Oxford Handbook of Geriatric Medicine (2 edn)
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Appendix
Dermatomes 686
Geriatric Depression Scale 687
Barthel Index 688
The abbreviated mental test score 690
Mini-Mental State Examination 691
Confusion Assessment Method (CAM) 692
Clock-drawing and the Mini-CogTM 693
Clock-drawing test interpretation 694
Malnutrition universal screening tool (MUST) 695
Glasgow Coma Scale 696
Dermatomes (Fig. A.1)
Overview of the dermatomes, myotomes, and associated reflexes. Reproduced from Ward et al. (2009) Oxford Handbook of Clinical Rehabilitation, 2nd edn, Figure 20.1, p.317, with permission from OUP.
Geriatric Depression Scale
Suitable as a screening test for depressive symptoms in the elderly. Ideal for evaluating the clinical severity of depression, and therefore for monitoring treatment. It is easy to administer, needs no prior psychiatric knowledge and has been well validated in many environments—home and clinical.
The original GDS was a 30-item questionnaire—time consuming and challenging for some patients (and staff). Later versions retain only the most discriminating questions; their validity approaches that of the original form. The most common version in general geriatric practice is the 15-item version.
Instructions
The test (Table A.1) is undertaken orally. Ask the patient to reply indicating how they have felt over the past week. Obtain a clear yes or no reply. If necessary, repeat the question. Each depressive answer (bold) scores 1.
1 | Are you basically satisfied with your life? | Yes/No |
2 | Have you dropped many of your activities and interests? | Yes/No |
3 | Do you feel that your life is empty? | Yes/No |
4 | Do you often get bored? | Yes/No |
5 | Are you in good spirits most of the time? | Yes/No |
6 | Are you afraid that something bad is going to happen to you? | Yes/No |
7 | Do you feel happy most of the time? | Yes/No |
8 | Do you often feel helpless? | Yes/No |
9 | Do you prefer to stay at home, rather than going out and doing new things? | Yes/No |
10 | Do you feel you have more problems with memory than most? | Yes/No |
11 | Do you think it is wonderful to be alive now? | Yes/No |
12 | Do you feel pretty worthless the way you are now? | Yes/No |
13 | Do you feel full of energy? | Yes/No |
14 | Do you feel that your situation is hopeless? | Yes/No |
15 | Do you think that most people are better off than you are? | Yes/No |
1 | Are you basically satisfied with your life? | Yes/No |
2 | Have you dropped many of your activities and interests? | Yes/No |
3 | Do you feel that your life is empty? | Yes/No |
4 | Do you often get bored? | Yes/No |
5 | Are you in good spirits most of the time? | Yes/No |
6 | Are you afraid that something bad is going to happen to you? | Yes/No |
7 | Do you feel happy most of the time? | Yes/No |
8 | Do you often feel helpless? | Yes/No |
9 | Do you prefer to stay at home, rather than going out and doing new things? | Yes/No |
10 | Do you feel you have more problems with memory than most? | Yes/No |
11 | Do you think it is wonderful to be alive now? | Yes/No |
12 | Do you feel pretty worthless the way you are now? | Yes/No |
13 | Do you feel full of energy? | Yes/No |
14 | Do you feel that your situation is hopeless? | Yes/No |
15 | Do you think that most people are better off than you are? | Yes/No |
Scoring intervals
0–4 No depression
5–10 Mild depression
11+ Severe depression
Barthel Index
Bowel status
0 Incontinent
1 Occasional accident (once a week or less)
2 Continent
Bladder status
0 Incontinent, or catheterized and unable to manage
1 Occasional accident (maximum once in 24hr)
2 Continent (for more than 7 days)
Grooming
0 Needs help with personal care (face, hands, teeth, shaving)
1 Independent (with equipment provided)
Toilet use
0 Dependent
1 Can do some tasks, needs assistance
2 Independent (on/off, wiping, dressing)
Feeding
0 Dependent
1 Can do about half, needs help with cutting, etc.
2 Independent (food within reach)
Transfers
0 Unable (no sitting balance)
1 Major help (eg two people)
2 Minor help, able to sit (eg one person verbal or physical)
3 Independent
Mobility
0 Immobile
1 Wheelchair independent
2 Able to walk with the help of one person
3 Independent (can use walking aids if necessary)
Dressing
0 Unable
1 Can do about half unaided, needs some help
2 Independent
Stairs
0 Unable
1 Needs some help (including stair lift)
2 Independent up and down
Bathing
0 Dependent
1 Independent
TOTAL POSSIBLE SCORE = 20
Aim to record what the patient actually does do in daily life, not what he/she can do (ie a poorly motivated but capable patient may score poorly)
The score reflects the degree of independence from help provided by another person:
If supervision is required, the patient is not independent
If aids and devices are used but no help is required, the patient is independent
Use the best available evidence, asking the patient or relatives, carers, nurses and therapists, and using common sense. Observing the patient is helpful, but direct testing is not necessary
Middle categories imply that the patient supplies over 50% of the effort
It is useful to also ask about abilities before admission or acute illness, and to compare both the total Barthel score and elements of it to determine the magnitude and nature of the setback
Source
The abbreviated mental test score
The AMTS is a widely applicable, well validated, brief screening test of cognitive function.
