Utilization of the Assessment tools:
Translating numbers and data into ACTION
Dr. Pamela Thornton
Geriatrician
November, 2016
A couple cases to keep in mind
Case 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.
Community
Comprehensive
Geriatric
Assessment
Form
All information is
important to the senior
and their health.
Only useful if used to
make positive change
for the patient!
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
Montreal Cognitive Assessment
(MoCA)
 Screening test for abnormal cognition (MCI, early
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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
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
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
Mini-Cog
 Three Word Registration
 Clock Drawing
 Three Word Recall
(no score)
0 or 2 points (N or not)
0-3 points
_____________________
Total
0-5 points
Cut-off: <3 for dementia screening
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)
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.
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
Five Times Sit to Stand Test
 Performance 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).
Five Times Sit to Stand Test in
Community Dwelling Elderly
 Test is timed and score is ZERO if patient cannot
complete.
 For community-dwelling elderly, cut off of > 12-15 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
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.
Is this Frailty?
By age…
By functional status…
By social vulnerability…
By medical condition…
By comorbidity or medications…
Frailty Index
 Considers the cumulative effect of multiple factors
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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.
Frailty Index
 FI is the Ratio of Number of Deficits present / Total
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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.
Frailty Index with Age (years)
Frailty Index and Mortality
Clinical Frailty Scale - K. Rockwood
 Assessor 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
Back to the cases…
 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.
Medical/Surgical History
 Degenerative disc disease, facet OA and chronic back
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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
Social/Functional History
 xSmoker, min ETOH
 Widow; daughter in California, son local (teacher)
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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
Medications
 Atorvastatin 20mg daily
 Terazocin 5mg daily
 Gabapentin 300mg hs
 ES Tylenol Back Pain BID prn
 Advil 200mg prn
 Ventolin inhaler prn
 OTC sleeping medication prn
Physical Exam
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Alert, oriented, normal speech and affect
5’5”/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)
Investigations
 Labs:
 normal CBC, electrolytes, eGFR 60
 Total cholesterol 3.21, LDL 1.05, HDL 1.76, C/HDL ratio
1.82, Triglycerides 0.87
Tools completed
 MoCA: 25/30
 5x sit to stand: 17 seconds
 FAST: stage 2
 Clinical Frailty Scale: 4
 Completed CGA
The Comprehensive Geriatric
Assessment (CGA) forms
 What are the issues?
 What can be done about them?
 Who is going to do it?
The Problem List
The Problem List
 Falls
 Pain
 Osteoporosis
 Edema
 Med review
 Future planning
The Patient’s Goals
 Improve balance and strength
 Be 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
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.
Medical/Surgical History
 Hypertension
 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
Social/Functional History
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Lives 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
Medications
 Ramipril 5mg po BID
 Hydrochlorothiazide 25mg po daily
 Amlodipine 10mg po daily
 Levothyroxine 100mcg po daily
 Pantoprazole 40mg po daily
 Multivitamin daily
Physical Exam
 Thin, decreased muscle bulk, bit disheveled
 Occasional word finding problems, bit repetitive, off on
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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.
Investigations
 Normal electrolytes, CBC, liver enzymes, calcium
 eGFR 50, Albumin 28, B12 209
 HbA1c 7.6%, Fasting glucose 8
 TSH 10.5 (0.3-5.5) , fT4 5 (8-15)
Tools completed
 MoCA: 14/30
 Mini-Cog: 1
 5x sit to stand: 15 sec
 FAST: stage 4
 Clinical Frailty Scale: 5
 Completed CGA
The Comprehensive Geriatric Assessment
(CGA) forms
 What are the issues?
 What can be done about them?
 Who is going to do it?
The Problem List
The Problem List
 Medication Compliance
 Cognition
 Weight loss/poor nutrition
 Hypothyroidism
 Diabetes
 Edema
 Socialization
 Future planning
 Caregiver stress
The Patient’s Goals
 Stay at home
 Maintain independence
 Not be a burden on the children
 Not feel so lonely
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):
http://www2.gov.bc.ca/gov/content/health/practitionerprofessional-resources/bc-guidelines/cognitive-impairment
Dementia Diagnosis
 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)
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Mild Cognitive Impairment
 When 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)
Vascular Dementia (VaD)
 A heterogeneous group with a number of different
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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.
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
Frontotemporal Dementia
 A group of dementias:
 behavioural variant
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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.
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Occur most often in middle aged persons
Memory, perception and spatial skills often remain
intact
Parkinson’s Dementia
 Similar to DLB
 Parkinson’s motor features precede cognitive change
by years
 BC Guidelines information on Dementia types:
http://www2.gov.bc.ca/assets/gov/health/practitionerpro/bc-guidelines/cogimp-appendix-a.pdf
Dementia evaluation
 Rule out contributors to cognitive decline
 Medications, Alcohol, Drugs
 Metabolic or medical illness
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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
MoCA vs MMSE: where to start
The average MoCA score for MCI
is 22 (range 19-25) and the
average MoCA score for Mild AD
16 (range 11-21).
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)
General Care and Supportive
Management of Dementia
 Focus on Brain Health
 Body Maintenance
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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
General Care and Supportive Management
of Dementia
 Safety:
 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
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
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
NMDA Receptor Antagonist
 Memantine (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
NMDA Receptor Antagonist
 Relative 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:
http://www2.gov.bc.ca/assets/gov/health/practitionerpro/bc-guidelines/cogimp-appendix-e.pdf
Dementia Referrals
 Alzheimer’s Society; First Link
 Home 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
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…