Saint Louis University Geriatric Evaluation

AINT
OUIS
NIVERSITY
ERIATRIC
VALUATION
NEMONICS AND
CREENING TOOLS
S
L
U
G
E
M
S
To order additional copies of
SLU GEMS,
send an e-mail to
[email protected].
To order additional copies of
SLU GEMS,
send an e-mail to
[email protected].
SLU Geriatric Evaluation Mnemonic Screening Tools 1
This book is published by
Saint Louis University School of Medicine
Division of Geriatric Medicine
and the
Geriatric Research, Education, and Clinical Center
St. Louis VA Medical Center
This project is supported by funds from the Division of State, Community
and Public Health (DSCPH), Bureau of Health Professions (BPHr), Health
Resources and Services Administration (HRSA), Department of Health and
Human Services (DHHS) under grant number D31HP08827; Gateway Geriatric
Education Center for $1.2 million. This information or content and conclusions
are those of the authors and should not be construed as the offcial position
or policy of, nor should any endorsements be inferred by the DSCPH, BHPr,
HRSA, DHHS, or the U.S. Government.
JOSEPH H. FLAHERTY, M.D.
NINA TUMOSA, PH.D.
2 SLU Geriatric Evaluation Mnemonic Screening Tools
TABLE OF CONTENTS
TITLE PAGE
INTRODUCTION
AGING SUCCESSFULLY PASSPORT TO AGING
AGING SUCCESSFULLY POSTER
ALCOHOL CAGE QUESTIONNAIRE
ANTICOAGULATION HEMORR
2
HAGES
CHADS
2

CANCER SCREENING CAUTION
DEHYDRATION SIMPLE SCREEN FOR DEHYDRATION
DELIRIUM ACUTE CHANGE IN MS
CAM
COCOA-PHSS
DELIRIUM
BE AWARE/PREVENT
AVOID RESTRAINTS
DEMENTIA VAMC SLUMS EXAM
DEMENTIA
THE CARING GUIDE
DEPRESSION GDS
SIG E CAPS
CORNELL SCALE FOR DEPRESSION
DIZZINESS BPPV
DIZZINESS
V
2
ERTIGO PM
ELDER ABUSE NEGLECT
EYES AND EARS VISION
HEARING
FALLS DUAL TASKING
AGAIN IVE FALLEN
TIMED UP & GO
SAFE AND SOUND
1-LEG STANDING
5-CHAIR STANDS
4
5
6-7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26-27
28
29
30
31
32-33
34
35
36
37
38
TABLE OF CONTENTS
TITLE PAGE
FRAILTY FRAIL
FRAILTY
FUNCTION ADLS
INDICATORS FOR PATIENT THERAPY I
INDICATORS FOR PATIENT THERAPY II
INDICATORS FOR PATIENTTHERAPY III
HOSPITALIZATION DR. IATROS
BED REST IS BAD
DC PLAN
FOLEY GUIDELINES
HYPOGONADISM ADAM
INCONTINENCE DRIP
2
OR DOUSE
INTL PROSTATE SYMPTOM SCORE
OAB-V8
INSOMNIA HELP ME SLEEP
MEDICATIONS BEERS
AVOID TOO MANY
NUTRITION MEALS ON WHEELS
SNAQ
BMI
MNA
SCALES
DENTAL
OSTEOPOROSIS RISK FACTORS FOR OSTEOPOROSIS
PAIN PAIN ASSESSMENT TOOL
PAINS
PALLIATIVE CARE & END OF LIFE PAIN WISDOM
MANAGING END-OF-LIFE SYMPTOMS
PRESSURE ULCERS STAGING PRESSURE ULCERS
MANAGEMENT GUIDELINES
SLEEP EPWORTH QUESTIONNAIRE
39
40
41
42
43
43
44
45
46
47
48
49
50-51
52
53
54-55
56
57
58
59
60-61
62
63
64
65
66
67
68-69
70
71
72
INTRODUCTION
Mnemonics have long been used as memory aids
(especially to assist people in passing examinations).
The mnemonics here have been developed because
of the often complex and multifactorial nature of
illnesses and syndromes in the elderly and the time
constraints of the present health care environment.
These mnemonics are intended to assist the clini-
cian in developing differential diagnoses, risk as-
sessments, or evaluation and management plans for
common geriatric problems. These mnemonics will
also enable the clinician to do this in a quick, yet
comprehensive manner.
The screening tools have been chosen to comple-
ment the problems, syndromes, and illnesses that are
covered by the mnemonics.
When was your last pap smear?
When was your last mammogram?
Do you check your breasts monthly?
Are you satisfied with your sex life?
Do you have trouble passing urine?
Have you discussed PSA testing with your
doctor?
What is your ADAM score?
M

A

L

E

S
F
E
M
A
L
E
S
Now, please answer the four questionnaires on the next page.
* This questionnaire is based on the health promotion and prevention guidelines developed by Gerimed
and Saint Louis University Division of Geriatric Medicine.

