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 H&P 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 Functional ability Physical health (pharmacy)
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).

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? 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 9. Can you manage your own money? Completely unable to handle money 1
1. Can you use the telephone?
Without help
with some help
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
Completely unable to do any shopping 1
4. Can you prepare your own meals?
Without help 3
Completely unable to prepare any meals 1
5. Can you do your own housework?
Completely unable to do any housework 1

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
One measure of independence is the capacity to perform functional tasks
Necessary for daily living.
Katz’s ADL’s----developed in the 1960’s. Measuring six functions,each noted
either as independent or dependent
Initially used by a professional (nurse in an inpt setting) based on observations
over a week
Since then, many modifications
Mnemonic---- “DEATH” --- a way to help you remember the activities
Evaluated--- D= dressing, E=eating, A=ambulating, T= toileting, H=hygiene
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
Labor saving equipment may change laundry from an impossiblity to a
manageable task
Some men who can not prepare meals may simply not know how to cook
Instrumental (community interactions)--- mnemonic “SHAFT”
S=shopping, 2.H=housework, 3. A=Accounting, 4. F=food preparation and
5. T=transportation
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, 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:
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:

20. IADLs 1 impairment, OR=1 2 impairments, OR=2.34 3 impairments, OR=4.54
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

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
<10 Freely mobile
<20 Mostly independent
Variable mobility
>30 Assisted mobility
Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the “Get-up and Go” test. Arch phys Med Rehabil ; 67(6):

24. 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.

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 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

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
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
Cardiac
Fourth heart sound (S4)
Systolic ejection, regurgitant murmurs
Left ventricular thickening
Valvular arteriosclerosis
Pulmonary
Barrel chest
Emphysema
Shortness of breath
Asthma, cardiomyopathy, chronic obstructive pulmonary disease, congestive heart failure
Breasts
Masses
Cancer, fibroadenoma
Abdomen
Pulsatile mass
Aortic aneurysm
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
Abnormalities of the feet
Bunions, onychomycosis
Diminished or absent lower extremity pulses
Peripheral vascular disease, venous insufficiency
Heberden nodes
Osteoarthritis
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
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.
I have three or more drinks of beer, liquor, or wine almost everyday.
I have tooth or mouth problems that make it hard for me to eat.
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.
Without wanting to, I have lost or gained 10 Ib in the past six months.
I am not always physically able to shop, cook, or feed myself.

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%
>90 years 17%
NH patients 17%
Prevalence of functional visual impairment
71-74 years 7%
>90 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%
>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.

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.

40. Hearing Impairment Audioscope Whisper Test
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
secs : Normal time
10-19 secs : Fairly mobile
20-29 secs : Variable mobility
30 sec or more : Functionally dependent in balance and mobility

48. OSTEOPOROSIS Dual-Energy X-ray Absorptiometry USPSTF recommendations:
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.
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.
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.

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)
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.
Moderate
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.
Ticlopidine*
Safer, effective alternatives available.

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
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
Digoxin >0.125 mg/day
In heart failure, higher dosages associated with no additional benefit and may increase risk of toxicity; decreased renal clearance and increased risk of toxic effects.
Avoid
Nifedipine, immediate release*
Potential for hypotension; risk of precipitating myocardial ischemia.
Spironolactone >25 mg/day
In heart failure, the risk of hyperkalemia is higher in older adults if taking >25 mg/day.
Avoid in patients with heart failure or with a CrCl <30 mL/min.
  Moderate Strong

53. DRUG
Rationale
Recommendation
Quality Of evidence
Tertiary TCAs, alone or in combination:
Amitriptyline
Chlordiazepoxide-amitriptyline
Clomipramine
Doxepin >6 mg/day
Imipramine
Highly anticholinergic, sedating, and cause orthostatic hypotension; the safety profile of low-dose doxepin (≤6 mg/day) is comparable to that of placebo.
Avoid
High
Strong
Antipsychotics, first- (conventional) and second- (atypical) generation (see Table 8 for full list)
Increased risk of cerebrovascular accident (stroke) and mortality in persons with dementia.
Avoid use for behavioral problems of dementia unless non-pharmacologic options have failed and patient is threat
Barbiturates
Pentobarbital*
Phenobarbital
High rate of physical dependence; tolerance to sleep benefits; greater risk of overdose at low dosages.
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.

