Comprehensive Geriatric Assessment

Thank you for referring this patient to Geriatric Medicine for a comprehensive assessment of their geriatric needs.

Reason for Assessment

81 yo F, Eleanor Vance (PHN: 9842-710-382, DOB: 14/05/1943), referred on 12/11/2024 for evaluation of progressive short-term memory decline and 2 mechanical falls over the past 18 mos.

Collateral Hx obtained from daughter, Sarah Vance, who accompanied pt to clinic and visits 3x/wk.

History

Insidious onset of cognitive decline noted approximately 18 mos ago, initially manifesting as repetitive questioning and misplacing household items. Over the past 6 mos, functional decline has progressed; she burned a pot on the stove last month and missed several bill payments. Behavioural changes include mild apathy and withdrawal from her weekly bridge club, though no agitation or aggression is reported.

Cognition

Cognitive areas reported as affected: Short-term memory, executive function, and word-finding.

• Significant impairment in short-term recall; frequently forgets recent conversations, appointments, and whether she has taken daily medications.

• Speech remains fluent and grammatical with normal comprehension.

• Occasional word-finding pauses and circumlocution during conversation.

• Visuospatial skills mildly impaired; scraped car fender in familiar parking garage 3 mos ago.

• Impaired executive function; unable to manage household finances or follow multi-step recipes.

• Socially appropriate and polite during interaction, though less主动 in initiating social contact.

• Attention is intact in quiet settings, with mild distractibility in busy environments.

• Denies depressed mood, guilt, or suicidal ideation. Daughter notes reduced initiative and loss of interest in hobbies over the past yr, consistent with apathy rather than primary affective disorder.

• GDS-15: 3/15 (negative for depression); GAD-7: 2/21.

• No visual or auditory hallucinations.

• Sleep Concerns: Yes; fragmented sleep with 2–3 awakenings nightly for nocturia, occasional daytime napping.

Falls/Mobility

• Dizziness with postural change: Yes; brief lightheadedness upon standing rapidly from bed in the morning.

• Tremor: No.

• Falls: Yes; 2 mechanical falls in the past 6 mos (tripped on living room rug in 07/2024; slipped in bathroom in 10/2024). No LOC or head trauma.

• Handwriting remains legible and unchanged in size.

• Gait: Yes; slightly slower cadence and cautious stride over the past yr.

• Mild ecchymosis to R forearm following the 10/2024 fall; no fractures sustained.

Medical History

HTN, dyslipidemia, bilateral knee OA, and mild presbycusis. No Hx of CVA, TIA, or TBI.

Laparoscopic cholecystectomy (2004), R total knee arthroplasty (2016), bilateral cataract extraction (2021).

Functional Assessment

• Independent with all BADLs (bathing, dressing, toileting, transferring, continence, feeding).

• Dependent on daughter for finances, medication management (blister packs), and complex meal preparation; stopped driving 2 mos ago; independent with light housekeeping and telephone use.

• Ambulates independently indoors; cautious gait with reduced stride length.

• Uses a single-point cane for outdoor ambulation; grab bars recently installed in shower.

• MoCA: 20/30 (lost 4/5 delayed recall [0 with category cue, 2 with multiple choice], 1/1 cube copy, 1/1 clock hands, 1/3 serial 7s, 1/1 verbal fluency, 2/6 orientation [date, day]). MMSE: 24/30. Timed Up and Go (TUG): 15 seconds.

Social History

• Lives alone in a single-level ground-floor condominium in Vancouver, BC.

• Daughter lives 15 mins away, visits 3x/wk, and holds Enduring Power of Attorney. Son lives in Toronto.

• Retired elementary school teacher (retired 2008).

• Lifetime non-smoker; rare ETOH (1 glass of wine on holidays); no recreational drug use.

Other Geriatric Syndromes

• High fall risk secondary to mild orthostasis, OA, and environmental hazards.

• Unintentional weight loss of 2.5 kg over the past 6 mos due to reduced cooking.