Please complete this questionnaire before seeing your physician and take it with you when you go.
Passport to Aging Successfully*
NAME AGE
BLOOD PRESSURE laying down: standing:
WEIGHT now: 6 months ago: change:
HEIGHT at age 20: now:
CHOLESTEROL LDL: HDL:
VACCINATIONS Influenza (yearly) Pneumococcal Tetanus (every 10 years)
TSH Date: FASTING GLUCOSE Date:
Do you SMOKE?
How much ALCOHOL do you drink? per day
Do you use your SEATBELT?
Do you chew TOBACCO?
EXERCISE: How often do you...
do endurance exercises (walk briskly 20 to 30 minutes/day or climb 10 flights of stairs) /week
do resistance exercises? /week do balance exercises? /week
do posture exercises? /week do flexibility exercises? /week
Can you SEE ADEQUATELY in poor light?
Can you HEAR in a noisy environment?
Are you INCONTINENT?
Have you a LIVING WILL or durable POWER OF ATTORNEY FOR HEALTH?
Do you take ASPIRIN daily (only if you have had a heart attack or have diabetes)?
Do you have any concerns about your PERSONAL SAFETY?
When did you last have your STOOL TESTED for blood?
When were you last screened for OSTEOPOROSIS?
Are you having trouble REMEMBERING THINGS?
Do you have enough FOOD?
Are you SAD?
Do you have PAIN?
If so, which face best
describes your pain?
0 1 2 3 4 5 0 1 2 3 4 5
Saint Louis University Division of Geriatrics
Aging Successfully
AGING SUCCESSFULLY
A GUIDE TO HEALTH PROMOTION OVER THE LIFESPAN
40-o0 YEARS
1. Exercise regularly
2. Avoid obesity
3. Ingest
adequate
calcium and
vitamin D
4. Eat sh
5. Wear your seatbelt
6. Drink in moderation and do
not smoke
7. Have your
blood
pressure
checked
8. Get your
cholesterol and glucose
checked
9. Screen for
breast and colon
cancer, high
blood pressure,
and diabetes
10. Have Pap smears (females)
11. Have regular mental activity
and socialize!
12. Avoid taking
too many
medicines
13. Consider
hormone
replacement
(men)
See ya
later,
Doc!
o0-80 YEARS
1. Exercise
regularly,
including
balance and
resistance
exercises
2. Avoid weight loss
3. Ingest adequate calcium and
vitamin D
4. Eat sh
5. Wear your
seatbelt
6. Drink in moder-
ation and do not
smoke
7. Screen for breast and colon
cancer, high blood pressure,
osteoporosis, and diabetes
8. Get your
cholesterol
checked
9. Have u and
pneumococcal vaccinations
10. Have Pap
smears (females)
11. Have regular
mental activity
and socialize!
12. Avoid taking
too many
medicines
80+
1. Exercise regularly,
including balance
and resistance
exercises
vitamin D
4. Be screened for osteoporosis
6. Drink in moderation and do not
smoke
7. Have your blood
pressure checked
8. Do monthly breast self-exams
9. Have u and pneumococcal
vaccinations
10. Safety-proof your home
to prevent falls. If you are
unsteady, use a cane and
consider hip protectors
11. Have regular mental activity.
Socialize, and avoid being
depressed.
12. Avoid taking
too many
medicines
13. Keep doing what you
are doing.
Remember, most of
your physicians wont
reach your age!
0-20 YEARS
1. Exercise
regularly
2. Avoid
obesity
3. Ingest
adequate
calcium
4. Eat nutritious foods
6. Do not smoke or
drink
7. Get your vaccinations
8. Avoid violence and illicit
drugs
IRIOR TO BIRTH
1. Choose
long-lived
parents
2. Have your
mother
get regular check-ups during
pregnancy
3. Have your mother not smoke
or drink alcohol
4. Have your mother
take pre-natal
vitamins including
folate.
20-40 YEARS
2. Avoid obesity
3. Ingest adequate
calcium
4. Eat sh
5. Wear your
seatbelt
5. Drink in
moderation
and do not smoke
6. Drive at a
safe speed
7. Avoid
violence and
illicit drugs
8. Check your breasts regularly
(females)
Aging Successfully
AGING SUCCESSFULLY
A GUIDE TO HEALTH PROMOTION OVER THE LIFESPAN
40-o0 YEARS
2. Avoid obesity
3. Ingest
adequate
calcium and
vitamin D
4. Eat sh
6. Drink in moderation and do
not smoke
7. Have your
blood
pressure
checked
8. Get your
cholesterol and glucose
checked
9. Screen for
breast and colon
cancer, high
blood pressure,
and diabetes
10. Have Pap smears (females)
11. Have regular mental activity
and socialize!
12. Avoid taking
too many
medicines
13. Consider
hormone
replacement
(men)
See ya
later,
Doc!
o0-80 YEARS
1. Exercise
regularly,
including
balance and
resistance
exercises
vitamin D
4. Eat sh
5. Wear your
seatbelt
6. Drink in moder-
ation and do not
smoke
7. Screen for breast and colon
cancer, high blood pressure,
osteoporosis, and diabetes
8. Get your
cholesterol
checked
9. Have u and
pneumococcal vaccinations
10. Have Pap
smears (females)
11. Have regular
mental activity
and socialize!
12. Avoid taking
too many
medicines
80+
1. Exercise regularly,
including balance
and resistance
exercises
vitamin D
4. Be screened for osteoporosis
6. Drink in moderation and do not
smoke
7. Have your blood
pressure checked
8. Do monthly breast self-exams
9. Have u and pneumococcal
vaccinations
10. Safety-proof your home
to prevent falls. If you are
unsteady, use a cane and
consider hip protectors
11. Have regular mental activity.
Socialize, and avoid being
depressed.
12. Avoid taking
too many
medicines
13. Keep doing what you
are doing.
Remember, most of
your physicians wont
reach your age!
0-20 YEARS
1. Exercise
regularly
2. Avoid
obesity
3. Ingest
adequate
calcium
4. Eat nutritious foods
6. Do not smoke or
drink
7. Get your vaccinations
8. Avoid violence and illicit
drugs
IRIOR TO BIRTH
1. Choose
long-lived
parents
2. Have your
mother
get regular check-ups during
pregnancy
3. Have your mother not smoke
or drink alcohol
4. Have your mother
take pre-natal
vitamins including
folate.
20-40 YEARS
2. Avoid obesity
3. Ingest adequate
calcium
4. Eat sh
5. Wear your
seatbelt
5. Drink in
moderation
and do not smoke
6. Drive at a
safe speed
7. Avoid
violence and
illicit drugs
8. Check your breasts regularly
(females)
Aging Successfully
CAGE QUESTIONNAIRE FOR ALCOHOLISM*
Ever felt the need to cut down on your drinking?
Yes/No
Ever felt annoyed by criticism of your drinking?
Yes/No
Ever felt guilty about your drinking?
Yes/No
Ever take a morning drink (eye-opener)?
Yes/No
*Two affrmative answers may be suggestive of alcoholism.
Ewing, J Am Med Assoc 252:1905-1907, 1984.
Copyrighted 1984, American Medical Association
Alcohol
Anticoagulation
HEMORR
2
HAGES
H epatic or renal disease 1
E thanol abuse 1
M alignancy 1
O lder (age >75 years) 1
R educed platelet count or function 1
R e-bleeding Risk 2
H ypertension (uncontrolled) 1
A nemia 1
G enetic factors 1
E xcessive fall risk 1
S troke 1
TOTAL SCORE
Scoring:
Risk of Hemorrhage: With each additional point, the rate of
bleeding per 100 patient-years of warfarin increases:
1.9 (0.6-4.4) for 0
2.5 ( 1.3-4.3) for 1
5.3 (3.4-8.1) for 2
8.4 (4.9-13.6) for 3
10.4 (5.1-18.9) for 4
12.3 (5.8-23.1) for > 5
Gage BF, et al. Am Heart J 151(3):713-9, 2006.
Anticoagulation
CHADS
2
Risk of Stroke for People with Atrial Fibrillation if
Warfarin* Not Used
C ongestive heart failure 1
H ypertension 1
A ge 75 or older 1
D iabetes 1
S troke or TIA in the past 2

TOTAL SCORE
Risk of stroke: With each additional point, the rate of stroke
per 100 patient-years without antithrombotic therapy (i.e., the
use of aspirin instead of warfarin) increases:
1.9 (95% CI, 1.2-3.0) for a score of 0;
2.8 (95% CI, 2.0-3.8) for 1;
4.0 (95% CI, 3.1-5.1) for 2;
5.9 (95% CI, 4.6-7.3) for 3;
8.5 (95% CI, 6.3-11.1) for 4;
12.5 (95% CI, 8.2-17.5) for 5;
18.2 (95% CI, 10.5-27.4) for 6.
Gage BF, et al. Validation of clinical classifcation schemes for predicting stroke: results from the
National Registry of Atrial Fibrillation. J Am Med Assoc 285(22):2864-70, 2001.
*For calculating warfarin dosing, see www.warfarindosing.org.
CAUTION
Cancer Warning Signs
C hange in bowel or bladder habits
A sore that does not heal
U nusual bleeding or discharge
T hickening or lump in breast or elsewhere
I ndigestion or diffculty in swallowing
O bvious change in wart or mole
N agging cough or hoarseness
Cancer Screening
SIMPLE SCREEN FOR DEHYDRATION
D rugs, e.g., diuretics
E nd of life
H igh fever
Y ellow urine turns dark
D izziness (orthostasis)
R educed oral intake
A xilla dry
T achycardia
I ncontinence (fear of)
O ral problems/sippers
N eurological impairment (confusion)
S unken eyes
Thomas DR, et al. J Am Med Dir Assoc, June 2008.
Dehydration
Mental Status: DELIRIUM
ACUTE CHANGE IN MS
Medications that can Cause or have been Reported to Cause an
Acute Change in Mental Status
A ntiparkinsons drugs
C orticosteroids
U rinary incontinence drugs
T heophylline
E mptying drugs
1
C ardiovascular drugs
2
H
2
blockers
3
A ntibiotics
4
N SAIDs
5
G eropsychiatry drugs
6
E NT drugs
7
I nsomnia drugs
8
N arcotics
9
M uscle relaxants
10
S eizure drugs
1 E.g., metoclopramide, compazine.
2 In particular, centrally-acting drugs (e.g., clonidine), digoxin, some antiarrhythmics.
3 Particularly for patients with renal insuffciency because these drugs are renally excreted.
4 Although not a common cause of mental status change, several antibiotics have been reported in the
literature in the form of case reports.
5 Also not common, but case reports exist.
6 A large category because, in general, most of these are centrally-acting.
7 Some are worse than others. In general, non-sedating antihistamines are probably safe, but
combination drugs are risky.
8 Beware of over-the-counter sleeping agents. Most contain diphenhydramine.
9 Usually only seen with acute use, not chronic. Meperidine (Demerol) not recommended in the elderly.
10 These are centrally-acting, not locally at muscles.
Flaherty JH. Commonly prescribed and over-the-counter medications: Causes of confusion. Clin Geriatr
Med 14:101-127, 1998.
CAM
The Confusion Assessment Method Diagnostic Algorithm
Feature 1: Acute Onset and Fluctuating Course
This feature is usually obtained from a family member or nurse and
is shown by positive responses to the following questions: Is there
evidence of an acute change in mental status from the patients
baseline? Did the (abnormal) behavior fuctuate during the day, that is,
tend to come and go, or increase and decrease in severity?
Feature 2: Inattention
This feature is shown by a positive response to the following question: Did
the patient have diffculty focusing attention, for example, being easily
distractible, or having diffculty keeping track of what was being said?
Feature 3: Disorganized thinking
This feature is shown by a positive response to the following question:
Was the patients thinking disorganized or incoherent, such as
rambling or irrelevant conversation, unclear or illogical fow of ideas,
or unpredictable switching from subject to subject?
Feature 4: Altered Level of Consciousness
This feature is shown by any answer other than alert to the
following question: Overall, how would you rate this patients level of
consciousness? (Alert [normal], Vigilant [hyperalert], Lethargic [drowsy,
easily aroused], Stupor [diffcult to arouse], or Coma [unarousable]).
The diagnosis of delirium by CAM requires the presence of features 1
and 2 and either 3 or 4.
CAM Instrument and Algorithm adapted from Inouye S, van Dyck E, Alessi C, Balkin S, Siegal A,
Horwitz R. (1990). Clarifying confusion: the confusion assessment method. Ann Intern Med 113(12),
941-8. Reprinted with permission.
Dementia
Alert
Disoriented
Steady slow decline
Chronic
Usually normal
Usually normal
Usually not present
Usually normal
Aphasic, anomic,
diffculty fnding words
COCOA PHSS
Differentiating Delirium from Dementia
C onsciousness
O rientation
C ourse
O nset
A ttention
P sychomotor
H allucinations
S leep-wake cycle
S peech
Delirium
Decreased or hyperalert,
clouded
Disorganized
Fluctuating
Acute or subacute
Impaired
Agitated or lethargic
Perceptual disturbances,
may have hallucinations
Abnormal
Slow, incoherent
DELIRIUM(S)
Differential Diagnosis for Patients with Delirium
(Remember, delirium usually has more than one cause)
D rugs
1
E yes, ears
2
L ow O
2
states (MI, stroke, PE)
3
I nfection
R etention (of urine or stool)
I ctal
U nderhydration/Undernutrition
M etabolic
(S) ubdural
1 See mnemonic ACUTE CHANGE IN MS (page 11)
2 Poor vision and hearing are considered more risk factors than true cause, but should be fxed or
improved, if possible. Cerumen is common cause of hearing impairment.
3 Low O
2
state does NOT necessarily mean hypoxia, rather it is a reminder that patients with a hypoxic
insult (e.g., MI, stroke, PE) may present with mental status changes with or without other typical
symptoms/signs of these diagnoses.
Risk Factors for Delirium (B-E A-W-A-R-E) and Targeted
Interventions (P-R-E-V-E-N-T) Based on Intervention Trial to Prevent
Delirium.*
B aseline dementia?
E ye problems?
A ltered sleep/wake cycle?
W ater or dehydration problems?
A dding >3 medications, especially sedating and psychoactive
ones?
R estricted mobility?
E ar problems?
P rotocol for sleep (back massage, relaxation music, decreased
noise, warm milk or caffeine-free herbal tea)
R eplenish fuids and recognize volume depletion
E ar aids (amplifer or patients own hearing aid)
V isual aids (patients own glasses, magnifying lens)
E xercise or ambulation as soon as possible
N ame person, place and time frequently for reorientation
T aper or discontinue unnecessary medications. Use alternative
and less harmful medications.
* Inouye SK, Bogardus ST Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium
in hospitalized older patients. N Engl J Med 340:669-76, 1999.
BE AWARE PREVENT
AVOID RESTRAINTS
Non-Pharmacological Approaches to Patients with Behavioral
Problems (Associated with Dementia or Delirium)
A void exacerbating factors
V ague complaints? May represent delirium or other medical
illness
O ut of room; out of bed
I nsomnia protocol (e.g., warm milk, back rub/massage)
D istraction techniques
R elatives or friends to sit with/visit patient
E nvironmental adaptations
S cheduled acetaminophen for possible pain
T herapies (RT, PT, OT)
R eview medications as cause of problems
A larm on bed; low beds
I Vs or other tubes, monitors bothering patients? Discontinue
if possible or hide them
N urses station (bring patient out to station to sit)
T oilet frequently
S ensory impairments? Get glasses, hearing aides
Mental Status: DEMENTIA
DEMENTIA
Potential Reversible Causes of Dementia
D rugs

