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G

A

SUNNY A. LINNEBUR

L O

1. Describe standard physical assessments necessary in geriatric patients.

Compare and contrast mood, behavioral, cognitive, and functional assessments commonly utilized in clinical

practice and research settings.

Describe important social assessments that should be performed in geriatric patients.

Explain changes that might be necessary for performing assessments in institutionalized patients and those

with cognitive impairment.

K T  D

ADL: Activities of daily living, such as bathing, dressing, and feeding.

ADVANCE DIRECTIVES: Legal documents that allow patients to have their medical decisions known and

followed when receiving care.

GDS: Geriatric depression scale, a tool speciﬁcally for geriatric patients to screen for depression.

IADL: Instrumental activities of daily living, such as shopping, paying bills, and managing medications.

MMSE: Mini-mental state examination, a tool commonly used in screening for cognitive impairment.

NPI-Q: Neuropsychiatric inventory questionnaire, a tool used in clinical practice to help with assessing

neuropsychiatric symptoms of dementia.

TUG: Timed “up and go” test, used to assess balance and fall risk in the elderly.

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| Fundamentals of Geriatric Pharmacotherapy

I

ue to the complexity of geriatric patients,

assessment by healthcare providers typi-

cally requires more extensive investigation than

for younger adults and may involve multiple

healthcare practitioners. Furthermore, the frail

elderly patient frequently presents with symp-

toms that are atypical for a speciﬁc disease.

This makes diagnosis, treatment, and moni-

toring a challenge. A full assessment should

include physical assessment and laboratory

tests, a review of medical problems and medi-

cations, cognitive assessment, neuropsychi-

atric assessments, functional assessment, and

social assessments. In addition to the evalua-

tion of current medical problems, screening

for diseases or conditions and plans for health

promotion and disease prevention are also

likely to be included when assessing relatively

healthy elderly patients. Health promotion in the

form of testing, diagnosing, and treating may be

omitted in patients where life expectancy is not

likely long enough to receive beneﬁt from the

intervention (e.g., lag time to beneﬁt is longer

than life expectancy).

Caregivers, children, the medical power of

attorney, and other individuals involved in the

care for geriatric patients should be included in

visits, if feasible, to assist in reviewing medical

information about the patient. Typically, more

than one visit is required to complete a compre-

hensive assessment of geriatric patients. It is

also important to note that changes in the geri-

atric assessment may be required in those who

are institutionalized or have cognitive impair-

ment. Overall, the geriatric assessment should

be tailored to the individual patients, based on

their age, frailty, and living situation and, when-

ever possible, should include assessments from

interprofessional team members and caregivers.

Interprofessional team members who may

be involved in assessing geriatric patients

include physicians, nurse practitioners, physi-

cian assistants, nurses, pharmacists, social

workers, physical therapists, occupational thera-

pists, neuropsychologists, dentists, and nursing

aides and assistants. Although pharmacists can

be involved in every step of the geriatric assess-

ment, the most critical place for pharmacists

to take an active role is in the assessment of

medications and medication-related problems.

Pharmacists are uniquely trained to identify drug

therapy problems and to make recommenda-

tions regarding drug therapy, immunizations,

and adherence. Capitalizing on the individual

strengths of the geriatric interprofessional team

members, including the pharmacist, allows for a

more comprehensive assessment.

The purpose of this chapter is to discuss

in detail the steps involved in a comprehensive

assessment of a geriatric patient and to under-

score the importance of the assessment in the

overall treatment plan for the patient.

KEY POINT:

e geriatric

assessment should be tailored to the

individual patient, based on his or her

age, frailty, and living situation.

P A 

L E

Physical assessment in the elderly involves

elements typically performed in younger adults,

with additions based speciﬁcally on the likeli-

hood of chronic disease states, such as diabetes,

chronic kidney disease, dementia, and depres-

sion. Physical assessment for a new patient

should include review of all systems, vital signs,

and examination of the eyes, skin, lungs, cardio-

vascular system, head and neck, musculoskel-

etal system, abdomen, and neurologic system.

