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CHAMPCHAMP

Improving Hospital Systems of Care:Improving Hospital Systems of Care: Making the Case for Identifying and Making the Case for Identifying and

Assessing the Frail ElderlyAssessing the Frail Elderly

Paula Podrazik, MDPaula Podrazik, MDUniversity of ChicagoUniversity of Chicago

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New AdmissionNew Admission

Mrs.G 80 y/o BF DM type II, htn, s/p CVA, OA, OPMrs.G 80 y/o BF DM type II, htn, s/p CVA, OA, OPadmitted for wt. loss, confusion, falls. Recentlyadmitted for wt. loss, confusion, falls. Recentlyhospitalized at an outside institution.hospitalized at an outside institution.Meds: glipizide, lisinopril, lasix, asa, celebrex, fosamax qMeds: glipizide, lisinopril, lasix, asa, celebrex, fosamax qweekweekExam: Unkempt. A, O x 2 VS Afebrile BP 178/87 P 84Exam: Unkempt. A, O x 2 VS Afebrile BP 178/87 P 84RR 16 Lungs clear, Cor RRR, Neuro non-focalRR 16 Lungs clear, Cor RRR, Neuro non-focalER evaluation—unremarkable blood work, CT head—ER evaluation—unremarkable blood work, CT head—no bleedno bleedIntern reports patient is at baseline per daughter andIntern reports patient is at baseline per daughter andcomments patient is just a “FTT.”comments patient is just a “FTT.”

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Questions raised:Questions raised:

How do you recognize frailty ?How do you recognize frailty ?How do you define frailty?How do you define frailty?What is the importance of identifying What is the importance of identifying

frailty in the hospital setting?frailty in the hospital setting?What do you need to screen in the What do you need to screen in the

suspected frail patient during suspected frail patient during hospitalization? hospitalization?

Can you prevent hospitalization-Can you prevent hospitalization-associated decline?associated decline?

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Overview: Overview: Inpatient Setting Important for the Inpatient Setting Important for the ElderlyElderly

• Crucial step in the health care continuum Crucial step in the health care continuum – High rates of hospitalizationHigh rates of hospitalization

• Account for 47% of all inpatient days (but represent Account for 47% of all inpatient days (but represent only 13% of the population)only 13% of the population)

• Age 85 and over, twice hospitalization riskAge 85 and over, twice hospitalization risk

– High rates of readmissionHigh rates of readmission• 25% of hospital admissions represent readmission of 25% of hospital admissions represent readmission of

older adultsolder adults

– Cost—outcomesCost—outcomes

Fethke CC, Smith IM, Johnson N. Risk factors affecting readmission to the health care system. Medical Care. 1986;24:429-437Graves EJ, Gillum BS. National Hospital Discharge Survey: annual summary, 1994. Vital Health Stat. 1997;13:128

Iatrogenic Problems—a subset Iatrogenic Problems—a subset of Hazards of Hospitalizationof Hazards of Hospitalization

Affects nearly 1 in 3 hospitalized elderly patientsAffects nearly 1 in 3 hospitalized elderly patients

Adverse drug reactions are the most common formAdverse drug reactions are the most common form

• Other complications of hospitalization:Other complications of hospitalization:DeconditioningDeconditioningDeliriumDeliriumFallsFallsNosocomial InfectionNosocomial InfectionPressure ulcersPressure ulcersMalnutritionMalnutritionDysphagia→Aspiration PneumoniaDysphagia→Aspiration PneumoniaPolypharmacyPolypharmacy

Atypical Presentations, Atypical Presentations, Multiple CausesMultiple Causes

• Functional decline, altered mental statusFunctional decline, altered mental status

e.g., delirium or falls due to UTI or fecal impactione.g., delirium or falls due to UTI or fecal impaction• Misleading symptomsMisleading symptoms

e.g., pneumonia with normal or low temperature & e.g., pneumonia with normal or low temperature & normal or low WBC countnormal or low WBC count

