m3 seminar september 2006 1 “geriatrics” in a nutshell karen e. hall, m.d., ph.d. clinical...

M3 SeminarSeptember 2006 1

“Geriatrics”in a Nutshell

Karen E. Hall, M.D., Ph.D.

Clinical Associate Professor of Internal MedicineUniversity of Michigan, Ann Arbor VA Health Systems

Research Scientist,Geriatric Research, Education and Clinical Center

M3 SeminarSeptember 2006 2

Learning OutcomesLearning Outcomes

• Review common Geriatric Syndromes In Coursetools

htps://ctools.umich.edu/portal

• Review geriatric assessment

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M3 Clinical CompetenciesM3 Clinical Competencies(from CourseTools)(from CourseTools)

• Geriatric syndromes and conditions

• Diseases more common in older patients

• Psychosocial issues

• Disease prevention

• Ethical Issues

• Health Care Financing (Medicare)

• Cultural aspects of aging

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Geriatric Syndromes (hospital)Geriatric Syndromes (hospital)

• Dementia, delerium, depression common, not documented

• Inappropriate medications anticholinergic

• Gait and mobility impairment not documented

• Incontinence

• Iatrogenic complications constipation, pressure ulcers

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Geriatric Syndromes Geriatric Syndromes (outpatient)(outpatient)

• Dementia, Depression, Delerium

• Incontinence

• Osteoporosis

• Falls

• Hearing and vision impairment

• Sleep disorders

• Failure to thrive

• Iatrogenic (medications)

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Geriatric SyndromesGeriatric Syndromes

• Dementia, Depression, Delerium Cognitive screen, ask about depression, check

orientation and concentration (serial 7’s) Delerium has variable orientation/concentration,

dementia doesn’t

• Incontinence Stress, urge, overflow Stress – small volume; urge – larger volume Check for UTI with incontinence Ditropan can cause overflow

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Geriatric SyndromesGeriatric Syndromes• Osteoporosis

Risk – asian > caucasian > AA/black Kyphosis on physical exam Dexa scan (femoral neck; L spine) Everyone gets 1000-1500 mg Ca + 400-800 IU Vit D Treatment: Alendronate > calcitonin; estrogen/reloxifene;

weight lifting

• Falls How many “Any in past 6 months?” What happened – “trip, slip, drop” Injury? Mandatory: test sensation, balance, GAIT (TUG test)

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Geriatric SyndromesGeriatric Syndromes

• Hearing and vision impairment Whisper test, check with glasses on

• Sleep disorders Normal aging – sleep cycles only 3-5 hours max Going to bed too early? ETOH; Tylenol PM? Depression/anxiety? Hot milk, read outside of bed, consider trazodone

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Geriatric SyndromesGeriatric Syndromes

• Failure to thrive “Dwindling” Weight loss Increased frailty Not able to live independently (without human

assistance) Check for cognition, mobility, medication side effects Cancer? Consider hospice for refractory situation (sometimes

people get better with hospice!)

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Geriatric SyndromesGeriatric Syndromes• Iatrogenic

• Medications Anticholinergics Narcotics - don’t forget the laxative

• Stool softener alone will not be enough Antiarrhythmics Dilantin (nausea; vertigo) Neuroleptics PPIs – nausea, diarrhea; Aricept (diarrhea)

• Bed Rest (hospitalization) Rapid loss of muscle strength (>80 years: lose 1 ADL in 3-

5 d)

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Common Diseases in ElderlyCommon Diseases in Elderly• Neurologic (Parkinsons, stroke, TIA)

• Rheumatologic (RA, PMR, vasculitis)

• Genitourinary (BPH, sexual dysfunction)

• Cardiovascular (afib, CAD, CHF, HTN)

• Endocrine (hypothyroid, diabetes type II, Paget’s)

• Renal (HTN, fluid/lyte abnormalities)

• Infections (pneumonia, UTI, TB)

• Gastrointestinal (dysphagia, constipation, ‘tics)

• Oncologic (colon, breast, prostate, hematologic)

• Psychiatric (depression, psychosis)

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Documentation/SkillsDocumentation/Skills

First rule of history and physical exam

“To treat the problem, you have to

document the problem”

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DocumentationDocumentation

First rule of geriatrics (similar to first rule of

real estate sales)

“Function, Function, Function”

Patients don’t care about their diagnoses,

they care about their function

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Ask about….

• ADLs (Activities of Daily Living)

• IADLs (Independent Activities of Daily Living)

• Mobility

• Incontinence

• Affect/Mood

• Cognition (Memory)

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These items go into the historyThese items go into the history

Either “Social History” or

“Functional History”

Or

In the HPI!

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Physical ExamPhysical ExamTest the following:

Mobility – Timed Up and Go test- stand, walk, turn, sit

Cognition – Mini-Cog (3 item recall) or MMSE (Mini Mental Status Exam)

Affect – Two question Depression screen

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The results go in the Physical The results go in the Physical ExamExam

“Timed Up and Go was 15 seconds, patient walked slowly, unsteady, had to hold rail for support”

“Two question depression screen positive”

“Patient only remembered 2 of 3 items on Mini-Cog”

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Documentation does not Documentation does not necessarily mean “Diagnosis”necessarily mean “Diagnosis”Diagnosis belongs in the “Impression/Plan” section

BUT….

Rule #1: Avoid the trap of “premature labeling”

Problem 1. “Falls” – (list the differential here)

Not Problem 1. “Probable spinal stenosis”

Or Problem 1. “Musculoskeletal System”

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Develop a Plan rather than a Develop a Plan rather than a DiagnosisDiagnosis

Rule #2:You can start addressing functional impairments without having a specific diagnosis

Patients appreciate a practical plan

Home safety, mobility aids, social supports

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Prevention = “Screening”Prevention = “Screening”Back to First rule of History and Physical

Examination ….

“To prevent it, you have to document it”

Learn about primary and secondary prevention screening that maximizes function and minimizes future impairment

Keep current about age-associated recommendations for tertiary prevention (“treatment”)

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Social, Ethical, CulturalSocial, Ethical, CulturalLearn about cultural influences on health behavior

•DNR, family involvement

Learn about stressors that affect patients and families

•Caregiver stress, finances

Know what resources are out there to help

•Social work (Turner clinic + other), types of assisted living, medication assistance, Area Agency on Aging, 3 day inpatient requirement for Medicare payment of CNH!

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Social, Ethical, CulturalSocial, Ethical, CulturalAsk the patient what THEY WANT TO DO about their problem

“Do not assume your preference is their preference!”

This will avoid more lawsuits than any other intervention!