Comprehensive Geriatric Assessment

Geriatric Assessment for FPP? The number of elderly Americans older than 65

yrs of age could increase from 34 million in 1998 to approximately 69 million in 2030.

Approximately one-half of the ambulatory primary care for adults older than 65 years is provided by family physicians.

It is estimated that older adults will comprise at least 30 percent of patients in typical family medicine outpatient practices, 60 percent in hospital practices, and 95 percent in nursing home and home care practices.

Geriatric EvaluationGeriatric H&PFunctional Cognitive/AffectiveMedications NutritionalBone Integrity/FallsStrength/

Sarcopenia

ContinenceEyes/EarsETOH/Tobacco/SexEnviroSocialCapacity

Similarities and differences from standard medical evaluation ?

Incorporates all facets of a conventional medical history: The approach being more specific to older persons.

Including non-medical domains Emphasis on functional capacity and

quality of life Incorporating a multidisciplinary team

Defining Goals:

Diagnosis of medical conditions

Development of treatment and follow-up plans

Coordination of management of care

Evaluation of long-term care needs and optimal placement.

Tailored practice to meet busy clinical demands!

Less comprehensive and more problem-directed.

Incorporation of various tools and survey instruments in the assessments.

Patient-driven assessment instruments which are time efficient.

Is this compromising patient care ?

Structured ApproachMultidimensional Multidisciplinary

Functional ability

Physical health (pharmacy)

Cognition

Mental health

Socio-environmental

Physician

Social worker

Nutritionist

Physical therapist

Occupational therapist

Family

Functional Ability

Functional status refers to a person's ability to perform tasks that are required for living.

Two key divisions of functional ability: Activities of daily living (ADL) Instrumental activities of daily living (IADL).

ADL

ADL : self-care activities that a person performs daily (e.g., eating, dressing, bathing, transferring between the bed and a chair, using the toilet, controlling bladder and bowel functions).

IADL IADL are activities that are needed to live

independently (e.g., doing housework, preparing meals,

taking medications properly, managing finances, using a telephone)

Lawton Instrumental Activities of Daily Living Scale1. Can you use the telephone?

Without help 3

with some help 2

Completely unable to use the telephone 1

2. Can you get to places that are out of walking distance?

without help 3

With some help 2

Completely unable to travel unless special arrangements are made

1

3. Can you go shopping for groceries?

Without help 3

With some help 2

Completely unable to do any shopping 1

4. Can you prepare your own meals?

Without help 3

With some help 2

Completely unable to prepare any meals 1

5. Can you do your own housework?

Without help 3

With some help 2

Completely unable to do any housework 1

6. Can you do your own handyman work?

Without help 3

With some help 2

Completely unable to do any handyman work 1

7. Can you do your own laundry?

Without help 3

With some help 2

Completely unable to do any laundry 1

8a. Do you use any medications?

Yes (If “yes,” answer question 8b) 1

No (If “no,” answer question 8c) 2

8b. Do you take your own medication?

Without help (right doses at right time) 3

With some help (prepare or reminds) 2

Completely unable 1

8c. If you had to take medication, could you do it?

Without help (right doses at right time) 3

With some help prepare or reminds) 2

Completely unable 1

9. Can you manage your own money?

Without help 3

With some help 2

Completely unable to handle money 1

KATZ INDEX OF ACTIVITIES OF KATZ INDEX OF ACTIVITIES OF DAILY LIVINGDAILY LIVING

The katz index of independence in activity of daily living (ADL), is the most used scale to screen for basic functional activities of older patients.

•BathingBathing•DressingDressing•ToiletingToileting•TransferTransfer•ContinenContinencece•FeedingFeeding

IndependeIndependentntAssistanceAssistanceDependenDependentt

Katz S et al. Studies of Illness in the Aged: The Index of ADL; 1963.Katz S et al. Studies of Illness in the Aged: The Index of ADL; 1963.

