Principles of Geriatric Assessment
Transitional Care
-A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location -Potential hazards of hospitalization ~immobility ~delirium ~medication side effects and errors ~malnutrition ~pressure ulcers ~procedures ~hospital-acquired infections Rationale of transitional care -increased vulnerability to environmental changes ~increased stress and unfamiliarity -multiple care providers in multiple settings ~often operate independently -associated risks ~medical errors, service duplication, inappropriate care, medication discrepancies, "falling through the cracks"
Geriatric Assessment
-Broad term used to describe health evaluation of older patients -Doesn't center on treating diseases as they occur -Health status of older patients is dependent on issues beyond medical conditions including social, psychological, and environmental factors -Geriatric assessment is sometimes used to refer to evaluation by individual clinician and at other times to the more comprehensive interdisciplinary approach, comprehensive geriatric assessment (CGA) -Affected by multiple factors ~underreporting of symptoms and impairments ~atypical presentation of disease ~altered spectrum of health conditions ~not limited to acute and chronic diseases but includes geriatric syndromes, cognitive, and physical disabilities -Goal of clinical encounter is to identify impairments, diseases, and other factors impeding the patient's preferences and goals. Interindividual variability in all these factors combine to make assessment challenging in older adults -CGA focuses on the physical, psychosocial, and environmental factors that influence well being in older adults. -CGA interdisciplinary teams include geriatrician, social worker, nurse, pharmacist, psychiatrist, dietitian, rehab services (PT,OT) -Examples of CGA teams ~Geriatric Evaluation & Management Programs (GEMS) ~Primary Care Teams in Managed Care ~Program for All-Inclusive Care of the Elderly (PACE) ~Geriatric Assessment and Intervention Network (GAIN)
Medication Reconciliation
-The comprehensive evaluation of a patients medication regimen any time there is a change in therapy in an effort to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions, as well as to observe compliance and adherence patterns. -should occur at EVERY transition of care in which new medications are ordered, existing orders are rewritten of adjusted, or if the patient has added nonprescriptions medications to his/her self-care 8 Foundational Concepts 1. Medication reconciliation is a key process required to improve patient care and outcomes in care transitions. 2. Medication reconciliation is a patient-centered process focusing on patient safety. 3. Medication reconciliation requires and interdisciplinary collaborative approach. 4. Medication reconciliation must be based on a culture of accountability. 5. Medication reconciliation should be standardized. 6. Effective medication reconciliation required effective communication 7. Medication reconciliation requires integration of health information technology solutions. 8. Medication reconciliation requires a process of continuous quality improvement Role of Pharmacists -Medication Reconciliation Managers 1. Oversee all of the patient's medications 2. Have direct contact with patients and other healthcare providers to ensure medication information is transferred accurately and completely. 3. Perform final review of current and discharge medications 4. Ensure patient/caregiver understands how each medication is to be used, how to administer it, if or when to discontinue, and who to consult after discharge for questions or concerns -Identification and resolution of medication discrepancies ~compare admission and discharge med lists ~clarify differences with the patient ~provide patient with a copy of med list ~ask for patient questions/concerns ~provide detailed med reconciliation in the discharge summary -Discharge Medication List ~Name ~Dosage ~Route ~Schedule ~Indication ~Identify discontinued medications <reason for discontinuation
GEMS
-develop initial care plans based on comprehensive medical, cognitive, environmental, social, and economic assessments -team members typically work in the same organization together -patients with multiple problems in many domains who require comprehensive assessment may benefit from this type of care team
Primary Care Management Teams
-manage complex chronic conditions of patients who are frequently hospitalized or in the emergency room -team members are generally not assigned to work in the same space or area. -complex patients with multiple chronic conditions that are not well managed may benefit from this type of care team
PACE
-manage complex medical, cognitive, emotional, and functional needs of community elders eligible for nursing home placement -team members typically work in the same area, generally see patients multiple times a week, and share caseloads. -frail elders who are nursing home eligible but wish to remain in the community may benefit from this type of care team.
