Geriatric Assessment Workshop

Transcription

1 MONTEFIORE MEDICAL CENTER The University Hospital for the Albert Einstein College of Medicine ALBERT EINSTEIN COLLEGE OF MEDICINE OF YESHIVA UNIVERSITY Geriatric Assessment Workshop Introduction to Clinical Medicine The Physical Examination Albert Einstein College of Medicine Bronx, New York Prepared by: Laurie G. Jacobs, MD Professor of Clinical Medicine Division Head, Geriatrics Supported by the D.W. Reynolds Foundation 1

2 Geriatric Assessment Workshop Materials Page 1. Faculty Guide 3 2. Workshop Schedule 7 3. Simulated Patient Role and Instructions 7 4. Geriatric Assessment Forms 9 a. Neuropsychological & Cognitive Assessment form 10 b. Functional Assessment forms Student Evaluation form References 28 2

3 Geriatric Assessment Workshop Faculty Guide Introduction Physicians will increasingly encounter older adults within their practice now and in the future. Although most physicians are generally well trained in the basic skills of taking a medical history and performing a physical examination, they often lack the skill to perform a cognitive or functional assessment. Both functional and cognitive impairment are increasing prevalent as the population ages. An assessment of cognition is required when obtaining a history and in obtaining informed consent, as well as in other common clinical activities, in addition to the evaluation of cognitive impairment. Functional status determines the ability to live independently. Assessment of function is critical for planning treatment, care and support for older adults in every setting, and particularly during transitions of care. It is our philosophy that these skills should be taught early, along with instruction in other basic history taking and physical examination skills. Teaching and training medical students in these skills is necessary, but not sufficient, for the practice of medicine. Trainees such residents, fellows, as well as practicing physicians, must have the opportunity to review and reinforce these skills. These materials were developed for a half-day workshop on geriatric assessment for second year students during their physical diagnosis course. However, we also request that residents participate, and that the geriatrics fellows and faculty be formally trained prior to teaching the workshop, reinforcing their skills. The format is a 45-minute didactic talk covering issues in history taking, functional and cognitive assessment skills to assess older patients. A two-hour small group session is held following this session: one hour with a functionally impaired older adult and one hour with a simulated patient, to teach elementary functional and cognitive assessment skills. Goals and Objectives The goal of this workshop is to describe geriatric assessment, understand that it strives to promote wellness and independent function, and train learners in cognitive and functional assessment skills. The specific objectives are to: Describe physical function Utilize standardized methods to assess physical function Describe neuropsychiatric function Utilize standardized tools to assess cognition 3

4 Workshop Structure The workshop is a 3½ hour afternoon session for the full class of medical students. It can be similarly designed for other groups of learners; however, separate workshops for those at differing levels of training are recommended. Didactic Lecture The first hour is a lecture followed by a question and answer session. The lecture describes the components of geriatric assessment, aging demographics and census data about the prevalence of cognitive and functional impairment, suggestions about obtaining the chief complaint and history of present illness in older adults, components and questions of a geriatric review of systems, definitions of function and disability, and training in performing a Timed Get Up and Go test including a video clip, balance testing, and neuropsychological evaluation including the components of mental status and their definitions, and specific training in testing attention, language fluency, memory and the MiniCog test with three item recall and clock drawing. The Timed Get Up and Go and the MiniCog were chosen as instruments because they are short, easy to learn and perform, and encompass several important domains of functional and cognitive assessment. Other instruments or tests may be selected if preferred. The MiniCog, by combining the most sensitive item on the MMSE (three-item recall) and a visual task, the clock-drawing (examining parietal dysfunction, some aspects of frontal and executive function) has been shown to perform as well as or slightly better than the full MMSE in identifying probable Alzheimer s disease and some other dementias. It has also been validated in multiethnic populations. Small Group Sessions The trainees are assigned to separate groups. Each group comprised no more than 15 students. As we have 180 students, 12 groups were held. The goals and objectives of the workshop are restated and attendance taken. One hour is dedicated to functional assessment, held with an actual patient, and one hour for cognitive assessment with a simulated patient. A 15-minute break occurs between the two sessions, and 10 minutes at the end is required for the students to complete the anonymous structured evaluation form. Usually we suggest that half of the groups complete the functional assessment in the first hour, while the other half completes the cognitive assessment. This allows for the patients to meet with two groups over the afternoon, requiring half as many patients. Functional Assessment Session One hour is dedicated to learning and practicing functional assessment skills. This is accomplished with participation of a patient for each group. One or two preceptors are recommended. The session is framed for the students and patient by saying that the patient is here for an appointment due to complaints about his/her walking ability. The student is to play the role of the physician evaluating the patient, and will be demonstrating for the group. 4

