gPodGeriatric Pearls On

Demand

Brian Christopher Misiaszek, MD, FRCPS(C)Asst. Professor of Geriatric and Internal Medicine,

Michael G. DeGroote School of Medicine at McMaster

Intro

• Why do we do Comprehensive Geriatric Assessments?

• Assessment tools and instruments for getting the job done

• How to use these instruments and where to find them

Goals of Geriatric Medicine:

• To help manage chronic medical problems in seniors

• Assess and improve on function, cognition & behaviour

• to maximize the positive aspects of aging and to improve the QOL of seniors.

• To help keep persons safely in their homes or with their families as long as safely possible

Comprehensive Geriatric Assessment?

• A systematic comprehensive evaluation of an older adult using validated screening instruments.

• Attention is paid not just to the medical problems, but how the patient’s cognition, mood and the home situation affects them

• Special attention is paid to cognitive and mental health issues & screening for any problems

•The focus is on function, not cure

Red flags for an Assessment?

•Frail elderly (>75 years)

•and 3 or more of:•Needs help with ADLs/IADLs by CCAC

or caregiver

• Lives alone

• Falls

•Delirium/confusion

• Incontinence

•>2 admissions to acute care hospital/year

Many unique domains covered :

• HPI & Past Medical History

• Medication optimization

• Functional assessment

• Current living situation; BADLs & IADLs

• Vision/Hearing/Mobility/ Continence/Diet

• Physical examination

• Cognitive assessment

• Screening mood issues of patient & caregivers

• Targeted investigations

How to do this? Systematically follow checklist & use validated

tools/instruments!

Past Medical History & ROS

• In particular, ask about any MI’s (when, how treated), CVA, DM (how long, are they seeing a diabetic specialist), bone fractures (how treated), memory troubles, or recent hospitalizations.

• Ask about under-reported disorders, such as bladder or bowel problems, falls, pain, alcohol use, & weight loss

• Get family to help out with these

Don’t forget to look at old hospital notes, especially if there are memory issues

Medication Review

• Ask about all prescriptions and OTC meds, and any recent changes

• They can’t quite remember ? (“It’s a little white pill for my heart!”)

•“Brown Bag Technique”

•Old hospital charts

•Call their pharmacy!

•Current Hospital Cardex (don’t trust the computer!)

Every medication should have a diagnosis & every diagnosis the appropriate

medication!

Some drugs to avoid or minimize

• Sedatives

• Long acting benzos

• Long acting narcotics

• Anticholinergics (gravol, detrol, flexeril, TCAs)

• Beers Listed meds*

Even good drugs can be bad actors with the wrong dose or

taken at the wrong time

Beers list of potentially inappropriate meds

• Expert consensus panel statement

• Meds that have high risk of ADRs in seniors or are unsafe in certain co-morbid disease

• Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Fick & Beers et all, Arch Intern Med. 2003;163:2716-2724.

• Google : Beers inappropriate meds

Review with patient/family:

and disss:•Possible effects of medications on

adverse health

•Possibility of dose reduction or elimination of chronic meds

•Are medications properly taken (i.e. puffers, sprays, insulin) or stale dated?

•Providing home pharmacy and Family MD with up to date listing

•using a dosette box or blister-packs to help with adherence?

Functional Inquiry•BADLs & IADLs

•Mobility, falls, gait aids

•Vision and Hearing

•Continence

•Appetite, weight, diet

•Biography &Living Situation

•CCAC & other Services

•POA & Advance Directives

Instrumental Activities of Daily Living (IADLs)

•Tasks and roles you do at home

•Shopping, meal planning & preparation, housekeeping, laundry, transit, financial management, using a telephone, medication management, & driving

•In research often captured with the Lawton-Brody instrument

Think of things you have to do to go away to college/university!

Basic Activities of Daily Living(BADLs)

•Toileting, self hygiene, bathing, grooming, dressing, feeding, and ambulation (stairs too).

• For each ask if independent, needs assistance or dependententirely on a caregiver.

•Captured in Barthel ADL index (BAI) in research

Think of BADLs as those personal things a grade 1 student has to do each morning to get ready of

school.

Mobility issues?

• Independent with walking?

• Are they falling? How often? What circumstances?

• Previous bone fracture (think osteoporosis!)?

• Do they use an assistive gait device, such as a cane, quad-cane, walker, or wheelchair?

• Was the latter prescribed for them? When and why? Are they using them?

Ask about Continence

• Any problems with their bladder or bowels (and what does their caregiver say?)?

• Ask, “Pardon me, but have you ever had “an accident” with your bowels or bladder?”

• Do they have to wear a pad or adult diapers? Should they?

• Are they up frequently in the night to toilet? Why?

Sensory Inquiry• problems with their vision?

Glasses? When were they last changed?

• Problems driving? Reading? Watching TV? When was the last time they saw their eye doctor?

• Hearing problems? Have they ever had audiology testing? Do they have a hearing aid (and do they use it? Change batteries?)

Get a brief Biography

•Where were they born? Educational achievements?

•What did they do for a living? Ever in the military?

