Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3098_Библиотеки_им_академика_М_И_Перельмана
.pdf
4 - Geriatric Assessment |
87
CLOCK SCORING
NORMAL CLOCK
A NORMAL CLOCK HAS ALL OF THE FOLLOWING ELEMENTS:
All numbers 1–12, each only once, are present in the correct order and
direction (clockwise).
Two hands are present, one pointing to 11 and one pointing to 2.
ANY CLOCK MISSING ANY OF THESE ELEMENTS IS SCORED
ABNORMAL. REFUSAL TO DRAW A CLOCK IS SCORED
ABNORMAL.
SOME EXAMPLES OF ABNORMAL CLOCKS (THERE ARE MANY OTHER KINDS)
Abnormal Hands Missing Number
Figure 4-1 (cont’d).
Source: Mini-Cog
TM
, Copyright S. Borson. Reprinted with permission of the author, solely for clinical and teach-
ing use. May not be modified or used for research without permission of the author (soob@uw.edu). All rights
reserved.
https://t.me/medicina_free
88
| Fundamentals of Geriatric Pharmacotherapy
S
CORING
HIGH SCHOOL EDUCATION LESS THAN HIGH SCHOOL EDUCATION
27-30 Normal 25-30
21-26 MNCD* 20-24
1-20 Dementia 1-19
* Mild Neurocognitive Disorder
VAMC
SLUMS Examination
__/1
__/1
__/1
__/3
__/3
__/5
__/2
__/4
__/2
__/8
Name Age
Is patient alert? Level of education
1
1
1
1
2
0 1
0 1 1
2
2
1
1
2
2
2
2
1. What day of the week is it?
2. What is the year?
3. What state are we in?
4. Please remember these five objects. I will ask you what they are later.
Apple Pen Tie House Car
5. You have $100 and you go to the store and buy a dozen apples for $3 and a tricycle for $20.
How much did you spend?
How much do you have left?
6. Please name as many animals as you can in one minute.
0-4 animals 5-9 animals 10-14 animals 15+ animals
7. What were the five objects I asked you to remember? 1 point for each one correct.
8. I am going to give you a series of numbers and I would like you to give them to me backwards.
For example, if I say 42, you would say 24.
87 649 8537
9. This is a clock face. Please put in the hour markers and the time at
ten minutes to eleven o’clock.
Hour markers okay
Time correct
10. Please place an X in the triangle.
Which of the above figures is largest?
11. I am going to tell you a story. Please listen carefully because afterwards, I’m going to ask you
some questions about it.
Jill was a very successful stockbroker. She made a lot of money on the stock market. She then met
Jack, a devastatingly handsome man. She married him and had three children. They lived in Chicago.
She then stopped work and stayed at home to bring up her children. When they were teenagers, she
went back to work. She and Jack lived happily ever after.
What was the female’s name? What work did she do?
When did she go back to work? What state did she live in?
TOTAL SCORE
2 3
Questions about this assessment tool? E-mail aging@slu.edu.
Figure 4-2. Saint Louis University Mental Status (SLUMS) Examination.
Tariq SH, Tumosa N, Chibnall JT, et al. Comparison of the Saint Louis University mental status examination and the mini-
mental state examination for detecting dementia and mild neurocognitive disorder––a pilot study. Am J Geriatr Psychiatry.
2006;14:900–910.
VAMC
SLUMS Examination
Questions about this assessment tool? E-mail aging@slu.edu
https://t.me/medicina_free
4 - Geriatric Assessment |
89
visuoconstructional skills, conceptual thinking,
calculations, and orientation.
33
The MoCA exami-
nation has been found to be more effective than
MMSE at differentiating patients with MCI at high
risk of dementia.
33,34
Tools used in research must measure
severity of disease and detect changes over
time, and as such the tools are longer and take
more time to administer. Clinical trials assessing
cognition typically utilize the MMSE and
Alzheimer’s Disease Assessment Scale-cogni-
tive subscale (ADAS-cog) for those with mild to
moderate impairment and the MMSE and Severe
Impairment Battery (SIB) for those with moderate
to severe impairment.
35
The Clinician’s Interview
Based Impression of Change-Plus Caregiver
Input (CIBIC-Plus) is a complementary assess-
ment of cognition and function utilized in clinical
trials evaluating patients with cognitive impair-
ment.
36
Pharmacists should be familiar with
these instruments to provide adequate critique
to study results.