5 The past medical history, geriatric review of systems, medications, family history, social history and other items, can be optional depending on the comfort of the patient in discussing these issues, which should be discussed by the preceptor with the patient prior to beginning with the students. In addition, these may be time-consuming, and are not the main objectives of the workshop. Selection of an appropriate patient for this exercise is critical. Six patients required for 12 groups (alternate with the cognitive assessment hour). Additional backup patients, 2 extra for 6, should be invited, and if all attend, two groups can be divided. The patients must have good hearing, an obvious gait impairment, be able to ambulate either independently or with an assistive device, enjoy people and being asked questions, and have the stamina to spend the entire afternoon participating in this exercise. Transportation, a snack, and a $25 honorarium, was provided. The patients truly enjoyed it and asked to come back the following year. They should be asked to arrive 30 minutes prior to the time set for small groups. A staff member should greet them, review the conduct of the session with them and their role, in particular, and direct them to their rooms where they can meet with the preceptor for a few minutes prior to the students arrival. One student is selected to perform each of the following skills with the patient in front of the group. All of the students should document their observations on the Geriatric Assessment form provided to them. This section should take about 45 minutes. History of present illness related to the gait problem (section 3) Geriatric review of systems items pertaining to falls, ADL, IADL status (section 3d) Standing balance; Static balance semi-tandem; full tandem stance Gait 360 Degree Turn Timed Get up and Go Test Optional additional tests depending upon time: Tinetti Performance-Oriented Assessment of Balance Tinetti Performance-Oriented Assessment of Gait Following the demonstration of these skills, you may ask the patient to leave to have a break prior to the next group session. A 15-minute discussion should then be held to: Describe relevant ROS and history and the ADL/IADL status Describe the impairments that they observed Discuss simple neurological/medical causes of such impairments and their treatment/remediation If the session is held with residents or fellows, a more detailed discussion of impairments, a differential diagnosis and treatment plan, should be held. Simulated Patient Cognitive Assessment Session The preceptor should make general comments about how to interview and approach a patient who may have cognitive impairment. The packet of geriatric assessment forms 5

6 should be used as a guide. As history taking is time consuming in patients with dementia, and the objective of this session is to teach assessment skills, the history of present illness, past medical history, geriatric review of systems, medications, and physical examination findings are provided. The preceptor should review these aloud with the group. A simulated patient is used for teaching cognitive assessment, as it is too difficult and burdensome for an actual patient to participate in this type of exercise. The simulated patient can be a paid and trained actor or one of the two preceptors. We have used both. The simulated patient must be familiar with the role and deficits prior to the session, including how to draw the impaired clock. These materials are provided ahead of time for them to study. It is less costly and perhaps easier to use a staff member, but training is just as critical for them as for an actor. This session is conducted similarly to the functional assessment session. A student is asked to demonstrate the performance of each of the following tests or activities with the simulated patient in front of the entire group. Students record their observations. Tasks: Mini Cog 3 item recall & clock drawing Digit repetition Timed Naming Confusion Assessment Method (optional) Geriatric Depression Scale (optional) Following the completion of all the tasks, a discussion is held and students are asked to: Describe the mental status Describe the impairments that they observed Discuss score of the minicog and the interpretation Following this, a discussion of simple neurological and/or medical causes of such impairments and their treatment/remediation is held for the students interest. This is much more detailed if the session is held with residents and fellows. Preceptors Preceptors can be selected from a variety of disciplines, including geriatrician faculty, community geriatricians and voluntaries, geropsychiatrists, fellows, and neurologists and/or physiatrists. Generally we have used the same preceptor for one group over both sessions, but if they have special expertise, they can be paired with a patient or role-play the simulated patient. One preceptor per group is required, with an additional staff member to play the simulated patient. We encourage fellows to play the role of a second preceptor to enhance their skills and confidence in teaching. In total, two additional preceptors are included as some may not be able to come at the last minute. The preceptors themselves must be trained; a two hour train-the-trainer session (with CME credit) is held at least several weeks before the workshop. During this session, the same lecture that the students will hear is presented, although somewhat more rapidly. Following this, a demonstration of the skills to be taught is done, and questions 6

7 entertained. Finally, the conduct of session, including student behavior, timing, managing the patient and simulated patient, as well as evaluation procedures is described. The assessment form, lecture slides and a queuing card provided. On the day of the workshop, faculty are invited at noon, the session begins for students at 1pm with the lecture. This provides two hours if they arrive on time. Lunch is provided, and the goals, objectives, conduct of the session, materials, management of the patients and simulated patients, and evaluation procedures are reviewed. In addition, a quick review and/or demonstration of specific skills are presented. Workshop Schedule: 12 2 pm Faculty Meeting/Orientation (called at 12, lunch available then) Review program roles and tasks Review the cases as written and practice scripted roles Discuss evaluation 1 2 pm Lecture for students: Geriatric Assessment 1:30 2 pm Patient Meeting (lunch or snack) Greet patients, Explain session goals and their role Assign rooms 2:00 2:15 All Students, Faculty and Patients go to assigned rooms. Sign-in, Review Goals and Objectives 2:15 3:15 Patient/Functional Assessment Session Or Simulated Patient/Cognitive Assessment Session 3:15 3:30 Patients switch rooms, break 3:30 4:30 Patient/Functional Assessment Session Or Simulated Patient/Cognitive Assessment Session 4:30 4:40 Student Evaluation 4:40-5 pm Faculty Wrap Up Simulated Patient Description and instructions You will play a 78-year old retired secretary (woman) or office manager for a bank (man) from the Bronx, who has come to the doctor's office with your spouse for a general checkup. If asked why you are here, you respond that your spouse wanted you to come. You have recently been having difficulty with your memory and misplacing items. Some of these problems, such as forgetting appointments, have been present for years, but only recently you became lost while trying to drive home from a place that you go regularly. You do not tell the doctor about these problems, but he or she discovers them by talking with your spouse. You and your spouse have four children who live throughout the United States. The closest is a daughter who lives in Chicago. You do not smoke or drink. You and your spouse still live in the apartment you have lived in for over 50 years. 7