E yes, ears
M etabolic (e.g., thyroid, calcium)
E motion (i.e., depression)
N ormal pressure hydrocephalus (Wacky, Wobbly, and Wet)
T umor (or other space-occupying lesion)
I nfection (e.g., neurosyphilis)
A nemia (i.e., B
12
defciency)
THE CARING GUIDE
Management Guidelines for Caregivers of Persons with Dementia
T ime
1
H ome Health
2
E yes, Ears
3
C ar
4
A dvance Directive
R estraints
5
I ncontinence
N o $$$
G roup Support
6
G ait
7
U ndernutrition/Underhydration
I dentifcation (ID bracelet)
8
D rugs
9
E motions
10
1 Evaluate amount of time caregiver (CG) is spending with patient; consider respite.
2 Does CG need help in the home (e.g., choreworker, nursing aide)?
3 Impaired communication can be stressful and burdensome for CG. Cerumen is common cause of
hearing defcit.
4 Is patient still driving?
5 Restraints (especially physical) can be associated with increased agitation.
6 The Alzheimers Association (AA) is a good source of support groups for CGs. Visit www.alz.org.
7 Dementia may be a risk factor for falls.
8 Check with the AA for details about their Safe Return program (web or call).
9 See mnemonic ACUTE CHANGE IN MS on page 11.
10 Both patient and CG are at increased risk for depression.
Mental Status: DEPRESSION
GDS
Geriatric Depression Scale (Short Form)
1. Are you basically satisfed with your life?
2. Have you dropped many of your activities and interests?
3. Do you feel that your life is empty?
4. Do you often get bored?
5. Are you in good spirits most of the time?
6. Are you afraid that something bad is going to happen to you?
7. Do you feel happy most of the time?
8. Do you often feel helpless?
9. Do you prefer to stay at home rather than going out
and doing new things?
10. Do you feel you have more problems with memory than most?
11. Do you think it is wonderful to be alive now?
12. Do you feel pretty worthless the way you are now?
13. Do you feel full of energy?
14. Do you feel your situation is hopeless?
15. Do you think that most persons are better off than you?
Scoring: Score one point for each depressed answer (in box).
Score of >5 suggests probable depression.
For other languages, see http://www.stanford.edu/~yesavage/GDS.html
Sheikh JL, Yesavage JA. Clin Gerontol 5:165-72, 1986. Yesavage JA, et al. J Psychiatr Res 17:27, 1983.
NO
YES
YES
NO
YES
NO
NO
NO
NO
NO
YES
NO
YES
NO
NO
NO
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
SIG E CAPS
Signs and Symptoms of Depression
S leep problems
I nterest (lack of) (Anhedonia)
G uilt/Worthlessness
E nergy (lack of)
C oncentration problems
A ppetite problems
P sychomotor retardation
S uicide ideations
CORNELL SCALE FOR DEPRESSION IN DEMENTIA
Name___________________________ Age___ Sex___ Date___________
Inpatient Nursing Home Resident Outpatient
Person performing evaluation: Clinician Nurse Family Member Other
Scoring System
A=unable to evaluate 0=absent 1=mild or intermittent 2= severe
Base ratings on symptoms and signs occurring during the week prior to interview.
No score should be given in symptoms resulting from physical disability or illness.
A. Mood-Related Signs
1. Anxiety: anxious expression, ruminations, worrying a 0 1 2
2. Sadness: sad expression, sad voice, tearfulness a 0 1 2
3. Lack of reactivity to pleasant events a 0 1 2
4. Irritability: easily annoyed, short-tempered a 0 1 2
B. Behavioral Disturbance
5. Agitation: restlessness, handwringing, hairpulling a 0 1 2
6. Retardation: slow movement, slow speech, slow reactions a 0 1 2
7. Multiple physical complaints (score 0 if GI symptoms only) a 0 1 2
8. Loss of interest: less involved in usual activities a 0 1 2
(score only if change occurred acutely, i.e., in less than one month)
C. Physical Signs
9. Appetite loss: eating less than usual a 0 1 2
10. Weight loss (score 2 if greater than 5 lbs. in one month) a 0 1 2
11. Lack of energy: fatigues easily, unable to sustain activities a 0 1 2
(score only if change occurred acutely, i.e., in less than one month)
D. Cyclic Functions
12. Diurnal variation of mood: symptoms worse in morning a 0 1 2
13. Diffculty falling asleep: later than usual for this individual a 0 1 2
14. Multiple awakenings during sleep a 0 1 2
15. Early morning awakening: earlier than usual for this individual a 0 1 2
E. Ideational Disturbance
16. Suicide: feels life is not worth living, has suicidal wishes or a 0 1 2
makes suicide attempt
17. Poor self-esteem: self-blame, self-deprecation, feelings of failure a 0 1 2
18. Pessimism: anticipation of the worst a 0 1 2
19. Mood congruent delusions: delusions of poverty, illness, loss a 0 1 2
A score of >8 suggests signifcant depressive symptoms.
Alexopoulos G, Abrams R, Young R, et al. Cornell Scale for Depression in Dementia. Biol Psych 23, 271-84,
1988.
BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV)
BPPV is one of the most common causes of dizziness. It is often characterized
by vertigo that occurs a few seconds after specifc head movements, such as
rolling over in bed, bending over, or looking upward. The vertigo usually
lasts no more than a minute. The symptoms are most often experienced when
patients lie down, which distinguishes BPPV from orthostatic hypotension.
BPPV may be recurrent.
The Dix-Hallpike test is specifc for the diagnosis of BPPV.
While sitting on an examining table, the patients head is turned either
to the right or to the left by about 45. The patient is then moved rapidly
from a sitting position to a supine position with the head hanging off of
the back of the examining table while the head continues to be in the same
45 position. The patient is instructed to keep his/her eyes open so that the
examiner can see eye movement during the entire procedure. If BPPV is
present, vertigo will begin after a latency of 5 to 10 seconds and usually
will last 30 seconds to a minute. Rotary nystagmus will occur and the
patient will complain of dizziness.
After the nystagmus and the vertigo subside, the patient is returned to the
sitting position. The rotary nystagmus may reverse in direction and the
patient may again experience vertigo. If a positive response occurs, the
same maneuver is repeated. Usually, the severity of the vertigo and the
rotary nystagmus are reduced during the repeat maneuver. This reduction
is termed fatigue. The opposite ear is then tested in a similar fashion.
The offending ear is the one that is toward the ground when BPPV occurs
during the Dix-Hallpike maneuver.
Sloane PD. Evaluation and Management of Dizziness in the Older Patient. Clin Geriatr Med 12:785-
801, 1996. http://www.earaces.com/BPPV.htm. Parts of this are reprinted from http://www.earaces.
com/bppv.html with permission from Atlantic Coast Ear Specialists, P.C.
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Dizziness
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2
ERTIGO PM
V ision problem, hyperVentilation
E quilibrium disorders
Dep R ession
T ransient ischemic attacks, heart disease
I nfarction (cerebral)
G rowths (tumors)
O rthostatic dysregulation
P aroxymal positioning vertigo
M edications
NEGLECT ABUSE
Risk Factors and Clues for Possibility* of Neglect or Abuse**
N o money or low income
E motion (depression) of either patient or caregiver
G rave illness (cancer, Alzheimers)
L oss of weight or dehydration
E arlier evidence of neglect or abuse
C ognitive or physical impairment
T oo many or too few doctor/emergency department visits
A lcohol or drug use
B ehavioral problems
U nkempt or poor hygiene
S kin tears, bruises or sores
E asily frightened
*Caution should be used before labeling someone neglectful or abusive without complete information.
**Neglect and abuse are combined in this mnemonic because it is often diffcult to differentiate between
the two, and both may be a consequence of the patients or caregivers circumstances. They may not be
intentional.
Elder Neglect or Abuse
Eyes and Ears
SNELLEN CHART
Near Vision Assessment
Hold in good light, 14 inches from eye.
THE HEARING HANDICAP INVENTORY FOR THE
ELDERLY (HHIE) SCREENING VERSION
(4 points for each positive answer)
Note: One of the most common causes of impaired hearing is
cerumen. ALWAYS examine ear canals when hearing is abnormal.
1. Does a hearing problem cause you to feel embarrassed when you
meet new people?
2. Does a hearing problem cause you to feel frustrated when talking to
members of your family?
3. Do you have diffculty hearing when someone speaks in a whisper?
4. Do you feel handicapped by a hearing problem?
5. Does a hearing problem cause you diffculty when visiting friends,
relatives, or neighbors?
6. Does a hearing problem cause you to attend religious services less
often than you would like?
7. Does a hearing problem cause you to have arguments with family
members?
8. Does a hearing problem cause you diffculty when listening to
television or radio?
9. Do you feel that any diffculty with your hearing limits or hampers
your personal or social life?
10. Does a hearing problem cause you diffculty when in a restaurant
with relatives or friends?
Score Likelihood ratio (95% CI)
0-8 0.36 (0.19-0.68)
10-24 2.30 (1.22-4.32)
26-40 12.00 (2.62-55.0)

