Physical & Functional Assessments in Older Adults

Scott Martin Vouri, PharmD, MSCI, BCPS, CGP, FASCP

St. Louis College of Pharmacy

Faculty Disclosure

• Dr. Vouri is funded by the Washington University Institute of Clinical and Translational Sciences grants UL1 TR000448 and KL2 TR000450 from the National Center for Advancing Translational Sciences. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Learning Objectives

At the conclusion of this application-based activity, participants should be able to:

1. Identify appropriate assessment instruments to use for a given set of symptoms or patient complaints.

2. Identify a variety of screening and assessment tools (e.g., mini-cog exam, Katz index of activities of daily living, geriatric depression scale, and others).

3. Apply principles to a geriatric patient case.

Geriatric Assessment• Full assessment includes

• Physical assessment• Laboratory tests• Review of medical problems and medications• Cognitive assessment• Functional assessment• Social Assessment• Family history

• Assessment tailored to patient• Age• Frailty • Living situation• Includes caregivers / family • Includes interdisciplinary team

Linnebur SA. Et als. Fundamentals of geriatric pharmacotherapy: an evidence-based approach. 1st ed. Bethesda (MD): American Society of Health-System Pharmacists; 2010. p 71-90.

Geriatric Assessment - Brief Topics• Physical Assessment

• Observations

• Vitals signs, weight

• Eyes, ears, mouth, skin

• Cardiovascular, musculoskeletal, abdominal

• Urologic, neurologic, others

Williams ME, et al Case-based geriatrics: a global approach. 1st ed. New York:McGraw-Hill;2011. p 59-68.Linnebur SA. Et als. Fundamentals of geriatric pharmacotherapy: an evidence-based approach. 1st ed. Bethesda (MD): American Society of Health-System Pharmacists; 2010. p 71-90.Kane RL, Ouslander, Abrass IB. Essentials of clinical geriatrics. 5th ed. New York: McGraw-Hill. 2004

Geriatric Assessment - Brief Topics• History

• Social History• Tobacco, alcohol, illicit drug-use

• Full Medication History/Medication Reconciliation• Includes where medications are stored and pharmacy used

• Past Medical History• Helps better understand appropriateness

• Drug-induced adverse events/Prescribing Cascade

Linnebur SA. Et als. Fundamentals of geriatric pharmacotherapy: an evidence-based approach. 1st ed. Bethesda (MD): American Society of Health-System Pharmacists; 2010. p 71-90.

Medication Assessment• Immunizations

• Influenza (inactivated) • Standard dose versus high dose

• Pneumococcal• PPSV23 and PCV13

If… Then…

≥ 65 and no PPSV23 or no PCV13 PCV13 followed by PPSV23 (6-12 months later)

≥ 65 and PPSV23 and no PCV13 PCV13 one year after PPSV23

≥ 65 and PCV13 and no PPSV23 PPSV23 6-12 months after PCV13

<65 when administered PPS23 and now ≥ 65

PCV13 on year after (initial) PPSV23 then PPSV23 at least one year after PCV13 and at least 5 years after initial PPSV23

Granados et al. N Engl J Med. 2014;371:635-645.Izurieta et al. Lancet Infect Dis. 2015;15(3):293-300.Richardson et al. Clin Infect Dis. 2015;61(2):171-176.http://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html

Medication Assessment• Medication Adherence

• Understand who is in charge and what method of administration is used

• Intentional versus non-intentional non-adherence• Intentional – costs or adverse effects• Non-Intentional – too complex/forgets (or takes too much)

• Medication adherence tools• Modified-Morisky scale• Trails B test

• Medication adherence actions• Pill counts• Fill history per pharmacy

Shalansky et al. Ann Pharmacother. 2004;38(9):1363-1368.Chung et al. J Am Geriatr Soc. 2015;63(S1):S76.

Medication Assessment• Medication Duration

• Certain medications should only be taken for a specific duration

• Extended exposure to these medications may provide no further benefit and contribute to harm

• These, plus other medications, should have initial year of started medications documented or assessed to avoid overtreatment

Medication Duration Risk

Bisphosphonates 3-5 years Atypical fractures

PPI for GERD ≤ 1 month Fractures, malabsorption, electrolyte issues (Mg)

Dual-Antiplatelet 1-2.5 years GI Bleed

Gedmintas et al. J Bone Miner Res. 2013;28(8):1729-1737.Yang et al. JAMA. 2006;296(24):2947-2953.Cutlip et al. Topic 1572 Version 42.0. Accessed July 11,2015.

