Module 2: Patient Assessment and Evaluation

Current Content Expert Kevin W. Chamberlin, PharmD Assistant Clinical Professor University of Connecticut School of Pharmacy & UConn Center on Aging Farmington, CT Legacy Content Experts Sean M. Jeffery, PharmD, CGP, FASCP Assistant Clinical Professor University of Connecticut School of Pharmacy & Clinical Pharmacy Specialist Geriatrics and Extended Care Connecticut VA Healthcare System Dennis J. Chapron, MS, RPh Associate Professor University of Connecticut School of Pharmacy & University of Connecticut Health Center Kevin W. Chamberlin, PharmD Assistant Clinical Professor of Internal Medicine & Geriatrics University of Connecticut School of Pharmacy & University of Connecticut Health Center Tanya C. Knight, PharmD, CGP, FASCP Clinical Assistant Professor of Pharmacy Temple University School of Pharmacy Philadelphia, PA Module Objectives: At the conclusion of this application based activity, the participant will be able to: Interpret subjective and objective findings to identify actual or potential drug-related problems and to develop an appropriate corresponding therapeutic plan

Explain the importance of basing diagnoses and recommendations on the integration of physical assessment data Explain how the clinical interview can contribute to the affective assessment of the geriatric patient Describe laboratory studies commonly used with elderly patients, their purpose, and the application of the test results

Module 2, Section 1: The Geriatric Health History

02.01.01 Components of the Geriatric Assessment HEALTH HISTORY Physical Examination Functional, Cognitive and Affective Assessments Laboratory Tests

Obtaining a thorough health history is essential in contributing to the overall picture of the patients health status. Along with the other components of the geriatric assessment, it aids in the diagnosis and treatment of many medical problems. In addition to the standard history and physical, additional functional, cognitive and affective assessments are often conducted in the elderly to gain a sense of the patients ability to live independently in the community. Once all of the components of the geriatric assessment are completed, an interpretation of the findings, (often by an interdisciplinary team), should lead to a development of a therapeutic plan that is agreeable with the patient, caregivers, and team. 02.01.02 The Standard Health History Most health care providers utilize the "SOAP" note format Subjective information: Chief complaint (CC)

 History of present illness (HPI) Review of systems (ROS) Objective information: Past and present medical problems (PMHx) Surgical history Allergies Medication history Social history (SHx) Sexual history Family history (FHx) Nutrition history Vital signs (VS) Physical examination (PE) Laboratory and diagnostic information Assessments: Plans:

Interviewing the patient to assess his or her health history is usually the first step in beginning the patient-clinician relationship. More than just an opportunity to gather patient data, it provides an opportunity to build trust and rapport. The standard components of the health history are listed on your screen in the order in which they usually appear. This standard approach is used to ensure consistency in conducting and reporting the history and physical. Several of these components will be highlighted here, focusing particularly on the medication history. For additional information about the full health history, please refer to the references at the end of this review concept. 02.01.03 The Medication History: Preparing for the Interview Search existing records Determine primary interviewee Select proper location Know in advance what information you want to communicate and know what information you want to illicit

Before actually conducting a medication history, there are several steps you can take to increase the likelihood of a successful interview. Begin by researching the patients medical illnesses, medications, labs and other pertinent information. Determine if the patient has any cognitive impairment that will preclude effective communication. Determine who is responsible for managing the patients medications. If it is not the patient make sure that the responsible person is also present for the interview. Prior to the interview, ask the patient to bring with them anything they put on or in their bodies, including all their medications and medication, over-the-counter medications, old medicines, herbals, vitamins and minerals, borrowed medicines, pill boxes, and inhalers. If you dont have the luxury of a clinic, office or personal living space that is quiet and private, try and find a location that will provide a good forum for communication. Ensure that the room is well lit, quiet and at a comfortable temperature. Make sure that both the patient and caregiver are comfortable. If the patient requires eyeglasses or hearing aids, be sure that they are worn and in good working condition. If you know in advance what information you would like to obtain during the interview, provide the patient with a list of questions you will be asking. If you plan on providing the patient any printed materials make sure that the printed information is written in a large print, as well as a color and font that is easy for the patient to see. Finally, allow adequate time for the interview. No one wants to feel rushed, especially the elderly. 02.01.04 The Medication History: Data Collection Gather Data on Current and Past Medications: Prescription medications Non-prescription medications including Vitamins and supplements Herbals, neutraceuticals, homeopathic medications Vaccines and immunizations Indications Doses Routes of administration Frequency and timing of administration Allergies or adverse reactions Duration of therapy

Make sure to document your findings

Now you are ready to conduct the interview. Performing a thorough medication history is important because many elderly take duplicate, contraindicated, or unnecessary drugs obtained from a variety of sources. Some elderly patients may be taking expired or discontinued medications. Others may be taking potentially harmful combinations of drugs prescribed by multiple healthcare providers and/or obtained from several pharmacies. Thus, obtaining a complete medication history provides an opportunity to gather valuable information that may be used to identify potential or actual drug-related problems and to optimize drug therapy. Here are some tips you may consider when conducting the interview: Inquire about all medications being taken, including prescription and nonprescription medications, herbals, vitamins, and vaccinations. Rather than ask if the patient uses non-prescription medications, ask what they would use to treat particular ailments such as: headaches, coughs, fevers, aches and pains, and upset stomachs. Additionally you should inquire specifically about preparations such as laxatives, nasal sprays, eye drops and creams/ointments. Ask the patient to open a vial or pill box cell to determine if they have limited dexterity, for example tremor or arthritis that prevents the patient from opening the containers. With each prescription, ask the patient if they recognize the medication and if they know why they are taking it. Determine if the patient knows how many of each they take at one time and how many times a day they take it. Try and determine how long the patient has been taking their current medications. Then determine if the length of therapy is appropriate to the disease being treated. Inquire about and differentiate between allergies to medications and medication intolerances. Ask about the manifestation and treatment of prior allergies or adverse events, and ensure they are appropriately documented in the patients chart Ask if the patient has ever run out of medication. Try to determine the frequency with which this occurs. Determine early on who manages the medications and inquire about difficulties in keeping all of the medications

organized and seeing to it that they are taken on time and as directed. Patients may be intentionally or unintentionally non-adherent for many reasons. Therefore, be sure to ask if the patient is taking all of their medications. 02.01.05 The Medication History Identify actual or potential drug-related problems: Adverse drug events Adverse drug withdrawal events Medication errors Overdose/Overuse Underuse/Therapeutic failure Nonadherence Graves T, Hanlon JT, Schmader KE, et al. (1997). Adverse events afterdiscontinuing medications in elderly outpatients. Arch Intern Med. 157: 2205-10. With information gathered from the medical records and from the medication history, identify actual or potential drug-related problems including those listed on your screen. Identify and differentiate between the occurrence of a drug allergy and an adverse drug event, and document accordingly. Keep in mind that elderly patients may present with atypical signs of disease. Adverse drug events may go unrecognized. For example, the geriatric patient with digoxin toxicity may merely present with confusion or psychosis, and not with the well-recognized arrythmogenic or appetite-suppressant affects of digoxin toxicity, or even the less-common yellow-green halos in their visual fields. Therefore, a thorough examination of all potential drug-related problems is needed. Some medications may precipitate an adverse drug withdrawal event, so inquire about medications that have recently been discontinued. Effects of adverse drug withdrawal events can include exacerbation of the underlying disease state, or a manifestation of a new symptom set. Medications known to induce an adverse drug withdrawal event by exacerbation of an underlying disease state include: anti-Parkinson medications, diuretics, clonidine, and digoxin. Medications causing a physiological withdrawal include antipsychotics, corticosteroids, antidepressants, benzodiazepines, and narcotics.