KATZ INDEX OF ACTIVITIES OF DAILY KATZ INDEX OF ACTIVITIES OF DAILY LIVINGLIVING

KATZ INDEX OF ACTIVITIES OF DAILY KATZ INDEX OF ACTIVITIES OF DAILY LIVINGLIVING

INSTRUMENTAL ACTIVITIES INSTRUMENTAL ACTIVITIES OF DAILY LIVINGOF DAILY LIVING

The IADLs are assessed using the Lawton-Brody instrumental activities of daily living (IADL) scale.

•TelephoneTelephone•TravelingTraveling•ShoppingShopping•Preparing Preparing meals meals •HouseworkHousework•MedicationMedication•MoneyMoney

IndependeIndependentntAssistanceAssistanceDependenDependentt

The Oars Methodology: Multidimensional Functional Assessment Questionnaire; 1978.The Oars Methodology: Multidimensional Functional Assessment Questionnaire; 1978.

Lawton-Brody instrumental activities of daily living (IADL) scale

Lawton-Brody instrumental activities of daily living (IADL) scale

IADLSJAGS, April, 1999- community dwelling,

65y/o and older. Followed up at 1yr, 3yr, 5yr

Four IADLsTelephoneTransportationMedicationsFinances

Barberger-Gateau, Pascale and Jean-Francois Dartigues, “Four Instrumental Activities of Daily Living Score as a Predictor of One-year Incident Dementia”, Age and Ageing 1993; 22:457-463.

Berbeger-Gateau, Pascale and Fabrigoule, Colette et al. “Functional Impairment in Instrumental Activities of Daily Living: An Early Clinical Sign of Dementia?”, JAGS 1999; 47:456-463

IADLsAt 3yrs, IADL impairment is a predictor of

incident dementia

1 impairment, OR=12 impairments, OR=2.343 impairments, OR=4.544 impairments, lacked statistical power

MobilityThe Get Up and Go Test is a practical

balance and gait assessment test for an office assessment. The Timed Up and Go Test is another test of basic functional mobility for frail elderly persons.

Balance can also be evaluated using the Functional Reach Test. In this test the patient stands next to a wall with feet stationary and one arm outstretched. They then lean forward as far as they can without stepping. The reach distance of less than six inches is considered abnormal. If further testing is advisable, the Tinetti Balance and Gait Evaluation is the standard.

Get up and Go testStaff should be trained to perform the “Get

Up and Go Test” at check-in and query those with gait or balance problems for falls. Rise from an armless chair without using hands.Stand still momentarily. Walk to a wall 10 feet away.Turnaround without touching the wall.Walk back to the chair.Turn around.Sit down.Individuals with difficulty or demonstrate

unsteadiness performing this test require further assessment.

“Get up and Go”ONLY VALID FOR PATIENTS NOT USING

AN ASSISTIVE DEVICEGet up and walk 10ft, and return to chair

Seconds Rating<10 Freely mobile<20 Mostly independent20-29 Variable mobility>30 Assisted mobility

Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the “Get-up and Go” test. Arch phys Med Rehabil. 1986; 67(6): 387-389.

Get up and GoSensitivity 88%Specificity 94%Time to complete <1min.Requires no special equipment

Cassel, C. Geriatric Medicine: An Evidence-Based Approach, 4th edition, Instruments to Assess Functional Status, p. 186.

Shoulder FunctionA simple test is to inquire about pain and

observe range of motion. Ask the patient to put their hands behind their head and then in back of their waist. If any pain or limitation is present, a more complete examination and potentially referral are recommended.

Hand Function

The ability grasp and pinch are needed for dressing, grooming, toileting and feeding.

to pick up small objects (coins, eating utensils, cup) from a flat surface.

Another measure is of grasp strength. The patient is asked to squeeze two of the

physician or examiner’s fingers with each hand. Pinch strength can be assessed by having the

patient firmly hold a paper between the thumb and index finger

PHYSICAL HEALTH Incorporates all facets of a conventional

medical history: However the approach should be specific to older persons.

