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4 - Geriatric Assessment |
97
C 1: Comprehensive Interprofessional Geriatric
Assessment
Setting:
Ambulatory.
Subjective:
MP is an 85-year-old woman who is new to the community. She recently moved to an assisted
living facility in your area, as she was recently widowed. Previously, she lived with her husband
in their own home. Her daughter requested she move into the assisted living facility, as it
is close to her daughter’s home. She relies on the facility to provide assistance for cooking,
cleaning, and medication management. She is initiating care at a local seniors clinic for the first
time. Your consulting firm provides clinical pharmacist services at the assisted living facility
and at the seniors clinic where she is scheduled for a new patient appointment. Her daughter
asks what to expect at the first visit.
Past Medical History:
Mild cognitive impairment, osteoporosis, hypertension, osteoarthritis, insomnia, and anemia.
Medications:
Acetaminophen, aspirin, alendronate, lisinopril, hydrochlorothiazide, zolpidem, ranitidine as
needed, multivitamin, and calcium/vitamin D.
Social History:
No history of smoking; occasional alcohol socially.
Family History:
Sister died of a stroke 3 years ago, otherwise unknown.
Assessment:
MP will undergo comprehensive geriatric assessment at the seniors clinic, and she and her
daughter want to know what to expect.
Plan:
Provide education to patient and caregiver on items involved in comprehensive geriatric
assessment by an interprofessional team. Reassure that these assessments may take more
than one visit.
1.
Medical history: past medical records, immunization history (pneumococcal, influ
-
enza, herpes zoster, tetanus), history of falls and fall risk, gait and balance, physical
activity and current diet, history of osteoporosis (past DEXA results).
2.
Social history and functional status: ADs, assisted living contact information, trans-
portation, driving ability, sexual activity, recent life changes, ADLs, IADLs, insurance
status.
3. Review of systems: pain assessment and sleep, bowel, and bladder habits.
4. Physical assessment: vital signs (including pain score), height and weight, hearing
and eye tests, physical examinations, oral examination.
5. Laboratory: thyroid, vitamin B12, complete blood count, basic metabolic panel,
fasting lipid panel, vitamin D.
6. Neuropsychiatric assessment: screening for depression (GDS or GDS-I), cognitive
impairment (SLUMS, 7MS, or MoCA), and possibly other neuropsychiatric screening
depending on results.
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| Fundamentals of Geriatric Pharmacotherapy
7. Medication review: review of her medications (including OTC agents) for drug therapy
problems.
Rationale:
1. A comprehensive interprofessional geriatric assessment does not always occur
in routine medical practice. Problems both simple and complex can be missed in
assessment of the elderly patient due to atypical disease presentation and an attitude
that many symptoms are normal in the aging adult. Establishing care at an interpro
-
fessional senior clinic will provide MP the best opportunity to attain optimal health
and well-being.
2.
The medical history will establish the baseline of disease states present and preven-
tive services necessary for MP. Social and functional history will allow appropriate
referrals for social services and support. They will also assist with gauging the need
for services to be provided by her assisted living facility, as these services can be
very expensive. The review of systems and physical assessment will identify what
additional tests and evaluations may be needed and will discover if disease targets
are being met (e.g., hypertension). Laboratory tests will evaluate MP’s anemia,
fracture risk, and whether there are reversible causes of cognitive impairment, such
as hypothyroidism, low hemoglobin, or low vitamin B12. Neuropsychiatric testing will
establish the severity of the cognitive impairment and possibly clarify symptoms of
insomnia. Other causes of these problems, such as depression, may be established.
Finally, a medication review will enable the assisted living facility and caregiver to
know what medication management issues may be present. Establishing the pattern
of use for prescription and OTC medication in this patient may uncover reversible
causes of cognitive impairment (e.g., zolpidem) and insomnia. Certain medications
might be discontinued (e.g., aspirin, alendronate, multivitamin) if not clearly indicated.
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99
C 2: R C
P L-T C
S
Setting:
Long-term care.