Finally, dont forget to check for medication errors, medication misuse, and nonadherence. Remember Dr. Avorns comments about Americas hidden drug problem: that in the elderly, non-adherence may be intentional or unintentional. 02.01.06 Additional Methods to Determine Medication Appropriateness Drug utilization review (DUR) Drug utilization evaluation (DUE) Medication Appropriateness Index (MAI) Is there an indication for the drug? Is the medication effective for the condition? Is the dosage correct? Are the directions correct? Are the directions practical? Are there clinically significant drug-drug interactions? Are there clinically significant drug-disease interactions? Is there unnecessary duplication with other drugs? Is the duration of therapy acceptable? Is this drug the least expensive alternative compared to others of equal utility? Hanlon JT, Schmader KE, Samsa GP, et al. A method of assessing drug therapy appropriateness. JClin Epidemiol. 1992 ; 45(10): 1045-51. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_ui ds=1474400&dopt=Abstract Beers Criteria http://www.americangeriatrics.org/health_care_professionals/clinica l_practice/clinical_guidelines_recommendations/2012

Additional methods to investigate medication appropriateness include drug utilization review and drug utilization evaluation. A drug utilization evaluation is a literature-based, systematic evaluation of a particular medication or medication class to determine whether the medication is being used according to set process and outcome criteria. The Medication Appropriateness Index, or MAI, is a tool that has been determined to be both valid and reliable in assessing medication

appropriateness. The list of questions in the MAI is listed on your screen. For further information about the MAI, consult its reference which is linked to on your screen and is also listed at the end of this Review Concept. The Beers criteria was developed by an expert panel of geriatric health care providers who identified medications that should be avoided in the elderly. The Beers list is not just a catalog of drugs to avoid, but also a list of potentially harmful drug-disease interactions. A list of those medications can be found in the most recent version of the Beers criteria by clicking on the reference link on your screen (below). The presence of a Beers medication found on medication history should be a red flag to further assess risk versus benefit of use in that patient. The 2012 Beers Criteria, see: http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clin ical_guidelines_recommendations/2012

Which of the following is NOT assessed by the Medication Appropriateness Index? A. B. C. D. Whether the dose is correct Whether the directions are practical Whether the duration is acceptable Whether adherence is adequate

CORRECT ANSWER: D. Adequate adherence is not directly assessed by the MAI.

STOPP /START Criteria

Gallagher P, O'Mahony D. STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions): application to acutely ill elderly patients and comparison with Beers' criteria. Age and Ageing 2008;37:673-9. Barry PJ, Gallagher P, Ryan C, O'Mahony D. START (screening tool to alert doctors to the right treatment)an evidence-based screening tool to detect prescribing omissions in elderly patients. Age and Ageing 2007;36:632-8. Gallagher PF, et al. Clin Pharm & Ther. 2011;89(6):845-854. The STOPP / START Criterion was developed by Paul Gallagher, PhD and colleagues and validated in 2008. While the study was not powered to evaluate outcomes like falls or adverse drug effects, the study did show significant improvements in medical appropriateness and underutilization of medications. With a list of medical conditions and an accurate medical history, applying the STOPP/START criteria was found to take a median of 3 minutes, making it an option for both inpatient and outpatient settings. Certain drugs on the Beers list are controversial because they sometimes ARE appropriate in older patients, such as amitriptyline, amiodarone, and naproxen. STOPP includes some of these, but provides more guidance on where they may be appropriate. For more information:

http://www.cumbria.nhs.uk/ProfessionalZone/MedicinesManagement/Guidelines/ StopstartToolkit2011.pdf 02.01.07 Social History Gather Data on the Patients Social Network: Extent of social network Level of contact/isolation Living conditions Family, friends, and/or contacts that provide: Assistance Information Emotional support Companionship

It has been said that the most important member of the geriatric interdisciplinary team is the social worker. That is why the social history becomes an extremely important component of the geriatric assessment. Lack of social support is a predictor of declining functional status and mortality in the elderly. You should try to identify the patients social support network. Try to determine if the patient lives alone and who the primary caregiver is. Be certain to obtain contact numbers from caregivers. Inquire about children and where they live; the realization is that many elderly patients have children that are a great distance away. Also inquire about other companions and identify the quality of the relationship the patient has with others. For instance, does the patient have only acquaintances, or does the patient have close relatives or friends that he or she would be able to confide in and depend on? In order for the pharmacist to creatively provide solutions to complex medication management problems, the pharmacist often needs to know and rely upon a patients social network. 02.01.08 Nutrition History Look for Indications of Malnutrition Medications

Emotional problems Anorexia/Alcoholism Late life paranoia Swallowing difficulties Oral factors No money Wandering Hyperthyroidism Enteric problems Eating problems Low salt/Low fat diets Social problems http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_ui ds=7486469&dopt=Abstract Identify Drug-Nutrient Interactions Eliminate Unlikely Causes and Treat the Underlying Condition

Morley LE, Silver AJ. Nutritional issues in nursing home care. Ann Intern Med. 1995; 123: 850-59. Boullata JI and Armenti VT. Handbook of Drug-Nutrient Interactions. Totowa, New Jersey: Humana Press, 2004.

A nutrition history is a fundamental part of the health history. Malnutrition may result from a variety of chronic conditions, and in turn, can result in impaired wound healing, osteopenia, risk of falls, and other chronic conditions. Medications can ultimately cause weight loss by causing dysphagia (difficulty swallowing), nausea, vomiting, diarrhea, anorexia, and dysgeusia, or taste disturbances. The Centers for Medicare and Medicaid Services (CMS) includes weight loss as a quality measure in nursing homes, so active pharmacist involvement in the assessment and management of weight loss will likely be necessary. In addition to weight loss, medications may also be the cause or object of drug-nutrient interactions. Drug-nutrient interactions may be due to: altered nutrient absorption such as fat soluble vitamin malabsorption with cholestyramine; altered medication absorption

such as decreased absorption of ciprofloxacin with enteral feedings and chelation with calcium-rich foods; and finally, altered metabolism of medication by a nutrient such as altered first-pass metabolism of buspirone in the presence of grapefruit juice. For additional information on drug-nutrient interactions, please refer to the references listed on your screen and at the end of this Review Concept. 02.01.09 Family History Note examples of familial diseases and look for trends in frequency and severity of familial diseases Medical Cancer Diabetes Alzheimers disease Cardiovascular disease Alcohol abuse / Substance abuse / Tobacco abuse Psychiatric Depression Mood disorders Schizophrenia

The family history sheds light on inherited disorders or genetic predispositions that may affect the patients health status. Conditions such as diabetes, Alzheimers disease, and other disorders that have an inheritable component should be identified and considered. The documentation of family information can provide important insights for treating the elderly patient. One must always remember, however, that a familial tendency to inherit a particular disease does not guarantee that the patient will experience the same clinical course. Modern technology allows us to detect such diseases much earlier in their progression, and more effective treatments are being developed every day. 02.01.10 Development of an Assessment and Plan Create a problem list, noting: Description of complaints Duration complaints

Signs and symptoms related to complaints Actions taken to alleviate complaints Effectiveness of treatments

Identify drug-related problems: Adverse drug events Medication errors Overuse/Underuse Non-adherence Develop appropriate plans: Clear, executable directions Monitoring parameters for effectiveness Monitoring parameters for toxicity Clear goals

You should explore patient complaints to determine if a condition exists in which drug therapy may be helpful but is not currently being used or used optimally. Recognize that some elderly may under-report problems they feel are attributed to growing old. For example, pain is often under-reported. Some diseases, such as depression, are associated with stigmas and therefore the elderly are less likely to openly acknowledge any thoughts of depression. In addition to exploring overt patient complaints, another important part of assessment is the identification of other actual or potential drug-related problems, as described earlier. Once your assessment is complete, develop an appropriate plan that includes realistic treatment goals agreed to by the patient and team. The goals of treatment may be to prevent disease, to cure acute disease, or to prevent further decline from disease. Maximizing function and optimizing quality of life to the fullest extent possible are always treatment goals. Lastly, include executable monitoring parameters for effectiveness and toxicity. Please note that clinical assessments and therapeutic plans may not be developed until all components of the full geriatric assessment are complete. Therefore, although not yet discussed in this Review Concept, physical examination data and laboratory data, in addition to functional assessments may need to be considered before developing a patient assessment and plan. After collecting pertinent subjective and objective information, an assessment and plan is needed. Which of the following is NOT a component of a well written plan?

A. B. C. D.

Rationale for assessing a drug related problem exists Clear goals of therapy Monitoring parameters for effectiveness Monitoring parameters for toxicity

Answer response: Correct answer is A. Clear, defined goals of therapy, coupled with monitoring parameters for both effectiveness and toxicity are imperative pieces of well written patient plan.

02.01.11 Resources For additional information, see: Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 2003 Dec 822;163(22):2716-24. Boullata JI and Armenti VT. Handbook of Drug-Nutrient Interactions. Totowa, New Jersey: Humana Press, 2004. Graves T, Hanlon JT, Schmader KE, et al. Adverse events afterdiscontinuing medications in elderly outpatients. Arch Intern Med. 1997;157:2205-2210. Hanlon JT, Schmader KE, Samsa GP, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol. 1992;45(10):1045-1051. Hanlon JT, Shimp LA, Semla TP. Recent advances in geriatrics: drug-related problems in the elderly. Ann Pharmacother. 2000;34:360-365. Kimberlin CL. Communicating with the elderly. In: Delafeunte JC, Stewart RB, eds. Therapeutics in the Elderly. 3rd ed. Cincinnati, OH: Harvey Whitney Books Co, 2001: 63-85. Maka DA, Murphy LK. Drug-nutrient interactions: a review. Advanced Practice in Acute and Critical Care. 2000;11(4):580-589. Morley JE, Silver AJ. Nutritional issues in nursing home care. Ann Intern Med. 1995;123: 850-859.

