Belgian Minimum Data Set for Comprehensive Geriatric Assessment Consensus conference May 7th, 2004

1. Belgian Minimum Data Setfor Comprehensive Geriatric AssessmentConsensus conference May 7th, 2004 College of Geriatrics www.geriatrie.be

2. introduction • continuous registration of quality variables is an obligation • the Ministry intends to ask this registration  College & BVGG : choose it ourselves !

3. BMDS : methods • Questionnaire sent by e-mail; surface mail, downloadable (www.geriatrie.be) • used and proposed scales for minimal geriatric assessment • domains : ADL; I-ADL; falls; cognition; depression; social; nutrition; pain; QOL

4. results • 59 questionnaires • acute and subacute G beds

5. conclusions • response rate • geriatricians : interested in CGA • transparency of geriatric units quality of questionnaire not enough CGA lack of uniformity CGA ~ no consensus

6. perspectives working groups to propose “minimal” tools of CGA for a Consensus Conference • specific, sensitive, validated • feasible • screening tools • a basis for further algorithms

7. Working groups ADL-IADL • P Devriendt, G Dargent, C Swine Qol • P Devriendt, G Dargent, C Swine Mobility • JP Baeyens , Ghesquière Cognition • M Lambert , E Gorus, C Sachem Depression • A Velghe, Th Pepersack Social • JP Baeyens , Van de kerkof Nutrition • T Pepersack, H Daniels, J Pétermans, C Gazzotti Pain • N Vandennoorgate, A Pepinster Frailty • C Swine, G Dargent, P Devriendt

8. ADL-IADL P Devriendt, G Dargent, C Swine

9. ADL (1) • Definition (Reuben et al., 1989) • 3 levels of functioning, stratified according to difficulty and complexity: • Basic: elemental functions, self-care • Intermediate: essential to maintain independent living • Crucial to live alone • Advanced activities of daily living: luxury items, beyond what is needed to be independent, volitional, infuenced by cultural and motivational facors • Terms: • BADL: Basale ADL • IADL: Instrumentele ADL • AADL: Arbeid en ontspanning

10. ADL (2) • Important to measure in G- setting (Reuben, 1989; Gallo et al., 2003): • BADL • IADL

11. ADL: BADL and IADL • Criteria for assessment-tools, according presentation wintermeeting 2004 and working group • Specific, sensitive, validated • Feasible • Screening tools • For all patients • A basis for further algorithms • What ‘s already used and proposed by the respondents/geriatricians in the survey !! • The future??

12. Used tools Katz (50%) Barthel (6%) Fim (4%) Smaf (2%) Proposed tools Katz (31%) Aggir (9%) Barthel (6%) Fim (4%) BADL-tools

13. Used tools Lawton (38%) Smaf (3%) Barthel (3%) Proposed tools Lawton (32%) Aggir (5%) Barthel (5%) IADL-tools

14. ADL: BADL and IADL • Literature search: • A lot of assessment - tools • ‘What’ they measure • Pure BADL: only a few tools • Pure IADL: only a few tools • Combined BADL and IADL or ADL and other (eg. cognition, behaviour): the most tools • Type of patient • All patients • Condition or disease specific • Assessed by • Direct observation • Self-report ‣ patient of proxy • Interview

15. ADL: BADL and IADL:selection of tools according the criteria • Pure BADL • Katz: original instrument or Belgian version • Barthel - index • Pure IADL • Lawton – scale • Combined • RAI • AGGIR • FIM • SMAF • References available on the last slides

16. ADL: BADL and IADL: proposal (1) • Question: • Choose an instrument already used or proposed or … • Choose an instrument that will be ‘the future’ obligation instead of the Katz?

