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The 10 Min Geriatric Assessment

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The 10 Min Geriatric Assessment

  1. 1. THE 10 MINUTE GERIATRIC ASSESSMENT <ul><li>Fredrick T. Sherman, MD, MSc </li></ul><ul><li>Medical Director </li></ul><ul><li>SENIOR HEALTH PARTNERS </li></ul><ul><li>Mount Sinai School of Medicine </li></ul><ul><li>www.geri.com </li></ul>
  2. 2. OFFICE-BASED ASSESSMENT <ul><li>Common syndromes “Geriatric Giants” of the elderly </li></ul><ul><li>Based on literature review </li></ul><ul><li>Use principles of EBM </li></ul><ul><li>Easy to remember MNEUMONICS </li></ul>
  3. 3. Falls “ Phalls” Confusion Incontinence Iatrogenic disorders Impaired homeostasis GERIATRIC GIANTS
  4. 4. “ DEEP IN” FOR QUICK SCREENING <ul><li>D - D ementia, D epression, D rugs </li></ul><ul><li>E - E yes </li></ul><ul><li>E - E ars </li></ul><ul><li>P - P hysical Performance, P halls, P sychosocial </li></ul><ul><li>I - I ncontinence </li></ul><ul><li>N - N utrition </li></ul>
  5. 5. SILENT DEMENTIA <ul><li>Family Not Aware: 21% of family members fail to recognize a problem with memory in demented seniors. (JAMA, 277, 1997) </li></ul><ul><li>Physicians Fail to Evaluate: 53% of seniors whose family DID recognize memory problem did NOT receive an evaluation </li></ul><ul><li>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) </li></ul>
  6. 6. DEMENTIA SCREEN 1 THREE ITEM RECALL <ul><li>THREE ITEM RECALL AT ONE MINUTE </li></ul><ul><li>RECALLS LESS THAN 2 (1 OR 0)--LR-3.1 </li></ul><ul><li>RECALLS 2 --LR-0.5 </li></ul><ul><li>RECALLS ALL 3 ITEMS - 0.06 </li></ul>
  7. 7. DEMENTIA SCREEN 2 VERBAL FLUENCY-CATEGORY RETRIEVAL or “ANIMAL NAMING” <ul><li>Measures impairment in verbal production and </li></ul><ul><li>access to semantic memory </li></ul><ul><li>A timed test of animal naming </li></ul><ul><li>Name as many animals as you can in one </li></ul><ul><li>minute </li></ul><ul><li>Scoring equals number named in one minute </li></ul>
  8. 8. 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 .
  9. 9. DEMENTIA SCREEN 3 <ul><li>Clock Completion Test </li></ul><ul><li>Draw 3” Circle On Unlined Paper </li></ul><ul><li>“ Put The Numbers In The Clock” </li></ul><ul><li>Score By Quadrants </li></ul><ul><li>Fourth Quadrant Most Sensitive </li></ul>
  10. 10. Watson YL et al., Clock Completion: An Objective screening test for dementia. JAGS 1993; 41:1235-40
  11. 11. CLOCK COMPLETION TEST (CCT) <ul><li>A Screening Test for Dementia </li></ul><ul><li>Retrospective analysis of clock drawing errors and prospective validation </li></ul><ul><li>76 consecutive OPD patients; Age 55-92(aver 76) </li></ul><ul><li>40 patients with dementia/36 not demented; Neuropsych testing </li></ul><ul><li>Sen/spec for 4th quadrant predicting dementia 87%/82% </li></ul><ul><li>Sen/spec of Short Blessed Test 82%/87% </li></ul><ul><li>CCT not good for grading severity of dementia </li></ul>
