Transcript Slide 1

Geriatric Assessment
Anthony J. Caprio, MD
Ellen Roberts, PhD, MPH
Jan Busby-Whitehead, MD
The University of North Carolina at Chapel Hill
With Support from The Donald W. Reynolds Foundation
© The University of North Carolina at Chapel Hill, Center for Aging and Health.
All Rights Reserved.
Objectives
1) To illustrate the importance of physical,
cognitive, and psychosocial assessments
for older adults
2) To describe Activities of Daily Living
(ADLs) and Instrumental Activities of Daily
Living (IADLs)
3) To demonstrate gait assessment and falls
risk assessment with an older adult
4) To demonstrate cognitive and depression
screening with an older adult
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Function, Function, Function
• In real estate it’s “location,” in geriatric assessment the
focus is on function
• Physical Functioning
•Gait and balance
•Ability to perform daily self-care activities
• Cognitive Functioning
•Memory, reasoning, and judgment
•Ability to perform “life-maintenance” activities
• Psychosocial Functioning
•Depression and mental health
•Adequate caregiver support
•Financial resources
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What Does Every Practitioner Need to
Know?
• Overall functional assessment or impression: Big
Picture
• Ask questions, but..
• Don’t just tell me, show me. (performance-based
testing)
• Make careful observations!
• Trust your gut, if something doesn’t look right, it
probably isn’t
• Screen and know when to refer for further evaluation
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Asking About Function
"Can you tell me what your typical day is like?”
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When do you get up?
What do you do in the morning?
Do prepare your own meals?
How many meals do you usually eat?
Do you get out of the house? Shopping? Church?
How do you spend the rest of the day?
Do you watch TV? Read?
When do you go to bed?
Are you generally satisfied with how you spend your
days?
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Activities of Daily Living (ADLs)
Dressing
• Transferring
Eating (feeding)
• Walking
Ambulating (transferring)
• Toileting
Toileting (continence)
• Bathing
• Dressing
Hygiene (bathing)
• Eating (feeding)
Independent
Partially Dependent
Dependent
• Continence
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Instrumental Activities of
Daily Living (IADLs)
Shopping
Housekeeping
Accounting
Food preparation
Transportation
• Driving or using the bus
(transportation)
• Using the telephone
• Managing medications
• Buying groceries
• Preparing meals
• Housework, laundry
• Paying bills, managing
money
Independent
Partially Dependent
Dependent
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Why are ADLs/IADLs Important?
• ADL impairment is a stronger predictor of hospital
outcomes than admitting diagnoses, Diagnosis
Related Group (DRG), or other physiologic indices of
illness burden
• Functional decline
• Length of stay
• Institutionalization (nursing home placement)
• Death
• Approximately 25% to 35% of older patients admitted
to the hospital for treatment of acute medical illness
lose independence in one or more ADLs
• Implications for discharge planning and post-acute
care
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Best Test is a “Real World” Performance Test
• Easy to perform in an office/clinic/hospital room
• Easy to evaluate (can do, can’t do, or time to completion)
• Can be integrated into what you do already
• Provide objective information about a person’s actual
function in daily living
• Assessment starts the minute you start observing the
patient.
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Assessing Function
• Perform a task
• Walk over to the exam table
• Get on/off the exam table
• Unbutton sleeve, take shirt off
• Put shirt back on, button sleeve, tie shoes
• Standardized tests
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Assessing Physical Functioning:
Gait and Risk for Falling
• 35-40% of community-dwelling older adults
fall each year
• 10 to 15% of falls result in a fracture or other
serious injury
• 72% of all fall-related deaths are in the age
65+ population
• Approximately 40-70% of fallers develop fear
of falling
Risk Factor
Relative Risk (RR) for Falls
Leg Weakness
4.4
Gait Deficit
2.9
Impaired ADL
2.3
Depression
2.2
Cognitive Impairment
1.8
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Timed “Get Up and Go" Test
• Patient sits in a chair, rises and walks ten
feet (3 meters), turns, and returns to the chair
• Should be able to do this in <20 seconds, if
>30 seconds functionally dependent (higher risk for
falls)
• Identifying fallers: Sensitivity and Specificity = 87%
• Abnormalities in mobility should prompt referral for
physical therapy or a further diagnostic work-up
• Predicts ADL disability and nursing home admission
Phys Ther. 2000;80:896 –903.
J Am Geriatr Soc 2010;58:844–852.
J Am Geriatr Soc 2004;52:1343–1348.
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Timed “Get Up and Go”
Shortcut (2) to TUG Good.lnk
Video courtesy of the Tiffany Shubert, PhD, MPT, UNC School of Medicine.
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Chair Rise
• Use a standard chair with arms
Picture of chair
• Ask the subject to rise from the chair
• If they are able to do that, then ask them to rise from the
chair without the assistance of pushing-off of the arms of
the chair with their hands
• It may be helpful to have the subject fold their arms
across their chest during the maneuver
• Proximal muscle weakness, including trunk and proximal
thighs, makes this maneuver difficult and is a risk factor
for falls
• Can be timed (should take <15 seconds for 5 repetitions)
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Video courtesy of the Tiffany Shubert, PhD, MPT, UNC School of Medicine.