•Ever married? How many times? How old were they? And their spouse?? Any children? Where are they now?

•When did they retire? Why?

And how much did they have to struggle to tell you this information?

Current Living Situation?• Type of residence (house,

apt., granny flat, RH, NH)?

• With whom do they live (alone, spouse, child, friend, or ?) and their health (if appropriate)?

• Vices? (smoker, ETOH)

• Current diet? (makes meals, MOW, skips meals, etc.)

• Informal supports (family, neighbours, church)?

• Power of Attorney?

Physical Examination of the Older Adult

• Much like usual exam, but try to be more efficient with minimal position changes

• Ensure you do good set of vitals including postural vitals (BP and HR)

• Get the patient's weight

• screening respiratory, cardiac and neurological exams often most revealing

• may find primitive reflexes (i.e. palmomental)

Measure Postural Vitals• BP supine after 5 minute rest,

then standing at 1 & 3 minutes (or 0 and 2 minutes)

• Orthostatic hypotension (OH)defined at BP drop of 20 mmHg systolic or 10 diastolic afterstanding

• OH associated with dizziness, cognitive impairments, and increased falls

• Not normal for BP to drop and HR unchanged (autonomic AbN)

Sensory Screening• Check vision with Snellen

eye chart

• Red reflex present? (nil=cataract)

• Whisper Test screen for hearing (standing behind patient softly say letters and words for them to repeat with ear canal blocked; Sn/Sp 0.8-1.0/0.8-0.89)

Balance/Gait Assessment•Gait aid? Can stand up

without hands?

•Standing balance with Romberg?

•Walking: ankle distance, stance, step off, speed, scuffing, arm-swing, turns, deviation from path, touches wall, falls down?

•Silly footwear/shoes?

3 meter "Timed up & Go"(TUG)

• Patient is timed standing up from a chair, walking 3 m, turning around and sitting down

• N is ~10 seconds (95% <13 s)

• ~20 seconds for frail adult; needs gait assessment +/- aid

• 30+ seconds; likely unsafe on own, definitely needs gait aid and probably supervision

Cognitive Examination of the Older Adult

Cognitive Impairments

•A cognitive impairment is a decrement in how a person thinks, reacts to emotions, or behaves.

• It may involves changes in one or more domains including ---->

•Memory•Language

•Perception

•Judgment & insight

•Attention

•Ability to perform BADLs & IADLs

Causes of Cognitive Impairments in Seniors?

• Delirium (acute confusion, usually reversible)

• Dementia (chronic confusion, not usually reversible)

• Depression*(temporary, usually reversible)

• Drugs (reversible)

Screening for Cognitive Problems?

•CAM (confusion assessment method) for delirium

•Standardized Mini Mental Exam (SMMSE)

•Clock Drawing Test (CDT)

•Testing language, reasoning, & safety problem solving

•Frontal Lobe Testing Batteries (FAB)

•Other tests (MoCA, CCT, etc.)

Confusion Assessment Method (CAM) for delirium

1. History of acute onset of change in patient’s normal mental status & fluctuating course?

AND2. Lack of attention?

AND EITHER

3. Disorganized thinking?4. Altered Level of Consciousness?

Inouye SK: Ann Intern Med 1990;113(12):941-8Arch Intern Med. 1995; 155:301

Sensitivity: 94-100%Specificity: 90-95%Kappa: 0.81

Standardized Mini Mental State Exam

•A validated and commonly used screening tool for cognitive impairments

•SMMSE does NOT diagnose dementia

•is insensitive to MCI, early dementia and/or FTD

•A common cut-off is a score of 23 or less out of 30

Note: SMMSE is language, age and education dependent

SMMSE Pearls•If the attention portion of the

test is 0/5, is highly suggestive for delirium, not dementia.

•If 3-word recall is 3/3 (perfect), yet the history is positive for cognitive decline this strongly suggests a diagnosis other than Alzheimer’s dementia

•Poor pentagons that don't intersect correlated with poor driving ability

Clock Drawing Test (CDT)•NOT part of the SMMSE;

tests abstraction and visual-spatial cognition

• Draw a circle, and ask the patient to write in all the numbers to make a clock face, then ask them “Please set hands of the clock to 10 after 11”

•Various scoring systems, but essentially numbers and hand placement should both normal

Normal

AbN “concrete” clock.

Other helpful Tests

Problem solving

•“You smell smoke and looking through the window see flames coming from the home next door; what do you do? “

Fund of knowledge testing:

•What happened on 9/11? Who is the Canadian PM? Current US President? (may ask re: local mayor, sports events, soap opera plots, etc.)

Verbal fluency

(abstract thought test)

•subject asked to name as many 4 legged animals as they can think of in sixty seconds

•Normal is 20 +/- 5 animals for <65, or 15+/- 5 if over 85*.

* at no time should the number be less 10 if English 1st

language and if they have completed grade school in Canada!

Confrontational naming:

• “What’s this?” and point to wrist-watch, and sub-parts including band, stem, crystal.

•ditto try eye-glasses; frames/earpieces/lens.

