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.
In the elderly patient, actively inquire about non-prescription medication use (e.g., herbal medicines, cough drops, over-the-counter drugs, vitamins).
In the elderly patient, screen for modifiable risk factors (e.g., visual disturbance, impaired hearing) to promote safety and prolong independence.
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.
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
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)
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
ADLs (dressing, eating, ambulating, toileting, transferring, hygiene/bath)
IADLs (shopping, housework, accounting, food prep, telephone, transportation, taking meds)
Fall risk (postural hypotension, vertigo)
Polypharmacy - Meds
Non-prescription medication (herbal, OTC, vitamins)
Consider efficacy/side effect profiles
Dispill / Blister pack
Avoid treating side effect with another medication (medication cascade)
Social and Environmental
Social activities, hobbies, interests
Care support, POA
Managing at home (financial, legal)
Anticipate need for increased services
Advance care planning (resuscitation)
Modifiable Risk Factors in the Elderly
Dizziness or orthostasis
Cancer, AAA screening
Osteoporosis (Calcium, vitamin D, BMD)
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)
Age Ageing 2015. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4339726/
BC 2017. https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/frailty-full_guideline.pdf
J Am Board Fam Med 2012. https://www.ncbi.nlm.nih.gov/pubmed/22218629