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Functional Decline

Prerequisites

Describe and discuss:

  • Normal findings of the Neurologic Examination including mini mental status exam
  • Normal Psychiatric Examination
  • Normal Activities of Daily Living

Demonstrate:

  • Ability to take a complete medical history including communication with family members
  • Complete screening physical exam
  • Detailed neurologic/musculoskeletal exam including mental status examination
  • Psychiatric interview including global assessment of function

 

Apply Medical Knowledge in the Clinical Encounter

Risk Factors and Prevention of functional decline

Appropriate screening times and techniques for functional decline

Quantification of the severity of functional decline/impairment

 

Diagnose

  1. Obtain, document, and present an age-appropriate medical history that differentiates among etiologies of disease, including:
    1. characterization of a patient’s functional decline:
      1. temporal sequence: onset, frequency, duration, progression
      2. associated symptoms: nausea, vomiting, fever, chills, anorexia, weight change, dysphagia, dysuria, altered bowel function, loss of balance, gait changes, weakness, numbness, changes in speech, sleep patterns, mood/behavior changes.
      3. exacerbating and remitting factors: position, activity, medications
    2. pertinent medical history: prior surgical and medical history, other illness (attn. to diabetes, cardiovascular disease, immunosuppression)
    3. medications: prescription and supplements (attn. to anticoagulation, steroids)
    4. family history
    5. Social History/Assess Social support.
  2. Perform a physical exam to establish the diagnosis and severity of disease including:
    1. correct order and technique for performing a screening physical exam
    2. Perform a detailed neurologic exam including mental status examination
    3. Perform a psychiatric assessment including mood
  3. Generate a list of the most important and likely causes of a patient’s functional decline, recognizing specific history and physical exam findings that distinguish between potential causes, including normal aging.
  4. Recommend when to order the following diagnostic and laboratory tests necessary to determine the cause of a patient’s functional decline. Be able to interpret them, both prior to and after initiating treatment based on the differential diagnosis, including consideration of costs and test performance characteristics as well as patient preferences.
    1. Head CT/brain MRI
    2. Imaging of vessels of head and neck (carotid ultrasound, CTA, MRA, angiography)
    3. Lumbar puncture with measurement of opening pressure
    4. Neuropsychiatric testing
    5. EEG
    6. Laboratory screening, including TSH, B12, RPR
  5. Compose appropriate admission orders as part of the initial assessment and care of patients with acute or acute-on-chronic functional decline.
  6. Explain the results of the evaluation to the patient and/or caregivers, taking into consideration their knowledge about his/her condition.
  7. Record, present, research, critique, and manage clinical information.

 

Develop a Management Plan

Discuss the relative urgency of treating various causes of functional decline

Communicate the diagnosis/differential diagnosis, treatment plan and prognosis of the cause of functional decline to patients and/or caregiver.  This should include communicating in a compassionate manner, reflecting an understanding of the emotional impact of disease and its effect on lifestyle of the patient as well as family/caregivers.

Provide education for the patient about their treatment plan, including counseling related to preventive measures (fall precautions, supervision, long-term care, etc.)

Refer for psychological support for patient and caregivers if indicated.

Develop a plan for monitoring and for follow-up including awareness of resources and limitations to support caregivers and patients.

 

Diagnosis

Urinary Incontinence

  • Urge Incontinence
  • Stress Incontinence
  • Bladder Outlet Obstruction
  • Detrusor underactivity

Dementia

  • Alzheimer’s type dementia
  • Vascular Dementia
  • Lewy body dementia
  • Frontotemporal dementia
  • Normal Pressure Hydrocephalus
  • Trauma

Delirium

  • Agitated Delirium
  • Hypoactive Delirium

Depression and other Mood Disorders

  • Depression
  • Hyperthyroidism/Hypothyroidism
  • Adjustment Disorder

Musculoskeletal injury/Arthritis/Osteoporosis

  • Back Pain/injury
    • Sciatica
    • Compression fracture/vertebral body disease
    • Cauda Equina
    • Muscular injury/strain
  • Hip/Knee/Shoulder pain/injury
  • Fall Prevention, evaluation and treatment
  • Fragility Fracture

Stroke

  • Cardioembolic
  • Large-artery disease
  • Small-vessel disease
  • Anterior circulation
  • Posterior circulation

Other neurodegenerative diseases

  • Amyotrophic Lateral Sclerosis
  • Parkinson’s Disease
  • Huntington’s Disease
  • Chronic alcoholism

Polypharmacy/Pharmacotherapy

  • Age-associated changes in pharmacodynamics/metabolism/body composition
  • Cardiovascular drugs, diuretics, nonsteroidal anti-inflammatory drugs, hypoglycemic, atypical antipsychotics and anticoagulants are most often associated with preventable adverse drug events