Download Belgian Minimum Data Set for Comprehensive Geriatric

Belgian Minimum Data Set
for Comprehensive Geriatric Assessment
Consensus conference May 7th, 2004
College of Geriatrics
www.geriatrie.be
introduction
• continuous registration of quality variables
is an obligation
• the Ministry intends to ask this registration
 College & BVGG : choose it ourselves !
BMDS : methods
• Questionnaire
sent by e-mail; surface mail,
downloadable (www.geriatrie.be)
• used and proposed scales for minimal
geriatric assessment
• domains : ADL; I-ADL; falls; cognition;
depression; social; nutrition; pain; QOL
results
• 59 questionnaires
• acute and subacute G beds
conclusions
response rate
geriatricians : interested in CGA
transparency of geriatric units
quality of questionnaire
not enough CGA
lack of uniformity CGA
~ no consensus
perspectives
working groups to propose “minimal” tools
of CGA for a Consensus Conference
– specific, sensitive, validated
– feasible
– screening tools
– a basis for further algorithms
Working groups
ADL-IADL
• P Devriendt, G Dargent, C Swine
Qol
• P Devriendt, G Dargent, C Swine
Mobility
• JP Baeyens , Ghesquière
Cognition
• M Lambert , E Gorus, C Sachem
Depression
• A Velghe, Th Pepersack
Social
• JP Baeyens , Van de kerkof
Nutrition
• T Pepersack, H Daniels, J
Pétermans, C Gazzotti
Pain
• N Vandennoorgate, A Pepinster
Frailty
• C Swine, G Dargent, P
Devriendt
ADL-IADL
P Devriendt, G Dargent, C Swine
ADL (1)
• Definition (Reuben et al., 1989)
– 3 levels of functioning, stratified according to difficulty
and complexity:
• Basic: elemental functions, self-care
• Intermediate: essential to maintain independent living
– Crucial to live alone
• Advanced activities of daily living: luxury items, beyond what
is needed to be independent, volitional, infuenced by cultural
and motivational facors
– Terms:
• BADL: Basale ADL
• IADL: Instrumentele ADL
• AADL: Arbeid en ontspanning
ADL (2)
• Important to measure in G- setting (Reuben,
1989; Gallo et al., 2003):
– BADL
– IADL
ADL: BADL and IADL
• Criteria for assessment-tools, according
presentation wintermeeting 2004 and working
group
–
–
–
–
–
–
Specific, sensitive, validated
Feasible
Screening tools
For all patients
A basis for further algorithms
What ‘s already used and proposed by the
respondents/geriatricians in the survey !!
– The future??
BADL-tools
• Used tools
–
–
–
–
Katz (50%)
Barthel (6%)
Fim (4%)
Smaf (2%)
• Proposed tools
–
–
–
–
Katz (31%)
Aggir (9%)
Barthel (6%)
Fim (4%)
IADL-tools
• Used tools
– Lawton (38%)
– Smaf (3%)
– Barthel (3%)
• Proposed tools
– Lawton (32%)
– Aggir (5%)
– Barthel (5%)
ADL: BADL and IADL
– Literature search:
• A lot of assessment - tools
• ‘What’ they measure
– Pure BADL: only a few tools
– Pure IADL: only a few tools
– Combined BADL and IADL or ADL and other (eg. cognition,
behaviour): the most tools
• Type of patient
– All patients
– Condition or disease specific
• Assessed by
– Direct observation
– Self-report
– Interview
‣ patient of proxy
ADL: BADL and IADL:
selection of tools according the criteria
• Pure BADL
– Katz: original instrument or Belgian version
– Barthel - index
• Pure IADL
– Lawton – scale
• Combined
–
–
–
–
RAI
AGGIR
FIM
SMAF
» References available on the last slides
ADL: BADL and IADL: proposal (1)
• Question:
– Choose an instrument already used or proposed
or …
– Choose an instrument that will be ‘the future’
obligation instead of the Katz?
ADL: BADL and IADL: proposal (2)
• BADL: Katz
• IADL: Lawton-scale
>Already used (50% and 38%)
Alzheimermedication, Elderly Home
Proposed (31% and 32%)
Feasible:
time needed: less than 5’ each (Rubenstein et al., 1988)
References (1)
• Katz:
– Katz et al., Studies of Illness in the Aged, the
Index of ADL: a Standardized Measure of
Biological and Psychosocial Function, JAMA,
sept 21; 1963
• Barthel:
– Mahoney and Barthel, Functional Evaluation:
the Barthel Index, Maryland State Medical
Journal, 1965; 14(2): 61-5
References (2)
• AGGIR
• FIM
– Deutsch et al., The Functional Independent
Measure (FIM) and the FIM for children
(WeeFIM): then years of development; Critical
Reviews in Physical Rehabilitation Medicine,
8, 267-281
References (3)
• SMAF
– Hebert et al., The Functional Autonomy measurement
system (SMAF): despcription and validation of an
instrument for the measurement of handicaps, Age and
Aging, 17, 293-302
– Desrosiers et al., Reliability of the revides fucntional
autonomy measurement system (SMAF) for
epidemiological research, Age and Aging, 24, 402-406
– Hebert et al., Setting the minimal metrically detectable
change on disability rating scales, Archieves of
Physical Medicine ans Rehabilitation, 78, 1305-1308
References (4)
• Lawton-scale
– Lawton et al., Assessment of older people: Self-maintaining and
instrumental activities of daily living, Gerontologist, 1969;9:179186
• RAI
– Achterberg et al., Het Ressident Assessment Instrument (RAI): een
overzicht van internationaal onderzoek naar de psychommetrische
kwaliteiten en effecten van implementatie in verpleeghuizen,
Tijdschrift Gerontologie en Geriatrie, 1999; 30
– Frijters et al., Tijdschrift Gerontologie en Geriatrie, 2001; 32: 8
• InterRAI SCREENER
Quality of life
P Devriendt, G Dargent, C Swine
To measure Quality of Life
• QoL:
– Can be seen as overall measure
– Includes ADL
Quality of Life
• Definition: as many as there are autors, but in common
– Perception (subjective)
– Expectations
– Multidimensional
•
•
•
•
•
•
Pschycological
Physiological
Social
Material
Cultural
Existantial
– Interdependent
– Compensatory
QoL-tool
• Assessment – tool:
– SF – 36; derived from the Medical Outcomes Study
(MOS)
• Heahlt related QoL !
