Goals of geriatric assessment
1-Focus on preventive medicine rather than acute medicine.
2-Maintaining functional ability and not necessarily a “cure.
3-- Aid in the diagnosis of health-related problems.
4-Develop plans for treatment, follow-up
and coordination of care.
5-Determine optimal use of health care resources.
It is can be divided into four categories: medical, functional, psychological,
and social.
Medical assessment
1-Includes a review of the patient’s medical record, medication
history (past and present), and a nutritional evaluation
2-Review of the
1-patient’s current medication list,
2-including over-the-counter (OTC)
3-medications, as well as any drug allergies or previous adverse drug
reactions (ADRs), is a necessary component of the geriatric
assessment.
4-Poly-pharmacy is defined as taking more than four
medications and is an independent risk factor for both delirium and
falls.
4-Nutritional evaluation as type, quantity, and frequency of food
eaten should be determined. Malnutrition and under nutrition can lead
to health problems, including delayed healing and longer hospital stays .
-Ability to chew and swallow should also be evaluated. It may be
impaired by xerostomia (dryness of mouth), which is common in
elderly persons. Decreased taste or smell may reduce the pleasure of
eating, so patients may eat less.
Functional assessment
1-Measures an individual’s ability to manage everyday life.
Focuses on
-activities of daily living (ADLs) and risk screening for falls. The basic
ADLs include eating, dressing, bathing, transferring, and toileting; to
provide self-care.
-The instrumental activities of daily living (IADLs) consist of
shopping, managing, money, driving, using the telephone,
housekeeping, laundry, meal preparation, and managing medications
I to perform higher-level functions.
2-Mobility is an important consideration, and observation of the patient
provides the most insight. Observing whether the patient can get up
easily from a chair, walk steadily, turn around, walk back, and sit
down provides significant insight into his or her functional status.
3- Checking an individual’s balance with his or her eyes closed and
hands at the sides is also important.
4- A simple method of screening patients for gait and mobility problems
is to ask,
“Have you fallen all the way to the ground in the past 12
months?” A positive screen should lead to a more thorough evaluation
and consideration of a physical therapy referral
Psychological assessment
1-screens for cognitive impairment and depression
2-, two
1-conditions that significantly impact both the patient and the family.
The most studied test to screen for cognition is the Mini-Mental State
Examination, which is best for identifying patients with moderate or
severe dementia.
2-Depression can be readily screened with shorter
versions of the original 30-item Yesavage Geriatric Depression Scale
(GDS).
Social assessment
1- important to assess the patient’s living situation and social
support when performing a geriatric assessment.
2-The living situation
should be evaluated for potential hazards, especially if the patient is
identified as being at risk of falling.
3-The social assessment also
includes questions about financial stressors and caregiver concerns.
Elder patients should be screening
Diagnostic evaluation
testing such as a
1- complete blood
count, chemistry profile, urine analysis and TSH if not recently
available.
2-Screening tests for breast cancer, cervical cancer and cancer colon.
3-Although abnormal laboratory findings occur regularly in an elderly
population and are often attributed to aging, few are truly the result of
advanced age. Misinterpretation can lead to either under-diagnosis or over-
treatment.
3-E x a m p l e s p o p u l a t i o n :
ofCommonlyabnormallaboratoryfindingsinanelderly
1- Albumin: Frequently low in the elderly but often a sign of poor nutrition.
2-Alkaline phosphatase: Mild asymptomatic elevations common. Liver or
bone disease should be considered when values exceed 1.5 times normal.
3-Creatinine: Low in the elderly due to decreases in lean body mass: high-
normal and mildly elevated values may indicate significant renal impairmen
Hearing loss
1-Hearing loss is the third most prevalent chronic condition in
elderly people, after hypertension and arthritis, and its prevalence and
2-severity increase with age. Screening for hearing loss can be
accomplished using two Office-based methods:
1-the audioscope
(objective) and a validated short questionnaire (subjective) the
audioscope is a handheld instrument that functions as an otoscope
and
2-audiometer and can be used to visualize the ear canal and eardrum and
remove cerumen if necessary. The Hearing Handicap Inventory for
the Elderly—Short Version (HHIE-S) is a subjective, 10-item, 5-
3-minute questionnaire with an overall accuracy of 75% in identifying
hearing loss.
