This document provides an overview of an internist's perspective on assessing older patients, known as a G-60 assessment. It discusses the importance of conducting a comprehensive initial assessment that evaluates physical and cognitive function, social supports, living situation, and advance directives. It also outlines ways to prevent patient harm, such as functional decline, delirium, infections, malnutrition, pressure ulcers, and adverse drug events. The document emphasizes improving the patient experience through effective communication techniques.

1. Internist’s Perspective on G-60
Brian T. Sidoti, MD
Medical Director Hospitalist Program
HonorHealth John C. Lincoln Medical Center

2. Initial Assessment
 Usual H & P isn’t sufficient
 Need to assess other important factors
that determine “physiologic age”
 Physical function
 Cognition
 Social supports
 Living situation
 Advance directives
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3. Initial Assessment
 Physical and Cognitive function
 IADL’s - financial bookkeeping, transportation,
cooking, etc.
 ADL’s - assistance with bathing, dressing, toileting,
feeding, transferring, continence
 Assess mobility - DME use, balance trouble, fall
history, stamina/stairs
 Visual/auditory impairments
 Urinary continence - why? (meds, mobility,
cognitive, etc.)
 Mini cognitive evaluation - (3 item recall and clock
drawing test)
 “Describe what a good day is like for you”
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4. Initial Assessment
 Social Supports and Living Situation
 Who lives with you?
 Who helps you in times of need?
 What kind of help do you have at home?
 Meals prepared, assistance with meds,
accuchecks, BP, etc.
 Facility living - tease out if independent,
assisted living (how much assistance?), or
nursing home
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5. Initial Assessment
 Advance Directives
 Do they exist?
 Who is your MPOA? - have this verified with
documents
 Document code status and list limitations
(tube feeds, ventilator, etc.)
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6. Initial Assessment
 Why screen for functional and physiologic
status?
 Risk factors for new onset of disability at
discharge when presenting independent:
 age > 80
 dependence with multiple ADL’s
 poor baseline mobility (incline/stairs)
 severe cognitive impairment
 medical conditions:
 metastatic cancer, albumin < 3
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7. Initial Assessment
 Pain assessment - how does it affect
function at home?
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8. Initial Assessment
 Medication Reconciliation
 NEVER assume it’s correct on every patient,
every time!
 Verify complete and accurate list, including OTC
meds
 Difficult if transitioning through multiple phases
of care (recent hospital stay/nursing home) -
verify complete and most recent med list from
facilities
 Pharmacy can review for drug-drug interactions
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9. Preventing Patient Harm and
Other Adverse Outcomes
 Functional decline
 At risk for falls, delirium, pressure ulcers, DVT
 Avoid bed rest whenever possible
 In chair for meals and mobilize with PT
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10. Preventing Patient Harm and
Other Adverse Outcomes
 Delirium
 Control pain
 Protect sleep time - without meds!
 Avoid offending meds (NSAIDs, opiates,
anticholinergics, SSRIs, TCAs, antiemetics,
antispasmodics, imodium, H2 blockers, benzos,
muscle relaxants, steroids)
 Avoid sensory deficits - eyeglasses/hearing
aids present
 Mobilize early
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11. Preventing Patient Harm and
Other Adverse Outcomes
 Hospital Acquired Infections
 Discoverable to the public
 Reportable to Medicare and can affect Value
Based Purchasing scores and
reimbursement
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12. Preventing Patient Harm and
Other Adverse Outcomes
 Hospital Acquired Infections
 Clostridium difficile
 Minimize broad spectrum antibiotics
 Hand hygiene - going in and out of rooms
 Avoid PPI’s - lower gastric pH
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13. Preventing Patient Harm and
Other Adverse Outcomes
 Hospital Acquired Infections
 Hospital Acquired Pneumonia - 48 or more
hours after admission
 Risk factors - mechanical ventilation, advanced
dementia, severe Parkinson’s disease, other
neurologic conditions, antipsychotic use
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14. Preventing Patient Harm and
Other Adverse Outcomes
 Hospital Acquired Infections
 Hospital Acquired Pneumonia
 Prevention - oral hygiene, feed only when upright
and alert
 Cough with eating?? - speech therapy c/s for
swallow evaluation
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15. Preventing Patient Harm and
Other Adverse Outcomes
 Hospital Acquired Infections
 CAUTI’s – Catheter associated UTI’s
 Atypical presentations are common: fever,
ALOC, hypotension, metabolic acidosis,
respiratory alkalosis
 Avoid foley use if possible AND remove foley
ASAP
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16. Preventing Patient Harm and
Other Adverse Outcomes
 Malnutrition
 Contributing factors: delirium, poor appetite,
nausea, constipation, restricted movement,
lack of dentures, difficulty with self feeding,
NPO orders
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17. Preventing Patient Harm and
Other Adverse Outcomes
 Malnutrition prevention
 Out of bed for meals
 Assistance with feeding
 Avoid restricted diet - do they really need to be on a
2 gram low sodium cardiac diet??
