Comprehensive Geriatric Assessment - Dr

Geriatric Assessment

Dolores Buscemi, MDDept. of Internal Medicine

Objectives

Understand that geriatric patients have multiple problems that often require a multidisciplinary approach

Understand the benefits of geriatric assessment

Be able to identify which persons benefit the most from geriatric assessment

Know how to identify functional impairments in an elderly person

Geriatric Medicine

What is geriatric medicine?

Geriatric Medicine

Definition: 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 work

Geriatric Medicine

Why are we concerned?

Geriatric Medicine

Elderly people are subject to deteriorating function, diverse diseases and environmental challenges that can lead to the development of frailty and the inability to live independently

Demography

1900 people > 65: 4% population 2000 : 12% 2030 : 20%

Total number of elderly was 3.1 million in 1900/ by 2000 it was 35 million

Life expectancy: 75 years at birth 82 years at 65

Demography

Aging of the population has heightened demand for comprehensive health services

Persons > 65 account for 1/3 health expenditures More frequent and more prolonged

hospitalization 85% at least one chronic illness/30% 3

or more

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Disease 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 disability

Aging

Processes occurring during the postmaturational life span that progressively decreases the ability of an organism to adapt to environmental change and increases likelihood of dying Includes alterations in biochemistry,

decrease in physiologic capacity and increased disease susceptibility

Theories of Aging

Two representative categories of aging theory

Oxidative stress Genetically regulated aging

Oxidative Stress

Normal metabolism generates oxygen – free radicals that lead to cumulative damage of DNA, proteins and lipids over time Supported by observation that low

levels of oxygen free radicals or overexpression of protective antioxidant enzymes leads to longer lifespan in some species

Oxidative Stress

Aging may occur as result of cumulative mutations in DNA or errors in transcription or translation

May occur as result of oxidative damage or spontaneoulsy

Insufficient to explain all age related physiologic changes

Genetically Regulated

Programmed control aging process Telomere attrition

Telomeres are redundant DNA sequences at ends of chromosomes essential for mitosis

Certain cell lines have less activity of telomerase over time

Further cell division no longer possible

Normal Aging

Physiologic functioning is highly variable among older individuals Aging populations without disease on

average are characterized by physiologic decline

Often difficult to distinguish “normal aging” from disease associated with the aging process

Normal Aging

Normal aging (absence of disease) often classified into two categories: Usual

Aging accompanied by typical nonpathologic losses of physiologic function

Successful Physiologic decline during aging is

minimal/absent

Normal Aging

Physiologic losses have been attributed to modifying effects of extrinsic variables Diet Exercise Psychosocial factors

Need for further research into strategies by which life-style modifications might reduce morbidity

An 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.

Atypical Presentation of Illness

Age and other factors affect signs and symptoms of illness in older people

Factors That Influence Response

Age-associated changes in physiologic function (Host factors) Alterations of perception to pain Absence of signs or symptoms seen in younger

patients Burden of Co-morbid disease

Acute illness in one system may stress reduced reserve capacity of another

Produces unrelated signs and symptoms that can distract from correct etiology

Urosepsis presenting as delirium in a person with cognitive impairment

Factors That Influence Response

Treatment of Disease Treatment of one illness may unmask

previously undiagnosed pathologic condition

Urinary outlet obstruction may become apparent when pharmacologic agent with anticholinergic properties is given and provokes urinary retention

Treatment of Disease Signs and symptoms may appear

straightforward, further evaluation to uncover an occult contributing disease is appropriate

Certain nonspecific syndromes require more thorough investigation Failure to thrive Acute change in appetite Decline in self-care capacity Onset of falls Change in intellectual function New onset of incontinence

Hazards of Bed Rest

Imposition of bed rest has been shown to have physiologic and psychologic hazards Elderly persons have less physiologic

reserve More prone to the adverse effects of

bed rest

Hazards of Bed Rest

Physiologic Consequences Cardiac output declines/Pulmonary

volumes decline Urinary concentrating ability decreases

Calcium and nitrogen loss can exceed intake Decrease in muscle strength/ Decrease in

endurance Skin breakdown/Pressure sores Increased risk for DVT Central nervous system function altered

Emotional lability; poor short-term memory

Hazards of Bed Rest

Prevention Passive range of motion exercises Assumption of upright posture several

minutes/day Frequent changes of position Routine orders for hospitalized patients

to be out of bed for meals and daily ambulation

Comprehensive Geriatric Assessment

NIH 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 person’s problems.”

