THE 10 MINUTE GERIATRIC ASSESSMENT

Fredrick T. Sherman, MD, MScMedical Director

SENIOR HEALTH PARTNERSMount Sinai School of Medicine

www.geri.com

OFFICE-BASED ASSESSMENT

• Common syndromes “Geriatric Giants” of the elderly

• Based on literature review

• Use principles of EBM

• Easy to remember MNEUMONICS

Falls

“Phalls”Confusion Incontinence

Iatrogenic disorders

Impairedhomeostasis

GERIATRIC GIANTS

“DEEP IN”FOR QUICK SCREENINGD - Dementia, Depression, DrugsE - EyesE - EarsP - Physical Performance, Phalls, Psychosocial I - IncontinenceN -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 2VERBAL 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/minLess than 12/min is abnormalCorrelates well with MMSE scores(r=0.77)Worsens with time in AD

Neurology.1989;39:1159-1165.

DEMENTIA SCREEN 3Clock 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 4FOUR 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 handsSolomon, PR, et al, Arch Neurology, JJ, March 1998 (349-355)

• 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)

7 MINUTE NEUROCOGNITIVE SCREEN

D - Drugs, DeliriumE - Etoh, , Eyes, EarsM - Multiple, MetabolicE - EndocrineN - Nutrition, NPHT - TraumaI - Infection, InfarctA - Affective, Alzheimer’sS - 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 No(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*Sens. 97 (.94)/Spec. 85(.83) PPV - .85 (.82) NPV - .97 (.94)Single Question Sen .85/Spec.65Hoyl, 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 LOSSQuestion/Test Time to Administer Comments

Audioscope 1-2 min Sen 87-90%Spec 80-100%

Whisper Test 1 min Sen 80-100%Spec 82-89%

Hearing-Handicap Inventory for the elderly

2 min Sen 48-63%Spec 75-86% At cut point >8

NHANES Battery < 2 min Sen 80%Spec 80% at cut point of >3

EARSWHISPERED 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%

EARSBUY AUDIOSCOPE

• 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

EYESBECAUSE 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 AgeFemaleLiving AloneNon-whitePoorLess Education

SmokingHBPAbnormal BMIHeart DiseaseCognitive Impairment

ADL DEPENDENCE IN MILD/MOD DEMENTIA

Prospective, Longitudinal Study of 1,103 Elderly (Age 72 & Older) with Mild/Mod Dementia, Independent In ADLAssessed 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 Normal

High Risk12/31 (39%)

10 ft. Rapid Gait/3 Chair Rises

High Risk13/38 (34%)

Low Risk

6/128 (4.7%)

Abnormal Normal

SIMPLE TESTS OF LOWER EXTREMITY STRENGTH,

BALANCE, GAIT & FALL RISKQuestion/Test Time to

AdministerComments

Functional reach 1 min If FR < 7” unable to:1) Leave neighborhood2) Stand on one foot3) Do tandem walkingAdjusted Odds Ratio for >2 falls in

6 months1) 8.1 if unable to reach2) 4.0 if < 6 inches3) 2.0 if > 6 inches < 10 inches

RELATIVE RISKS OF SEVERE WALKING DISABILITY: COMBINED DISTRIBUTION OF KNEE STRENGTH

TERTILES AND BALANCE CATEGORESKnee Strength Tertiles

Weakest(<10.6 kg)

Average(10.6-15.1 kg)

Strongest(<15.1kg)

Balance Categories

RR RR RR

S-S<10 seconds 5.12 1.49 3.08

SS (10)+ST (10) +TS (<3S)

1.87 1.58 1.18

SS (10)+ST (10) +TS (>3s)

0.97 1.14 1

JAGS, 2001-Vol.49, No.1

Balance CategoriesThe 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.

37.1

14.75.312.7 13.2

6.121.6

9.63.1

0

1020

30

40

SS<10 s TS<3 s TS>3 s

Strongest

Average

Weakest

Knee Extension Strength Tertiles

JAGS, 2001-Vol.49,No1

Geriatric Syndromes PHALLS (Falls)

M Maladaptive equipment Medical (acute) Medical (chronic) MultipleE Environment Ethanol Eyes/EarsO Orthostatic signs or symptomsW 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 - UrgeP - Physical/Psychological

NUTRITION SCREENSQuestion/Test Time to

AdministerComments

•Weight (kg) /Height (m2) 1 min BMI <22 or >25

•>10lb wt loss over 6 mo <1min RR of death 2.0

•Weight < 100lbs. 1 min PPV malnutrition .99

Nutrition Screening <5 min Sen 36%, Spec 85% for intake of > 3 nutrients below 75% of RDA at cut point > 6 points

NHANES 14-item scale to detect hypoalbuminemia

5-10 min Odds Ratio 2.7 if 3-5 RF, 6.4 if > 6 RF

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 admissionLancet 2000;356:563

“DEEP IN”For QUICK Screening

D - Dementia, Depression, DrugsE - EyesE - EarsP - Physical Performance, Phalls, Psychosocial I - IncontinenceN -Nutrition