Comprehensive Geriatric Assessment

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Title: Comprehensive Geriatric Assessment

1
Comprehensive Geriatric Assessment
2
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.

3
Geriatric Evaluation

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

Continence
Eyes/Ears
ETOH/Tobacco/Sex
EnviroSocial
Capacity

4
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

5
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.

6
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 ?

7
Structured Approach

Multidimensional

Multidisciplinary

Physician
Social worker
Nutritionist
Physical therapist
Occupational therapist
Family

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

8
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).

9
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).

10
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11
IADL

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

12
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

13
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.
14
KATZ INDEX OF ACTIVITIES OF DAILY LIVING
15
KATZ INDEX OF ACTIVITIES OF DAILY LIVING
16
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.
17
Lawton-Brody instrumental activities of daily
living (IADL) scale
18
Lawton-Brody instrumental activities of daily
living (IADL) scale
19
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

20
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

21
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.

22
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.

23
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.

24
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.

25
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.

26
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

27
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

28
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
29
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
30

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
31
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

32
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
33

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.

34
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

35
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.

36
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.
37
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.

38
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.
39
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.
40
Hearing Impairment

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

3 words
12 to 24 inches
Macphee GJA Age Aging, 1988
41
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? ______ ______ --------
42
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.

43
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.

44
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?

45
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.

46
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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48
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.

49
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

50
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
51
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
52
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
53
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
54
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
55
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
56
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
57
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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60
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.

61
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.

62
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
63
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)
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Socioenvironmental Circumstances