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Belgian Minimum Data Set for Comprehensive Geriatric Assessment Consensus conference May 7th, 2004. College of Geriatrics. introduction. continuous registration of quality variables is an obligation the Ministry intends to ask this registration  College & BVGG : choose it ourselves !.

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belgian minimum data set for comprehensive geriatric assessment consensus conference may 7th 2004

Belgian Minimum Data Setfor Comprehensive Geriatric AssessmentConsensus conference May 7th, 2004

College of Geriatrics

www.geriatrie.be

introduction
introduction
  • continuous registration of quality variables is an obligation
  • the Ministry intends to ask this registration

 College & BVGG : choose it ourselves !

bmds methods
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

results
results
  • 59 questionnaires
  • acute and subacute G beds
conclusions
conclusions
  • response rate
  • geriatricians : interested in CGA
  • transparency of geriatric units

quality of questionnaire

not enough CGA

lack of uniformity CGA

~ no consensus

perspectives
perspectives

working groups to propose “minimal” tools of CGA for a Consensus Conference

  • specific, sensitive, validated
  • feasible
  • screening tools
  • a basis for further algorithms
working groups
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
adl iadl

ADL-IADL

P Devriendt, G Dargent, C Swine

adl 1
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
adl 2
ADL (2)
  • Important to measure in G- setting (Reuben, 1989; Gallo et al., 2003):
    • BADL
    • IADL
adl badl and iadl
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??
badl tools
Used tools

Katz (50%)

Barthel (6%)

Fim (4%)

Smaf (2%)

Proposed tools

Katz (31%)

Aggir (9%)

Barthel (6%)

Fim (4%)

BADL-tools
iadl tools
Used tools

Lawton (38%)

Smaf (3%)

Barthel (3%)

Proposed tools

Lawton (32%)

Aggir (5%)

Barthel (5%)

IADL-tools
adl badl and iadl14
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
adl badl and iadl selection of tools according the criteria
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
adl badl and iadl proposal 1
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?
adl badl and iadl proposal 2
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)
references 1
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
references 2
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
references 3
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
references 4
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
quality of life

Quality of life

P Devriendt, G Dargent, C Swine

to measure quality of life
To measure Quality of Life
  • QoL:
    • Can be seen as overall measure
    • Includes ADL
quality of life24
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
qol tool
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
references
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
mobility

Mobility

JP Baeyens , Ghesquière

introduction28
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
get up and go test
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

get up and go test30
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

timed up and go test
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

stratify score st thomas s risk assessment tool in falling elderly inpatients
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

stratify score st thomas s risk assessment tool in falling elderly inpatients33
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
stratify score st thomas s risk assessment tool in falling elderly inpatients34
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.

cognition

Cognition

M Lambert , E Gorus, C Sachem

slide36

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

slide37

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

slide38

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

slide39

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

slide40

- 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

slide41

- AMTS

pro : short & simple

recommended RCP & BGS

con : not widely used

no translation

Hodkinson. Age Ageing 1972; 1

Qureshi & Hodkinson. Age Ageing 1974; 3

slide42

- 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

slide43

V. general remarks

consensus :

time (stabilised illness)

place

version

depression

Depression

A Velghe, Th Pepersack

depression45
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
screening questionnaires
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

