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45 Cards in this Set
- Front
- Back
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importance of functional measures in predicting mortality among older hospitalized patients 1. what are functional measures strong indicators of? 2. what should an optimal risk adjustment for older hospitalized patients incorporate? |
1. functional measures are strong predictors of 90 day and 2 year mortality after hospitalization functional status measures are stronger predictors of hospital outcomes than admitting diagnosis, including: - functional decline - length of stay - institutionalization - death 2. functional status variables |
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function as an equation |
function = (physical capabilities x medical management x motivation) ------------------------------------------------------------------- (social, psychological and physical environment) |
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functional assessment (8) |
1. evaluation of daily activities 2. mobility 3. special senses 4. cognition 5. continence 6. nutrition 7. specific psychosocial issues 8. pain |
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activities of daily living (ADL) (7) |
1. dressing 2. eating 3. ambulating or transferring 4. toileting 5. hygiene or bathing 6. grooming 7. continence |
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katz index |
ADLs - three tiered scale/framework to assess if a patient can live independently - focus on function abilities in order to match services - keys in on specific tasks to focus intervention - useful tool in following progress or decline |
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instrumental activities of daily living |
- shopping - cooking - cleaning - laundry - paying bills - managing medications - writing - reading - climbing stairs - using telephone - ability to perform paid employment duties or outside work - ability to travel (transit, out of town) |
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lawton scale |
IADLs - reflection of "self- maintaining" - instrumental activities - independent vs. needs assistance vs. dependent |
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4 ADL and 2 IADL necessary to identify patients with limitations |
ADL items recognized 95.3% of patient with limitations 1. ascend and descend stairs 2. urine continence 3. bath/shower 4. walking on a corridor IADL items 1. shopping 2. food preparation |
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mobility - what is necessary to do? - how do you properly assess? - what can restore function? |
detect changes and reduction in mobility early! - will identify those with reduced mobility, deconditioning and risk for injury - direct assessment is required to identify problems in gait, balance, ability to transfer and joint function - exercise and rehab assist in restoration of function, maintenance of current abilities and reduction or risk of falls |
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mobility evaluation 1. what do you inquire about? 2. what do you consider? 3. what should a complete analysis include? |
1. recent falls and test gait performance in older adults 2. consider source of information about functional impairment - patients overrate their status - family underrate - providers most accurate 3. complete assessment of balance |
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what is the leading cause of accidental death in the elderly? what cause 90% of hip fractures |
falls |
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falls what are the factors? 1. intrinsic 2. extrinsic 3. environmental what is a sign of? |
1. poor balance, weakness, chronic illness, visual or cognitive impairment 2. polypharmacy 3. poor lighting, no safety equipment, loose carpets commonly a nonspecific sign for one of many acute illnesses in older adults |
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what should you consider when evaluating a fall? |
1. circumstances of the fall 2. associated symptoms 3. relevant comorbid conditions 4. exclude acute illness or underlying systemic or metabolic process 5. determine if syncopal or non-syncopal 6. previous falls 7. medication review 8. ability to perform ADLs 9. difficulties with walking or balance, fear of falling |
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falls physical exam (5) |
- vital signs - head and neck (visual impairment) - motion or joint limitations, muscle strength - neurologic: reflexes, cognition, balance, tremor - heart arrhythmias, cardiac valve dysfunction |
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falls diagnostic tests (7) |
- CBC, serum electrolytes, BUN, creatitine, glucose, B12, TFT, vit D - drug levels - bone densitometry - neuroimaging if indicated cardiac - echocardiography - holter monitoring is rarely helpful - EKG |
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falls gait, balance and mobility assessment (4) |
1. functional gait: get up and go test 2. balance: functional reach test 3. mobility: observe patient's use and fit of assistive device or personal assistance, extent of ambulation, footwear eval 4. ADLs: evaluation of skills |
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mobility testing (5) |
1. tinetti balance and gait evaluation 2. get up and go test 3. functional reach test 4. shoulder function 5. wrist strength |
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tinetti balance and gait evaluation 1. what does it assess? 2. what score indicates a problem? 3. why is it important over the patient's care? 4. why else is it useful? |
1. assesses specific components of gait 2. lower scores indicates a problem 3. able to monitor change over time 4. more inter-rater reliability |
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get up and go test |
- have the patient sit in a straight- backed, high-seat chair - instructions for patient > get up (without use of armrests) > stand still momentarily > walk forward 10 feet > turn around and go back to chair > turn and be seated - 15 seconds or longer is associated with an increased risk of falling |