8 In your 20s, you had your appendix removed. You have a history of high blood pressure, for which you have been prescribed two medications. Nonetheless, your blood pressure is too high when checked at this visit. You also have arthritis of the knees, and are taking two aspirin tablets twice a day for knee pain. You have crusting patches of redness on the skin of your forehead, cheeks, and ears. The rest of your physical exam is normal. As your medical student conducts the functional assessment, you should respond in a manner that is consistent with the description and documents on the previous page, and with the instructions to follow. If the student leaves out a component of the functional assessment, do not correct him or her. Questions About Function: The student will probably open the conversation with a question about how you are functioning. If so, respond that everything is fine. As a patient with a dementing illness, you have no insight into the deficits identified by your spouse. The learner should next ask specific questions about function, focusing on the levels of activities of daily living - dressing, bathing, toileting, and other similar tasks. If you have trouble doing a particular activity, the doctor should ask who, if anyone, does it for you. When asked about instrumental activities of daily living, many patients with Alzheimer's disease say everything is fine, and the spouse will often contradict and provide the more correct assessment. However, in this simulated encounter, you will admit to your problems when asked. You have difficulty with cooking, cleaning, and managing money, all of which are handled by your spouse. You are able to do all other instrumental activities of daily living independently. If the student asks about performing employment duties, you say something like "I'm retired, so that doesn't apply to me." If he or she asks about home maintenance, you reply to the effect that "I don't worry about that anymore." Digit Recall Test The student will ask you to remember 2 then 3 then 4 numbers and repeat them. This will go on until you make an error. Try to do it correctly for 4 or 5 numbers and then either mix them up or say you can t remember after the first 2 or 3. Language Fluency The student will ask you to name as many animals or vegetables or fruits as you can. Name about 6 or 7 and then start repeating the earlier ones (perseveration) even though you will be asked to come up with new ones. Three-Item Recall and clock drawing 8

9 The student will ask you to remember 3 items apple, table, penny and then do a clock drawing. When asked to recall the items, just name one apple and then say you can t remember. When asked to draw a clock, draw the same one you have been given here to practice. 9

10 Geriatric Assessment Workshop Assessment Forms: Cognitive Assessment Functional Assessment Introduction to Clinical Medicine The Physical Examination Albert Einstein College of Medicine Bronx, New York 10

11 Part I: NEUROPSYCHOLOGICAL ASSESSMENT Patient s Name: Simulated female patient Mrs. Jones Date: Age: Chief complaint: I am not really sure why I am here Spouse: For a routine checkup 2. Reported by: spouse predominantly, and patient 3. History of Present Illness: The husband reports that his wife has had difficulty with her memory, misplacing cooking utensils, and cannot make a complete meal. Her memory problems, such as forgetting appointments, have been present for years, but more recently she became lost while trying to walk home from the local store. 4. Past Medical History: hypertension, osteoarthritis affecting her knees. Surgical history - appendectomy in her 20s, bilateral cataract surgery a. General Review of Systems: patient denies any problems; husband complains of urinary frequency and occasional incontinence b. Geriatric Review of Systems 1) General Health: In general, would you say your health is: fine 2) How is your walking? ok Have you had any falls? No 3) How is your memory? Patient: fine; Husband: she only remembers the past 4) Are you having any pain? No 5) How is your sleep? Patient ok; husband she gets up and wanders around at night 6) Do you often feel sad or depressed? Patient: no; Husband not really, but not involved in things the way she used to be. 7) How is your appetite? Ok ; husband - She likes sweets now but she never did before. 8) Have you lost or gained weight in the last 6 months? No 9) How is your urination? Ok; husband she has to go very frequently, day and night. 10) Do you have bladder control problems? No; husband yes, especially at night 11) How are your bowels? Ok c. Additional Geriatric Review of Systems: Husband answers for her. 1) Do you have difficulty with driving, TV, or reading due to poor eyesight? No 2) Do you have trouble hearing conversation? No Do you use hearing aides? No 3) How much alcohol do you drink? None Do you smoke or did you in the past? No 4) Are you sexually active? Not often 5) Health Maintenance: Have you had a shot to prevent pneumonia? Yes in 2005 Influenza vaccine this year? Yes in the fall Last mammogram: 2007 Pap Smear: uncertain Colonoscopy:

12 d. Activities of Daily Living: Are you Independent (I), Require assistance (A) or dependent (D) with each of these tasks? Activities of Daily Living (ADLs): Instrumental Activities of Daily Living (IADL): Walking I A D Using Telephone I A D Dressing I A D Preparing Meals I A D Bathing I A D Shopping I A D Eating I A D Housework I A D Toileting I A D Taking Medications I A D Driving I A D Managing Finances I A D 5. Allergies: no allergies 6. Medications (including prescribed, over the counter, vitamins) Hydrochlorothiazide 25 mg daily, atenolol 100 mg daily, Aspirin 325 mg two tablets BID as needed for knee pain 7. Family History Is your mother alive? If not, at what age did she die? Husband she died at age 80 of natural causes; Is your father alive? If not, at what age did he die? Age 50 of a heart attack Other family history: she has a sister with breast cancer 8. Social History a. Do you live with anyone? Only us (husband and wife) b. Do you have home care services or help at home? A cleaning lady once a week c. Who would help you in an emergency? Our son who lives in the next town d. Who would help with health decisions if you could not able to communicate your wishes? Husband I decide for her; wife nods yes Do you have a health care proxy? No e. Has anyone intentionally tried to harm you? No f. What is your day usually like? We get up at 8, have breakfast, read the paper, go to the store, have lunch, take a walk, watch TV g. What was your occupation? store clerk When/why did you retire? At age 60, store closed 9. Physical Examination (including full Neurological examination) BP 180/80, P 70, R18, T 98, Wt 115 kg, Ht 5 4 HEENT pigmented nodule on right cheek with telangiectasia. EYES PERRLA, visual acuity 20/20 OD and 20/20 OS with glasses. EARS TMs, canals clear. No LA. Thyroid not palp. No bruits. LUNGS clear to A & P. HEART RRR without extra sounds. ABD soft without masses, normal bowel sounds. EXT mild tenderness medial joint lines of both knees, no edema GYN: GU, & RECTAL exams normal, stool hemoccult negative. NEURO reflexes, strength, and sensory exams normal. 12

13 10. Neuropsychological Assessment a. Level of alertness, appearance & mood b. Orientation (name,date, place, etc) c. Cognitive Screening: The Mini-Cog 1 Score: The Mini-Cog, a composite of three-item recall and clock drawing, was developed as a brief test for discriminating demented from non-demented persons in a community sample of culturally, linguistically, and educationally heterogeneous older adults. Likelihood of cognitive impairment is high with scores of 0 2, and low with a score of 3 5 (76% sensitivity; 89% specificity for dementia; Positive Likelihood Ratio 13.0 [9.9-17]; Negative Likelihood Ratio 0.25 [ ]). 1,2 1) Three Item Recall Subscore (score 0-3) Instructions for Three-Item Recall: Registration - Tell the patient to listen carefully, you will be asked to repeat these words later: Apple, penny, table. Pause one second after saying each. Now repeat the three words. If the patient is unable to register, you can repeat the words up to five times. Now remember the three words, I will ask you to repeat them later. Do not help or cue in any way. Engage in a distraction activity for at least 3 minutes. Usually do clock drawing during this time. Recall - Ask the patient Please say the 3 words again. Record the number of correctly repeated words (0 3). Be encouraging but do not provide cues. Record only the first attempt. The sequence of the repeated words is not important. 2) Clock Drawing Test 1,2,3,4,5,6,7 Subscore (score 0 or 2) The Clock Drawing Test evaluates long term memory, visuo-spacial representation, global attention, and executive function. Instructions: Give the patient a sheet of paper with a large predrawn circle on it or ask them to draw the circle. Indicate the top of the page, and ask the patient to draw numbers in the circle to make the circle look like the face of a clock and then draw the ands of the clock to read 11:10 am. Give the patient as much time as needed. Scoring when a part of the Mini-Cog Test: 0 = abnormal # s, positions, or hands; 2= normal 13

14 Clock Drawing Name Date 14

15 d. Attention: Digit Repetition Task 8 Score Instructions: Ask the patient to repeat a list of numbers as dictated by the examiner. Tell the patient: I am going to say some simple numbers. Listen carefully and when I am finished say the numbers after me. Say the numbers in a normal tone of voice at a rate of one digit per second. Do not group digits in pairs. (e.g. 2-6, 5-9) or in sequences that could serve as an aide in repetition (e.g. in telephone number form, such as ). Numbers should be presented randomly, without natural sequences (e.g. not ). Begin with a two digit number sequence, and continue until the patient fails to repeat all the numbers correctly. Scoring: A normal score for a patient of average intelligence is digits. A patient of average intelligence can accurately repeat five to seven numbers without difficulty. In a person without retardation or obvious aphasia, the inability to repeat more than five numbers indicates defective attention. e. Language Fluency: 1) Shopping List: Score: Instructions: Ask the patient to name as many different items that you can find or buy in a supermarket. You have one minute as they can. Record the number. (If the patient stops, you can encourage him or her you still have time, what else can you find? ) Scoring: Normal = >13 different items in one minute; all repetitions should be noted. More than 2 are a sign of perseveration. i 2) Timed Naming (animals, vegetables, fruits) 10 Score: Instructions: Ask the patient to name as many different animals in one minute as they can. Record the number. Scoring: Normal = per minute without cueing. 3) Controlled Word Association Test 10 Score: Instructions: List as many words in one minute beginning with the letter F (or A or S as alternatives) Scoring: normal 10 in one minute. The CWAT tests verbal fluency, access to semantic memory, and the ability to organize rapid retrieval. 15

