Geriatric Assessment
Welcome to the Geriatric Assessment and Planning module.
This module will provide you with an interactive case study in which you will consider the components of geriatric assessment and care planning.
Once you have completed the Pre-Module Test below you will be able to commence the Geriatric Assessment and Planning Case Study.
If you are returning to the module you can skip the Pre-Test by clicking on the Continue button to go straight to the case
Module
- Interactive Case Study
- ACAT Assessment
- Interview - Mr and Mrs Doherty
- Assessment of Living Environment
- Medication Review
- Stage Summary
- Physical Assessment
- Cognitive Assessment
- Geriatric Depression Scale
- Investigations
- Treatment Outcome
- Functional Assessment
- ADL and IADL
- Falls Risk Assessment
- Gait Assessment
- Pharmacological Management
- Further multidisciplinary care
- Case Conclusion
Katherine Doherty is a 76 year old woman who has been referred by her GP for an ACAT assessment. The GP feels that she is not coping well at home or in the community.
Review Mrs Doherty’s history through the links below before moving on to her assessments.
- History of Presenting Complaint
- Medical History
- Medication History
- Social History
Over the last 6 months, the GP has noticed a decline in Mrs Doherty’s personal hygiene and presentation. Previously she had impeccable grooming, but now sometimes comes to clinic with unironed clothes and without her hair set. The GP is also concerned about Mrs Doherty’s diet as she has experienced a 10kg weight loss over the last 6 months and now weighs a very slight 56kg and her dentures are ill-fitting. The GP is aware that Mr and Mrs Doherty are very close and rely on each other to a large extent. He would like to see them remain living in the community if possible, but feels that assessment and ongoing support will be required.
The GP initiates a referral to the local ACAT (Aged Care Assessment Team).
Mrs Doherty has a number of health problems, including ischemic heart disease – with known non-occlusive disease on an angiogram in 2006, hypertension, type 2 diabetes mellitus and a history of 2 previous strokes- the last 9 months ago, leaving her with a weak right leg. She also has mild osteoarthritis in her hands and lower back.
She is currently experiencing shortness of breath and intermittent chest pain and has reported some troubles with reflux symptoms (causing a loss of appetite), sleeping and occasional bouts of constipation. She has reduced mobility due to ongoing shortness of breath and long periods of inactivity. She is otherwise alert and socially interactive.
Mrs Doherty is on a range of medications to treat her heart disease, diabetes, high blood pressure and arthritis, and has been for some time. These medications include;
- Perindopril 5mg od
- Clopidogrel 75mg
- Gliclizide 80mg bd
- Anginine tablets prn
- Metformin 500mg bd
- Paracetamol 500mg
- Simvastatin 20mg
- Senokot 2 tab prn
Katherine Doherty is 76 years old and lives at home with her husband, Benjamin (79). They have been happily married for 55 years but were unable to conceive any children. They have one dog and three cats, who they regard as their family. Mr Doherty is otherwise well but has advanced glaucoma and relies on Mrs Doherty for food shopping, meal preparation, paying bills and general home maintenance. His favourite part of the day is when Katherine and he sit down with and cup of tea in the afternoon while she reads to him. Their favourite books are crime thrillers and historical fiction, but they are also known to read the occasional romance story!
They moved to a two bedroom duplex three years ago when Mr Doherty’s eyesight had progressed to the point where it became difficult to maintain a large house and garden on their own. They chose the location of their new home as it was a short walk to the local shopping centre and medical centre. Following her stroke, Katherine no longer feels safe to drive and has given up her license. The Doherty’s are feeling socially isolated since their move and are missing the familiarity of their old neighbourhood, where they had lived for 28 years. They are finding it difficult to get to know their neighbours and engage in the community. They used to enjoy a game of croquet, bingo and fishing in the river. They would regularly meet neighbours in the street and stop to chat, inevitably ending up at someone’s house for a cup of tea, a glass of beer or a nip of port if it was cold.
Mrs Doherty’s parents both died at young ages, her father during the war and her mother of tuberculosis at the age of 39. She had one sister, who passed away at age 71 from bowel cancer. Her two nephews both live overseas.