Lichtenstein MJ, et al. Validation of screening tools for identifying hearing-impaired elderly in primary
care. J Am Med Assoc 259(19);2875-8, 1988.
Probability of hearing
impairment given an
HHIE score:
Eyes and Ears
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Falls
Falls
AGAIN IVE FALLEN
Evaluation/Causes/Risk Factors for Falls
A gain
1
G ait and balance
A DL loss
I mpaired cognition
N umber and type of drugs
2
I llness
3
V estibular function
E yes, ears
F eet
A lcohol
L ow blood pressure
4
L ower extremity weakness
E nvironment
N eurological
1 Those who have fallen before are at higher risk to fall again compared to non-fallers.
2 At least 4 types of drugs according to one meta-analysis (40 studies) are associated with increased
risk for falls: antipsychotics, antidepressants, anxiolytics, sedative/hypnotics (Leipzig RM. J Am
Geriatr Soc 47:40-50, 1999). Both SSRIs and TCAs (secondary amines) increase risk according to
case control study (n=8,239). (Liu B, et al. Lancet 351:1303-7, 1998).
3 Look for new illness. Up to one-third of hospital visits for falls may be associated with an acute
illness. A fall also may be considered a DELIRIUM equivalent.
4 Including orthostatic or postural hypotension.
Falls
TIMED UP AND GO TEST
Patients who require >10 seconds for this test have limited
physical mobility and may be at risk for falls.
Instructions: Have the patient
-rise from the chair
-walk 10 feet (or 3 meters) forward
-turn around
-walk back to the chair
-and sit down
Normal time to complete the test = 7-10 seconds.
Also, observe gait and balance for abnormalities during the test.
Podsiadlo & Richardson, J Am Geriatr Soc 39:142, 1991.
Falls
SAFE AND SOUND
Home Assessment for Falls
S trength problems
A lcohol
F ood associated hypotension
E nvironmental factors
A therosclerotic disease (syncope)
N o freedom (restraints)
D rugs
S ight problems
O rthostatic hypotension
U nsteady balance
N octuria
D elirium or dementia
Falls
ONE-LEG STANDING
Standing on One Foot
Purpose:
Improve balance.
Starting position:
Stand close to a wall, chair, or table for balance.
Action:
Shift your weight onto one leg. Stand on that foot and stretch the
other leg out in front of you, a few inches off the foor.
Stand on one leg for eight counts.
For an extra workout, fex and point your lifted foot. That is, bend
the ankle so your toes point away from you, then fex the ankle to
bring the toes back towards you. Flex and point eight times.
Slowly return your leg to the starting position. Repeat with the
other leg.
Repeat 6 to 8 times.
Falls
THE 5 CHAIR-STANDS*
Instructions:
Have patient sit in a chair (preferably without armrests). Cross arms at chest.
Stand and sit 5 times (keeping arms crossed). Can the patient complete the
task? Yes/No Amount of time to complete: ________
Scoring:
Lower extremity weakness is one of the most important risk factors for falls. In
one guideline/review of studies on falls, this was the risk factor (out of 11) most
consistently found to be associated with falls. On average, lower extremity
weakness (measured in various ways) had an odds ratio or relative risk associated
with falls of 4.4 (range was 1.5 to 10.3) compared to people without lower extremity
weakness.
**

Since this is a proxy measure of lower extremity strength,
***
scoring does not have
specifc cut off points, but should be used to determine degree of abnormality based
on healthy elderly and risk for falls.
The average time it takes healthy sexagenarians to complete the test is 11.34+2.44
seconds
.****
If unable to do within 30 seconds, the risk of >1 falls in next 6 months increases
(OR 2.5, CI 1.5-4.1) compared to those who can do this, and the risk of recurrent
falls (>2) in the next 6 months increases (OR 4.8, CI 2.5-9.3). All patients in this
study were over 70 years of age.
*****
*
Also called: Sit-to-stand performance; Repeating 5 chair-stands; 5 Up-and-down.
**
Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society,
and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. J Am Geriatr Soc 49(5):664-72,
2001.
***
It is a dynamic measure, and is better than the traditional neurological exam for lower limb strength based on
the 0-5 scale.
****McCarthy EK, Horvat MA, Holtsberg PA, et al. Repeated Chair Stands as a Measure of Lower Limb
Strength in Sexagenarian Women. J Gerontol Series A: Bio Sci Med Sci 59:1207-1212; 2004
*****
Graafmans WC, Ooms ME, Hofstee HM, et al. Falls in the elderly: a prospective study of risk factors and
risk profles. Am J Epid 143(11):1129-36, 1996

FRAIL
F atigue
R esistance (ability to climb one fight of stairs)
A mbulation (ability to walking one block)
I llnesses (more than fve)
L oss of weight (more than fve percent in one year)
van Kan, GA, Rolland YM, Morley JE, Vellas B. Frailty: Toward a clinical defnition. J Am Med Dir
Assoc 9:71-2, 2008.
Frailty
Frailty
FRAILTY
Preventive Strategies to Slow the Onset of Frailty
F ood intake maintenance
R esistance exercises
A therosclerosis prevention
I solation avoidance (i.e., depression)
L imit pain
T ai Chi and other balance exercises
Y early check for testosterone defciency (see ADAM on
page 58)
Function
ADLS
Activities of Daily Living
BASIC ADLS
Bathing
Dressing
Toileting
Transfers
Continence
Feeding

