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Comprehensive Geriatric assessment


Comprehensive Geriatric assessment

Comprehensive Geriatric assessment

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  • 1.  A multidisciplinary diagnostic process intended to determine a frail older person’s medical, functional, and psychosocial status and limitations in order to develop a plan for treatment and long-term follow-up.
  • 2.  Physician Nurse Practitioner or Physician Assistant Nurse Social Worker Physical/Occupational/Speech /psychological Therapist Pharmacist Dietician DentistEach member of team sees every patient
  • 3.  Highest priority:  Prevention of decline in the independent performance of ADLs  Drives the diagnostic process and clinical decision making Screen for preventable diseases Screen for functional impairments that may result in physical disability and amenable to intervention
  • 4.  Improve diagnostic accuracy Guide selection of interventions to restore or preserve health Recommend optimal living environment Monitor clinical change over time Predict outcomes
  • 5. 1. Screening or targeting of appropriate patients.2. Assessment and development of recommendations.3. Implementation of recommendations (physician and patient adherence).
  • 6. 1. Healthy elderly persons – living in the community2. Frail elderly persons – living in the community3. Institutionalized or severely impaired elderly persons
  • 7.  Frail because of age Decrease in functional status Change in mental status- cognition/affect Multiple medical problems Multiple psychosocial problems Take multiple medications New onset urinary or fecal incontinence Involuntary weight loss Frequent falls One or more sensory impairments Disruptive behavior or personality changes
  • 8.  Common problems that have been identified as warranting special attention in elderly3. Cognitive Disorders:(Dementia/Delirium)4. Polypharmacy5. Falls/Gait Instability6. Urinary Incontinence7. Depression8. Malnutrition
  • 9.  Medical assessment Cognitive Function Affective Disorders Visual Impairment Hearing Impairment Dental Health Functional Status Nutritional Status Gait and Balance Impairment Social Support Environment Advance directives
  • 10.  History. (H) Examination.(E) Assessment tool . (T) Referral. (R)
  • 11.  Interview both( pt , care giver) Use old medical records More time consuming dt:  Communication problem (hearing, vision,slow processing and cognitive impairment)  Underreporting  Vague nonspecific symptoms  Atypical presentation  Multiple comorbidity,etiologies
  • 12.  Previous surgical procedures Major illnesses and hospitalizations Previous transfusions Immunization status Preventive health measures Mammography Papanicolaou (Pap) smear Tuberculosis history and testing Medications Previous allergies , adverse reactions History of herbals, vitamins, laxatives sleeping pills and cold preparations Topical, OTC drugs
  • 13. SEXUAL HISTORY: Active or notFAMILY HISTORY Irrelevant for dementia Psychiatric illness are relevant like depression and dysthymiaPAIN HISTORY Characteristics of the pain Relation of pain to impairments in physical and social function Analgesic history Patients attitudes and beliefs about pain and its management Effectiveness of treatments
  • 14. Psychological history: Sleep pattern Behavioral history Cognitive function Affective disorder Psychiatric disorder
  • 15.  Respiratory Cardiovascular Gastrointestinal Genitourinary Musculoskeletal Neurological Psychological
  • 16.  Multiple complaints Select the bothering one The recently changing one The new one The backache for last 10 y with same ccc isn’t worrisome but increasing severity is
  • 17. Weight changes  Weight gain should prompt search for edema or ascites  Gradual loss of small amounts of weight is common  losses in excess of 5% of usual body weight over 12 months or less should prompt search of underlying disease Poor personal grooming and hygiene Can be signs of poor overall function, caregiver neglect, and/or depression; often indicates a need for intervention
