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A (hopefully) Practical Approach to the Geriatric Complete Physical in Family Medicine. Dr. C Hoggard R1’s of 2016 Disclosure • No disclosures • I have borrowed heavily from many different doctor’s presentations • None of the pictures used are mine (except 1) My Goals for this talk • Introduce the Complete Geriatric Assessment (GCA) • Introduce the Geriatric Syndromes aka Geriatric Giants • How do you screen for these syndromes in the office • Focusing on aspects of Geriatrics that we are never taught • Billing • Bring it all together with a couple of cases Geriatrics Why is Geriatrics Important?: Case • Gwendolyn Ricci is new to your practice and arrives with her family for an initial assessment. Her family does most of the talking for her and Gwendolyn often looks at them for assistance in answering your questions. You note she has a shuffling wide based gait, and turns on block. She even has a fall in the office! She exit seeks and is incontinent of bladder and bowels. Her family seems to think this is normal. What action do you take? Why is Geriatrics Important? Case answer • Nothing! Gwendolyn is 1 year old. Like pediatrics, geriatrics deals with a special population requiring a specialized set of skills. They are not merely “older adults”. What is the Geriatric Assessment? Brace Yourself Components of a Geriatric Assessment • • • • • • • • • • Vision Hearing Cognition Depression Falls/mobility Cardiovascular risk factors, symptoms etc Respiratory-COPD Endocrine-thyroid, diabetes GI-bowels GU-incontinence, sexual function • • • • • • • • • • Neuro- Strokes etc MSK –osteoporosis, arthritis Skin Medications Immunizations POA/PD/AD Smoking and alcohol ADL, IADLS, Living situation Driving Abuse and Care-giver burnout • Capacity The Complete Geriatric Assessment What should we be doing? • Functional Assessment –Collateral is nice • Geriatric Syndrome screening • Quarterbacking (ie Case Managing: What we are trained to do but never taught) – Legal Paperwork/awkward conversations – Standard Regular screening/ Preventative Medicine Functional Assessment Functional Assessment Activities of Daily Living Eating Transfer Grooming Dressing Toileting Bathing Instrumental Activities of Daily Living Medication Cooking Cleaning/ Laundry Finances Shopping Telephone Use/ Computer Driving* Functional Assessment iADLs History to Illicit Medications Blister packing, can they walk you through their medications, Banking What do they pay? Missed bills, problem with PINS, Automatic banking, know where their money comes from? Cooking Have they changed what they eat? Different tasting, frozen meals, weight loss Shopping List generation, find what they want Cleaning Change in the living condition *Telephone/ Computer use Can they work their new _____? *Driving Get lost? The finger? Others concerned? accidents? Grandchild test? Screen for the Geriatric Syndromes • • • • • • • • • Cognition/ Delirium/ Depression Polypharmacy Incontinence Falls Osteoporosis Orthostatic Hypotension FTT Abuse **Driving Screen for the Geriatric Syndromes • • • • • • • • • Cognition/ Delirium/ Depression Polypharmacy Incontinence Falls Osteoporosis Orthostatic Hypotension FTT Abuse **Driving The 3 D’s of Geriatrics • Depression, Dementia and Delirium – look the same, smell the same, mimic each other and are often in combination. Dementia • Routine screening not recommended • This will come to you in three ways 1. Family is worried 2. Functional Change 3. Hospital Admission Dementia • There must be a FUNCTIONAL DECLINE Activities of Daily Living Instrumental Activities of Daily Living Eating Medication Transfer Cooking Grooming Cleaning/ Laundry Dressing Finances Toileting Shopping Bathing Telephone Use/ Computer Driving* Testing for Dementia • SIMARD