• 8 subscales:
– Physical, functioning, role limitations due to physical problems,
due to emotional problems, bodily pain, general health
perceptions, vitality, social functioning, mental health
•
•
•
•
2 summary scores
Self - report questionnaire (10’), possible as interview
User’s Manual
Good psychometrics
References
• MOS SF – 36
– Stewart et al., The MOS Short-from General Health
Survey: Reliability and validity in a patient population,
Med Care, 1988; 26:724-735
– Stewart et al., Functional Status and well-being of
patients with chronic cobnditions: Results from the
Medical Outcome Study, JAMA, 1989; 262: 914-919
– MC Horney, Measuring and monitoring general health
status in elderly persons: practical and methodological
issues in using the SF-36 health survey, Geronotologist,
1996, 36: 571-583
Mobility
JP Baeyens , Ghesquière
Introduction
Assessment of MOBILITY
• GET-UP-AND-GO test
• TIMED UP AND GO TEST
Assessment of MUSCLE STRENGHT
• MRC-scale (0-5)
• HAND DYNAMOMETER of Jamar
Evaluation of FALL RISK
• STRATIFY score
GET-UP-AND-GO test
Version 1
• Get Up
• Standing
• Go
• Turning
• Sit down
Scores:
0=impossible
1=with help (manual or instrumental)
2=autonomous
GET-UP-AND-GO test
Version 2
• Get up, standing, go, turning and sit down
Score 1 till 5
-1 no instability
-2 very slowly execution
-3 hesitating, abnormal compensatory movements of
body or arms
-4 patient is stumbling
-5 permanent risk of fall
S.Mathias, U.Nayak, B.Isaacs, 1985,
Arch.Phys.Med.Rehab. 67(6), 387-9
TIMED UP AND GO TEST
• Id, walk of 3 meters, but
• Timed in seconds
• < 20 sec. : independantly mobile
• > 30 sec. : dependent on help for basic
transfers
D.Podsaldio, S.Richardson, 1991,
JAGS, 39(2), 142-8
STRATIFY score
(St.Thomas’s Risk Assessment Tool In Falling elderly Inpatients)
YES or NO:
• Patient is admitted with falls, or presented
falls since admission
• Is he agitated?
• Has he impaired vision?
• Has he frequently to go to the toilet
• Has he a transfer- and mobility- score of
less than 3 or 4?Oliver et al. 1997
STRATIFY score
(St.Thomas’s Risk Assessment Tool In Falling elderly Inpatients)
Transfer score
• 0=impossible
• 1=help of 1 or 2 persons
• 2=help with words or other fysical support
• 3=autonomous
Mobility score
• 0=motionless
• 1=autonomous with help of wheelchair
• 2=march with physical or oral help of 1 person
• 3=autonomous
STRATIFY score
(St.Thomas’s Risk Assessment Tool In Falling elderly Inpatients)
If result is 2 or more:
Risk of falling within the week.
Retesting by the nurse every week.
Cognition
M Lambert , E Gorus, C Sachem
I. introduction
- high prevalence of cognitive disorders in
elderly
- undetected
- reversible causes
- clinical implications
e.g. treatment adherence
decision making capacity
institutionalisation
risk for complications
II. tests currently used
cfr. assessment questionnaire
III. literature
lots of different available tests
but… poorly studied or validated
unknown
not translated (Flemish & French)
time consuming
few international guidelines for acute
geriatric care
IV. pro’s & contra’s
- MMSE
pro : short (10 min.)
several cognitive functions
widely used
validated
geriatric population = high risk
con : cut off-score?
age; education
no validated Flemish version
French/German version ?
dialect? ; Walloon?
different versions :
orientation place
registration & recall: words
calculation &/or spelling; word choice
language : phrase
3 stage command
copy design
Folstein et al. J Psychiatric Res 1975; 12
Derousné et al. La Presse Med 1999; 28
- Clock drawing test
pro : short (2 min.)