• Signs of one disease obscured by anotherSigns of one disease obscured by another

e.g., Pneumonia obscured by CHFe.g., Pneumonia obscured by CHF

● ● Inability to communicateInability to communicate

e.g., new pressure ulcer obscured in patient post –e.g., new pressure ulcer obscured in patient post –CVA w/ aphasia or with dementiaCVA w/ aphasia or with dementia

● ● No presentation symptomsNo presentation symptoms

e.g., silent MI , painless acute abdomene.g., silent MI , painless acute abdomen

Determinates of Determinates of Hospitalization OutcomeHospitalization Outcome

Baseline Frailty

Acute illness

Hazards of the Hospitalization

Hospitalization Outcome

Podrazik PM, Whelan CT. Med Clin N Am 2008

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Words that trigger the need to Words that trigger the need to ID ID & teach about frailty& teach about frailty

Failure to thriveFailure to thrive Dwindles Dwindles Declining Declining A/O x 1 or 2 A/O x 1 or 2 Confused Confused Poor historianPoor historianMalodorousMalodorousRecent dischargeRecent discharge UnkemptUnkemptNursing homeNursing homeWeight lossWeight lossAge 75 or overAge 75 or overNon-compliantNon-compliantNeeds assistance/ has caregiverNeeds assistance/ has caregiverFallsFalls

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New Admission—Triggers to TeachNew Admission—Triggers to TeachID/discuss frailtyID/discuss frailty

Mrs.G 80 y/o BF DM type II, htn, s/pCVA, OA, OPMrs.G 80 y/o BF DM type II, htn, s/pCVA, OA, OPadmitted for wt. loss, confusion, falls.admitted for wt. loss, confusion, falls.Recently hospitalized at an outside institution.Recently hospitalized at an outside institution.Meds: glipizide, lisinopril, lasix, asa, celebrex, Meds: glipizide, lisinopril, lasix, asa, celebrex,

fosamaxfosamaxq weekq weekExam: Unkempt. A, O x 2 VS Afebrile BP 178/87 P Exam: Unkempt. A, O x 2 VS Afebrile BP 178/87 P

8484RR 16 Lungs clear, Cor RRR, Neuro non-focalRR 16 Lungs clear, Cor RRR, Neuro non-focalIntern reports patient is at baseline per daughter Intern reports patient is at baseline per daughter

andandcomments patient is just a “FTT.”comments patient is just a “FTT.”

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Geriatricians ID frailty Geriatricians ID frailty featuresfeatures

At least 50% of Geriatricians cited each of the following characteristicsAt least 50% of Geriatricians cited each of the following characteristicsassociated w/frailtyassociated w/frailty

– Under nutritionUnder nutrition– Functional dependenceFunctional dependence– Prolonged bedrestProlonged bedrest– Pressure soresPressure sores– Generalized weaknessGeneralized weakness– Aged >90Aged >90– Wt lossWt loss– AnorexiaAnorexia– Fear of fallingFear of falling– DementiaDementia– Hip fractureHip fracture– DeliriumDelirium– ConfusionConfusion– Going outdoors infrequently Going outdoors infrequently – PolypharmacyPolypharmacy Fried LP, Walston J. Principles of Geriatric Fried LP, Walston J. Principles of Geriatric Medicine & Gerontology 5Medicine & Gerontology 5thth ed. 2003:1487- ed. 2003:1487-

1502.1502.

A Public Health Blueprint for Healthy Aging. Linda P Fried MD MPH

Compression of MorbidityCompression of Morbidity

Describe the Aging Describe the Aging PopulationPopulation

Heterogeneous PopulationHeterogeneous PopulationFactors that contribute to Factors that contribute to

heterogeneityheterogeneityAging physiologyAging physiologyCollected co-morbid conditionsCollected co-morbid conditionsFunctional statusFunctional statusLife style/environmental factorsLife style/environmental factorsGeneticsGenetics

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What happens to reserves What happens to reserves w/aging?w/aging?

