Morse Fall Scale

Purpose:
Identify individuals at risk for falls.

In the original study (Morse 2009) sensitivity was 78% and specificity 83%

In a validation study (Eagle 1999) the Morse Fall Scale had a sensitivity of 72% and a specificity of 51%.

References:
Morse, J. M., Morse, R., & Tylko, S. (1989). Development of a scale to identify the fall-prone patient. Canadian Journal on Aging, 8, 366-377.

Eagle, J., Salamara, S., Whitman, D., Evans, L.A., Ho, E., & Olde, J. (1999).
Comparison of three instruments in predicting accidental falls in selected inpatients in a general teaching hospital. Journal of Gerontological Nursing, 25(7), 40-45.

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CAM (Confusion Assessment Method)

Purpose:
A method for detecting delerirum in a high risk setting.

Rationale:
Delirium is common among hospitalized elderly patients and is associated with increased morbidity and mortality. Delirium commonly goes unrecognized. Existing cognitive tools were inadequate for detecting delirium.

The Method:
The method consists of two phases. The first is an assessment instrument and the second is a diagnostic algorithm.

An example and description is available at:
http://consultgerirn.org/uploads/File/Confusion%20Assessment%20Method%20%28CAM%29.pdf

Several versions of the diagnostic algorithm:
http://www.viha.ca/NR/rdonlyres/24020AE2-09A5-45ED-A1D9-21F933BA9169/0/cam_09.pdf

http://www.bcguidelines.ca/gpac/pdf/cognitive_appendix_a.pdf

http://www.rgpc.ca/best/Geriatric%20Fast%20Facts/CONFUSION%20ASSESSMENT%20METHOD.pdf

Validation:
In the orginal validation study CAM had a sensitivity of 94-100% and specificity of 90-95% with a high inter-rater reliability.

References:
Inouye S, van Dyck CH, Alessi CA, Balkin S, Siegal A, Horwitz RI. Clarifying Confusion: The Confusion Assessment Method. Ann Internal Med. 1990;113(12):941-948.

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CSHA Clinical Frailty Scale

Purpose:
Tool for measuring frailty.

Rationale:
Previous frailty tools, although shown to predict death and institutionalization, have not gained acceptance among practising clinicians. Thus the need for a tool that would be easier to use.

The Tool:
An example and description is available at: http://geriatricresearch.medicine.dal.ca/clinical_frailty_scale.htm

Validation:
Correlation with the Frailty Index was high (Pearson coefficient 0.80, p < 0.01). Reliability was very high (intraclass correlation coefficient 0.97, p < 0.001). Hazard ratios for death and entry into an institutional facility showed increasing risk with increasing frailty. Each 1-category increment on the Clinical Frailty Scale significantly increased the medium-term risks of death (21.2%, 95% CI 12.5%–30.6%) and entry into institutional care (23.9%, 95% CI 8.8%–41.2%).

References:
Rockwood K, Song X, MacKnight C, Bergman H, Hogan D, McDowell I, Mitnitski A. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005;173(5):489-95

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HABAM (Hierarchical Assessment of Balance and Mobility)

Purpose:
Display changes in balance and mobility graphically in the acute hospital setting.

Rationale:
Several tools are available to measure balance and mobility, but have been developed in community, outpatient, or nursing-home settings and may not be useful in the acute-care hospital where marked changes can occur rapidly.

The Tool:
An example and description is available at: http://geriatricresearch.medicine.dal.ca/habam.htm.

Validation:
Reliability was high at Rj = 0.94. The HABAM correlated well with the Barthel Index and its mobility subscale, but did not correlate with changes in the MMSE, IADL, and Spitzer QL Index. The HABAM is responsive as measured by both relative efficiency and effect size statistics.

References:
MacKnight C, Rockwood K. A hierarchical assessment of balance
and mobility. Age Ageing 1995;24:126–30.

MacKnight C, Rockwood K. Rasch analysis of the hierarchical assessment of
balance and mobility (HABAM). Journal of clinical epidemiology. 53, no. 12, (2000): 1242-1247

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MoCA (Montreal Cognitive Assessment)

Purpose:
Detection of mild cognitive impairment.

Rationale:
Previous screening tolls, like the MMSE, do not adequately detect mild cognitive impairment.

The Test:
The test is availabe online in several languages here: http://www.mocatest.org/.

Validation:
In the original study (Nasreddine 2005) using a cutoff score of 26 the sensitivity was 90% for MCI and 100% for AD. Specificity was 87% in both groups.