CGA: Components
-physical, functional, socio-economic, psychological -function is central focus
Hearing Evaluation
Age-Related Hearing loss -can result in social isolation or inappropriate diagnosis (e.g., depression, dementia) Screening Test -stand behind patients and assess ability to follow verbal commands without visual cues (e.g., raise your right hand) -Finger friction test -The Weber Test Self-assessment tool -The Hearing Handicap Inventory for the Elderly (HHIE-S) is a 10 question self-assessment tool that can be used to evaluate how a patient's hearing loss impacts their everyday life
CGA-The Patient History
Challenges -Communication -Underreporting of symptoms -Vague or Non-specific Symptoms -Multiple Complaints The Patient Interview -Listen to the patient Setting the Stage -Minimize extraneous noise -Speak slowly and in deep tones -Face the patient -Provide adequate lighting Eliciting Complete and Accurate Information -Ask specific questions -Include additional information sources The Patient History -Chief Complaint (CC) ~check every encounter -History of Present Illness (HPI) -Past Medical History (PMH) -Screening Examinations/Immunization History -Social History (SH) ~critical component not to be overlooked ~living arrangements, social support, expectations of family/caregivers, transportation, advance advance directives ~"Compression of Morbidity"-older adults who do not smoke, aren't overweight, and who are physically active delay onset of minimal disability by approx. 7 years. ~Check for alcohol and drug use (drug-drug, drug-alcohol interactions) -Family History (FH) -Functional History ~check ability to conduct daily activities ~specific persons available to help patient ~check need for assistive devices ~driving history -Medication Review ~check every encounter -Review of Systems (ROS) ~complaints are often nonspecific and may be difficult to interpret or go unreported (fatigue, anorexia/weight loss, insomnia) ~vision, hearing, mobility, and cognition should be assessed every visit ~check recent change in functional status <Respiratory> -increasing dyspnea, persistent cough <Cardiovascular> -orthopnea, edema, angina, syncope, claudication, palpitations, dizziness <Gastrointestinal> -difficulty chewing, dysphagia, abdominal pain, changes in bowel habits <Genitourinary> -frequency, urgency, nocturia, heistancy, incontinence, hematuria, vaginal bleeding <Musculoskeletal> -focal or diffuse pain or weakness <Neurological> -visual disturbances, hearing loss, falls <Psychological> -depression, anxiety, forgetfulness, confusion
Assessment Tools for Pain
Check for pain during patient history -characteristics, relation to impairments in physical and social function, treatment history and response, attitudes and beliefs, satisfaction with current pain management, social support and health care accessibility During physical exam -careful examination of site of pain, focus on musculoskeletal and neurologic systems, observation of physical, psychological, and cognitive function Brief Pain Inventory (Short-Form) 0-10 Numeric Rating Scale -good first choice for measuring pain intensity in most older persons Verbal Descriptor Scale -verbally rate pain from no pain to the most intense pain imaginably Faces Pain Scale -alternative for non-verbal or cognitively impaired patients Pain Thermometer -alternative for non-verbal or cognitively impaired patients Self report should be used as often as possible. Many studies have shown that observers often underestimate a patient's true pain level
Assessment of Mood
Depression often presents nonspecifically and atypically in geriatric patients and is often overlooked and underdiagnosed in this population. Recognition and appropriate management of the onset and recurrence of geriatric depression are critical in improving quality of life and function as well as for preventing other associated co-morbidities Patient Health Questionnaires (PHQ-2 and PHQ-9) Geriatric Depression Scale (GDS) Long and Short Forms -Short Form= 15 items, score of 5 or above suggestive of depression; scores of 10 or above are almost always indicative of depression -Long Form= 30 items, scores of 0-9 are normal, 10-19 suggestive of mild depression, and 20-30 suggestive of severe depression. Zung Depression Rating Scale Inventory None of these tools is thought superior to the others. Few substantial differences. Neuropsychiatric Inventory (NPI) -to evaluate dementia patient's psychotic and behavioral problems in patients with dementia to evaluate patient safety and ability of the patient to remain in current living situation -primarily used in research settings Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD) -to evaluate dementia patient's psychotic and behavioral problems in patients with dementia to evaluate patient safety and ability of the patient to remain in current living situation -primarily used in research settings Neuropsychiatric Inventory Questionnaire (NPI-Q) -to evaluate dementia patient's psychotic and behavioral problems in patients with dementia to evaluate patient safety and ability of the patient to remain in current living situation -developed for use in clinical practice -takes usually 5 minutes or less -severity of behavioral symptoms and caregiver distress are rated by the caregiver informant and higher scores indicate increased severity in both areas
