Geriatric Assessment

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Geriatric Assessment

• Practical Approaches for Primary Care
  Practitioners
• Presented by Dr. Marwan Zoghbi
• Moderator Dr. Nabil Naja
• Dar Al-Ajaza Al-Islamia Hospital
• Beirut, Jan 2003

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Challenges of Geriatrics in Primary Care

• Short visit times
• Low reimbursement rates
• Multiple co-morbidities
• Needs of caregiver and patient
• Ever-expanding diagnostic and therapeutic options
• Cross cultural communication

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KEYS TO SURVIVAL

• Time management
• You dont have to do everything yourself
• Working knowledge of geriatric assessment tools
• Determine when to refer someone for comprehensive
  geriatric assessment

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Overview and Learning Objectives

• At the end of this lecture, you should be able to
  answer
• Why is assessment important?
• What are some useful tools for Assessment?
• How can assessment be incorporated into a short
  visit?
• What are some strategies for making a visit more
  efficient?
• Is there any Evidence to support the use of
  Geriatric Assessment?

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Why is assessment important?

• Lebanese are aging !
• 1972 4
• 1996 7.5
• 2000 8.6
• 2025 14
• 2050 20
• Life expectancy
• 1950 54 years
• 2002 70 years

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Why is Assessment Important?

• Americans are aging!
• 1998 Age 65 numbered 34 million
• 2030 Age 65 will number 70 million
• Largest increases in those over age 85
• Older population more ethnically diverse
• Majority of elderly will be cared for by
  internists and family practitioners
• ACP 1998 Internists should be measuring
  functional deficits and identifying dependency
  needs of older adults

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Why is Assessment Important?

• Usual care may not meet elders needs
• The 80 survey
• 75 said MD unaware of social needs
• 37 said MD unaware of physical needs
• 42 said MD was unaware of their emotional needs
• 50 said Medical Care could be improved
• Patterson 1998

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What is Geriatric Assessment?

• Different models and definitions exist
• Geriatrics is often best practiced as an
  interdisciplinary team approach
• Evaluates different domains medical, cognitive,
  psychological, social, physical
• Expands scope of interest to include caregiver
  and environment
• Emphasis on optimization of function and increase
  in active life expectancy

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Active Life Expectancy at 75
Total Active Disabled White women 11.8
9.0 2.8 Black women 13.4 10.4
3.4 Black men 7.6 6.0 1.6 White
men 7.1 5.7 1.5 Guralnik, NEJM, 1993
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DOMAINS OF CGA
MEDICAL
COGNITIVE
QUALITY OF LIFE
FUNCTIONAL STATUS
AFFECTIVE
ENVIRONMENTAL
SOCIAL SUPPORT
ECONOMIC
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Selected Tools for Assessment

• Lachs Simple screen
• Similar version validated by Moore and Siu in
  1996
• Good inter-rater reliability
• Easy to use
• 7-10 minutes to administer
• Can be administered by non-MD personnel
• UCSF version

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Areas covered in Lachs Tool

• Vision
• Hearing
• Incontinence
• Falls and Gait
• Upper extremity function
• Cognition ( 3 item recall)
• Depression
• Medications
• ADLs and IADLs

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Underreporting Common

• Underreporting of symptoms common in the elderly
• Many elderly attribute treatable symptoms to
  aging and stated nothing can be done about it
  anyway
• 1/2-1/3 of symptoms may go unreported to
  physicians
• So its important to do a geriatric ROS

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Quick Clues to Dementia

• About 2/3 of mild-moderate dementia missed by
  providers
• Content empty speech
• Loss of IADL function
• Inability to recall 3 items at 5 minutes
• Inability to draw clock

Larson 1998, JAGS Siu 1991, Ann Int Med
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Screening Tests for Dementia
Test Result LR PTP given prevalence of 3 item
recall 2 10 50 recalls lt2 3.1 6 26 76 recall
s 3 .06 .1 .7 6 Clock Draw abnormal 24 32 72 96
almost normal .8 2 8 44 normal .2 4 6 17
Siu, Ann Intern Med, 1991
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The MMSE

• Well validated
• Good predictive accuracy
• Easy and relatively quick to administer
• Cut off usually cited as 24
• Sensitivity 85
• Specificity 90
• Tombaugh JAGS 1992, Siu, Annals 1991

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The MMSE Limitations

• Education, cultural, and age biases
• Crum JAMA 1994
• Score impacted by vision, literacy, depression.
• Floor and ceiling effects
• Best to use as one tool in evaluation

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Falls and Gait Disorders
Falls and gait disorders are common among the
elderly are a major cause of morbidity and
mortality 1/3 of elderly fall each year Major
cause of NH placement Falls, mobility impairment,
and functional impairment closely related
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Falls and Gait Disorders

