Transcript COMPREHENSIVE GERIATRIC ASSESSMENT CGA

EVALUATION OF FUNCTIONAL
CAPACITY AND HISTORY &
PHYSICAL
Samira Khazravan, M.D.
Geriatric Fellow
Department of Geriatrics
Mary Immaculate Hospital
Assessment of the Geriatric
Patient
COMPREHENSIVE GERIATRIC
ASSESSMENT
CGA
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Diagnose and develop an overall plan of care
for treatment and long term follow up
Optimizes independence and prevent future
disabilities.
Consist of set professionals that make up a
multidisciplinary team.
Includes evaluation of physical and mental
health, functional status, social function, and
environment.
WHY CGA?
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Great success in improving function.
Decreases multiple negative variables, such as
nursing home placement, medication use, and
mortality.
It increases diagnostic accuracy and
independence.
SUCCESSFUL MANAGEMENT
OF CGA
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Accomplished when the Geriatric Team takes
over the direct care of the patient.
Unlikely to be successful in improving patient
outcomes when the Geriatric Team assumes a
purely consultative role.
Barriers to the CGA is that it is time-consuming
and expensive.
MEDICAL ASSESSEMENT
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Should focus on specific conditions that are
common to the elderly and have significant
impact on function.
These include impairments of vision, hearing,
mobility and falls, malnutrition, urinary
incontinence, and polypharmacy.
VISUAL IMPAIRMENT
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Major eye diseases such as cataract, macular
degeneration, glaucoma, and diabetic retinopathy
increases with age.
Require eye glasses due to presbyopia.
Often unaware of their visual deficits.
Should ask questions regarding reading, watching
television, or driving.
Snellen Chart is used to screen for visual deficits.
Patient stands 20 ft. from the chart and read letters
using corrective lens.
Inability to read >20/40 implies impairment in
vision.
HEARING IMPAIRMENT
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Associated with decreased cognition, depression,
dissatisfaction with life, and withdrawal from
social activities.
Usually bilateral.
Occurs in the high frequency range.
Can be assessed using a hand-held audio scope.
Inability to hear 40 decibles tone at 1000 or
2000 Hz in one or both ears implies failed
hearing test.
WHISPER VOICE TEST
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An alternative to hand-held audio scope.
Done by whispering 3 – 6 words at a distance of
8, 12, or 24 inches from the patient’s ear.
Examiner should stand behind the patient and
have one ear covered during the examination.
Inability to repeat >50% of the whispered
words is considered a failed screening.
NUTRITION
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Inadequate nutrition – due to concurrent
medical illness; depression; inability to shop,
cook or feed oneself; and financial hardship.
Elderly people should have their weights
measured routinely.
Unintentional weight loss of >10lbs in the past
6 months suggests poor nutrition in the absence
of other medical problems.
NUTRITION (contd.)
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Important prognostic factors of mortality:
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Low cholesterol and low albumin
Serum cholesterol is a valuable marker for older
persons at risk for adverse events even though
they are associated with evidence of
inflammation rather than malnutrition in
hospitalized patients.
However, among community dwelling older
persons obesity is the most common nutritional
disorder.
NUTRITIONAL-RELATED
SCREENING EVALUATION
YES
1. Do you have an illness or condition that made you change the kind and amount of
food you eat.
2
2. Do you eat fewer than two meals per day.
3
3. Do you eat few fruits, vegetables, or milk products.
2
4. Do you have 3 or more drinks of beer, liquor or wine almost every day.
2
5. Do you have tooth or mouth problems that make it hard for you to eat.
2
6. Do you always have enough money to buy food.
4
7. Do you eat alone most of the time.
1
8. Do you take 3 or more different prescribed or over the counter drugs per day.
1
9. Without wanting to, have you lost or gained 10lbs. in the last 6 months.
2
10. Are you physically unable to shop, cook, or feed yourself.
2
A score of 0-2 is good, 3-5 moderate nutritional risk and greater than 6
equal high nutritional risk.
COGNITIVE IMPAIRMENT
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Increases risk for inability, delirium, medical
non-adherence, and accidents.
Cognitive abilities decline with age after
adulthood is reached.
Decline doubles every 5 years after age 65.
One common cause of cognitive decline is
Alzheimer's Disease.
