Comprehensive Geriatric Assessment

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Comprehensive Geriatric Assessment

• Mohamad Sabbah M.D
• Family Medicine

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A- Learning Objectives

• To know the Definition of Comprehensive Geriatric
  Assessment.
• To understand the Importance of Comprehensive
  Geriatric Assessment.
• To know the multiple Domains of Geriatric
  evaluation.
• To know the Useful tools used for evaluation

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B- Outline

• Introduction Case
• Defining Comprehensive Geriatric assessment (CGA)
• Explain the importance of CGA based on
  literature.
• Domains of evaluation list and tools.
• Conclusion

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C- Introduction

• K.R, 85 year old Female, living at home by
  herself, had fallen down the stairs one week ago.
  Since her fall, she walks slowly while holding
  her hands to the furniture, doesnt want to leave
  the apartment, not eating well and calling
  anxiously her daughter multiple times per day.
• Her daughter brought to the primary care clinic
  for evaluation.
• Physical exam practically normal.
• How can the family physician (or the Referral
  Geriatrician) evaluate this patient?

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1-Comprehensive Geriatric Assessment Definition

• Multidimensional,Multidisciplinary diagnostic
  process.
• Goal determine a frail elderly persons
  medical,psychosocial, and functional capacities
  and problems.
• Objective develop an overall plan of treatment
• long-term follow-up.
• Concept started in 1930 (Dr Warren) now regarded
  as the technology of geriatric medicine.

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1- Definition of Comprehensive Geriatric
Assessment

• Assessment involves an interdisciplinary team
• - Geriatrician or primary care physician
  
• - Geriatric nurse
• - Social worker
• - Physical therapist/Occupational
  therapist
• - Pharmacist
• - Psychologist/Psychiatrist
• - Dietitian

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2- Importance of Comprehensive Geriatric
assessment

• Population is aging
• 1998 Age 65 numbered 34 million (in USA)
• 2030 Age 65 will number 70 million
• Largest increase in those over age 85
• Majority of elderly will be cared for by
  internists and family practitioners

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CGA benefits

• Survival benefit Clearly demonstrated in
  inpatient
• settings and in home healthcare (3-4)
• Not proved in outpatient settings (5)
• Other quality of life, functional status,
  patient
• satisfaction, rate of institutionalization
  or
• hospitalization
• Clear benefit

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• --------------------------------------------------
  -------------------------

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3- Domains evaluated by CGA?
Domain
Functional status
Physical health
Cognitive/mental health
Socio-environmental factors
Assessment
ADLs/IADLs
HP Medication review
Dementia/depression screening
Home safety, caregiver burden, social barriers to care, nutritional risk
Example
Can the patient bathe, shop, etc.?
Look for polypharmacy, side effects
Have you often been bothered by a lack of interest or pleasure in doing things?
Fall risks, transportation issues, neighborhood safety
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3-Domains evaluated by CGA? Functional status

• Level of
• dependence
• Katz activities of daily living (ADL)
• Lawton Instrumental Activities
• of Daily Living (IADL scale)

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• Small changes in function make a big
  difference
• in quality of life for patients and their
  caregivers.

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3-Domains evaluated by CGA? Physical health

• Vision dont forget Underreporting of symptoms
• Hearing Presbycusis present in gt 50 of older
  persons.
• Urinary continence
• Sexual History discomfort may result from
  physician rather than patients attitudes
  simple open-ended question.
• Falls and Gait medications

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3-Domains evaluated by CGA? Nutritional Status

• MNA mini-nutritional assessment
• -30 items
• -Association of anthropometric and dietary
  parameters,
• global evaluation and a subjective
  evaluation of health
• -The first 6 items are enough for screening
• -Well validated in USA and Europe (6)
• - Able to classify 75 of patients
• - Good nutritionnal status
  gt24
• - Denutrition
  lt 17

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3-Domains evaluated by CGA? Cognitive / Mental
health

• Depression screening

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3-Domains evaluated by CGA? Cognitive / Mental
health

• Depression Evaluation
• Geriatric Depression scale GDS
• -15 items
• -Validated in multiple countries for
  ambulatory patients.
• -Score gt 6/15 --gt depression Se 92 Sp
  81.
• -To be used only for patients with a
  mini-mental gt 14/30

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3-Domains evaluated by CGA? Cognitive / Mental
health
2 simple and brief tests Blessed memory test
-Recall of 5-item (name and address).
-Re-ask after few minutes of distraction
-() if failure to recall 3 out of 5. One minute
verbal fluency test - Ask to name 10 animal
names - () inability to name at least 10
different animals in one minute.
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When do we do dementia evaluation?
3-Domains evaluated by CGA? Cognitive / Mental
health
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3-Domains evaluated by CGA? Cognitive / Mental
health

• Cognitive Evaluation MMSE Folstein
• Orientation (5 5)
• Registration name 3 common objects (3)
• Attention and calculation serials of 7 backwards
  stop after5 answers, alternatively spell world
  backwards (5)
• Recall (3)
• Language (9)
• Cut off usually cited as 24

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3-Domains evaluated by CGA? Cognitive / Mental
health

• MMSE
• Pattern of misses more important to
  interpretation than overall score.
• Education, cultural, and age biases
• Score impacted by literacy, depression, CVAs
• Version exist in Arabic

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4- Domains evaluated by CGA
Socio-environmental Factors

• Detailed knowledge of any change in living, who
  is available at home or in the local community.
• Inquiring about stairs, rugs, thresholds,
  bathing facilities, heating.
• Home visit is the best method
• Extent of Social relationships is a powerful
  predictor of functional status and mortality.

