Samira Khazravan, M.D.Samira Khazravan, M.D.Geriatric FellowGeriatric Fellow

Department of GeriatricsDepartment of GeriatricsMary Immaculate Hospital

EVALUATION OF FUNCTIONAL EVALUATION OF FUNCTIONAL CAPACITY AND HISTORY & CAPACITY AND HISTORY &

PHYSICALPHYSICAL

Assessment of the Assessment of the Geriatric PatientGeriatric Patient

COMPREHENSIVE GERIATRIC COMPREHENSIVE GERIATRIC ASSESSMENTASSESSMENT

CGACGA Diagnose and develop an overall

plan of care for treatment and long term follow up

Optimizes independence and prevent future disabilities.

Consist of set professionals that make up a multidisciplinary team.

Includes evaluation of physical and mental health, functional status, social function, and environment.

WHY CGA?WHY CGA?

Great success in improving function.Great success in improving function. Decreases multiple negative Decreases multiple negative

variables, such as nursing home variables, such as nursing home placement, medication use, and placement, medication use, and mortality.mortality.

It increases diagnostic accuracy and It increases diagnostic accuracy and independence.independence.

SUCCESSFUL SUCCESSFUL MANAGEMENTMANAGEMENT

OF CGAOF CGA Accomplished when the Geriatric Accomplished when the Geriatric

Team takes over the direct care of Team takes over the direct care of the patient.the patient.

Unlikely to be successful in Unlikely to be successful in improving patient outcomes when improving patient outcomes when the Geriatric Team assumes a purely the Geriatric Team assumes a purely consultative role.consultative role.

Barriers to the CGA is that it is time-Barriers to the CGA is that it is time-consuming and expensive.consuming and expensive.

MEDICAL MEDICAL ASSESSEMENTASSESSEMENT

Should focus on specific conditions Should focus on specific conditions that are common to the elderly and that are common to the elderly and have significant impact on function.have significant impact on function.

These include impairments of vision, These include impairments of vision, hearing, mobility and falls, hearing, mobility and falls, malnutrition, urinary incontinence, malnutrition, urinary incontinence, and polypharmacy.and polypharmacy.

VISUAL IMPAIRMENTVISUAL IMPAIRMENT Major eye diseases such as cataract, Major eye diseases such as cataract,

macular degeneration, glaucoma, and macular degeneration, glaucoma, and diabetic retinopathy increases with age.diabetic retinopathy increases with age.

Require eye glasses due to presbyopia.Require eye glasses due to presbyopia. Often unaware of their visual deficits.Often unaware of their visual deficits. Should ask questions regarding reading, Should ask questions regarding reading,

watching television, or driving.watching television, or driving. Snellen Chart is used to screen for visual Snellen Chart is used to screen for visual

deficits.deficits. Patient stands 20 ft. from the chart and Patient stands 20 ft. from the chart and

read letters using corrective lens.read letters using corrective lens. Inability to read >20/40 implies Inability to read >20/40 implies

impairment in vision.impairment in vision.

HEARING IMPAIRMENTHEARING IMPAIRMENT

Associated with decreased cognition, Associated with decreased cognition, depression, dissatisfaction with life, and depression, dissatisfaction with life, and withdrawal from social activities.withdrawal from social activities.

Usually bilateral.Usually bilateral. Occurs in the high frequency range.Occurs in the high frequency range. Can be assessed using a hand-held Can be assessed using a hand-held

audio scope.audio scope. Inability to hear 40 decibles tone at Inability to hear 40 decibles tone at

1000 or 2000 Hz in one or both ears 1000 or 2000 Hz in one or both ears implies failed hearing test.implies failed hearing test.

WHISPER VOICE TESTWHISPER VOICE TEST

An alternative to hand-held audio scope.An alternative to hand-held audio scope. Done by whispering 3 – 6 words at a Done by whispering 3 – 6 words at a

distance of 8, 12, or 24 inches from the distance of 8, 12, or 24 inches from the patient’s ear.patient’s ear.

Examiner should stand behind the patient Examiner should stand behind the patient and have one ear covered during the and have one ear covered during the examination.examination.

