1. In the elderly patient taking multiple medications, avoid polypharmacy by:

    • monitoring side effects.

    • periodically reviewing medication (e.g., is the medication still indicated, is the dosage appropriate).

    • monitoring for interactions.

  2. In the elderly patient, actively inquire about non-prescription medication use (e.g., herbal medicines, cough drops, over-the-counter drugs, vitamins).

  3. In the elderly patient, screen for modifiable risk factors (e.g., visual disturbance, impaired hearing) to promote safety and prolong independence.

  4. In the elderly patient, assess functional status to:

    • anticipate and discuss the eventual need for changes in the living environment.

    • ensure that social support is adequate.

  5. In older patients with diseases prone to atypical presentation, do not exclude these diseases without a thorough assessment (e.g., pneumonia, appendicitis, depression).

Comprehensive Geriatric Assessment

  • Medical

    • Immunizations (influenza, tetanus/diphteheria, pneumococal, herpes zoster)

    • Habits (smoking, alcohol, substance, sexual)

    • Nutrition (diet, appetite, weight loss, dentition,m swallowing)

    • Bowel and Bladder (incontinence, constipation, diarrhea)

    • Communication (vision, hearing)

    • Pain

    • Cancer screening

  • Psychological

    • Cognition: MCI vs dementia vs. Delirium– MMSE / MOCA

      • BPSD (Behavioural and Psychological Symptoms of Dementia)- SMART approach

        • Safety – remove patient to safe environment

        • Medical – perform an organic workup to treat reversible causes; reduce medication load

        • Assess competency – decisions regarding personal care, finances, driving; protect assets

        • Rest, nutrition, hydration ensured; address problems with pain, ambulation, vision, hearing, constipation

        • Trial of medication – cholinesterase inhibitor/antipsychotic/antidepressant/ mood stabilizer

    • Mood – Depression (MSIGECAPS) – PHQ-9 or geriatric depression scale

    • Elder mistreatment/abuse

  • Function

    • ADLs (dressing, eating, ambulating, toileting, transferring, hygiene/bath)

    • IADLs (shopping, housework, accounting, food prep, telephone, transportation, taking meds)

    • Fall risk (postural hypotension, vertigo)

      • Vision

      • Hearing

    • Physical activity

    • Mobility

    • Driving

  • Polypharmacy - Meds

    • Non-prescription medication (herbal, OTC, vitamins)

    • Consider efficacy/side effect profiles

      • Convenient dosing/route

      • Dispill / Blister pack

    • Avoid treating side effect with another medication (medication cascade)

    • Beer's Criteria

  • Social and Environmental

    • Social activities, hobbies, interests

    • Care support, POA

    • Local resources

    • Managing at home (financial, legal)

      • Anticipate need for increased services

    • Advance care planning (resuscitation)

Modifiable Risk Factors in the Elderly

  • Medical

    • Visual/hearing impairment

    • Polypharmacy

    • Dizziness or orthostasis

    • Incontinence

    • Diabetes

    • Depression

    • Cognitive impairment/Dementia

    • Vaccines

    • Cancer, AAA screening

    • Osteoporosis (Calcium, vitamin D, BMD)

  • Mobility

    • Balance/gait impairment

    • Muscle weakness

    • Exercise level

    • Environmental lighting

    • Footwear

  • Habits

    • Smoking

    • Alcohol

Atypical presentations

  • Lack of symptoms (eg. fever), or may present with confusion/delirium

  • Commonly missed diagnoses are cancer, pulmonary embolus, coronary disease, aneurysms, appendicitis

  • Depression can present with somatic complaints (cognition, functional, sleep, energy)