Functional Assessment - The Key to Geriatric Care in the 21st Century
The next 30 years will result in a unique change in population demographics in this country. This change is already beginning. The baby boomers are getting old. The over 65 population will increase from being the 13% of the population it is today to 20% by the year 2030. More people than ever will reach the 100-year mark.
All aspects of the adult health care delivery system will feel the effect of this dramatic change. We will have more old people with chronic illnesses that require care in the ambulatory, hospital, and nursing home settings.
Patients with respiratory illnesses, cardiovascular disease and cancer will only increase in number. Many internists and family practitioners already have the skills to manage these conditions. However, additional expertise will be required to care for patients with functional impairments. Understanding the common types of functional impairments for which the elderly are at risk and how to identify and manage them in a cost effective manner may be the most important health care challenge facing clinicians and the health care system in the first half of the 21st century.
Developing the skills necessary to identify and manage patients who are at high risk for the complications that go along with functional impairment is essential for clinicians in training as well as for those already in practice.
Common conditions caused by functional deterioration include
- Skin breakdown
- Social isolation
- Urinary incontinence
- Medication related morbidity
The complications related to functional deterioration generally lead to the following consequences:
- Nursing home placement
- Increased home care services
- Caregiver stress
- Financial hardship
- Reduced quality of life
- Social isolation
These consequences have and will continue to result in escalating costs, which will magnify the financial strain on our Medicare and Medicaid programs.
How can we do a better job managing this population and meeting the challenges that face us in the next several decades?
Thinking and Acting Like a Geriatric
Residency programs will not be able to supply enough new fellowship trained geriatricians in sufficient numbers to meet the upcoming needs of our society. Many internists and family practitioners care for a large number of elderly patients. Educating and supporting today’s practitioners so that care for the elderly is improved is an important aspect of meeting the needs of our aging population. Providing new physicians with geriatric training in medical school and residency is also an important priority. Geriatrics uses a few principles that guide the approach to patient evaluation and treatment. By learning and applying these principles, care for the older adult can be enhanced.
These principles of geriatric care include
- The Law of Parsimony often fails
- Presenting symptoms of diseases are at the weakest link
- Abnormal findings are common but not always relevant
- Prevention becomes more important and cost effective with increasing age
- Improving function complements and sometimes supercedes diagnosis and treatment
- Atypical disease presentation is common
- Physicians have been shown to be poor estimators of functional status
These principles provide the foundation upon which the basis for functional assessment rests. Taken collectively, they provide the framework on which to identify areas of function assessment, and identify which practitioners need to be proficient.
The Law of Parsimony
As medical students, we are initially taught to identify a chief complaint and to then analyze history, exam, and lab findings to formulate a diagnosis. A typical scenario is the following:
A 40-year-old woman presents with several days of urinary frequency, increased thirst and no dysuria. The patient’s presentation quickly leads to the suspicion that she has diabetes. A urinalysis and a blood sugar determination quickly confirm the diagnosis and lead to a treatment plan.
The law of parsimony tells us that we should look at the organ system specific to the patient’s symptoms and positive exam findings to arrive at the correct diagnosis. In this case the symptoms lead us to the diagnosis of diabetes.
Now, let’s take a different example.
An 85-year-old woman presents with urinary frequency and urinary incontinence. She has no fever or dysuria. This patient does not have a urinary tract infection or diabetes. In fact the primary organ system that is causing her problem is not even her genitourinary system. This patient has mild congestive heart failure causing a polyuric state. She also has arthritis and is slow getting to the bathroom. The combination of her heart failure and arthritis result in her urinary frequency and her incontinence of urine.
This case illustrates the common reality of geriatric medicine. Many geriatric patients have multiple organ systems that may be compromised. The organ system that may appear to be the primary source of the patient’s symptoms often is not. Multiple organ systems may impact and produce discernable symptoms in a completely different system.
This leads to the next geriatric principle:
Diseases Present at the Weakest Link
It must be remembered that, in the elderly, deterioration in level of function may be the first symptom of an acute illness. Worsening impairments in ambulation or mentation are common symptoms of acute illnesses that in a younger patient would present in a different manner.
Common examples of this phenomenon so prevalent in geriatrics include pneumonia, which presents as confusion, and gastrointestinal bleeding which presents as syncope. In the first example a respiratory ailment presents with symptoms of brain dysfunction and in the second a GI problem presents with what appears to be a cardiac condition.
