Comprehensive Geriatric Assessment

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Comprehensive Geriatric Assessment
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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.

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Geriatric Evaluation

• Geriatric HP
• Functional
• Cognitive/Affective
• Medications
• Nutritional
• Bone Integrity/Falls
• Strength/Sarcopenia

• Continence
• Eyes/Ears
• ETOH/Tobacco/Sex
• EnviroSocial
• Capacity

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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

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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.

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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 ?

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Structured Approach

• Multidimensional

• Multidisciplinary

• Physician
• Social worker
• Nutritionist
• Physical therapist
• Occupational therapist
• Family
• 
  

• Functional ability
• Physical health (pharmacy)
• Cognition
• Mental health
• Socio-environmental

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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).

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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).

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IADL

• IADL are activities that are needed to live
  independently
• (e.g., doing housework, preparing meals, taking
  medications properly, managing finances, using a
  telephone)

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Lawton Instrumental Activities of Daily Living
Scale

• 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

• 1. 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

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KATZ INDEX OF ACTIVITIES OF DAILY 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.

• Bathing
• Dressing
• Toileting
• Transfer
• Continence
• Feeding

Independent Assistance Dependent
Katz S et al. Studies of Illness in the Aged The
Index of ADL 1963.
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KATZ INDEX OF ACTIVITIES OF DAILY LIVING
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KATZ INDEX OF ACTIVITIES OF DAILY LIVING
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INSTRUMENTAL ACTIVITIES OF DAILY LIVING
The IADLs are assessed using the Lawton-Brody
instrumental activities of daily living (IADL)
scale.

• Telephone
• Traveling
• Shopping
• Preparing meals
• Housework
• Medication
• Money

Independent Assistance Dependent
The Oars Methodology Multidimensional Functional
Assessment Questionnaire 1978.
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Lawton-Brody instrumental activities of daily
living (IADL) scale
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Lawton-Brody instrumental activities of daily
living (IADL) scale
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IADLS

• JAGS, April, 1999- community dwelling, 65y/o and
  older. Followed up at 1yr, 3yr, 5yr
• Four IADLs
• Telephone
• Transportation
• Medications
• Finances
• 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 22457-463.
• Berbeger-Gateau, Pascale and Fabrigoule, Colette
  et al. Functional Impairment in Instrumental
  Activities of Daily Living An Early Clinical
  Sign of Dementia?, JAGS 1999 47456-463

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IADLs

• At 3yrs, IADL impairment is a predictor of
  incident dementia
• 1 impairment, OR1
• 2 impairments, OR2.34
• 3 impairments, OR4.54
• 4 impairments, lacked statistical power

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Mobility

• The 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.

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Get up and Go test

• Staff 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.

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Get up and Go

• ONLY VALID FOR PATIENTS NOT USING AN ASSISTIVE
  DEVICE
• Get up and walk 10ft, and return to chair
• Seconds Rating
• lt10 Freely mobile
• lt20 Mostly independent
• 20-29 Variable mobility
• gt30 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.

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Get up and Go

• Sensitivity 88
• Specificity 94
• Time to complete lt1min.
• Requires no special equipment
• Cassel, C. Geriatric Medicine An Evidence-Based
  Approach, 4th edition, Instruments to Assess
  Functional Status, p. 186.

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Shoulder Function

• A 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.

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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 examiners fingers with each hand.
• Pinch strength can be assessed by having the
  patient firmly hold a paper between the thumb and
  index finger

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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

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Vital signs Vital signs Vital signs Vital signs
Blood pressure Hypertension 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
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Signs Signs
Cardiac Fourth heart sound (S4) Systolic ejection, regurgitant murmurs Left ventricular thickening Valvular arteriosclerosis
Pulmonary Pulmonary Barrel chest Emphysema
Shortness of breath Asthma, cardiomyopathy, chronic obstructive pulmonary disease, congestive heart failure
Breasts Breasts Masses Cancer, fibroadenoma
Abdomen Abdomen Pulsatile mass Aortic aneurysm
Gastrointestinal, genital/rectal Gastrointestinal, 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 hypertrophy
Prostate nodules Prostate cancer
Rectal mass, occult blood Colorectal cancer
Urinary incontinence Bladder or uterine prolapse, detrusor instability, estrogen deficiency
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Extremities Extremities Abnormalities of the feet Bunions, onychomycosis
Diminished or absent lower extremity pulses Peripheral vascular disease, venous insufficiency
Heberden nodes Osteoarthritis
Muscular/skeletal Muscular/skeletal Diminished range of motion, pain Arthritis, 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, malnutrition
Proximal muscle pain and weakness Polymyalgia rheumatica
Skin 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
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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

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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 dont 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
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• 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.