 Consider regular diet, diabetic, or renal if severe
CKD
 Get correct consistency - chopped/pureed if
dentures at home
 Supplements - Boost 8 oz chocolate drink = 250
calories
 Tube feeds ONLY if can’t take orals AND consistent
with patient’s wishes
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18. Preventing Patient Harm and
Other Adverse Outcomes
 Pressure Ulcers
 Contributing factors: poor nutritional status,
incontinence, immobility, neurologic
impairment
 Prevention: optimize nutrition, turn every 2
hours, pressure reduction over dependent
points (heel protectors, special beds, etc.)
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19. Preventing Patient Harm and
Other Adverse Outcomes
 Venous thromboembolism
 Everyone is at risk!
 Prevention: SCDs on uninjured lower legs,
pharmacologic therapy, or IVC filter if high
bleeding risk and prolonged immobility
anticipated
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20. Preventing Patient Harm and
Other Adverse Outcomes
 Adverse Drug Events
 Insulin – hypoglycemia
 Sulfonylureas – hypoglycemia
 Digoxin - delirium, heart block
 Benzodiazepines - FALL RISK
 Diphenhydramine - delirium, urinary retention, constipation
 Opiates - constipation, urinary retention, delirium, respiratory
depression codeine, meperidine, pentazocine, butorphanol, and
nalbuphine are WORSE than fentanyl, morphine, or oxycodone
 Antipsychotics - DEATH in dementia patients, pneumonia
 Fluoroquinolones - tendon rupture (esp. with steroids), hypoglycemia,
QT prolongation, C diff
 Nitrofurantoin - pulmonary and liver toxicity. Poor choice for UTI’s in
the elderly, as CrCl needs to be > 60 to achieve high urine
concentrations
 Bactrim - hyperkalemia and hypoglycemia (with sulfonylurea use)
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21. Drug Prescribing
 Anticholinergics - adverse effects: poor memory, confusion,
hallucinations, dry mouth, blurred vision, constipation, nausea,
urinary retention, tachycardia
 High anticholinergic effects:
 Antihistamines benadryl, hydroxyzine, chlorpheniramine
 Antiparkinson effects - benztropine (cogentin)
 Overactive bladder - tolterodine (detrol), oxybutinin
 Anti-spasm - dicyclomine, hyoscyamine
 Inhaled bronchodilators - ipratropium (atrovent), tiotripium
(spiriva)
 Antiemetics - hydroxyzine, meclizine, promethazine (phenergan),
scopolamine
 Muscle relaxants - tizanidine (zanaflex)
 Antipsychotics - chlorpromazine (thorazine), fluphenazine
(prolixin), clozapine (clozaril)
 Antidepressants - tricyclics (amitriptyline, doxepin, imipramine,
nortriptyline)
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22. Drug Prescribing
 Beers Criteria (2012 revision) - American
Geriatrics Society
 Divides drugs into 3 categories:
 meds always to avoid
 potentially inappropriate meds based on other
health factors
 meds to use with caution
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23. Drug Prescribing
 Beers Criteria - Meds to Avoid
 1st generation antihistamines
 benztropine (cogentin)
 antispasmodics (dicyclomine, scopolamine)
 nitrofurantoin for long term suppression of UTI’s or CrCl < 60
 digoxin 0.25mg dose
 TCA’s
 antipsychotics in dementia unless other options fail and patient is danger to
self/others
 barbiturates
 benzodiazepines for insomnia/agitation/delirium
 ambien - chronic use
 sliding scale insulin (high risk of hypoglycemia without improved glucose
control)
 sulfonylureas - chlorpropamide and glyburide
 metoclopramide (reglan) (except for gastroparesis)
 meperidine (demerol)
 NSAID’s – chronic use without GI protection, indometacin, ketorlac
 muscle relaxants - carisoprodol (soma), cyclobenzaprine (flexeril), metaxalone