simple
con : different versions
different scoring protocols
limited number cog. functions
often used in combination
Shulman et al. Int J Geriatr Psychiatry 1986; 1
Richardson & Glass. JAGS 2002; 50
- AMTS
pro : short & simple
recommended RCP & BGS
con : not widely used
no translation
Hodkinson. Age Ageing 1972; 1
Qureshi & Hodkinson. Age Ageing 1974; 3
- IQCODE
pro : longitudinal perspective
translated into French
con : no informant available
no Flemish version
Jorm & Jacomb. Psych Med 1989; 19
Mulligan et al. Arch Neur 1996; 53
V. general remarks
consensus :
time (stabilised illness)
place
version
Depression
A Velghe, Th Pepersack
Depression
•
•
•
•
•
•
Community elderly subjects 1-3%
Hospitalized elderly 10-15%
associated with higher risk of disability
worses the outcome of several diseases
associated with increased use of medical service
fewer than 50% of older elderly subjects receive a
correct diagnosis
 screening should be part of CGA
Screening questionnaires
• Beck Depression Inventory for Primary Care (BDI-PC)
Behav Res Ther 1997;35:785-791
• Zung Self Rated Rating Scale
Arch Gen Psychiatry 1965;12:63-70
• Center for Epidempiological Studies Depression Scaale (CES-D)
Appl Psychol Measaure 1992;343-351
• Hamilton Rating Scale for Depression (HAM-D)
J Neurol Neurosurg Psychiatry 1960;23:56-62
• Montgomery-Asberg Depression Rating Scale (MADRS)
• Cornell Scale for Depression in Dementia (CSDD)
• Geriatric Depression scale (GDS)
Clin Gerontol 1982;1:37-43
Hamilton Rating Scale for Depression
HAM-S
• developed as a measure of treatment
outcome rather than a screening tool
• 21 items
• completed by a trained observer after a 30
min interview...
Zung Self-rating Depression scale
SDS
• Used in epidemiological studies
• 20 items
• uses graded responses (never, sometimes, usually)
that may be confusing in elderly patients
• many normal elders assessed as false-positives
• misses depression in the elderly if multiple
somatic complaints
• a short form (12 items)
• not recommended in the elderly...
Montgomery-Asberg Depression Rating Scale
MADRS
• Sensitive to measuring change in symptoms with
treatment over time
• Interview
• 10 questions (6 possible ratings)
• not sufficiently validated in the geriatric
population
Geriatric Depression Scale
• originally contained 100 items,
• condensed to 30 questions that indicate presence
of depression.
• self-administered test
• "yes/no" question format, which may be more
acceptable in the elderly population.
• initially validated among patients hospitalized for
depression and among normal elderly living in the
community without complaints of depression or
history of psychiatric illness.
Geriatric Depression Scale
• A cutoff score of 11 on the GDS yields an 84%
sensitivity rate and a 95% specificity rate
• a cutoff score of 14 yields a slightly lower
sensitivity rate of 80%, but a 100% specificity
rate.
• During the development of the GDS, it was noted
that vegetative symptoms failed to differentiate
depressed and nondepressed elders, thus these
symptoms are largely not assessed by the GDS.
Geriatric Depression Scale
• The GDS has been well studied in various
geriatric populations unlike the other instruments
discussed. It has been found to be a valid measure
of depression in elderly medical inpatients.
• however, the GDS does not maintain its validity
in populations that contain large numbers of
cognitively impaired patients.
• In one study, the GDS maintained validity in
cognitively impaired patients (MMSE score, 17.1)
Geriatric Depression Scale
• The GDS is available in several languages, and it
has been found to maintain its reliability and
validity when administered by telephone, which
may be useful in a variety of epidemiological and
clinical settings.
• A collateral source version of the GDS has been
developed, although not extensively tested, which
may prove useful as a screening instrument in
those with aphasia, other communication deficits,
or cognitive impairment.
Geriatric Depression Scale Short Form
GDS-SF 15 items
• 5-7 min
• long-form and the short-form are highly correlated
(r = 0.84, P < .001).
• short form has been validated in a geriatric
affective disorder outpatient clinic (N = 116;
average age 75.7 years).
• Using an optimal cutoff score of 5-6, the shortform GDS showed a sensitivity of 85% and
specificity of 74%
Geriatric Depression Scale Short Form
GDS-SF 10, 5 ,4 , 1 item(s)
• GDS 10-, 5-, 4-, and 1-item versions.
• GDS-4 had lower internal consistency than the
GDS -15, but missed only 5 of 46 depressed
patients in this sample.
• useful as a minimal screening procedure for
detecting depression in elderly, primary care
patients, especially among practitioners who feel
that the 15-item GDS is too long.
• There has not been further validation of these
shorter scales in other studies.
Depression Scales for Patients
With Dementia
• Use outside informants (caregivers, nursing home
staff) to provide history and reliable symptom
reporting.
• A collateral source form of the GDS has been
developed for use in the cognitively impaired,
although it has not been validated in a demented
population.
Depression Scales for Patients
With Dementia
• The best validated scale for dementia
patients is the Cornell Scale for Depression
in Dementia (CSDD).
• The CSDD is an interviewer-administered
scale that uses information both from the
patient and an outside informant.
• The scale has correlated well with
depression as classified by the Research
Diagnostic Criteria
Depression Scales for Patients
With Dementia
• Factor structure analysis reveals 4 to 5 factors that
are assessed by the CSDD, including general
depression, biologic rhythm disturbances,
agitation/psychosis, and negative symptoms.
• However, even the CSDD has been better
validated in patients with mild to moderate
dementia, compared with patients with severe
dementia.
• The CSDD has been used in aphasic patients and
compared with Research Diagnostic Criteria.
Summary
• Based on the research, it is clear the GDS is
the best validated instrument in various
geriatric populations.
• The CSDD may be better given its inclusion
of information from caregivers, but further
research in the severely demented elderly is
needed
Friedhoff AJ. Consensus development conference statement --diagnosis and treatment of depression in late life. In: Schneider LS, Reynolds CF, Lebowitz BD,
Friedhoff AJ (eds). Diagnosis and Treatment of Depression in Late Life. Washington DC: American Psychiatric Press;1994:493-551.
