1 Community Actions & Resources Empowering Seniors (CARES)Utilization of the Assessment tools: Translating numbers and data into ACTION Dr. Pamela Thornton Geriatrician November, 2016

2 A couple cases to keep in mindCase 1: Mr. Slip 79 y/o male lives alone in 3rd floor condo comes in with complaints of feeling ‘fuzzy headed’ and having fallen outside while gardening at his son’s. Case 2: Ms. Muddled 83 y/o lady lives alone in a townhome. Family concerned re forgetfulness and weight loss. They note they are supporting her more and that she is increasingly socially isolated.

3 Community Comprehensive Geriatric Assessment FormAll information is important to the senior and their health. Only useful if used to make positive change for the patient!

4 Tools used in the Comprehensive Geriatric Assessment (CGA)Montreal Cognitive Assessment (MoCA) Mini-Cog Functional Assessment Staging Test (FAST) Five Times Sit to Stand Test Rockwood Clinical Frailty Scale

5 Montreal Cognitive Assessment (MoCA)Screening test for abnormal cognition (MCI, early dementia) Tests the various cognitive functions affected by AD and MCI High sensitivity (80-90%) for MCI High specificity (80-87%) Further clinical assessment is necessary to assess the etiology of cognitive impairment and to make a diagnosis of dementia MoCA: Anatomical and Pathologic correlations to tests of cognitive function Diffuse Cerebral Cortex involvement: Seen in Delirium, aphasia Tests of Attention (Digit Span, Sentence Repetition) Frontal-Subcortical involvement: Seen in anxiety, depression, VaD, AD, LBC, FTD Tests of Concentration and Executive Function (Trails, Cube, Clock, Letter tapping, Serial 7s, Word list generation, Similarities, Memory list) Temporal / Papez Circuit (hippocampus, fornix, mammilary bodies, thalamus) involvement: Seen in anxiety, depression, VaD, AD, LBD, FTD Tests of Memory (Memory list, Orientation) Right Parietal Involvement: Seen in AD, VaD, LBD Tests of Spatial Function (Clock, Cube) Sylvian Valley involvement: Seen in AD, LBD, FTD, VaD, PPA Tests of Language and Calculation (Naming, Word list Generation, Serial 7s, Sentence repetition)

6 Alternate Versions and Alternate Languages available.Approx 5-10 minutes to administer Score of 26 or above is considered normal Roughly: MCI 20-25 Dementia <20

7 MoCA: Scoring and Tips Out of 30; add additional point if < 12 years of education. Cube and Similarities: often failed if less education Attention, Digit Span: usually preserved in mild AD. Memory: Not usually improved with cuing in AD Can improve with cuing in those with anxiety, depression, or frontal subcortical vascular disease

8 Mini-Cog Three Word Registration (no score)Clock Drawing 0 or 2 points (N or not) Three Word Recall 0-3 points _____________________ Total points Cut-off: <3 for dementia screening

9 Mini-Cog Validation study showed the Mini-Cog to have comparable psychometric properties to the MMSE with a sensitivity of 76% (versus 79%) and a specificity of 89% (versus 88%) for dementia (Borson et al., 2003). The Mini-Cog was found to be equal or better than the MMSE in detecting dementia in multi-ethnic elderly individuals, easier to administer to non-English speakers, and was less biased by low education and literacy (Borson et al., 2005)

10 Functional Assessment Staging of Alzheimer’s Disease (FAST)The FAST scale is a functional scale designed to evaluate patients at the more moderate-severe stages of dementia when the MMSE no longer can reflect changes in a meaningful clinical way. In the early stages the patient may be able to participate in the FAST administration but usually the information should be collected from a caregiver.

11 The FAST scale has seven stages:1 normal adult 2 normal older adult 3 early dementia 4 mild dementia 5 moderate dementia 6 (a-e) moderately severe dementia 7 (a-e) severe dementia

12 Five Times Sit to Stand TestPerformance measure of functional mobility and strength of the lower extremities. An individual is asked to rise from sitting to standing with arms crossed and repeat 5x. Timing begins at GO and ends when the buttocks touch the seat at the last repetition. Practice trial may be given (or demonstrated if you feel the patient may be too fatigued to practice first).

