Comprehensive Geriatric Assessment

a multidisciplinary diagnostic and treatment process that identifies medical, psychosocial, and functional limitations of a frail (weak) older person in order to develop a coordinated plan to maximize overall health with aging. geriatric assessment can help clinicians manage these conditions and prevent or delay their complications.

Comprehensive Geriatric Assessment

An interdisciplinary approach to the evaluation of older persons physical and psychosocial impairments and their functional disabilities C G A--are made in order to develop a comprehensive plan for prevention, treatment and rehabilitation. Interdisciplinary team---focuses on physical, mental and social issues.

Comprehensive Geriatric Assessment 3-step process:

1. Targeting appropriate patients 2. Assessing patients and developing recommendations 3. Implementing recommendations

Comprehensive Geriatric Assessment

Who Needs Assessments? 1. For patients with living situation in transition 2. Recent development of physical or cognitive impairments 3. Patients with fragmented specialty medical care 4. Evaluating patient competency/capacity 5. Dealing with medico-legal issues

The Assessment Team

The CGA Process Relies On A Core Team Consisting of a: physician, nurse, social worker, physical and occupational therapists, nutritionists, pharmacists, psychiatrists, psychologists, dentists, audiologists, podiatrists, and opticians.

WHY CGA?
Great success in improving function. B. Decreases multiple negative variables, such as nursing home placement, medication use, and mortality. C. It increases diagnostic accuracy and independence.
A.

Criteria Used By CGA Programs To Identify Patients Include:

1. Age 2. Medical co-morbidities such as heart failure or cancer.

3. Psychosocial disorders such as depression or isolation.

4. Specific geriatric conditions such as dementia, falls, or

functional disability. 5. Previous or predicted high health care utilization 6. Consideration of change in living situation (eg, from independent living to assisted living, nursing home, or in-home caregivers)

The Overall Care Rendered By CGA Teams Can Be Divided Into Six Steps :
be successful at achieving maximal health and functional benefits.
1. Data gathering.

Each of these steps is essential if the process is to

2. Discussion among the team.

3. Development of a treatment plan. 4. Implementation of the treatment plan.

5. Monitoring response to the treatment plan.

6. Revising the treatment plan.

Assessment Tools A pre-visit questionnaire sent to the patient or caregiver prior to the initial assessment can be a timesaving method to gather a large amount of information. These questionnaires can be used to gather information about general history (eg, past medical history, medications, social history, review of systems), as well as gather information specific to CGA, such as: 1. Ability to perform functional tasks and need for assistance

2. Fall history 3.Sources of social support, particularly family or friends 4. Depressive symptoms 5. Vision or hearing difficulties 6. Whether the patient has specified a durable power of attorney

MAJOR COMPONENTS Core Components Of Comprehensive Geriatric Assessment (CGA) that should be evaluated during the assessment process are as follows:

1. Functional capacity 2. Fall risk 3. Cognition 4. Mood 5.Polypharmacy 6. Social support 7. Financial concerns 8. Advanced care preferences

 Additional

components may also include evaluation of the following: 1. Nutrition/weight change 2. Urinary continence 3. Sexual function 4. Vision/hearing 5. Dentition 6. Living situation 7. Spirituality

Aspects Of The Geriatric Assessment 1. Functional Status

- refers to the ability to perform activities necessary or desirable in daily life. - it is directly influenced by health conditions, particularly in the context of an elder's environment and social support network. - Changes in functional status (eg, not being able to bathe independently) should prompt further diagnostic evaluation and intervention.

Aspects Of The Geriatric Assessment

2. Activities Of Daily Living An Older Adult's Functional Status Can Be Assessed At Three Levels:
A. Basic Activities Of Daily Living (BADLs), B. Instrumental Or Intermediate Activities Of Daily Living (IADLs) C. Advanced Activities Of Daily Living (AADLs).

A. BADLs - refers to self-care tasks which include:

a. Bathing e. Dressing b. Toileting f. Maintaining continence c. Grooming g. Feeding oneself d. Transferring (from bed to chair) 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.

B. IADLs- refers to the ability to maintain an independent household which include:

1. Shopping for groceries 2. Driving or using public transportation 3. Using the telephone 4. Performing housework 5. Doing home repair 6. Preparing meals 7. Doing laundry 8. Taking medications 9. Handling finances

Aspects Of The Geriatric Assessment

3. Gait Speed predicts functional decline and early mortality in older adults.
Assessing gait speed in clinical practice may identify

patients who need further evaluation, such as those at increased risk of falls. Additionally, assessing gait speed may help identify frail patients who might not benefit from treatment of chronic asymptomatic diseases such as hypertension.

4. Falls/imbalance Patients who have fallen or have a gait or balance problem are at higher risk of having a subsequent fall and losing independence.
An assessment of fall risk should be integrated into the history and physical examination of all geriatric patients

Aspects Of The Geriatric Assessment

5.

Cognition The incidence of dementia increases with age, particularly among those over 85 years, yet many patients with cognitive impairment remain undiagnosed.

Aspects Of The Geriatric Assessment

6. Mood disorders Depressive illness in the elder population is a serious health concern leading to unnecessary suffering, impaired functional status, increased mortality, and excessive use of health care resources. 7. Polypharmacy Older persons are often prescribed multiple medications by different health care providers, putting them at increased risk for drug-drug interactions and adverse drug events.

Aspects Of The Geriatric Assessment

8. Social and Financial Support The existence of a strong social support network in an elder's life can frequently be the determining factor of whether the patient can remain at home or needs placement in an institution.

Aspects Of The Geriatric Assessment

9. Advanced care preferences Clinicians should begin discussions with all patients about preferences for specific treatments while the patient still has the cognitive capacity to make these decisions. 10. Efficacy Most meta-analyses have found that comprehensive geriatric assessment (CGA) leads to improved detection and documentation of geriatric problems.

Several Meta-analyses Of Randomized Trials Have Evaluated Five Models Of CGA

Home geriatric assessment Acute geriatric care units Post-hospital discharge Outpatient consultation Inpatient consultation

Home assessment

Home Geriatric Assessment programs focus primarily on preventive rather than rehabilitative services. Programs include a visiting nurse trained in geriatric care, as well as a physical therapist, social worker, psychologist, and specialty referrals when appropriate. In addition to home visits, telephone follow-up is routinely performed. Patients assessed at home are usually followed for at least one year.

Acute Geriatric Care Units

ACE units initially included structural modifications to promote mobility and simulate living conditions at home in preparation for a return to independence.

Post-Hospital Discharge
Key elements of post-hospital discharge geriatric assessment include targeting criteria to identify vulnerable patients. are supplemented by telephone calls and additional visits by physical therapy, occupational therapy, social work, and/or home nursing services when indicated.

Outpatient consultation

Programs that address adherence to program recommendations and treat patients at higher risk of hospitalization have led to improved outcomes.

Inpatient consultation Inpatient

consultation for CGA has largely been abandoned except in teaching settings.