Specific topics include: Nutrition Vision Hearing Fecal and urinary continence Balance and fall prevention, osteoporosis and Polypharmacy

Vital signsBlood pressureHypertension Adverse effects from

medication, autonomic dysfunction

Orthostatic hypotension Adverse effects from medication, atherosclerosis, coronary artery disease

Heart rate Bradycardia Adverse effects from medication, heart block

Irregularly irregular heart rate

Atrial fibrillation

Respiratory rate

Increased respiratory rate greater than 24 breaths per minute

Chronic obstructive pulmonary disease, congestive heart failure, pneumonia

Temperature Hyperthermia, hypothermia Hyper- and hypothyroidism, infection

SignsCardiac Fourth heart sound (S4)

Systolic ejection, regurgitant murmurs

Left ventricular thickeningValvular arteriosclerosis

Pulmonary Barrel chest EmphysemaShortness of breath Asthma, cardiomyopathy, chronic

obstructive pulmonary disease, congestive heart failure

Breasts Masses Cancer, fibroadenomaAbdomen Pulsatile mass Aortic aneurysmGastrointestinal, genital/rectal

Atrophy of the vaginal mucosa

Estrogen deficiency

Constipation Adverse effects from medication, colorectal cancer, dehydration, hypothyroidism, inactivity, no fibre

Fecal incontinence Fecal impaction, rectal cancer, rectal prolapse

Prostate enlargement Benign prostatic hypertrophyProstate nodules Prostate cancerRectal mass, occult blood

Colorectal cancer

Urinary incontinence Bladder or uterine prolapse, detrusor instability, estrogen deficiency

Extremities Abnormalities of the feet

Bunions, onychomycosis

Diminished or absent lower extremity pulses

Peripheral vascular disease, venous insufficiency

Heberden nodes OsteoarthritisMuscular/skeletal Diminished range

of motion, painArthritis, fracture

Dorsal kyphosis, vertebral tenderness, back pain

Cancer, compression fracture, osteoporosis

Gait disturbances Adverse effects from medication, arthritis, deconditioning, foot abnormalities, Parkinson disease, stroke

Leg pain Intermittent claudication ,neuropathy, OA radiculopathy, venous insufficiency

Muscle wasting Atrophy, malnutritionProximal muscle pain and weakness

Polymyalgia rheumatica

Skin Erythema, ulceration over pressure points, unexplained bruises

Anticoagulant use, elder abuse, idiopathic thrombocytopenic purpura

Premalignant or malignant lesions

Actinic keratoses, BCC, malignant melanoma, pressure ulcer, squamous cell carcinoma

Nutrition :Four components specific to the geriatric assessment

Nutritional history performed with a nutritional health checklist

Record of a patient's usual food intake based on 24-hour dietary recall

Physical examination with particular attention to signs associated with inadequate nutrition or overconsumption and

Select laboratory tests, if applicable

Nutritional Health Checklist

Statement Yes

I have an illness or condition that made me change the kind or amount of food I eat. 2

I eat fewer than two meals per day. 3

I eat few fruits, vegetables, or milk products. 2

I have three or more drinks of beer, liquor, or wine almost everyday. 2

I have tooth or mouth problems that make it hard for me to eat. 2

I don’t always have enough money to buy the food I need. 4

I eat alone most of the time. 1

I take tree or more different prescription or over-the-counter drugs per day. 1

Without wanting to, I have lost or gained 10 Ib in the past six months. 2

I am not always physically able to shop, cook, or feed myself. 2

Scoring:

0-2= You have good nutrition. 3 to 5= You are at moderate nutritional risk, 6 or more= You are at high nutritional risk,

Adapted with permission from the clinical and cross-effectiveness of medical nutrition therapies: evidence and estimates of potential medical savings from the use of selected nutritional intervention. June 1996, summary report prepared for the nutrition screening initiative, a project of the American Academy of Family Physicians, the American Dietetic Association, and the National Council on the Aging, INC.

