THE 10 MINUTE GERIATRIC ASSESSMENT

THE 10 MINUTE GERIATRIC ASSESSMENT Fredrick T. Sherman, MD, MSc Medical Director SENIOR HEALTH PARTNERS Mount Sinai School of Medicine www.geri.com OFFICE-BASED • Common syndromes “Geriatric Giants” of the elderly • Based on literature review • Use principles of EBM • Easy to remember MNEUMONICS ASSESSMENT GERIATRIC GIANTS Falls “Phalls” Confusion Incontinence Impaired homeostasis Iatrogenic disorders “DEEP IN” FOR QUICK SCREENING D - Dementia, Depression, Drugs E - Eyes E - Ears P - Physical Performance, Phalls, Psychosocial I - Incontinence N -Nutrition 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) 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 DEMENTIA SCREEN 2 VERBAL 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 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. 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 Watson YL et al., Clock Completion: An Objective screening test for dementia. JAGS 1993; 41:1235-40 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 INSTRUMENTAL ACTIVITIES OF DAILY LIVING • • • • Meal preparation Housework Laundry Medication management • • • • Telephone Shopping Transportation Money management 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 DEMENTIA SCREEN 5 Seven Minute Neurocognitive Screening for Alzheimer’s 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) 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 > 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) D - Drugs, Delirium E - Etoh, , Eyes, Ears M - Multiple, Metabolic E - Endocrine N - Nutrition, NPH T - Trauma I - Infection, Infarct A - Affective, Alzheimer’s S - Surgery, Subcortical 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) 5 ITEM GDS Yes (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 > 2 = depressed No  *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. 47:873-78, 1999. DRUGS • Greater Than Or Equal To Four Prescribed • Any Of The “Antis” • Benzos • Non Rxed • Alternative SIMPLE SCREENS OF HEARING LOSS Question/Test Time to Administer Comments Audioscope Whisper Test Hearing-Handicap Inventory for the elderly NHANES Battery 1-2 min 1 min 2 min < 2 min Sen 87-90% Spec 80-100% Sen 80-100% Spec 82-89% Sen 48-63% Spec 75-86% At cut point >8 Sen 80% Spec 80% at cut point of >3 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% EARS • 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 BUY AUDIOSCOPE EYES BECAUSE OF YOUR EYESIGHT, DO YOU HAVE DIFFICULTY WITH. . . . • Driving • Watching TV • Reading • Or Any Daily Activity 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 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 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 PHYSICAL PERFORMANCE TESTING DISADVANTAGES • 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 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? RISK FACTORS FOR FUNCTIONAL DEPENDENCE Older Age Female Living Alone Non-white Poor Less Education Smoking HBP Abnormal BMI Heart Disease Cognitive Impairment 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. 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. PREDICTORS OF ADL DEPENDENCE TIMED PERFORMANCE TESTS 1) Rapid Gait>11sec (rr-6.4) [10 Ft Out and Back “as quickly as possible”] 2) Three (3) Chair Stands > 10 sec (rr-4.4) QUALITATIVE CHAIR STAND Abnormal High Risk 12/31 (39%) Abnormal High Risk 13/38 (34%) Normal 10 ft. Rapid Gait/3 Chair Rises Normal Low Risk 6/128 (4.7%) SIMPLE TESTS OF LOWER EXTREMITY STRENGTH, BALANCE, GAIT & FALL RISK Question/Test Functional reach Time to Administer 1 min Comments If FR < 7” unable to: 1) Leave neighborhood 2) Stand on one foot 3) Do tandem walking Adjusted Odds Ratio for >2 falls in 6 months 1) 8.1 if unable to reach 2) 4.0 if < 6 inches 3) 2.0 if > 6 inches < 10 inches RELATIVE RISKS OF SEVERE WALKING DISABILITY: COMBINED DISTRIBUTION OF KNEE STRENGTH TERTILES AND BALANCE CATEGORES Knee Strength Tertiles Balance Categories S-S<10 seconds SS (10)+ST (10) +TS (<3S) SS (10)+ST (10) +TS (>3s) JAGS, 2001-Vol.49, No.1 Weakest (<10.6 kg) RR 5.12 1.87 Average (10.6-15.1 kg) RR 1.49 1.58 Strongest (<15.1kg) RR 3.08 1.18 0.97 1.14 1 37.1 14.7 21.6 12.7 9.6 3.1 SS<10 s TS<3 s TS>3 s 40 30 20 10 0 13.2 6.1 5.3 Weakest Average Strongest Knee Extension Strength Tertiles 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. JAGS, 2001-Vol.49,No1 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 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 PERSISTENT UI S - Stress O - Overflow U - Urge P - Physical/Psychological NUTRITION SCREENS Question/Test •Weight (kg) /Height (m2) •>10lb wt loss over 6 mo Time to Administer 1 min <1min Comments BMI <22 or >25 RR of death 2.0 •Weight < 100lbs. Nutrition Screening 1 min <5 min PPV malnutrition .99 Sen 36%, Spec 85% for intake of > 3 nutrients below 75% of RDA at cut point > 6 points Odds Ratio 2.7 if 3-5 RF, 6.4 if > 6 RF NHANES 14-item scale to 5-10 min detect hypoalbuminemia 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 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 (<3) Lancet 2000;356:563 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 (p=0.42) • 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 2000;356:563 “DEEP IN” For QUICK Screening D - Dementia, Depression, Drugs E - Eyes E - Ears P - Physical Performance, Phalls, Psychosocial I - Incontinence N -Nutrition