hamilton rating scale for depression ham s
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...
zung self rating depression scale sds
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...
montgomery asberg depression rating scale madrs
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
geriatric depression scale
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.
geriatric depression scale51
Geriatric Depression Scale
  • A cutoff score of 11 on the GDS yields an 84% sensitivity rate and a 95% specificity rate
  • a cutoff score of 14 yields a slightly lower sensitivity rate of 80%, but a 100% specificity rate.
  • During the development of the GDS, it was noted that vegetative symptoms failed to differentiate depressed and nondepressed elders, thus these symptoms are largely not assessed by the GDS.
geriatric depression scale52
Geriatric Depression Scale
  • The GDS has been well studied in various geriatric populations unlike the other instruments discussed. It has been found to be a valid measure of depression in elderly medical inpatients.
  • however, the GDS does not maintain its validity in populations that contain large numbers of cognitively impaired patients.
  • In one study, the GDS maintained validity in cognitively impaired patients (MMSE score, 17.1)
geriatric depression scale53
Geriatric Depression Scale
  • The GDS is available in several languages, and it has been found to maintain its reliability and validity when administered by telephone, which may be useful in a variety of epidemiological and clinical settings.
  • A collateral source version of the GDS has been developed, although not extensively tested, which may prove useful as a screening instrument in those with aphasia, other communication deficits, or cognitive impairment.
geriatric depression scale short form gds sf 15 items
Geriatric Depression Scale Short FormGDS-SF 15 items
  • 5-7 min
  • long-form and the short-form are highly correlated (r = 0.84, P < .001).
  • short form has been validated in a geriatric affective disorder outpatient clinic (N = 116; average age 75.7 years).
  • Using an optimal cutoff score of 5-6, the short-form GDS showed a sensitivity of 85% and specificity of 74%
geriatric depression scale short form gds sf 10 5 4 1 item s
Geriatric Depression Scale Short FormGDS-SF 10, 5 ,4 , 1 item(s)
  • GDS 10-, 5-, 4-, and 1-item versions.
  • GDS-4 had lower internal consistency than the GDS -15, but missed only 5 of 46 depressed patients in this sample.
  • useful as a minimal screening procedure for detecting depression in elderly, primary care patients, especially among practitioners who feel that the 15-item GDS is too long.
  • There has not been further validation of these shorter scales in other studies.
depression scales for patients with dementia
Depression Scales for Patients With Dementia
  • Use outside informants (caregivers, nursing home staff) to provide history and reliable symptom reporting.
  • A collateral source form of the GDS has been developed for use in the cognitively impaired, although it has not been validated in a demented population.
depression scales for patients with dementia57
Depression Scales for Patients With Dementia
  • The best validated scale for dementia patients is the Cornell Scale for Depression in Dementia (CSDD).
  • The CSDD is an interviewer-administered scale that uses information both from the patient and an outside informant.
  • The scale has correlated well with depression as classified by the Research Diagnostic Criteria
depression scales for patients with dementia58
Depression Scales for Patients With Dementia
  • Factor structure analysis reveals 4 to 5 factors that are assessed by the CSDD, including general depression, biologic rhythm disturbances, agitation/psychosis, and negative symptoms.
  • However, even the CSDD has been better validated in patients with mild to moderate dementia, compared with patients with severe dementia.
  • The CSDD has been used in aphasic patients and compared with Research Diagnostic Criteria.
summary
Summary
  • Based on the research, it is clear the GDS is the best validated instrument in various geriatric populations.
  • The CSDD may be better given its inclusion of information from caregivers, but further research in the severely demented elderly is needed
slide60

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  • Alexopoulos GS, Abrams RC, Young RC, et al. Cornell Scale for Depression in Dementia. Biol Psychiatry. 1988;23;271-284.
  • Harwood DG, Ownby RL, Barker WW, et al. The factor structure of the Cornell Scale for Depression in Dementia among Alzheimer's disease patients. Am J Psychiatry. 1998;6;212-220.
  • Vida S, DesRosiers P, Corrier L, et al: Depression in Alzheimer's disease: Receiving operating characteristic analysis of the Cornell Scale for Depression in Dementia and the Hamilton Depression Scale. J Ger Psychiatry Neurology 7;159-162, 1997.
  • Katz IR. Diagnosis and treatment of depression in patients with Alzheimer's disease and other dementias. J Clin Psychiatry. 1998;59(suppl 9):S38-S44.
  • Herrmann M, Bartels C, Wallesch CW. Depression in acute and chronic aphasia: symptoms, pathoanatomical, clinical correlations and functional implication. J Neurol Neurosurg Psychiatry. 1993;56;672-678.
slide61

Schrijnemaekers VJJ, Hareman MJ. Depression in frail Dutch elderly: the reliability of the Zung scale. Clin Gerontologist. 1993;13:59-66.