Upon entering the home, the ACAT assessor, Sue, introduces herself to Mr and Mrs Doherty and says she is there to have a chat with them about their home life and to assess any difficulties they might be having.
Mrs Doherty invites Sue inside and offers her a cup of tea, a task which she carries out safely and adequately.
The Doherty’s and Sue settle in the living room to talk.
In order to assess how well Mrs Doherty is coping at home Sue needs to ask her a series of questions. Please click on the questions below to obtain Mrs/Mr Doherty’s answers.
- Thank you very much for the tea. As you know your Dr has asked me to come and find out if we can help you at all. Can you tell me how things are going?
- I can understand you feeling like that. If it is OK though, I would still like to find out a bit more about how things are going. How do you spend your free time?
- Do you have any friends close by?
- Are you able to do your own shopping, cooking and other day to day tasks?
- Do you have any difficulties dressing yourself, feeding yourself or using the bathroom?
- Have you experienced any memory problems?
- Have you experienced any falls recently?
- Do you have any pain or troubling symptoms?
- What medications are you currently taking?
- Are you taking the medications as directed by your doctor?
- Is there anything about your home that causes difficulty for you?
- Has anyone tried to intentionally harm you or coerce you into giving them money?
- Do you drink any alcohol or smoke tobacco?
Sue asks Mr and Mrs Doherty whether they mind if she has a look around their home, particularly the kitchen, bathroom and living area. They are happy for her to do so.
There is very little food in the refrigerator or cupboards. Some of the foods are out of date. It appears that the couple may have been living on tinned or packet foods, long life milk, frozen dinners, cheese, white bread and sweet biscuits. There is no fresh fruit or vegetables.
It is apparent that the house has not been adequately cleaned for quite some time. The house is untidy and there are streaks on the floor. There are piles of unwashed clothes in the laundry. The smell of cat urine is also evident.
Even though the house is in disrepair, it is clear that this is a loving home. The pets are happy and content and Mr and Mrs Doherty appear very supportive of each other.
There are various medications scattered around on the bathroom shelves, some of which are out of date or judging by the date of prescription, should have been finished months ago if taken as directed. This prompts you to compare what you find with the list the GP sent you:
You find some:
- Paracetamol 500mg tablets
- “rennies” overt the counter antacid tablets – several packets around
- Perindopril 5mg tablets
- Voltaren 50 mg tablets
- Aspirin 150mg tablets
- Clopidogrel 75mg tablets
- Simvastatin 20mg tablets
- Metformin 500mg bd – not taking
- Codeine/Paracetamol 8/500 tablets
- Amoxicillin 250mg tablets – left over from a chest infection
- GTN spray (exp date 2006)
- Anginine tablets – not taking
- Nitrazepam 5mg tablets
Medications prescribed by GP
The GP list states that Mrs Doherty is on the following medications.
Click each to find out the reason for prescription.
- Perindopril 5mg od
- Clopidogrel 75mg od
- Gliclizide 80mg bd
- Anginine tablets prn
- Metformin 500mg bd
- Paracetamol 500mg
- Simvastatin 20mg
- Senokot 2 tab prn
For high blood pressure and congestive heart failure
To inhibit formation of blood clots
To stimulate the release of insulin and diminish the peripheral resistance to insulin in order to treat diabetes
To relieve pain of angina attacks
For the management of type II diabetes mellitus
For occasional arthritic pain
To lower cholesterol and triglyceride levels
To relieve constipation
Discussing medications
Discuss the differences in medications found and prescribed with Mrs Doherty, by clicking on the questions below to reveal her answer.
- Mrs Doherty, you have quite a few packets of rennies in the house. Have you been taking them often?
- I also noticed that you have two medications to help prevent blood clots, aspirin and clopidogrel. Have you been taking both of these?
- Were you advised to stop taking the aspirin when you left the hospital after your last stroke?
- You have also been prescribed some anginine tablets to help with the pain associated with your angina. Are you still taking these?
- Yes, I noticed that you had a GTN spray, but it is past its expiry date. When was the last time you used it?
- Also, I noticed that you arent taking the metformin, which are the tablets prescribed for your diabetes.
- Was it Gliclizide?
- Do you take the sleeping pills often?
- And what tablets do you take for arthritic pain?
