B245 assessment of the older adult

B245: Assessment of the Older Adult

Assignment Objectives

  1. Incorporate valid and reliable tools to assess the physical and functional status of an older adult client.
  2. Communicate effectively, respectfully, and compassionately with an older adult client and his/her family.

Directions

To complete this assignment, you will need to assess the health status of an adult over the age of 65 years. You must have the verbal consent of the older adult. The purpose of the exercise is for you, the student, to gain experience with older adult assessments, not to diagnose or make recommendations. If the client has specific health questions, please refer to the primary care provider. Notice that the focus of older adult assessment is functional, not purely physical assessment. This paper will need to be typed. Use the form on the following pages to complete your assessment. The paper including all supporting documents (assessment tools (a through e), the worksheet, and your typed paper) must be compiled into one document and uploaded into Canvas by the date and time set by your faculty.

Preparation for Assignment

Prior to performing the Assessment of the Older Adult:

Read the Assessment of the Older Adult Chapter in your textbook prior to meeting your patient.

Reference www.consultgeri.org (Visit “Tools” then select “Videos” and then “How to Try This”)

 

B245: ASSESSMENT OF THE OLDER ADULT

Student:Amanda PullinDate: 03/30/2018

Client Initials: JKP Sex: Female Race: White

DOB: 04/29/1947 Marital Status: Married Height: 5’2 Weight: 140 lbs.

Past Medical History (include dates):

Pt was diagnosed with Hypoglycemia in 1973 physician treated it for two years after Pt no longer showed signs, Pt currently no longer takes medication for it. Diagnosed with Hypertensive in 1985 Pt indicates this disease was caused by genetics because both her parents had it. Diagnosed with Emphysema in 1998 caused from smoking cigarettes. Diagnosed with Chronic Obstruction Pulmonary Disease in 2008 caused from smoking cigarettes. Pt was diagnosed with Glaucoma in 2010 due to old age and history of poor visual acuity. Diagnosed with Cataracts in 2015 Pt refuses to receive treatment because of the anesthetics the HCP would use to operate on her eyes and she fears she will stop breathing if she was put under anesthetics.

Past Surgical History (include dates):

Tonsillectomy in 1953 and Caesarean section delivery of second child in 1983

Medication (prescription and over the counter):

Dosage

Frequency

Reason for taking

Bisoprolol

25mg

1 tablet per day

Hypertension

Cetirizine (hydrochloride)

10mg

1 tablet per day

Allergies

Esomeprazole

20 mg

1 tablet per day

Acid reflex

Ipratropium Bromide and Albuterol Sulfate

0.5mg/3mg per 3mL

4X a day with a nebulizer

Mucus built up in the lungs

Qvar

80mg

Once a day inhaler

Opens airway

Oxygen

2L

Continuous

O2 decreases without oxygen

Allergies: (drugs, food, tape, dyes) ¨Yes

List Allergies: Skin allergies towards laundry detergents (Tide/Gain), bar soap (scented), and lotion (scented) and Levofloxacin an (antibiotic).

Reaction: Breaks Pt out in a rash with laundry detergents, bar soaps, lotions and if left untreated her skin starts to peel off. Breaks out into hives after taking the antibiotic.

Health Maintenance Perception Pattern (from Client’s Viewpoint):

USE OF TOBACCO: ¨None ¨Quit (Date)) She quit smoking in 2012 ¨Pipe ¨Cigar 

¨<1 pk/day ¨ 1-2 pks/day ¨ >2 pks/day ¨ Pks/Year history 2 pks/day when she was smoking. Was a smoker from 1962 to 2012 decided to quit after having severe pneumonia and physician telling her she would die if she didn’t quit smoking. Pks/years history equal 100.

USE OF ALCOHOL: ¨ None Type __________ Amount _____ /day _____ /week _____ /month

OTHER DRUGS: ¨Yes ¨ No Type __________ Use__________

Activity/Exercise Pattern (complete Katz, Activity of Daily Living Assessment.)

Assistive Devises: ¨ None ¨Crutches ¨Walker ¨ Cane ¨ Bedside Commode

¨ Splint/Brace ¨ Wheelchair ¨ Other Oxygen Concentrator

Nutrition/Metabolic Pattern (complete the Hartford Mini Nutritional Assessment)

Nutritional status from client’s viewpoint): Pt views her nutritional status as healthy. I pulled up the Food Plate that we learned about in Assessment and she indicated that she tries eating out of each category listed but dairy. Avoids dairy due to constipation. For snacks she likes to eat peanuts and cashews. Pt. avoids fried and spicy foods because it causes her stomach to be hyperactive and BM’s to be painful. Pt loves vegetables her favorite is broccoli and carrots.

Special diet/supplements: No diet

Previous Dietary Instructions: ¨Yes ¨ No

Appetite: ¨ Normal ¨Increased ¨ Decreased ¨ Decreased taste sensation ¨ Nausea ¨Vomiting ¨ Stomatitis

Weight Fluctuations last 6 months: ¨ None ¨ Gained ¨ Lost Lbs _____

Swallowing Difficulty (Dysphagia): ¨ None ¨ Solids ¨ Liquids

Dentures: ¨ None ¨Upper ( ) Partial ( ) Full ¨ Lower ( ) Partial ( ) Full

History of Skin/Healing Problems: ¨ None ¨Abnormal Healing ¨ Rash ¨ Dryness

Elimination Pattern (from Client’s viewpoint):Pt views her elimination pattern as different. There are good days and then there are bad days. It all depends on what she eats or if she has stress throughout the day. Pt claims she drank Pepsi every day with every meal for about 30 years until her health care provider educated her that drinking water is better and to quit drinking the Pepsi. With her age she has noticed it is harder to control bladder urges she has only had one accident where she missed the toilet when she coughed hard but other than that she knows when she must void. Pt must watch food habits because she does become constipated if she digests something that does not sit well in her stomach. When Pt becomes stressed she has diarrhea.

Bowel Habits: # BMs/day: 1 Date of last BM: 03/29/2018

¨ Constipation ¨Diarrhea ¨ Incontinence

¨Ostomy: Type: 2 Appliance ________

Self-Care ¨ Yes ¨ No

Describe: BM’s tend to be light to dark brown color. Consistency is firm poop (lumpy, sausage-shaped poop)- Type 2. Occasionally becomes constipated when she eats food out of her norm.

 

Bladder Habits: ¨ Frequency ¨Dysuria ¨ Nocturia ¨ Urgency ¨Hematuria ¨ Retention

Describe: Urine is yellow/clear color. Voids more frequently than she did when she was younger. Also wakes up in the middle of the night to void more than once. No burning sensation or pain in lower abdomen when voiding.

Incontinency: ¨Yes ¨ No _____ Total ¨Daytime ¨Nighttime

¨Occasional ¨Difficulty/delaying voiding ¨ Difficulty reaching toilet

Describe: Pt has no issues with incontinency.

Assistive Devices: ¨ Intermittent catheterization ¨ Indwelling catheter

¨ External catheter ¨ Penile implant Type

¨ Incontinent briefs ¨ None

 

Sleep/Rest Pattern: Use Pittsburg Sleep Quality Assessment and assess from client’s viewpoint:After completing the Pt’s sleep/rest pattern with the Pittsburg Sleep Quality Assessment she scored poor. Pt stated since she was diagnosed with COPD her sleeping patterns have changed. Pt can’t sleep laying in a supine position because she can’t breathe comfortably. She can only fall asleep sitting up in a Fowlers position on her couch with her O2 NC on 2L. She has coughing episodes more frequent than normal due to her medical conditions COPD and Emphysema.

Habits: 8 hrs/night ¨ AM nap ¨ PM nap

Problems: ¨ None ¨ Early waking ¨ Insomnia ¨ Nightmares

Feel rested after sleep: ¨ Yes ¨ No

Cognitive-Perceptual Pattern (from Client’s viewpoint): Pt views her ability to comprehend and her sensory functions are operating very well. Pt states she understands what is going on and she is aware of her sensory input.