• Fall History Assessment
• Ask the Patient Have you fallen in the past
  year?
• Gait Assessment
• Up and Go Test
• Rise from chair, walk 10 feet, turn around, walk
  back, sit down
• Timed Up and Go Test normal less than 10
  seconds
• Tinetti ( or POMA)
• Timed Up and Go If greater than 30 seconds,
  only 23 independent in tub or shower, only 4
  can climb stairs

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BALANCE AND GAIT EVALUATION

• Balance
• Sitting, rising from a chair
• Immediate and prolonged standing balance
• Withstanding nudge on chest
• Standing balance with eyes closed
• TURNING BALANCE (360 degrees)
• Sitting down

• Gait observations
• Initiation of gait
• Step length, height, continuity, symmetry
• Walking stance
• Amount of trunk sway
• Path deviation

Tinetti. Am J Med 1986 80429
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Why Assess Function?

• Medical conditions may present first (or only) as
  functional disturbances
• Functional loss highly impacts quality of life
• Functional losses may lead to further disability
  and institutionalization
• Functional losses impact patient and caregiver

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Functional Impairments
IADLs Using telephone Shopping Food
preparation Housekeeping Laundry Transportation Me
dications Managing money
ADLs Bathing Dressing Toileting Transfers Contin
ence Feeding
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Difficulty with ADLs and IADLs by Age
US Census Bureau, 1990
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AADLs

• Patient specific activities that can be used to
  detect subtle functional losses in high
  functioning patients
• Can be job or recreation oriented
• Socializing, playing bridge, working, playing
  golf, playing music, dancing, practicing law,
  flying a plane, gardening.

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Other measures available

• Upper extremity mobility
• Manual dexterity
• Lower extremity mobility
• Combination of both
• Balance and gait evaluation

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Using Functional Information

• Use functional status as baseline
• Use it to guide recommendations for exercises,
  PT, adaptive devices for impairments
• Consider home evaluation for highly impaired
• Potential marker of caregiver stress
• Useful for evaluating risk of need for placement

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Depression

• Geriatric depression scale
• 30 item instrument
• Yes/no to series of questions
• 10-15 minutes, self or interviewer to administer
• Scores
• lt9 less probability
• gt11 higher likelihood
• gt18 highest possibility

Brink. Clin Gerontol 1982 137
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Geriatric depression scale

• Shorter version
• 15 item, less certain diagnostic accuracy
• SCORE 0-5 NORMAL,
• gt5 SUGGEST DEPRESSION
• gt10 almost always depression

Sheikh, Yesavage. Clin Gerontol. 1986 5165-172
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Disadvantage in frail elderly

• Hard to administer with concomitant cognitive
  impairment
• Cornell scale
• 19 items caregiver is asked variety of questions
• Scores 8-12 possible depression, gt12 probable
• Useful screening for major depression in both
  demented and non-demented patients

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Other psychiatric problems to look for

• Delirium (confusion assessment method)
• Anxiety
• Hostility
• Psychosis
• Behavioral problems

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Malnutrition risk factors

• Chronic disease
• Poverty
• Social isolation
• Cognitive impairment
• Functional disability

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Indicators of poor nutrition

• Impaired wound healing
• Increased surgical complications
• Increased mortality

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Screening assessment

• WEIGHT lt100 lbs IN AMBULATORY OLDER PATIENTS, NOT
  ALWAYS ACCURATE
• Weight loss gt 10 body weight
• Physical findings
• Chelosis, glossitis, loss of subQ body fat,
  muscle, wasting, edema
• Lab
• Decreased serum albumin, lymphocyteslt1000
• Body mass index, mid arm circumference, triceps
  skin folds

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Visual and hearing impairments

• Visual impairment
• 13 older persons
• Hearing impairment
• Age 65-74 25
• Age gt85 50
• Increase risk injury
• Increased disability in physical and psychosocial
  function
• Decreased quality of life

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Vision screening

• Sensitivity and specificity for screening tests
  by primary care Dr not established
• Limited accuracy of glaucoma screening
• Snellen test
• Specific questions regarding vision

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Hearing screening

• Hand held audioscope 500
• 40db TONES AT 500, 1000, 2000, 4000 hz
• Takes 90 seconds, 94 sensitive, 72 specific
• Increase accuracy with short questionnaire
• Whispered voice or finger rub
• Cheaper
• Subject to variation between examiners

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Remember the caregiver!