ADL Score: ___/6
INSTRUMENTAL ADLS (IADLS)
Using the telephone
Shopping
Food preparation
Housekeeping
Laundry
Transportation
Taking medicine
Managing money
IADL Score: ___/8
GRECC 1998
Supported by the Offce of Geriatrics and Extended Care. Department of Veterans Affairs, Washington,
DC, 3
rd
Edition.
Function
INDICATORS FOR PATIENTS NEEDING PHYSICAL
THERAPY
A Range of Motion and Strength.
Patient unable to do actively or passively:
Flex shoulder 90
o
Bring hand to mouth
Bring hand to overhead
Bring hand to low back
Flex hip 90
o
Bend knee 90
o
Dorsifex foot (foot drop)
Arm/leg shakes
B Bed Mobility
Patient requires more than minimal assist for:
Rolling in bed
Sitting up
Getting up from chair/bed
C Balance and Gait
Patients who drop a level in ambulation on the activity
section of the nursing admission assessment.
Any patient admitted due to fall or with history (Hx) of
falling.
Patients unable to stand in one spot with both feet on the
ground for 30 seconds without holding on.
Patients unable to walk straight forward, need hand hold
assist, or need assistive device to walk. Patients afraid to
walk, hesitates.
Patients who need reassessment on equipment currently
being used with walker, cane.
Patients unable to go up/down stairs safely.
Function
INDICATORS FOR PATIENTS NEEDING
OCCUPATIONAL THERAPY
A Patients having diffculty in self-care, homemaking, leisure, or
working skills.
B Patients who display a decrease in cognitive, perceptual, or
sensorial awareness of their surroundings.
C Patients who have positioning problems with arms or legs due
to recent onset of trauma or illness (a splint or orthotic device
may improve positioning, i.e., resting hand or drop foot splint).
INDICATORS FOR PATIENTS NEEDING SPEECH
THERAPY
A Patients who demonstrate swallowing diffculty such as pocketing
within mouth, drooling, excessive chewing, decreased attempts
at food intake, signifcant weight loss, signifcant increased time
required for mealtime intake.
B Patients who demonstrate decreased communication abilities,
expressively and/or receptively.
C Patients who demonstrate diffculty with organizing/processing
thoughts, memory, sequencing, problem-solving, and judgment.
DR IATROS
Potential Areas for Iatrogenesis Related to Hospitalization
The following can be used as a daily checklist to prevent iatrogenesis.
D rug use
1
R estraints
2
I nfection
3
A ltered mental status (delirium)
4
T herapy (immobility)
R etention (of urine or feces)
O verzealous labeling
S tarvation
5
1 Risk of adverse drug event increases with number of medications. Risk approaches 100% at 10
medications.
2 Physical restraints do not prevent falls; may cause harm.
3 Most common nosocomial infection is UTI, associated with an indwelling urinary catheter. Risk of
infection from straight catheterization is far less than from an indwelling catheter.
4 Develops during hospitalization, not just on admission.
5 Restricted diets (e.g., heart healthy, 1800 calorie ADA) not indicated for older hospitalized
patients who are malnourished (see pages 32-33).
Hospitalization
Hospitalization
BED REST IS BAD
B ed sores
E motion (depression risk)
D VT risk
R etention of stool or urine
E at less
S leep-wake cycle disruptions
T akes longer to recover
I nfection risk (pneumonia)
S tool or urinary incontinence
B one loss
A trophy of muscle
D rop in blood pressure after getting up (orthostatic
hypotension)
Hospitalization
DC PLAN
Discharge Planning Check List
D rugs are all appropriate
C alled family
P CP notifed or is aware of plan
L ow income or money issues addressed (e.g., paying for meds)
A ppointments made and appropriate
N ote for transfer (dictation) done if going to another facility
Hospitalization
FOLEY
Use of an indwelling urinary catheter (Foley catheter) is associated
with bacteruria, urinary tract infections, bacteremia, even death. Other
associations include nephrolithiasis, bladder stones, epididymis,
chronic renal infammation, and pyelonephritis. It can also be
considered a one-point restraint.
Thus, use of Foley catheters should be reserved for the following:
Short-term decompression of acute urinary retention
Chronic retention not manageable by intermittent catheterization
To aid in urologic surgery or other surgery on contiguous
structures
Very ill patients who cannot tolerate garment changes or are at
end-of-life
Patients who request catheterization despite informed consent
regarding risks
Incontinence and risk of pressure ulcers are not indications for a
urinary catheter.
A FOLEY CATHETER IS A ONE-POINT RESTRAINT!
Hypogonadism
ADAM
Androgen Defciency in Aging Males
1. Do you have a decrease in libido (sex drive)?
2. Do you have a lack of energy?
3. Do you have a decrease in strength and/or endurance?
4. Have you lost height?
5. Have you noticed a decreased enjoyment of life?
6. Are you sad and/or grumpy?
7. Are your erections less strong?
8. During sexual intercourse, has it been diffcult to maintain your
erection to completion of intercourse?
9. Are you falling asleep after dinner?
10. Has there been a recent deterioration in your work performance?
Scoring: Yes to #1 and #7, or any 3 others is a positive screen for
possible hypogonadism.
Morley JE, et al. Metabolism 49(9):1239-42, 2000.
Incontinence
DRIP
2
OR DOUSE
Urinary Incontinence
DRIP: Acute causes of urinary incontinence
Drugs, Delirium
Retention of urine, Restraints
Infection, Impaction of stool
Polyuria, Prostatitis
DOUSE: Chronic causes of urinary incontinence
DHIC*
Overfow (Lower Urinary Tract Symptomatology)
+
Urge
Stress
External causes (e.g., functional)
*
Detrussor hyperactivity, impaired contractility
+
Includes BPH but also dysynchrony of bladder contractions in both women and men.
Incontinence
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Incontinence
OAB-V8
Overactive Bladder Validated 8 Question Awareness Tool
1
RESPONSE CHOICES POINTS
Not at all 0
A little bit 1
Somewhat 2
Quite a bit 3
A great deal 4
A very great deal 5
How bothered have you been by
1. Frequent urination during the daytime hours?
2. An uncomfortable urge to urinate?
3. A sudden urge to urinate with little or no warning?
4. Accidental loss of small amounts of urine?
5. Nighttime urination?
6. Waking up at night because you had to urinate?
7. An uncontrollable urge to urinate?
8. Urine loss associated with a strong desire to urinate?
Add 2 points to your score if you are male.
Add points for your responses to the questions above.
If your score is 8 or greater, you may have overactive bladder.
1
Coyne KS, Zyczynski T, Margolis MK, Elinoff V, Roberts RG. Validation of an overactive bladder
awareness tool for use in a primary care setting. Adv Ther 2204;381-94, 2005.
Insomnia
HELP ME SLEEP
Checklist for Evaluation of and Interventions for Insomnia
H erbal tea or warm milk
E valuate medication list for causes of insomnia
L imit nighttime interruptions (e.g., vital signs)*
P ostpone morning labs*
M assage
E valuate daytime activity
S ound reduction
L ight reduction at night
E nvironment changes (e.g., temperature of room, single
room)
E asy listening music or white sound
P ain relief
*only pertains to hospitalized persons
Medication
Potentially Inappropriate Medications for Older
Adults Independent of Diagnosis (partial list)*
DRUG CONCERN
Propoxyphene (Darvon) and
combinations (Darvon with
ASA, Darvon-N, Darvocet-N)
1