Owens NJ, Silliman RA, Fretwell MD. The relationship between comprehensive functional assessment and optimal pharmacotherapy in the older adult. DICP. 1989;23:847-854. Pytlarz A. Medications and involuntary weight loss. Consult Pharm. 2002;17(6):485-6, 488, 491-2, 494-5. Reuben DB, Siu AL, & Kimpau S. The predictive validity of self-report and performance-based measures of function and health. J Gerontol. 1992;47:M106-M110. Gallagher P, O'Mahony D. STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions): application to acutely ill elderly patients and comparison with Beers' criteria. Age and Ageing 2008;37:673-679. Barry PJ, Gallagher P, Ryan C, O'Mahony D. START (screening tool to alert doctors to the right treatment)an evidence-based screening tool to detect prescribing omissions in elderly patients. Age and Ageing 2007;36:632-638. Gallagher PF, OConnor MN, OMahony D. Prevention of potentially inappropriate prescribing for elderly patients: a randomized controlled trial using STOPP/START criteria. Clin Pharm & Ther. 2011;89(6):845-854.

Websites: American Society of Consultant Pharmacists: http://www.ascp.com Nursing Home Compare: www.medicare.gov/NH Compare/home.asp

Module 2, Section 2: Physical Examination of the Elderly

02.02.01 Role of the Physical Examination in Geriatric Assessments Health History Physical Examination Functional, Cognitive and Affective Assessments Laboratory Tests

The physical examination is a crucial component of the geriatric health assessment. In addition to confirming information gathered during the health history, the physical exam provides data on the patients overall health status, and may uncover new information that is critical to the differential diagnosis and treatment of the patients medical complaints and conditions. 02.02.02 The General Sequence of the Physical Examination Vital signs General appearance Skin Head, ears, eyes, nose and throat (HEENT) Neck Breasts Lungs Heart Abdomen Genitalia/Rectum Extremities Neurological examination

The general components of the physical examination are listed in the order in which they usually appear, although some minor variation exists. Knowing how various diseases and disorders manifest themselves in a patient is essential to the pharmacist. Knowing what to look for is more important than knowing what to look at. A complete description of techniques used to conduct the physical exam

will not be given. For a complete review of the physical examination, please refer to the references at the end of this Review Concept. 02.02.03 Physical examination: Vital signs Blood pressure Staging and Goals: BP Classification Normal Prehypertension Stage 1 hypertension Stage 2 hypertension Systolic BP, mm Hg* <120 120-139 140-159 >160 and or or or Diastolic BP, mm Hg* <80 80-89 90-99 >100

Treatment determined by highest BP category Treat patients with CHRONIC KIDNEY DISEASE or DIABETES to BP goal of less than 130/80 mm Hg **** Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.

FROM: National Guideline Clearinghouse: www.guidelines.gov: http://www.guidelines.gov/summary/summary.aspx?doc_id=4771&nbr=3450&stri ng=Seventh+AND+report+AND+Joint+AND+National+AND+Committee+AND+Pr event JNC VII: Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ; Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee. Hypertension. 2003 Dec;42(6):1206-1252. America Diabetes Association Clinical Practice Recommendations: Diabetes Care. 2011;34 (Supplement 1). http://care.diabetesjournals.org/content/34/Supplement_1/S11.full

Recommended goal blood pressures are listed for you on your screen. Blood pressure goals are the same for elderly patients as they are for younger patients. At times, it is often difficult to reach these goals for various reasons; sometimes the risk of hypotension with orthostasis and falls is too great, sometimes the patients blood pressure may be resistant to change, and in other instances, pseudohypertension may be suspected. However, none of these suggest that blood pressure cannot or should not be treated in the elderly. Many patients can achieve goal blood pressures without excessive risk and lowering blood pressure is associated with significant reductions in coronary heart disease (JNC VII). It is, however, suggested that stringent blood pressure goals in accordance with the likes of JNC VII guidelines may not be reasonable for all elderly patients. In 2011, the American College of Cardiology Foundation (ACCF) / American Heart Association (AHA) Task Force suggested that a higher systolic goal of say 140145mmHg may be good enough to gain the benefits of blood pressure control while minimizing the risks. Thus, the most important clinical pearl in managing elderly hypertensive patients is that each patient should be handled carefully, and in relation to their concurrent therapies. That said, some problems associated with blood pressure monitoring that the pharmacist needs to know include: Pseudohypertension is a falsely elevated blood pressure reading in some patients with arterial disease. Oslers sign is a test one can perform when pseudohypertension is suspected. It is the presence of a palpable radial artery despite inflation of the blood pressure cuff above the systolic pressure. Normally, the artery would not be palpable at that time, but due to stiffened arteries that are not able to occlude adequately, a pulse can still be palpated. Note that Oslers sign is not very sensitive or specific and therefore is not diagnostic of pseudohypertension, but it can be used to troubleshoot.

02.02.04 Vital Signs: Blood Pressure Blood Pressure Orthostasis: Decrease in systolic blood pressure 20mmHg or Decrease in diastolic blood pressure 10mmHg or Rise in heart rate 10 bpm upon change in position (supine to sitting, sitting to standing) Factors affecting blood pressure readings: Inappropriate cuff size Pain, anxiety Post-meal readings Dehydration Pulse pressure = Systolic blood pressure Diastolic blood pressure

Blood pressure should be measured in the older adult on several occasions and in different positions. Orthostasis is common in patients who are dehydrated and is also caused by many different classes of medications including many cardiovascular agents, anti-Parkinsonian drugs, and anti-psychotic agents. Patients should be counseled to change positions slowly to avoid drops in blood pressure.

Several factors can affect blood pressure and these should be considered when interpreting readings. For instance, using a cuff that is too large for a patient may lead to an underestimation of blood pressure. Conversely, using a cuff that is too small can lead to an overestimation of blood pressure. Pain, anxiety, agitation, excessive physical exertion will all increase blood pressure, and volume depletion and recent consumption of a large meal can decrease blood pressure.

Pulse pressure is the difference between the systolic and diastolic blood pressures. It is normally between 30 and 70 mmHg. A widened pulse pressure is suggestive of atherosclerosis, aortic valve insufficiency, or anemia. 02.02.05 Vital Signs: Heart Rate, Respiratory Rate, Temperature, and Pain Heart rate: Sinus bradycardia < 50 bpm, sinus tachycardia > 100 bpm Respiratory rate: Normal 12 20 respirations per minute Temperature: Thermoregulatory dysfunction occurs in the elderly Pain: The fifth vital sign Respiratory rate is commonly known to be affected by respiratory disease such as chronic obstructive pulmonary disease and pneumonias, but dont forget nonpulmonary causes of altered respiratory rate. For instance, anxiety can cause tachypnea (respiratory rate > 20 breaths per minute) while narcotics can cause bradypnea (respiratory rate < 10 breaths per minute). Thermoregulatory dysfunction occurs in the aged so that elderly patients are prone to both hypothermia and hyperthermia. They are able to sweat less and can become overheated easily. At the same time, patients may be afebrile despite infection because they cant mount an increase in body temperature as well as young patients. 02.02.06 Physical Examination: General Orientation: Alert and oriented to person, place, and time (A&Ox3) Fully alert vs. disoriented Affect: Agitated, anxious, complacent, withdrawn Signs of distress: Respiratory distress with labored breathing, emotional distress, signs of pain Hygiene: Well groomed, disheveled, fetid odor Skin color:

 Pallor (white or non-colored) Jaundice (yellow) o Example: http://jaundicesymptoms.org/ Hypoxic, cyanotic (blue / ashen) Erythematous (red) When observing the general appearance of a patient, utilize your visual, olfactory, and auditory senses. An assessment of these items listed on your screen can be performed by a pharmacist in almost any setting. Inspect the patient for signs of disorientation and confusion. The key is to be observant. Note the patients general appearance. Do they look agitated, uncomfortable, or content? Look for visible signs of respiratory distress which may suggest cardiopulmonary problems or anxiety or agitation. Look for apparent weight changes such as ill-fitting clothing. Inspect their skin for color changes. Pallor skin may be suggestive of anemia, while yellow skin may be suggestive of hepatobiliary disease or hemolysis. Blue skin color is suggestive of cardiopulmonary disease, peripheral vascular disease or methemoglobinemia. 02.02.07 Physical Examination: Select Skin Findings Skin disorders: In addition to observing the skin for general health, learn to recognize common skin diseases in the elderly, including drug-induced reactions For a more detailed discussion, refer to the Dermatology Review Concepts. Angioedema: Non-pitting edema sometimes associated with medications such as angiotensin converting enzyme inhibitors and angiotensin II receptor antagonists Actinic keratosis Basal cell carcinomas Drug eruption: Maculopapular rash associated with virtually any drug Herpes Zoster

Vesicular rash usually appearing along a dermatome caused by the herpes zoster virus.