Benefits of Comprehensive Geriatric Assessment

May reveal previously undetected medical or psychiatric diagnoses that need evaluation or treatment

Identification of functional deficits predicts need for social and environmental interventions Improve use of community services/more

appropriate placement

Benefits of Comprehensive Geriatric Assessment

Improves function Repetition of functional assessment may

be used to gauge impact of therapy More appropriate medication use May decrease number of acute care days

Functional Status

The 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)

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Who should be evaluated?

Three patient categories

1. Healthy elderly persons – living in the community

2. Frail elderly persons – living in the community

3. Institutionalized or severely impaired elderly persons

Patients who benefit most Frail because of age Decrease in functional status Change in mental status- cognition/affect Multiple medical problems Multiple psychosocial problems Take multiple medications New onset urinary or fecal incontinence Involuntary weight loss Frequent falls One or more sensory impairments Disruptive behavior or personality changes

Multi-Disciplinary Team Approach

Interdisciplinary team to make assessments and develop a diagnosis and treatment plan

Each member of team sees every patient Team Members: physician, nurse, social

worker, physical and occupational therapy, psychology, rehabilitation medicine, audiology, clinical pharmacy and nutrition

Multi-Disciplinary Team Approach

Model has been limited Shortage of health care professionals

trained in geriatric medicine Poor reimbursement

Methods have been developed to administer functional status assessments in physician offices

Components of CGA

Complete History and Physical Laboratory as indicated Prevention Screening

Geriatric Syndromes

Common problems that have been identified as warranting special attention in elderly

1. Cognitive Disorders Dementia/Delirium

2. Polypharmacy3. Falls/Gait Instability4. Urinary Incontinence5. Depression6. Malnutrition

Components of CGA

Set of assessment protocols that focus on screening for physical and psychosocial impairments and disabilities

Components of CGA

Measures to evaluate disability and functional status Activities of Daily Living Instrumental Activities of Daily Living

Consideration of living situation – adequacy and safety

Discussion with patient/family regarding preferences for future medical care

Screening Assessments Used in Comprehensive Geriatric Assessment

A 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.

Cognitive Impairment

Dementia is common but often goes unrecognized

Some cases are potentially treatable or reversible

Important to identify patients with impairment, even if not treatable, in order to plan for future care

Cognitive Impairment

Prevalence of cognitive impairment varies greatly by age and clinical setting Community dwelling patients

> 65 y/o have 10% Alzheimer’s rate > 85 y/o have 47% rate

Prevalence much greater in institutionalized settings

Cognitive Impairment

Extensive screening batteries for cognitive impairment have been developed

Most widely used is the Mini-Mental State Examination (MMSE) Takes about 5-10 minutes to administer

TOTAL SCORE 30; SCORE < 20 PROBABLE DEFICIENCY

Folstein Mini-Mental Status Exam

ORIENTATION Ask for year, season,

date, day, month Ask for state, county,

town, place,street REGISTRATION

Name three unrelated objects. Ask patient to repeat

ATTENTION/ CALCULATION

- Subtract 7 from 100,repeat 5 times

RECALL Recall three previous

objects LANGUAGE

Show wrist watch and ask what it is

Ask to repeat “no, ifs ands or buts”

On blank piece of paper print “Close your eyes” and ask patient to do it

Give patient a blank piece of paper and ask him to write a sentence

Cognitive Impairment

Positive result indicated need for further evaluation

Can use for monitoring by repeating screen at later date and see if improvement or deterioration takes place

Depression

Common disorder in the elderly Under diagnosed Impairments range from depressive

symptoms to major depression

Depression-Screening

Geriatric Depression Scale Designed specifically for frail older

patients Series of 30 YES/NO questions covering

symptoms and manifestations of depression

Takes 10-15 minutes to administer Score > 14 greatly increases

probability of depression Score < 9 greatly decreases probability

Geriatric Depression Scale

Are 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/No

Do you think most people are better off than you? YES/No

Depression- Screening

Demented patients frequently suffer from depression

Measures have been developed to screen for depression without reliance on patient self-report Caregiver asked questions about

presence of a number of symptoms/manifestations of depression

Depression

Should be aware of other problems causing cognitive impairment Delirium Anxiety Hostility Psychosis Behavioral Problems

An 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 HTN 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.