COGNITIVE IMPAIRMENT
(contd.)
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Alzheimer’s have cognitive changes that differ in
magnitude and extent compared to normal aging
process.
Patients with Dementia do not volunteer
symptoms of cognitive impairment or complain
of memory loss unless specifically questioned.
Cognitive change associated with aging are
related to a generalized slowing of mental
process or cognitive speed rather than a loss of
memory.
FOLSTEIN MINI-MENTAL
STATE EXAMINATION (MMSE)
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Used to evaluate cognition.
Assesses orientation.
Registration and recall.
Attention and calculation.
Language and visual-spatial skills.
Scores are interpreted in the context of educational
attainment and age.
A score <23 is diagnostic of Dementia.
Single best assessment question for Dementia is a recall
of 3 words after 1 minute since short-term memory is
generally the first sign.
Failure to recall the 3 words require further evaluation.
MMSE
Orientation
Name: hospital/floor/town/state/country
5 (1 for each name)
Registration
Identify three objects by name and ask patient to repeat3
(1 for each object)
Attention and calculation
Serial 7s; subtract from 100 (e.g., 93-86-79-72-65)
5 (1 for each subtraction)
Recall
Recall the three objects presented earlier
3 (1 for each object)
Language
Name pencil and watch
2 (1 for each object)
Repeat "No ifs, ands, or buts“
1
Follow a 3-step command (e.g., "Take this paper,,
fold it in half and place it on the table")
3 (1 for each command)
Write "close your eyes" and ask patient to obey
written command
1
Ask patient to write a sentence
1
Ask patient to copy a design (e.g., intersecting pentagons)
1
TOTAL
30
PSYCHOLOGICAL ASSESSEMENT
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Major depression occurs in 1% -2% of the elderly
population.
A large number of elderly have symptoms of depression
below the severity threshold of major depression.
Sub-threshold symptoms are associated with increased risk
of physical disability, slower recovery after an acute
disabling event, and increased cost of medical services.
Anxiety and worries in the elderly can be a manifestation of
an underlying depressive disorder.
A simple question to ask is “Do you feel sad or depressed?”
A positive answer warrants further investigation. This can
be done by using the Geriatric Depression Scale (GDS).
The short form of the GDS consists of 15 questions:
1. Are you basically satisfied with your life?
yes/no
2. Have you dropped many of your activities and interest?
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. you prefer to stay at home rather than staying out and doing new things?
yes/no
10. Do you feel that 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
Bold answers are scored, with one point for each of these answers. Normal is
equal to 0-5; and greater than 5 suggest depression.
SOCIAL ASSESSMENT
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Should include availability of help in case of
emergency.
Availability of a personal support system.
Need for a caregiver.
Caregiver burdens.
Economic status.
Elder mistreatment.
Advanced directives.
SOCIAL ASSESSEMENTS (contd.)
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For the frail elderly availability of help from
family or friends can determine whether a
functionally dependent person remains at home
or is institutionalized.
For those frail elders that lack support, a visiting
nurse may be helpful in the assessment of home
safety and level of personal risk, i.e., stairs,
location of bathrooms, bathroom grab bars, and
smoke alarms.
URINARY INCONTINENCE
Common occurrence among the elderly especially women.
 Can go unrecognized in men and women for variable
reasons.
 Women may be embarrassed to discuss the issue especially
if the clinician is male, or may regard it as a normal part of
aging that is best controlled with pads.
 Two screening questions to ask are:
 In the last year have you lost your urine and gotten wet?
If the answer is YES then the patient is asked,
 Have you lost urine on 6 separate days?
An answer of YES to both questions have a 75% - 79%
accuracy for urinary incontinence.
 Other associated signs and symptoms include frequency,
urgency, nocturia, hesitancy, dribbling, and intermittent flow.
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POLYPHARMACY
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Due to care from multiple providers.
Fill their prescriptions at various pharmacies.
Patients should bring in all their current medications at
each office visit and have them checked against their
medication list in their medical chart.
Increases the chance for drug-drug interactions (DDI)
which increases the risk for adverse drug events (ADE).
Cardiovascular and psychotropic drugs are the most
common medications involved in ADE’s.
Common ADE’s are neuropsychological (confusion) or
cognitive impairments, hypotension, and acute renal
failure.
