Assessment

3


Assessment





Objectives


Upon completion of this chapter, the reader will be able to:


• Know that successful care of an older adult requires an individualized approach based on the patient’s values and preferences.


• Be aware that geriatric patients with common diseases may have uncommon or ill-defined presenting symptoms.


• Know that a detailed history is the major component of initial geriatric assessment.


• Understand that functional assessment provides a window into a patient’s overall well-being and can help in prioritizing treatment plans.


• Know that the geriatric physical examination should focus on systems that affect function.


• Maintain realistic expectations when planning for the encounter; complete geriatric assessment will often take several clinic visits to accomplish.


Geriatric assessment is a challenging process that integrates patient-centered medical care and broad medical knowledge. A special approach is needed to care for older adults given the complexity in this patient population. Older adults often have subtle manifestations of disease and an increased prevalence of chronic illness, which make caring for them a challenge. In addition, many older adults will evolve in their health care priorities, which require an adjustment in the provider’s clinical approach. Priorities often change from prolongation of life to prolongation of independence and quality of life. These attributes of older adults necessitate individualized care. Caring for older adults does not tend to follow an algorithm, nor is it “cookie cutter” medicine; rather, it requires attention to specific patient needs. Successful care plans align with patients’ individual preferences and values.


Adequate evaluation of this challenging, yet very rewarding, cohort requires both an organized approach and flexibility. Geriatric assessment encompasses four main domains of patient care: mental, physical, functional, and social/economic. Not all elements need to be addressed during the initial assessment for every patient; however, each element should be considered eventually as each significantly contributes to overall patient well-being. Complete geriatric assessment will take planning and organization to accomplish over a series of visits. The physician’s goal for the initial assessment is not to cover each domain or all of the topics that are covered in this chapter, but rather, to prioritize and plan for the future. Time is often a limiting factor in assessment of the geriatric patient.


Geriatrics by nature is interprofessional. The clinic nursing staff will play an essential role in data collection and patient assessment. Other professionals, such as home health care providers, physical and occupational therapists, and social workers can provide services that will greatly enhance patient care. Communication with these other team members will provide insights that are otherwise unavailable (see Chapter 2).


One practice model through which geriatric interprofessional care works well is the patient-centered medical home. This model of patient care emphasizes the team medical approach, with the physician as the leader of a team of professionals focused on providing care that reflects the patient’s individual priorities. The physician coordinates and facilitates care provided by different participants in the health care team. Disciplines within the patient-centered medical home may include nursing, pharmacy, social work, physical and occupational therapy, and specialty providers. This care model focuses on shared decision making with the patients.



An individualized approach based on a patient’s preferences and values is needed for successful care of an older patient.




CASE 1   Ms. M (Part 1)


Ms. M is an 84-year-old female who visits a clinic to establish care. She has recently relocated to live closer to her daughter after her husband passed away. She is now living in an independent living apartment as part of a senior living center. She is accompanied by her daughter today in the clinic, but she does state, “I could have come alone if I wanted to.” As the nurse takes Ms. M into the examination room you note that her gait is relatively stable with use of a cane. The nurse begins the encounter by obtaining vital signs and reviewing the medications that she has brought with her. You sit down to review your notes from her past medical records.





Common barriers to care


Several unique challenges are often encountered when caring for older people. The patient ideally should be able to participate in the creation and negotiation of the plan of care. This can be particularly difficult with older adults for several reasons, the first of which is sensory deficits, specifically hearing and vision loss. Providers will often expect that a patient who may be unable to hear verbal or see written instructions is following along, when, in fact, this may not be the case. It is important to ensure that written and pictorial information is visible to older patients with visual impairment. Similarly, when with a patient who is hard of hearing, ensure that the room is quiet and face the patient to enable lip reading. These simple maneuvers ensure that the patient has the best chance of retaining the information. Undiagnosed sensory deficits can lead to inadequate understanding of care plans. Beyond sensory impairments, diminished health literacy decreases a patient’s ability to process information presented to him or her in either a verbal or written format. (To assess a patient’s health literacy, consider using an assessment tool such as the Rapid Estimate of Adult Literacy in Medicine—Short Form [REALM-SF]1 or a similar instrument.) For these reasons, it is crucial that a provider use “teach back” methods to ensure appropriate understanding of the treatment plan. If a patient can explain the medical plan to a family member or friend, chances are improved that she will be able to implement the plan at home.