  • 18. COMMON PHYSICAL FINDINGS AND THEIR POTENTIAL SIGNIFICANCE IN GERIATRICS VITAL SIGNS Blood Pressure Psuedo hypertension:( no end organ damage, osler’s maneuver  Assess Orthostatic Hypotension 3 min 20/10 Irregular pulse  Arrhythmias are relatively common in otherwise asymptomatic elderly Temperature  Hypothermia is more common  Absent fever not exclude infection
  • 19. Tachypnea Baseline rate should be accurately recorded to help assess future complaints (such as dyspnea) or conditions (such as pneumonia or heart failure) Pain  is the 5th vital sign
  • 20. Ulcerations  Lower extremity vascular and neuropathic ulcers common  Pressure ulcers common and easily overlooked in immobile patients Diminished turgor  Often results from atrophy of subcutaneous tissues rather than volume depletion when dehydration suspected, skin turgor over chest and abdomen most reliable  Bruising :suspect abuse
  • 21.  Nail:  Longitudinal ridges  Thin nail plate  Lost lanula  Ingrowing toe nail Face:  Temporal a palpation ,tenderness  xanthoma Eye  Enophtalmus:dt loss orbital fat  Entropion  Ectropion  Arcus senilis Mouth Missing teeth Dentures often present; they should be removed to check for evidence of poor fit and other pathology in oral cavity  Xerostomia, fissured tongue, leukoplakia, bleeding gum edentulous
  • 22. Gum health Area under the tongue is a common site for early malignancies SKIN Multiple lesions  Actinic keratoses and basal cell carcinomas common; most other lesions benign  Ecchymosis may be a sign of abuse CHEST Abnormal lung sounds  Crackles can be heard in the absence of pulmonary disease and heart failure; often indicate atelectasis
  • 23. CARDIOVASCULARSystolic murmurs  S4 normally may be heard in elderly  Ejection systolic murmur is Common and most often benign; clinical history and bedside maneuvers can help to differentiate those needing further evaluation. Vascular bruits  Carotid bruits may need further evaluation as it confers more coronary and cerebrovascular events  Femoral bruits often present in patients with symptomatic peripheral vascular disease Diminished distal pulses  Presence or absence should be recorded as this information may be diagnostically useful at a later time (e.g., if symptoms of claudication or an embolism develop)
  • 24. BREAST EXAMINATION Retraction of Nipple and areola  Exclude cancer Masses or fixed breast  Test for Consistency and mobility to Exclude cancer ABDOMEN and RECTAL EXAMINATION Prominent aortic pulsation Suspected abdominal aneurysms should be evaluated by ultrasound Fecal impaction  Common  Should be treated
  • 25. GENITOURINARY Atrophy  Testicular atrophy normal  Atrophic vaginal tissue may cause symptoms (such as dyspareunia and dysuria) and treatment may be beneficial Pelvic prolapse (cystocele, rectocele) Common and may be unrelated to symptoms; gynecologic evaluation helpful if patient has bothersome, potentially related symptoms Adnexal mass  Malignancy should be excluded Urinary incontinence OR A chronically overfilled and distended bladder  Search for prostate
  • 26. EXTREMITIES Periarticular pain Can result from a variety of causes and is not always the result of degenerative joint disease; each area of pain should be carefully evaluated and treated Limited range of motion  Often caused by pain resulting from active inflammation, scarring from old injury, or neurologic disease; if limitations impair function, a rehabilitation therapist could be consulted Edema Can result from venous insufficiency and/or heart failure; mild edema often a cosmetic problem; treatment necessary if impairing ambulation, contributing to nocturia, predisposing to skin breakdown, or causing discomfort  Unilateral edema should prompt search for a proximal obstructive process
  • 27. NEUROLOGIC Abnormal mental status (i.e., confusion, depressed affect)  Delirium, dementia or depression should be assessed. Weakness  Arm drift may be the only sign of residual weakness from a stroke Proximal muscle weakness (e.g., inability to get out of chair) should be further evaluated; physical therapy may be appropriate
  • 28.  Major eye diseases such as cataract, macular degeneration, glaucoma, and diabetic retinopathy increases with age. Require eye glasses due to presbyopia. Often unaware of their visual deficits.