Malar rash with systemic lupus erythmatosus: Rash on the cheeks and bridge of the nose resembling a butterfly Seborrheic dermatitis: Flaking of skin with yellow greasy looking scales common on the scalp and face Stevens Johnson syndrome: Mild to severe, exfoliative rash associated with sulfonamides, nonsteroidal anti-inflammatory drugs, penicillins, allopurinol, carbamazepine, amiodarone, and viruses and bacteria Toxic Epidermal Necrolysis: Acute, severe and extensive rash associated with fluid electrolyte imbalances due to water losses Can be caused by sulfonamides, phenytoin, carbamazepine, allopurinol, and barbiturates Skin turgor: The rate at which the skin returns to the pre-pinched state after pinching Decreased skin turgor is suggestive of dehydration in younger adults, but may be misleading in the elderly Learn to recognize the following skin reactions: Angioedema: Commonly involves the eyes, lips, tongue, and throat. Associated with Angiotensin converting enzyme inhibitors and less so with Angiotensin II receptor blockers Drug eruption: Can occur with any drug anywhere on the body. It is important to ascertain the relationship between the drug eruption and the time course for exposure. Herpes zoster: Common infection in immunocompromised elderly. The rash is characteristically visible along a dermatome. Malar rash: The pharmacist should recognize this characteristic sign of systemic lupus erythmatosus. Note however, that this rash may be absent in elderly lupus patients. Seborrheic dermatitis: Excessive production of sebum. Appears as yellowish-red, greasy scales on the scalp, face, and eyebrows.

Stevens-Johnson syndrome: Often drug induced. Can be caused by sulfonylureas, penicillins and nonsteroidal anti-inflammatory drugs. Toxic Epidermal Necrolysis (TEN): Drug induced. Causes include sulfonylureas, nonsteroidal anti-inflammatory drugs, phenytoin, and others.

Skin turgor is the ability of the skin to smooth out after pinching it between the thumb and forefinger, and it varies with age and hydration. In well hydrated individuals, the skin usually smoothes out after it is pinched. In dehydrated, younger patients, tenting, occurs, or the skin appears to stay in its pinched state. However, elastin and collagen are decreased in the elderly so that the skin is not as elastic as it once was and the tenting may be retained even in individuals without dehydration. 02.02.08 Physical Examination: Head, Ears, Eyes, Nose and Throat (HEENT) Look for: Nystagmus: Involuntary movement of the eyes in any of direction (horizontal, vertical, diagonal) Can occur with phenytoin toxicity For an example of nystagmus, see: http://www.mrcophth.com/eyeclipartchua/opticokineticnystagmus.html Xanthelasma: Lipid plaque deposits on or near the eyelids suggestive of hyperlipidemia o Example: http://www.healthcare.uiowa.edu/dermatology/Xanthel001.htm Angular cheilitis: Chronic inflammation of the skin around the mouth causing erosion and fissures Caused by nutritional deficiencies and dermatitis Example: http://angularcheilitis.us/angular-cheilitis-information Smooth tongue: Occurs with B12, folic acid, iron, B6 deficiencies Example: http://www.library.vcu.edu/tml/oralpathology/soft.html

Fissured tongue: Often benign and occurs with aging, but exacerbated by xerostomia (dry mouth) which in turn is caused by many medications (anticholinergic medications) Example: http://www.library.vcu.edu/tml/oralpathology/soft.html Oral candidiasis: Infection of the oral mucosa caused by candidal infections Drug induced causes include steroids (specifically inhaled) and other immunosuppressants, and antibiotics Example: http://oralcancerfoundation.org/dental/candida.htm Gingival hyperplasia: Overgrowth (not inflammation) of gingival, common with phenytoin and calcium channel blockers Example: http://www.sciencephoto.com/media/257364/enlarge 02.02.09 Physical examination: Select Neck Findings Jugular Venous Distension (JVD): FROM: http://www.aafp.org/afp/20000301/1319.html Jugular venous pressure (JVP): A surrogate for right atrial pressure (or central venous pressure) Measured as the vertical distance between the top of the pulsation and the sternal angle with the head of the bed elevated 30O, normally less than 3-4 cm, elevated with right sided heart failure Hepatojugular reflux (HJR): Visible congestion in the jugular veins when the liver is compressed for ~ 30 seconds Elevated in heart failure

Thyromegaly/thyroid nodules: Nonspecific and may be associated with hypothyroidism, euthyroidism, or hyperthyroidism

Even if you dont perform these physical examination techniques in your practice, you should be able to recognize and appropriately interpret their results when seen in a medical chart. Elevated jugular venous pressure and hepatojugular reflux have pharmacological implications since elevated findings may suggest

fluid overload and the need for optimization of diuretic therapy in a patient with heart failure. 02.02.10 Physical examination: Select Lung Findings Lung fields: Areas of the lung that can be auscultated (heard with a stethoscope) and percussed (tapped) For chest sites: http://medinfo.ufl.edu/year1/bcs/clist/chest.html#AA4 Lung sounds (breath sounds) on percussion include: Flat: High pitch, short duration Heard with pleural effusions Dull: Medium pitch, medium duration Heard with pneumonia and large effusions Resonant: Low pitch, long duration Heard with normal lungs, chronic bronchitis, and early heart failure Hyperresonant: Lower pitch, longer duration than resonant Heard with emphysema, pneumothorax, and asthma Tympanic: High pitch, musical sounding Heard with pneumothorax

Breath sounds on auscultation: Decreased with certain forms of pneumonia, effusion, asthma, chronic obstructive pulmonary disease Rales (crackles): Sound like crackling of hair between your fingers Suggestive of fluid in the lungs Occurs with heart failure and pneumonia Wheezes: Occurs during expiration or with expiration and inspiration Occurs with chronic bronchitis and asthma Rhonchi: Possesses a snoring-like quality Occurs with chronic bronchitis

These, as well as adventitious lung sounds (wheezes, rhonchi, crackles) can be heard at: http://www.cvmbs.colostate.edu/clinsci/callan/breath_sounds.htm

Accessory muscles: Neck muscle (sternocleidomastoid and anterior and middle scalene) contractions visible with labored breathing, as occurs with chronic obstructive pulmonary disease

Lung sounds can be assessed by percussion (tapping) and auscultation (hearing with a stethoscope). Abnormal lung sounds, or breath sounds, on percussion include flatness, dullness, resonance, hyperresonance, and tympany. Accessory muscles are neck muscles visible with labored breathing. 02.02.11 Physical examination: Select Heart Findings Where to listen to the heart: Heart sounds can be heard at the apex (usually at the left 5th intercostal space at the midclavicular line), lower left sternal border (3rd 5th intercostal space at the left side of the sternal border), second left and right intercostal spaces to the left and right of the sternal border respectively Normal heart sounds: S1, S2 (sounds like lub-dub) Which represents AV (mitral and tricuspid) valve closure and semilunar (aortic and pulmonic) valve closure, respectively Abnormal heart sounds: S3 (sounds like lub-da-bub) Representing early diastolic ventricular filling Common in heart failure but need not be heard in patients with heart failure S4, (late diastole) Murmurs, rubs, or gallops

For more information and a demonstration on hearing heart sounds, murmurs, rubs and gallops, see: The Auscultation Assistant

The grading scale for heart murmurs was included for a review, so even if the

pharmacist does not listen to the heart in practice, they can still interpret the grading of the murmur when listed in the patient chart. 02.02.12 Physical examination: Abdomen Bowel sounds: Active Overactive Underactive Absent Boating / constipation: Easily elicited from interview Exacerbated by medications Lack of adequate exercise Lack of adequate hydration For a review on abdominal findings, such as organomegaly, please see the references at the end of this Review Concept Abdominal pain: Diverticular disease Cancers (e.g., colon, pancreatic) Gall bladder Exam findings: Ascites / distension Fluid thrill Fluid wave GI Blood loss: BRBPR: Bright, Red Blood Per Rectum suggests that there is bleeding in the lower gastrointestinal system Melena: Dark blood per rectum suggests there is bleeding in the upper gastrointestinal system (allowing the blood to be digested) Enlarged prostate: Occurs in patients with benign prostatic hyperplasia (BPH) The prostate undergoes 2 growth spurts: One at puberty and another around 45 years of age In the young adult, it weighs approximately 20 grams and grows during this second growth spurt

The size of the prostate does not correlate well with symptoms of BPH

An abdominal exam is necessary any time a patient presents with changes in bowel function or new onset abdominal pain. Changes in bowel function can result in either diarrhea, constipation or flatulence secondary to such common diseases as diverticulosis, Parkinsons disease, diabetes mellitus, and clostridium difficile infection. Pain can be an early sign of cancer of the pancreas or colon. Pain can also be related to biliary disease, perforation of the stomach or intestines, ulcers and hernias. While most pharmacists will never perform an abdominal exam, it is important to understand the importance of a patients complaints and the need to refer to a physician.

