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• Skin: new moles, pigmentation, turgor, rashes, pressure
ulcers
• Neurologic: tremor, gait, weakness, reflexes, cranial nerves,
tone, sensation, Romberg, cogwheel rigidity
Functional Assessment
Performing a functional assessment can greatly enhance the
evaluation of the older adult in the following ways:
• Ensures patients will have treatments tailored to their
individual level of capability.
• Allows for monitoring response to interventions and
medications
• Predicts mortality and morbidity [3, 4]
• Helps prognosticate likely outcomes from surgery or
chemotherapy
• Helps identify new diagnoses
• Helps determine proper level of assistance in the home
and proper housing options (Table 3.1)
Health Promotion and Disease Prevention
Health promotion and disease prevention strategies should
always consider the individual’s health beliefs and goals and
life expectancy. The risk and benefit of each intervention
should be carefully weighed before subjecting patients to
unnecessary or potentially harmful interventions.
Vaccines for Individuals Over 65 Years of Age [6]
Influenza—seasonal yearly vaccine, given throughout the flu
season [6]
Pneumococcal—pneumococcal 13-valent conjugate (PCV13)
should be ideally given first followed by pneumococcal poly-
saccharide vaccine 23 (PPSV23) 1 year later. If already vac-
cinated with PPSV23, then wait 1 year and give PCV 13 [7].
3. Home Care/Care of Elderly
58
Table 3.1 Procedure for functional assessment screening in the
elderly
Target
Assessment
Procedure
Abnormal
Result
Suggested
Intervention
Vision Test each eye
with jaeger
card while
patient wears
corrective
lenses (if
applicable)
Inability
to read
greater
than 20/40
Refer to
ophthalmologist
Hearing Whisper a
short, easily
answered
question such
as “What is
your name?” in
each ear while
examiner’s face
is out of view
Inability
to answer
question
Examine auditory
canals for cerumen
and clean if
necessary. Repeat
test; if still abnormal
in either ear, refer
for audiometry and
possible prosthesis
Arm Proximal:
“Touch the
back of your
head with both
hands”
Distal: “Pick
up the spoon.”
Inability to
do task
Examine the arm
fully (muscle, joint,
nerve), paying
attention to pain,
weakness, limited
range of motion.
Consider referral to
physical therapy
Leg Observe the
patient after
asking: “Rise
from your
chair, walk ten
feet, return, sit
down.”
Inability to
do task
Do full neurological
and musculoskeletal
evaluation, paying
attention to strength,
pain, range of
motion, balance,
and traditional
assessment of gait.
Consider referral for
physical therapy
(continued)
V.M. LoFaso
59
(continued)
Target
Assessment
Procedure
Abnormal
Result
Suggested
Intervention
Urinary
incontinence
Ask: “Do you
ever lose your
urine and get
wet?”
Yes Ascertain frequency
and amount. Search
for remediable
causes including
local infections,
polyuric states, and
medications. Consider
urologic referral
Nutrition Weigh the
patient.
Measure height
Weight
below
acceptable
range for
height
Do appropriate
medical evaluation
Mental status Instruct:” I am
going to name
three objects
(pencil, truck,
book). I will
ask you to
repeat their
names now and
then again in
a few minutes
from now.”
Inability
to recall
all three
objects
after 1 min
Administer Folstein
MMSE. If score
is <24, search for
causes of cognitive
impairment. Ascertain
onset, duration, and
fluctuation of overt
symptoms. Review
medications. Assess
consciousness and
affect. Do appropriate
laboratory tests
Depression Ask: “Do you
often feel sad
or depressed?”
Yes Administer Geriatric
Depression Scale.
If positive (normal
score, 0–10), check
for antihypertensive,
psychotropic, or
other pertinent
medications.
Consider appropriate
pharmaceutical or
psychiatric treatment
Table 3.1
(continued)
3. Home Care/Care of Elderly
60
Target
Assessment
Procedure
Abnormal
Result
Suggested
Intervention
ADL-IADL Ask: “Can
you get out of
bed yourself?”
