Clinical Examination of Older Adults including Comprehensive Geriatric assessment

Structure

1.0 Objectives
1.1 Introduction
1.2 Approaching an Older Adult
1.3 Concept of Comprehensive geriatric Assessment ( CGA)
1.3.1 Definition
1.3.2 Components and settings
1.4 Physical assessment
1.4.1 History
1.4.2 Systemic examination
1.4.3 Nutritional assessment
1.4.4 Medication review
1.4.5 Ordering relevant investigations
1.5 Functional assessment
1.5.1 Screening for vision and hearing
1.5.2 Screening for Activities of Daily Living ( ADL)
1.5.3 Screening for Gait and Balance issues
1.5.4 Screening for memory and affective disorders

1.6 Screening for other Geriatric Syndromes.

1.7 Social and environmental assessment

1.8 Creating problem list and further planning

Objectives

After completing this chapter the learner will be able to

Elicit history and analyze the symptoms of the older patient.

Decide about the need for comprehensive Geriatric assessment

Plan and execute the various components of the CGA

List the problems and determine the need for relevant referral and further follow up.

Introduction

From the theory units, you may have appreciated that older patients are heterogeneous and in
varying phases of age-related structural and functional changes in organ systems. Atypical
presentations of diseases are very common. Late presentations of diseases are also seen more
frequently. Older patients are also known to have multiple health conditions. Almost all acute
and chronic illnesses can reduce functioning. But impaired cognition, impaired special senses,
problems with gait and mobility, poor health habits, poor nutrition, poly pharmacy,
incontinence, psychosocial factors are easily overlooked as the contributors of functional
decline. Well-designed multidimensional approach helps to deal with these complex problems,
prioritizing the treatment according to the needs of the patient in a systematic manner.

The principles of assessment of a patient remain same in all age groups in the practice of

medicine and surgery. However, the techniques of assessment and interpretation of clinical

Information is different in older patients as compared to younger individuals.

In this unit you will be learning about the history taking and symptom based clinical
examination. You will also be learning about what is Comprehensive Geriatric Assessment
from the primary care physicians’ point of view.
Approaching an older adult

The most important thing in clinical practice is to gain the confidence and trust of the older

patients. You must recognize that the older person in front of you is not merely a case or

disease, but a human being with an identity, some unique characteristics and experience of

lifetime. You as a physician need to respect these human aspects of the patient and note:

 Name, Age, Address of the patient

 Name, relationship and address of the caregiver(s) who might be required to contact in
emergency and also decision making
 Marital status (married with spouse living, widowed, separated, never married)
 Present occupation and past occupation
 Living arrangement (alone or with spouse only, in extended family with children and '
their family or other relatives, in old age accommodation or destitute)
 Financially dependent or independent

After deriving these information, you need to divide your patients (arbitrarily) into three

groups by age as well as functionality in your mind. By age older people can be young-old

(60-70 years), old - very old (70- 85 years) and .oldest-old or frail old (above 85 years). Each
grouping has different tasks, abilities and issues.. Functionally they can be completely
independent, practically dependent and completely dependent. Such an arbitrary subdivision is
essential while planning investigation and treatment of disease. For e.g., the young old group
may still be employed and more active whereas, the frail old may be completely dependent for
their daily activities, medications and also will have multiple comorbidities.

We need to recollect a few concepts of geriatric medicine as you approach an older patient:

 Symptoms develop early in the course of illness, atypical presentations are very
common in the oldest age group.
 As multiple diseases and disabilities are the rule rather than the exception, multiple
diagnosis is also the rule and all symptoms cannot be explained by a single diagnosis.
  Symptoms will be manifested as dysfunction of the most vulnerable organ rather than
the actually diseased organ. Most of the diseases present as one or more combinations
of Geriatric giants like Falls, Incontinence, confusion or immobility.
 Minor dysfunctions of many organs can lead to major disability. There will be
enormous overall improvement if those minor dysfunctions are taken care of.
 Adverse consequences of diseases are also more severe in elderly.