What are your main concerns about Mr and Mrs Doherty’s situation at this point? Please answer the question by clicking the button below:
General Appearance:
Mrs Doherty appears well. Her affect is reactive.
Height: 178cms
Weight: 56kg (a drop of 10kg over the last 6 months)
The next step in Mrs Doherty’s Geriatric Assessment is to examine her physical health. Please move your mouse cursor over Mrs Doherty as if you were examining her. You must complete the examination before you go on.
he results of Mrs Doherty's cognitve assessment are:
MMSE – 27/30, losing 2 points on recall and one point on serial sevens
Clock Drawing Test – normal
There is more detailed information on cognitive assessments in the dementia and delirium modules.
Click here to see Mrs Doherty's completed Geriatric Depression Scale
Mrs Doherty scores 4/15 on the GDS – She feels her health issues are getting on top of her and wishes she could maintain her house like she used to.
Based on this result, your preferred course of action would be to:
(click on your response to obtain feedback)
- Start Mrs Doherty on anti-depressants
- Attempt to control Mrs Doherty’s immediate medical problems and see if her mood improves
- Refer Mrs Doherty to a Clinical Psychologist
Anti-depressants are generally not indicated unless there is other clinical evidence of more severe depression
Correct! If Mrs Doherty’s current symptoms can be resolved, her mood may well improve
Generally, a score of 5 or more on the GDS warrants further investigation and referral to a psychologist
Give some thought as to what tests you might order to investigate Mrs Doherty's symptoms. From the list below, click on the tests you would like to order to see the results (if indicated).
- Full Blood Count
- Serum Cholesterol
- Blood Glucose
- Exercise Stress Test
- Electrolytes
- Thyroid Function Tests
- ECG
- Chest X-ray
- Brain MRI
- Vitamin B12 and Folate
- Gastroscopy and Colonoscopy
- Faecal Occult Blood test
- Angiogram
Hb 86 g/L (normal range 115-160 g/L for adult females)
MCV 74 fl (normal range 80-100 fl)
WCC 7.8x109/L (normal range 4.0-11.0x109/L)
Platelets 266x109/L (normal range 150-400x109/L)
Mrs Doherty is already on a statin. It might be useful to ensure it is efficacious, however not particularly relevant to her current issues.
Fasting 7.8 mmol/L (normal range <=6 mmol/L)
HbA1C 7.6 (normal range <6.0%)
This suggests Mrs Doherty's diabetes is under acceptable control, but could be improved.
Normal <6.0%
Good control 6.0-7.0%
Acceptable control 7.1-8.0%
Poor control >8.1%
Although Mrs Doherty does complain of some shortness of breath and has recently used her aniginine spray, other tests need to be performed first.
Na 138 mmol/L (normal range 134-146 mmol/L)
K+ 4.6 mmol/L (normal range 3.4-5.0 mmol/L)
Cr 110 µmol/L (normal range 50-95 µmol/L for adult females)
Urea 12.8 mmol/L (normal range 3.0-8.0 mmol/L)
TSH 1.4 mU/L (normal range 0.40-4.0 mU/L)
Evidence of old lateral infarct
Mrs Doherty complains of shortness of breath, so this is a reasonable request, although other investigations should be done first given her respiratory examination was normal.
There is no evidence on history or examination that intracranial pathology is of concern. Brain MRI is therefore not indicated.
B12 144 pmol/L (normal range 120-680 pmol/L)
Folate 66 nmol/L (normal range 230-1600 nmol/L)
On the ball! You note Mrs Doherty is both anaemic, complaining of indigestion and new onset constipation in the setting of recent weight loss. You are right to be concerned about gastro- intestinal pathology.
Pleasingly, her colonoscopy is normal. Her gastroscopy demonstrates a large prepyloric ulcer with erosion into the serosa. Biopsies are taken that don’t reveal any cancerous change, however she is H Pylori positive.
Photo source: www.EndoAtlas.com
Positive – this is not a very helpful test in someone with active GI symptoms, like constipation, microcytic anaemia or worsening indigestion, as there are high rates of false negative tests. It is however useful as a screening tool on a population basis.