Active LearningYou are the consultant pharmacist at a short-term rehabilitation. You’ve made it a point to ensure vaccinations are up-to-date. You are evaluating a 68 year old patient with history of HTN, smoking, and recent stroke. Her vaccinations include:

• Influenza 10/2014• PPSV23 7/2017• Tdap Booster 5/2012• Hepatitis A/B titers present

What vaccinations would you recommenda) Vaccinations up-to-dateb) Herpes Zoster onlyc) PCV13 only d) Both Herpes Zoster and PCV13

Active LearningWhen performing a medication assessment, which of the following is the most important to assess how long the patient has been taking the medication?

a) Tamoxifen for breast cancer

b) Loop diuretic for CHF

c) 5ARI for BPH

d) Pravastatin for CAD prevention

Other Assessments

• Cognitive

• Mood

• Behavior

• Functional

• Pain

• Others

Cognitive AssessmentTest Abbreviation Interpretation Comment

Mini-Mental State Exam

MMSE

24-30 normal; 18-23 mild; 10-17 moderate; <10 severe

30 point evaluation; copyrighted

Montreal CognitiveAssessment

MoCA26-30 normal; <26 MCI or dementia

30 point evaluation; validated in >20 languages; more sensitive than MMSE

St. Louis University Mental Status Exam

SLUMS27-30 normal; 21-26

MCI; <21 dementiaRarely used; Normal, MCI, Dementia

Short Blessed Test SBT0-4 Normal; 5-9questionable; 10 or more dementia

Evaluates 6 items (28 total points); more sensitive than MMSE

Alzheimer’s Disease Assessment Scale –Cognitive subscale

ADAS-cogChanges in 4 points considered significant

Used for Research Purposes; 0-70 0=no cognitive impairment

Williams ME, et al. Case-based geriatrics: a global approach. 1st ed. New York:McGraw-Hill;2011. p 59-68.Nasreddine et al. J Am Geriatr Soc. 2005;53(4):695-9Rockwood et al. BMC Neurology. 2007;7(26):doi:10.1186/1471-2377-7-26.Carpenter et al. Acad Emerg Med. 2011;18(4):374-384.

Cognitive AssessmentClinical Dementia Rating (CDR)

Impairment

None (0) Questionable (0.5) Mild (1) Moderate (2) Severe (3)

Memory

Orientation

Judgement/ Problem Solving

Community Affairs

Home/Hobbies

Personal Care

Morris et al. Neurology. 1993;43:2412-14.http://www.dementia-assessment.com.au/global/cdr_scale.pdfhttps://www.alz.washington.edu/cdrnacc.html

Executive Function

• Trail-Making Tests• TMT-B

• Variable cut-offs

• >273 seconds – impaired

http://www.nhtsa.gov/people/injury/olddrive/OlderDriversBook/pages/Trail-Making.htmlhttp://doa.alaska.gov/dmv/akol/pdfs/uiowa_trailmaking.pdf

Neuropsychiatric Assessment• Depression

• Geriatric Depression Scale (GDS)• Long-Form (30 items)• Short-Form (15 items)

• Patient Health Questionnaire • PHQ-2 and PHQ-9

• Cornell Scale for Depression in Dementia• Ratings based on patient signs and symptoms over one week• Scale of 0,1,2 with >12 is probable depression

• Beck Depression Inventory• Self-rated scale containing 22 questions

• Hamilton Depression• Training rated• Needs existing diagnosis of depression

Kane RL, et alEssentials of clinical geriatrics. 5th ed. New York: McGraw-Hill. 2004Thielke S et al. Case-based geriatrics: a global approach. 1st ed. New York: McGraw-Hill;2011. p 491-504.Ownby et al. Am J Geriatr Psychiatry. 2001;9:217-224.