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Screening for Specific ProblemsFalls and Gait
Disorders

• Major cause of morbidity and mortality
• - 1/3 of elderly fall each year
• - Major cause of NH placement
• - Falls, mobility impairment, and functional
• impairment closely related

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• Fall History Assessment
• Ask the Patient Have you fallen in the past
  year?
• Gait Assessment
• Up and Go Test
• Rise from chair, walk 10 feet, turn around, walk
  back, sit down
• Timed Up and Go Test- normal less than 10
  seconds

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Screening for Specific ProblemsCaregiver
Stress and Abuse

• Caregiver stress highly correlated with
  increased risk
• of institutionalization, abuse and neglect.
• Education support of Caregiver is very
  important.
• Clues Caregiver miss appointments,concerned
  about medical costs, history of substance abuse,
  dominates interview,defensive, hostile,
  dependence on patient for income.
• Q A Do you feel Safe at home?

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Screening for Specific ProblemsMedications

• Elderly use 3X more medications than younger
  patients.
• Drug distribution, elimination, excretion,
  pharmacodynamics altered in elderly.
• ADRs and drug-drug interactions increase
  markedly with drugs used.
• Medications linked to reversible dementias,
  falls, incontinence, hospitalizations, death.

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Clinical Case

• K.R, 85 year old Female, living at home by
  herself, had fallen down the stairs one week ago.
  Since her fall, she walks slowly while holding
  her hands to the furniture, doesnt want to leave
  the apartment, not eating well and calling
  anxiously her daughter multiple times per day.
• Her daughter brought to the primary care clinic
  for evaluation.
• Physical exam practically normal.
• How can the family physician (or the Referral
  Geriatrician) evaluate this patient?

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Clinical Case

• Get up and go test takes 45 sec difficulty
  rising of the
• chair incapacity of advancement without
  holding to the
• furniture.
• ADL (5/6) needs aid for toileting and
  eating.
• IADL (10/14) (budget management issue)
• MMS 20/30 (short term memory problems,
  moderate temporo-spatial disorientation,
  calculcation problems)
• GDS 8/15
• MNA 23/30
• Social evaluation daughter is 55 y o with a
  husband having lung cancer can take her home on
  weekends a niece available twice per week earns
  600 dollars per month cant perceive any
  allocation at home

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• Impression post-fall syndrome with depressive
  symptomatology Recent loss of autonomy moderate
  cognitive problems De-nutrition risk.
• Management proposed by the doctor
• Physical therapy at home.
• Antidepressant treatment.
• Visiting nurse at home twice a week (for complete
  toileting)
• Family intervention on week-end and for budget
  management.
• Visiting maid for help in eating
• Follow-up evaluation in 2 months.

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Conclusion

• Primary health care practitioners play important
  roles in patient care.
• The primary health care system is not well
  established in Lebanon elderly assessment is
  shifted to hospitals and specialist care.
• GPs need to learn more about geriatric care.
• Importance of multidisciplinary Geriatric
  assessment
• Assess all the domains
• Screen for geriatric syndromes
• falls, incontinence, dementia, depression,
  hearing, vision, pain

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Thank you
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References

• 1- JKH lukU et al. Using the CGA technique to
  assess elderly patient
• HMMJ Vol 6 No 1 March 2000.
• 2- Rainfray Muriel et al. Comprehensive
  Geriatric assessment a useful tool for
  prevention of acute situation in elderly
  Ann.Med.Interne,2002153,6,347-402.
• 3-Saldvedt et al. Reduced mortality in treating
  acutely sick, frail older patients in a geriatric
  evaluation and management unit.
  J.Am.Geriatr.Soc,2002 50,792-798.
• 4- Appelgate et al. 1991Geriatric evaluation
  and management current status and future
  research directions.J.Am.Geriatr.Soc39,2S-7S.
• 5- H-K kuo et al.The influence of outpatient
  Geriatric assessment on survival a
  meta-analysis Arch of Geront and Geriartrics 39
  (2004) 245-254.

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• 6- Scheikh Ji, Yesavage Ja Geriatric depression
  scale (GDS) recent evidence and development of a
  shorter version.Clin Gerontol, 19865161-173.
• 7- Guigoz et al. mini-nutritionnal assessment a
  practical assessment tool for grading
  nutritionnal state of elderly patients. Facts Res
  Gerontol, 199421-60.