VISION

The U.S. Preventive Services Task Force (USPSTF) : found insufficient evidence to recommend for or against screening with ophthalmoscope in asymptomatic older patients.

Common causes of vision impairment : presbyopia, glaucoma, diabetic retinopathy, cataracts, and ARMD

HEARINGUpdated USPSTF recommendations

since 1996:

Recommends screening older patients for hearing impairment by periodically questioning them about their hearing.

(Hearing Handicap Inventory for the Elderly)

Audioscope examination, otoscopic examination, and the whispered voice test are also recommended.

Visual ImpairmentVisual Impairment

Prevalence of functional blindness (worse than 20/200)71-74 years 1%>90 years 17%NH patients 17%

Prevalence of functional visual impairment71-74 years 7%>90 years 39%NH patients 19%

Salive ME Ophthalmology, 1999.Salive ME Ophthalmology, 1999.

Visual ImpairmentOlder persons with visual impairment are

twice as likely to have difficulties performing ADLs and IADLs.

quality of life, mental health, life satisfaction, involvement in home and community

activities.

Hearing Impairment

Hearing ImpairmentPrevalence:

65-74 years = 24%>75 years = 40%

National Health Interview Survey30% of community-dwelling older adults30% of >85 years are deaf in at least one ear

Nadol, NEJM, 1993Nadol, NEJM, 1993

Moss Vital Health Stat, 1986.Moss Vital Health Stat, 1986.

Screening version of the hearing handicap inventory for the elderly

Question Yes (4 points)

Sometime(2 points)

No (0 points)

Does a hearing problem cause you to feel embarrassed when you meet new people?Does a hearing problem cause you to feel frustrated when talking to members of your family?Do you have difficulty hearing when someone speaks in a whisper? Do you feel impaired by a hearing problem?Does a hearing problem cause you difficulty when you visiting friends, relatives or neighbors?Does a hearing problem cause you to attend religious services less often than you would like?Does a hearing problem cause you to have arguments with family members?Does a hearing problem cause you difficulty when listening to the television or radio?Do you feel that any difficulty with your hearing limits or hampers your personal or social life?Does a hearing problem cause you difficulty when in a restaurant with relatives or friends?

Raw Score (some of the points assigned to each of the items)

Note: A raw score of 0 to 8= 13 percent probability of hearing impairment (no handicap/no referral); 10 to 24= 50 percent probability of hearing impairment (mild to moderate handicap/referral); 26 to 40= 84 percent probability of hearing impairment (severe handicap/referral)Adapted with permission from Ventry IM, Weinstein BE, Identification of elderly people with hearing problems. ASHA 1983,25(7):42.

Hearing Impairment

AudioscopeA handheld otoscope with a built-in

audiometerWhisper Test

12 to 24 inches12 to 24 inches

3 words3 words

Macphee GJA Age Aging, 1988Macphee GJA Age Aging, 1988

Hearing Handicap Inventory for the Elderly

QuestionYes (4 points)

Sometimes (2 points)

No (0 points)

Does a hearing problem cause you to feel embarrassed when you meet new people?

_____ _____ ______

Does a hearing problem cause you to feel frustrated when talking to members of your family?

______ ______ ______

Do you have difficulty hearing when someone speaks in a whisper?

______ ______ ______

Do you feel impaired by a hearing problem? ______ ______ ______Does a hearing problem cause you difficulty when visiting friends, relatives, or neighbors?

______ ______ ______

Does a hearing problem cause you to attend religious services less often than you would like?

______ ______ ______

Does a hearing problem cause you to have arguments with family members?

______ ______ ______

Does a hearing problem cause you difficulty when listening to the television or radio?

______ ______ ______

Do you feel that any difficulty with your hearing limits or hampers your personal or social life?

______ ______ ______

Does a hearing problem cause you difficulty when in a restaurant with relatives or friends?