• Eats 2 meals/day (mostly toast, soup, and fruit); fluid intake approx 1 L/day.

• Chronic bilateral knee pain (L > R), well-managed with PRN analgesics.

• Nocturia x2–3/night disrupting sleep continuity.

Physical Examination

• BP 136/78 mmHg (supine), HR 64 bpm; BP 120/72 mmHg (standing 1 min), HR 70 bpm; Temp 36.6 °C; SpO2 98% RA; Wt 58.2 kg; BMI 22.1 kg/m².

• Well-groomed elderly female, pleasant, cooperative, NAD.

• Normal S1/S2, regular rhythm, no murmurs, rubs, or gallops; JVP 2 cm ASA; no peripheral edema.

• Chest clear to auscultation bilaterally, no wheezes or crackles.

• Abdomen soft, non-tender, non-distended, normal bowel sounds, no hepatosplenomegaly.

• Heberden's nodes bilaterally; L knee crepitus with flexion; well-healed R knee scar; normal ROM in upper extremities.

• CN II–XII intact; normal tone, no cogwheeling or rigidity; strength 5/5 throughout; DTRs 2+ symmetric; plantar responses flexor; mild decreased vibration sense at great toes bilaterally; gait slightly slow with normal base, negative Romberg.

Investigations

CT Head (02/11/2024): Mild-to-moderate generalized cerebral atrophy with disproportionately prominent bilateral hippocampal atrophy; mild periventricular microvascular ischemic changes; no acute infarct, hemorrhage, or mass effect.

Labs (01/11/2024): WBC 6.2 x 10^9/L, Hb 128 g/L, Plt 215 x 10^9/L, Na 139 mmol/L, K 4.2 mmol/L, Cr 74 umol/L (eGFR 68 mL/min), Corrected Calcium 2.32 mmol/L (normal), TSH 2.14 mIU/L (normal), Vitamin B12 340 pmol/L (normal), HbA1c 5.6%. ECG: Normal sinus rhythm, HR 62 bpm, PR 168 ms, QTc 420 ms.

Impression

81 yo F presenting with an 18-month history of insidious, progressive amnestic and executive cognitive decline resulting in IADL dependency, alongside neuroimaging demonstrating hippocampal atrophy and negative reversible dementia screen. Clinical findings are most consistent with probable mild Alzheimer's disease, complicated by mild orthostatic hypotension and mechanical falls.

Plan and Recommendations

Optimize non-pharmacological dementia management including daily cognitive and social stimulation, structured routines, and pharmacy blister-packing with family supervision. To address orthostasis and falls, advised slow postural transitions, increased daytime fluid intake, and reduction of amlodipine (Norvasc®) from 10 mg PO daily to 5 mg PO daily. Continue paracetamol (acetaminophen, Tylenol®) 650 mg PO TID PRN for knee OA and rosuvastatin (Crestor®) 10 mg PO daily.

Referred to Home and Community Care for an in-home OT home safety assessment and Meals on Wheels setup, as well as the Alzheimer Society of BC First Link program for caregiver support.

Donepezil: We agreed to begin Donepezil. I submitted a request for Blue Cross special authorization. I prescribed 5mg p.o. daily, with an intended increase to 10mg p.o. daily after 4 weeks if tolerated. We reviewed the potential benefits and risks of Cholinesterase inhibitors. I explained that these drugs are cognitive enhancers used for mild or early Alzheimer's disease and Lewy Body Dementia. They do not cure either condition or prevent its progression. About one third of patients experience some cognitive and functional improvement, another third remain at their current level for longer, and the final third decline at the same pace. Possible adverse effects include GI upset, diarrhea, anorexia, sleep disturbance, bradycardia, falls, and dizziness. These drugs should not be used in people with bradycardia or conduction abnormalities.

Follow-up

RTC in 3 mos to assess donepezil tolerability, repeat HR/BP check, and evaluate cognitive and functional stability; follow up with GP in 4 wks for resting HR check prior to donepezil dose escalation.