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 Multidisciplinary
 Physician
 Functional ability
 Social worker
 Physical health
(pharmacy)  Nutritionist

 Physical therapist
 Cognition

 Occupational therapist
 Mental health
 Family

 Socio-environmental
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
Without help 3
With some help 2
with some help 2
Completely unable to do any handyman work 1
Completely unable to use the telephone 1 7. Can you do your own laundry?
2. Can you get to places that are out of walking Without help 3
distance?
With some help 2
without help 3
Completely unable to do any laundry 1
With some help 2
8a. Do you use any medications?
Completely unable to travel unless special
Yes (If “yes,” answer question 8b) 1
arrangements are made 1
No (If “no,” answer question 8c) 2
3. Can you go shopping for groceries?
8b. Do you take your own medication?
Without help 3
Without help (right doses at right time) 3
With some help 2
With some help (prepare or reminds) 2
Completely unable to do any shopping 1
Completely unable 1
4. Can you prepare your own meals?
8c. If you had to take medication, could you do it?
Without help 3
Without help (right doses at right time) 3
With some help 2
With some help prepare or reminds) 2
Completely unable to prepare any meals 1
Completely unable 1
5. Can you do your own housework?
9. Can you manage your own money?
Without help 3 Without help 3
With some help 2 With some help 2
Completely unable to do any housework 1 Completely unable to handle money 1
 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
Independent
•Toileting
Assistance
•Transfer
Dependent
•Continence
•Feeding
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 Independent
•Preparing meals Assistance
•Housework Dependent
•Medication
•Money
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 Rating
<10 Freely mobile
<20 Mostly independent
20-29 Variable mobility
>30 Assisted mobility
 Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the “Get-up and Go” test.
Arch phys Med Rehabil. 1986; 67(6): 387-389.
Get up and Go
Sensitivity 88%
Specificity 94%
Time to complete <1min.
Requires no special equipment

 Cassel, C. Geriatric Medicine: An Evidence-Based Approach, 4 th 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 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 Chronic obstructive pulmonary

than 24 breaths per minute disease, congestive heart failure,
pneumonia

Temperature Hyperthermia, hypothermia Hyper- and hypothyroidism,

infection
Signs
Cardiac Fourth heart sound (S4) Left ventricular thickening
Valvular arteriosclerosis
Systolic ejection, regurgitant
murmurs
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, Atrophy of the vaginal Estrogen deficiency
genital/rectal mucosa
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
Extremities Abnormalities of the Bunions, onychomycosis
feet

Diminished or absent Peripheral vascular disease, venous insufficiency

lower extremity pulses
Heberden nodes Osteoarthritis
Muscular/skeletal Diminished range of Arthritis, fracture
motion, pain
Dorsal kyphosis, Cancer, compression fracture, osteoporosis
vertebral tenderness,
back pain
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 Polymyalgia rheumatica
and weakness
Skin Erythema, ulceration Anticoagulant use, elder abuse, idiopathic
over pressure points, thrombocytopenic purpura
unexplained bruises
Premalignant or Actinic keratoses, BCC, malignant melanoma,
malignant lesions pressure ulcer, squamous cell carcinoma
 Nutrition :Four components specific to
the geriatric assessment
 Nutritional history performed with a nutritional health
checklist
 Record of a patient's usual food intake based on 24-
hour dietary recall
 Physical examination with particular attention to signs
associated with inadequate nutrition or
overconsumption and
 Select laboratory tests, if applicable
 Nutritional Health Checklist
Statement Yes
I have an illness or condition that made me change the kind or amount of food I eat. 2
I eat fewer than two meals per day. 3
I eat few fruits, vegetables, or milk products. 2
I have three or more drinks of beer, liquor, or wine almost everyday. 2
I have tooth or mouth problems that make it hard for me to eat. 2
I don’t always have enough money to buy the food I need. 4
I eat alone most of the time. 1
I take tree or more different prescription or over-the-counter drugs per day. 1
Without wanting to, I have lost or gained 10 Ib in the past six months. 2
I am not always physically able to shop, cook, or feed myself. 2
Scoring:
0-2= You have good nutrition.
3 to 5= You are at moderate nutritional risk,
6 or more= You are at high nutritional risk,

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

 The U.S. Preventive Services Task Force (USPSTF) :

found insufficient evidence to recommend for or
against screening with ophthalmoscope in
asymptomatic older patients.

 Common causes of vision impairment : presbyopia,

glaucoma, diabetic retinopathy, cataracts, and ARMD
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 (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.