is not validated • MOCA – for executive functioning and mild cognitive impairment • MMSE – for more severe impairment, language based, needed to assess supports • Clock Drawing • Rudas • The “head turning sign” Dementia Dementia Depression • Do you feel sad/depressed? • Do you feel hopeless? • Do you feel life is not worth living? GDS 15 >5 is worrisome for Depression Depression The Geriatric Depression Scale (GDS) Delirium • • • • Fluctuating Behavioral Change Hyperactive/ Hypoactive What is your name? Where are you? What is the date? • 1/3 of patients >70 yo in hospital are delirious and it can take up to 3 months to resolve! Screen for the Geriatric Syndromes • • • • • • • • • Cognition/ Delirium/ Depression Polypharmacy Incontinence Falls Osteoporosis Orthostatic Hypotension FTT Abuse **Driving Polypharmacy Polypharmacy • Have your pharmacist do a medication review – 03.01NM (communication with pharmacy if pharmacy initiated) • Watch for prescription cascades • Watch for errors of omission • Watch for inappropriate medications Ativan Polypharmacy Disease What are they on? What should they be on? What should they avoid HTN Ramipril 2.5mg Antihypertensive NSAIDS DIABETES Metformin 1000mg BID Glucose lowering agent, ?ASA, ?Statin, ?Renal protection Hypoglycemic agents Arthritis Ibuprofen Diclofenac Gel, Tylenol, Injections Narcotics? Braces? Ativan Screen for the Geriatric Syndromes • • • • • • • • • Cognition/ Delirium/ Depression Polypharmacy Incontinence Falls Osteoporosis Orthostatic Hypotension FTT Abuse **Driving Incontinence Incontinence • Do you have trouble with urine leaking? • Do you have difficulty controlling your bowels or bladder? • Have you ever not made it to the toilet? • Are you afraid to leave the house if there is no bathroom easily accessible? Screen for the Geriatric Syndromes • • • • • • • • • Cognition/ Delirium/ Depression Polypharmacy Incontinence Falls Osteoporosis Orthostatic Hypotension FTT Abuse **Driving Falls • Have you fallen in the last year? • Chair Raises • The timed up and go test aka “TUG” Test – <10 sec is normal – <20sec can go out alone – > 20sec is a fall risk Screen for the Geriatric Syndromes • • • • • • • • • Cognition/ Delirium/ Depression Polypharmacy Incontinence Falls Osteoporosis Orthostatic Hypotension FTT Abuse **Driving Osteoporosis Osteoporosis • Are you shorter? • Do your pants or skirts seem longer/hit the floor? • Have you ever broken a bone? • Have you had prolonged unusual back pain? Osteoporosis • TUG • > 3cm (men) 2 cm (women) height loss in a year • Wall to occiput • Bone Mineral Density Osteoporosis • BMD can’t do it alone! – FRAX – CAROC A fragility fracture is OP. Your diagnosis is made! No BMD needed! Screen for the Geriatric Syndromes • • • • • • • • • Cognition/ Delirium/ Depression Polypharmacy Incontinence Falls Osteoporosis Orthostatic Hypotension FTT Abuse **Driving Orthostatic Hypotension • Just do it • Systolic goal 150 >80 yo or Frail Screen for the Geriatric Syndromes • • • • • • • • • Cognition/ Delirium/ Depression Polypharmacy Incontinence Falls Osteoporosis Orthostatic Hypotension FTT Abuse **Driving Failure to Thrive • Has your weight changed? • Look at their clothes • Have you been buying new clothes? • Are you driving? • Any accidents in the last 5 years? Nutrition • Weigh your patients at every visit – Unintentional weight loss – 10% in the last 3-6 months • Under-nutrition is often overlooked. • Ask: – Have you lost weight? – What is your usual weight? – Have you had to buy new clothes, how are your clothes fitting? – How are your dentures fitting? – Who makes the meals? Nutrition • Causes: “normal aging physiology”, depression, dementia, delirium, isolation, medication, $, mobility, dental care…..etc • Quick Fixes: Tx dx and change meds, meals on