The two principles noted above lead to the following reality regarding disease presentation in the elderly:
Atypical Disease Presentation is Common
Related to the Law of Parsimony is the fact that in the geriatric population diseases often present atypically. Pneumonia may not present with a cough, a myocardial infarction may not cause chest pain, and a urinary tract infection may not trigger dysuria. A change in mental status may herald a developing pneumonia, falling may be the first sign that there is a UTI. Weakness may be the first sign of a pulmonary embolus and vomiting in the absence of chest pain may be the first hint of a myocardial infarction.
One of the factors that makes caring for the geriatric patient so challenging is the atypical presentation of illnesses. A high index of suspicion must be maintained when a patient does not respond to treatment, the diagnosis may be incorrect.
Improving Function Complements and May Supplant Diagnosis and Treatment
Physicians who care for older patients do not cure many of the conditions that affect them. The goals of treatment are often framed in the context of quality of life and functional status. A palliative approach often makes more sense in the elderly. Aggressively treating pain is often of greater benefit than aggressively trying to kill tumor cells. Focusing on prevention of narcotic induced constipation may do more to enable a patient to function in a home setting than tightly controlling blood sugars.
Teaching patients and family members how to live and function with an impairment from arthritis may be a more effective use of time, energy, and resources than trying a fourth nonsteroidal anti-inflammatory agent, repeating an MRI, or referring to a subspecialist. Sometimes more can be done to enhance independence and improve quality of life by simply teaching how to ambulate with an assistive device or how to don and doff socks than through high tech interventions.
Abnormal Findings are Common But Not Always Relevant
As mentioned in the previous sections, elderly patients often have multiple impaired organ systems that may be compensated and asymptomatic. Abnormal physical exam and laboratory findings may be present but are often not causing symptoms or are unrelated to the presenting condition. Heart murmurs, arthritic changes, bacteriuria, elevated blood sugars, cognitive impairment, compression fractures, arrhythmias, and neuropathies are all examples of common findings that may be unrelated to the reason for a patient’s acute illness or functional decline. The geriatric practitioner needs to be skillful not only in identifying these conditions, but also in determining their relevance to the patient’s symptoms.
A corollary to the above principle is that:
Treating Abnormal Findings May Do More Harm Than Good
When treating the older population, the risk of procedure related complications and untoward effects from medications is greatly enhanced. Procedure related complications such as infection and bleeding may be more common and more severe in the elderly. In addition, older patients have other comorbidities that may affect the utility of attempting to diagnose and treat some conditions. The risk benefit analysis from a procedure or treatment may be skewed in an older individual. The following example illustrates this point:
An 85-year-old male with moderately advanced dementia is found to have an elevated PSA of 7. Diagnostic and treatment options could include biopsy, prostatectomy or radiation therapy. What should the management of this patient be? Many would argue that “watchful waiting” would be the most appropriate thing to do. This patient is at increased risk for urinary incontinence, infections and deconditioning related to aggressive treatment. Subjecting this patient to radiation or a surgical procedure is very unlikely to prolong life and will in all likely reduce the quality of life for this patient.
Another example is a 70-year-old woman with severe arthritis of the left knee reducing the ability to climb stairs. She also has an ischemic cardiomyopathy with an ejection fraction of 25%. The patient wonders whether a knee replacement will help her ambulate and go up and down stairs better. The question for the physician to ask regarding this patient is whether her cardiac disease will prevent her from achieving improved function even if she does have an uneventful knee replacement.
Prevention Becomes More Important and Cost Effective with Increasing Age
When a younger patient is treated for hypertension or an elevated cholesterol, it may take decades before a stroke or a myocardial infarction is prevented. During that time period the cost of daily medications, periodic labwork and visits to physicians and other health care practitioners accumulates. Other diseases, illnesses and accidents may occur during the life of the younger patient. The result may be that the disease which the patient is trying to prevent doesn’t have the opportunity to develop. An example of this scenario is a 30-year-old male with hypertension who takes blood pressure medications for 25 years only to develop pancreatic cancer at age 55. The benefit from years of MD visits, lab tests and medication use is never realized.
In a recent editorial in the New England Journal of Medicine it was noted that “neglect of health promotion late in life is based on two myths.” The first is that “increased risk of disease in older persons reflects normal aging” and is an “…inevitable…process that is largely genetically determined. The second…is that the aged body…cannot respond to lifestyle changes. Both myths have been disproved.”