Check your progress 1

1. How will you arbitrarily group the elderly? What is the basis of the classification?
2. Choose the wrong statement
a. Diseases present as one or more of the Geriatric syndromes.
b. The techniques of assessment and interpretation are same in young and elderly.
c. Multiple diagnosis/ disabilities based treatment plan is the rule rather than exception
in elderly patients.
d. Age related structural and functional changes are respnsible for atypical presentations
of diseases.
3. State True or False
a. Social history includes the details of care giver.
b. Oldest old will always be functionally dependent.
c. Grouping the elderly patient based on age can lead to undesirable effect of
ageism.

Concept of Comprehensive Geriatric Assessment

CGA is defined as multidisciplinary diagnostic and treatment process that identifies medical,
psycho social and functional capacities of an older adult to develop a coordinated plan to
maximize overall health with ageing.it is based on the premise that a systematic evaluation of
frail older persons by a team of health professionals may identify a variety of treatable health
problems and lead to better outcomes.
Components of CGA

 Physical assessment-
 General and systemic examination depending on patient’s symptoms,
 Nutritional assessment,
 Review of medications and screening for polypharmacy
 Screening for specific geriatric syndromes
 Functional Assessment – Screening for Visual and hearing impairment,
Activities of daily living
 screening for gait and balance problems
 screening for memory and affective disorders
 other specific Geriatric symptoms- incontinence,
 Social and environmental assessment
 Living arrangement and home safety issues,
 financial status,
 possibility of elder abuse,
 advance directives.

As we are learning this module from the perspective of primary care physician, the following
arrangement can be followed.

Basic health workers, pre visit Demography, socio-economic details

questionnaire, telephonic interviews
Trained Nurses, nursing Assistant Symptom list,
details of past medical problems,
complete medication list
Primary care physician Symptom based examination,
Systemic examination,
search of complications of pre-existing disease,
medication review,
Screening for Geriatric syndromes,
functional assessment
Specialist Evaluation and Treatment of specific problem
Therapists ( physio, occupational) Addressing specific problem
The art of history taking in elderly

An older patient may have a long medical history, and a long list of symptoms. The clinician
should be able to pick up the relevant symptoms and direct the examination accordingly.

The patient may not be able to provide a coherent history due to sensory impairment, cognitive
impairment, illiteracy or due to misconception that the symptoms are irrelevant and may ignore
to mention them.

The clinician should review patient’s hospital files, discharge summaries, recent investigations
and prescriptions to have an insight about patient’s illness. This will also give an opportunity to
correlate the present symptoms to a systemic disease and to ignore the irrelevant ones. For
example, a past history of myocardial infarction or stroke can direct the physician to consider
atherosclerotic vascular disease as the cause of nocturnal lower limb pain of the patient,
whereas, the past history of prostatic surgery for BPH may not have any relation to patient’s
present problem of functional impairment. The Table summarises the difficulties.

Patient’s own statement about current health status compared to previous one gives good
insight about the deterioration in physical/ cognitive or functional status of the patient.

Table Difficulties in History taking in older adult

Long list of symptoms- both relevant and irrelevent

Difficulty in recalling and narrating history due to sensory and cognitive impairment
Record keeping of old records may not be adequate
Emphasizing irrelevant past history, leaving out relevant ones.

Major complaints:

Primary examination should be based on patient’s symptoms. In under graduation, you are
made familiar with the cardinal manifestation of all systemic problems. You will also be aware
that some symptoms can occur with dysfunction of more than one system. Best example is
dyspnea, which can manifest in respiratory, cardiovascular, metabolic problems.
Detailed schemas of examination of individual systems are discussed in the subsequent
chapters of this practical manual.

