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INTRODUCTION

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The principles of geriatric assessment focus on function, cognition, and safety. An acute hospitalization is a critical time in which geriatric patients are particularly vulnerable to complications such as delirium, falls, and deconditioning. Using illustrative cases, this chapter focuses on basic skills of geriatric assessment including screening for cognitive and functional impairment. Age-related changes in anatomy and physiology which affect the nervous system are outlined. Changes in pharmacokinetics and pharmacodynamics, which affect medication management in geriatric patients, are reviewed. Included are strategies for identifying potentially inappropriate medications and common medication safety concerns in older adults. The Acute Care of the Elderly unit model incorporates key strategies to minimize the risks of hospitalization and engage an interprofessional team in establishing safe disposition plans for geriatric patients. Key principles of decisional capacity assessment and elder abuse reporting are also included.

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CASE 5-1

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Ms. J is a 78-year-old widow with type 2 diabetes mellitus and hypertension who lives alone and was employed as a high school English teacher prior to retiring at age 65. She was admitted to the hospital after being brought to the emergency department (ED) during an episode of right arm weakness, right facial droop, and aphasia. Her symptoms started approximately 1 hour before arrival and completely subsided 2 hours after onset and prior to any intervention. A brain MRI did not show any acute or chronic infarcts. An electrocardiogram showed atrial fibrillation (AF), and a carotid Doppler ultrasound showed 30% stenosis of the right internal carotid artery (ICA). Her blood glucose on arrival was 220 mg/dL. A transient ischemic attack (TIA) caused by a cardioembolic source was suspected and she was started on warfarin and atorvastatin. During her medication reconciliation, it was noted that although the pharmacy had a prescription for insulin glargine 20 units daily on file, Ms. J was not able to recall the dose she takes or explain how she administers her injection. This persisted throughout the stay despite resolution of her aphasia in the emergency room and stable mental status for three days. The primary team placed a consult for diabetes education and it was noted that despite several attempts to teach appropriate insulin administration, Ms. J was not able to draw up the correct dose and administer the injection on her own. This raised concerns for the presence of a cognitive deficit, as well as Ms. J’s ability to return home safely.

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What changes in cognition are expected with normal aging?

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  • Memory, as measured by immediate recall, declines with normal aging. Therefore, it takes individuals longer to learn new information and this accounts for declines in delayed recall as well.1

  • Cognitive changes that occur with normal aging are different than those seen in the early stages of dementing illnesses such as Alzheimer disease (AD).1

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How are the cognitive changes of AD different from that of normal aging?

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