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 Sometime No
(4 points) (2 points) (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
Question points) points) points)
Does a hearing problem cause you to feel embarrassed when you meet _____ _____ ______
new people?
Does a hearing problem cause you to feel frustrated when talking to ______ ______ ______
members of your family?
Do you have difficulty hearing when someone speaks in a whisper? ______ ______ ______
Do you feel impaired by a hearing problem? ______ ______ ______
Does a hearing problem cause you difficulty when visiting friends, ______ ______ ______
relatives, or neighbors?
Does a hearing problem cause you to attend religious services less ______ ______ ______
often than you would like?
Does a hearing problem cause you to have arguments with family ______ ______ ______
members?
Does a hearing problem cause you difficulty when listening to the ______ ______ ______
television or radio?
Do you feel that any difficulty with your hearing limits or hampers ______ ______ ______
your personal or social life?
Does a hearing problem cause you difficulty when in a restaurant with ______ ______ -------
relatives or friends? -
Interpretation
 A raw score of 0 to 8 = 13 percent probability of hearing
impairment (no handicap/no referral)
 10 to 24 = 50 percent probability of hearing impairment
(mild to moderate handicap/referral)
 26 to 40 = 84 percent probability of hearing impairment
(severe handicap/referral).

 Potentially ototoxic drugs.

 Failure of screening tests should be referred to an
otolaryngologist.
 Treatment of choice - Hearing aids
 To minimize hearing loss and improve daily
functioning.
URINARY CONTINENCE

 Complications: decubitus ulcers, sepsis, renal failure,

urinary tract infections, and increased mortality.

 Psychosocial implications : loss of self-esteem,

restriction of social and sexual activities, and
depression.

 Key deciding factor: Nursing home placement.

Questions to ask?
Urge incontinence :
 “Do you have a strong and sudden urge to void that
makes you leak before reaching the toilet?”

Stress incontinence :
 “Is your incontinence caused by coughing, sneezing,
lifting, walking, or running?”
BALANCE AND FALL
PREVENTION
 Leading cause of hospitalization and injury-related
death in persons 75 years and older.
 Tool to assess a patient's fall risk- 16 seconds

The Tinetti Balance and Gait Evaluation:

 This test involves observing as a patient gets up from a
chair without using his or her arms, walks 10 ft, turns
around, walks back, and returns to a seated position.
 Failure or difficulty to perform the test : increased risk
of falling and need further evaluation.
Interpretation Of Test

 7 -10 secs : Normal time

 10-19 secs : Fairly mobile

 20-29 secs : Variable mobility

 30 sec or more : Functionally dependent in balance

and mobility
OSTEOPOROSIS
 Osteoporosis may result in low-impact or spontaneous
fragility fractures, which can lead to a fall.

 Dual-Energy X-ray Absorptiometry

 ( Total hip, femoral neck, or lumbar spine, with a T-score of –2.5 or
below)

 USPSTF recommendations:
 Routine screening of women 65 years and older for
osteoporosis with DEXA of the femoral neck.
POLYPHARMACY
 Multiple medications or the administration of more
medications than clinically indicated.

 30 percent of hospital admissions and many

preventable problems: are 2/2 to adverse drug
effects.

 The Centers for Medicare and Medicaid Services

encourages the use of the Beers criteria, as part of
medication assessment to reduce adverse effects
 Evidence
Clinical recommendation rating
The U.S. Preventive Services Task Force found insufficient evidence to recommend C
for or against screening with ophthalmoscopy in asymptomatic older patients.

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

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

The U.S. Preventive Services Task Force has advised routinely screening women 65 A
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 C
criteria as part of an older patient's medication assessment to reduce adverse effects.
 2012 AGS Beers Criteria for Potentially
Inappropriate Medication Use in Older Adults
Organ System/ Therapeutic Rationale Recommen Quality of Stren
Category/Drug(s) dation Evidence gth

Anticholinergics (excludes TCAs)

First-generation antihistamines (as single Highly anticholinergic; clearance reduced with Avoid Hydroxyzine Strong
agent or as part of combination products) advanced age, and tolerance develops when and
used as hypnotic; increased risk of confusion, promethazin
Chlorpheniramine dry mouth, constipation, and other e: high; All
Cyproheptadine anticholinergic effects/toxicity. others:
Diphenhydramine (oral) Use of diphenhydramine in special situations moderate
Hydroxyzine such as acute treatment of severe allergic
Promethazine reaction may be appropriate.