The Physical Examination (PE)
General appearance ~facial expressions, personal grooming and hygiene, signs of trauma or injury, movement abnormalities Initial Observations ~Dress (fit?, appropriate for season, shoes) ~Language (speed of speech, difficulty with word finding or comprehension, concentration, is patient or caregiver answering questions?) Vital Signs ~auscultatory gap common in elderly patients with hypertension (can give falsely low systolic reading) ~orthostatic BP measurements may be needed due to aging, disease, and medication-related causes Respiratory and Chest Cardiovascular System ~check for murmurs and arrythmias (including atrial fibrillation) Abdomen ~palpated to check for muscle weakness that may result in hernias. A palpable pulsatile mass may indicate abdominal aneurysm that should be evaluated by ultrasound Genitourinary System Extremities ~range of motion (ROM) Special Considerations -to systems that play direct role in functional status such as vision, hearing, mobility, and cognition
Prioritizing Healthcare Needs
Maintenance of independence is of primary importance. Work with patient to clarify treatment goals and develop a monitoring plan that should be periodically reassessed. Recommended care should be based on evidence where possible. Prognosis can help determine the appropriateness of screening tests and treatments. Recommending screenings may not be appropriate if the beneficial effects will not be realized within the patient's expected survival period. Treatment recommendations are often extrapolated beyond the existing evidence. It is important to determine the patient's goals because the often differ from the physician's. This might lead to care decisions that are not evidence-based, even when such care is available. Meeting the patient's healthcare needs -continual goal re-evaluation ~focus on immediate issues: concerns and threats to quality of life ~also keep long-term issues in mind Life tables are available and can be used to estimate remaining life expectancy by age, sex, and race. Life tables do not consider clinical characteristics or functional status which can relult in potentially wide variations in actual survival times. Categorize Current and Future Issues -Short-Term (within the next year) ~rehab following a fall-related injury ~fall risk reduction -Mid-Range (within the next 5 years) ~geriatric syndromes (e.g., functional status, cognition, depression) ~support, resources, and referrals ~preventive care >social and lifestyle issues >vaccinations >screening tests (USPSTF Preventive Services Database) >when to stop screening -Long-Term (beyond 5 years) ~future planning considerations >living situations, functional decline, frailty >durable power of attorney
Functional Assessment
Measures of Physical Function (ADLs and IADLs) -ability to perform without human assistance -ability to perform with some human assistance -inability to perform, even with assistance Katz Index of Independence in ADLs -evaluates 6 categories of ADL's with higher scores indicating more independence and a higher level of functioning Lawton IADL Scale -assesses patient's ability to do 8 tasks: use telephone, shop, prep meals, maintain light housework, do laundry, travel independently, take medications, and handle finances. -higher scores indicate higher functional abilities Vulnerable Elder 13 Survey (VES-13) -13 item screening tool developed to identify community dwelling elders at increased risk for functional decline and death over the next 5 years -based on ability to perform functional and physical activities, self-rated health, and age Additional Tools Dependent on Setting -Short Form 36=outpatient setting ~global measure of function and well-being ~doesn't distinguish between sick and very sick older people -Minimum Data Set (MDS)= Medicare/Medicaid certified nursing facilities ~comprehensive assessment mandated on admission with quarterly updates -Functional Independence Measure (FIM)= rehabilitation settings ~monitors functional status progress -Reuben's Physical Performance Test ~evaluation of performance and prognostic information. A 4 item scale (the Mini Physical Performance Test) is also available and may be useful in the clinical setting -The Timed Get-Up-and Go Test supplemented with the modified Romberg Test or the balance component of the Short Physical Performance Battery, along with simple screening in shoulder and hand function can also provide useful information about functional status.