Subjective:
MP is now 88 years old and is entering a long-term care setting because of advancing
dementia with hallucinations and delusions. The consultant pharmacist who serves the long-
term care facility must identify needed evaluations for assessment of MP’s medication regimen.
Past Medical History:
Alzheimer disease, osteoporosis, hypertension, osteoarthritis, depression, hypothyroidism,
constipation, hallucinations, delusions.
Medications:
Acetaminophen, low-dose aspirin, ibandronate, lisinopril, levothyroxine, risperidone, rivastig
-
mine, zolpidem, multivitamin, calcium/vitamin D, hydrocodone/acetaminophen as needed,
esomeprazole as needed, and milk of magnesia as needed.
Social History:
No history of smoking; no alcohol.
Family History:
Sister died of a stroke 6 years ago, otherwise unknown.
Assessment:
Additional information required for initial pharmacist consultation.
Plan:
Obtain the following information/tests:
Information from MP, her daughter, or the nursing staff regarding sleep habits, bowel habits, ADLs,
and insurance status (including formulary listings). Physical assessments should include her
current vital signs, pain assessment using a pain rating scale that she can respond to, height, and
weight. Laboratory measurements for TSH, basic metabolic panel, and CBC are requested. Neuro
-
psychiatric evaluations to review include MMSE, NPI-NH, and GDS-I. Frequency of administration
of acetaminophen,
risperidone, zolpidem, hydrocodone/acetaminophen, esomeprazole, and milk
of magnesia should be obtained from the medication administration record.
Rationale:
1.
Both subjective and objective information will aid in evaluation of the effectiveness and
risk-benefit ratio of several of MP’s medications. The continued need for risperidone,
rivastigmine, and zolpidem require special scrutiny of the objective neuropsychiatric
assessments, as well as physical examination, laboratory findings, and pain ratings.
Inadequately treated pain, constipation, or hypothyroidism in MP could manifest them-
selves as agitation resulting in inappropriate use of psychotropic medications. New
conditions, such as hyponatremia or a urinary tract infection, could also cloud the picture.
2.
Whether MP has Medicare Part D or other insurance to cover prescription medi-
cations should be determined. Admission to a nursing home involves a different
Medicare Part D insurer that includes a long-term care pharmacy provider, which
may be advantageous to MP. Her medications should be reviewed to identify potential
opportunity to convert to generic or preferred brand name prescriptions to reduce
costs without reducing quality of care.
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| Fundamentals of Geriatric Pharmacotherapy
C S
A comprehensive assessment of geriatric
patients encompasses multiple types of assess-
ments including medical, cognitive, neuropsychi-
atric, functional, and social assessments. Elderly
patients presenting to a primary care provider
for the first time should attempt to bring previous
medical records. If possible, family and care-
givers should also accompany them to the visits
to provide supporting information. Completing all
of the necessary assessments may take several
visits with a primary care provider.
S-A Q
1. How might the physical examination be
different for ambulatory elderly compared to
more frail, institutionalized elderly patients?
2. When screening for common conditions in
the elderly, what laboratory parameters are
commonly evaluated?
3. How is cancer screening in the geriatric
patient different when the patient becomes
older and frailer?
4. What specific areas should a pharmacist
focus on when performing a medication
assessment?
5. What are the major differences between the
tools commonly used for cognitive assess-
ment?
6. How might a clinician implement a tool
into his or her clinical practice to evaluate
geriatric patients for neuropsychiatric prob-
lems?
7.
What are the tools available to help assess
functional abilities, and how can they be
specifically utilized?
8. What are the important aspects of a
complete social assessment for elderly
patients?
9. Which interprofessional team members help
contribute to a comprehensive assessment
of a geriatric patient?
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• Pharmacists documenting assessments as part of MTM services can alert the provider
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4 - Geriatric Assessment |
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5
A D E,
P,
M
M
EMILY R. HAJJAR, JOSEPH T. HANLON,
and ROBERT L. MAHER, JR.
L O
1. Define the term suboptimal drug use and discuss the prevalence of the three different types in the elderly.
2.
Define the term adverse drug event and discuss the epidemiology of the three different types in the elderly.