For the geriatric patient measures which prevent diseases or illnesses may have a more immediate effect. Rather than waiting decades before the preventive measure has an effect there is benefit often in just a few years in the older patient. Pneumococcal vaccinations can prevent severe pneumonia and reduce hospitalization rates, performing sigmoidoscopies may cure colon cancers, and treating hypertension can reduce cardiovascular morbidity.
Screening for and identifying functional impairments is a worthwhile endeavor in the geriatric population. Functional assessment can result in a reduction in fall risk, hospitalization avoidance, treatment of depression and even delay in nursing home placement. The following sections will discuss in further detail techniques for performing functional assessments in older patients.
Physicians Have Been Shown to be Poor Estimators of Functional Status
It is clear that physicians are not able to identify subtle deficits in functional status through the standard history and physical. Cognitive deficits, difficulties with activities of daily living, incontinence and depression are but a few of the areas of function that are commonly not identified through standard methods of providing routine care.
The reasons for the difficulties physicians have estimating functional status are two-fold. Physicians may not know how to effectively screen for certain functional deficits in the office, and may not have the resources necessary to evaluate function within the patient’s home.
It has been demonstrated that standard neuromuscular exams are not particularly sensitive in detecting functional deficits related to mobility. Patients may have cognitive problems and need help with basic functions such as dressing, or they may be depressed, not eating well, losing their urine or almost blind without their physician’s being aware. Despite performing yearly physicals, managing diabetes, high blood pressure and treating the episodic illnesses of their patients, many physicians do not know about key areas of function in those for whom they provide frequent care.
Later sections of this course will review techniques for assessing function that complement the standard techniques of performing history and physicals.
What do Geriatricians do Differently?
While there are areas of special knowledge that a geriatrician may possess, there are a few key aspects to geriatric care that can be developed by any clinician. Among the basic skills of the geriatric practitioner are the ability to
- Evaluate and optimize functional status
- Work with and lead multidisciplinary teams
- Integrate functional performance in disease assessment and management
Evaluate and Optimize Functional Status
Medical school and residency training programs place a great deal of emphasis on performing physical exams. Senior physicians may take time to do an elaborate evaluation of a patient’s reflexes and test the strength of individual muscle groups. The results of the exam are carefully recorded in the medical record. When that record is reviewed there are often critical areas regarding patient function that cannot be determined from the data provided. Was the patient able to transfer and ambulate unassisted? Could she dress herself? Was she continent?
The geriatrician recognizes that often the assessments done on patients do not evaluate function. For the geriatrician, identifying functional status is a critical aspect of evaluating a patient. Many deficits in function are not identified by physicians. Each time this happens, an opportunity to improve function is lost.
The geriatrician has learned how to use a variety of standardized tools and techniques to assess function. These methods are integrated into the clinician’s practice. To be effective, the geriatrician must build support systems which facilitate the evaluation process and provide appropriate treatment for the patient.
Work with Multidisciplinary Teams
Caring for older patients is done most effectively through a team approach. In order for clinicians to incorporate the evaluation of function as part of their day to day practice, systems and supports must be in place and built into the practice. It is through this team approach that the physician can efficiently and completely evaluate and treat patients with function deficits.
It is common that patients with functional deficits require the services of a variety of health care professionals. The geriatrician is often the leader of this team. Getting input from team members and integrating that input into a care plan that takes into account the patient’s medical condition, prognosis, social support, and values is the cornerstone to providing effective care.
Members of the multidisciplinary team that support the physician may include:
- Advanced practice clinician?performing history, exam, recommendations, teaching
- Medical assistant?performing simple screening, teaching
- Receptionist?giving appropriate instructions, bring all meds, glasses
- Social worker?assessing home supports psychosocial, financial issues
- Case manager?obtaining appropriate home services, insurance/financial options,
- Placement when needed
- Pharmacist?identify medication interactions, simplify meds, assess compliance
- Visiting nurse?assess home environment, teaching
- Physical, occupational and speech therapist?work with ADL deficits, home safety
- Mental health?treat and monitor psychiatric issues
- Neurologist?support diagnosis and management of dementia, CVA, Parkinson’s, etc.
- Pharmacist?medication compliance, check for interactions, proper dosage
In addition, physicians often need to enlist the support of and collaborate with family members and friends of the patient. Understanding the role of each of these professionals and using them effectively is a critical function of the geriatrician.
