THE 10 MINUTE GERIATRIC ASSESSMENT

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THE 10 MINUTE GERIATRIC ASSESSMENT

• Fredrick T. Sherman, MD, MSc
• Medical Director
• SENIOR HEALTH PARTNERS
• Mount Sinai School of Medicine
• www.geri.com

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OFFICE-BASED ASSESSMENT

• Common syndromes Geriatric Giants of the
  elderly
• Based on literature review
• Use principles of EBM
• Easy to remember MNEUMONICS

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GERIATRIC GIANTS
Falls Phalls
Confusion
Incontinence
Iatrogenic disorders
Impaired homeostasis
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DEEP INFOR QUICK SCREENING

• D - Dementia, Depression, Drugs
• E - Eyes
• E - Ears
• P - Physical Performance, Phalls, Psychosocial
• I - Incontinence
• N -Nutrition

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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)

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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

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DEMENTIA SCREEN 2VERBAL 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

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ANIMAL NAMING
Useful screening tool for dementia Average
performance18/min Less than 12/min is
abnormal Correlates well with MMSE
scores(r0.77) Worsens with time in AD

Neurology.1989391159-1165.
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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

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Watson YL et al., Clock Completion An Objective
screening test for dementia. JAGS 1993
411235-40
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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

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INSTRUMENTAL ACTIVITIES OF DAILY LIVING

• Meal preparation
• Housework
• Laundry
• Medication management

• Telephone
• Shopping
• Transportation
• Money management

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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

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DEMENTIA SCREEN 5 Seven Minute Neurocognitive
Screening for Alzheimers 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)

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7 MINUTE NEUROCOGNITIVE SCREEN

• Mean time to administer 7 minutes, 42 secs
• Sen/Spec 92/96 in detecting AD
• Identify all AD patients with MMSE gt 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)

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• D - Drugs, Delirium
• E - Etoh, , Eyes, Ears
• M - Multiple, Metabolic
• E - Endocrine
• N - Nutrition, NPH
• T - Trauma
• I - Infection, Infarct
• A - Affective, Alzheimers
• S - Surgery, Subcortical

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DEPRESSION

• 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)

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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 gt 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. 47873-78, 1999.

?
?
?
?
?
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DRUGS

• Greater Than Or Equal To Four Prescribed
• Any Of The Antis
• Benzos
• Non Rxed
• Alternative

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SIMPLE SCREENS OF HEARING LOSS
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EARS

• 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

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EARS

• 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

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EYES

• BECAUSE OF YOUR EYESIGHT, DO YOU HAVE DIFFICULTY
  WITH. . . .
• Driving
• Watching TV
• Reading
• Or Any Daily Activity

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EYES

• 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

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Physical 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

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PHYSICAL PERFORMANCE TESTING (PPT)

• ADVANTAGES
• Yields 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

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PHYSICAL PERFORMANCE TESTINGDISADVANTAGES

• 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

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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?

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RISK FACTORS FOR FUNCTIONAL DEPENDENCE
Smoking HBP Abnormal BMI Heart Disease Cognitive
Impairment
Older Age Female Living Alone Non-white Poor Less
Education
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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 199550AM235-241.
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PREDICTORS OF ADL DEPENDENCE
SELF REPORTED RISK FACTORS ASSOCIATED WITH ONSET
OF ADL (plt.O5) 1) Lived Alone (rr-3.8)
2) Not Currently Married (rr-4.3) 3)
Impairments gt 4 IADLs (rr-2.9)
J Gerontol Med Sci 199550AM235-241.
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PREDICTORS OF ADL DEPENDENCE

• TIMED PERFORMANCE TESTS
• Rapid Gaitgt11sec (rr-6.4) 10 Ft Out and
• Back as quickly as possible
• 2) Three (3) Chair Stands gt 10 sec (rr-4.4)

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QUALITATIVE CHAIR STAND
Abnormal
Normal
10 ft. Rapid Gait/3 Chair Rises
High Risk 12/31 (39)
Normal
Abnormal
Low Risk 6/128 (4.7)
High Risk 13/38 (34)
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SIMPLE TESTS OF LOWER EXTREMITY STRENGTH,
BALANCE, GAIT FALL RISK
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RELATIVE RISKS OF SEVERE WALKING DISABILITY
COMBINED DISTRIBUTION OF KNEE STRENGTH TERTILES
AND BALANCE CATEGORES
JAGS, 2001-Vol.49, No.1
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Balance CategoriesThe 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
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Geriatric Syndromes PHALLS (Falls)

• M Maladaptive equipment
• Medical (acute)
• Medical (chronic)
• Multiple
• E Environment
• Ethanol
• Eyes/Ears
• O Orthostatic
• signs or symptoms
• W Weakness Prox
• Diffuse

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INCONTINENCE

• 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

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PERSISTENT UI

• S - Stress
• O - Overflow
• U - Urge
• P - Physical/Psychological

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NUTRITION SCREENS
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GERIATRIC Weight Loss

• D - Drugs - anorexia, xerostomia, nausea,
  diarrhea
• E - Eating skills, 80 of elderly had oral
  health
• problem that interfered with mastication
• A - Access to Food
• D - Disease - 75 of cases of weight loss

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OLD PEOPLE AT HOME Empty Refrigerator Predicts
Hospitalization

• Simple way to detect malnutrition in elderly
• Is refrigerator contents (RCs) related to health
  status?
• Prospectively compared RCs with hospital
  admissions over 3 month period
• 132 seniors over age 65 in Geneva, Switzerland
• Two MDs assessed RCs on month post D/C
• Contents adequate, inadequate (rotten) or empty
  (lt3)
• Lancet 2000356563

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EMPTY REFRIGERATOR PREDICTS HOSPITALIZATION (2)

• Mean age 81 74 female 70 live along
• 132 Refrigerator 40 adequate or inadequate
  food (13 RFs) 10 empty
• 31 of empty RF owners admitted in 4 wks compared
  with 8 of filled RFs owners (p0.42)
• Mean time to admission 34 vs. 100 days (p.002)
• Adjusted risk for admission increase 3x greater
  if refrigerator empty
• Quality of food had no influence on admission
• Lancet 2000356563

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DEEP INFor QUICK Screening

• D - Dementia, Depression, Drugs
• E - Eyes
• E - Ears
• P - Physical Performance, Phalls, Psychosocial
• I - Incontinence
• N -Nutrition