January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 1 Geriatric Assessment Practical Approaches for Primary Care Practitioners Presented by Dr. Marwan

January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut

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Geriatric Assessment

Practical Approaches for Primary Practical Approaches for Primary Care PractitionersCare Practitioners

Presented by Dr. Marwan ZoghbiPresented by Dr. Marwan Zoghbi

Moderator : Dr. Nabil NajaModerator : Dr. Nabil Naja

Dar Al-Ajaza Al-Islamia HospitalDar Al-Ajaza Al-Islamia Hospital

Beirut, Jan 2003Beirut, Jan 2003


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Challenges of Geriatrics in Primary Care

Short visit timesShort visit times Low reimbursement ratesLow reimbursement rates Multiple co-morbiditiesMultiple co-morbidities Needs of caregiver and patientNeeds of caregiver and patient Ever-expanding diagnostic and therapeutic Ever-expanding diagnostic and therapeutic

optionsoptions Cross cultural communicationCross cultural communication


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KEYS TO SURVIVAL

Time managementTime management You don’t have to do everything You don’t have to do everything

yourselfyourself Working knowledge of geriatric Working knowledge of geriatric

assessment toolsassessment tools Determine when to refer someone Determine when to refer someone

for comprehensive geriatric for comprehensive geriatric assessmentassessment


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Overview and Learning Objectives

At the end of this lecture, you should be able to At the end of this lecture, you should be able to answer:answer: Why is assessment important?Why is assessment important? What are some useful tools for Assessment?What are some useful tools for Assessment? How can assessment be incorporated into a short How can assessment be incorporated into a short

visit?visit? What are some strategies for making a visit more What are some strategies for making a visit more

efficient?efficient? Is there any Evidence to support the use of Is there any Evidence to support the use of

Geriatric Assessment?Geriatric Assessment?


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Why is assessment important?

Lebanese are aging !:Lebanese are aging !: 1972: ~ 4%1972: ~ 4% 1996: ~ 7.5%1996: ~ 7.5% 2000: 8.6%2000: 8.6% 2025: ~ 14%2025: ~ 14% 2050: ~ 20%2050: ~ 20%

Life expectancy:Life expectancy: 1950: 54 years1950: 54 years 2002: ~ 70 years2002: ~ 70 years


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Why is Assessment Important? Americans are aging!Americans are aging!

1998: Age 65+ numbered 34 million1998: Age 65+ numbered 34 million 2030: Age 65+ will number 70 million2030: Age 65+ will number 70 million Largest increases in those over age 85Largest increases in those over age 85 Older population more ethnically diverseOlder population more ethnically diverse

Majority of elderly will be cared for by internists and Majority of elderly will be cared for by internists and family practitionersfamily practitioners

ACP 1998: “Internists should be measuring ACP 1998: “Internists should be measuring functional deficits and identifying dependency needs functional deficits and identifying dependency needs of older adults”of older adults”


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““Usual” care may not meet elders’ needsUsual” care may not meet elders’ needs The 80+ survey:The 80+ survey:

75% said MD unaware of social needs75% said MD unaware of social needs 37% said MD unaware of physical needs37% said MD unaware of physical needs 42% said MD was unaware of their 42% said MD was unaware of their

emotional needsemotional needs 50% said Medical Care could be improved50% said Medical Care could be improved

Patterson 1998Patterson 1998

Why is Assessment Important?


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What is Geriatric Assessment?

Different models and definitions existDifferent models and definitions exist Geriatrics is often best practiced as an Geriatrics is often best practiced as an

interdisciplinaryinterdisciplinary team approach team approach Evaluates different domains: medical, cognitive, Evaluates different domains: medical, cognitive,

psychological, social, physicalpsychological, social, physical Expands Expands scopescope of interest to include caregiver of interest to include caregiver

and environmentand environment Emphasis on optimization of function and Emphasis on optimization of function and

increase in increase in active life expectancyactive life expectancy


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Active Life Expectancy at 75

Total Active DisabledWhite 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 1.5Guralnik, NEJM, 1993