02.02.13 Physical examination: Select Extremities Findings Peripheral edema: Swelling with or without pitting Observed with heart failure, hepatic disease and nephritic syndrome Clubbing: Physical deformity of the fingers and toes in which the angle between the nail and skin is lessened and the nail becomes convex Observed in heart failure and chronic obstructive pulmonary disease Cyanosis: Seen in cardiopulmonary disease and in Raynauds disease Raynauds disease is characterized by intermittent, poor circulation to the extremities, leading to paroxysmal pallor and cold fingers and toes

Peripheral edema, clubbing and cyanosis are all easily assessed by the pharmacist upon inspection in almost any setting. Pitting edema may be a sign of worsening heart failure, in which case optimization of diuretic therapy may be warranted. Cyanosis due to Raynauds disease may be exacerbated by the use of beta blockers.

Clubbing is associated with COPD and poor oxygen saturation, possibly indicative of the need for better bronchodilator therapy or oxygen supplementation. 02.02.14 Physical examination: Select Musculoskeletal findings Osteoarthritis (OA): Joint hypertrophy Palpable nodes with proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints Joint crepitus (grinding) Physical exam shows restricted joint movement Pain Rheumatoid Arthritis (RA): Boutonniere deformity, swan neck deformity, and ulnar deviation are all joint deformities that occur with severe RA Boutonniere deformity is flexion of the proximal interphalangeal (PIP) joint with hyperextension of the distal interphalangeal (DIP) joint Example: http://www.cedars-sinai.edu/Patients/HealthConditions/Arthritis---Rheumatoid-Arthritis-Osteoarthritis-andSpinal-Arthritis.aspx Swan neck deformity is hyperextension of the proximal interphalangeal (PIP) joint with flexion of the distal interphalangeal (DIP) joint Ulnar deviation is deviation of the digits away from the thumb toward the ulnar bone Physical deformities associated with osteoarthritis and rheumatoid arthritis (RA) are easy to identify. Learn to familiarize yourself with these findings so you can spot RA easily. Severe deformity may preclude the patient from opening a medication vial and taking their medication. If you are interviewing a patient with OA or RA, attempt to have them open their vials and pour out the medication so you can better determine if medication handling and adherence are affected. It is important to recognize and interpret muscle strength. Know what a scale of 2 means as opposed to a scale of 5. Dont confuse these numbers with those

used to test reflexes the scales are different. Muscle strength is affected by numerous diseases in the aged. Negative consequences on instrumental activities of daily living, including medication management can occur with decreased muscle strength. Muscle strength: Scale of 0 5 0: No contraction detected 1: Barely detectable contraction 2: Movement with gravity eliminated 3: Movement against gravity 4: Movement against gravity with resistance 5: Movement against gravity with strong resistance

02.02.15 Physical examination: Select Neurological Findings Mini Mental State Examination: See cognitive assessments in section 2.03 Motor: Tardive dyskinesias: Neurological syndrome related to long-term use of neuroleptic drugs Repetitive, involuntary, purposeless movements Grimacing, tongue protrusion, lip smacking, lip puckering / pursing, rapid eye blinking Rapid movements of arms, legs, or trunk may also occur Involuntary movements of fingers may be look like the patient is playing an invisible guitar or piano Oral facial dyskinesias: Repetitive, rhythmic movements of the face commonly involving the tongue, mouth, lips and jaw When caused by antipsychotics, referred to as tardive dyskinesia Hypomimia: Masked facies, or expressionless face that occurs in Parkinsons Disease Resting tremor: Often described as pill rolling, occurs at rest and is alleviated by purposeful movement Occurs with Parkinsons Disease Cogwheel rigidity:

Rigidity of the arm upon flexion or extension similar to that of a ratchet observed in patients with Parkinsons disease or drug induced Parkinsonism (example: due to antipsychotics) Asterixis: Flap of both hands when hyperextended, suggestive of a metabolic encephalopathy Essential tremor: Also called action tremor or postural tremor Reflexes: Scale of 0-4 (biceps, triceps, brachial, patellar, achilles) 0: 1 hypoactive 2: Normal 3-4: Hyperactive

02.02.16 Results of the Physical Examination Integrate Data from the health history, physical exam, functional assessments, and diagnostic tests Develop a Complete Picture of the Patient Document and Interpret Findings Once the physical examination has been completed, specific laboratory tests must be ordered to investigate suspected disorders and provide any necessary monitoring data. The results of these tests will help provide a physiological basis for the patients complaints and conditions. In interpreting the results of the health history and physical examination, keep in mind that numbers and isolated findings should not dictate recommendations or a diagnosis. Incorporate findings from the health history, physical examination, functional assessments and laboratory data before developing a care plan. 02.02.17 Resources For additional information, see: Bickley LS, Szilagyi, PG. Bates Guide to Physical Examination and History Taking, 8th ed. Philadelphia, PA: Lippincott, Williams & Wilkins, 2003.

Willms JL, Schneiderman H, Algranati PS. Physical Diagnosis: Bedside Evaluation of Diagnosis and Function. Baltimore, MD: Williams and Wilkins, 1994. American College of Cardiology Foundation Task Force on clinical expert consensus documents, American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, European Society of Hypertension, Aronow WS, Fleg JL, et al. ACCF/AHA 2011 expert consensus document on hypertension in the elderly. J Am Coll Cardiol 2011;20:2037-114. Websites: Angular chelitis: http://www.stevedds.com/toppage2.htm Ascites: http://www.murrasaca.com/Hepaticirrosis.htm Clubbing: http://home.cwru.edu/~dck3/heart/observe.html Fissured Tongue: http://www.dent.ohio-state.edu/oralpath2/tongue.htm JVD: http://www.aafp.org/afp/20000301/1319.html Nystagmus example: http://www.mrcophth.com/eyeclipartchua/opticokineticnystagmus.html OA: http://www.nlm.nih.gov/medlineplus/ency/imagepages/17105.htm The Auscultation Assistant: http://www.wilkes.med.ucla.edu/intro.html DermIS: http://dermis.multimedica.de/

Module 2, Section 3: Functional, Cognitive, and Affective Assessment of the Elderly

02.03.01 The Importance of Specialized Geriatric Assessments Health History Physical Examination Functional, cognitive, and affective assessments Laboratory Tests

In addition to taking a patients health history and conducting a physical examination, it is important to assess his or her functional status, mental status and affective status. Without the results of these additional assessments, the geriatric health assessment would be incomplete. Remember that each assessment provides only one piece of the puzzle; the results of all tests must be considered when developing the patient care plan. 02.03.02 Specialized Assessments Functional Status Assessment: Activities of Daily Living (ADLs) Instrumental Activities of Daily Living (IADLs) Cognitive Status Assessment: Mini-Mental State Examination (MMSE) CLOX Drawing Test EXIT Interview Global Status Assessment: Clinician Interview-Based Impression of Change (CIBIC) Affective Status Assessment: Depression scales: Geriatric Depression Scale (GDS) Hamilton Depression Rating Scale (HAM-D) Anxiety scales: Hamilton Rating Scale for Anxiety (HAM-A) Sheehan Patient Rated Anxiety Scale

Functional limitations are known to increase with age, and they tend to affect females more often than males and African Americans more often than Caucasians. Functional limitations are associated with increased risk of institutionalization and death, and when experienced suddenly, are reliable signs of disease. Both activities of daily living and instrumental activities of daily living should be included in the functional assessment. It is also essential to assess the mental status of the patient and note any decline of cognitive abilities. The nature and duration of such declines are crucial in determining whether cognitive dysfunction is irreversible as in the case of dementia or reversible as in the case of delirium. The Mini-Mental State Examination is one tool used to assess cognition. Lastly, affective status should also be examined. Depression may be a symptom of an underlying disease; it may be misdiagnosed as cognitive dysfunction and likewise, cognitive dysfunction may be misdiagnosed as depression. Psychological tests that examine depression include the geriatric depression scale and others that are explained later in this Review Concept. 02.03.03 Functional Status Assessment: Activities of Daily Living (ADLs) Dressing Eating Ambulating Bed to chair Walking Getting outside Toileting Hygiene Bathing Brushing teeth Fixing hair

For more information: Katz Activities of Daily Living Scale - The Merck Manual of Geriatrics Basic activities of daily living include personal care tasks such as dressing, eating, ambulating, toileting and hygiene. Comorbid conditions can cause limitations in these activities. You should assess the patients functional status by asking about his ability to dress himself, feed himself, and move around the house. Also ask about toileting: ask the patient if they have difficulty getting to the bathroom or using the bathroom independently. Inquire about incontinent

episodes that may occur while trying to get to the restroom. Try and determine the amount of urine lost per episode and determine the frequency of incontinent episodes. Hygiene includes activities such as bathing, brushing teeth, and fixing hair. Declines in ADLs should be noted and evaluated further to assess the degree of dependence. Once assessments regarding the activities of daily living have been determined, the clinician may use these findings to establish a benchmark against which posttherapy functional assessments can be compared. Once interpreted, the results of this assessment will also help the health care team to determine some of the support needs of the patient. The goal of therapy is always to maximize functional ability and foster independence to the extent possible. 02.03.04 Functional Status Assessments: Instrumental Activities of Daily Living (IADLs) Shopping Housework Accounting (Banking) Food preparation (Cooking) Transportation Medication management For more information: Lawton Instrumental Activities of Daily Living Scale The Merck Manual of Geriatrics

Instrumental activities of daily living, or IADLs, include home management tasks required for independent living, and are evidence of a higher level of functioning than ADLs represent. These tasks include cooking, shopping, light and heavy housework, personal accounting, transportation, and medication management. When interpreting levels of dependence in instrumental activities of daily living, keep in mind that social factors may play a significant role. For example, providing ones own transportation may be easier if a bus stop is nearby. If a patient never learned to cook as a young adult, they will be less likely to cook as an elderly adult. As with ADLs, declines in IADLs should be noted and assessed further. Again, the goal of therapy is always to maximize functional ability and foster independence to the extent possible. IADLs tend to decline before ADLs do.