The cardinal symptoms of each system which should be enquired to every patient is listed in
the following Table

Table Cardinal systemic symptoms

Cardio respiratory system Breathlessness, cough and expectoration,

chest pain, wheezing, hemoptysis, palpitation
Gastrointestinal system Dysphagia, heartburn,
dyspepsia(Indigestion), abdominal pain and
distension, altered bowel habits, black stools
Genito- urinary system Lower abdominal pain, difficulty in
initiation/ stream of urine, increased
frequency, pain and burning sensation during
urination, discharge from genitals
Neurological system Altered mental status, weakness, altered
sensation, pain, abnormal movement
Musculo skeletal system Pain, stiffness, swelling of joints or muscles,
difficulty in carrying out activities
Hematopoietic system Fatigue, fever, night sweats, edema, dyspnea,
bleeding tendencies, lymphnode enlargement.

General examination:

As the patient comes in to the room, good observation initiates the examination. Some of the
factors which should be observed are

- The need for assistance either by attendant or by assistive device/ whether the patient uses
them correctly
- Gait of the patient
 - Edema of the limbs
- The way the patient is dressed
- General mood of the patient
- The ability to see , hear and understand the conversation

If possible a drawing of a man with pictures of above narration

While taking the vital signs, always record BP in lying down and standing positions at 1 minute
and 3 minutes. This is to find out if there is orthostatic fall of BP- a systolic fall of ≥ 20 mm of
Hg and Diastolic fall of ≥ 10 mm of Hg is significant.

The other usual thing to be examined or

Built, nourishment, consciousness, orientation, Pallor, Jaundice, Edema, Generalised

Lymphnode enlargement, State of skin, presence of any peculiar odour as in DKA, Hepatic
encephalopathy, alcoholic usage etc.,

Focused examination for Long term complication of comorbid conditions:

The detailed systemic examination should be done based on the symptoms. The next part of the
examination is directing the clinical examination as per the comorbid conditions as reported by
the patient. You can have an idea about this by the patients past history and medication history.

For e.g., if the patient is having long standing diabetes, look for the complications like
retinopathy, nephropathy, neuropathy etc., some of this may not be evident on clinical
examination and we have to plan relevant investigation/ referral to other specialists for
diagnosing them out.

Nutritional assessment

Calculate the BMI- the body mass Index using height and weight. Use MNA scale to find out
the adequacy of nutrition- at risk/ malnourished.
Medication review
1.Take full medication history including over the counter drugs, Illicit drug use, herbal
preparation etc. Review the prescriptions used by the patient for procuring drugs.

2.Follow Brown Bag technique- which means requesting the patient to bring all the drugs they
are using and verify that there are no duplications, errors etc. find out the patients
understanding about the timing of a drug ( before food, after food, to be taken when needed
etc). This exercise also gives opportunity to find out the cost of a drug limiting its correct
usage.

3.Take the person's opinion about each drug like swallowing difficulty for big capsule or
tablets, belief about effect or side effect etc.

4.Review the drug list for Pharmacological interaction or possible side effects. Correlate with
the clinical examination.

5. Review each medication, assess its need at present.

6. prepare a revised prescription and explain to the patient.

Assess the
Examine by
List the needs/
Brown bag Revise
medicines Possible
technique
ADR
We have discussed so far the examination pattern to be followed for all elderly patients.

At the end of this session we will have an idea about

Patient’s Problem/ problems list based on the symptomatology.

Presence / absence of Disabilities because of the problems
Revised prescription
List of further investigations
List of any referral
Review plans based on the investigations and specialist opinions.

Check your Progress 2

1.While planning CGA, the following has to be done necessarily only by physician

a. Collection of demographic details.

b. Review of patient records to get an idea about comorbid conditions
c. Decision on referral to the higher centres
d. Screening for malnutrition.

2. Medication review helps in all except

a. To find out Drug- Drug interaction.

b. To stop oral hypoglycemic drugs after the age of 85.

c. To verify patient’s understanding about the drugs.

d. To reduce the number of drugs.