A second significant challenge is that of cognitive impairment. It becomes significantly more difficult to collaborate with a patient regarding a treatment plan if that patient is unable to articulate symptoms or concerns. A caregiver or family member’s corroborative history in such a circumstance is invaluable. However, it is important not to ignore the patient. It remains important to involve patients with cognitive impairment in the decision-making process to the greatest extent possible. Building a treatment plan based on a patient’s preferences and priorities (see later discussion of goals of care) enables better adherence to the treatment plan regardless of cognitive abilities. It is also wise to send written instructions with all patients, but especially those with cognitive impairment, for later reference. Their written instructions should be written at an appropriate level given a patient’s health literacy, which can be assessed using a straightforward tool developed by the Agency for Healthcare Research and Quality. (See active link in web resources.)


A third barrier to care of older adults is that many in the current cohort are passive in interactions with providers. Some will attribute pathologic change to normal aging and pass off important complaints as “no different than anyone else my age.” They do not want to be seen as complainers, or worse, burdensome to their caregivers. Additionally, some older patients will be embarrassed by common symptoms such as urinary incontinence, constipation, or falls. Patients will often not bring up symptoms unless asked directly. For this reason, it is important to conduct a complete review of systems, focused on geriatric syndromes.



Aspects of care unique to older adults


Several health conditions are peculiar to older adults. Some can be the result of decreased physiologic reserve and functional decline, for example, delirium. Others, including Alzheimer’s and Parkinson’s diseases, result from neurodegeneration. (See Box 3-1 for a complete list.) Many of these diseases will be co-managed with specialists. This necessitates frequent communication for best patient management. Furthermore, older adults commonly have multiple chronic diseases, or comorbidities. Patients with multiple comorbidities have poorer self-rated functional status and overall health.2 They also use health care services to a greater degree than older adults with single diseases. Additionally, with increasing comorbid chronic disease, dependency for activities of daily living (ADLs) is seen to increase.3



BOX 3-1   DISEASES MOST SPECIFIC TO THE GERIATRIC POPULATION



















Hip fracture Polymyalgia rheumatica
Parkinson’s disease Dementia
Osteoporosis Stroke
Macular degeneration Sexual dysfunction
Malnutrition Sleep disorders


Certain common conditions in older patient populations have been termed geriatric syndromes. Geriatric syndromes typically reflect the loss of a person’s physiologic reserve caused by the combination of aging and multiple comorbid pathologies. Examples of geriatric syndromes include delirium (loss of brain reserve), urinary incontinence (loss of bladder reserve), and falls (loss of musculoskeletal reserve). Often, screening for geriatric syndromes is incorporated into the history portion of the patient encounter or by incorporating a review of functions into the review of systems.


Geriatric medicine is made more challenging by the way in which common clinical entities present in an uncommon fashion. Older patients will often have ill-defined presenting symptoms such as fatigue, weakness, dizziness, or simply “not feeling well.” Such symptoms are nonspecific and difficult to interpret. However, they are often the only presenting symptoms for serious underlying processes. On the other hand, common disease markers in a younger patient population such as fever, leukocytosis, tachycardia, or chest pain may be absent in the elderly because of medication use or physiologic aging. Atypical disease presentation is made more difficult by the fact that geriatric patients have multiple medical comorbidities, often involving more than one organ system, with many overlapping symptoms. Additionally, an older patient may be unable to effectively communicate as a result of limitations in cognition or language. In the absence of stated symptoms, disease processes may present as new functional deficits, delirium, or other geriatric syndromes. A change in functional status should alert an astute practitioner as a potential sign of a serious condition such as infection or worsening of an underlying preexisting condition such as heart failure.



Geriatric patients will often experience common diseases in an uncommon fashion with vague symptoms.