4-The evaluation can assist in determining the need for further testing or
management, including hearing aid, medical treatment, or surgical
intervention.
Cancer screening
Cancer screening in w o m e n includes
1-annual Pap smears and annual
mammograms. Women over 65 who have had normal prior Pap smears
and three consecutive normal results may be given the option of
discontinuing cervical cancer screening. Although women with
significant comorbid disease may not benefit from continued breast
cancer screening, healthy elderly women who desire mammography
should be offered annual screening until their life expectancy falls
below 5 to 10 years.
- There are no recommendations to perform routine ovarian or uterine
cancer screening.
-2-For men, annual prostate examination and PSA testing should be
limited to those with a life expectancy of 10 years or more. Although
there is no clear-cut age at which to discontinue colon cancer screening,
most clinicians offer it to healthy individuals over age 65 until their life
expectancy is less than 5 to 10 years.
-3-There is no evidence supporting routine screening for lung, skin, or oral cancers
Immunization
1-Tetanus immunization should be updated every 10 years.
2-All patients over 65 years of age should receive pneumococcal and
influenza vaccines. Influenza vaccines are administered annually. High-
risk individuals are often given pneumococcal boosters every 5 to 7
years.
3-Vaccination against herpes zoster is recommended as a one-time
injection after age 60.
What are types of urinary incontence
1. Stress incontinence
2. Urge incontinence
3. Mixed incontinence
4. Overflow incontinence
5. Functional incontinence
Behavioral interventions
1-Minimizing late afternoon and evening fluid intake may decrease
nocturnal episodes for some patients.
2-Voiding more frequently will reduce the amount of bladder
distention and the sense of urinary urgency.
3-Providing physical assistance in going to the toilet on a regular
basis can reduce incontinence episodes.
4-Pelvic floor muscle (Kegel) exercises remain one of the mainstays
of behavioral therapy in the treatment of urinary incontinence. The
exercises involve repetitive contractions and relaxations of the
pelvic floor muscles.
5-Self -catheterization.
Medical treatment
1anti -muscarinic medications prescribed for urge or mixed
incontinence.
2-Estrogen prescribed for Urge associated with severe vaginal
atrophy or atrophic vaginitis.
-3-Cholinergic Agonists prescribed for Overflow incontinence with
atonic bladder.
4-α-Adrenergic antagonists are helpful in Urge and symptoms
associated with BPH.
Surgical treatments
1-The sling procedure is the primary form of open surgical treatment in
women with stress incontinence.
2-Peru urethra injection of bulking agents can be an effective treatment is
some elderly women with stress incontinence.
Hearing loss
1-Hearing loss is the most common sensory impairment of old age;
approximately 40% of elderly individuals have some type of hearing loss.
2-presbycusis or age-related hearing loss is a bilateral sensorineural
impairment of the higher frequencies that may compromise speech
comprehension
3-. Other causes of hearing loss include ototoxicity,
otosclerosis, Ménière disease, and cerumen impaction.
Presbyopia
1-s age-associated loss of the eye’s ability to accommodate,
2-and most individuals need glasses for reading by their fifties
Glaucoma
1-characterized by an elevated intraocular pressure and an
2-increased optic cup-to-disc ratio. If untreated, glaucoma can lead to the
3-loss of peripheral vision and eventually blindness.
3-Treatment is indicated when pressures are elevated (>25 mmHg) or in the
4-presence of optic nerve atrophy or visual field loss. Pharmacologic
treatment with drops that either decrease aqueous production (e.g., beta
/blockers, adrenergic agents) or increase aqueous drainage (e.g., miotics)
/can lower pressure. Surgery is indicated when pressures are poorly
/controlled by topical agents or visual loss progresses
Cataracts
1-risk factors for include sun exposure, smoking, steroid use,
and diabetes mellitus. Treatment consists of surgical removal of the lens
2-and is indicated if the visual acuity is 20/50 or worse and/or there is
significant functional impairment from the cataract
Falls
1-Patient falls are a common cause of injury, both within and outside of
health care settings. More than one-third of adults over 65 fall each year.
2-Injuries can include bone fractures and head injury/intracranial bleeding,
which both can lead to death.