Antiparkinson agents Not recommended for prevention of Avoid Moderate Strong

Benztropine (oral) extrapyramidal symptoms with antipsychotics;
Trihexyphenidyl more effective agents available for treatment
of Parkinson disease.
Antithrombotics
Dipyridamole, oral short-acting* (does not May cause orthostatic hypotension; more Avoid Moderate Strong
apply to the extended-release combination effective alternatives available; IV form
with aspirin) acceptable for use in cardiac stress testing.

Ticlopidine* Safer, effective alternatives available. Avoid Moderate Strong

DRUG Rationale Recommendation Quality of Strength of
evidence recommendation
Alpha1 blockers High risk of orthostatic hypotension; not Avoid use as an Moderate Strong
Doxazosin recommended as routine treatment for antihypertensive.
Prazosin hypertension; alternative agents have
Terazosin superior risk/benefit profile.
Alpha blockers, High risk of adverse CNS effects; may cause Avoid clonidine as a first-line Low Strong
central bradycardia and orthostatic hypotension; antihypertensive.
Clonidine not recommended as routine treatment for
Methyldopa hypertension.
Antiarrhythmic Data suggest that rate control yields better Avoid antiarrhythmic drugs High Strong
drugs (Class Ia, Ic, balance of benefits and harms than rhythm as first-line treatment of
III) control for most older adults. atrial fibrillation.
Amiodarone Amiodarone is associated with multiple
Flecainide toxicities, including thyroid disease,
Procainamide pulmonary disorders, and QT interval
Sotalol prolongation.

Digoxin >0.125 In heart failure, higher dosages associated Avoid Moderate Strong
mg/day with no additional benefit and may
increase risk of toxicity; decreased renal
clearance and increased risk of toxic
effects.
Nifedipine, Potential for hypotension; risk of Avoid High Strong
immediate precipitating myocardial ischemia.
release*

