Knowing this will save you a lot of time—and probably more than one life. If you want to do some good in your working day, get a grip on global functional assessment (see further reading). Add to this a test of gait, and you are on your way to doing some good in this world.
Activities of Daily Living (ADLs): “BATTED”
ADLs are the essential elements of self-care. Inability to independently perform even one activity may indicate a need for supportive services.
“Do you have difficulty or require assistance with any of the following?”
- Bathing
- Ambulation
- Toileting
- Transfers
- Eating
- Dressing
IADLs are associated with independent living in the community and provide a basis for considering the type of services necessary in maintaining independence.
Identification of Seniors at Risk (ISAR) screening tool
Modified Falls Efficacy Scale
falling
Screen for gait instability and risk of falls by watching the patient perform in a Timed Get Up and Go test:
- Rise from the chair
- Walk to the line on the floor (10 feet)
- Turn
- Return to the chair
- Sit down again
Cognitive Functioning
To diagnose dementia requires a thorough history and physical examination, yet a few rapid screening tests can be used to rule out a dementia of significant degree.
Patients with suspected cognitive impairment should be screened for both delirium and depression.
Delirium is a disorder of attention, and should be considered in patients with waxing and waning attention or level of consciousness. It is commonly a side effect of medications, and is often overlooked by clinical staff.
Delirium is suggested by the presence of cognitive impairment with:
- Acute onset (hours to days) and fluctuating course
- Inattention (difficulty maintaining focus)
- Disorganized thinking OR Altered level of consciousness
A delirium is a medical emergency.
Cognitive impairment screen – Mini-Cog:
This comprises two parts: a 3-item recall and a clock draw test (CDT)
- Instruct the patient to listen carefully as you name 3 unrelated objects
and then to repeat the object names. - “Draw the face of a clock.” (Have them draw either on a blank sheet of paper, or on a sheet with the clock circle already drawn on the page). “Now draw the hands of the clock to read 11:20.” (Repeat instructions as necessary without adding further details. Give the patient as much time as necessary to complete the task.)
- Repeat the 3 previously presented object names.
The CDT is considered normal if all numbers are present in the correct sequence and position, and the hands readably display the requested time.
- A score of 0 indicates dementia (regardless of CDT results).
- A score of 1 or 2 with an abnormal CDT indicates dementia
- A score of 1 or 2 with a normal CDT indicates absence of dementia
- A score of 3 indicates absence of dementia (regardless of CDT results).
Three-item recall at 1 minute (i.e. after the CDT distractor) has a negative likelihood ratio of 0.06-0.1. The CDT has a negative likelihood ratio of 0.1-0.2.
Screen for depression in patients 80 years of age or older who:
- complain of sleep disturbance, lack of energy, poor appetite, or “just feeling
bad” - suffer a functional decline
- have difficulty taking medications
Major Depressive Illness – two-question screen:
- “During the past month, have you often been bothered by feeling
down, depressed, or hopeless?” [Negative likelihood ration 0.25] - “During the past month, have you often been bothered by little interest
or pleasure in doing things?”
Test is negative for patients who respond “no” to both questions.
The Geriatric Depression Scale (GDS) is a 15-item written questionnaire that can be offered, before or after a visit, to high-risk patients. A GDS < 6 has a negative likelihood ratio for depression of 0.30.
Download: Tinetti Performance Oriented Mobility Assessment (POMA)
[Tinetti ME. Williams TF, Mayewski R. Fall Risk: lndex for elderly patients based on number of chronic disabilities. Am J Med /986:80:429-434. This version available at TinettiPOMA.pdf (fullerton.edu).]
Global Assessment of Functioning (GAF) Scale – DSM IV. Available at Microsoft Word – axisv.doc (albany.edu).
Reference
Parts of this overview are taken directly from the Geriatric Functional Assessment Tool of the University of Michigan Medical School. Available at GeriatricFunctionalAssess.pdf (umich.edu).
Further Reading
- Comprehensive Geriatric Assessment – Up to Date. January 21, 2016
- Hospital Discharge and Readmission – Up to Date. January 26, 2016
- ED Prevention of Geriatric Falls – EMJClub.com Podcast. November 2014
- The ‘MUST’ Explanatory Book: A Guide to the ‘Malnutrition Universal Screening Tool’ (‘MUST’) for Adults – British Association for Parenteral and Enteral Nutrition (BAPEN). November, 2011
- Jorm A, Mackinnon A. Psychogeriatric Assessment Scales (PAS): User’s Guide (4th Edition). © Jorm & Mackinnon 1995
- Jorm A, Mackinnon A. Psychogeriatric Assessment Scales (PAS): Subject Interview. © Jorm & Mackinnon 1995
- Jorm AF, Christensen H, Jacomb PA, Korten AE, Mackinnon AJ. The cognitive decline scale of the psychogeriatric assessment scales (PAS): longitudinal data on its validity. Int J Geriatr Psychiatry. 2001 Mar;16(3):261-5.
- Folstein MF, Folstein SE, McHugh PR. Mini-mental state: A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-198 [link to MMMSE here]
