Well-patient care (geriatrics): Clinical sciences

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Introduction 0:00–0:44

Well-patient geriatric care for adults aged 65 years and older is an annual checkup 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.

H&P 0:44–1:16

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.

Screening and counseling1:16–8:49

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 on to 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 golden 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 9 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.
OK, 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 tests. 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 CAT's 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 BP, 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. OK, now ask your patient about their medication use and assess for polypharmacy, which is defined as the regular use of at least 5 medications.
Screen patients for inappropriate medications using the screening tool of older person's prescriptions, also known as stop, and the screening tool to alert to right treatment, also known as SART.
Monitor your patient's active medication list and counsel them about unnecessary medications to mitigate risk of any adverse drug events.
Here's a clinical pearl. The beer 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.
Next, screen all patients for hepatitis C until age 79. Patients are often unaware of their infection status, since it can present without symptoms in the early stages.
Counsel your patient about preventative measures, including safe sex and avoiding injection of illicit drugs, and talk about how early detection and treatment can prevent complications, including cirrhosis and liver cancer.
Moving on to sexual dysfunction. Use a validated tool such as the sexual functioning questionnaire to identify a sexual problem that could be a warning sign of an undiagnosed medical condition, medication side effect, or sexually transmitted infection.
Encourage your patient to share any sexual concerns to fully evaluate the underlying causes and promote healthy sexual activity.
Next, ask your patient about urinary incontinence using a validated tool such as the geriatric Self-efficacy Index for urinary incontinence.
Aside from primary urological disorders, remember medications such as anticholinergics and alpha agonists have urinary incontinence as a side effect, so do a thorough medication reconciliation.
Moving on to malnutrition, use the mini nutritional assessment to assess their dietary habits. Your patient may need referrals for nutritional support, weight monitoring, or an in-depth nutritional assessment.
Last up is hearing and vision loss. All patients should have a vision test yearly and a hearing exam with whispered voice or audiometry every 1 to 3 years.
If there is vision or hearing impairment, refer for a comprehensive assessment and prompt intervention to mitigate adverse consequences, including falls.
OK, now let's review screening and counseling for high-risk patients. A patient is considered high risk and in need of further workup and counseling if they have disease-specific risk factors.

High-risk patients 8:49–10:18

First up is pre-diabetes and diabetes. If your patient is overweight or obese, obtain a fasting glucose, hemoglobin A1C, or oral glucose tolerance test every 3 years, counsel them on lifestyle interventions, and initiate treatment as needed.
For primary prevention of cardiovascular disease, use the American College of Cardiology and American Heart Association estimator to calculate the 10-year cardiovascular disease risk.
For patients up to age 75 years old, start a moderate intensity statin if they have one or more cardiovascular risk factors, and an estimated 10-year cardiovascular disease risk of 10% or greater.
Lastly, obtain a latent tuberculosis screening if your patient immigrated from a country with increased prevalence of tuberculosis, or if they live in a high-risk congregate setting, such as homeless shelters, prisons, or long-term care facilities.
These patients should also obtain a screening tuberculin skin test or interferon gamma release assay, also known as IGRA.
OK, now that we've reviewed screening for all patients, including those at high risk, let's discuss well, patient care specific to your patient's biological sex.

Review patient’s biological sex 10:18–10:28

For biological females, start by screening for cervical cancer until age 65, with primary HPV testing alone or combined with cytology.

Biological females 10:28–11:21

Also screened for breast cancer up to age 74 with biennial mammograms. Finally, screen patients who are 65 years or older for osteoporosis with bone mineral density testing, including DEXA scanning and quantitative ultrasound to prevent osteoporotic fractures.
And here's your final clinical pearl. Although biological males are not routinely screened for osteoporosis, certain factors increase their risk of osteoporotic fractures, including long-term corticosteroid use, low BMI, smoking, and excessive alcohol consumption.
Biological males need screening for prostate cancer using shared decision making and weighing the benefits and harms. And for biological males with a tobacco history, don't forget a one-time screening for abdominal aortic aneurysm with ultrasound in those aged 65 to 75.

Biological males 11:21–11:42

Alright, as a quick recap, well-patient geriatric care is a yearly checkup that promotes physical, mental, and social health.

Review 11:42–12:21

Start each visit with a comprehensive history and physical exam, including BMI and vital signs. Next, screen and counsel your patient about a variety of topics such as substance use, mental health, functional status, fall risk, diet, and physical activity.
You may need to have additional screening and counseling for certain high-risk groups. Lastly, provide additional screening and counseling based on your patient's biological sex.
Well-patient care (geriatrics): Video and Steps | Osmosis