It would be important to ensure there is no other reason for Mrs Doherty’s shortness of breath or chest pain prior to consideration of an angiogram, given the risks of the procedure and the clinical likelihood that her symptoms are related to her gastrointestinal system.
Because of Mrs Doherty’s anaemia and symptomatic angina, she is admitted to hospital for a blood transfusion and is commenced on high dose PPI (pantoprazole) and has a week long course of triple antibiotic therapy to eradicate the H pylori.
While Mrs Doherty was in hospital, the social worker arranged for HACC (Home and Community Care) funded servcies to visit Mr Doherty daily, to assist in some of his ADL’s and IADL’s.
A repeat scope at six weeks demonstrates good healing of the ulcer. The angina disappears and she regains her appetite and energy, although is still more frail than she used to be.
In order to ensure that Mr and Mrs Doherty are able to continue living at home, further assessments need to be conducted.
Health is more than absence of active disease. What matters most to people is how well they can function in the life they wish to lead.
The functional assessment is a core part of the older person’s assessment, for a number of reasons:
- As patients live longer with chronic conditions, they survive longer periods with functional impairments that require some sort of medical and social response
- Society places emphasis on autonomy and independence, both of which are directly threatened by functional disability
- In older people, the first sign of a medical problem is commonly manifest as a change in functional status.
Activities of Daily Living (ADL’s): are self-care activities that people must accomplish to survive independently. They include bathing, dressing, toileting, transferring, continence and feeding. Other ADLs include communication, grooming, visual capability, walking and the use of the upper extremities.
Click on the image below to see the ACAT assessment of Mrs Doherty's ADL's
Instrumental Activities of Daily Living (IADL’s): are those higher-level activities people must perform in order to remain independent in a house or apartment. They include the functional ability to shop, prepare food, clean the house, do laundry, drive or use public transportation, administer medications, and handle finances. These activities are bit more subjective than the ADL's since they are more complex and involve a person's interaction with his or her environment. An example of the distinction between ADL and IADLs is the ability to simply eat a meal versus the ability to prepare it.
Click on the image below to see the ACAT assessment of Mrs Doherty's ADL's
In order to assess the risk of falls, a gait and balance assessment, for both Mr and Mrs Doherty, should be performed. Mrs Doherty has mobility issues and Mr Doherty, eyesight issues.
One way of assessing balance is to use the Berg balance Scale. The Berg Balance Scale is a test that was originally developed to determine the ability of the elderly to keep their balance. The results are based on how long it takes to complete specific tests and how well the tests are performed.
The fourteen tasks evaluated in the Berg Balance Scale test include:
- sitting unsupported
- change of position: sitting to standing to assess possible lower limb dysfunction
- change of position: standing to sitting
- transfers
- standing unsupported to assess postural drop and/or vestibular dysfunction
- standing with eyes closed (Romberg’s test) to assess proprioceptive loss
- standing with feet together
- tandem standing
- standing on one leg
- turning trunk (feet fixed)
- retrieving objects from floor – to assess possible postural problems
- turning 360 degrees
- stool stepping
- reaching forward while standing (forward flexion of head and torso)
Click here to see more about the Berg Balance Scale
The Timed Get Up and Go Test is commonly used to assist examination of gait and functional mobility in older people. In addition to the ability to rise from a chair, walk a short distance, turn and return to sit in the chair, you might also assess posture for possible kyphosis (curvature of upper spine), loss of lumbar lordosis (loss of curvature of the lumbar spine) and increased flexion at the shoulders and knees. Gait velocity, gait character [stance width, arm swing, gait initiation, ataxia/lateral sway, foot clearance and step length, symmetry, continuity & height], path taken, use of aids and ability to turn should also be noted.
Click below to see the reports for Mr and Mr Doherty's gait assessments.
Mrs Doherty’s gait and balance
Mr Doherty’s gait and balance
Examine Mrs Doherty’s medications based on her current state of health.
After discussing the medications with Mrs Doherty and reviewing her case with the GP, which of the following medications will you recommend for Mrs Doherty?
Click each of those medications to receive feedback.