3. You have a physician assistant, reception clerk to help in your clinic. How will you assign the
various tasks of CGA?
 The same patient should be considered for doing Comprehensive Geriatric assessment in
the following situations. This can be obtained by the history.

Indications of CGA

Advanced Age- age more than 75 years

When reporting recent onset Geriatric syndromes- functional decline and immobility,
recurrent falls, incontinence, cognitive impairment, undue tiredness, loss of weight

Before treatment- Hip replacement, TVAR, Renal replacement therapy, cancer

chemotherapy

Recurrent In-patient admissions, recent discharge from hospital

Change of living arrangement- from home environment to nursing home, assisted

living facilities

Let us recap the components of CGA

They are

Functional Assessment

Screening For Geriatric Syndromes

Social and environmental assessment

Functional Assessment

Vision and Hearing

Vision is an essential component needed for effective functioning. As one ages, ageing changes
like cataract, macular degeneration and effect of chronic diseases like diabetes, SHT and drugs
like steroid causes visual impairment. A primary care physician should be able to effectively
screen the visual ability and to refer appropriately whenever necessary. By asking them if they
have any difficulty in seeing TV /reading books, or if they complain blurred vision / halos
around light, it has to be further investigated. The acuity of vision can be screened in clinical set
up.

The Snellen Chart is used in most facilities for testing distance vision. They are designed to be
read at 6 metres or 3 metres (usually indicated on chart) .Dr. Snellen also created a chart called
the “Tumbling E” chart, which can be used by illiterate,who don’t know the alphabet. Instead of
using different letters, the “Tumbling E” eye chart uses a capital letter E that faces in different
directions. The eye doctor asks the person being tested to use their fingers to show the direction /
tell the direction in their own language in which the “fingers” of the E are pointing.

The steps to be followed are,

 Allow the patient to use their usual corrective glasses.

Test each eye separately using cupped hand or patch or occlude for the
untested eye.

If the patient cannot read any of the lines, make them read from the distance of
3 meters..

If they cant read still, keep the hands at 1 meter distance and find out if they can
count fingers.

Even if this is not possible , test for perception of hand movements and if the
patient cannot do any of this, test for light perception using pen torch.

Record as CF 9 Count fingers)/ HM 9 Hand Movements)/ LP 9 light perception)/

NLP( no light perception)

Hearing

Hearing loss prohibits patients from understanding conversations, contributes to cognitive

decline, and leads to social isolation. This impairment is the third most chronic impairment
among older people. It is also useful to ask the patient and family if they have noticed any
changes in hearing, to describe any changes and if they have had any prior treatment. A thirty dB
loss of hearing which can significantly affect communication can be screened by Whisper test.
Ear wax is very common reversible cause of hearing impairment, and it should be ruled out
before this test.

WHISPER TEST*

Instructions

 The examiner stands at arm's length (~0.6 m) behind the patient (to prevent lip reading).
  The opposite auditory canal is occluded by the patient or examiner and the tragus is
rubbed in a circular motion (goal; to block hearing from that ear)
 The examiner exhales and whispers a combination of numbers and letters (example 4-
K-2). Whispering at the end of exhalation is to ensure as quiet and as standardized voice
as possible.
 If the patient responds correctly, hearing is considered normal and no further screening
is necessary on that ear.
 If the patient responds incorrectly, then repeat using a different number-letter
combination.
 If on repeated testing, the patient can answer three out of a possible six numbers-letters
correctly, the patient passes. If they cannot answer three out of six or more, the patient
fails in that ear.
 Repeat the sequence in the opposite ear using different combinations of numbers and
letters. (Note: patients with memory problems may need a simplified letter/number
combination to compensate for their inability to remember)

stand at arm's length (~0.6 m) behind the patient

The opposite auditory canal is occluded by the patient or

examiner

The examiner exhales and whispers a different combination

of numbers and letters (example 4-K-2). Twice if necessary

If 3/6 words repeated , considered normal

Repeat the sequence in the opposite ear using different

combinations of numbers and letters.
Activities of daily Living ( ADL)