The Alzheimer’s Disease Assessment Scale
was designed to measure severity of the most
important symptoms of Alzheimer disease.
37
The ADAS-cog is considered the gold standard
of cognitive tests used in clinical trials studying
patients with mild to moderate cognitive impair-
ment. Total scores range from 0 to 70, with higher
scores (≥18) indicating greater cognitive impair-
ment. A 4-point change in 6 months is recog-
nized as a clinically important difference.
38
The SIB is a research tool designed to
assess later stages of dementia.
35
Overall scores
can range from 0 to 100, allowing for classifica-
tion of degree of impairment; lower scores indi-
cate greater cognitive impairment. The CIBIC-
Plus differs from the ADAS-cog and SIB because
it relies on the caregiver interpretation of change
in cognition and functioning from baseline to
follow-up. The scoring ranges from 1 to 7 points,
with 4 points indicating no change. A score of
one point is very much improved, and a score
of seven means very much worse. The CIBIC-
Plus is better at estimating decline rather than
improvement.
Clinical interpretation of changes in the cogni-
tive assessments described above is controver-
sial. In general, as patients with dementia age,
their scores on the assessments will decline.
Clinical trials studying the effects of medications,
such as cholinesterase inhibitors or memantine,
and use of some of the above measurements
(e.g., MMSE, ADAS-cog, SIB) have found statisti-
cally significant improvements.
39
However, many
experts question the clinical significance of these
modest improvements.
40
N
A
Because depression is common in the elderly,
all geriatric patients presenting for the first time
should be screened for depression. Screening
after baseline can be done based on clinical
suspicion for depression or periodically there-
after. Compared to younger adults, elderly
patients with depression may not have typical
signs and symptoms of depression. For this
reason, the Geriatric Depression Scale (GDS)
is a more specific screening tool for the geriatric
population (Figure 4-3). The GDS is a self-report
screening tool that relies on the patient to provide
yes/no answers to questions about feelings and
symptoms associated with depression.
41
It has
been studied and validated in multiple geri-
atric populations and settings including outpa-
tient settings, nursing home settings, inpatient
settings, patients with normal cognition, patients
with dementia, patients with visual impair-
ment, patients who are non-English speaking,
and when administered over the telephone.
42,43
The 15-item version is used when patients are
fatigued or less time is available. In patients
who are unwilling or unable to complete the
GDS, both versions are also available in a vali-
dated informant version (GDS-I).
44,45
Scoring and
clinical application of the GDS is based on total
points (e.g., 15 or 30), with some points awarded
for positive responses and some points awarded
for negative responses. A variety of scores have
been used as cut-off points to indicate depres-
https://t.me/medicina_free
90
| Fundamentals of Geriatric Pharmacotherapy
Geriatric Depression Scale
Choose the best answer for how you felt over the past week.
1. Are you basically satisfied with your life?
Yes/No
2. Have you dropped many of your activities and interests?
Yes/No
3. Do you feel that your life is empty?
Yes/No
4. Do you often get bored?
Yes/No
5. Are you hopeful about the future?
Yes/No
6. Are you bothered by thoughts you can’t get out of your head?
Yes/No
7. Are you in good spirits most of the time?
Yes/No
8. Are you afraid that something bad is going to happen to you?
Yes/No
9. Do you feel happy most of the time?
Yes/No
10. Do you often feel helpless?
Yes/No
11. Do you often get restless and fidgety?
Yes/No
12. Do you prefer to stay at home, rather than going out and doing new things?
Yes/No
13. Do you frequently worry about the future?
Yes/No
14. Do you feel you have more problems with memory than most?
Yes/No
15. Do you think it is wonderful to be alive now?
Yes/No
16. Do you often feel downhearted and blue?
Yes/No
17. Do you feel pretty worthless the way you are now?
Yes/No
18. Do you worry a lot about the past?
Yes/No
19. Do you find life very exciting?
Yes/No
20. Is it hard for you to get started on new projects?
Yes/No
21. Do you feel full of energy?
Yes/No
22. Do you feel that your situation is hopeless?
Yes/No
23. Do you think that most people are better off than you are?
Yes/No
24. Do you frequently get upset over little things? Yes/No
25. Do you frequently feel like crying?
Yes/No
26. Do you have trouble concentrating? Yes/No
27. Do you enjoy getting up in the morning? Yes/No
28. Do you prefer to avoid social gatherings?
Yes/No
29. Is it easy for you to make decisions? Yes/No
30. Is your mind as clear as it used to be? Yes/No
Figure 4-3. Geriatric Depression Scale.