______ ______ --------

Interpretation A raw score of 0 to 8 = 13 percent probability of

hearing impairment (no handicap/no referral) 10 to 24 = 50 percent probability of hearing

impairment (mild to moderate handicap/referral) 26 to 40 = 84 percent probability of hearing

impairment (severe handicap/referral).

Potentially ototoxic drugs. Failure of screening tests should be referred to

an otolaryngologist. Treatment of choice - Hearing aids To minimize hearing loss and improve

daily functioning.

URINARY CONTINENCE Complications: decubitus ulcers, sepsis,

renal failure, urinary tract infections, and increased mortality.

Psychosocial implications : loss of self-esteem, restriction of social and sexual activities, and depression.

Key deciding factor: Nursing home placement.

Questions to ask?Urge incontinence : “Do you have a strong and sudden urge to

void that makes you leak before reaching the toilet?”

Stress incontinence : “Is your incontinence caused by coughing,

sneezing, lifting, walking, or running?”

BALANCE AND FALL PREVENTION Leading cause of hospitalization and injury-

related death in persons 75 years and older. Tool to assess a patient's fall risk- 16 seconds

The Tinetti Balance and Gait Evaluation: This test involves observing as a patient gets up

from a chair without using his or her arms, walks 10 ft, turns around, walks back, and returns to a seated position.

Failure or difficulty to perform the test : increased risk of falling and need further evaluation.

Interpretation Of Test

7 -10 secs : Normal time

10-19 secs : Fairly mobile

20-29 secs : Variable mobility

30 sec or more : Functionally dependent in balance and mobility

OSTEOPOROSIS Osteoporosis may result in low-impact or

spontaneous fragility fractures, which can lead to a fall.

Dual-Energy X-ray Absorptiometry ( Total hip, femoral neck, or lumbar spine, with a T-score of –

2.5 or below)

USPSTF recommendations: Routine screening of women 65 years and older

for osteoporosis with DEXA of the femoral neck.

POLYPHARMACY Multiple medications or the administration of

more medications than clinically indicated.

30 percent of hospital admissions and many preventable problems: are 2/2 to adverse drug effects.

The Centers for Medicare and Medicaid Services encourages the use of the Beers criteria, as part of medication assessment to reduce adverse effects

Clinical recommendationEvidence rating

The U.S. Preventive Services Task Force found insufficient evidence to recommend for or against screening with ophthalmoscopy in asymptomatic older patients.

C

Patients with chronic otitis media or sudden hearing loss, or who fail any hearing screening tests should be referred to an otolaryngologist.

C

Hearing aids are the treatment of choice for older patients with hearing impairment, because they minimize hearing loss and improve daily functioning.

A

The U.S. Preventive Services Task Force has advised routinely screening women 65 years and older for osteoporosis with dual-energy x-ray absorptiometry of the femoral neck.

A

The Centers for Medicare and Medicaid Services encourages the use of the Beers criteria as part of an older patient's medication assessment to reduce adverse effects.

C

2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

Organ System/ Therapeutic Category/Drug(s)

Rationale Recommendation

Quality of Evidence

Strength

Anticholinergics (excludes TCAs) First-generation antihistamines (as single agent or as part of combination products)

Chlorpheniramine Cyproheptadine Diphenhydramine (oral) Hydroxyzine Promethazine

Highly anticholinergic; clearance reduced with advanced age, and tolerance develops when used as hypnotic; increased risk of confusion, dry mouth, constipation, and other anticholinergic effects/toxicity. Use of diphenhydramine in special situations such as acute treatment of severe allergic reaction may be appropriate.

Avoid Hydroxyzine and promethazine: high; All others: moderate

Strong

Antiparkinson agents Benztropine (oral) Trihexyphenidyl

Not recommended for prevention of extrapyramidal symptoms with antipsychotics; more effective agents available for treatment of Parkinson disease.