  • Kivela S, Pahkala K. Sex and age differences of factor pattern and reliability of the Zung self-rating depression scale in a Finnish elderly population. Psychol Reports. 1986;59:587-597.
  • Gosker CE, Berger H, Deelman BG. Depression in independently living elderly, a study with the Zung-12. Tijdschr Gerontol Geriatr (Netherlands). 1994;24:157-162.
  • Hulstijn EM, Deelman BG, de Graaf A, et al. The Zung-12: a questionnaire for depression in the elderly. Tijdschr Gerontol Geriatr (Netherlands). 1992;23:85-93
  • Montgomery SA, Asberg M. A new depression scale designed to be sensitive to change. Brit J Psychiatry. 1979;134:382-389.
  • Maier W, Heuser I, Philipp M, et al. Improving depression severity assessment -- II. Content, concurrent, and external validity of three observer depression scales. J Psychiatr Res. 1988;22:13-19.
  • Waltis JP, Davies KN, Bunn WK, et al: Correlation between Hospital Anxiety Depression (HAD) scale and other measures of anxiety and depression in geriatric inpatients. Int J Gen Psych. 1993; 9:61-63.
  • van Marwijk H, Hoeksema HL, Hermans J. Prevalence of depressive symptoms and depressed disorders in primary care patients over 65 years of age. Fam Pract. 1994;11:80-84.
  • Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiat Res. 1982-1983:17:37-49.
  • Hyer L, Blount J. Concurrent and discriminant validities of the Geriatric Depression Scale with older psychiatric inpatients. Psychol Rep. 1984;54:611-616.
  • Rapp SB, Parisi SA, Walsh DA, et al. Detecting depression in elderly medical inpatients. J Consult Clin Psychol. 1988;56:509-513.
  • Koenig HG, Meader KG, Cohen HJ, et al. Self-rated depression scales and screening for major depression in the older hospitalized patient with medical illness. J Am Geriatr Soc. 1988;36:699-706.
  • Norris JT, Gallagher D, Wilson A, et al. Assessment of depression in geriatric medical outpatients: the validity of two screening measures. J Am Geriatr Soc. 1987;35:989-995.
  • Zgourides G, Spofford M, Doppett L. The Geriatric Depression Scale: discriminant validity and elderly day-treatment clients. Psychol Rep. 1989;64:1082.
  • Kafonek SD, Roca RP. Proper scoring of the Geriatric Depression Scale (letter). J Am Geriatr Soc. 1989;37, 819-820.
  • Parmalee PA, Lawton MP, Katz IR. Psychometric properties of the Geriatric Depression Scale among the institutionalized aged. Psychological Assessments. 1989;4:331-338.
  • Lesher EL. Validation of the Geriatric Depression Scale among nursing home residents. Clin Gerontologist. 1986;4:21.
  • Hickie C, Snowdon J. Depression scales for the elderly: GDS, Gilleard, Zung. Clin Gerontologist. 1987;6:51.
  • Kafonek S, Ettinger WH, Roca R, et al. Instruments for screening for depression and dementia in a long-term care facility. J Am Geriatr Soc. 1989;37:29-34.
  • Folsten MF, Folsten SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189-198.
  • McGivney SA, Mulvihill M, Taylor B. Validating the GDS depression screen in the nursing home. J Am Geriatr Soc. 1994;42:490-492.
