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Description : Geriatrics is the assessment and treatment of disease in a person who is 60 years or older.

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Published on : Jan 17, 2023 | Views : 3893 | Downloads : 6

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Geriatric Assessment and Diagnosis
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Introduction Geriatrics is the assessment and treatment of disease in a person who is 60 years or older. Goal: Optimize function How fast one ages is a function of genetics, lifestyle, and attitude. The process of aging is slow and starts much earlier than most people appreciate.
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Why are we concerned? Elderly people are subject to deteriorating function, diverse diseases, and environmental challenges that can lead to the development of frailty and the inability to live independently.
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Life expectancy
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Demographics “Young Old” 65-74 Baby Boomers 2011 “Old” 75-84 “Oldest-Old 85+
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www.census.gov/popclock
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General Considerations It is vital to understand and appreciate how the life of an elderly person might differ from yours. It takes time and patience to interact with an elderly person. Avoid ageism: Not all older people have dementia. Not all older people are hard of hearing. Not all older people are sedentary or immobile.
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Organizations for the Older Adult American Bar Association Commission on Law and Aging Administration on Aging Alzheimer’s Association American Association of Retired Persons (AARP) American Geriatrics Society (AGS)
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Professional Support Services Centers for Medicare and Medicaid Services John A. Hartford Foundation Institute for Geriatric Nursing National Council on the Aging
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A Comprehensive Geriatric Assessment Inter-professional approach to the evaluation of older adults’ physical, psychological, social, and spiritual functioning. Nurse practitioners, physicians, social workers, and therapists assess and plan care addressing the multiple needs of older adults. A comprehensive geriatric assessment should always involve family members and caregivers, as appropriate
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Preparing for a Geriatric Assessment Make the client comfortable and establish rapport. Eliminate noise and promote attention and concentration. This will allow clients to answer questions to the best of their ability.
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Critical Components of the Geriatric Assessment Function Cognition Fall risk Mood Polypharmacy Social support Financial concerns Advanced care preferences When older adults experience the onset of disease, changes in function and cognition are often the first symptom
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Health History Collateral contacts – Family, caregivers, interdisciplinary teamsollateral and Interdisciplinary Team The Five I’s of Geriatrics Intellectual impairment Immobility Instability Incontinence Iatrogenic disorders Comprehensive Geriatric Health Assessment
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Comprehensive Geriatric Assessment
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Geriatric Examination History Ask the client to describe a typical day Ask about any specific concerns Give the client time to reply If warranted, a mental status exam should be done early in the interview process to ensure reliability of the answers Look at verbal and nonverbal cues Lowered voice, tears, subdued enthusiasm Sleep and appetite, FTT Change in fit of dentures Ask about immunizations
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MMSE (Folstein TEST)
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Scoring
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Function Functional assessment : systematic attempt to measure objective performance in ADLs, including bathing, dressing, toileting, eating, ambulating, and continence. An older adult’s ability to independently complete activities of daily living (ADLs) is a benchmark for health. If an older adult becomes incontinent or unable to bathe themselves, this often requires a change in the level of care. Moreover, an acute decline in functional status frequently signals the onset of physiological disease among older adults.
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Instrumental activities of daily living Instrumental activities of daily living (IADLs) are the more complex tasks people need for independent living. The IADLs include being able to shop, cook, manage finances, manage transportation, do housework and manage medications. With the older adult, the ultimate goal is to maintain optimal function and be as independent as possible.
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KATZ ADL
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Function Gait speed Predicts functional decline Identify those at risk for falls (>13 sec to walk 10 meters; 0.8m/s) (Stride) Identify frail clients to determine risk vs. benefit of certain treatments
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Cognition Because altered cognitive status is one of the more commonly occurring symptoms of disease among older adults, cognitive assessment is an essential skill to be acquired by nurse practitioners caring for the older population.