Avoid Moderate Strong

Antithrombotics Dipyridamole, oral short-acting* (does not apply to the extended-release combination with aspirin)

May cause orthostatic hypotension; more effective alternatives available; IV form acceptable for use in cardiac stress testing.

Avoid Moderate Strong

Ticlopidine* Safer, effective alternatives available. Avoid Moderate Strong

DRUG Rationale Recommendation Quality of evidence

Strength of recommendation

Alpha1 blockers Doxazosin Prazosin Terazosin

High risk of orthostatic hypotension; not recommended as routine treatment for hypertension; alternative agents have superior risk/benefit profile.

Avoid use as an antihypertensive.

Moderate Strong

Alpha blockers, central Clonidine Methyldopa

High risk of adverse CNS effects; may cause bradycardia and orthostatic hypotension; not recommended as routine treatment for hypertension.

Avoid clonidine as a first-line antihypertensive.

Low Strong

Antiarrhythmic drugs (Class Ia, Ic, III) Amiodarone Flecainide Procainamide Sotalol

Data suggest that rate control yields better balance of benefits and harms than rhythm control for most older adults. Amiodarone is associated with multiple toxicities, including thyroid disease, pulmonary disorders, and QT interval prolongation.

Avoid antiarrhythmic drugs as first-line treatment of atrial fibrillation.

High Strong

Digoxin >0.125 mg/day

In heart failure, higher dosages associated with no additional benefit and may increase risk of toxicity; decreased renal clearance and increased risk of toxic effects.

Avoid Moderate Strong

Nifedipine, immediate release*

Potential for hypotension; risk of precipitating myocardial ischemia.

Avoid High Strong

Spironolactone >25 mg/day

In heart failure, the risk of hyperkalemia is higher in older adults if taking >25 mg/day.

Avoid in patients with heart failure or with a CrCl <30 mL/min.

Moderate Strong

DRUG Rationale Recommendation Quality Of evidence

Tertiary TCAs, alone or in combination: Amitriptyline Chlordiazepoxide-amitriptyline Clomipramine Doxepin >6 mg/day Imipramine

Highly anticholinergic, sedating, and cause orthostatic hypotension; the safety profile of low-dose doxepin (≤6 mg/day) is comparable to that of placebo.

Avoid High Strong

Antipsychotics, first- (conventional) and second- (atypical) generation (see Table 8 for full list)

Increased risk of cerebrovascular accident (stroke) and mortality in persons with dementia.

Avoid use for behavioral problems of dementia unless non-pharmacologic options have failed and patient is threat

High Strong

Barbiturates Pentobarbital* Phenobarbital

High rate of physical dependence; tolerance to sleep benefits; greater risk of overdose at low dosages.

Avoid High Strong

Benzodiazepines Short- and intermediate-acting: Alprazolam Lorazepam Oxazepam Temazepam

Long-acting: Chlordiazepoxide Clonazepam Diazepam

Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents. In general, all benzodiazepines increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents in older adults. May be appropriate for seizure disorders, rapid eye movement sleep disorders, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, periprocedural anesthesia, end-of-life care.

Avoid benzodiazepines (any type) for treatment of insomnia, agitation, or delirium.

High Strong

Drug Rationale Recommendation

Quality of evidence

Strength of rec

Estrogens with or without progestins

Evidence of carcinogenic potential (breast and endometrium); lack of cardioprotective effect and cognitive protection in older women. Evidence that vaginal estrogens for treatment of vaginal dryness is safe and effective in women with breast cancer, especially at dosages of estradiol <25 mcg twice weekly.

Avoid oral and topical patch. Topical vaginal cream: Acceptable to use low-dose intravaginal estrogen for the management of dyspareunia, lower urinary tract infections, and other vaginal symptoms.

Oral and patch: high Topical: moderate

Oral and patch: strong Topical: weak

Insulin, sliding scale Higher risk of hypoglycemia without improvement in hyperglycemia management regardless of care setting.

