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Comprehensive Geriatric Assessment. John E Morley St Louis University St Louis VAMC GRECC. “Old age is like a plane flying through a storm. Once you are aboard there is nothing you can do about it.” - Golda Meier. Typical medical evaluation and intervention:.

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comprehensive geriatric assessment

Comprehensive Geriatric Assessment

John E Morley

St Louis University

St Louis VAMC GRECC

slide2
“Old age is like a plane flying through a storm.Once you are aboard there is nothing you can do about it.”- Golda Meier
typical medical evaluation and intervention
Typical medical evaluationand intervention:
  • 85 year old woman has uncontrolled hypertension on one blood pressure medication (185/80)
  • Plan: Add a second blood pressure medication
comprehensive geriatric assessment6
Comprehensive Geriatric Assessment
  • 85 year old woman has uncontrolled hypertension on one blood pressure medication
    • Lives alone
    • Gait and balance abnormality
    • Osteoporosis
    • Mild memory impairment
    • Incontinent of urine
    • Vision impairment
    • OTC meds
    • Difficulty with cleaning
comprehensive geriatric assessment7
Comprehensive Geriatric Assessment
  • 85 year old woman has uncontrolled hypertension on one blood pressure medication
    • Lives alone (daughter will help with meds)
    • Gait and balance abnormality (home therapy)
    • Osteoporosis (treated)
    • Mild memory impairment (eval for dementia)
    • Incontinent of urine (treated)
    • Vision impairment (fix or find glasses, ophtho. appt)
    • OTC meds (discard)
    • Difficulty with cleaning (Home OT-eval fall risk)
comprehensive geriatric assessment8
Comprehensive Geriatric Assessment
  • 85 year old woman had uncontrolled hypertension on one blood pressure medication (2nd visit):
    • Daughter came, helping with meds, BP fine
    • Gait and balance is better-no falls
    • No longer rushing to the bathroom (not incontinent)
    • Discussion about dementia and best options to keep her living independently
comprehensive geriatric assessment cga
Comprehensive Geriatric Assessment (CGA)
  • Older patients may have multiple problems, that interact
  • Looks at these interactions (i.e. whole patient)
  • Identifies current and potential problems
comprehensive geriatric assessment10
Comprehensive Geriatric Assessment
  • GEMU 1.68 (1.17 - 2.41)
  • Hospital 1.49 (1.12-1.98)
  • Home assessment 1.20 (1.05 – 1.37)

LIVING AT HOME

Comprehensive geriatric assessment: a meta-analysis of controlled trials

Stuck et al, Lancet 342:1032, 1993

comprehensive geriatric assessment11
Comprehensive Geriatric Assessment
  • 7 or more medicines
  • Fatigue
  • Cannot climb stairs or walk one block
  • Sadness
  • Memory problems
  • Weight loss
  • Falls
  • Urinary incontinence
  • Uncontrolled pain
  • Help with managing money or shopping
  • Unhappy with physicians treatment
slide12

I

The I’s of Geriatrics

The Modern Geriatric Giants

Instability (frailty)

Incontinene

Intellectual impairment

Iatrogenesis

Incoherence (delirium)

Insulin resistance (diabetes)

Immobility

Inanition (malnutrition)

Impoverishment

lawton s iadls
Lawton’s IADLs
  • Telephone
  • Shopping
  • Food Preparation
  • Housekeeping
  • Laundry
  • Transportation
  • Taking medicine
  • Managing Money
slide16

Status Post Fall

is a

Delirium Equivalent

Vowel test

Confusion Assessment Methodology

slide18

Mini-Mental Status Examination

  • Folstein et al. 1975
  • Educationally dependent
  • Both false positives and false negatives
  • Minimal testing of visuospatial system
depression
Depression
  • Are you sad?
  • Beck Depression Inventory
  • Yesavage Geriatric Depression Scale
slide22

FRAILTY DEFINITION OBJECTIVE

Fried et al J Gerontol 56A M146,2001

  • Weight Loss(10 lbs in 1 year)
  • Exhaustion(self-report)
  • Weakness (grip strength;lowest 20%)
  • Walking speed(15 feet; slowest 20%)
  • Low Physical Activity(Kcals/week;lowest 20%)

Female > Male

6.9%

frailty
FRAILTY
  • Fatigue
  • Resistance (Climb stairs)
  • Aerobic (Walk one blocK)
  • Illnesses
  • Loss of weight
gait and balance
Gait and Balance
  • Get up and Go
  • One leg stand
  • Tinetti Gait and Balance
  • Dual Tasking
  • Dancing
  • Strength (Cybex)
  • Muscle Pain (Polymyalgia Rheumatica)
objective measures of physical function
Get-Up-and-Go