Instrumental Activities of Daily living differ from Activities of Daily Living in that they: A. B. C. D. E. Examine home management tasks instead of personal care tasks Are not necessary for independent living Are not affected by social factors Don't need to be assessed in the elderly Require ADLs to be assessed first

CORRECT ANSWER: A. Instrumental activities of daily living, or IADLs, include home management tasks required for independent living, and are evidence of a higher level of functioning than ADLs represent.

02.03.05 Assessing Cognition Obtain a history of cognitive changes from: The patient Family members and friends Other caregivers Patient records Establish a baseline from: Reports of prior functioning Explore in more detail: When symptoms began Whether the onset was sudden or gradual Whether the progression of symptoms is rapid or slow The nature of the changes Note discrepancies between cognitive assessment and functional assessment

Obtaining and documenting a history of potential cognitive decline is a fundamental component to the full work- up of dementia. Because self-reports may be unreliable, obtaining information from a caregiver is important. When questioning family members on such matters, always ask them to elaborate. Ask about the nature of the patients personality, thinking and functional skills prior to the onset of the symptoms in order to establish a baseline. Note when cognitive changes began.

Note whether the onset was sudden or gradual. Strokes are often associated with a stepwise cognitive decline that occurs with each acute vascular insult while Alzheimers disease progresses more insidiously and steadily. A full workup for dementia includes the history and physical examination including the neurological component, cognitive assessments, and laboratory work. We will discuss several of the cognitive assessment tools used to screen for dementia and to monitor dementia once diagnosed. 02.03.06 The Mini Mental State Examination (MMSE)* Assesses orientation, registration, attention and calculation, recall and language, praxis (motor tasks) Is simple and quick to administer (~10 minutes) Is widely used in the clinical setting Has been demonstrated to be valid in content and reliable upon repeat testing Is useful in screening patients for cognitive impairment but is not diagnostic for dementia Heavily dependent upon language, vision, dexterity, and education Please note that copyright issues may be a concern when using this tool.

Mini Mental State Examination Medafile: electronic MMSE *Folstein MF, Folstein S, McHugh PR. Mini Mental State: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189-198.

Cognitive impairment is associated with not only impairment in memory, but also impairment in other related skills such as language, judgment and calculation. Many medical conditions, drugs and age-related changes can impair cognitive function. There are many tools used to assess cognition, but they are not all widely administered in the clinical setting because they are time intensive and used more for research purposes. These scales will not be discussed here; however, a common tool used as a bedside screen for cognitive impairment is the Folsteins Mini Mental State Exam, or MMSE. This interview based assessment test takes about ten minutes to administer, and has high test-retest reliability. It can be used to screen for cognitive impairment, but as is the case with any other single tool, it cannot be used alone to diagnose dementia. A poor MMSE score merely prompts the clinician to conduct a further

work up including laboratory measurements which will be discussed in the next Review Concept. 02.03.07 Interpreting MMSE Scores Scoring (0-30 possible points earned): 26: 20 26: 10 19: < 10: Normal or mild cognitive impairment (subclinical) Mild cognitive impairment (MCI) Moderate cognitive impairment Severe cognitive impairment

Cut-off scores for cognitive decline (adjusted for educational background): Some clinicians use a cut-off = 17 for patients with low education levels

Scores on the Mini Mental Status Exam range from 0 to 30. Scores greater than 26 are considered normal, or, may reflect mild cognitive impairment that is subclinical. Scores of 20 to 26 suggest mild clinical cognitive impairment, while scores of 10-19 suggest moderate cognitive impairment, or MCI. A score of below 10 is suggestive of severe cognitive impairment. Several caveats must be considered when interpreting scores on the MMSE. Since the MMSE requires patients to do some elementary reading, writing and math, a patients educational level must be considered. Also, patients with visual or auditory impairment may not be able to complete some portions of the MMSE and may lose points if the sensory impairment is not recognized or accounted for. Using adjusted cut off scores for patients with varying levels of education has been suggested.

When assessing a patients cognitive status, it is essential to identify: A. The patient's general intelligence quotient (IQ) B. The progression of cognitive changes C. The education level of the patient's parents D. All of the above CORRECT ANSWER: B. Perhaps the most critical bit of information from assessing a patients cognitive status is to identify trendsthe progression or maintenance of ones cognitive decline or function.

02.03.08 Screening for Alzheimers Disease: Other Tests CLOX Drawing Test & The Executive Interview CLOX Drawing Test: Differentiates between patients with Alzheimers disease and those with depression and normal mental status Valid and reliable tool with high sensitivity and specificity Easy to administer and quick to administer Example form: http://www.nccd-crc.org/nccd/dnld/APS/clox.pdf

The Executive Interview: Also called EXIT25 Scores range from 0 to 50 Higher scores correlate to greater impairment Cut-off of 15/50 best separates non-demented elderly from demented elderly EXIT25 is more sensitive than the MMSE to early cognitive impairment

The CLOX Drawing Test is a test of executive function. It requires patients to draw a clock in a preformed circle. Patients earn points for drawing a figure that resembles a clock. Specifically they receive points for writing in the numbers correctly in their appropriate positions, with appropriate spacing between the numbers. They receive points for drawing an hour hand and a minute hand correctly and positioning it correctly to identify the time they are told to identify. Patients with Alzheimers disease have a particularly hard time conceptualizing and drawing the clock. The CLOX Drawing Test is a simple and quick test to administer to screen for Alzheimers disease. It is usually administered along with the Mini Mental State Examination. The EXIT Interview, or EXIT-25, is another measure of executive control. A test based out of 50 points, it has been identified by Royall et al., amongst others, to be a better correlate with early cognitive impairment than its MMSE counterpart. A higher score on the EXIT Interview suggests greater impairment, with scores less than 15 being the cut-off for non-demented individuals.

Both the CLOX Drawing Test and the EXIT Interview are assessments that force the patient to take a verbal command, format a plan, and execute that plan effectively. Other cognitive assessments used in older adults include the MOCA (Montreal Cognitive Assessment) and the SLUMS (St. Louis University Mental Status Exam). For more information see: MOCA - http://www.mocatest.org/ SLUMS - http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf 02.03.09 Global Functioning Clinician Interview- Based Impression of Change (CIBIC): Evaluates global functioning, including cognition, behavior, and function Less structured interview-based assessment, sometimes videotaped Physician rates their impression of change in global functioning 7 point scale: 1 (marked improvement) to 7 (marked worsening) 4 being no change CIBIC-Plus includes caregivers perception of change Inter-rater reliability low but used clinically because an interview is conducted routinely anyway and because caregiver input is always sought Several versions exist

Quinn J, Moore M, Benson DF, et al. A videotaped CIBIC for dementia patients: validity and reliability in a simulated clinical trial. Neurology. 2002;58(3):433-437.

The CIBIC and CIBIC-Plus are less structured interview-based assessments that use open-ended questions to gain a sense of the patients overall global functioning. It informally evaluates cognition, behavior and function. Because there is not a set of standard questions that are asked for the different domains it assesses, it cannot be used to quantitate change in any area. It is merely used during the interview process with patients or patients and caregivers to gain a better sense of improvement or decline from baseline. 02.03.10 Affective Status Assessment Affective Status Assessment

Depression assessments: Geriatric Depression Scale (GDS): popular, easy to administer, short assessment tool deemed valid and reliable, several variations exist, scoring depends on the version used Hamilton Depression Scale (HAM-D): also popular but lengthier Anxiety assessments: Hamilton Anxiety Scale (clinician-rated): HAM-A Sheehan Patient Rated Anxiety Scale Conduct a clinical interview to confirm symptoms and investigate: Onset and length of episode History of previous episodes and treatment for it Family history of condition History of drug and alcohol abuse Document and interpret findings

Geriatric Depression Scale - The Merck Manual of Geriatrics (online) Sheehan Patient Rated Anxiety Scale. From: Diagnosis and Treatment of Anxiety Disorder: A Physicians Handbook. American Psychiatric Press, 1989. Hamilton M. Hamilton Anxiety Scale: The assessment of anxiety states by rating. British Journal of Medical Psychology. 1959;32:50-55.