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functional reach test |
- subject stands with fist extended alongside wall - patients leans forward as far as possible moving fist along the wall without taking a step or losing stability - measures length of fist movement - distance of less than 6 inches indicates increased risk of falling |
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shoulder and hand function shoulder (2) hand (3) |
shoulder: - reach behind head - reach behind back hand: - grasp strength - pinch strength - observation of writing a sentence in mini mental status exam |
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range of motion |
hands behind head tests for internal and external rotation |
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complications of immobility |
- malnutrition - pressure ulcers - constipation - UTI - DVT - pneumonia - deconditioning - contractures - depression |
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exercise in the elderly - who does it have the most effect on? - best exercises? - what should you know about exercise? |
- most effect on sedentary - best: walking, swimming, stationary skiing, bicycling - many phenomena associated with growing old can be partially reversed and largely prevented with exercise |
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presbyopia |
vision loss due to age changes
if no snellen chart available, hold up the news paper and ask to read headline and subheader |
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presbycusis |
most common hearing disorders in adults |
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tips on speaking to a patient with presbycusis |
- hearing aids enhance selected frequencies - battery changes are tough - telephone device for the deaf - cochlear implants - speak slowly and distinctly, don't shout - stand 2-3 feet away - speak toward the better ear - rephrase rather than repeat - pause at the end of phrases or ideas |
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cognition |
- dementia is common in the elderly but is commonly missed by the primary care provider - as treatments become more effective, early diagnosis becomes more important dementia is NOT a normal part of aging clue: avoid former activities they enjoyed |
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mini cog problem? |
- registration of 3 objects - clock drawing - recall of 3 objects not sensitive for mild cognitive impairment |
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mini mental status exam |
good baseline test to determine cognitive impairment scores < 30 indicate cog decline |
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continence (4) also, list helpful questions to ask |
- urinary incontinence is NOT a normal part of aging - often goes unmentioned - simple question about involuntary leakage of urine is a reasonable screen - has more than one cause in most older adults do you wear a pad? do you ever go in your underwear? |
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transient causes of incontinence |
DRIIIPP - delirium - restricted mobility - infection, inflammation, impaction - polyuria - pharmaceuticals |
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continence history |
- onset, frequency, volume, timing, precipitants - sudden compelling urgency - loss with cough, laugh or bend - continuous leakage |
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continence physical exam |
- functional status - mental status - findings: volume overload bladder distension edema cord compression sacral root integrity rectal mass or impaction |
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"I have a weak bladder" could be |
1. stress urinary incontinence, accidental leaks when patient coughs, laughs, sneezes 2. overflow urinary incontinence: inability to control urine leaking from the bladder |
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"I cannot wait" |
urge urinary incontinence hurrying to toilet and not always making it in time |
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"I cannot walk to the bathroom" |
functional urinary incontinence: cognitive or physical impairment that prevent patient from using toilet or commode |
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continence management nonpharm behavioral therapy (8) |
- bladder retraining (timed toileting) - prompted toileting - restrict fluid intake 4 hours before bedtime - pelvic muscle exercises (kegel exercises) - pelvic floor electrical stimulation - pessiaries - weight loss - evaluate for HF, poorly controlled diabetes |
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continence management pharm therapy |
- eliminate medications causing/exacerbating UI - antimuscarinics for urge and mixed UI - topical postmenopausal estrogen therapy |
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continence management surgical therapy |
- consider 50% of women whose stress UI does not respond to behavioral therapy or exercise |
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continence management catheter care |
ONLY for - chronic urinary retention - protect pressure ulcers - comfort care at end of life |
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continence management enviroment |
make sure home is safe to go to the bathroom, ie no throw rugs |
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nutrition red flags |
weight loss > 5% in 1 month > 10% in 6 months albumin less than 3.2 BMI less than 20, greater than 25 |
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depression and social support |
risk factors: female single widow lack of social support males more likely to commit suicide - more likely to tell you somatic complaints instead of feelings, my stomach hurts, I don't feel right ask who can help in illness or emergency |
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pain (2) |
1. acute: distinct onset, usually evident pathology, short duration, common causes, trauma, postsurgical pain 2. persistent pain: due to ongoing nociceptive, neuropathic, or mixed pathophysiologic processes, often associate with functional and psychologic impairment - can fluctuate in character and intensity over time |