Integrate Functional Performance in Disease Assessment and Management
Older patients often have multiple illnesses and comorbidities. While it is important to know the ejection fraction in a patient with congestive heart failure, the glycosylated hemoglobin of a diabetic, the MRI result of the patient with a lacunar infarct, and the FEV1 of the patient with COPD, none of this information alone describes function.
The geriatrician needs to assess how well patients can function with their unique combination of medical illness, functional impairment, and social supports. Examples include whether
- The CHF patient who has cognitive impairment can take medications properly
- The patient who had a small stroke can safely negotiate stairs in her 2 story home to reach the upstairs bathroom, or
- The visually impaired diabetic with extensive osteoarthritis of the hands can draw up and administer insulin properly
The next section of this course focuses on a number of issues related to functional performance. These issues include how and what to screen for as well as how to integrate screening measures into an already busy office practice.
In many respects, geriatrics is the management of increasing frailty. A key aspect of functional assessment is understanding, identifying, and managing the common final pathway of multiple disease and aging processes.
There is a complex interplay of factors that result in frailty. Genetics, hormonal changes, and comorbid diseases are one aspect. Environment factors such as exercise and nutrition are another. Diseases and wear and tear related to normal aging make up yet other factors in the development of frailty. How to identify, measure, and monitor frailty is one aspect of geriatric care. Optimizing the function of the frail patient is another important goal of the geriatrician.
Geriatric Functional Screening Assessment
Much study has been done to identify what areas of function should be screened for and how to screen for those particular areas. These areas include
- Social Supports
- Medication Use
Each of these areas are generally inadequately addressed by a traditional history and physical. Understanding how to weave screening for functional deficits in these areas into the H and P is important for clinicians who do primary care for older patients.
The discussions that follow will demonstrate how functional evaluation complements the traditional H and P and enables the clinician to more fully address important patient care issues. By doing so, patients can reduce their risks for falls, hospitalizations, and nursing home placement. The end result of functional assessment is reducing costs and improving quality of life.
The physician needs to be a teacher and a delegator. As the various areas of functional assessment are reviewed, examples of how the physician needs to empower team members to help in the evaluation and treatment process will be provided.
Mobility is often described as the ability to transfer and ambulate safely. Approximately 35% to 40% of individuals over the age of 65 fall each year. Major injury occurs in 10% to 15% of those falls. Of those over 85, 10% to 20% have difficulty transferring from bed to chair.
When mobility becomes impaired, fall risk goes up as does the ability to function independently. Impaired mobility leads to falls, injuries, hospitalization, loss of independence, and nursing home placement. Patients with impaired mobility are more at risk for being incontinent, getting skin breakdown, being socially isolated, and getting depressed. Treating the complications of impaired mobility costs billions of dollars each year. Identifying patients who are at risk for falls and intervening so as to reduce fall risk is a core goal of functional assessment.
Working in geriatrics and being a parent have some features in common. As a parent, one can observe how a child progressively develops more functional independence.Why is it that in a single day a baby who has been crawling is suddenly able to walk? What was it that changed physiologically that enabled an individual who required a hand held assist with ambulation to walk independently in such a short period of time?
In geriatrics we often deal with the opposite situation. Within a day or two patients can change functional level from being able to ambulate safely at home to being bedbound or requiring assistance getting out of bed to the bathroom.
There are obviously many factors that affect the ability to ambulate. Several organ systems must interact simultaneously to achieve successful mobility. Muscle strength, cognition, joint stiffness, pain, balance and nerve function all play roles in the ability to ambulate. Many elderly patients have deficits in several of these areas yet can be independent in their mobility. Until one deficit or a combination of deficits becomes severe falls may not occur. Being able to recognize that a patient is at risk for falls enables the clinician to implement measures to reduce that risk.
The Get Up and Go Test
Many practices are “efficiently” set up so the patient is undressed and sitting on the exam table when the clinician enters the room. This efficiency may result in a lost opportunity to learn important information about the patient, such as how the patient walked and transferred, how the patient was dressed, and how the patient managed undressing.
Mary Tinetti has demonstrated that standard neuromuscular examinations do not adequately assess function. Standards tests of strength, sensation and reflexes may detect pathology such as neuropathy, focal weakness or lack of coordination. They do not necessarily detect how well a patient can get up from a chair and ambulate. Furthermore they are not sensitive in assessing fall risk. In addition, abnormal findings do not correlate with the ability to transfer and ambulate. Many poor mobility performers did not have neuromuscular abnormalities on a standard physical exam.