Inability to repeat >50% of the whispered Inability to repeat >50% of the whispered words is considered a failed screening.words is considered a failed screening.

NUTRITIONNUTRITION

Inadequate nutrition – due to concurrent Inadequate nutrition – due to concurrent medical illness; depression; inability to medical illness; depression; inability to shop, cook or feed oneself; and financial shop, cook or feed oneself; and financial hardship.hardship.

Elderly people should have their weights Elderly people should have their weights measured routinely.measured routinely.

Unintentional weight loss of >10lbs in Unintentional weight loss of >10lbs in the past 6 months suggests poor the past 6 months suggests poor nutrition in the absence of other medical nutrition in the absence of other medical problems.problems.

NUTRITION (contd.)NUTRITION (contd.) Important prognostic factors of Important prognostic factors of

mortality:mortality: Low cholesterol and low albuminLow cholesterol and low albumin

Serum cholesterol is a valuable marker Serum cholesterol is a valuable marker for older persons at risk for adverse for older persons at risk for adverse events even though they are associated events even though they are associated with evidence of inflammation rather with evidence of inflammation rather than malnutrition in hospitalized than malnutrition in hospitalized patients.patients.

However, among community dwelling However, among community dwelling older persons obesity is the most older persons obesity is the most common nutritional disorder.common nutritional disorder.

YEYESS

1. Do you have an illness or condition that made you change the 1. Do you have an illness or condition that made you change the kind and amount of food you eat.kind and amount of food you eat.

22

2. Do you eat fewer than two meals per day.2. Do you eat fewer than two meals per day. 33

3. Do you eat few fruits, vegetables, or milk products.3. Do you eat few fruits, vegetables, or milk products. 22

4. Do you have 3 or more drinks of beer, liquor or wine almost 4. Do you have 3 or more drinks of beer, liquor or wine almost every day.every day.

22

5. Do you have tooth or mouth problems that make it hard for you 5. Do you have tooth or mouth problems that make it hard for you to eat.to eat.

22

6. Do you always have enough money to buy food.6. Do you always have enough money to buy food. 44

7. Do you eat alone most of the time.7. Do you eat alone most of the time. 11

8. Do you take 3 or more different prescribed or over the counter 8. Do you take 3 or more different prescribed or over the counter drugs per day.drugs per day.

11

9. Without wanting to, have you lost or gained 10lbs. in the last 6 9. Without wanting to, have you lost or gained 10lbs. in the last 6 months.months.

22

10. Are you physically unable to shop, cook, or feed yourself.10. Are you physically unable to shop, cook, or feed yourself. 22

A score of 0-2 is good, 3-5 moderate nutritional risk and greater than 6 equal high nutritional risk.

NUTRITIONAL-RELATED NUTRITIONAL-RELATED SCREENING EVALUATIONSCREENING EVALUATION

COGNITIVE COGNITIVE IMPAIRMENTIMPAIRMENT

Increases risk for inability, delirium, Increases risk for inability, delirium, medical non-adherence, and medical non-adherence, and accidents.accidents.

Cognitive abilities decline with age Cognitive abilities decline with age after adulthood is reached.after adulthood is reached.

Decline doubles every 5 years after Decline doubles every 5 years after age 65.age 65.

One common cause of cognitive One common cause of cognitive decline is Alzheimer's Disease.decline is Alzheimer's Disease.

COGNITIVE IMPAIRMENT COGNITIVE IMPAIRMENT (contd.)(contd.)

Alzheimer’s have cognitive changes Alzheimer’s have cognitive changes that differ in magnitude and extent that differ in magnitude and extent compared to normal aging process.compared to normal aging process.

Patients with Dementia do not Patients with Dementia do not volunteer symptoms of cognitive volunteer symptoms of cognitive impairment or complain of memory impairment or complain of memory loss unless specifically questioned.loss unless specifically questioned.

Cognitive change associated with Cognitive change associated with aging are related to a generalized aging are related to a generalized slowing of mental process or cognitive slowing of mental process or cognitive speed rather than a loss of memory.speed rather than a loss of memory.

