Anthony J. Caprio, MD Ellen Roberts, PhD, MPH Jan Busby-Whitehead, MD The University of North Carolina at Chapel Hill With Support from The Donald W. Reynolds Foundation Geriatric Assessment © The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights Reserved.

2 Objectives 1)To illustrate the importance of physical, cognitive, and psychosocial assessments for older adults 2)To describe Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) 3)To demonstrate gait assessment and falls risk assessment with an older adult 4)To demonstrate cognitive and depression screening with an older adult

3 Function, Function, Function In real estate it’s “location,” in geriatric assessment the focus is on function Physical Functioning Gait and balance Ability to perform daily self-care activities Cognitive Functioning Memory, reasoning, and judgment Ability to perform “life-maintenance” activities Psychosocial Functioning Depression and mental health Adequate caregiver support Financial resources

4 What Does Every Practitioner Need to Know? Overall functional assessment or impression: Big Picture Ask questions, but.. Don’t just tell me, show me. (performance-based testing) Make careful observations! Trust your gut, if something doesn’t look right, it probably isn’t Screen and know when to refer for further evaluation

5 Asking About Function "Can you tell me what your typical day is like?” When do you get up? What do you do in the morning? Do prepare your own meals? How many meals do you usually eat? Do you get out of the house? Shopping? Church? How do you spend the rest of the day? Do you watch TV? Read? When do you go to bed? Are you generally satisfied with how you spend your days?

6 Activities of Daily Living (ADLs) Dressing Eating (feeding) Ambulating (transferring) Toileting (continence) Hygiene (bathing)  Independent  Partially Dependent  Dependent  Independent  Partially Dependent  Dependent Transferring Walking Toileting Bathing Dressing Eating (feeding) Continence

7 Instrumental Activities of Daily Living (IADLs) Shopping Housekeeping Accounting Food preparation Transportation Driving or using the bus (transportation) Using the telephone Managing medications Buying groceries Preparing meals Housework, laundry Paying bills, managing money  Independent  Partially Dependent  Dependent  Independent  Partially Dependent  Dependent

8 Why are ADLs/IADLs Important? ADL impairment is a stronger predictor of hospital outcomes than admitting diagnoses, Diagnosis Related Group (DRG), or other physiologic indices of illness burden Functional decline Length of stay Institutionalization (nursing home placement) Death Approximately 25% to 35% of older patients admitted to the hospital for treatment of acute medical illness lose independence in one or more ADLs Implications for discharge planning and post-acute care

9 Best Test is a “Real World” Performance Test Easy to perform in an office/clinic/hospital room Easy to evaluate (can do, can’t do, or time to completion) Can be integrated into what you do already Provide objective information about a person’s actual function in daily living Assessment starts the minute you start observing the patient.

10 Perform a task Walk over to the exam table Get on/off the exam table Unbutton sleeve, take shirt off Put shirt back on, button sleeve, tie shoes Standardized tests Assessing Function

11 Assessing Physical Functioning: Gait and Risk for Falling 35-40% of community-dwelling older adults fall each year 10 to 15% of falls result in a fracture or other serious injury 72% of all fall-related deaths are in the age 65+ population Approximately 40-70% of fallers develop fear of falling Risk Factor Relative Risk (RR) for Falls Leg Weakness 4.4 Gait Deficit 2.9 Impaired ADL 2.3 Depression 2.2 Cognitive Impairment 1.8

12 Timed “Get Up and Go" Test Patient sits in a chair, rises and walks ten feet (3 meters), turns, and returns to the chair Should be able to do this in <20 seconds, if >30 seconds functionally dependent (higher risk for falls) Identifying fallers: Sensitivity and Specificity = 87% Abnormalities in mobility should prompt referral for physical therapy or a further diagnostic work-up Predicts ADL disability and nursing home admission Phys Ther. 2000;80:896 –903. J Am Geriatr Soc 2010;58:844–852. J Am Geriatr Soc 2004;52:1343–1348.

