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N107: Chronic Illness & the Older Person M – multiple pathology (i.e.

LT Manahan, PhD, RN (02/13/17) dementia)

Objectives: P – Polypharmacy

- Introduce CGA *** BEERS Criteria - Interaction of Drugs

- Not all be done (N107 & N117)
- A practical scenario *** (look for the pdf. Sobrang dami kaya
medj trivial na siguro to)
Components of Comprehensive Geriatric
Assessment: S – Social adversity

- Medical assessment Older Person & Chronic Illness

- Functional assessment – ADLs,
Activity/Exercise status, Gait/Balance - Many common conditions can exist
- Psychological – cognitive, without their characteristic features.
mood/depression - Instead, they may have ≥ 1 nonspecific
- Social – informal supports/assets, care geriatric syndromes (e.g. delirium,
resource eligibility/financial assessment dizziness, syncope, falling, weight loss,
- Environment – home safety, assistive incontinence)
device, etc - These syndromes result from multiple
disorders and impairments:
Comprehensive geriatric Assessment (CGA) nonetheless, patients may improve
when only some of the precipitating
- Older patients may have multiple
factors are corrected.
problems, that interact
- An even better strategy is to identify risk
- Looks at these interactions (i.e. whole
factors for these syndromes and correct
*** Framework of Aging as many as possible, thus reducing the
Genetics and Epigenetics likelihood of the syndrome’s developing
*** Epigenetics is the study of the at all
carefully orchestrated chemical
reactions that activates and
deactivates part of the genome at Heart failure may cause:
strategic times in specific locations.
- Identifies current and potential - Confusion, agitation, lethargy
problems - Anorexia, weight loss
- Weakness, fatigue
Unique Features of the Older Patients - Patients may not report dyspnea
(because it is common inelderly)
RAMPS - Orthopnea may cause nocturnal
agitation in patients who also have
R – reduced body reserve
A – atypical presentation - Peripheral edema is less specific as a
sign of heart failure in elderly than in
younger patients
- In bedbound patients, edema may - Fever and a change in mental status
occur in the sacral area rather than in without symptoms of meningeal
the lower extremities. irritation (eg. headache, nuchal rigidity)
- Kernig’s and Brudzinski
MI may manifest as:
- Diaphoresis, dyspnea, epigastric
discomfort, syncope, weakness, UTI may be present in afebrile OP patients
vomiting or confusion rather than as
- These patients may not report dysuria,
chest pain
*** OLD PRACTICE: frequency, or urgency but may
Hypogastric pain Maalox experience dizziness, confusion,
anorexia, fatigue, or weakness
Not resolved resolved
Other problems that may manifest differently in
MI not MI the elderly include alcohol abuse, adverse drug
- After the onset of chest pain or other effects, depression, pulmonary embolism,
presenting symptoms of MI, elderly systemic infections, and unstable angina
patients tend to delay longer than
younger patients in seeking medical Endocrine
Hypothyoridism may manifest subtly in OP
Pneumonia may be indicated by patients.