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DOMAINS OF CGA

FUNCTIONALSTATUS

QUALITY OF LIFE

MEDICALCOGNITIVE

AFFECTIVE

ENVIRONMENTAL

ECONOMIC

SOCIAL SUPPORT


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Selected Tools for Assessment Lachs: Simple screenLachs: Simple screen Similar version validated by Moore and Siu in Similar version validated by Moore and Siu in

19961996 Good inter-rater reliabilityGood inter-rater reliability Easy to useEasy to use 7-10 minutes to administer7-10 minutes to administer Can be administered by non-MD personnelCan be administered by non-MD personnel UCSF versionUCSF version


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Areas covered in Lachs Tool

VisionVision HearingHearing IncontinenceIncontinence Falls and GaitFalls and Gait Upper extremity functionUpper extremity function Cognition ( 3 item recall)Cognition ( 3 item recall) DepressionDepression MedicationsMedications ADLs and IADLsADLs 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 About 2/3 of mild-moderate dementia missed by providersby providers

Content empty speechContent empty speech Loss of IADL functionLoss of IADL function Inability to recall 3 items at 5 minutesInability to recall 3 items at 5 minutes Inability to draw clockInability 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 <2 3.1 6 26 76recalls 3 .06 .1 .7 6

Clock Drawabnormal 24 32 72 96almost normal .8 2 8 44normal .2 4 6 17

Siu, Ann Intern Med, 1991


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The MMSE

Well validated Well validated Good predictive accuracyGood predictive accuracy Easy and relatively quick to administerEasy and relatively quick to administer ““Cut off” usually cited as 24Cut off” usually cited as 24

Sensitivity 85%Sensitivity 85% Specificity 90%Specificity 90%

Tombaugh JAGS 1992, Siu, Annals 1991Tombaugh JAGS 1992, Siu, Annals 1991


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The MMSE: Limitations

Education, cultural, and age biasesEducation, cultural, and age biases Crum JAMA 1994Crum JAMA 1994

Score impacted by vision, literacy, Score impacted by vision, literacy, depression.depression.

Floor and ceiling effectsFloor and ceiling effects Best to use as one tool in evaluationBest to use as one tool in evaluation


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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

Falls and Gait Disorders


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Falls and Gait Disorders Fall History Assessment:Fall History Assessment:

Ask the Patient: Have you fallen in the past year?Ask the Patient: Have you fallen in the past year? Gait AssessmentGait Assessment

Up and Go Test Up and Go Test Rise from chair, walk 10 feet, turn around, walk back, Rise from chair, walk 10 feet, turn around, walk back,

sit downsit down Timed Up and Go Test – normal less than 10 secondsTimed Up and Go Test – normal less than 10 seconds Tinetti ( or POMA)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 BalanceBalance

Sitting, rising from a chairSitting, rising from a chair Immediate and prolonged Immediate and prolonged

standing balancestanding balance Withstanding nudge on chestWithstanding nudge on chest Standing balance with eyes Standing balance with eyes

closedclosed TURNING BALANCE (360 TURNING BALANCE (360

degrees)degrees) Sitting downSitting down

Gait observationsGait observations Initiation of gaitInitiation of gait Step length, height, Step length, height,

continuity, symmetrycontinuity, symmetry Walking stanceWalking stance Amount of trunk swayAmount of trunk sway Path deviationPath deviation

Tinetti. Am J Med 1986; 80:429


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Why Assess Function?

