Benefits of Comprehensive Geriatric Assessement
Geriatric Assessmentjunaidi . arDept. of Internal Medicine1ObjectivesUnderstand that geriatric patients have multiple problems that often require a multidisciplinary approachUnderstand the benefits of geriatric assessmentBe able to identify which persons benefit the most from geriatric assessmentKnow how to identify functional impairments in an elderly person
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Geriatric Medicine
What is geriatric medicine?
3Geriatric MedicineDefinition:Comprehensive assessment and management of the older patient with chronic disability, multiple medical and social problems
Goal:Optimize function Multiple disciplines involved physician, nursing, rehabilitation medicine, social work4Geriatric Medicine Why are we concerned?
5Geriatric MedicineElderly people are subject to deteriorating function, diverse diseases and environmental challenges that can lead to the development of frailty and the inability to live independently6Demography1900 people > 65: 4% population2000 : 12%2030 : 20%
Total number of elderly was 3.1 million in 1900/ by 2000 it was 35 million
Life expectancy:75 years at birth82 years at 657DemographyAging of the population has heightened demand for comprehensive health services Persons > 65 account for 1/3 health expendituresMore frequent and more prolonged hospitalization85% at least one chronic illness/30% 3 or more8
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9Disease and disability are common at advanced age but it is unclear whether the continued growth of the older population will lead to increased numbers of debilitated elderly requiring extensive medical/social support
Disease prevention and health promotion might be developed to delay the onset of chronic illness and disability10AgingProcesses occurring during the postmaturational life span that progressively decreases the ability of an organism to adapt to environmental change and increases likelihood of dyingIncludes alterations in biochemistry, decrease in physiologic capacity and increased disease susceptibility11Theories of AgingTwo representative categories of aging theory
Oxidative stressGenetically regulated aging12Oxidative StressNormal metabolism generates oxygen free radicals that lead to cumulative damage of DNA, proteins and lipids over timeSupported by observation that low levels of oxygen free radicals or overexpression of protective antioxidant enzymes leads to longer lifespan in some species
13Oxidative StressAging may occur as result of cumulative mutations in DNA or errors in transcription or translationMay occur as result of oxidative damage or spontaneoulsyInsufficient to explain all age related physiologic changes14Genetically RegulatedProgrammed control aging processTelomere attritionTelomeres are redundant DNA sequences at ends of chromosomes essential for mitosisCertain cell lines have less activity of telomerase over timeFurther cell division no longer possible15Normal AgingPhysiologic functioning is highly variable among older individualsAging populations without disease on average are characterized by physiologic declineOften difficult to distinguish normal aging from disease associated with the aging process
16Normal AgingNormal aging (absence of disease) often classified into two categories:UsualAging accompanied by typical nonpathologic losses of physiologic functionSuccessfulPhysiologic decline during aging is minimal/absent17Normal AgingPhysiologic losses have been attributed to modifying effects of extrinsic variablesDietExercisePsychosocial factorsNeed for further research into strategies by which life-style modifications might reduce morbidity18An 85 year old man is admitted to the hospital with dehydration, fever and marked disorientation. He is presumed to have fallen, because he was found lying on the floor in his bedroom. He had been discharged from a rehabilitation hospital 2 months ago, after recovering from an acute CVA. At that time he was able to ambulate with a walker, and do basic self-care. He is febrile and tachypneic and has dry mucous membranes. Chest x-ray is consistent with a left lower lobe pneumonia.19Atypical Presentation of IllnessAge and other factors affect signs and symptoms of illness in older people20 Factors That Influence ResponseAge-associated changes in physiologic function(Host factors)Alterations of perception to painAbsence of signs or symptoms seen in younger patientsBurden of Co-morbid diseaseAcute illness in one system may stress reduced reserve capacity of anotherProduces unrelated signs and symptoms that can distract from correct etiologyUrosepsis presenting as delirium in a person with cognitive impairment21Factors That Influence ResponseTreatment of DiseaseTreatment of one illness may unmask previously undiagnosed pathologic conditionUrinary outlet obstruction may become apparent when pharmacologic agent with anticholinergic properties is given and provokes urinary retention22Treatment of DiseaseSigns and symptoms may appear straightforward, further evaluation to uncover an occult contributing disease is appropriateCertain nonspecific syndromes require more thorough investigationFailure to thriveAcute change in appetiteDecline in self-care capacityOnset of fallsChange in intellectual functionNew onset of incontinence23Hazards of Bed RestImposition of bed rest has been shown to have physiologic and psychologic hazardsElderly persons have less physiologic reserveMore prone to the adverse effects of bed rest24Hazards of Bed RestPhysiologic ConsequencesCardiac output declines/Pulmonary volumes declineUrinary concentrating ability decreasesCalcium and nitrogen loss can exceed intakeDecrease in muscle strength/ Decrease in enduranceSkin breakdown/Pressure soresIncreased risk for DVTCentral nervous system function alteredEmotional lability; poor short-term memory25Hazards of Bed RestPreventionPassive range of motion exercisesAssumption of upright posture several minutes/dayFrequent changes of positionRoutine orders for hospitalized patients to be out of bed for meals and daily ambulation26Comprehensive Geriatric AssessmentNIH Consensus Conference:
The multiple problems of older persons are uncovered, described and explained, if possible, and the resources and strengths of the person are catalogued, the need for services assessed, and a coordinated care plan developed to focus interventions on the persons problems.