13 Five Times Sit to Stand Test in Community Dwelling ElderlyTest is timed and score is ZERO if patient cannot complete. For community-dwelling elderly, cut off of > sec to identify need for further assessment of falls risk. https://www.youtube.com/watch?v=4N4PhZlyYGM Estimate value for normal performance: 60-69 y/o = 11.4 sec 70-79 y/o = 12.6 sec 80-89 y/o = 14.8 sec (Tiedemann, 2008; n = 362 older community-dwelling people aged years, Community-Dwelling Elderly) Initial screening tool-cut off score of greater than or equal to 12 seconds to identify need of further assessment for fall risk. (Buatois, 2010; n = 1,618 community-dwelling people over 65 years of age, Community-Dwelling Elderly) To assess risk of recurrent falls-cut off score of > 15 seconds, especially in moderate risk category (Mong, 2010, Community-Dwelling Elderly) To discriminate between healthy elderly and those with chronic stroke, cut off score of 12 seconds (Bohannon, 2006; individuals greater than 60 years of age, Community-Dwelling Elderly) Estimate values for normal performance in community dwelling older adults 60-69 years: 11.4 sec (mean time) 70-79 years: 12.6 sec 80-89 years: 14.8 sec Falls Risk: Geriatrics: > 12 seconds for further assessment; > 15 seconds increased risk of recurrent falls Vestibular Disorders: Fall risk if > 15 sec Parkinson’s Ds: Fall risk if >16 sec

14 Frailty in Seniors Frail elderly are often NOT included in research trials. Older adults who are frail have limited global physiologic reserve and are not able to withstand stressors. They are associated with increased susceptibility to disability and poor health care outcomes. Frailty is easier to recognize than define.

16 Frailty Index Considers the cumulative effect of multiple factors indicating physical and cognitive decline Predicts survival, risk of disease progression, need for institutionalization and use of healthcare services. As we age, we begin to accumulate deficits. Those with less deficits are more fit; those with more deficits are more frail. Minimum 30 items which cover a range of health indicators, including chronic conditions, physical/cognitive limitations, and general health.

17 Frailty Index FI is the Ratio of Number of Deficits present / Total Possible Deficits looked at. Expressed as a 0 (lowest) to 1 (highest level of frailty) score No universally agreed upon scoring. Generally: 0 – 0.08 = Non-frail 0.09 – 0.24 = Pre-frail 0.25 or higher = Frail Those with FI of > 0.5 have near 100% mortality at 20 months (useful for end of life discussions). FI >0.7 usually not compatible with living. Song X, Mitnitski A, Rockwood K. Prevalence and 10-year outcomes of frailty in older adults in relation to deficit accumulation. Journal of the American Geriatrics Society 2010; 58(4): = Non frail 0.25 or higher = frail

18 Frailty Index with Age (years)Upper line = institutionalized persons Lower line = community dwelling persons

19 Frailty Index and MortalityTop = Male Bottom = Female Frailty is more lethal for men than women

20 Clinical Frailty Scale - K. RockwoodAssessor makes judgment about degree of frailty based on clinical assessment. 9 point ordinal scale. Health care professional utilizes information from history and physical exam about: Cognition Mobility Function Comorbidities

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22 Back to the cases… Mr. Slip: 79 y/o male lives alone in 3rd floorcondo comes in with complaints of feeling ‘fuzzy headed’ and having fallen outside while gardening at his son’s.

23 Medical/Surgical HistoryDegenerative disc disease, facet OA and chronic back discomfort Mild lumbar spinal stenosis and vertebral fractures on CT spine 1 year ago Benign Prostatic Hypertrophy Mild COPD Hyperlipidemia Right THR for fracture after falling off a stepladder 3 y/a Remote appendectomy, tonsillectomy and bilateral cataract surgeries

24 Social/Functional HistoryxSmoker, min ETOH Widow; daughter in California, son local (teacher) who sees him weekly Retired salesman; grade 11 education Drives and manages all ADL, IADLs. Walks a bit; previously golfed regularly and volunteered at Rotary but this has decreased Recently purchased a cane No formal supports but son encouraging him to get a housecleaner

25 Medications Atorvastatin 20mg daily Terazocin 5mg dailyGabapentin 300mg hs ES Tylenol Back Pain BID prn Advil 200mg prn Ventolin inhaler prn OTC sleeping medication prn

26 Physical Exam Alert, oriented, normal speech and affect5’5”/165cm (3”reported ht loss); 65kg/143lb (BMI 24) BP 120/70 seated, 95/55 standing, HR 80 Normal heart sounds, chest clear, abdo benign Pitting edema to ankles bilaterally Dorsal kyphosis, mild quad weakness, mild decreased knee and ankle jerks, possible decreased sensation to feet No focal neurologic findings Difficulty rising from a chair, slow gait (furniture surfs)

27 Investigations Labs: normal CBC, electrolytes, eGFR 60Total cholesterol 3.21, LDL 1.05, HDL 1.76, C/HDL ratio 1.82, Triglycerides 0.87

28 Tools completed MoCA: 25/30 5x sit to stand: 17 seconds FAST: stage 2Clinical Frailty Scale: 4 Completed CGA

29 The Comprehensive Geriatric Assessment (CGA) formsWhat are the issues? What can be done about them? Who is going to do it?

