Transcript Assessment-EMORY-university

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 Evaluation
 Geriatric H&P
 Continence
 Functional
 Eyes/Ears
 Cognitive/Affective
 ETOH/Tobacco/Sex
 Medications
 EnviroSocial
 Nutritional
 Capacity
 Bone Integrity/Falls
 Strength/Sarcopenia
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 Approach
Multidimensional
 Functional ability
Multidisciplinary
 Physician
 Social worker
 Physical health (pharmacy)
 Nutritionist
 Cognition
 Physical therapist
 Mental health
 Occupational therapist
 Socio-environmental
 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 Scale
6. Can you do your own handyman work?
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 do any handyman work 1
7. Can you do your own laundry?
Without help
3
without help
3
With some help
2
With some help
2
Completely unable to do any laundry
1
Completely unable to travel unless special
arrangements are made
8a. Do you use any medications?
1
3. Can you go shopping for groceries?
Yes (If “yes,” answer question 8b)
1
No (If “no,” answer question 8c)
2
Without help
3
8b. Do you take your own medication?
With some help
2
Without help (right doses at right time)
Completely unable to do any shopping
1
With some help (prepare or reminds) 2
4. Can you prepare your own meals?
Completely unable
Without help
3
With some help
2
Without help (right doses at right time)
Completely unable to prepare any meals
1
With some help prepare or reminds) 2
5. Can you do your own housework?
3
With some help
2
1
8c. If you had to take medication, could you do it?
Completely unable
Without help
3
3
1
9. Can you manage your own money?
Without help
3
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.
KATZ INDEX OF ACTIVITIES OF DAILY LIVING
KATZ INDEX OF ACTIVITIES OF DAILY LIVING
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.
Lawton-Brody instrumental activities of daily
living (IADL) scale
Lawton-Brody instrumental activities of
daily living (IADL) scale
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; 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

IADLs
 At 3yrs, IADL impairment is a predictor of incident
dementia
 1 impairment, OR=1
 2 impairments, OR=2.34
 3 impairments, OR=4.54
 4 impairments, lacked statistical power
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.
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.







“Get up and Go”
 ONLY VALID FOR PATIENTS NOT USING AN
ASSISTIVE DEVICE
 Get up and walk 10ft, and return to chair