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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

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HEARING

• Updated 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.

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Visual Impairment

• Visual Impairment
• Prevalence of functional blindness
  (worse than 20/200)
• 71-74 years 1
• gt90 years 17
• NH patients 17
• Prevalence of functional visual impairment
• 71-74 years 7
• gt90 years 39
• NH patients 19

Salive ME Ophthalmology, 1999.
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Visual Impairment

• Older 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.

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Hearing Impairment

• Hearing Impairment
• Prevalence
• 65-74 years 24
• gt75 years 40
• National Health Interview Survey
• 30 of community-dwelling older adults
• 30 of gt85 years are deaf in at least one ear

Nadol, NEJM, 1993 Moss Vital Health Stat, 1986.
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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. 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. 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. 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.
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Hearing Impairment

• Audioscope
• A handheld otoscope with a built-in audiometer
• Whisper Test

3 words
12 to 24 inches
Macphee GJA Age Aging, 1988
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Hearing Handicap Inventory for the Elderly
Question Yes (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? ______ ______ --------
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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.

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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.

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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?

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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.

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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

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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.

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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

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Clinical recommendation Evidence 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
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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) Anticholinergics (excludes TCAs) Anticholinergics (excludes TCAs) Anticholinergics (excludes TCAs) 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 Antithrombotics Antithrombotics Antithrombotics 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
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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 gt0.125 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 gt25 mg/day In heart failure, the risk of hyperkalemia is higher in older adults if taking gt25 mg/day. Avoid in patients with heart failure or with a CrCl lt30 mL/min.   Moderate Strong   Moderate Strong
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DRUG Rationale Recommendation Quality Of evidence
Tertiary TCAs, alone or in combination Amitriptyline Chlordiazepoxide-amitriptyline Clomipramine Doxepin gt6 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
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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 lt25 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
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Drug Rationale Recommendation Quality of evidence Strength
NonCOX-selective NSAIDs, oral Aspirin gt325 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 gt75 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 36 months, and in about 24 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
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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 lt30 mL/min Use with caution in adults 75 years old or if CrCl lt30 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
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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.

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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.

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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 (1110). 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.

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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
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The Mini-Cog

• Components
• 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 performance
• Recall 0, or
• Recall 2 AND CDT abnormal

Borson S. et al Int J Geriatr Psychiatry
2000151021-1027
64
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 oclock (1110). 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.

65
Clock Drawing Test

• Clock Drawing Test
• Draw a clock
• Sensitivity75.2
• Specificity94.2

Wolf-Klein GP JAGS, 1989.
66
Clock Drawing Test Instructions

• Subjects told to
• Draw a large circle
• Fill in the numbers on a clock face
• Set the hands at 820
• No time limit given
• Scoring (subjective)
• 0 (normal)
• 1 (mildly abnormal)
• 2 (moderately abnormal)
• 3 (severely abnormal)

12
1
11
2
10
3
9
4
8
5
7
6
Borson S. et al Int J Geriatr Psychiatry
2000151021-1027
67
Animal Naming Test

• Category fluency
• Highly sensitive to Alzheimers disease
• Scoring equals number named in 1 minute
• Average performance 18 per minute
• lt 12 / minute abnormal
• Requires patient to use temporal lobe semantic
  stores
• 60 seconds
• Using 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)
68
Socioenvironmental Circumstances

• Multidisciplinary team approach
• Family

69
ETOH/Tobacco/Sex

• Alcohol and Smoking Common
• CAGE?
• Smoking Cessation
• Sex Also Common
• Major QOL

70
Enviro-Social Status

• Does The Elder Live Alone?
• Who Functionally Assists?
• Home Assessment, If Necessary

71
Enviro-Social Status

• Social Activity, Relationships and Resources
• Caregiver Burden
• Quality Of Life Issues
• Advance Directives
• Capacity

72
Determining Capacity

• Describe Illness and Course
• Explain Proposed Treatment
• Understand Treatment Consequences
• Understand Risks and Benefits

73
Develop Plan

• Set Goals
• Realistic, Measurable, Achievable
• Discuss With Family, If Appropriate
• Develop Stepwise Approach

74
Assessment Plan Holistic approach

• Formulate problem list
• Necessary intervention
• Appropriate referral

75
Comprehensive Geriatric Assessment

• Other 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