Musculoskeletal Impairment and Immobility

Unsteadiness Abnormality sitting or getting up from a

chair Turning or walking with difficulty Step height

Impairments in these areas increase the risk of falling in older persons

Often undetected in a standard history and physical

Screening Tests

Upper extremity mobility Manual dexterity Lower extremity mobility

BALANCE SCORE ___/16 < 10 = HIGH FALL RISK

Evaluations of Balance and Gait

Balance Measures Sitting balance (leaning vs steady) Ability to rise from chair Immediate standing balance Standing balance (wide based, narrow

based or assisted) Sternal nudge Standing balance w/ eyes closed

GAIT SCORE ___/12 < 9 = HIGH FALL RISK

Evaluations of Balance and Gait Gait Observations

Initiation of gait Step length Step height Step continuity Step symmetry Walking stance Amount of trunk sway Path deviation

Malnutrition

Increased risk for poor nutritional status because of chronic disease, poverty, social isolation, cognitive impairment and functional disability

Associated with impaired wound healing, increased surgical complications and increased mortality

Indicators Body weight < 100 pounds highly

sensitive Can also occur patients > 100 pounds

Historical clues Involuntary weight loss of 10% body fat

Physical Exam Glossitis, loss of subcutaneous fat, muscle

wasting, edema Lab

Serum albumin

DETERMINE Checklist

Tool developed by Nutrition Screening Initiative

Based on warning signs described by the word Disease, Eating poorly, Tooth loss/mouth pain, Economic hardship, Reduced social contact, Multiple Medicines, Involuntary weight loss/gain, Needs assistance in self-care, Elderly years >80

Score 0-2 Good 3-5 Moderate risk >6 High risk

Visual and Hearing Impairment

Visual impairment 13%

Hearing impairment 65-74y/o 25% >85y/o 50%

Visual Impairment

Methods available for office screening have limitations Sensitivity/Specificity have not been

established in older adults Limitations in diagnostic accuracy of

glaucoma screening by primary care physician

Visual Impairment

Screening should be performed using Snellen test

Specific questions about functional disability that might be due to poor vision

Referral to Ophthalmologist if needed

Hearing Impairment

Hand held audioscope Performed in 90 seconds 94% sensitive, 72% specific

Physical exam techniques such as whispered voice or finger rub can be used

Accuracy of tests may be enhanced if combined with short questionnaire on functional disability associated with hearing impairment

Functional Assessment

Complement to screening for specific impairments Help with determining overall health

and well being Guide to treatment plan Help to plan long-term care services Monitor effectiveness of

interventions

Functional Assessment

Choice between methods and instruments to measure function depends on frailty of patient population, time available for assessment and intended use of information

Activities of Daily Living

One of the original methods and in wide use today

Focuses on basic activitiesBathing TransferringDressing ContinenceToileting Feeding

Instrumental Activities of Daily Living

Focus on more complex activities important for independent living in the community

ShoppingUsing the telephoneHandling financesHousekeepingUsing transportationFood preparationTaking medication

Assessment of Home Safety

Throughout the interior several common features Scatter rugs, adequate lighting, enough

room for easy mobility, emergency telephone numbers posted

Kitchen Bathroom Outside the home

Assessment of Social Support

Assess the patient’s emotional support

Identify actual/potential caregivers Ask who would be available in an

emergency Social information and background

may help assess coping ability

Long Term Options/Placement

Support for remaining in the home Home health Provider service Day care

If unable to remain in the home Assisted living facility Subsidized senior apartments Nursing home

Conclusions

Value of CGA has been evaluated in the inpatient and outpatient settings

Demonstrated to improve medical care provided to frail elderly

Controlled studies have shown improved patient outcomes

No study has shown worse outcomes Inpatient units may improve survival

CGA should be targeted to patients with potentially improvable function

Optimal targeting criteria have not been established

May be that a patient without potential for improved function might benefit from depression screening, medication review

Conclusions

Comprehensive Geriatric Assessment has been advanced as a means to more effectively diagnose and manage complex medical problems of frail elderly

Conclusions