17. ADL: BADL and IADL: proposal (2) • BADL: Katz • IADL: Lawton-scale >Already used (50% and 38%) Alzheimermedication, Elderly Home • Proposed (31% and 32%) • Feasible: • time needed: less than 5’ each (Rubenstein et al., 1988)

18. References (1) • Katz: • Katz et al., Studies of Illness in the Aged, the Index of ADL: a Standardized Measure of Biological and Psychosocial Function, JAMA, sept 21; 1963 • Barthel: • Mahoney and Barthel, Functional Evaluation: the Barthel Index, Maryland State Medical Journal, 1965; 14(2): 61-5

19. References (2) • AGGIR • FIM • Deutsch et al., The Functional Independent Measure (FIM) and the FIM for children (WeeFIM): then years of development; Critical Reviews in Physical Rehabilitation Medicine, 8, 267-281

20. References (3) • SMAF • Hebert et al., The Functional Autonomy measurement system (SMAF): despcription and validation of an instrument for the measurement of handicaps, Age and Aging, 17, 293-302 • Desrosiers et al., Reliability of the revides fucntional autonomy measurement system (SMAF) for epidemiological research, Age and Aging, 24, 402-406 • Hebert et al., Setting the minimal metrically detectable change on disability rating scales, Archieves of Physical Medicine ans Rehabilitation, 78, 1305-1308

21. References (4) • Lawton-scale • Lawton et al., Assessment of older people: Self-maintaining and instrumental activities of daily living, Gerontologist, 1969;9:179-186 • RAI • Achterberg et al., Het Ressident Assessment Instrument (RAI): een overzicht van internationaal onderzoek naar de psychommetrische kwaliteiten en effecten van implementatie in verpleeghuizen, Tijdschrift Gerontologie en Geriatrie, 1999; 30 • Frijters et al., Tijdschrift Gerontologie en Geriatrie, 2001; 32: 8 • InterRAI SCREENER

22. Quality of life P Devriendt, G Dargent, C Swine

23. To measure Quality of Life • QoL: • Can be seen as overall measure • Includes ADL

24. Quality of Life • Definition: as many as there are autors, but in common • Perception (subjective) • Expectations • Multidimensional • Pschycological • Physiological • Social • Material • Cultural • Existantial • Interdependent • Compensatory

25. QoL-tool • Assessment – tool: • SF – 36; derived from the Medical Outcomes Study (MOS) • Heahlt related QoL ! • 8 subscales: • Physical, functioning, role limitations due to physical problems, due to emotional problems, bodily pain, general health perceptions, vitality, social functioning, mental health • 2 summary scores • Self - report questionnaire (10’), possible as interview • User’s Manual • Good psychometrics

26. References • MOS SF – 36 • Stewart et al., The MOS Short-from General Health Survey: Reliability and validity in a patient population, Med Care, 1988; 26:724-735 • Stewart et al., Functional Status and well-being of patients with chronic cobnditions: Results from the Medical Outcome Study, JAMA, 1989; 262: 914-919 • MC Horney, Measuring and monitoring general health status in elderly persons: practical and methodological issues in using the SF-36 health survey, Geronotologist, 1996, 36: 571-583

27. Mobility JP Baeyens , Ghesquière

28. Introduction Assessment of MOBILITY • GET-UP-AND-GO test • TIMED UP AND GO TEST Assessment of MUSCLE STRENGHT • MRC-scale (0-5) • HAND DYNAMOMETER of Jamar Evaluation of FALL RISK • STRATIFY score

29. GET-UP-AND-GO test Version 1 • Get Up • Standing • Go • Turning • Sit down Scores: 0=impossible 1=with help (manual or instrumental) 2=autonomous

30. GET-UP-AND-GO test Version 2 • Get up, standing, go, turning and sit down Score 1 till 5 -1 no instability -2 very slowly execution -3 hesitating, abnormal compensatory movements of body or arms -4 patient is stumbling -5 permanent risk of fall S.Mathias, U.Nayak, B.Isaacs, 1985, Arch.Phys.Med.Rehab. 67(6), 387-9

31. TIMED UP AND GO TEST • Id, walk of 3 meters, but • Timed in seconds • < 20 sec. : independantly mobile • > 30 sec. : dependent on help for basic transfers D.Podsaldio, S.Richardson, 1991, JAGS, 39(2), 142-8

32. STRATIFY score(St.Thomas’s Risk Assessment Tool In Falling elderly Inpatients) YES or NO: • Patient is admitted with falls, or presented falls since admission • Is he agitated? • Has he impaired vision? • Has he frequently to go to the toilet • Has he a transfer- and mobility- score of less than 3 or 4? Oliver et al. 1997

33. STRATIFY score(St.Thomas’s Risk Assessment Tool In Falling elderly Inpatients) Transfer score • 0=impossible • 1=help of 1 or 2 persons • 2=help with words or other fysical support • 3=autonomous Mobility score • 0=motionless • 1=autonomous with help of wheelchair • 2=march with physical or oral help of 1 person • 3=autonomous

34. STRATIFY score(St.Thomas’s Risk Assessment Tool In Falling elderly Inpatients) If result is 2 or more: Risk of falling within the week. Retesting by the nurse every week.