Hearing: ¨ Impaired ( ) Right ( ) Left ¨ Deaf ( ) Right ( ) Left

¨ Hearing Aid ¨ Tinnitus

Describe: No hearing problems

Vision: ¨Eye Glasses ¨ Contact Lens ¨ Impaired ( ) Right ( ) Left

¨ Blind ( ) Right ( ) Left ¨ Cataract ( ) Right ( ) Left

Describe: Pt has glaucoma which has impaired her vision. The cataract has impaired both right and left and has worsen in the right eye as she is getting older. Pt has had myopia her whole life. Wears contact lens and eye glasses equally throughout the days.

Vertigo: ¨ Yes ¨ No

Discomfort/Pain: ¨ None ¨ Acute ¨Chronic

Describe: Pt has no pain currently.

Pain Management: Pt manages her pain by using her nebulizer for breathing treatments. Pt claims other than having trouble breathing she no pain anywhere.

 

Coping Stress Tolerance/Self-Perception/Self-Concept Pattern

Are there currently any stressors in your life? Please discuss:

Pt has a son who is having difficulties finding a full-time job due to a medical condition (ADHD). Bills are tight now that her and her husband are both retired. Pt stresses about everything especially leaving the house because of her conditions she fears of catching a cold. Pt has two Pomeranians that she never lets outside because she is afraid they will run away or get sick from eating something outside. Her oldest granddaughter was just diagnosed with HPV and she stress’s out over that because she wants her to be able to have children one day.

Major loss/change in past year: ¨Yes ¨No

Discuss: Pt states her mother-in-law just passed away at the age of 93 due to dementia. The Pt and her husband took care of her mother-in-law at home because they didn’t want her to be in a nursing home. Pt states, “it was very tough taking care of her the last two years she was alive because she would walk outside in the middle of the night thinking it was daytime and she would become real hateful when things didn’t go her way.” The Pt described towards the last few months her mother-in-law was alive she lost the will to live so changing her briefs and rolling her every two hours was hard on both the Pt and her husband. Pt’s mother-in-law died September of 2017. Pt states she misses her a lot.

Mobility: Assess patient’s mobility. Discuss findings below:

Pt moves around independently. She does tend to move at a slower pace because she is hooked up to NC O2 all the time. When she walks her back is hunched and her head is always looking down to the floor. She gets SOB quick due to her medical conditions (COPD) and emphysema. Pt is very mobile though for being hooked up to an oxygen tank.

Safety: Assess patient’s home safety. Discuss findings below:

I provided a good overview scope of the patient’s home. I identified personal safety hazards that could present a threat to the Pt’s safety, which include: unsafe kitchen appliances, unstable family members, and potentially dangerous pets. The Pt is on oxygen continuously and needs to stay on oxygen because if she doesn’t have it her oxygen saturations decrease, and she can’t breathe. The stove is a gas stove and oxygen and gas do not mix well together could explode. The Pt has 34-year-old son who does not take his ADHD medication routinely and has temper tantrums occasionally and makes the Pt upset by verbally abusing her. The Pt has two Pomeranians that are very hyper and always bouncing off the walls; could potentially cause the Pt to trip over NC or them if they were to get in her way while the Pt was walking.

Discuss Patient’s Living arrangements:

Pt disclosed that she only goes to her health care provider when she has her appointments scheduled. Pt has her husband or son transport her. Other than doctor visits, she stays at home and never leaves the house because she fears of becoming ill if she gets out in public areas. For groceries she orders all of them online from Walmart and her son goes and picks them up from Walmart same with prescriptions. Pt stated if she were to catch a cold it takes her body to work 10X harder to fight off infections due to her medical conditions COPD and Emphysema. Since she fears that her two Pomeranians could get sick from going outside she allows them to void on piddle pads in the house, which was not to bad on observing but she cleans up their messes mostly.

Adult Children (ages, sex, location, frequency of contact):

A 49-year-old son who lives in Florida and a 34-year-old son who lives at home with Pt.

Friends, Social Activities, Work, Volunteer Activities, Pets, Hobbies: Pt states many of her friends have passed away but she keeps in touch with a few friends through Facebook who are still alive. Pt enjoys playing online crossword puzzle and online poker games with online players. Pt has two small Pomeranian’s that are very hyper due to them being very young in age. The two dogs keep her busy with mobility because they are always getting into stuff they are not supposed to. Pt does not have many hobbies anymore she used to collect anything with frogs now she has all of her frog collection boxed away.

Transportation: Pt does not drive and has not drove for two years. Pt has son and husband that transports her to doctor visits.

CV/PV System

Pulse rate: 76 Peripheral Pulses: Carotid pulse 3+; Apical pulse 3+; Brachial pulse 3+; Popliteal Pulse 2+; Dorsalis Pedis Pulse 2+; Posterior Tibial Pulse 2+

Heart sounds: Soft heart sounds. Interposition of lung between the heart and chest wall (hyper inflated lungs)

Respiratory System

Quality: ¨Shallow ¨Rapid ¨ Labored Breath sounds: Decrease breath sounds with continuous rhonchi in anterior, posterior, right and left lungs.

Cough: ¨Present ¨ Not present

Metabolic/Integumentary

Skin Color: ¨ Pale ¨ Cyanotic ¨ Ashen ¨Jaundice ¨ Other

Temperature: ¨Warm ¨Cool ¨ Dry

Turgor: ¨ WNL ¨Poor

Edema: ¨Yes ¨ No Description/Location: Swelling of left ankle caused from medication/steroid doctors are aware of the side effect.

Lesions: ¨ Yes ¨ No Description/Location _____________________

Bruises: ¨Yes ¨No Description/Location _____________________

Reddened: ¨ Yes ¨ No Description/Location _____________________

Pruritus: ¨ Yes ¨ No Description/Location _____________________

Tubes: None Specify _________________________________________________

Mouth ¨Lesions ¨Other Lips are pink, smooth, and moist without lesions. Buccal mucosa is pink, moist, and without exudates. Equal bilateral strength in tongue. Ventral surface of tongue smooth and pink with small amount of white fluffs. Tonsils are not present.

Gums: Describe: Pink without redness or swelling.

Teeth: Describe: 32 yellowish teeth present with 6 fillings.

Neuro/Sensory

Mental Status: ¨ Alert ¨Oriented to: person, place, and time ¨Confused ¨Unresponsive ¨Receptive Aphasia ¨Poor Historian ¨Combative

Speech: ¨ Normal ¨ Slurred ¨ Garbled ¨Expressive Aphasia

Spoken Language: English Interpreter: ______________________

Pupils: ¨PERRLA Describe: Pupils are equal and round but are NOT reactive to light and do NOT accommodate. I believe this is caused by her cataracts.

Eyes: ¨ Clear ¨Draining ¨Reddened ¨ Other: Cloudy

Muscular-Skeletal

Complete the Fall Risk Assessment for Older Adults: The Hendrich II Fall Risk Model.

Range of motion: ¨Full ¨Other

Gait: ¨ Steady ¨ Unsteady

Upper Extremity Strength: ¨Equal ¨Strong ¨Weakness/Paralysis ( ) Right ( ) Left

Lower Extremity Strength: ¨ Equal ¨ Strong ¨ Weakness/Paralysis ( ) Right ( ) Left

Current health issues - Written submission required (Can type into this document):

  1. Discuss health status from your Client’s perception (Write at least 2 full paragraphs (6-8 sentences in each paragraph)).
  2. Discuss your perception of your client’s health status based on your client’s scores on the following assessment tools for older adults (Write at least 2 full paragraphs (6-8 sentences in each paragraph) ):

My Clients Perception

After completion of the assessment on my older adult client, I asked her to discuss her perception on her health status. The client was very emotional while discussing her health status because her COPD and emphysema was all self-inflicted by her choices in life with smoking “KOOL” menthol cigarettes for 50 years and she understands that. She indicated that she wished she never would have started smoking cigarettes at a young age because she hates not being able to do what other people do normally with daily activities as a 71-year-old and there is nothing she can do to fix it because the damage has been done to her lungs. I will never forget what she said when she stated: “I am going to die one day because of this disease but until then I am going to live my life as best as I can. COPD is not going to crack my drive to stay alive right now.” She described her struggle with breathing by comparing herself to a fish that jumped out of water, which is scary to think because when you catch that fish from the water you are killing it but suffocation. Imagine suffocating daily, who would want that? She said that every day is a struggle for her to breath, sleep, and be mobile. She can’t sprawl out on her bed because the moment she lays flat she can’t breathe. She feels like her mental health has worsen since she was put on an oxygen in 2012. She thinks others perceive her differently when she wears her oxygen and she becomes embarrassed to be seen in public.