Avoid Moderate Strong

Sulfonylureas, long-duration Chlorpropamide Glyburide

Chlorpropamide: prolonged half-life in older adults; can cause prolonged hypoglycemia; causes SIADH Glyburide: higher risk of severe prolonged hypoglycemia in elderly

Avoid High Strong

Pioglitazone, rosiglitazone

Potential to promote fluid retention and/or exacerbate heart failure.

Avoid High Strong

Drug Rationale Recommendation

Quality of evidence

Strength

Non–COX-selective NSAIDs, oral Aspirin >325 mg/day Diclofenac Ibuprofen Ketoprofen Mefenamic acid Meloxicam Naproxen Piroxicam Sulindac Tolmetin

Increases risk of GI bleeding/peptic ulcer disease in high-risk groups, including those >75 years old or taking oral or parenteral corticosteroids, anticoagulants, or antiplatelet agents. Use of proton pump inhibitor or misoprostol reduces but does not eliminate risk. Upper GI ulcers, gross bleeding, or perforation caused by NSAIDs occur in approximately 1% of patients treated for 3–6 months, and in about 2%–4% of patients treated for 1 year. These trends continue with longer duration of use.

Avoid chronic use unless other alternatives are not effective and patient can take gastroprotective agent (proton-pump inhibitor or misoprostol).

All others: moderate

Strong

Indomethacin Ketorolac, includes parenteral

Increases risk of GI bleeding/peptic ulcer disease in high-risk groups (See above Non-COX selective NSAIDs) Of all the NSAIDs, indomethacin has most adverse effects.

Avoid Indomethacin: moderate Ketorolac: high;

Strong

Pentazocine* Opioid analgesic that causes CNS adverse effects, including confusion and hallucinations, more commonly than other narcotic drugs; is also a mixed agonist and antagonist; safer alternatives available.

Avoid Low Strong

Skeletal muscle relaxants Carisoprodol Chlorzoxazone Cyclobenzaprine Metaxalone Methocarbamol

Most muscle relaxants poorly tolerated by older adults, because of anticholinergic adverse effects, sedation, increased risk of fractures; effectiveness at

Avoid Moderate Strong

2012 AGS Beers Criteria for Potentially Inappropriate Medications to Be Used with

Caution in Older Adults Drug Rationale Recommendation

Quality of evidence

Strength

Aspirin for primary prevention of cardiac events

Lack of evidence of benefit versus risk in individuals ≥80 years old.

Use with caution in adults ≥80 years old.

Low Weak

Dabigatran Increased risk of bleeding compared with warfarin in adults ≥75 years old; lack of evidence for efficacy and safety in patients with CrCl <30 mL/min

Use with caution in adults ≥75 years old or if CrCl <30 mL/min.

Moderate Weak

Prasugrel Increased risk of bleeding in older adults; risk may be offset by benefit in highest-risk older patients (eg, those with prior myocardial infarction or diabetes).

Use with caution in adults ≥75 years old.

Moderate Weak

Antipsychotics Carbamazepine Mirtazapine SNRIs SSRIs TCAs

May exacerbate or cause SIADH or hyponatremia; need to monitor sodium level closely when starting or changing dosages in older adults due to increased risk.

Use with caution. Moderate Strong

Vasodilators May exacerbate episodes of syncope in individuals with history of syncope.

Use with caution. Moderate Weak

Cognition and Mental Health(Depression and Dementia) USPSTF screening recommends for Depression:

Screen all adults for depression if systems of care are in place

Geriatric Depression Scale : Hamilton Depression Scale

Simple two-question screening tool (as effective as longer scales)

“During the past month, have you been bothered by feelings of sadness, depression, or hopelessness?”

“Have you often been bothered by a lack of interest or pleasure in doing things?”

Positive screening test :Responding in the affirmative to one or both of these questions , that requires further evaluation.

Dementia As few as 50 percent of dementia cases are

diagnosed by physicians Early diagnosis of dementia allows :

patients timely access to medications prepares families for the future

Mini-Cognitive Assessment Instrument is the preferred test for the family physician because of its speed.

