Geriatric Assessment

Geriatric Assessment: Fall Risk

-Hendrich II Fall Risk Assessment - Morse Fall Scale (MFS)

Geriatric Assessment: Physical Function

-Katz Index of Activities of Daily Living - Lawton Instrumental Activities of Daily Living (IADL) Scale - Pressure Ulcer Risk Assessment: Braden Scale

Geriatric Assessment

An interprofessional approach for evaluating the physical and psychosocial impairments and functional disabilities of older adults

Pain Assessment Tools Including the Faces of Pain Scale

Assessment of pain includes: • Location • Characteristics • Onset • Duration • Frequency • Quality • Intensity • Precipitating and aggravating factors

SPICES

Framework for targeted assessment for an older adult -Addresses common syndromes of older adults that require nursing assessment and intervention -Used for change of shift handoff, interprofessional rounds, etc S: Sleep P: Problems with Eating/Feeding I: Incontinece C: Confusion E: Evidence of Falls S: Skin Breakdown

GDS

The short form includes 15 questions and measures depression in the older adult. A score >5 for the responses in bold is suggestive of depression and indicates the need for further screening.

Cognitive Function

• Assessment of cognition is vital to the comprehensive assessment of older adults • Knowing a patient's baseline cognitive function is important as the first sign of illness among older adults is often an acute change in mental status

Conduct a Baseline Pain Assessment

• Baseline vital signs • Ability to walk, stand, or move about in bed • Baseline agitation level • Appetite and eating patterns • Sleep patterns • Elimination habits • Cognitive function and mood • Use of medications and other interventions and responses

Assessment for Cognitively or Verbally Impaired Patients

• Do more frequent assessments • Obtain baseline information from a family member Look for nonverbal signs of pain: • Grimacing, moaning, tearfulness, and/or fidgeting • Guarded movements • Bracing, tense body language • Sad, frightened facial expressions • Wandering and/or delusions • Repetitive verbalization • Noisy breathing • Tense body language • Repeated nighttime awakenings • Hallucinations • Perseverant verbalizations or verbal outbursts

Geriatric Depression Scale (GDS) Short Form

• Overview: 15 questions used to screen for depression ("long form" has 30 questions) - Has been used in all care settings - Yes/No responses • Administration Time: Administered in 5-10 minutes • Assessment: Screens for depression. Recommended as a routine part of a comprehensive geriatric assessment • Scoring: 0-4 No cause for concern 5-8 Mild depression 9-11 Moderate depression 12-15 Severe depression

Morse Fall Scale (MFS)

• Overview: A rapid and simple method of assessing a patient's likelihood of falling. The MFS is used widely in acute care settings • Administration Time: Administered in 5 Minutes • Assessment: Areas of fall risk that are assessed with MFS: - History of falling - Secondary diagnosis - Ambulatory aid - IV therapy/heparin (saline) lock - Gait - Mental status • Scoring: No risk 0-24; Low risk 25-50; High Risk >51

Montreal Cognitive Assessment (MOCA) Cognition Assessment tool

• Overview: A rapid screening instrument for mild cognitive dysfunction • Administration Time: Time to administer the MOCA is approximately 10 minutes • Assessment: It assesses different cognitive domains: attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation. • Scoring: There are 11 sections of the assessment, with a total of 30 possible points • Administration Issues: Animal naming-often older adults have trouble naming the animal, especially if English is not their primary language

Lawton Instrumental Activities of Daily Living (IADL) Scale Physical Function

• Overview: An easy to administer assessment instrument that provides self-reported information about functional skills necessary to live in the community. Specific deficits identified can assist nurses and other disciplines in planning for safe discharge • Administration Time: Administered in 10-15 minutes • Assessment: Assesses independent living skills; skills are considered more complex than the basic activities of daily living • There are eight domains of function measured with the Lawton IADL scale. Women are scored on all eight areas of function; men, the areas of food preparation, housekeeping, laundering are excluded. • Most useful for identifying how a person is functioning at the present time, and to identify improvement or deterioration over time. • Scoring: Clients are scored according to their highest level of functioning in that category. A summary score ranges from 0 (low function, dependent) to 8 (high function, independent) for women, and 0 through 5 for men. • Administration Issues: Self-report or surrogate report method of administration rather than a demonstration of the functional task. • Self report can lead either to over-estimation or under-estimation of ability • Test may not be sensitive to small, incremental changes in function

