NURSES CAN IDENTIFY MISSOURI ELDERS AT RISK USING RAPID GERIATRIC ASSESSMENT. (Peer Reviewed).
The Rapid Geriatric Assessment tools (Morley, Little, & Berg-Weger, 2017) are being disseminated to health professionals across the state of Missouri as part of a Geriatric Workforce Enhancement Program grant from the Health Resources and Services Administration (HRSA), awarded to the Saint Louis University Gateway Geriatric Education Center (GEC). Dr. John Morley and Dr. Marla Berg-Weger are the Co-Directors. The focus of the grant is to provide students and health care professionals with information and training on the care of older adults. The geriatric assessment tools provide a number of advantages:
* Provide brief, reliable methods for detecting common problems in older adults
* Help identify problems early, when interventions are most likely to be successful
* Track changes over time
The Rapid Geriatric Assessment (RGA) tools can be administered in just a few minutes and address four important health issues for older adults: frailty, sarcopenia, nutrition, and cognition. While each health profession has different expertise to address these issues, assessment and referral can be done by all health professionals who come into contact with older adults. Nurses can assess older people in many settings using these assessment tools that are free to copy and use in any practice or teaching setting. They can be used together or individually. The assessment questions and information on scoring and interpretation are provided in Tables 1-4. The tools have been studied and found valid and reliable and references for each are provided below for more information.
Rapid Geriatric Assessment Tools
Frailty. Frailty is a clinical syndrome in older adults characterized by declines in functional ability and physiological characteristics such as fatigue. Frailty is often associated with mobility problems and comorbidity, resulting in dependence (Ebrahimi et al., 2013). As older adults become frail, they often need to move to more supportive environments, such as assisted living or nursing homes. Many older people want to maintain their independence and stay in their homes. Helping them identify changes that might interfere with their wishes, such as those identified by this tool, is important.
The Simple FRAIL Questionnaire (Morley, Malmstrom, & Miller, 2012) includes 5 questions that represent the key symptoms of frailty: fatigue, walking, ability to climb stairs, number of medical conditions, and weight loss. More than 3 positive answers indicate frailty. If the older adult has more than 2 positive answers, they are pre-frail. Older adults with signs of frailty should have a complete evaluation to identify any medical problems or medications that might be causing symptoms. The older person should be referred to exercise programs or physical therapy to improve mobility and get them started exercising.
Sarcopenia. Sarcopenia is the loss of muscle mass and strength with aging that can affect physical performance in older adults. Although some of these changes occur with normal aging, other factors such as genetics, lack of physical activity, and poor nutrition can contribute to these losses (Eglseer, Eminovic, & Lohrmann, 2016). Further, older people with sarcopenia have difficulties with mobility and activities of daily living, and have a risk of functional decline and nursing home placement.
The SARC-F (Malmstrom & Morley 2013) questionnaire for sarcopenia is similar to the frailty questionnaire including questions about ability to perform several physical activities. However, individuals can have sarcopenia even if they are not frail (Morley, Little, & Berg-Weger, 2017). Each of the 5 items has a score of 0-2, and an overall score of 4 or more indicates sarcopenia. Early identification is import for interventions similar to those for frailty, including exercise, nutritional counseling to increase dietary protein, and a medical evaluation.
The SARC-F includes a question about falls in the past year, often an important sign of sarcopenia. A past fall is one of the best predictors of future falls, which can also mean injuries. Older people who fall have a high risk of hip fracture, hospitalization, and nursing home placement (Centers for Disease Control, 2017). In a recent national study, Missouri was in the top 5 states for fall injuries (Bergen, Stevens, & Burns, 2016). Older adults with falls or worry about falling need a complete evaluation of gait, balance, and postural hypotension. Older adults with falls also should be referred to fall prevention programs, which are available in many Missouri communities. A recent survey identified that classes including A Matter of Balance, Fall Proof, T'ai Chi, and other exercise programs were offered. The Show Me Falls Free Missouri Coalition website (https://www.preventmofalls.org/) has information on fall programs and events around Missouri.
Nutrition. The Simplified Nutritional Assessment Questionnaire (SNAQ) assesses poor appetite or anorexia in older adults (Malmstrom & Morley, 2013), a common cause of weight loss. A positive screen indicates a high risk for weight loss and malnutrition. Weight loss in the older adult can contribute to memory loss, decreased immune function, decreased muscle mass, bone loss, weakness, poor wound healing, and increased mortality.
The SNAQ has 4 questions, each with 5 response options for a maximum score of 20. A higher score indicates better appetite, and a score below 15 suggests the older person has a high risk of weight loss. Older adults with a positive screen should be referred for a more thorough evaluation of weight loss and nutritional intake, including referral to a dietitian.