30 The Problem List

31 The Problem List Falls Pain Osteoporosis Edema Med reviewFuture planning

32 The Patient’s Goals Improve balance and strengthBe able to do the stairs if the elevator is out Manage pain Feel up to volunteering at the Rotary club and golfing again Feel more in control of my health Stay independent

33 Case 2: Ms. Muddled 83 y/o lady lives alone in atownhome. Family concerned re forgetfulness and weight loss. They note they are supporting her more and that she is increasingly socially isolated.

34 Medical/Surgical HistoryHypertension Diet controlled type II Diabetes Mellitus Hypothyroidism GERD Remote Peptic Ulcer; H pylori treated Childhood left ankle fracture Few Basal Cell carcinomas removed from face/neck

35 Social/Functional HistoryLives alone in townhome with her cat Grade 12 education plus 1 year university courses Worked as a bank teller Divorced (since widowed) 2 daughters nearby who see her most days. Independent with ADLs, doing less laundry, eating more pre-prepared meals or daughters bring in, late on bill payments and less organized. No formal supports. Non-smoker; no alcohol

36 Medications Ramipril 5mg po BID Hydrochlorothiazide 25mg po dailyAmlodipine 10mg po daily Levothyroxine 100mcg po daily Pantoprazole 40mg po daily Multivitamin daily

37 Physical Exam Thin, decreased muscle bulk, bit disheveledOccasional word finding problems, bit repetitive, off on timing of events, pleasant, affect good. 5’8”/173cm; 55kg/121lb (reported 25lb wt loss); BMI 18.5 BP 180/90seated, 175/90standing; HR 60 Dry skin, mild peripheral edema, normal pedal pulses Chest clear, Heart sounds normal Abdomen scaphoid but nil acute Reflexes sluggish, generally slowed down No other focal neurologic findings Mild diffusely enlarged thyroid Gait, cautious and slowed but steady without aids.

38 Investigations Normal electrolytes, CBC, liver enzymes, calciumeGFR 50, Albumin 28, B12 209 HbA1c 7.6%, Fasting glucose 8 TSH 10.5 ( ) , fT4 5 (8-15)

39 Tools completed MoCA: 14/30 Mini-Cog: 1 5x sit to stand: 15 secFAST: stage 4 Clinical Frailty Scale: 5 Completed CGA

40 The Comprehensive Geriatric Assessment (CGA) formsWhat are the issues? What can be done about them? Who is going to do it?

41 The Problem List

42 The Problem List Medication Compliance CognitionWeight loss/poor nutrition Hypothyroidism Diabetes Edema Socialization Future planning Caregiver stress

43 The Patient’s Goals Stay at home Maintain independenceNot be a burden on the children Not feel so lonely

44 Dementia “progressive, irreversible brain disease leading to a decline in memory and other cognitive functions sufficient to impact activities of daily living” Estimated 70,000 persons in BC have dementia; 60% female Approx 5% of people between the ages of 65–74 have dementia; 47% of people over the age of 85 have some form of dementia. BC Guidelines for Cognitive Impairment: Recognition, Diagnosis and Management in Primary Care (Jn 2016; Doctors of BC and Ministry of Health):

45 Dementia Diagnosis Alzheimer’s Disease:Impairment in 2 or more cognitive domains: Language, memory, visuospatial, executive function, behavior Impairment causes a significant functional decline in usual activities or work Impairment is not better explained by delirium or other major psychiatric disease Alzheimer’s Disease: Diagnosis as above Most common form of dementia alone or mixed Most common domain affected early is memory loss Symptoms not explained by other neurologic (eg CVA) or medical disorder Gradual progressive change (months to years)

46 Mild Cognitive ImpairmentWhen the person exhibits cognitive decline but doesn’t meet criteria for dementia due to either: 2nd cognitive deficit is lacking OR Doesn’t significantly affect usual activities or work Higher than average risk of progressing to dementia (12% per year) than the general population (2% per year)

47 Vascular Dementia (VaD)A heterogeneous group with a number of different diagnostic criteria Can be due to a clinically overt stroke, large or small vessel disease and both cortical and subcortical Small vessel disease often accompanies AD Neuroimaging is helpful in supporting the diagnosis Early impact on executive dysfunction and speed of cognitive processing, with memory loss often a later feature.

