THE 10 MINUTE GERIATRIC

ASSESSMENT
Fredrick T. Sherman, MD, MSc
Medical Director
SENIOR HEALTH PARTNERS
Mount Sinai School of Medicine
www.geri.com
 OFFICE-BASED
ASSESSMENT
• Common syndromes “Geriatric
Giants” of the elderly
• Based on literature review
• Use principles of EBM
• Easy to remember MNEUMONICS
 GERIATRIC GIANTS

Falls Confusion Incontinence

“Phalls”

Impaired Iatrogenic
homeostasis disorders
 “DEEP IN”
FOR QUICK SCREENING
D - Dementia, Depression, Drugs
E - Eyes
E - Ears
P - Physical Performance, Phalls, Psychosocial

I - Incontinence
N -Nutrition
 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)
 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
 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
 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.
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
Watson YL et al., Clock Completion: An Objective screening test for dementia.
JAGS 1993; 41:1235-40
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
 INSTRUMENTAL ACTIVITIES
OF DAILY LIVING
• Meal preparation • Telephone
• Housework • Shopping
• Laundry • Transportation
• Medication • Money management
management
 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
 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)
 7 MINUTE
NEUROCOGNITIVE SCREEN
• 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)
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
 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)
 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.
 DRUGS
• Greater Than Or Equal To Four
Prescribed
• Any Of The “Antis”
• Benzos
• Non Rxed
• Alternative
SIMPLE SCREENS OF HEARING LOSS
Question/Test Time to Administer Comments

Audioscope 1-2 min Sen 87-90%

Spec 80-100%
Whisper Test 1 min Sen 80-100%
Spec 82-89%
Hearing-Handicap 2 min Sen 48-63%
Inventory for the Spec 75-86%
elderly At cut point >8
NHANES Battery < 2 min Sen 80%
Spec 80% at cut
point of >3
 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%
 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
 EYES
BECAUSE OF YOUR EYESIGHT, DO
YOU HAVE DIFFICULTY WITH. . . .
• Driving
• Watching TV
• Reading
• Or Any Daily Activity
 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
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
 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
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
 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?
 RISK FACTORS FOR
FUNCTIONAL DEPENDENCE
Older Age Smoking
Female HBP
Living Alone Abnormal BMI
Non-white
Poor Heart Disease
Less Education Cognitive
Impairment
 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.

 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.
 PREDICTORS OF ADL
DEPENDENCE
TIMED PERFORMANCE TESTS
1) 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)
QUALITATIVE CHAIR STAND
Abnormal Normal

High Risk
10 ft. Rapid Gait/3 Chair Rises
12/31 (39%)

Abnormal Normal

High Risk Low Risk

13/38 (34%) 6/128 (4.7%)
 SIMPLE TESTS OF LOWER
EXTREMITY STRENGTH,
BALANCE, GAIT & FALL RISK
Question/Test Time to Comments
Administer
Functional reach 1 min If FR < 7” unable to:
1) Leave neighborhood
2) Stand on one foot
3) Do tandem walking
Adjusted Odds Ratio for >2 falls in
6 months
1) 8.1 if unable to reach
2) 4.0 if < 6 inches
3) 2.0 if > 6 inches < 10 inches
RELATIVE RISKS OF SEVERE WALKING DISABILITY:
COMBINED DISTRIBUTION OF KNEE STRENGTH
TERTILES AND BALANCE CATEGORES
Knee Strength Tertiles
Weakest Average Strongest
(<10.6 kg) (10.6-15.1 kg) (<15.1kg)
Balance RR RR RR
Categories
S-S<10 seconds 5.12 1.49 3.08
SS (10)+ST (10) 1.87 1.58 1.18
+TS (<3S)
SS (10)+ST (10) 0.97 1.14 1
+TS (>3s)

JAGS, 2001-Vol.49, No.1

 37.1

14.7
40 5.3
30 12.7 13.2
21.6 6.1 Weakest

20 9.6 Average
10 3.1
Strongest
0
SS<10 s TS<3 s TS>3 s Knee Extension
Strength Tertiles
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. JAGS, 2001-Vol.49,No1
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
 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
 PERSISTENT
UI
S - Stress
O - Overflow
U - Urge
P - Physical/Psychological
 NUTRITION SCREENS
Question/Test Time to Comments
Administer
•Weight (kg) /Height (m2) 1 min BMI <22 or >25

•>10lb wt loss over 6 mo <1min RR of death 2.0

•Weight < 100lbs. 1 min PPV malnutrition .99

Nutrition Screening <5 min Sen 36%, Spec 85% for

NHANES 14-item scale to 5-10 min
detect hypoalbuminemia
intake of > 3 nutrients
below 75% of RDA at cut
point > 6 points
Odds Ratio 2.7 if 3-5 RF,
6.4 if > 6 RF
 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
 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
 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
 “DEEP IN”
For QUICK Screening
D - Dementia, Depression, Drugs
E - Eyes
E - Ears
P - Physical Performance, Phalls, Psychosocial

I - Incontinence
N -Nutrition