Spironolactone In heart failure, the risk of hyperkalemia is Avoid in patients with heart
  Moderate Strong
>25 mg/day higher in older adults if taking >25 mg/day. failure or with a CrCl <30
mL/min.
DRUG Rationale Recommendation Quality
Of
evidence
Tertiary TCAs, alone or in Highly anticholinergic, sedating, and cause Avoid High Strong
combination: orthostatic hypotension; the safety profile of
Amitriptyline low-dose doxepin (≤6 mg/day) is comparable to
Chlordiazepoxide- that of placebo.
amitriptyline
Clomipramine
Doxepin >6 mg/day
Imipramine
Antipsychotics, first- Increased risk of cerebrovascular accident Avoid use for behavioral High Strong
(conventional) and (stroke) and mortality in persons with dementia. problems of dementia
second- (atypical) unless non-pharmacologic
generation (see Table 8 options have failed and
for full list) patient is threat
Barbiturates High rate of physical dependence; tolerance to Avoid High Strong
Pentobarbital* sleep benefits; greater risk of overdose at low
Phenobarbital dosages.
Benzodiazepines Older adults have increased sensitivity to Avoid benzodiazepines High Strong
Short- and intermediate- benzodiazepines and decreased metabolism of (any type) for treatment of
acting: long-acting agents. In general, all insomnia, agitation, or
Alprazolam benzodiazepines increase risk of cognitive delirium.
Lorazepam impairment, delirium, falls, fractures, and motor
Oxazepam vehicle accidents in older adults.
Temazepam May be appropriate for seizure disorders, rapid
eye movement sleep disorders, benzodiazepine
Long-acting: withdrawal, ethanol withdrawal, severe
Chlordiazepoxide generalized anxiety disorder, periprocedural
Clonazepam anesthesia, end-of-life care.
Diazepam
Drug Rationale Recommendation Quality of Strength of
evidence rec
Estrogens with or Evidence of carcinogenic Avoid oral and topical patch. Oral and patch: Oral and patch: strong
without progestins potential (breast and Topical vaginal cream: high Topical: weak
endometrium); lack of Acceptable to use low-dose Topical:
cardioprotective effect and intravaginal estrogen for the moderate
cognitive protection in older management of dyspareunia,
women. lower urinary tract infections,
Evidence that vaginal and other vaginal symptoms.
estrogens for treatment of
vaginal dryness is safe and
effective in women with
breast cancer, especially at
dosages of estradiol <25 mcg
twice weekly.
Insulin, sliding scale Higher risk of hypoglycemia Avoid Moderate Strong
without improvement in
hyperglycemia management
regardless of care setting.
Sulfonylureas, long- Chlorpropamide: prolonged Avoid High Strong
duration half-life in older adults; can
Chlorpropamide cause prolonged
Glyburide hypoglycemia; causes SIADH
Glyburide: higher risk of
severe prolonged
hypoglycemia in elderly
Pioglitazone, Potential to promote fluid Avoid High Strong
rosiglitazone retention and/or exacerbate
heart failure.
Drug Rationale Recomm Quality of Streng
endation evidence th
Non–COX-selective Increases risk of GI bleeding/peptic ulcer disease in high- Avoid chronic All others: Strong
NSAIDs, oral risk groups, including those >75 years old or taking oral or use unless moderate
Aspirin >325 mg/day parenteral corticosteroids, anticoagulants, or antiplatelet other
Diclofenac agents. Use of proton pump inhibitor or misoprostol alternatives
Ibuprofen reduces but does not eliminate risk. Upper GI ulcers, gross are not
Ketoprofen bleeding, or perforation caused by NSAIDs occur in effective and
Mefenamic acid approximately 1% of patients treated for 3–6 months, and patient can
Meloxicam in about 2%–4% of patients treated for 1 year. These take
Naproxen trends continue with longer duration of use. gastroprotectiv
Piroxicam e agent
Sulindac (proton-pump
Tolmetin inhibitor or
misoprostol).
Indomethacin Increases risk of GI bleeding/peptic ulcer disease in high- Avoid Indomethacin: Strong
Ketorolac, includes risk groups (See above Non-COX selective NSAIDs) moderate
parenteral Of all the NSAIDs, indomethacin has most adverse effects. Ketorolac: high;
Pentazocine* Opioid analgesic that causes CNS adverse effects, Avoid Low Strong
including confusion and hallucinations, more commonly
than other narcotic drugs; is also a mixed agonist and
antagonist; safer alternatives available.
Skeletal muscle relaxants Most muscle relaxants poorly tolerated by older adults, Avoid Moderate Strong
Carisoprodol because of anticholinergic adverse effects, sedation,
Chlorzoxazone increased risk of fractures; effectiveness at
Cyclobenzaprine
Metaxalone
Methocarbamol
 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 Lack of evidence of benefit versus risk Use with caution in adults ≥80 Low Weak
prevention of cardiac in individuals ≥80 years old. years old.
events
Dabigatran Increased risk of bleeding compared Use with caution in adults ≥75 Moderate Weak
with warfarin in adults ≥75 years old; years old or if CrCl <30
lack of evidence for efficacy and safety mL/min.
in patients with CrCl <30 mL/min

Prasugrel Increased risk of bleeding in older Use with caution in adults ≥75 Moderate Weak
adults; risk may be offset by benefit in years old.
highest-risk older patients (eg, those
with prior myocardial infarction or
diabetes).
Antipsychotics May exacerbate or cause SIADH or Use with caution. Moderate Strong
Carbamazepine hyponatremia; need to monitor sodium
Mirtazapine level closely when starting or changing
SNRIs dosages in older adults due to
SSRIs increased risk.
TCAs

Vasodilators May exacerbate episodes of syncope in Use with caution. Moderate Weak
individuals with history of syncope.
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 Interpretation of screen for

recalled Clock drawing test result dementia
0 Normal Positive

0 Abnormal Positive

1 Normal Negative

1 Abnormal Positive

2 Normal Negative

2 Abnormal Positive

3 Normal Negative

3 Abnormal Negative
The Mini-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 12
11 1
 Set the hands at 8:20
10 2
 No time limit given
 Scoring (subjective): 9 3
 0 (normal) 8 4
 1 (mildly abnormal)
7 5
 2 (moderately abnormal) 6
 3 (severely abnormal)

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

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
QuickTime™ and a
Treatment TIFF (Uncompressed) decompressor
are needed to see this picture.

Understand Treatment
Consequences
Understand Risks and
Benefits
Develop Plan
Set Goals
Realistic, Measurable,
Achievable
Discuss With Family,
If Appropriate
Develop Stepwise
Approach
Assessment & Plan – Holistic
approach
Formulate
problem list

Necessary
intervention

Appropriat
e referral
Comprehensive Geriatric
Assessment
Other domains to be assessed:
Current health status:
 nutritionalrisk,
 health behaviors,
 tobacco,
 and alcohol use,
 Bladder Continence
Social assessments:
 especially elder abuse,
 caregiver availability and stress,
 living situation