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Hammering Skills in Assessment ofthe Elderly: Falls and Cognition—Who to Screen, How to Treat?
John M Carment, MD, FACP
ACP OK Chapter Scientific Meeting
September 26, 2014
Disclosure I have no financial relationships with any entity
producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
John Carment, MD, FACP
Assistant Professor of Geriatrics
NE Region Clinical Director, OHAI
Objectives
Utilize case scenarios for examining best practice with respect to falls and dementia
Recognize the risk factors for falls Implement evidence-based interventions to
reduce falls Discuss clinically efficient means of
addressing cognitive impairment in elders
Case 1 76-year-old woman with is seen for her
semi-annual visit wrote “increased forgetfulness” on the line for her concerns today
You note that the ROS checkbox for “falls in the last year” is checked
PMHx: Osteoporosis, HTN and OA left knee
Meds: Lisinopril, alendronate, metoprolol and acetaminophen
Which statement has the best supporting evidence for a clinical practice guideline?A. Adults aged > 75 yrs should
be screened for dementia biannually
B. Adults who fall should be screened for osteoporosis
C. The MMSE should be administered annually to geriatric patients
D. Adults aged> 70 should be screened for falls annually Adults
aged > 75 yrs sh
o...
Adults w
ho fall s
hould be...
The MM
SE should be ad...
Adults aged> 70 sh
ould b...
0% 0%0%0%
Which guideline is best?
A. Dementia screen biannually
B. Osteoporosis screen in fallers
C. Annual MMSE
D. Annual fall screen
A. B. C. D.
0% 0%0%0%
USPSTF does not support generalized dementia screening Brief screening measures have only
fair specificity Current treatments are symptomatic
with modest effect Unclear whether benefit outweighs
harm
www.ahrq.gov/clinic/uspstf/uspsdeme.htm
Case 1 Discussion
The Medicare Annual Wellness Visit does require “screening” for cognition Does not require use of a specific instrument
MMSE score alone does not diagnose dementia
Screening criteria for osteoporosis is not inclusive of those older adults who have falls
USPSTF recommends annual screening for falls Ask all patients > 70 years old about falls and
balance or gait difficulties annually Observe patients walking and getting into/out
of a chair Further assessment for all those with two or
more falls or balance/gait impairment
AGS, BGS, AAOS Panel on Falls Prevention. J Am Geriatr Soc 2010.
Case 2 88-year-old male is seen for several recent
falls after discharge from a skilled nursing facility. He had been hospitalized the previous month for pneumonia.
PMHx: Parkinson’s disease, BPH, OA bil knees
Meds: Carbidopa/levodopa, tamsulosin, and hydrocodone/acetaminophen.
Which risk factor most strongly predicts future falls? A. Cognitive impairment
B. Lower extremity weakness
C. Use of assistive device
D. Visual impairment
Which risk factor is highest for falls ?
A. Cognitive impairment
B. Lower extremity weakness
C. Use of assistive device
D. Visual impairment
A. B. C. D.
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Risk Factors Across Multiple Observational Studies Lower extremity
weakness (RR 4.4) Balance & gait
impairment (RR 2.9) Use of assistive device
(RR 2.6) Visual impairment
(RR 2.5)
Tinetti ME, NEJM 2003; 348:42-49.
Arthritis (RR 2.4) Depressive symptoms (RR 2.2) Cognitive impairment (RR 1.9) Use of four or more medications Age > 80 yrs
AGS, BGS, AAOS Panel on Falls Prevention. J Am Geriatr Soc 2001; 49:664-72.
USPSTF focus on 4 factors
Age History of falls History of mobility problems Poor performance on the timed Get
Up and Go Test
http://www.uspreventiveservicestaskforce.org/uspstf11/fallsprevention/
Timed “ Up and Go ” Test Simple test of observing a person stand up from
a chair (without use of arms), walk 10 feet, turn around, walk back, and sit down again.
Normal person takes < 10 seconds when timed > 16 seconds is considered positive > 20 seconds are at risk of falls outside their homes
Sensitivity 54-87%; Specificity 74-87% for falls
Posiadlo et al, J Am Geriatr Soc. 1991; 39:142-148
RCT evidence best supports which treatment option(s) to reduce fall risk? A. Referral for PT or exercise therapy
B. Prescribing vitamin D
C. Adaptation or modification of the home environment
D. All of the above
RCT evidence-based treatment to reduce fall risk ?
