Assessment of geriatrics

Geriatrics
• Geriatrics, or geriatric medicine, is a specialty
that focuses on health care of elderly people.
It aims to promote health by preventing and
treating diseases and disabilities in older
adults.
 Comprehensive Geriatric
Assessment

• NIH Consensus Conference:

• “The multiple problems of older persons are
uncovered, described and explained, if
possible, and the resources and strengths
of the person are catalogued, the need for
services assessed, and a coordinated care
plan developed to focus interventions on
the person’s problems.”
 Benefits of Comprehensive Geriatric
Assessment

• May reveal previously undetected medical or

psychiatric diagnoses that need evaluation or
treatment
• Identification of functional deficits predicts
• need for social and environmental
interventions
• Improve use of community services/more
• appropriate placement
• Improves function
• Repetition of functional assessment may be
used to gauge impact of therapy
• More appropriate medication use
• May decrease number of acute care days
 Functional status
• The capacity of an individual to function in
multiple domains(physical, mental, social,
emotional) and at multiple levels (organ
function, function of person as whole,
function of person in society)
 Three patient categories
• 1.Healthy elderly persons – living in the
community
• 2.Frail elderly persons – living in the
community
• 3.Institutionalized or severely impaired elderly
persons
 Multi-Disciplinary Team Approach
• Interdisciplinary team to make assessments
and develop a diagnosis and treatment plan
• Each member of team sees every patient
• Team Members: physician, nurse, social
worker, physical and occupational
therapy, psychology, rehabilitation
medicine, audiology, clinical pharmacy
and nutrition
 Components of CGA
• Complete History and Physical
Laboratory as indicated
Prevention Screening
 Components of CGA
• Measures to evaluate disability and functional
status
• Activities of Daily Living
• Instrumental Activities of Daily Living
• Consideration of living situation –adequacy
and safety
• Discussion with patient/family regarding
preferences for future medical care
 Patients who benefit most
• Frail because of age
• Decrease in functional status
• Change in mental status- cognition/affect
• Multiple medical problems
• Multiple psychosocial problems
• Take multiple medications
• New onset urinary or fecal incontinence
• Involuntary weight loss
• Frequent falls
• One or more sensory impairments
• Disruptive behavior or personality changes
 Geriatric syndromes
• Common problems that have been identified as
• warranting special attention in elderly
• Cognitive Disorders
• Dementia/Delirium
• Visual and hearing impairments
• Falls/Gait Instability
• Urinary Incontinence
• Depression
• Malnutrition
 Cognitive Impairment
• Dementia is common but often goes
unrecognized
• Some cases are potentially treatable or
reversible
• Important to identify patients with
impairment, even if not treatable, in order to
plan for future care
• Extensive screening batteries for cognitive
impairment have been developed
• Most widely used is the Mini-Mental State
Examination (MMSE)
• takes about 5-10 minutes to administer
 Mini-Mental Status Exam
• ORIENTATION
• Ask for year, season, date, day, month
• Ask for state, county, town, place,street
• REGISTRATION
• Name three unrelated objects. Ask patient to repeat
• ATTENTION/CALCULATION
• - Subtract 7 from 100, repeat 5 times
• RECALL
• Recall three previous objects
• LANGUAGE
• Show wrist watch and ask what it is
• Ask to repeat “no, ifs ands or buts”
• On blank piece of paper print “Close your eyes” and ask patient to do it
• Give patient a blank piece of paper and ask him to write a sentence
• Positive result indicated need for further
evaluation
• Can use for monitoring by repeating
• screen at later date and see if
improvement or deterioration takes
place
 Depression
• Common disorder in the elderly
• Under diagnosed impairments range from
depressive symptoms to major depression
 Depression-Screening
• Geriatric Depression Scale
• Designed specifically for frail older patients
• Series of 30 YES/NO questions covering
symptoms and manifestations of depression
• Takes 10-15 minutes to administer
• Score > 14 greatly increases probability of
depression
• Score < 9 greatly decreases probability
 Geriatric Depression Scale
• Are you basically satisfied with your life?
• Yes/NO
• Have you dropped many of your interests?
• YES/No
• Do you feel your life is empty?
• YES/No
• Do you often feel bored?
• YES/No
• Are you in good spirits most of the time?
• Yes/NO
• Afraid something bad is going to happen?
• YES/No
• Do you feel happy most of the time?
• Yes/NO
 Geriatric Depression Scale Cont…
• Do you often feel helpless?
• YES/No
• Do you prefer to stay at home?
• YES/No
• Do you feel you have memory problems?
• YES/No
• Do you think it is wonderful to be alive?
• Yes/NO
• Do you feel worthless?
• YES/No
• Do you feel full of energy?
• Yes/NO
• Do you feel your situation is hopeless?
• YES/No
• Do you think most people are better off than you?YES/No
• Demented patients frequently suffer from
depression
• Measures have been developed to screen for
depression without reliance on patient self-
report
• Caregiver asked questions about presence of a
number of symptoms/manifestations of
depression
 Depression
• Should be aware of other problems causing
cognitive impairment
• Delirium
Anxiety
Hostility
Psychosis
Behavioral Problems
 Musculoskeletal Impairment and
Immobility