Offers few analgesic advantages over
acetaminophen, yet has the adverse
effects of other narcotics
Indomethacin Of all available NSAIDs, this drug
produces most CNS adverse effects
Muscle relaxants and antispasmod-
ics: methocarbamol (Robaxin), ca-
risoprodol (Soma), Chlorzoxazone
(Parafex), metaxalone (Skelaxin),
cyclobenzaprine (Flexeril)
Most muscle relaxants and antispasmod-
ics are poorly tolerated by elderly pa-
tients, since these cause anticholinergic
adverse effects, sedation, and weakness.
Additionally, their effectiveness at doses
tolerated by elderly is questionable.
Amitriptyline (Elavil), Imipramine,
Chlordiazepoxide-amitriptyline
(Limbitrol), and perphenazine-
amitriptyline (Triavil)
Because of its strong anticholinergic
and sedation properties, amitriptyline is
rarely the antidepressant of choice for
elderly.
Doses of short-acting benzodiaz-
epines (BDZ): doses greater than
lorazepam (Ativan), 3 mg; oxaz-
epam (Serax), 60 mg; alprazolam
(Xanax), 2 mg; temazepam (Re-
storil), 15 mg; triazolam (Hal-
cion), 0.25 mg
Because of increased sensitivity to ben-
zodiazepines in elderly patients, smaller
doses may be effective as well as safer.
Total daily doses should rarely exceed
the suggested maximums.
Long-acting benzodiazepines: chlor-
diazepoxide (Librium), diazepam
(Valium), chlorazepate (Tranxene)
These drugs have a long half-life in elderly
patients, producing sedation and increas-
ing risk of falls and fractures.
1
While this drug has high-addicting potential and in most patients less pain control, it inhibits NMDA which
plays a role in perpetuating chronic pain. However. some persons get better relief of pain with propoxyphene
and this should be documented.
Medication
*For full list and details, see reference: Fick DM, Cooper JW, Wade WE, et al. Updating the Beers
Criteria for potentially inappropriate medication use in older adults: Results of a US consensus panel of
experts. Arch Intern Med 163(22):2716-24, 2003.
Digoxin (Lanoxin) (should not
exceed >.125 mg/day except
when treating atrial arrhythmias)
Decreased renal clearance may lead
to increased risk of toxic effects.
Meperidine (Demerol) Not an effective oral analgesic
in doses commonly used, may
cause confusion and has many
disadvantages to other narcotics
Ketorolac (Toradol) Immediate and long-term use should
be avoided.
Daily fuoxetine (Prozac) Long half-life and risk of producing
excessive side effects, sleep
disturbance, and increasing agitation.
Safer antidepressants available.
Short acting nifedipine
(Procardia, Adalat)
Potential for hypotension
Clonidine (Catapres) Potential for CNS adverse effects.
Diphenhydramine (Benadryl) May cause confusion and sedations.
Should not be used as a hypnotic, and
when used to treat emergency allergic
reactions, it should be used in smallest
possible doses.
DRUG CONCERN
Potentially Inappropriate Medications for Older
Adults Independent of Diagnosis (partial list)* (continued)
Medication
AVOID TOO MANY
Guidelines for Proper Medication Prescribing, Prevention
of Polypharmacy, and Medication Reduction
A lternatives
1
V ague history or symptoms
2
O TC
3
I nteractions (drug-drug, drug-disease)
D uration
4
T herapeutic vs. preventive
5
O nce a day vs. BID, TID, QID
6
O ther MDs
M oney issues
A dverse drug effects of other drugs
7
N eed
8
Y es/No
9
1 Use non-pharmacological therapies whenever possible (e.g., warm milk instead of a sleeping agent).
2 Do not treat vague symptoms with drugs (e.g., vague gastrointestinal upset with H
2
blocker).
3 Over-the-counter drugs do count as drugs.
4 If possible (e.g., symptomatic drugs), decide on duration of therapy. If no positive effect after trial
period, stop before adding another medication.
5 Depending on life expectancy, preventive drug therapy may not beneft patient. In general,
therapeutic drugs should have priority over preventive drugs.
6 In general, once a day improves compliance, but may be more expensive than TID or QID drugs.
7 Do not treat adverse drug effects with a different drug if offending agent can be stopped or changed.
8 Does the person really need a medication now?
9 Refers to compliance. Is the person taking the current medication?
Nutrition
MEALS ON WHEELS
Common causes of malnutrition in older persons
M edications
1
E motion (i.e., depression)
A norexia (nervosa or tardive), Alcoholism, Abuse (elder)
L ate-life paranoia or alcoholism
S wallowing disorders
O ral factors (see DENTAL on page 36)
N o money, Nosocomial infections
W andering and other dementia-related behaviors
H yperthyroidism, Hyperparathyroidism, Hypoadrenalism, Hyperglycemia
E ntry problems/Malabsorption
E ating problems
2
L ow-salt or low-cholesterol diet
S hopping and food prep problems, Stores
1 Digoxin, theophylline, psychotropic drugs.
2 Severe tremor, stroke, weakness.
Nutrition
SNAQ
Simplifed Nutritional Assessment Questionnaire
Name:________________________________ Sex: M F
Age:______ Height:___________ Weight:_________ Date:________
Food tastes
a. very bad
b. bad
c. average
d. good
e. very good
Normally I eat
a. less than one meal a day.
b. one meal a day.
c. two meals a day.
d. three meals a day.
e. more than three meals a day.
My appetite is
a. very poor
b. poor
c. average
d. good
e. very good
When I eat
a. I feel full after eating only a few
mouthfuls.
b. I feel full after eating about a
third of a meal.
c. I feel full after eating over half
a meal.
d. I feel full after eating most of the
meal.
e. I hardly ever feel full.
Tally the results based on the following numerical scale: a=1; b=2,
c=3, d=4, e=5. The sum of the scores for the individual items consti-
tutes the SNAQ score. A SNAQ score of < 14 indicates signifcant
risk of at least 5% weight loss within six months.
Wilson, et al. Am J Clin Nutr 82:1074-81, 2005.
SNAQ
Simplifed Nutritional Assessment Questionnaire
BMI
Nutrition
B
M
I
1
9
2
0
2
1
2
2
2
3
2
4
2
5
2
6
2
7
2
8
2
9
3
0
3
1
3
2
3
3
3
4
3
5
3
6
3
7
3
8
3
9
4
0
4
1
4
2
4
3
4
4
4
5
4
6
4
7
4
8
4
9
5
0
5
1
5
2
5
3
5
4
H
e
i
g
h
t
(
i
n
c
h
e
s
)
B
o
d
y

