EVALUATION OF FUNCTIONAL CAPACITY AND HISTORY & PHYSICAL
Samira Khazravan, M.D. Geriatric Fellow Department of Geriatrics Mary Immaculate Hospital
Assessment of the Geriatric Patient
COMPREHENSIVE GERIATRIC ASSESSMENT CGA
Diagnose and develop an overall plan of care for treatment and long term follow up Optimizes independence and prevent future disabilities. Consist of set professionals that make up a multidisciplinary team. Includes evaluation of physical and mental health, functional status, social function, and environment.
Great success in improving function. Decreases multiple negative variables, such as nursing home placement, medication use, and mortality. It increases diagnostic accuracy and independence.
SUCCESSFUL MANAGEMENT OF CGA
Accomplished when the Geriatric Team takes over the direct care of the patient. Unlikely to be successful in improving patient outcomes when the Geriatric Team assumes a purely consultative role. Barriers to the CGA is that it is time-consuming and expensive.
Should focus on specific conditions that are common to the elderly and have significant impact on function. These include impairments of vision, hearing, mobility and falls, malnutrition, urinary incontinence, and polypharmacy.
Major eye diseases such as cataract, macular degeneration, glaucoma, and diabetic retinopathy increases with age. Require eye glasses due to presbyopia. Often unaware of their visual deficits. Should ask questions regarding reading, watching television, or driving. Snellen Chart is used to screen for visual deficits. Patient stands 20 ft. from the chart and read letters using corrective lens. Inability to read >20/40 implies impairment in vision.
Associated with decreased cognition, depression, dissatisfaction with life, and withdrawal from social activities. Usually bilateral. Occurs in the high frequency range. Can be assessed using a hand-held audio scope. Inability to hear 40 decibles tone at 1000 or 2000 Hz in one or both ears implies failed hearing test.
WHISPER VOICE TEST
An alternative to hand-held audio scope. Done by whispering 3 – 6 words at a distance of 8, 12, or 24 inches from the patient’s ear. Examiner should stand behind the patient and have one ear covered during the examination. Inability to repeat >50% of the whispered words is considered a failed screening.
Inadequate nutrition – due to concurrent medical illness; depression; inability to shop, cook or feed oneself; and financial hardship. Elderly people should have their weights measured routinely. Unintentional weight loss of >10lbs in the past 6 months suggests poor nutrition in the absence of other medical problems.
Important prognostic factors of mortality:
Low cholesterol and low albumin
Serum cholesterol is a valuable marker for older persons at risk for adverse events even though they are associated with evidence of inflammation rather than malnutrition in hospitalized patients. However, among community dwelling older persons obesity is the most common nutritional disorder.
NUTRITIONAL-RELATED SCREENING EVALUATION
1. Do you have an illness or condition that made you change the kind and amount of food you eat.
2. Do you eat fewer than two meals per day. 3. Do you eat few fruits, vegetables, or milk products. 4. Do you have 3 or more drinks of beer, liquor or wine almost every day. 5. Do you have tooth or mouth problems that make it hard for you to eat. 6. Do you always have enough money to buy food. 7. Do you eat alone most of the time. 8. Do you take 3 or more different prescribed or over the counter drugs per day. 9. Without wanting to, have you lost or gained 10lbs. in the last 6 months. 10. Are you physically unable to shop, cook, or feed yourself. A score of 0-2 is good, 3-5 moderate nutritional risk and greater than 6 equal high nutritional risk.
3 2 2 2 4 1 1 2 2
Increases risk for inability, delirium, medical non-adherence, and accidents. Cognitive abilities decline with age after adulthood is reached. Decline doubles every 5 years after age 65. One common cause of cognitive decline is Alzheimer's Disease.
COGNITIVE IMPAIRMENT (contd.)
Alzheimer’s have cognitive changes that differ in magnitude and extent compared to normal aging process. Patients with Dementia do not volunteer symptoms of cognitive impairment or complain of memory loss unless specifically questioned. Cognitive change associated with aging are related to a generalized slowing of mental process or cognitive speed rather than a loss of memory.