35. Cognition M Lambert , E Gorus, C Sachem

36. I. introduction - high prevalence of cognitive disorders in elderly - undetected - reversible causes - clinical implications e.g. treatment adherence decision making capacity institutionalisation risk for complications

37. II. tests currently used cfr. assessment questionnaire III. literature lots of different available tests but… poorly studied or validated unknown not translated (Flemish & French) time consuming few international guidelines for acute geriatric care

38. IV. pro’s & contra’s - MMSE pro : short (10 min.) several cognitive functions widely used validated geriatric population = high risk con : cut off-score? age; education

39. no validated Flemish version French/German version ? dialect? ; Walloon? different versions : orientation place registration & recall: words calculation &/or spelling; word choice language : phrase 3 stage command copy design Folstein et al. J Psychiatric Res 1975; 12 Derousné et al. La Presse Med 1999; 28

40. - Clock drawing test pro : short (2 min.) simple con : different versions different scoring protocols limited number cog. functions often used in combination Shulman et al. Int J Geriatr Psychiatry 1986; 1 Richardson & Glass. JAGS 2002; 50

41. - AMTS pro : short & simple recommended RCP & BGS con : not widely used no translation Hodkinson. Age Ageing 1972; 1 Qureshi & Hodkinson. Age Ageing 1974; 3

42. - IQCODE pro : longitudinal perspective translated into French con : no informant available no Flemish version Jorm & Jacomb. Psych Med 1989; 19 Mulligan et al. Arch Neur 1996; 53

43. V. general remarks consensus : time (stabilised illness) place version

44. Depression A Velghe, Th Pepersack

45. Depression • Community elderly subjects 1-3% • Hospitalized elderly 10-15% • associated with higher risk of disability • worses the outcome of several diseases • associated with increased use of medical service • fewer than 50% of older elderly subjects receive a correct diagnosis • screening should be part of CGA

46. Screening questionnaires • Beck Depression Inventory for Primary Care (BDI-PC) Behav Res Ther 1997;35:785-791 • Zung Self Rated Rating Scale Arch Gen Psychiatry 1965;12:63-70 • Center for Epidempiological Studies Depression Scaale (CES-D) Appl Psychol Measaure 1992;343-351 • Hamilton Rating Scale for Depression (HAM-D) J Neurol Neurosurg Psychiatry 1960;23:56-62 • Montgomery-Asberg Depression Rating Scale (MADRS) • Cornell Scale for Depression in Dementia (CSDD) • Geriatric Depression scale (GDS) Clin Gerontol 1982;1:37-43

47. Hamilton Rating Scale for DepressionHAM-S • developed as a measure of treatment outcome rather than a screening tool • 21 items • completed by a trained observer after a 30 min interview...

48. Zung Self-rating Depression scaleSDS • Used in epidemiological studies • 20 items • uses graded responses (never, sometimes, usually) that may be confusing in elderly patients • many normal elders assessed as false-positives • misses depression in the elderly if multiple somatic complaints • a short form (12 items) • not recommended in the elderly...

49. Montgomery-Asberg Depression Rating ScaleMADRS • Sensitive to measuring change in symptoms with treatment over time • Interview • 10 questions (6 possible ratings) • not sufficiently validated in the geriatric population

50. Geriatric Depression Scale • originally contained 100 items, • condensed to 30 questions that indicate presence of depression. • self-administered test • "yes/no" question format, which may be more acceptable in the elderly population. • initially validated among patients hospitalized for depression and among normal elderly living in the community without complaints of depression or history of psychiatric illness.