The Comprehensive Geriatric Assessment and Geriatric Syndromes

The University of Texas Health Science Center at Houston (UTHealth)

$b%ectives

Describe a Comprehensive Geriatric Assessment (CGA) and its importance to eriatric care!

Discuss the components of a CGA throu h case studies!

"evie# common eriatric syndromes includin dia nosis and mana ement!

&elcome to .our /uture

&hy Geriatrics'

A in ( )f you*re luc+y, you #ill do itAs a healthcare professional, you #ill have to practice itAs a youn person, you have to respect itAs a contributor, you should #ant to ma+e a difference-

&elcome to .our /uture1ro%ection on /uture 0umber of Geriatricians in the United States! =ay 7655 .ear 0o! of 1opulation 1opulation Geriatricians Geriatricians 23 and older 23 and 456,666 23 older456,666 and older 7666 7656 7676 76;6 7696 7636 2,287 8,238 2,386 :,;8; 2,;:6 2,789 58,866,282 5:,288,55; 77,9<7,7:9 ;;,;62,3<6 99,;9;,58: 9:,9;9,;;8 5,886 5,:22 7,79< ;,;;5 9,9;9 9,:9; 9!2 ;!8 ;!9 7!3 5!2 5!3

Source: Census data from the Administration on Aging Table on Projected Future Growth of the lder Population: !"## to $#%#

Comprehensive Geriatric Assessment

Cornerstone of Geriatric =edicine &hat sets us apart from other disciplines 1atients and families appreciate this approach to patient care Ho# patient care should be done

Comprehensive Geriatric Assessment

1rocess intended to determine a patient*s medical, psychosocial, and functional capabilities and limitations Goal is to develop an overall plan for treatment and lon (term follo#(up )mplemented by a hi hly(trained team

Geriatric Team

Geriatrician Geriatric 0urse 1ractitioner Social &or+er Clinical 0urse Case =ana er Therapists (1T4$T) $ther Geriatric Specialists

Comprehensive Geriatric Assessment

Screen for Depression> Geriatric Depression Scale (GDS) Screen for Co nition> ==S?, S@U=S (slide <), =ini(Co /unctional Status> Activities of Daily @ivin (AD@s) and )nstrumental Activities of Daily @ivin ()AD@s) (see slide 56) =obility Status> Get Up and Go Test (see slide 55) 0utritional Assessment> =ini 0utritional Assessment =edication "evie# Comprehensive History and 1hysical ?xam

/unctional Status
AD@s

)AD@s

Aathin Dressin Toiletin Transfer Continence /eedin

Independent Assistance Dependent

Telephone Travelin Shoppin 1reparin meals House#or+ "epairs @aundry =edication =oney

Get Up and Go Test

As+ the patient to perform the follo#in series of maneuvers>
5!

Sit comfortably in a strai ht(bac+ed chair! "ise from the chair! Stand still momentarily! &al+ a short distance (approximately ; meters)! Turn around! &al+ bac+ to the chair! Turn around! Sit do#n in the chair!

7! ;! 9!

3! 8! 2! :!

$bserve the patientBs movements for any deviation from a confident, normal performance! Use the follo#in scale> 5 C 0ormal 7 C Dery sli htly abnormal ; C =ildly abnormal 9 C =oderately abnormal 3 C Severely abnormal A patient #ith a score of ; or more on the Get(up and Go is at ris+ of fallin !

Assess 0utritional Status

=ini 0utritional Assessment Aarriers to adeEuate inta+e

Cost )ll(fittin dentures 1resentation of food Social )solation

=edication "evie#

1rescribed and $TC meds Dru (Dru )nteractions Safety in ?lderly "e imen

Traditional Use of Geriatric Assessment

1rimary Care(Geriatrician is not %ust about consultation! They are primary careGeriatric Consultation ?valuate the need for lon (term care or for transitions of care =ultiple applications of Geriatric Assessment to aid in the medical decision ma+in for elders

Comprehensive Geriatric Assessment

Has rendered successful outcomes in improvin function, allo#in patients to remain at home and decreasin hospital readmissions

CGA is an invaluable tool in assessin the eriatric patient and can be applied in multiple settin s

CGA and the Cancer 1atient

Case of =rs! T!@!

