Comprehensive Geriatric Assessment

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Comprehensive Geriatric Assessment

• John E Morley
• St Louis University
• St Louis VAMC GRECC

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Old age is like a plane flying through a
storm.Once you are aboard there is nothing you
can do about it.- Golda Meier
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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

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Typical medical evaluationand intervention2
weeks later.
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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

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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)

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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

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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

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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 3421032, 1993
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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

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I
The Is of Geriatrics The Modern Geriatric Giants
Instability (frailty) Incontinene Intellectual
impairment Iatrogenesis Incoherence
(delirium) Insulin resistance (diabetes) Immobilit
y Inanition (malnutrition) Impoverishment
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Geriatrics is a TEAM Sport
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Lawtons IADLs

• Telephone
• Shopping
• Food Preparation
• Housekeeping
• Laundry
• Transportation
• Taking medicine
• Managing Money

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Status Post Fall is a Delirium Equivalent
Vowel test Confusion Assessment Methodology
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Families and physicians fail to recognize
dementia.
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• Mini-Mental Status Examination
• Folstein et al. 1975
• Educationally dependent
• Both false positives and false negatives
• Minimal testing of visuospatial system

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SLUMS
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ROCs For SLUMS MMSE for MCI gt HS Education
SLUMS
MMSE
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Depression

• Are you sad?
• Beck Depression Inventory
• Yesavage Geriatric Depression Scale

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FRAILTY DEFINITION OBJECTIVE Fried et al J
Gerontol 56A M146,2001

• Weight Loss(10 lbs in 1 year)
  
• Exhaustion(self-report)
• Weakness (grip strengthlowest 20)
• Walking speed(15 feet slowest 20)
• Low Physical Activity(Kcals/weeklowest 20)

Female gt Male 6.9
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FRAILTY

• Fatigue
• Resistance (Climb stairs)
• Aerobic (Walk one blocK)
• Illnesses
• Loss of weight

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Gait and Balance

• Get up and Go
• One leg stand
• Tinetti Gait and Balance
• Dual Tasking
• Dancing
• Strength (Cybex)
• Muscle Pain (Polymyalgia Rheumatica)

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Objective Measures of Physical Function

• Get-Up-and-Go
• 6 Meter walk
• Gait Speed
• 6 Minute Walk

• gt30 sec fall risk
• lt5.8 sec
• gt6.0 sec
• lt300 m mortality
• lt400 m functional impairment

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Fear of Falling
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Measure Blood PressureStanding in ALL Older
Persons
WRONG
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ORTHOSTATIC HYPOTENSION
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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

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PSEUDOHYPERTENSION

• OSLER MANEUVER
• (Messerli)
• PREVALENCE 7.2
• Poor predictive value
• Predicts cardiovascular disease

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WHITE COAT HYPERTENSION

• PREVALENCE 7.1 TO 21
• No LVH
• AMBULATORY MONITORING

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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

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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

lt 15 predicts significant weight loss within 6
months
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SNAQ
Sensitivity () Specificity ()
5 weight loss 81.3 76.4
10 weight loss 88.2 83.5
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Malnutrition Universal Screening Tool
BMI Score BMI gt20-0 (gt30 obese)
0 BMI 18.5-20.0 1 BMI lt18.5
2
Weight Loss Score (unplanned wt loss
in 3-6 mo) Wt loss lt5 0 Wt loss
5-10 1 Wt loss gt10 2
Acute Disease Effect Score Add a score of 2 if
there has been or is likely to be no
nutritional intake for gt5 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

• Repeat screening
• Hospital weekly
• Care homes-monthly
• Community-annually for special
• Groups (e.g. those gt75yrs)

• 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 ____

• 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

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• The Mini-Nutritional Assessment (MNA) Scale

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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

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Abdominal AdiposityThe Critical Adipose Depot
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A little poison now and then makes for agreeable
dreams, and much poison in the end for an
agreeable death
Nietzche Thus Spoke Zorathiestra
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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?

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Other Tests

• Hearing
• Vision
• Sleep apnea
• Advance Directives
• Health Promotion
• Hallpike-Dix
• Driving
• Guns
• Sex (ADAM)

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Questions ?