The 10 Min Geriatric Assessment

THE 10 MINUTE GERIATRIC ASSESSMENT

Fredrick T. Sherman, MD, MSc

Medical Director

SENIOR HEALTH PARTNERS

Mount Sinai School of Medicine

www.geri.com

OFFICE-BASED ASSESSMENT

Common syndromes “Geriatric Giants” of the elderly

Based on literature review

Use principles of EBM

Easy to remember MNEUMONICS

Falls “ Phalls” Confusion Incontinence Iatrogenic disorders Impaired homeostasis GERIATRIC GIANTS

“ DEEP IN” FOR QUICK SCREENING

D - D ementia, D epression, D rugs

E - E yes

E - E ars

P - P hysical Performance, P halls, P sychosocial

I - I ncontinence

N - N utrition

SILENT DEMENTIA

Family Not Aware: 21% of family members fail to recognize a problem with memory in demented seniors. (JAMA, 277, 1997)

Physicians Fail to Evaluate: 53% of seniors whose family DID recognize memory problem did NOT receive an evaluation

Physicians Fail to Chart: 76% who screened positive for Mod/Sev D were not noted to be demented on chart review. (Ann Int Med, 109, 1995)

DEMENTIA SCREEN 1 THREE ITEM RECALL

THREE ITEM RECALL AT ONE MINUTE

RECALLS LESS THAN 2 (1 OR 0)--LR-3.1

RECALLS 2 --LR-0.5

RECALLS ALL 3 ITEMS - 0.06

DEMENTIA SCREEN 2 VERBAL FLUENCY-CATEGORY RETRIEVAL or “ANIMAL NAMING”

Measures impairment in verbal production and

access to semantic memory

A timed test of animal naming

Name as many animals as you can in one

minute

Scoring equals number named in one minute

ANIMAL NAMING Useful screening tool for dementia Average performance=18/min Less than 12/min is abnormal Correlates well with MMSE scores(r=0.77) Worsens with time in AD Neurology.1989;39:1159-1165 .

DEMENTIA SCREEN 3

Clock Completion Test

Draw 3” Circle On Unlined Paper

“ Put The Numbers In The Clock”

Score By Quadrants

Fourth Quadrant Most Sensitive

Watson YL et al., Clock Completion: An Objective screening test for dementia. JAGS 1993; 41:1235-40

CLOCK COMPLETION TEST (CCT)

A Screening Test for Dementia

Retrospective analysis of clock drawing errors and prospective validation

76 consecutive OPD patients; Age 55-92(aver 76)

40 patients with dementia/36 not demented; Neuropsych testing

Sen/spec for 4th quadrant predicting dementia 87%/82%

Sen/spec of Short Blessed Test 82%/87%

CCT not good for grading severity of dementia

INSTRUMENTAL ACTIVITIES OF DAILY LIVING

Meal preparation

Housework

Laundry

Medication management

Telephone

Shopping

Transportation

Money management

DEMENTIA SCREEN 4

FOUR IADL SCORE FOR RISK OF DEMENTIA

ONE YEAR LATER

“ DO YOU NEED HELP WITH...

Money Management

Medication Management

Telephone Use

Using Transportation

Odds Ratio: 1-10; 2-15; 3-59; 4-318

DEMENTIA SCREEN 5 Seven Minute Neurocognitive Screening for Alzheimer’s Disease

1) Benton Temporal Orientation

• month, date, year, day, time

2) Enhanced Cued Recall

• recall of 16 pictures

3) Category Fluency

• “ animal naming”

4) Clock Drawing

• numbers and hands

Solomon, PR, et al, Arch Neurology, JJ, March 1998 (349-355)

Mean time to administer: 7 minutes, 42 secs

Sen/Spec: 92/96 in detecting AD

Identify all AD patients with MMSE > 24

Age/Sex/Education: not significant factors

High sen/spec in very mild, mild & mod AD

www.memorydoc.org/scoring.asp

Solomon, PR, et al, Arch Neurology, JJ, March 1998 (349-355)

