Comprehensive Geriatric Assessment: A Multidimensional Approach, Exams of Nursing

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NR 601 Midterm Exam review

Week 1

Developmental changes

o Review Kennedy readings for age related changes o Physiological

Physiological

Age related Change Functional Change Implications

Integumentary System

Loss of dermal and epidermal thickness

Loss of subcutaneous tissue and thin epidermis.

Prone to skin breakdown and injury

Decreased vascularity • Atrophy of sweat glands resulting in decreased sweat production

• Alteration in thermoregulatory response
• Fluid requirements may change seasonally
• Loss of skin water
• Increased risk of heat stroke
• Decreased body odor
• Decreased heat loss
• Dryness

Respiratory System

Decreased lung tissue elasticity

Decreased vital capacity

Reduced overall efficiency of ventilatory exchange

Cilia atrophy Change in mucociliary transport

Increased susceptibility to infection

Decreased respiratory • Reduced ability to Increased risk of

muscle strength (^) handle secretions and reduced effectiveness against noxious foreign particles

• Partial inflation of lungs at rest

atelectasis

Cardiovascular System

Heart valves thicken and become fibrotic

Reduced stroke volume, cardiac output; may be altered

Decreased responsiveness to stress

Fibroelastic thickening of the sinoatrial node; decreased number of pacemaker cells

Slower heart rate Increased prevalence of arrhythmias

Decreased baroreceptor sensitivity (stretch receptors)

Decreased sensitivity to changes in blood pressure

Prone to loss of balance, which increases the risk for falls

GI

Liver becomes smaller Decreased storage capacity

Decreased muscle tone

Altered motility Increases risk of constipation, functional bowel syndrome, esophageal spasm, diverticular disease

Decreased basal metabolic rate (rate at which fuel is

May need fewer calories

converted into energy)

o Lab results

Lab results

Lab Test Normal Changes with age

Comments

UA

Protein 0-5mg/100ml Rises slightly May be due to kidney changes with age, urinary tract infection, renal pathology

Specific Gravity

1.005- 1.020 Lower max in elderly 1.016-

Decline in nephrons impairs ability to

1.022 concentrate urine

Hematolog y

ESR Men: 0 - 20

Women: 0 - 30

Significant increase

Neither sensitive nor specific in aged

Iron Binding

50 - 160mcg/dl

230 - 410mcg/dl

Slight decrease

Decrease

Hemoglobin Men: 13 -

18g/100ml

Women: 12 - 16g

Men: 10 - 17g

Women: None noted

Anemia common in the elderly

Hematocrit Men: 45 - 52% Slight Decline in

Women 37 - 48%

decreased

speculated

hematopoiesisLeu

Leukocytes (^) 4,300–

10,800/mm

Drop to 3,100– 9,000/mm

Decrease may be due to drugs or sepsis and should not be attributed immediately to age

Lymphocytes 00 – 2,400 T

cells/mm3 50 – 200 B cells/mm

T-cell and B-cell levels fall

Infection risk higher; immunization encouraged

Platelet 150,000–

350,000/

No change in number

Blood Chemistry

Albumin 3.5–5.0 Decline Related to decrease in liver size and enzymes; protein-energy malnutrition common

Globulin 2.3–3.5 Slight increase

Total serum protein

6.0–8.4 g No change Decreases may indicate malnutrition, infection, liver disease

Blood urea nitrogen

Men: 10 – 25

Women: 8 – 20 mg

Increases significantly up to 69 mg

Increases significantly up to 69 mg

Creatinine 0.6–1.5 mg Increases to 1. mg

Related to lean body mass decrease

Creatinine clearance

104 – 124

mL/min

Decreases 10%/decade after age 40 years

Used for prescribing medications for drugs excreted by kidney

Glucose tolerance

62 – 110 mg/dL after fasting;