6 Meter walk

Gait Speed

6 Minute Walk

>30 sec fall risk

<5.8 sec

>6.0 sec

<300 m mortality

<400 m functional impairment

Objective Measures of Physical Function
postprandial hypotension big mac attack
POSTPRANDIAL HYPOTENSION(“BIG MAC ATTACK”)
  • VARIABLE
  • MORE COMMON IN AM
  • PREVALENCE 26%
  • falls

syncope

stroke

myocardial infarction

death

  • STIMULATED BY

CARBOHYDRATE

  • DUE TO CGRP RELEASE
pseudohypertension

PSEUDOHYPERTENSION

OSLER MANEUVER

(Messerli)

PREVALENCE 7.2%

Poor predictive value

Predicts cardiovascular disease

white coat hypertension

WHITE COAT HYPERTENSION

PREVALENCE 7.1 TO 21%

No LVH

AMBULATORY MONITORING

slide33
BMD
  • Done in all women by 50 years or at menopause
  • Done in men by 70 years
  • Repeat in 2 year in same season to see rate of fall
slide34

S.N.A.Q

When I eat, I feel full after

Eating only a few mouthfuls

Eating about a third of a plateful

Eating over half a plateful

Eating most of the food

Hardly ever

  • My appetite is
  • Very poor
  • Poor
  • Average
  • Good
  • Very good

Normally I eat

Less than one full meal a day

One meal a day

Two meals a day

Three meals a day

More than three meals a day, including snacks

Food tastes

Very bad

Bad

Average

Good

Very good

< 15 predicts significant

weight loss within 6 months

slide36

Malnutrition Universal Screening Tool

BMI Score

BMI >20-0 (>30 obese*) = 0

BMI 18.5-20.0 = 1

BMI <18.5 = 2

Weight Loss Score

(unplanned wt loss in 3-6 mo)

Wt loss <5% = 0

Wt loss 5-10% = 1

Wt loss >10% = 2

Acute Disease Effect

Score

Add a score of 2 if there has

been or is likely to be no

nutritional intake for >5 days

Add all scores

Overall Risk of Malnutrition and Management Guidelines

Predicts mortality and length of stay

0

Low risk

1

Medium Risk

2 or more

High risk

Observe

Treat*

Routine clinical care

  • Refer to dietician, nutrition
  • support team or implement
  • local policy
  • Improve and increase overall
  • Nutritional intake
  • Monitor and review care plan
  • Hospital – weekly
  • Care home – monthly
  • Community – monthly
  • Unless detrimental or no benefit
  • is expected from nutritional
  • support e.g. imminent death
  • Repeat screening
  • Hospital – weekly
  • Care homes-monthly
  • Community-annually for special
  • Groups (e.g. those >75yrs)
  • Document dietary intake for
  • 3 days if subject in hospital
  • or care home
  • If improved or adequate
  • intake, little clinical
  • concern; if no improvement,
  • clinical concern – follow local
  • Policy
  • Repeat screening
  • Hopital –Weekly
  • Care home – at least monthly
  • Community – at least every ____
anthropometric parameters
Anthropometric Parameters
  • Weight change
  • BMI
  • Arm span
  • Mid-arm or Calf Circumference
  • Triceps skinfold
  • MAMC and MAMA
  • Waist Circumference
  • Bioelectrical impedance
  • Dual photon absorptiometry (DEXA)
  • CT/MRI
  • Ultrasound
  • Underwater weighing
  • Stable isotopes
slide40

A little poison now and then makes for

agreeable dreams, and much poison in the

end for an agreeable death

Nietzche: Thus Spoke Zorathiestra

elementary my dear watson

Approach to Drug History

  • What is the target problem being treated?
  • Is the drug necessary?
  • Are nonpharmacologic therapies available?
  • Is this the lowest practical dose?
  • Could discontinuing therapy with a medicine help reduce symptoms?
  • Does this drug have adverse effects that are more likely to occur in an older patient?
  • Is this the most cost-effective choice?
  • By what criteria, and at what time, will the effects of therapy be assessed?
Elementary, My Dear Watson
other tests
Other Tests
  • Hearing
  • Vision
  • Sleep apnea
  • Advance Directives
  • Health Promotion
  • Hallpike-Dix
  • Driving
  • Guns
  • Sex (ADAM)