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Comprehensive Geriatric Assessment: Functional Assessment Strategies for Clinical Practices

Learn the principles of Comprehensive Geriatric Assessment and adapt strategies for individual clinical practices. Understand Functional Assessment evolution, importance, core team roles, and targeting strategies for frail elders.

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Comprehensive Geriatric Assessment: Functional Assessment Strategies for Clinical Practices

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  1. Functional Assessment Janice E. Knoefel, MD, MPH Professor of Medicine & Neurology University of New Mexico Retired - Geriatrics/Extended Care New Mexico Veterans Affairs Healthcare System Albuquerque, NM

  2. Disclosure Statement:Dr. Knoefel has nothing to disclose

  3. Learning Objectives:1. Understand the principles of Comprehensive Geriatric Assessment 2. Develop strategies to adapt CGA for individual clinical practices

  4. Functional Assessment • The model, borrowed from traditional rehabilitation by the geriatric community, has developed into the principle of comprehensive geriatric assessment (CGA) • Rehabilitation wishes to identify and treat patients who benefit from rehabilitation; the clinician wishes to identify elderly at risk for functional decline and treat appropriately.

  5. Functional Assessment • Developed in the late 1940s in the United Kingdom as a way to identify seniors in need of services • Adapted in the 1970s by US as a way to screen frail seniors who appeared to require nursing home care because of physical or cognitive decline. • Many undiagnosed illnesses, 15% mortality at 6 months • Initially an inpatient model, now outpatient care

  6. Traditional Rehabilitation • Disease -> impairment -> disability -> handicap • Example: Degenerative joint disease (DJD) -> pain -> gait disturbance -> unable to access 2nd-floor apartment • Interventions: Disease-specific (nonsteroidal anti-inflammatory drugs [NSAIDs], total knee replacement [TKR]) -> impairment management (pain control) -> disability compensation (cane) ->environmental modification (move to 1st-floor apartment)

  7. Functional Assessment • Clinicians often back into the issue: • Patient is failing, family is complaining, something is changing. • Why is patient not the same as last year, 2 years ago? • ?Undiagnosed new illness • ?Chronic condition worsening • ?Deconditioning,?Drug effects, ?Dementia

  8. Functional Assessment: Goals • Identify limitations of patient ability to function in daily life. • Develop strategies/interventions to improve function. • In other words: What cannot be done, why cannot it, what can be done to fix the limitation (patient-based intervention) or change task (environmental remediation)

  9. Functional Assessment • Dimensions of assessment: • Medical, including drug use • Functional • Physical • Cognitive • Sensory • Psychologic • Social

  10. Functional Assessment • Core team members: • Physician/healthcare professional • Nurse/nurse practitioner/home care nurse • Social worker • Makeup of core team members dependent on setting, specific goals of assessment team

  11. Functional Assessment • Ad hoc team members: • Dietitian • Pharmacist • Rehabilitation therapist(s) • Psychologist • Dentist • Spiritual counselor • Audiologist

  12. Functional Assessment • Consultative versus primary care practice • Settings: • Outpatient clinic • Inpatient unit • Home and community • Long-term care facility

  13. Functional Assessment • Components of assessment: • Targeting patients likely to benefit • Performing the evaluation, making recommendations • Implementing recommendations • Monitoring outcomes

  14. Functional Assessment: Targeting Frail Elders • Prevalence of disability increases with age and some have recommended using age as one criteria (ie, all individuals older than 75 years). • Investigational criteria use a number of factors: Age, comorbidity, known functional deficits, psychologic and social factors (depression, social isolation), use of health care services

  15. Functional Assessment: Targeting Frail Elders • Researchers have proposed using hospitalizations or ER visits as a proxy for a high-risk population. • Post hoc analysis showed that predictive factors were: • Number of medical diagnoses • Number of drugs • Loss of 2 or more intermediate activities of daily living (IADLs)

  16. Functional Assessment: Targeting Frail Elders • My criteria: • New drug compliance issues • Cancellation or no-show for appointments • Family members start calling office • Family members start to accompany patient to office • Unexplained weight loss • Change in appearance or behavior

  17. Functional Assessment: Targeting New Elders • New Medicare approved “Welcome to Medicare” examination - meant as a screening and preventive examination. • This is a one-time comprehensive medical review and physical examination in the first 6 months that patient has Part B Medicare coverage. • Good way to get baseline on patients newly eligible for Medicare, however, few meet the frail elderly designation.