120 mg/dL after 2 hours postprandial

Slight increase of 10 mg/dL/decade after 30 years of age

Diabetes increasingly prevalent; drugs may cause glucose intolerance

Alkaline phosphatase

13 – 39 IU/L Increase by 8 –

10 IU/L

Elevations >20% usually due to disease; elevations may be found with bone abnormalities, drugs (e.g., narcotics), and eating a fatty meal

o Atypical disease presentations o Geriatric syndromes

Exercise in Older adults

o Exercise recommendations for specific diagnoses (Kennedy)

Osteoarthritis

Walking, aquatic activities, tai chi, resistance exercises, cycling

Vary type and intensity to avoid overstressing joints; heated pool

Coronary artery disease

Walking, treadmill walking, cycle ergometry

Supervised program with BP and heart rate monitoring

Congestive heart failure

Walking, treadmill walking, cycle ergometry

Individualize to client; supervised program

Type 2 diabetes mellitus

Resistive, aerobic, aquatic, recreational activities

Proper shoe fit; may need insulin reduction if insulin dependent

Anxiety disorders

Walking, biking, weight lifting

If able to do high-intensity exercise, this benefits anxiety

Depression

Walking, cycling, recreational activities

Group participation helpful to keep patient engaged

Fibromyalgia

Aerobic, aquatic therapy, strengthening, tai chi, Pilates

Heated pool, gentle stretches, counsel about possible increased pain initially

Chronic obstructive pulmonary disease

Cycle ergometer, treadmill walking; individualize

Supervised program—consider pulmonary rehabilitation program

Chronic venous insufficiency

Walking, standing exercises

Supervised program

Osteoporosis

Weight-bearing exercises, weight training

Assess balance and risk for falls before beginning

Parkinson’s disease

Walking, treadmill walking, stationary bike, dancing, tai chi, Pilates, boxing

Assess balance and risk for falls before beginning; American Parkinson’s Disease Association resources

Peripheral arterial disease

Lower extremity exercises, treadmill walking, walking

Very short intervals initially, progress as tolerated

Age-related sleep disorders

Tai chi, walking, aquatherapy, biking

Assess balance and risk for falls before beginning

Dementia

Walking, recreational activities

Provide safe environment, assess fall risk and ability to participate (Kennedy-Malone, 20181030, p. 21)

o Testing prior to exercise initiation o Barriers, facilitators and contraindications

Barriers ■ Lack of time ■ Perceived need for equipment ■ Perceived barrier to beginning exercise/physical activity ■ Disability or functional limitation ■ Unsafe neighborhood or weather conditions ■ No parks or walking trails ■ Depression ■ High body mass index (BMI) ■ Lack of motivation ■ Interpersonal loss or significant life event ■ Ignorance of what to do

Patient Facilitators

■ Social support ■ Positive self-efficacy ■ Motivation to engage in physical activity ■ Good health, no functional limitations ■ Frequent contact with prescriber ■ Regular schedule, planned program ■ Satisfaction with program ■ Insurance incentive ■ Improvement in mobility or health condition ■ Staff

Contraindications

■ Unstable angina ■ Uncompensated heart failure ■ Severe anemia ■ Uncontrolled blood glucose ■ Unstable aortic aneurysm ■ Uncontrolled hypertension or tachycardia ■ Severe dehydration or heat stroke ■ Low oxygen saturation

Health promotion

o Immunizations

Influenza vaccine is now recommended annually for all adults over 50 years old, unless contraindicated (Table 2-1). Residents of long-term care facilities that house persons with chronic medical conditions are at especially high risk for developing the disease. Health-care workers also should receive the vaccine, preferably before the end of October (Resnick, 2018). Patients with a severe egg allergy or severe reaction to the influenza vaccine in the past and patients with a prior history of Guillain-Barré syndrome should talk with their health-care provider before getting the vaccine.

Tetanus-diphtheria toxoids with acellular pertussis (Tdap) vaccine is administered as a once-in-a-lifetime booster to every adult. Following this, a tetanus-diphtheria (Td) booster is recommended every 10 years.