Many of the additional assessments necessary

in elderly patients evaluate for the presence or

consequences of chronic diseases.

Of note, the physical assessments and labo-

ratory evaluations described below are for healthy

elderly patients and may need to be altered or

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4 - Geriatric Assessment |

eliminated in frail elderly patients, depending on

the patient’s goals for care and life expectancy.

Acute illness in frail patients is often atypical and,

therefore, requires very careful assessment to

avoid underdiagnosis, overdiagnosis, or misdi-

agnosis. Speciﬁc aspects of these challenges

are discussed in the organ system chapters, but

it is important to remember that incomplete or

suboptimal assessment in these individuals may

not only lead to inaccurate diagnosis but, subse-

quently, to inappropriate medication therapy.

Vital Signs

Typical vital signs (blood pressure, pulse,

temperature, respiratory rate, and level of pain)

are standard measurements necessary for a

medical assessment in the elderly, and for the

most part they can easily be performed by a

pharmacist. In the elderly, pain is especially

important to evaluate because of the high inci-

dence of osteoarthritis and chronic pain and

often needs investigation beyond a pain score.

At a minimum, patients should also be evaluated

for the location and type of pain they are expe-

riencing. Blood pressure measurements in the

elderly must be done with care. For example, it

is important to select the correct size cuff (e.g.,

small, regular, or large) and to inﬂate it sufﬁciently

to make sure the correct systolic measurement

is taken. An auscultatory gap is a common

phenomenon among older patients with hyper-

tension, so care must be taken to avoid a falsely

low systolic measurement. This can be achieved

by inﬂating the cuff to approximately 200 mmHg.

Because this may be uncomfortable for some

patients, one can palpate the radial pulse prior

to assessing blood pressure and then inﬂate the

cuff at least to the point where this radial pulse

can no longer be detected, rather than routinely

inﬂating to 200 mmHg. Orthostatic blood pres-

sure measurements may also need to be evalu-

ated due to aging, disease, and drug-related

causes of orthostatic hypotension. Heart rate

should also be assessed when performing ortho-

static hypotension assessments to aid in the

differentiation between orthostasis and syncope.

When assessing the pulse, it is important to note

whether the patient has a regular or irregular

rhythm. As a standard vital sign, temperature

should be checked at all visits. Any elevated

temperature in the elderly is worrisome and

should not be disregarded. Repeated tempera-

ture measurements greater than 99°F on two or

more occasions, or an increase in temperature of

more than 2°F above baseline, usually indicate

fever in an elderly patient.

Patients with clinical signs or symptoms of

infection but with normal oral or tympanic temper-

atures should have a rectal temperature measure-

ment performed, as it can be more accurate in

elderly patients.

3,4

Height and weight should be

measured at the ﬁrst visit, and weight should be

measured at all future visits. Weight and appetite

should be evaluated to assess whether the patient

is under- or overweight. Both obesity and malnu-

trition occur in the elderly, but in the very elderly

malnutrition is more common. Multiple studies indi-

cate that older adults who are undernourished have

increased morbidity and mortality.

If the patient is

obese, undernourished, or underweight, an inter-

vention should be made. Referral to a dietitian for

nutrition counseling, a speech-language patholo-

gist for a swallow study, or a dentist for an oral

evaluation can be helpful in patients with malnutri-

tion. The United States Preventive Services Task

Force (USPSTF) recommends that all adults be

screened for obesity utilizing a body mass index

(BMI) calculation, with multicomponent behav-

ioral interventions offered to anyone found to be

obese (e.g., BMI > 30 kg/m

Measured height

can be compared with patient-reported height to

help identify whether the patient may have verte-

bral fractures. If the patient is unable to get out

of bed or has signiﬁcant kyphosis, height can be

estimated using knee height, forearm length, total

arm length, or demi-span (the distance from the

middle of the sternal notch to the tip of the middle

ﬁnger).

