Elderly
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
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)
References:
STOPP/START
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