There are a variety of ways to assess the gait of patients. One of the most well known and reliable techniques is the “Get up and go test.” As its name implies, the patient is asked to get up from a chair ambulate 15 feet then turn around and sit down again. The clinician observes and times the patient while doing the maneuver. Taking more than 20 seconds to complete the maneuver is considered abnormal. The key to this test is knowing what to observe while the patient performs the maneuver.
The test can be divided into 4 sections
- Getting up from the chair. The chair should have no armrests so that leg strength not arm strength is used. Look for patients pushing off with their hands from the surface of the seat. Patients having difficulties with this aspect of the maneuver may have quadriceps weakness. Also check for unsteadiness on arising.
- Ambulating – Observe for equal stride length, shuffling, proper heel-toe strike and gait speed.
- Turning – observe for unsteadiness, balance difficulties
- Sitting down in the chair – check for an uncontrolled descent with a flop backwards
An additional maneuver that can be helpful in assessing mobility as well as fall risk in an office setting is the Functional Reach Test.
Functional Reach Test
This simple maneuver helps predict which patients may be at increased risk for falls. It is performed by attaching a yardstick to a wall horizontally at shoulder level. The patient is then asked to stand upright sideways near the wall, feet together, with the arm nearest the wall outstretched with the hand in a fist. The patient is then asked to reach forward as far as possible without moving the feet. The inability to reach forward at least six inches is associated with a significantly higher risk of falls.
Patients who appear to have difficulty with one or both of these maneuvers may be at increased risk for falls. If deficits are identified, further medical evaluation may be indicated to assess neurological and musculoskeletal function. At the same time, methods to reduce fall risk need to be implemented as well. This is where the physician may activate the multidisciplinary team to provide support.
Interventions that may be helpful for the patient with increased fall risk include
- Physical therapy evaluation to assess for walking aid, transfer teaching, strengthening exercises, proper shoes
- Home safety evaluation to assess lighting, environmental obstacles including rugs and furniture, evaluate stairs and hand rails, bathroom hazard
- Check for postural hypotension
- Medication review
As our population ages, impaired cognition is a growing problem. The number of individuals in our society with dementia is likely to triple over the next 30 years. Studies have shown that 20% to 50% of those over 85 have dementia. Alzheimer’s disease makes up the majority of those with cognitive impairment. Other causes of dementia can include multi-infarct dementia, Parkinson’s dementia, and other rarer disorders.
From the ages of 65 to 85, the incidence of Alzheimer’s disease doubles every 5 years. Patients with dementia are at higher risk for needing home care services and eventually nursing home placement. Delirium is also more common in patients with dementia and carries with it increased risk of morbidity and mortality. Caregivers, often daughters, play a major role in providing care for patients with dementia. Caregiver burnout is an important factor in nursing home placement.
A 1995 Mayo Clinic Symposium on geriatrics noted clinicians either fail to detect dementia in 21% to 72% of affected patients, especially early in the course of the disease, or may dismiss true cognitive impairment as normal aging. What is the best way for primary care clinicians to screen for dementia? Clinicians need an objective easy to use method for screening patients for cognitive impairment. Asking the patient about cognition is not a reliable screening technique. It is important to have a consistent technique for making this assessment.
Because memory impairment is a common feature of dementia, asking the patient to repeat the names of three objects and then asking again in three minutes is a reasonable screening technique. Patients who demonstrate difficulty with remembering two out of three objects should go on to have a more thorough evaluation.
The Folstein Mini-Mental Status Exam
The Folstein Mini-Mental Status exam is the gold standard for performing an initial cognitive assessment. This series of questions tests memory, language, calculation and orientation. A 30-point scale is used. The test is useful for identifying patients with no impairments and with more severe dysfunction. The test is less sensitive for patients with a moderate degree of dementia. The test may be administered by appropriately trained office staff.
MMSE scores under 24 are indicative of significant impairment. Factors unrelated to dementia that may lower test scores include educational level, depression, mental retardation, and delirium.
The test can be administered in less than 10 minutes and can be performed by appropriately trained office staff. Performing the test on older patients can be very helpful when administered every 1 to 3 years. Subtle changes can be identified in this manner.
Whenever cognitive impairment is suspected, obtaining corroborative evidence from close friends or family members is extremely helpful. It is important to receive permission from the patient prior to discussing health related issues with another party.