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 <25 mcg twice weekly.
Avoid oral and topical patch.
Topical vaginal cream: Acceptable to use low-dose intravaginal estrogen for the management of dyspareunia, lower urinary tract infections, and other vaginal symptoms.
Oral and patch: high
Topical: moderate
Oral and patch: strong
Topical: weak
Insulin, sliding scale
Higher risk of hypoglycemia without improvement in hyperglycemia management regardless of care setting.
Avoid
Moderate
Strong
Sulfonylureas, long-duration
Chlorpropamide
Glyburide
Chlorpropamide: prolonged half-life in older adults; can cause prolonged hypoglycemia; causes SIADH
Glyburide: higher risk of severe prolonged hypoglycemia in elderly
High
Pioglitazone, rosiglitazone
Potential to promote fluid retention and/or exacerbate heart failure.

55. Drug Rationale Recommendation Quality of evidence Strength
Non–COX-selective NSAIDs, oral
Aspirin >325 mg/day
Diclofenac
Ibuprofen
Ketoprofen
Mefenamic acid
Meloxicam
Naproxen
Piroxicam
Sulindac
Tolmetin
Increases risk of GI bleeding/peptic ulcer disease in high-risk groups, including those >75 years old or taking oral or parenteral corticosteroids, anticoagulants, or antiplatelet agents. Use of proton pump inhibitor or misoprostol reduces but does not eliminate risk. Upper GI ulcers, gross bleeding, or perforation caused by NSAIDs occur in approximately 1% of patients treated for 3–6 months, and in about 2%–4% of patients treated for 1 year. These trends continue with longer duration of use.
Avoid chronic use unless other alternatives are not effective and patient can take gastroprotective agent (proton-pump inhibitor or misoprostol).
All others: moderate
Strong
Indomethacin
Ketorolac, includes parenteral
Increases risk of GI bleeding/peptic ulcer disease in high-risk groups (See above Non-COX selective NSAIDs)
Of all the NSAIDs, indomethacin has most adverse effects.
Avoid
Indomethacin: moderate
Ketorolac: high;
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.
Low
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

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 <30 mL/min
Use with caution in adults ≥75 years old or if CrCl <30 mL/min.
Moderate
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.
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.
Strong
Vasodilators
May exacerbate episodes of syncope in individuals with history of syncope.

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.

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 (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.

62. Mini-Cognitive Assessment Interpretation
Number of items correctly recalled
Clock drawing test result
Interpretation of screen for dementia
Normal
Positive
Abnormal 1
Negative 2 3

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
What is mini-cog? There are two parts. First part, 3 item recall from MMSE, uncued ,give 3 items and ask to repeat; divert with something for short period of time and asking if he/she remembered the 3 items. The second part is CDT, many ways of scoring but what these authors determined.
Abnl mini-cog ---- if recall is zero or if recall>0, then look at CDT
Borson S. et al Int J Geriatr Psychiatry 2000;15:

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 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.

65. Clock Drawing Test Clock Drawing Test: “Draw a clock”
Sensitivity=75.2%
Specificity=94.2%
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 8:20
No time limit given
Scoring (subjective):
0 (normal)
1 (mildly abnormal)
2 (moderately abnormal)
3 (severely abnormal) 12 11 1 2 10 9 3 8 4 5 7 6
Borson S. et al Int J Geriatr Psychiatry 2000;15:

67. 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)

68. Socioenvironmental Circumstances
Multidisciplinary team approach Family

69. ETOH/Tobacco/Sex Alcohol and Smoking Common Sex Also 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 Discuss With Family, If Appropriate
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
These other domains have to be assessed as well. But we are not emphasizing
Them in this presentation.
Most sensitive question for nutrition is---- have you lost weight, how much and
over what period of time. Diet history, height and weight
ETOH screening --- as previously discussed
Social--- living situation, caregiver stress, elder abuse screening if suspected,
Family income,social support