RISK FACTORS ASSOCIATED
WITH ADVERSE DRUG EVENTS
(ADE)
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>6 concurrent diagnosis.
>12 doses of medications per day.
A prior ADE.
A low body weight or BMI.
Age >85 years.
Creatinine clearance <50ml/minute.
MOBILITY AND BALANCE
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Impairments in mobility and balance is due to
musculoskeletal (osteoarthritis) and neurological
(neuropathies/motor dysfunctions) disorders.
Sequelae of previous falls such as fractures,
unequal leg length, or fear of falling can worsen
impairments in gait and balance in the elderly
thus leading to more functional impairments.
MOBILITY AND BALANCE RISK
ASSESSEMENT FOR FALLS
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Testing for balance, gait, lower extremity strength.
Previous history of falls causes and treatments.
Balance, gait, and lower extremity strength can best
be assessed by observing the patient performing
specific task.
Lower extremity or quadriceps weakness can
evaluated by asking the patient to stand from a
seated position in a hard back chair while keeping
their hands folded.
Inability to complete this task suggest lower
extremity weakness and is highly predictive for
future disability.
MOBILITY AND BALANCE RISK
ASSESSEMENT FOR FALLS
(contd.)
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Once standing he/she should be instructed to walk back and
forth over 10ft, ideally with their walking aid.
Abnormalities are path deviation, diminished step height or
length, trips, slips, near-falls, and difficulty turning.
The task of rising from an armless chair, walking 10ft, turn,
walk back and sit down is termed the “Get-up and Go Test.”
Those taking long than 10 seconds to complete this tasks are
at increased risk for falls.
10 – 19 seconds is considered freely mobile.
20 – 29 seconds variable mobility.
>30 seconds dependent on balance and mobility.
MOBILITY AND BALANCE
(contd.) GAIT SPEED
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Gait speed can be used as an alternative predictor
for future disability.
Speed of 0.8 meters/sec indicates that the patient
is capable of independent ambulation within the
community.
A speed of 0.6 meters/sec indicates participation in
community activities without the use of a
wheelchair.
Patients who can ambulate 50 feet in the office
corridor in 20 seconds or less should be able to
walk independently in normal activities.
MOBILITY AND BALANCE
(contd.)
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Balance can be assessed by instructing the patient to stand
with his/her feet side by side then in semi-tandem and
finally in tandem position.
Difficulty in any of these positions suggest an increase risk
of falling.
The Performance Oriented Mobility Assessment (POMA)
consists of a set of tasks that may be used to quantify
impairments in gait and balance and make
recommendations for an assisted walking device.
In addition, during these assessments the physician should
observe for the use of proper footwear that is flat and has a
hard sole.
FUNCTIONAL STATUS
ASSESSMENT
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Evaluates the tasks a person can do within the
context of their medical problems and
everyday life.
It is split into 3 levels:
1.
2.
3.
Basic Activities of Daily Living (BADL)
Instrumental/Intermediate Activities of Daily
Living (IADL)
Advance Activities of Daily Living (AADL)
Basic Activities of Daily Living
(BADL)
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Evaluates the ability of the person to complete basic selfcare tasks that are considered essential to independent
living. These are:
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Transferring from bed to chair
Toileting
Bathing
Grooming
Dressing
Feeding oneself
Bathing is the BADL that is associated with the
highest prevalence of disability and is one of the
most common reasons why elders receive home
aide services.
Instrumental/Intermediate Activities
of Daily Living (IADL)
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Assesses the persons ability to upkeep an
independent household.
It consists of:
Laundry
 Housework
 Shopping
 Using the telephone
 Preparing meals
 Taking medications
 Managing household finance and transportation
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Advance Activities of Daily Living
(AADL)
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Evaluates the persons ability to participate in
societal, community, and family roles.
It also assesses for recreational and occupational
activities. These activities varies among
individuals and may be a valuable tools in
monitoring functional status prior to the
development of disability.
Advance Activities of Daily Living
(AADL) contd.
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In addition useful information on function can
be obtained when physicians observe how their
patients complete simple tasks such as buttoning
or unbuttoning a shirt or blouse, taking off and
putting on shoes, picking up a pencil and writing
a sentence, touching the back of their head with
both hands, and climbing up and down from the
examination table.
Thank You