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Comprehensive Geriatric Assessment‐ C.G.A
Nabil NAJA M.DGeriatric Medicine
Year 1970Ministry of Planning
1996MOSA
2005Sibai et al.
Total fertility rate 4.6 3.0 2.1
Crude death rate per 1000 9.1 7.0 7.1
Life expectancy at birth 66 72 74
Proportion elderly >65 yrs 5% 7% 7.8%
Demographic aspects:Ageing in Lebanon
Ministry of Planning (1970). Estimates of Lebanese Population, 1970.MOSA. (1996). Population & Household survey 1996Sibai et al. (2004). Bulletin of the World Health Organization, 82 (3), 219-225
Sources:
-14.25
-15.45
-13.21
-10.20
-7.63
-5.85
-5.66
-5.59
-5.13
-3.99
-2.73
-2.51
-2.81
-4.89
14.08
12.85
10.06
7.55
6.27
6.05
5.71
5.18
3.73
2.81
2.46
2.68
5.02
15.41
-15.00 -10.00 -5.00 0.00 5.00 10.00 15.00
0-4
10-14
20-24
30-34
40-44
50-54
60-64
Age
grou
p
%
Males Females
-11.37
-10.64
-10.47
-10.11
-9.32
-8.29
-7.20
-6.00
-4.91
-4.19
-3.79
-3.53
-3.18
-6.99
10.70
9.75
9.43
9.02
8.61
7.90
6.68
5.39
4.47
3.95
3.66
3.23
7.21
10.00
-15.00 -10.00 -5.00 0.00 5.00 10.00 15.00
0-4
10-14
20-24
30-34
40-44
50-54
60-64
%
Males Females
-8.91-9.24-9.38-9.32-8.35-7.80-7.66-7.38-6.77-5.97-5.10-4.12-3.19-8.91
8.47
8.928.877.987.467.256.996.656.305.704.713.648.47
8.79
-15.00 -10.00 -5.00 0.00 5.00 10.00 15.00
0-4
10-14
20-24
30-34
40-44
50-54
60-64
%
Males Females
-7.15-7.51-7.56-7.59-7.05-6.62-7.21-8.23-8.33-7.26-6.23-4.75-3.74
-10.74
6.55
6.896.876.466.397.037.968.107.196.304.923.99
14.46
6.86
-15.00 -10.00 -5.00 0.00 5.00 10.00 15.00
0-4
10-14
20-24
30-34
40-44
50-54
60-64
%
Males Females
Population Pyramid, Lebanon 1970 Population Pyramid, Lebanon 1996
Population Pyramid, Lebanon 2016 Population Pyramid, United States, 2000
5% 7%
9% 12.5%
Clinical Case:• K.R, 85 year old Female, living at home by herself, had fallen down the stairs one week ago. Since her fall, she walks slowly while holding her hands to the furniture, doesn’t want to leave the apartment, not eating well and calling anxiously her daughter multiple times per day.
• Her daughter brought to the primary care clinic for evaluation.
• Physical exam practically normal.• How can the family physician evaluate this patient?
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
2 weeks later….
1‐Comprehensive Geriatric AssessmentDefinition
• Multidimensional,Multidisciplinary diagnostic process.• Goal: determine a frail elderly person’s medical,psychosocial, and functional capacities and problems.
• Objective: develop an overall plan of treatment& long‐term follow‐up.
• Concept started in 1930 (Dr Warren); now regarded as the “technology” of geriatric medicine.
JKH luk, HKMJ 2000;6:93-8 Rubenstein.Clin Geriatr Med 1987;3:1-
15.
