The 10 Min Geriatric Assessment

1. THE 10 MINUTE GERIATRIC
ASSESSMENT
Fredrick T. Sherman, MD, MSc
Medical Director
SENIOR HEALTH PARTNERS
Mount Sinai School of Medicine
www.geri.com

2. OFFICE-BASED
ASSESSMENT
•Common syndromes “Geriatric
Giants” of the elderly
•Based on literature review
•Use principles of EBM
•Easy to remember MNEUMONICS

3. Falls
“Phalls”
ConfusionIncontinence
Iatrogenic
disorders
Impaired
homeostasis
GERIATRIC GIANTS

4. “DEEP IN”
FOR QUICK SCREENING
D - Dementia, Depression, Drugs
E - Eyes
E - Ears
P - Physical Performance, Phalls, Psychosocial

I - Incontinence
N -Nutrition

5. SILENT DEMENTIA
•Family Not Aware: 21% of family members fail to
recognize a problem with memory in demented
seniors. (JAMA, 277, 1997)
•Physicians Fail to Evaluate: 53% of seniors whose
family DID recognize memory problem did NOT
receive an evaluation
•Physicians Fail to Chart: 76% who screened
positive for Mod/Sev D were not noted to be
demented on chart review. (Ann Int Med, 109, 1995)

6. DEMENTIA SCREEN 1
THREE ITEM RECALL
•THREE ITEM RECALL AT ONE MINUTE
•RECALLS LESS THAN 2 (1 OR 0)--LR-3.1
•RECALLS 2 --LR-0.5
•RECALLS ALL 3 ITEMS-0.06

7. DEMENTIA SCREEN 2
VERBAL FLUENCY-CATEGORY
RETRIEVAL or “ANIMAL NAMING”
•Measures impairment in verbal production and
access to semantic memory
•A timed test of animal naming
•Name as many animals as you can in one
minute
•Scoring equals number named in one minute

8. ANIMAL NAMING
Useful screening tool for dementia
Average performance=18/min
Less than 12/min is abnormal
Correlates well with MMSE scores(r=0.77)
Worsens with time in AD
Neurology.1989;39:1159-1165.

9. DEMENTIA SCREEN 3
Clock Completion Test
•Draw 3” Circle On Unlined Paper
•“Put The Numbers In The Clock”
•Score By Quadrants
•Fourth Quadrant Most Sensitive

10. Watson YL et al., Clock Completion: An Objective screening test for dementia.
JAGS 1993; 41:1235-40

11. CLOCK COMPLETION TEST (CCT)
A Screening Test for Dementia
•Retrospective analysis of clock drawing errors and
prospective validation
•76 consecutive OPD patients; Age 55-92(aver 76)
•40 patients with dementia/36 not demented;
Neuropsych testing
•Sen/spec for 4th quadrant predicting dementia
87%/82%
•Sen/spec of Short Blessed Test 82%/87%
•CCT not good for grading severity of dementia

12. INSTRUMENTAL ACTIVITIES
OF DAILY LIVING
•Meal preparation
•Housework
•Laundry
•Medication
management
•Telephone
•Shopping
•Transportation
•Money management

13. DEMENTIA SCREEN 4
FOUR IADL SCORE FOR RISK OF DEMENTIA
ONE YEAR LATER
“DO YOU NEED HELP WITH...
•Money Management
•Medication Management
•Telephone Use
•Using Transportation
•Odds Ratio: 1-10; 2-15; 3-59; 4-318

14. DEMENTIA SCREEN 5
Seven Minute Neurocognitive
Screening for Alzheimer’s Disease
1) Benton Temporal Orientation
• month, date, year, day, time
2) Enhanced Cued Recall
• recall of 16 pictures
3) Category Fluency
• “animal naming”
4) Clock Drawing
• numbers and hands
Solomon, PR, et al, Arch Neurology, JJ, March 1998 (349-355)

15. •Mean time to administer: 7 minutes, 42 secs
•Sen/Spec: 92/96 in detecting AD
•Identify all AD patients with MMSE > 24
•Age/Sex/Education: not significant factors
•High sen/spec in very mild, mild & mod AD
•www.memorydoc.org/scoring.asp
Solomon, PR, et al, Arch Neurology, JJ, March 1998 (349-355)
7 MINUTE
NEUROCOGNITIVE SCREEN

16. D - Drugs, Delirium
E - Etoh, , Eyes, Ears
M - Multiple, Metabolic
E - Endocrine
N - Nutrition, NPH
T - Trauma
I - Infection, Infarct
A - Affective, Alzheimer’s
S - Surgery, Subcortical

17. DEPRESSION
•Single Question: Do You Often Feel
Sad Or Depressed?
(Sen/spe-.85/.65)
•5 Item Geriatric Depression Scale
(Sen/spe-.97/.85)
•15 Item Gds (Sen/spec-.94/.83)

