Hello, I'm Christophe Bula. Welcome to this video dedicated to the screening for common geriatric conditions in ambulatory practice. In this video, you will learn simple and brief strategies to screen for functional impairment, cognitive impairment, malnutrition and hearing impairment in older persons. Depression is covered in a separate lecture. But let's start with some brief background. The rationale behind using a comprehensive and structured assessment in the older person was already described in 1940 by Marjorie Warren, one of the pioneer of geriatric medicine, as she observed misdiagnoses, over and under use of investigations and interventions, polymedication and iatrogenesis all resulting in premature long term care placement of vulnerable older persons. These gaps in our care results from specific difficulties in the assessment and management of older persons due to communication problems because of hearing impairment or vision impairment or psychomotor retardations. Penalization of symptoms such as false belief, for example incontinence is normal with aging, fear of new diagnoses for example, depression or cognitive impairment. Vague and nonspecific symptoms due to alteration of physiological responses, for example fever, atypical presentation of diseases, for example delirium. Multiple complaints resulting from polymorbidity and interaction between diseases as well as between diseases and their treatments. And finally heterogeneity in house and functional status or care expectations. A structured and standardized approach, usually referred as comprehensive geriatric assessment, has progressively become central to the care of older persons. Meta analysis of studies in community dwelling older population have shown benefits in terms of improved function, prolonged home stay, decreased needs for long term care and in some studies decreased hospital admission as well as decreased mortality without increasing costs. The approach proposed in this lecture on screening in the elderly is considered as a first step to identify vulnerable older persons and better targeting those who might need further more comprehensive assessment. Moving now to the assessment of function. Assessment of daily function is key to early detection of decline in order to propose intervention to restore the function or address resulting needs for care and support, as well as for the early identification of atypical manifestation of common diseases and prediction of a person's future functional trajectory. Two domains are important to assessing screening. Basic activities of daily living, which are considered self-care activities, and instrumental activities of daily living, which are activities that allow a person to be independent in her or his environment. These can be assessed with simple instruments. These diagrams show the six basic activities of daily living to investigate for difficulties or dependence. As can be seen, there is an implied order for loss and gain of activities. And here are the eight instrumental activities of daily living. These are: using the phone, grocery shopping, preparing meals, housekeeping, doing the laundry, using public transportation, taking own medications and handling finances. Difficulties or dependence reported should trigger intervention to restore the function when appropriate such as rehabilitation, and further inquiry about available or needed resources to best address these difficulties. Moreover, functional difficulties in basic activities of daily living and the instrumental activities of daily living, are important predictors of an older person's future. This was shown in a study that compared two all the persons without difficulty in performing any of four instrumental activities of daily living that included using the phone, using public transportation, taking their own medications and handling finances. As can be seen in this table, the odds of developing dementia within the 12 months follow up increased about four times in those reporting one difficulty, and up to about 10 times in those reporting three or four difficulties in these instrumental activities of daily living. Moving now to the screening of cognition for cognitive impairment. In most developed countries, about a third to a half of older patients suffering from dementia are not diagnosed. Although the value of cognitive screening in older adults is still debated, the prevalence of cognitive impairment after 80 years, which is up to 20%, supports promoting systematic screening. As can be seen on this figure, there is an exponential increase in dementia prevalence after age 65. Therefore, primary care physician or any other healthcare providers, should have a low threshold for further investigating cognitive impairment in these patients. Among the multiple brief tests available to screen for cognitive impairment, the Mini-Cog appears as the best suited test for primary care practice. As can be seen in this diagram, the Mini-Cog contains a three-word recall and a clock drawing test. If the person is unable to recall any word or only recalls one or two words and has an abnormal clock drawing test, then further investigation for dementia should be considered. The sensitivity and specificity of the Mini-Cog have been shown to ranged from 73 to 99%, and from 75 to 93% respectively. Moving now to the assessment of nutritional status for screening for malnutrition. Malnutrition is frequent in the older population. And even if community dwelling elderly persons are not those at highest risk, they should still be screened. This can be seen in this table where the reported prevalence of malnutrition is up to 10% in community dwelling older persons. Unfortunately, screening instruments are not used in clinical practice as they do not have sufficient sensitivity and specificity, and they have not been adequately validated. For the primary care physician or healthcare provider, besides monitoring weight, a simple recommendation for screening is to ask about a weight loss. A loss of 5% or more in one month or 10% or more in six months or body mass index inferior to 22 kilograms per square meters, are used to suspect malnutrition. And finally screening for hearing impairment. Hearing impairment is the most common sensory impairment in older persons. As can be seen in this table, it has a prevalence up to 45% in persons age 80 years and over. Hearing impairment is associated with increased risk for depression, for poorer cognitive performance, social isolation and decreased quality of life. Physicians and other healthcare providers would usually notice problems during their conversation with an older person. The use of a single question is also a simple first step that has been shown to be cost effective. The single question is, "Do you feel you have a hearing loss?" A positive answer should trigger a referral for an audiological evaluation. An alternative is the use of the whisper test. To conduct the whisper test, stand behind the patient at arm's length from ear, cover the untested ear, fully exhale, and whisper a combination of three numbers and letters, for example seven C four. Ask the patient to repeat the numbers and letters. If unable to repeat all three, repeat the test with a second set. Hearing impairment should be suspected if the patient is unable to repeat at least 3 out of the 6 numbers and letters. In adult studies, the whisper tests has a sensitivity of 90 to 100% and a specificity of 70 to 87% percent using audiometry as the criterion standard. In conclusion, a brief and structured assessment is feasible in primary care practice. It can be useful as a first step to detect several geriatric conditions that are common in older persons, and to better targeting those who might need further, more comprehensive assessment because these conditions are likely to have a high impact on this patient future healthcare needs and functional trajectories if left unaddressed. It is important to keep in mind that as with all screening programs, if a problem is detected, follow up intervention and appropriate treatment are critical. Thank you for your attention.