  • Burke WJ, Houston MJ, Boust SJ, et al. Use of the Geriatric Depression Scale in dementia of the Alzheimer's type. J Am Geriatr Soc. 1989;37:856-860.
  • Burke WJ, Nitcher RL, Roccaforte WH, et al. A prospective evaluation of the Geriatric Depression Scale in an outpatient geriatric assessment center. J Am Geriatr Soc. 1992;40:1227-1230.
  • Izal M, Montorio I. Adaptation of the Geriatric Depression Scale in Spain: a preliminary study. Clin Gerontologist. 1993;13:83-91.
  • Burke WJ, Roccaforte WH, Wengel SP, et al. The reliability and validity of the Geriatric Depression Rating Scale administered by telephone. J Am Geriatr Soc. 1995;43:674-679.
  • Nitcher RL, Burke WJ, Roccaforte WH, Wengel SP. A collateral source version of the Geriatric Depression Rating Scale. Am J Geriatr Psychiatry. 1993;1;143-152.
  • Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. In: Clinical Gerontology: A Guide to Assessment and Intervention. New York, NY: The Haworth Press; 1986:165-173.
  • Herrman N, Mittmann N, Silver IL, et al. A validation study of the Geriatric Depression Scale short form. Int J Geriatr Psychiatry. 1996;11:451-460.
  • Lesher EL, Berryhill JS. Validation of the Geriatric Depression Scale -- Short Form among inpatients. J Clin Psychol. 1994;50:256-260.
  • D'Ath P, Katona P, Mullan E, et al. Screening, detection and management of depression in elderly primary care attendees I: The acceptability and performance of the 15 Item Geriatric Depression Scale (GDS15) and the development of short versions. Family Pract. 1994;1:260-266.
  • Scogin F. The concurrent validity of the Geriatric Depression Scale with depressed older adults. Clin Gerontologist. 1987; 7:23-31.
  • MacKenzie TB, Robiner WM, Knopman DS. Differences between patient and family assessment of depression in Alzheimer's disease. Am J Psychiatry. 1989;146;1174-1178.
  • Logsdon RG, Teri L: Depression in Alzheimer's disease patients: Caregivers as surrogate reporters. J Am Geriatr Soc. 1995;43;150-155.
  • Alexopoulos GS, Abrams RC, Young RC, et al. Cornell Scale for Depression in Dementia. Biol Psychiatry. 1988;23;271-284.
  • Harwood DG, Ownby RL, Barker WW, et al. The factor structure of the Cornell Scale for Depression in Dementia among Alzheimer's disease patients. Am J Psychiatry. 1998;6;212-220.
  • Vida S, DesRosiers P, Corrier L, et al: Depression in Alzheimer's disease: Receiving operating characteristic analysis of the Cornell Scale for Depression in Dementia and the Hamilton Depression Scale. J Ger Psychiatry Neurology 7;159-162, 1997.
  • Katz IR. Diagnosis and treatment of depression in patients with Alzheimer's disease and other dementias. J Clin Psychiatry. 1998;59(suppl 9):S38-S44.
  • Herrmann M, Bartels C, Wallesch CW. Depression in acute and chronic aphasia: symptoms, pathoanatomical, clinical correlations and functional implication. J Neurol Neurosurg Psychiatry. 1993;56;672-678.
social