  18. Functional Assessment: Outcomes • Decreased NH admissions • Decreased drug use • Major and minor new diagnoses • Decreased annual medical cost of care • Decreased mortality rate, no loss of quality of life (QOL) • Increased independent function • Increased patient/family satisfaction

  19. Functional Assessment • Medical assessment: • Current condition • Medical and surgical history • Drugs: Prescriptions, herbal supplements, and over-the-counter (OTC) drugs • Allergies • Habits: Tobacco, alcohol, diet, exercise • Health maintenance: Immunizations; dental, eye and hearing examinations; Fecal Occult Blood; mammogram; Pap test; breast examination • Family history

  20. Functional Assessment • Social assessment: • Marital status, family members • Educational and occupational history • Housing status • Financial concerns, income status • Hobbies and activities • Sexual history • Religious preferences

  21. Functional Assessment • Functional status: Activities of daily living (ADL) • Bathing • Dressing • Personal grooming • Eating • Transfers • Toileting • Continence • Ambulation

  22. Functional Assessment • Functional status: IADL • Shopping • Meal preparation • Taking drugs • Housekeeping • Laundry • Transportation • Telephone use/communication • Managing personal finances

  23. Functional Assessment • Functional status review counts as review of systems (ROS) • Supplement for additional ROS as needed • Advance directives • Driving: • Still driving? • Any accidents? • Change of driving habits? • Gotten lost, lost the car?

  24. Functional Assessment • Physical examination: • Need to include some measure of visual and auditory acuity • Cognitive examination: Mini-Mental State Examination (MMSE) • Psychiatric examination: Geriatric Depression Scale • Performance examination: Get-up-and-go test • Neurologic examination: Other measures of balance and gait

  25. Functional Assessment • Coding: Use evaluation and management (E/M) codes, aim for level 5 • History: • Chief report, history of present illness • Medical and surgical history • Drug review • Family and social history • ROS need to review 10+ systems • Examination: Multisystem examination needs to look at 8 of the 12 areas

  26. Functional Assessment • Decision-making needs to be high complex: • 8 or more diagnoses • Review management of all diagnoses, but do not need to change if in agreement. • Diagnoses include constipation, pain, hearing loss, skin dx, dry eyes, etc. • Counseling can upgrade 1 level: Include time in minutes and subject of discussion

  27. Functional Assessment • Delegate data collection • Minimize data recording time • Keep information needed for decision-making readily available • Delegate plan execution

  28. Strategies for Saving Time • Previsit questionnaire: • Medical history: • Current drugs • Drug allergies • Surgical and medical diagnosis and procedures • Social history • Health maintenance and preventive services • Home safety checklist • Advance directives

  29. Strategies for Saving Time • Specific questions on: • Vision • Hearing • Dentition • Falls • Urinary incontinence • Nutrition • Depression symptoms • Functional status

  30. Strategies for Saving Time • Minimize data recording time: • Dictation • Templates • Word processing programs • Computerized medical records

  31. Strategies for Saving Time • Keep information needed for decision-making readily available: • Pocket guides • PDA programs • Useful books and charts • Computer retrieval system

  32. Strategies for Saving Time • Delegate plan execution: • Network of health professionals • Health educators • Patient education handouts

  33. Assessing Care of the Vulnerable Elderly • Assessing Care of the Vulnerable Elders (ACOVE) • http://www.geronet.ucla.edu/centers/acove/index.htm • Can find: • Office forms • Physician education • Patient education • More information and reprints

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