Before all the respiratory issues occurred, she made a justifiable comment that she probably would have avoided cigarettes if her parents would have been non-smokers. Her sister and herself both were exposed to cigarettes by their mother and father and both children were smokers when they became of age. She even stated children of smokers are twice as likely to smoke because the child observes the bad behavior and they think it is okay. She said her father being an alcoholic and abusive towards her mother, her sister, and herself caused her a lot of stress and anxiety. She said when she picked up her first cigarette it gave a super high and she didn’t want that to ever go away because of all the pain she suffered mentally she had to undergo. The sad part is her mental health never got better. The client realized that her second son at the age of thirty-eight had serious health issues because she didn’t quit smoking during pregnancy and it caused her child a potential health risk.

My Perception

My perception on my clients’ health status is based off the assessment tools that were provided for this assignment. The Katz Index of Independence in Activities of Daily Living (ADL) scored my client at a 6 meaning she has high independence of performing ADLs. The client was able to move independently in daily activities for example: bathing themselves, dressing themselves, using the toilet, transferring oneself from the bed to the chair, feeding themselves. I do believe that my client was correct about suffering from stress and anxiety. She worries way too much on things she can’t control, and the client scored a negative screen for dementia on The Mini Cog screening. This means the client is not suffering from dementia. My concerns for this clients’ mental health status would be vocalize to the physician about the clients’ mental health and focus on her anxiety and stress with a therapeutic approach. I think the client is still grieving after the death of her mother-in-law. She went into emotional detail about her passing.

The Pittsburgh Sleep Quality test that I performed during our assessment scored my client with poor sleeping habits. My client has COPD and Emphysema, which can cause severe problems with breathing while laying down in a supine position for bed. She normally sleeps sitting up in a Fowlers position because sitting up allows her to breathe. Her and her husband do not sleep together anymore. Around the older adult age group, you lose sexual urges this is common to see partners sleeping in different beds. My perception of the clients’ nutritional status seems to be working for her. While assessing the client by using “The Mini-Nutritional Assessment Short-Form” the client scored the max points of 14. This means the client has a normal nutritional status. Accidental falls can stem from slipping, tripping, or other accidents. They’re frequently linked to extrinsic factors. To help reduce risk, evaluate the physical environment continually for safety hazards. Be aware that falls in hospitals and other acute-care settings most often occur in patient rooms, when patients are alone, or when they attempt to go to the bathroom. The client scored as a high risk on the fall risk assessment.

From The Hartford Institute for Geriatric Nursing, New York University, College of Nursing

Best Practices in Nursing

Care to Older Adults

generalassessmentseries

Issue Number 2, Revised 2012 Editor-in-Chief: Sherry A. Greenberg, PhD(c), MSN, GNP-BC

New York University College of Nursing

Katz Index of Independence in Activities of Daily Living (ADL)

By: Mary Shelkey, PhD, ARNP, Virginia Mason Medical Center, and

Meredith Wallace, PhD, APRN, BC, Fairfield University School of Nursing

WHY: Normal aging changes and health problems frequently show themselves as declines in the functional status of older adults. Decline may place the older adult on a spiral of iatrogenesis leading to further health problems. One of the best ways to evaluate the health status of older adults is through functional assessment which provides objective data that may indicate future decline or improvement in health status, allowing the nurse to plan and intervene appropriately.

BEST TOOL: The Katz Index of Independence in Activities of Daily Living, commonly referred to as the Katz ADL, is the most appropriate instrument to assess functional status as a measurement of the client’s ability to perform activities of daily living independently. Clinicians typically use the tool to detect problems in performing activities of daily living and to plan care accordingly. The Index ranks adequacy of performance in the six functions of bathing, dressing, toileting, transferring, continence, and feeding. Clients are scored yes/no for independence in each of the six functions. A score of 6 indicates full function, 4 indicates moderate impairment, and 2 or less indicates severe functional impairment.

TARGET POPULATION: The instrument is most effectively used among older adults in a variety of care settings, when baseline measurements, taken when the client is well, are compared to periodic or subsequent measures.

VALIDITY AND RELIABILITY: In the forty-eight years since the instrument has been developed, it has been modified and simplified and different approaches to scoring have been used. However, it has consistently demonstrated its utility in evaluating functional status in the elderly population. Although no formal reliability and validity reports could be found in the literature, the tool is used extensively as a flag signaling functional capabilities of older adults in clinical and home environments.

STRENGTHS AND LIMITATIONS: The Katz ADL Index assesses basic activities of daily living. It does not assess more advanced activities of daily living. Katz developed another scale for instrumental activities of daily living such as heavy housework, shopping, managing finances and telephoning. Although the Katz ADL Index is sensitive to changes in declining health status, it is limited in its ability to measure small increments of change seen in the rehabilitation of older adults. A full comprehensive geriatric assessment should follow when appropriate. The Katz ADL Index is very useful in creating a common language about patient function for all practitioners involved in overall care planning and discharge planning.

MORE ON THE TOPIC:

Best practice information on care of older adults: www.ConsultGeriRN.org.

Graf, C. (2006). Functional decline in hospitalized older adults. AJN, 106(1), 58-67.

Hartigan, I. (2007). A comparative review of the Katz ADL and the Barthel Index in assessing the activities of daily living of older people. International Journal of Older People Nursing, 2(3), 204-212.

Katz, S. (1983). Assessing self-maintenance: Activities of daily living, mobility and instrumental activities of daily living. JAGS, 31(12), 721726.

Katz, S., Down, T.D., Cash, H.R., & Grotz, R.C. (1970) Progress in the development of the index of ADL. The Gerontologist, 10(1), 20-30.

Katz, S., Ford, A.B., Moskowitz, R.W., Jackson, B.A., & Jaffe, M.W. (1963). Studies of illness in the aged: The index of ADL: A standardized measure of biological and psychosocial function. JAMA, 185(12), 914-919.

Kresevic, D.M. (2012). Assessment of physical function. In M. Boltz, E. Capezuti, T.T. Fulmer, & D. Zwicker (Eds.), A. O’Meara (Managing Ed.), Evidence-based geriatric nursing protocols for best practice (4th ed., pp 89-103). NY: Springer Publishing Company, LLC.

Permission is hereby granted to reproduce, post, download, and/or distribute, this material in its entirety only for not-for-profit educational purposes only, provided that 

The Hartford Institute for Geriatric Nursing, New York University, College of Nursing is cited as the source. This material may be downloaded and/or distributed in electronic format, including PDA format. Available on the internet at www.hartfordign.org and/or www.ConsultGeriRN.org. E-mail notification of usage to: hartford.ign@nyu.edu.

Katz Index of Independence in Activities of Daily Living

ACTIVITIES

POINTS (1 OR 0)

INDEPENDENCE:

(1 POINT)

NO supervision, direction or personal assistance

DEPENDENCE:

(0 POINTS)

WITH supervision, direction, personal assistance or total care

BATHING

POINTS: 1

(1 POINT) Bathes self completely or needs help in bathing only a single part of the body such as the back, genital area or disabled extremity.

(0 POINTS) Needs help with bathing more than one part of the body, getting in or out of the tub or shower. Requires total bathing.

DRESSING

POINTS: 1

(1 POINT) Gets clothes from closets and drawers and puts on clothes and outer garments complete with fasteners. May have help tying shoes.

(0 POINTS) Needs help with dressing self or needs to be completely dressed.

TOILETING

POINTS: 1

(1 POINT) Goes to toilet, gets on and off, arranges clothes, cleans genital area without help.

(0 POINTS) Needs help transferring to the toilet, cleaning self or uses bedpan or commode.

TRANSFERRING

POINTS: 1

(1 POINT) Moves in and out of bed or chair unassisted. Mechanical transferring aides are acceptable.