- Malaise, anorexia, or confusion. - Most common symptoms are

- Tachycardia and tachypnea are common nonspecific (eg. fatigue, weakness,
but fever may be absent d/t deceased falling)
neutrophil count - Anorexia, weight loss, and athralgias
- Coughing may be mild and without may occur
copious, purulent sputum, especially - Less common than younger persons are
dehydrated patients cold intolerance, weight gain,
depression, paresthesias, hair loss, and
TB may manifest differently in elderly muscle cramps
patients with coexisting disorders. - More common is cognitive dysfunction
- The most specific sign – delayed tendon
- Symptoms may be nonspecific (eg. reflex relaxation – may not be
Fever, weakness, confusion, anorexia). detectable in elderly patients because
- Pulmonary TB may manifest with fewer of decreased amplitude or absent
respiratory symptoms (eg. cough, reflexes.
excessive sputum production,
hemoptysis) than in younger patients Hyperthyroidism may not cause the
characteristic signs (eg. eye signs, enlarged
Neuro thyroid gland)
Meningitis may cause:
- instead, symptoms and signs may be - However, tenderness in this quadrant is
subtle and may include tachycardia, a significant early sign.
weight loss, fatigue, weakness,
Biliary disorders
palpitations, tremor, atrial fibriliation,
and heart failure - May result in nonspecific mental and
- Patients may appear apathetic rather
physical deterioration (eg. malaise,
than hyperkinetic
confusion, loss of mobility) without
Hyperparathyroidism may cause jaundice, fever, or abdominal pain.
nonspecific symptoms: - Abnormal liver function test results may
be the only indication.
- Fatigue, cognitive dysfunction,
emotional instability, anorexia, *** Always check stool of patients for occult
constipation and hypertension
- Characteristic symptoms are often
Immune system
- Causes a low-grade (at least) fever in
Peptic ulcer disease may not cause
most OP patients, although fever may
characteristic ulcer symptom:
be absent
- The source of bacteremia may be
- Pain may be absent or nonspecific
- Dyspnea (usually epigastric discomfort difficult to identify
- Elderly patients may have nonspecific
with bloating, nausea, or early satiety)
is more common among OP than manifestations (eg. general malaise,
anorexia, night sweats, unexplained
among younger patients.
- OP patients have more frequent, more change in mental status)
severe GI bleeding, which may be
Comprehensive Geriatric Assessment
painless. Slow unrecognized blood loss
may occur, resulting in severe anemia.
- Multidimensional, multidisciplinary
Acute bowel infarction
diagnostic process
- Goal: determine a frail elderly person’s
- May be indicated by acute confusion.
Abdominal pain and tenderness may be medical psychosocial and functional
capacities and problems
minimal or absent
- Objectives: develop an overall plan of
Appendicitis treatment & long-term follow-up
- Concept started in 1930 (Dr. Warren);
- pain tends to begin in the right lower now regarded as the ‘technology’ of
quadrant rather than periumbilically. geriatric medicine
- Eventually, pain may be diffuse in the - Done even before but fragmented
abdomen rather than localized to the
right lower quadrant.
Aim of the CGA
Results to the: review
Cognitive/mental Dementia/depression
- Restoration of healthy function and health screening
independence, where possible Socio- Home safety,
- As well as the amelioration of disability environmental caregiver burden,
and distress factors social barriers to
care, nutritional risk
Who Benefits

- Functionally impaired (ADL difficulty) History

- Impaired mobility
- Multiple co-Morbidities History taking

Who does not benefit 1. History of fall, incontinence

2. Pain assessment
- Functionally independent 3. Drug history; polypharmacy!!!
- Advanced dementia 4. Nutritional history
- Terminally ill 5. Lifestyle; smoke, drink, exercise, aids &
Benefits of CGA 6. Vaccination; influenza, tetanus,
pneumococcal (in OP)
- Decreased nursing-home placement
- Improved survival-short term
*** In children, check for vaccinations such
- Improved functional status
- Improved mental status? as varicella, BCG, hepa b, mumps, etc
- Fewer discharge medications
Past medical history:
Who do the CGA
- Only major illness leading to admission
Assessment involves an interdisciplinary or absence from work
team: - Chronic illness: atherosclerosis (DM, HT,
ischemic heart disease, cerebrovascular
- Geriatrician or primary care physician disorder, dyslipidemia), TB,
- Geriatric nurse osteoarthritis
- Social worker - Personal history: smoking, alcohol
- Physical therapist/Occupational drinking
therapist - Family History: family member and
- Pharmacist status
- Psychologist/Psychiatrist - Drug history: polypharmacy, eye drops,
- Dietician
skin preparation, over-the-counter
Domains evaluated by CGA drugs

Domain Assessment
Functional status ADLs/IADLs Blood pressure (2 → ↓ hypertension
Physical heath H&P; Medication positions) Postural hypotension
Body weight → ↓under-nutrition
Special sense (VA, → ↓ disability, fall two key divisions of functional ability:
hearing) activities of daily living (ADL) and
Breast → ↓breast cancer instrumental activities of daily living
(IADL), meals, taking medications
Get-up-and-go → ↓fall, immobility
properly, managing finances, using a
3. Cognition
Preparing for the CGA
Components of Geriatric Care
- The most effective way to perform the
- Sickness
assessment is to make the client
- The Older person
comfortable and establish a rapport
- Family members
- Eliminating noise and promoting
attention concentration will allow BARTHEL INDEX OF ADL
clients to answer the questions to the
best of their ability. 1. Transfer
2. Mobility
Patience 3. Toilet use
4. Grooming
1. Do not hurry the patient. 5. Bladder
- Give them five seconds to respond. 6. Bowel
2. Break a task into small parts. 7. Bathing
- One instruction given at a time. 8. Feeding
9. Dressing
Tailored fit to be motivated 10. Use of Stairs