Neuropsychiatric Assessment• Behavior

• Behavioral Pathology in Alzheimer’s Disease Rating Scale (BEHAVE-AD)

• Neuropsychiatric Inventory (NPI)• BEHAVE-AD and NPI-Q used in research settings

• Neuropsychiatric Inventory Questionnaire (NPI-Q)• Can be completed in <5 minutes and validated against NPI

• 13 Yes/No and Severity questions • Delusions, hallucinations, agitation, depression, anxiety, elation,

apathy,• Disinhibition, irritability, motor disturbance, nighttime

behaviors, appetite

Linnebur SA. Et al. . Fundamentals of geriatric pharmacotherapy: an evidence-based approach. 1st ed. Bethesda (MD): American Society of Health-System Pharmacists; 2010. p 71-90.Kaufer et al. J Neuropsychiatry Clin Neurosci. 2000;12(2):233-239.https://www.alz.washington.edu/NONMEMBER/UDS/DOCS/VER2/IVPforms/B5.pdf

Functional Assessment• Function

• Measures of Physical Function (ADLs & IADLs)• Ability to perform without human assistance

• Independent

• Ability to perform with some human assistance• Partially independent

• Inability to perform, even with assistance• Dependent

• Vulnerable Elders Survey• Predictors risk for death or functional decline• Assesses

• ADLs/IADLS• Shopping, light housework, finances, walking across room, and bathing

• Patient characteristics/ Disease states• Age, Self-rate health, and disease states – dementia, DM, stroke, MI,

valvular disease, etc• Score 3 or more are 4x at risk compared to <3

Kane RL, et al. Essentials of clinical geriatrics. 5th ed. New York: McGraw-Hill. 2004Katz S, et al. Gerontologist. 1970;10(1):20-30.http://www.rand.org/health/projects/acove/survey.html

Functional AssessmentFalls/Balance

Name Abbreviation Description Interpretation

Timed Up and Go Test

TUGFrom seated position rise, walk 3M, return and sit

<20 seconds –independent>14 seconds – fall risk

Romberg Test

RTStand with feet together with eyes open and closed

Five TimesSit to Stand

FTSSArms crossed, stand and sit 5 times

>14 seconds – fall risk

Shumway-Cook et al. Physical Therapy. Buatosis, et al. J Am Geriatr Soc. 2008;56(8):1575-1576.

Assessment for Pain

P – Provoking

Q – Quality

R – Region/Radiates

S – Severity

T – Timing / Temporal

U – Impact on “U”

Pain Scales

• Scales for Assessing Pain Severity• 0-10 Numeric Rating Scale

• Verbal Descriptor

• Faces Pain Scale• http://www.wongbakerfaces.org/

• Pain Thermometer• http://www.geriatricpain.org/Content/Assessment/Intact/Page

s/PainThermometerScale.aspx

Nutritional Assessment• Mini-Nutritional Assessment (MNA)

• Mini-Nutritional Assessment-Short Form (MNA-SF)• http://www.mna-elderly.com/

• Malnutrition Universal Screening Tool (MUST)• http://www.bapen.org.uk/screening-for-

malnutrition/must/introducing-must

Leigh AE et al. Case-based geriatrics: a global approach. 1st ed. New York: McGraw-Hill;2011. p 465-79.Stratton RJ et al. Br J Nutr. 2006;95(2):325-30.

Nutritional Assessment• Simplified Nutrition Assessment Tool (SNAQ)

• Subjective Global Assessment (SGA)

• Seniors in the community: Risk Evaluation for Eating and Nutrition Version II (Screen II)

Leigh AE et al. Case-based geriatrics: a global approach. 1st ed. New York: McGraw-Hill;2011. p 465-79.

Other Assessments• Abnormal Involuntary Movement Scale (AIMS)

• http://www.cqaimh.org/pdf/tool_aims.pdf

• Tests for tardive dyskinesia over time

• Dopamine blocking agents• 1st generation antipsychotics (AP)> 2nd generation AP

• Other DA blocking agents metoclopramide

• Highest level of severity • Not simply adding up numbers

Rush JA. Handbook of Psychiatric Measures, American Psychiatric Association, 200, 166-168.

Active Learning

You would like to incorporate a cognitive assessment into clinic. What is the best/most practice assessment tool that can be used?

a) MMSE

b) MOCA

c) ADAS-Cog

d) CDR

Active Learning

You would like to incorporate an assessment for depression screening into clinic. All of the following tools, EXCEPT ________ should be considered.

a) GDS

b) PHQ-9

c) Cornell

d) Hamilton

Conclusion

• There are many assessments that can be performed in older adults• Pharmacists should be able to perform medication-

related assessments

• Pharmacists should be able to understand other assessments