Geriatric Medicine Comprehensive Assessment

Today I met with Arthur Pendelton in person at the Geriatric Outpatient Clinic on 14/05/2024. Arthur is a 82 years old male and was seen for cognitive decline and recurrent falls. He was last seen in this clinic on 10/11/2023. He attended today's appointment accompanied by his daughter, Sarah Pendelton. He was referred by Dr. Evelyn Vance, who is also his primary care physician.

Past Medical History

Hypertension Atrial fibrillation (followed by Dr. R. Sidhu, Cardiology) Type 2 diabetes mellitus Osteoarthritis of the bilateral knees Benign prostatic hyperplasia Cataracts (bilateral extraction in 2019, Dr. K. Lee)

Medications

apixaban (Eliquis) 5 mg PO BID metoprolol 25 mg PO BID ramipril (Altace) 5 mg PO daily metformin (Glucophage) 500 mg PO BID tamsulosin (Flomax) 0.4 mg PO daily paracetamol (acetaminophen, Tylenol) 650 mg PO TID PRN colecalciferol (vitamin D3) 1,000 IU PO daily, cyanocobalamin (vitamin B12) 1,000 mcg PO daily, calcium carbonate 500 mg PO daily

Allergies

Penicillin (maculopapular rash)

History of Present Illness

INTERVAL HISTORY: Since the last assessment 6 months ago, his daughter reports a gradual progression in short-term memory deficits. He frequently repeats questions within the same conversation and recently left the stove burner on twice. Word-finding difficulties have become more noticeable, though he remains pleasant and cooperative.

Falls: He has experienced two mechanical falls at home over the past 3 months. Both occurred while rising from a chair to use the washroom at night. He did not sustain any head trauma or fractures, and there was no associated loss of consciousness, dizziness, or prodromal symptoms.

Review of Systems

CNS events: Negative for history of stroke, TIA, seizures, or significant head trauma.

Cognition: Progressive short-term memory loss and executive dysfunction as noted above. Long-term memory remains relatively preserved. No visual hallucinations or fluctuating alertness.

Mood: Euthymic. Denies anhedonia, feelings of worthlessness, or suicidal ideation. GDS-15 score 2/15.

Falls/Mobility: Two falls in the past 6 months. Reports mild unsteadiness when turning quickly.

Bone health: No history of fragility fractures. No prior BMD testing. Takes daily calcium and vitamin D supplementation.

Hearing/Vision: Uses bilateral hearing aids with good effect. Wears corrective lenses for reading; routine optometry follow-up is up to date.

Sleep: Sleeps 22:00 to 06:30. Awakens twice nightly for nocturia. No symptoms suggestive of OSA or REM sleep behaviour disorder.

Nutrition: Appetite is fair. Weight has been stable at 74 kg over the past year. Daughter provides pre-made meals.

Continence: Occasional urinary urgency and nocturia x2, managed with pads. Continent of stool; regular daily bowel movements.

Functional History

ADLs: Independent with feeding, dressing, grooming, transfers, and toileting. Requires verbal reminders and minimal setup assistance for bathing twice weekly.

iADLs: Dependent on his daughter for finances, medication management (uses a blister pack), shopping, and transportation. He can prepare simple breakfasts and make tea, and remains able to use the telephone via speed dial.

Arthur ambulates with a 4-wheeled walker outdoors and a single-point cane indoors.

Home health care visits twice weekly to assist with bathing.

Social History

Education: Completed high school (Grade 12) and a trade certificate in carpentry.

Employment: Worked as a self-employed carpenter; retired at age 65 in good health.

Support/Living: Widowed 4 years ago. Lives alone in a single-level ground-floor condominium. His daughter lives 10 minutes away and visits every second day.

Hobbies: Watches hockey, listens to the radio, and enjoys sitting on his patio.

Advanced care planning: MOST status is M2 (medical care without ICU/intubation). His daughter, Sarah Pendelton, is his designated Representative under a Representation Agreement.

Substance use: Ex-smoker (quit 30 years ago, 15 pack-year history). No alcohol or recreational drug use.

Family History

Siblings: One brother, age 79, alive with hypertension.

Maternal: Mother died at age 88 of late-onset Alzheimer disease.

Paternal: Father died at age 74 of a myocardial infarction.

