Clinic case

1. Geriatric Assessment:Enhancing Your Patient’s Functional StatusEric J H Troyer, MDSixth Annual Geriatric Medicine SymposiumSwedish Medical CenterSeptember 13, 2002

2. Clinic case • Geriatric Assessment Outline • Take Home Points • 1. Routine assessment of the elderly is important. • 2. It is quick & easy to assess and intervene appropriately. • 3. Standardized tools and algorithms exist. • 4. You can incorporate elements of geriatric assessment into a routine office visit. • 5. It is targeted at improving your patient’s function and quality-of-life. • 6. It communicates your concern for your patient’s well-being. • Introduction • 1. Prevalence of geriatric syndromes in the community-dwelling elderly is high. • 2. Geriatric Assessment Defined: • Multidimensional and systematic evaluation of your patient that focuses on actual abilities and function as well as common problems of the elderly. It has the goal of intervention and prevention. • 3. Multiple Domains: • a. Physical health • b. Mental health • c. Functional status • d. Social assessment • e. Economic status • f. Potential caregiver strain • g. Personal values • h. Advance care directives • i. Elder abuse • 4. Benefits: • a. Helps your patient’s function & quality of life. • b. Allows you to streamline care. • c. Helps you recognize the need for available resources. • d. Can be personally satisfying. • e. Better predict outcomes compared with using medical diagnoses. • f. Find undetected and treatable disease. • g. Improves outcomes via interventions. • h. Allows you to wisely spend your valuable time. • Targeting your vulnerable population • 1. ACOVE VES-13 Survey • 2. Chart Reviews, Database Reports • Review of elements of routine geriatric assessment • 1. What should be included? • a. Common problems • b. Those amenable to intervention • c. Exam can focus on functional skills • 2. Cognition • a. Mini-Cog • b. MMSE • c. IQCDE • 3. Mood • a. Yale Depression Screen: “Do you often feel sad or depressed?” • b. Two questions: “During the past month, have you often been bothered by: 1) little interest or pleasure in doing things? OR 2) feeling down, depressed, or hopeless?” • c. GDS • 4. Activities of Daily Living • a. Basic ADL’s • 1. Bathing • 2. Dressing • 3. Ambulating • 4. Toileting • 5. Grooming • 6. Feeding • b. Instrumental ADL’s • 1. Telephone use • 2. Shopping • 3. Food preparation • 4. Housekeeping • 5. Laundry • 6. Transportation • 7. Medications • 8. Finances • c. Six Questions: • i. “Are you able to do strenuous activities, like fast walking or bicycling?” • ii. “Are you able to do heavy work around the house, like washing windows, walls, or floors?” • iii. “Are you able to go shopping for groceries or clothes?” • iv. “Are you able to get to places that are out of walking distance?” • v. “Are you able to bathe – sponge bath, tub bath, or shower?” • vi. “Are you able to dress, like put on a shirt, button and zip your clothes, or put on your shoes?” • d. Performance Test of ADL (PADL) • e. Interventions • 5. Fall risk • a. Single question: “Have you had an accidental fall to the ground in the past six-twelve months?” • b. Timed “Up and Go” • c. Tinetti’s POMA • d. Home safety evaluation / questionnaire • e. Multiple algorithms available for fall evaluation and intervention • 6. Incontinence • a. Two questions: “Do you ever lose urine when you don’t want to?” and “Have you lost urine on at least six separate days?” • b. To elicit evidence of stress incontinence, “Do you ever lose urine when you cough, exercise, lift, sneeze, or laugh?” • c. Incontinence workup • d. Consult the MIAH Urinary Incontinence Toolkit • 7. Hearing • a. Whisper Test • b. Examine auditory canals for cerumen; clean if needed, then retest • c. HHIE-S • d. If available, use audioscope set at 40 dB and test using 1000 and 2000 Hz. • e. Refer for audiometry and possible prosthesis • 8. Vision • a. Two simple questions: “Because of your eyesight, do you have trouble driving a car, watching television, reading, or doing any of your daily activities?” and “Has it been greater than two years since your last complete eye exam?” • b. Jaeger eye test (at 14”) or Snellen eye chart (at 20’); if 20/40 or worse then: • c. Refer to ophthalmologist • 9. Nutrition • a. BMI <22 or weight loss > 10# in 6-12 months • b. Evaluate dentition (Consider using GOHAI) • c. Nutrition Screening Initiative Tools (AAFP) • 10. Caregiver strain • a. With patient of our room, ask caregiver about physical and emotional strain • b. Caregiver Strain Index • c. Referral to community resources • 11. Medication review • a. List all drugs • b. ACOVE guidelines • c. Inappropriate medications list • 12. Social/Financial • a. “Who is your primary caregiver?” • b. “Do you live alone?” and “How do you spend your day?” • c. “Who could you turn to for help in the event that you are unable to take care of yourself?” • 13. Screen for other diseases (e.g., BPH with AUA Symptom Index) • Case Example • Conclusions • Handouts