Functional Reserve of Older Functional Reserve of Older AdultsAdults

Vision loss: 27% those over age 85Vision loss: 27% those over age 85 Cognitive impairment: 50% over age 85Cognitive impairment: 50% over age 85 Assistance w/ADL: > 50% over age 85 Assistance w/ADL: > 50% over age 85

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What is frailty?What is frailty?

Definition must include:Definition must include:Association with agingAssociation with agingMulti-system impairmentMulti-system impairment InstabilityInstabilityChange over timeChange over timeAllowance for heterogeneity within the populationAllowance for heterogeneity within the populationAssociation with an increased risk of adverse Association with an increased risk of adverse

outcomesoutcomes

Can include co-morbiditiesCan include co-morbidities Can include a disabilityCan include a disability

Rockwood K, et al. Drugs & Aging 2000 Oct 17(4):295-302Rockwood K, et al. Drugs & Aging 2000 Oct 17(4):295-302Fried LP, et al. J Gerontol Med Sci.2001 56A;M146-M156Fried LP, et al. J Gerontol Med Sci.2001 56A;M146-M156

ACOVEACOVE - A model to ID/define the - A model to ID/define the at riskat risk Vulnerable ElderVulnerable Elder

Assessing the Care of the Vulnerable Elder: Assessing the Care of the Vulnerable Elder: ACOVE Project OverviewACOVE Project OverviewDeveloped a definition of “vulnerable elders”—Developed a definition of “vulnerable elders”—

community dwellers, >65 & at high risk of community dwellers, >65 & at high risk of functional decline or death using a retrospective functional decline or death using a retrospective look at Medicare datalook at Medicare data

Developed a screen to ID frail elders→the VES 13:Developed a screen to ID frail elders→the VES 13:includes age, self-perceived health, aspects of includes age, self-perceived health, aspects of

functional status.functional status. if screen “frail” on the VES 13 then anticipate an if screen “frail” on the VES 13 then anticipate an

increased risk of morbidity & mortality increased risk of morbidity & mortality Developed set of Quality IndicatorsDeveloped set of Quality Indicators

Wenger NS, Shekelle PG, et al. Ann Int Med 2001;135(8) Supplement:642-646

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Frailty Suspected:Frailty Suspected:Why screen?Why screen?

Impact on Outcomes Impact on Outcomes PreventionPrevention

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Risk of rehospitalization—one Risk of rehospitalization—one outcomes look at frailtyoutcomes look at frailty

Age over 80Age over 80 Inadequate social supportInadequate social support Multiple active chronic health problemsMultiple active chronic health problems History of depressionHistory of depression Moderate-severe functional impairmentModerate-severe functional impairment Multiple hospitalizations past 6 monthsMultiple hospitalizations past 6 months Hospitalization past 30 daysHospitalization past 30 days Fair or poor health self ratingFair or poor health self rating History of non-adherence to medical regimenHistory of non-adherence to medical regimen

Naylor M, Brooten D, Campbell, et al. JAMA. 1999;17:613-620Naylor M, Brooten D, Campbell, et al. JAMA. 1999;17:613-620

Frailty suspected…Frailty suspected…What about prevention of hazards of What about prevention of hazards of

hospitalization?hospitalization?PreventionPrevention Delirium—Inouye model—orientation & cognitive exercises, early Delirium—Inouye model—orientation & cognitive exercises, early

mobilization, prevent dehydration, hearing aides/glassesmobilization, prevent dehydration, hearing aides/glasses Deconditioning—out of bed, PT/OTDeconditioning—out of bed, PT/OT Falls—bed alarms, padsFalls—bed alarms, pads Pressure ulcers—nutrition, frequent repositioning, special Pressure ulcers—nutrition, frequent repositioning, special

mattressesmattresses Adverse drug reactions—med review for best drug choicesAdverse drug reactions—med review for best drug choices Comprehensive discharge planning—recognize need @ admission Comprehensive discharge planning—recognize need @ admission

w/ social work involvementw/ social work involvement

Models of improved care for frail elders:Models of improved care for frail elders: HELP (Hospital Elder Life Program), GEM (GeriatricHELP (Hospital Elder Life Program), GEM (Geriatric