  • 29.  Should ask questions regarding reading, watching television, or driving. (H) Snellen Chart is used to screen for visual deficits. (T)  Patient stands 20 ft. from the chart and read letters using corrective lens.  Inability to read >20/40 implies impairment in vision. Referral to Ophthalmologist if needed. (R)
  • 30.  Associated with decreased cognition, depression, dissatisfaction with life, and withdrawal from social activities. Usually bilateral. Occurs in the high frequency range.
  • 31.  Questions about hearing difficulties. (H) Inspect ear for impacted cerumen. (E) Whisper voice ,finger rub test . (E) Audioscope (T) Hearing Handicap Inventory. (T) Referral . (R)
  • 32.  Inability to hear 40 decibles tone at 1000 or 2000 Hz in one or both ears implies failed hearing test.
  • 33.  An alternative to hand-held audio scope. Done by whispering 3 – 6 words at a distance of 8, 12, or 24 inches from the patient’s ear. Examiner should stand behind the patient and have one ear covered during the examination. Inability to repeat >50% of the whispered words is considered a failed screening.
  • 34.  Whisper Test 3 words 12 to 24 inches Macphee GJA Age Aging, 1988
  • 35. 3. D o e s a h e a r in g p r o b le m c a u s e y o u t o f e e l e m b a r r a s s e d w h e n y o u m e e t n e w p e o p le ? Ye s       S o m e t im e s         N o4. D o e s a h e a r in g p r o b le m c a u s e y o u t o f e e l f r u s t r a t e d w h e n t a lk in g t o m e m b e r s o f y o u r f a m ily ? Ye s       S o m e t im e s       N o5. Do yo u ha ve d if f ic u lt y w h e n s ome one s p e a k s in a w h is p e r ? Ye s       S o m e t im e s   No6. D o y o u f e e l h a n d ic a p p e d b y a h e a r in g p r o b le m ? Ye s       S o m e t im e s       N o7. Does a h e a r in g p r o b le m c aus e yo u d if f ic u lt y w h e n v is it in g f r ie n d s , r e la t iv e s , o r n e ig h b o r s ? Ye s       S o m e t im e s       N o8. Does a h e a r in g p r o b le m c a u s e y o u t o a t t e n d r e lig io u s s e r v ic e s le s s o f t e n t h a n y o u w o u ld lik e ? Ye s       S o m e t im e s       N o
  • 36.  INSTRUCTIONS: The purpose of this scale is to identify the problems your hearing loss may be causing you. Please select YES, SOMETIMES, or NO for each question. Do not skip a question if you avoid a situation because of your hearing problem. If you use a hearing aid, please answer the way you hear without a hearing aid. Total ‘No’ _____ X 0 = _______ Total ‘Yes’ _____ X 4 = _______ Total ‘Sometimes’ _____ X 2 = _______ TOTAL SCORE _______ If your score is greater than 10, a hearing test is recommended
