Aging: Tools for Assessment Eugenia L. Siegler, MD Mason Adams Professor of Geriatric Medicine Weill Cornell Medicine New York, New York San Antonio, Texas: August 21 to 23, 2017 Learning Objectives After attending this presentation, learners will be able to: List at least four domains of comprehensive geriatric assessment Use basic geriatric assessment tools Access the aging services network in their county Slide 3 of XX Slide 4 of 27 Screening of People with HIV: Who Might Benefit From Geriatric Assessment??
Slide 5 of 27 Screening of People with HIV: Who Might Benefit From Geriatric Assessment? Over 60(?) Want to discuss aging Falls/functional impairment Cognitive impairment Multimorbidity Polypharmacy Incontinence Isolated Other Comprehensive Geriatric Assessment Has Multiple Domains Slide 6 of 27 Basic ADL Instrumental ADL Geriatric syndromes/frailty Medical comorbidities Nutritional status Medication appropriateness Social network/financial status Living situation/ environment Affect Cognition Advance directives Quality of life Slide 7 of 27 Formal Assessment is More Sensitive Than Clinical Judgment Clinical judgment can identify severe impairment Recognition of moderate impairments is better with use of formal assessment # of patients with impairment 30 25 20 15 10 5 0 Clinical Judgement CGA Pinholt et al. Arch Intern Med 1987;147:484-488
What Do You Want to Measure? Multimorbidity Slide 8 of 27 Functional Impairment Frailty Poor Health Considerations: Domain/Impairment Sensitivity Specificity Time/ Ease of administration Cultural/ Social appropriateness Aging? Start with Function Slide 9 of 27 Function is the ability to do specific tasks Functional status is an independent predictor of mortality and morbidity https://i.ytimg.com/vi/btgqut2heku/maxresdefault.jpg Slide 10of of 27 Basic Activities of Daily Living Grooming Bathing Dressing Toileting Transferring/mobility Continence Feeding Assessment Tool: Katz ADL scale Instrumental Activities of Daily Living Telephone Travel Shop Meals Housekeeping Manage Meds Manage Finances Assessment Tool: Lawton IADL scale
Slide 11 of 27 Mobility and Gait: Timed Up and Go Test Podsialdo et al., JAGS 1991 Seconds Rating <10 Freely mobile 12 seconds Higher risk of falling Slide 12 of 27 Practice: Timed Up and Go Slide 13 of 27 How about Cognition?
Mini-Cog (Borson et al, 2000; 2003) Slide 14 of 27 Three-item recall + Clock Drawing Test Quick Minimally dependent on education Review of brief cognitive tests for patients with suspected dementia (2014) doi: 10.1017/S1041610214000416 Slide 15 of 27 Montreal Cognitive Assessment (MoCA) Attention Concentration Executive functions Memory Language Visuoconstructional skills Conceptual thinking Calculations Total Possible Score: 30 points Normed for education Add 2 points for 4-9 yrs education Add 1 point for 10-12 yrs education Normal 26 MCI: 19-25.2 Alzheimer disease: 11.4-21 Diagnosis of dementia requires functional impairment Clock Drawing Test Slide 16 of 27 Draw a clock face with hands set at a designated time Two versions- with circle vs. patient draw circle Simplest Method Ask patients to draw the face of the clock and then to place the hands to indicate 10 minutes past 11 Score 0 4 one point for drawing a closed circle one point for placing numbers in the correct position one point for including all 12 correct numbers one point for placing hands in the correct positions
Slide 17 of 27 Practice: Clock Drawing Test Score This Clock Slide 18 of 27 Slide 19 of 27 Score This Clock
Slide 20 of 27 Score This Clock Slide 21 of 27 Assessing Mental Health Slide 22 of 27 Mental Health: Depression Scales Simplest Screen: Are you depressed?
Slide 23 of 27 Mental Health: GAD-7 Anxiety Screen 7-item Administration time 2-5 min Spitzer RL et al Arch Intern Med. 2006;166:1092-1097. Slide 24 of 27 Most Efficient: PHQ-4 Total score ranges from 0-12: None 0-2 Mild 3-5 Mod 6-8 Severe 9-12 On each subscale, a score of 3 or greater is considered positive for screening purposes Anxiety subscale: sum of items 1 & 2 (range, 0-6) ( 3 sens 95.2%) Depression subscale: sum of items 3 & 4 (range, 0-6) ( 3 sens 93.4%) Kroenke K, Spitzer RL, Williams JBW, Löwe B. An ultra-brief screening scale for anxiety and depression: the PHQ-4 Psychosomatics 2009;50:613-621. On-line Resources Slide 25 of 27 National Association of Area Agencies on Aging NECA AETC Aging Toolkit.pdf
Every County has an Area Agency on Aging and Most Have an Aging and Disability Resource Center Slide 26 of 27 Slide 27 of 27 Thanks to Drs. Karen Ouchida and Sharda Ramsaroop for some of the assessment slides