Evaluation and Management) unit, ACE ( Acute Care ofEvaluation and Management) unit, ACE ( Acute Care of

the Elderly)unit modelsthe Elderly)unit models

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Hospital Elder Life Program:Hospital Elder Life Program:A program of preventionA program of prevention

Yale hospital system, ≥ age 70, Yale hospital system, ≥ age 70, admitted to acute care hospitaladmitted to acute care hospitalScreened for cognitive impairment, sleep Screened for cognitive impairment, sleep

deprivation, immobility, dehydration, deprivation, immobility, dehydration, vision or hearing impairmentvision or hearing impairment

Targeted interventionsTargeted interventionsOutcomesOutcomes

Decrease in delirium rate in intervention Decrease in delirium rate in intervention groupgroup

Decrease in functional decline (14%vs. 33%)Decrease in functional decline (14%vs. 33%)Decrease in cognitive decline (8%vs. 26%)Decrease in cognitive decline (8%vs. 26%)

Inouye S, et al JAGS 2000; 48:1697-1706

Inouye SK, et al. NEJM. 1999;340:669-676

Inouye SK , et al. Ann Intern Med. 1993;119:474-481

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Targeted InterventionsTargeted Interventions

Orientation/Activities

CognitiveImpairment

Sleep Deprivation

Non-drug; sleep enhancement

Immobility

EarlyMobilization

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Targeted InterventionsTargeted Interventions

Visual Aids, Devices

Visual Impairment Hearing Impairment

Hearing devices,Remove earwax

Dehydration

Early recognition& po repletion

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Prevention ProtocolsPrevention Protocols

Inouye SK, et al. NEJM. 1999;340:669-676 SEE CHALK

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Predicting Delirium:Predicting Delirium:PredisposingPredisposing Risk Factors Risk Factors

DEVELOPMENT COHORTDEVELOPMENT COHORT N=107 RRN=107 RR

1. 1. Vision Vision 3.53.5 (1.2-(1.2-10.7)10.7)

2. Severe Illness 2. Severe Illness 3.53.5 (1.5-8.2)(1.5-8.2)

3. 3. Cognition Cognition 2.82.8 (1.2-6.7) (1.2-6.7)

4. BUN/Cr > 184. BUN/Cr > 18 2.02.0 (1.1-4.6) (1.1-4.6)

VALIDATION COHORTVALIDATION COHORT N=174 RRN=174 RR

1.1. Low Risk (0)Low Risk (0) 1.01.02.2. Int. Risk (1-2) Int. Risk (1-2) 2.52.53.3. High Risk (3-4) High Risk (3-4) 9.29.2

Inouye SK , et al. Ann Intern Med. 1993;119:474-481

Cognitive Impairment (MMSE < 24); Vision Impairment > 20/70; BUN/CR > 18/1; Severe Illness= APACHE II > 16 OR CHARLSON ORDINAL CLINICAL = RATED AS SEVERE

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Triggers to Recognize & Triggers to Recognize & Screen for FrailtyScreen for Frailty

Advanced age (>70, Advanced age (>70, > > 75, 75, > > 80???)80???)Suspected functional impairments Suspected functional impairments Suspected cognitive impairment Suspected cognitive impairment Consider if /andConsider if /and

Multiple co-morbiditiesMultiple co-morbiditiesPsychosocial issuesPsychosocial issuesSensory impairmentsSensory impairmentsSevere acute illnessSevere acute illness

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What to screen? What to screen?