•Shoe; heel/lace/tongue

• stethoscope

Verbal AbstractionVerbal abraction

• “What’s the difference between:"

•lie/mistake?

•child/midget?

•river/canal ?

• “How are these the same?”

•car/airplane

•orange/banana

•clock/money

Frontal Lobes•The frontal lobes contain

brain structures important for executive functions, such as planning, judgement, regulating behavior and exercising self-control.

• If damaged, may result in range of behaviors such as apathy, swearing, undressing, urinating in public, eating & drinking non-food items and so on

•SMMSE can't capture this!

Frontal Lobe Tests:• Lexical Fluency: (abstract thought test) Asked to

name as many words that begin with the letter S as they can think of in sixty seconds (Normal is 10+)

• Conceptionalization (how are an apple and a pear the same? A rose and a daisy? A bed and a desk?

• Interference testing (Go/ No Go, then change the rules)

• Pattern replication (ie. Luria Hand Test, alternating peaks and valleys).

• Prehension Ability (“Don’t shake my hands!”)

Various batteries of these tests, and others, are available, i.e.. Frontal Assessment Battery or FAB

Montreal Cognitive Assessment (MoCA)

•Useful for screening for Mild Cognitive Impairment (MCI) not dementia; scored / 30

•N 27 (SD 2.0)

•MCI 22.5 (SD 3.1)

•AD 16.7 (SD 5.1)

www.mocatest.org

Screening for DepressionDepression is the most common mental illness in older adults; it is under diagnosed and under treated.

•Ask “Do you often feel downhearted and sad?”(Sn/Sp 0.85/0.65)

•ask about suicidal or pessimistic thoughts

•Do a GDS (next)

Geriatric Depression Scale (GDS)

• For the 15 item the GDS; 5+ is suggestive, 10+ points is very suggestive for depression

• (SN/SP 0.94/0.83).

• If a positive on the screen, follow up with a more thorough MSE interview using SIGGCAPS

• Note: GDS isn't valid or accurate if a patient has dementia!

Targeted lab tests• Order investigations only to

confirm or rule out hypotheses generated during the Hx and Px

• for dementia, usual screening investigations are:

• CBC, TSH, serum electrolytes, serum calcium & serum glucose

• +/- CT Head (as per new 2006 Canadian Consensus Guidelines)

If you can measure a drug's serum concentration, do so

Estimate GFR (eGFR)•estimation of renal function based on age,

body mass & serum Creatinine•SI metric Cockcroft-Gault formula

estimated CrCl=•(140-age) x weight x 1.23 x (0.85 if female)•Creatinine [micromol/l]• http://nephron.com/cgi-bin/CGSI.cgi

•Google for: SI GFR calculator on the Webor use PDA / calculators

End stage/terminal renal failure<15 mL/minute

Severe impairments; as above, cognitive & fatigue effects, consider planning for dialysis

29-15 mL/minute

Moderate impairments; as above, consider investigations, follow and adjust renally excreted meds

60-30 mL/minute

Mild impairments; observe BP & risk factors

89-60 mL/minute

Clinical correlate of renal dysfunctionCrCl (~eGFR)

Note: normal CrCl/eGFR is greater 90 mL/minute

Calculate eGFR on all your patients:

Impression and Plan•a comprehensive

"Care Plan" or blueprint of action is the end result of the assessment

•Often a balance between short and long term goals

A good assessment plan will:

• ID all problems & address WHAT YOU ARE GOING TO DO ABOUT THEM!

• specific medical tests & interventions

• medication changes

• actions & referrals required

• CCAC resources needed

•A CGA may discover one or more reversible causes of an older person’s problems limiting their function,cognition & behaviour

•Specific clinical mgt. depends on the specific clinical entities uncovered & the adherence to suggestions made!

•Very complex problems may require admission into a specialized Day Hospital or Geriatric Assessment Unit (GAU)

•There they can be seen by specialized allied health services for review (i.e. OT for kitchen assessment, PT for gait retraining, SLP for swallowing issues, etc.)

Follow up planning

•Regular follow up via clinic or home visits often needed to make adjustments to the care plan as required

•May allow for ongoing caregiver education & avoid unnecessary hospital admissions or caregiver burnout

•Stable? Family MD may take over this role

Summary: 8 steps• Step 1: Get the History

• Step 2: Medication Review

• Step 3: Functional Inquiry

• Step 4: Physical Examination

• Step 5: Cognitive Testing

• Step 6: Screening for Emotional Problems

• Step 7: Targetted Lab investigations

• Step 8: Impression, plan, and follow-up.

Summary of Geriatric Pearls

Final Pearls• Never assume that a distressing

symptom or sign is caused just by “old age” (i.e. memory loss, falls, pain, incontinence)

• Look for dementia and delirium, and screen for them.

• Look for all the causes of health problem in an older adult, not just one.

• Get old hospital charts and previous consultations notes

• The telephone can be used to contact Family and Family MD’s to help with the history if the patient cannot provide it.

Have fun using your new gPod!

Brian Misiaszek, MD, FRCPS(C)