3. Clinic case • Geriatric Assessment Outline • Take Home Points • 1. Routine assessment of elderly is important. • 2. It is quick & easy to assess and intervene appropriately. • 3. Standardized tools and algorithms exist. (in many formats, helps communicate severity and map progress/decline, validated instruments) • 4. You can incorporate elements of geriatric assessment into a twenty-minute office visit. • 5. Geriatric assessment is targeted at improvement in your patient’s function and QOL. (may be more important to your patients than diseases we as physicians normally focus) • 6. It can communicate your concern for your patient’s well-being. • Introduction • 1. Prevalence of geriatric syndromes in the community-dwelling elderly • a. 20% of those over 65 have ADL difficulties • 2. Definition: • a. Multidimensional and systematic evaluation of your patient that focuses on actual abilities and function as well as common problems of the elderly. • 3. Domains: • a. Physical health • b. Mental health • c. Functional status • d. Social assessment • e. Economic status • f. Potential caregiver strain • g. Personal values • h. Advance care directives • i. Elder abuse • 4. Benefits: • a. Helps your patient’s function & QOL • b. Allows you to streamline care (gives you an orderly way to screen for conditions with high impact on your patients; especially those that don’t fit into any medical/disease framework) • c. Helps you recognize the need for available resources • d. Can be personally satisfying • e. Better predict outcomes compared with use of medical diagnoses (hosp, instit, death…; why, because it integrates complexity, multiplicity, & severity of dz) • f. Can point to undetected, treatable disease (your dx skills will improve) • g. Improves outcomes via interventions (treating dz, changing pt’s environment) • h. Allows you to wisely spend your valuable time (in place of full PE in asymptomatic pts) • Targeting your vulnerable population • 1. ACOVE VES-13 Survey • 2. • Review of elements of routine geriatric assessment • 1. What should be included? • a. Common problems • b. Those amenable to intervention • c. Exam can focus on functional skills (hearing, vision not tm’s and fundus; gait/balance not reflexes/romberg • 2. Cognition • a. Mini-Cog (http://208.234.121.168/handouts/2002/docs/leipzig.pdf) • i. Scored positive if recall = 0 –or- CDT abnormal c/ recall <2 • ii. Takes 2 minutes complete • iii. Not affected by education or language • iv. Mini-Cog outperformed the MMSE and CASI in sensitivity (99%) and had acceptable specificity (93%) [LR+ 14 and LR-0.01]. • b. MMSE (score less than 24 generally indicates cognitive dysfnx) • c. IQCDE • 3. Mood • a. Yale Depression Screen: “Do you often feel sad or depressed?” • b. Two questions: “During the past month, have you often been bothered by: 1) little interest or pleasure in doing things? OR 2) feeling down, depressed, or hopeless?” • c. GDS (0-10 normal, 11-13 borderline, >13 depression) • 4. ADL’s • a. Duke OARS • i. Basic ADL’s (deficits here would indicate unable to live alone) • 1. Bathing • 2. Dressing • 3. Ambulating • 4. Toileting • 5. Grooming • 6. Feeding • ii. Instrumental ADL’s (deficits here would indicate need for assistance, red flag for further eval of cognition or physical state) • 1. Telephone use • 2. Shopping • 3. Food preparation • 4. Housekeeping • 5. Laundry • 6. Transportation • 7. Medications • 8. Finances • b. Six Questions: • i. “Are you able to do strenuous activities, like fast walking or bicycling?” • ii. “Are you able to do heavy work around the house, like washing windows, walls, or floors?” • iii. “Are you able to go shopping for groceries or clothes?” • iv. “Are you able to get to places that are out of walking distance?” • v. “Are you able to bathe – sponge bath, tub bath, or shower?” • vi. “Are you able to dress, like put on a shirt, button and zip your clothes, or put on your shoes?” • c. Consider use of the Performance Test of ADL (PADL) • d. Interventions • 5. Fall risk • a. Single question: “Have you had an accidental fall to the ground in the past six months?” • b. Get Up and Go (postural stability, steppage, stride length, sway, strength, transfer; 15sec) • c. Tinetti’s POMA • d. Home safety evaluation / questionnaire • e. Multiple algorithms available for fall evaluation and intervention • 6. Incontinence • a. Two questions: “Do you ever lose urine when you don’t want to?” and “Have you lost urine on at least six separate days?” • b. To elicit evidence of stress incontinence, “Do you ever lose urine when you cough, exercise, lift, sneeze, or laugh?” • c. Incontinence workup • d. Consult the MIAH Urinary Incontinence Toolkit • 7. Hearing • a. Whisper Test (1-2’ behind, cover one ear, whisper) • b. Examine auditory canals for cerumen; clean if needed, then retest • c. HHIE-S (http://216.157.50.80/docs_ch37/doc_ch37.17.html#A37.17.2) • d. If available, use audioscope set at 40 dB and test using 1000 and 2000 Hz. • e. Refer for audiometry and possible prosthesis • 8. Vision • a. Two simple questions: “Because of your eyesight, do you have trouble driving a car, watching television, reading, or doing any of your daily activities?” and “Has it been greater than two years since your last complete eye exam?” • b. Jaeger eye test (at 14”) or Snellen eye chart (at 20’); if 20/40 or worse then: • c. Refer to ophthalmologist • 9. Nutrition • a. BMI <22 or weight loss > 10# in 6-12 months • b. Evaluate dentition (Consider using GOHAI) • c. Nutrition Screening Initiative Tools (AAFP) • 10. Caregiver strain • a. With patient of our room, ask caregiver about physical and emotional strain • b. Referral to community resources • 11. Medication review • a. List all drugs • b. ACOVE guidelines • 12. Social/Financial • a. “Who is your primary caregiver?” • b. “Who could you turn to for help in the event that you are unable to take care of yourself?” • c. Do you live alone? • 13. Screen for other diseases (e.g., BPH with AUA) • Case Example • Recap • Handouts