- Perindopril
- Clopidogrel
- Gliclizide
- GTN spray
- Metformin
- Voltaren
- Simvastatin
- Senokot
- Amoxicillin
- Nitrazepam
It is appropriate that Mrs Doherty continue taking this for high blood pressure and congestive heart failure
It is appropriate that Mrs Doherty continue taking anti-platelet medication to prevent blood clots
It is appropriate that Mrs Doherty continue taking this for type 2 diabetes mellitus
It is appropriate that Mrs Doherty continue taking this to reduce the pain of acute angina attack
It is appropriate to stop Metformin as Mrs Doherty reported side effects and she is already taking Gliclizide
Cease voltaren. Paracetamol and non- pharmacologic strategies are preferred first line treatments*
It is appropriate that Mrs Doherty continue taking this for high cholesterol
Advise only to take if constipation recurs
This is not indicated as no evidence of UTI
Use of sedatives is not recommended due increased risk of falls and other potentially harmful side effects
*Please note that Voltaren is not recommended for people with heart disease and/or a history of stroke. Elderly people may also be at increased risk for serious stomach/intestinal bleeding*
A multidisciplinary focus is essential in Geriatric Assessment and in establishing a care plan.
Click on the tabs below for assessment outcomes facilitated by other members of the multidisciplinary team.
- Social Worker
- Occupational Therapist
- Dietitian
- Dentist
- Pharmacist
- Optometrist
With the help of the social worker and local community agencies, the Doherty’s are participating more in community life. The local church has bingo once a fortnight and they have been regularly attending the local senior citizens centre to make new friends and participate in the many and varied activities and excursions offered.
Their neighbour’s teenage children have offered to walk the dog daily and appropriate litter trays have been installed for the cats, who were having trouble accommodating to toileting in the enclosed courtyard after years of having the run of a large back yard.
The Doherty’s have lived with Mr Doherty’s restricted eyesight for quite some time and as such, their home is well equipped to reduce falls risk. There are no obstacles that may cause tripping, grab bars have been installed and non-slip mats are present in the toilet, bathroom, kitchen and laundry. Their home has no stairs or steps, which was a factor they took into account when purchasing the property. The only recommendation made was to install a lamp beside the bed to ensure adequate visibility if either of them have to get up during the night. Likewise, installation of nightlights in the hallways would be useful.
Mrs Doherty was experiencing difficulty eating due to reflux symptoms caused by a stomach ulcer. Her sleeping patterns had also been disturbed, caused at least in part by congestive heart failure. This was complicated by the couples inability to visit the shopping centre regularly to buy fresh food and Mrs Doherty’s inability to prepare healthy meals of account of her tiredness and shortness of breath. As such, they have been living on processed foods of poor nutritional quality, leading to constipation (inadequate fibre and dehydration) and weight loss. The weight loss further exacerbated the problem as Mrs Doherty’s ill-fitting dentures made it more difficult for her to eat.
Mrs Doherty has been counselled about her nutrient intake and the importance of maintaining an appropriate diet on account of her diabetes and heart disease. With an improved diet, Mrs Doherty’s constipation (due to dehydration and inadequate fibre intake) has resolved. She is sleeping better and is able to eat reasonably good sized meals Now that Mrs Doherty is feeling more herself, she feels she would like to start cooking for her and her husband again a few times a week. They will have pre-prepared meals delivered 5 days per week and she will cook something simple on the other days.
Due to Mrs Doherty’s recent weight loss, it was necessary to modify and refit her dentures.
Blister packs for Mr and Mrs Doherty’s medications have been arranged, as well as a clear and concise medication list allowing Mrs Doherty to understand what each of her medications are for. Mr Doherty’s blister pack is enabled for the visually impaired.
Mr Doherty was referred for review of his advanced glaucoma. Mr Doherty’s intraocular pressure is up 2mmHg since his last visit and is now 26mmHg. This is of concern as it suggests that his glaucoma is progressing despite treatment. Non-compliance or ineffective administration of the eye drops could be a possible contributing factor. Mr Doherty said that he sometimes runs out of drops and it might up to a week before they can have the script re-filled, but assures me that his wife is very particular about making sure he uses the drops every day.
