Well-patient care (geriatrics): Clinical sciences

Well-patient geriatric care for adults aged 65 years and older, is an annual check-up that promotes physical, mental, and social health while building trust between the healthcare provider and patient.

For all patients, each visit includes a comprehensive history and physical exam, followed by screening and counseling about a variety of topics such as substance use, mental health, functional status, and fall risk; and optimizing diet and physical activity. Additional screening and counseling are provided based on risk status and biological sex.

When a geriatric patient presents for well-patient care, begin with a comprehensive history and physical examination.

Review your patient’s age; past medical and surgical history; their family and social history; sexual activity; medications; and diet and exercise habits. Next, complete a physical examination including height, weight, body mass index, or BMI, and vital signs.

Your next step is to provide screening and counseling for all geriatric patients, regardless of age or risk factors.

First, review age-appropriate immunizations which includes COVID-19, influenza, RSV, and pneumococcal vaccines. Also, patients who have not completed their shingles vaccinations should do it now. Lastly, ensure your patient receives a Tdap or Td vaccine every 10 years.

Next, ask about alcohol, tobacco, and substance use through direct conversation with your patient or by using validated questionnaires like the CAGE questionnaire for alcohol use; Fagerstrom questionnaire for nicotine dependence, and the Substance Use Brief Screen, or SUBS, for substance use. Because alcohol use, tobacco use, and substance use are significant preventable causes of disease, disability, and death, provide counseling and connect them to resources and referrals for further intervention and support.

Let’s move onto cancer screenings for geriatric patients, including colorectal and lung cancer screening. For colorectal cancer, screen up to age 75 using stool-based tests every 1 to 3 years. Alternatively, your patient may opt for direct visualization with a colonoscopy every 10 years, which is the gold-standard for colon cancer screening; sigmoidoscopy every 5 years; or CT colonography every 5 years. Also recommend lung cancer screening with an annual low dose lung CT for patients up to age 80 with a 20-pack-year smoking history that currently smoke or have quit smoking in the last 15 years.

Next, screen for depression using a validated metric such as the nine-item patient health questionnaire, or PHQ-9. A positive screening should prompt further evaluation in addition to evaluating suicide risk. Along with medical management, your patient may benefit from pharmacologic therapy and counseling interventions, such as cognitive behavioral therapy and interpersonal therapy.

Let’s move on to elder abuse. Screen patients for elder abuse using a validated screening tool such as the Elder Abuse Suspicion Index, better known as EASI. If there’s a reasonable suspicion of elder abuse or a positive screen, report your concerns to an elder abuse reporting agency for further investigation.

Okay, next assess your patient’s risk of falls with a validated tool such as the Home Safety Self-Assessment tool to check for potential hazards that could cause a fall. If hazards are present take steps to ensure their home is set up safely by removing loose rugs, using non-slip mats, and ensuring proper lighting.

Also, assess your patient’s balance, coordination, and fall risk using the Get-up and Go, or similar test. As needed, encourage exercise to improve balance and coordination or provide a referral for physical therapy.

Next up is functional status. Ask your patient about their activities of daily living, or ADLs, with a validated tool such as the Katz ADL scale, which includes questions about bathing, dressing, toileting, and feeding. If your patient requires assistance with their ADLs, they may benefit from rehabilitation, assistive devices, or assistance in the home.

Moving on, assess for risk factors for high blood pressure, such as a diet high in sodium, excess weight, and lifestyle factors such as smoking, alcohol consumption, and lack of physical activity. Provide counseling on lifestyle modifications, as needed, to prevent complications such as cardiovascular and kidney disease!

Next, screen for obesity, which is defined as BMI of 30 or greater. Obesity increases the risk of chronic health conditions including cardiovascular disease, type 2 diabetes, liver disease, sleep apnea, and certain types of cancers including endometrial cancer, so provide individualized counseling on weight reduction with a healthy diet and physical activity.

Okay, now ask your patient about their medication use and assess for polypharmacy, which is defined as the regular use of at least five medications. Screen patients for inappropriate medications using the Screening Tool of Older Persons’ Prescriptions, also known as STOPP, and the Screening Tool to Alert to Right Treatment, also known as START. Monitor your patient’s active medication list and counsel them about any unnecessary medications to mitigate risk of any adverse drug events.

Here’s a clinical pearl! The Beers criteria provide guidance and recommendations for appropriate use of medications in older adults due to physiological changes associated with aging and subsequent susceptibility to adverse drug reactions.