Week 1 Discussion on Evaluation Comment
Discussion #1
You are evaluating a 78-year-old white male who comes to your office today with unintentional weight loss of 10 lbs. in the last year, self-reported exhaustion weakness based on grip strength, and slow walking speed, and low physical activity. Patient notes that he has been feeling worse over the past 6 months and just does not have the strength to do anything anymore. The patient states he is not currently on any medications except a multivitamin. He notes that he lives alone and does not want to leave his house. Answer the following questions with supportive rationale:
- What questions should you as the patient/family ask to further assess?
I would further assess his unintentional weight loss of 10 lbs. in the last year. How many times do you eat a day? What do your meals consist of? Is he able to make his own food? Is he able to feed himself? Are there any illnesses or conditions that might change the food you eat? Are they any teeth or mouth issues that is causing him to not eat? Do you eat alone or with someone? What medications do you take? Does he have enough money to buy food? Is he having any GI issues such as nausea, vomiting, or diarrhea? There are many things that can cause changes in nutrition in older adults. These things include loss of lean body mass, a slower metabolism, and an increase in body fat. Unintended weight loss in individuals older than 65 years old is associated with an increase morbidity and mortality rate. Social factor may contribute to this weight loss. People with this type of weight loss could lead to functional declines in ADLs (Gaddey & Holder, 2014).
- What screening tools would be appropriate in this case?
A nutritional screen would be appropriate for this case. There are many different malnutritional screen tools out. There is the Malnutrition Universal Screening Tool (MUST), Mini Nutritional Assessment (MNA), and the Malnutrition Screening Tool (MST). The MUST give a score of malnutrition risk. They range from low, medium or high determined by three components. The components are BMI, history of unexplained weight loss and acute illness. This test was developed for primary use in the community but has shown a high predictive validity in hospital environment (Harris & Haboubi, 2005). There other screening tools that can be done such as CBC, BMP, liver function tests, thyroid function tests, erythrocyte sedimentation rate, glucose measurement, and an Abdominal ultrasonography could be considered.
- Do you have concerns with frailty in this patient? If so, why?
I do have concerns for this patient for frailty. This is commonly associated with aging. Frailty is a clinical syndrome in which three or more of the following criteria is present: unintended weight loss, self-reported exhaustion, weakness (grip-strength), slow walking speed, and low physical activity. This individual meet all of the criteria. This patient is at a high risk for infection because his immune system does not work as well. The simplest infection could cause harm or even death in this person (Torphy, Lynm, & Glass, 2006).
- What referrals should be made, if any, on this patient?
There is some referral that should be made for this patient. The first would be a dietitian nutritionist to help with his eating. The person will come up with a plan to help the person regain his weight or maintain his weight and improve his overall nutritional status. People who are
underweight need more calories, protein, or other nutrients. They come up with an eating plan based on that particular person nutritional needs (Gordon, 2019). Another referral I would make is therapist or counseling. Malnutrition and depression are two disorders that ae closely link. A person that is depressed can lead them to being malnourish and a person who is malnourish can end up being depressed. For someone who has bad eating habits, the resulting malnutrition and nutrient deficiency can lead to depression. Lastly, I would refer this individual to PT and OT to assist with his everyday life and help him get his energy back. He currently has weak, slow walking speed, and low physical activity which all could be helped by a therapist. They could help him perform his ADLs better and build up strength. 
Discussion #2
- What questions should you as the patient/family ask to further assess?
The questions to further evaluate the patient’s symptoms would include his diet, recent lifestyle changes or events, onset on symptoms, past medical history, family history, duration of symptoms, characteristics of fatigue and weakness, and any aggravating or relieving factors. These questions would address the OLD CART method for assessment to thoroughly gather objective and subjective data. An example of aggravating factors in this situation would be stressful events with weight loss, interrupted sleep with fatigue, and poor diet contributing to weakness (Dunphy, Winland-Brown, Porter, & Thomas, 2017).
- What screening tools would be appropriate in this case?
When considering the patient’s symptoms of weakness, decreased physical activity, and weight loss, a tool the provider could use to assess the patient’s function is the SPICE tool for geriatric syndrome. The SPICE tool will assess the patient for sleep disturbances, problems with eating or feeding, incontinence, confusion, evidence of falls, and skin breakdown. The symptoms experienced by geriatric patients may not be related to a certain disease and may be the result from a combination of disease and requires a more detailed assessment and treatment plan. To assess the patient’s level of frailty, two tools that are easily used in the clinical setting are the Study of Osteoporotic Fractures and the Canadian Study of Health and Aging Clinical Frailty Scale. Additionally, the provider would want to gather laboratory studies as well (Dunphy, Winland-Brown, Porter, & Thomas, 2017).
- Do you have concerns with frailty in this patient? If so, why?
The patient’s level of frailty will indicate their level of vulnerability and likeliness of decline in health. Frailty can be caused by a cognitive, medical, functional, and social deficits. These four areas of deficits should be addressed to improve patient’s quality of life and prevent the progression of geriatric syndrome. Characteristics of frailty include unexplained anemia, functional decline, mild cognitive impairment, poor endurance, glucose intolerance, muscle weakness, clotting proclivity, social withdrawal, and worsening disease states (Watson, 2017).
- What referrals should be made, if any, on this patient?
Referral would be necessary if laboratory studies showed any progressive illness that could not be treated in the primary care setting, such as advanced staged kidney disease, or heart failure. When screening the patient for frailty and geriatric syndrome, the provider should refer the patient to a specialist if there are any signs of severe depression or suicidal ideation. In addition, the patient may need a referral for physical therapy if the muscle weakness is biological and would benefit from this type of treatment.