Baseline functioning level of a person can be understood by enquiring about Activities of Daily
Living ( ADL) and Instrumental activities of daily living ( IADL). These are the activities in
which the patients are engaged on day to day basis- the former in taking care of personal hygiene
and the later in taking care of the environment in which they live along with the ability to lead an
independent livelihood. In other words the scales designed for this can identify persons who need
assistance and the level of assistance, this helps us in planning further evaluation and
investigations. Generally any acute illness will affect these and serial assessment will help us to
measure the improvement as well as to understand the areas which can be improved by active
intervention. Thus they are helpful in assessing the prognosis, monitoring the progress and in
guiding the rehabilitation. As one of the principles of Geriatrics is to restore the pre illness
functional level, these tools are valuable in achieving the goal.

There are several scales. The following two are well validated and easy to administer. They are
Katz Index of independence in ADL and Lawton’s index of independence in Instrumental
activities of Daily Living.
Let us understand the importance of these scales with the help of an example. You have a 75
year old female, a case of SHT/ DM coming for 6 monthly follow up. She is recently discharged
from hospital after having undergone hip replacement surgery for fracture hip. You know that
she was previously independent in carrying out basic activities as well as instrumental activities
of daily living. From Katz’ tool you have identified that she has become dependent on 4 out of 6
basic activities Viz, transferring, bathing, dressing and toileting, all needing the functioning of
the lower limbs. By educating her the need for physiotherapy and coordinating the same along
with suggestion for environmental modifications, she can be gradually restored to the pre illness
level of functioning in 4 to 6 weeks time. This will also motivate her to undertake the
instrumental activities as before. Suppose, if these are not progressing, the scores after a month
will give us an insight about the problems and help us in further planning. It could be operative
sight pain, malnutrition leading to poor wound healing, UTI as the result of catheterization in a
diabetic, fear of fall preventing her from cooperating with physiotherapy, demotivation by family
members, depression or unattended environment. As a family physician, she can be helped with
all these treatable problems.

Gait and Balance

Impaired gait, balance and strength of lower extremities are key factors which cause falls in
elderly.early identification of problems with gait and balance and targeted interventions prevent
fall, improves mobility and quality of life of elderly. To understand the mobility issues of an
elderly, we need to know from patient by way of diligent history the following points

 Prior level of mobility- or what are the functions the patient was able to do previously .
 Any inability to carry out the specific function and the time period in which it has
occurred or noticed by the patient.
 Any weakness/ abnormal movement/ sensory impairment as noticed by the patient.
 What does the patient need to lead a normal life.
 Any prior intervention to improve the mobility.

General examination as explained above will give us an idea about patient’s gait, use of assistive
devices, sensory impairment if any. Brief neurological examination and musculo skeletal
examination will help us identify any so far undiagnosed neurological/ musculo skeletal
condition and arrange for referral.

The gait and balance assessment is useful to find the risk of fall and to plan intervention in

Those who report a fall

Those who are diagnosed to have a neurological problem e.g recent CVA, Parkinsonism

Those who have reported to have recent onset decreased mobility.

The screening tests are 5 times chair raise test ( 5X SST), and timed up and Go test ( TUG).
Those who have problems in oerforming this test to be subjected to Short Physical performance
Battery test ( SPPB) for confirmation and further referral.

Chair Raise test- The five Times Sit to Stand Test (5x Sit-To-Stand Test) commonly
abbreviated as 5XSST.

This test assess

 Functional Lower extremity strength

 Transitional movement
 Balance
 Fall risk

The 5XSST scoring is based on the amount of time (to the nearest decimal in seconds) a
patient is able to transfer from a seated to a standing position and back to sitting five times.
The equipment needed- Stopwatch and standard height chair with straight back (43-45 cm,
17-18 inches high ) and without arm. The steps to be followed are
The lower the time to complete the test the better the outcome of the test. A time period of
more than 14 seconds to complete the test is considered abnormal and SPPB should be done
further.

