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The Stealth Geriatrician: How to learn what you need to know from your patients The Stealth Geriatrician: How to learn what you need to know from your patients Tiffany Shubert, MPT Anthony Caprio, MD

Course Objectives n n Identify four key risk factors for falling in older adults Course Objectives n n 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

Who is going to fall? Who is going to fall?

How will you identify who will fall? How will you identify who will fall?

A comprehensive geriatric assessment uncovers falls risk A comprehensive geriatric assessment uncovers falls risk

What you can find in your comprehensive exam If you take their shoes off! What you can find in your comprehensive exam If you take their shoes off!

Introducing Mrs. Jones Introducing Mrs. Jones

Chief Complaint n It depends on who you ask: n Patient: “No complaints, I Chief Complaint n It depends on who you ask: n Patient: “No complaints, I feel fine” n Daughter: “Difficulty getting around the house, I am afraid she may fall” n MD: “Blood pressure should be better controlled”

History of Present Illness n What do you want to know? n Changes in History of Present Illness n What do you want to know? n Changes in medications n Trips to the opthamologist n Trips to the ER n Changes in mood/activity levels n Previous falls n Consult with family members

Past Medical History Hypertension Paroxysmal Atrial Fibrillation Chronic Renal Insufficiency Anxiety/Depression “Dizziness” Osteoporosis Past Medical History Hypertension Paroxysmal Atrial Fibrillation Chronic Renal Insufficiency Anxiety/Depression “Dizziness” Osteoporosis

Medication List n n n Metoprolol Hydrochlorothiazide Digoxin Warfarin Sertraline n n n Diazepam Medication List n n n Metoprolol Hydrochlorothiazide Digoxin Warfarin Sertraline n n n Diazepam Zolpidem Meclizine Fosinopril Alendronate

Medication Review n > 4 Drugs = Increased risk of falls n Red Flags Medication Review n > 4 Drugs = Increased risk of falls n Red Flags – Classes that increase falls risk n Benzodiazepines (short and long-acting agents) n Antidepressants (tricyclics and SSRIs) n Antipsychotics n Anticonvulsants n Opioids n Antispasmodics n Over the counter medications

Social History n What do you want to know? n Living Situation n Type Social History n What do you want to know? n Living Situation n Type of house? Stairs? ADLs, IADLs Social Supports n Economic Status n Smoke/Drink n Current Activity Level n Fear of Falling n

Review of Systems n Systems vs. Syndromes Organ-based review may give you limited information Review of Systems n Systems vs. Syndromes Organ-based review may give you limited information n Geriatric syndromes encompass multiple organ systems n n Falls Dizziness, Vision, hearing n Cardiovascular n Orthopedic problems, arthritis, neuropathy n Depression, cognitive impairment n

Activities of Daily Living: Ask or Observe n ADLs n IADLS n Transferring n Activities of Daily Living: Ask or Observe n ADLs n IADLS n Transferring n Transportation n Toileting n Use the phone n Bathing n Buy groceries n Dressing n Meal preparation n Continence n Housework n Feeding n Medication n Pay bills

Physical Exam Findings n n General Impression Vital Signs n n n HEENT n Physical Exam Findings n n General Impression Vital Signs n n n HEENT n n n Bilateral cataracts, difficulty reading magazine and wall poster CV n n BP sitting 140/90, HR 88 BP standing 110/80, HR 100 Grade II/VI systolic murmur (right upper sternal border) MS Neuro

Pain n Pain assessment n Pain management Pain n Pain assessment n Pain management

Functional Assessment: Timed Up and Go Functional Assessment: Timed Up and Go

Functional Assessment: Walking Speed Functional Assessment: Walking Speed

Gait Speed: Mrs. Jones Gait Speed: Mrs. Jones

Functional Assessment: Timed Chair Rise Functional Assessment: Timed Chair Rise

Functional Assessment: Chair Rise Mrs. Jones Functional Assessment: Chair Rise Mrs. Jones

Functional Assessment: Balance Functional Assessment: Balance

Functional Assessment: Observation Functional Assessment: Observation

Quick Functional Scan Quick Functional Scan

Functional Assessment n What Do You Learn? n How Do You Assess? n Referral Functional Assessment n What Do You Learn? n How Do You Assess? n Referral

Cognitive Assessment n Mini Mental State Exam n Clock Draw Test Cognitive Assessment n Mini Mental State Exam n Clock Draw Test

Mrs. Jones Clock Mrs. Jones Clock

Clock Draw Example Clock Draw Example

Home Safety Evaluation n Use an environmental assessment sheet n Occupational therapy n Financial Home Safety Evaluation n Use an environmental assessment sheet n Occupational therapy n Financial difficulties may be culprit

Labs n Volume depletion n Drug effects and levels n n n B 12, Labs n Volume depletion n Drug effects and levels n n n B 12, TSH Occult Infections n n PT/INR Digoxin Neuropathy n n CBC (anemia) Chemistries (BUN, Cr, Na) UA, CBC Vitamin D level

Assessment: Mrs. Jones n What are the problems? n History of falls n 3 Assessment: Mrs. Jones n What are the problems? n History of falls n 3 of the 4 risk factors for falls n Leg muscle weakness, poor walking, polypharmacy n Orthostatic Hypotension n Osteoporosis

Plan: Mrs. Jones n What will you do about it? Fix orthostasis n Address Plan: Mrs. Jones n What will you do about it? Fix orthostasis n Address osteoporosis n Modify medications n n Who will you refer to? Occupational Therapy for a home safety eval n Physical Therapy for leg strengthening, gait training, and assessment for assistive device n Consult with pharmacy about current medication list and insurance coverage n

Synthesis n n Evaluating major risk factors for falls is fundamental to a geriatric Synthesis n n 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 n Today – work with Carol Woods Residents n n Physical, Cognitive, and Practice n Today – work with Carol Woods Residents n n Physical, Cognitive, and Medication Assessment On the wards Perform at least one mini-Mental and clock draw n Shadow a physical therapist and perform 1 -2 functional assessments n Identify which of your patients are at risk for falls n