27Benefits of Comprehensive Geriatric AssessmentMay reveal previously undetected medical or psychiatric diagnoses that need evaluation or treatment
Identification of functional deficits predicts need for social and environmental interventionsImprove use of community services/more appropriate placement28Benefits of Comprehensive Geriatric AssessmentImproves functionRepetition of functional assessment may be used to gauge impact of therapy More appropriate medication useMay decrease number of acute care days
29Functional StatusThe capacity of an individual to function in multiple domains (physical, mental, social, emotional) and at multiple levels (organ function, function of person as whole, function of person in society)30
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31Who should be evaluated?32Three patient categoriesHealthy elderly persons living in the communityFrail elderly persons living in the communityInstitutionalized or severely impaired elderly persons33Patients who benefit mostFrail because of ageDecrease in functional statusChange in mental status- cognition/affectMultiple medical problemsMultiple psychosocial problemsTake multiple medicationsNew onset urinary or fecal incontinenceInvoluntary weight lossFrequent fallsOne or more sensory impairmentsDisruptive behavior or personality changes34Multi-Disciplinary Team ApproachInterdisciplinary team to make assessments and develop a diagnosis and treatment planEach member of team sees every patientTeam Members: physician, nurse, social worker, physical and occupational therapy, psychology, rehabilitation medicine, audiology, clinical pharmacy and nutrition35Multi-Disciplinary Team ApproachModel has been limitedShortage of health care professionals trained in geriatric medicinePoor reimbursement
Methods have been developed to administer functional status assessments in physician offices36Components of CGAComplete History and PhysicalLaboratory as indicatedPrevention Screening37Geriatric SyndromesCommon problems that have been identified as warranting special attention in elderly
Cognitive Disorders Dementia/DeliriumPolypharmacyFalls/Gait InstabilityUrinary IncontinenceDepressionMalnutrition38Components of CGASet of assessment protocols that focus on screening for physical and psychosocial impairments and disabilities
39Components of CGAMeasures to evaluate disability and functional statusActivities of Daily LivingInstrumental Activities of Daily LivingConsideration of living situation adequacy and safetyDiscussion with patient/family regarding preferences for future medical care40
41Screening Assessments Used in Comprehensive Geriatric Assessment42A 72 year old man is brought to your office by his son because he is unable to handle his financial affairs. The patient is a retired accountant and has enjoyed good health. He has some insight into his mental problems. He is taking no medication. Since his wife died 6 months ago, he has lived alone
Physical examination reveals blood pressure of 180/100 and a left carotid artery bruit. The rest of the exam and lab work is unremarkable. MRI of the head is unremarkable.43Cognitive ImpairmentDementia is common but often goes unrecognizedSome cases are potentially treatable or reversibleImportant to identify patients with impairment, even if not treatable, in order to plan for future care44Cognitive ImpairmentPrevalence of cognitive impairment varies greatly by age and clinical settingCommunity dwelling patients> 65 y/o have 10% Alzheimers rate> 85 y/o have 47% ratePrevalence much greater in institutionalized settings45Cognitive ImpairmentExtensive screening batteries for cognitive impairment have been developedMost widely used is the Mini-Mental State Examination (MMSE)Takes about 5-10 minutes to administer46TOTAL SCORE 30; SCORE < 20 PROBABLE DEFICIENCYFolstein Mini-Mental Status ExamORIENTATIONAsk for year, season, date, day, monthAsk for state, county, town, place,streetREGISTRATIONName three unrelated objects. Ask patient to repeatATTENTION/ CALCULATION - Subtract 7 from 100,repeat 5 times