FOLSTEIN MINI-MENTAL FOLSTEIN MINI-MENTAL STATE EXAMINATION STATE EXAMINATION

(MMSE)(MMSE) Used to evaluate cognition.Used to evaluate cognition. Assesses orientation.Assesses orientation. Registration and recall.Registration and recall. Attention and calculation.Attention and calculation. Language and visual-spatial skills.Language and visual-spatial skills. Scores are interpreted in the context of Scores are interpreted in the context of

educational attainment and age.educational attainment and age. A score <23 is diagnostic of Dementia.A score <23 is diagnostic of Dementia. Single best assessment question for Dementia Single best assessment question for Dementia

is a recall of 3 words after 1 minute since is a recall of 3 words after 1 minute since short-term memory is generally the first sign.short-term memory is generally the first sign.

Failure to recall the 3 words require further Failure to recall the 3 words require further evaluation.evaluation.

MMSEMMSEOrientation Orientation Name: hospital/floor/town/state/country 5 (1 for each name)Name: hospital/floor/town/state/country 5 (1 for each name)

Registration Registration Identify three objects by name and ask patient to repeat3 (1 for each object)Identify three objects by name and ask patient to repeat3 (1 for each object)

Attention and calculation Attention and calculation Serial 7s; subtract from 100 (e.g., 93-86-79-72-65) 5 (1 for each subtraction)Serial 7s; subtract from 100 (e.g., 93-86-79-72-65) 5 (1 for each subtraction)

RecallRecallRecall the three objects presented earlier 3 (1 for each object)Recall the three objects presented earlier 3 (1 for each object)

LanguageLanguageName pencil and watch 2 (1 for each object)Name pencil and watch 2 (1 for each object)

Repeat "No ifs, ands, or buts“ 1Repeat "No ifs, ands, or buts“ 1

Follow a 3-step command (e.g., "Take this paper,, Follow a 3-step command (e.g., "Take this paper,, fold it in half and place it on the table") 3 (1 for each command)fold it in half and place it on the table") 3 (1 for each command)

Write "close your eyes" and ask patient to obey 1Write "close your eyes" and ask patient to obey 1written commandwritten command

Ask patient to write a sentence 1Ask patient to write a sentence 1

Ask patient to copy a design (e.g., intersecting pentagons) 1Ask patient to copy a design (e.g., intersecting pentagons) 1

TOTALTOTAL 3030

PSYCHOLOGICAL PSYCHOLOGICAL ASSESSEMENTASSESSEMENT

Major depression occurs in 1% -2% of the elderly Major depression occurs in 1% -2% of the elderly population.population.

A large number of elderly have symptoms of A large number of elderly have symptoms of depression below the severity threshold of major depression below the severity threshold of major depression.depression.

Sub-threshold symptoms are associated with Sub-threshold symptoms are associated with increased risk of physical disability, slower increased risk of physical disability, slower recovery after an acute disabling event, and recovery after an acute disabling event, and increased cost of medical services.increased cost of medical services.

Anxiety and worries in the elderly can be a Anxiety and worries in the elderly can be a manifestation of an underlying depressive manifestation of an underlying depressive disorder.disorder.

A simple question to ask is “Do you feel sad or A simple question to ask is “Do you feel sad or depressed?” A positive answer warrants further depressed?” A positive answer warrants further investigation. This can be done by using the investigation. This can be done by using the Geriatric Depression Scale (GDS).Geriatric Depression Scale (GDS).

The short form of the GDS consists of 15 questions:The short form of the GDS consists of 15 questions:

1. Are you basically satisfied with your life? 1. Are you basically satisfied with your life? yesyes//nono

2. Have you dropped many of your activities and interest?2. Have you dropped many of your activities and interest? yesyes/no /no

3. Do you feel that your life is empty? 3. Do you feel that your life is empty? yesyes/no /no

4. Do you often get bored? 4. Do you often get bored? yesyes/no /no

5. Are you in good spirits most of the time? 5. Are you in good spirits most of the time? yes/yes/nono

6. Are you afraid that something bad is going to happen to you? 6. Are you afraid that something bad is going to happen to you? yesyes/no/no