Medical conditions may present first (or only) Medical conditions may present first (or only) as functional disturbancesas functional disturbances

Functional loss highly impacts quality of lifeFunctional loss highly impacts quality of life Functional losses may lead to further disability Functional losses may lead to further disability

and institutionalizationand institutionalization Functional losses impact patient and caregiverFunctional losses impact patient and caregiver


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Functional Impairments

ADLsBathingDressingToiletingTransfersContinenceFeeding

IADLsUsing telephoneShoppingFood preparationHousekeepingLaundryTransportationMedicationsManaging money


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Difficulty with ADLs and IADLs by Age

0

10

20

30

40

50

60

ADL problem IADL Problem

% w

ith

Dif

ficu

lty

Age 65-7470-7475-7980-8485+

US Census Bureau, 1990


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AADLs

Patient specific activities that can be used to Patient specific activities that can be used to detect subtle functional losses in high detect subtle functional losses in high functioning patientsfunctioning patients

Can be job or recreation orientedCan be job or recreation oriented Socializing, playing bridge, working, playing Socializing, playing bridge, working, playing

golf, playing music, dancing, practicing law, golf, playing music, dancing, practicing law, flying a plane, gardening.flying a plane, gardening.


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Other measures available

Upper extremity mobilityUpper extremity mobility Manual dexterityManual dexterity Lower extremity mobilityLower extremity mobility Combination of bothCombination of both Balance and gait evaluationBalance and gait evaluation


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Using Functional Information

Use functional status as baseline Use functional status as baseline Use it to guide recommendations for exercises, Use it to guide recommendations for exercises,

PT, adaptive devices for impairmentsPT, adaptive devices for impairments Consider home evaluation for highly impairedConsider home evaluation for highly impaired Potential marker of caregiver stressPotential marker of caregiver stress Useful for evaluating risk of & need for Useful for evaluating risk of & need for

placementplacement


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Depression Geriatric depression scale Geriatric depression scale

30 item instrument30 item instrument Yes/no to series of questions Yes/no to series of questions 10-15 minutes, self or interviewer to 10-15 minutes, self or interviewer to

administeradminister ScoresScores

<9 less probability <9 less probability >11 higher likelihood>11 higher likelihood>18 highest possibility>18 highest possibility Brink. Clin Gerontol 1982; 1:37


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Geriatric depression scale

Shorter version Shorter version 15 item, less certain diagnostic accuracy15 item, less certain diagnostic accuracy SCORE: 0-5 NORMAL, SCORE: 0-5 NORMAL,

>5 SUGGEST DEPRESSION>5 SUGGEST DEPRESSION

>10 almost always depression>10 almost always depression

Sheikh, Yesavage. Clin Gerontol. 1986; 5:165-172


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Disadvantage in frail elderly

Hard to administer with concomitant cognitive Hard to administer with concomitant cognitive impairmentimpairment

Cornell scale Cornell scale 19 items caregiver is asked variety of questions19 items caregiver is asked variety of questions Scores: 8-12 possible depression, >12 probableScores: 8-12 possible depression, >12 probable Useful screening for major depression in both Useful screening for major depression in both

demented and non-demented patientsdemented and non-demented patients


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Other psychiatric problems to look for

Delirium (confusion assessment method)Delirium (confusion assessment method) AnxietyAnxiety HostilityHostility PsychosisPsychosis Behavioral problemsBehavioral problems


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Malnutrition risk factors

Chronic diseaseChronic disease PovertyPoverty Social isolationSocial isolation Cognitive impairmentCognitive impairment Functional disabilityFunctional disability


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Indicators of poor nutrition

Impaired wound healingImpaired wound healing Increased surgical complicationsIncreased surgical complications Increased mortalityIncreased mortality


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Screening assessment WEIGHT <100 lbs IN AMBULATORY OLDER WEIGHT <100 lbs IN AMBULATORY OLDER

PATIENTS, NOT ALWAYS ACCURATEPATIENTS, NOT ALWAYS ACCURATE Weight loss > 10% body weightWeight loss > 10% body weight Physical findingsPhysical findings

Chelosis, glossitis, loss of subQ body fat, muscle, Chelosis, glossitis, loss of subQ body fat, muscle, wasting, edemawasting, edema

LabLab Decreased serum albumin, lymphocytes<1000Decreased serum albumin, lymphocytes<1000

Body mass index, mid arm circumference, triceps skin Body mass index, mid arm circumference, triceps skin foldsfolds


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Visual and hearing impairments

Visual impairment Visual impairment 13% older persons13% older persons

Hearing impairmentHearing impairment Age 65-74: 25%Age 65-74: 25% Age >85: 50%Age >85: 50%