  • 37. MMSEMini-cog testClock drawing testAnimal naming test
  • 38. ‫‪‬مقياس الحالة العقليةالتوجه ) الهتداء(‬ ‫‪ ‬تقدر تقول لي إحنا في سنة كام ؟‬ ‫‪‬تقدر تقول لي إحنا في فصل إيه؟‬ ‫‪ ‬تقدر تقول لي إحنا في شهر إيه؟‬ ‫/5‬ ‫تقدر تقول لي النهاردة إيه؟‬ ‫‪ ‬تاريخ النهاردة ايه ؟‬ ‫‪‬‬ ‫إحنا فين دلوقت؟‬ ‫إحنا في الدور الكام؟‬ ‫`‬ ‫أنت تتبع حي إيه؟‬ ‫‚‬ ‫أنت تتبع محافظة إيه؟‬ ‫°‬‫/5‬ ‫‚ إحنا في جمهورية إيه؟‬
  • 39. ‫تسجيل المعلومات‬ ‫ا قولك 3 كلمات, قولهم ورايه, ها سالك عليهم تاني كمان شويه )كورة- شجرة- قلم(‬ ‫/3‬ ‫) أكثر من 5 سنوات دراسة( اطرح 7 من 001 و الباقي شيل منه 7 و أنت نازل, و توقف بعد 5‬ ‫مرات:) 39-68-97-27-56(‬ ‫ذا كان غير قادر علي الطرح: يتهجا كلمة أسيوط‬‫) اقل من 5 سنوات دراسة ( اطرح 3 من 02 و الباقي شيل منه 3 وأنت نازل و توقف بعد 5 مرات‬ ‫/5‬ ‫استرجاع الذاكرة:‬ ‫/3‬ ‫قول ال 3 كلمات اللي قولناهم قبل كده )كورة –شجرة- قلم(‬ ‫اللغة:‬
  • 40. ‫اكتب جملة مفيدة أو قول جملة مفيدة‬ ‫•‬‫/1‬ ‫ارسم هذا الشكل‬ ‫‪‬‬ ‫____________‪Date‬‬ ‫‪_____ Total Score ‬‬
  • 41.  Subjects told to 1 point for the clock circle ▪ Draw a large circle 1 point for all the numbers being in ▪ Fill in the numbers on a clock the correct order face 1 point for the numbers being in the ▪ Set the hands at 8:20 proper special order 1 point for the two hands of the No time limit given clock Scoring (subjective): 1 point for the correct time. ▪ 0 (normal) ▪ 1 (mildly abnormal) ▪ 2 (moderately abnormal) ▪ 3 (severely abnormal) A normal score is four or five points.
  • 42.  Components  3 item recall: give 3 items, ask to repeat, divert and recall  Clock Drawing Test (CDT) ▪ Normal (0): all numbers present in correct sequence and position and hands readably displayed the represented time Give 1 point for each recalled word after the CDT distractor. Score 1–3.  A score of O indicates positive screen for dementia.  A score of 1 or 2 with an abnormal CDT indicates positive screen for dementia.  A score of 1 or 2 with a normal CDT indicates negative screen for dementia.  A score of 3 indicates negative screen for dementia
  • 43.  Category fluency Highly sensitive to Alzheimer’s disease Scoring equals number named in 1 minute  Average performance = 18 per minute  < 12 / minute = abnormal Requires patient to use temporal lobe semantic stores 60 seconds Using a cutoff of 15 in one minute:  Sens 87% - 88%  Spec 96%