7. Do you feel happy most of the time? 7. Do you feel happy most of the time? yes/yes/nono

8. Do you often feel helpless? 8. Do you often feel helpless? yesyes/no/no

9. you prefer to stay at home rather than staying out and doing new things? 9. you prefer to stay at home rather than staying out and doing new things? yesyes/no/no

10. Do you feel that you have more problems with memory than most?10. Do you feel that you have more problems with memory than most? yesyes/no/no

11. Do you think it is wonderful to be alive now? 11. Do you think it is wonderful to be alive now? yes/yes/nono

12. Do you feel pretty worthless the way you are now?12. Do you feel pretty worthless the way you are now? yesyes/no/no

13. Do you feel full of energy? 13. Do you feel full of energy? yes/yes/nono

14. Do you feel that your situation is hopeless? 14. Do you feel that your situation is hopeless? yesyes/no/no

15. Do you think that most people are better off than you are? 15. Do you think that most people are better off than you are? yesyes/no/no

Bold answers are scored, with one point for each of these answers. Normal is equal to 0-5; and greater than 5 suggest depression.

SOCIAL ASSESSMENTSOCIAL ASSESSMENT

Should include availability of help in Should include availability of help in case of emergency.case of emergency.

Availability of a personal support Availability of a personal support system.system.

Need for a caregiver.Need for a caregiver. Caregiver burdens.Caregiver burdens. Economic status.Economic status. Elder mistreatment.Elder mistreatment. Advanced directives.Advanced directives.

SOCIAL ASSESSEMENTS SOCIAL ASSESSEMENTS (contd.)(contd.)

For the frail elderly availability of help For the frail elderly availability of help from family or friends can determine from family or friends can determine whether a functionally dependent whether a functionally dependent person remains at home or is person remains at home or is institutionalized.institutionalized.

For those frail elders that lack support, For those frail elders that lack support, a visiting nurse may be helpful in the a visiting nurse may be helpful in the assessment of home safety and level of assessment of home safety and level of personal risk, i.e., stairs, location of personal risk, i.e., stairs, location of bathrooms, bathroom grab bars, and bathrooms, bathroom grab bars, and smoke alarms.smoke alarms.

URINARY URINARY INCONTINENCEINCONTINENCE Common occurrence among the elderly especially Common occurrence among the elderly especially

women.women. Can go unrecognized in men and women for variable Can go unrecognized in men and women for variable

reasons.reasons. Women may be embarrassed to discuss the issue Women may be embarrassed to discuss the issue

especially if the clinician is male, or may regard it as especially if the clinician is male, or may regard it as a normal part of aging that is best controlled with a normal part of aging that is best controlled with pads.pads.

Two screening questions to ask are:Two screening questions to ask are: In the last year have you lost your urine and gotten In the last year have you lost your urine and gotten

wet? If the answer is YES then the patient is wet? If the answer is YES then the patient is asked,asked,

Have you lost urine on 6 separate days?Have you lost urine on 6 separate days? An answer of YES to both questions have a 75% - An answer of YES to both questions have a 75% -

79% accuracy for urinary incontinence.79% accuracy for urinary incontinence. Other associated signs and symptoms include Other associated signs and symptoms include

frequency, urgency, nocturia, hesitancy, dribbling, frequency, urgency, nocturia, hesitancy, dribbling, and intermittent flow.and intermittent flow.

POLYPHARMACYPOLYPHARMACY Due to care from multiple providers.Due to care from multiple providers. Fill their prescriptions at various pharmacies.Fill their prescriptions at various pharmacies. Patients should bring in all their current Patients should bring in all their current

medications at each office visit and have them medications at each office visit and have them checked against their medication list in their checked against their medication list in their medical chart.medical chart.

Increases the chance for drug-drug Increases the chance for drug-drug interactions (DDI) which increases the risk for interactions (DDI) which increases the risk for adverse drug events (ADE).adverse drug events (ADE).

Cardiovascular and psychotropic drugs are the Cardiovascular and psychotropic drugs are the most common medications involved in ADE’s.most common medications involved in ADE’s.

