Comprehensive Geriatric Assessment

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Comprehensive Geriatric Assessment

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Unique Features of the Elderly Patient

• RAMPS
• R- reduced body reserve
• A- atypical presentation
• M- multiple pathology
• P- polypharmacy
• S- social adversity

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Geriatric Assessment

• Physical
• Mental
• Functional status
• Social status

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Physical Assessment

• History taking
• chief complaint
• history of present illness
• past medical history
• family history
• drug history

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History taking

• History of fall, incontinence
• Pain assessment
• Drug history polypharmacy!
• Nutritional history
• Life-style smoke, drink, exercise, aids
  appliances
• Vaccinations influenza, tetanus, pneumococcal ?

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History taking

• cognitive impairment, look for relatives
• not respond to verbal command 3 Ds
• dysphasia, depression, deafness.
• adequate exposure but no direct light
• private place with minimal distraction
• face to face with slow and clear conversation
• use aids and appliances, if necessary
• use yes or no in motor aphasia
• need more time than the young
• multiple pathology rather than one disease
• nutritional assessment dietary recall, MNA

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History taking

• Past medical history
• only major illness leading to admission or
  absence from work
• Chronic illness atherosclerosis (DM, HT,
  ischemic heart disease, cerebrovascular disorder,
  dyslipidemia), TB, osteoarthritis
• Personal history smoking, alcohol drinking
• Family history family member and status
• Drug history polypharmacy, eye drop, skin
  preparation, over-the-counter drugs
• Systemic review geriatric syndrome

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• Abbreviated Mental Test
• Age
• Time
• Address
• Year
• Name of institution
• Recognition of two persons
• Date of birth
• Year of first world war
• Name of present monarch
• Count backwards 20 to 1

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Thai Mini-mental State Examination (TMSE)
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Thai Mini-mental State Examination (TMSE)
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Screening for depression

• In practice ask 2 questions
• Over the past 2 weeks, have you felt down,
  depressed, or hopeless?
• Over the past 2 weeks, have you felt little
  interest or pleasure in doing things?

If yes for both questions, proceed to Thai
Geriatric Depression Scale
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• (Thai Geriatric Depression Scale TGDS)
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  Thailand)

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• (Thai Geriatric Depression Scale TGDS)
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  Thailand)

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• Barthel Index of Activity of daily living
• Transfer
• Mobility
• Toilet use
• Grooming
• Bladder
• Bowel
• Bathing
• Feeding
• Dressing
• Stair

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• Functional Status Assessment
• (instrumental activity of daily living-ADL)
• washing cleaning
• cooking
• shopping
• communication transport
• financial management
• drug administration

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Social assessment - relationship in family

• Caregiver aware of elder abuse in dementia
• Physical abuse
• Caring abuse nutrition, drug compliance,
  pressure ulcer, incontinence, instrumentation
• Financial family support, welfare
• Environment housing, neighbor, elderly club,
  community

Pay attention to living alone, poor !!
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• Physical Examination for the Elderly Patient
• Vital signs temperature- look for hypothermia
• pulse - rhythm, amplitude
• blood pressure postural hypotension, white
  coat hypertension, pseudohypertension
• respiration - Cheyne-Stokes respiration
• General appearance body weight, height,
  apathetic face (Parkinsonism, hypothyroidism,
  depression)
• Eye fundoscopy difficulty due to cataract,
  pupillary constriction

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• Physical Examination for the Elderly Patient
• Ear ear wax impaction, external otitis
• Oral cavity oral hygiene, chronic ulcer or mass
• Neck range of motion (stiff neck ?), dizziness
• Thyroid, carotid bruit, cervical lymph nodes
• CVS aortic murmur, innocent or pathologic S4
• Lung non-significant crepitation disappears when
  sighing
• Breasts mass or skin infection
• Back pressure ulcer

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• Physical Examination for the Elderly Patient
• Abdomen collapsed thoracic cage closed to
  anterior superior iliac spine
• full bladder, fecal mass, abdominal
  aortic aneurysm
• PR for mass and prostate gland
• Foot diabetic foot, callus, onychogryphosis
• Nervous system non-significant signs (absent
  ankle jerk, decreased vibration sense at foot,
  frontal lobe releasing signs e.g. palmomental
  reflex, grasping, glabella tap sign, snout
  reflex.
• Get-up-and-go test, gait

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Comprehensive geriatric assessment- Examination

• Blood pressure ? ? hypertension
• (2 positions) postural hypotension
• Body weight ? ? under-nutrition
• Special sense ? ? disability, fall
• (VA, hearing)
• Breast examination ?? breast cancer
• Get-up-and-go test ?? fall, immobility

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Comprehensive geriatric assessment- Laboratory

• Pap smear ? ? CA cervix
• Fecal occult blood ? ? CA colon
• Fasting blood glucose ? ? DM
• Cholesterol ? ? dyslipidemia
• TSH ? ? hypothyroidism
• Osteoporosis screen ? ? fracture
• NB PSA ??