:9 year old African American /emale #ith history of Depression, =oderate AlFheimer*s Disease, Hypertension, Diabetes =ellitus and Hyperlipidemia presented to clinic in Guly 766< to establish care! Comprehensive Geriatric Assessment at onset>

GDS> :453 ==S?> 5:4;6 AD@s> dependent for bathin )AD@s> dependent for shoppin , transportation, finances, house+eepin , and laundry Get Up and Go> normal

CGA and the Cancer 1atient

Aasic labs done( Serum Alanine Aminotransferase (A@T)> 33H Serum Aspartate Aminotransferase (AST)> 9; 1hysical ?xam normal )n Au ust, the patient*s dau hter called and said that her mom*s color had turned yello#1atient seen next business day and #or+(up pursued includin ima in , labs! CT scan done sho#ed a small pancreatic mass #ith obstruction! Aiopsy consistent #ith pancreatic cancer and a biliary stent #as placed!

CGA and the Cancer 1atient

Had a family meetin , findin s #ere presented and recommendations made! "ecommended hospice for symptom mana ement and end(of(life care! Sur ery team recommended sur ical resection and referred patient to $ncolo y! $ncolo y recommended chemotherapy and more a ressive treatment! 1atient and family both a reed on hospice and comfort care! The patient had a #onderful Than+s ivin holiday surrounded by family and friends and passed a#ay the next day!

?astern Cooperative $ncolo y Group (?C$G)

Grade 6 I fully active, able to carry on all pre(disease performance #ithout restriction Grade 5 I "estricted in physically strenuous activity, but ambulatory and able to carry out #or+ of a li ht or sedentary nature, i!e! li ht house#or+, office #or+ Grade 7 I Ambulatory and capable of all self(care, but unable to carry(out any #or+ activities! Up and about J36K of #a+in hours Grade ; I Capable of only limited self(care, confined to bed or chair J36K of #a+in hours Grade 9 I Completely disabled! Cannot carry(out any self(care! Totally confined to bed or chair! Grade 3 I Dead

?astern Cooperative $ncolo y Group (?C$G)

% 100 0 !0 $0 % 100 0 !0 $0 Ambulation Full Full Full %educed Activity Level Evidence of disease Normal No disease Normal Some disease Normal "it# effort Some disease Can&t do normal 'ob or "ork Some disease Can&t do #obbies or #ouse"ork Significant disease Can&t do any "ork Extensive disease As above As above As above As above 2 Self Care Full Full Full Full Intake Normal Normal Normal or reduced As above Level of Consciousness Full Full Full Full

(0

(0

%educed

)ccasional assistance needed Considerable assistance needed +ainly Assistance /otal Care As above As above 2

As above

Full or confusion Full or confusion Full or dro"sy or confusion As above As above 1ro"sy or coma 2

*0

*0

+ainly sit and lie +ainly in bed .edbound .edbound .edbound 1eat#

As above

,0 -0 00 10 0

,0 -0 00 10 0

As above %educed +inimal +out# care only 2

CGA and the Cancer 1atient

$ncolo ists and Geriatricians have not al#ays #or+ed to ether&idely +no#n and studied that functional status is most important predictor of mortality! Studies of CGA and eriatric cancer patients demonstrated that functional status predicts survival, chemotoxicity, and post operation morbidity and mortality! Use of the CGA can further enhance the information obtained or interpreted from Larnofs+y or ?C$G scales!

&'termann ( and A )urria* Comprehensive Geriatric Assessment for lder Patients with Cancer* + Clin ncol $##, (ay !#-$%.!/0: !1$/2!13!

CGA and the Sur ical 1atient The Case of =rs! A!H!

"eason /or Consult> MDeliriumN :6( year(old female admitted to General Sur ery Team

The Case of =rs! A!H!, =edical History

1ast =edical History
5! 7! ;! 9! 3! 8! 2! :!

Diabetes =ellitus Hypertension Coronary Artery Disease =yocardial )nfarction S41 Coronary Artery Aypass Graft Con estive Heart /ailure Areast Cancer Depression $steoporosis

The Case of =rs! A!H!, =edical History (continued)

1atient #as noted to have left breast mass found in September 766: and #as referred to $ncolo y! 1atient #as enrolled in trial of Dasatinib, and one #ee+ after initiation of therapy, patient had =yocardial )nfarction (=)) and a Coronary Artery Aypass Graft performed at a community hospital! Dau hter attributed the chemotherapy to the =) and decided to pursue no further chemotherapy!