Memory and Cognition. Problems with memory and thinking are common among older adults, but often go undetected (Morley, Little, & Berg-Weger, 2017). Early identification is important because some causes of memory loss are reversible. The most frequent causes of memory loss are Alzheimer's disease and vascular dementia, which are progressive (Jablonski, 2013). Cognitive screening is critical to identify older adults with memory impairment who should have further evaluation to determine if there is underlying disease. Early identification of problems can help both health professionals and family members who can provide appropriate treatment and support.
The Rapid Cognitive Screen (RCS) includes recall of 5 objects to test short term memory (Malmstrom, et al., 2015). The participant also draws a clock with the numbers and marks a set time. Then the tester reads a brief story and asks a question related to the contents. Older people with dementia will often have difficulty with short term recall, and difficulty with spacing the numbers on a clock face, or setting the time correctly. The RCA scores range from 0-10, with 0-5 suggesting dementia, 6-7 mild cognitive impairment, and 8-10 a normal score. The older adult should be encouraged to discuss their scores with their health care provider and whether further evaluation is needed.
Using the Rapid Geriatric Assessment Tools
There are a few tips for administering the screening questionnaires. First, find a quiet environment to ask the questions, not noisy or distracting. The older adult should use their glasses and hearing aids if they have them. Allow ample time to answer questions. Sometimes the tests can be uncomfortable to take, but nurses should present the tests to the older adult just like any other medical test, such as a blood pressure check. Instruct the person to answer the questions based on how they have been feeling in general, not just the day of testing. They may have aches or pains that day, but the tools should address their usual abilities. When participants have answered all the questions, the nurse can score each questionnaire and discuss the results. The older adults should follow up with their health care provider, and share their test scores, especially when potential problems are identified.
The Geriatric Education Center offers the RGA several different ways. Screening events are offered in the St. Louis metropolitan area at sites such as churches, community centers, health fairs, and residential communities. Handouts on healthy aging topics are given out based on participant results. Teams of health professions students have been trained and work together at screenings. Geriatric specialists are exploring how to integrate the assessment tools into clinical practice. Some of our health care partners are screening patients coming to the hospital or clinic sites, and some are incorporating the tools into the electronic medical record to make it easier to administer and track.
We hope nurses across the state will use the Rapid Geriatric Assessment tools with older adults in all kinds of settings. A training video on how to conduct the assessments is available at https://youtube/z79-UQvTOXs. For further information, see the Gateway Geriatric Education Center web site: aging.slu.edu. We hope nurses will share their experiences with these tools and let us know other geriatric resources that would be helpful to them.
The author acknowledges the Geriatric Education Center and its co-directors Dr. John Morley, and Dr. Marla Berg-Weger, and support from the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U1QHP28716 Geriatrics Workforce Enhancement Program for $843,079. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. Government.
Bergen, G., Stevens, M. R., & Burns, E. R. (2016). Falls and fall injuries among adults aged > 65 years--United States, 2014. Morbidity and Mortality Weekly, 65, 993-998. doi:10.15585/mmwr. mm6527a2
Center for Disease Control and Prevention (2016). Important Facts about Falls. Retrieved from https://www. cdc.gov/homeandrecreationalsafety/ falls/adultfalls.html
DeGrauw, X., Annest, J. L., Stevens, J. A., Xu, L., & Coronado, V. (2016). Unintentional injuries treated in hospital emergency departments among persons aged 65 years and older, United States, 2006-2011. Journal of Safety Research, 56, 105-109. doi:10.1016/j.jsr.2015.11.002
Ebranhini, Z., Wihelmson, K., Eklund, K., Moore, C. D., & Jakobsson, A. (203). Health despite frailty: Exploring influences on frail older adults' experiences of health. Geriatric Nursing, 34(4), 289-294. doi.org/10.1016/j. gerinurse.2013.04.008
Eglseer, D., Eminovic, S., & Lorhmann, C. (2016). Association between sarcopenia and nutritional status in older adults: A systematic literature review. Journal of Gerontological Nursing, 42(7), 33-41. doi: 10.3928/00989134-20160613-03
Jablonski, R. A. (2013). Dementia is not dementia is not dementia. Journal of Gerontological Nursing, 39(1), 3-5.