Social

JP Baeyens , Van de Kerckhof

social network diagram

Friends

Family

First floor:

Daughter and husband

granddaughter

District nurse

Neigbourgh -------2/7---

Groundfloor

Patient aged 90 yrs

<…1/7…………………Granddaughter

Social Network Diagram

R.Capildeo t al., B Med J, 1976, 1, 143-4

socios
Socios

Future of patients

  • S1 no changes expected (or not known)
  • S2 only minor changes needed
  • S3 change in living place
  • S4 actions to be taken by expected death
socios65
Socios

Group context

  • G1 only information is needed
  • G2 patient and family needs guidelines
  • G3 patient and family is not able to organise anything
  • G4 conflict is present
socios66

Group

context

Future of patients

S1

S2

S3

S4

G1

A

A

A

A

G2

A

B

B

B

G3

A

B

B

B

G4

B

C

C

C

Socios
nutrition

Nutrition

T Pepersack, H Daniels, J Pétermans, C Gazzotti

malnutrition screening
Malnutrition screening
  • Anthropometric measures
  • Scale to assess the risk
    • Nutritional Screening questionnaire
    • MNA,
    • MUST
malnutrition screening69
Malnutrition screening
  • Anthropometric measures
  • Scale to assess the risk
    • Nutritional Screening questionnaire
    • MNA,
    • MUST
slide70
Anthropometric cut-off values that include body mass index for detecting underweight or undernutrition in adults
malnutrition risk screening
Malnutrition risk screening
  • Anthropometric measures
  • Scale to assess the risk
    • Nutritional Screening questionnaire
    • MNA,
    • Nursing Nutritional checklist
    • MUST
nsi checklist to determine your nutritional health
NSI Checklist To Determine Your Nutritional Health

-2 indicates good nutrition3-5 indicates moderate risk6 or more indicates high nutritional risk

Reprinted with permission by the Nutrition Screening Initiative, a project of the American Academy of Family Physicians, the American Dietetic Association and the National Council on the Aging, Inc., and funded in part by a grant from Ross Products Division, Abbot Laboratories, Inc.

malnutrition risk screening74
Malnutrition risk screening
  • Anthropometric measures
  • Scale to assess the risk
    • Nutritional Screening questionnaire
    • MNA,
    • Nursing Nutritional checklist
    • MUST
mna screening tool
MNA screening tool
  • Complete the Screening section by filling in the boxes with the numbers. Add the numbers in the boxes, for the screen.
  • Screening questions: ABCDEF

http://www.mna-elderly.com/clinical-practice.htm

slide76
AHas food intake declined over the past three months due to loss of appetite, digestive problems, chewing or swallowing difficulties?0 = Severe loss of appetite1 = Moderate loss of appetite2 = No loss of appetite
  • Ask patient
    • ‘Have you eaten less than normal over the past three months?’
    • If so, ‘is this because of lack of appetite, chewing or swallowing difficulties?’
    • If yes, ‘have you eaten much less than before or only a little less?’If this is a re-assessment, then rephrase the question
    • ‘Has the amount of food you have eaten changed since your last assessment?’
slide77
B Weight loss during the last 3 months?0 = weight loss greater than 3kg (6.6lbs)1 = does not know2 = weight loss between 1 and 3 kg (2.2 and 6.6 lbs)3 = no weight loss
  • Ask patient / from notes if long term patient or residential care
    • ‘Have you lost any weight over the last 3 months?’
    • ‘Has your clothes got looser?’
    • ‘How much weight do you think you have lost?’
slide78
C Mobility?0 = bed or chair bound1 = able to get out of bed/chair but does not go out2 = goes out
  • Patient notes/ information from carer/ ask patient if necessary
    • ‘Are you presently able to get out of bed/ chair?’
    • ‘Are you able to get out of the house?’
slide79
D Has the patient suffered psychological stress or acute disease in the past three months?0 = yes2 = no
  • Patient notes/ professional judgement/ ask patient
    • ‘Have you suffered a bereavement recently?’
    • ‘Have you recently moved your home?’
    • ‘Have you been unwell recently?’
  • If the patient’s notes specify an acute disease score 0
slide80
E Neuropsychological problems?0 = severe dementia or depression1 = mild dementia2 = no psychological problems
  • Patient notes/ professional judgement
    • Some indication of mental state of the patient may be obtained from the caregiver, nursing staff or medical records.If the patient is severely confused all answers to the following questions should be checked for accuracy with caregiver/ nursing staff (questions A, B, C, D, G, J, K, L, M, O & P)
slide81
F Body mass index (BMI)?