(0 POINTS) Needs help in moving from bed to chair or requires a complete transfer.

CONTINENCE

POINTS: 1

(1 POINT) Exercises complete self control over urination and defecation.

(0 POINTS) Is partially or totally incontinent of bowel or bladder.

FEEDING

POINTS: 1

(1 POINT) Gets food from plate into mouth without help. Preparation of food may be done by another person.

(0 POINTS) Needs partial or total help with feeding or requires parenteral feeding.

TOTAL POINTS = 6 6 = High (patient independent) 0 = Low (patient very dependent)

Slightly adapted from Katz, S., Down, T.D., Cash, H.R., & Grotz, R.C. (1970) Progress in the development of the index of ADL. The Gerontologist, 10(1), 20-30.

Copyright © The Gerontological Society of America. Reproduced [Adapted] by permission of the publisher.

Best Practices in Nursing

Care to Older Adults

A series provided by The Hartford Institute for Geriatric Nursing,

New York University, College of Nursing

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generalassessmentseries

From The Hartford Institute for Geriatric Nursing, New York University, College of Nursing

BestPracticesinNursing

CaretoOlderAdults

generalassessmentseries

Issue Number 3, Revised 2013 Editor-in-Chief: Sherry A. Greenberg, PhD(c) MSN, GNP-BC New York University College of Nursing

Mental Status Assessment of Older Adults: The Mini-CogTM

By: Deirdre M. Carolan Doerflinger, CRNP, PhD, Inova Fairfax Hospital, Falls Church, Virginia

WHY: Five and a third (5.3) million Americans of all ages have Alzheimer’s disease or other dementias. Age is by far the greatest risk factor. One in ten individuals over 65 and nearly half of those over 85 are affected. A new case of dementia in some form is diagnosed every 70 seconds according to the 2010 Alzheimer’s Disease Facts and Figures; Older Americans 2010 Key Indicators of Well-Being. The increased availability of successful treatments for dementia and dementia-related illnesses means there is a substantial need for increased early identification of cognitive impairment, particularly in the geriatric population. Using a reliable and valid tool that clinicians can quickly implement facilitates early identification and allows the person to receive prompt treatment. Early identification and intervention in the form of medication and behavioral therapy may slow disease progression, delay functional decline, allow for pre-planning, and postpone nursing home placement. 

BEST TOOL: The Mini-CogTM is a simple screening tool that is well accepted and takes up to only 3 minutes to administer. This tool can be used to detect cognitive impairment quickly during both routine visits and hospitalizations. The Mini-CogTM serves as an effective triage tool to identify patients in need of more thorough evaluation. The Clock Drawing Test (CDT) component of the Mini-CogTM allows clinicians to quickly assess numerous cognitive domains including cognitive function, memory, language comprehension, visual-motor skills, and executive function and provides a visible record of both normal and impaired performance that can be tracked over time.

TARGET POPULATION: The Mini-CogTM is appropriate for use in all health care settings. It is appropriate to be used with older adults at various heterogeneous language, culture, and literacy levels.

VALIDITY AND RELIABILITY: The Mini-CogTM was developed as a brief screening tool to differentiate patients with dementia from those without dementia. Depending on the prevalence of dementia in the target population, the Mini-CogTM has sensitivity ranging from 76-99%, and specificity ranging from 89-93% with 95% confidence interval. A chi square test reported 234.4 for Alzheimer’s dementia and 118.3 for other dementias (p<0.001). This tool has strong predictive value in multiple clinical settings (Borson et al., 2003). Newer research suggests that a 5-point numerical scoring system based on the original algorithm may be easier to apply: repeating three items (0 points), a clock drawing distractor (CDT) (0-2 points), and recall of the earlier three items after the CDT (0-3 points). A score of 3-5 out of 5 is a negative screen for dementia (Borson et al., 2006), but a cut score of 4-5 out of 5 may increase detection of mild cognitive impairment (McCarten et al., 2012). The Mini-CogTM by itself is not considered a valid tool for this use. For further assessment of mild cognitive impairment, consider administering the Montreal Cognitive Assessment (MoCA) (See Try This:® MoCA). STRENGTHS AND LIMITATIONS:

The Mini-CogTM takes up to 3 minutes to administer. The clock drawing component of the test is scored simply as normal or abnormal for the purpose of the Mini-CogTM and specific scoring rules are included with the tool. More comprehensive analysis of the CDT does not improve detection of dementia and would increase complexity of the currently simple training requirements for clinicians and perhaps decrease its attractiveness as a simple screening tool. The Mini-CogTM is not strongly influenced by education, culture, or language and it was perceived as less stressful to the patient than other longer mental status tests. The accuracy of the Mini-CogTM in heterogeneous groups may increase the identification of dementia in populations less diagnosed thereby increasing minority participation in research and improving parity of early treatment.

MORE ON THE TOPIC:

Best practice information on care of older adults: www.ConsultGeriRN.org.

2010 Alzheimer’s Disease Facts and Figures. (2010). Alzheimer’s and Dementia, 6, 10. Retrieved November 28, 2012 from http://www.alz.org/documents_ custom/report_alzfactsfigures2010.pdf.

Borson, S., Scanlan, J., Hummel, J., Gibbs, K., Lessig, M., & Zuhr, E. (2007). Implementing routine cognitive screening of older adults in primary care: Process and impact on physician behavior. Journal of General Internal Medicine, 22(6), 811-817.

Borson, S., Scanlan, J.M., Chen, P., & Ganguli, M. (2003). The Mini-Cog as a screen for dementia: Validation in a population-based sample. JAGS, 51(10), 14511454.

Borson, S., Scanlan, J.M., Watanabe, J., Tu, S.P., & Lessig, M. (2005). Simplifying detection of cognitive impairment: Comparison of the Mini-Cog and MiniMental State Examination in a multiethnic sample. JAGS, 53(5), 871-874.

Borson, S., Scanlan, J.M., Watanabe, J., Tu, S.P., & Lessig, M. (2006). Improving identification of cognitive impairment in primary care. International Journal of Geriatric Psychiatry, 21(4), 349-355.

Ismail, Z., Rajji, T., & Shulman, K. (2010). Brief cognitive screening instruments: An update. International Journal of Geriatric Psychiatry, 25(2), 111-120.

Lessig, M., Scanlan, J., Nazemi, H., & Borson, S. (2008). Time that tells: Critical clock-drawing errors for dementia screening. International Psychogeriatrics, 20(3), 459-470.

McCarten, J.R, Anderson, P., Kuskowski, M., McPherson, S., Borson, S., & Dysken, M. W. (2012). Finding dementia in primary care: The results of a clinical demonstration project. JAGS, 60(2), 210-217.

Older Americans 2010 Key Indicators of Well-being. (2010). Retrieved November 28, 2012, from http://www.agingstats.gov/agingstatsdotnet/Main_Site/ Data/2010_Documents/Docs/OA_2010.pdf.

Permission is hereby granted to reproduce, post, download, and/or distribute, this material in its entirety only for not-for-profit educational purposes only, provided that 

The Hartford Institute for Geriatric Nursing, New York University, College of Nursing is cited as the source. This material may be downloaded and/or distributed in electronic format, including PDA format. Available on the internet at www.hartfordign.org and/or www.ConsultGeriRN.org. E-mail notification of usage to: hartford.ign@nyu.edu.

The Mini CogTM

Administration:

  1. Instruct the patient to listen carefully to and remember 3 unrelated words and then to repeat the words. The same 3 words may be repeated to the patient up to 3 tries to register all 3 words. Pt Scored 3-3 on remembering the words: coffee, pedicure, and shrimp. Pt repeated the same 3 words 3X and Pt registered the 3 words 3X.
  2. Instruct the patient to draw the face of a clock, either on a blank sheet of paper or on a sheet with the clock circle already drawn on the page. After the patient puts the numbers on the clock face, ask him or her to draw the hands of the clock to read a specific time. The time 11:10 has demonstrated increased sensitivity. Pt drew a clock in the circle and put all the numbers in the circle and was instructed after that to draw the hand to show ten past eleven. Pt completed this task within 3 minutes. Pt scored 2 for normal.
  3. Ask the patient to repeat the 3 previously stated words. 3-3 for remembering the words: coffee, pedicure, and shrimp.