13 Timed “Get Up and Go” Video courtesy of the Tiffany Shubert, PhD, MPT, UNC School of Medicine.

14 Chair Rise Use a standard chair with arms Ask the subject to rise from the chair If they are able to do that, then ask them to rise from the chair without the assistance of pushing-off of the arms of the chair with their hands It may be helpful to have the subject fold their arms across their chest during the maneuver Proximal muscle weakness, including trunk and proximal thighs, makes this maneuver difficult and is a risk factor for falls Can be timed (should take <15 seconds for 5 repetitions) Picture of chair

15 Video courtesy of the Tiffany Shubert, PhD, MPT, UNC School of Medicine.

16 Cognitive Evaluation Prevalence of cognitive impairment 3% among persons ≥65 years of age Doubles every 5 years 40-50% among persons ≥90 years of age Unrecognized cognitive impairment Adherence to medications or treatment plans Difficulty navigating the health care system Caregiver stress Most common causes of cognitive impairment Delirium Dementia Depression

17 Delirium: More Than “Confusion” Sudden and fluctuating change in cognition Altered way of perceiving the world Hallucinations or delusions Might be disoriented Agitated or excessively sleepy Conversations don’t make sense

18 Confusion Assessment Method (CAM) 1) Acute onset and fluctuating course and 2) Inability to focus (inattention) 3) Disorganized thinking or 4) Change in the level of consciousness

19 Folstein Mini-Mental State Exam (MMSE) Orientation Registration/Recall (3 objects) Attention and Calculation (WORLD  DLROW, serial 7s) Language (naming, repetition, 3 stage command, reading, writing) Visual-Spatial (Copy Design)

20 Interpretation of MMSE Scores Score < 24 considered abnormal Ranges:20-25 Mild impairment Moderate impairment 0-10 Severe impairment Depends on literacy and native language Adjustments have been made for: Age Educational level

21 Mini-Cog 3 item recall after clock drawing task (CDT) Easy to administer Sensitivity: 76-99%, Specificity: 89-93% Not as dependent on education and language J Am Geriatr Soc 2003; 51: Ann Intern Med 1995; 122:

22 Mini-Cog 3 Items 0 Items Recalled POSITIVE SCREEN 1-2 Items Recalled Normal Clock Drawing Abnormal Clock Drawing POSITIVE SCREEN

23 Clock Drawing Test: “10 Minutes After 11”

24 Clock Drawing Test: Mild Impairment

25 Clock Drawing Test: Right-Sided Neglect

26 Severely Impaired Clock Drawing

27 At the End of an Encounter… Teach-back method: “We discussed a lot of things today and I want to make sure that I explained things well, can you summarize what we talked about today?” “So let’s review our plan. What will you do when you get home today? What will you do before our next visit? How will you take this medication?”

28 Psychological Assessment Prevalence of major depression Outpatient primary care: 6% - 10% Inpatient : 11% - 45% Persons aged ≥65 <13% of the populations 25% of suicides

29 Screening for Depression Single Question: “Do you often feel sad or depressed?” Sensitivity 69-85% Specificity 65-90% 2-Item Screening Depressed Mood: "During the past month, have you often been bothered by feeling down, depressed, or hopeless?" Anhedonia: " During the past month, have you often been bothered by little interest or pleasure in doing things?“ Test is negative for patients who respond "no" to both questions

30 Geriatric Depression Scale (GDS) Long (30-item) and short forms (15 or 5 items) GDS 15-Item Screen: Score > 5 points suggests depression Sensitivity 97% Specificity 85%

31 Case 1 86 yo female presents to the emergency department with a two-day history of nausea, vomiting, and unsteadiness. She lives independently in the community. Her ECG shows atrial tachycardia (rate=150) with AV block. Patient’s medication list includes digoxin 0.125mg po daily. Labs show normal renal function but a critically high digoxin level.

32 Case 2 88 yo male is admitted for elective surgery. He had an unremarkable pre-op evaluation one week prior to admission. He was considered low risk for the planned surgical procedure. The surgery was uneventful, but in the PACU, the patient is very agitated and confused. He is trying to get out of bed to “catch a train”. His nurse calls the resident because she is concerned that he may have had a stroke during the procedure. A stat head CT is negative for an acute process.

33 Case 3 78 yo female sustained a mechanical fall at home with a left foot fracture and right wrist fracture. She is given a walking boot for her foot and a splint for her wrist. No surgical intervention is indicated. She lives alone and insists that she will be just fine at home. Her daughter lives about an hour away but will check on her on the weekends and help with grocery shopping.

34 Basic Geriatric Assessment 1)Functional Impairments  Activities of Daily Living (ADLs)  Instrumental Activities of Daily Living (IADLs) 2)Gait and Fall Risk Assessment  Timed “Get Up and Go” Test  Chair Rise 3)Cognitive Assessment  Confusion Assessment Method (CAM)  Mini-Cog  Teach-back method 4)Depression Screen  One or Two-item questions  Geriatric Depression Scale (GDS )

35 Acknowledgments and Disclaimers This project was supported by funds from The Donald W. Reynolds Foundation. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by The Donald W. Reynolds Foundation. The UNC Center for Aging and the UNC Division of Geriatric Medicine also provided support for this activity. This work was compiled and edited through the efforts of Carol Julian.

36 © The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights Reserved.