Remember: The patient can only have INTRODUCTION

motivations ascribed to them only if they have
enough cognitive capacity left to have a motive. 1. The index should be a record of what a
patient does not what a patient could
***Measure Blood Pressure STANDING in ALL do.
older persons. 2. Establish degree of independent from
any help: physical or verbal however
COMPETENCIES: minor and for whatever reason.
3. The need for supervision renders the
1. Do we have it all
2. .Recognition of other professionals patient NOT independent.
3. Scarcity of other professionals. 4. A patient’s performance should be the
usual source should be established
SCREENING: using the best available evidence.
Asking the patient friends/relatives and
1. Functional ability
nurses will be the usual source but
2. Functional status refers to a person’s
direct observation and common senses
ability to perform tasks that are
are also important. However, direct
required for living. The geriatric
testing is not needed.
assessment begins with a review of the
5. Usually the performance over the  0-4 Normal
preceding 24-48 hours is important but  5-8 more information required;
occasionally longer periods will be informant section
relevant.  9 significant cognitive impairment;
6. Unconscious patients should score “0” further testing MMSE, NPI
throughout even if not yet incontinent.
7. Middle categories imply that patient INFORMANT INTERVIEW
supplies over 50% of the effort.
 0-3 of “No”, “Don’t Know” or “NA” -
8. Use of aids to be independent is
Cognitive impairment is indicated

AD8 Administration and Scoring
1. This is an interview; may reassess with
actual performance if within the 1. Sensitive to detecting early cognitive
institution or succeeding visit. changes not diagnosing
2. The inclusive time of performance is 2. Self administration can be read aloud
usually in the last 24-48 hours thru phone
- Bowels preceding week. 3. If informant is around- preferable
respondent (memory/denial)
4. Scores: 0-1 Normal Cognition
** In assessing geria patients:
>2 Cognitive impairment likely
- First look if s/he can walk, who is present
s/he with, concern/complaint
Complaint of relatives? OR
Compliants of the patient?
 0-2 God; recheck in 6 months
- If the client can stand (for some  3-5 Moderate nutritional risk; note what
time only), weigh immediately can be improved; recheck in 3 months
 6 or more High nutritional risks; bring
the checklist when you visit the doctor
1. Washing & cleaning and nutritionist; seek help
2. Shopping
3. Cooking Nutrition
4. Communication and Transport
5. Financial Management Determine using the questionnaire:
6. Drug Administration
D- disease, 1
Cognition Screening E- eating poorly. 2.3
T- tooth loss/ oral pain, 5
OF COGNITION R- reduced social contact, 7
M- multiple medicine, 8
Look at the scoring
I-involuntary weight loss or gain, 9 3. Do you feel ANNOYED by people
N-needs assistance, 10 complaining about your drinking
E-elder years (above 80) 4. Do you ever feel GUILTY about your
MOBILITY 5. Do you ever drink an EYE OPENER to
relieve the shakes
1. Balance and gait disorders affect 10-
15% of older persons increasing risk of HOME SAFETY CHECKLIST
2. Accidents are the 5th leading cause of 1. Housekeeping (spills, floors, mess)
death in older adults. 2. Floors (wet, waxed, rugs, carpets)
3. Falls account for 2/3 of these accidental 3. Bathroom (rubber mat, non-slip, grab
deaths bar)
4. 1/3 of adults over 65 living in the 4. Traffic lane (maneuvering in the home)
5. Lighting (switches accessible, night
community fall at least once a year.
5. This rises ½ of adults over age 80. lamp)
6. 5% of these falls result in a fracture or 6. Stairways (rail, ergonomics)
7. Ladder and step stools
8. Outdoor areas (free of breaks, holes)
7. Mobility abnormalities affect 20-40% of
9. Footwear
adults over 65 and 40-50% of adults 10. Personal precautions (pets, body
over age 85 alignment, body mechanics)
*** Poor righting reflex

Righting reflex, or the Labyrinthine righting “Once you fall, you have the tendency to fall
reflex, is a reflex that corrects the orientation again… only applicable to older persons.”
of the body when it is taken out of its normal (Manahan, 2017)
upright position.


1. Medication review
2. ADL and IADL assessment
3. Orthostatic blood pressure
4. Vision assessment
5. Gait and balance evaluation
6. Cognitive evaluation
7. Assessment f environmental hazards


2. Have you felt the need to CUT DOWN
on your drinking