Comprehensive Geriatric Assessment

1. Comprehensive Geriatric Assessment John E Morley St Louis University St Louis VAMC GRECC

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

4. 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

5. Typical medical evaluationand intervention:2 weeks later….

6. 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

7. 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)

8. 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

9. 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

10. 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

11. 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

12. 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

13. Geriatrics is a TEAM Sport

15. Lawton’s IADLs • Telephone • Shopping • Food Preparation • Housekeeping • Laundry • Transportation • Taking medicine • Managing Money

16. Status Post Fall is a Delirium Equivalent Vowel test Confusion Assessment Methodology

17. Families and physicians fail to recognize dementia.

18. Mini-Mental Status Examination • Folstein et al. 1975 • Educationally dependent • Both false positives and false negatives • Minimal testing of visuospatial system

19. SLUMS

20. ROCs For SLUMS &MMSE for MCI > HS Education SLUMS MMSE

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

22. 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%

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

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

25. 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

26. Fear of Falling

28. Measure Blood PressureStanding inALL Older Persons WRONG

29. ORTHOSTATIC HYPOTENSION

30. 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

31. PSEUDOHYPERTENSION OSLER MANEUVER (Messerli) PREVALENCE 7.2% Poor predictive value Predicts cardiovascular disease

32. WHITE COAT HYPERTENSION PREVALENCE 7.1 TO 21% No LVH AMBULATORY MONITORING

33. 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

34. 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

35. SNAQ

36. 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 ____

37. The Mini-Nutritional Assessment (MNA) Scale

38. 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

39. Abdominal Adiposity:The Critical Adipose Depot

40. A little poison now and then makes for agreeable dreams, and much poison in the end for an agreeable death Nietzche: Thus Spoke Zorathiestra

43. 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

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

46. Questions ?