Pneumococcal vaccine is recommended as follows: Administer a one-time dose to PCV13-naïve adults at age 65 years, followed by a dose of PPSV23 12 months later.

Hepatitis B vaccine is recommended for high-risk persons such as IV drug users, persons who are sexually active with multiple partners, those living with someone with chronic hepatitis B, patients less than 60 years old with diabetes, and all desiring protection from hepatitis B. The initial dose is given, followed 1 month later by the second dose, then the third dose is given 4 to 6 months after the second dose.

Shingrix is a new vaccine for zoster and is recommended over Zostavax. It is administered in two doses. The second dose can be given from 2 to 6 months after the initial one. Persons who have had Zostavax should now be immunized with Shingrix (Resnick, 2018). Those who have had a prior episode of zoster should be vaccinated (CDC, Adult Immunization Schedule, 2017; www.immunize.org).

o Recommended health screenings- age ranges and frequency

Travel

o Risks related to travel: Patients with chronic disease that is well managed at home may decompensate in foreign environments because of heat, humidity, altitude, fatigue, changes in diet, and exposure to infectious diseases.Fever is not always a reliable indicator of illness in the older adult. Seroconversion rates decrease with age, rendering some vaccines less effective for older travelers

o Immunizations for travel : all immunizations should be current. influenza, pneumococcal, Td/Tdap (tetanus, diphtheria, and acellular pertussis), zoster, and for some, hepatitis B vaccination. Yellow fever and herpes zoster vaccine are the only live virus vaccines that people over age 50 receive. Immune response can be impaired if live virus vaccines are given within a 28- to 30-day interval of each other. Yellow fever vaccine is not effective until 10 days after administration. If the NP gives a patient a herpes

zoster vaccine, that patient cannot receive a yellow fever vaccine for 30 days. If the patient is required to have a yellow fever vaccine for travel, he or she cannot enter a yellow fever country until 10 days after receiving the yellow fever vaccine. If a patient receives a yellow fever vaccine, he or she cannot receive a herpes zoster vaccine for 28 days. The patient may receive both vaccines on the same day with no decrease in immune response

The most common vaccines used for protecting travelers are hepatitis A, hepatitis B, typhoid fever, yellow fever, adult booster polio, Japanese encephalitis, meningococcal, and rabies.

Comprehensive Geriatric Assessment

DOMAINS OF COMPREHENSIVE GERIATRIC ASSESSMENT Physical health chief complaint, history of present illness, past history, family and social history, and a review of systems),

DIMENSIONS OF COMPREHENSIVE GERIATRIC ASSESSMENT History taking Physical examination Diagnostics Nutritional assessment Medication review

Functional health the Katz Activities of Daily Living Scale

Activities of daily living Instrumental activities of daily living Sensory assessment (hearing, vision) Gait and balance

Psychological health MMSE: the Mini-Cog, Montreal Cognitive Assessment (MoCA), and Saint Louis University Mental Status Examination (SLUMS)

Cognitive disorders (delirium, dementia, mild cognitive impairment)

Affective disorders (depression, anxiety) Spiritual well-being

Socioenvironmental Social network and support

Supports Living situation

Lubben Social Network Scale Environmental safety Economic resources

Quality of life measures The Medical Outcomes Study—Short-Form 36

Physical conditions Social conditions Environmental conditions Personal resources (mental health, life perspective) Preferences for care

Beers Criteria

o Guide to use for medical management of geriatric patient’s o List of potentially inappropriate medications for the elderly-listed by drug category and diagnosis o Lists alternative drugs that can be used safely in older adults o Drug to drug interactions listed, dosage for kidney impairment graded as high, medium, or low to assist with decision making.

