The Stealth Geriatrician:
How to learn what you need to
know from your patients
Tiffany Shubert, Ph.D., MPT
Zeke Zamora, MD
Anthony Caprio, MD
Course Objectives

Define “geriatric syndrome”

Identify key risk factors for falling



Perform a comprehensive geriatric
functional assessment
Identify appropriate interventions
“Build a Team” – Determine disciplines,
community resources, and evidence-based
programs to manage patient health
Why falls?
> 35% of your patients fall annually
AAMC Minimum Competency
 All adults over 65 years should be asked a
falls history
 All adults should be observed and
assessed rising from a chair and walking
 All patients who have fallen or at risk of
falling should have a differential diagnosis
and evaluation plan
Standard of Care
AGS/BMJ Practice Guidelines
http://www.medcats.com/FALLS/frameset.htm
 All older adults screened for falls by health
care provider
 Key questions




Two or more falls in prior 12 months
Presents with acute fall
Difficulty with walking or balance
If yes to any question, then comprehensive
falls assessment
4
Who is going to fall?
How do you identify fallers?
Comprehensive Falls Risk =
Comprehensive Geriatric Assessment





History of falls
Medications
Gait, balance,
mobility
Visual acuity
Other neurological
impairments





Muscle strength
Heart rate/rhythm
Postural
hypotension
Feet and footware
Environmental
hazards
http://www.medcats.com/FALLS/frameset.htm
Comprehensive geriatric
assessment = falls risk
A comprehensive exam:
A standard review of systems = limited information
Functional assessment and a comprehensive exam
will identify multiple factors contributing to falls
Geriatric Syndromes

Multiple underlying factors (interacting
causes) affecting multiple systems



Delirium, Incontinence, Frailty, Falls
Shared risk factors such as older age,
cognitive impairment, functional
impairment
Falls as a geriatric syndrome




Dizziness, auditory, hearing
Cardiovascular
Orthopedic, arthritis, neuropathy
Depression, cognitive impairment
Introducing Mrs. Jones
Chief Complaint

It depends on who you ask:



Patient: “No complaints, I feel fine”
Daughter: “Difficulty getting around the
house, I am afraid she may fall”
MD: “Blood pressure should be better
controlled”
History of Present Illness

What do you want to know?

Previous Falls

Changes in medications

Trips to the opthamologist

Trips to the ER

Changes in mood/activity levels
Past Medical History






Hypertension
Paroxysmal Atrial Fibrillation
Chronic Renal Insufficiency
Anxiety/Depression
“Dizziness”
Osteoporosis
Medication List





Metoprolol
Hydrochlorothiazide
Digoxin
Warfarin
Sertraline





Diazepam
Zolpidem
Meclizine
Fosinopril
Alendronate
Medication Review

> 4 Drugs = Increased risk of falls

Red Flags – Classes that increase falls risk

Benzodiazepines (short and long-acting
agents)

Antidepressants (tricyclics and SSRIs)

Antipsychotics

Anticonvulsants

Opioids

Antispasmodics

Over the counter medications
Social History

What do you want to know?
 Living Situation
 Type
of house? Stairs? ADLs, IADLs
Social Supports
 Economic Status
 Smoke/Drink
 Current Activity Level
 Fear of Falling

Activities of Daily Living:
Ask or Observe

ADLs

IADLS

Transferring

Transportation

Toileting

Use the phone

Bathing

Buy groceries

Dressing

Meal preparation

Continence

Housework

Feeding

Medication

Pay bills
Physical Exam Findings


General Impression
Vital Signs




HEENT



Bilateral cataracts, difficulty reading magazine and wall
poster
CV


BP sitting 140/90, HR 88
BP standing 110/80, HR 100
Pain
Grade II/VI systolic murmur (right upper sternal border)
MS
Neuro
Functional Assessment:
Timed Up and Go
Functional Assessment:
Walking Speed
Functional Assessment:
Timed Chair Rise
Functional Assessment:
Chair Rise Mrs. Jones
Functional Assessment:
Balance
Mrs. Jones
What Happens at Home
Cognitive Screening
Cognitive Impairment



Cognitive assessment should be performed in
all adults > 65 years
23.4% community dwelling elderly have
some level of cognitive impairment
Mild – moderate cognitive impairment
increases risk of falls and hip fracture
*Neurology 2001 Nov 13; 57(9): 1655-62
Screening Tools: MMSE

Screens for Alzheimer’s Disease







Orientation
Registration
Attention/Calculation
Recall
Language
Copy Pentagons
Limitations


Age, education, cultural, socioeconomic, English
proficiency affects scores
Length to administer
Screening Tools: Mini-Cog
General screen for cognitive impairment
1.
2.
3.
Dictate three items, ask to repeat
Clock Drawing Test
Ask to recall the three items
Screening Tools: Mini-Cog


Score 1 point for each recalled word
Score normal/abnormal clock draw
 Score of 0 positive screen for dementia
 Score of 1 or 2 with abnormal clock draw
positive screen for dementia
 Score of 1 or 2 with normal clock negative for
screen for dementia
 Score of 3 negative screen for dementia
Mrs. Jones Clock
Clock Draw Example
Home Safety Evaluation



Use an environmental assessment
sheet
Must utilize occupational therapy,
social work, etc to have an effect
Financial difficulties may be culprit
Comprehensive Geriatric Assessment:
Ms. Jones





History of falls
Medications
Gait, balance,
mobility
Visual acuity
Other neurological
impairments





Muscle strength
Heart rate/rhythm
Postural
hypotension
Feet and footware
Environmental
hazards
http://www.medcats.com/FALLS/frameset.htm
Assessment: Mrs. Jones

What are the risk factors?

History of falls

Leg muscle weakness

Polypharmacy

Orthostatic Hypotension

Osteoporosis

? Cognition
Plan: Mrs. Jones

What will you do about it?




Fix orthostasis
Address osteoporosis
Modify medications
Interventions?




Occupational Therapy - home safety evaluation
Physical Therapy - leg strengthening, gait training,
and assessment for assistive device
Consult with pharmacy about current medication list
and insurance coverage
Community Services for behavior change programs,
wellness and socialization activities
Community Resources

North Carolina Roadmap for Healthy Aging



www.ncroadmap.org
Locates evidence-based programs in your
area
NC Division of Aging and Adult Services


http://www.ncdhhs.gov/aging/
For every county: health promotion, long term
care, in-home care, caregiver resources,
meals on wheels, etc
Synthesis




Evaluating major risk factors for falls is
fundamental to a geriatric assessment
A functional assessment will identify
individuals at risk for falls
A functional assessment can (and should)
be done with your older patients
Refer to other disciplines to best manage
complex older adults
Key Physical Findings in Older Adults
I HATE FALLING
I Inflammation of joints or joint deformity
H Hypotension (orthostatic)
A Auditory/visual problems
T Tremor (Parkinson’s disease)
E Equilibrium (balance problems)
F Foot problems
A Arrhythmia, heart block
L Leg length discrepancy
L Lack of conditioning

Practice Practice Practice

Practice with volunteers


Physical, Cognitive, and Medication
Assessment
On the wards



Perform at least one mini-Cog
Shadow a physical therapist and perform 1-2
functional assessments
Identify which of your patients are at risk for
falls