  • 44.  Highest prevalence of depression and suicide in elderly Geriatric Depression Screen (GDS)- Yesavage  30 y/n questions  15 y/n questions Single question just as sensitive ▪ Do you feel sad or depressed? ▪ Are you worried something bad will happen to you?
  • 45. ‫:‬ ‫‪ ‬ﺈختر الجواب اﻷنسب لحالتك النفسية خلل اﻷسبوع الماضي‬ ‫1- هل ﺃنت بشك ٍ عام را ٍ عن حياتك ؟ نعم ‪ ‬كل ‪‬‬ ‫ض‬ ‫ل‬ ‫‪‬‬ ‫2- هل تخّيت عن العديد من نشاطاتك و ﺇهتماماتك ؟ نعم ‪ ‬كل ‪‬‬ ‫ل‬ ‫‪‬‬ ‫3- هل تشعرۥ ﺃ ّ حياتك فارغة ؟ نعم ‪ ‬كل ‪‬‬ ‫ن‬ ‫‪‬‬ ‫4- هل تصاب بالملل عادة" ؟ نعم ‪ ‬كل ‪‬‬ ‫‪‬‬ ‫5- هل ﺃنت في مزا ٍ حسن في ﺃغلبية الوقت ؟ نعم ‪ ‬كل ‪‬‬ ‫ج‬ ‫‪‬‬ ‫6- هل تخاف ﺃن يصيبك مكروه ؟ نعم ‪ ‬كل ‪‬‬ ‫‪‬‬ ‫7- هل تشعرۥ بالسعادة ﺃغلبية الوقت ؟ نعم ‪ ‬كل ‪‬‬ ‫‪‬‬ ‫8- هل تشعرۥ عادة" ﺃّك بحاجة ﺇلى مساعدة ؟ نعم ‪ ‬كل ‪‬‬ ‫ن‬ ‫‪‬‬ ‫9- هل تف ّل البقاء في غرفتك على الخروج و القيام بنشاطا ٍ جديدة ؟ نعم ‪ ‬كل ‪‬‬ ‫ت‬ ‫ض‬ ‫‪‬‬ ‫01- هل تشعرۥ ﺃ ّ مشاكل الذاكرة تصيبك ﺃكثر من غيرك ؟ نعم ‪ ‬كل ‪‬‬ ‫ن‬ ‫‪‬‬ ‫11- هل تعتقد ﺃّه ﻷم ٌ رائع بقاؤك حيا" الن ؟ نعم ‪ ‬كل ‪‬‬ ‫ر‬ ‫ن‬ ‫‪‬‬ ‫21- هل تشعرۥ ﺃّك ل تجدي نفعا" في الوقت الحالي ؟ نعم ‪ ‬كل ‪‬‬ ‫ن‬ ‫‪‬‬ ‫31- هل تشعرۥ ﺃّك شديد النشاط ؟ نعم ‪ ‬كل ‪‬‬ ‫ن‬ ‫‪‬‬ ‫41- هل تعتقد ﺃ ّ وضعك ميؤوس منه ؟ نعم ‪ ‬كل ‪‬‬ ‫ن‬ ‫‪‬‬ ‫51- هل تعتقد ﺃ ّ ﺃغلبية الّاس بوض ٍ ﺃفضل من اّذي ﺃنت عليه ؟ نعم ‪ ‬كل ‪‬‬ ‫ل‬ ‫ع‬ ‫ن‬ ‫ن‬ ‫‪‬‬ ‫‪‬‬
  • 46. Choose the best answer for how you have felt over the past week: 1. Are you basically satisfied with your life? YES / NO 2. Have you dropped many of your activities and interests? YES / NO 3. Do you feel that your life is empty? YES / NO 4. Do you often get bored? YES / NO 5. Are you in good spirits most of the time? YES / NO 6. Are you afraid that something bad is going to happen to you? YES / NO 7. Do you feel happy most of the time? YES / NO 8. Do you often feel helpless? YES / NO 9. Do you prefer to stay at home, rather than going out and doing new things? YES / NO
  • 47.  10. Do you feel you have more problems with memory than most? YES / NO 11. Do you think it is wonderful to be alive now? YES / NO 12. Do you feel pretty worthless the way you are now? YES / NO 13. Do you feel full of energy? YES / NO 14. Do you feel that your situation is hopeless? YES / NO 15. Do you think that most people are better off than you are? YES / NO Answers in bold indicate depression. Although differing sensitivities and specificities have been obtained across studies, for clinical purposes a score > 5 points is suggestive of depression and should warrent a follow- up interview. Scores > 10 are almost always depression.