Can you dress
yourself?,”
“Can you
make your
own meals?,”
“Can you
do your own
shopping?”
No to any
question
Corroborate
responses with
patients’ appearance;
question family
members if accuracy
is uncertain.
Determine reasons
for inability
(motivation
compared with
physical limitation).
Institute appropriate
medical, social,
and environmental
interventions
Home
environment
Ask:” Do you
have trouble
with stairs
inside or
outside your
home?” Ask
about potential
hazards inside
the home with
bathtubs, rugs,
or lighting
Yes Evaluate home
safety and institute
appropriate
countermeasures
Social
support
Ask: “How
would be
able to help
you in case
of illness or
emergency?”
List identified
persons in the
medical record.
Become familiar with
available resources
for the elderly in the
community
Lachs MS et al. [5]
Table 3.1
(continued)
V.M. LoFaso
61
Tdap—one booster dose if never vaccinated. Tdap should be
give regardless of when last Td or tetanus was received.
Repeat Tdap every 10 years [8].
Herpes zoster—not needed if patient has received chicken
pox vaccine. It is a live vaccine and therefore is contraindi-
cated in some immunocompromised individuals. The vaccine
is indicated even if a patient has had shingles in the past [9].
Primary and Secondary Disease Prevention [10]
The US Preventive Services Task Force is an excellent refer-
ence for age-appropriate screening procedures. See www.
uspreventiveservicestaskforce.org.
Calculating life expectancy can be a helpful guide when
considering which interventions to institute for an older
adult. See www.eprognosis.org [11].
Lifestyle and Behaviors
• Exercise—physical activity in older adults should focus on
moderate-intensity aerobic activity, muscle-strengthening
activity, having an active lifestyle, and risk management. A
goal of 150 min moderate aerobic exercise/week including
2 days per week of muscle-strengthening activity and bal-
ance exercises (e.g., Tai Chi) [12].
• Alcohol—NIH recommends no more than seven alcoholic
beverages per week and no more than three alcoholic bev-
erages on any given day for older adults.
• Smoking cessation—should be encouraged and use of
nicotine replacement therapy as needed.
• Social Supports—data show that individuals with robust
social networks who remain engaged in activities and have
purpose have better health outcomes [13].
3. Home Care/Care of Elderly
62
Geriatric Syndromes
Geriatric syndromes are clinical syndromes commonly
encountered in older adults.
Urinary Incontinence (Table 3.2)
Dementia (See Chap. 35)
Dementia is a progressive neurocognitive disorder mani-
fested by decline in mental function that results in significant
functional impairment usually affecting individuals after age
65. Approximately 5.1 million people over age 65 have
Alzheimer’s dementia [14]. Caring for the needs of patients
with dementia, which is fulfilled mostly by family and friends,
often results in financial, psychological, and physical stress. It
is crucial when evaluating a patient with dementia to consider
the caregivers and support them throughout the course of
this difficult disease. Social work consultation is often needed
and appreciated by families. Referral to dementia support
groups, elder lawyers, and geriatric care managers is a useful
intervention for caregivers:
• www.alz.org/caregiversupport
• www.dementiasociety.org
Delirium
Although delirium is more often encountered in the inpa-
tient setting during acute illness, it can still be encountered
in the outpatient setting and must always be distinguished
from dementia and depression. For the diagnosis of delir-
ium, the CAM (Confusion Assessment Method) method can
be utilized.
V.M. LoFaso
63
Table 3.2 Evaluating urinary incontinence
Type Gender Amount Risk factor Complaint Timing Treatment
Urge M = F Large Idiopathic,
poststroke,
local bladder
abnormalities,
lesions in the
inhibitory nerve
pathways
Sudden need
to void
Day and
night
(N > D)
Anti-muscarinic
Bladder regimen
Stress F > M Small Multiple or
large births,
postmenopausal
estrogen loss, pelvic
floor weakening,
obesity, sphincter
failure (men)
Leakage with
coughing or
sneezing or
exercise
Day Kegel exercises
Pessary
Mixed
(stress
+urge)
F > M Variable See above Leakage
with exercise,
coughing—
sense of
urgency
Day and
night
Anti-muscarinic
Kegel exercises
3. Home Care/Care of Elderly
64
Functional M = F Variable Functional
impairment,
mobility disorder
Can’t make
it to the
bathroom
Day and
night
Environmental
modification,
assistive devices
DHIC
a
M = F Variable Overactive
detrusor
Incomplete
emptying.