7,8

Ophthalmic, Otoscopic, and Oral

Assessments

Eye examinations in the elderly should be

performed by an optometrist at least annually.

With increasing age, vision can deteriorate, and

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| Fundamentals of Geriatric Pharmacotherapy

there is an increased risk for ophthalmic disor-

ders, such as glaucoma, macular degeneration,

cataracts, and diabetic retinopathy. If driving,

the patient should be assessed for the ability to

see well enough to drive an automobile. In some

states a driver’s license lasts for 10–20 years;

during the time that the license is still active,

vision changes can occur that cause problems

when driving. To prevent accidents in the home

or automobile, it is important to reassess vision

periodically even if the patient is not complaining

of vision changes. Also, the patient may need

referral to an ophthalmologist if the optometrist

cannot fully assess the patient or he or she has

complications of an ophthalmic disorder.

Ear examinations are also necessary in the

elderly, as many may have hearing loss. Ears

should be examined speciﬁcally for impacted

cerumen, which is often due to dry cerumen and/

or the use of hearing aids. The inability to hear

can have negative consequences in the elderly,

such as the appearance of cognitive impairment

and low health literacy. In addition, impacted

cerumen can make patients dizzy, predisposing

them to falls. Hearing tests by an audiologist

and further use of corrective hearing aids may

improve quality of life. In patients with dementia,

a ﬁnger rub or ﬁnger friction test can be utilized

to assess hearing and has been shown to have

high sensitivity and speciﬁcity compared to audi-

ometry.

Microphones with connected headsets

(e.g., Pocket Talker) can also be used by health-

care practitioners to improve communication

with patients who have hearing impairment.

Oral problems often contribute to malnutri-

tion in the elderly patient. Both medical providers

and dentists can evaluate elderly patients for

dryness, but dentists are better suited to eval-

uate for the number of teeth present, denture

ﬁt (if applicable), the ability to chew food, and

the presence of dental caries and oral cancers.

If xerostomia is present, pharmacists can work

with dentists and medical providers to reduce

drug causes of xerostomia.

Skin Assessment

Skin examinations in the elderly should focus

on dryness, cellulitis, edema, and cancer. Due

to impaired sensation in the skin and impaired

vision, elderly patients may not realize that their

skin is dry, damaged, or infected. This is espe-

cially true for patients with diabetes, who often

suffer from neuropathies in their extremities, as

their sensation may be diminished and their

report inaccurate. Edema is more prevalent in

patients with heart failure but can also occur as a

side effect of medications or just poor circulation.

In addition to a skin and extremities examination,

weight can also be used to help determine how

much ﬂuid overload is present.

Pulmonary Assessment

Lung examinations in the elderly are similar to

those in younger patients, taking into account

that those with kyphosis may require a more

meticulous assessment. If a patient has heart

failure, the lung examination may also include an

assessment for pulmonary edema (e.g., rales).

Pulmonary function tests are also helpful to eval-

uate the severity of asthma and chronic obstruc-

tive lung disease. Patients may also be candi-

dates for further testing with a sputum test, chest

x-ray, or computed tomography (CT) to screen

for lung cancer if they meet the following char-

acteristics: (1) their age is less than 75–80 years,

(2) they have at least a 30 pack-year smoking

history, (3) they are currently smoking or stopped

within the past 15 years, or (4) they are in fairly

good health and/or are able and willing to have

curative lung surgery if cancer is detected.

