Sandra Qaseem MD UNM SOM 8/4/17 Functional Assessment in the Elderly Sandra Qaseem MD UNM SOM 8/4/17

Goals and Objectives Enable learners to assess functional, cognitive and affective status of older adults To assess and determine appropriate level of care for elder with functional and or cognitive deficits Know what is available in terms of placement/ care for elders in the community

Case Scenario- Mrs G You are on inpatient service with 15 patients you have just rounded on- you have about an hour to complete usual tasks – order tests, prepare for teaching/ work rounds, write daily orders Mrs G is an 85 y/o scheduled for discharge today, looked fine on rounds and all dc orders were written last night- RN reports to you that dtr has just called and said she cannot take the patient home because she “couldn’t handle her” and the patient would be “too much to take care of at home” The dtr is on jury duty and cannot be reached until 5 pm What next?

Goal Understand what problems Mrs G might have had functioning at home Patient is dressed and ‘ready to go’ What is your approach??

Communication Well lit room but do not sit in front of window or light source Facilitate wearing glasses Reduce extraneous noise- hearing aids/ pocket amplifier Speak slowly in an even tone and check that patient can hear you Face patient at eye level Use paper/ white board to write questions in large block print Take your time- leave enough pauses for patient to answer

Assessment of function ADL’s IADL’s Gait Impairment Cognition- mini-cog, MOCA Affect- depression screen

DEATTH SHAFTTT ADL’s and IADL’s

Basic ADLs D Dressing E Eating A Ambulation T Transfers T Toileting H Hygiene Grooming Bathing

Advanced ADLs (IADLs) S Shopping H Housekeeping A Accounting = $ Cleaning Laundry A Accounting = $ F Food Preparation T Telephone T Transportation T Taking Medications

Clinical Implications 75% of 75 and older limit their activities due to functional impairment Almost 50% of 85 + require assistance in 1 or more ADL’s ADL impairment is a stronger predictor of hospital outcomes than admitting diagnosis, DRG, illness burden etc. 25-35% of older patients admitted for treatment of acute medical illness lose independence in 1 or more ADL- risk factors being cognitive impairment, advanced age and IADL impairment on admission

Screening for Cognitive Impairment Mini- Cog- 3 item recall and clock drawing MOCA- 30 items R/O delirium- inattention, acute onset, disorganized thinking or altered level of consciousness R/O depression Diagnosis of dementia is more involved but screening is fairly predictive Score of less than 3 indicative of need for further dementia screening Patients who score + for any screen for dementia should be further evaluated Neg likelihood ration is likelihood of having disease if screen -

Mini Cog Contents Advantages +3 +2 Verbal Recall (3 points) Clock Draw (2 points) Advantages Quick (2-3 min) Easy High yield (executive fx, memory, visuospatial) Subject asked to recall 3 words Leader, Season, Table +3 Subject asked to draw clock, set hands to 10 past 11 +2 Speaker Notes: Ask the audience why setting the time for “ten past eleven” is a sensitive marker of cognitive decline? Answer: time is an abstract concept. Ten after is symbolically represented by the 2. Our brains do this type of mental gymnastic easily because we do not have dementia. But, patients with early Alzheimer’s disease lose symbolic, abstract thinking. A common response on this part of the task is to draw one line to the ten and one line to the eleven because those are the two numbers you mentioned in the instructions. Their thinking becomes more concrete. The clock is scored all or nothing, 0 or 2 points, because it has been shown to be a very sensitive marker of early cognitive decline. Borson et al., 2000

Prevalence and clinical implications 3% sig cognitive impairment at age 65 and doubles every 5 years 50% in 90 year old Patients do not complain of memory loss Often undiagnosed Effects are poor med compliance, poor compliance with behavioral recommendations, difficulty navigating health system, and caregiver stress

Screening for Depression 2 question screen GDS short/ long PHQ-9 Medical disorders can mimic – hypothyroidism, PD, dementia, malignancy and depression likewise accompanies many major illnesses GDS less than 6 depression less likely, 6-9 possible/ probable greater than 9 depression likely

PHQ-2

Prevalence and clinical implications 6-10% in ambulatory clinic elderly- major depression 11-45% inpatient elderly- major depression 65 and older less than 13% of population but 25% of suicides More than 75% of people who commit suicide suffered major depression and majority have seen a physician in the last month Subsyndromal depressions even more common Depression lowers QOL and leads to poor adherence