Common ADE’s are neuropsychological Common ADE’s are neuropsychological (confusion) or cognitive impairments, (confusion) or cognitive impairments, hypotension, and acute renal failure.hypotension, and acute renal failure.

RISK FACTORS RISK FACTORS ASSOCIATED WITH ASSOCIATED WITH

ADVERSE DRUG EVENTS ADVERSE DRUG EVENTS (ADE)(ADE)

>6 concurrent diagnosis.>6 concurrent diagnosis. >12 doses of medications per day.>12 doses of medications per day. A prior ADE.A prior ADE. A low body weight or BMI.A low body weight or BMI. Age >85 years.Age >85 years. Creatinine clearance <50ml/minute.Creatinine clearance <50ml/minute.

MOBILITY AND MOBILITY AND BALANCEBALANCE

Impairments in mobility and balance is Impairments in mobility and balance is due to musculoskeletal (osteoarthritis) due to musculoskeletal (osteoarthritis) and neurological (neuropathies/motor and neurological (neuropathies/motor dysfunctions) disorders.dysfunctions) disorders.

Sequelae of previous falls such as Sequelae of previous falls such as fractures, unequal leg length, or fear of fractures, unequal leg length, or fear of falling can worsen impairments in gait falling can worsen impairments in gait and balance in the elderly thus leading and balance in the elderly thus leading to more functional impairments.to more functional impairments.

MOBILITY AND BALANCE MOBILITY AND BALANCE RISK ASSESSEMENT FOR RISK ASSESSEMENT FOR

FALLSFALLS Testing for balance, gait, lower extremity Testing for balance, gait, lower extremity strength.strength.

Previous history of falls causes and Previous history of falls causes and treatments.treatments.

Balance, gait, and lower extremity strength Balance, gait, and lower extremity strength can best be assessed by observing the patient can best be assessed by observing the patient performing specific task.performing specific task.

Lower extremity or quadriceps weakness can Lower extremity or quadriceps weakness can evaluated by asking the patient to stand from evaluated by asking the patient to stand from a seated position in a hard back chair while a seated position in a hard back chair while keeping their hands folded.keeping their hands folded.

Inability to complete this task suggest lower Inability to complete this task suggest lower extremity weakness and is highly predictive extremity weakness and is highly predictive for future disability.for future disability.

MOBILITY AND BALANCE MOBILITY AND BALANCE RISK ASSESSEMENT FOR RISK ASSESSEMENT FOR

FALLS (contd.)FALLS (contd.) Once standing he/she should be instructed to walk Once standing he/she should be instructed to walk

back and forth over 10ft, ideally with their walking back and forth over 10ft, ideally with their walking aid.aid.

Abnormalities are path deviation, diminished step Abnormalities are path deviation, diminished step height or length, trips, slips, near-falls, and height or length, trips, slips, near-falls, and difficulty turning.difficulty turning.

The task of rising from an armless chair, walking The task of rising from an armless chair, walking 10ft, turn, walk back and sit down is termed the 10ft, turn, walk back and sit down is termed the “Get-up and Go Test.” Those taking long than 10 “Get-up and Go Test.” Those taking long than 10 seconds to complete this tasks are at increased seconds to complete this tasks are at increased risk for falls.risk for falls.

10 – 19 seconds is considered freely mobile.10 – 19 seconds is considered freely mobile. 20 – 29 seconds variable mobility.20 – 29 seconds variable mobility. >30 seconds dependent on balance and mobility.>30 seconds dependent on balance and mobility.

MOBILITY AND BALANCE MOBILITY AND BALANCE (contd.) GAIT SPEED(contd.) GAIT SPEED

Gait speed can be used as an alternative Gait speed can be used as an alternative predictor for future disability.predictor for future disability.

Speed of 0.8 meters/sec indicates that Speed of 0.8 meters/sec indicates that the patient is capable of independent the patient is capable of independent ambulation within the community.ambulation within the community.

A speed of 0.6 meters/sec indicates A speed of 0.6 meters/sec indicates participation in community activities participation in community activities without the use of a wheelchair.without the use of a wheelchair.

