N107: Chronic Illness & the Older Person
incontinence,
LT Manahan, PhD, RN (02/13/17)
Objectives:
- Introduce CGA
- Not all be done (N107 & N117)
- A practical scenario
Components of Comprehensive Geriatric
Assessment:
- Medical assessment
- Functional assessment – ADLs,
Activity/Exercise status, Gait/Balance
- Psychological – cognitive,
mood/depression
- Social – informal supports/assets, care
resource eligibility/financial assessment
- Environment – home safety, assistive
device, etc
Comprehensive geriatric Assessment (CGA)
- Older patients may have multiple
problems, that interact
- Looks at these interactions (i.e. whole
patient)
*** Framework of Aging
Genetics and Epigenetics
*** Epigenetics is the study of the
carefully orchestrated chemical
reactions that activates and
deactivates part of the genome at
strategic times in specific locations.
- Identifies current and potential
problems
Unique Features of the Older Patients
RAMPS
R – reduced body reserve
A – atypical presentation
M – multiple pathology (i.e.
dementia)
P – Polypharmacy
*** BEERS Criteria - Interaction of Drugs
*** (look for the pdf. Sobrang dami kaya
medj trivial na siguro to)
S – Social adversity
Older Person & Chronic Illness
- Many common conditions can exist
without their characteristic features.
- Instead, they may have ≥ 1 nonspecific
geriatric syndromes (e.g. delirium,
dizziness, syncope, falling, weight loss,
incontinence)
- These syndromes result from multiple
disorders and impairments:
nonetheless, patients may improve
when only some of the precipitating
factors are corrected.
- An even better strategy is to identify risk
factors for these syndromes and correct
as many as possible, thus reducing the
likelihood of the syndrome’s developing
at all
Cardiac
Heart failure may cause:
- Confusion, agitation, lethargy
- Anorexia, weight loss
- Weakness, fatigue
- Patients may not report dyspnea
(because it is common inelderly)
- Orthopnea may cause nocturnal
agitation in patients who also have
dementia
- Peripheral edema is less specific as a
sign of heart failure in elderly than in
younger patients
 - In bedbound patients, edema may
occur in the sacral area rather than in
the lower extremities.
MI may manifest as:
- Diaphoresis, dyspnea, epigastric
discomfort, syncope, weakness,
vomiting or confusion rather than as
chest pain
*** OLD PRACTICE:
Hypogastric pain Maalox
Not resolved resolved
MI not MI
- After the onset of chest pain or other
presenting symptoms of MI, elderly
patients tend to delay longer than
younger patients in seeking medical
assistance
Pneumonia may be indicated by
- Malaise, anorexia, or confusion.
- Tachycardia and tachypnea are common
but fever may be absent d/t deceased
neutrophil count
- Coughing may be mild and without
copious, purulent sputum, especially
dehydrated patients
TB may manifest differently in elderly
patients with coexisting disorders.
- Symptoms may be nonspecific (eg.
Fever, weakness, confusion, anorexia).
- Pulmonary TB may manifest with fewer
respiratory symptoms (eg. cough,
excessive sputum production,
hemoptysis) than in younger patients
Neuro
Meningitis may cause:
- Fever and a change in mental status
without symptoms of meningeal
irritation (eg. headache, nuchal rigidity)
- Kernig’s and Brudzinski
Urinary
UTI may be present in afebrile OP patients
- These patients may not report dysuria,
frequency, or urgency but may
experience dizziness, confusion,
anorexia, fatigue, or weakness
Other problems that may manifest differently in
the elderly include alcohol abuse, adverse drug
effects, depression, pulmonary embolism,
systemic infections, and unstable angina
Endocrine
Hypothyoridism may manifest subtly in OP
patients.
- Most common symptoms are
nonspecific (eg. fatigue, weakness,
falling)
- Anorexia, weight loss, and athralgias
may occur
- Less common than younger persons are
cold intolerance, weight gain,
depression, paresthesias, hair loss, and
muscle cramps
- More common is cognitive dysfunction
- The most specific sign – delayed tendon
reflex relaxation – may not be
detectable in elderly patients because
of decreased amplitude or absent
reflexes.
Hyperthyroidism may not cause the
characteristic signs (eg. eye signs, enlarged
thyroid gland)
 - instead, symptoms and signs may be
subtle and may include tachycardia,
weight loss, fatigue, weakness,
palpitations, tremor, atrial fibriliation,
and heart failure
- Patients may appear apathetic rather
than hyperkinetic
Hyperparathyroidism may cause
nonspecific symptoms:
- Fatigue, cognitive dysfunction,
emotional instability, anorexia,
constipation and hypertension
- Characteristic symptoms are often
absent.
GIT
Peptic ulcer disease may not cause
characteristic ulcer symptom:
- Pain may be absent or nonspecific
- Dyspnea (usually epigastric discomfort
with bloating, nausea, or early satiety)
is more common among OP than
among younger patients.
- OP patients have more frequent, more
severe GI bleeding, which may be
painless. Slow unrecognized blood loss
may occur, resulting in severe anemia.
Acute bowel infarction
- May be indicated by acute confusion.
Abdominal pain and tenderness may be
minimal or absent
Appendicitis
- pain tends to begin in the right lower
quadrant rather than periumbilically.
- Eventually, pain may be diffuse in the
abdomen rather than localized to the
right lower quadrant.
- However, tenderness in this quadrant is
a significant early sign.
Biliary disorders
- May result in nonspecific mental and
physical deterioration (eg. malaise,
confusion, loss of mobility) without
jaundice, fever, or abdominal pain.
- Abnormal liver function test results may
be the only indication.
*** Always check stool of patients for occult
blood
Immune system
Bacteremia
- Causes a low-grade (at least) fever in
most OP patients, although fever may
be absent
- The source of bacteremia may be
difficult to identify
- Elderly patients may have nonspecific
manifestations (eg. general malaise,
anorexia, night sweats, unexplained
change in mental status)
Comprehensive Geriatric Assessment
Definition
- Multidimensional, multidisciplinary
diagnostic process
- Goal: determine a frail elderly person’s
medical psychosocial and functional
capacities and problems
- Objectives: develop an overall plan of
treatment & long-term follow-up
- Concept started in 1930 (Dr. Warren);
now regarded as the ‘technology’ of
geriatric medicine
- Done even before but fragmented
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 &
appliances
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