RECALLRecall three previous objectsLANGUAGEShow wrist watch and ask what it isAsk to repeat no, ifs ands or butsOn blank piece of paper print Close your eyes and ask patient to do itGive patient a blank piece of paper and ask him to write a sentence47Cognitive ImpairmentPositive result indicated need for further evaluationCan use for monitoring by repeating screen at later date and see if improvement or deterioration takes place48DepressionCommon disorder in the elderlyUnder diagnosedImpairments range from depressive symptoms to major depression49Depression-ScreeningGeriatric Depression ScaleDesigned specifically for frail older patientsSeries of 30 YES/NO questions covering symptoms and manifestations of depressionTakes 10-15 minutes to administerScore > 14 greatly increases probability of depressionScore < 9 greatly decreases probability50Geriatric Depression ScaleAre you basically satisfied with your life?Yes/NOHave you dropped many of your interests?YES/NoDo you feel your life is empty?YES/NoDo you often feel bored?YES/NoAre you in good spirits most of the time?Yes/NOAfraid something bad is going to happen?YES/NoDo you feel happy most of the time?Yes/NODo you often feel helpless?YES/NoDo you prefer to stay at home?YES/NoDo you feel you have memory problems?YES/NoDo you think it is wonderful to be alive?Yes/NODo you feel worthless?YES/NoDo you feel full of energy?Yes/NODo you feel your situation is hopeless?YES/NoDo you think most people are better off than you?YES/No51Depression- ScreeningDemented patients frequently suffer from depressionMeasures have been developed to screen for depression without reliance on patient self-reportCaregiver asked questions about presence of a number of symptoms/manifestations of depression52DepressionShould be aware of other problems causing cognitive impairmentDeliriumAnxietyHostilityPsychosisBehavioral Problems53An 85 year old woman comes to your office for the first time because she ahs lost 9.1 kg in the last 6 months. She has no appetite and foods taste different to her. A careful history fails to identify a likely cause for weight loss. She has and OA.
Physical exam shows a markedly underweight and frail woman. Her gait is slow and she has difficulty getting out of a chair without assistance. 54Musculoskeletal Impairment and ImmobilityUnsteadinessAbnormality sitting or getting up from a chairTurning or walking with difficultyStep height
Impairments in these areas increase the risk of falling in older personsOften undetected in a standard history and physical55Screening TestsUpper extremity mobilityManual dexterityLower extremity mobility
56BALANCE SCORE ___/16 < 10 = HIGH FALL RISKEvaluations of Balance and GaitBalance MeasuresSitting balance (leaning vs steady)Ability to rise from chairImmediate standing balanceStanding balance (wide based, narrow based or assisted)Sternal nudgeStanding balance w/ eyes closed 57GAIT SCORE ___/12 < 9 = HIGH FALL RISKEvaluations of Balance and GaitGait ObservationsInitiation of gaitStep lengthStep heightStep continuityStep symmetryWalking stanceAmount of trunk swayPath deviation58MalnutritionIncreased risk for poor nutritional status because of chronic disease, poverty, social isolation, cognitive impairment and functional disabilityAssociated with impaired wound healing, increased surgical complications and increased mortality59IndicatorsBody weight < 100 pounds highly sensitiveCan also occur patients > 100 poundsHistorical cluesInvoluntary weight loss of 10% body fatPhysical ExamGlossitis, loss of subcutaneous fat, muscle wasting, edemaLabSerum albumin60DETERMINE ChecklistTool developed by Nutrition Screening InitiativeBased on warning signs described by the wordDisease, Eating poorly, Tooth loss/mouth pain, Economic hardship, Reduced social contact, Multiple Medicines, Involuntary weight loss/gain, Needs assistance in self-care, Elderly years >80Score0-2 Good3-5 Moderate risk>6High risk61Visual and Hearing ImpairmentVisual impairment13%
