Human Growth and Development: Geriatrics Small Group Session Karen Hall, M.D. Division of Geriatric Medicine University of Michigan and Ann Arbor VA Health Systems

Intended Learning Outcomes Understand components of a functionally-oriented geriatrics assessment. Identify and document functional impairments in older patients. Identify nutritional risk and assess nutritional status in older patients.

The Geriatric Gap Despite population aging: Only 600 of ~100,000 medical school faculty list Geriatrics as their primary specialty.

Most physicians will be “geriatricicans” If you see any patients aged >60, you will encounter “geriatric” issues. Geriatric-aged patients are more likely to have: disease functional impairment psychosocial needs This presentation will give you the tools to quickly and easily screen for impairments important in all older patients.

A CONTROLLED TRIAL OF INPATIENT AND OUTPATIENT GERIATRIC EVALUATION AND MANAGEMENT Conclusions: Inpatient and Outpatient Geriatric Assessment significantly reduced functional decline and improved mental health with no increase in costs. Cohen et al.; N Engl J Med 2002;346:905-12

Functional status predicts outcomes Sager et al., 1996 Risk factors for greatest risk of functional decline following hospitalization among patients > 70 years: increasing age Pre-admission disability in independent activities of daily living (IADLs) lower cognitive status

How can non-geriatricians deliver good “geriatric” medical care? Recognize FUNCTION as an outcome. Learn how to assess FUNCTION. Activities of Daily Living (ADLs, IADLs) Mobility, Cognition, Affect Nutritional Assessment

Functional Assessment in Older Adults Most useful in High Risk Patients: Complex, multiple medical disease Frailty, age >75 Atypical and obscure disease presentation Physical, cognitive, and affective problems Vulnerability to iatrogenic disability Socially isolated and economically deprived Failure to cope at home (1) Slide of noninstitutionalized disabled Noninstitutionalized. Institutionalized higher. Show walking and other ADL deficits. (2) Definition of functional assessment (READ). The different disciplines include nursing, social work, physical and occupational therapists. Why would we do functional assessment? Most recent suggestions that frail or disabled older adults would benefit most from this type of assessment. The group aged 75 and particularly 85 and over are disproportionately represented in hospitalized, at risk for institutionalization, and already disabled populations, which is why age, per se, may also be a reasonable criterion. These populations require this type of assessment because of the following factors that may be present: (READ) Note that as part of this comprehensive assessment, we also assess the health status and the presence and severity of disease, which is separate from its impact on functional performance. We also focus on geriatric syndromes, such as incontinence and immobility. I will talk about a simple screening tool that gets at the broader issues of a full geriatric assessment at the end.

Patient Outcomes improved by Functional Assessment Improve: activity level, diagnostic accuracy, living situation Reduce polypharmacy, prescribe appropriate medications Decrease hospitalizations/nursing home use Increase home health care Reduce medical costs Prolong survival (4) Positive results of assessment Rubenstein summarizes the outcomes of research on the effectiveness of overall assessment, not just functional assessment. I should note that not all of the literature shows positive results in every area. (READ) The success of these programs depends upon a lot of different factors including: Targeting and a multidisciplinary approach, as I have mentioned Linking assessment closely with treatment and follow-up, so that recommendations are followed. Case management and an array of services, such as social support and home care, appear to be important for implementation. A focus on areas of common geriatric syndromes, such as malnutrition, immobility, mental impairment, as I will show you at the end. And perhaps the enthusiasm, caring, and attention that the older adult receives. (5) Applegate survival These results are based on randomized clinical trials of functionally impaired older adults as well. In a study conducted in a community rehabilitation hospital, cumulative mortality in the controls, the dashed line, was higher than that in the patients assigned to the geriatric assessment unit, the solid line.