CGA
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
examination
(IADL), meals, taking medications
Get-up-and-go → ↓fall, immobility
properly, managing finances, using a
test
telephone.
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.
***Measure Blood Pressure STANDING in ALL
older persons.
COMPETENCIES:
1. Do we have it all
2. .Recognition of other professionals
3. Scarcity of other professionals.
SCREENING:
1. Functional ability
2. Functional status refers to a person’s
ability to perform tasks that are
required for living. The geriatric
assessment begins with a review of the
1. The index should be a record of what a
patient does not what a patient could
do.
2. Establish degree of independent from
any help: physical or verbal however
minor and for whatever reason.
3. The need for supervision renders the
patient NOT independent.
4. A patient’s performance should be the
usual source should be established
using the best available evidence.
Asking the patient friends/relatives and
nurses will be the usual source but
direct observation and common senses
are also important. However, direct
testing is not needed.
 5. Usually the performance over the
preceding 24-48 hours is important but
occasionally longer periods will be
relevant.
6. Unconscious patients should score “0”
throughout even if not yet incontinent.
7. Middle categories imply that patient
supplies over 50% of the effort.
8. Use of aids to be independent is
allowed.
TIME FACTOR
1. This is an interview; may reassess with
actual performance if within the
institution or succeeding visit.
2. The inclusive time of performance is
usually in the last 24-48 hours
- Bowels preceding week.
(REVIEW THE HANDOUTS GIVEN)
** In assessing geria patients:
- First look if s/he can walk, who is
s/he with, concern/complaint
Complaint of relatives? OR
Compliants of the patient?
- If the client can stand (for some
time only), weigh immediately
IADL
1. Washing & cleaning
2. Shopping
3. Cooking
4. Communication and Transport
5. Financial Management
6. Drug Administration
Cognition Screening
GPCOG-GENERAL PRACTITIONER ASESSMENT
OF COGNITION
Look at the scoring
 0-4 Normal
 5-8 more information required;
informant section
 9 significant cognitive impairment;
further testing MMSE, NPI
INFORMANT INTERVIEW
 0-3 of “No”, “Don’t Know” or “NA” -
Cognitive impairment is indicated
AD8 Administration and Scoring
1. Sensitive to detecting early cognitive
changes not diagnosing
2. Self administration can be read aloud
thru phone
3. If informant is around- preferable
respondent (memory/denial)
4. Scores: 0-1 Normal Cognition
>2 Cognitive impairment likely
present
NUTRITIONAL HEALTH
Scores:
 0-2 God; recheck in 6 months
 3-5 Moderate nutritional risk; note what
can be improved; recheck in 3 months
 6 or more High nutritional risks; bring
the checklist when you visit the doctor
and nutritionist; seek help
Nutrition
Determine using the questionnaire:
D- disease, 1
E- eating poorly. 2.3
T- tooth loss/ oral pain, 5
E- economic hardship, 6, 3
R- reduced social contact, 7
M- multiple medicine, 8
I-involuntary weight loss or gain, 9
N-needs assistance, 10
E-elder years (above 80)
MOBILITY
1. Balance and gait disorders affect 10-
15% of older persons increasing risk of
falling.
2. Accidents are the 5th leading cause of
death in older adults.
3. Falls account for 2/3 of these accidental
deaths
4. 1/3 of adults over 65 living in the
community fall at least once a year.
5. This rises ½ of adults over age 80.
6. 5% of these falls result in a fracture or
hospitalization.
7. Mobility abnormalities affect 20-40% of
adults over 65 and 40-50% of adults
over age 85
*** Poor righting reflex
3. Do you feel ANNOYED by people
complaining about your drinking
4. Do you ever feel GUILTY about your
drinking
5. Do you ever drink an EYE OPENER to
relieve the shakes
HOME SAFETY CHECKLIST
1. Housekeeping (spills, floors, mess)
2. Floors (wet, waxed, rugs, carpets)
3. Bathroom (rubber mat, non-slip, grab
bar)
4. Traffic lane (maneuvering in the home)
5. Lighting (switches accessible, night
lamp)
6. Stairways (rail, ergonomics)
7. Ladder and step stools
8. Outdoor areas (free of breaks, holes)
9. Footwear
10. Personal precautions (pets, body
alignment, body mechanics)

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.

FALLS RISK ASSESSMENT FEATURE

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

ALCOHOLISM

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