Polypharmacy o Multiple definitions (review discussion)

• Polypharmacy o Prescribing many drugs, prescribing 5 or more drugs, or prescribing potentially inappropriate medications. o The use of multiple pharmacies (providers & self-prescribers) o Providers should routinely evaluate medication appropriateness to avoid the risk of polypharmacy o Have new patients bring in all medications to their first visit o Review med list at every visit o Ask if any other provider has changed or added any meds

o Update med list at every visit o Three available tools to evaluate patient’s prescriptions ▪ STOPP (screening tool of older persons’ potentially inappropriate prescriptions ▪ MAI (Medication Appropriateness Index) ▪ ARMOR (Assess, Review, Minimize, Optimize, Reassess)

Week 2

COPD

o Signs and symptoms : Dyspnea, chronic cough with or without sputum production, decreased activity tolerance, wheezing.dyspnea, chronic cough with or without sputum production, recurrent lower respiratory infections, wheezing, chest tightness, fatigue, weight loss, and/or anorexia. increased anteroposterior diameter of the thorax, use of accessory muscles for respiration, prolonged expiration, hyperresonance on percussion, decreased heart and breath sounds, tachypnea, neck vein distention during expiration in absence of heart failure, ruddy or cyanotic skin color, and clubbing of nail beds o Diagnostic criteria

FEV1/FVC ratio (<70%)

▪ Stage 1 : Very mild COPD with a FEV1 about 80 percent or more of normal. ▪ Stage 2 : Moderate COPD with a FEV1 between 50 and 80 percent of normal. ▪ Stage 3 : Severe emphysema with FEV1 between 30 and 50 percent of normal. ▪ Stage 4 : Very severe COPD with a lower FEV1 than Stage 3, or those with Stage 3 FEV1 and low blood oxygen levels

Asthma

o Signs and symptoms

recurrent wheezing, cough (especially at night), recurrent chest tightness, shortness of breath (Kennedy-Malone, p. 155).

o Diagnostic criteria

FEV 1 /FVC ratio before and after bronchodilator challenge, showing an improvement of 12%

and 200 mL, indicates reversible airway obstruction; If spirometry is near normal,

bronchoprovocation such as a methacholine challenge test may help to differentiate other

conditions with a similar presentation (Kennedy-Malone, p. 155).

o Severity classifications (Kennedy-Malone, p. 156)

Intermittent: < 2 days/w ; nighttime awakenings: ≤2x/month

Persistent

Mild: 2 days/week but not daily; nighttime awakenings: 3–4x/month

Moderate: daily; nighttime awakenings: 1x/week but not nightly

Severe: Throughout the day; nighttime awakenings: often 7x/week

Interstitial Lung Disease

ILD comprises a heterogeneous group of diseases that cause inflammation and fibrosis of the lower respiratory tract.

Four infections may be associated with the cause or onset of most of the various diseases:

Ø disseminated fungus (coccidioidomycosis, blastomycosis, histoplasmosis),

Ø disseminated mycobacteria

Ø Pneumocystis pneumonia,

Ø and certain viruses.

The largest group comprises

Ø occupational and environmental inhalant diseases; these include diseases resulting from inhalation of inorganic dusts, organic dusts, gases, fumes, vapors, and aerosols.

Ø Other categories include ILDs caused by drugs, irradiation, poisons, neoplasia, and chronic cardiac failure.

Ø unknown causes are idiopathic pulmonary fibrosis (IPF) and connective tissue

dermatomyositis, and Sjögren’s syndrome.

Seven major entities that are most frequently associated with diffuse ILD are

(1) IPF, (2) bronchiolitis obliterans organizing pneumonia, (3) connective tissue (collagen vascular) diseases (SLE, RA, progressive systemic sclerosis [scleroderma], and polymyositis-dermatomyositis),

(collagen vascular) disorders with ILD, including rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), progressive systemic sclerosis, polymyositis-

(4) systemic granulomatous vasculitides (Wegener’s granulomatosis, lymphomatoid granulomatosis, and allergic angiitis and granulomatosis),

(5) drug-induced pulmonary disease, (6) sarcoidosis, and (7) hypersensitivity pneumonitis. (These entities are briefly discussed further in Box 31.4.Page : 416 Dunphy)

The first symptom of ILD is usually progressive dyspnea on exertion or a nonproductive cough. The patient initially notices dyspnea only during heavy exertion, but in very advanced stages of the disease, dyspnea occurs at rest.