  • 48.  Basic Activities of Daily Living (ADLs)  Tasks essential to be independent in your own home or room Instrumental Activities of Daily Living (IADLs)  Tasks essential to be independent in the community Advanced Activity of Daily Living (AADLs)
  • 49. Bathing (sponge, shower, or tub) Independent: needs no assistance Assisted: needs assistance only in bathing a single part (as back or disabled extremity) Dependent: needs assistance in bathing more than one part of the body and in getting in or out of tub or does not bathe self Dressing Independent: gets clothes from closets and drawers; puts on clothes, outer garments, braces; manages fasteners; act of tying shoes excluded Assisted: need partial assistant Dependent: does not dress self or remains partly undressed Toileting Independent: gets to toilet; gets on and off toilet; arranges clothes; cleans organs of excretion (may manage own bedpan used at night only and may not be using mechanical supports) Assisted: receives assistance in getting to and using toilet Dependent: uses bedpan or commode
  • 50. Transfer Independent: moves in and out of bed independently and moves in and out of chair independently Assisted: using mechanical supports Dependent: assistance in moving in or out of bed and/or chair; does not perform one or more transfers Continence Independent: urination and defecation entirely self-controlled Assisted: : partial or incontinence in urination or defecation; or partial control by enemas, catheters, or regulated use of urinals and/or bedpans Dependent total incontinence in urination or defecation; partial or total control by enemas, catheters, or regulated use of urinals and/or bedpansFeeding: Independent: gets food from plate or its equivalent into mouth (precutting of meat and preparation of food, as buttering bread, are excluded from evaluation) Assisted: assistance in act of feeding Dependent: does not eat all or parenteral feeding
  • 51.  The Index of Independence in Activities of Daily Living is based on an evaluation of the functional independence or dependence of patients in bathing, dressing, toileting,transferring, continence, and feeding. Specific definitions of functional independence and dependence appear below the index. A – Independent in feeding, continence, transferring, toileting, dressing, and bathing B – Independent in all but one of these functions C – Independent in all but bathing and one additional function D – Independent in all but bathing, dressing, and one additional function E – Independent in all but bathing, dressing, toileting, and one additional function F – Independent in all but bathing, dressing, toileting, transferring, and one additional function G – Dependent in all six functions Other – Dependent in at least two functions, but not classifiable as C, D, E, or F.
  • 52. bility to Use Telephone Operates telephone on own initiation, looks up and dials numbers, etc. 1 Dials a few well-known numbers 1 Answers telephone but does not dial 1 Does not use telephone at all 0hopping Takes care of all shopping needs independently 1 Shops independently for small purchases 0 Needs to be accompanied on any shopping trip 0
  • 53. ousekeepingMaintains house alone or with occasional assistance (e.g., on heavy work-domestic help‌) 1Performs light daily tasks such as dishwashing, bed making 1Performs light daily tasks but cannot maintain acceptable level of cleanliness 1Needs help with all home maintenance tasks 1 Does not participate in any housekeeping tasks 0 aundry Does personal laundry completely 1 Launders small items ”rinses socks, stockings, etc. 1
  • 54. esponsibility for Own MedicationsIs responsible for taking medication in correct dosages at correct times 1Takes responsibility if medication is prepared in advance in separate dosages 0Is not capable of dispensing own medication 0 bility to Handle Finances Manages financial matters independently (budgets, write checks, pays rent, bills, goes tobank), collects and keeps track of income 1
  • 55.  Evaluates the persons ability to participate in societal, community, and family roles. It also assesses for recreational and occupational activities. These activities varies among individuals and may be a valuable tools in monitoring functional status prior to the development of disability.
  • 56.  Patient specific activities that can be used to detect subtle functional losses in high functioning patients Can be job or recreation oriented Socializing, playing bridge , working, playing golf, playing music, dancing, practicing law, flying a plane, gardening.
  • 57.  Food taken (type, quantity, frequency) No of hot meal / week Characteristic diet (low salt , low protein) Alcohol intake Fluid intake Dietary fiber OTC vitamin , herbal medicine pt’s ability to feed himself Change in taste ,smell, teeth
  • 58.  MNA® Short Form Nutrition Screening Initiative  DETERMINE checklist MUST (Malnutrition Universal Screening Tool) Nutrition Risk Screening (NRS) (ESPEN)
  • 59. 1. Body mass index (BMI)(kg/m2)2. Weight loss in past 3 months?3. Acute illness or major stress inpast 3 months?4. Mobility5. Dementia or depression6. Has appetite & food intakedeclined in past 3 months?
