Human Growth and Development: Geriatrics Small Group Session

1. Human Growth and Development:Geriatrics Small Group Session Karen Hall, M.D. Division of Geriatric Medicine University of Michigan and Ann Arbor VA Health Systems

2. Intended Learning Outcomes • Understand components of a functionally-oriented geriatrics assessment. • Identify and document functional impairments in older patients. • Identify nutritional risk and assess nutritional status in older patients.

3. The Geriatric Gap Despite population aging: Only 600 of ~100,000 medical school faculty list Geriatrics as their primary specialty.

4. Most physicians will be “geriatricicans” • If you see any patients aged >60, you will encounter “geriatric” issues. • Geriatric-aged patients are more likely to have: • disease • functional impairment • psychosocial needs This presentation will give you the tools to quickly and easily screen for impairments important in all older patients.

5. A CONTROLLED TRIAL OF INPATIENT AND OUTPATIENT GERIATRIC EVALUATION AND MANAGEMENT Conclusions: Inpatient and Outpatient Geriatric Assessment significantly reduced functional decline and improved mental health with no increase in costs. Cohen et al.; N Engl J Med 2002;346:905-12

6. Functional status predicts outcomes • Sager et al., 1996 • Risk factors for greatest risk of functional decline following hospitalization among patients > 70 years: • increasing age • Pre-admission disability in independent activities of daily living (IADLs) • lower cognitive status

7. How can non-geriatricians deliver good “geriatric” medical care? • Recognize FUNCTION as an outcome. • Learn how to assess FUNCTION. • Activities of Daily Living (ADLs, IADLs) • Mobility, Cognition, Affect • Nutritional Assessment

8. Functional Assessment in Older Adults • Most useful in High Risk Patients: • Complex, multiple medical disease • Frailty, age >75 • Atypical and obscure disease presentation • Physical, cognitive, and affective problems • Vulnerability to iatrogenic disability • Socially isolated and economically deprived • Failure to cope at home

9. Patient Outcomes improved by Functional Assessment • Improve: activity level, diagnostic accuracy, living situation • Reduce polypharmacy, prescribe appropriate medications • Decrease hospitalizations/nursing home use • Increase home health care • Reduce medical costs • Prolong survival

10. How to assess and document Any patient aged 65 or older should have documentation of: • Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs) **”..need help?” • Vision, Hearing • Cognition • Mobility – strength, gait • Affect (Mood) • Nutrition

11. Katz Basic (Physical) Activities of Daily Living - ADLs • Definition: Things you have to be able to do yourself to be left alone for a few hours – Predicts “placement” • Bathing (sponge, shower, tub) • Dressing, Undressing, Grooming • Toileting (include on/off toilet, clean self) • Continence (includes using catheter) • Transferring (in and out of bed, chair) • Feeding • These Tasks cannot be delegated

12. Basic (Physical) Activities of Daily Living • Rated as: • Independent (alone or with device) • Dependent (require human assistance) • Hierarchical in loss and regaining function. • Bathing is first • Feeding is last

13. Instrumental Activities of Daily Living (IADLs) • Definition: Things someone else can do – predicts assisted living • Using telephone (dial, make, receive, look up #) • Travel/transportation (private, public) • Shopping (include food, clothes) • Preparing meals (include plan and cook) • Housework (includes cleaning, moving stuff) • Taking medication (right pill, right dose, right time) • Managing money (include write checks, pay bills) • These tasks may be delegated

14. Cognitive Assessment • 18% of patients over 75, 40% of patients over 85 have cognitive impairment – predicts delerium and “placement” • Folstein Mini Mental Status Exam (30 points): - Orientation (date, place) - Registration (immediate repetition: Ball, Cup, Flag) - Serial 7’s (100-93-86-79-72-65) (or WORLD backwards) - Recall of 3 items after 1 minute - Language: naming, repeating, writing - Executive: 3-step command; read and perform task; copy intersecting pentagons

15. Cognitive Assessment (“1 minute”) Mini-Cog: • Registration: 3 objects (Ball, Cup, Flag) • Distractor: Clock Draw: hands and numbers at 8:20 or 11:20 • Recall of 3 items after 1 minute • Score: # objects remembered at 1 minute/3 • Score 3/3 is 99% specific to exclude cognitive impairment 12 12 9 3 9 3 6 6

16. Screening for Depression (Affect) Depression is the most common psychiatric condition – especially in older patients • May present as anxiety, anhedonia Validated screening tools: • 2 question depression screen (rapid “rule-out”) • Geriatric Depression Scale (GDS)

17. Two-Question Depression Screen 1. "During the past month, have you often been bothered by feeling down, depressed, or hopeless? 2. "During the past month, have you often been bothered by little interest or pleasurein doing things?" If asked exactly as above: “No” to both: -99% specific to exclude depression

18. Geriatric Depression Scale (15 item) - Dropped many of your activities and interests? - Feel your life is empty? - Often get bored? - Afraid something bad will happen to you? - Often feel helpless? - Prefer to stay at home rather than going out? - Feel you have more problems with memory than most? - Feel pretty worthless the way you are now? - Feel your situation is hopeless? - Think that most people are better off than you? - Not satisfied with life? Poor spirits most of the time? Not wonderful to be alive? Lacking energy?