16 f. Executive function: Shopping Task Instructions: Ask the patient to do the following calculation: If you want to buy 2 loaves of bread, and they cost 75 cents per loaf, and you have $2, how much change will you receive? Other Tests of frontal executive function: similarities, word-list generation, proverb interpretation, alternating design copying, clock drawing. 11. Other assessments: (optional) Geriatric Depression Scale (Short Form) 11 Instructions: Ask the patient the following questions and circle their answers. Answers indicating depression are bold and italicized; score one point for each. Add up the total score. A score of 0 to 5 is normal; scores above 5 are consistent with depression. Answer Score 1. Are you basically satisfied with your life Yes No 2. Have you dropped many of your activities and interests? Yes No 3. Do you feel that your life is empty? Yes No 4. Do you often get bored? Yes No 5. Are you in good spirits most of the time? Yes No 6. Are you afraid that something bad is going to happen to you? Yes No 7. Do you feel happy most of the time? Yes No 8. Do you often feel helpless? Yes No 9. Do you prefer to stay at home, rather than going out and doing new things?yes No 10. Do you feel you have more problems with memory than most people? Yes No 11 Do you think it is wonderful to be alive? Yes No 12. Do you feel pretty worthless the way you are now? Yes No 13. Do you feel full of energy? Yes No 14. Do you feel that your situation is hopeless? Yes No 15. Do you think that most people are better off than you are? Yes No TOTAL Score Scoring: Answers indicating depression are in bold and italicized; score one point for each one selected. A score 0 to 5 is normal. A score greater than five suggests depression. 16

17 11. Other assessments: Confusion Assessment Method (CAM) 12 An instrument primarily used to detect delirium. Instructions: Assess the following factors Acute Onset 1. Is there evidence of an acute change in mental status from the patient s baseline? Yes No Uncertain Not applicable Inattention (The questions listed under this topic are repeated for each topic where applicable.) 2a. Did the patient have difficulty focusing attention (for example, being easily distractible or having difficulty keeping track of what was being said)? Not present at any time during interview Present at some time during interview, but in mild form Present at some time during interview, in marked form Uncertain 2b. (If present or abnormal) Did this behavior fluctuate during the interview (that is, tend to come and go or increase and decrease in severity)? Yes No Uncertain N/a 2c. (If present or abnormal) Please describe this behavior. Disorganized Thinking 3. Was the patient s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable, switching from subject to subject? Yes No Uncertain Not applicable Altered Level of Consciousness 4. Overall, how would you rate this patient s level of consciousness? Alert (normal) Vigilant (hyperalert, overly sensitive to environmental stimuli, startled very easily) Lethargic (drowsy, easily aroused) Stupor (difficult to arouse) Coma (unarousable) Uncertain Disorientation 5. Was the patient disoriented at any time during the interview, such as thinking that he or she was somewhere other than the hospital, using the wrong bed, or misjudging the time of day? Yes No Uncertain Not applicable Memory Impairment 6. Did the patient demonstrate any memory problems during the interview, such as inability to remember events in the hospital or difficulty remembering instructions? 17

18 Yes No Uncertain Not applicable Perceptual Disturbances 7. Did the patient have any evidence of perceptual disturbances, such as hallucinations, illusions, or misinterpretations (for example, thinking something was moving when it was not)? Yes No Uncertain Not applicable Psychomotor Agitation 8a. At any time during the interview, did the patient have an unusually increased level of motor activity, such as restlessness, picking at bedclothes, tapping fingers, or making frequent, sudden changes in position? Yes No Uncertain Not applicable Psychomotor Retardation 8b. At any time during the interview, did the patient have an unusually decreased level of motor activity, such as sluggishness, staring into space, staying in one position for a l long time, or moving very slowly? Yes No Uncertain Not applicable Altered Sleep-Wake Cycle 9. Did the patient have evidence of disturbance of the sleep-wake cycle, such as excessive daytime sleepiness with insomnia at night? Yes No Uncertain Not applicable CAM Scoring: For a diagnosis of delirium by the CAM, the patient must display: 1. Presence of acute onset and fluctuating discourse AND 2. Inattention AND, EITHER 3. Disorganized thinking OR 4. Altered level of consciousness 18

