Frailty, Comorbidity, & Geriatric Assessment

Components of Mental status assessment

- Alertness/ LOC - Attention - Comprehension - Construction - Emotional Status - Higher memory function

Montreal Cognitive Assessment (MoCA) Domains that are assessed

1. Attention/Concentration 2. Executive functions 3. Memory 4. Language 5. Conceptual thinking/ Abstraction 6. Calculations 7. Orientation

Mini Mental State Exam (MMSE) Score

25-30 = normal 18-24 = mild to moderate impairment <18 = severe impairment

MINI-COG

3-minute instrument that can increase detection of cognitive impairment in older adults. Consists of 2 components: a 3 item recall test a simply scored clock drawing test NOT DX test for disease

Braden Scale Scoring

<9 = severe risk 10-12 = high risk 13-14 = moderate risk 15-18 = mild risk 19-23 = no risk

Timed Up & Go (TUG) Scoring

>/= 12 secs high fall Risk

Katz ADL scoring

A score of 6 indicates full function, 4 indicates moderate impairment, and 2 or less indicates severe functional impairment.

Montreal Cognitive Assessment (MoCA)

Allows for early detection that leads to finding the root cause of an illness, which improves a patient's QOL by being diagnosed faster and better treatment plans Useful for Alzheimer's disease, Parkinson's disease, Huntington's disease, Lewy Body, VCI/ stroke, frontotemporal dementia, etc.

Timed Up & Go (TUG)

Assess: Fall risk, balance, and gait Patients are instructed to stand up from a chair, move 3 meters or 10 feet away (marked line or tape on floor) at a normal pace, and walk back to the chair. Total time is recorded.

MINI-COG scoring

Can score between 0-5 points 0-2: POSITIVE for dementia 3-5: NEGATIVE

CAM Scoring

Dx of delirium by CAM requires the presence of *BOTH* features A & B A) *Acute onset & fluctuating course* B) *Inattention* AND the presence of *EITHER* feature C or D C) Disorganized thinking D) altered LOC

Mini Mental State Exam (MMSE)

Gold standard assessment screening tool that is thoroughly assess mental status - used to help screen for dementia and other cognitive disabilities; assists with staging dementia and its progression; tests different mental abilities, including memory, attention and language

Clinical manifestations of frailty

Include 3 or more · Unintentional weight loss · Self-reported exhaustion · Weakness-diminished handgrip strength · Slow walking speed · Low level of physical activity

IADL

Instrumental activities of daily living complex skills needed for independent living, such as shopping, cooking, housework, using the telephone, managing medications and finances, and being able to travel by car or public transportation

Morse Fall Scale (MFS) Scoring

Low risk = 25-50 Highest risk = >51

Lawton IADLs Scoring

Minimum - 0; Maximum - 5 (women) 8 (men)

Hendrich II Fall Risk Tool Scoring

Minimum score = 0 - no loss of balance while walking - nothing impeding their ability to stand or walk alone Maximum score = 16 - pt is confused, disoriented, or impulsive, has sx depression, altered eliminated patterns, some form of dizziness and/or vertigo

SPICES Assessment Tool Scoring

No quantitative scoring; rather, areas that are flagged as "yes" trigger the need for further assessment and preventative measures

Frailty:

Progressive physiological decline, often accompanied by chronic disease a multisystem progressive decline that increases vulnerability to poor health effects.

SPICES Assessment Tool

S=Sleep Disorders P=Problems Eating or Feeding I=Incontinence C=Confusion E=Evidence of falls S=Skin breakdown

Frailty Index for Elders (FIFE) Scoring

Scoring: FIFE is a 10-item assessment instrument with scores ranging from 0-10. o 0 -> no frailty o 1-3 -> frailty risk o ≥ 4 -> frailty.

MAHC 10 Fall Risk assessment Scoring

Scoring: fall risk with a score of 4 or more out of a 10

Hendrich II Fall Risk Tool

Screens for fall risk and is integral in a *post-fall assessment for the secondary prevention of falls.* It provides a determination of risk for falling based on gender, mental and emotional status, symptoms of dizziness, and known categories of medications increasing risk for falls

The Falls Efficacy Scale-International (FES-I) Scoring

The level of concern is measured on a four-point Likert scale (1=not at all concerned to 4=very concerned) Minimum = 16 Maximum = 64

MAHC 10 Fall Risk assessment

To determine fall risk for Home Care Nursing assessment use

Patient Health Questionnaire-9 (PHQ-9)

To screen, dx, and monitor severity of depression over time for newly/currently dx pts w/ depression must be verified by the clinician Min score = 1-4 Max score = 20-27

Braden Scale

a tool used to identify patients at-risk for pressure injuries determined by several categories including sensory perception, moisture, activity, mobility, nutrition, and friction and shear

ADL

activities of daily living - bathing, - dressing - grooming - eating - toileting - Transferring

Comprehensive Geriatric Assessment

an interdisciplinary approach to the evaluation of older person's physical and psychosocial impairments and their functional disabilities - ADL - IADL

Katz ADL

assesses functional status as a measurement of the client's ability to perform activities of daily living independently. o The Index ranks adequacy of performance in the six functions of bathing, dressing, toileting, transferring, continence, and feeding.

Lawton IADLs

assesses independent living skills that is considered more complex than the basic ADLs

Morse Fall Scale (MFS)

consists of 6 variables to assess risk for patients fall 1. history of falls 2. Secondary diagnosis 3. Ambulatory aid 4. IV/Heparin lock 5. Gait/transferring 6. Mental status

Frailty Index for Elders (FIFE)

developed to assess for frailty risk in older adults using items collected in existing nursing datasets. This maximizes the use of data collected during nursing assessment and reduces testing fatigue for the patient, family, and nurse.

The Falls Efficacy Scale-International (FES-I)

measures the level of concern about falling during 16 social and physical activities inside and outside the home whether or not the person actually does the activity; *assesses a patient's fear of falling*

Hearing Handicap Inventory for the Elderly Screening: (HHIE-S) Scoring

ranges from 0-40. The higher the score, the higher the probability of hearing impairment. o 0-8 a normal hearing test. o 10+ indicate hearing handicap and a referral to a hearing specialist must be given.

The Geriatric Depression Scale -Short Form: (GDS SF) scoring

score one point for each one selected; a score *greater than 5 suggests depression.* Max range = 12-15 (severe depression) Min range = 0-4 (normal)

Impaired mobility

shown to be an early predictor of physical disability, associated with *falls, loss of independence, institutionalization, and death*

Confusion Assessment Method (CAM)

standardized evidence-based tool that enables non-psychiatrically trained clinicians to identify and recognize delirium

The Geriatric Depression Scale -Short Form: (GDS SF)

to screen depression in healthy, medically ill and mild to moderately cognitively impaired geriatrics Short form: 15 question screening tool in a Y/N format

Hearing Handicap Inventory for the Elderly Screening: (HHIE-S)

tool used to assess an individual's emotional and social responses to hearing loss. cannot measure the amount of hearing sensitivity loss as detected by an audiometric test

Risk factors for frail older persons

• Dependency • Institutionalization • Falls • Injuries • Hospitalization • Slow recovery from illness • Increased risk of mortality