CASE 1   Ms. M (Part 2)


On review of the medical record you have learned that Ms. M has a medical history significant for hypertension, diabetes mellitus that is diet controlled, hypothyroidism, osteoarthritis, hyperlipidemia, and a stroke with mild residual left-side weakness. With regard to health care maintenance, she is up to date with her annual flu shot, tetanus, and zoster immunizations. She has not had a pneumococcal vaccine, so you make a note for the nurse to administer it later in the visit. She had a bone density scan showing osteopenia approximately 1 year ago. Her last colonoscopy was 8 years ago, with recommended 10-year follow-up. It is unclear when her last pelvic exam with Papanicolaou smear was done. It is also not evident in the medical records when her last eye and dental exams took place. You make a note to enquire regarding all three screens. image




Pre-encounter preparation


When preparing for a new patient visit, it is prudent to review the patient’s medical record ahead of time for an overall understanding of the patient’s past medical history. This preview of the available medical information will guide the visit, allowing the provider to prioritize the pertinent medical issues. It will also aid in efficiency because there is often much to cover in little time at the initial visit. A preview of the medical history allows for identification of gaps in understanding. It is wise to review the record for information regarding health care maintenance including vaccinations and screenings (such as dual-energy x-ray absorptiometry scan if appropriate). It is also important to have annual eye and dental exams, because both can be areas of complication with older patients. Medical record review allows for knowledge regarding any specialists also involved in the patient’s care with whom coordination will be needed. On the day of the visit, it is important to ask patients to bring their medications (including over-the-counter preparations, and preferably all medications in their original containers), assistive devices (canes, walkers), glasses, and hearing aids with them. If needed, involve family members and caregivers in the visit. Caregivers may be needed for collateral history if there is a question of cognitive impairment, and their presence provides information regarding available caregiver support.


Ideally, the office design and patient flow should keep older patients in mind. The needs of older individuals vary, but it is often necessary to ensure wheelchair accessibility and close parking. It is also helpful to employ rooms large enough to accommodate the patient as well as family members who may accompany the patient. When possible, scheduling should be done in such a way that allows for adequate time for a new patient encounter (often about 50 to 60 minutes).



History


A detailed history is often the majority of the initial assessment and remains a crucial part of follow-up visits. Although it is unnecessary (and often not feasible) to discuss all of the following with every visit, it is important to maintain a complete understanding of the full patient history and problem list (Box 3-2). Consider allowing the patient to remain dressed for this portion of your patient encounter. This allows patients to remain comfortable (many older adults do not tolerate temperature extremes) and maintain their dignity. It is wise to ensure that enough chairs are available for all parties to be seated. Sitting down while eliciting the history gives reassurance that you are interested in what the patient has to say. It also minimizes dominance in a provider’s body language. Finally, it gives the appearance of being unrushed. At some point during the encounter it is appropriate to ask any accompanying family members to step out of the room. This allows for privacy for the patient to speak about any sensitive issues including, but certainly not limited to, elder abuse or sexual dysfunction. It also presents an opportunity for a member of the clinic staff to obtain a collaborative history from the patient’s family member(s).



BOX 3-2   COMPONENTS OF GERIATRIC HISTORY



Chief complaint


History of present illness


Past medical history


Medications


Social history


Family history


Functional status


Review of systems




CASE 1   Ms. M (Part 3)


After initial introduction, Ms. M says that overall she has been doing fairly well since her move to your town. She has been feeling somewhat more fatigued than is normal for her. She has been sleeping well, approximately 7 to 8 hours per night. She states that she simply feels more run down. She does note that she has not yet started water aerobics classes, which had always helped her to stay active in her previous town. image




Chief complaint


It is recommended to start the history with the patient’s chief concern. This may be as simple as a bothersome symptom, or potentially involved, such as why the patient is transferring care to a new health care provider. Allowing the patient to set the agenda helps him or her to feel more in control. It also establishes rapport if your focus at the onset of the encounter is that which is most important to the patient. After understanding what is most important to the patient you should proceed with other concerns that are pressing either from previous visits or review of the medical record. When evaluating a new patient, important insight can be gained into a patient’s understanding of her health by eliciting her understanding of her medical diagnoses.