19 Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1: Acute Onset and Fluctuating Course This feature is usually obtained from family or the nurse and is shown by positive responses to the following questions: Is there evidence of an acute change in mental status from the patient's baseline? Did the (abnormal) behavior fluctuate during the day; that is, did it tend to come and go, or increase and decrease in severity? Feature 2: Inattention This feature is shown by a positive response to the following question: Did the patient have difficulty focusing attention; for example, being easily distractible, or having difficulty keeping track of what was being said? Feature 3: Disorganized Thinking This feature is shown by a positive response to the following question: Was the patient's thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? Feature 4: Altered Level of Consciousness This feature is shown by any answer other than "alert" to the following question: Overall, how would you rate this patient's level of consciousness? (alert [normal], vigilant [hyperalert], lethargic [drowsy, easily aroused], stupor [difficult to arouse], or coma [unarousable] 19

20 Part II: FUNCTIONAL ASSESSMENT Patient s Name (Real patient) Date: 1. Chief complaint: I am having difficulty walking 2. Reported by: Patient 3. History of Present Illness: 4. Past Medical History: (optional) 5. a. General Review of Systems (optional) b. Geriatric Review of Systems (optional) 1) General Health: In general, would you say your health is: 2) How is your walking? Have you had any falls? Yes No 3) How is your memory? 4) Are you having any pain? Yes No On a scale of 1-10, how would you rate it? 5) How is your sleep? 6) Do you often feel sad or depressed? 7) How is your appetite? 8) Have you lost or gained weight in the last 6 months? Yes No 9) How is your urination? Do you have bladder control problems? Yes No 10) How are your bowels? c. Additional Geriatric Review of Systems: (optional) 1) Do you have difficulty with driving, TV, or reading due to poor eyesight? Yes No 2) Do you have trouble hearing conversation? Yes No Do you use hearing aides? Yes No 3) How much alcohol do you drink? 4) Do you smoke or did you in the past? Yes No How much? When and why did you quit? 5) Are you sexually active? Yes No 6) Health Maintenance: Have you had a shot to prevent pneumonia? Yes No When Influenza vaccine this year? Yes No Last mammogram: Pap Smear Colonoscopy 20

21 d. Activities of Daily Living: Are you Independent (I), Require assistance (A) or dependent (D) with each of the following tasks? Activities of Daily Living (ADLs): Instrumental Activities of Daily Living (IADL): Walking I A D Using Telephone I A D Dressing I A D Preparing Meals I A D Bathing I A D Shopping I A D Eating I A D Housework I A D Toileting I A D Taking Medications I A D Driving I A D Managing Finances I A D 6. Allergies no allergies 7. Medications (including prescribed, over the counter, vitamins) 8. Family History (optional) Is your mother alive? If not, at what age did she die? Is your father alive? If not, at what age did he die? Other family history 9. Social History (optional) a. Do you live with anyone? Yes No With Whom b. Do you have home care services or help at home? c. Who would help you in an emergency? d. Who would help with health decisions if you could not able to communicate your wishes? Do you have a health care proxy? Yes No e. Has anyone intentionally tried to harm you? Yes No f. What is your day usually like? g. What is/was your occupation? h. When/why did you retire? 21

22 10. Functional Assessment: a. Timed Get Up and Go Evaluation 14, 15, 16 Score Instructions: Apply guarding techniques. Perform in a well lit area with a chair &10 ft. of space. Time performance. Instruct patient to: Rise from a chair without using hands Stand still momentarily Walk 10 feet away Turn around Walk back to chair Turn around Sit down Score: Interpretation: <10 sec Functionally independent; low risk of falls sec Independently mobile but at increased risk for falls >30 sec Poor mobility, needs assistance with ADLs; at incr. risk for falls Identification of Fall Risk: Sensitivity 87%; Specificity 87% Retest Reliability ; Intra-rater reliability 0.98; Inter-rater reliability 0.99 b. Observations of mobility: 1) Rise from chair (proximal muscle strength) 2) Static balance: semi-tandem & full-tandem stance (observe for 10 seconds) 3) Full Turn (Turns taking >4 sec is associated with increased risk of falls & disability) 4) Rhomberg 5) Use of assistive device: 22

23 c. Neurological examination: (optional) 1) Mental status and speech: 2) Cranial nerves (include hearing, vision) 3) Motor strength testing, and tone): 4) Gait/Balance (Rhomberg, walking heel-to-toe, hop in place on each foot, walk on toes, heels) 5) Coordination (Rapid alternating movements, finger-to-nose testing; any tremor?) 5) Sensory testing (pain, light touch, vibration) 6) Reflexes (0 to 4+): Bicepts (C5, C6) Tricepts (C7, C8) Knee (L2, L3, L4) Ankle jerk (S1, S2) Plantar (L4, L5, S1, S2) (if hyperreflexic, test for clonus) d. Performance Oriented Assessment of Balance 17 Patient's Name: Date: Instructions: The patient begins the assessment seated in a hard, straight-backed, armless chair. Ask the patient to perform each of the maneuvers described in the chart. Record the observations made according to the possible responses. The patient s response to each maneuver will align most closely with one of the criteria in the tool. Accurate assessment is dependent upon close observation of the patient during each maneuver. 23