Seconds
<10
<20
20-29
>30
Rating
Freely mobile
Mostly independent
Variable mobility
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 Go
 Sensitivity 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 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.
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 signs
Blood pressure
Heart rate
Hypertension
Adverse effects from medication,
autonomic dysfunction
Orthostatic hypotension
Adverse effects from medication,
atherosclerosis, coronary artery disease
Bradycardia
Adverse effects from medication, heart
block
Irregularly irregular heart rate
Atrial fibrillation
Respiratory rate
Increased respiratory rate greater than 24 Chronic obstructive pulmonary disease,
breaths per minute
congestive heart failure, pneumonia
Temperature
Hyperthermia, hypothermia
Hyper- and hypothyroidism, infection
Signs
Cardiac
Pulmonary
Breasts
Abdomen
Gastrointestinal,
genital/rectal
Fourth heart sound (S4)
Systolic ejection, regurgitant
murmurs
Barrel chest
Shortness of breath
Left ventricular thickening
Valvular arteriosclerosis
Emphysema
Asthma, cardiomyopathy, chronic obstructive
pulmonary disease, congestive heart failure
Masses
Pulsatile mass
Atrophy of the vaginal mucosa
Cancer, fibroadenoma
Aortic aneurysm
Estrogen deficiency
Constipation
Adverse effects from medication, colorectal
cancer, dehydration, hypothyroidism,
inactivity, no fibre
Fecal impaction, rectal cancer, rectal prolapse
Fecal incontinence
Prostate enlargement
Prostate nodules
Rectal mass, occult blood
Urinary incontinence
Benign prostatic hypertrophy
Prostate cancer
Colorectal cancer
Bladder or uterine prolapse, detrusor
instability, estrogen deficiency
Extremities
Abnormalities of the feet
Muscular/skeletal
Diminished or absent lower Peripheral vascular disease, venous insufficiency
extremity pulses
Heberden nodes
Osteoarthritis
Diminished range of
Arthritis, fracture
motion, pain
Dorsal kyphosis, vertebral Cancer, compression fracture, osteoporosis
tenderness, back pain
Skin
Gait disturbances
Bunions, onychomycosis
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 Polymyalgia rheumatica
weakness
Erythema, ulceration over Anticoagulant use, elder abuse, idiopathic
pressure points,
thrombocytopenic purpura
unexplained bruises
Premalignant or malignant Actinic keratoses, BCC, malignant melanoma, pressure
lesions
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
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.
Visual Impairment
 Visual Impairment
 Prevalence of functional blindness
 71-74 years
 >90 years
 NH patients
(worse than 20/200)
1%
17%
17%
 Prevalence of functional visual impairment
 71-74 years
7%
 >90 years
39%
 NH patients
19%
Salive ME Ophthalmology, 1999.
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.
Hearing Impairment
 Hearing Impairment
 Prevalence:
 65-74 years = 24%
 >75 years = 40%
 National Health Interview Survey
 30% of community-dwelling older adults
 30% of >85 years are deaf in at least one ear
Nadol, NEJM, 1993
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
 Audioscope
 A handheld otoscope with a built-in audiometer
 Whisper Test
3 words
12 to 24 inches
Macphee GJA Age Aging, 1988
Hearing Handicap Inventory for the Elderly
Someti
Yes (4
mes (2 No (0
points) points) points)
_____
_____ ______
Question
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 recommendation
The U.S. Preventive Services Task Force found insufficient evidence to recommend for or
against screening with ophthalmoscopy in asymptomatic older patients.
Evidence
rating
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
Recommen
dation
Quality of
Evidence
Stren
gth
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
promethazin
e: high; All
others:
moderate
Strong
Not recommended for prevention of
extrapyramidal symptoms with antipsychotics;
more effective agents available for treatment of
Parkinson disease.
Avoid
Moderate
Strong
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
Anticholinergics (excludes TCAs)
First-generation antihistamines (as single
agent or as part of combination products)
Chlorpheniramine
Cyproheptadine
Diphenhydramine (oral)
Hydroxyzine
Promethazine
Antiparkinson agents
Benztropine (oral)
Trihexyphenidyl
Antithrombotics
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.
Potential for hypotension; risk of
precipitating myocardial ischemia.
Avoid
Moderate
Strong
Avoid
High
Strong
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
Nifedipine,
immediate
release*
Spironolactone
>25 mg/day
Strong
DRUG
Rationale
Recommendation
Tertiary TCAs, alone or in
combination:
Amitriptyline
Chlordiazepoxideamitriptyline
Clomipramine
Doxepin >6 mg/day
Imipramine
Antipsychotics, first(conventional) and
second- (atypical)
generation (see Table 8
for full list)
Highly anticholinergic, sedating, and cause
orthostatic hypotension; the safety profile of
low-dose doxepin (≤6 mg/day) is comparable to
that of placebo.
Avoid
Increased risk of cerebrovascular accident
(stroke) and mortality in persons with dementia.
Barbiturates
Pentobarbital*
Phenobarbital
Benzodiazepines
Short- and intermediateacting:
Alprazolam
Lorazepam
Oxazepam
Temazepam
High rate of physical dependence; tolerance to
sleep benefits; greater risk of overdose at low
dosages.
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.
Long-acting:
Chlordiazepoxide
Clonazepam
Diazepam
Quality
Of
evidence
High
Strong
Avoid use for behavioral
problems of dementia
unless non-pharmacologic
options have failed and
patient is threat
High
Strong
Avoid
High
Strong
Avoid benzodiazepines
(any type) for treatment of
insomnia, agitation, or
delirium.
High
Strong
Drug
Rationale
Recommendation
Quality of Strength of
evidence 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.
Higher risk of hypoglycemia
without improvement in
hyperglycemia management
regardless of care setting.
Chlorpropamide: prolonged
half-life in older adults; can
cause prolonged
hypoglycemia; causes SIADH
Glyburide: higher risk of
severe prolonged
hypoglycemia in elderly
Potential to promote fluid
retention and/or exacerbate heart
failure.
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
Avoid
Moderate
Strong
Avoid
High
Strong
Avoid
High
Strong
Insulin, sliding scale
Sulfonylureas, longduration
Chlorpropamide
Glyburide
Pioglitazone, rosiglitazone
Drug
Rationale
Recomm
endation
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 highrisk 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
All others:
use unless
moderate
other
alternatives are
not effective
and patient can
take
gastroprotectiv
e agent
(proton-pump
inhibitor or
misoprostol).
Strong
Indomethacin
Ketorolac, includes
parenteral
Increases risk of GI bleeding/peptic ulcer disease in highrisk 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 Avoid
confusion and hallucinations, more commonly than other
narcotic drugs; is also a mixed agonist and antagonist;
safer alternatives available.
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
Moderate
Strong
Avoid
Quality of
evidence
Streng
th
2012 AGS Beers Criteria for Potentially Inappropriate
Medications to Be Used with Caution in Older Adults
Drug
Rationale
Recommendation
Quality of Strength
evidence
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
Use with caution.
hyponatremia; need to monitor sodium
level closely when starting or changing
dosages in older adults due to increased
risk.
Moderate
Strong
Vasodilators
May exacerbate episodes of syncope in
individuals with history of syncope.
Moderate
Weak
Use with caution.
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
0
Normal
Interpretation of screen for
dementia
Positive
0
Abnormal
Positive
1
Normal
Negative
1
Abnormal
Positive
2
Normal
Negative
2
Abnormal
Positive
3
Normal
Negative
3
Abnormal
Negative
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 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 Test
 Clock Drawing Test:
 “Draw a clock”
 Sensitivity=75.2%
 Specificity=94.2%
Wolf-Klein GP JAGS, 1989.
Clock Drawing Test Instructions
 Subjects told to
 Draw a large circle
 Fill in the numbers on a clock
face
 Set the hands at 8:20
 No time limit given
 Scoring (subjective):
 0 (normal)
 1 (mildly abnormal)
 2 (moderately abnormal)
 3 (severely abnormal)
Borson S. et al Int J Geriatr Psychiatry 2000;15:1021-1027
11
12
1
2
10
9
3
4
8
7
6
5
Animal Naming Test
 Category fluency
 Highly sensitive to Alzheimer’s disease
 Scoring equals number named in 1 minute
 Average performance = 18 per minute
 < 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)
Socioenvironmental Circumstances
Multidisciplinary team approach
Family
ETOH/Tobacco/Sex
 Alcohol and Smoking
Common
 CAGE?
 Smoking Cessation
 Sex Also Common
 Major 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 Burden
 Quality Of Life Issues
 Advance Directives
 Capacity
Determining Capacity
 Describe Illness and
Course
 Explain Proposed
Treatment
 Understand Treatment
Consequences
 Understand Risks and
Benefits
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Develop Plan
 Set Goals
 Realistic, Measurable,
Achievable
 Discuss With Family, If
Appropriate
 Develop Stepwise
Approach
Assessment & Plan – Holistic
approach
Formulate
problem list
Necessary
intervention
Appropriate
referral
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