Elevated
post- void
residual
Day and
night
Beta3-adrenergic
agonist (mirabegron)
Overflow M > F Dribbling Outlet
obstruction—
prostate
enlargement,
cystocele
Dribbling,
hesitancy,
weak stream
Elevated
PVR
Day and
night
(D > N)
Alpha-blockers, type
II 5 alpha reductase
inhibitors, TURP
a
DHIC detrusor hyperactivity with impaired contractility
V.M. LoFaso
65
Confusion Assessment Method (CAM)—short version [15]:
1. Acute onset and fluctuating course
2. Inattention
3. Disorganized thinking
4. Altered level of consciousness
For diagnosis of delirium, must have #1 and #2 and either
#3 or #4.
Delirium can manifest as either quiet delirium or active
delirium. In the former patients may seem sedated, disen-
gaged, sleepy, and withdrawn, and this presentation can be
easily overlooked and ascribed to the patient being fatigued
or depressed. In reality quiet delirium can be a life-threaten-
ing condition resulting from sepsis, stroke, hypercarbia, or
dehydration, among other considerations. Active delirium,
which can manifest with agitation, hallucinations, and even
violent behavior, is much less likely to be overlooked as the
caregiver can easily see the patient is distressed and is there-
fore more likely to intervene.
Delirium Evaluation
• Review of medications
• Consider drug or alcohol ingestion or withdrawal
• Ascertain any history of psychiatric illness
• Assess vital signs: fever, tachycardia, orthostatic changes
• Complete examination: especially neurological and car-
diac exams, signs of urinary retention or fecal impaction
• Check pulse oximetry and blood gas if indicated: hypoxia,
hypercarbia
• Check glucose and electrolyte measurements: hypoglyce-
mia, hypernatremia, hyponatremia, hypercalcemia
• Imaging of the brain: CVA, tumor, hemorrhage
• EKG: MI, arrhythmia
• Environmental factors: lack of sleep, light deprivation,
sensory impairments
• Assess for untreated pain
Management of delirium is targeted at treating the under-
lying condition.
3. Home Care/Care of Elderly
66
Behavioral and environmental modifications can help
reorient the delirious patient. Controlling pain, ensuring
adequate sleep, treating dehydration, and improving oral
intake can all help to reorient the patient. Establishing a
sleep-wake cycle, having family and friends at bedside, and
avoiding unnecessary interruptions by staff throughout the
night can all be helpful interventions. Lastly, ensuring den-
tures, glasses, hearing aids, and home assistive devices are
present can all give patients a sense of normalcy and increase
their engagement with their environment.
The use of antipsychotic medications is reserved for situa-
tions where the patient is a danger to self or others. Olanzapine
(2.5–5 mg), risperidone (0.5 mg), haloperidol (0.5 mg), and
quetiapine (12.5–25 mg) are advisable as needed.
The prognosis for delirium is generally recovery within a
few days of treating the underlying condition; however, cases
of protracted delirium do occur and can last weeks to months.
Pharmacologic interventions should be evaluated daily and
discontinued as soon as possible.
Depression
Although depression is commonly seen in older adults, it
should not be considered a normal part of aging. Untreated
depression can lead to adverse health outcomes and signifi-
cant impairment in quality of life. Late-onset depression is
more likely to be of vascular etiology rather than genetic
origin and may even be a harbinger of early dementia [16].
Medication Management
Dosing should start low and be titrated up slowly. Older
patients will usually need the full dose to achieve therapeu-
tic effects. The full therapeutic effect on mood may not be
seen for 4–6 weeks after initiating treatment. Therapy
should continue for approximately 6–12 months after the
V.M. LoFaso