Affective status assessments evaluate the emotional state of the patient and help in the diagnosis of psychiatric illnesses such as anxiety and depression. The Geriatric Depression Scale, for example, is designed specifically for identifying and measuring depression in the elderly. The Geriatric Depression Scale can be easily administered, and helps assess the severity of the depression. The Hamilton Depression Scale is also helpful in assessing depression. Anxiety assessment scales include the clinician-rated Hamilton Anxiety Scale and the Sheehan Patient Rated Anxiety Scale, although other assessment tools exist. Clinician-rated scales are preferred in long-term care settings. In addition to these instruments, a clinical interview is fundamental for both patients and family members.

Length of the depressive episode, history of previous episodes, family history of depression, and history of drug and alcohol abuse should be obtained. Elderly patients may present with atypical signs of depression; patients may complain of lack of energy and may not disclose much else. In diagnosing anxiety disorders, symptoms should be confirmed, and the duration of symptoms identified. Depression and anxiety can both cause and be caused by many other conditions. The clinical interview will further help the clinician screen the patient for depression or anxiety so he or she can receive appropriate treatment. 02.03.11 Resources For additional information, see: Alexopoulos GS, Katz IR, Reynolds CF, Carpenter D, Docherty JP. The Expert Consensus Guideline Series: Pharmacotherapy of Depressive Disorders in Older Patients. A Postgraduate Medicine Special Report. October 2001. Beers MH, Berkow R. The Merck Manual of Geriatrics. 3rd ed. Whitehouse Station, NJ: Merck Research Laboratories; 2000. Crum RM, Anthony JC, Bassett SS, et al. Population-based norms for the MiniMental State Examination by age and educational level. JAMA. 1993;269(18):2386-2391. Folstein MF, Folstein S, McHugh PR. Mini Mental State: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189-198. Jacob GM, Palmer RM. Tools for assessing the frail elderly: geriatric evaluation focuses on improving quality of life. Postgraduate Medicine. 1998;104(1):135153. Owens NJ, Silliman RA, Fretwell MD. The relationship between comprehensive functional assessment and optimal pharmacotherapy in the older patient. DICP. 1989;23:847-854. Quinn J, Moore M, Benson DF, et al. A videotaped CIBIC for dementia patients: validity and reliability in a simulated clinical trial. Neurology. 2002 Feb 12;58(3):433-437. Royall DR, Cordes JA, Polk M. CLOX: an executive clock drawing task. J Neurol Neurosurg Psychiatry. 1998 May;64(5):588-594.

Wolf-Klein GP, Silverstone FA, Levy AP, et al. Screening for Alzheimer's disease by clock drawing. J Am Geriatr Soc. 1989 Aug;37(8):730-734. Zisook S, Downs NS. Diagnosis and treatment of depression in late life. J Clin Psychiatry. 1998;59(Suppl 4):80-91. Websites: Medafile: http://www.medafile.com/mmses.htm The Merck Manual of Geriatrics (online): Katz Activities of Daily Living Scale - The Merck Manual of Geriatrics Lawton Instrumental Activities of Daily Living Scale The Merck Manual of Geriatrics

Module 2, Section 4: Laboratory Tests and Their Interpretation

02.04.01 The Importance of Specialized Geriatric Assessments Medical History Physical Examination Functional, Cognitive, and Affective Assessments Laborartory Tests

The geriatric clinician has an array of diagnostic tests and laboratory studies available to help diagnose and monitor the aging patient. The gathering of diagnostic test data is also crucial to judging the severity of the patients illness, to predicting its course and prognosis, to estimating the patients probable response to treatment, and to determining the patients actual response to therapy. Laboratory studies are especially useful in the management of elderly patients because they can often aid in the diagnosis and management of some medical problems when invasive procedures are too risky. 02.04.02 Reference Ranges and Laboratory Results in the Elderly Lab values and reference ranges are unique to the specific lab where testing occurred Reference ranges are dependent on the type of machine and reagents the particular lab is using The reference range should be noted before lab results are interpreted The reference range for most tests are the same for the elderly as they are for younger adults

Select Laboratory Results in the Elderly: Electrolytes: Fluid status can easily be disrupted in older patients Usually seen in changes in serum sodium (Na)

Hypernatremia = dehydration

Fasting glucose: Higher in the non-diabetic elderly Suggestive of declining glucose tolerance Erythrocyte sedimentation rate (ESR): Synonymous with Westergren Sedimentation Rate Increases with age Age is used in the calculation of ESR Elevations are also likely due to increased inflammatory disease in the elderly Westergren: women = (age + 10)/2 Westergren: men = age/2 Albumin: Slightly depressed in healthy elderly, but low albumin more likely due to malnutrition May also be decreased in patients with underlying liver (production) or kidney (elimination) disease TSH: Hypothyroidism is more common in the elderly than younger patients, reflected by an increase in TSH Hemoglobin (Hgb) and Hematocrit (Hct): Hgb < 13 Gm for males, < 12 Gm for females, are by definition anemic Such levels are a sign of an underlying problem requiring further investigation which cannot alone be ascribed to aging For example: iron-deficiency from probable GI tract bleeding B12 Levels: Can be depressed Reflective of: Autoimmune destruction Atrophic gastritis secondary to long-standing H. pylori Neurologic consequences of B12 deficiencies can be devastating and irreversible Prostate specific antigen (PSA): Levels increase with age, but interpretation is difficult and has yet to reach a consensus Cholesterol: Generally increases with age

Serum creatinine and creatinine clearance: Scr may appear normal in the elderly despite true decline in renal function because creatinine production in the elderly is decreased Since the Scr value is often deceivingly normal, an estimation of the creatinine clearance (CrCl) is a better marker of renal function Cockroft-Gault estimation of CrCl= (140-age) x (weight, kg*) (72) x (Scr mg/dL) x 0.85 for females

*Use ideal body weight (IBW) normally Use total body weight (TBW) if TBW < IBW Use adjusted body weight (ABW) if obese > 120% of IBW Adjusted body weight = 0.4 x (TBW IBW) + IBW Refer to GPR.com Module 17 for a more detailed discussion of renal function in the elderly Cockroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron. 1976;16:31-41.

Lab results and references ranges are unique to the specific laboratory where the analysis was performed. Reference ranges are dependent on the type of diagnostic equipment and reagents the laboratory is using. These reference ranges (although normally pretty similar) must be taken into account in order to accurately interpret test results. The reference ranges for most tests are the same for the elderly as they are for younger adults. While it is true that some laboratory measurements are elevated or depressed in the elderly, this is mainly due to subclinical or clinical disease, and usually not due to changing normal values in the elderly. For example, hemoglobin and hematocrit are often depressed in the elderly, but this is not because different norms exist; rather it is more likely that subclinical anemia exists. Likewise, while albumin levels may decrease slightly in healthy elderly, low albumin levels are more likely due to malnutrition. Some laboratory measurements warrant additional comment: Fasting glucose levels may be slightly higher in the non-diabetic elderly patient because the elderly take longer to clear their blood of glucose, suggestive of declining glucose tolerance. A clinically important exception is the serum creatinine. The serum creatinine value may appear to be normal in the elderly despite the presence of true renal insufficiency. Creatinine is a by-product of muscle metabolism and the

elderly have a reduction in their lean body mass as they get older and therefore synthesize less creatinine. This decrease in creatinine production is offset by a decrease in creatinine clearance so that the serum creatinine value appears normal despite an actual depressed clearance of the substance. A 24-hour urine collection is often unreliable in patients who have urinary incontinence or urinary retention due to benign prostatic hyperplasia. 02.04.03 Common Problems in Laboratory Specimen Collection Specimen Contamination Improper collection of specimens: Venipuncture must be collected in appropriate vials for assay; many tubes have ingredients to help with the test such as EDTA (a preservative) for CBC Specimens must be collected under sterile conditions and stored in sterile containers prior to being sent to the lab Improper transport of specimens: Refrigeration may be needed (especially if collection occurs at home) If tube is held in facility too long, blood may hemolyze or urine containers may overgrow with contaminates