Scoring: (Out of total of 5 points) Pt scored 5.

Give 1 point for each recalled word after the CDT distractor. Recall is scored 0-3.

The CDT distractor is scored 2 if normal and 0 if abnormal.

(Note: The CDT is considered normal if all numbers are present in the correct sequence and position, and the hands readably display the requested time. Length of hands is not considered in the score.)

Interpretation of Results:

0-2: Positive screen for dementia 3-5: Negative screen for dementia

Sources:

Borson, S., Scanlan, J., Brush, M., Vitallano, P., & Dokmak, A. (2000). The Mini-Cog: A cognitive ‘vital signs’ measure for dementia screening in multi-lingual elderly. International Journal of Geriatric Psychiatry, 15(11), 1021-1027.

Borson, S., Scanlan, J.M., Watanabe, J., Tu, S.P., & Lessig, M. (2006). Improving identification of cognitive impairment in primary care. International Journal of Geriatric Psychiatry, 21(4), 349-355.

Lessig, M., Scanlan, J., Nazemi, H., & Borson, S. (2008). Time that tells: Critical clock-drawing errors for dementia screening. International Psychogeriatrics, 20(3), 459-470.

Copyright S. Borson. All rights reserved. Reprinted with permission.

BestPracticesinNursing

CaretoOlderAdults

A series provided by The Hartford Institute for Geriatric Nursing,

New York University, College of Nursing

EMAIL

 

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From The Hartford Institute for Geriatric Nursing, New York University, College of Nursing

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Issue Number 6.1, Revised 2012

Series Editor: Marie Boltz, PhD, GNP-BC

Series Co-Editor: Sherry A. Greenberg, MSN, GNP-BC

New York University College of Nursing

The Pittsburgh Sleep Quality Index (PSQI)

By: Carole Smyth MSN, APRN, BC, ANP/GNP, Montefiore Medical Center

WHY: Sleep is an important aspect of maintaining the body’s circadian rhythm. Inadequate sleep contributes to heart disease, diabetes, depression, falls, accidents, impaired cognition, and a poor quality of life. While normal aging changes interfere with the quality of sleep, other disease conditions and medications used by older adults compromise sleep patterns. A nursing assessment of sleep begins with a comprehensive assessment of sleep quality and sleep patterns. The nurse may be able to improve the sleep problem immediately with interventions or work with the health care team to assess the sleep issue in greater depth.

BEST TOOL: The Pittsburgh Sleep Quality Index (PSQI) is an effective instrument used to measure the quality and patterns of sleep in the older adult. It differentiates “poor” from “good” sleep by measuring seven domains: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medication, and daytime dysfunction over the last month. The client self-rates each of these seven areas of sleep. Scoring of the answers is based on a 0 to 3 scale, whereby 3 reflects the negative extreme on the Likert Scale. A global sum of “5”or greater indicates a “poor” sleeper. Although there are several questions that request the evaluation of the client’s bedmate or roommate, these are not scored, nor reflected in the attached instrument. An update to the scoring: if 5J is not complete or the value is missing, it now counts as a “0”. More information on administration and scoring is available at the University of Pittsburgh, Sleep Medicine Institute, Pittsburgh Sleep Quality Index (PSQI) website at http://www.sleep.pitt.edu/content.asp?id=1484&subid=2316.

TARGET POPULATION: The PSQI can be used for both an initial assessment and ongoing comparative measurements with older adults across the health care continuum.

VALIDITY AND RELIABILITY: The PSQI has internal consistency and a reliability coefficient (Cronbach’s alpha) of 0.83 for its seven components. Numerous studies using the PSQI in a variety of older adult populations internationally have supported high validity and reliability.

STRENGTHS AND LIMITATIONS: The PSQI is a subjective measure of sleep. Self reporting by clients though empowering, may can reflect inaccurate information if the client has difficulty understanding what is written, or cannot see or physically write out responses. The scale has been translated into over 56 languages. For those with visual impairments, the nurse can read the PSQI as written to the client.

MORE ON THE TOPIC:

Best practice information on care of older adults: www.ConsultGeriRN.org.

University of Pittsburgh, Sleep Medicine Institute, Pittsburgh Sleep Quality Index (PSQI). 

Available at http://www.sleep.pitt.edu/content.asp?id=1484&subid=2316.

Alessi, C.A., Martin, J.L., Webber, A.P., Alam, T., Littner, M.R., Harker, J.O., & Josephson, K.R. (2008). More daytime sleeping predicts less functional recovery among older people undergoing inpatient post-acute rehabilitation. Sleep 31(9), 1291-1300.

Buysse, D.J., Reynolds III, C.F., Monk, T.H., Berman, S.R., & Kupfer, D.J. (1989). The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Journal of Psychiatric Research, 28(2), 193-213.

Carney, S., Koetters, T., Cho, M., West, C., Paul, S.M. , Dunn, L., Aouizerat, B.E., Dodd, M., Cooper, B., Lee, K. Wara, W., Swift, P., & Miaskowski, C. (2011). Differences in sleep disturbance parameters between oncology outpatients and their family caregivers. Journal of Clinical Oncology, 29(8), 1001-1006.

Taibi, D.M., Vitiello M.V. (2011). A pilot study of gentle yoga for sleep disturbance in women with osteoarthritis. Sleep Med, 12(5), 512-517. Neale, A., Hwalek, M., Scott, R., Sengstock, M., & Stahl, C. (1991). Validation of the Hwalek-Sengstock elder abuse screening test. 

Journal of Applied Gerontology, 10(4), 406-418.

Permission is hereby granted to reproduce, post, download, and/or distribute, this material in its entirety only for not-for-profit educational purposes only, provided that

The Hartford Institute for Geriatric Nursing, New York University, College of Nursing is cited as the source. This material may be downloaded and/or distributed in electronic format, including PDA format. Available on the internet at www.hartfordign.org and/or www.ConsultGeriRN.org. E-mail notification of usage to: hartford.ign@nyu.edu.

The Pittsburgh Sleep Quality Index (PSQI)

Instructions: The following questions relate to your usual sleep habits during the past month only. Your answers should indicate the most accurate reply for the majority of days and nights in the past month. Please answer all questions. During the past month,

  1. When have you usually gone to bed? 22:00
  2. How long (in minutes) has it taken you to fall asleep each night? 30 minutes
  3. When have you usually gotten up in the morning? 7:00
  4. How many hours of actual sleep do you get at night? (This may be different than the number of hours you spend in bed) 8 hours

5. During the past month, how often have you 

Not during

Less than

Once or

Three or

had trouble sleeping because you…

the past

once a

twice a

more times

 

month (0)

week (1)

week (2)

week (3)

a. Cannot get to sleep within 30 minutes

 

1

   

b. Wake up in the middle of the night or early morning

     

3

c. Have to get up to use the bathroom

     

3

d. Cannot breathe comfortably

     

3

e. Cough or snore loudly

     

3

f. Feel too cold

     

3

g. Feel too hot

0

     

h. Have bad dreams

 

1

   

i. Have pain

0

     

j. Other reason(s), please describe, including how often you have had trouble sleeping because of this reason(s):

0

     

6. During the past month, how often have you taken medicine (prescribed or “over the counter”) to help you sleep?

0

     

7. During the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in social activity?

0

     

8. During the past month, how much of a problem has it been for you to keep up enthusiasm to get things done?

     

3

 

Very

Fairly

Fairly

Very

 

good (0)

good (1)

bad (2)

bad (3)

9. During the past month, how would you rate your sleep quality overall?

 

1

   

Component 1 

#9 Score. C1: 1

 

Component 2 

 #2 Score (≤15min=0; 16-30 min=1; 31-60 min=2, >60 min=3) + #5a Score (if sum is equal 0=0; 1-2=1; 3-4=2; 5-6=3). C2: 1

 

Component 3 

#4 Score (>7=0; 6-7=1; 5-6=2; <5=3). C3: 1

 

Component 4 

 (total # of hours asleep) / (total # of hours in bed) x 100

>85%=0, 75%-84%=1, 65%-74%=2, <65%=3. C4: 0

 

Component 5 

Sum of Scores #5b to #5j (0=0; 1-9=1; 10-18=2; 19-27=3). C5: 2

 

Component 6 

#6 Score. C6: 0

 

Component 7 

#7 Score + #8 Score (0=0; 1-2=1; 3-4=2; 5-6=3). C7: 2

 
 

Add the seven component scores together: 11Global PSQI ScorePoor

 

Buysse, D.J., Reynolds III, C.F., Monk, T.H., Berman, S.R., & Kupfer, D.J. (1989). The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Journal of Psychiatric Research, 28(2), 193-213.

