Comprehensive Geriatric Assessment

"Thank you for referring this patient to Geriatric Medicine for comprehensive geriatric assessment" Reason for Assessment: - The patient was referred for assessment due to frequent falls and memory concerns. - Collateral history was obtained from the patient's daughter. History: The patient, an 82-year-old female, has experienced increasing forgetfulness and has had three falls in the past six months. Cognition: - Cognitive domains affected include short term memory and executive function. - Short term Memory issues: The patient struggles to recall recent events and often misplaces items. - Executive function: Difficulty in planning and organizing daily activities. - Mood: The patient appears mildly anxious but denies feeling depressed. - Hallucinations: No hallucinations reported. - Sleep concerns: Yes, the patient reports difficulty falling asleep and frequent awakenings. Falls/mobility: - Dizziness with postural change: Yes, the patient experiences dizziness when standing up quickly. - Tremor: No. - Falls: Yes, the patient has had three falls recently, one resulting in a minor wrist injury. - Change in gait: Yes, the patient has a shuffling gait. Medical History: - Past medical history includes hypertension and osteoarthritis. - Previous surgeries: Hip replacement in 2018. Functional Assessment: - Activities of daily living (ADLs): The patient requires assistance with bathing and dressing. - Instrumental activities of daily living (IADLs): The patient struggles with managing finances and medication. - Mobility and gait: The patient uses a walker for stability. Social History: - Living situation: Lives alone in a single-story home. - Support system: Regular visits from her daughter and a home care nurse. - Occupation and retirement status: Retired school teacher. - Alcohol, tobacco, and substance use: Occasional glass of wine, non-smoker. Other Geriatric Syndromes: - Falls: Yes, as noted above. - Weight changes: No significant changes. - Dietary intake: Balanced diet with adequate nutrition. - Chronic pain issues: Mild joint pain due to osteoarthritis. - Sleep issues: Yes, as noted above. Physical Examination: - Vital signs: Blood pressure 140/85 mmHg, heart rate 72 bpm. - General appearance: Alert and oriented, but appears frail. - Cardiovascular system: Regular heart sounds, no murmurs. - Respiratory system: Clear breath sounds bilaterally. - Abdominal examination: Soft, non-tender. - Musculoskeletal system: Decreased range of motion in hips. - Neurological examination: Mild weakness in lower limbs. Investigations: - Neuroimaging: CT scan shows mild cerebral atrophy. - Pertinent lab work: B12, TSH, and calcium levels are within normal limits. Impression: The patient presents with cognitive decline, likely due to early Alzheimer's disease, and recurrent falls possibly related to postural hypotension. Plan and Recommendations: - Management plan: Initiate fall prevention strategies and cognitive support. - Referrals to specialists or services: Referral to physiotherapy for balance training. - Donepezil: We have decided to start Donepezil. I have applied for Blue Cross special authorization. I have prescribed 5mg p.o. daily with a goal to increase to 10mg p.o. daily in 4 weeks if tolerated. We discussed the risks/benefits of Cholinesterase inhibitors. I advised that they are considered cognitive enhancers and indicated for mild/early Alzheimer’s disease or Lewy Body Dementia. They are not a cure nor do they stop the progression. Approximately one third of patients see some cognitive and functional benefit, one third maintain at their current state longer and one third continue to decline at the same rate. These medications have several side effects including GI upset, diarrhea, anorexia, sleep disturbances, bradycardia, falls, dizziness. They are contraindicated in patients with bradycardia or conduction abnormalities. Follow-up: Schedule a follow-up appointment in 6 weeks to assess medication tolerance and effectiveness.