To be able to rely on the accuracy of lab results, care must be taken to avoid problems during specimen collection. Specimens that are collected or transported improperly may become contaminated, compromising the reliability of the findings. Each clinical laboratory has specific procedures for avoiding such problems, and is required to report any problems with specimen collection or testing. 02.04.04 Common Laboratory Measurements for Selected Medications Lab Reference: Kratz A, Ferraro M, Sluss PM, Lewandrowski KB. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Laboratory reference values. N Engl J Med. 2004 Oct 7;351(15):1548-1563. ACEIs/ ARBs: In general, check chem7 approximately 1 week after start of therapy, and after dose changes

Allopurinol: Monitor uric acid levels, CBC, alkaline phosphatase, AST/ALT, BUN/Scr Amiodarone: Monitor EKG, thyroid function tests (TFTs), liver function tests (LFTs), baseline pulmonary function tests (PFTs) Repeat periodically and when symptoms suggest adverse event Carbamazepine (CBZ) & Valproic acid (VPA): Monitor serum levels, sodium, LFTs (especially during the first 6 months for valproic acid), CBC periodically Thiazides & Loop diurectics: Check chem7 approximately 1 week after start and after dose change Clozapine: WBC must be at least 3500 and ANC must be at least 2000 to initiate therapy Monitor WBC weekly for the first 6 months, then every other week thereafter if WBC remains normal After 12 months of continuous therapy (6 months of continuous weekly followed by 6 months of continuous biweekly monitoring), blood monitoring may be done every 4 weeks thereafter Continue monitoring WBC weekly for 4 weeks after therapy is discontinued Increase in fasting blood sugars (*as you may likely also see with atypical antipsychotics) Digoxin: Monitor digoxin level when appropriate at least 6 hours post dose, and preferably at trough Check digoxin level when: Renal function changes When drug interactions are suspected When digoxin toxicity is suspected Routine levels are probably appropriate yearly and are probably not needed more often Check potassium, magnesium, calcium, and renal function periodically Digoxin is often effective at a dose which produces a lower serum level than typical reference ranges suggest as therapeutic In CHF patients, mortality benefits can be derived by keeping digoxin levels between 0.2 0.8 ng/mL Rathore SS, Curtis JP, Wang Y, Bristow MR, Krumholz HM. Association of serum digoxin concentration and outcomes in patients with heart failure. JAMA. 2003 Feb 19;289(7):871-878.

HMG-CoA reductase inhibitors: In general, check LFTs at baseline, after 6 and 12 weeks of therapy, and semiannually thereafter In general, check fasting lipid panel at baseline and approximately 1 month after dose changes For specific manufacturer recommendations of LFT monitoring, see prescribing information Levothyroxine: Check TSH approximately 4 6 weeks after dose adjustment Levels monitored prematurely will not be accurate Lithium: Monitor lithium level at least 8 12 hours post dose Check levels twice a week until stable, then every 1 2 months Check CBC, UA, chem7, Ins & Outs (Is & Os), TFTs periodically Phenytoin (PHY): Monitor total phenytoin levels and corrected phenytoin levels in patients with low albumin (see next screen) Check folic acid, LFTs, CBC periodically Thiazolidinediones (TZDs): Check LFTs q 2 months for 1 year then periodically thereafter Check fasting blood glucose Check HgbA1c every 3 months HgbA1C can be tested every 6 months if at goal x 2 occasions Warfarin: Initiation in most patients requires at least 4 5 days of bridge therapy with heparin or a low-molecular weight heparin (LMWH) Check INR at least monthly in stable patients Compliance with monthly INRs is assessed as part of the Drug Regimen Review in the long term care setting The screen includes select medications commonly used in the older adult that necessitate laboratory monitoring. Note that these medications can also require monitoring of certain indices that are not required of the laboratory and these monitoring parameters will not be discussed. Rather, only true diagnostic and laboratory measurements are included. For instance, amiodarone requires monitoring of the heart rate and an ophthalmologic examination is also recommended, but these are not included as required laboratory measurements.

Allopurinol can cause bone marrow suppression, renal impairment, and liver function abnormality. Follow the indices on your screen, especially at the start of therapy. Adjust dose for renal insufficiency. Amiodarone requires close monitoring in any patient. It can cause both hypoand hyperthyroidism, although hypothyroidism is more likely. Pulmonary infiltrates and fibrosis can occur, and baseline PFTs are indicated because patients with preexisting pulmonary disease may be more likely to develop pulmonary toxicity from amiodarone. Amiodarone can also cause a prolongation in the QT interval so exercise caution and monitor closely in patients with preexisting arrhythmia and in patients on other medications that can also prolong the QT interval. Carbamazepine can cause hyponatremia due to the syndrome of inappropriate antidiuretic hormone (SIADH). Carbamazepine and valproic acid can both cause hepatic toxicity and bone marrow suppression. Clozapine can cause agranulocytosis and its distribution is limited. Strict monitoring of WBC is mandatory. Digoxin is commonly prescribed and several laboratory measurements are needed to monitor therapy. Digoxin levels are sometimes ordered when they are not needed. The optimum frequency with which to monitor digoxin levels routinely is debatable, but routine measurements are probably not needed more than once yearly. Digoxin levels are clearly indicated when toxicity is suspected, when renal function declines and when drug interactions are suspected. Potassium, magnesium, and calcium also need to be monitored, especially in volume depleted patients. Hypokalemia, hypomagnesemia, and hypercalcemia can all predispose patients to digoxin toxicity and cardiac arrhythmia. Lithium can cause a whole host of side effects and adverse drug events, including hypothyroidism, renal toxicity, and leukocytosis. Monitoring sodium levels and preventing dehydration is important because hyponatremia and volume depletion can lead to lithium toxicity. Phenytoin and other anticonvulsants can cause folate deficiency. Some clinicians will monitor folic acid while others will simply recommend folic acid supplementation. Additionally, vitamin D levels may decrease as a result of increased metabolism of vitamin D secondary to hepatic induction. This can result in secondary hyperparathyroidism due to a reduction in calcium absorption from the gut. Periodic monitoring of 25-hydroxy vitamin D is necessary. Check LFTs, CBC and albumin periodically as phenytoin can cause leucopenia and hepatitis. Be sure to correct for low albumin levels when evaluating phenytoin levels. One may check phenytoin levels pre-steady state to ensure the

level is not rising too quickly and into the toxic range but caution adjusting the dose based on pre-steady state determinations. Phenytoin undergoes nonlinear kinetics and its half life varies greatly in patients, making monitoring difficult. 02.04.05 Interpreting Laboratory Findings Labs should be compared to baseline values if available Use lab results and other clinical findings to adjust dosing rather than preestablished therapeutic dosing values

Phenytoin: A subtherapeutic value of phenytoin (corrected for albumin) may be appropriate if patient is not seizing Corrected phenytoin for low albumin levels (Shiner-Tozer equation): (Observed phenytoin concentration) [(1 0.1) albumin/4.4 g/dL)] + 0.1 Winters ME. Basic Clinical Pharmacokinetics, 4th ed. San Francisco: Lippincott, Williams, and Wilkins, 1994. The value of any laboratory finding lies in its interpretation. Laboratory results should be compared to baseline values if available. When considered in the context of other clinical factors, these findings can provide amore reliable basis for dosing adjustments than the normal therapeutic dosing values. For example, a patient who is not seizing may benefit from a lower dose of phenytoin than indicated by the normal therapeutic range. Digoxin is also often effective at serum levels that are lower than typical reference ranges would suggest is therapeutic. 02.04.07 Use of Laboratory Findings: A Summary 1. 2. 3. 4. 5. 6. 7. Select and order laboratory tests Collect specimens for analysis, handle properly Review laboratory results and reference ranges Compare findings to baseline Rule out drug interference and other complicating factors Document and interpret findings Treat the patient accordingly

Remember, while laboratory results provide important pieces to the clinical puzzle, your goal is to treat the patient, not the lab value. By following the steps shown on your screen, you will ensure that any laboratory data collected supports rather than confounds therapeutic goals. 02.04.08 Resources For additional information, see: Canas F, Tanasijevic MJ, Ma'luf N, Bates DW. Evaluating the appropriateness of digoxin level monitoring. Arch Intern Med. 1999 Feb 22;159(4):363-368. Delafuente J, Stewart R. Therapeutics in the Elderly, 3rd ed. Cincinnati OH: Harvey Whitney Books Company, 2001. Palacioz K. Scheduling of liver function tests. Pharmacists Letter. 17:Number 171712. Shargel L, Wu-Pong S, Yu ABC. Applied Biopharmaceutics and Pharmacokinetics, 5th ed. McGraw-Hill Medical, 2004. Rathore SS, Curtis JP, Wang Y, Bristow MR, Krumholz HM. Association of serum digoxin concentration and outcomes in patients with heart failure. JAMA. 2003 Feb 19;289(7):871-878. Winters ME. Basic Clinical Pharmacokinetics, 4th ed. San Francisco: Lippincott, Williams, and Wilkins, 1994.