Patients who score abnormally on the MMSE may require
- Further neurological evaluation including checking a B12 and TSH
- Case management or VNA referral to assess the home safety
- Medication compliance assessment when treating other conditions
The “MINI-MENTAL STATE.” A PRACTICAL METHOD FOR GRADING THE COGNITIVE STATE OF PATIENTS FOR THE CLINICIAN. Journal of Psychiatric Research, 12(3): 189-198, 1975. 1975, 1998 MiniMental LLC.
Urinary incontinence is a condition that is often present in patients yet the physician does not know it. From 15% to 30% of community dwelling older adults have at least occasional urinary incontinence. The frequency in women is twice that of men. The two main reasons the physician doesn’t know is that the patient often is embarrassed and does not volunteer the information and the physician does not ask. Urinary incontinence can lead to social isolation, depression and is often the functional change that precipitates nursing home placement. The unfortunate aspect to urinary incontinence is that it is often treatable, yet patients do not get treated.
Asking about urinary incontinence can easily be incorporated into the review of systems. Routinely asking patients if they ever lose their urine, and if so, how often, as well as how frequently they get up to urinate at night can provide the information the clinician needs to identify the problem. The common causes of urinary incontinence include
- Stress incontinence – Often this is from weak sphincter muscles that can be related to child bearing and estrogen deficiency in women and caused by post operative changes from prostate surgery in men.
- Urge incontinence – Most commonly caused by overactive detrusor muscles in the urinary bladder. Local irritation from cystitis can be a precipitant as well as neurological damage related to strokes, Parkinson’s disease, and diabetic neuropathy.
- Urinary retention – In men this is most commonly related to outlet obstruction. Anticholinergic medications can precipitate this condition in the setting of prostate enlargement. Both men and women can have this from hypotonic detrusor muscles or even fecal impaction.
- Functional incontinence – In this condition the patient is unable to get to the bathroom quickly enough. There is often an environmental or a functional deficit that prevents the patient from reaching the toilet. Examples include patients in bed who need assistance with ambulation or have difficulty communicating the need to void.
The treatment of urinary incontinence can include:
- Stress incontinence – hormone replacement, alpha adrenergic medications which increase sphincter tone, pessaries, occasional surgical procedures.
- Urge incontinence – biofeedback, medications which reduce detrusor contractility.
- Urinary retention – correction of outlet obstruction, occasionally medications which increase detrusor contractility, catheterization.
- Functional incontinence – Removing barriers such as restraints and siderails, implementing a toileting schedule, relieve discomfort from arthritis that impairs ambulation or prescribing an appropriate walking aid.
Often a good history, a pelvic/rectal exam, and checking a post void residual urine can supply enough information to determine the source of the incontinence. Occasional urological referral and urodynamic studies are needed to arrive at an appropriate diagnosis and treatment.
Medications are a common cause of morbidity and even mortality in the geriatric population. A significant number of hospitalizations are related to adverse response to medications or to noncompliance with medication use. Some of the physiological factors that play a role in this higher complication rate include the reduced creatinine clearance that is inevitable with aging. This reduction in creatinine clearance can increase serum concentrations of many medications. Other factors that predispose older patients to medication toxicity and side effects include the prevalence of obstructive uropathy, the frequency of constipation, cognitive impairment, and enhanced sensitivity to anticholinergic side effects.
Common medication related problems in the elderly include
- Urinary retention – from over the counter allergy and cold medications
- Constipation – from narcotics
- Congestive heart failure?from NSAIDS
- Delirium – as seen with meperidine and its anticholinergic metabolites
- Toxicity – as occurs with lanoxin
- Hypotension – from cardiac and blood pressure medications
- Diarrhea – pseudomembranous colitis post antibiotics
- Falls – from long acting benzodiazepenes, antihypertensive agents
- Hyperkalemia – from angiotensin converting enzyme inhibitors
- Drug interactions – because the physician was not aware of other medications the patient was taking
- Bleeding – related to warfarin dosing and monitoring
Selecting the appropriate medication and balancing its positive effect with its potential complications needs to be carefully considered in the older patient.
Compliance with medication use is another important factor informing adverse medication-related outcomes. A number of different factors can be involved:
- Did the patient understand the instructions on how to administer the medications?
- Could the patient hear the medication administration instructions?
- Could the patient afford the medication?
- Is the patient cognitively capable of taking the medication properly?
- Did the patient have an easy way to contact the physician when a side effect developed?
