Geriatrics

Geriatric Assessment Program (GAC)

GUIDELINES FOR RESIDENTS AND STUDENTS

(Please review this sheet prior to or as you proceed through clinic)

These notes will assist you in understanding and contributing to the geriatric assessment of older patients. The Resident may be asked to perform a medical evaluation of the patient and discuss findings at a multi disciplinary team conference. Students will observe the assessment process. The process of geriatric assessment is outlined below.

Upon arriving to the Geriatric Clinic, please alert the nurses of your arrival and begin reviewing this sheet. The student or resident should follow one patient through all aspects of the evaluation. Select a chart (in the Steven Conference Room) to begin familiarizing yourself with the patient. You will not be allowed in the room once the Geriatric psychiatrist or NeuorPsychologist begins. Please arrive prior to 7:15.

Goals:

  1. To become familiar with the process of Comprehensive Geriatric Assessment
  2. To understand the indications and usefulness of referral for a Comprehensive Assessment
  3. To witness the performance of the various aspects of the assessment

Objectives: The Resident/Student will:

  1. be able to identify the indications for Comprehensive Geriatric Assessment
  2. be able to list the components of the Comprehensive Geriatric Assessment
  3. be able to perform an MMSE (Mini-Mental Status Exam), Functional Disability Screening, and GDS (Geriatric Depression Scale).
  4. describe the function and participate in a interdisciplinary team meeting
  5. know and be able to perform the components of a functional screening

Patient Referral Received from:

Eastern Nebraska Office on Aging, Adult Protective Services, private physicians, community health nurses, emergency rooms, yellow pages in the phone book, family members and/or word of mouth.

Intake Procedure:

Intake calls are processed and screened for appropriateness of referral by the GAP social worker. Families and agencies may be contacted to determine results of prior evaluations, what services are being provided, results from evaluations and services, and pertinent medical and social history. (see chart 2)

Clinical Operation:

The GAP is similar to those you will read about in the literature. We have a multi disciplinary team that interviews and assesses the patient and gathers collateral histories from the family/care giver during the first appointment. Appointments are generally made for three new patients each Wednesday. Each new patient can expect to be in the Clinic four to five hours. Diagnostic studies are scheduled in the afternoon. Conferences for patients and families are schedules at a later date after results from diagnostic studies are received.

Clinic Day Sequence:

The patient is seen sequentially by: (usually in this order) start time approx. 7:00

1st & 2nd - Geriatric psychiatry
- Neuro psychologist (neuropsychiatric testing)
approx. 7:15 - 7:30
3rd & 4th - Geriatrician
- Pharmacology
to follow
5th - Geriatric nursing assessment to follow
Last: - The GAP team discussion & planning 3:00 - 4:30 pm

GAP team Discussion & Planning:

Purpose: To review findings from the morning clinic and formulate recommendations.
Note: simultaneously during this clinic, the social worker, RN and Pharmacist are obtaining history from the family.

Evaluator Main Tasks

  • Geriatric Nursing Assessment - functional evaluation, coordination of clinic
  • Gero-Psychiatry - cognitive and mood assessments
  • Gero-Psychologist - evaluation of affected cognitive domains
  • Geriatrician - medical evaluation and post-evaluation, management teaming with clinic nurse
  • Pharmacology Drug - medication evaluation, interactions, adverse reactions
  • Social Worker - intake, social history

TEAM PROTOCOL FOR INITIAL VISIT:

  1. Review the past medical history, social history, and/or nursing evaluation before the patient is seen. Collateral source history and social assessment of family and patient is completed.
  2. The chief complaint is identified after considering concerns of the patient and care giver(s). Often there are 2 different sets of concerns and priorities that need to be addressed.
    1. Primary Medical Problems: Definition of present problem, identification of other medical problems, identification of expectations of the patient and the referral source.
    2. Primary Social/Nursing Problems: Identification of current living situation, support structures, financial status and informal and formal supports. Assessment of patient's functional status, expectations for independence and outcome of referral. Identify both patient and family expectations of the Geriatric Assessment Team.
  3. Complete medical history involving patient, medical records and care givers, when appropriate.
    1. History of Present Illness - Attention to date of onset, specifics of behavioral and cognitive disturbances, reason for referral and course.
    2. Past Medical History - Special attention to medications and illness history that may relate to functional deficits.
    3. Social History - Historical data pertinent to presenting problem.
    4. Detailed Review of Systems - Specific attention is given to symptoms of organ insufficiency, neurological deficits, gait, incontinence, ambulatory abilities, hygiene, nutrition, endocrine, and ability to care for self (i.e. functional problems).
  4. Definition of the Desired Outcome: Obtain information from patient and care givers.
    Examples may be:
    1. To live at home with more in-home support;
    2. Relocation to assisted living, or
    3. No change.
  5. Complete Physical Examination: Special attention is given to the musculoskeletal, Cardiopulmonary, and neurological exam including gait, motor and sensory function. Vision and hearing screens also are part of the exam.
  6. GAP Team Conference: Discussion of the patients seen in clinic that day. Those present will include members of the Geriatric team, students, and resident. During the team conference, problems will be identified and recommendations formulated, assets identified, and goals set.

FOLLOW-UP VISIT (Usually 2-3 weeks after first appointment)

  1. Review of diagnostic data by MD and determination of further new medical problems.
  2. Review of social developments by social worker with patient and care givers.
  3. Review of functional status and teaching of health maintenance and prevention by RN and other team members.
  4. Review of psychiatric or neurological evaluations, if done.
  5. Review of medications.
  6. Interval history from patient and care giver. Interval physical examination if necessary.
  7. Subsequent lab data gathering as indicated by above steps. Final concluding conference of all the involved parties. The assessment team conference meeting minutes/notes are used to discuss details of the diagnostic and treatment plans recommended to the patient and family.

Detailed letter to primary physician detailing evaluation, interventions, and recommendations.

We hope this has helped initiate you into the Geriatric Assessment Program. We look forward to working with you during this rotation. 

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