ACTIVITY DISCLAIMER. Geriatric Assessment DISCLOSURE. Irene Hamrick, MD, FAAFP. Learning Objectives. Audience Engagement System Step 1 Step 2 Step 3

Transcription

1 Geriatric Assessment Irene Hamrick, MD, FAAFP ACTIVITY DISCLAIMER The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations. The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP. DISCLOSURE It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose. The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices. Irene Hamrick, MD, FAAFP Professor, Department of Family Medicine and Community Health/Geriatric Services Director/Medical Director of UW APP in LTC Program, University of Wisconsin School of Medicine and Public Health, Madison Dr. Hamrick has been teaching geriatrics for more than 20 years. Since many older patients receive their health care from a primary care physician, it is her mission to train family physicians in geriatrics. She primarily works with older patients in hospital, nursing home, home, and clinic settings. In light of the trend toward a longer life expectancy, the challenge in geriatrics is to improve patients quality of life in their remaining years. Dr. Hamrick s approach with her patients is to prolong good quality of life by addressing risk factors in the context of normal aging changes. She uses her knowledge of geriatrics to explain the pathophysiology and come up with a mutually agreeable plan of care. Dr. Hamrick has received numerous awards in recognition of her skill as a physician and teacher. She writes commentaries for Primary Care PracticeUpdate, has a Twitter feed, and posts many of her presentations online. Learning Objectives 1. Develop and implement a practice specific clinical screening needed for geriatric patients. Audience Engagement System Step 1 Step 2 Step 3 2. Review tools such as the Lawton Instrumental ADL Scale to assess geriatric patients activities of daily living. 3. Review current USPSTF recommendations for screening of geriatrics. 4. Discuss the importance of functional assessment, and describe it in terms of activities of daily living (ADL) and instrumental activities of daily living (IADL). 1

2 Components of Assessment Medical HPI PMH Medications Beers Criteria Family History Genetic background History ROS Review of Systems Hidden Illnesses in the Elderly Skin Vision Hearing Dentition Nutrition Ambulation Appetite Bowel Last BM Bladder Memory Mood Sleep Pain Incontinence Vision Hearing Dentition Constipation Accidental Bowel Leakage Dementia Foot problems Dizziness Depression Falls Sexual Dysfunction Sleep Disorders 40% 30% 20% 10% 0% Prevalence of Incontinence Age 70 Age 90 Urinary Incontinence Men s.html Medication Prescribing Review the med list & ask the patient to bring in their meds Do a home visit: outdated meds, OTC, herbals, Weigh risks & benefits of starting a medication Start low, go slow Link the diagnosis with each med Beers Criteria AGS 2015 Beers Criteria, 2015 J Am Geriatr Soc. 63 (11);

3 ABCs of Prescribing Keep going if indicated, stop if no benefit Simplify medication schedules to increase compliance Start one medication at a time Always suspect meds as the cause of a major medical or cognitive change Avoid the Polypharmacy Merry-Go-Round Treating a side effect from a drug with another drug Components of Assessment Geriatric Functional Assessment IADLs (Instrumental activities of daily living) Transportation Phone use Shopping Preparing Meals Housework Taking Medication Personal Finances Executive Function Loss IADLs age % age % age > 85 58% Lawton MP, Brody EM. Gerontologist 1969;9(3): Geriatric Functional Assessment ADLs (Activities of daily living) Bathing Ambulation Dressing Grooming Transferring Toileting Eating Functional Loss ADLs age % age % age >85 45% Katz S, et al JAMA 185:914-9 Function and Cognition Loss of IADL predicts mild cognitive impairment from normal cognitive function Most discriminating functions with area under curve 81%: Shopping Balancing check book Rodakowski J, et al J Am Geri Soc 62(7):

4 Components of Assessment USPSTF Dementia Screening Current evidence is insufficient to assess the balance of benefits and harms of screening for cognitive impairment. Grade I recommendation Mini-Cog Name 3 items to remember Clock drawing test: 11:10 Recall 3 items to remember 3 items correct- normal 3 items wrong- dementia 1 or 2 items recalled correctly: If clock is normal- normal If clock is abnormal- dementia Annals of Long Term Care, Trends Report CNS Diseases, December 2013 Borson S, et al J Am Geriatr Soc 51: Clock Test The Montreal Cognitive Assessment (MoCA): A Brief Screening Tool For Mild Cognitive Impairment. Tuokko H, et al. The Clock Test. J Am Geriatr Soc 1992; 40: Nasreddine ZS, et al J Am Geri Soc 53:695 9 MOCA is better than MMSE Lam 2013 J Am Geri Soc 61(12):