Reprinted with permission from copyright holder for educational purposes per the University of Pittsburgh, Sleep Medicine Institute, Pittsburgh Sleep Quality Index (PSQI) website at http://www.sleep.pitt.edu/content.asp?id=1484&subid=2316.

BestPracticesinNursing

CaretoOlderAdults

A series provided by The Hartford Institute for Geriatric Nursing,

New York University, College of Nursing

EMAIL

 

hartford.ign@nyu.edu

HARTFORD

 

INSTITUTE

 

WEBSITE

 

www.hartfordign.org

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generalassessmentseries

Issue Number 8, Revised 2013 Editor-in-Chief: Sherry A. Greenberg, PhD(c) MSN, GNP-BC New York University College of Nursing

Fall Risk Assessment for Older Adults: The Hendrich II Fall

Risk ModelTM

By: Ann Hendrich, PhD, RN, FAAN Patient Safety Organization (PSO); Ascension Health

WHY: Falls among older adults, unlike other ages tend to occur from multifactorial etiology such as acute1,2 and chronic3,4 illness, medications,5 as a prodrome to other diseases,6 or as idiopathic phenomena. Because the rate of falling increases proportionally with increased number of pre-existing conditions and risk factors,7 fall risk assessment is a useful guideline for practitioners. One must also determine the underlying etiology of why a fall occurred with a comprehensive post-fall assessment.8 Fall risk assessment and post-fall assessment are two interrelated, but distinct approaches to fall evaluation, both recommended by national professional organizations.9

Fall assessment tools have often been used only on admission or infrequently during the course of an illness or in the primary care health management of an individual. Repeated assessments, yearly, and with patient status changes, will increase the reliability of assessment and help predict a change in condition signaling fall risk.

BEST PRACTICE APPROACH: In acute care, a best practice approach incorporates use of the Hendrich II Fall Risk ModelTM, which is quick to administer and provides a determination of risk for falling based on gender, mental and emotional status, symptoms of dizziness, and known categories of medications increasing risk.10 This tool screens for primary prevention of falls and is integral in a post-fall assessment for the secondary prevention of falls.

TARGET POPULATION: The Hendrich II Fall Risk ModelTM is intended to be used in the acute care setting to identify adults at risk for falls. The Model is being validated for further application of the specific risk factors in pediatrics and obstetrical populations.

VALIDITY AND RELIABILITY: The Hendrich II Fall Risk ModelTM was originally validated in a large case control study in an acute care tertiary facility with skilled nursing, behavioral health, and rehabilitation populations. The risk factors in the model had a statistically significant relationship with patient falls (Odds Ratio 10.12-1.00, .01 > p <.0001). Content validity was established through an exhaustive literature review, use of accepted nursing nomenclature and the extensive experience of the principal investigators in this area.11

From The Hartford Institute for Geriatric Nursing, New York University, College of Nursing

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CaretoOlderAdults

generalassessmentseries


The instrument is sensitive (74.9%) and specific (73.9%), with inter-rater reliability measuring 100% agreement.11 Numerous national and international published and unpublished studies and presentations have tested the Hendrich II Fall Risk ModelTM in diverse settings. For example, a recent study reported on the adaptation and evaluation of the Hendrich II Fall Risk ModelTM for use in inpatient settings in Portugal.12 The authors reported a sensitivity of 93.2% at admission and 75.7% at discharge, with positive and negative predictive values of 17.2% and 97.3%, respectively. The Model was also recently adapted for use in Italian geriatric acute care settings, with high specificity, sensitivity, and inter-rater reliability.13 A comparison of the Hendrich II ModelTM to other fall risk models in the acute care setting found similar, strong sensitivity compared to other models, but acceptable specificity only with the Hendrich II ModelTM.14 

STRENGTHS AND LIMITATIONS: The major strengths of the Hendrich II Fall Risk ModelTM are its brevity, the inclusion of “risky” medication categories, and its focus on interventions for specific areas of risk rather than on a single, summed general risk score. Categories of medications increasing fall risk as well as adverse side effects from medications leading to falls are built into this tool. Further, with permission, the Hendrich II Fall Risk ModelTM can be inserted into existing electronic health platforms, documentation forms, or used as a single document. It has been built into electronic health records with targeted interventions that prompt and alert the caregiver to modify and/or reduce specific risk factors present.11

FOLLOW-UP: Fall risk warrants thorough assessment as well as prompt intervention and treatment. The Hendrich II Fall Risk ModelTM may be used to monitor fall risk over time, minimally yearly, and with patient status changes in all clinical settings. Post-fall assessments area also critical for an evidencedbased approach to fall risk factor reduction.

REFERENCES:

Best practice information on care of older adults: www.ConsultGeriRN.org.

  1. Gangavati, A., Hajjar, I., Quach, L., Jones, R.N., Kiely, D.K., Gagnon, P., & Lipsitz, L.A. (2011). Hypertension, orthostatic hypotension, and the risk of falls in a community-dwelling elderly population: The maintenance of balance, independent living, intellect, and zest in the elderly of Boston study. JAGS, 59(3), 383-389.
  2. Sachpekidis, V., Vogiatzis, I., Dadous, G., Kanonidis, I., Papadopoulos, C., & Sakadamis, G. (2009). Carotid sinus hypersensitivity is common in patients presenting with hip fracture and unexplained falls. Pacing and Clinical Electrophysiology, 32(9), 1184-1190.
  3. Stolze, H., Klebe, S., Zechlin, C., Baecker, C., Friege, L., & Deuschl, G. (2004). Falls in frequent neurological diseases-prevalence, risk factors and etiology. Journal of Neurology,

251(1), 79-84.

  1. Roig, M., Eng, J.J., MacIntyre, D.L., Road, J.D., FitzGerald, J.M., Burns, J., & Reid, W.D. (2011). Falls in people with chronic obstructive pulmonary disease: An observational cohort study. Respiratory Medicine, 105(3), 461-469.
  2. Cashin, R.P., & Yang, M. (2011). Medications prescribed and occurrence of falls in general medicine inpatients. The Canadian Journal of Hospital Pharmacy, 64(5), 321-326.
  3. D.L., Waxman, H., Cavalieri, T., & Lage, S. (1994). Prodromal falls among older nursing home residents. Applied Nursing Research, 7(1), 18-27.
  4. Tinetti, M.E., Williams, T.S., & Mayewski, R. (1986). Fall risk index for elderly patients based on number of chronic disabilities. American Journal of Medicine, 80(3), 429-434.
  5. Gray-Miceli, D., Johnson, J, & Strumpf, N. (2005). A step-wise approach to a comprehensive post-fall assessment. Annals of Long-Term Care, 13(12), 16-24.
  6. Panel on Prevention of Falls in Older Persons. American Geriatrics Society, British Geriatrics Society, & American Academy of Orthopaedic Surgeons Panel on Falls Prevention. (2011). Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. JAGS, 59(1), 148-157.
  7. Hendrich, A.L. Bender, P.S. & Nyhuis, A. (2003). Validation of the Hendrich II Fall Risk Model: A large concurrent case/control study of hospitalized patients. Applied Nursing Research, 16(1), 9-21.
  8. Hendrich, A., Nyhuuis, A., Kippenbrock, T., & Soga, M.E. (1995). Hospital falls: Development of a predictive model for clinical practice. Applied Nursing Research, 8(3), 129-139.
  9. Caldevilla, M.N., Costa, M.A., Teles, P., & Ferreira, P.M. (2012). Evaluation and cross-cultural adaptation of the Hendrich II Fall Risk Model to Portuguese. Scandinavian Journal of Caring Sciences. doi: 10.1111/j.1471-6712.2012.01031.x
  10. Ivziku, D, Matarese, M., & Pedone, C. (2011). Predictive validity of the Hendrich Fall Risk Model II in an acute geriatric unit. International Journal of Nursing Studies, 48(4), 468-474.
  11. Kim, E.A., Mordiffi, S.Z., Bee, W.H., Devi, K., & Evans, D. (2007). Evaluation of three fall-risk assessment tools in an acute care setting. Journal of Advanced Nursing, 60(4), 427435.