7 MINUTE NEUROCOGNITIVE SCREEN

D - D rugs, D elirium

E - E toh, , E yes, E ars

M - M ultiple, M etabolic

E - E ndocrine

N - N utrition, N PH

T - T rauma

I - I nfection, I nfarct

A - A ffective, A lzheimer’s

S - S urgery, S ubcortical

D EPRESSION

Single Question: Do You Often Feel Sad Or Depressed? (Sen/spe-.85/.65)

5 Item Geriatric Depression Scale (Sen/spe-.97/.85)

15 Item Gds (Sen/spec-.94/.83)

5 ITEM GDS

Yes No

(1) Are you basically satisfied with

your life?

(2) Do you often get bored?

(3) Do you often feel helpless?

(4) Do you prefer to stay at home rather

than going out and doing new things?

(5) Do you feel pretty worthless

the way you are now?

0- 1 = not depressed > 2 = depressed

*Sens. 97 (.94)/Spec. 85(.83) PPV - .85 (.82) NPV - .97 (.94)

Single Question Sen .85/Spec.65

Hoyl, MT et al. Development and Testing of a Five-item Version of the Geriatric Depression Scale. JAGS. 47:873-78, 1999.

    

D RUGS

Greater Than Or Equal To Four Prescribed

Any Of The “Antis”

Benzos

Non Rxed

Alternative

SIMPLE SCREENS OF HEARING LOSS Sen 80% Spec 80% at cut point of > 3 < 2 min NHANES Battery Sen 48-63% Spec 75-86% At cut point >8 2 min Hearing-Handicap Inventory for the elderly Sen 80-100% Spec 82-89% 1 min Whisper Test Sen 87-90% Spec 80-100% 1-2 min Audioscope Comments Time to Administer Question/Test

E ARS

WHISPERED VOICE TEST—

NO EQUIPMENT BUT MUST BE STANDARDIZED

Explain That You Will Whisper Some Numbers

Ask Senior To Close Eyes

12-18 Inches Apart

You Exhale And Then Whisper 4 Random Single Numbers At 1 Sec Intervals

Fail Screen If Senior Cannot Hear at least 2 numbers

Sen/spec-80-100%/82-89%

E ARS

BUY AUDIOSCOPE

Audioscope Set At 40 Db

Four Tones --500, 1000, 2000, 4000 Hz

Test Hearing Using 1000 And 2000 Hz

Inability To Hear 1000 OR 2000 Hz In Both Ears Or Either Of These Freq In One Ear

Sen/spec-.94/.72

If Positive, Formal Testing

E YES

BECAUSE OF YOUR EYESIGHT, DO YOU HAVE DIFFICULTY WITH. . . .

Driving

Watching TV

Reading

Or Any Daily Activity

E YES

IF “YES” TO QUESTION THEN

Test Each Eye With Snellen Chart While Patient Wears Glasses

Inability To Read Greater Then 20/40 On Snellen Chart

P hysical Performance Testing in the Elderly (PPT)

Ideally, provides information about the:

Prognosis for ADL Impairment

Ability to Live Independently

Need for Treatment

Health Care Requirements

P HYSICAL PERFORMANCE TESTING (PPT)

+ ADVANTAGES

Y ields repeatable, quantifiable results

Eliminates any discrepancies between

patient and proxy reports and actual PPT

Confirms statements of patient or proxy

May help select high risk group for

targeting interventions

P HYSICAL PERFORMANCE TESTING DISADVANTAGES

Must be conducted in the presence of a trained observer

Equipment is sometimes too specialized for office, adult or nursing home setting

PT models only part of the more complex ADL

PT may fail to reflect typical performance in home environment

WHAT IS THE RISK OF ADL DEPENDENCE IN THE AGED WITH COGNITIVE IMPAIRMENT?

10% Of Independently Living Elderly In

Community Lose 1 Or More ADL /Year

? Are There PPTs That Will Predict Which Elderly

Will Lose ADLs?