Hearing impairment65-74y/o25%>85y/o50%62Visual ImpairmentMethods available for office screening have limitationsSensitivity/Specificity have not been established in older adultsLimitations in diagnostic accuracy of glaucoma screening by primary care physician63Visual ImpairmentScreening should be performed using Snellen testSpecific questions about functional disability that might be due to poor visionReferral to Ophthalmologist if needed64Hearing ImpairmentHand held audioscopePerformed in 90 seconds94% sensitive, 72% specificPhysical exam techniques such as whispered voice or finger rub can be usedAccuracy of tests may be enhanced if combined with short questionnaire on functional disability associated with hearing impairment65Functional AssessmentComplement to screening for specific impairmentsHelp with determining overall health and well beingGuide to treatment planHelp to plan long-term care servicesMonitor effectiveness of interventions66Functional AssessmentChoice between methods and instruments to measure function depends on frailty of patient population, time available for assessment and intended use of information67Activities of Daily LivingOne of the original methods and in wide use todayFocuses on basic activitiesBathingTransferringDressingContinenceToiletingFeeding68Instrumental Activities of Daily LivingFocus on more complex activities important for independent living in the community
ShoppingUsing the telephoneHandling financesHousekeepingUsing transportationFood preparationTaking medication69Assessment of Home SafetyThroughout the interior several common featuresScatter rugs, adequate lighting, enough room for easy mobility, emergency telephone numbers postedKitchenBathroomOutside the home
70Assessment of Social SupportAssess the patients emotional supportIdentify actual/potential caregiversAsk who would be available in an emergencySocial information and background may help assess coping ability71Long Term Options/PlacementSupport for remaining in the homeHome healthProvider serviceDay careIf unable to remain in the homeAssisted living facilitySubsidized senior apartmentsNursing home72ConclusionsValue of CGA has been evaluated in the inpatient and outpatient settingsDemonstrated to improve medical care provided to frail elderlyControlled studies have shown improved patient outcomesNo study has shown worse outcomesInpatient units may improve survival73CGA should be targeted to patients with potentially improvable functionOptimal targeting criteria have not been establishedMay be that a patient without potential for improved function might benefit from depression screening, medication reviewConclusions74 Comprehensive Geriatric Assessment has been advanced as a means to more effectively diagnose and manage complex medical problems of frail elderlyConclusions75Asesmen geriatri Suatu analisa multidisiplin yang dilakukan seorang geriatris atau tim interdisipliner geriatri atas seorang penderita usia lanjut untuk mengetahui kapabilitas medis, fungsional, psiko sosial agar dapat dilakukan penatalaksanaan menyeluruh dan berkesinambungan .76Tujuan : Untuk memperbaiki kualitas hidup lansia.
Kualitas dipengaruhi oleh status kesehatan , faktor sosial ekonomi , dan lingkungan 77Quality of lifeHealth status Physical,sosial,mental healhtyDisease status
Physiological measuressSign and sympiomsPrognosis Fungtional status
Daily activitiesAchievement Disabilities Socioeconomy status
Environment 78Kapasitas fungsional : ADL
Fungtionsl Status medicalCognitive Affective environmentSocial support economicspiritualityInteraksi dimensi dimensi asesmen geriatri 79Skala asesmen kuantitatifDalam PelaksanaanPanduan evaluasiMembantu diagnosa Interpretasi /keterbatasan/form80Asesmen fungsional Gg beragam sebab potensial, perubahan menua ADL IADL25% lansia butuh bantuan orang lain81Asesmen medis 1. masalah mobilitas dan keseimbangan.The timed up & go test dan the performance oriented of balance2. gg penglihatan 3. gg dengar 4. malnutrisi5. Polifarmasi 6. inkontenensia 82Asesmen Kognitif Dimensia
MMSE Mini mental state examClock drawing test
83Asesmen Afektif Depresi 10 - 15% R jalan 20% r inap GDS geriatric depression scale 84Asesmen sosial Dukungan terhadap Caregiver /perumat Abuse and neglectThe burden interview 85Asesmen lingkungan Keamanan lingkungan rumah Kemudahan akses Pemakaian piranti adaptif
86Asesmen Ekonomi Sumber daya penghasilan Emosional
87Asesmen spiritual Agama !88Kesimpulan Asesmen G merupakan tata cara evaluasi yg komperhensif atas status kesehatan lansia Kepekaan perhatian terhadap lansia Kewaspadaan aspek aspek unik permasalahan medis Ber-interaksi Kesabaran Prespektif cara pandang dewasa dan lansia .89terimakasih
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