CognitionCognitionFunctionFunctionAffectAffectSensorySensorySocialSocial

Comprehensive Geriatric Comprehensive Geriatric AssessmentAssessment

Functional AbilityFunctional Ability

Physical assessmentPhysical assessment

Cognitive assessment Cognitive assessment

Psychological assessmentPsychological assessment

Social/environmental assessmentSocial/environmental assessment

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New Admission—Triggers to recognize & New Admission—Triggers to recognize &

screen for cognitionscreen for cognition

Mrs.G 80 y/o BF DM type II, htn, s/pCVA, OA, OPMrs.G 80 y/o BF DM type II, htn, s/pCVA, OA, OPadmitted for wt. loss, confusion, falls.admitted for wt. loss, confusion, falls.Recently hospitalized at an outside institution.Recently hospitalized at an outside institution.Meds: glipizide, lisinopril, lasix, asa, celebrex, Meds: glipizide, lisinopril, lasix, asa, celebrex,

fosamaxfosamaxq weekq weekExam: Unkempt. A, O x 2 VS Afebrile BP 178/87 P Exam: Unkempt. A, O x 2 VS Afebrile BP 178/87 P

8484RR 16 Lungs clear, Cor RRR, Neuro non-focalRR 16 Lungs clear, Cor RRR, Neuro non-focalIntern reports patient is at baseline per daughter Intern reports patient is at baseline per daughter

andandcomments patient is just a “FTT.”comments patient is just a “FTT.”

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New Admission—Triggers to recognize & New Admission—Triggers to recognize & screen for physical functionscreen for physical function

Mrs.G 80 y/o BF DM type II, htn, s/pCVA, OA, OPMrs.G 80 y/o BF DM type II, htn, s/pCVA, OA, OPadmitted for wt. loss, confusion, falls.admitted for wt. loss, confusion, falls.Recently hospitalized at an outside institution.Recently hospitalized at an outside institution.Meds: glipizide, lisinopril, lasix, asa, celebrex, Meds: glipizide, lisinopril, lasix, asa, celebrex,

fosamaxfosamaxq weekq weekExam: Unkempt. A, O x 2 VS Afebrile BP 178/87 P Exam: Unkempt. A, O x 2 VS Afebrile BP 178/87 P

8484RR 16 Lungs clear, Cor RRR, Neuro non-focalRR 16 Lungs clear, Cor RRR, Neuro non-focalIntern reports patient is at baseline per daughter Intern reports patient is at baseline per daughter

andandcomments patient is just a “FTT.”comments patient is just a “FTT.”

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ID patients at significant risk for ID patients at significant risk for functional decline while functional decline while hospitalizedhospitalized

Independent Risk FactorsIndependent Risk Factors

1) Pressure ulcer?1) Pressure ulcer?

2) Baseline cognitive deficits?2) Baseline cognitive deficits?

3) Baseline functional impairments?3) Baseline functional impairments?

4) Baseline low social activity level?4) Baseline low social activity level?

Score risk for functional decline: Score risk for functional decline:

no =8%risk; yes to 1-2 questions =28% risk; no =8%risk; yes to 1-2 questions =28% risk;

yes to > 2 questions=63% riskyes to > 2 questions=63% risk

Inouye SK, et al.J Gen Intern Med1993;8(12):645-52.

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Functional decline occurs in the Functional decline occurs in the hospitalhospital

Functional limitations increase with age.Functional limitations increase with age.Functional decline occurs in approx. Functional decline occurs in approx. 34-50% hospitalized older pts.34-50% hospitalized older pts.

Higher mortality—twice the risk Higher mortality—twice the risk Higher rates of institutionalizationHigher rates of institutionalizationProlonged hospital stayProlonged hospital stay

Interventions can decrease functional Interventions can decrease functional decline (Hospital Elder Life Program).decline (Hospital Elder Life Program).

Functional status determines D/C plan.Functional status determines D/C plan.

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The Hospital CGA? –a The Hospital CGA? –a comprehensive assessment of comprehensive assessment of functional statusfunctional status

● ● Screen ADLsScreen ADLs(Activities of Daily Living) (Activities of Daily Living) & & IADLsIADLs(Instrumental Activities of Daily (Instrumental Activities of Daily Living).Living).