Malmstrom, T. K., & Morley, J. E. (2013). SARC-F: A simple questionnaire to rapidly diagnose sarcopenia. Journal of the American Medical Directors Association, 14, 531-532. doi: 10.1016/j. jamda.2013.05.018
Malmstrom, T. K., Voss, V. B., Cruz-Oliver, D. M., Cummings-Vaughn, L. A., Tumosa, N., Grossberg, G. T. & Morley, J. E. (2015). The Rapid Cognitive Screen (RCS): A point of care screening for dementia and cognitive impairment. Journal of Nutrition, Health, & Aging. 19(7), 741-744. doi:10.1007/s12603-015-0564-2
Malmstrom, T. K., Miller, D. K., Simonsek, E. M., Ferruci, L., & Morley, J. E. (2013). SARC-F: A simple tool to predict persons at risk for poor functional outcomes. Journal of Cachexia, Sarcopenia, and Muscle, 7, 28-36. doi: 10.1002/jcsm.12048
Morley, J. E., Malmstrom, T. K., & Miller, D. K. (2013). A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans. Journal of Nutrition and Health in Aging. 16(7), 601-608.
Morley, J. E., Little, M. O., & Berg-Weger, M. (2017). Rapid geriatric assessment: A tool for primary care physicians. Journal of the American Medical Directors Association, 18(1), 195-199. doi:10.1016/j. jamda.2016.11.017
University of Missouri Extension (2013). Missouri Senior Report. Retrieved from http://missouriseniorreport.org.
Helen W. Lach, PhD, RN, CNL, FGSA, FAAN
Table 1. Simple Frail Questionnaire Question Score Fatigue: Are you fatigued? 0 = No 1 = Yes Resistance: Are you unable to climb a flight of stairs? 0 = No 1= Yes Aerobic: Are you unable to walk a block? 0 = No 1 = Yes Illnesses: Do you have more than 5 illnesses? 0 = No 1 = Yes Loss of weight: Have you lost more than 5% of your 0 = No weight in the last 6 months? 1 = Yes __Total Score Scores range from 0-5, with a score of 3 or more indicating frailty, a score of 1 or 2 = prefrail. Table 2. SARC-F Screen for Sarcopenia Question Score Strength: How much difficulty do you have in 0 = None lifting and carrying 10 pounds? 1 = Some 2 = A lot/Unable Walking: How much difficulty do you have walking 0 = None across the room? 1 = Some 2 = A lot/Unable Getting Up: How much difficulty do you have 0 = None transferring from a chair or bed? 1 = Some 2 = A lot/Unable Stairs: How much difficulty do you have climbing a 0 = None flight of ten stairs? 1 = Some 2 = A lot/Unable Falls: How many times have you fallen in the last 0 = None year? 1 = Some 2 = A lot/Unable __Total Score Scores range from 0-10, with a score of 4 or more indicating sarcopenia. Table 3. Rapid Cognitive Screen Question Score 1. Please remember these 5 objects (Read each one at 1 second intervals): Apple Pen Tie House Car 2. (Hand out a blank sheet with circle for 0 = Numbers incorrect the clock face). This is a clock face. Please 2 = Numbers correct put in the hour markers and the time at 10 0 = Time Incorrect minutes to 11 o'clock. 2 = Time Correct 3. What were the 5 objects I asked you to remember? Apple Pen Tie House Car (1 point __= # Correct each) 4. I'm going to read you a story. Please 0 = Incorrect listen carefully because afterwards, I'm 1 = Correct going to ask you about it. "Jill was a very successful stockbroker. She made a lot of money on the stock market. She then met Jack, a devastatingly handsome man. She married him and had 3 children. They lived in Chicago. She then stopped work and stayed home to bring up her children. When they were teenagers, she went back to work. She and Jack lived happily ever after." What country did they live in? Total Score Scores range from 0 to 10, with a score of 8-10 = normal, 6-7 = mild cognitive impairment, 0-1 = dementia. Table 4. Simplified Nutritional Appetite Questionnaire Question Score 1. My appetite 0 = Very poor is: 1 = Poor 2 = Average 3 = Good 4 = very good 2. When I eat: 1 = I feel full after eating only a few mouthfuls 2 = I feel full after eating about a third of a meal 3 = I feel full after eating over half a meal 4 = I feel full after eating most of the meal 5 = I hardly ever feel full 3. Food tastes: 1 = Very bad 2 = Bad 3 = Average 4 = Good 5 = Very good 4. Normally 1 = Less than 1 meal a day I eat: 2 = 1 meal a day 3 = 2 meals a day 4 = 3 meals a day 5 = More than 3 meals a day __Total Score Scores range from 4 to 20, a score of less than 15 indicates a high risk of weight loss
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|Author:||Lach, Helen W.|
|Date:||Sep 22, 2017|
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