Diagnosis

The occupational and environmental history is the single most helpful tool to determine whether a respiratory problem may be related to an environmental exposure

Diseases in other organs may present as ILD, so a detailed review of systems is important (ROS)

Abnormalities on chest x-ray may be the first clue to the presence of ILD; however, the patient with ILD may be asymptomatic or symptomatic with either normal or abnormal chest x-ray results. The initial abnormality on the chest x-ray film is usually described as a ground glass, A scattered reticulonodular pattern or hazy appearance of the lungs

PFT : Normal FEV 1 /FVC ratio but decreased FVC and FEV 1 ; decreased total lung capacity, residual volume, and functional residual capacity. Residual volume–to–total lung capacity ratio is normal to low.

A transbronchial biopsy is the leading invasive tool for evaluating and treating patients with a wide spectrum of pulmonary disorders.

DLCO is a good reflection of alveolar capillary surface area. Destruction of lung parenchyma results in a reduction in DLCO as ILD progresses. An abnormal DLCO(decrease in single breath diffusing lung capacity for carbon monoxide) may be the earliest evidence of ILD found on standard PFTs.

Management

Ø The first course of action when faced with a patient with ILD is to determine whether exposure to environmental agents or drugs is the cause and to discontinue the exposure

Ø Second, the best chance for therapeutic success begins with the correct diagnosis.

Ø Finally, in cases in which specific medication is used, such as prednisone or cytotoxic agents, there is usually suppression rather than cure of the primary process.

Initial Management

Ø Corticosteroids 1 to 2 mg/kg/day, or 60 to 100 mg/day

Ø Cyclophosphamide (Cytoxan), an alkylating drug, is a potent immunosuppressant and seems to be effective in patients with ILD who are not helped with corticosteroids. Cytotoxic agents, including azathioprine (Imuran) and cyclophosphamide (Cytoxan), are given concurrently with prednisone or in place of it if the patient cannot tolerate high-dose prednisone therapy

Self-care measures:

Ø Pulmonary medications

Ø Diet Fluid intake

Ø Smoking cessation

Ø Environmental control Awareness of early signs of infection

Ø Chest therapy: Relaxation and guided imagery Breathing retraining Controlling dyspneic episodes Postural drainage

Ø Progressive exercise conditioning: Walking programs Treadmill or bicycle exercise training Arm or leg range-of-motion exercises

Ø Respiratory equipment: Oxygen therapy Handheld nebulizer

Prevention/Prophylaxis : Give patients pneumococcal, pneumonia and influenza vaccines

• types

Community Acquired Pneumonia (CAP)

o Signs and symptoms

Typical symptoms include fever, chills, cough, and rusty or thick sputum, with associated

gastrointestinal upset or anorexia, malaise, and diaphoresis; pleuritic chest pain may also be

present, crackles. Older patient - mental status changes, falls, inc. resp. rate, hypotension,

anorexia, new onset of urinary incontinence (Kennedy-Malone, p. 192-193).

o Diagnostic criteria

CURB -65 (each criteria worth 1 pt)

C - Confusion

U - BUN >19 ng/dL

R - Respiratory rate ≥ 30 breaths/min

B - BP: Systolic <90 mm Hg OR Diastolic <60 mm Hg

Scoring

0-1: Low risk; consider outpatient treatment

2: Brief hospitalization or closely monitored outpatient treatment

≥ 3: Severe, hospitalize and possible ICU

o Radiographic findings

chest x-ray is considered the gold standard for the diagnosis of pneumonia; C-reactive protein

