The Stealth Geriatrician:How to learn what you need to know from your patients
Tiffany Shubert, Ph.D., MPTTony Caprio, MD
Course Objectives
Identify four key risk factors for falling in older adults
Perform a comprehensive geriatric functional assessment
Evaluate the need for referral “Build a Team” – Determine
disciplines and community resources to aid in patient health management
Why Falls?
AAMC Minimum Competency All adults over 65 years should be
asked about falls All adults should be observed and
assessed rising from a chair and walking
All patients who have fallen should have a differential diagnosis and evaluation plan to address the fall and potential risk of falls
Why Falls?
Medicare PQRI Program Incentive pay for falls screening!
Good Practice Facilitates successful aging Opportunity for health promotion
Collaboration with other disciplines Collaboration with community
Who is going to fall?
How will you identify who will fall?
A comprehensive geriatric assessment uncovers falls risk
What you can find in your comprehensive exam
If you take their shoes off!
Introducing Mrs. Jones
Chief Complaint
It depends on who you ask:
Patient: “No complaints, I feel fine”
Daughter: “Difficulty getting around the house, I am afraid she may fall”
MD: “Blood pressure should be better controlled”
History of Present Illness
What do you want to know? Changes in medications Trips to the opthamologist Trips to the ER Changes in mood/activity levels Previous falls
Past Medical History
HypertensionParoxysmal Atrial FibrillationChronic Renal InsufficiencyAnxiety/Depression“Dizziness”Osteoporosis
Medication List
Metoprolol Hydrochlorothiazid
e Digoxin Warfarin Sertraline
Diazepam Zolpidem Meclizine Fosinopril Alendronate
Medication Review > 4 Drugs = Increased risk of falls Red Flags – Classes that increase falls risk
Benzodiazepines (short and long-acting agents)
Antidepressants (tricyclics and SSRIs) Antipsychotics Anticonvulsants Opioids Antispasmodics Over the counter medications
Social History
What do you want to know? Living Situation
Type of house? Stairs? ADLs, IADLs Social Supports Economic Status Smoke/Drink Current Activity Level Fear of Falling
Activities of Daily Living:Ask or Observe
ADLs Transferring Toileting Bathing Dressing Continence Feeding
IADLS Transportation Use the phone Buy groceries Meal preparation Housework Medication Pay bills
Review of Systems Systems vs. Syndromes
Organ-based review may give you limited information
Geriatric syndromes encompass multiple organ systems
Falls Dizziness, Vision, hearing Cardiovascular Orthopedic problems, arthritis,
neuropathy Depression, cognitive impairment
Physical Exam Findings General Impression Vital Signs
BP sitting 140/90, HR 88 BP standing 110/80, HR 100 Pain
HEENT Bilateral cataracts, difficulty reading magazine
and wall poster CV
Grade II/VI systolic murmur (right upper sternal border)
MS Neuro
Functional Assessment:Timed Up and Go
Functional Assessment: Walking Speed
Functional Assessment:Timed Chair Rise
Functional Assessment:Chair Rise Mrs. Jones
Functional Assessment:Balance
Mrs. JonesWhat Happens at Home
Functional Assessment
What Do You Learn?
How Do You Assess?
Referral
Cognitive Assessment
Clock Draw Test
Mini-Cog
Mrs. Jones Clock
Clock Draw Example
Home Safety Evaluation
Use an environmental assessment sheet
Occupational therapy
Financial difficulties may be culprit
Assessment: Mrs. Jones
What are the problems? History of falls 3 of the 4 risk factors for falls
Leg muscle weakness, poor walking, polypharmacy
Orthostatic Hypotension Osteoporosis
Plan: Mrs. Jones What will you do about it?
Fix orthostasis Address osteoporosis Modify medications
Who will you refer to? Occupational Therapy - home safety eval Physical Therapy - leg strengthening, gait
training, and assessment for assistive device Consult with pharmacy about current
medication list and insurance coverage Community Services for behavior change
programs, wellness and socialization activities
Synthesis Evaluating major risk factors for falls
is fundamental to a geriatric assessment
A functional assessment will identify individuals at risk for falls
A functional assessment can (and should) be done with your older patients
Refer to other disciplines to best manage complex older adults
Practice Practice Practice
Practice with volunteers Physical, Cognitive, and Medication
Assessment On the wards
Perform at least one mini-Mental and clock draw
Shadow a physical therapist and perform 1-2 functional assessments
Identify which of your patients are at risk for falls
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