Mini-Cognitive Assessment Instrument Step 1. Ask the patient to repeat three

unrelated words, such as “ball,” “dog,” and “window.”

Step 2. Ask the patient to draw a simple clock set to 10 minutes after eleven o'clock (11:10). A correct response is drawing of a circle with the numbers placed in approximately the correct positions, with the hands pointing to the 11 and 2.

Step 3. Ask the patient to recall the three words from Step 1. One point is given for each item that is recalled correctly.

Mini-Cognitive Assessment Interpretation

Number of items correctly recalled

Clock drawing test result

Interpretation of screen for dementia

0 Normal Positive

0 Abnormal Positive

1 Normal Negative

1 Abnormal Positive

2 Normal Negative

2 Abnormal Positive

3 Normal Negative

3 Abnormal Negative

The Mini-CogComponents

3 item recall: give 3 items, ask to repeat, divert and recall

Clock Drawing Test (CDT)Normal (0): all numbers present in correct sequence

and position and hands readably displayed the represented time

Abnormal Mini-Cog scoring with best performanceRecall =0, orRecall ≤2 AND CDT abnormal

Borson S. et al Int J Geriatr Psychiatry 2000;15:1021-1027

Mini-Cognitive Assessment Instrument Step 1. Ask the patient repeat three

unrelated words, such as “ball”, “dog”, and “window”.

Step 2. Ask the patient to draw a simple clock set to 10 minutes after eleven o’clock (11:10). A correct response is drawing of a circle with the number placed in approximately the correct position, with the hands pointing to the 11 and 2.

Step 3. Ask the patient to recall the three words from step 1. one point is given for each item that is recalled correctly.

Clock Drawing TestClock Drawing Test:

“Draw a clock”Sensitivity=75.2%Specificity=94.2%

Wolf-Klein GP JAGS, 1989.Wolf-Klein GP JAGS, 1989.

Clock Drawing Test Instructions

Subjects told toDraw a large circleFill in the numbers on a

clock faceSet the hands at 8:20

No time limit givenScoring (subjective):

0 (normal)1 (mildly abnormal)2 (moderately

abnormal)3 (severely abnormal)

Borson S. et al Int J Geriatr Psychiatry 2000;15:1021-1027

121

2

3

45

67

8

9

10

11

Animal Naming TestCategory fluencyHighly sensitive to Alzheimer’s diseaseScoring equals number named in 1 minute

Average performance = 18 per minute< 12 / minute = abnormal

Requires patient to use temporal lobe semantic stores

60 secondsUsing a cutoff of 15 in one minute:

Sens 87% - 88%Spec 96%

Canninng, SJ Duff, et al.; Diagnostic utility of abbreviated fluency measures in Alzheimer disease and vascular dementia; Neurology Feb. 2004, 62(4)

Socioenvironmental Circumstances

Multidisciplinary team approach Family

ETOH/Tobacco/Sex

Alcohol and Smoking CommonCAGE?Smoking Cessation

Sex Also CommonMajor QOL

Enviro-Social Status

Does The Elder Live Alone?

Who Functionally Assists?

Home Assessment, If Necessary

Enviro-Social Status

Social Activity, Relationships and Resources

Caregiver BurdenQuality Of Life

IssuesAdvance

DirectivesCapacity

Determining Capacity

Describe Illness and Course

Explain Proposed Treatment

Understand Treatment Consequences

Understand Risks and Benefits

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Develop Plan

Set GoalsRealistic,

Measurable, Achievable

Discuss With Family, If Appropriate

Develop Stepwise Approach

Assessment & Plan – Holistic approachFormulate problem list

Necessary intervention

Appropriate referral

Comprehensive Geriatric AssessmentOther domains to be assessed:

Current health status: nutritional risk, health behaviors, tobacco, and alcohol use, Bladder Continence

Social assessments: especially elder abuse, caregiver availability and stress, living situation