• 80 of care of elderly is informal unpaid
• High caregiver stress highly correlated with
  increased risk of institutionalization, excess
  caregiver mortality, abuse, and neglect
• Education support of caregiver may be critical
  part of keeping your patient at home and safe
• Zarit Caregiver Burden Interview or question
  about caregiver stress (caregiver alone)
• Solutions Respite, day care, support groups

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Abuse and Neglect Helpful Questions

• S - Do you feel Safe at home? What Stress do you
  feel in your relationship?
• A - Do you feel Afraid or have you been Abused by
  any of your caregivers?
• F - Are there any Family or Friends that you
  could ask for help or support?
• E Do you have a safe place to go in case of an
  Emergency? Is it an Emergency now?

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Abuse and Neglect Caregiver Risk Factors and
Clues

• Caregiver does not come to appointments
• Is concerned about medical costs
• History of substance abuse, mental health
  problems, conflicts with patient
• Dominates interview, wont leave, wont let
  patient talk
• Defensive, hostile, or indifferent
• Dependence on patient for income/housing

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Review medications

• Elderly use 3X more medications than younger
  patients
• Drug distribution, elimination, excretion,
  pharmacodynamics altered in elderly
• ADRs and drug-drug interactions increase
  markedly with drugs used
• Medications linked to reversible dementias,
  falls, incontinence, hospitalizations, death

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Nonadherance and Drugs
Percent Adherence
of drugs
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Reviewing Medications

• Have patient bring in all medications, including
  OTCs, herbs, dietary supplements
• Ask about other providers
• Consider home visit if high risk
• Eliminate questionable medications
• Simplify regimens or consider Medi-sets,
  visiting nurses, or involving caregiver
• For new medications, start low and go slow, but
  get there!

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Practical Tips for Practicing Geriatrics in your
Office
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Planning the initial office interview

• Relaxed and efficient atmosphere
• Good acoustic conditions and no interruptions
• Efficient appointment system
• Wheel chair accessible
• Hearing device amplifier and microphone
• Paper/plastic bag test (bring all meds)
• Obtain prior medical records

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Make Your Life Easier

• Send out pre-visit questionnaire (e.g., UCLA)
• Use brief screening tests (e.g. Lachs) or single
  questions when possible
• Use more detailed tests only when indicated
• Have forms handy
• Train nursing and ancillary staff to perform
  screening tests

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Interview techniques

• In clinic obtain data at several appointments
  over time
• Introduce yourself
• Ask how the patient would like to be addressed
• Traditional chief complaint may not be
  appropriate for most older patients
• How can I help you today? Better than what seems
  to be the problem?

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Make Your Life Easier

• Discuss patient goals early
• Focus visit on patients goals and priorities,
  not you clinics quality improvement checklist
• Realize that patients goals and priorities may
  change over time
• Change your clinics quality improvement
  checklist to reflect the priorities of geriatrics!

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History of the elderly patient

• Patient profile, social history
• History of current problems
• Review of symptoms and systems
• Medical history
• Medication history
• Caregivers status
• Family history
• Functional history, ADLss
• Community services currently provided

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Minimal social assessment

• Content of average day for patient
• Abilities in ADLs
• Suitability and safety of home
• Availability, attitude and health of caregivers
  and neighbors
• Services received and/or needed
• Transportation needs
• Financial status
• Occupational history and interests

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Agir

• The French experience
• Explore multiple aspects of social, cognitive,
  medical life.
• 17 items, 3 possibilities.
• 4 B or C required.

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Indications for a home visit visit

• Living alone, especially if recently bereaved or
  separated
• Mental impairment
• Major mobility problems
• Several risk factors for dependency
• History of falling or accidents
• Imminent institutionalization
• Recent hospital discharge, especially if recovery
  was incomplete

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Get Help!

• Involve social worker and other team members
  early
• When you are overwhelmed
• Consider home nursing visits
• Consider referral to team geriatric program
• Consider other community referrals (case
  management programs, etc.)

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Geriatric Assessment The Evidence
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Why use assessment instrument?

• Research
• Clinical practice guide
• Screening (identify unrecognized disease)
• Case finding
• Monitor patients throughout course of disorder
• Follow response to treatment

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Does Geriatric Assessment Improve Outcomes?

• Results mixed in RCTs
• Most robust outcomes seen in studies with a
  intervention component and follow up
• Increased case finding with GA screens
• Less institutionalization noted in a
  meta-analysis of GA
• Less disability noted in study of home GA

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Summary

• Aging is a big issue!
• Focus on function
• Consider caregivers and abuse
• Review medications
• Screen for geriatric syndromes
• falls, incontinence, dementia, depression,
  hearing, vision, pain
• Abbreviate and target PE and assessment tools
  when possible
• Get help, use a team when possible!

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thank you