24 Maneuver Patient Response to Maneuver Normal = 2 Adaptive = 1 Abnormal = 0 Score Sitting in chair Steady, stable Holds onto chair to keep upright Rising from chair Immediate standing balance (first 3 to 5 seconds after standing) Standing balance Balance with eyes closed (with feet as close together as possible) Turning balance (360 ) Nudge on sternum (patient should stand with feet as close together as possible; examiner pushes with light, even pressure over sternum 3 times; reflects ability to withstand displacement) Neck turning (patient is asked to turn head side to side and then to look up while standing with feet as close together as possible) Able to rise in a single movement without using arms Steady without holding onto walking aid or other object for support Steady, able to stand with feet together without holding object for support Steady without holding onto any object with feet together No grabbing or staggering; no need to hold onto any objects; steps are continuous (turn is a flowing movement) Steady, able to withstand pressure Able to turn head at least halfway side to side and able to bend head back to look at ceiling; no staggering, grabbing, or symptoms of lightheadedness, unsteadiness, or pain Uses arms to hold onto chair or walking aid to pull or push up and/or moves forward in chair before attempting to rise Steady, but uses walking aid or other object for support Steady, but cannot put feet together Steady with feet apart Steps are discontinuous (puts one foot completely on floor before raising other foot) Needs to move feet, but able to maintain balance Decreased ability to turn side to side and to extend neck backward, but no staggering, grabbing, or symptoms of lightheadedness, unsteadiness, or pain Leans, slides down in chair Multiple attempts required or unable without personal assistance Any sign of unsteadiness (e.g., grabbing objects for support, staggering, moving feet, more than minimal trunk sway) Any sign of unsteadiness regardless of stance or holds onto an object Any sign of unsteadiness or holds onto an object Any sign of unsteadiness or holds onto an object Begins to fall, or examiner has to help maintain balance Any signs of unsteadiness or symptoms when turning head or extending neck backward 24

25 Maneuver One leg standing balance Back extension (ask patient to lean back as far as possible without holding onto object if possible) Reaching up (have patient attempt to remove an object from a shelf high enough to necessitate stretching or standing on toes) Bending down (ask patient to pick up small objects, such as a pen, from the floor) Sitting down Patient Response to Maneuver Normal = 2 Adaptive = 1 Abnormal = 0 Score Able to stand on one leg for 5 seconds without holding object for support Good extension without holding object or staggering Able to take down object without needing to hold onto other object for support and without becoming unsteady Able to bend down and pick up the object; able to get up easily in single attempt without needing to pull self up with arms Able to sit down in one smooth movement TOTAL PATIENT SCORE A higher score reflects better balance ability Tries to extend, but range of motion is decreased (compared with other patients of the same age) or needs to hold object to attempt extension Able to get object but needs to steady self by holding onto something for support Able to get object and get upright in single attempt but needs to pull self up with arms or hold onto something for support Needs to use arms to guide self into chair or not a smooth movement Unable Will not attempt, no extension ability, or staggers Unable or unsteady Unable to bend down, unable to get upright after bending down, or takes multiple attempts to upright self Falls into chair or misjudges distances and lands off center 25

26 e. Performance Oriented Assessment of Gait 17 Instructions: Ask the patient to perform each of the maneuvers described below. The patient should stand with the examiner in an obstacle-free hallway, and use usual walking aid, if necessary. Examiner should ask the patient to walk down the hallway at his or her usual pace and observes one component of gait at a time. For some components, the examiner walks behind the patient; for others, the examiner walks next to the patient. It may require several trips to complete the assessment. Record the observations made according to the types of responses. The patient s response to each maneuver will align most closely with one of the criteria in the tool. Accurate assessment is dependent upon close observation of the patient during each maneuver. Components^ Patient Response to Maneuver Score Initiation of gait (patient asked to begin walking down hallway) Step height (begin observing after first few steps: observe one foot, then the other; observe from side) Step length (observe distance between toe of stance foot and heel of swing foot; observe from side; do not judge first few or last few steps; observe one side at a time) Step symmetry (observe the middle part of the patch, not the first or last steps; observe from side; observe distance between heel of each swing foot and toe of each stance foot) Step continuity Path deviation (observe from behind; observe one foot over several strides; observe in relation to line on floor (e.g., tiles) if possible; note: difficult to assess if patient uses a walker Trunk stability (observe from behind; side-to-side motion of trunk may be a normal gait pattern; need to differentiate this from instability) Walk stance (observe from behind) Turning while walking Normal = 1 Abnormal = 0 Hesitates; multiple attempts; initiation of gait not a smooth motion Begins walking immediately without observable hesitation; initiation of gait is single, smooth motion Swing foot completely clears floor but by no more than 1-2 inches At least the length of individual s foot between the stance toe and swing heel (step length usually longer but foot length provides basis for observation) Step length same or nearly same on both sides for most step cycles Begins raising heel of one foot (toes off) as heel of other foot touches the floor (heel strike); no breaks or stops in stride; step lengths equal over most cycles Foot follows close to straight line as patient advances Trunk does not sway; knees or back are not flexed; arms are not abducted in effort to maintain stability Feet should almost touch as one passes other No staggering, turning continuous with walking, and steps are continuous while turning Swing foot is not completely raised off floor (may hear scraping) or is raised too high (> 1-2 inches)** Step length less than described under normal** Step length varies between sides or patient advances with same foot with every step Places entire foot (heel and toe) on floor before beginning to raise other foot; or stops completely between steps; or step length varies over cycles** Foot deviates from side to side or toward one direction# Any of preceding features present# Feet apart with stepping++ Staggers, stops before initiating turn, or steps are discontinuous TOTAL PATIENT SCORE A higher score reflects better functional mobility ^ Also ask patient to walk at a "more rapid than usual pace and observe whether any walking aid is used correctly. ** Abnormal gait finding may reflect a primary neurologic or musculoskeletal problem directly related to the findings or reflect a compensatory maneuver for other, more remote problem. # Abnormality may be corrected by walking aid such as cane; observe with and without walking aid, if possible. ++ Abnormal finding is usually a compensatory maneuver rather than a primary problem. 26

