COMPREHENSIVE GERIATRIC ASSESSMENT CGA

Document Sample
COMPREHENSIVE GERIATRIC ASSESSMENT CGA Powered By Docstoc
					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
   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?
   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
   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
   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
   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
   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
   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
   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.)
   Important prognostic factors of mortality:
       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     2
food you eat.
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
   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.)
   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)
   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               1
written command

Ask patient to write a sentence                               1

Ask patient to copy a design (e.g., intersecting pentagons)   1

TOTAL                                                                  30
    PSYCHOLOGICAL ASSESSEMENT
   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

   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.)
   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.
             POLYPHARMACY
   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)
   >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

   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
   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.)
   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
   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.)
   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
   Evaluates the tasks a person can do within the
    context of their medical problems and
    everyday life.
   It is split into 3 levels:
     1.   Basic Activities of Daily Living (BADL)
     2.   Instrumental/Intermediate Activities of Daily
          Living (IADL)
     3.   Advance Activities of Daily Living (AADL)
          Basic Activities of Daily Living
                        (BADL)
   Evaluates the ability of the person to complete basic self-
    care tasks that are considered essential to independent
    living. These are:
       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)
   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
    Advance Activities of Daily Living
                (AADL)
   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.
   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