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Geriatric Assessment

Practical Approaches for Primary Care Practitioners Presented by Dr. Marwan Zoghbi Moderator : Dr. Nabil Naja Dar Al-Ajaza Al-Islamia Hospital Beirut, Jan 2003. Geriatric Assessment. Challenges of Geriatrics in Primary Care. Short visit times Low reimbursement rates

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Geriatric Assessment

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  1. Practical Approaches for Primary Care Practitioners Presented by Dr. Marwan Zoghbi Moderator : Dr. Nabil Naja Dar Al-Ajaza Al-Islamia Hospital Beirut, Jan 2003 Geriatric Assessment Dar Al-Ajaza Al-Islamia Hospital in Beirut

  2. Challenges of Geriatrics in Primary Care • Short visit times • Low reimbursement rates • Multiple co-morbidities • Needs of caregiver and patient • Ever-expanding diagnostic and therapeutic options • Cross cultural communication Dar Al-Ajaza Al-Islamia Hospital in Beirut

  3. KEYS TO SURVIVAL • Time management • You don’t have to do everything yourself • Working knowledge of geriatric assessment tools • Determine when to refer someone for comprehensive geriatric assessment Dar Al-Ajaza Al-Islamia Hospital in Beirut

  4. Overview and Learning Objectives • At the end of this lecture, you should be able to answer: • Why is assessment important? • What are some useful tools for Assessment? • How can assessment be incorporated into a short visit? • What are some strategies for making a visit more efficient? • Is there any Evidence to support the use of Geriatric Assessment? Dar Al-Ajaza Al-Islamia Hospital in Beirut

  5. Why is assessment important? • Lebanese are aging !: • 1972: ~ 4% • 1996: ~ 7.5% • 2000: 8.6% • 2025: ~ 14% • 2050: ~ 20% • Life expectancy: • 1950: 54 years • 2002: ~ 70 years Dar Al-Ajaza Al-Islamia Hospital in Beirut

  6. Why is Assessment Important? • Americans are aging! • 1998: Age 65+ numbered 34 million • 2030: Age 65+ will number 70 million • Largest increases in those over age 85 • Older population more ethnically diverse • Majority of elderly will be cared for by internists and family practitioners • ACP 1998: “Internists should be measuring functional deficits and identifying dependency needs of older adults” Dar Al-Ajaza Al-Islamia Hospital in Beirut

  7. Why is Assessment Important? • “Usual” care may not meet elders’ needs • The 80+ survey: • 75% said MD unaware of social needs • 37% said MD unaware of physical needs • 42% said MD was unaware of their emotional needs • 50% said Medical Care could be improved Patterson 1998 Dar Al-Ajaza Al-Islamia Hospital in Beirut

  8. What is Geriatric Assessment? • Different models and definitions exist • Geriatrics is often best practiced as an interdisciplinary team approach • Evaluates different domains: medical, cognitive, psychological, social, physical • Expands scope of interest to include caregiver and environment • Emphasis on optimization of function and increase in active life expectancy Dar Al-Ajaza Al-Islamia Hospital in Beirut

  9. Active Life Expectancy at 75 TotalActiveDisabled White 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 1.5 Guralnik, NEJM, 1993 Dar Al-Ajaza Al-Islamia Hospital in Beirut

  10. DOMAINS OF CGA MEDICAL COGNITIVE QUALITY OF LIFE FUNCTIONAL STATUS AFFECTIVE ENVIRONMENTAL SOCIAL SUPPORT ECONOMIC Dar Al-Ajaza Al-Islamia Hospital in Beirut

  11. Selected Tools for Assessment • Lachs: Simple screen • Similar version validated by Moore and Siu in 1996 • Good inter-rater reliability • Easy to use • 7-10 minutes to administer • Can be administered by non-MD personnel • UCSF version Dar Al-Ajaza Al-Islamia Hospital in Beirut

  12. Areas covered in Lachs Tool • Vision • Hearing • Incontinence • Falls and Gait • Upper extremity function • Cognition ( 3 item recall) • Depression • Medications • ADLs and IADLs Dar Al-Ajaza Al-Islamia Hospital in Beirut

  13. 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” Dar Al-Ajaza Al-Islamia Hospital in Beirut

  14. Quick Clues to Dementia • About 2/3 of mild-moderate dementia missed by providers • Content empty speech • Loss of IADL function • Inability to recall 3 items at 5 minutes • Inability to draw clock Larson 1998, JAGS Siu 1991, Ann Int Med Dar Al-Ajaza Al-Islamia Hospital in Beirut

  15. Screening Tests for Dementia • Test & Result LR PTP given prevalence of: • 3 item recall2% 10% 50% • recalls <2 3.1 6 26 76 • recalls 3 .06 .1 .7 6 • Clock Draw • abnormal 24 32 72 96 • almost normal .8 2 8 44 • normal .2 4 6 17 Siu, Ann Intern Med, 1991 Dar Al-Ajaza Al-Islamia Hospital in Beirut