How to assess and document Any patient aged 65 or older should have documentation of: Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs) **”..need help?” Vision, Hearing Cognition Mobility – strength, gait Affect (Mood) Nutrition Key documentation: ADLs

Katz Basic (Physical) Activities of Daily Living - ADLs Definition: Things you have to be able to do yourself to be left alone for a few hours – Predicts “placement” Bathing (sponge, shower, tub) Dressing, Undressing, Grooming Toileting (include on/off toilet, clean self) Continence (includes using catheter) Transferring (in and out of bed, chair) Feeding These Tasks cannot be delegated Key documentation: ADLs

Basic (Physical) Activities of Daily Living Rated as: Independent (alone or with device) Dependent (require human assistance) Hierarchical in loss and regaining function. Bathing is first Feeding is last

Instrumental Activities of Daily Living (IADLs) Definition: Things someone else can do – predicts assisted living Using telephone (dial, make, receive, look up #) Travel/transportation (private, public) Shopping (include food, clothes) Preparing meals (include plan and cook) Housework (includes cleaning, moving stuff) Taking medication (right pill, right dose, right time) Managing money (include write checks, pay bills) These tasks may be delegated

Cognitive Assessment 18% of patients over 75, 40% of patients over 85 have cognitive impairment – predicts delerium and “placement” Folstein Mini Mental Status Exam (30 points): - Orientation (date, place) - Registration (immediate repetition: Ball, Cup, Flag) - Serial 7’s (100-93-86-79-72-65) (or WORLD backwards) - Recall of 3 items after 1 minute - Language: naming, repeating, writing - Executive: 3-step command; read and perform task; copy intersecting pentagons

Cognitive Assessment (“1 minute”) Mini-Cog: Registration: 3 objects (Ball, Cup, Flag) Distractor: Clock Draw: hands and numbers at 8:20 or 11:20 Recall of 3 items after 1 minute Score: # objects remembered at 1 minute/3 Score 3/3 is 99% specific to exclude cognitive impairment 12 12 9 3 9 3 6 6

Screening for Depression (Affect) Depression is the most common psychiatric condition – especially in older patients May present as anxiety, anhedonia Validated screening tools: 2 question depression screen (rapid “rule-out”) Geriatric Depression Scale (GDS)

Two-Question Depression Screen 1. "During the past month, have you often been bothered by feeling down, depressed, or hopeless? 2. "During the past month, have you often been bothered by little interest or pleasure in doing things?" If asked exactly as above: “No” to both: - 99% specific to exclude depression

Geriatric Depression Scale (15 item) - Dropped many of your activities and interests? - Feel your life is empty? - Often get bored? - Afraid something bad will happen to you? - Often feel helpless? - Prefer to stay at home rather than going out? - Feel you have more problems with memory than most? - Feel pretty worthless the way you are now? - Feel your situation is hopeless? - Think that most people are better off than you? - Not satisfied with life? Poor spirits most of the time? Not wonderful to be alive? Lacking energy?

Detailed Assessment: Depression Geriatric Depression Scale Questions exclude “pains, aches” from Standard Depression Scale of 30 items Score as # positive/15 Positive: > 5/15 Significant predictor for depression: raises pre-test likelihood from 30% to 70+% in geriatric age patients

Nutrition Malnutrition is underdiagnosed in older patients: risk for infection, falls, poor healing ”Determine” the risk: D - Disease, acute and chronic E - Eating poorly T - Teeth problems E - Economic hardship R - Reduced social contact M - Medications I - Involuntary weight loss N - Needs ADL or IADL assistance E – Elderly

Nutrition (5 second screen) Rapid Screen: Has there been weight loss >10% in 6 months? Yes – do Mini Nutritional Assessment

Mini Nutritional Assessment A. Has food intake declined over the past three months due to loss of appetite, digestive problems, chewing or swallowing difficulties? 0 = severe 1 = moderate 2 = no decrease B. Weight loss during last three months 0 = weight loss greater than 3 kg (6.6 lbs) 1 = does not know 2 = weight loss between 1 and 3 kg (2.2 and 6.6 lbs) 3 = no weight loss C. Mobility 0 = bed or chair bound 1 = able to get out of bed/chair but does not go out 2 = goes out D. Has suffered psychological stress or acute disease in the past three months 0 = yes 2 = no