W
e
i
g
h
t

(
p
o
u
n
d
s
)
5
8
9
1
9
6
1
0
0
1
0
5
1
1
0
1
1
5
1
1
9
1
2
4
1
2
9
1
3
4
1
3
8
1
4
3
1
4
8
1
5
3
1
5
8
1
6
2
1
6
7
1
7
2
1
7
7
1
8
1
1
8
6
1
9
1
1
9
6
2
0
1
2
0
5
2
1
0
2
1
5
2
2
0
2
2
4
2
2
9
2
3
4
2
3
9
2
4
4
2
4
8
2
5
3
2
5
8
5
9
9
4
9
9
1
0
4
1
0
9
1
1
4
1
1
9
1
2
4
1
2
8
1
3
3
1
3
8
1
4
3
1
4
8
1
5
3
1
5
8
1
6
3
1
6
8
1
7
3
1
7
8
1
8
3
1
8
8
1
9
3
1
9
8
2
0
3
2
0
8
2
1
2
2
1
7
2
2
2
2
2
7
2
3
2
2
3
7
2
4
2
2
4
7
2
5
2
2
5
7
2
6
2
2
6
7
6
0
9
7
1
0
2
1
0
7
1
1
2
1
1
8
1
2
3
1
2
8
1
3
3
1
3
8
1
4
3
1
4
8
1
5
3
1
5
8
1
6
3
1
6
8
1
7
4
1
7
9
1
8
4
1
8
9
1
9
4
1
9
9
2
0
4
2
0
9
2
1
5
2
2
0
2
2
5
2
3
0
2
3
5
2
4
0
2
4
5
2
5
0
2
5
5
2
6
1
2
6
6
2
7
1
2
7
6
6
1
1
0
0
1
0
6
1
1
1
1
1
6
1
2
2
1
2
7
1
3
2
1
3
7
1
4
3
1
4
8
1
5
3
1
5
8
1
6
4
1
6
9
1
7
4
1
8
0
1
8
5
1
9
0
1
9
5
2
0
1
2
0
6
2
1
1
2
1
7
2
2
2
2
2
7
2
3
2
2
3
8
2
4
3
2
4
8
2
5
4
2
5
9
2
6
4
2
6
9
2
7
5
2
8
0
2
8
5
6
2
1
0
4
1
0
9
1
1
5
1
2
0
1
2
6
1
3
1
1
3
6
1
4
2
1
4
7
1
5
3
1
5
8
1
6
4
1
6
9
1
7
5
1
8
0
1
8
6
1
9
1
1
9
6
2
0
2
2
0
7
2
1
3
2
1
8
2
2
4
2
2
9
2
3
5
2
4
0
2
4
6
2
5
1
2
5
6
2
6
2
2
6
7
2
7
3
2
7
8
2
8
4
2
8
9
2
9
5
6
3
1
0
7
1
1
3
1
1
8
1
2
4
1
3
0
1
3
5
1
4
1
1
4
6
1
5
2
1
5
8
1
6
3
1
6
9
1
7
5
1
8
0
1
8
6
1
9
1
1
9
7
2
0
3
2
0
8
2
1
4
2
2
0
2
2
5
2
3
1
2
3
7
2
4
2
2
4
8
2
5
4
2
5
9
2
6
5
2
7
0
2
7
8
2
8
2
2
8
7
2
9
3
2
9
9
3
0
4
6
4
1
1
0
1
1
6
1
2
2
1
2
8
1
3
4
1
4
0
1
4
5
1
5
1
1
5
7
1
6
3
1
6
9
1
7
4
1
8
0
1
8
6
1
9
2
1
9
7
2
0
4
2
0
9
2
1
5
2
2
1
2
2
7
2
3
2
2
3
8
2
4
4
2
5
0
2
5
6
2
6
2
2
6
7
2
7
3
2
7
9
2
8
5
2
9
1
2
9
6
3
0
2
3
0
8
3
1
4
6
5
1
1
4
1
2
0
1
2
6
1
3
2
1
3
8
1
4
4
1
5
0
1
5
6
1
6
2
1
6
8
1
7
4
1
8
0
1
8
6
1
9
2
1
9
8
2
0
4
2
1
0
2
1
6
2
2
2
2
2
8
2
3
4
2
4
0
2
4
6
2
5
2
2
5
8
2
6
4
2
7
0
2
7
6
2
8
2
2
8
8
2
9
4
3
0
0
3
0
6
3
1
2
3
1
8
3
2
4
6
6
1
1
8
1
2
4
1
3
0
1
3
6
1
4
2
1
4
8
1
5
5
1
6
1
1
6
7
1
7
3
1
7
9
1
8
6
1
9
2
1
9
8
2
0
4
2
1
0
2
1
6
2
2
3
2
2
9
2
3
5
2
4
1
2
4
7
2
5
3
2
6
0
2
6
6
2
7
2
2
7
8
2
8
4
2
9
1
2
9
7
3
0
3
3
0
9
3
1
5
3
2
2
3
2
8
3
3
4
6
7
1
2
1
1
2
7
1
3
4
1
4
0
1
4
6
1
5
3
1
5
9
1
6
6
1
7
2
1
7
8
1
8
5
1
9
1
1
9
8
2
0
4
2
1
1
2
1
7
2
2
3
2
3
0
2
3
6
2
4
2
2
4
9
2
5
5
2
6
1
2
6
8
2
7
4
2
8
0
2
8
7
2
9
3
2
9
9
3
0
6
3
1
2
3
1
9
3
2
5
3
3
1
3
3
8
3
4
4
6
8
1
2
5
1
3
1
1
3
8
1
4
4
1
5
1
1
5
8
1
6
4
1
7
1
1
7
7
1
8
4
1
9
0
1
9
7
2
0
3
2
1
0
2
1
6
2
2
3
2
3
0
2
3
6
2
4
3
2
4
9
2
5
6
2
6
2
2
6
9
2
7
6
2
8
2
2
8
9
2
9
5
3
0
2
3
0
8
3
1
5
3
2
2
3
2
8
3
3
5
3
4
1
3
4
8
3
5
4
6
9
1
2
8
1
3
5
1
4
2
1
4
9
1
5
5
1
6
2
1
6
9
1
7
6
1
8
2
1
8
9
1
9
6
2
0
3
2
0
9
2
1
6
2
2
3
2
3
0
2
3
6
2
4
3
2
5
0
2
5
7
2
6
3
2
7
0
2
7
7
2
8
4
2
9
1
2
9
7
3
0
4
3
1
1
3
1
8
3
2
4
3
3
1
3
3
8
3
4
5
3
5
1
3
5
8
3
6
5
7
0
1
3
2
1
3
9
1
4
6
1
5
3
1
6
0
1
6
7
1
7
4
1
8
1
1
8
8
1
9
5
2
0
2
2
0
9
2
1
6
2
2
2
2
2
9
2
3
6
2
4
3
2
5
0
2
5
7
2
6
4
2
7
1
2
7
8
2
8
5
2
9
2
2
9
9
3
0
6
3
1
3
3
2
0
3
2
7
3
3
4
3
4
1
3
4
8
3
5
5
3
6
2
3
6
9
3
7
6
7
1
1
3
6
1
4
3
1
5
0
1
5
7
1
6
5
1
7
2
1
7
9
1
8
6
1
9
3
2
0
0
2
0
8
2
1
5
2
2
2
2
2
9
2
3
6
2
4
3
2
5
0
2
5
7
2
6
5
2
7
2
2
7
9
2
8
6
2
9
3
3
0
1
3
0
8
3
1
5
3
2
2
3
2
9
3
3
8
3
4
3
3
5
1
3
5
8
3
6
5
3
7
2
3
7
9
3
8
6
7
2
1
4
0
1
4
7
1
5
4
1
6
2
1
6
9
1
7
7
1
8
4
1
9
1
1
9
9
2
0
6
2
1
3
2
2
1
2
2
8
2
3
5
2
4
2
2
5
0
2
5
8
2
6
5
2
7
2
2
7
9
2
8
7
2
9
4
3
0
2
3
0
9
3
1
6
3
2
4
3
3
1
3
3
8
3
4
6
3
5
3
3
6
1
3
6
8
3
7
5
3
8
3
3
9
0
3
9
7
7
3
1
4
4
1
5
1
1
5
9
1
6
6
1
7
4
1
8
2
1
8
9
1
9
7
2
0
4
2
1
2
2
1
9
2
2
7
2
3
5
2
4
2
2
5
0
2
5
7
2
6
5
2
7
2
2
8
0
2
8
8
2
9
5
3
0
2
3
1
0
3
1
8
3
2
5
3
3
3
3
4
0
3
4
8
3
5
5
3
6
3
3
7
1
3
7
8
3
8
6
3
9
3
4
0
1
4
0
8
7
4
1
4
8
1
5
5
1
6
3
1
7
1
1
7
9
1
8
6
1
9
4
2
0
2
2
1
0
2
1
8
2
2
5
2
3
3
2
4
1
2
4
9
2
5
6
2
6
4
2
7
2
2
8
0
2
8
7
2
9
5
3
0
3
3
1
1
3
1
9
3
2
6
3
3
4
3
4
2
3
5
0
3
5
8
3
6
5
3
7
3
3
8
1
3
8
9
3
9
6
4
0
4
4
1
2
4
2
0
7
5
1
5
2
1
6
0
1
6
8
1
7
6
1
8
4
1
9
2
2
0
0
2
0
8
2
1
6
2
2
4
2
3
2
2
4
0
2
4
8
2
5
6
2
6
4
2
7
2
2
7
9
2
8
7
2
9
5
3
0
3
3
1
1
3
1
9
3
2
7
3
3
5
3
4
3
3
5
1
3
5
9
3
6
7
3
7
5
3
8
3
3
9
1
3
9
9
4
0
7
4
1
5
4
2
3
4
3
1
7
6
1
5
6
1
6
4
1
7
2
1
8
0
1
8
9
1
9
7
2
0
5
2
1
3
2
2
1
2
3
0
2
3
8
2
4
6
2
5
4
2
6
3
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Nutrition
Nutrition
SCALES
Protocol for Evaluating Risk of Malnutrition in the Elderly
S adness: GDS of 10-14 = 1 point
GDS of > 15 = 2 points
C holesterol: <160 mg/dl = 1 point
A lbumin: 3.5-4 mg/dl = 1 point
< 3.5 mg/dl = 2 points
L oss of weight: 1 kg / 1 month = 1 point
3 kg / 6 months = 2 points
E at: Does person need assistance? Yes = 1 point
S hopping: Does person need assistance? Yes = 1 point
Scoring: > 3 points indicates patient is at risk.
Morley JE. J Am Geriatr Soc 39:1139-40, 1991.
Nutrition
Nutrition
DENTAL
Screening Assessment Tool for Dental Conditions that
may Interfere with Proper Nutritional Intake and Possibly
Dispose a Person to Involuntary Weight Loss
D ry mouth (2 points)
E ating diffculty (1 point)
N o recent dental care
1
(1 point)
T ooth or mouth pain (2 points)
A lterations or change in food selection (1 point)
L esions, sores, or lumps in mouth (2 points)
Scoring: A score of > 3 points could indicate a dental problem.
Patient may need evaluation by dentist.
1
within 2 years
Osteoporosis
RISK FACTORS FOR OSTEOPOROSIS
L w calcium intake
eizure medications (anticonvulsants)
hin build
thanol (excess alcohol)
Hyp gonadism
rior fracture
Thyr id excess
ace (Caucasian/Asian)
ther relatives with osteoporosis/fractures
teroids
nactivity
moking
O
S
T
E
O
P
O
R
O
S
I
S
Pain
PAIN ASSESSMENT TOOL
Name _________________________________________________
1. Do you have any pain? YES NO
1a. How much pain do you have? Circle 0 if no pain.
1b. Which face best describes how you feel?
2. Are you sad/blue/unhappy? YES NO
3. What would you say your overall quality of health has been over
the past month?
4. What would you say your overall quality of life has been over the
past month?
IF YOU HAVE PAIN OR ARE SAD, TELL YOUR
HEALTH PROVIDER. THEY CAN HELP YOU.
0 1 2 3 4 5 6 7 8 9 10
NO
Pain
Mild Moderate Severe Very
Severe
Worst
Possible Pain
0 1 2 3 4 5
Pain
PAINS
Evaluation of the Different Characteristics of Pain
P rovocative factors
1