CASE 1   Ms. M (Part 4)


Ms. M brings a bag of her medications with her. She has brought in an angiotensin-converting enzyme inhibitor for hypertension, thyroid replacement, a statin for hyperlipidemia, and an aspirin, all of which were anticipated from review of her medical record. In addition, she brings in a calcium/vitamin D supplement, ibuprofen that she takes for pain, and a multivitamin. She uses a pill organizer to help her remember what medications she takes when. She denies any problems with missing medication doses. You notice that her thyroid dose is actually different than what was noted in the last clinic visit chart from her previous provider. She also has remembered to bring in her over-the-counter medications, which is extremely informative. You make a note to discuss with her possible alternatives to nonsteroidal antiinflammatory drugs, given their many risks in older patients, when discussing her pain later in the visit. image




Medications


During each encounter it is necessary to document an updated, reconciled medication list. Accurate knowledge of a patient’s medications is crucial to appropriate prescribing and for quality medical care. Similar to discerning a patient’s understanding of medical diagnoses, checking for a patient’s understanding of medications can give important information about adherence and cognitive abilities. Discuss with patients their method of medication administration (pillboxes, for example) to see if education or simplification of the regimen can be used to improve adherence. Medication changes and generic medication names are often not recalled accurately, so asking patients to bring their medications to each clinic visit is very helpful. Having access to the actual medication bottles also provides insight into the number of pharmacies and prescribers involved, and refill dates may also be useful in assessing adherence. This is important to reduce redundant prescribing (see Chapter 6). On review of a patient’s medication list, one should scrutinize for problem medications (medications that may be inappropriate for older adults, medications requiring lab follow-up, etc.). It is also important to ensure that your list of patient allergies is up to date.



CASE 1   Ms. M (Part 5)


Ms. M denies tobacco or recreational drug use. She is taking her medications as prescribed. She does drink one glass of wine each evening with her evening meal. She lives alone in an independent living apartment. She has two daughters, one who lives in town and one who lives out of state. Her local daughter is her health care power of attorney. Ms. M notes that she feels safe in her place of residence, although she does not yet feel like it is home. She is continuing to adjust to life in a new city and without her husband of 62 years. When asked to talk a little more about herself, her interests, and her values she mentions that her family has always been the most important thing in her life. She attends church and finds a great deal of comfort in her faith. She has always been active in her community, volunteering and participating in civic organizations. She also mentions that she enjoys playing cards, and she is hoping to find a bridge group soon. When asked about exercise, Ms. M states that she does water aerobics twice weekly, although her daughter disagrees, noting that she has not done this in 6 months.





Social history


Social history can be an enlightening section of the history. Habits, such as tobacco use, alcohol consumption, and exercise, as well as prescription and nonprescription drug use, should be discussed. Alcohol abuse can masquerade as other conditions common in the older population. Alcohol abuse, for example, can appear as gait instability or functional impairment. A person who has a history as a long time social drinker can get into trouble with continued use of alcohol as he or she ages because of changes in metabolism. Similarly, alcohol abuse can slow cognitive functioning or make underlying cognitive dysfunction significantly worse. Additionally, being aware of a person’s alcohol habits can be helpful if the patient is ever admitted to the hospital, because withdrawal can be an occult cause of delirium (see Chapter 16).


Beyond discussing a patient’s health-related habits, it is important to inquire about a patient’s support system at home. Who lives at home? Are there adult children who live in the area? Is the spouse still living? Does the patient serve in a caregiving role? The overarching goal of this discussion is to determine the strengths and weaknesses of an elder’s support system. The majority of older adults will experience a period of dependency in their later life. Knowledge of family resources in such cases is helpful in providing optimal care. Additionally, it is important to evaluate for home safety. Does the person feel safe in his or her own home? Are there any concerns for potential elder abuse (financial abuse, caregiver or self-neglect)? It is also important to note who the patient prefers as a surrogate decision maker and to ensure that this is documented in the medical record.

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Jun 8, 2016 | Posted by in GERIATRICS | Comments Off on Assessment

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