Increase risk injuryIncrease risk injury Increased disability in physical Increased disability in physical

and psychosocial functionand psychosocial function Decreased quality of lifeDecreased quality of life


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Vision screening

Sensitivity and specificity for screening tests by Sensitivity and specificity for screening tests by primary care Dr not establishedprimary care Dr not established

Limited accuracy of glaucoma screeningLimited accuracy of glaucoma screening Snellen testSnellen test Specific questions regarding visionSpecific questions regarding vision


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Hearing screening Hand held audioscope $500Hand held audioscope $500

40db TONES AT 500, 1000, 2000, 4000 hz40db TONES AT 500, 1000, 2000, 4000 hz Takes 90 seconds, 94% sensitive, 72% specificTakes 90 seconds, 94% sensitive, 72% specific Increase accuracy with short questionnaireIncrease accuracy with short questionnaire

Whispered voice or finger rubWhispered voice or finger rub CheaperCheaper Subject to variation between examinersSubject 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 S - Do you feel SafeSafe at home? What at home? What StressStress do do you feel in your relationship?you feel in your relationship?

A - Do you feel A - Do you feel AfraidAfraid or have you been or have you been AbusedAbused by any of your caregivers? by any of your caregivers?

F - Are there any F - Are there any FamilyFamily or or FriendsFriends that you that you could ask for help or support?could ask for help or support?

E – Do you have a safe place to go in case of an E – Do you have a safe place to go in case of an EmergencyEmergency? Is it an ? Is it an EmergencyEmergency now? now?


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Abuse and Neglect: Caregiver Risk Factors and Clues

Caregiver does not come to appointmentsCaregiver does not come to appointments Is concerned about medical costsIs concerned about medical costs History of substance abuse, mental health History of substance abuse, mental health

problems, conflicts with patientproblems, conflicts with patient Dominates interview, won’t leave, won’t let Dominates interview, won’t leave, won’t let

patient talkpatient talk Defensive, hostile, or indifferentDefensive, hostile, or indifferent Dependence on patient for income/housingDependence on patient for income/housing


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Review medications

Elderly use 3X more medications than younger Elderly use 3X more medications than younger patientspatients

Drug distribution, elimination, excretion, & Drug distribution, elimination, excretion, & pharmacodynamics altered in elderlypharmacodynamics altered in elderly

ADR’s and drug-drug interactions increase ADR’s and drug-drug interactions increase markedly with # drugs usedmarkedly with # drugs used

Medications linked to “reversible dementias”, Medications linked to “reversible dementias”, falls, incontinence, hospitalizations, deathfalls, incontinence, hospitalizations, death


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Nonadherance and # Drugs

0%

20%

40%

60%

80%

100%

1 2 3 4 5 >6

Percent Adherence

# of drugs


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Reviewing Medications

Have patient bring in all medications, including Have patient bring in all medications, including OTC’s, herbs, dietary supplementsOTC’s, herbs, dietary supplements

Ask about other providersAsk about other providers Consider home visit if high riskConsider home visit if high risk Eliminate questionable medicationsEliminate questionable medications Simplify regimens or consider “Medi-sets”, visiting Simplify regimens or consider “Medi-sets”, visiting

nurses, or involving caregivernurses, or involving caregiver For new medications, start low and go slow, but get For new medications, start low and go slow, but get

there!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 atmosphereRelaxed and efficient atmosphere Good acoustic conditions and no interruptionsGood acoustic conditions and no interruptions Efficient appointment systemEfficient appointment system Wheel chair accessibleWheel chair accessible Hearing device: amplifier and microphoneHearing device: amplifier and microphone Paper/plastic bag test (bring all meds)Paper/plastic bag test (bring all meds) Obtain prior medical recordsObtain prior medical records