? What Self Reported Characteristics are Associated

With New Dependence In ADL?

RISK FACTORS FOR FUNCTIONAL DEPENDENCE Older Age Female Living Alone Non-white Poor Less Education Smoking HBP Abnormal BMI Heart Disease Cognitive Impairment

ADL DEPENDENCE IN MILD/MOD DEMENTIA Prospective, Longitudinal Study of 1,103 Elderly (Age 72 & Older) with Mild/Mod Dementia, Independent In ADL Assessed I Yr Later For Development Of ADL Impairment and Risk Factors What PPTS Predicted Maintenance of ADL? J Gerontol Med Sci 1995;50A:M235-241.

PREDICTORS OF ADL DEPENDENCE SELF REPORTED RISK FACTORS ASSOCIATED WITH ONSET OF ADL (p<.O5) 1) Lived Alone (rr-3.8) 2) Not Currently Married (rr-4.3) 3) Impairments > 4 IADLs (rr-2.9) J Gerontol Med Sci 1995;50A:M235-241.

PREDICTORS OF ADL DEPENDENCE

TIMED PERFORMANCE TESTS

Rapid Gait>11sec (rr-6.4) [10 Ft Out and

Back “as quickly as possible”]

2) Three (3) Chair Stands > 10 sec (rr-4.4)

QUALITATIVE CHAIR STAND Abnormal Normal High Risk 12/31 (39%) 10 ft. Rapid Gait/3 Chair Rises High Risk 13/38 (34%) Low Risk 6/128 (4.7%) Abnormal Normal

SIMPLE TESTS OF LOWER EXTREMITY STRENGTH, BALANCE, GAIT & FALL RISK

If FR < 7” unable to:

Leave neighborhood

Stand on one foot

Do tandem walking

Adjusted Odds Ratio for >2 falls in 6 months

8.1 if unable to reach

4.0 if < 6 inches

2.0 if > 6 inches < 10 inches

1 min Functional reach Comments Time to Administer Question/Test

RELATIVE RISKS OF SEVERE WALKING DISABILITY: COMBINED DISTRIBUTION OF KNEE STRENGTH TERTILES AND BALANCE CATEGORES JAGS, 2001-Vol.49, No.1 1 1.14 0.97 SS (10)+ST (10) +TS (>3s) 1.18 1.58 1.87 SS (10)+ST (10) +TS (<3S) 3.08 1.49 5.12 S-S<10 seconds RR RR RR Balance Categories Strongest (<15.1kg) Average (10.6-15.1 kg) Weakest (<10.6 kg) Knee Strength Tertiles

Balance Categories The rates of onset of severe walking disability in groups based on baseline knee-extension strength tertiles and standing balance categories in women who did not have severe walking disability at baseline. The follow-up time was 3 years with examinations taking place every 6 months. Knee Extension Strength Tertiles JAGS, 2001-Vol.49,No1

Geriatric Syndromes P HALLS (Falls)

M M aladaptive equipment

M edical (acute)

M edical (chronic)

M ultiple

E E nvironment

E thanol

E yes/ E ars

O O rthostatic

signs o r symptoms

W W eakness Prox

Diffuse

I NCONTINENCE

Two Questions:

In The Last Year, Have You Ever Lost Your Urine And Gotten Wet? Have You Lost Urine On At Least 6 Separate Days?

If Yes To Both ?S, PPV-.86/NPV-.96;

83% Agreement Between PAT Response & UROL Assessment

PERSISTENT UI

S - S tress

O - O verflow

U - U rge

P - P hysical/ P sychological

NUTRITION SCREENS Odds Ratio 2.7 if 3-5 RF, 6.4 if > 6 RF 5-10 min NHANES 14-item scale to detect hypoalbuminemia Sen 36%, Spec 85% for intake of > 3 nutrients below 75% of RDA at cut point > 6 points <5 min Nutrition Screening PPV malnutrition .99 1 min