Geriatric Assessment

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The term geriatric assessment is used to describe the interdisciplinary team evaluation of the frail, complex elderly patient. Such a team may include but is not limited to a geriatrician, nurse, pharmacist, case manager/social worker, physical therapist, oc cupational therapist, speech therapist, psychologist, nutritionist, dentist, optometrist, and audiologist. Assessment may be performed in a centralized geriatric clinic, or by a series of evaluations performed in separate settings. The team may conduct an interdisciplinary case conference to discuss the patient's assessment and plan. For a healthy, active elderly patient, the assessment might require only two to three members of this team, with coordination of care provided by the patient's geriatrician.

Patient Interview

The clinical approach to assessing older adults frequently goes beyond a traditional "history and physical" used in general internal medicine practice.3 Functional status must be determined, which includes the patient's activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Refer to Table 2-5 for descriptions of ADLs and IADLs. Evidence of declining function in specific organ systems is sought. Of particular importance is cognitive assessment, which may require history gathering from family, friends, or other caregivers, and is important in determination of the patient's competence to consent to medical treatment.34 The mini-cog

mental status exam, shown in Figure 2-2, is a quick tool to assess patient's cognitive impairment. Commonly there is decreased visual acuity, hearing loss, dysphagia, and manual dexterity. Decreased skin integrity, if present, greatly increases risk for pressure ulcers. Sexual function is a sensitive but important area, which should be specifically inquired about. Cardiac, renal, hepatic, and digestive insufficiencies can have significant implications for pharmacotherapy. Inadequate nutritional status may lead to weight loss, and impaired functioning at the cellular or organ level as discussed previously. See Table 2-6 for common problems experienced by older adults.

Patient Encounter 3

PW is an 83-year-old African American male who has been living in a long-term care facility for 4 years after his wife passed away. He has been eating one to two meals a day with complaints of trouble swallowing, constipation, depressed mood, and fatigue. He has lost 2 kg in last 6 months and has developed a new coccyx ulcer.

PMH: Hypertension, diabetes, hyperlipidemia, hypothyroidism, Parkinson's disease, osteoarthritis, constipation, allergic rhinitis

FH: Father died of stroke at age 82; mother died of breast cancer at age 67 SH: 40-year smoking history but quit 9 years ago; no alcohol drinking

Allergies: NKDA

Meds: (1) Aspirin 81 mg daily, (2) hydrochlorothiazide 25 mg daily, (3) lisinopril 10 mg twice daily, (4) glipizide 5 mg twice daily, (5) metformin 500 mg twice daily, (6) levothyroxine 25 mcg daily, (7) carbidopa/levodopa 25 mg/100 mg three times daily, (8) ibuprofen 600 mg three times daily, (9) docusate sodium 100 mg twice daily, (10) lorazepam 2 mg twice daily, (11) diphenhydramine 25 mg at bedtime, (12) amitriptyl-ine 10 mg at bedtime

VS: BP 122/62, P 60, RR 14, T 36.8°C (98.3°F), pain 3/10 (on scale of 0-10) Labs: Complete metabolic panel is within normal limits; CBC pending What potential drug-related problems does PW have? What quality indicators can you identify in this nursing home resident? What recommendations can be made about his medication regimen?

Table 2-5 ADL and IADL

ADL

Transfer?

Dressing Mobility Eating

frathing

uiNrio Grooming

IADL

Using transpor

If still driving, assess driving abi ty

tation

{including cognitive function

medications that can inhibit ability to

drive, vision, neuromuscular conditions

that may interfere with reaction Time,

ability to turn head) at the time of license

renewal

Using the

Check for emergency phone numbers

telephone

located near the telephone

Management of

Assess the ability to balance checkbook and

finances

pay bills on time

Cooking

Check for safe operation of appliances and

cooking tools as well as ability to prepare

balanced meals

Housekeeping

Check for decline in cleanliness or neatness

Medication

Assess organization skills and adherence

administration

ADL. activities of daily living; IADLr instrumental activities of daily living.

Three item recall

1. Ask the patient if you may test his or her memory.

2. Give the patient 3 words (e.g., apple, table, penny) to repeat and remember.

3. Have the patient repeat the 3 words from memory later (e.g., after the clock drawing test).

Clock drawing test

1. Have the patient draw the face of a clock, including numbers.

2. Instruct the patient to place the hands at a specific time, such as 11:10.

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Constipation Prescription

Constipation Prescription

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