● ● Evaluate physical mobility Evaluate physical mobility

● ● Evaluate for sensory impairments—Evaluate for sensory impairments—hearing & sighthearing & sight

● ● Screen for dementiaScreen for dementia

● ● Screen for depressionScreen for depression

● ● Screen for environment/social factorsScreen for environment/social factors

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Functional impairment and age Functional impairment and age as measured by ADLs as measured by ADLs

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Activities of Daily LivingActivities of Daily Living

BathingBathing

DressingDressing

TransferenceTransference

ContinenceContinence

FeedingFeeding

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Instrumental Activities of Daily LivingInstrumental Activities of Daily Living

Using the phoneUsing the phone

TravelingTraveling

ShoppingShopping

Preparing mealsPreparing meals

HouseworkHousework

Taking medicineTaking medicine

Managing moneyManaging money

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Gait-timed get up and goGait-timed get up and go

Quantitative evaluation of general Quantitative evaluation of general

functional mobilityfunctional mobilityTimed command w/Timed command w/rise from chair;rise from chair;

walk 10 feet; turn around; walk back walk 10 feet; turn around; walk back

and sit in chair.and sit in chair.

Wall JC, Bell C, Campbell S, et al J Rehabil Res Dev 200 37(1):109-113

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Gait assessment scoring to Gait assessment scoring to assess physical mobilityassess physical mobility

Usual time to completion 10 secondsUsual time to completion 10 secondsFrail elder usually < 20 secondsFrail elder usually < 20 seconds> 20 seconds needs PT evaluation> 20 seconds needs PT evaluationPerformance on test associated with:Performance on test associated with:

ADL/IADL performanceADL/IADL performance

Falls riskFalls risk

Risk of nursing home placementRisk of nursing home placement

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Trigger to Recognize & Teach:Trigger to Recognize & Teach:Who to screen for functional Who to screen for functional impairment?impairment?

Who to screen?Who to screen? Patients @ advanced age (>70, Patients @ advanced age (>70, >>75, 75,

>>80 ???)80 ???) Patient who is re-admitted in past monthPatient who is re-admitted in past month Person with at least 1 risk factorPerson with at least 1 risk factor

Cognitive impairmentCognitive impairmentFunctional impairmentFunctional impairmentPressure ulcerPressure ulcerLow social activity scoreLow social activity score

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Screening for Functional Status in Screening for Functional Status in the Hospitalized Elderlythe Hospitalized Elderly

When to screen?When to screen? Review ADLs/IADLs prior to the patient’s hospitalizationReview ADLs/IADLs prior to the patient’s hospitalization Determine new set of ADLs/IADLs after stabilization of Determine new set of ADLs/IADLs after stabilization of

acute illnessacute illness Readdress patient’s ADLs and IADLs prior to hospital Readdress patient’s ADLs and IADLs prior to hospital

dischargedischarge

What to do?What to do? Chart orders- walking and range of motion TIDChart orders- walking and range of motion TID Ambulation problem- physical therapyAmbulation problem- physical therapy Dressing/bathing/feeding- occupational therapyDressing/bathing/feeding- occupational therapy Discharge planning early in hospitalization w/social work Discharge planning early in hospitalization w/social work

intervention intervention

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How common is dementia?How common is dementia?

Age strongest risk factor for dementiaAge strongest risk factor for dementiaAt age 65, prevalence 8-12%At age 65, prevalence 8-12%At age 85, prevalence 50%At age 85, prevalence 50%

Persons with dementia in US- 4 millionPersons with dementia in US- 4 millionProjected number by 2040- 14 millionProjected number by 2040- 14 million25% of older hospitalized adults 25% of older hospitalized adults

admitted to medicine have impaired admitted to medicine have impaired cognitioncognition

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Dementia and DeliriumDementia and Delirium

MMSE <24/30MMSE <24/30→→ Delirium risk Delirium risk 2.82 2.82 (1.19-6.65)(1.19-6.65)

Delirium associated with worse outcomesDelirium associated with worse outcomes Orientation board and cognitive Orientation board and cognitive

stimulation decreased confusion 8% vs. stimulation decreased confusion 8% vs. 26%.26%.