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Make Your Life Easier

Send out pre-visit questionnaire (e.g., UCLA)Send out pre-visit questionnaire (e.g., UCLA) Use brief screening tests (e.g. Lachs) or single Use brief screening tests (e.g. Lachs) or single

questions when possiblequestions when possible Use more detailed tests only when indicatedUse more detailed tests only when indicated Have forms handyHave forms handy Train nursing and ancillary staff to perform Train nursing and ancillary staff to perform

screening testsscreening tests


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Interview techniques In clinic: obtain data at several In clinic: obtain data at several

appointments over timeappointments over time Introduce yourselfIntroduce yourself Ask how the patient would like to be Ask how the patient would like to be

addressedaddressed Traditional “chief complaint” may not be Traditional “chief complaint” may not be

appropriate for most older patientsappropriate for most older patients How can I help you today? Better than what How can I help you today? Better than what

seems to be the problem?seems to be the problem?


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Make Your Life Easier

Discuss patient goals earlyDiscuss patient goals early Focus visit on patient’s goals and priorities, not you Focus visit on patient’s goals and priorities, not you

clinic’s quality improvement checklistclinic’s quality improvement checklist Realize that patient’s goals and priorities may Realize that patient’s goals and priorities may

change over timechange over time Change your clinic’s quality improvement checklist Change your clinic’s quality improvement checklist

to reflect the priorities of geriatrics!to reflect the priorities of geriatrics!


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History of the elderly patient Patient profile, social historyPatient profile, social history History of current problemsHistory of current problems Review of symptoms and systemsReview of symptoms and systems Medical historyMedical history Medication historyMedication history Caregiver’s statusCaregiver’s status Family historyFamily history Functional history, ADLs’sFunctional history, ADLs’s Community services currently providedCommunity services currently provided


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Minimal social assessment

Content of average day for patientContent of average day for patient Abilities in ADL’sAbilities in ADL’s Suitability and safety of homeSuitability and safety of home Availability, attitude and health of caregivers and Availability, attitude and health of caregivers and

neighborsneighbors Services received and/or neededServices received and/or needed Transportation needsTransportation needs Financial statusFinancial status Occupational history and interestsOccupational history and interests


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Agir

The French experienceThe French experience Explore multiple aspects of social, cognitive, Explore multiple aspects of social, cognitive,

medical life.medical life. 17 items, 3 possibilities.17 items, 3 possibilities. 4 B or C required.4 B or C required.


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Indications for a home visit visit

Living alone, especially if recently bereaved or Living alone, especially if recently bereaved or separatedseparated

Mental impairmentMental impairment Major mobility problemsMajor mobility problems Several risk factors for dependencySeveral risk factors for dependency History of falling or accidentsHistory of falling or accidents Imminent institutionalizationImminent institutionalization Recent hospital discharge, especially if recovery was Recent hospital discharge, especially if recovery was

incompleteincomplete


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Get Help!

Involve social worker and other team members earlyInvolve social worker and other team members early When you are overwhelmedWhen you are overwhelmed

Consider home nursing visits Consider home nursing visits Consider referral to “team geriatric program”Consider referral to “team geriatric program” Consider other community referrals (case Consider other community referrals (case

management programs, etc.)management programs, etc.)


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Geriatric Assessment:

The Evidence


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Why use assessment instrument?

ResearchResearch Clinical practice guideClinical practice guide Screening (identify unrecognized disease)Screening (identify unrecognized disease) Case findingCase finding Monitor patients throughout course of disorderMonitor patients throughout course of disorder Follow response to treatmentFollow response to treatment


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Does Geriatric Assessment Improve Outcomes?

Results mixed in RCTsResults mixed in RCTs Most robust outcomes seen in studies with a Most robust outcomes seen in studies with a

intervention component and follow upintervention component and follow up Increased “case finding” with GA screensIncreased “case finding” with GA screens Less institutionalization noted in a meta-Less institutionalization noted in a meta-

analysis of GAanalysis of GA Less disability noted in study of home GALess 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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Documents

January 2003 Dar Al-Ajaza Al-Islamia Hospital in Beirut 1 Geriatric Assessment Practical Approaches for Primary Care Practitioners Presented by Dr. Marwan