Permission is hereby granted to reproduce, post, download, and/or distribute, this material in its entirety only for not-for-profit educational purposes only, provided that 

The Hartford Institute for Geriatric Nursing, New York University, College of Nursing is cited as the source. This material may be downloaded and/or distributed in electronic format, including PDA format. Available on the internet at www.hartfordign.org and/or www.ConsultGeriRN.org. E-mail notification of usage to: hartford.ign@nyu.edu.

Risk Factor

Score

Confusion/disorientation/impulsivity

0

Symptomatic depression

3

Altered elimination

0

Dizziness/vertigo

0

Gender (FEMALE)

1

Any administered antiepileptics

0

Any administered benzodiazepines

0

Multiple attempts to risk from a chair in get up and go test

1

Total

5 (High Risk) 

The Hartford Institute would like to acknowledge the original author of this Try This:®, Deanna Gray-Miceli, DNSc, APRN, BC, FAANP

BestPracticesinNursing

CaretoOlderAdults

A series provided by The Hartford Institute for Geriatric Nursing,

New York University, College of Nursing

EMAIL

 

hartford.ign@nyu.edu

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INSTITUTE

 

WEBSITE

 

www.hartfordign.org

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generalassessmentseries

Issue Number 9, Revised 2012 Editor-in-Chief: Sherry A. Greenberg, PhD(c) MSN, GNP-BC

New York University College of Nursing

Assessing Nutrition in Older Adults

From The Hartford Institute for Geriatric Nursing, New York University, College of Nursing

BestPracticesinNursing

CaretoOlderAdults

generalassessmentseries

By: Rose Ann DiMaria-Ghalili, PhD, RN, CNSC, Drexel University College of Nursing and Health

Professions and Elaine J. Amella, PhD, RN, FAAN, Medical University of South Carolina College of Nursing

WHY: While poor nutrition is not a natural concomitant of aging, older adults are at risk for malnutrition due to physiological, psychological, social, dietary, and environmental risk factors. Weight loss in older adults loss is often associated with a loss of muscle mass and can ultimately impact functional status. Malnutrition in older adults is associated with complications and premature death. The progression to malnutrition is often insidious and often undetected. The nurse plays a key role in prevention and early intervention of nutritional problems.

BEST TOOL: The Mini-Nutritional Assessment Short-Form (MNA®-SF) is a screening tool used to identify older adults (> 65 years) who are malnourished or at risk of malnutrition. The MNA®-SF is based on the full MNA®, the original 18-item questionnaire published in 1994 by Guigoz, et al. The most recent version of the MNA®-SF was developed in 2009 (Kaiser et al., 2009) and consists of 6 questions on food intake, weight loss, mobility, psychological stress or acute disease, presence of dementia or depression, and body mass index (BMI). When height and/or weight cannot be assessed, then an alternate scoring for BMI includes the measurement of calf circumference. Scores of 12-14 are considered normal nutritional status; 8-11 indicate at risk of malnutrition; 0-7 indicate malnutrition. An advantage of the tool is that no laboratory data are needed. An in-depth assessment and physical exam should be performed when patients are identified to be malnourished or at nutritional risk. A review of symptoms and objective clinical findings should be assessed in addition to the patient’s cultural factors, preferences, social needs/desires surrounding meals. A 72-hour food dairy recording the patent’s consumption is another important supplement to the MNA®-SF.

TARGET POPUTLATION: The MNA®-SF provides a simple, quick method of identifying older adults who are at risk of malnutrition. The

MNA®-SF should be completed quarterly for institutionalized older adults and yearly for normally nourished community-dwelling older adults.

VALIDITY AND RELIABILITY: The full MNA® has been validated in many research studies with older adults in hospital, nursing home, ambulatory care, and community settings. Studies have demonstrated internal consistency and inter-observer reliability to range from 0.51 to 0.89 (Guigoz, 2006). The MNA®-SF has a sensitivity of 89%, specificity of 82%, and a strong positive predictive value (Youden Index = 0.70) (Kaiser et al., 2009). While the MNA®-SF was developed from the full MNA®, reliability of the MNA®-SF is not yet available (Skates & Anthony, 2012).

STRENGTHS AND LIMITATIONS: Unlike many other nutritional instruments, the full MNA® and the MNA®-SF were developed to be userfriendly, quick, non-invasive, and inexpensive. The MNA®-SF takes about 5 minutes to complete and the questions can easily be incorporated into a complete geriatric assessment. The MNA® and MNA®-SF have been used extensively in clinical research in over 200 international studies (Cereda, 2012). A limiting factor may be accurate assessment of height and weight to obtain BMI in bedridden individuals. To that end, users of the MNA®-SF can substitute calf circumference for BMI. However, clinician lack of familiarity with the requirement of measuring calf circumference is a potential limitation (DiMaria-Ghalili & Guenter, 2008). Question A focuses on food intake (not artificial nutrition), and the appropriateness of the MNA®-SF for use in older adults who receive tube-feeding (Bauer, et al., 2008) or total parenteral nutrition needs to be considered. Patients receiving tube-feeding or total parenteral nutrition should be monitored by a dietitian or trained nutrition support professional.

MORE ON THE TOPIC:

Best practice information on care of older adults: www.ConsultGeriRN.org.

Mini Nutritional Assessment (MNA®) Home Page: Most recent research with excellent information for both nurses and older adults: www.mna-elderly.com.

Bauer, J.M., Kaiser, M.J., Anthony, P., Guigoz, Y., & Sieber, C.C. (2008). The Mini Nutritional Assessment--Its history, today’s practice, and future perspectives. Nutrition in Clinical Practice, 23(4), 388-396.

Cereda, E. (2012). Mini nutritional assessment. Current Opinion in Clinical Nutritition and Metabolic Care, 15(1), 29-41.

DiMaria-Ghalili, R.A., & Guenter, P.A. (2008). How to Try This: The mini nutritional assessment. AJN, 108(2), 50-59.

Guigoz, Y., Vellas, B., & Garry, P.J. (1994). Mini Nutritional Assessment: A practical assessment tool for grading the nutritional state of elderly patients. Facts and Research in Gerontology, 4 (Suppl.2), 15-59.

Kaiser, M.J., Bauer, J.M., Uter, W., Donini, L.M., Stange, I., Volkert, D., . . . Sieber, C.C. (2011). Prospective validation of the modified mini nutritional assessment short-forms in the community, nursing home, and rehabilitation setting. JAGS, 59(11), 2124-2128.

Loreck, E., Chimakurthi, R., & Steinle, N.I. (2012). Nutritional assessment of the geriatric patient: A comprehensive approach toward evaluating and managing nutrition. Clinical Geriatrics, 20(4), 20-26.

Skates, J. J., & Anthony, P. S. (2012). Identifying geriatric malnutrition in nursing practice: the Mini Nutritional Assessment (MNA®)-An evidence-based screening tool. Journal of Gerontological Nursing, 38(3), 18-27.

Permission is hereby granted to reproduce, post, download, and/or distribute, this material in its entirety only for not-for-profit educational purposes only, provided that 

The Hartford Institute for Geriatric Nursing, New York University, College of Nursing is cited as the source. This material may be downloaded and/or distributed in electronic format, including PDA format. Available on the internet at www.hartfordign.org and/or www.ConsultGeriRN.org. E-mail notification of usage to: hartford.ign@nyu.edu.