10,11

Cardiovascular Assessment

Cardiovascular examinations should evaluate

patients for murmurs and arrhythmias, such as

atrial ﬁbrillation. Blood pressure (both regular

and orthostatic) as indicated above should be

assessed and evaluated, recording time of day

and corresponding heart rate. Based on the

patient goals, for a patient with hypertension a

fasting lipid panel should also be performed to

evaluate whether he or she has dyslipidemia. If

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4 - Geriatric Assessment |

the patient has a sustained blood pressure of at

least 135/80 mmHg, the USPSTF recommends

screening the patient for type 2 diabetes every

3 years, typically using a fasting plasma glucose

concentration or an HbA

measurement.

electrocardiogram, carotid auscultation, and an

echocardiogram may also be needed to further

evaluate for arrhythmias, stroke risk, and heart

failure, respectively. If the patient has a history

of cardiovascular disease or cardiac risk factors,

he or she should also be evaluated for peripheral

vascular disease (PVD) with the ankle-brachial

index. This simple calculation divides the

systolic blood pressure in the ankle/foot by the

systolic blood pressure in the arm to determine

the index. A quotient below 0.8 is considered

positive for PVD.

Musculoskeletal Assessment

Musculoskeletal examination in the elderly

should evaluate range of motion in the joints;

stability; strength; and the ability to rise from a

sitting position, stand, bend forward, bend down,

walk, and rotate the head around naturally. A

proper amount of space is required to evaluate

the patient. Some gait changes occur naturally

with aging, such as narrowing or widening of the

stance. Gait and balance will also be discussed

further (see Functional Assessment).

Abdominal and Urologic Assessment

Palpation of the abdomen in the elderly is impor-

tant to identify any masses and hernias. In this

population, abdominal examinations often elicit

a history of constipation, which is common

because of the adverse effects of medications,

decreased water and ﬁber intake, and lack of

activity. A rectal examination may identify hemor-

rhoids and/or an enlarged prostate in men. Pros-

tate cancer screening with a prostate-speciﬁc

antigen (PSA) blood test is extremely contro-

versial and is no longer recommended by the

USPSTF. The American Cancer Society recom-

mends that providers discuss screening in men

with a life expectancy of at least 10 years.

evaluation for colon cancer (such as a colonos-

copy) every 10 years, a ﬂexible sigmoidoscopy

every 5 years, a double contrast barium enema

every 5 years, or a CT colonography every 5

years should also be offered.

Due to the inva-

siveness of colon cancer screening procedures

and the lag time to beneﬁt of approximately 10

years, there is no agreement about how long

to continue testing.

The USPSTF recommends

stopping screening at 75 years of age, but

regardless of age, if a patient is frail and would

choose not to treat a detected cancer, there

is often no beneﬁt to performing screening.

Urologic examinations should focus on urinary

retention, incontinence, and benign prostatic

hypertrophy. Many clinics now have ultrasound

machines that can evaluate post-void residuals

in patients with urinary retention; this can also

can be done with a urinary catheter. Pap smears

in women can be stopped at age 65 if patients

have had regular cervical cancer screening with

normal results or if they are otherwise not at high

risk for cancer.

However, the American Cancer

Society recommends continuing testing for at

least 20 years after diagnosis of any serious

cervical pre-cancer.

Elderly women should also

be asked about symptoms of vaginal dryness.

Neurologic Assessment

Thorough neurologic examination in the elderly

can identify many subtle abnormalities in muscle

strength, sensation, reﬂexes, sensory motor

skills, coordination, tremor, muscle tone, and

postural stability. In a study of older, commu-

nity-dwelling adults without overt neurological

disease, multiple subtle neurologic abnormali-

ties were associated with cognitive and func-

tional decline and independently predicted

mortality and cerebrovascular events.

In addi-

tion, cognition should be evaluated either with

the neurologic examination, or separately. A

discussion of cognitive assessment is found later

in this chapter.

Other Assessments

Other evaluations that should be done in the

elderly include an assessment of sleep, and a

foot examination to evaluate for pulses, dryness,

nails, ulcers, and deformities. Patients with

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| Fundamentals of Geriatric Pharmacotherapy

foot abnormalities or functional deﬁcits can be

referred to a podiatrist for further evaluation.