5 Screening Test Comparison The Saint Louis University Mental Status (SLUMS) Examination for Detecting Mild Cognitive Impairment and Dementia is more sensitive than the Mini-Mental Status Examination (MMSE) SH Tariq, et al. J Am Geriatric Psych 2006;14: SLUMS comparable to MMSE Maybe better in mild cognitive impairment Tariq, et al. Am J Geriatr Psychiatry Nov;14(11): MoCA better than MMSE Dementia rating scale by Mattis Detailed neuropsych testing Lam B, et al JAGS 61; Dementia- DSM-V Criteria Major and mild neurocognitive disorder decline from previous level (difference from DSM-IV: Memory impairment) impairment Impairs independent function Not due to delirium or other CNS conditions: Parkinsons, strokes, subdural hematoma, American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC Dementia Poor judgment and decision making Inability to manage a budget Losing track of the date and the season Difficulty having a conversation Losing things and not being able to remember Is it Just Old Age? Age Related Changes Making a poor decision once in a while Occasionally missing a monthly payment Forgetting what date it is and remembering it later Occasionally forgetting what word to use Losing things and being able to retrace steps Components of Assessment Depression Acute, non-progressive Affective before cognitive Attention impaired Orientation intact Mentions memory complaint Gives up on testing Patient complains Better at night Criticizes self Self referred Language intact Dementia Insidious, progressive before affective Recent memory impaired Orientation impaired Denies or minimizes memory loss Confabulates unknown Family complains Sun-downing Criticizes others Referred by others Difficulty speaking, aphasia 5

6 Depression Diagnosis DSM-5 not significantly different from DSM-4 tr Diagnostic and Statistical Manual 2000 Washington, DC American Psychiatric Association p327 5 symptoms in 2 week period with at least 1: Depressed mood Loss of interest or pleasure Sx impair social, occupational or other function Not due to substance abuse or medical conditions Not due to bereavement, or lasting >2 mo, or cause: psychosis, suicidal ideation, psychomotor retardation or morbid preoccupation with worthlessness Unusual Presentation 75 yo presented with memory loss Not usual Sadness Crying Usual feelings of Worthlessness Helplessness USPSTF Depression Screening The USPSTF recommends screening for depression in the general adult population. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. Grade B recommendation Depression Screening Geriatric Depression Scale PHQ-9 (Patient Health Questionnaire) Part of nursing home MDS (minimal data set) PHQ-2 In the past two weeks did you feel down, depressed or hopeless little interest or pleasure in doing things 100% sensitive, 77% specific in elderly Li C, et al J Am Geri Soc 55(4): Geriatric Depression Scale 1. Do you feel that your situation is hopeless? 2. Do you think that most persons are better off than you are? 3. Have you dropped many of your interests and activities? 4. Do you feel that your life is empty? 5. Are you afraid that something bad is going to happen to you? 6. Do you feel that you have more problems with memory than most? 7. *Do you feel pretty worthless the way you are now? 8. *Do you prefer to stay home at night rather than go out and do new things? 9. *Do you often feel helpless? 10. *Do you often get bored? 11. *Are you basically satisfied with your life? 12. Are you in good spirits most of the time? 13. Do you feel happy most of the time? 14. Do you think it is wonderful to be alive now? 15. Do you feel full of energy? Yesavage JA & Sheikh JI 1986 Clinical Gerontologist 5(1-2); Geriatric Depression Scale On previous 15 questions, the first 10 are positive if answered yes 5 or more of 15 is positive Sensitivity 74 to 100% Specificity 53 to 98% Watson LC, et al J Fam Pract 52(12): Of 5 *questions 2 or more is positive As effective, sens 98%, spec 85% Hoyl MT, et al J Am Geriatr Soc 47(7):

7 suicideresearch/suichart. cfm Components of Assessment For every decade our caloric needs decrease by 10% 2500 Skin Kcal Age Adapted from: Timiras, Paola S. editor, Physiological Basis of Aging and Geriatrics, 2nd ed, 1994, CRC Press, page 274 Max Heart Rate (220- age) x 85% (220-90) x 0.85= 110 7