  12. 12. INSTRUMENTAL ACTIVITIES OF DAILY LIVING <ul><li>Meal preparation </li></ul><ul><li>Housework </li></ul><ul><li>Laundry </li></ul><ul><li>Medication management </li></ul><ul><li>Telephone </li></ul><ul><li>Shopping </li></ul><ul><li>Transportation </li></ul><ul><li>Money management </li></ul>
  13. 13. DEMENTIA SCREEN 4 <ul><li>FOUR IADL SCORE FOR RISK OF DEMENTIA </li></ul><ul><li>ONE YEAR LATER </li></ul><ul><li>“ DO YOU NEED HELP WITH... </li></ul><ul><li>Money Management </li></ul><ul><li>Medication Management </li></ul><ul><li>Telephone Use </li></ul><ul><li>Using Transportation </li></ul><ul><li>Odds Ratio: 1-10; 2-15; 3-59; 4-318 </li></ul>
  14. 14. DEMENTIA SCREEN 5 Seven Minute Neurocognitive Screening for Alzheimer’s Disease <ul><li>1) Benton Temporal Orientation </li></ul><ul><li>• month, date, year, day, time </li></ul><ul><li>2) Enhanced Cued Recall </li></ul><ul><li>• recall of 16 pictures </li></ul><ul><li>3) Category Fluency </li></ul><ul><li>• “ animal naming” </li></ul><ul><li>4) Clock Drawing </li></ul><ul><li>• numbers and hands </li></ul><ul><li>Solomon, PR, et al, Arch Neurology, JJ, March 1998 (349-355) </li></ul>
  15. 15. <ul><li>Mean time to administer: 7 minutes, 42 secs </li></ul><ul><li>Sen/Spec: 92/96 in detecting AD </li></ul><ul><li>Identify all AD patients with MMSE > 24 </li></ul><ul><li>Age/Sex/Education: not significant factors </li></ul><ul><li>High sen/spec in very mild, mild & mod AD </li></ul><ul><li>www.memorydoc.org/scoring.asp </li></ul><ul><li>Solomon, PR, et al, Arch Neurology, JJ, March 1998 (349-355) </li></ul>7 MINUTE NEUROCOGNITIVE SCREEN
  16. 16. <ul><li>D - D rugs, D elirium </li></ul><ul><li>E - E toh, , E yes, E ars </li></ul><ul><li>M - M ultiple, M etabolic </li></ul><ul><li>E - E ndocrine </li></ul><ul><li>N - N utrition, N PH </li></ul><ul><li>T - T rauma </li></ul><ul><li>I - I nfection, I nfarct </li></ul><ul><li>A - A ffective, A lzheimer’s </li></ul><ul><li>S - S urgery, S ubcortical </li></ul>
  17. 17. D EPRESSION <ul><li>Single Question: Do You Often Feel Sad Or Depressed? (Sen/spe-.85/.65) </li></ul><ul><li>5 Item Geriatric Depression Scale (Sen/spe-.97/.85) </li></ul><ul><li>15 Item Gds (Sen/spec-.94/.83) </li></ul>
  18. 18. 5 ITEM GDS <ul><li> Yes No </li></ul><ul><li>(1) Are you basically satisfied with </li></ul><ul><li>your life? </li></ul><ul><li>(2) Do you often get bored? </li></ul><ul><li>(3) Do you often feel helpless? </li></ul><ul><li>(4) Do you prefer to stay at home rather </li></ul><ul><li>than going out and doing new things? </li></ul><ul><li>(5) Do you feel pretty worthless </li></ul><ul><li>the way you are now? </li></ul><ul><li>0- 1 = not depressed > 2 = depressed </li></ul><ul><li>*Sens. 97 (.94)/Spec. 85(.83) PPV - .85 (.82) NPV - .97 (.94) </li></ul><ul><li>Single Question Sen .85/Spec.65 </li></ul><ul><li>Hoyl, MT et al. Development and Testing of a Five-item Version of the Geriatric Depression Scale. JAGS. 47:873-78, 1999. </li></ul>    
  19. 19. D RUGS <ul><li>Greater Than Or Equal To Four Prescribed </li></ul><ul><li>Any Of The “Antis” </li></ul><ul><li>Benzos </li></ul><ul><li>Non Rxed </li></ul><ul><li>Alternative </li></ul>