A. PT referral / Exercise therapy
B. Vit D Rx
C. Home environment modifications
D. All of above
A. B. C. D.
0% 0%0%0%
Interventions Proven in RCTs Muscle-strengthening and balance re-
training Treatment with Vitamin D
Even if levels are normal Home hazard evaluation Tai Chi Gradual withdrawal of psychotropic meds Multidisciplinary geriatric assessment
Cochrane Database Syst Review 2009
Evidence-based programs, such as: o Chronic Disease Self Management Programo REACH (Resources for Enhancing Alzheimer’s Caregiver Health)o Eat Better, Move Moreo Tai Chi: Moving for Better Balanceo Diabetes Self Management Program
Annual themes, such as:o Medication Managemento Physical Activityo Diabeteso Healthy Brain, Healthy Mind
Education Center Activity
USPSTF recommends “Grade B” Provide intervention consisting of
exercise or physical therapy and/or vitamin D supplementation. Group classes, at-home physiotherapy Vit D median dose 800 IU/day, median
duration 12 months
http://www.uspreventiveservicestaskforce.org/uspstf11/fallsprevention/
USPSTF recommends against “Grade C” In-depth multifactorial risk
assessment and comprehensive management to prevent falls for all community-dwelling adults aged 65 years and older Small benefit is found, but not applicable to
heterogeneous population of all older persons.
http://www.uspreventiveservicestaskforce.org/uspstf11/fallsprevention/
Most effective components
Most effective components of a multifactorial risk assessment and comprehensive management approach Evaluation of balance and mobility Vision assessment Orthostatic blood pressure measurement Review of medications Home environment assessment
AGS, BGS, AAOS Panel on Falls Prevention. J Am Geriatr Soc 2010.
Case 3 An 81-year-old female is seen for
increasing memory loss and difficulty managing changes in her warfarin dosing. The anticoagulation nurse was concerned as she is increasing out of therapeutic range.
PMHx: Afib, depression, urge incontinence, osteoporosis
Meds: Warfarin alternating 2.5 mg and 5 mg,atenolol, oxybutnin, sertraline, raloxifene
What is the most efficient approach to evaluate her cognitive status ? A. Folstein Mini-Mental Status Examination
B. Montreal Cognitive Assessment
C. St. Louis Univ Mental Status (SLUMS) Exam
D. Collateral historian to determine functional independence with IADLs
Most efficient approach?
A. MMSE
B. MOCA
C. SLUMS
D. Collateral Hx for IADLs
A. B. C. D.
0% 0%0%0%
DSM-V Criteria for DementiaSignificant cognitive impairment in at least one of the following:
Learning and memory Complex attention Language Perception-motor function Executive function Social cognition
DSM-V. 1st ed. American Psychiatric Assoc. 2013.
DSM-V Criteria for Dementia Acquired and decline from previous
level Must interfere with independence
in everyday activities Not delirium or better accounted for
by a different mental disorder
DSM-V. 1st ed. American Psychiatric Assoc. 2013.
Clinical Evaluation for Dementia Critical to have a knowledgeable
informant Explore IADLs (medication
managment, driving, finances, shopping) as early indicators of functional loss
Clinical Evaluation for Dementia Abnormal cognitive test scores alone
do not diagnose dementia Mild cognitive impairment
No benefit from cognition-enhancing medications unless fulfills criteria for dementia
Efficient Evaluation for Dementia Take clinical history on first visit, perform
cognitive testing and physical exam at following visit
MMSE or Mini-Cog if suspect dementia based in multiple IADL impairment
Prefer MOCA, SLUMS, or neuropsychological testing if daily function is mostly preserved
Montreal Cognitive Assessment (MOCA) Validated tool sensitive for detecting MCI Condensed neuropsychological testing
Requires 10-15 min to administer Limited for visually/hearing impaired persons
Freely available in 31 languages at www.mocatest.org
Nasreddine et al. J Am Geriatr Soc. 2005; 53: 695-99
St. Louis Univ Mental Status Exam (SLUMS) 30-point battery similar format to MMSE Enhanced immediate/delayed recall,
animal naming, attention, numeric calculation, recall of facts from a paragraph
Sensitivity and specificity for dementia were equal to MMSE in a pilot study of 702 veterans
Tariq SH et al. Am J Geriatr Psych. 2006; 19: 600-10
Visual or dexterity limitationsBlessed Memory Test "John Brown, 42 Market Street, Chicago, Illinois"
and One-minute animal fluency (normal > 11)
Combination has similar sensitivity and specificity to the MMSE for dementia
Conclusions
Screen annually for falls, don’t screen for dementia
Add the following to your toolbox Timed “Get up and go” test PT/Exercise + Vitamin D +/- Home Safety Eval Know your local resources for seniors Use IADL impairment to guide cognitive screen
test selection