* Confusion = loss of 2 points on MMSE* Confusion = loss of 2 points on MMSE

Inouye SK, et al Ann Intern Med 1992;119:474-481

Cognitive AssessmentCognitive Assessment

–Screen with 3 item recall in 1 minuteScreen with 3 item recall in 1 minute

–Mini-CogMini-Cog

–Folstein Mini-Mental State Examination Folstein Mini-Mental State Examination (MMSE)(MMSE)

–Clock-drawing testClock-drawing test

–Montreal Cognitive AssessementMontreal Cognitive Assessement

–St. Louis University Mental Status ExamSt. Louis University Mental Status Exam

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Screening Tools: Mini-cogScreening Tools: Mini-cog

Step 1:Remember & repeat three unrelated wordsStep 1:Remember & repeat three unrelated words Step 2: Clock-drawing test (CDT)—distracter Step 2: Clock-drawing test (CDT)—distracter Step 3: Repeat 3 previously presented wordsStep 3: Repeat 3 previously presented words Step 4: Scoring:1 pnt. for each recalled wordStep 4: Scoring:1 pnt. for each recalled word

• Score=0; + screen for dementiaScore=0; + screen for dementia• Score=1-2 with abnl CDT; + screen for dementiaScore=1-2 with abnl CDT; + screen for dementia• Score=1-2 with nl CDT; neg. screen for dementiaScore=1-2 with nl CDT; neg. screen for dementia• Score=3; neg. screen for dementiaScore=3; neg. screen for dementia

Borson S, et al. Int J Geriatr Psychiatry2000;15:1021-1027

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Folstein MMSEFolstein MMSE

30 point screening test30 point screening test Screens multiple cognitive domainsScreens multiple cognitive domains Not a direct screen of executive functionNot a direct screen of executive function Studies usually use cut off 24 for positive Studies usually use cut off 24 for positive Reliability of results dependent on age & Reliability of results dependent on age &

education education

Folstein M, Folstein S, McHugh P. J Psychiatr Res. 1975;12:189-198Folstein M, Folstein S, McHugh P. J Psychiatr Res. 1975;12:189-198

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Troubleshooting the MMSETroubleshooting the MMSE

Validation done under rigorous technique Validation done under rigorous technique Serial 7’s vs. spelling WORLD backwards Serial 7’s vs. spelling WORLD backwards

88thth grade education or < grade education or < →→ WORLD WORLD>8>8thth grade education grade education→→ serial 7’s serial 7’s

Administer in quiet, non-threatening Administer in quiet, non-threatening environment environment

Correct sensory deficits as much as Correct sensory deficits as much as possiblepossible

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Reminders about MMSEReminders about MMSE

Screening test for cognitive impairmentScreening test for cognitive impairmentCan help to risk stratify— delirium, Can help to risk stratify— delirium,

functional decline, iatrogenic injury, functional decline, iatrogenic injury, pressure ulcerspressure ulcers

Useful as a baseline to monitor changeUseful as a baseline to monitor changeNot a determination of decision-making Not a determination of decision-making

capacitycapacity

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Screening Tests for Cognition:Screening Tests for Cognition:Summary Teaching PointsSummary Teaching Points

Mini-cog—quick bedside toolMini-cog—quick bedside toolMMSE—screening tool onlyMMSE—screening tool only If patient screens positive:If patient screens positive:

Use orientation boardUse orientation boardEarly mobilizationEarly mobilizationDischarge plan—unique D/C needsDischarge plan—unique D/C needsScreen for functional, sensory Screen for functional, sensory

impairmentsimpairments

Depression and functional Depression and functional statusstatus

Hospitalized elderly with higher Hospitalized elderly with higher depressiondepression

scores had worse outcomesscores had worse outcomesDependent 1 ADLDependent 1 ADL 3.23(1.76-5.95)3.23(1.76-5.95)Dependent >/= 3 IADLDependent >/= 3 IADL 2.67 (1.33-3.56)2.67 (1.33-3.56)Not satisfied with lifeNot satisfied with life 3.05(1.06-8.75)3.05(1.06-8.75)Fair to poor healthFair to poor health 3.11(1.65-5.87)3.11(1.65-5.87)*Similar results 30 and 90 days*Similar results 30 and 90 days

Covinsky K, Fortinsky R, Palmer R. Relation between symptoms of depression and health Covinsky K, Fortinsky R, Palmer R. Relation between symptoms of depression and health statusstatus

outcomes in acutely ill hospitalized older persons. Ann of Int Med. 1997;126:417-425.outcomes in acutely ill hospitalized older persons. Ann of Int Med. 1997;126:417-425.

