Lecture #59: DPR: History and Physical Exam of the Aging Patient

What is geriatrics?

The branch of medicine focused on the care of older adults, emphasizing prevention, chronic disease management, and maintenance of function

Who is considered a geriatric patient?

By convention, any individual age 65 years or older, with the oldest old defined as age 80 years or older

What is meant by the demographic imperative in geriatrics?

Not only increasing life span, but maximizing function and independence for as long as possible

What is aging?

The inevitable, irreversible decline in organ function over time, even in the absence of disease, injury, or poor lifestyle choices

Which organ systems are especially vulnerable to aging?

Cardiovascular, renal, and central nervous systems

What is frailty?

A state of decreased physiologic reserve and increased vulnerability to stressors, leading to higher risk of adverse health outcomes

What are common geriatric syndromes?

Gait disorders and falls, malnutrition, disability, urinary incontinence, delirium, sleep disorders, and cognitive impairment

Why are multiple comorbidities common in older adults?

Aging reduces homeostatic reserve, and chronic diseases accumulate, interacting to alter presentation and recovery

How can disease presentation differ in older adults?

Symptoms often appear in the most compromised organ system rather than presenting classically

What is polypharmacy?

The use of multiple medications, increasing risk of adverse effects, drug interactions, and altered pharmacokinetics

How does aging affect drug metabolism?

Changes in absorption, volume of distribution, protein binding, and elimination increase risk of under or overdosing

Why is disability often multifactorial in older adults?

Reduced muscle mass, lower body fat changes, decreased energy efficiency, neurologic dysfunction, cognitive impairment, and poor nutrition contribute

When does disability typically occur in aging?

Late in the process, after physiologic reserves and compensatory mechanisms are exhausted

What physiologic changes occur in the cardiovascular system with aging?

Reduced compliance, decreased maximal heart rate, and increased susceptibility to orthostatic hypotension

What sensory changes occur with aging?

Reduced visual acuity, hearing loss, and altered temperature regulation

What musculoskeletal changes occur with aging?

Loss of lean muscle mass, reduced strength, decreased bone density, and increased fracture risk

What are Activities of Daily Living, or ADLs?

Basic self care tasks such as bathing, dressing, toileting, transferring, continence, and feeding

What are Instrumental Activities of Daily Living, or IADLs?

More complex tasks such as managing finances, transportation, shopping, cooking, and medication management

What are key components of a geriatric assessment?

Comprehensive history, medication review, functional assessment, cognitive evaluation, goals of care discussion, and team based planning

Why is medication review essential in geriatric care?

To identify inappropriate medications, reduce adverse effects, and prevent harmful drug interactions

What is the Beers Criteria?

A guideline listing potentially inappropriate medications in older adults to improve prescribing safety

What are common areas requiring special attention in geriatric history?

Functional impairments, medication side effects, smoking, alcohol use, nutrition, pain, cognitive changes, incontinence, and falls

What is the Mini Mental State Examination?

An 11 question screening tool assessing orientation, registration, attention, calculation, recall, and language, with a maximum score of 30

What MMSE score suggests cognitive impairment?

A score of 23 or lower

What are limitations of the MMSE?

Performance may be affected by language barriers, visual or hearing impairment, fatigue, and educational background

What is the Montreal Cognitive Assessment?

A screening tool for mild cognitive impairment assessing multiple cognitive domains including executive function and memory

What is the Mini Cog?

A rapid screening tool combining three word recall and clock drawing, useful for detecting cognitive dysfunction

What is the Timed Get Up and Go test?

A functional assessment measuring fall risk by timing how long it takes a patient to stand, walk, turn, and sit

What are key preventive care measures in geriatrics?

Exercise promotion, fall prevention, immunizations, home safety evaluation, and screening for elder abuse

What is DEXA scanning used for?

Measuring bone mineral density to assess osteoporosis and fracture risk

Who should receive routine bone density screening?

Women age 65 and older, men age 70 and older, or younger individuals with significant risk factors

What is the FRAX tool?

A calculator estimating 10 year risk of major osteoporotic fracture based on clinical risk factors and bone density

What are major contributors to fracture risk assessed by FRAX?

Age, sex, weight, height, prior fracture, parental hip fracture, smoking, steroid use, rheumatoid arthritis, secondary osteoporosis, alcohol use, and femoral neck T score

Why is communication especially important in geriatric care?

Older adults may have sensory deficits, cognitive changes, or cultural considerations affecting understanding

What is the role of a team based approach in geriatric medicine?

Coordination among physicians, nurses, social workers, therapists, and caregivers improves outcomes and long term planning

What is the overarching principle of geriatric care?

Maintain independence, optimize function, prevent complications, and align treatment with patient goals and quality of life