18. 5 ITEM GDS
Yes No
(1) Are you basically satisfied with
your life?
(2) Do you often get bored?
(3) Do you often feel helpless?
(4) Do you prefer to stay at home rather
than going out and doing new things?
(5) Do you feel pretty worthless
the way you are now?
0- 1 = not depressed > 2 = depressed
*Sens. 97 (.94)/Spec. 85(.83) PPV - .85 (.82) NPV - .97 (.94)
Single Question Sen .85/Spec.65
Hoyl, MT et al. Development and Testing of a Five-item Version of the Geriatric
Depression Scale. JAGS. 47:873-78, 1999.
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19. DRUGS
•Greater Than Or Equal To Four
Prescribed
•Any Of The “Antis”
•Benzos
•Non Rxed
•Alternative

20. SIMPLE SCREENS OF HEARING LOSS
Sen 80%
Spec 80% at cut
point of >3
< 2 minNHANES Battery
Sen 48-63%
Spec 75-86%
At cut point >8
2 minHearing-Handicap
Inventory for the
elderly
Sen 80-100%
Spec 82-89%
1 minWhisper Test
Sen 87-90%
Spec 80-100%
1-2 minAudioscope
CommentsTime to AdministerQuestion/Test

21. EARS
WHISPERED VOICE TEST—
NO EQUIPMENT BUT MUST BE STANDARDIZED
•Explain That You Will Whisper Some Numbers
•Ask Senior To Close Eyes
•12-18 Inches Apart
•You Exhale And Then Whisper 4 Random Single
Numbers At 1 Sec Intervals
•Fail Screen If Senior Cannot Hear at least 2 numbers
Sen/spec-80-100%/82-89%

22. EARS
BUY AUDIOSCOPE
•Audioscope Set At 40 Db
•Four Tones --500, 1000, 2000, 4000 Hz
•Test Hearing Using 1000 And 2000 Hz
•Inability To Hear 1000 OR 2000 Hz In Both Ears
Or Either Of These Freq In One Ear
•Sen/spec-.94/.72
•If Positive, Formal Testing

23. EYES
BECAUSE OF YOUR EYESIGHT, DO
YOU HAVE DIFFICULTY WITH. . . .
•Driving
•Watching TV
•Reading
•Or Any Daily Activity

24. EYES
IF “YES” TO QUESTION THEN
•Test Each Eye With Snellen Chart
While Patient Wears Glasses
•Inability To Read Greater Then 20/40
On Snellen Chart

25. Physical Performance Testing
in the Elderly (PPT)
Ideally, provides information about the:
•Prognosis for ADL Impairment
•Ability to Live Independently
•Need for Treatment
•Health Care Requirements

26. PHYSICAL PERFORMANCE
TESTING (PPT)
+ ADVANTAGES
• Yields repeatable, quantifiable results
• Eliminates any discrepancies between
patient and proxy reports and actual PPT
• Confirms statements of patient or proxy
• May help select high risk group for
targeting interventions

27. PHYSICAL PERFORMANCE
TESTING
DISADVANTAGES
• Must be conducted in the presence of a
trained observer
• Equipment is sometimes too specialized for
office, adult or nursing home setting
• PT models only part of the more complex
ADL
• PT may fail to reflect typical performance in
home environment

28. WHAT IS THE RISK OF ADL
DEPENDENCE IN THE AGED WITH
COGNITIVE IMPAIRMENT?
• 10% Of Independently Living Elderly In
Community Lose 1 Or More ADL /Year
? Are There PPTs That Will Predict Which Elderly
Will Lose ADLs?
? What Self Reported Characteristics are Associated
With New Dependence In ADL?

29. RISK FACTORS FOR
FUNCTIONAL DEPENDENCE
Older Age
Female
Living Alone
Non-white
Poor
Less Education
Smoking
HBP
Abnormal BMI
Heart Disease
Cognitive
Impairment

30. ADL DEPENDENCE IN MILD/
MOD DEMENTIA
Prospective, Longitudinal Study of 1,103 Elderly
(Age 72 & Older) with Mild/Mod Dementia,
Independent In ADL
Assessed I Yr Later For Development Of ADL
Impairment and Risk Factors
What PPTS Predicted Maintenance of ADL?
J Gerontol Med Sci 1995;50A:M235-241.

31. PREDICTORS OF ADL
DEPENDENCE
SELF REPORTED RISK FACTORS
ASSOCIATED WITH ONSET OF ADL
(p<.O5)
1) Lived Alone (rr-3.8)
2) Not Currently Married (rr-4.3)
3) Impairments > 4 IADLs (rr-2.9)

J Gerontol Med Sci 1995;50A:M235-241.