19. Detailed Assessment: Depression Geriatric Depression Scale • Questions exclude “pains, aches” from Standard Depression Scale of 30 items • Score as # positive/15 • Positive: > 5/15 • Significant predictor for depression: raises pre-test likelihood from 30% to 70+% in geriatric age patients

20. Nutrition Malnutrition is underdiagnosed in older patients: risk for infection, falls, poor healing ”Determine” the risk: • D - Disease, acute and chronic • E - Eating poorly • T - Teeth problems • E - Economic hardship • R - Reduced social contact • M - Medications • I - Involuntary weight loss • N - Needs ADL or IADL assistance • E – Elderly

21. Nutrition (5 second screen) Rapid Screen: Has there been weight loss >10% in 6 months? Yes – do Mini Nutritional Assessment

22. Mini Nutritional Assessment A. Has food intake declined over the past three months due to loss of appetite, digestive problems, chewing or swallowing difficulties? 0 = severe 1 = moderate 2 = no decrease B. Weight loss during last three months 0 = weight loss greater than 3 kg (6.6 lbs) 1 = does not know 2 = weight loss between 1 and 3 kg (2.2 and 6.6 lbs) 3 = no weight loss C. Mobility 0 = bed or chair bound 1 = able to get out of bed/chair but does not go out 2 = goes out D. Has suffered psychological stress or acute disease in the past three months 0 = yes 2 = no

23. Mini Nutritional Assessment - 2 E. Neuropsychological problems 0 = severe dementia or depression 1 = mild dementia 2 = no psychological problems F. Body Mass Index (BMI) (weight in kg)/(height in m)2 0 = BMI less than 19 1 = BMI 19 to less than 21 2 = BMI 21 to less than 23 3 = BMI 23 or greater Screening score (subtotal max. 14 points) 12 points or greater: Normal – no need for further assessment 11 points or below: Risk for malnutrition – consider supplements, check serum albumin, institute monitoring/plan

24. Assessing mobility predicts outcomes Dargent-Molina et al., 1996 • Fall-related predictors of hip fracture: • slower gait speed • difficulty with tandem (heel-toe) walk • decreased visual acuity • small calf circumference

25. Mobility Validated Tests: • Timed Up and Go (TUG: a quick screen) • Tinetti Gait and Balance (detailed) Not validated but very useful: Observed Gait – comment on ability to rise from chair, walking, turning, get on exam table

26. Timed Up and Go test (TUG) Rise from chair Walk 3 meters in straight line (10 feet) Turn Return to chair Sit in chair Time to do above: if 10 seconds or less – not impaired No need for further assessment

27. Tinetti Gait and Balance Assessment (Balance portion only) BALANCE Instructions: Subject is seated in hard, armless chair. The following maneuvers are tested: 1. Sitting balance leans or slides in chair = 0 steady, safe = 1 2. Arising unable without help = 0 able but uses arm to help = 1 able without use of arms = 2 3. Attempting to arise unable without help = 0 able but requires more than 1 attempt = 1 able to arise with 1 attempt = 2

28. Balance -2- 4. Immediate standing balance (first 325 seconds) unsteady (staggers, moves feet, marked trunk sway) = 0 steady, but uses walker or cane or grabs other objects for support = 1 steady without walker or cane or other support = 2 5. Standing balance unsteady = 0 steady, but wide stance (heels >4” apart) or uses cane or other support = 1 narrow stance without support = 2 6. Nudge (patient standing with feet as close together as possible; examiner pushes with light, even pressure over sternum 3 times; reflects ability to withstand displacement) begins to fall = 0 staggers, grabs, but catches self = 1 steady = 2

29. Balance -3- 7. Eyes closed (with feet as close together as possible) unsteady = 0 steady = 1 8. Turn (360°) discontinuous steps = 0 continuous steps = 1 unsteady (grabs, staggers) = 0 steady = 1 9. Sitting down unsafe; misjudges distance; falls into chair = 0 uses arms or not a smooth motion = 1 safe, smooth motion = 2 BALANCE SCORE: _____ / 16 (Less than 10 = High Fall Risk)

30. Function Test Hearing Unable to answer whispered question Vision Unable to read vision card @ 20/40 Nutrition >10% weight loss in last 6 months Arm Unable to touch head, pick up spoon Leg strength and Timed Up and Go >10 seconds balance Incontinence Lose urine and get wet? Polypharmacy Number and dose of medications Mental status Mini-cog (less than 3/3 correct at 1 min) Depression Feel sad (Yes to 2 question screen) Rapid screening tools for Geriatric Screening Medical Assessment Moore & Siu; Am J Med 100:438, 1996

31. Bottom line: Use functional assessment to improve clinical care of older patients • Screen for risk factors or undetected problems. • Assist in diagnosis. • Establish baseline, set rehabilitation or therapeutic goals, and monitor patient course. • Plan for appropriate care needs.

32. Intended Learning Outcomes – achieved (!) • Understand components of a functionally-oriented geriatrics assessment. • Identified and documented functional impairments and nutritional status in our patient. Next step – practice! Try these tools when you are assessing patients in the clinic or hospital. • Additional resources: Geriatric Portfolio, Geriatric Center Website (Clinical page – Geriatric assessment)