(CRP) and/or urine specific antigen when there is a question about when, or if, to start antibiotic

therapy ; CT scan of the chest is often ordered and is more accurate than a chest x-ray;

Pulmonary infiltrate, lobular consolidation, or opacities found on chest x-ray, CT scan, or

ultrasound confirm the diagnosis of pneumonia

Obstructive & Restrictive Airway Disease

o Understand the PFT interpretation for both https://www.alphanetbfrg.org/pdfs/Understanding-PFT.pdf

• Obstructive pattern o Decreased FEV 1 , normal or decreased FVC, and decreased FEV 1 /FVC o Classically, these are the patients with asthma, chronic bronchitis, or emphysema ▪ PFTs can help further distinguish between the above three: ▪ Bronchodilator responsiveness - an increase in the FEV 1 by 12% following bronchodilator use suggests asthma ▪ Bronchial provocation - inducing asthmatic obstruction of reactive lower airways by administering methacholine, histamine, or adenosine monophosphate ▪ DLCO will be decreased in patients with emphysema, and can be normal or increased in patients with asthma o Lower airway obstruction vs. upper airway obstruction ▪ Lower airway obstruction typically displays impaired expiratory capacity (see image below), while upper airway obstruction has impaired inspiratory capacity, which can be evident on the flow volume loop (seen as flattening of the inspiratory arm).
• Restrictive pattern o Decreased TLC, FEV 1 , and FVC with a normal FEV 1 /FVC, and a low DLCO o Typically these are patients with interstitial lung disease, severe skeletal abnormalities, or diaphragmatic paralysis o The flow volume loop is generally normal in appearance, but has low lung volumes

o Spirometry

• PFTs can be used in a variety of settings, and they are generally ordered to: o Look for evidence of respiratory disease when patients present with respiratory symptoms (e.g. dyspnea, cough, cyanosis, wheezing, etc.); o Assess for any progression of lung disease; o Monitor the efficacy of a given treatment; o Evaluate patients pre-operatively; and o Monitor for potentially toxic side effects of certain drugs (e.g. amiodarone)
• The components of PFTs include: o Lung volumes o Spirometry and flow volume loops o Diffusing capacity

o Know definitions for each spirometry criteria

Spirometry measures two key factors: expiratory forced vital capacity (FVC) and forced expiratory volume in one second (FEV1). Your doctor also looks at these as a combined number known as the FEV1/FVC ratio. If you have obstructed airways, the amount of air you’re able to quickly blow out of your lungs will be reduced. This translates to a lower FEV1 and FEV1/FVC ratio.

Forced vital capacity (FVC). This is the largest amount of air that you can forcefully exhale after breathing in as deeply as you can. A lower than normal FVC reading indicates restricted breathing.

Forced expiratory volume (FEV). This is how much air you can force from your lungs in one second. This reading helps your doctor assess the severity of your breathing problems. Lower FEV-1 readings indicate more significant obstruction.

o Know criteria to determine severity (FEV1)

https://goldcopd.org/wp-content/uploads/2018/11/GOLD-2019-POCKET-GUIDE-DRAFT-v1.7-14Nov2018- WMS.pdf

o Know criteria for diagnosis of obstruction (FEV1/FVC ratio)

An FEV 1 /FVC <80% suggests obstructive lung disease, while restrictive lung disease typically has normal or increased FEV 1 /FVC

o Know criteria for diagnosis of reversible versus irreversible

FEV 1 /FVC ratio before and after bronchodilator challenge, showing an improvement of 12%

and 200 mL, indicates reversible airway obstruction

Sleep apnea (Kim R)

o Diagnostic criteria - Sleep apnea is defined as a temporary pause in breathing during sleep that lasts at least 10 seconds. For a confirmed diagnosis, this should occur a minimum of five times an hour. o Signs and symptoms-

Hypersomnolence is the single most important presenting symptom of sleep apnea

Daytime symptoms include a morning headache (from hypercapnia) and neuropsychological disturbances, including falling asleep while performing purposeful activities. The patient may complain of nocturnal restlessness, frequent urination or enuresis, and choking. Patients also may report impaired intellectual performance, such as decreased concentration, ambition, and memory loss.