  • 60.  MNA > 23: dietary informations MNA < 17: refer to a specialist, do more comprehensive assessment, using biological markers: albumin, CRP.. MNA between 17 and 23: Were the patient have difficulties, how can we help, useful for intervention studies
  • 61. YES1. Do you have an illness or condition that made you change the kind and amount of 2food you eat.2. Do you eat fewer than two meals per day. 33. Do you eat few fruits, vegetables, or milk products. 24. Do you have 3 or more drinks of beer, liquor or wine almost every day. 25. Do you have tooth or mouth problems that make it hard for you to eat. 26. Do you always have enough money to buy food. 47. Do you eat alone most of the time. 18. Do you take 3 or more different prescribed or over the counter drugs per day. 19. Without wanting to, have you lost or gained 10lbs. in the last 6 months. 210. Are you physically unable to shop, cook, or feed yourself. 2A score of 0-2 is good, 3-5 moderate nutritional risk and greater than 6equal high nutritional risk.
  • 62.  Diet  A more precise questionnaire is needed to have the correct amount of consumed intake. ▪ The 7-day dietary record routine seems to have a good reproducibility in assessing the intake of energy and fluids in geriatric patients, but may be to long and to complex for non expert professionals. ▪ 3-day food records could be sufficient for a correct estimation of current food intake.  Some new validated method is proposed as the photography method of nutritional assessment
  • 63.  Physical Exam ▪ Loss of SQ fat ▪ Muscle wasting ▪ Edema in ankles ▪ Edema in sacral area ▪ Ascites ▪ Anthropometric parameters Weight, body mass index are the most important anthropometrics parameters,
  • 64.  WeightIndividuals removed shoes and heavy cloths prior to weighing. HeightSubjects stood with their scapula, buttocks and heels resting against a wall, the neck was held in a natural non-stretched position, the heels were touching each other, the toe tips formed a 45° angle and the head was held straight with the inferior orbital border in the same horizontal plane as the external auditive conduct (Frankforts plane). Body circumferencesMid-brachial, calf, waist and hip circumferences were measured using a flexible non-elastic measuring tape. Individuals stood with feet together and arms resting by their sides. The hip circumference was measured from the maximum perimeter of the buttocks. The waist circumference was taken as the plane between the umbilical scar and the inferior rib border. The waist circumference was used to identify individuals with possible health risks based upon threshold values of ≥ 88 cm for women and ≥ 102 cm for men Knee-heel length Body-mass index (BMI)BMI was estimated by dividing weight (kg) by height2 (m2) . Individuals were considered malnourished if their BMI was less than 18.5, normal from 18.5 to 24.9 and overweight if ≥ 25 Waist to hip ratio (WHR)This was estimated by dividing waist circumference by hip circumference . The threshold WHR was ≥ 0.85 for women and ≥ 1.00 for men
  • 65.  Biochemical parameters  Plasma albumin, Cholesterol, Hemoglobin and Transferrin are the most used laboratory parameters in long term care.  CRP, total lymphocytes may also be used linked to higher mortality)
  • 66.  At entry: Weight, BMI, MNA, Every 3 months: Weight, if weight loss more than 2 kg, ▪ MNA ▪ Weight each months
  • 67.  >6 concurrent diagnosis. >12 doses of medications per day. A prior ADE. A low body weight or BMI. Age >85 years. Creatinine clearance <50ml/minute.
  • 68.  Previous history of falls causes and treatments. Did you fall last year ? Location & circumstances of Fall Associated symptoms Other falls or near falls Medications (including nonprescription) and alcohol Injury & ability to get up
  • 69.  Lower extremity or quadriceps weakness can evaluated by asking the patient to stand from a seated position in a hard back chair while keeping their hands folded. Inability to complete this task suggest lower extremity weakness and is highly predictive for future disability.