(skelaxin), methocarbamol (robaxin)
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24. Drug Prescribing
 Beers Criteria - Potentially Inappropriate meds based on other
factors
 Heart failure - NSAIDs and Cox 2 inhibitors, thiazolidinediones
(rosiglitazone - Avandia, pioglitazone - Actos)
 Syncope - alpha blockers (doxazosin, terazosin, prazosin),
chlorpromazine (thorazine), olanzapine (zyprexa)
 Epilepsy - tramadol
 Delirium - TCA’s, anticholinergics, benzodiazepines, steroids, H2
blockers, meperidine
 Dementia - anticholinergics, benzodiazepines, H2 receptor blockers,
zolpidem, antipsychotics
 History of falls or fractures - anticonvulsants, antipsychotics,
benzodiazepines, other anti-insomnia meds, TCA’s, SSRI’s
 Insomnia - pseudoephedrine, theophylline, caffeine
 Parkinson’s - metoclopramide, prochlorperazine, promethazine
 Chronic constipation - highly anticholinergic drugs
 BPH - highly anticholinergic drugs
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25. Drug Prescribing
 Beers Criteria - Drugs to use with Caution
 Syncope - vasodilators
 Hyponatremia/SIADH - SSRI’s,
carbamazepine, TCA’s
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26. Drug Prescribing
 Renal Impairment
 Not all creatinine's are created equally!
 Decreased muscle mass in the elderly leads to
lower creatinine levels
 Cockcroft-Gault formula for CrCl: sex, age, ideal
weight, Cr
 40 yo male weighing 70 kg with Cr 1.0 has CrCl of
97
 40 years later at age 80 with same data - CrCl is 58
(stage 3 CKD)
 Start at lower doses, frequencies - check with
pharmacy or drug app (Epocrates)
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27. Drug Prescribing
Summary
 Are short and long term benefits worth the
risk???
 If yes, then treat!
 Consider adverse drug event for any new
symptom
 Use safer alternatives when able (tylenol instead
of NSAIDs)
 Consider non-pharmacologic treatments
 Reduce the dose to minimize chance of adverse
events
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28. Patient Experience
 Institute for Healthcare Improvement - Triple
Aim Initiative
 Improve health of populations, reduce per
capita cost of health care, improve the patient
experience of care - quality and satisfaction
 Paradigm shift in healthcare
 Publicly shared comparative data
 Metric for CEO’s to report to Board of Directors
for institutions
 Value Based Purchasing points = at risk $$ from
CMS
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29. Patient Experience
 R.I.S.E. Rounds
 R ound with the nurse
 I ntroduce yourself and your role
 S it down at eye level with the patient
 E xplain what you are going to do
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30. Patient Experience
 White boards are a great tool
 identifies care team
 identifies plan of care (including surgical
diagrams)
 identifies discharge plan and needs
 provides space for questions from patient
and family
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31. Patient Experience
 Effective, quick tips to improve patient experience
and save you time
 “Describe what a good day is like for you” -
addresses physical and cognitive function
 “What matters most to you today?” - gives the
patient an opportunity to participate in the
development of their care plan
 Teach back method - checks the quality of effective
communication from care team to the patient:
“Sometimes we physicians have difficulty explaining our plan
of care in the best way to our patients. Just to make sure I did
a good job, can you tell me what you would tell your family is
going on with you when they visit you tonight?”
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