Psychological AssessmentPsychological Assessment

– Screen with “Do you often feel sad or Screen with “Do you often feel sad or depressed?”depressed?”

– Perform Geriatric Depression ScalePerform Geriatric Depression Scale– Assess risk of suicideAssess risk of suicide– Ask about anxieties and worries and recent Ask about anxieties and worries and recent

bereavementbereavement

Geriatric Depression ScaleGeriatric Depression Scale(GDS)(GDS)

• Short formShort form– 15 items from the original 3015 items from the original 30– Score ≥ equal to 5 → Score ≥ equal to 5 → Sensitivity ~90%, Sensitivity ~90%,

specificity 70%specificity 70%

Geriatric Depression Scale: Geriatric Depression Scale: Short FormShort Form

1. Are you basically satisfied with your life?1. Are you basically satisfied with your life?2. Have you dropped many of your activities and interests? 2. Have you dropped many of your activities and interests? 3. Do you feel that your life is empty? 3. Do you feel that your life is empty? 4. Do you often get bored? 4. Do you often get bored? 5. Are you in good spirits most of the time? 5. Are you in good spirits most of the time? 6. Are you afraid that something bad is going to happen to you? 6. Are you afraid that something bad is going to happen to you? 7. Do you feel happy most of the time? 7. Do you feel happy most of the time? 8. Do you often feel helpless? 8. Do you often feel helpless? 9. Do you prefer to stay at home, rather than going out & doing new9. Do you prefer to stay at home, rather than going out & doing new things? things? 10. Do you feel you have more problems with memory than most? 10. Do you feel you have more problems with memory than most? 11. Do you think it is wonderful to be alive now?11. Do you think it is wonderful to be alive now?12. Do you feel pretty worthless the way you are now? 12. Do you feel pretty worthless the way you are now? 13. Do you feel full of energy? 13. Do you feel full of energy? 14. Do you feel that your situation is hopeless? 14. Do you feel that your situation is hopeless? 15. Do you think that most people are better off than you are? 15. Do you think that most people are better off than you are?

Sheikh et al. J Psychiatric Res 1983;17:37-49.

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Frailty & the Hospital: Frailty & the Hospital: A Final WordA Final Word

Frail elders occupy approx. 25% medicine Frail elders occupy approx. 25% medicine beds.beds.

Frail elders @ high risk for worse outcomes.Frail elders @ high risk for worse outcomes. Screen for cognition, functional status, Screen for cognition, functional status,

psychosocial, sensory impairments.psychosocial, sensory impairments. Screen based on advanced age (>70) & Screen based on advanced age (>70) &

suspected functional impairments.suspected functional impairments. Take measures to prevent delirium, falls and Take measures to prevent delirium, falls and

functional decline.functional decline. Recognizing frailty begs for a Recognizing frailty begs for a

comprehensive D/C plan and Med Review.comprehensive D/C plan and Med Review.

Special ThanksSpecial Thanks

• CHAMP investigators, faculty & CHAMP investigators, faculty & course participantscourse participants

• Joseph ShegaJoseph Shega• Don ScottDon Scott• Aliza BaronAliza Baron• Greg SachsGreg Sachs• Vinay KutagulaVinay Kutagula

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CHAMP Website & MaterialsCHAMP Website & Materials

CHAMP Website @CHAMP Website @

http://champ.bsd.uchicago.edu

Reynolds Foundation supported Portal Reynolds Foundation supported Portal ofof

Geriatric Online Education website @Geriatric Online Education website @www.pogoe.com