Timed Up and Go test ( TUG)

Note: A practice trial should be completed before the timed trial

Observations

While the patient performs the test, note postural stability, gait, stride length and sway.

The presence of slow tentative pace, loss of balance, short strides, little or no arm swing,
steadying self on walls, shuffling, difficulty in turning 180 degrees and improper use of
assistive devices will need further evaluation and intervention.

An older adult who takes ≥12 seconds to complete the TUG is at risk for falling.

Short Physical Performance battery (SPPB)

This is a group of tests which measure gait speed, chair stand and balance tests. The scores range
from 0 ( worst performance) to 12 ( best performance). This test has predictive validity in
predicting the risk of mortality, nursing home placement, and disability.

Components

Gait speed- Fastest recorded time in the two timed trials of 3 meters or 4 meters walk.

Chair stand- Time to raise from chair five times.

Balance component- Ability to stand for 10 seconds with feet in 3 different positions- side by
side, semi tendem, and tandem
The SPPB score of 0-9 indicates limited mobility and 10- 12 indicates normal mobility. Thus
this test helps you to identify patients who needs recommendation and referral for multimodal
exercises, nutrition advice (increased protein intake) after detailed assessment of risk of falls,
rehabilitation and assistive devices .The multimodal exercise programs are designed to improve
the strength of the muscles ( resistance exercises), endurance ( cardiovascular exercises), and
improve balance

Screening for Memory and affective problems

You know that cognitive impairment can occur in elderly due to various factors. It could be age
related memory impairment, dementia due to various etiologies, trauma related or due to tother
CNS disprders. If unrecognized, it can lead to various health related and social consequences.
Early identification requires active screening. Subjective Memory impairment as reported by the
patient himself may not always be associated with actual memory problems, whereas if reported
by the patient’s nearest relative like spouse, it can be considered.
The Mini-Cog is a simple screening tool that is well accepted and takes up to only 3 minutes to
administer. It has 2 components- Three item recall and The clock drawing test. The patient is
first made to repeat the three unrelated words as told by the examiner and made to recall them
after the patient completes the clock drawing.

 It is appropriate to be used with older adults at various heterogeneous language, culture,

and literacy levels.

 This tool can be used to detect cognitive impairment quickly during both routine visits
and hospitalizations.

 The Clock Drawing Test (CDT) component of the Mini-Cog allows clinicians to quickly
assess numerous cognitive domains including cognitive function, memory, language
comprehension, visual-motor skills, and executive function and provides a visible record
of both normal and impaired performance that can be tracked over time

 The Mini-Cog serves as an effective test that helps to identify individuals in need of more
thorough evaluation.

3-Item Recall Score:

1 point for each word recalled without cues, for a 3-item recall score of 1, 2, or 3.

Clock Drawing Score:

2 points for a normal clock or 0 (zero) points for an abnormal clock drawing. A normal clock
must include all numbers (1-12), each only once, in the correct order and direction
(clockwise). There must also be two hands present, one pointing to the 11 and one pointing to
2. Hand length is not scored in the Mini-Cog algorithm.

Interpretation of Mini – Cog test

Screening for Dementia 0/3 words recalled+ normal or abnormal clock drawing
positive

1/3 or 2/3 w1/3or 2/3words recalled+ abnormal clock drawing

Screening for Dementia 3/3 words recall+ normal or abnormal clock drawing
Negative

1/3 or 2/3 words recalled + normal clock drawing

Those who have shown positive screening for dementia should be further evaluated. The other
elaborative screening tests are Mini Mental state Examination ( MMSE) or Montreal Cognitive
Assessment ( MoCA). If these tests are alos positive for cognitive decline,, they should be
referred for evaluation by Geriatric Physician, Neurologist and Neuro Psychologist for
confirmation, lab examination and treatment.