  16. The MMSE • Well validated • Good predictive accuracy • Easy and relatively quick to administer • “Cut off” usually cited as 24 • Sensitivity 85% • Specificity 90% Tombaugh JAGS 1992, Siu, Annals 1991 Dar Al-Ajaza Al-Islamia Hospital in Beirut

  17. The MMSE: Limitations • Education, cultural, and age biases • Crum JAMA 1994 • Score impacted by vision, literacy, depression. • Floor and ceiling effects • Best to use as one tool in evaluation Dar Al-Ajaza Al-Islamia Hospital in Beirut

  18. Falls and Gait Disorders 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 Dar Al-Ajaza Al-Islamia Hospital in Beirut

  19. Falls and Gait Disorders • Fall History Assessment: • Ask the Patient: Have you fallen in the past year? • Gait Assessment • Up and Go Test • Rise from chair, walk 10 feet, turn around, walk back, sit down • Timed Up and Go Test – normal less than 10 seconds • Tinetti ( or POMA) • Timed Up and Go: If greater than 30 seconds, only 23% independent in tub or shower, only 4% can climb stairs Dar Al-Ajaza Al-Islamia Hospital in Beirut

  20. Balance Sitting, rising from a chair Immediate and prolonged standing balance Withstanding nudge on chest Standing balance with eyes closed TURNING BALANCE (360 degrees) Sitting down Gait observations Initiation of gait Step length, height, continuity, symmetry Walking stance Amount of trunk sway Path deviation BALANCE AND GAIT EVALUATION Tinetti. Am J Med 1986; 80:429 Dar Al-Ajaza Al-Islamia Hospital in Beirut

  21. Why Assess Function? • Medical conditions may present first (or only) as functional disturbances • Functional loss highly impacts quality of life • Functional losses may lead to further disability and institutionalization • Functional losses impact patient and caregiver Dar Al-Ajaza Al-Islamia Hospital in Beirut

  22. Functional Impairments • IADLs • Using telephone • Shopping • Food preparation • Housekeeping • Laundry • Transportation • Medications • Managing money • ADLs • Bathing • Dressing • Toileting • Transfers • Continence • Feeding Dar Al-Ajaza Al-Islamia Hospital in Beirut

  23. Difficulty with ADLs and IADLs by Age US Census Bureau, 1990 Dar Al-Ajaza Al-Islamia Hospital in Beirut

  24. AADLs • Patient specific activities that can be used to detect subtle functional losses in high functioning patients • Can be job or recreation oriented • Socializing, playing bridge, working, playing golf, playing music, dancing, practicing law, flying a plane, gardening. Dar Al-Ajaza Al-Islamia Hospital in Beirut

  25. Other measures available • Upper extremity mobility • Manual dexterity • Lower extremity mobility • Combination of both • Balance and gait evaluation Dar Al-Ajaza Al-Islamia Hospital in Beirut

  26. Using Functional Information • Use functional status as baseline • Use it to guide recommendations for exercises, PT, adaptive devices for impairments • Consider home evaluation for highly impaired • Potential marker of caregiver stress • Useful for evaluating risk of & need for placement Dar Al-Ajaza Al-Islamia Hospital in Beirut

  27. Depression • Geriatric depression scale • 30 item instrument • Yes/no to series of questions • 10-15 minutes, self or interviewer to administer • Scores • <9 less probability • >11 higher likelihood • >18 highest possibility Brink. Clin Gerontol 1982; 1:37 Dar Al-Ajaza Al-Islamia Hospital in Beirut

  28. Geriatric depression scale • Shorter version • 15 item, less certain diagnostic accuracy • SCORE: 0-5 NORMAL, >5 SUGGEST DEPRESSION >10 almost always depression Sheikh, Yesavage. Clin Gerontol. 1986; 5:165-172 Dar Al-Ajaza Al-Islamia Hospital in Beirut

  29. Disadvantage in frail elderly • Hard to administer with concomitant cognitive impairment • Cornell scale • 19 items caregiver is asked variety of questions • Scores: 8-12 possible depression, >12 probable • Useful screening for major depression in both demented and non-demented patients Dar Al-Ajaza Al-Islamia Hospital in Beirut

  30. Other psychiatric problems to look for • Delirium (confusion assessment method) • Anxiety • Hostility • Psychosis • Behavioral problems Dar Al-Ajaza Al-Islamia Hospital in Beirut

  31. Malnutrition risk factors • Chronic disease • Poverty • Social isolation • Cognitive impairment • Functional disability Dar Al-Ajaza Al-Islamia Hospital in Beirut

  32. Indicators of poor nutrition • Impaired wound healing • Increased surgical complications • Increased mortality Dar Al-Ajaza Al-Islamia Hospital in Beirut

  33. Screening assessment • WEIGHT <100 lbs IN AMBULATORY OLDER PATIENTS, NOT ALWAYS ACCURATE • Weight loss > 10% body weight • Physical findings • Chelosis, glossitis, loss of subQ body fat, muscle, wasting, edema • Lab • Decreased serum albumin, lymphocytes<1000 • Body mass index, mid arm circumference, triceps skin folds Dar Al-Ajaza Al-Islamia Hospital in Beirut

