditions in the elderly interfere with absorption, digestion, increased nutritional needs or require dietary restrictions .
![Page 32: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/32.jpg)
Depression
• Common due to chronic disease ,chronic pain, isolation, loss of spouse and peers
• Financial stressors• Old age home placement• Being alone – most important cause• Self esteem diminished due to loss of
independence
![Page 33: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/33.jpg)
Depression
![Page 34: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/34.jpg)
Driving
• Predictors of poor driving events:• 1. Vision impairment• 2. Hearing impairment• 3. Minimental impairment• 4. Fewer blocks walked• 5. Foot abnormalities
![Page 35: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/35.jpg)
Incontinence• Urinary incontinence: 30 % community• 50% nursing home • Up to 80 years : Female 2 x > Male• “ DRIIIPP”• D- Delirium• R-Restricted mobility• I : Infection( UTI); Inflammation(Atrophic vaginitis );
Impaction of faces• P-Pharmaceuticals • P-Post prostatectomy/ post bladder surgery
![Page 36: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/36.jpg)
Pressure sores
![Page 37: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/37.jpg)
Pressure ulcers/sores
• Risk factors for development of pressure ulcers:
• 1. Alterations in sensation or response to discomfort:
• Degenerative neurological disease, CVA’s, CNS injury ,Depression , Drugs that affect alertness
• 2. Alteration in mobility: • -2.1. Neurological diseases • -2.2. Fractures, Pain , Restraints
![Page 38: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/38.jpg)
Pressure ulcers cont.
• 3. Change in weight the past 6 months: Protein calorie under nutrition , Edema
• 4. Incontinence: Bowel or Bladder
![Page 39: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/39.jpg)
Summary
• DEEP MIC N:• D- Depression, Dementia, Delirium , Dental, Dermis.• E- Eyes• E- Ears• P-Polypharmacia• M-Malignancies, Metabolic• I- Incontinence• C – Cardiac failure and coronary artery disease• N – Nutritional state
![Page 40: Geriatric assessment Prof Mollentze / Dr. D. Greyling.](https://reader033.fdocuments.in/reader033/viewer/2022061520/56649e165503460f94b00fc4/html5/thumbnails/40.jpg)
References
• Brown JS; Ann Intern Med 144: 715, 2006• Cassel CK; Geriatric Medicine, 4th ed,2003• Reuben DB; Geriatrics at your finger tips:2007;
8th ed.• Geriatric secrets ; 3 rd ed.• Hazzards: Geriatric Medicine • and Gerontology ; 6 th ed. • Davidson ‘s