32. PREDICTORS OF ADL
DEPENDENCE
TIMED PERFORMANCE TESTS
3)Rapid Gait>11sec (rr-6.4) [10 Ft Out and
Back “as quickly as possible”]
2) Three (3) Chair Stands > 10 sec (rr-4.4)

33. QUALITATIVE CHAIR STAND
Abnormal
Normal
High Risk
12/31 (39%)

10 ft. Rapid Gait/3 Chair Rises
High Risk
13/38 (34%)
Low Risk
6/128 (4.7%)
Abnormal
Normal

34. SIMPLE TESTS OF LOWER
EXTREMITY STRENGTH,
BALANCE, GAIT & FALL RISK
If FR < 7” unable to:
2)Leave neighborhood
3)Stand on one foot
4)Do tandem walking
Adjusted Odds Ratio for >2 falls in
6 months
•8.1 if unable to reach
•4.0 if < 6 inches
•2.0 if > 6 inches < 10 inches
1 minFunctional reach
CommentsTime to
Administer
Question/Test

35. RELATIVE RISKS OF SEVERE WALKING DISABILITY:
COMBINED DISTRIBUTION OF KNEE STRENGTH
TERTILES AND BALANCE CATEGORES
11.140.97SS (10)+ST (10)
+TS (>3s)
1.181.581.87SS (10)+ST (10)
+TS (<3S)
3.081.495.12S-S<10 seconds
RRRRRRBalance
Categories
Strongest
(<15.1kg)
Average
(10.6-15.1 kg)
Weakest
(<10.6 kg)
Knee Strength Tertiles
JAGS, 2001-Vol.49, No.1

36. Balance Categories
The rates of onset of severe walking disability in groups based on baseline
knee-extension strength tertiles and standing balance categories in women who
did not have severe walking disability at baseline. The follow-up time was 3
years with examinations taking place every 6 months.
37.1
14.7
5.3
12.713.2
6.1
21.6
9.6
3.1
0
10
20
30
40
SS<10 sTS<3 sTS>3 s
Strongest
Average
Weakest
Knee Extension
Strength Tertiles
JAGS, 2001-Vol.49,No1

37. Geriatric Syndromes
PHALLS (Falls)
M Maladaptive equipment
Medical (acute)
Medical (chronic)
Multiple
E Environment
Ethanol
Eyes/Ears
O Orthostatic
signs or symptoms
W Weakness Prox
Diffuse

38. INCONTINENCE
•Two Questions:
•In The Last Year, Have You Ever Lost
Your Urine And Gotten Wet? Have You
Lost Urine On At Least 6 Separate Days?
•If Yes To Both ?S, PPV-.86/NPV-.96;
•83% Agreement Between PAT Response
& UROL Assessment

39. PERSISTENT
UI
S - Stress
O - Overflow
U - Urge
P - Physical/Psychological

40. NUTRITION SCREENS
Odds Ratio 2.7 if 3-5 RF,
6.4 if > 6 RF
5-10 minNHANES 14-item scale to
detect hypoalbuminemia
Sen 36%, Spec 85% for
intake of > 3 nutrients
below 75% of RDA at cut
point > 6 points
<5 minNutrition Screening
PPV malnutrition .991 min•Weight < 100lbs.
RR of death 2.0<1min•>10lb wt loss over 6 mo
BMI <22 or >251 min•Weight (kg) /Height (m
2
)
CommentsTime to
Administer
Question/Test

41. GERIATRIC
Weight Loss
D - Drugs - anorexia, xerostomia, nausea, diarrhea
E - Eating skills, 80% of elderly had oral health
problem that interfered with mastication
A - Access to Food
D - Disease - 75% of cases of weight loss

42. OLD PEOPLE AT HOME:
Empty Refrigerator Predicts Hospitalization
•Simple way to detect malnutrition in elderly
•Is refrigerator contents (RCs) related to health status?
•Prospectively compared RCs with hospital
admissions over 3 month period
•132 seniors over age 65 in Geneva, Switzerland
•Two MDs assessed RCs on month post D/C
•Contents: adequate, inadequate (rotten) or empty (<3)
Lancet 2000;356:563

43. EMPTY REFRIGERATOR
PREDICTS HOSPITALIZATION (2)
•Mean age 81; 74% female; 70% live along
•132 Refrigerator: 40% adequate or inadequate food; (13 RFs)
10% empty
•31% of empty RF owners admitted in 4 wks compared with
8% of filled RFs owners (p=0.42)
•Mean time to admission: 34 vs. 100 days (p=.002)
•Adjusted risk for admission increase 3x greater if refrigerator
empty
•Quality of food had no influence on admission
Lancet 2000;356:563

44. “DEEP IN”
For QUICK Screening
D - Dementia, Depression, Drugs
E - Eyes
E - Ears
P - Physical Performance, Phalls, Psychosocial

I - Incontinence
N -Nutrition