  34. Visual and hearing impairments • Visual impairment • 13% older persons • Hearing impairment • Age 65-74: 25% • Age >85: 50% • Increase risk injury • Increased disability in physical and psychosocial function • Decreased quality of life Dar Al-Ajaza Al-Islamia Hospital in Beirut

  35. Vision screening • Sensitivity and specificity for screening tests by primary care Dr not established • Limited accuracy of glaucoma screening • Snellen test • Specific questions regarding vision Dar Al-Ajaza Al-Islamia Hospital in Beirut

  36. Hearing screening • Hand held audioscope $500 • 40db TONES AT 500, 1000, 2000, 4000 hz • Takes 90 seconds, 94% sensitive, 72% specific • Increase accuracy with short questionnaire • Whispered voice or finger rub • Cheaper • Subject to variation between examiners Dar Al-Ajaza Al-Islamia Hospital in Beirut

  37. 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 Dar Al-Ajaza Al-Islamia Hospital in Beirut

  38. Abuse and Neglect: Helpful Questions • S - Do you feel Safe at home? What Stress do you feel in your relationship? • A - Do you feel Afraid or have you been Abused by any of your caregivers? • F - Are there any Family or Friends that you could ask for help or support? • E – Do you have a safe place to go in case of an Emergency? Is it an Emergency now? Dar Al-Ajaza Al-Islamia Hospital in Beirut

  39. Abuse and Neglect: Caregiver Risk Factors and Clues • Caregiver does not come to appointments • Is concerned about medical costs • History of substance abuse, mental health problems, conflicts with patient • Dominates interview, won’t leave, won’t let patient talk • Defensive, hostile, or indifferent • Dependence on patient for income/housing Dar Al-Ajaza Al-Islamia Hospital in Beirut

  40. Review medications • Elderly use 3X more medications than younger patients • Drug distribution, elimination, excretion, & pharmacodynamics altered in elderly • ADR’s and drug-drug interactions increase markedly with # drugs used • Medications linked to “reversible dementias”, falls, incontinence, hospitalizations, death Dar Al-Ajaza Al-Islamia Hospital in Beirut

  41. Nonadherance and # Drugs Percent Adherence # of drugs Dar Al-Ajaza Al-Islamia Hospital in Beirut

  42. Reviewing Medications • Have patient bring in all medications, including OTC’s, herbs, dietary supplements • Ask about other providers • Consider home visit if high risk • Eliminate questionable medications • Simplify regimens or consider “Medi-sets”, visiting nurses, or involving caregiver • For new medications, start low and go slow, but get there! Dar Al-Ajaza Al-Islamia Hospital in Beirut

  43. Practical Tips for Practicing Geriatrics in your Office Dar Al-Ajaza Al-Islamia Hospital in Beirut

  44. Planning the initial office interview • Relaxed and efficient atmosphere • Good acoustic conditions and no interruptions • Efficient appointment system • Wheel chair accessible • Hearing device: amplifier and microphone • Paper/plastic bag test (bring all meds) • Obtain prior medical records Dar Al-Ajaza Al-Islamia Hospital in Beirut

  45. Make Your Life Easier • Send out pre-visit questionnaire (e.g., UCLA) • Use brief screening tests (e.g. Lachs) or single questions when possible • Use more detailed tests only when indicated • Have forms handy • Train nursing and ancillary staff to perform screening tests Dar Al-Ajaza Al-Islamia Hospital in Beirut

  46. Interview techniques • In clinic: obtain data at several appointments over time • Introduce yourself • Ask how the patient would like to be addressed • Traditional “chief complaint” may not be appropriate for most older patients • How can I help you today? Better than what seems to be the problem? Dar Al-Ajaza Al-Islamia Hospital in Beirut

  47. Make Your Life Easier • Discuss patient goals early • Focus visit on patient’s goals and priorities, not you clinic’s quality improvement checklist • Realize that patient’s goals and priorities may change over time • Change your clinic’s quality improvement checklist to reflect the priorities of geriatrics! Dar Al-Ajaza Al-Islamia Hospital in Beirut

  48. History of the elderly patient • Patient profile, social history • History of current problems • Review of symptoms and systems • Medical history • Medication history • Caregiver’s status • Family history • Functional history, ADLs’s • Community services currently provided Dar Al-Ajaza Al-Islamia Hospital in Beirut

  49. Minimal social assessment • Content of average day for patient • Abilities in ADL’s • Suitability and safety of home • Availability, attitude and health of caregivers and neighbors • Services received and/or needed • Transportation needs • Financial status • Occupational history and interests Dar Al-Ajaza Al-Islamia Hospital in Beirut

  50. Agir • The French experience • Explore multiple aspects of social, cognitive, medical life. • 17 items, 3 possibilities. • 4 B or C required. Dar Al-Ajaza Al-Islamia Hospital in Beirut

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