In addition, a clinical breast examination and

mammography is recommended annually in

women if they are in good health,

and a dual-

energy x-ray absorptiometry (DEXA) is recom-

mended for all elderly women and high-risk men

to evaluate their bone mineral density for osteo-

porosis. The DEXA should be performed on all

eligible patients as long as they are able to lay

down comfortably during the procedure and are

eligible for osteoporosis treatment. Medicare will

cover one screening DEXA test every 2 years.

Evaluating and assessing osteopenia or osteo-

porosis further can be facilitated by using the

World Health Organization Fracture Risk Assess-

ment Tool (FRAX) available online at http://www.

shef.ac.uk/FRAX/.

The tool takes into account

patient-speciﬁc risk factors such as age, height,

weight, race, country of origin, concomitant

medications, disease states, and bone mineral

density (if available) to estimate the 10-year

probability of fracture. The tool can also be used

to decide whether drug treatment is warranted

based on the cost-effectiveness of treatment.

Laboratory Measurements

Typical baseline laboratory measurements that

should be obtained in the elderly include thyroid

stimulating hormone (TSH), complete blood

count (CBC), and a basic metabolic panel to

evaluate electrolytes and serum creatinine (SCr).

In patients with a life expectancy of 3 years or

more, a fasting lipid panel to screen for hyper-

cholesterolemia may be indicated. Using the

SCr, an estimation of creatinine clearance (CrCl)

should be performed on all elderly patients at

baseline and if the SCr increases signiﬁcantly.

Although it may underestimate the CrCl slightly,

the Cockcroft-Gault equation is still preferred

for use in the elderly to estimate kidney function

and adjust medication doses, as discussed in

Chapter 3.

Additional laboratory measurements are

indicated in speciﬁc situations: an HbA

if the

patient is diabetic; vitamin B12 if the patient is

malnourished or has memory loss, anemia,

depression, fatigue, or neuropathy; serum drug

concentrations for certain narrow therapeutic

index drugs (e.g., digoxin, phenytoin); liver func-

tion tests if the patient is on medications that

can raise these concentrations; and a serum

25-hydroxy vitamin D concentration, especially

if the patient has a history of falls or osteopo-

rosis, is obese, takes no vitamin D supplement,

or is institutionalized. After laboratory tests have

been measured once, Medicare may not reim-

burse for them again for a certain time period.

For example, unless the patient has an indica-

tion such as hyperlipidemia, hypertension, or

coronary disease, Medicare may not reimburse

for another screening fasting lipid panel for 5

years. Medicare also has the restriction that

HbA

cannot be checked more often than once

a month.

KEY POINT:

e type and frequency

of laboratory examinations in the

elderly are often governed by Medicare’s

reimbursement restrictions.

Assessments in ose Who Cannot

Provide a Self-Report

Physical examination and review of systems in

patients who cannot provide a self-report is often

difﬁcult and may rely on caregiver input. In patients

who are institutionalized or who cannot provide

a self-report, some examinations and screen-

ings may be eliminated because the provider is

limited to bedside assessments. Certain screen-

ings may not be necessary. Generally, the risks

and beneﬁts of the examination/screening can

be reviewed by the provider, patient, family, or

medical power of attorney to help determine how

aggressive or limited to make the examination.

Vision and hearing assessment are typically only

necessary for establishing a patient’s quality of

life. However, if the patient is unable to respond,

it is not always possible to get accurate results.

Studies of pain assessment in elderly patients

with cognitive impairment indicate that self-

report pain scales can still be used.

17-19

Based on

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4 - Geriatric Assessment |

several studies, it appears that elderly persons

with cognitive impairment respond reasonably

well to the Verbal Rating Scale (none, mild,

moderate, or severe), the Numeric Rating Scale

(1–10 horizontal scale), and the FACES rating

scale (utilizes facial expressions to rate pain).

17-19

Other means of assessing pain may be neces-

sary in nonverbal patients or those with severe

cognitive impairment.