FOLSTEIN MINI-MENTAL STATE EXAMINATION (MMSE)
Used to evaluate cognition. Assesses orientation. Registration and recall. Attention and calculation. Language and visual-spatial skills. Scores are interpreted in the context of educational attainment and age. A score <23 is diagnostic of Dementia. Single best assessment question for Dementia is a recall of 3 words after 1 minute since short-term memory is generally the first sign. Failure to recall the 3 words require further evaluation.
Orientation Name: hospital/floor/town/state/country Registration Identify three objects by name and ask patient to repeat3 Attention and calculation Serial 7s; subtract from 100 (e.g., 93-86-79-72-65) Recall Recall the three objects presented earlier Language Name pencil and watch Repeat "No ifs, ands, or buts“ Follow a 3-step command (e.g., "Take this paper,, fold it in half and place it on the table") Write "close your eyes" and ask patient to obey written command Ask patient to write a sentence Ask patient to copy a design (e.g., intersecting pentagons) TOTAL 5 (1 for each name) (1 for each object) 5 (1 for each subtraction) 3 (1 for each object) 2 (1 for each object) 1 3 (1 for each command) 1 1 1 30
Major depression occurs in 1% -2% of the elderly population. A large number of elderly have symptoms of depression below the severity threshold of major depression. Sub-threshold symptoms are associated with increased risk of physical disability, slower recovery after an acute disabling event, and increased cost of medical services. Anxiety and worries in the elderly can be a manifestation of an underlying depressive disorder. A simple question to ask is “Do you feel sad or depressed?” A positive answer warrants further investigation. This can be done by using the Geriatric Depression Scale (GDS).
The short form of the GDS consists of 15 questions:
1. Are you basically satisfied with your life? 2. Have you dropped many of your activities and interest? 3. Do you feel that your life is empty? 4. Do you often get bored? 5. Are you in good spirits most of the time? 6. Are you afraid that something bad is going to happen to you? 7. Do you feel happy most of the time? 8. Do you often feel helpless? 9. you prefer to stay at home rather than staying out and doing new things? 10. Do you feel that you have more problems with memory than most? 11. Do you think it is wonderful to be alive now? 12. Do you feel pretty worthless the way you are now? 13. Do you feel full of energy? 14. Do you feel that your situation is hopeless? 15. Do you think that most people are better off than you are? yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no yes/no
Bold answers are scored, with one point for each of these answers. Normal is equal to 0-5; and greater than 5 suggest depression.
Should include availability of help in case of emergency. Availability of a personal support system. Need for a caregiver. Caregiver burdens. Economic status. Elder mistreatment. Advanced directives.
SOCIAL ASSESSEMENTS (contd.)
For the frail elderly availability of help from family or friends can determine whether a functionally dependent person remains at home or is institutionalized. For those frail elders that lack support, a visiting nurse may be helpful in the assessment of home safety and level of personal risk, i.e., stairs, location of bathrooms, bathroom grab bars, and smoke alarms.
Common occurrence among the elderly especially women. Can go unrecognized in men and women for variable reasons. Women may be embarrassed to discuss the issue especially if the clinician is male, or may regard it as a normal part of aging that is best controlled with pads. Two screening questions to ask are: In the last year have you lost your urine and gotten wet? If the answer is YES then the patient is asked, Have you lost urine on 6 separate days? An answer of YES to both questions have a 75% - 79% accuracy for urinary incontinence. Other associated signs and symptoms include frequency, urgency, nocturia, hesitancy, dribbling, and intermittent flow.
Due to care from multiple providers. Fill their prescriptions at various pharmacies. Patients should bring in all their current medications at each office visit and have them checked against their medication list in their medical chart. Increases the chance for drug-drug interactions (DDI) which increases the risk for adverse drug events (ADE). Cardiovascular and psychotropic drugs are the most common medications involved in ADE’s. Common ADE’s are neuropsychological (confusion) or cognitive impairments, hypotension, and acute renal failure.