A ggravating factors
2

I s the pain aching, gnawing, knife-like, burning, cramping?
N ame where the pain is/where it goes
S everity
3
1
What brings on the pain?
2
What makes it worse?
3
Rate on a scale of 1-10.
Palliative Care and End-of-Life
PAIN WISDOM
Ten Potential Problems that Occur in a Terminally Ill Person
P ain
A nxiety
I mpaction of stool
N utrition problems
W ater (hydration problems)
I nfection
S ocial and spiritual issues
D epressed mood
O xygen (dyspnea vs. hypoxia)
M outh, skin, eyes which are dry
NON-PHARMACOLOGICAL PHARMACOLOGICAL
Provide psychological support and
regular visitors/outings.
D
E
P
R
E
S
S
I
O
N
Trazodone if associated with poor
sleep. Mirtazapine if associated
with anorexia. Desipramine/Nor-
triptyline. Selective Serotonin
Reuptake Inhibitors (SSRIs).
Provide emotional support. En-
courage small, frequent meals with
calorie supplements between meals.
Consider multivitamin. Consider
glass of wine/beer.
Sit upright (may need armchair).
Reduce room temperature. Maintain
humidity. Avoid activities that increase
dyspnea. Avoid irritants, e.g., smoke.
Raise head of bed. Use O
2
when
wanted. (Remember, cannula/mask
can be irritating). Use a fan.
Megestrol acetate (if anorexic use
new formulation to enhance absorp-
tion). Dronabinol (causes munchies,
use only when weight gain is not a
major concern). Testosterone (ef-
fectiveness uncertain).
Treat anxiety with benzodiazepines
(Lorazepam). Dronabinol for CO
2

retainers. Opiates. Low dose nebu-
lized morphine. Steroids. Scopolo-
mine/atropine/glycopyrollate (dries
secretions, prevents death rattle).
D
Y
S
P
N
E
A
Consider drugs as cause. Increase
fuid intake. Exclude fecal impac-
tion. Toilet after meals with gastro-
colic refex.
Check to make sure diarrhea is not
due to osmotic laxative. Rehydrate.
Use mainly osmotic laxatives:
Sorbitol, Lactulose, Polyethylene
glycol.
D
I
A
R
R
H
E
AUse Kaopectate, Loperamide, Pros-
taglandin inhibitors, or Octreotide
(somatostatin analog)
A
N
O
R
E
X
I
A
/
C
A
C
H
E
X
I
A
Consider medication effect. Provide
help at home. Provide emotional
support. Use energy conservation
strategies. Check sleeping patterns.
Utilize PT/OT. Exercise.
Treat depression. If anemic, use
Erythropoietin or Darbopoietin X.
Testosterone. Dexamethosone (4-6
week beneft). Methylphenidate.
F
A
T
I
G
U
E
C
O
N
S
T
I
P
A
T
I
O
N
Management of End-of-Life Symptoms
I
N
S
O
M
N
I
A
Supportive nursing. Consider drugs
as possible cause. Ensure adequate-
ly lighted room. Avoid illusional
objects. Have someone in room
(e.g., use delirium ICU).
NON-PHARMACOLOGICAL PHARMACOLOGICAL
D
E
L
I
R
I
U
M
Avoid drugs. If essential: Trazodone
(25-50mg 2-4 times per day), for
agitation. Haloperidol (0.5-1mg q d).
Respiridol (1-2mg q d) for paranoia.,
hallucinations, rarely for agitation. IV
Lorazepam (0.25-1mg) for sedation to
allow for medical procedures.
Make use of massage therapy. Try
heat/cold, Transcutaneous Electri-
cal Nerve Stimulation (TENS),
lidocaine patch, and activity/dis-
traction therapy.
P
A
I
N
Use WHO Analgesic Ladder. Try ace-
tominophen, NSAIDS, weak opioids,
strong opioids, adjuvant drugs, e.g.,
Neurontin
, (Gabapentin). All drugs

scheduled by the clock and use PRNs for
breakthrough pain. DO NOT USE ME-
PERIDINE due to seizure potential.
Provide psychological support,
help with social issues, and spiri-
tual support. Limit loneliness.
Increase activities within patients
limitations. Keep out of bed.
E
N
D
-
O
F
-
L
I
F
E

I
S
S
U
E
S
Treat depression & anxiety. Consider
dronabinol for general end-of-life
care ( food intake & sleep, nausea
and pain, and general well-being).
Use low doses & introduce 1st dose
at bedtime to limit delirium.
A
N
X
I
E
T
Y
Avoid sleeping all day. Increase
daytime activity. Control pain.
Indulge in warm milk before
sleeping. Get out of bed during
the daytime. No reading or televi-
sion in bed.
Try supportive therapy and/or re-
laxation therapy. Consider various
causes such as pulmonary embolus
or myocardial infarction.
N
A
U
S
E
A
/
V
O
M
I
T
I
N
G
Check to make sure it is not due
to drugs.
Dopamine antagonist. H
2
blockers.
Serotonin antagonists. Prokinetic
agents. Low-dose Dronabinol.
Treat depression.
Treat anxiety.
Treat pain.
Ambien
. Sonata
. Lunesta
.
Trazodone.
Lorazepam.
Buspirone.
Trazodone.
Management of End-of-Life Symptoms
Pressure Ulcers
STAGING PRESSURE ULCERS
Stage 1
Non-blanchable erythema of intact skin. The ulcer appears as a
defned area of persistent redness in lightly pigmented skin, whereas
in darker skin tones, the ulcer may appear with persistent red,
blue, or purple hues. In individuals with darker skin, discoloration
of the skin, warmth, edema, induration, or hardness may also be
indicators.
Stage 2
Partial thickness skin loss involving epidermis, dermis, or both. The
ulcer is superfcial and presents clinically as an abrasion, blister, or
shallow crater.
Stage 3
Full thickness skin loss involving damage to or necrosis of
subcutaneous tissue that may extend down to, but not through,
underlying fascia. The ulcer presents clinically as a deep crater with
or without undermining of adjacent tissue.
Stage 4
Full thickness skin loss with extensive destruction, tissue necrosis,
or damage to muscle, bone, or supporting structures (e.g., tendon,
joint capsule). Undermining and sinus tracts also may be associated
with Stage 4 pressure ulcers.
Reverse Staging
Clinical studies indicate that as deep ulcers heal, the lost muscle,
fat, and dermis is NOT replaced. Instead, granulation tissue flls
the defect before re-epithellalization. Given this information, it
is not appropriate to reverse stage a healing ulcer. For example, a
pressure ulcer stage 3 does not become a stage 2 or a stage 1 in
your documentation during healing. You must chart the progress by
noting an improvement in the characteristics (size, depth, amount of
necrotic tissue, amount of exudate, etc.) One tool to do so is called
the PUSH Tool 3.0. See www.npuap.org for details.
Pressure Ulcers
MANAGEMENT GUIDELINES
Principles: Relieve pain
Relieve pressure
Avoid dehydration
Remove necrotic debris
Stage I and II: Needs - Clean, moist surface
- Protect from external environment
Options - Wet-to-moist saline gauze
- Thin flm polymer
- Hydrocolloid

Stage III and IV with Needs -Clean, moist surface
deadspace, exudate - Protect from external environment
- Absorption of exudate
- Obliteration of dead space
Options - Wet-to-moist saline gauze
- Hydrocolloid dressing
- Synthetic absorption dressing
- Hydrogel
Stage III and IV Needs - Clean, moist surface
with necrosis - Protect from external environment
- Debridement
Options - Surgical; Autolytic; Enzymatic
Heel Ulcers Needs - Protect from external environment
- Complete Pressure-reduction
- DO NOT debride (unless abscess, infection)
EPWORTH SLEEPINESS QUESTIONNAIRE
Screening for Sleep Disorders
How likely are you to doze off or to fall asleep in the following
situations, in contrast to just feeling tired? This refers to your usual
way of life in recent times.
0 = would never doze
1 = slight chance of dozing
2= moderate chance of dozing
3 = high chance of dozing
Situation
Sitting and reading
Watching TV
Sitting inactive in a public place
As a passenger in a car for an hour
Lying down to rest in the afternoon
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car while stopped for a few minutes
Scoring: Out of 24, the higher the number, the more likely patient has
a sleeping disorder.
Johns MW. Sleepiness in different situations measured by the Epworth Sleepiness Scale. Sleep
17(8):703-10, 1994.
Sleep
HEALTH
LITERACY
The degree to which individuals have the capacity to obtain,
process, and understand basic health information and services needed
to make appropriate health decisions.
Risk Factors for Health Literacy
H ealth information diffcult to locate
E ducation level may be low
A frican American*
L earning disabilities
T erminology: lack of understanding of medical terms
H ispanic*
L ow income
I mmigrant*
T reatment options may be poorly understood
E lderly*
R eading ability may be below 7
th
grade level
A ctivity limitations
C ognitively impaired
Y ahoo (older persons may struggle with computer literacy)
*Older people in these populations often had limited access to education.

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, (Gabapentin). All drugs

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