R  M

P  M

The medical history of a geriatric patient can

be extremely complex and time consuming to

elicit. Often, the patient may not have previous

medical records and may not fully remember his

or her medical history, so care must be taken to

order pertinent medical records from previous

providers and hospitals. A complete medical

history should include a family history, history

of present illness, active medical problems,

past medical problems, past hospitalizations,

and past surgical procedures. It is especially

helpful to identify the dates because they can

change current medical therapy. For example,

if a patient had a coronary stent placed several

years ago, it may be possible to reduce dual

antiplatelet therapy, unlike a patient who had a

coronary stent placed in the last several months.

A functional health literacy assessment can also

be performed to assess the patient’s ability to

obtain, process, and understand basic health

information and make appropriate health deci-

sions.

Examples of formal assessments of

health literacy include the Rapid Estimate of

Adult Literacy in Medicine (REALM) and the

Test of Functional Health Literacy in Adults

(TOFHLA).

21,22

The short forms of these assess-

ments, along with the Newest Vital Sign (NVS),

are quicker to administer and, therefore, may be

more appropriate for clinical practice.

A recent immunization history should be

obtained for every elderly patient, as multiple

immunizations are indicated for them. All patients

should be evaluated for a history of pneumo-

coccal vaccination, yearly inﬂuenza vaccina-

tions, herpes zoster vaccination, and a tetanus/

diphtheria (Td) or tetanus/diphtheria/acellular

pertussis (Tdap) booster. Unvaccinated older

adults can be referred to their local pharmacies

for indicated immunizations.

A full medication assessment is also essen-

tial for geriatric patients. This should include

current use of prescription drugs and over-

the-counter (OTC) vitamins, supplements, and

herbal medications. The patient’s pharmacy

contact information should be obtained as well.

Past use of medications for chronic diseases,

such as chronic pain, diabetes, and hyperten-

sion, can also be useful to optimize future therapy

and to update the allergy/adverse event proﬁle,

if applicable. A pharmacist is well equipped to

perform the medication assessment or provide

valuable input. Special insight from the pharma-

cist can help to identify drugs with no medical

indications, drugs treating side effects of other

drugs, duplications in therapy, drug–drug and

drug–disease interactions, adverse effects,

inappropriate or inadequate prescribing, nonad-

herence, and other drug therapy problems.

Pharmacists are integral in reducing drug-

related costs for elderly patients. This can be

accomplished in many ways, but it typically

includes increasing Medicare Part D formulary

adherence to lower tier medications and recom-

mendations for discontinuing medications.

Pharmacists can also help patients utilize phar-

macy-speciﬁc drug discount programs (e.g., $4

generics) and manufacturer patient assistance

programs, and they can ensure that the patient

applies for extra assistance from state or federal

programs (e.g., Social Security extra assistance

or Medicaid).

KEY POINT:

Insight from the pharmacist

can help identify drug therapy problems,

opportunities for reducing drug-related

costs, and the need for patient education.

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| Fundamentals of Geriatric Pharmacotherapy

Along with a functional health literacy

assessment, it is helpful to assess under-

standing of medications and disease states.

How skilled a patient is in the self-administration

of medications should also be determined. If

the patient cannot perform these duties, plans

for assistance should be made. Simple devices,

such as pillboxes or calendars, can help many

elderly patients remember to take their medi-

cations. For those with cognitive impairment or

complex medication regimens, family members

or caregivers may have to assist with administra-

tion. Nonadherence in the elderly can be inten-

tional (e.g., to save money or to prevent side

effects) or unintentional (e.g., too complex for

patient to handle or forgetting to order reﬁlls). For

institutionalized patients, medication adherence

cannot be assumed because patients still have

the ability to refuse their oral medications and

unforeseen circumstances may prevent admin-

istration. Speciﬁc tools, such as the Morisky

Scale, the Drug Regimen Unassisted Grading

Scale (DRUGS), and Medication Manage-

ment Instrument for Deﬁciencies in the Elderly

(MedMaIDE

) instruments, can assist the phar-

macist in assessing the patient’s capacity to

manage medications, including adherence.