  20. 20. 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
  21. 21. E ARS <ul><li>WHISPERED VOICE TEST— </li></ul><ul><li>NO EQUIPMENT BUT MUST BE STANDARDIZED </li></ul><ul><li>Explain That You Will Whisper Some Numbers </li></ul><ul><li>Ask Senior To Close Eyes </li></ul><ul><li>12-18 Inches Apart </li></ul><ul><li>You Exhale And Then Whisper 4 Random Single Numbers At 1 Sec Intervals </li></ul><ul><li>Fail Screen If Senior Cannot Hear at least 2 numbers </li></ul><ul><li>Sen/spec-80-100%/82-89% </li></ul>
  22. 22. E ARS <ul><li>BUY AUDIOSCOPE </li></ul><ul><li>Audioscope Set At 40 Db </li></ul><ul><li>Four Tones --500, 1000, 2000, 4000 Hz </li></ul><ul><li>Test Hearing Using 1000 And 2000 Hz </li></ul><ul><li>Inability To Hear 1000 OR 2000 Hz In Both Ears Or Either Of These Freq In One Ear </li></ul><ul><li>Sen/spec-.94/.72 </li></ul><ul><li>If Positive, Formal Testing </li></ul>
  23. 23. E YES <ul><li>BECAUSE OF YOUR EYESIGHT, DO YOU HAVE DIFFICULTY WITH. . . . </li></ul><ul><li>Driving </li></ul><ul><li>Watching TV </li></ul><ul><li>Reading </li></ul><ul><li>Or Any Daily Activity </li></ul>
  24. 24. E YES <ul><li>IF “YES” TO QUESTION THEN </li></ul><ul><li>Test Each Eye With Snellen Chart While Patient Wears Glasses </li></ul><ul><li>Inability To Read Greater Then 20/40 On Snellen Chart </li></ul>
  25. 25. P hysical Performance Testing in the Elderly (PPT) <ul><li>Ideally, provides information about the: </li></ul><ul><li>Prognosis for ADL Impairment </li></ul><ul><li>Ability to Live Independently </li></ul><ul><li>Need for Treatment </li></ul><ul><li>Health Care Requirements </li></ul>
  26. 26. P HYSICAL PERFORMANCE TESTING (PPT) <ul><li>+ ADVANTAGES </li></ul><ul><li>Y ields repeatable, quantifiable results </li></ul><ul><li>Eliminates any discrepancies between </li></ul><ul><li>patient and proxy reports and actual PPT </li></ul><ul><li>Confirms statements of patient or proxy </li></ul><ul><li>May help select high risk group for </li></ul><ul><li>targeting interventions </li></ul>
  27. 27. P HYSICAL PERFORMANCE TESTING DISADVANTAGES <ul><li>Must be conducted in the presence of a trained observer </li></ul><ul><li>Equipment is sometimes too specialized for office, adult or nursing home setting </li></ul><ul><li>PT models only part of the more complex ADL </li></ul><ul><li>PT may fail to reflect typical performance in home environment </li></ul>
  28. 28. WHAT IS THE RISK OF ADL DEPENDENCE IN THE AGED WITH COGNITIVE IMPAIRMENT? <ul><li>10% Of Independently Living Elderly In </li></ul><ul><li>Community Lose 1 Or More ADL /Year </li></ul><ul><li>? Are There PPTs That Will Predict Which Elderly </li></ul><ul><li>Will Lose ADLs? </li></ul><ul><li>? What Self Reported Characteristics are Associated </li></ul><ul><li>With New Dependence In ADL? </li></ul>
  29. 29. RISK FACTORS FOR FUNCTIONAL DEPENDENCE Older Age Female Living Alone Non-white Poor Less Education Smoking HBP Abnormal BMI Heart Disease Cognitive Impairment
  30. 30. 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.
  31. 31. 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.