Screening for Affective disorders:

Mood disorders particularly depressive disorders are common in elderly. They present with
vague symptoms. If left undetected and untreated, it can lead to considerable distress and
functional impairment. It is a public health problem as it affects the individual, family and
society. Depression should be suspected when the older person complains of vague, multiple and
unrelated complaints, sleep disturbance, recent alteration in weight or appear withdrawn. There
are several validated instruments. Let us see two out of them- one for screening and another for
confirmation.

Screening

4 Item Geriatric Depression Scale ( GDS -4)

 Are you basically satisfied with your life?

 Do you feel that your life is empty?
 Are you afraid that something bad is going to happen to you?
 Do you feel happy most of the time?
Score of 1 given for Yes answers and 0 for No answers. 2-4=Depressed, 1=uncertain, 0=Not
depressed.

IF the score range comes in Uncertain or in Depressed range, PHQ-9 can be administered for
confirmation. PHQ depression scale (which we call the PHQ-9) is half the length of many other
depression measures, has comparable sensitivity and specificity, and consists of the actual 9
criteria upon which the diagnosis of DSM-IV depressive disorders is based. It scores each of the
nine DSM-IV criteria as "0" (not at all) to "3" (nearly every day). It has been validated for use in
primary care. The PHQ-9 has the potential of being a dual-purpose instrument that, with the
same 9 items, can establish depressive disorder diagnosis as well as grade depressive symptom
severity.

Interpretation of score
If screening for cognitive decline/ depression is positive, as a primary care physician, you can
look for some treatable conditions like malnutrition, anemia, thyroid disorders, sexually
transmitted diseases ( HIV, Syphilis) and initiate treatment if necessary. You can do a basic
imaging like CT scan of brain in case there is clinical suspicion of any trauma, or if there are
any focal neurological deficits.

The other roles of a primary care physicians are counseling/ educating the attenders, controlling
of co morbid conditions and providing continuing support and periodic review of the patient.
This includes palliative and end of life care also toward the end.

Responsibilities of primary care physicians

Screening for dementia and depression
Investigations for common treatable conditions
Follow up the patient who is on medication, control comorbids, look for drug interactions, ADR
Caring for care givers including care giver burden
Preparing the patient and care givers for the eventuality
Providing end of life care
After care for the attenders

1.5.5 Screening of other Geriatric syndromes•

Urinary Incontinence

It is a very common and under recognized problem in elderly. More common in

females than males.as it is regarded as normal aspect of ageing, it may not be
rported by patients. Hence it has to be enquired to the patients.

Two screening questions to ask are:

• In the last year have you lost your urine and gotten wet? If the answer is
YES then the patient is asked,

• Have you lost urine on 6 separate days?

 An answer of YES to both questions has 75% - 79% accuracy for urinary
incontinence.

The 3 IQ questionnaire is another brief interviewer administered instrument with

high specificity and sensitivity. It can differentiate the types of incontinence too.

3 IQ questionnaire

1. During the last three months, have you leaked urine (even a small amount)?

 Yes means go to question 2 No- Questionnaire completed.

2. During the last three months, did you leak urine (check all that apply):

 When you were performing some physical activity, such as coughing, sneezing, lifting, or
exercise?
 When you had the urge or feeling that you needed to empty your bladder, but you could
not get to the toilet fast enough?
 Without physical activity and without a sense of urgency?

3. During the last three months, did you leak urine most often (check only one):

 When you are performing some physical activities, such as coughing, sneezing, lifting, or
exercise?
 When you had the urge or feeling that you needed to empty your bladder, but you could
not get to the toilet fast enough?
 Without physical activity or a sense of urgency?
 About equally as often with physical activities as with a sense of urgency?

Definitions of the type of urinary incontinence are based on responses to Question 3

Response to question 3- Type of incontinence

Most often with physical activity Stress only or stress predominant

 Most often with the urge to empty the bladder Urge only or urge predominant

. Without physical activity or sense of Other cause only or other cause predominant
urgency
About equally with physical activity and Mixed
sense of urgency

Further work up

Ask for pain, dysuria and hematuria- these symptoms need urgent attention.

