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8/12/2019 Geriatrics Presentation
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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
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M3 SeminarSeptember 2006 2
Learning Outcomes
Review common Geriatric
Syndromes
In Coursetoolshtps://ctools.umich.edu/portal
Review geriatric assessment
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M3 SeminarSeptember 2006 3
M3 Clinical Competencies
(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)
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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M3 SeminarSeptember 2006 5
Geriatric Syndromes
(outpatient) Dementia, Depression, Delerium
Incontinence
Osteoporosis Falls
Hearing and vision impairment
Sleep disorders
Failure to thrive Iatrogenic (medications)
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M3 SeminarSeptember 2006 6
Geriatric Syndromes
Dementia, Depression, Delerium Cognitive screen, ask about depression, check
orientation and concentration (serial 7s)
Delerium has variable orientation/concentration,
dementia doesnt
Incontinence Stress, urge, overflow
Stresssmall volume; urgelarger volume
Check for UTI with incontinence Ditropan can cause overflow
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Geriatric Syndromes
Osteoporosis Riskasian > 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 happenedtrip, slip, drop
Injury?
Mandatory: test sensation, balance, GAIT (TUG test)
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Geriatric Syndromes
Hearing and vision impairment Whisper test, check with glasses on
Sleep disorders
Normal agingsleep 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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M3 SeminarSeptember 2006 9
Geriatric Syndromes
Failure to thrive Dwindling
Weight loss
Increased frailty
Not able to live independently (without humanassistance)
Check for cognition, mobility, medication side effects
Cancer?
Consider hospice for refractory situation (sometimespeople get better with hospice!)
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M3 SeminarSeptember 2006 10
Geriatric Syndromes
Iatrogenic
Medications Anticholinergics
Narcotics - dont forget the laxative
Stool softener alone will not be enough Antiarrhythmics
Dilantin (nausea; vertigo)
Neuroleptics
PPIsnausea, 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 Elderly
Neurologic (Parkinsons, stroke, TIA) Rheumatologic (RA, PMR, vasculitis)
Genitourinary (BPH, sexual dysfunction)
Cardiovascular (afib, CAD, CHF, HTN)
Endocrine (hypothyroid, diabetes type II,Pagets)
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/Skills
First rule of history and physical exam
To treat the problem, you have todocument the problem
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Documentation
First rule of geriatrics (similar to first rule of
real estate sales)
Function, Function, Function
Patients dont care about their diagnoses,they care about their function
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M3 SeminarSeptember 2006 14
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 history
Either Social History or
Functional History
Or
In the HPI!
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Physical Exam
Test the following:
MobilityTimed Up and Go test- stand, walk,
turn, sitCognitionMini-Cog (3 item recall) or MMSE
(Mini Mental Status Exam)
AffectTwo question Depression screen
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The results go in the Physical
ExamTimed 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
necessarily mean DiagnosisDiagnosis belongs in the Impression/Plan
section
BUT.Rule #1:Avoid the trap of premature labeling
Problem 1. Falls (list the differential here)
NotProblem 1. Probable spinal stenosis
OrProblem 1. Musculoskeletal System
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Develop a Plan rather than a
Diagnosis
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
Back to First rule of History and PhysicalExamination .
To prevent it, you have to document it
Learn about primary and secondary preventionscreening that maximizes function and minimizesfuture impairment
Keep current about age-associatedrecommendations for tertiary prevention(treatment)
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Social, 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, AreaAgency on Aging, 3 day inpatient requirement
for Medicare payment of CNH!
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Social, Ethical, Cultural
Ask 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 otherintervention!
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