Ophthalmoscopic examination of the anterior segment of the optic nerve shows a small degree of cupping, presumably due to the concurrent rise in intraocular pressure. This increase in pressure is likely to have caused further damage to the optic nerve, thus explaning Mr Doherty’s recent worsening of eyesight. If intraocular pressure can be reduced with treatment, the swelling of the optic disc may reduce and result in an improvement in visual acuity for Mr Doherty.
Photo source: Moran Eye Centre
There are also advancing areas of localised visual field loss or areas that are outside normal limits. Based on these results, Mr Doherty’s medications have been modified. He will now take Latanoprost 0.005% twice daily, administered 12 hours apart. Review is recommended in 3 months and 6 monthly thereafter.
With help from the multi-disciplinary team an individualised Home Care Package was established to support Mrs Doherty. The package provides personal care, and other assistance (such as with shopping).
Home and Community Care (HACC) services, organised for Mr Doherty, also continued to provide some domestic assistance with housework and laundry.
Mr and Mrs Doherty are able to remain living at home.
Geriatric Assessment Post-Module Test
Module Feedback
Select the appropriate user group to ensure that your feedback is delivered appropriately:
- WACHS Users
- ECU Nursing
- All other users
General Appearance:
Mr Thomas is sweating and looks short of breath. His legs are constantly moving and he appears confused and agitated. His skin is moist and tribal scarring is noted on left and right upper arms, midline of chest and left and right thighs. His eyes are wandering and he appears to have trouble maintaining attention, although this does fluctuate. Admission staff report that his speech was slow and at times, incoherent. Mr Thomas also exhibited impaired orientation. His wife reports that he had trouble sleeping last night.
Height: 168cms
Weight: 75kgs
Temperature: 36.7
Respirations: 28 shallow
Please move your cursor over Mr Thomas as if you were examining him. You must complete the examination before you go on.
General Observations:
Patient answered greeting when approached. He is sitting in a chair with no evidence of agitation or distress. Mr Thomas is now eating a full diet, opens bowels daily and urine output is in keeping with fluid intake. His mouth is moist and mucosa intact. The IV access is removed.
Height: 168cms
Weight: 75kgs
Temperature: 36.7
Respirations: 18 even
Cognitive Testing
MMSE – 25/30 – may indicate resolution of delirium
KICA – 35/39 –Improvement in KICA score supports diagnosis of delirium.
Mrs Thomas does not think Mr Thomas is quite back to baseline, but is improving day by day.
General Appearance:
Mr Scott looks well. His affect is reactive but be appears to be slightly anxious.
Height: 184cms
Weight: 98kg (which has remained constant)
Please move your cursor over Mr Scott as if you were examining him. You must complete the examination before you go on.
General Appearance:
Mrs Scott looks well. She is reactive but has restricted mobility.
Height: 164cms
Weight: 76kg (which has remained constant)
Please move your cursor over Mrs Scott as if you were examining her. You must complete the examination before you go on.
Please move your cursor over Dr Zheng as if you were examining him. You must complete the examination before you go on.
General Appearance:
No tremor is observed. He is well groomed and does not appear anxious. He has normal attention and affect.
Height: 160cms
Weight: 70kgs
Temperature: 37.1
Please move your cursor over Mr Thomas as if you were examining him. You must complete the examination before you go on.
General Appearance:
General Appearance: Mrs Browning looks well. Her affect is reactive and she doesn’t appear to be distressed or anxious.
Height: 178cms
Weight: 65kg (has remained constant)
Please move your cursor over Mrs Browning as if you were examining her. You must complete the examination before you go on.
General Appearance:
Mrs Browning looks happy and healthy.
Height: 178cms
Weight: 65kg (has remained constant)
Please move your cursor over Mrs Browning as if you were examining her. You must complete the examination before you go on.
General Appearance:
Mrs Browning appears well. She is well presented, and is in high spirits.
Height: 178cms
Weight: 66kg (an increase of 1 kg)
Please move your cursor over Mrs Browning as if you were examining her. You must complete the examination before you go on.
General Appearance:
Your general observation is that Mrs Browning appears to be a very alert, independent and capable elderly woman. She is cheery, well presented and easily mobile.
Height: 178cms
Weight: 67.5kg (an increase of 1.5 kg)
Please move your cursor over Mrs Browning as if you were examining her. You must complete the examination before you go on.