Small GW. Recognition and treatment of depression in the elderly. J Clin Psychiatry 1991;52:(suppl):S11-S22.
Reifler BN. Depression: diagnosis and comorbidity. In: Schneider LS, Reynolds CF, Lebowitz BD, Friedhoff AJ (eds). Diagnosis and Treatment of Depression in
Late Life. Washington DC: American Psychiatric Press;1994:55-59.
Blazer DG, ed. Diagnosis and Treatment of Depression in Late Life. St. Louis Mo: Mosby-Yearbook, Inc;1993.
Lesse S. Masked Depression. New York, NY: Jason Aronson;1974.
Applegate WB. Use of assessment instruments in clinical settings. J Am Geriatr Soc. 1987;34:45-50.
Ware JE. Methodologic considerations in the selection of health status assessment procedures. In: Wenger NK, Mattsan ME, Furberg CD, Elinson J, eds. Assessment
of Quality of Life in Clinical Trials of Cardiovascular Therapies. New York, NY: LeJacq Publishing Inc;1984:87-111.
Hamilton M: A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960; 23:56-62.
Clayton AH, Holroyd S, Sheldon-Keller A: Geriatric Depression Scale vs Hamilton Rating Scale for Depression in a sample of anxiety patients. Clin Gerontologist
1997;17:3-13.
Fleiss JL. The Design and Analysis of Clinical Experiments. New York, NY: John Wiley and Sons; 1986: 208.
Maier W, Philipp M. Comparative analysis of observer depression scales. Acta Psychiatr Scand. 1985:72:239-245.
Lichtenberg PA, Marcopulos BA, Steiner DA et al. Comparison of the Hamilton Depression Rating Scale and the Geriatric Depression Scale: detection of depression
in dementia patients. Psychol Rep (United States). 1992;70:515-521.
Zung WW. A self-rating depression scale. Arch Gen Psychiatry. 1965:12:63-70.
Brink TL, Yesavage JA, Lum O, et al. Screening tests for geriatric depression. Clin Gerontologist. 1:37-44, 1982.
Zung WWK. The Measurement of Depression. Columbus, Ohio: Merrill; 1975.
Zung WW, Green RL. Detection of affective disorders in the aged. In: Eisderfer C, Fann WE, eds. Psychopharmacology and Aging. New York, NY: Plenum
Press;1973.
Raft D, Spencer RF, Toomey T, et al. Depression in medical outpatients: use of the Zung scale. Dis Nerv Syst (United States). 1977;38:999-1004.
Myers JK, Weissman MM. Use of a self-report symptom scale to detect depression in a community sample. Am J Psychiatry. 1980:137:1081-1084.
Carroll BJ, Fielding JM, Blashki TG. Depression rating scales: a critical review. Arch Gen Psychiatry.1973;28:361-366.
Kitchell MA, Bernes RF, Veith RC, et al. Screening for depression in hospitalized geriatric medical patients. J Am Geriatr Soc. 1982;30:174-177.
Okimoto JT, Barnes RF, Veith RC, et al. Screening for depression in geriatric medical patients. Am J Psychiatry. 1982;139:799-802.
Schrijnemaekers VJJ, Hareman MJ. Depression in frail Dutch elderly: the reliability of the Zung scale. Clin Gerontologist. 1993;13:59-66.
Kivela S, Pahkala K. Sex and age differences of factor pattern and reliability of the Zung self-rating depression scale in a Finnish elderly population. Psychol Reports.
1986;59:587-597.
Gosker CE, Berger H, Deelman BG. Depression in independently living elderly, a study with the Zung-12. Tijdschr Gerontol Geriatr (Netherlands). 1994;24:157-162.
Hulstijn EM, Deelman BG, de Graaf A, et al. The Zung-12: a questionnaire for depression in the elderly. Tijdschr Gerontol Geriatr (Netherlands). 1992;23:85-93
Montgomery SA, Asberg M. A new depression scale designed to be sensitive to change. Brit J Psychiatry. 1979;134:382-389.
Maier W, Heuser I, Philipp M, et al. Improving depression severity assessment -- II. Content, concurrent, and external validity of three observer depression scales. J
Psychiatr Res. 1988;22:13-19.
Waltis JP, Davies KN, Bunn WK, et al: Correlation between Hospital Anxiety Depression (HAD) scale and other measures of anxiety and depression in geriatric
inpatients. Int J Gen Psych. 1993; 9:61-63.
van Marwijk H, Hoeksema HL, Hermans J. Prevalence of depressive symptoms and depressed disorders in primary care patients over 65 years of age. Fam Pract.
1994;11:80-84.
Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiat Res. 1982-1983:17:3749.
Hyer L, Blount J. Concurrent and discriminant validities of the Geriatric Depression Scale with older psychiatric inpatients. Psychol Rep. 1984;54:611-616.
Rapp SB, Parisi SA, Walsh DA, et al. Detecting depression in elderly medical inpatients. J Consult Clin Psychol. 1988;56:509-513.
Koenig HG, Meader KG, Cohen HJ, et al. Self-rated depression scales and screening for major depression in the older hospitalized patient with medical illness. J Am
Geriatr Soc. 1988;36:699-706.
Norris JT, Gallagher D, Wilson A, et al. Assessment of depression in geriatric medical outpatients: the validity of two screening measures. J Am Geriatr Soc.