Evaluating Gait Instability or Falls 8-19% of non- institutional older adults have difficulty walking or require assistance of another person or special equipment to walk Walking disability increases with age 6% of 65 y/o and to 40% in 85 or older 30-40% of community dwelling elders fall each year, increases to 60% in those with a previous fall in prior year Complications from falls are leading cause of death from injury in elders 10-15 % falls result in serious injury 40-70% of fallers develop fear of falling

All elderly patients should be asked about falls If they report a single fall should undergo the Timed up and Go

Timed Up and Go Place a marker on the floor ten feet from patient’s chair Instructions: Rise from chair Walk 10 feet Turn Return to chair Sit down Score is time in seconds, should use regular aids

Results Normal is less than ten seconds Further evaluation required if not performed in 20 seconds Patients who require 20 s or more are at greater risk from falls and may require assistance of others. Patients with abnormal gait should be further evaluated Patients who have fallen require further evaluation and should be referred to those with skills to evaluate and manage appropriately

Other tests of mobility Chair sit to stand Get up and go Gait speed Functional reach PT assessment is invaluable

Timed up and go

30 second chair stand test

4 stage balance test

Where do the elderly live? Own home independently Senior living Own home with assistance Child’s home Assisted living Small group or shelter care home Nursing home All except nursing home can be +/- adult day care

PACE- Program All Inclusive Care of Elderly- Innovage Non-residential Patient lives at home/ ALF Dual eligible Medicaid /Medicare “managed care” Provides transportation/ MD/ Pharmacy/ PT/ OT/ ST/ SW Includes home health aids etc to help patient maintain independence at home Nursing home eligible patient

Paid Caregivers Private- can do whatever you require Through agency- agency will decide Medicaid Waiver Program- meals, bathing, light housework Driving to appointments- often not available

Senior Living Primarily room and board Some contract with agencies to provide medication management/ toileting/ mobility at extra and significant cost

Assisted Living Various options range from small number of beds to multi story Will distribute meds Toileting Bathing Mobility Transport to meals Feeding Transport to appointments These are usually add ons- the more dependent you are the more costly

Small Group or Shelter Care Homes Usually around 8 beds, private or semi- private In a regular home 1-2 caregivers present Give full assistance including feeding if necessary Need high school diploma to manage a home- very variable Regulated as ALF

Nursing Home Skilled care 30 days Medicare/ 31-90 days copay and Medicare Custodial care- private pay or Medicaid Full assistance- highest level of dependency Regulated by state and federal government, must have medical director/ RN

THE NURSING HOME POPULATION Need assistance with 3+ ADLs 80% Dependent on assistance for eating 57% Incontinence >60% Hearing and Visual Impairments 33% Ambulate without assistance 9.4% Rely on chair for mobility 60.6% ADLs = activities of daily living Functional disability is prevalent in nursing-home residents. More than half of long-stay nursing-home residents require supervision or hands-on assistance from another person in 5 ADLs (ie, eating, dressing, bathing, transferring, and toileting). Topic

Financing options Medicare- DOES NOT pay for custodial care, only skilled Medicaid- if qualify due to ADL deficiency Medicaid will pay for a number of hours of assistance in home or a contribution to board in select ALF. When all funds depleted elders will often end up in Nursing Home with institutional Medicaid- this is the most expensive option for state

Back to our case……

Case Scenario- Mrs. G You are on inpatient service with 15 patients you have just rounded on- you have about an hour to complete usual tasks – order tests, prepare for teaching/ work rounds, write daily orders Mrs. G is an 85 y/o scheduled for discharge today, looked fine on rounds and all dc orders were written last night- RN reports to you that dtr has just called and said she cannot take the patient home because she “couldn’t handle her” and the patient would be “too much to take care of at home” The dtr is on jury duty and cannot be reached until 5 pm What next?

What do you do? Background if possible H+P including social hx- hopefully should be available USE TEAM Social work consult- use IDT PT/ OT assessment Dietary/ Speech Options for care Skilled nursing placement- requirement for 3 x midnight in hospital

Case Resolution Pt was discharged to NH for PT/ OT Further evaluation showed deficits in cognition and difficulty with independent ambulation, deficits in ADL’s After 3 weeks was discharged to Small Group Shelter Care Home close to dtr Private pay----until funds are depleted then usually custodial care is in NH Medicaid funded Many agencies exist to assist families in finding placement for loved ones, “A Place for Mom” , office of senior affairs

Summary Functional assessment very important involves evaluation of ADL’s, IADL’s, cognition, mobility, mood Many options for placement determined by availability, funding, physical/ mental capacity of pt