Comprehensive Geriatric Assessment (CGA) • Physical health. • Mental health • Functional status • Social functioning • Environment.
Comprehensive Geriatric Assessment • focuses on elderly individuals with complex problems • functional status and quality of life • interdisciplinary team of providers
Teams: • Physician geriatrician (internal medicine or family practice) • Nursing professional • Social worker Can be enriched by collegues from: - Geriatric psychiatry, neurology, podiatry, pharmacy, palliative care, sleep disorders, rehabilitation, dentistry, continence, and/or spiritual counselors.
Benefits of CGA • Decreased nursing facility admission • Decreased medication use • Decreased mortality • Decreased annual medical care costs • Increase diagnostic accuracy • Improved independence
"Five I's of Geriatrics" • intellectual impairment • immobility • Instability • incontinence • iatrogenic disorders
nutrition • vulnerable to inadequate nutrition • limited dentition ill-fitting dentures • loneliness, depression. • Drugs • prevalent medical conditions including constipation,congestive heart failure, cancer and dementia. • Conversely, an elder is at increased risk of obesity by inactivity.
Social • Living arrangements • financial security • transportation • crime • access to medical services • risk factors for injury • social networks • death of a spouse or detachment
Environmental • Identify SAFETY RISKS (home visit) – lighting, loose mats, handrails, stairs, showers/bath, kitchen storage • Communication – telephone, alarms • Good Surveillance system – frequent visits from Dr, Community nurses, social workers etc • Nutrition • PREVENTIVE REHABILITATION – for all illness
Medical history • Patient profile: current residence (house, apartment, nursing facility) • Medication review • Family history • Social history • Past history (prosthetic valves, artificial joints, metal plates or screws) • Review of systems (special attention to alterations in memory, weight change, falls, sleep problems, sensory losses, urinary incontinence, information about bowel habits, dietary history)
Review of systemsvision • Loss of near vision (presbyopia) • Loss of central vision • Loss of peripheral vision • Glare from lights at night • Eye pain • common with age • macular degeneration • glaucoma, stroke • cataracts • glaucoma, temporal arteritis
auditory • Hearing loss • Loss of high-frequency range (presbycussis) • acoustic neuroma, wax,Paget's disease, • drug-induced ototoxicity/common with age
GIT • Constipation • Fecal incontinence • hypothyroidism, dehydration,hypokalemia, colorectal cancer,inadequate fiber, inactivity. • drugs ,fecal impaction, rectal carcinoma
Laboratory tests • Serum cholesterol • Blood glucose – glucose intolerance increases with aging. • Heamoglobin. • Vitamin B12 • Thyroid function tests
Effect of medical & nursing care HOSPITALISATION Clinical Iatrogenesis Functional Iatrogenesis Side effects of: Side effects of: Medical intervention Diagnostic intervention Therapeutic intervention The process of These Interventions >50% of patients over 70 years experience a decline in Physical and/or Cognitive function Unrelated to the admitting diagnosis
Additional Interventions Restraints Psychotropics NG feeds Catheters Additional Complications Pressure sores Delirium Agitation DVT & PE Aspiration Pneumonia UTI’s Bacteraemia Depression Disruptive behaviour FUNCTIONAL LOSS Hospitalization Excess Bed rest Immobility Falls Incontinence Delirium Anorexia
Remember the caregiver! • 80% of care of elderly is informal & unpaid • Education & support of caregiver may be critical part of keeping your patient at home and safe
Abuse and Neglect: Caregiver Risk Factors and Clues • Caregiver does not come to appointments • Is concerned about medical costs • History of substance abuse, mental health problems, conflicts with patient • Dominates interview, won’t leave, won’t let patient talk • Defensive, hostile, or indifferent • Dependence on patient for income/housing
Advance directive • Instructions given by patients for their future treatment should they become incompetent to consent to, or refuse, such treatment
Advance directives • Living will • Enduring power of attorney Suggested Reading: McQuoid-Mason, D. Advance Directives and the National Health Act. SAMJ 2006, 96, 12: 1236-1238
Prevention Works for Older Adults • Longer life • Reduced disability • Later onset • Fewer years of disability • prior to death • Fewer falls • Improved mental health • Positive effect on depressive symptoms • Possible delays in loss of cognitive function • Lower health care costs www.healthyagingprograms.org/content.asp?sectionid=85&ElementID=304
Preventive Interventions • Screening • Immunizations • counseling.
screening • Alcohol misuse • Blood pressure • Breast • Cervical • Colorectal • Depression • Obesity • Osteoporosis • Smoking • Diabetes • dyslipideamia
Immunizations Influenza • Influenza infections cause substantial morbidity and mortality among older persons: • Annual influenza vaccination for all those aged 65 and older is widely recommended • Pneumococcal
chemoprophylaxis • Aspirin- patients at increased cardiovascular risk
“Honest doc--if I had known I was gonna to live this long, I’d have taken better care of myself.”