Patients who can ambulate 50 feet in Patients who can ambulate 50 feet in the office corridor in 20 seconds or less the office corridor in 20 seconds or less should be able to walk independently in should be able to walk independently in normal activities.normal activities.

MOBILITY AND BALANCE MOBILITY AND BALANCE (contd.)(contd.)

Balance can be assessed by instructing the Balance can be assessed by instructing the patient to stand with his/her feet side by side patient to stand with his/her feet side by side then in semi-tandem and finally in tandem then in semi-tandem and finally in tandem position.position.

Difficulty in any of these positions suggest an Difficulty in any of these positions suggest an increase risk of falling.increase risk of falling.

The Performance Oriented Mobility Assessment The Performance Oriented Mobility Assessment (POMA) consists of a set of tasks that may be (POMA) consists of a set of tasks that may be used to quantify impairments in gait and balance used to quantify impairments in gait and balance and make recommendations for an assisted and make recommendations for an assisted walking device.walking device.

In addition, during these assessments the In addition, during these assessments the physician should observe for the use of proper physician should observe for the use of proper footwear that is flat and has a hard sole.footwear that is flat and has a hard sole.

FUNCTIONAL STATUS FUNCTIONAL STATUS ASSESSMENTASSESSMENT

Evaluates the tasks a person can do Evaluates the tasks a person can do within the context of their medical within the context of their medical problems and everyday life.problems and everyday life.

It is split into 3 levels:It is split into 3 levels:1.1. Basic Activities of Daily Living (BADL)Basic Activities of Daily Living (BADL)

2.2. Instrumental/Intermediate Activities Instrumental/Intermediate Activities of Daily Living (IADL)of Daily Living (IADL)

3.3. Advance Activities of Daily Living Advance Activities of Daily Living (AADL)(AADL)

Basic Activities of Daily Basic Activities of Daily Living (BADL)Living (BADL)

Evaluates the ability of the person to complete Evaluates the ability of the person to complete basic self-care tasks that are considered basic self-care tasks that are considered essential to independent living. These are:essential to independent living. These are: Transferring from bed to chairTransferring from bed to chair ToiletingToileting BathingBathing GroomingGrooming DressingDressing Feeding oneselfFeeding oneself

Bathing is the BADL that is associated Bathing is the BADL that is associated with the highest prevalence of disability with the highest prevalence of disability and is one of the most common reasons and is one of the most common reasons why elders receive home aide services.why elders receive home aide services.

Instrumental/Intermediate Instrumental/Intermediate Activities of Daily Living Activities of Daily Living

(IADL)(IADL) Assesses the persons ability to Assesses the persons ability to upkeep an independent household.upkeep an independent household.

It consists of:It consists of: LaundryLaundry HouseworkHousework ShoppingShopping Using the telephoneUsing the telephone Preparing mealsPreparing meals Taking medicationsTaking medications Managing household finance and Managing household finance and

transportationtransportation

Advance Activities of Daily Advance Activities of Daily Living (AADL)Living (AADL)

Evaluates the persons ability to Evaluates the persons ability to participate in societal, community, participate in societal, community, and family roles.and family roles.

It also assesses for recreational and It also assesses for recreational and occupational activities. These occupational activities. These activities varies among individuals activities varies among individuals and may be a valuable tools in and may be a valuable tools in monitoring functional status prior to monitoring functional status prior to the development of disability.the development of disability.

Advance Activities of Daily Advance Activities of Daily Living (AADL) contd.Living (AADL) contd.

In addition useful information on In addition useful information on function can be obtained when function can be obtained when physicians observe how their patients physicians observe how their patients complete simple tasks such as buttoning complete simple tasks such as buttoning or unbuttoning a shirt or blouse, taking or unbuttoning a shirt or blouse, taking off and putting on shoes, picking up a off and putting on shoes, picking up a pencil and writing a sentence, touching pencil and writing a sentence, touching the back of their head with both hands, the back of their head with both hands, and climbing up and down from the and climbing up and down from the examination table.examination table.

Thank YouThank You