1987;35:989-995.
Zgourides G, Spofford M, Doppett L. The Geriatric Depression Scale: discriminant validity and elderly day-treatment clients. Psychol Rep. 1989;64:1082.
Kafonek SD, Roca RP. Proper scoring of the Geriatric Depression Scale (letter). J Am Geriatr Soc. 1989;37, 819-820.
Parmalee PA, Lawton MP, Katz IR. Psychometric properties of the Geriatric Depression Scale among the institutionalized aged. Psychological Assessments.
1989;4:331-338.
Lesher EL. Validation of the Geriatric Depression Scale among nursing home residents. Clin Gerontologist. 1986;4:21.
Hickie C, Snowdon J. Depression scales for the elderly: GDS, Gilleard, Zung. Clin Gerontologist. 1987;6:51.
Kafonek S, Ettinger WH, Roca R, et al. Instruments for screening for depression and dementia in a long-term care facility. J Am Geriatr Soc. 1989;37:29-34.
Social
JP Baeyens , Van de Kerckhof
Social Network Diagram
Friends
Family
First floor:
Daughter and husband
granddaughter
District nurse
Groundfloor
Patient aged 90 yrs
Neigbourgh -------2/7--
R.Capildeo t al., B Med J, 1976, 1,
143-4
<…1/7…………………Granddaughte
r
Socios
Future of patients
• S1
no changes expected (or not
known)
• S2
only minor changes needed
• S3
change in living place
• S4
actions to be taken by expected
death
Socios
Group context
• G1
only information is needed
• G2
patient and family needs
guidelines
• G3
patient and family is not able to
organise anything
• G4
conflict is present
Socios
Group
context
Future of
patients
S1
S2
S3
S4
G1
A
A
A
A
G2
A
B
B
B
G3
A
B
B
B
G4
B
C
C
C
Nutrition
T Pepersack, H Daniels, J Pétermans, C Gazzotti
Malnutrition screening
• Anthropometric measures
• Scale to assess the risk
– Nutritional Screening questionnaire
– MNA,
– MUST
Malnutrition screening
• Anthropometric measures
• Scale to assess the risk
– Nutritional Screening questionnaire
– MNA,
– MUST
Anthropometric cut-off values that include body mass index
for detecting underweight or undernutrition in adults
Anthropometric criteria
BMI < 18.0
BMI < 18.5
BMI < 19.0
Recommended/type of
study using criteria
Elderly
International classification
for anorexia nervosa
Nursing home
Community and hospital
Community and hospital
BMI < 20
Community and hospital
BMI < 20
Hospital and community
studies
Elderly in hospital
Free-living elders (>70y)
Community and hospital
Community
BMI < 17.0
BMI < 17.5
BMI < 21
BMI < 22
BMI < 23.5
BMI < 24 (and other
criteria)
BMI < 24 (and other
criteria)
Recipents of “meals on
wheels”
Reference
Wilson, Morley 1988
WHO 1992
Lowik et al 1992
Elia 2000, Kelly et al 2000
Dietary Guidelines for Americans
1995, Nightingale et al 1996
Jallut et al 1990, Vlaming et al
1999
McWhirter Pennington 1994,
Edington 1996, 1999
Incalzi et al 1996
Posner et al 1994
Potter 1998, 2001
Gray-Donald 1995
Coulston et al 1996
Categories of BMI for identifying
risk of chronic PEM in adults
BMI
<18.5
18.5-20
20-25
25-30
>30
Weight category
Underweight
Underweight
Desirable weight
Overweight
Obese
Interpretation
Chronic malnutrition probable
Chronic malnutrition probable
Chronic malnutrition unlikely (low risk)
 risk of complications associated with chronic overnutrition
Moderate (30-35), High (35-40), very high risk (>40) of
obesity-related complications
Malnutrition risk screening
• Anthropometric measures
• Scale to assess the risk
– Nutritional Screening questionnaire
– MNA,
– Nursing Nutritional checklist
– MUST
NSI Checklist To Determine Your
Nutritional Health
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/day.
3
I eat few fruits or 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 three or more different prescribed or OTC drugs a day.
1
Without wanting to, I have lost or gained 10 pounds in the last 6 months.
2
I am not always physically able to shop, cook, or feed myself.
2
Total nutritional score
______
-2 indicates good nutrition
3-5 indicates moderate risk
6 or more indicates high nutritional risk
Reprinted with permission by 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., and funded in part by a
grant from Ross Products Division, Abbot Laboratories, Inc.
Malnutrition risk screening
• Anthropometric measures
• Scale to assess the risk
– Nutritional Screening questionnaire
– MNA,
– Nursing Nutritional checklist
– MUST
MNA screening tool
• Complete the Screening section by
filling in the boxes with the numbers.
Add the numbers in the boxes, for the
screen.
• Screening questions: A B C D E F
http://www.mna-elderly.com/clinical-practice.htm
A
Has food intake declined over the past three
months due to loss of appetite, digestive problems,
chewing or swallowing difficulties?
0 = Severe loss of appetite
1 = Moderate loss of appetite
2 = No loss of appetite
• Ask patient
– ‘Have you eaten less than normal over the past three
months?’
– If so, ‘is this because of lack of appetite, chewing or
swallowing difficulties?’
– If yes, ‘have you eaten much less than before or only a little
less?’
If this is a re-assessment, then rephrase the question
– ‘Has the amount of food you have eaten changed
since your last assessment?’
B
Weight loss during the last 3 months?