In another study (Smith 2007), in a memory clinic setting, sensitivity was 83% for MCI and 94% for AD. However, specificity was only 50%.

A validation of a Korean version (Lee 2008), using a cutoff score of 22/23, had a sensitivity of 89% and a specificity of 84% for screening MCI. Internal consistency and test−retest reliability were good.

Another validation study (Luis 2009) examined a community-based cohort residing in the Southeastern United States for MCI. Using the cut-off score of 26, the sensitivity was 97%, but specificity was only 35%. Using a lower cut-off score of 23, sensitivity was 96% and specificity was 95%.

A validation in an oupatient cardiac and diabetic/endocrine clinics patient population was performed. (McLennan 2011) The presence of MCI was determined using the Neuropsychological Assessment Battery Screening Module (NAB-SM). Using a cutoff of 24, sensitivity for amnestic MCI was 100% and for multiple-domain MCI it was 83.3%. Specificity rates for amnestic MCI and multiple-domain MCI were 50.0% and 52% respectively.

References:
Nasreddine, Z. S., Phillips, N. A., Bédirian, V., Charbonneau, S., Whitehead, V., Collin, I., Cummings, J. L., … Chertkow, H. (January 01, 2005). The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. Journal of the American Geriatrics Society, 53, 4, 695-9.

Smith, T., Gildeh, N., & Holmes, C. (January 01, 2007). BRIEF COMMUNICATION – The Montreal Cognitive Assessment: Validity and Utility in a Memory Clinic Setting. Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie, 52, 5, 329.

Lee, J.-Y., Dong, W. L., Cho, S.-J., Na, D., Hong, J. J., Kim, S.-K., You, R. L., … Maeng, J. C. (January 01, 2008). Brief Screening for Mild Cognitive Impairment in Elderly Outpatient Clinic: Validation of the Korean Version of the Montreal Cognitive Assessment. Journal of Geriatric Psychiatry and Neurology, 21, 2, 104-110.

Koski, L., Xie, H., & Finch, L. (January 01, 2009). Measuring Cognition in a Geriatric Outpatient Clinic: Rasch Analysis of the Montreal Cognitive Assessment. Journal of Geriatric Psychiatry and Neurology, 22, 3, 151-160.

Luis, C. A., Keegan, A. P., & Mullan, M. (July 01, 2009). Cross validation of the Montreal Cognitive Assessment in community dwelling older adults residing in the Southeastern US. International Journal of Geriatric Psychiatry, 24, 2, 197-201.

McLennan, S. N., Mathias, J. L., Brennan, L. C., & Stewart, S. (January 01, 2011). Validity of the Montreal Cognitive Assessment (MoCA) as a Screening Test for Mild Cognitive Impairment (MCI) in a Cardiovascular Population. Journal of Geriatric Psychiatry and Neurology, 24, 1, 33-38.

Bernstein, I., Lacritz, L., Barlow, C., Weiner, M., & DeFina, L. (January 01, 2011). Psychometric Evaluation of the Montreal Cognitive Assessment (MoCA) in Three Diverse Samples. The Clinical Neuropsychologist, 25, 1, 119-126.

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Memory Impairment Screen

Purpose:
Screening test for Alzheimer’s Disease and other dementias.

Rationale:
This screen addresses the problem with many delayed recall memory screens in that they have a high rate of false negative and false positive errors. Increasing the number of items to recall increases the time to administer the test and makes it less useful for screening. Therefore the authors created a four item screen. Additionally this screen uses cuing to
ensure attention, induce semantic processing, optimize encoding specificity, increase retrieval, and improve discrimination.

The Test:
Subjects are given a piece of paper with four items, for example:

Brown
Happiness
Tulip
Eye Dropper

They are then asked to read them and given a category cue for each item, for example; Q: Which of these is a medical device? A: Eye dropper.

They are told they will need to remember the items in 2-3 minutes.

They get 2 points for each item remembered without a cue and 1 point for each item remembered with a cue.

Validation:
A cut-score of 4 provided a sensitivity (0.80), specificity (0.96).

References:
Buschke H, Kuslansky G, Katz M, et al. Screening for dementia with the memory impairment screen. Neurology 1999;52:231-8.

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Welcome to The Comprehensive Geriatric Assessment

This site is an online resource providing access to valuable information and a forum for discussion for those health care workers ineterested in providing better care for the elderly through the use of assessment tools and other resources.

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