  32. 32. PREDICTORS OF ADL DEPENDENCE <ul><li>TIMED PERFORMANCE TESTS </li></ul><ul><li>Rapid Gait>11sec (rr-6.4) [10 Ft Out and </li></ul><ul><li>Back “as quickly as possible”] </li></ul><ul><li>2) Three (3) Chair Stands > 10 sec (rr-4.4) </li></ul>
  33. 33. 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
  34. 34. SIMPLE TESTS OF LOWER EXTREMITY STRENGTH, BALANCE, GAIT & FALL RISK <ul><li>If FR < 7” unable to: </li></ul><ul><li>Leave neighborhood </li></ul><ul><li>Stand on one foot </li></ul><ul><li>Do tandem walking </li></ul><ul><li>Adjusted Odds Ratio for >2 falls in 6 months </li></ul><ul><li>8.1 if unable to reach </li></ul><ul><li>4.0 if < 6 inches </li></ul><ul><li>2.0 if > 6 inches < 10 inches </li></ul>1 min Functional reach Comments Time to Administer Question/Test
  35. 35. 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
  36. 36. 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
  37. 37. Geriatric Syndromes P HALLS (Falls) <ul><li>M M aladaptive equipment </li></ul><ul><li>M edical (acute) </li></ul><ul><li>M edical (chronic) </li></ul><ul><li>M ultiple </li></ul><ul><li>E E nvironment </li></ul><ul><li>E thanol </li></ul><ul><li>E yes/ E ars </li></ul><ul><li>O O rthostatic </li></ul><ul><li>signs o r symptoms </li></ul><ul><li>W W eakness Prox </li></ul><ul><li>Diffuse </li></ul>
  38. 38. I NCONTINENCE <ul><li>Two Questions: </li></ul><ul><li>In The Last Year, Have You Ever Lost Your Urine And Gotten Wet? Have You Lost Urine On At Least 6 Separate Days? </li></ul><ul><li>If Yes To Both ?S, PPV-.86/NPV-.96; </li></ul><ul><li>83% Agreement Between PAT Response & UROL Assessment </li></ul>
  39. 39. PERSISTENT UI <ul><li>S - S tress </li></ul><ul><li>O - O verflow </li></ul><ul><li>U - U rge </li></ul><ul><li>P - P hysical/ P sychological </li></ul>
  40. 40. 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 <ul><li>Weight < 100lbs. </li></ul>RR of death 2.0 <1min <ul><li>>10lb wt loss over 6 mo </li></ul>BMI <22 or >25 1 min <ul><li>Weight (kg) /Height (m 2 ) </li></ul>Comments Time to Administer Question/Test
  41. 41. GERIATRIC Weight Loss <ul><li>D - D rugs - anorexia, xerostomia, nausea, diarrhea </li></ul><ul><li>E - E ating skills, 80% of elderly had oral health </li></ul><ul><li>problem that interfered with mastication </li></ul><ul><li>A - A ccess to Food </li></ul><ul><li>D - D isease - 75% of cases of weight loss </li></ul>
  42. 42. OLD PEOPLE AT HOME: Empty Refrigerator Predicts Hospitalization <ul><li>Simple way to detect malnutrition in elderly </li></ul><ul><li>Is refrigerator contents (RCs) related to health status? </li></ul><ul><li>Prospectively compared RCs with hospital admissions over 3 month period </li></ul><ul><li>132 seniors over age 65 in Geneva, Switzerland </li></ul><ul><li>Two MDs assessed RCs on month post D/C </li></ul><ul><li>Contents: adequate, inadequate (rotten) or empty (<3) </li></ul><ul><li>Lancet 2000;356:563 </li></ul>
  43. 43. EMPTY REFRIGERATOR PREDICTS HOSPITALIZATION (2) <ul><li>Mean age 81; 74% female; 70% live along </li></ul><ul><li>132 Refrigerator: 40% adequate or inadequate food; (13 RFs) 10% empty </li></ul><ul><li>31% of empty RF owners admitted in 4 wks compared with 8% of filled RFs owners (p=0.42) </li></ul><ul><li>Mean time to admission: 34 vs. 100 days (p=.002) </li></ul><ul><li>Adjusted risk for admission increase 3x greater if refrigerator empty </li></ul><ul><li>Quality of food had no influence on admission </li></ul><ul><li>Lancet 2000;356:563 </li></ul>
  44. 44. “ DEEP IN” For QUICK Screening <ul><li>D - D ementia, D epression, D rugs </li></ul><ul><li>E - E yes </li></ul><ul><li>E - E ars </li></ul><ul><li>P - P hysical Performance, P halls, P sychosocial </li></ul><ul><li>I - I ncontinence </li></ul><ul><li>N - N utrition </li></ul>

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