comprehensive geriatric assessment - dr
DESCRIPTION
4-11-06TRANSCRIPT
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