• Unsteadiness
• Abnormality sitting or getting up from a chair
• Turning or walking with difficulty
• Step height
• Impairments in these areas increase the risk of
falling in older persons
• Often undetected in a standard history
 Screening Tests
• Upper extremity mobility
• Manual dexterity
• Lower extremity mobility
 Evaluations of Balance and Gait
• Balance Measures
• Sitting balance
Ability to rise from chair
Immediate standing balance
Standing balance (wide based, narrow based
or assisted)
• Standing balance w/ eyes closed
 Evaluations of Balance and Gait
• Gait Observations
• Initiation of gait
Step length
Step height
Step continuity
Step symmetry
Walking stance
Amount of trunk sway
Path deviation
 Malnutrition
• Increased risk for poor nutritional status
because of chronic disease,
poverty, social isolation, cognitive
impairment and functional disability

• Associated with impaired wound healing,

increased surgical complications and increased
mortality
 Indicators
• Body weight < 100 pounds highly sensitive
• Can also occur patients > 100 pounds
• Historical clues (health.drug.diet.socioeconomic)
• Involuntary weight loss of 10% body fat
• Physical Exam
• Glossitis, loss of subcutaneous fat, muscle wasting,
edema
• Lab
• Serum albumin (3.4-5.4g/dl)
 DETERMINE Checklist
• Disease, Eating poorly, Tooth loss/mouth
pain,
• Economic hardship, Reduced social
contact, Multiple Medicines, Involuntary
weight loss/gain, Needs assistance in
self-care,
 Visual and Hearing Impairment
• Visual impairment
• 13%
• Hearing impairment
• 65-74y/o
• 25%
• >85y/o
• 50%
 Visual Impairment

• Cataract (clouding of lens) and glaucoma

(increased intraocular pressure)
• Methods available for office screening have
limitations
• Limitations in diagnostic accuracy of glaucoma
screening by primary care physician
• Screening should be performed using Snellen
test
• Specific questions about functional disability
that might be due to poor vision
• Referral to Ophthalmologist if needed
 Hearing Impairment
• Hand held audioscope
• Performed in 90 seconds
• 94% sensitive, 72% specific
• Physical exam techniques such as whispered
voice or finger rub can be used
• Accuracy of tests may be enhanced if combined
with short questionnaire on functional disability
associated with hearing impairment
 Functional Assessment
• Choice between methods and instruments to
measure function depends on frailty of patient
population, time available for assessment and
intended use of information
 Activities of Daily Living
• One of the original methods and in wide use
today
• Focuses on basic activities
• Bathing
• Transferring
• Dressing
• Continence
• Toileting
• Feeding
 Instrumental Activities of Daily
Living

• Focus on more complex activities important for

independent living in the community
• Shopping
• Using the telephone
• Handling finances
• Housekeeping
• Using transportation
• Food preparation
• Taking medication
 Assessment of Home Safety
• Throughout the interior several common
features
• Scatter rugs, adequate lighting, enough room
for easy mobility, emergency telephone
numbers posted
• Kitchen
Bathroom
Outside the home
 Assessment of Social Support
• Assess the patient’s emotional support
• Identify actual/potential caregivers
• Ask who would be available in an emergency
• Social information and background may help
assess coping ability
 Functional Assessment
• Complement to screening for specific
impairments
• Help with determining overall health and well
being
• Guide to treatment plan
Help to plan long-term care services
Monitor effectiveness of interventions
 Long Term Options/Placement
• Support for remaining in the home
• Home health
Provider service
Day care

• If unable to remain in the home

• Assisted living facility
Subsidized senior apartments
Nursing home
 Conclusions
• Value of CGA has been evaluated in the
inpatient and outpatient settings
• Demonstrated to improve medical care
provided to frail elderly
• Controlled studies have shown improved
patient outcomes
• No study has shown worse outcomes
• Inpatient units may improve survival
 Conclusions
• CGA should be targeted to patients with
potentially improvable function
• Optimal targeting criteria have not been
established
• May be that a patient without potential for
improved function might benefit from
depression screening, medication review
 Conclusions
• Comprehensive Geriatric Assessment has
been advanced as a means to more effectively
diagnose and manage complex medical
problems of frail elderly