The Case of =rs! A!H!, =edical History (continued)

The patient received care at other sites until =ay 766<, #here she presented to the hospital $ncolo y Clinic #ith a 2cm x 2cm inflammatory lesion #ith central nipple ulceration and bloody dischar e of the left breast! The patient #as then referred to the General Sur ery clinic for a palliative =odified "adical =astectomy (="=) #ith split thic+ness s+in raft to be performed! The dau hter desired no further chemotherapy! Her $ncolo ist stated M) have no options for her!N

The Case of =rs! A!H!, =edical History (continued)

1atient seen by Cardiolo y for clearance! 1atient seen by Geriatrics for clearance! Geriatric Assessment> GDS> 7453

==S?( unable to complete due to visual impairment! AD@s> dependent for bathin only )AD@s> dependent for preparin food, ta+in medications, shoppin , transportation, finances, laundry, and house+eepin Get Up and Go> abnormalH ambulates at home by #heelchair

1atient deemed intermediate sur ical ris+!

The Case of =rs! A!H!, Hospital Course

1atient under#ent ="= #ith split thic+ness s+in raft on Au ust ;, 766<, and then admitted to the General Sur ery Team! Cardiolo y #as consulted to mana e blood pressure issues! $n hospital day t#o, Geriatrics #as consulted for evaluation of delirium!

The Case of =rs! A!H!, Hospital Course (continued)

Geriatric Assessment> Unable to perform ==S? and GDS due to deliriumH =emorial Delirium Assessment Scale> 7;4;6H AD@s I some assistance reEuired and dependent for )AD@s! /amily support provided by her dau hter! 1atient #as dia nosed #ith =ixed Type Delirium and started on Haldol, #hich #as titrated to achieve effect! Geriatrics assumed primary care #hen her sur ical issues #ere stable! 1atient*s delirium #as resolvin and she #as then transferred to a eriatric patient care unit in a nei hborin hospital!

Areast Cancer )ncidence and =ortality by A e

1reoperative Assessment of Cancer in the ?lderly (1AC?)

1ilot Study published in 766; in Supportive Cancer Therapy. )nstruments included>

==S? AD@s )AD@s GDS Arief /ati ue )nventory ?C$G 1erformance Status American Society of Anesthesiolo ists (ASA) 1hysical Status Scale Satariano*s )ndex of Comorbidities

PAC& participants4 Audisio4 5*A*4 Pope4 6*4 et al* Shall we operate7 Preoperative Assessment of Cancer in the &lderly .PAC&0 can help* A S8 G surgical tas9 force prospective study* Crit Rev Oncol Hematol. $##1 Feb :%.$0: !%:2:3*

1reoperative Assessment Havin one dependent )AD@, abnormal presentin symptoms, or moderate4severe blood flo# index increased the patient*s li+elihood of have any sur ical complication by 36K!

1reoperative Assessment

CGA and the Sur ical 1atient

This patient had a ma%or sur ery #ith subseEuent complications and a very difficult post operative course!

/ollo#(up visits #ith the patient in the 1alliative Clinic determined that her delirium did resolve eventually and the patient #as bedbound and completely dependent for care!

She #as ultimately placed on home hospice!

CGA and the Dulnerable 1atient

)nvesti atin cases of suspected elder abuse can be a dauntin tas+ for all involved! "eEuires a multidisciplinary approach to the patient includin local Adult 1rotective Services authorities, the %udicial system and the eriatric team!

The #or+ of the medical case mana ement team enerally occurs in three phases
5! 7!

;!

)nvesti ation or assessment made by the referrin a ency Comprehensive Geriatric Assessment done by the medical team led by the Geriatrician )nterprofessional Team =eetin to develop a %oint intervention plan
6yer C;4 )eisler C+4 <im =C* Community Approaches to &lder Abuse* Clin Geriatric (ed* $##% (ay -$!.$0:/$"2//,

CGA and the HospitaliFed 1atient

Used in AC? (Acute Care of the ?lderly) units!

1rovided as a part of a Geriatric consult!

0o study is #orth more value than the appreciation from other disciplines, the +ind #ords from families and the %oy on a patient*s face seen #hen you say! ! !

M ) am trained to ta+e care of .$U and your friends-N

1olypharmacy

Defined as reater than four prescription medications or three ne# medications in a 79(hour period!

reater than

/our or more prescription medications increases the ris+ for falls in the elderly! /ive or more prescription medications increases the ris+ of adverse dru reactions! ;6K of older adult hospital admissions can be lin+ed to dru (related effects, and polypharmacy is the fifth leadin cause of death for hospitaliFed elders!