Any associated neurological symptoms, genito urinary surgical conditions ( e.g Prolapse,
Prostatic enlargement), mass abdomen etc needs referral for further evaluation.

Medication review of drugs prescribed or comorbid conditions to be done and modified if

necessary.

For patients with acute incontinence, biochemical investigations and specialist referral may be
essential.

Please refer to the Urinary incontinence chapter for further details.

Socio- economic status

Social and economic assessment

It can be assessed by casual conversation with the elder about his/her friends, family, neighbours
and care givers. This assessment is very important in whom we have identified problems with
ADL. Even in healthy adults we should discuss the possibility of being cared for when needed,
so that a voluntary or paid care giver can be identified in case of emergency. This is very helpful
in elders who are living alone.

Similarly, as a primary physician we should know about the economic status of the elderly.
Whether they are independently supporting themselves or depend on other means like support
from the children/ society/ any voluntary organization. In elderly, any problems with health like
malnutrition, medication non adherence, self neglect and depression should be viewed from
economic point of view also. The economic status of the elderly also determines the nature of
referral centres – either a government/ private sector, nature of long term care centres in case of
need.

Environmental assessment
Safety of home environment- this should be assessed generally for all elderly who are likely to
have developed age related sensory impairments like visual and hearing impairment. More so, in
vulnerable elderly like those who live alone, have cognitive impairment, those who have
mobility and balance issues, and those who have functional impairment environmental
assessment should be done in a systematic way. It can be done by questioning by the physician,
home assessment done by nurse/ social worker or physiotherapist. Home safety issues are
discussed in detail in the chapter on Falls.

Creating problem list and further planning

At the end of CGA, the problems identified in each domain should be listed like Postural
hypotension, Diabetic neuropathy, diabetic retinopathy, high fall risk, clinical depression and
poor environmental conditions etc.

Referral to specialists, physiotherapist can be planned and necessary and relevant investigations
can be done. Sometimes, patient may need admission also.

Referral considerations

Nutrition Oral health problems- Dentist

At risk of Malnutrition, Malnourished Dyspepsia, Dysphagia, Thyroid disorders -
Physician
For enteral/ Parenteral nutrition-
Gastroenterologist
Vision Ophthalmologist, Opthometrist
Hearing Audiometry/ ENT specialist
Functional Dependence Physiotherapist, Orthopaedician, Neurologist,
occupational therapist
Balance and gait Issues Physiotherapists, Neurologists, occupational
therapist
Affective disorders Psychiatrist, Psychologist
Cognitive impairment Physician, Neurologist
Urinary Incontinence Urologist, Gynecologist
Then considering patient’s wish, care giver’s ability, and patient’s socio economic conditions
short term and long term goals have to be set. Periodic review of the patient with all team
members and interaction between team members are needed for better outcome. This is also the
right time to advice the patient regarding advance directives.

Advance directives are legal documents that extend a person's control over health care decisions
in the event that the person becomes incapacitated. These documents usually address decisions
regarding end-of-life care but may also address any aspect of care.

There are 2 primary types of advanced directives:

1.Living will, Expresses preferences for medical treatment and end-of-life care will allow people
to express preferences for the amount and nature of their health care, from no interventions to
maximum treatment. Including information in a living will about one’s core values relating to
end-of-life care, personal priorities, and goals of care can be just as helpful. A living will cannot
compel health care practitioners to provide health care that is medically or ethically unwarranted.
Living wills go into effect when people are no longer able to make their own health care
decisions or a medical condition specified in the directives usually a terminal condition,
permanent vegetative state, or the end-stage of a chronic condition.

2.Durable power of attorney for health care: Designates a surrogate decision maker the power of
attorney for health care, one person (the principal) names another person (the agent, proxy,
health care representative, or surrogate, depending on the state) to make decisions about health
care and only health care.