Cognitive Assessment
Mini Mental State Exam (MMSE) -recall, orientation, attention, language, retention -assesses cognitive impairment associated with dementia -typically used to stage Alzheimer's Disease -30 is highest possible score (24-30= no cognitive impairment, 18-23= mild, 10-18= moderate, <10= severe) -disadvantages= education and language barriers can influence the results Mini-Cog Screen for Dementia -Three-item recall, clock-drawing test -takes only 3 minutes to administer -simple tool to identify patients at high risk for dementia -not influenced by culture, language, or education Montreal Cognitive Assessment (MoCA) -can be used to screen for mild cognitive impairment -assesses attention and concentration, executive functions, memory, language, visuocontructional skills, conceptual thinking, calculations, and orientation. -available in public domain for nonprofit use The Saint Louis University Mental Status Examination (SLUMS) -similar in format to the MMSE -scores are based on education levels -patients classified as normal, having mild neurocognitive disorder, or having dementia -comparable to MMSE at detecting cognitive impairment and may be advantageous in identifying mild neurocognitive disorder.
Medication Assessment
Optimizing Drug Therapy Regimens -use appropriate medications as indicated to maximize effectiveness -avoid adverse drug events Potential Challenges -disproportionate use of healthcare resources -multiple co-morbidities -polypharmacy -Pharmacokinetic (PK), pharmacodynamic (PD) alterations -Potentially inappropriate medications (PIMs) -Barriers to medication adherence (e.g., cost) Create a Patient Database -review each med for indications, effectiveness, safety, monitoring, errors, cost, underuse, overuse, appropriateness, adverse effects, and adherence -create a medication-related problem list and set priorities Create a Plan (for each identified problem) -implement the plan -follow up and make interventions as needed MASTER-Rules for Rational Geriatric Drug Therapy Minimize the number of drugs used Alternatives should be considered Start low and go slow Titrate therapy Educate the patient Review regularly Medication-Related Problems -unnecessary drug therapy -need for additional drug therapy -ineffective drug -dosage too low -dosage too high -adverse drug reaction -nonadherence Medication Appropriateness Index -a rating scale that provides criteria to evaluate 10 key components of medication prescribing. Each med is rated as appropriate, marginally appropriate, of inappropriate. A numeric score is assigned to each criteria. The sum of the individual scores determines the total score. Higher scores on the MAI indicate less appropriate prescribing 1. Is there an indication for the drug? 2. Is the medication effective for the condition? 3. Is the dosage correct? 4. Are the directions correct? 5. Are the directions practical? 6. Are there clinically significant drug-drug interactions? 7. Are there clinically significant drug-disease interactions? 8. Is there unnecessary duplication with other drugs? 9. Is the duration of therapy acceptable? 10.Is the drug the least expensive alternative compared with others of equal utility?
Impact of Functional Barriers-These indicators can help identify patients at risk for non-adherence. Needs intervention.
Poor Vision -reading prescription labels of medication lists Arthritis, Neuropathy, Weakness -difficulty opening prescription bottles Medication Side Effects -physical effects may lead to discontinuation Cognitive Dysfuntion -cause of impairment in all 4 functional domains -delirium ~acute onset=reversible ~often due to medication side effects or illness ~common form of atypical disease presentation <under-recognition or misinterpretation -dementia ~gradual onset; progressive in nature ~consider severity of condition (impact on medication administration and adherence) -separate and distinct processes ~delirium can occur in patients with dementia -Impact on medication therapy (adherence and self-care capacity) ~dementia and delirium (taking more or less med than prescribed, stopping meds completely) ~additional mood/psychiatric disorders (depression, anxiety, schizophrenia) Dizziness and Falls -Dizziness ~identification of underlying cause (CV disease, orthostatic hypotension, meds with CNS activity) ~complications (falls, decreased ambulation, medication treatment) -Falls ~risk factors (history of previous fall, mobility aids, medications) Causes of Delirium -Medical conditions ~anemia/bleeding ~depression ~electrolyte abnormalities ~hypoxia ~infection ~malignancy ~metabolic disturbances ~pain -Medications ~anticholinergics ~corticosteroids ~digoxin ~H2-Antagonists ~narcotic analgesics ~psychoactive medications Consequences of Interventions -Depression ~dizziness, falls, cognitive impairment, constipation, appetite and sleep-wake changes -Nutrition/Weight Loss ~mood/anxiety effects, edema/CHF exacerbations, thromboembolism risk -Osteoporosis ~constipation, gastritis, esophagitis, hypocalcemia, thromboembolism -Urinary Incontinence ~BP and HR elevations, cognitive impairment, constipation, vision disturbances, sedation, orthostatic hypotension