24,25

The Morisky Scale consists of yes/no questions for

patients to ascertain whether they are forgetting

to take medication or are purposefully choosing

to stop due to hassles or side effects. It has

been adapted and validated for use in hyperten-

sion in seniors. The DRUGS evaluation involves

asking patients about each of their own medi-

cations and comparing their responses to the

medication directions, calculating a percentage

of answers regarding naming the drug, identi-

fying the correct directions, and identifying the

time of day for administration. Poorer scores are

associated with lower Mini-Mental State Exami-

nation (MMSE) scores and increased risk of

institutionalization. The MedMaIDE

instrument

is designed to identify whether a patient under-

stands what his or her medications are for, and

how to obtain and administer them.

Pharmacists providing medication therapy

management (MTM) services will typically

perform a thorough medical, medication, and

adherence assessment. Pharmacists directly

working with the primary care provider may have

access to the medical records for the patient, but

pharmacists providing services from a commu-

nity pharmacy setting or through the Medicare

Part D plan may only have access to limited

medical record information along with medical

and drug claims data. Pharmacists seeing

patients in person for MTM can perform their

own vital signs to evaluate the patient’s drug

therapy. Overall, pharmacists have the knowl-

edge and ability to make many recommenda-

tions for patients to optimize their medications,

improve adherence, reduce drug costs, and

prevent adverse drug events.

Pharmacists providing MTM services or

seeing geriatric patients in the community may

refer patients to a geriatrician for a more thor-

ough medical review. Moreover, interprofes-

sional teams are important for quality care for

complex geriatric patients. Depending on the

state in which they practice, pharmacists can

directly refer patients to a physical therapist,

occupational therapist, social worker, or dietitian

for additional assistance with their healthcare,

functioning, or social issues, although a physi-

cian’s order may be necessary for Medicare to

pay for the services.

C A

Although the USPSTF concluded that evidence

is insufﬁcient to assess the balance of beneﬁts

and harms of cognitive screening, many clini-

cians prefer to screen for cognitive impair-

ments in older adults. If cognitive screening is

warranted, assessment should be performed at

one of the ﬁrst visits and then yearly, or as often

as determined to be clinically relevant. There

are multiple tools to assess cognition, but typi-

cally clinicians will utilize the MMSE, Mini-Cog,

or the St. Louis University Mental Status (SLUMS)

Examination.

26-28

These tools are most utilized as

they are quick to perform and are often reprinted

for clinic use. They can be utilized in the outpa-

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4 - Geriatric Assessment |

tient or institutional settings. Pharmacists in

many settings can easily initiate screening if they

detect potential cognitive impairment, such as

while performing MTM services or discussing

adherence. In patients who may have complex

cognitive impairment or for clinicians who are

not comfortable with cognitive testing, refer-

ring patients to a neuropsychologist, speech-

language pathologist, or neurologist trained in

cognitive testing can be useful.

KEY POINT:

ere are multiple

tools to assess cognition, but typically

clinicians will utilize the Folstein Mini-

Mental State Examination (MMSE),

Mini-Cog, or the SLUMS Examination.

The MMSE is a widely used clinical tool

for assessing cognitive impairment associated

with dementia and is typically used to stage

Alzheimer disease as mild, moderate, or severe.

It includes 11 questions assessing ﬁve different

domains: short-term memory (recall), orienta-

tion, attention, language, and short-term memory

(retention).

The maximum possible score for

the test is 30 points. Typically, a score of 24–30

indicates a negative screen, 19–23 indicates

mild deﬁcits, 10–18 indicates moderate impair-

ment, and less than 10 indicates severe cogni-

tive impairment. The examination takes approxi-

mately 7–10 minutes to administer but possibly

longer if the patient has more severe cognitive

impairment. Some disadvantages of the MMSE

are that education level and language barriers

can inﬂuence the results. It is also copyrighted

and must only be used with permission or for

a fee. However, the MMSE has been translated

into multiple languages, making it appropriate

for use in a broad population of patients.