48 Dementia with Lewy Bodies (DLB)Core features: Fluctuating cognition with pronounced variation in attention and alertness Recurrent visual hallucinations (well formed/detailed) Spontaneous motor features of Parkinsonism (Dementia precedes Parkinsonism) Supportive features: Repeated falls Syncope or transient loss of consciousness Hypersensitivity to antipsychotics Systematized delusions; non-visual hallucinations Usually lacks response to Levodopa Often has REM sleep disorder

49 Frontotemporal DementiaA group of dementias: behavioural variant Personality changes, apathy, disinhibition, executive function problems Decline in hygiene, mental rigidity, distractibility, hyper-orality, perseveration progressive aphasias: (prominent language changes with reduction in verbal output) progressive non-fluent aphasia semantic dementia Logopenic progressive aphasia. Occur most often in middle aged persons Memory, perception and spatial skills often remain intact

50 Parkinson’s Dementia Similar to DLBParkinson’s motor features precede cognitive change by years BC Guidelines information on Dementia types:

51 Dementia evaluation Rule out contributors to cognitive declineMedications, Alcohol, Drugs Metabolic or medical illness Eg. Depression, Delirium, Renal or hepatic failure abnormalities in labs: TSH, Calcium, electrolytes, CBC, B12, blood glucose Ask about function (ADL, IADL) Get Collateral Physical with emphasis on neurologic exam MMSE, MoCA

52 MoCA vs MMSE: where to startThe average MoCA score for MCI is 22 (range 19-25) and the average MoCA score for Mild AD 16 (range 11-21).

53 Should I do a CT scan? Recommended indications for head CT scan:Age <60 y/o Onset is abrupt or progress rapid History of recent head injury Atypical presentation/uncertain diagnosis Cancer history (esp breast, lung) New localizing neurologic signs/symptoms Suspect cerebrovascular disease On anticoagulants or has a bleeding disorder Combination of early cognitive impairment with urinary incontinence and gait disorder (r/o NPH)

54 General Care and Supportive Management of DementiaFocus on Brain Health Body Maintenance Exercise (aerobic and resistance) Protect your brain (helmets, drugs, meds) Sleep Vascular risks (smoking, BP, Cholesterol, blood sugar) Proper nutrition Whole foods (not processed), foods rich in antioxidants, fish Don’t overindulge on alcohol Mind Brain stimulation, try something new Mood management Spirit Stay socially active

55 General Care and Supportive Management of DementiaSafety: Living alone Stove use Medication management Risk of getting lost Driving Self neglect, Neglect, Abuse Caregiver Stress & Education Future planning: Will Power of Attorney Representation Agreement Advanced Directives Living Situation

56 AcetylCholinesterase Inhibitors (AChE I)Donepezil (Aricept) – mild-severe dementia Rivastigmine (Exelon), Galantamine (Reminyl) Mild-moderate dementia Non-curative, symptomatic treatment Modest ability to stabilize and slow progression of dementia (AD, VaD, LBD, PD) No benefit in MCI Side-effects: primarily GI, dizziness, nightmares Side-effects often resolve with use

57 AcetylCholinesterase Inhibitors (AChE I)Relative Contraindications Cardiac conduction abnormalities (other than RBBB) Recent GI Bleed or increased risk of GI Bleed Severe COPD/asthma or Cardiac disease eGFR <30 or severe liver disease Seizure disorder Trouble with urinary retention Low weight

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59 NMDA Receptor AntagonistMemantine (Ebixa) Moderate to severe Dementia Not curative, symptomatic treatment Used alone in those intolerant to AChE I Most effective when combined with AChE I Side-effects: less common; fatigue, dizziness, HTN, GI, sleep disturbance

60 NMDA Receptor AntagonistRelative contraindications: Severe heart or lung disease Seizure disorder End stage renal disease or hepatic disease BC Guidelines on Comprehensive Pharmacotherapy Information for Acetylcholinesterase Inhibitors and Memantine:

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62 Dementia Referrals Alzheimer’s Society; First LinkHome Health / Allied Health Personal Care help Respite, Adult Day programs Caregiver support Home evaluation for safety Transition to alternate living situations Specialist (Geriatrics, Neurology, Psychiatry) Diagnostic uncertainty Rapid decline Young age Management issues

63 Reasons to refer to Geriatric Medicine (Specialized Seniors Clinics)Memory /Cognitive Changes Behavioural changes Falls Changes in function (ADL/IADL) Complex Medical issues Frailty or “Failure to Thrive” Polypharmacy Other issues: incontinence, bone health, Parkinsons…