0 = weight loss greater than 3kg (6.6lbs)
1 = does not know
2 = weight loss between 1 and 3 kg (2.2 and 6.6 lbs)
3 = no weight loss
• Ask patient / from notes if long term patient or
residential care
– ‘Have you lost any weight over the last 3 months?’
– ‘Has your clothes got looser?’
– ‘How much weight do you think you have lost?’
C
Mobility?
0 = bed or chair bound
1 = able to get out of bed/chair but does not go out
2 = goes out
• Patient notes/ information from carer/ ask patient
if necessary
– ‘Are you presently able to get out of bed/ chair?’
– ‘Are you able to get out of the house?’
D
Has the patient suffered psychological stress or
acute disease in the past three months?
0 = yes
2 = no
• Patient notes/ professional judgement/ ask
patient
– ‘Have you suffered a bereavement recently?’
– ‘Have you recently moved your home?’
– ‘Have you been unwell recently?’
• If the patient’s notes specify an acute disease
score 0
E
Neuropsychological problems?
0 = severe dementia or depression
1 = mild dementia
2 = no psychological problems
• Patient notes/ professional judgement
– Some indication of mental state of the patient may be
obtained from the caregiver, nursing staff or medical records.
If the patient is severely confused all answers to the
following questions should be checked for accuracy with
caregiver/ nursing staff (questions A, B, C, D, G, J, K, L, M,
O & P)
F
Body mass index (BMI)?
0 = BMI less than 19
1 = BMI 19 to less than 21
2 = BMI 21 to less than 23
3 = BMI 23 or greater
• Before calculating BMI, ensure that the patient’s
weight and height are recorded on the MNA® form.
• 1. For conversion of weight and height
• 2. If height has not been measured, please measure using a
stadiometer (height gauge)
• 3. If the patient is unable to stand, please calculate height from
demispan
• 4. On the BMI chart match up the height and weight of the
patient, and read off the BMI score
• 5. Fill in the appropriate box on the MNA® form to represent the
BMI of the patient
Malnutrition risk screening
• Anthropometric measures
• Scale to assess the risk
– Nutritional Screening questionnaire
– MNA,
– MUST
(i) BMI
0= >20.0
1= 18,5-20.0
2=<18.5
(ii) Weight loss in 3-6 months
0= <5%
1= 5-10%
2=>10%
(iii) Acute disease effect
Add a score of 2 if there has been
or is likely to be no or very little
nutritional intake for > 5 days
Overall risk of undernutrition
0
1
LOW
MEDIUM
Routine clinical care
Observe
Repeat screening
Hospital: document dietary
Hospital: every week
and fluid intake for 3 days
Care Homes: every month
Care Homes: (as for
Community: every year>75y hospital)
Community: repeat
screening 1-6 mths
 Adequate intake (or
improving to near normal)
 Little or no clinical
concern
2
HIGH
Treat
Hospital: refer to dietitian or
implement local policies
(supplements)
Care Homes: (as for
hospital)
Community: (as for
hospital)
 Inadequate intake or
deteriorating
 Clinical concern
The Malnutrition Universal Screening Tool (MUST) (BAPEN)
http://www.bapen.org.uk/screening.htm
References
•
•
•
•
•
•
•
•
•
•
•
•
•
•
www.mna-elderly.com
www.nutrition.org
http://www.medscape.com/viewarticle/418
398_5
http://www.ltcnutrition.org/
http://www.nature.com/ejcn/
http://www.espen.org/
http://www.cerin.org/
http://navigator.tufts.edu/
http://www.sfnep.org/
http://www.nutritioncare.org/homelink.asp?
Link=www.nutritioncare.org/profdev/stnds.
html
www.mna-elderly.com
www.asev.net
www.geriatrie.be
www.anaes.fr
Dwyer, J.T. (1991). Screening older American's nutritional health: Current practices and future
responsibilities. Washington D.C., Nutritional Screening Institute.
Dwyer, J.T., Gallo, J.J. & Reichel, W. (1993). Assessing nutritional status in elderly patients. American
Family Physician, 47(3), 613-620.
Posner, B.M., Jette, A.M., Smith, K.W., & Miller, D.R. (1993). Nutrition and health risks in the elderly:
The nutritional screening initiative. American Journal of Public Health, 83(7), 972-978.
Zembrzuski, C.D. (1997). A three-dimensional approach to hydration of elders: Administration, clinical
staff, and in-service education. Geriatric Nursing, 18(1), 20-26.