0 = BMI less than 19 1 = BMI 19 to less than 21 2 = BMI 21 to less than 23 3 = BMI 23 or greater

  • Before calculating BMI, ensure that the patient’s weight and height are recorded on the MNA® form.
      • 1. For conversion of weight and height
      • 2. If height has not been measured, please measure using a stadiometer (height gauge)
      • 3. If the patient is unable to stand, please calculate height from demispan
      • 4. On the BMI chart match up the height and weight of the patient, and read off the BMI score
      • 5. Fill in the appropriate box on the MNA® form to represent the BMI of the patient
malnutrition risk screening82
Malnutrition risk screening
  • Anthropometric measures
  • Scale to assess the risk
    • Nutritional Screening questionnaire
    • MNA,
    • MUST
references84
References
  • www.mna-elderly.com
  • www.nutrition.org
  • http://www.medscape.com/viewarticle/418398_5
  • http://www.ltcnutrition.org/
  • http://www.nature.com/ejcn/
  • http://www.espen.org/
  • http://www.cerin.org/
  • http://navigator.tufts.edu/
  • http://www.sfnep.org/
  • http://www.nutritioncare.org/homelink.asp?Link=www.nutritioncare.org/profdev/stnds.html
  • www.mna-elderly.com
  • www.asev.net
  • www.geriatrie.be
  • www.anaes.fr
slide85

Dwyer, J.T. (1991). Screening older American's nutritional health: Current practices and future responsibilities. Washington D.C., Nutritional Screening Institute.

Dwyer, J.T., Gallo, J.J. & Reichel, W. (1993). Assessing nutritional status in elderly patients. American Family Physician, 47(3), 613-620.

Posner, B.M., Jette, A.M., Smith, K.W., & Miller, D.R. (1993). Nutrition and health risks in the elderly: The nutritional screening initiative. American Journal of Public Health, 83(7), 972-978.

Zembrzuski, C.D. (1997). A three-dimensional approach to hydration of elders: Administration, clinical staff, and in-service education. Geriatric Nursing, 18(1), 20-26.

slide86

Pain

N Vandennoorgate, A Pepinster

pain assessment
Pain assessment
  • Cognitively intact elderly or those with mild to moderate dementia (group I)
  • Non communicative elderly or the elderly with moderate to severe dementia (group II)
pain assessment group i
Pain assessment: group I
  • Proposition I
    • Directly querying the patient
      • Presence of pain
      • Synonymous with pain
          • Burning
          • Discomfort
          • Aching
          • Soreness
          • Heaviness
          • Tightness

AGS panel; JAGS 2002; 50: S205-S224

Sebag-Lanoë; NPG 2003; 3(11,12): 4-10

pain assessment group i89
Pain assessment: group I
  • Proposition I (continuing)
    • Pro:
      • Easy and short
      • If the answer is yes, can be easily followed by further information concerning location, character, intensity and influence on activities
      • Can be followed by an appropriate scale if pain is present
    • Contra:
      • No validation (consensus report – level IIA)
      • No grading
pain assessment group i90
Pain Assessment: group I
  • Proposition II: Use of a scale
    • Numeric Rating Scale
      • A number between 0 (no pain) and 10 (extreme pain)
    • Verbal Rating Scale
      • 4 or 5 possible answers (absent-light-moderate-intolerable)
    • Visual Analoque Scale (VAS)
      • less useful in an elderly population
      • Vertical presentation more useful

Francois et al. Revue de gériatrie 2004;29(2):95-101

Trichet-LLory et al. Revue de gériatrie 2004;29(2):103-8

pain assessment group i91
Pain assessment: group I
  • Proposition II (continuing)
    • Alternatives of VAS

Faces pain scale

Pain Thermometer

pain assessment group i92
Pain assessment: group I
  • Proposition II (continuing)
    • Pro:
      • Accepted validity in this patient population
      • Vertical presentation seems to be more easy for people with cognitive impairment

AGS panel; JAGS 2002; 50: S205-S224

Sebag-Lanoë; NPG 2003; 3(11,12): 4-10

pain assessment group ii
Pain assessment: group II
  • Proposition I:
    • Direct observation/history from caregiver
      • Unusual behaviour
        • Trigger the assessment of pain
      • Pain related behaviour during movement
        • facial expressions, verbalization, vocalization, body movements, mental status changes
    • Pro
      • Easy and short
      • Can be followed by a scale
    • Contra
      • No validation (consensus report level II evidence)
      • No grading