Mini Nutritional Assessment - 2 E. Neuropsychological problems 0 = severe dementia or depression 1 = mild dementia 2 = no psychological problems F. Body Mass Index (BMI) (weight in kg)/(height in m)2 0 = BMI less than 19 1 = BMI 19 to less than 21 2 = BMI 21 to less than 23 3 = BMI 23 or greater Screening score (subtotal max. 14 points) 12 points or greater: Normal – no need for further assessment 11 points or below: Risk for malnutrition – consider supplements, check serum albumin, institute monitoring/plan

Assessing mobility predicts outcomes Dargent-Molina et al., 1996 Fall-related predictors of hip fracture: slower gait speed difficulty with tandem (heel-toe) walk decreased visual acuity small calf circumference

Mobility Validated Tests: Timed Up and Go (TUG: a quick screen) Tinetti Gait and Balance (detailed) Not validated but very useful: Observed Gait – comment on ability to rise from chair, walking, turning, get on exam table

Timed Up and Go test (TUG) Rise from chair Walk 3 meters in straight line (10 feet) Turn Return to chair Sit in chair Time to do above: if 10 seconds or less – not impaired No need for further assessment

Tinetti Gait and Balance Assessment (Balance portion only) Instructions: Subject is seated in hard, armless chair. The following maneuvers are tested: 1. Sitting balance leans or slides in chair = 0 steady, safe = 1 2. Arising unable without help = 0 able but uses arm to help = 1 able without use of arms = 2 3. Attempting to arise unable without help = 0 able but requires more than 1 attempt = 1 able to arise with 1 attempt = 2

Balance -2- 4. Immediate standing balance (first 325 seconds) unsteady (staggers, moves feet, marked trunk sway) = 0 steady, but uses walker or cane or grabs other objects for support = 1 steady without walker or cane or other support = 2 5. Standing balance unsteady = 0 steady, but wide stance (heels >4” apart) or uses cane or other support = 1 narrow stance without support = 2 6. Nudge (patient standing with feet as close together as possible; examiner pushes with light, even pressure over sternum 3 times; reflects ability to withstand displacement) begins to fall = 0 staggers, grabs, but catches self = 1 steady = 2

Balance -3- 7. Eyes closed (with feet as close together as possible) unsteady = 0 steady = 1 8. Turn (360°) discontinuous steps = 0 continuous steps = 1 unsteady (grabs, staggers) = 0 steady = 1 9. Sitting down unsafe; misjudges distance; falls into chair = 0 uses arms or not a smooth motion = 1 safe, smooth motion = 2 BALANCE SCORE: _____ / 16 (Less than 10 = High Fall Risk)

Rapid screening tools for Geriatric Screening Medical Assessment Function Test Hearing Unable to answer whispered question Vision Unable to read vision card @ 20/40 Nutrition >10% weight loss in last 6 months Arm Unable to touch head, pick up spoon Leg strength and balance Timed Up and Go >10 seconds Incontinence Lose urine and get wet? Polypharmacy Number and dose of medications Mental status Mini-cog (less than 3/3 correct at 1 min) Depression Feel sad (Yes to 2 question screen) Moore & Siu; Am J Med 100:438, 1996

Bottom line: Use functional assessment to improve clinical care of older patients Screen for risk factors or undetected problems. Assist in diagnosis. Establish baseline, set rehabilitation or therapeutic goals, and monitor patient course. Plan for appropriate care needs. (3) Clinical uses of functional assessment Screen: MMSE (READ, stop at planning) Planning for appropriate care then includes identifying support systems required for community living, or if assisted or supervised living an/or skilled care is required. Environments where assessment can be used include inpatient settings, such as geriatric and psychogeriatric assessment units or when geriatric inpatient consultation is obtained. Outpatient and home visit settings are useful, and lately, with the use of the MDS, even in skilled care facilities.

Intended Learning Outcomes – achieved (!) Understand components of a functionally-oriented geriatrics assessment. Identified and documented functional impairments and nutritional status in our patient. Next step – practice! Try these tools when you are assessing patients in the clinic or hospital. Additional resources: Geriatric Portfolio, Geriatric Center Website (Clinical page – Geriatric assessment)