A in and =edication =etabolism

@iver

Decline in the Cytochrome 1936 system

"enal

Decrease in Glomerular /iltration "ate Decrease in tubular function Decreased creatinine clearance
)ncreased serum levels )ncreased half life

1olypharmacy Si ns and Symptoms

Dry mouth Tachycardia Confusion Diarrhea Constipation 1eripheral edema ?xtra pyramidal side effects Syncope

$rthostatic hypotension Hypo lycemia Con estive heart failure4pulmonary edema /latulence Aloatin Somnolence @ethar y

>anderbilt ?niversity Senior Care: @uic9 5eference for Geriatric Syndromes

/actors Associated &ith 1olypharmacy

Patient Factors:

System Factors:

$lder a e /emale @o# education level "ural livin =ultiple chronic illnesses Use of multiple medications Havin multiple pharmacies dispense medications

=any different prescribers 1oor patient record +eepin /ailure to revie# patient*s medications at re ular intervals and post hospitaliFation

>anderbilt ?niversity Senior Care: @uic9 5eference for Geriatric Syndromes

1rinciples for 1rescribin for $lder Adults

)s the medication necessary' Do the benefits out#ei h the ris+s' &hat are the desired therapeutic effects and ho# #ill they be measured' &hat are the potential dru (dru interactions' Try to start only one ne# medication at a time! Titrate the dose slo#ly as tolerated by the patient! Start #ith a lo# dose! )dentify and explain the indications and the directions to the patient and the care iver! )dentify and stop any duplicate medications!

>anderbilt ?niversity Senior Care: @uic9 5eference for Geriatric Syndromes

=ana ement
Pharmacologic
Non-pharmacologic

&rite out schedules

=edication revie#

At every office visit After every hospitaliFation

&rite out indications for each medication Use pill boxes to trac+ adherence

?liminate medications #ith duplicate effects Stop medications that are ineffective or have sub(optimal therapeutic effects Add ne# medications one at a time Use the advice Mstart lo# and o slo#N for startin ne# medications Lno# all non(prescription medications, supplements, and herbal supplements!

Detailed explanations of each medication and the indication increase adherence

>anderbilt ?niversity Senior Care: @uic9 5eference for Geriatric Syndromes

Comprehensive History and 1hysical ?xam

History Taking and the Older Patient

Ditals $rthostatics @isten to the patient and care ivers1hysical ?xam

$lder patients tend to overestimate their health or underreport their symptoms

Accidentally or purposefully Consider most of their symptoms as normal a in ?mbarrassed and see symptoms as loss of virility4po#er Simply for et-

History Ta+in and the $lder 1atient

C O L D E S T

History of 1resent )llness

1ain Acute vs! 1ersistent Character, Onset, Location, Duration, Exacerbatin /actors, Stren th, Timin $ther co(morbidities

Does it fit #ith other eriatric syndromes'

History Ta+in and the $lder 1atient

Geriatric Syndromes

Dementia( MDo you feel li+e you have a problem #ith memory'N Delirium( MHave you noticed a sudden chan e in behavior or confusion'N /alls( MHave you had any falls recentlyN or MDo you fall freEuently'N Urinary )ncontinence( MAre you able to ma+e it to the bathroom #ithout any accidentsN Depression( MAre you depressed'N =alnutrition( MHo#*s your appetite'N or MDo you feel hun ry'N or MHo# do you et your meals everyday'N )nsomnia( MDo you have difficulty #ith sleep'N

Depression M&hy are older people so sad'N

1revalence of Depression

Community

7K ma%or, 56(;6K depressive symptoms 3(56K, 56(;6K 56(76K, 56(;6K 56K, ;6K

$utpatient

)npatient

@on Term Care Settin

)sn*t it an outpatient issue' 4 &hy screen in the hospital'

Up to one(half of all depressed elderly seen by a primary care physician are not identified as depressed! Depressive symptoms in hospitaliFed elders can increase ris+ of>

"eadmission /unctional Decline =ortality

C)A(P Curriculum: Care of the )ospitaliAed Aging (edical Patient

Depression in the HospitaliFed 1atient( &hy Screen'

Can increase len th of stay because it slo#s recovery and mobiliFation

)npatient is a ood time to ma+e a dia nosis and et referrals in place

Treatments are effective

C)A(P Curriculum: Care of the )ospitaliAed Aging (edical Patient

&ho is at "is+'