wheels, aids, companions, supplementation, presentation Social issues • Etoh/drugs • Isolation Screen for the Geriatric Syndromes • • • • • • • • • Cognition/ Delirium/ Depression Polypharmacy Incontinence Falls Osteoporosis Orthostatic Hypotension FTT Abuse **Driving Abuse • Abuse – – – – Verbal/emotional Financial (home?) Physical Computer scams • Is anyone making life difficult for you? • Is there someone in your life that you think does not have your best interests in mind? • Are you afraid of someone? Safety • Environmental assessment: • Personal safety – Wandering bracelets, fall detectors • Home hazards (think Rourke) – Guns, water temp, smoke detector, seat belts – Rugs, lighting, rails, bathing chair • Care giver burn out – Respite (over night and daytime) – Counseling – Support services (Kirby center, early dementia case worker, HC) Screen for the Geriatric Syndromes • • • • • • • • • Cognition/ Delirium/ Depression Polypharmacy Incontinence Falls Osteoporosis Orthostatic Hypotension FTT Abuse **Driving Driving Driving • Don’t Miss Dr. DeFina’s Amazing Talk!! Screen for the Geriatric Syndromes Geriatric Syndrome Quick Screen 3 D’s Functional Assessment Maybe a MMSE/MoCA/Clock Polypharmacy Cascades/ drug interactions Errors of omission Pharmacy involvement ? Incontinence 4 questions Falls 1 question Chair raise/ TUG Orthostatic BP Nurse? FTT Nurse? 2 questions Abuse 3 very important questions Driving 2 question Recap • Functional assessment • Geriatric Syndromes Quarterbacking • This is the “stuff” every talk glosses over BUT is perhaps the most beneficial to your patients. This is where WE, the family doctor, make a difference. WE do what no other physician can do. This is OUR “specialty”. Quarterback’s Check List Goals of Care talk Paperwork (PD/EPOA/Will) Immunizations Screening Safety (Abuse, Injury prevention) Driving Nutrition Social (Drinking, supports, ADLs/iADLs) HOME CARE! Goals of Care • It is not a legal document • 3% of all-comers survive resuscitation and ½ will have “significant impairment” • We don’t all have the same values and beliefs • Special populations • Discussions with the family (especially the Agent) Goals of Care • What phrases have you heard? • Keep the goals of care on the fridge, EMS is trained to look for it there. Goals of Care R1 R2 R3 M1 M2 C1 C2 “Full resuscitation” “No Chest Compressions ” “No machines” “No ICU” “No surgery unless for symptoms control” No hospital transfer Palliative Everything we could possibly do for them. CPR 3% unwitnessed in healthy adults Go to ICU Go to ICU for medications and post surgery People would do surgery and chemo. Active screening with these ppl Will go to hospital only if it improves symptoms For facility patients really Can go for things like fracture. Dying or terminal illness Personal Directives • Just do it Personal Directives • Must have decisional capacity to make a personal directive • Often done with a Lawyer but can just Google “Alberta Personal Directive” • Name an “Agent” and hopefully an alternate – caution with spouses. Watch for abuse. • The “Agent” can not be the witness Personal Directive • 2 Types of PDs – one that names whom can deem them incapable and one that deems them by two healthcare workers Personal Directives • Schedule 1 • A person can name a person to deem them incapable • If no person is chosen the default is a doctor or psychologist or designated capacity assessor Personal Directives • 03.04N is the code for enacting a PD (ie deeming someone incapable in one or more domains of decisional capacity) • You should cover this in your talk on capacity • Do not skip this day Enduring Power of Attorney • • • • Usually done with a Lawyer Two types of EPOAs Immediate Clause Springing Clause A Will • Deals with someone’s ESTATE after they DIE • Usually if this is up to date so