Source: Reprinted with permission from Yesavage JA, Brink TL. Development and validation of a geriatric
depression screening scale: a preliminary report. J Psychiatr Res. 1983;17(1):37–49.
https://t.me/medicina_free
4 - Geriatric Assessment |
91
sion; in general, the higher the score the more
severe the depression.
In addition to the GDS, clinicians may
prefer to use quicker tools to screen for depres-
sion, such as the Patient Health Questionnaire
(PHQ)-2 and PHQ-9 assessments. With two
and nine questions, respectively, these tools are
applicable to a broad range of patients. Patients
testing positive for depression with the PHQ-2
should be further assessed by the PHQ-9.
Although there have been multiple studies using
these tools to screen for depression in older
adults, some symptoms included in the PHQ-9
questions (e.g., trouble with sleep, moving or
speaking slowly, and feeling tired or having little
energy) are nonspecific and may be responded
to positively in many older adults without depres-
sion. Nevertheless, the PHQ-9 has been found
to screen for depression equally as well as the
GDS-15 in ambulatory older adults.
46
KEY POINT:
e GDS is a more specic
screening tool for the geriatric population
than other depression screening tools.
If a patient has dementia and needs to be
assessed for depression, the GDS or GDS-I can
be used. In addition, the Dementia Mood Assess-
ment Scale and the Cornell Scale for Depres-
sion in Dementia are screening tools that were
developed specifically for this population. Both
scales are completed by a caregiver or nursing
staff. Because of poor specificity in patients with
cognitive impairment, the PHQ-2 and PHQ-9 may
not be the most appropriate choices to screen for
depression in this patient group.
47
In patients with dementia, psychotic and
behavioral problems can also occur as the
disease state progresses. Assessment of
psychotic and behavioral problems in patients
with dementia and the ability of the caregiver(s)
to cope with the problems is important to eval-
uate the safety of the patient and the ability to
stay in the same living situation. Several rating
scales are available for behavioral assessment.
The Neuropsychiatric Inventory (NPI), Behave-
AD (Behavioral Pathology in Alzheimer’s Disease
Rating Scale), and NPI-Q (Neuropsychiatric
Inventory Questionnaire) are commonly used
assessments of behavioral problems.
48-50
The
NPI, Behave-AD, and CIBIC-Plus are longer
assessments used mainly in research settings
and clinical trials, whereas the NPI-Q was devel-
oped for clinical practice. The CIBIC-Plus, an
assessment tool described above (see Cognitive
Assessment), includes components of behav-
ioral assessment and is also used to evaluate
these symptoms in clinical trials.
The NPI is a validated evaluation of neuro-
psychiatric symptoms based on a structured
interview conducted by a provider with a care-
giver and takes about 10 minutes to complete.
It includes 12 symptom domains rated for
frequency and severity by the caregiver, for a total
of 144 points. Higher scores indicate more severe
neuropsychiatric illness. This tool has been trans-
lated into multiple languages, and clinical trials,
both in and outside the United States, often use
the NPI as a secondary outcome for drugs being
studied for dementia. The NPI-NH (developed
for use in nursing homes) can be completed by
certified nurses’ aides and licensed vocational
nurses for use as a tracking agent for behavioral
changes.
51
The Behave-AD is one of the earliest
neuropsychiatric rating scales similar to the NPI;
it is often included in clinical trials of drug treat-
ments in patients with Alzheimer disease. The
Behave-AD is a validated tool that evaluates 25
neuropsychiatric symptoms in seven categories
and includes a global rating of caregiver stress
associated with the symptoms. The Behave-AD
takes approximately 20 minutes to administer.