/emale Gender Divorced or separated status @o# socioeconomic status 1oor social support Comorbid illness

Co nitive impairment Adverse4Stressful life events /amily history 1rior depressive episodes 1revious suicide attempts /inancial stress

C)A(P Curriculum: Care of the )ospitaliAed Aging (edical Patient

Associated =edical 1roblems

Dementia Diabetes =ellitus "heumatoid Arthritis History of Cerebro(Dascular Accident =yocardial )nfarction Cancer 1ar+inson*s Disease

C)A(P Curriculum: Care of the )ospitaliAed Aging (edical Patient

Atypical 1resentation

$lder depressed patient often has different complaints and presentations than youn er patients @ess commonly experience Mmood symptomsN $lder patients often have more somatic symptoms and may end up hospitaliFed

C)A(P Curriculum: Care of the )ospitaliAed Aging (edical Patient

Depression in $lder Adults> &hat else to loo+ for'

)rritability, anxiety or decreased functional status "eco niFe that the role of co(existin medical problems, co nitive deficits, multiple medications complicates the picture =any assume depression is a normal part of a in

C)A(P Curriculum: Care of the )ospitaliAed Aging (edical Patient

&ho Should be Screened'

1atients #ith commonly associated medical problems Adverse life events 1hysical si ns and symptoms> pain, insomnia, fati ue and #ei ht loss

Screenin for Depression

Geriatric Depression Scale> 53 point Euestion scale <7K sensitivity and :<K specificity Gust as+, MAre you depressed'N

C)A(P Curriculum: Care of the )ospitaliAed Aging (edical Patient

=edications that can Cause Depression

Antihypertensives

Aeta Aloc+ers Clonidine Carbidopa4@evodopa AenFodiaFepines Antihistamines Aarbituates

Anti 1ar+inson*s =edications

$thers

C)A(P Curriculum: Care of the )ospitaliAed Aging (edical Patient

Treatment> =edications

Selective Serotonin "eupta+e )nhibitors (SS")s) are some#hat interchan eable re ardin effectiveness!

Choose an SS") based on side effect profile, dru interactions and compliance!

Citalopram and Sertraline are often recommended amon experts for efficacy and tolerability in the elderly!

1axil> Anticholiner ic properties

C)A(P Curriculum: Care of the )ospitaliAed Aging (edical Patient

Treatment> Therapy

Co nitive Aehavioral Therapy and )nterpersonal Therapy

)n the outpatient settin , medications and brief psychotherapy have been sho#n to be more effective than usual care!

C)A(P Curriculum: Care of the )ospitaliAed Aging (edical Patient

)nsomnia

Difficulty in initiatin or maintainin sleep 0$T excessive daytime sleepiness

Usually due to a primary sleep disorder (sleep apnea, narcolepsy, periodic limb movement disorder) 1sychiatric illness 1yschophysiolo ic problems Dru or Alcohol Dependence "estless @e Syndrome

=ost commonly due to

Treatment for )nsomnia

Alter the environment to ma+e it less disturbin at ni ht ! ! ! minimiFe ni ht time li htin , sounds and procedures (labs and vitals) and ma+e the bed comfortable (the fe#er restraints the better)! =a+e sure the patient is active (not nappin ) durin the day #ith physical therapy, family, and volunteers to help +eep the patient company! ?valuate the medications and ma+e sure the patient*s pain is #ell controlled! &arm mil+4tea, relaxin music4#hite sound, and massa es can be helpful! Safer medications for the eriatric population include lo# dose TraFodone or =irtaFapine!

$ri inal 1resentation Developed by

Lavon @! .oun , =!D! /ormer Assistant 1rofessor, Department of )nternal =edicine Division of Geriatric and 1alliative =edicine UTHealth

Credits
1hoto raphs use for the cover are allo#ed by the mor ue/ile free photo a reement and the "oyalty /ree usa e a reement at Stoc+!xchn ! They appear on the cover in this order> &allyir at mor uefile!com4archive4display4775763 =o+ra at ###!sxc!hu4photo43277:8 Clarita at mor uefile!com4archive4display4;;29; =icrosoft 1o#erpoint )ma es and Clipart> Slides> 2, ;2, 35, 32 )ma es from The University of Texas Health Science Center at Houston =ultimedia Scriptorium Slides> 58, 77