Positive family history of late-onset dementia in his mother; negative for Parkinson disease or major psychiatric disorders.

Examination

Arthur is right-handed.

Partial insight into cognitive deficits; affect is pleasant and cooperative; speech is fluent and normophonic; oriented to person, place, and year, but not month or date; limited awareness of current events.

Vitals: Sitting BP 134/78 mmHg, HR 68 bpm (irregular); Standing (1 min) BP 112/70 mmHg, HR 74 bpm; Standing (3 min) BP 114/72 mmHg, HR 72 bpm.

Cardiovascular exam reveals an irregularly irregular rhythm, normal S1/S2, and no murmurs. JVP is at 2 cm ASA. Chest is clear to auscultation bilaterally. Mild trace pedal edema bilaterally.

Bilateral knee crepitus noted on passive range of motion without joint effusion. Timed Up and Go (TUG) test completed in 16 seconds using a single-point cane.

Cranial nerves II–XII intact. Normal bulk and tone in all four extremities; no cogwheeling or rigidity. Strength 5/5 throughout. Reflexes 2+ and symmetric, plantars downgoing bilaterally. Gait is slightly wide-based and cautious with decreased arm swing, but no festination or shuffling. Romberg is negative.

MMSE today is 22/30 (lost 3/5 on orientation to time, 3/3 on delayed recall, 1/5 on WORLD backwards, and 1/1 on intersecting pentagons). Clock drawing test showed normal contour with minor spacing errors in number placement and incorrect hand placement for 10 past 11.

Prior Cognitive Testing

MoCA 21/30 on 10/11/2023 (lost 2/5 on visuospatial/executive, 1/3 on attention, 4/5 on delayed recall, and 2/6 on orientation).

Investigations

12/04/2024: Hb 132, WBC 6.4, Plt 210, Na 138, K 4.2, Cr 98, eGFR 61, Ca 2.35, Alb 40, TSH 2.1, HbA1c 6.8% (H), Vit B12 450. CT Head (15/10/2023): Mild-to-moderate generalized cerebral atrophy with disproportionately prominent bilateral hippocampal volume loss. Mild periventricular microvascular ischemic changes. No acute infarct, hemorrhage, or mass effect.

Pharmacy

Shoppers Drug Mart, 1234 West Broadway, Vancouver, BC.

Assessment & Plan

1. Major Neurocognitive Disorder due to probable Mixed Pathology (Alzheimer disease and Vascular): Progressing gradually with increased executive and short-term memory deficits impacting iADLs.

• Initiate donepezil (Aricept) 5 mg PO daily for 4 weeks, then increase to 10 mg PO daily if tolerated. Counselled patient and daughter regarding GI side effects and potential bradycardia.
• Provided safety recommendations: disconnect the stove when not in use; daughter will transition to providing microwave-only meals.
• Referred to the Alzheimer Society of BC First Link program for caregiver support and education.

2. Recurrent Falls & Orthostatic Hypotension: Documented systolic BP drop of 22 mmHg on standing today, likely contributing to nocturnal falls alongside BPH-related nocturia and osteoarthritis.

• Discontinue tamsulosin (Flomax) to mitigate orthostatic hypotension; monitor for urinary retention.
• Decrease ramipril (Altace) from 5 mg PO daily to 2.5 mg PO daily.
• Advised non-pharmacological measures: dorsiflexion exercises prior to standing, sitting at the edge of the bed for 1 minute before ambulating, and adequate daytime hydration.
• Referred to Community Home Health Occupational Therapy for a home safety assessment and equipment review (e.g., bedside commode, grab bars).

3. Bone Health: High fall risk with no prior fracture risk assessment.

• Continue colecalciferol 1,000 IU PO daily and dietary/supplemental calcium.
• Ordered baseline DEXA scan.

I will see the patient back in clinic in 6 months for reassessment, with a repeat ECG in 4 weeks to monitor heart rate and QTc interval on donepezil.

They were advised to make contact if any concerns developed before the planned follow-up. Thank you for the opportunity to contribute to your patient's care.

Dr. Marcus Thorne, MD, FRCPC Geriatric Medicine and Internal Medicine

Billing code: 00310, Time billed: 60 minutes, Collateral time: 15 minutes

Verbal consent was obtained from the patient and his substitute decision-maker to use an AI scribe during today's encounter.