The NPI-Q is a validated questionnaire for
clinical practice that can typically be completed
in 5 minutes or less. It has the same symptom
domains as the NPI: the caregiver-informant
rates the severity of behavioral symptoms and
the distress on the caregiver. Scores on the
NPI-Q range from 0 to 60, with higher numbers
indicating increased severity of symptoms and
increased stress on the caregiver. The NPI-Q has
been translated into Spanish.
https://t.me/medicina_free
92
| Fundamentals of Geriatric Pharmacotherapy
Similar to the cognitive tests described
previously, the definition of clinically significant
changes in neuropsychiatric tests is debat-
able. Clinical trials studying drugs for Alzheimer
disease typically find statistically significant
changes in these assessments, but it is very
difficult to tell if these changes are clinically
relevant as a whole. It may be useful to refer
complex patients to a neurologist or neuro-
psychologist for further evaluation and recom-
mendation. Although pharmacists are likely to
interact and recommend treatment for patients
with neuropsychiatric symptoms, it is unlikely
that they will be involved with neuropsychiatric
screening beyond use of the GDS screening tool
for depression.
F A
Functional assessments of geriatric patients
should be performed at the initial visit and at
regular intervals (e.g., annually) to assess for
changes in function that might require changes
in living situation. A comprehensive functional
assessment should include assessing activi-
ties of daily living (ADLs), instrumental activi-
ties of daily living (IADLs), gait and balance,
fall risk, and current level of physical activity.
Geriatric nurses, social workers, occupational
therapists, physical therapists, and caregivers
are especially helpful in performing functional
assessments of patients. Specifically, occupa-
tional therapists are typically trained in assessing
and making recommendations to improve ADLs
and IADLs. Physical therapists are helpful for
assessing and intervening on gait and balance
problems, fall risk, level of physical activity, and
use of assistive devices for walking. Multiple tools
are available to assist with assessing function.
Utilizing these tools in clinical practice may help
detect impairments that may not be adequately
recognized by clinicians.
52
Basic ADLs include self-care activities that
are required to sustain existence and indepen-
dence, such as bathing, dressing, toileting,
transferring from bed or chair, continence,
feeding, grooming, and walking. Patients should
be evaluated to determine whether they are
capable of performing ADLs independently,
with help, or if they are dependent on others
to perform them. Based on patients’ ability
to perform ADLs independently, they might
require assistance that varies from needing to
have a caregiver check on them several times
a week, living with a caregiver or in an assisted
living facility, or living in a long-term care center
(e.g., nursing home). Physicians can also order
home healthcare, including nursing, physical
therapy, and occupational therapy, for patients
who need assistance at home. Home health-
care agencies paid by Medicare are required to
perform a formal assessment of a patient’s need
for care (Outcome and Assessment Information
Set [OASIS]), including the ability of the patient
to perform ADLs and IADLs.
53
These data are
utilized by Medicare to monitor the quality of
home healthcare but can also be used by health-
care practitioners to monitor patient-specific
quality of care.
Multiple tools are available to assist in docu-
menting ADL assessments. The Katz ADL tool
is one of the oldest tools used in clinical prac-
tice and takes about 5 minutes to administer.
54
The tool scores patients 1 point for being inde-
pendent with six categories of ADLs (bathing,
dressing, toileting, transferring, continence, and
feeding) and 0 points for dependence with the
activities. Higher points indicate more indepen-
dence and functioning. The Alzheimer’s Disease
Cooperative Study Activities of Daily Living
Inventory (ADCS-ADL) tool is more detailed; typi-
cally used in research settings and clinical trials,
it includes an assessment of ADLs and IADLs.
The ADCS-ADL is a caregiver-rated question-
naire assessing 23 items; higher scores indi-
cate better functioning.
55
This tool is capable of
assessing function in a wider range of patients
with cognitive impairment than the Katz ADL
tool. Both tools can be used with patients living
in a variety of care settings and those of different
cultural and ethnic backgrounds.
IADLs consist of more complex activities
that are necessary to have a higher level of func-
https://t.me/medicina_free
4 - Geriatric Assessment |
93
tioning. The Lawton IADL tool is commonly used
in clinical practice and takes about 10 minutes to
administer. It assesses the ability to complete the
following eight tasks: ability to use a telephone,
shop, prepare meals, maintain light housework,
do laundry, travel independently, take medica-
tions, and handle finances.
56
Some IADLs are
learned skills and may be more a function of a
patient’s environment and previous training than
ADLs. A higher score on the Lawton IADL also
indicates higher functioning. IADL tools can be
completed by either the patient or a caregiver
and can be utilized in culturally diverse settings.
The Functional Assessment Screening
(FAST) scale is an additional tool often used in
clinical trials evaluating patients with dementia,
or by palliative care, hospice, and dementia
healthcare teams to evaluate and/or monitor the
ability of a patient to perform basic ADLs.