27 Evaluation: ICM Geriatrics Assessment Workshop Evaluation Albert Einstein College of Medicine INTRODUCTION TO CLINICAL MEDICINE: THE CLINICAL EXPERIENCE Student Evaluation of Geriatric Assessment Workshop Please rate how strongly you agree or disagree with the following statements about the workshop: Strongly Disagree (1) Disagree (2) Uncertain (3) Agree (4) The quality of the handouts was excellent. The lecture on Geriatric Assessment by Dr. Laurie Jacobs provided important background information for the workshop. The use of patients in the practice session greatly added to the value of the experience. The overall content of the program on geriatric assessment was excellent Strongly Agree (5) The practice session with patients increased: Strongly Disagree (1) My skill in performing GAIT assessment My confidence in performing GAIT assessment My skill in performing COGNITIVE assessment My confidence in performing COGNITIVE assessment Disagree (2) Uncertain (3) Agree (4) Strongly Agree (5) The two main things I learned in this workshop are 1) 2) An important question that remains unanswered is The workshop could be improved by 27

28 References 1. Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A The mini-cog: a cognitive 'vital signs' measure for dementia screening in multi-lingual elderly. Int J Geriatric Psychiatry 2000;15: Borson S. Scanlan JM, Chen P, Garguli M. The Mini-Cog a screen for dementia: validation in a population-based sample. J Am Geriatr Soc 2003;51: Scanlon J, Boorson S. The mini-cog had high sensitivity and specificity for diagnosing dementia in community-dwelling older adults. Int J Geriatr Psychiatry 2001;16: Schulman KI, Gold DP, Cohen CA, Zucchero CA. Clock Drawing and dementia in the community: a longitudinal study. Int J Geriatr Psychiatry 1993;8: Kirby M, Denihan A, Bruce I, Coakley D, Lawlor BA. The clock drawing test in primary care: sensitivity in dementia detection and specificity against normal and depressed elderly. Int J Geriatr Psychiatry 2001;16: Richardson HE, Glass JN. A comparison of scoring protocols on the clock drawing test in relation to ease of use, diagnostic group, and correlations with Mini-Mental State Examination. J Am Geriatr Soc 2002;50: Wolf-Klein G, Silverstone FA, Levy AP, Brod M. Screening for Alzheimer's disease by clock drawing. J Am Geriatr Soc Aug;37(8): Strub Rl, Black FW. The Mental Status Examination in Neurology. 4 th ed. Philadelphia: FA Davis Company; Gardner R Jr, Oliver-Munoz s, Fisher L, Empting L. Mattis Dementia Rating Scale: internal reliability study using a diffusely impaired population. J Clin Neuropsychology. 1981;3: Duff Canning SJ, Leach L, Stuss D, et al. Diagnostic utility of fluency measures in Alzheimer s disease and vascular dementia. Neurology 2004;62; Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol 1986;5: Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990;113(12): Hansen, K., Mahoney, J., Palta, M. (1999). Risk factors for lack of recovery of ADL independence after hospital discharge. J Am Geriatr Soc, 47, Schoppen, T., Boonstra, A., Groothoff, J. W., de Vries, J., Goeken, L. N., Eisma, W. H. (1999). The Timed "Up and Go" test: reliability and validity in persons with unilateral lower limb amputation. Arch Phys Med Rehabil, 80, Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in communitydwelling older adults using the Timed Up & Go Test. Phys Ther Sep;80(9): Lin MR, Hwang HF, Hu MH, Wu HD, Wang YW, Huang FC. Psychometric comparisons of the timed up and go, one-leg stand, functional reach, and Tinetti balance measures in community-dwelling older people. J Am Geriatr Soc. 2004;52(8): Tinetti ME. Performance-oriented assessment of mobility problems in elderly patients. J Am Geriatr Soc. 1986;34(2):