is the EPOA PD/EPOA/Will • Do this as part of your regular physical or swear I will haunt you until the end of your practice…. Immunizations for Seniors • Influenza – annually • Pneumococcal – – PCV13 (Prevnar) once if immunocomprimized – PSV 23 once or twice q 5 year apart (may have gotten it before 65 with resp disease or smoking) – Space PCV13 and PSV23 apart by 1 year • Tetanus-diptheria – q10 years • Shingles – once after 50 yo (60’s optimal?) Screening • To screen or not to screen Screening • Depends on the patient’s goals • Depends on the patient’s life expectancy – No survival benefit if the life expectancy is <5 years • No real evidence in this population for screening Screening • Don’t Forget: Vision, Hearing and Dental • Environmental assessment Screening: Vision • Vision: – Visual impairment is <20/40 (20% of 75+ seniors) and blindness is <20/200 (2% of the 75+seniors). – Ask: "has your vision changed??". – Snellen Chart = ocular vitals • Screening: Glaucoma - >50yo q 1-2 years. DM2 q 1-2years, Screening: Hearing • Hearing: presbycusis is the high frequencies loss first and difficulty with background noise. – Ask: Do other’s complain about the TV or Radio being too loud? Is conversation difficult with background noise? – Look for social isolation (humm is it depression or dementia?), misinterpretation of what you are saying. – Review medications for lasix, salicylates, vancomycin and gentamicin. Hearing: Tricks • Tricks for talking to someone with poor hearing are: – Look directly at them – Speak slowly (don't shout and use sentences so it is easier to lip read) – Write things down – Reduce background noise – Have the patient repeat what they have heard back to you Hearing • Aids: – Hearing aids. There should be feedback when they turn on. Red in Right ear and Blue in Left ear. – Don’t refer for a hearing aid if they won’t wear it as they cost $600-900!! At least do the 30day trial – Personal amplifiers – Telephone for the deaf/ – Texting/ emails YES! YOU CAN REALLY DO THIS!! Dr. Hoggard’s Geriatric Physical Template History Physical Plan At today’s visit: Issues: 1. 2… Orthostatic Vitals: _____/_______ Height: Weight: Labs ordered: F/u 1 year Nurse to perform GDS and MoCA ?? Driving assessment? Home Care? Pharmacy Review? Physio? Function: Independent in iADLs Screening: Pap, Mammogram, BMD, CRC, DRE Diet: Recommended Vit D, 3 servings of dairy Exercise: Sleep: Geriatric Syndromes: Cognition: NC Mood: NC Incontinence: NC OP: NC Falls: NC Polypharmacy: Reviewed Driving: Driving, NC PD/EPOA: Both completed GOC: M1 Vaccinations: UTD HEENT – Vision Hearing Dental: Up to date CVS – S1s2 GAEB Abdo – def MSK – TUG < 10sec -No Edema -Good shoes, no aids MoCA/ MMSE – “nurse to perform” GDS – “nurse to perform” Show me the money!!!! Billing: Office Practice Service Code Amount Regular office visit 03.03A Time modifier CMGP01-06 (15min units) 15.70 Complete Physical 03.04A + modifier 88.90 Complex Care Plan (can be billed with complete physical) 03.04J + 03.04A + time modifier 213.80 + 88.90 = >302.70! Psychiatric Code (290) 08.19G/ 08.19D (family member) 45ish/50ish Drivers Medical >74.5yo 03.05H 76.90 Geriatric Assessment 03.04K 300.00 Anticoagulation Management 03.01N 16.95 Phone Call Nursing/ pharmacy 03.01ng/03.01NM 16.95 Phone Call Patient/ family 03.05JR/ 03.05JP 35.91 (or 43.09 if >75 yo) 18.88/ ?50 Billing:LTC Service Code Amount Regular once weekly visit 03.03E 27.17 Admission to LTC 03.04D 105.50 Team Conference 03.05JD (per 5 min unit!!) 13.09 Formal Medication Review 03.05JE 27.29 Billing: Supportive Living Service Code Amount Regular once weekly visit 03.03NA (first visit onsite)/ 03.03NB (subsequent visits) Team Conference 03.05JD (per 5 min unit!!) 13.09 Formal Medication Review 03.05JE 27.29 Enacting a PD 03.04N $100 ish 84.61 + CMPG