3.
Describe evidence-based data from randomized controlled trials designed to improve suboptimal drug use and
reduce adverse drug events for geriatric patients in different settings.
4.
Describe medication therapy management techniques used to improve suboptimal drug use in the elderly.
K T D
ADVERSE DRUG EVENT: Undesirable health outcome associated with drug therapy due to an adverse drug
reaction, an adverse drug withdrawal event, or therapeutic failure.
ADVERSE DRUG REACTION: An appreciably harmful or unpleasant reaction resulting from an intervention
related to the use of a medicinal product, which predicts hazard from future administration and warrants
prevention or specific treatment, alteration of the dosage regimen, or withdrawal of the product.
ADVERSE DRUG WITHDRAWAL EVENT: A clinical set of symptoms or signs that are related to the removal of
a drug.
INAPPROPRIATE MEDICATION: Use of a medication whose potential risks outweigh its potential benefits or
that does not agree with accepted medical standards.
THERAPEUTIC FAILURE: Adverse health event due to failure to accomplish the goals of treatment resulting
from inadequate or inappropriate drug therapy and not related to the natural progression of disease.
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| Fundamentals of Geriatric Pharmacotherapy
UNDERUSE OF MEDICATION: Omission of or too low a dose of a needed drug for an established active disease
or condition.
UNNECESSARY MEDICATION: Medication that is prescribed or used without a supporting indication, lacks
effectiveness, or is a therapeutic duplication of another medication or drug.
I
M
edications may be prescribed to prevent
the onset of disease, treat symptoms
or complications of chronic illness, or cure
diseases. Older adults also frequently self-medi-
cate with over-the-counter (OTC) medications
and dietary supplements. Indeed, over one-third
of community-dwelling older adults aged 75
and older take five or more prescription medica-
tions, and over half take OTC or dietary supple-
ments that are frequently not reported to health
professionals unless specifically queried.
1
In U.S.
nursing homes, 40% of older residents take nine
or more medications.
2
Although these medica-
tions may be beneficial, drug-related problems
may also occur. Specifically, medications can
be suboptimal (i.e., too much, too little, or the
wrong drug) and adverse drug events (ADEs)
(undesirable health outcomes associated with
drug therapy) may occur.
3
This chapter will elaborate how common
types of suboptimal drug use due to potentially
unnecessary medications, inappropriate
medications, and/or underuse of medica-
tions occur in older adults. ADEs will also be
highlighted by reporting how often adverse
drug reactions, adverse drug withdrawal
events, and therapeutic failure occur in older
adults. Moreover, information will be discussed
about findings from randomized controlled trials
designed to improve suboptimal drug use and
reduce ADEs. Finally, the chapter will end with
a discussion about the role of pharmacists in
conducting medication therapy management to
reduce these drug-related problems.
S D U
Unnecessary Medications
Few studies have quantified the prevalence of
unnecessary medication use. A study of unnec-
essary drug use in a frail elderly Veterans’ Affairs
(VA) population defined unnecessary drug use
as a drug that lacks an indication, effectiveness,
or is a therapeutic duplication. They found that
44% of veterans had at least one unnecessary
medication at hospital discharge. The reasons
for an unnecessary medication included lack
of indication (33%), lack of efficacy (19%),
and therapeutic duplication (8%). The most
common unnecessary medications included
gastrointestinal agents, central nervous system
agents, and nutrients and minerals.
4
Another
study in an outpatient VA population reported that
approximately 60% of the patients had a medi-
cation that was ineffective, not indicated, or was
a duplication of another drug. It was also noted
that as the numbers of medications a patient was
taking increased so did the average number of
unnecessary drugs.
5
Evaluation of unnecessary
drug use in another outpatient VA population
also found that approximately 60% had at least
one unnecessary medication. The most common
reason for unnecessary drug use was lack of
efficacy.
6
Interventions to reduce unnecessary
drug use include incorporating a pharmacist into
an interprofessional team, pharmacist-led medi-
cation reviews, academic detailing, feedback
reporting, and physician medication review.
7
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