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Cognitive Evaluation
• Prevalence of cognitive impairment
• 3% among persons ≥65 years of age
• Doubles every 5 years
• 40-50% among persons ≥90 years of age
• Unrecognized cognitive impairment
• Adherence to medications or treatment plans
• Difficulty navigating the health care system
• Caregiver stress
• Most common causes of cognitive impairment
• Delirium
• Dementia
• Depression
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Delirium: More Than “Confusion”
• Sudden and fluctuating change in cognition
• Altered way of perceiving the world
• Hallucinations or delusions
• Might be disoriented
• Agitated or excessively sleepy
• Conversations don’t make sense
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Confusion Assessment Method
(CAM)
1) Acute onset and fluctuating course
and
2) Inability to focus (inattention)
3) Disorganized thinking
or
4) Change in the level of consciousness
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Folstein Mini-Mental State Exam
(MMSE)
• Orientation
• Registration/Recall (3 objects)
• Attention and Calculation
(WORLD  DLROW, serial 7s)
• Language (naming, repetition, 3 stage command,
reading, writing)
• Visual-Spatial (Copy Design)
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Interpretation of MMSE Scores
• Score < 24 considered abnormal
• Ranges: 20-25 Mild impairment
10-20 Moderate impairment
0-10 Severe impairment
• Depends on literacy and native language
• Adjustments have been made for:
• Age
• Educational level
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Mini-Cog
• 3 item recall after clock drawing task (CDT)
• Easy to administer
• Sensitivity: 76-99%, Specificity: 89-93%
• Not as dependent on education and language
J Am Geriatr Soc 2003; 51:1451-1454
Ann Intern Med 1995; 122:422-429
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Mini-Cog
3 Items
1-2 Items
Recalled
0 Items Recalled
POSITIVE
SCREEN
Normal Clock
Drawing
Abnormal Clock
Drawing
POSITIVE
SCREEN
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Clock Drawing Test: “10 Minutes After 11”
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Clock Drawing Test: Mild Impairment
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Clock Drawing Test: Right-Sided Neglect
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Severely Impaired Clock Drawing
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At the End of an Encounter…
Teach-back method:
“We discussed a lot of things today and I want
to make sure that I explained things well, can
you summarize what we talked about today?”
“So let’s review our plan. What will you do
when you get home today? What will you do
before our next visit? How will you take this
medication?”
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Psychological Assessment
• Prevalence of major depression
• Outpatient primary care: 6% - 10%
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Inpatient : 11% - 45%
Persons aged ≥65
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<13% of the populations
25% of suicides
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Screening for Depression
• Single Question: “Do you often feel sad or
depressed?”
• Sensitivity 69-85%
• Specificity 65-90%
• 2-Item Screening
• Depressed Mood:
"During the past month, have you often been bothered
by feeling down, depressed, or hopeless?"
• Anhedonia:
"During the past month, have you often been bothered
by little interest or pleasure in doing things?“
• Test is negative for patients who respond "no" to both
questions
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Geriatric Depression Scale (GDS)
• Long (30-item) and short forms (15 or 5 items)
• GDS 15-Item Screen:
Score > 5 points suggests depression
• Sensitivity 97%
• Specificity 85%
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Case 1
• 86 yo female presents to the emergency
department with a two-day history of nausea,
vomiting, and unsteadiness.
• She lives independently in the community.
• Her ECG shows atrial tachycardia (rate=150)
with AV block.
• Patient’s medication list includes digoxin
0.125mg po daily.
• Labs show normal renal function but a
critically high digoxin level.
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Case 2
• 88 yo male is admitted for elective surgery.
• He had an unremarkable pre-op evaluation one week
prior to admission. He was considered low risk for the
planned surgical procedure.
• The surgery was uneventful, but in the PACU, the
patient is very agitated and confused. He is trying to
get out of bed to “catch a train”.
• His nurse calls the resident because she is concerned
that he may have had a stroke during the procedure.
A stat head CT is negative for an acute process.
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Case 3
• 78 yo female sustained a mechanical fall at home with
a left foot fracture and right wrist fracture.
• She is given a walking boot for her foot and a splint for
her wrist. No surgical intervention is indicated.
• She lives alone and insists that she will be just fine at
home.
• Her daughter lives about an hour away but will check
on her on the weekends and help with grocery
shopping.
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Basic Geriatric Assessment
1) Functional Impairments
 Activities of Daily Living (ADLs)
 Instrumental Activities of Daily Living (IADLs)
2) Gait and Fall Risk Assessment
 Timed “Get Up and Go” Test
 Chair Rise
3) Cognitive Assessment
 Confusion Assessment Method (CAM)
 Mini-Cog
 Teach-back method
4) Depression Screen
 One or Two-item questions
 Geriatric Depression Scale (GDS)
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Acknowledgments and Disclaimers
This project was supported by funds from The
Donald W. Reynolds Foundation. This
information or content and conclusions are
those of the author and should not be construed
as the official position or policy of, nor should
any endorsements be inferred by The Donald W.
Reynolds Foundation.
The UNC Center for Aging and the UNC Division
of Geriatric Medicine also provided support for this
activity. This work was compiled and edited through
the efforts of Carol Julian.
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© The University of North Carolina at Chapel Hill,
Center for Aging and Health. All Rights Reserved.
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