Pressure Ulcer Risk Assessment: Braden Scale Physical Function

• Overview: Scale measures the following: - Sensory perception - Moisture - Activity - Mobility - Nutrition - Friction and shear • Administration Time: Administered in 10 minutes • Assessment: If a patient has major risk factors such as fever, diastolic pressure below 60, hemodynamic instability, advanced age, then move them to the next level of risk. • Assess all patients at time of admission • Reassessments (individualized and based on risk): - Acute care: Every 48 hours - Long term care: Weekly for first four weeks, then quarterly - Home care: Every RN visit • Scoring: Scale assigns an item score ranging from one (highly impaired) to three/four (no impairment). • Summing risk items yields a total overall risk, ranging from 6-23. Scores 15 to 18 indicate at risk, 13 to 14 indicate moderate risk, 10 to 12 indicate high risk, ≤ 9 indicate very high risk

Delirium Screening Tool: Confusion Assessment Method (CAM)

• Overview: The CAM provides initial and ongoing screening of older patients for signs and symptoms of delirium • Administration Time: The tool can be administered in less than 5 minutes • Assessment: Two part tool/ Part I: Assessment instrument that screens for overall cognitive impairment. Part II: Includes four features that were found to have the greatest ability to distinguish delirium from other types of cognitive impairment • Scoring: The diagnosis of delirium by CAM requires the presence of features 1 and 2 and either 3 or 4

Hendrich II Fall Risk Assessment

• Overview: The Hendrich II Fall Risk Model is intended to be used in the acute care setting to identify adults at risk for falls. • The major strengths of the Hendrich II Fall Risk Model - its brevity - the inclusion of "risky" medication categories - focus on interventions for specific areas of risk rather than on a single, summed general risk score • Administration Time: Administered in 5-10 minutes • Assessment: Focuses on eight independent risk factors: confusion, disorientation, and impulsivity; symptomatic depression; altered elimination; dizziness or vertigo; male sex; administration of antiepileptics (or changes in dosage or cessation); administration of benzodiazepines; and poor performance in rising from a seated position in the Get-Up-and-Go test • Scoring: A score of 5 or greater = high risk

Folstein Mini Mental Status Exam (MMSE) Cognitive Assessment Tool

• Overview: The mini-mental state examination (MMSE) or Folstein test is a sensitive, valid and reliable 30-point questionnaire that is used to measure cognitive impairment • Administration Time: Administration of the test takes between 5-10 minutes and examines functions including registration, attention and calculation, recall, language, ability to follow simple commands and orientation. • Assessment: Used for detecting cognitive impairment, assessing severity, and monitoring cognitive changes over time • Scoring: Scores range from 0-30 Scores of 25 or higher being traditionally considered normal Scores less than 10 generally indicate severe impairment Scores between 10 and 19 indicate moderate dementia • Administration Issues: May get false elevations or inaccurate low scores due to level of education and cultural influence - Need to be sure to administer to patient by him/herself without family present - Used extensively in a variety of care settings across the continuum - It can be cumbersome of administer to older adult who is ill-time consuming

Katz Index of Activities of Daily Living Physical Function

• Overview: Use to assess a patient's ability to perform activities of daily living in the areas of bathing, dressing, toileting, transferring, continence, and feeding • Administration Time: Administered in 10 minutes • Assessment: Six item, clinician administered instrument which measures adequacy of performance in six functions: Eating, dressing toileting, transferring, bathing, and continence. -- Test-retest reliability ranges from .95-.98 -- Despite widespread usage in a variety of settings, no documented validity • Scoring: Scoring: Independent = 1 point, dependent = 0 points Total score - 6 = full function - 4 = moderate impairment - 0 = severe impairment • Administration Issues: Advantages - Easy to use - Quick - Easy to understand - Widely used in a wide variety of clinical settings - Easy to adapt into electronic charting pathways

Mini-Cog Cognition Assessment tool

• Overview: Used to differentiate between individuals with dementia and those without • Administration Time: Takes about three to five minutes to administer • Assessment: The min-cog is a two part test of executive function (the ability to plan, manage time, organize activities, and manage working memory) which is impaired in mild cognitive impairment or dementia • Scoring: Three item recall and clock drawing test (The mini-Cog test cognition, using three-item recall and clock-drawing test. It takes about 3 minutes to administer and it is not affected by language, education, or culture. The tool is to differentiate those with dementia and those without)

Geriatric Assessment: Pain

• Subjectively according to the patient's self-report and through careful observation. • Asking questions like: Where is it? What is it like? Does it spread? What makes it worse? What improves it? Does it come and go? Which drugs have you tried? What is the interval between doses? Please rate the severity of the pain from 0 to 10 with 0 being no pain and 10 being the worst pain you have ever had. Gauging responses like: "Aches all the time" "Worse when I move" "Burning, stabbing" "Worse when I breathe."

Inappropriate Medication Use Tests

• The American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults • AIMS: Abnormal Involuntary Movement Scale