Derived by Hodkinson from a 26-item test, by dispensing with those questions which were poor discriminators of the cognitively sound and unsound (Table A.2)
| Age | Must be correct (years) |
|---|---|
Time | Without looking at timepiece; correct to nearest hour |
Short term memory | Give the address ‘42 West Street’ Check registration Check memory at end of test |
Month | Exact |
Year | Exact, except in January when the previous year is satisfactory. Replies ‘206’, ‘207’, etc in place of 2006, 2007 should be considered correct, as they confirm orientation |
Name of place | If not in hospital ask type of place or area of town |
Date of birth | Exact |
Start of World War 1 | Exact |
Name of present monarch | Exact |
Count from 20 to 1 (backwards) | Can prompt with 20–19–18, but no further prompts. Patient can hesitate and self correct but no other errors are permitted |
| Age | Must be correct (years) |
|---|---|
Time | Without looking at timepiece; correct to nearest hour |
Short term memory | Give the address ‘42 West Street’ Check registration Check memory at end of test |
Month | Exact |
Year | Exact, except in January when the previous year is satisfactory. Replies ‘206’, ‘207’, etc in place of 2006, 2007 should be considered correct, as they confirm orientation |
Name of place | If not in hospital ask type of place or area of town |
Date of birth | Exact |
Start of World War 1 | Exact |
Name of present monarch | Exact |
Count from 20 to 1 (backwards) | Can prompt with 20–19–18, but no further prompts. Patient can hesitate and self correct but no other errors are permitted |
Scoring intervals
8–10 Normal
7 Probably abnormal
<6 Abnormal
Source
Mini-Mental State Examination
The MMSE is a widely applicable and well-validated test of cognitive function.
It is a 30-point test, takes 10–15min to complete, and covers a broader range of cognitive domains than the AMTS. It is therefore less useful as a brief screening test in general medical or geriatric practice, but is very useful in:
Confirming the nature and magnitude of deficits identified by clinical suspicion, or by the AMTS
Tracking change, for example following the introduction of cholinesterase inhibitors in dementia
The MMSE is widely used. Its copyright is now being robustly defended, and permission to publish it has not been granted. It is however widely available in older texts.
It is possible that the robust defence of copyright will result in a rapid decline in the use of what has been a useful clinical tool, to be replaced by other well-validated instruments such as the clock-drawing test.
Confusion Assessment Method (CAM)
A positive test requires the presence of items 1 and 2, and 3 or 4.
The positive likelihood ratio is 5.06 and negative likelihood ratio is 0.23.
Acute onset and fluctuating course. Evidence of acute change in mental status from baseline; behavior fluctuates during the day
Inattention. Easily distracted, difficulty focusing attention and keeping track with conversation
Disorganized thinking. Irrelevant conversation, unclear flow of ideas, unpredictable switching from subject to subject
Any mental state, other than alert, is abnormal. Describe altered states as: (a) vigilant, (b) drowsy, (c) difficult or unable to arouse
Source
Clock-drawing and the Mini-CogTM
Clock-drawing tests (CDT) are widely accepted and well validated screening tools for dementia. Their strength is in the brisk assessment of multiple cognitive domains including long-term memory, auditory and visual processing, motor planning and execution, etc. There are many test methods. All ask subjects to draw a clock face showing a specific time, but other details and vary. Despite these differences, most appear sensitive and specific and are well tolerated. There is also evidence that non-systematic assessment—simply asking a patient to draw a clock-face showing a named time and assessing it informally—has great value in ruling in or ruling out significant cognitive dysfunction.
The Mini-CogTM
One test that has found widespread favour is the Mini-Cog, which combines a 3-item recall test with a CDT. It takes 2–3 minutes to administer, is sensitive and specific, and largely uninfluenced by level of education, language or other cultural factors.
Administration
1. Get the patient's attention then say three unrelated words (eg banana, sunrise, chair). Ask the patient to repeat the words to confirm registration. If the patient is unable to repeat the words after three attempts move onto the next item
2. Ask the patient to draw a clock face on a blank sheet of paper. You should prompt with:
‘First draw a large circle’
‘Now put all the numbers in the circle’
‘Now set the hands to show ten past eleven (11.10)’
Instructions may be repeated, but no more detail/help given. If they have not completed the clock in three minutes move to the next item.
3. Ask the patient to repeat the three words
Scoring
Give a point for each word correctly recalled after the CDT.
A normal clock scores 2, an abnormal clock scores 0 (see Fig. A.2).
Total score is therefore out of 5 points.
Positive screen for dementia is indicated by:
Score of 0, 1 or 2
Negative screen for dementia is indicated by:
Score of 3, 4 or 5
Source
S Borson. Reprinted with permission of the author, solely for clinical and teaching use. May not be modified or used for research without permission of the author ([email protected]). All rights reserved.
Further reading
Clock-drawing test interpretation (Fig. A.2)
Clock-drawing test.
Malnutrition universal screening tool (MUST) (Fig. A.3)
The malnutrition universal screening tool.
Source
Reproduced here with the kind permission of BAPEN (British Association for Parenteral and Enteral Nutrition) from the 'MUST' Explanatory Booklet. For further information see M www.bapen.org.uk.
Glasgow Coma Scale
The GCS provides a framework with which to describe a patient's state in terms of three elements of responsiveness: eye opening, verbal, and motor.
The GCS score is an artificial index that is obtained by adding scores for each of the three responses. The range of scores is 3 to 15, 3 being the worst, and 15 the best.
Best eye response
4 Spontaneous opening
3 Open to speech
2 Open to pain
1 No eye opening
Best verbal response
5 Orientated
4 Confused conversation
3 Inappropriate words
2 Incomprehensible sounds
1 None
Best motor response
6 Obey commands
5 Localize pain
4 Withdrawal from pain—pulls limb away
3 Abnormal flexion to pain (decorticate posture)
2 Extension to pain (decerebrate posture)
1 No motor response
Note that the term 'GCS 11' has limited meaning. It is important to state the components of the GCS, eg E2V2M4 = GCS 8.
Broadly, a GCS of:
≥13 suggests mild brain injury
9–12 suggests moderate injury
≤8 suggests severe brain injury (coma)