57
The
FAST scale is divided into seven major stages,
from normal (FAST stage 1) to severe dementia
(FAST stage 7). Stages 6 and 7 are further
divided into substages indicating loss of specific
types of independence (e.g., ability to dress
independently) or abilities (e.g., ambulation).
Falls, Gait, Balance, and Physical
Activity
A patient’s recent fall history (e.g., last 1–3
months) should be assessed at all medical visits,
and future fall risk should be assessed regularly
(e.g., annually). Assessing fall risk requires the
assessment of many factors, such as drugs (e.g.,
sedative/hypnotics) and disease states (e.g.,
heart disease, osteoarthritis, Parkinson disease)
in addition to gait, balance and strength, and
home safety (e.g., rugs, loose floor boards,
stairs, cluttered areas).
58
Both gait and balance can be assessed
utilizing the Berg Balance Scale (BBS) and the
Timed Up and Go Test (TUG).
59,60
The BBS
requires individuals to complete 14 balance-
challenging tasks of varying difficulty without
any assistive devices. For instance, the patient is
asked to go from a sitting position to a standing
position, to transfer between two chairs, to pick
up an object from the floor, to stand in tandem
stance, and to stand on one leg. Each item is
scored on a 5-point scale, with higher ratings
indicating better performance. The highest
number of points that patients can achieve is 56,
with 45 points and higher typically used as the
cut-off for patients who are not likely to fall. This
scale has good specificity (96%) for detecting
non-fallers.
61
It takes approximately 10–15
minutes to administer and requires some equip-
ment (e.g., chairs, stopwatch, yardstick, line on
floor).
The TUG is easier and quicker than the BBS
in assessing fall risk. The patient must sit in a
chair, safely rise from the chair, walk around a
visibly colored marker (e.g., orange cone) three
meters away, walk back, and then sit down in the
chair. Patients must be instructed to do all of this
as quickly and safely as they can. They can use
their assistive devices while taking the test, but
this typically slows them down. The test is timed;
those who complete the test in less than 20
seconds have been shown to be independent in
their transfers and mobility, and those requiring
30 seconds or longer have higher dependence
and frailty. In another study of the TUG, investiga-
tors found that older adults who take longer than
14 seconds to complete the test are at a high fall
risk.
62
Patients completing the test more quickly
can still be counseled to consider balance exer-
cises, and those in the high-risk group should be
advised to seek further assessment and inter-
vention for falls.
Assessment of physical activity is also
important in the ambulatory elderly, as increased
physical activity has been shown to be an impor-
tant predictor of functional status.
63
Surgeon
General and American Heart Association (AHA)
guidelines suggest 30 minutes or more of
moderate physical activity on five or more days
of the week.
63,64
The AHA guidelines also provide
very detailed recommendations for strength-
ening and stability. Older sedentary adults can
improve physical functioning by meeting these
suggested physical activity levels; dropping
below these levels has a negative effect on func-
tion.
63
Patients should be interviewed about the
https://t.me/medicina_free
94
| Fundamentals of Geriatric Pharmacotherapy
type of physical activity that they are involved in
and the amount of time they are spending doing
particular activities. Relatively brief counseling
about walking and strength exercise has been
shown to increase physical activity in elderly
patients.
65
Patients may be motivated to engage
in physical activity because it has been shown
to reduce mortality and maintain functioning in
older adults compared with a sedentary life-
style, even if the physical activity is initiated at an
advanced age.
66
S A
Social assessment of the elderly includes some
traditional aspects of a medical assessment of
a younger patient (e.g., smoking, alcohol status)
but moves beyond that to include areas essen-
tial to caring for an older adult (e.g., indepen-
dence, advance directives, insurance status,
transportation/driving status, sexual activity, life
changes). Social workers can provide invalu-
able assistance and information for clinicians,
patients, and caregivers when performing a
complete social assessment. Social assess-
ments may need to be tailored to the patient’s
cultural and religious preferences.
KEY POINT:
Social assessment includes
areas essential to caring for an older
adult: independence, advance directives,
insurance status, transportation/driving
status, sexual activity, and life changes.
Recent life changes should be considered
to fully appreciate goals that elderly patients may
have for their healthcare. Many elderly will have
faced new life changes, such as the death of a
spouse, illness, moving from their home to an
assisted living situation, and/or dealing with the
reality of their own eventual death. It is important to
understand how patients deal with these changes
and how they perceive themselves in order to
determine their overall adaptability to life changes.