Adverse Drug Events
Prescribing Cascade -occurs when an adverse effect of a medication is misinterpreted as a new condition or disease process -failure to recognize new symptoms as adverse medication effects can lead to the unnecessary prescribing of additional medications. -prescribers should consider adding or changing only one medication at a time in geriatric patients. This practice can be helpful in avoiding the prescribing cascade as it may enable practitioners to identify likely adverse effects related to a specific medication change, prior to initiating an additional medication. Increased Risk of ADEs -multiple factors -normal physiologic processes with aging Alterations in physiology and disease -Pharmacokinetics and Pharmacodynamics ~contribute to significant MRPs when not accounted for Age related changes-PK: Absorption -Stomach and GI tract (decreased HCl secretion and increased transit time) -aging doesn't seem to alter oral drug absorption to a large extent -decreased absorption can be clinically significant with medications that require active transport (e.g., Vitamin B12, calcium, and iron) -certain conditions in elderly can lead to impairments in drug absorption. Common example is furosemide resistance due to decreased blood flow to the intestinal tract and slowed gastric emptying in patients with decompensated heart failure. -med absorption through other routes may be altered by changes that occur with age. Atrophy of the skin, reduced blood flow, or decreased muscle mass may contribute to these alterations. Age related changes-PK: Distribution -decreased total body water ~ higher serum concentrations of digoxin, lithium, theophylline, morphine, ethanol(need lower dose) -decreased muscle mass ~digoxin (lower dose) -increased percentage of body fat ~can lead to prolonged durations of action and necessitate the need for lower drug doses or increased dosing intervals of phenytoin, valproic acid, diazepam, lidocaine, oxazepam -decreased serum albumin ~more common in malnourished or frail elderly ~increased unbound drug for meds extensively protein bound ~important for meds with narrow therapeutic index like phenytoin Age related changes-PK: Metabolism -Phase I reactions (cytochrome P450 system) ~often reduced in older patients due to decreases in liver size and hepatic blood flow -Start low and go slow...but go -Phase II reactions ~not altered by the normal aging process Age-related changes-PK: Elimination -Number of functioning glomeruli decreases -Renal blood flow decreases -Tubular functions decline -Glomerular filtration decreased by 25-50% between 20-90 years old -Assume lower doses of renally eliminated medications for elderly patients -Renal function may not be significantly impaired for all elderly patients; however, lower doses should be used initially for renally eliminated drugs in this population -Narrow Therapeutic Index Medications ~Measurement of serum drug concentrations ~accurate dosing and close monitoring Clinically, the most significant PK changes that occur with age are renal elimination and metabolism of drugs Age-related changes-PD: Cardiovascular System -Alpha 1 Blockers (e.g., prazosin, terazosin, doxazosin) ~blunted barorecptors= decreased vasoconstriction ~increase risk of orthostatic hypotension and falls -Verapamil ~less prolongation in PR interval on ECG= Higher concentrations to achieve same effect ~decreased heart rate= increase observed in younger patients (reflex tachycardia) ~increased hypotensive effects= increased sensitivity to vasodilator effects Age-related changes-PD: Central Nervous System -anticholinergic medications= cause confusion -antipsychotics, antiemetics= movement disorders -benzos= cognitive impairment, delirium, falls, fractures Age-related changes-PD: Autonomic Nervous System -Sulfonylureas= increase risk hypoglycemia ~decreased response to hypoglycemia ~decreased awareness to hypoglycemia BEERS Criteria (PIMs)-regardless of condition -Anticholinergics (1st line antihistamines, antiparkinson agents, antispasmodics) ~diphenhydramine, benztropine, dicyclomine -CNS agents ~tertiary TCAs (amitriptyline, imipramine) ~benzos= short acting-alprazolam, lorazepam = long acting-diazepam, clonazepam ~non-benzo hypnotics= eszopiclone, zolpidem, zapeplon -endocrine agents ~sliding scale insulin ~megestrol ~long acting sulfonylureas -GI agents ~metoclopramide (unless used for gastroparesis) -Pain agents ~meperidine= can cause neurotoxicity ~non-COX-selective NSAIDS (oral)-ASA >325mg, naproxen, diclofenac, ibuprofen ~indomethacin ~skeletal muscle relaxants=soma,flexeril PIMs Based on Diagnosis/Condition -Heart Failure= NSAIDS, COX-2 inhibitors, nondihydropyridine CCBs (systolic HF), pioglitazone, rosiglitazone, cilostazol, dronedarone -Delirium= All TCAs, anticholinergics, benzos, corticosteroids, meperidine, sedative-hypnotics, H2 receptor antagonists -Dementia and cognitive impairment= anticholinergics, benzos, H2-receptor antagonists, zolpidem, antipsychotics -History of Falls of Fractures= anticonvulsants, antipsychotics, benzos, non-benzo hypnotics, TCAs, and SSRIs PIMs: Use with caution -ASA (primary prevention) -Dabigatran -Prasurgrel -Vasodilators -Specific meds that may exacerbate or cause SIADH or Hyponatremia= antipsychotics, carbamazepine, carboplatin, vincristine, cisplatin, mirtazepine, SSRIs, SNRIs, TCAs STOPP Criteria (Screening Tool of Older Persons' Potentially Inappropriate Prescriptions) -alternative to BEERS criteria -includes 65 indicators, mostly focused on drug-drug and drug-disease interactions that influence risk for falls and duplications of common medication classes -includes consideration of diagnosis, psychosocial status, activities of daily living, and causality -the items are grouped based on physiologic systems and by drug class START Criteria (Screening Tool to Alert Doctors to the Right Treatment) -aims to identify common instances of potential errors or omissions -lists 22 evidence based prescribing indicators for drugs and drug classes that should be prescribed to older patients with specific clinical conditions Geriatric Syndromes -losses in ADL's -cognitive disfunction -depression -dizziness -osteoporosis -falls -sensory loss -nutrition and weight loss -pain -substance abuse -urinary incontinence -constipation Losses in ADL's -cognitive function=BZDs, hypnotics, anticholinergics, digoxin, antipsychotics, corticosteroids -motor function= antipsychotics, BZDs, hypnotics, metoclopramide, anticholinergics, anticonvulsants -sensory function= anticholinergics, NSAIDs, salicylates, aminoglycosides -psycho-social function= antidepressants, BZDs, hypnotics, stimulants, antipsychotics, anticholinergics
Nutritional Assessment
Screening for weight loss, malnutrition, and a nutritional assessment should be included as part of a comprehensive health care maintenance plan for all geriatric patients. No gold standard reference to assess nutritional status. Multiple tools are available for use in clinical practice. Currently available tools identify patients at risk for weight loss and malnutrition. Mini-Nutritional Assessment-Short Form (MNA-SF) -use to determine if a full MNA needs to be completed. Mini-Nutritional Assessment -2 part screening and assessment tool to identify patients 65 and over who are malnourished or who are at risk for malnourishment Malnutrition Universal Screening Tool (MUST) -can used in all care settings -can be used when patient's height and weight cannot be measured -not limited to geriatric population -the absence of a subjective component allows this tool to be used when patients are not able to answer questions -in British hospitalized patients over 65, MUST scores have shown correlations with outcomes and mortality Simplified Nutrition Assessment Tool (SNAQ) -used in community-dwelling adults and long-term care residents -predicts anorexia-related weight loss -focus is on appetite -requires patient cooperation to answer questions Subjective Global Assessment (SGA) -bedside nutritional assessment -based on history, physical exam, and practitioner's clinical judgement -does not detect acute declines in nutritional status -not recommended for the detection of malnutrition in obese patients -shown to be indicative of mortality and nutrition-related hospital readmissions in long-term care and hospitalized patients. Seniors in the Community: Risk Evaluation for Eating and Nutrition Version II (SCREEN II) -used in community setting -designed to identify older adults at risk for poor nutrition -consists of 17 items and can be administered by telephone