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Cognition Depression Underdiagnosed Atypical presentation 2 question quick screen: “During the past month, have you felt down, depressed, or hopeless?” “During the past month, have you had little interest or pleasure in doing things?” PHQ-9 Supplement to the questions Detects and monitors depressive symptoms among the elderly Reliable and valid measure of depression severity
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PHQ-9
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Distribution of PHQ-9 Scores According to Depression Diagnostic Status*
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GDS
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Polypharmacy Review meds at each visit Have the client bring in all of their medication bottles (prescription and nonprescription) at each visit. Electronic medication entry can avoid errors
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BEERS Criteria - 2019 To help prevent medication side effects and other drug-related problems in older adults, the American Geriatrics Society (AGS) has updated and expanded this important resource. The expanded AGS Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults identifies medications with risks that may be greater than their benefits for people 65 and older.
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Social support Social history Who is available to provide care if needed Caregivers should be screened periodically for burnout Elder mistreatment/abuse Must be screened in every geriatric assessment Contusions, burns, bites, pressure ulcers
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Occupation (past or present) Vocation* Retirement, Volunteerism Income level - any economic assistance programs Living arrangements Available transportation and access to shopping Educational level – reading ability Sleep Sexual Activity Exercise, Recreational Activity Substance Use Social History
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Advanced Directives Should be discussed with the client prior to cognitive impairment Durable power of attorney Wishes for treatment Will
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Nutrition Assess for undernutrition (P&A -protein0.8g/kg/d - pre-albumin) Special diet or “fad” diet Intake of dietary fiber, fluids Weight loss Money spent on food Accessibility to the food store Variety and freshness of foods Assess for ability to eat Xerostomia is common in the elderly
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1. I have an illness or condition that made me change the kind and/or amount of food I eat. 2. I eat fewer than two meals per day. 3. I eat few fruits, vegetables or milk products. 4. I have three or more drinks of beer, liquor, or wine almost every day. 5. I have tooth or mouth problems that make it hard for me to eat. 6. I don't always have enough money to buy the food I need. 7. I eat alone most of the time. 8. I take three or more different prescribed or over-the-counter drugs per day. 9. Without wanting to, I have lost or gained 10 lbs. in the last six months. 10. I am not always physically able to shop, cook, and/or feed myself. Nutritional Health Checklist
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Mini Nutritional Assessment
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MNA Scoring 12 – 14 Points Normal 8 – 11 Points At Risk 0 – 7 Points Malnourished
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Geriatric Syndromes in Primary Care Dementia, Depression, Delirium Incontinence Osteoporosis Falls / Abuse Hearing and Vision impairment Sleep disorders Failure to thrive Medications
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Geriatric Syndromes Dementia, Depression, Delirium Cognitive screening Depression survey Mini Mental Orientation Delirium has variable orientation/concentration, dementia does not Incontinence Almost exclusively in the elderly Stress, Overflow, Urge Check for UTI
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Instructions for the Mini-Cog Test The Mini-Cog test is a 3-minute instrument to screen for cognitive impairment in older adults in the primary care setting. The Mini-Cog uses a three-item recall test for memory and a simply scored clock-drawing test (CDT).