BestPracticesinNursing

CaretoOlderAdults

A series provided by The Hartford Institute for Geriatric Nursing,

New York University, College of Nursing

EMAIL

 

hartford.ign@nyu.edu

HARTFORD

 

INSTITUTE

 

WEBSITE

 

www.hartfordign.org

CLINICAL

 

NURSING

 

WEBSITE

 

www.ConsultGeriRN.org

generalassessmentseries

From The Hartford Institute for Geriatric Nursing, New York University, College of Nursing

BestPracticesinNursing

CaretoOlderAdults

generalassessmentseries

Issue Number 9, Revised 2012 Editor-in-Chief: Sherry A. Greenberg, PhD(c) MSN, GNP-BC

New York University College of Nursing

Assessing Nutrition in Older Adults

By: Rose Ann DiMaria-Ghalili, PhD, RN, CNSC, Drexel University College of Nursing and Health

Professions and Elaine J. Amella, PhD, RN, FAAN, Medical University of South Carolina College of Nursing

WHY: While poor nutrition is not a natural concomitant of aging, older adults are at risk for malnutrition due to physiological, psychological, social, dietary, and environmental risk factors. Weight loss in older adults loss is often associated with a loss of muscle mass and can ultimately impact functional status. Malnutrition in older adults is associated with complications and premature death. The progression to malnutrition is often insidious and often undetected. The nurse plays a key role in prevention and early intervention of nutritional problems.

BEST TOOL: The Mini-Nutritional Assessment Short-Form (MNA®-SF) is a screening tool used to identify older adults (> 65 years) who are malnourished or at risk of malnutrition. The MNA®-SF is based on the full MNA®, the original 18-item questionnaire published in 1994 by Guigoz, et al. The most recent version of the MNA®-SF was developed in 2009 (Kaiser et al., 2009) and consists of 6 questions on food intake, weight loss, mobility, psychological stress or acute disease, presence of dementia or depression, and body mass index (BMI). When height and/or weight cannot be assessed, then an alternate scoring for BMI includes the measurement of calf circumference. Scores of 12-14 are considered normal nutritional status; 8-11 indicate at risk of malnutrition; 0-7 indicate malnutrition. An advantage of the tool is that no laboratory data are needed. An in-depth assessment and physical exam should be performed when patients are identified to be malnourished or at nutritional risk. A review of symptoms and objective clinical findings should be assessed in addition to the patient’s cultural factors, preferences, social needs/desires surrounding meals. A 72-hour food dairy recording the patent’s consumption is another important supplement to the MNA®-SF.

TARGET POPUTLATION: The MNA®-SF provides a simple, quick method of identifying older adults who are at risk of malnutrition. The

MNA®-SF should be completed quarterly for institutionalized older adults and yearly for normally nourished community-dwelling older adults.

VALIDITY AND RELIABILITY: The full MNA® has been validated in many research studies with older adults in hospital, nursing home, ambulatory care, and community settings. Studies have demonstrated internal consistency and inter-observer reliability to range from 0.51 to 0.89 (Guigoz, 2006). The MNA®-SF has a sensitivity of 89%, specificity of 82%, and a strong positive predictive value (Youden Index = 0.70) (Kaiser et al., 2009). While the MNA®-SF was developed from the full MNA®, reliability of the MNA®-SF is not yet available (Skates & Anthony, 2012).

STRENGTHS AND LIMITATIONS: Unlike many other nutritional instruments, the full MNA® and the MNA®-SF were developed to be userfriendly, quick, non-invasive, and inexpensive. The MNA®-SF takes about 5 minutes to complete and the questions can easily be incorporated into a complete geriatric assessment. The MNA® and MNA®-SF have been used extensively in clinical research in over 200 international studies (Cereda, 2012). A limiting factor may be accurate assessment of height and weight to obtain BMI in bedridden individuals. To that end, users of the MNA®-SF can substitute calf circumference for BMI. However, clinician lack of familiarity with the requirement of measuring calf circumference is a potential limitation (DiMaria-Ghalili & Guenter, 2008). Question A focuses on food intake (not artificial nutrition), and the appropriateness of the MNA®-SF for use in older adults who receive tube-feeding (Bauer, et al., 2008) or total parenteral nutrition needs to be considered. Patients receiving tube-feeding or total parenteral nutrition should be monitored by a dietitian or trained nutrition support professional.

MORE ON THE TOPIC:

Best practice information on care of older adults: www.ConsultGeriRN.org.

Mini Nutritional Assessment (MNA®) Home Page: Most recent research with excellent information for both nurses and older adults: www.mna-elderly.com.

Bauer, J.M., Kaiser, M.J., Anthony, P., Guigoz, Y., & Sieber, C.C. (2008). The Mini Nutritional Assessment--Its history, today’s practice, and future perspectives. Nutrition in Clinical Practice, 23(4), 388-396.

Cereda, E. (2012). Mini nutritional assessment. Current Opinion in Clinical Nutritition and Metabolic Care, 15(1), 29-41.

DiMaria-Ghalili, R.A., & Guenter, P.A. (2008). How to Try This: The mini nutritional assessment. AJN, 108(2), 50-59.

Guigoz, Y., Vellas, B., & Garry, P.J. (1994). Mini Nutritional Assessment: A practical assessment tool for grading the nutritional state of elderly patients. Facts and Research in Gerontology, 4 (Suppl.2), 15-59.

Kaiser, M.J., Bauer, J.M., Uter, W., Donini, L.M., Stange, I., Volkert, D., . . . Sieber, C.C. (2011). Prospective validation of the modified mini nutritional assessment short-forms in the community, nursing home, and rehabilitation setting. JAGS, 59(11), 2124-2128.

Loreck, E., Chimakurthi, R., & Steinle, N.I. (2012). Nutritional assessment of the geriatric patient: A comprehensive approach toward evaluating and managing nutrition. Clinical Geriatrics, 20(4), 20-26.

Skates, J. J., & Anthony, P. S. (2012). Identifying geriatric malnutrition in nursing practice: the Mini Nutritional Assessment (MNA®)-An evidence-based screening tool. Journal of Gerontological Nursing, 38(3), 18-27.

Permission is hereby granted to reproduce, post, download, and/or distribute, this material in its entirety only for not-for-profit educational purposes only, provided that 

The Hartford Institute for Geriatric Nursing, New York University, College of Nursing is cited as the source. This material may be downloaded and/or distributed in electronic format, including PDA format. Available on the internet at www.hartfordign.org and/or www.ConsultGeriRN.org. E-mail notification of usage to: hartford.ign@nyu.edu.

Mini Nutritional Assessment

MNA

Last Name: Pullin First Name: Judy

Sex: Female Age: 71 Weight, kg: 63.5 Height, cm: 157.48 Date: 03/30/2018

 

Complete the screen by filling in the boxes with the appropriate numbers. Total the numbers for the final screening score.

Screening

A Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties?

0=severe decrease in food intake

1=moderate decrease in food intake

2+ no decrease in food intake

 B Weight loss during the last 3 months

0= weight loss is greater than 3 kg (6.6 lbs.)

1= does not know

2= weight loss between 1 and 3 kg (2.2 and 6.6 lbs.)

3= no weight loss

 C Mobility

0=bed or chair bound

1= does not know

2= goes out

 D Has suffered psychological stress or acute disease in the past 3 months?

0=yes 2=no  

 E Neuropsychological problems

0=severe dementia or depression

1= mild dementia

2=no psychological problems

F1 Body Mass Index (BMI) (weight in kg) (height in m2)

0= BMI less than 19

1= BMI 19 to less than 21

2= BMI 21 to less than 23

3= BMI 23 or greater

IF BMI IS NOT AVAILABLE, REPLACE QUESTION F1 WITH QUESTION F2

DO NOT ANSWER QUESTION F2 IF QUESTION F1 IS ALREADY COMPLETED

 F2 Calf circumference (CC) in cm

0=cc less than 31

3= CC 31 or greater

Screening Score (max. 14 points)

12-14 point: Normal nutritional status * Pt scored 14

8-11 point: At risk of malnutrition

0-7 Points: Malnourished

#$#.#+!#/

BestPracticesinNursing

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EMAIL

 

hartford.ign@nyu.edu

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WEBSITE

 

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WEBSITE

 

www.ConsultGeriRN.org

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