Laboratory Evaluation
The primary purpose is to inform clinical reasoning and decision making. Used to rule in or rule out certain conditions. What will you do with the results? Will testing change management? Issues with labs and diagnostic testing in geriatric patients fall into 4 main categories 1. "Normal" lab ranges are typically established by sampling a population of health adults; these samples may not be representative of the geriatric population. When a lab is slightly out of the normal reference range, it may be unclear if normal aging or a disease process is the cause. 2. You may find something unrelated to the reason the test was ordered. This may be beneficial to the patient in some cases (finding potential fatal condition at a treatable stage), and in other cases it may result in further testing that may or may not be worthwhile. 3. Test accuracy may be affected by the aging process. Clinicians must understand how results may be affected by age. 4. Age limits on screening tests are important and controversial issue in regard to timing of screening during a person's lifespan. Typical labs to consider at baseline in geriatrics include a TSH, CBC, and BMP. Additional labs may be indicated in specific situations. Abnormal lab findings aren't uncommon in geriatric patients. Some physiologic changes are associated with normal aging, few lab abnormalities are due to true age-related changes. Misinterpretation can result in underdiagnosis and undertreatment of many conditions. Abnormal lab values not affected by aging should prompt further evaluation. Laboratory Parameters (Unchanged) -Hemoglobin -Hematocrit -WBC Count -Platelet Count -Electrolytes (Na, K, Cl, HCO3) -BUN -Free Thyroxine Index -TSH -Calcium -Phosphorous -LFTs (transaminases, bilirubin, prothrombin time) Laboratory Parameters (Abnormal) -Sedimentation Rate (elevations of 10-20mm) -Glucose (tolerance decreases; elevations during acute illness) -Alkaline Phosphatase (mild asymptomatic elevations) ~if moderate elevations are present, hepatic or Paget's Disease should be considered -Albumin ~average values decline with age ~particularly in acute illness ~low levels generally indicate malnutrition -Serum Iron, Serum Iron Binding Capacity ~not an age related change ~decreases typically indicative of malnourishment and/or gastrointestinal blood loss -Serum Creatinine ~interpret with caution as declines in lean body mass and endogenous production occur with aging ~high normal and minimally elevated values may indicate substantially reduced renal function ~should never be used alone as a marker of renal function in elderly -Prostate Specific Antigen (PSA) ~may be elevated in males with BPH ~when marked elevations occur or values continue to increase over time, consideration may be given to further evaluation -Urinalysis ~asymptomatic pyuria and bacteriuria are common ~hematuria is abnormal Additional Diagnostic Considerations -Chest Radiographs ~interstitial changes are age related ~diffusely diminished bone density generally indicates advanced osteoporosis -Electrocardiogram ~ST-segment and T-wave changes ~Atrial and ventricular arrhythmias, and various blocks ~may not need treatment ~depends on specific clinical situation -Spirometry ~age-related declines in lung volume ~interpreted in relation to similarly aged people ~Forced Vital Capacity (FVC) is measurement -DEXA (Bone Mineral Density Measurements) ~T-Score vs. Z-Score ~T-Score= # of standard deviations by which patient's bone density departs from a healthy person around 30 years old. ~Z-Score= based on average bone density for and age-, sex-, and ethnicity-matched cohort and therefore can be useful to identify secondary causes of decreased bone mineral density in elderly patients whose scores fall more than 2 standard deviations of the mean value
Visual Examination
Visual Disturbances -Presbyopia= farsightedness caused by loss of elasticity of the lens in the eye -Cataracts= lens of the eye becomes progressively opaque causing blurred vision -Glaucoma= high eye pressure that causes damages optic nerve. Open angle most common. Angle closure glaucoma is rare, and a medical emergency causes by severe eye pain and visual disturbances. -Macular Degeneration= Blurred or nor vision in center of visual field Assessment -proptosis, ptosis, asymmetry, edema -discoloration, scleral icterus -testing of visual acuity -fundoscopic examination -evaluation of eye movements and pupillary reflexes