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Score – Mini-Cog 1 point for each recalled word Score clock drawing as Normal (the patient places the correct time and the clock appears grossly normal) or Abnormal Score 0 Positive for cognitive impairment 1-2 Abnormal CDT then positive for cognitive impairment 1-2 Normal CDT then negative for cognitive impairment 3 Negative screen for dementia (no need to score CDT)
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Geriatric Syndromes Osteoporosis Risk factors Dexa scan (femoral neck and L-spine) Supplements Falls Any in the past 6 months? What happened? (slip, trip) Injury? Test sensation, balance, and gait
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Geriatric Syndromes Hearing and Vision impairment Whisper test Check with glasses on Sleep disorders Normal aging – sleep cycle only 3-5 hours Going to bed too early? ETOH, Tylenol PM, Benadryl Depression/Anxiety
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Geriatric Syndromes Failure to thrive Weight loss Increased frailty Not able to live independently Check cognition, mobility, and medication SE Medications Anticholinergics Narcotics Dilantin PPI’s
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Common Diseases in the Geriatric Population Parkinson's, CVA Rheumatoid arthritis Benign prostatic hypertrophy Erectile dysfunction Afib, CAD, CHF, HTN Diabetes Fluid/electrolyte imbalances Pneumonia UTI Constipation, dysphagia Cancers Depression, psychosis
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Geriatric Examination Clinicians need to use history, PE, and lab tests to screen for disorders that occur in elderly Early diagnosis is essential First sign of a disorder is typically mental or emotional change
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Physical Examination Observe personal hygiene Weight should be done at every visit Height is recorded yearly Temperature is evaluated (50% have infection with NO T) Blood pressure and pulse are assessed in both arms Pulse assessed for a minimum of 30 seconds BP should be assessed after client is resting for more than 5 minutes, both feet flat and in the seating position
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Physical Examination Skin Normal findings: Uneven tanning, ecchymosis, thin nail plate, longitudinal ridges on the nails, and dry skin (xerosis), wrinkles (elasticity) Color (senile Purpura, Cherry angioma, senile macules) Premalignant and malignant lesions (AK, BCC) Pressure ulcers Unexplained bruises Head and Neck Normal findings: Lowered eyebrows, descent of the chin, thick terminal hairs on the ears, nose, upper lip, and chin Giant cell arteritis Common Disorders Enlarged thyroid
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Physical Examination Eyes Normal findings: Loss of orbital fat (enophthalmos) Pseudoptosis Entropion and Ectropion Eye exam by an Ophthalmologist is recommended every 1-2 years; more frequent if diabetic, HTN Ears Normal findings: Tophi on pinna, cerumen in ear canal Whisper test Webber/Rhine 3 – 6 random words or letters If client repeats ½ for each ear – normal hearing
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Physical Examination Mouth Normal findings: Darkened teeth Fissures Geographic tongue Gingival/periodontal disorder/ halitosis Caries Chest and Back Percussion and Auscultation Basilar rales are common but should clear with coughing
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Physical Examination Breasts Assessed yearly for irregularities and nodules in men and women Women – yearly mammograms and monthly self-exams Heart 4th sound is common without evidence of cardiovascular disease LV thickens about 10% Sinus bradycardia without symptoms can be normal
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Physical Examination Gastrointestinal Weak core muscles are common Hernias are common DRE (digital rectal exam) should be done in men and women to assess for fecal impaction, stricture, mass, tenderness Reproductive / Sexuality Men – prostate exam Women – Pap every 2-3 years until 70 years of age; then stop if last 2 were normal UTI
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Physical Examination Musculoskeletal Joint assessment Heberden’s nodes or Bouchard’s nodes : OA Subluxation: Chronic RA Feet Hallux valgus, hammer toe, claw toe Should see a podiatrist for regular evaluation Neurologic Same as adults but may be more difficult due to aging Tremors Weak muscle strength Sarcopenia is common in elderly Reaction time increases with aging Coordination decreases with aging
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Documentation Remember…. In order to treat the problem you have to document the problem.
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Documentation What belongs in the history or HPI section? Social history Functional history Where do the results go? In the physical exam section “Two question depression screen positive” “Client walked slowly, unsteady, and had to hold wall for support”
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Remember……. Ask about: ADL’s D-E-A-T-H IADL’s S-H-A-F-T Mobility/Function Memory/Cognition Affect/Mood Incontinence ENVIRONMENT DOCUMENT!!!!!
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Pearls of Wisdom Know what resources are out there for your patients Keep current about age-related recommendations for primary, secondary, and tertiary prevention Ask the client what THEY WANT TO DO about their problem Do not assume your preference is their preference
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Thank you