3-Performing a fall risk assessment will help to select patients who can
-benefit from preventative resources (e.g. one-to-one observation, non-slip
-flooring, lowering the bed height). It is important to identify patients at high
-risk of sustaining serious injury from a fall. The following are known risk
factors for patient fall:
• Advanced age (age >60)
• Muscle weakness
• Use of >4 prescription medications
• Impaired memory
• Difficulty walking (e.g., use of a cane or walker).
Dementia
Definition
D e m e n t i a refers to loss of memory with impairment of any other cognitive
function sufficient to interfere with social or occupational functioning.
Causes of dementia 1-reversible causes:
- include hypothyroidism,
-vitamin B12 deficiency,
-hepatic or uremic encephalopathy,
-CNS vasculitis, syphilis, brain abscess,
-brain tumor (primary or metastatic), medications (especially
anticholinergics)
- obstructive sleep apnea, central sleep apnea, trauma,
-subdural hematoma, normal pressure hydrocephalus (NPH), and depression.
2- Irreversible causes include progressive multifocal leukoencephalopathy,
/Alzheimer disease (60–80% of all cases), dementia with Lewy bodies,
frontotemporal degeneration including Pick disease, vascular dementia
/including multi-infarct dementia and Binswanger disease, and Creutzfeldt-
Jakob disease (CJD).
Clinical presentation
The most common cause of dementia is Alzheimer disease. Typically,
1-patients will present with problems in memory and visuospatial abilities that
2-generally occur early in the course of the disease. Social graces can be
3-retained despite significant loss of cognitive decline.
4-Hallucinations
5-personality changes typically occur late in the course of the disease.
Treatments
1-Ensuring that the family and the patient have the proper medical and
emotional support to cope with the disease
2-. Caregivers are at an increased
risk for depression and anxiety.
3-Their concerns and frustrations should be
addressed at frequent intervals. Raising the level of acetylcholine in CSF
benefits patients with Alzheimer disease.
-Pharmacotherapy with donepezil has been shown to improve cognitive
-function in mild to moderate dementia. Other anticholinesterase inhibitors
(rivastigmine, galantamine) appear to have similar efficacy. Memantine is a
-disease-modifying drug used in advanced disease either alone or with a
-cholinesterase inhibitor. Memantine seems to be neuroprotective and reduces
the rate of progression of disease.
Parkinson disease
Definition
Parkinson disease is a neurologic syndrome resulting from the deficiency
of the neurotransmitter dopamine as a consequence of degenerative,
vascular, or inflammatory changes in the basal ganglia.
Causes
1-Drugs: including neuroleptic agents (haloperidol, chlorpromazine),
2-antiemetics (metoclopramide), alpha-methyldopa, and reserpine
3-Poisoning from carbon monoxide, cyanide, and manganese
4-Any structural lesion around the basal ganglia (trauma, tumor, abscess,
infarct)
5-Survivors of encephalitis can develop postencephalitic Parkinsonism
Clinical presentation
1-The cardinal manifestations of Parkinson disease are bradykinesia
(manifested by slow movements, mask facies, reduction of automatic
movements),
2-cogwheel rigidity, postural instability, and resting tremor. A
useful mnemonic is to think of Mr. Parkinson as a fine BRITish
gentleman.
- Bradykinesia
-Rigidity (cogwheel)
-Instability (postural)
-Tremor (resting)
Diagnosis
The diagnosis of Parkinson disease is a clinical one. It is important to
1-identify any secondary causes of a patient’s Parkinsonism that are
2-potentially reversible. There is no diagnostic test of choice that can
3-identify patients with Parkinson diseas
Treatments
1-Levodopa remains the mainstay of therapy.
-2-Combinations of levodopa and carbidopa are the most effective ways to
get dopamine into the brain.
3-Dopamine is ineffective because it does not cross the blood–brain barrier;
However
4-levodopa is able to cross, and once in the brain is converted to
dopamine through decarboxylization. Carbidopa inhibits only the
peripheral decarboxylation of levodopa and lessens side effects by
5-enhancing the central availability of levodopa and making it possible to
reduce the therapeutic dose
6-Levodopa is usually the most effective for
bradykinesia and rigidity and less so for tremors.
7-Management of secondary parkinsonism depends on the cause./ In
arthrosclerotic parkinsonism and many other degenerative disorders,
/treatment is similar to that of PD. However, the response in these
conditions is less marked than that in PD.