AGS panel; JAGS 2002; 50: S205-S224

Sebag-Lanoë; NPG 2003; 3(11,12): 4-10

pain assessment group ii94
Pain assessment: group II
  • Proposition II: use of pain scale
    • Checklist of non-verbal Pain indicators
      • 6 questions with a score =0 if absent and score=1 if present; score between 0 and 6 correspond with the intensity of pain
    • ECPA (échelle comportementale de la douleur pour personnes âgées non communicantes)
      • 4 observation 5 min before the care (5 intensity ratings(0-4))
      • 4 observation during the care (5 intensity ratings (0-4))
    • Doloplus II scale

Feldt et al. JAGS 1998;46:1079-1085

AGS panel; JAGS 2002; 50: S205-S224

Sebag-Lanoë; NPG 2003; 3(11,12): 4-10

www.doloplus.com

pain assessment group ii95
Pain assessment: group II
  • Checklist of Non-verbal Pain Indicators (Feldt, 2000; Milisen K., 2002-verder onderzoek noodzakelijk)
  • Non-Verbaal
    • Pijngeluiden (afwezig=0; aanwezig=1)

Kermen, kreunen, huilen, hijgen, zuchten

2. Pijngrimassen (afwezig=0; aanwezig=1)

Opgetrokken wenkbrauwen, dichtgeknepen ogen, gespannen lippen, vertrokken mond, op elkaar geklemde tanden, verwrongen gelaatsuitdrukking, piijnkrampen, pijnrillingen

3. Krabben/ wrijven aan de wond (afwezig=0; aanwezig=1)

pain assessment group ii96
Pain assessment: group II
  • Checklist of non-verbal pain indicators (vervolg)

4. Vastklampen door pijn bij manipulatie of mobilisering

Grijpen naar of vastklampen aan hekjes, bed, nachtkastje of ondersteunen van wonde(afwezig=0; aanwezig=1)

5. Onrust/agitatie (afwezig=0; aanwezig=1)

Constante of onderbroken verandering van houding; constante of onderbroken handbewegingen, onmogelijk om stil te zitten

B. Verbaal

6. Pijnwoorden (afwezig=0; aanwezig=1)

‘Au’, dit doet pijn, vloeken tijdens bewegingen of uitdrukkingen van protest zoals ‘stop’, ‘genoeg’

Score (van 0 tot 6) geeft de intensiteit van de pijn weer

pain assessment group ii98
Pain assessment: group II
  • Proposition II (continuing)
    • Pro:
      • To do with some experience in about five minutes
      • Available in french and English
    • Contra:
      • Validation ?
      • Not suggested if the patient is communicative and cooperative
      • Suggested by the slightest doubt

DoloplusII

frailty

Frailty

C Swine, G Dargent, P Devriendt

frailty definition and framework
Frailty: definition and framework
  • Homeostasis (physiological)
  • Vulnerability (preclinical)
  • Frailty (impairments)
  • Functional decline (disability)
outcomes of frailty
Outcomes of frailty
  • Functional decline (disability, dependance)
  • Geriatric syndromes
  • Health services use
  • Institutionalisation
  • Failure to thrive
  • Death
frailty definition and framework102
Frailty: definition and framework
  • Homeostasis (physiological)
  • Vulnerability (preclinical)
  • Frailty (impairments)
  • Functional decline (disability)
risk for functional decline frailty screening
Risk for functional decline frailty screening
  • Early screening needed (admission)
  • Feasible in the admission unit (emergency)
  • Help for triage and further assessment
  • Potential tool for liaison geriatrics
existing tools
Existing tools
  • HARP Hospital Admission Risk ProfileSager et al. J Am Geriatr Soc 1996
  • ISARIdentification of Seniors At RiskMc Cusker J. et al : JAGS 1999; 47: 1229-1237
  • SIGNET Case finding in the EDMion L.C. et al. JAGS 2001; 49: 1379-1386
  • SHERPAScore hospitalier d’évaluation du risque de perte d’autonomieP. Cornette, et al. Revue Médicale de Bruxelles 2002 ;23-suppl1 :A181.
  • SEGAShort emergency geriatric assessmentSchoevaerdts et al. La revue de gériatrie 2004 in press
harp sager et al j am geriatr soc 1996
HARP Sager et al. J Am Geriatr Soc 1996