Social History: Tobacco and
Alcohol Use
Although most people do not start smoking
in advanced age, it is important to determine
the current smoking status of older adults, as
those who do smoke probably have a signifi-
cant smoking history. Similar to younger adults,
patients should be asked about the length of
their smoking history, how many cigarettes per
day they smoke, and about attempts to quit. In
addition, it is important to assess a patient’s will-
ingness to quit. Many elderly may believe that
they will not see a benefit from smoking cessa-
tion at this point in their lives. However, there is
evidence to show that smoking cessation at any
age, even after age 65, is beneficial for reducing
overall risk of death and disability.
67,68
If a patient
is willing to quit smoking, assistance with a plan,
whether pharmacologic or nonpharmacologic,
should be offered.
In addition to tobacco use, information about
alcohol consumption should be elicited from
elderly patients. Occasional alcohol use may be
permitted if it increases quality of life, but heavy
or persistent alcohol use can cause complica-
tions in the elderly. For example, alcohol may
increase a patient’s risk for falls and fractures
by impairing judgment and increasing balance
problems. Also, chronic alcohol consump-
tion may result in impaired hepatic function,
altering metabolism of medications. Because
many elderly are on multiple medications, there
is a high likelihood they will be on at least one
medication that is hepatically metabolized.
Furthermore, it is important to assess alcohol
consumption in elderly patients who become
hospitalized in order to prevent delirium tremens,
a potentially life-threatening consequence of
alcohol withdrawal. Older adults are likely to
have a higher blood alcohol level than younger
people for a given dose of alcohol due to their
less efficient hepatic metabolism.
69
If proper
assessment of alcohol use is not performed,
there is an increased risk of developing delirium
tremens when chronic drinkers are admitted to
the hospital.
https://t.me/medicina_free
4 - Geriatric Assessment |
95
Independence
Independence should be evaluated as
described above in the functional assessment.
If the patient lives in an assisted living facility,
the contact information for the facility should be
recorded. A complete list of healthcare providers
(e.g., specialists) should be recorded for future
reference. Family and caregiver information
should also be recorded at the initial visit and
updated as needed. If an elderly patient has
multiple family contacts, it is important to have
a primary contact designated so healthcare
providers are aware of which person to contact
first. It is helpful to have this information avail-
able before a patient becomes severely ill. If the
patient utilizes medication administration assis-
tance, this information should also be recorded
in case medication orders need to be submitted
to a facility in addition to the pharmacy.
In some cases, tests of cognitive impairment
or functional assessment do not clearly identify
problems with the executive function required to
manage medications or adhere to a treatment
plan. Tests focused on executive dysfunction,
such as the EXIT-25
70
or the Frontal Assessment
Battery,
71
can be administered to objectively
identify functional problems that may limit a
patient’s ability to live alone or manage his or her
medications, indicating a need for assistance or a
change in living situation to ensure patient safety.
Advance Directives
Assessment of advance directives (ADs) is
a vital, but sometimes neglected, part of the
medical assessment of elderly patients. ADs are
legal documents that allow patients to have their
medical decisions known and followed when
receiving care. These are so important to assess
that in 1990 the Federal Patient Self-Determina-
tion Act was passed, requiring that patients be
asked at the time of admission to a healthcare
service whether they have advance care plans.
72
ADs must be documented when patients still
have the capacity to make healthcare decisions.
Once an initial assessment of ADs is made, it is
important to regularly reassess a patient’s wishes
because they can change as the patient ages or
develops new health problems. Advance care
plans can be revised up until the last moment of
capacity to make decisions, so it is also impor-
tant for healthcare providers to assess whether
the most current decisions are on record.
Establishing whether ADs exist is impor-
tant not only for a patient but also for the family.
Having ADs in place alleviates some stress and
anxiety for family members. In many situations,
cultural and religious preferences may impact
the ADs of the patient and should always be
considered in discussions. Further information
regarding ADs is included in Chapter 2.
Insurance Coverage
Another important assessment topic is insurance
coverage, both government-provided (Medicare,
Medicaid, and military service) and private. Most
elderly will have Medicare coverage, and many
will supplement coverage with an additional
privately secured insurance plan. It is important
to determine a person’s eligibility for Medicare,
because the coverage is associated with signifi-
cant improvements in self-reported health trends
for previously uninsured patients, especially for
cardiovascular disease or diabetes.