The predominant physical examination findings of OSA reflect the risk factors: obesity (particularly of the upper body), increased neck size, crowded oropharynx (tonsillar hypertrophy and enlargement of soft palate [uvula] and tongue).

Week 3 Mood disorders

Anxiety

o Signs and symptoms

Excessive worrying that is difficult to control and interferes with daily life; can also manifest with somatic symptoms such as chest tightness, shortness of breath, upset stomach.

Predictors of late-onset anxiety include female gender, recent adverse life events, illness, cognitive impairment, and mental illness comorbidities, while poverty and poor psychological support during earlier years also contribute (Zhang et al., 2015). Comorbid dementia or depression are not uncommon in older patients experiencing anxiety

Signs and Symptoms: May include a sense of impending doom, trembling, breathlessness, and tachycardia. Anxiety may impair working memory, attention, and problem-solving skills (Andreescu & Varon, 2015). In older adults, somatic complaints are more common, such as constipation, nausea, and sleep disturbance. Worries about health, disability, and finances are also common. One is more likely to learn of a patient’s anxiety by asking the question, “How do you feel when you are under stress?” than by asking, “Are you anxious?” (National Institute of Mental Health, n.d.). Patients with specific phobias may have an irrational fear to something that poses little danger, such as fear of crowds or natural phenomena (heights, lightening). Specific phobias may occur following a traumatic event, such as falling. Symptoms of anxiety in older adults often overlap with symptoms of physical disorders, depression, and dementia (Koychev & Klaus 2016).

generalized anxiety disorder (GAD), social anxiety, specific phobia, and anxiety disorder related to substance use, medication, or another medical condition. Panic disorder and agoraphobia are less common in older adults

o Diagnostic criteria

A diagnosis of GAD according to the DSM-5 requires excessive anxiety, difficulty controlling worry, and associated symptoms (at least three) including restlessness, easy fatigability, difficulty concentrating, irritability, muscle tension, difficulty falling or staying asleep, or restlessness (APA, 2013)

Diagnostic Tests: Complete a history and physical examination. Laboratory tests can rule out medical conditions with anxiety symptoms, including complete blood count (CBC), CMP, and TSH. Order additional tests based on the findings of the history and physical examination. Valid assessment scales to help diagnosis and assess older adults for anxiety include the Geriatric Anxiety Inventory (GAI) and the Geriatric Assessment Scales (Clifford et al., 2015; Gould et al., 2014).

Differential Diagnosis: Includes medical conditions (hypoglycemia, hyperthyroidism, pain, brain tumor, chronic obstructive pulmonary disease [COPD], etc.) and substance use that precede new-onset anxiety symptoms. Many cardiac, respiratory, endocrine, hematologic, and neurological conditions may be associated with anxiety (Andreescu & Varon, 2015; Allahverdipour, Asghari-Jafarabadi, Heshmati, & Hashemiparast, 2013; Uchmanowicz, Jankowska-Polanska, Motowidlo, Uchmanowicz, & Chabowski, 2016). Medications, including anticholinergic drugs, dopamine agonists, levothyroxine, steroids, psychostimulants, and over-the-counter (OTC) sympathomimetics may be anxiogenic. Depression and dementia commonly overlap with anxiety in older adults (Andreescu & Varon, 2015; Lenze et al., 2015; Vasiliadis et al., 2013).

o 1st line treatment (mild, moderate, severe)

Treatment: Treatment for anxiety should reduce symptoms and improve functioning. Simply listening, being compassionate, and showing respect are important to improving outcomes. Comorbid depression

and medical conditions should be treated. There are no large-scale studies of pharmacotherapy for late- life anxiety disorders to guide treatment decisions, as randomized controlled trials largely exclude those