  • 70.  Gait Observations  Initiation of gait Step length Step height  Step continuity Step symmetry Walking stance  Amount of trunk sway Path deviation Gait speed ▪ 0.8 meters/sec indicates that the patient is capable of independent ambulation within the community. ▪ of 0.6 meters/sec indicates participation in community activities without the use of a wheelchair ▪ Patients who can ambulate 50 feet in the office corridor in 20 seconds or less should be able to walk independently in normal activities
  • 71.  Sitting balance (leaning vs steady) Ability to rise from chair Immediate standing balance Standing balance (wide based, narrow based or assisted) Sternal nudge Standing balance w/ eyes closed
  • 72. BALANCE SCORE = _____/16Gait score=- _____/12TOTAL SCORE (Gait + Balance ) = _____/28{< 19 high fall risk, 19-24 medium fall risk,25-28 low fall risk}
  • 73.  ONLY VALID FOR PATIENTS NOT USING AN ASSISTIVE DEVICE The task of rising from an armless chair, walking 10ft, turn, walk back and sit down is termed the “Get-up and Go Test.” Those taking long than 10 seconds to complete this tasks are at increased risk for falls Seconds Rating <10 freely mobile <20 mostly independent 20-29 variable mobility >30 assisted mobility Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the “Get-up and Go” test. Arch phys Med Rehabil. 1986; 67(6): 387-389.
  • 74. Pain Assessment
  • 75.  Location Quality Severity Duration Exacerbating/relieving factors Efficacy of current treatmen Impact on mobility Impact on sleep Impact on appetite Imact on mood Impact on social life
  • 76.  Numerical scales Visual analog scales Verbal Descriptor scales Behavioral cues
  • 77.  Grimacing Agitation Restlessness Moaning/crying Guarding Appetite and activity changes Irritability/swearing
  • 78.  Duration, severity, symptoms, previous treatment, medications, GU surgery 3 P’s  Position of leakage (supine, sitting, standing)  Protection (pads per day, wetness of pads)  Problem (quality of life) Reversible causes (Diappers) Categorize incontinence Bladder record or diary
  • 79.  Mental status Mobility Fluid overload Abdominal exam Neurologic exam Pelvic Rectal
  • 80.  Stress test (diagnostic for stress incontinence; specificity >90%) Post-void residual Blood Tests (calcium, glucose, BUN, Cr) Urine Culture Simple (bedside) Cystometrics
  • 81. Social Assessment
  • 82.  Should include availability of help in case of emergency. Availability of a personal support system. Living arrangement. Relationship with (family, friends, neighbours) Social activities, hobbies, spiritual participation Need for a caregiver. Caregiver burdens. Economic status. Elder mistreatment. Advanced directives.
  • 83.  For the frail elderly availability of help from family or friends can determine whether a functionally dependent person remains at home or is institutionalized. For those frail elders that lack support, a visiting nurse may be helpful in the assessment of home safety and level of personal risk, i.e., stairs, location of bathrooms, bathroom grab bars, and smoke alarms.
  • 84.  S - Do you feel Safe at home? What Stress do you feel in your relationship? A - Do you feel Afraid or have you been Abused by any of your caregivers? F - Are there any Family or Friends that you could ask for help or support? E – Do you have a safe place to go in case of an Emergency? Is it an Emergency now?
  • 85.  Caregiver does not come to appointments Is concerned about medical costs History of substance abuse, mental health problems, conflicts with patient Dominates interview, won’t leave, won’t let patient talk Defensive, hostile, or indifferent Dependence on patient for income/housing
  • 86. D - Dementia, Depression, DrugsE - EyesE - EarsP - Physical Performance, Phalls, PsychosocialI - IncontinenceN -Nutrition
  • 87.  Start low , go slow Try to limit number of medications and avoid prescribing “a pill for every ill” Try not to start two drugs at the same time Make sure it is the right dose Avoid “inappropriate medications”- Beers criteria Watch out for potential drug-drug, drug-disease interactions Make sure patient and caregiver understand what the medication is for , how and when to take it, possible side effects
  • 88. At least annually: Ask patient to bring in all medications (including OTC, herbal prep) Ask patient how each medication is being taken Look for medications with duplicate therapeutic or pharmacologic profiles Eliminate unnecessary medications Simply the medication regimen – fewest possible number of medications and doses per day Always review any changes in writing with the patient and caregiver, provide the changes in writing