Pain
N Vandennoorgate, A Pepinster
Pain assessment
• Cognitively intact elderly or those with mild
to moderate dementia (group I)
• Non communicative elderly or the elderly
with moderate to severe dementia (group II)
Pain assessment: group I
• Proposition I
– Directly querying the patient
• Presence of pain
• Synonymous with pain
»
»
»
»
»
»
Burning
Discomfort
Aching
Soreness
Heaviness
Tightness AGS panel; JAGS 2002; 50: S205-S224
Sebag-Lanoë; NPG 2003; 3(11,12): 4-10
Pain assessment: group I
• Proposition I (continuing)
– Pro:
• Easy and short
• If the answer is yes, can be easily followed by
further information concerning location, character,
intensity and influence on activities
• Can be followed by an appropriate scale if pain is
present
– Contra:
• No validation (consensus report – level IIA)
• No grading
Pain Assessment: group I
• Proposition II: Use of a scale
– Numeric Rating Scale
• A number between 0 (no pain) and 10 (extreme pain)
– Verbal Rating Scale
• 4 or 5 possible answers (absent-light-moderate-intolerable)
– Visual Analoque Scale (VAS)
• less useful in an elderly population
• Vertical presentation more useful
Francois et al. Revue de gériatrie 2004;29(2):95-101
Trichet-LLory et al. Revue de gériatrie 2004;29(2):103-8
Pain assessment: group I
• Proposition II (continuing)
– Alternatives of VAS
Faces pain scale
Pain Thermometer
Pain assessment: group I
• Proposition II (continuing)
– Pro:
• Accepted validity in this patient population
• Vertical presentation seems to be more easy for
people with cognitive impairment
AGS panel; JAGS 2002; 50: S205-S224
Sebag-Lanoë; NPG 2003; 3(11,12): 4-10
Pain assessment: group II
• Proposition I:
– Direct observation/history from caregiver
• Unusual behaviour
– Trigger the assessment of pain
• Pain related behaviour during movement
– facial expressions, verbalization, vocalization, body movements,
mental status changes
– Pro
• Easy and short
• Can be followed by a scale
– Contra
• No validation (consensus report level II evidence)
• No grading
AGS panel; JAGS 2002; 50: S205-S224
Sebag-Lanoë; NPG 2003; 3(11,12): 4-10
Pain assessment: group II
• Proposition II: use of pain scale
– Checklist of non-verbal Pain indicators
• 6 questions with a score =0 if absent and score=1 if present;
score between 0 and 6 correspond with the intensity of pain
– ECPA (échelle comportementale de la douleur pour personnes âgées non
communicantes)
• 4 observation 5 min before the care (5 intensity ratings(0-4))
• 4 observation during the care (5 intensity ratings (0-4))
– Doloplus II scale
Feldt et al. JAGS 1998;46:1079-1085
AGS panel; JAGS 2002; 50: S205-S224
Sebag-Lanoë; NPG 2003; 3(11,12): 4-10
www.doloplus.com
Pain assessment: group II
•
Checklist of Non-verbal Pain Indicators (Feldt,
2000; Milisen K., 2002-verder onderzoek noodzakelijk)
•
Non-Verbaal
•
Pijngeluiden
(afwezig=0; aanwezig=1)
Kermen, kreunen, huilen, hijgen, zuchten
2.
Pijngrimassen
(afwezig=0; aanwezig=1)
Opgetrokken wenkbrauwen, dichtgeknepen ogen, gespannen lippen, vertrokken
mond, op elkaar geklemde tanden, verwrongen gelaatsuitdrukking,
piijnkrampen, pijnrillingen
3.
Krabben/ wrijven aan de wond
(afwezig=0; aanwezig=1)
Pain assessment: group II
–
Checklist of non-verbal pain indicators (vervolg)
4. Vastklampen door pijn bij manipulatie of mobilisering
Grijpen naar of vastklampen aan hekjes, bed, nachtkastje of ondersteunen van
wonde
(afwezig=0; aanwezig=1)
5. Onrust/agitatie
(afwezig=0; aanwezig=1)
Constante of onderbroken verandering van houding; constante of onderbroken
handbewegingen, onmogelijk om stil te zitten
B. Verbaal
6. Pijnwoorden
(afwezig=0; aanwezig=1)
‘Au’, dit doet pijn, vloeken tijdens bewegingen of uitdrukkingen van protest
zoals ‘stop’, ‘genoeg’
Score (van 0 tot 6) geeft de intensiteit van de pijn weer
Pain assessment: group II
• Proposition II (continuing)
DoloplusII
– Pro:
• To do with some experience in about five minutes
• Available in french and English
– Contra:
• Validation ?
• Not suggested if the patient is communicative and
cooperative
• Suggested by the slightest doubt
Frailty
C Swine, G Dargent, P Devriendt
Frailty: definition and framework
•
Homeostasis
(physiological)
•
Vulnerability
(preclinical)
•
Frailty
(impairments)
•
Functional decline
(disability)
Outcomes of frailty
•
•
•
•
•
•
Functional decline (disability, dependance)
Geriatric syndromes
Health services use
Institutionalisation
Failure to thrive
Death
Frailty: definition and framework
•
Homeostasis
(physiological)
•
Vulnerability
(preclinical)
•
Frailty
(impairments)
•
Functional decline
(disability)
Risk for functional decline frailty
screening
• Early screening needed (admission)
• Feasible in the admission unit (emergency)
