Belgian Minimum Data Set for Comprehensive Geriatric Assessment Consensus conference May 7 th, 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 ØProposed (31% and 32%) ØFeasible: Øtime 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 (Wee. FIM): 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 • Inter. RAI SCREENER
Quality of life P Devriendt, G Dargent, C Swine
To measure Quality of Life • Qo. L: – Can be seen as overall measure – Includes ADL
Quality of Life • Definition: as many as there autors, but in common – Perception (subjective) – Expectations – Multidimensional • • • Pschycological Physiological Social Material Cultural Existantial – Interdependent – Compensatory
Qo. L-tool • Assessment – tool: – SF – 36; derived from the Medical Outcomes Study (MOS) • Heahlt related Qo. L ! • 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. Ageing 1972; 1 Qureshi & Hodkinson. 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 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
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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…………………Granddaughter
Socios Future of patients • S 1 no changes expected (or not known) • S 2 only minor changes needed • S 3 change in living place • S 4 actions to be taken by expected death
Socios Group context • G 1 only information is needed • G 2 patient and family needs guidelines • G 3 patient and family is not able to organise anything • G 4 conflict is present
Socios Group context Future of patients S 1 S 2 S 3 S 4 G 1 A A G 2 A B B B G 3 A B B B G 4 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
Categories of BMI for identifying risk of chronic PEM in adults
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 -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 3 kg (6. 6 lbs) 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
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: S 205 -S 224 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: S 205 -S 224 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: S 205 -S 224 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: S 205 -S 224 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) Doloplus. II – 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 P. Cornette, et al. Revue Médicale de Bruxelles 2002 ; 23 -suppl 1 : A 181. • SEGA 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 2 w 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 %AR*** likelihood* (**) • 2 or more yes 51% 72% 2, 0 (1, 7) • 3 or more yes 27% 44% 3, 0 (2, 2) • 4 or more yes 12% 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, i. ADL) 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 -suppl 1 : abst. O. 397, p A 181. • AGE MMS (21) i. ADL < 75 75 -84 >85 > 15 <14 6 -7 5 3 -4 0 -2 0 1. 5 3 0 2 0 1 2 3 Category % Low (0 -3) l Mild (3. 5 -4. 5) l Mod. (5 -6) l High (>6) 36 23 18 23 l l Falls (1 y) no 0 Yes 2 B s. p. H %FD 13 23 39 62 no 0 Yes 1. 5 OR 1 2 4 10
Frailty admission screening criteria common to the different tools • • • Age Cognitive function Medications Hospital use Help for ADL Sensory impairments Falls Health perception i. ADL ’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 > 1 y; 1 < 6 m good; fair; poor 7; 5 -6; < 5
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