RISK FACTORS ASSOCIATED WITH ADVERSE DRUG EVENTS (ADE)
>6 concurrent diagnosis. >12 doses of medications per day. A prior ADE. A low body weight or BMI. Age >85 years. Creatinine clearance <50ml/minute.
MOBILITY AND BALANCE
Impairments in mobility and balance is due to musculoskeletal (osteoarthritis) and neurological (neuropathies/motor dysfunctions) disorders. Sequelae of previous falls such as fractures, unequal leg length, or fear of falling can worsen impairments in gait and balance in the elderly thus leading to more functional impairments.
MOBILITY AND BALANCE RISK ASSESSEMENT FOR FALLS
Testing for balance, gait, lower extremity strength. Previous history of falls causes and treatments. Balance, gait, and lower extremity strength can best be assessed by observing the patient performing specific task. Lower extremity or quadriceps weakness can evaluated by asking the patient to stand from a seated position in a hard back chair while keeping their hands folded. Inability to complete this task suggest lower extremity weakness and is highly predictive for future disability.
MOBILITY AND BALANCE RISK ASSESSEMENT FOR FALLS (contd.)
Once standing he/she should be instructed to walk back and forth over 10ft, ideally with their walking aid. Abnormalities are path deviation, diminished step height or length, trips, slips, near-falls, and difficulty turning. The task of rising from an armless chair, walking 10ft, turn, walk back and sit down is termed the “Get-up and Go Test.” Those taking long than 10 seconds to complete this tasks are at increased risk for falls. 10 – 19 seconds is considered freely mobile. 20 – 29 seconds variable mobility. >30 seconds dependent on balance and mobility.
MOBILITY AND BALANCE (contd.) GAIT SPEED
Gait speed can be used as an alternative predictor for future disability. Speed of 0.8 meters/sec indicates that the patient is capable of independent ambulation within the community. A speed of 0.6 meters/sec indicates participation in community activities without the use of a wheelchair. Patients who can ambulate 50 feet in the office corridor in 20 seconds or less should be able to walk independently in normal activities.
MOBILITY AND BALANCE (contd.)
Balance can be assessed by instructing the patient to stand with his/her feet side by side then in semi-tandem and finally in tandem position. Difficulty in any of these positions suggest an increase risk of falling. The Performance Oriented Mobility Assessment (POMA) consists of a set of tasks that may be used to quantify impairments in gait and balance and make recommendations for an assisted walking device. In addition, during these assessments the physician should observe for the use of proper footwear that is flat and has a hard sole.
FUNCTIONAL STATUS ASSESSMENT
Evaluates the tasks a person can do within the context of their medical problems and everyday life. It is split into 3 levels:
Basic Activities of Daily Living (BADL) Instrumental/Intermediate Activities of Daily Living (IADL) Advance Activities of Daily Living (AADL)
Basic Activities of Daily Living (BADL)
Evaluates the ability of the person to complete basic selfcare tasks that are considered essential to independent living. These are:
Transferring from bed to chair Toileting Bathing Grooming Dressing Feeding oneself
Bathing is the BADL that is associated with the highest prevalence of disability and is one of the most common reasons why elders receive home aide services.
Instrumental/Intermediate Activities of Daily Living (IADL)
Assesses the persons ability to upkeep an independent household. It consists of:
Laundry Housework Shopping Using the telephone Preparing meals Taking medications Managing household finance and transportation
Advance Activities of Daily Living (AADL)
Evaluates the persons ability to participate in societal, community, and family roles. It also assesses for recreational and occupational activities. These activities varies among individuals and may be a valuable tools in monitoring functional status prior to the development of disability.
Advance Activities of Daily Living (AADL) contd.
In addition useful information on function can be obtained when physicians observe how their patients complete simple tasks such as buttoning or unbuttoning a shirt or blouse, taking off and putting on shoes, picking up a pencil and writing a sentence, touching the back of their head with both hands, and climbing up and down from the examination table.