AGE

75 y 0

75- 84 y 1

85 y 2

MMSa

15-21 0

0- 14 1

IADL 2w before admission

6- 7 0

0- 5 1

TOTAL

0 - 1 low risk

2 - 3 intermediate risk

4 - 5 high risk

slide106

ISARIdentification of Seniors At RiskIdentification Systématique des Aînés à RisqueMc Cusker J. et al : Detection of older people at increased risk of adverse health outcomes after an emergency visit: the ISAR screening tool. JAGS 1999; 47: 1229-1237

  • Self administred questionaire
  • Previous hosp. admission (6 m.) Yes/ No
  • Vision problems Yes/ No
  • Memory problems Yes/ No
  • Premorbid help need Yes/ No
  • Current help need Yes/ No
  • More than 3 medications Yes/ No
slide107

ISARIdentification of Seniors At RiskIdentification Systématique des Aînés à RisqueMc Cusker J. et al : Detection of older people at increased risk of adverse health outcomes after an emergency visit: the ISAR screening tool. JAGS 1999; 47: 1229-1237

Score prevalence %AR*** likelihood* (**)

  • 2 or more yes 51% 72% 2,0 (1,7)
  • 3 or more yes 27% 44% 3,0 (2,2)
  • 4 or more yes 12% 23% 4,7 (2,8)
  • *likelihood of adverse outcome or current disability
  • ** likelihood of adverse outcome (death, institutionalization, functional decline)
  • *** % of patients at risk detected
slide108

SIGNET: triage risk screening toolEstablishing a case-finding and referral system for at risk older individuals in an emergency department setting: the SIGNET model.Mion L.C. et al. JAGS 2001; 49: 1379-1386

1 Presence of cognitive impairment

2 Lives alone or no caregiver available

3 Difficulty walking, transfers or recent fall

4 Recent ED visit or hospitalization

5 Five or more medications

6 Need further follow-up at home(Abuse, neglect, compliance, iADL)

If yes at question 1 or at 2 other questions: further assessment

slide109

Factors predicting FD 3 months after hospital discharge in 600 older patients, a screening tool (SHERPA)P. Cornette, W. D'Hoore, C. Swine IDENTIFICATION DES PATIENTS AGES HOSPITALISES A RISQUE DE DECLINFONCTIONNELRevue Médicale de Bruxelles 2002 ;23-suppl1 :abst.O.397, p A181.

  • AGE < 75 0 75-84 1.5 >85 3 MMS (21) > 15 0 Falls (1y) no 0 <14 2 Yes 2 iADL 6-7 0 5 1 B s.p. H no 0 3-4 2 Yes 1.5 0-2 3
  • Category % %FD OR
  • Low (0-3) 36 13 1
  • Mild (3.5-4.5) 23 23 2
  • Mod.(5-6) 18 39 4
  • High (>6) 23 62 10
frailty admission screening criteria common to the different tools
Frailty admission screening criteria common to the different tools
  • Age <75; 75-85; >85
  • Cognitive function normal; delirium; dementia
  • Medications <3; 4-5; >5
  • Hospital use no; ED 1 m; H 6 m
  • Help for ADL no; elevated; increased
  • Sensory impairments no; hearing; vision
  • Falls no; 1 > 1y; 1 < 6 m
  • Health perception good; fair; poor
  • iADL ’s 7; 5-6; < 5