• Help for triage and further assessment
• Potential tool for liaison geriatrics
Existing tools
• HARP Hospital Admission Risk Profile
Sager et al. J Am Geriatr Soc 1996
• ISAR
Identification of Seniors At Risk
Mc Cusker J. et al : JAGS 1999; 47: 1229-1237
• SIGNET
Case finding in the ED
Mion L.C. et al. JAGS 2001; 49: 1379-1386
• SHERPA Score hospitalier d’évaluation du risque de perte
d’autonomie
• SEGA
P. Cornette, et al. Revue Médicale de Bruxelles 2002 ;23-suppl1 :A181.
Short emergency geriatric assessment
Schoevaerdts et al. La revue de gériatrie 2004 in press
HARP Sager et al. J Am Geriatr Soc 1996
AGE
75 y
75- 84 y
85 y
0
1
2
15-21
0- 14
IADL 2w before admission
6- 7
0- 5
0
1
MMSa
0
1
TOTAL
0 - 1 low risk
2 - 3 intermediate risk
4 - 5 high risk
ISAR
Identification of Seniors At Risk
Identification Systématique des Aînés à Risque
Mc Cusker J. et al : Detection of older people at increased risk of adverse health outcomes after an emergency visit: the
ISAR screening tool. JAGS 1999; 47: 1229-1237
•
•
•
•
•
•
• Self administred questionaire
Previous hosp. admission (6 m.) Yes/ No
Vision problems
Yes/ No
Memory problems
Yes/ No
Premorbid help need
Yes/ No
Current help need
Yes/ No
More than 3 medications
Yes/ No
ISAR
Identification of Seniors At Risk
Identification Systématique des Aînés à Risque
Mc Cusker J. et al : Detection of older people at increased risk of adverse health outcomes after an emergency visit: the
ISAR screening tool. JAGS 1999; 47: 1229-1237
Score
prevalence
• 2 or more yes 51%
• 3 or more yes 27%
• 4 or more yes 12%
%AR*** likelihood* (**)
72%
2,0 (1,7)
44%
3,0 (2,2)
23%
4,7 (2,8)
• *likelihood of adverse outcome or current disability
• ** likelihood of adverse outcome
(death, institutionalization, functional decline)
• *** % of patients at risk detected
SIGNET: triage risk screening tool
Establishing a case-finding and referral system for at risk older individuals in an emergency
department setting: the SIGNET model.
Mion L.C. et al. JAGS 2001; 49: 1379-1386
1 Presence of cognitive impairment
2 Lives alone or no caregiver available
3 Difficulty walking, transfers or recent fall
4 Recent ED visit or hospitalization
5 Five or more medications
6 Need further follow-up at home
(Abuse, neglect, compliance, iADL)
If yes at question 1 or at 2 other questions: further assessment
Factors predicting FD 3 months after hospital discharge in 600
older patients, a screening tool (SHERPA)
P. Cornette, W. D'Hoore, C. Swine IDENTIFICATION DES PATIENTS AGES HOSPITALISES A RISQUE DE DECLIN
FONCTIONNEL Revue Médicale de Bruxelles 2002 ;23-suppl1 :abst.O.397, p A181.
• AGE
MMS (21)
iADL
< 75
75-84
>85
> 15
<14
6-7
5
3-4
0-2
0
1.5
3
0
2
0
1
2
3
Falls (1y) no 0
Yes 2
B s.p. H

Category
%
%FD

Low (0-3)
Mild (3.5-4.5)
Mod.(5-6)
High (>6)
36
23
18
23
13
23
39
62



no 0
Yes 1.5
OR
1
2
4
10
ECHELLE SEGA*
profil de risque du patient âgé admis en urgence
Identification du patient :
Personne de référence (tel) :
Médecin traitant :
Destination :
Motif d’admission :
Facteurs de risque de déclin fonctionnel
0
1
2
74 ans ou moins
entre 75 et 84 ans
85 ans ou plus
Domicile
Domicile moyennant aide
MR ou MRS
3 ou moins
4 à 5 médicaments
Plus de 5 médicaments
Fonctions cognitives*
Normales
Peu altérées
Humeur*
Normale
Anxieux (BZD)
Très altérées (diagnostic de
démence)
Souvent triste et déprimé
Perception de santé (en général)*
Meilleure
Bonne
Moins bonne
Aucune
Une et sans gravité
Normal, poids stable,
apparence normale
Indépendant
Perte d’appétit, de poids
(3kg/3mois)
Soutien
Plusieurs, ou la chute est le
motif d’hospitalisation
Franchement dénutri
(BMI <21)
Incapacité
AVJ continence*
Indépendant
incontinence accidentelle
Incontinence
AVJ manger*
Indépendant
Préparation
Assistance
AVJi repas, téléphone
médicaments*
Indépendant
Partiellement dépendant
Dépendant
AGE
Provenance
Médicaments*
Chute les 6 derniers mois
Nutrition*
AVJ se lever, marcher*
/24
* évaluer la situation stable
existante avant l’admission
Facteurs susceptibles d’influencer le plan de sortie
Personne de référence et
perception de la charge
Hospitalisation récente (délai)
Maladies invalidante
(comorbidité)
Vision, audition
Habitat
Pas nécessaire
Charge importante
Pas ces 6 derniers mois
Il y a moins de 6 mois
Pas en dehors de l’AA
De 1 à 3
Normale
Diminuée, appareillée
Plus de 3, ou AVC, ou cancer
ou BPCO, ou Ins. Card. Cong.
Très diminuée, non appareillée
Couple (famille)
Seul avec aide
Seul sans aide
Aucune
Proches
Incertitude ou alternative
Incertitude ou alternative
Projet pour la sortie (proches)
Institutionnalisation
Professionnels
(nom, tel au verso)
Retour à domicile
Projet pour la sortie (patient)
Institutionnalisation
Retour à domicile
Aide existante à domicile
/16
Fait le :
avec l’aide de (proches) :
par :
Epuisement ou charge trop
importante
Dans le mois qui précède
Frailty admission screening criteria
common to the different tools
•
•
•
•
•
•
•
•
•
Age
Cognitive function
Medications
Hospital use
Help for ADL
Sensory impairments
Falls
Health perception
iADL ’s
<75; 75-85; >85
normal; delirium; dementia
<3; 4-5; >5
no; ED 1 m; H 6 m
no; elevated; increased
no; hearing; vision
no; 1 > 1y; 1 < 6 m
good; fair; poor
7; 5-6; < 5