The Mini-Cog (Figure 4-1) is a combina-

tion three-item recall and a Clock Drawing Test

(CDT). It is a simple, brief, and valid screening

tool designed to identify individuals at high

risk for dementia. Because the Mini-Cog takes

approximately 3 minutes to administer, it is

extremely simple for clinicians to remember and

use. Moreover, pharmacists can easily imple-

ment the Mini-Cog into their assessments when

discussing adherence, ability to self-admin-

ister medications, or medication management

services. The Mini-Cog assesses short- and

long-term memory, verbal comprehension,

conceptualization, and executive functioning. It

has a sensitivity of 76% to 99% and a speciﬁcity

of 89% to 93% at detecting cognitive impair-

ment.

Multiple studies have compared the Mini-

Cog to the MMSE and have found them to be

equally effective, but the Mini-Cog serves only

as a screening tool, whereas the MMSE can also

serve to stage the impairment.

Culture, educa-

tion, and language do not inﬂuence test results

of the Mini-Cog.

29,30

Additional screening tests for cogni-

tion include the SLUMS Examination (Figure

4-2), the Seven Minute Screen (7MS), and the

Montreal Cognitive Assessment (MoCA). The

SLUMS is similar in format to the MMSE, with

a 30-point, 11-item scale. Patients are scored

based on their level of education and classiﬁed

as normal, having mild neurocognitive disorder,

or having dementia. The SLUMS examination is

comparable to the MMSE at detecting cognitive

impairment and appears to be possibly better at

identifying mild neurocognitive disorder.

Many

clinic settings, along with most Veterans Affairs

facilities, utilize the SLUMS examination because

of its enhanced beneﬁt in identifying mild cogni-

tive disorders and lack of copyright issues.

The 7MS is another neurocognitive screening

tool developed to provide improved sensitivity.

It is composed of four brief tests: orientation,

enhanced cued recall, CDT, and verbal ﬂuency.

The 7MS administration time ranges from 6 to

11 minutes and has performed better than the

MMSE at evaluating very mild to mild Alzheimer

disease; also, it is not affected by gender, age,

or education level.

31,32

The MoCA examination

was designed to detect mild cognitive impair-

ment (MCI) and has been translated into many

languages for use. It takes about 10 minutes to

administer and assesses attention, concentra-

tion, executive functions, memory, language,

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| Fundamentals of Geriatric Pharmacotherapy

TE_________ ID_________________________

AGE____ GENDER M F LOCATION ______________________ TESTED BY________

MINI-COG™

GET THE PATIENT’S ATTENTION, THEN SAY: “I am going to say three words that I want you to remember now and later. The words

are:

Banana Sunrise Chair.

Please say

them for me now.” (Give the patient three tries to repeat the words. If unable after three tries, go to next item.)

(

Fold this page back at the TWO dotted lines BELOW to make a blank space and cover the memory

words. Hand the patient a pencil or

pen.)

SAY ALL THE FOLLOWING PHRASES IN THE ORDER INDICATED

: “Please draw a clock in the space below. Start by drawing a large

circle.”

When this is done, say:

“Put all the numbers in the circle.” When this is done, say: “Now set the hands to show 11:10 (10 past

11).”

If subject has not finished clock drawing in 3 minutes, discontinue and ask for recall items.

------------------------------------------------------------------------------------------------------------------------------

---------------------------------------------------------------------------------

-------------------------------------------------------------------------------------------------------------------------------

-------------------------------------------------------------------------------

SAY: “What were the three words I asked y

ou to remember?”

(Score 1 point for each) 3-Item Recall Score

Score the clock (see other side for instructions):

Normal clock 2 points

Clock Score

Abnormal clock 0 points

Total Score

= 3-item recall + clock score

0, 1, or 2 possible impairment; 3, 4, or 5 suggests no impairment

Figure 4-1. The Mini-CogTM tool is used to screen individuals at high risk for dementia.

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