73
Patients
can enroll in Medicare Part A, B, and/or D.
Medicare Part A covers hospitalizations; Part B
covers outpatient medical visits, infusions, most
immunizations, and medical supplies; and Part D
covers prescriptions and MTM. However, Medi-
care coverage is not free of charge other than for
Medicare Part A. Patients must pay for Medicare
Part B and D coverage and plan deductibles
and copays for products and services, unless
they have supplemental coverage for these
expenses. Medicare Part D covers prescription
drugs for any person with Medicare Part B. Some
elderly may qualify for extra help, depending
on their income in comparison to the federal
poverty levels. These dollar amounts fluctuate,
so checking the Medicare and Social Security
websites is important to determine whether a
patient may qualify for extra help. If the patient
qualifies, then his or her Medicare copays may
be reduced or eliminated.
https://t.me/medicina_free
96
| Fundamentals of Geriatric Pharmacotherapy
For patients with Medicare Part D it is
also advantageous to assess when and if they
will be in the “doughnut-hole” coverage gap.
Depending on the plan, during this time the
patient may be responsible for all prescription
drug costs until he or she spends up to a partic-
ular dollar amount designated by the selected
Medicare Part D plan. Elderly patients with no
prescription benefits while in this coverage gap
may become nonadherent with their medications
because of cost. These coverage gaps are to be
eliminated in the future.
Transportation and Driving
Assessment
Understanding transportation and driving ability
in the elderly is extremely important, as geriat-
rics may not be able to come to appointments
regularly, pick up their medications, shop for
groceries, or have social outlets. Assessing an
elderly person’s ability to drive is important in
balancing the individual’s independence with
personal (and public) safety. This assessment
is particularly important for people with cogni-
tive impairment or perception deficits such as
decreased vision, arthritis, seizures, stroke,
diabetes, or Alzheimer disease. Many elderly
link driving with independence and rely on it for
daily activities. Due to this, it may be difficult to
convince them they are no longer safe to operate
a motor vehicle. Social support from family and
friends is essential for elderly patients to arrive at
a decision to stop driving. Because many states
do not require drivers to come into the Depart-
ment of Motor Vehicles each time they renew
their licenses, caregivers, family members, clini-
cians, and even patients must play an important
role in assessing driving ability. When a patient
has been shown to be an unsafe driver, a referral
should be made to the proper organization per
each state’s protocol; if a patient is no longer
able to independently operate a motor vehicle, it
becomes important to assess his or her ability to
use other modes of transportation.
The ability to use other modes of transpor-
tation should be assessed for patients who do
not drive. Depending on the living situation of the
individual, transportation may be included with
his or her housing. If not, those living in more
rural areas may not have access to public trans-
portation, whereas those in urban areas may
have safety concerns with public transporta-
tion. In urban areas, nonprofit programs such as
Access-A-Ride can provide low-cost transporta-
tion for elderly patients with functional deficits.
An assessment completed by a physician may
be required to determine eligibility. Depending
on the state, Medicaid may also provide some
payment for transportation, including taxi fares.
Pharmacists can help patients with transporta-
tion challenges by reviewing local options for
low-cost transportation and by referring patients
to social workers who may have additional trans-
portation resources.
Sexual Activity
An assessment of sexual activity may be over-
looked in the elderly due to a perception that
they are not sexually active. The sexual activity of
elders is often underestimated, and monogamy
should not be assumed. Elders are still at risk
for acquiring sexually transmitted diseases when
sexually active with multiple partners or a single
new untested partner. Although adults over age
55 make up the smallest group of HIV positive
individuals in the United States, this age group is
growing as treatments prolong life expectancy.
If an elderly person is active and not practicing
safe sex, he or she should also be screened
for and educated about sexually transmitted
diseases.
On the other hand, many elderly suffer from
sexual difficulties such as impotence, decreased
libido, atrophic vaginitis, and dyspareunia.
Therefore, patients should also be questioned
about their desire to remedy these problems
and improve their sexual experience. In many
instances, these problems may be improved
with medication or vaginal lubricants. Unfortu-
nately, the biggest barrier to these improvements
is often communication between the provider
and patient.
https://t.me/medicina_free
Соседние файлы в папке Библиотека им академика М.И. Перельмана