Physicians need to prescribe medications their patients can afford and create a simple medication administrative schedule. They also need to know all the medications, including over-the-counter, that their patients are taking. Being aware of the issues outlined above allows clinicians to improve the care they provide for their patients.
Hearing loss is very common in the older population. Up to 75% of individuals over 80 have hearing impairment. High frequency hearing loss, or presbycusis, can result in difficulty discriminating spoken words. Consonants are more difficult to distinguish than vowels. This hearing difficulty is especially noticeable in crowded, noisy environments where there is significant ambient noise. Women’s and children’s voices present a significant challenge. The consequences of impaired hearing can include social isolation and depression to these patients.
The traditional exam of the ear involves checking the tympanic membrane for motility and a light reflex. While these anatomical structures are important they do not correspond with hearing ability. It is, however, important to check for cerumen impaction as a cause of hearing loss since this is easily correctable.
The Whisper Test
The Whisper Test is a technique for assessing hearing function in the exam room. The patient occludes one ear while the examiner whispers equally accented words into the nonoccluded ear. It is important that the examiner stands so that the patient cannot lip read. Exhaling fully before testing hearing ability is a method that can help modulate the voice. Examples of words that can be used include:
hot dog railroad baseball have not popcorn earache
Interventions that can assist the hearing impaired patients include hearing aids and adaptive phone or computer equipment that facilitate communication.
There are changes in vision with normal aging. Glare tolerance is reduced, dark adaption is lessened. Disease states which affect vision commonly include diabetes, macular degeneration, glaucoma, and cataracts. Deficits related to all of these conditions except for cataracts cannot generally be improved.
Patients with visual impairment have increased fall risk and may be socially isolated. Patients with impaired vision can be encouraged not to drive and may be eligible for community supports. When screening a patient for visual impairment, it is important that the patient bring his or her glasses to the appointment. The receptionist who makes the appointment plays an important role in reminding the patients of this.
Checking the globus and doing a funduscopic exam is not an effective technique for evaluating vision. There is a small hand held eye chart called the Jaeger eye chart. When held 14 inches from the patient the chart can be used to quickly screen for impaired vision. Patients that score below 20/40 may benefit from a referral to an optometrist. Office staff may be empowered to perform this screening for the clinician. A home visit can be helpful in removing hazards and improving lighting.
The activities of daily living (ADLs) and the instrumental activities of daily living (IADLs) are important measure of patient function. The IADLs are activities that require a higher level of function than the ADLs. A variety of medical conditions can impair these activities.
The IADLs are remembered by the pneumonic SHAFT.6 The pneumonic describes activities as outlined below:
S – shopping
H – housekeeping
A – accounting
F – food preparation
T – transportation
Patients with functional decline general lose the ability to do their IADLs prior to losing ADL function. An effective screening technique is to ask patients about two or three of the IADLs. If the patient is performing these independently then asking about ADL function is generally not likely to uncover further significant deficit.
If the patient is experiencing difficulty with IADLs then inquiring about ADL function is indicated. The ADLs are remembered by the pneumonic DEATH which includes:
D – dressing
E – eating (self feeding)
A – ambulating
T – transferring
H – hygiene
It is worthwhile to investigate each of the ADLs when impairment with IADL function is noted. Patients who have impaired ADL function are at higher risk for needing home care services and nursing home placement. By identifying patients with impaired ADLs, interventions can be put in place that may reduce the risk of further deterioration and maintain or even improve function in a home setting. These interventions may include:
- Home PT/OT
- Home health aid-helps with washing, dressing
- Homemaker (helps with cooking, cleaning)
- Meals on wheels
- Adaptive equipment such as commodes, tub seats, or raised toilet seats
Cost is an important factor in home care. There are limitations around the kinds of services that health insurance and community services will offer. Having a case manager or social worker involved can be very helpful in helping patients and families understand what services are needed and available as well as whether private payment is required.
We live in an era where families may be spread out and live all over the country, even all over the world. In addition, the children and grandchildren of our seniors often do not have a stay at home caregiver. Often both spouses work. With many of our elderly in their eighties and nineties there are often few family members alive, willing and able to provide assistance. The children of patients in their nineties may themselves be in their seventies.
The presence of a caregiver can be the difference between a senior living in a home setting versus living in a nursing facility. The physician plays an important role in identifying when extra help may be needed by a patient and enlisting the aid of a caregiver. Caregivers often need to be taught how assist a senior with functional deficits. The multidisciplinary team plays an important role in this regard.
