The Stealth Geriatrician:How to learn what you need to know from your patients

Tiffany Shubert, Ph.D., MPTTony Caprio, MD

Course Objectives

Identify four key risk factors for falling in older adults

Perform a comprehensive geriatric functional assessment

Evaluate the need for referral “Build a Team” – Determine

disciplines and community resources to aid in patient health management

Why Falls?

AAMC Minimum Competency All adults over 65 years should be

asked about falls All adults should be observed and

assessed rising from a chair and walking

All patients who have fallen should have a differential diagnosis and evaluation plan to address the fall and potential risk of falls

Why Falls?

Medicare PQRI Program Incentive pay for falls screening!

Good Practice Facilitates successful aging Opportunity for health promotion

Collaboration with other disciplines Collaboration with community

Who is going to fall?

How will you identify who will fall?

A comprehensive geriatric assessment uncovers falls risk

What you can find in your comprehensive exam

If you take their shoes off!

Introducing Mrs. Jones

Chief Complaint

It depends on who you ask:

Patient: “No complaints, I feel fine”

Daughter: “Difficulty getting around the house, I am afraid she may fall”

MD: “Blood pressure should be better controlled”

History of Present Illness

What do you want to know? Changes in medications Trips to the opthamologist Trips to the ER Changes in mood/activity levels Previous falls

Past Medical History

HypertensionParoxysmal Atrial FibrillationChronic Renal InsufficiencyAnxiety/Depression“Dizziness”Osteoporosis

Medication List

Metoprolol Hydrochlorothiazid

e Digoxin Warfarin Sertraline

Diazepam Zolpidem Meclizine Fosinopril Alendronate

Medication Review > 4 Drugs = Increased risk of falls Red Flags – Classes that increase falls risk

Benzodiazepines (short and long-acting agents)

Antidepressants (tricyclics and SSRIs) Antipsychotics Anticonvulsants Opioids Antispasmodics Over the counter medications

Social History

What do you want to know? Living Situation

Type of house? Stairs? ADLs, IADLs Social Supports Economic Status Smoke/Drink Current Activity Level Fear of Falling

Activities of Daily Living:Ask or Observe

ADLs Transferring Toileting Bathing Dressing Continence Feeding

IADLS Transportation Use the phone Buy groceries Meal preparation Housework Medication Pay bills

Review of Systems Systems vs. Syndromes

Organ-based review may give you limited information

Geriatric syndromes encompass multiple organ systems

Falls Dizziness, Vision, hearing Cardiovascular Orthopedic problems, arthritis,

neuropathy Depression, cognitive impairment

Physical Exam Findings General Impression Vital Signs

BP sitting 140/90, HR 88 BP standing 110/80, HR 100 Pain

HEENT Bilateral cataracts, difficulty reading magazine

and wall poster CV

Grade II/VI systolic murmur (right upper sternal border)

MS Neuro

Functional Assessment:Timed Up and Go

Functional Assessment: Walking Speed

Functional Assessment:Timed Chair Rise

Functional Assessment:Chair Rise Mrs. Jones

Functional Assessment:Balance

Mrs. JonesWhat Happens at Home

Functional Assessment

What Do You Learn?

How Do You Assess?

Referral

Cognitive Assessment

Clock Draw Test

Mini-Cog

Mrs. Jones Clock

Clock Draw Example

Home Safety Evaluation

Use an environmental assessment sheet

Occupational therapy

Financial difficulties may be culprit

Assessment: Mrs. Jones

What are the problems? History of falls 3 of the 4 risk factors for falls

Leg muscle weakness, poor walking, polypharmacy

Orthostatic Hypotension Osteoporosis

Plan: Mrs. Jones What will you do about it?

Fix orthostasis Address osteoporosis Modify medications

Who will you refer to? Occupational Therapy - home safety eval Physical Therapy - leg strengthening, gait

training, and assessment for assistive device Consult with pharmacy about current

medication list and insurance coverage Community Services for behavior change

programs, wellness and socialization activities

Synthesis Evaluating major risk factors for falls

is fundamental to a geriatric assessment

A functional assessment will identify individuals at risk for falls

A functional assessment can (and should) be done with your older patients

Refer to other disciplines to best manage complex older adults

Practice Practice Practice

Practice with volunteers Physical, Cognitive, and Medication

Assessment On the wards

Perform at least one mini-Mental and clock draw

Shadow a physical therapist and perform 1-2 functional assessments

Identify which of your patients are at risk for falls