8 Aging- Nervous System Consequences % decline handwriting speed 30% hand grip strength 22% vibratory sensation-toe 97% foot reaction time 19% stability of body axis standing still 32% Kokmen E, et al J Gerontol 32;411, 1977; Potvin AR, et al JAGS 28:1, 1980; Maki BE, et al. JAGS 38:1, Sway Diagram Age <16 Age Age >60 Adapted from: Sheldon, JH. Effect of Age on control of Sway Gerontology Clinics ; Falls in the Elderly Deaths per 100,000 Population Age in Years Mortality per 100, general population age age >85 12,000 deaths a year Cost $20.2 billion/ year Falls Prevention Screening The USPSTF recommends exercise or physical therapy and vitamin D supplementation to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk for falls. No Single tool is recommended Grade: Grade B Recommendation USPSTF does not recommend automatically performing an indepth multifactorial risk assessment. Grade C Recommendation Michael YL, et al Ann Intern Med 153: Timed up and go (TUG) <16 sec Mathias S, 1986;67:387-9 Chair Rise Test <12 in 30 sec Rikli & Jones 1999 Reach <6 in high risk Duncan 1990, 1992 Falls Screening Tests Performance oriented mobility assessment (POMA) Tinetti M, 1986 Bohannon s Timed Stance Battery Tandem, single leg, eyes closed Bohannon R 1984, 2006 Berg Balance Scale Balance (9), Gait (7) Berg 1989, 1992 Get Up and Go Test Have patient get up from a straight back chair and walk to the door, 10 feet, turn around and sit back down. This should take 16 seconds or less. Mathias S, Nayak US, Isaacs B Arch Phys med Rehabil 67:

9 Chair Rise Test, CDC STEADI <12 in >65 yo, graded by age Abnormality Possible Diagnoses Interventions Difficulty in getting up and sitting down Unsteadiness after nudge Myopathy, arthritis, Parkinson s Disease (PD), orthostasis, deconditioning, Dementia PD, Normal Pressure Hydrocephalus (NPH), Back Problems, Dementia Strengthening, tx training, high firm chairs, raised toilet seats Balance training Back exercises Environmental assessment Abnormality Differential Interventions Decreased step height Unsteadiness with turning Increased path deviation CNS disease, dementia, Parkinsons, NPH, Sensory deficits, Fear of falling PD, multiple sensory deficits, cerebellar disease, CVA Cerebellar disease, multiple sensory deficits, alcoholism, ataxia, Vitamin B-12 deficiency Sensory exam, proper footwear, low pile carpet, remove throw rugs, walking aid Gait training, proprioceptive exercises, walking aid Appropriate walking aid, Gait training, Replace Vitamin B-12 if <350 ng/ml Components of Assessment Pupillary Diameter (mm) Pupillary Response with Age Dark Adapted Light Adapted Adapted from: Timiras, Paola S. editor, Physiological Basis of Aging and Geriatrics, 3 rd ed, 2003, CRC Press, page 147, based on the data of Verriest, Age (years) Bull Acad. R. Med. Belg., 11, 527, WHO Global causes of blindness as a proportion of total blindness in

10 Vision screening The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for visual acuity for the improvement of outcomes in older adults. Grade: I recommendation Chou R, et al Ann Intern Med 151:44-58 The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for primary open-angle glaucoma in adults. Grade: I Recommendation Boland, et al Ann Intern Med 158: Age Related Hearing Loss Requires both: Genetic predisposition Noise exposure, cumulative through life More common in men High frequency is lost first Age Related Hearing Loss The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for hearing loss in asymptomatic adults aged 50 years or older. Grade: I Statement Chou R, et al Ann Intern Med 154: Communicating with Patients who have Hearing Loss Slow down, e.g. foreign language Face Patient Don t cover face or mouth Separate words Don t trail off or run words together Communicating with Patients who have Hearing Loss Turn off background noise, e.g. TV Close door Get person s attention first Announce change of subject Decreased Sensation Nose Decreased smell Mouth Decreased taste Dryness 10

11 Olfactory Impairment Olfactory impairment increases with age and is high. Age Prevalence % % % % % Murphy, C. et al JAMA 288 (18); Components of Assessment Social Living Situation Who, where, how long Who is in charge HCPOA Financial Insurance Prevention Immunizations Mammogram/Pap Colon cancer screening Exercise Osteoporosis prevention Injury prevention-seat belts/environmental assessment Years Life Expectancy by Age Median Life Expectancy Framework And in the end, it s not the years in your life that count. It s the life in your years Age Abraham Lincoln 11

12 Practice Recommendations Review ADLs and IADLs to keep patients safe and intervene early. Use the Beers Criteria to regularly review med. Prevent falls with exercise or physical therapy and vitamin D supplementation. Questions Thank you! ihamrick@wisc.edu 12