Asking the question “Who could stay with you if you became ill?” is an attempt to preemptively identify a potential caregiver. If such an individual is identified, permission may be requested to speak with that person to corroborate that the response is accurate. Lack of a caregiver can be a factor in hospital admission, extended hospital stays, and nursing home placement.
Enlisting the support of family members, neighbors, friends, church groups and other community services is an important aspect of caring for the patient with functional deficits.
Malnutrition is all too common in the elderly. Hospitalization, financial status and illness may lead to inadequate caloric intake. Often our efforts to treat diseases such as heart failure, diabetes and hypercholesterolemia can inadvertently result in diets that impair patients from a nutritional standpoint.
Weighing patients and checking for significant weight change is often the first step in detecting and treating nutritional problems. Asking patients about weight loss and investigating significant weight change is the key to effective screening. In general a weight loss of 5% or 5 pounds in 1 month as well as a loss of 10% or 10 pounds in 6 months is a reasonable guide for identifying significant weight loss.
When confronted with weight loss in the elderly, cancer is often high on the list of potential diagnoses. In geriatrics, other conditions need to be considered when confronted with a patient who is losing weight. These conditions include medical, psychosocial and environmental factors. Examples include:
- Medical illness
- Financial hardship
- Elder abuse
- Poor/absent teeth
- Alcohol abuse
- Inability to shop
- Altered sensation of hunger or thirst
- Inability to prepare food
The clinician caring for an elderly patient with weight loss needs to consider all the issues noted above. Often a home visit is very helpful in identifying a cause of weight loss. In geriatrics, patients with the Failure to Thrive Syndrome often present with weight loss. As is evident, from the above list, an investigation that goes beyond an exam and lab tests is often needed to come to the etiology of weight loss. A team approach is sometimes needed to determine the etiology of weight loss. The results of such an investigation often result in the identification of conditions that are treatable.
How often does a primary care clinician ask a patient “Have you had any chest pain lately?” Not surprisingly the answer probably is “all the time.” How often does that same clinician ask “Do you feel sad or depressed?” Although a simple question, it can be effective in identifying patients with potentially significant depression. It is not a question that is regularly asked.
Depression is a significant problem in the elderly. Patients with depression have longer hospital stays and are at higher risk to require nursing home placement. There are now a variety of medications that are effective in treating depression. With the advent of the SSRI’s(selective serotonin reuptake inhibitors) many elderly patients can take medication for their depression with a lower incidence of medication side effects than previously. In the past, tricyclic antidepressants were the mainstay of medication treatment for depression in the elderly. These medications have more potent anticholinergic effects than the SSRI’s. Anticholinergic side effects can include delirium, dry mouth, constipation and urinary retention. Many patients can not tolerate these side effects.
Identifying and treating depression can now be an aspect of care that primary care clinicians can actively diagnose and manage. It must be remembered that the elderly often do not use the term depressed. It is also important to realize that anxiety and worry may be symptoms of depression. Depression can also manifest itself with cognitive deficits and present as a pseudo-dementia. As mentioned earlier, when performing a MMSE, depression is in the differential diagnosis for someone with a low score.
When confronted with a potentially depressed patient, it is important to evaluate for other medical problems that may give symptoms of depression such as hypothyroidism or malignancy. One must also screen for medications that may cause depressive symptoms such as Beta-blockers. Finally it is important to ask patients who appear to be depressed if they are suicidal. Immediate evaluation and treatment may be indicated in this situation.
For patients that may have depression, the Yesavage Depression Scale(attachment 2) is an easy test to administer that can help with the diagnosis. The test consists of 15 yes/no questions. Scores over 5 may indicate depression while scores over 10 indicates a high probability of depression.
Clinicians may see functional assessment as a burden that does not provide critical information and that adds on to an already overwhelming amount of work that needs to be done. However the value of this aspect of patient care can be appreciated and performed with proper delegation of responsibilities, knowing how to integrate aspects of functional assessment into everyday patient care, and applying geriatric principles of patient management.
The New England Journal editorial mentioned at the beginning of this course states that “Reorientation of the Medicare Program toward the promotion of health and the prevention of disease would encourage healthier aging…and would in the long run enhance Medicare’s financial stability.”
In our present era of medicine, clinicians can find great professional satisfaction and perform a tremendous service for our older patients by identifying areas of functional impairment. Clinicians who can master these skills will be essential as we enter the 21st century.