• Assessment involves an interdisciplinary team:‐ Geriatrician & P.C.P‐ Geriatric nurse‐ Social worker‐ Physical therapist/Occupational therapist‐ Pharmacist‐ Psychologist/Psychiatrist‐ Dietitian
3‐ Domains evaluated by CGA:
◌WHO.health of the elderly.1989
DomainFunctional status ( Autonomy- dependence- Gait & balance…)
Physical health ( Full P.E, current treatment, medications available…)
Cognitive/mental health ( Memory & Behavior assessment, risks for Depression…)
Nutritional status ( Weight, BMI, risk for Malnutrition & Dehydration…)
Socio-environmental factors ( Home hazards, loneliness, isolation…)
Risk for pressure sores ( Bedridden pt.)
Functional status
• Level of dependence:
Katz activities of daily living (ADL)
Lawton Instrumental Activities of Daily Living (IADL scale)
Small changes in function make a big difference,in quality of life for patients and their caregivers.
Screening for Specific Problems:
Falls and Gait Disorders
Major cause of morbidity and mortality
- 1/3 of elderly fall each year
- Major cause of NH placement
- Falls, mobility impairment, and functional
impairment closely related
Gait and Balance• Get up and Go(>30 sec fall risk)• One leg stand• Tinetti Gait and Balance• 6 Meter walk(<5.8 sec)• 6 Minute Walk(<300 m
mortality<400 m functional impairment)
• Dancing• Strength (Cybex)• Muscle Pain (Polymyalgia
Rheumatica)
Screening for Specific Problems:
Medications• Elderly use 3Xmore medications than younger patients.
• Drug distribution, elimination, excretion, & pharmacodynamics altered in elderly
• ADR’s and drug‐drug interactions increase markedly with # drugs used.
• Medications linked to “reversible dementias”, falls, incontinence, hospitalizations, death.
Elementary, My Dear Watson
Approach to Drug History1. What is the target problem being treated?
2. Is the drug necessary?
3. Are non pharmacologic therapies available?
4. Is this the lowest practical dose?
5. Could discontinuing therapy with a medicine help reduce symptoms?
6. Does this drug have adverse effects that are more likely to occur in an older patient?
7. Is this the most cost-effective choice?
8. By what criteria, and at what time, will the effects of therapy be assessed?
GERIATRIC PRESCRIBING PRINCIPLES
• C Caution, Compliance• A Adjust dose for Age• R Review, Remove, Reduce• E Educate
START LOW & GO SLOW
Cognitive assessment
Families and physicians fail to recognize dementia.
Mini-Mental Status ExaminationFolstein et al. 1975
1. Educationally dependent
2. Both false positives and false negatives
3. Minimal testing of visuospatial system
Mini-Mental Status ExaminationFolstein et al. 1975
1. Educationally dependent
2. Both false positives and false negatives
3. Minimal testing of visuospatial system
Cognitive Evaluation MMSE: Folstein
• Orientation: (5 + 5)
• Registration: name 3 common objects (3)
• Attention and calculation: serials of 7 backwards stop after5 answers, alternatively spell world backwards (5)
• Recall (3)
• Language (9)
• “Cut off” usually cited as 24
MMSE
• Education, cultural, and age biases
• Score impacted by literacy, depression, CVAs
• Versions exist in Arabic
Crum; JAMA 1994
2 simple and brief tests:
Blessed memory test:-Recall of 5-item (name and address).-Re-ask after few minutes of distraction-(+) if failure to recall 3 out of 5.
One minute verbal fluency test:- Ask to name 10 animal names- (+) inability to name at least 10 different animals in one
minute.
2 simple and brief tests:
Blessed memory test:-Recall of 5-item (name and address).-Re-ask after few minutes of distraction-(+) if failure to recall 3 out of 5.
One minute verbal fluency test:- Ask to name 10 animal names- (+) inability to name at least 10 different animals in one
minute.
Risk for Depression
Geriatric Depression scale: GDS‐15 items‐Validated in multiple countries for ambulatory patients.‐Score > 6/15 ‐‐> depression : Se 92% Sp 81%.‐To be used only for patients with a mini‐mental > 14/30
SCHEIKH JI et al; Clin Gerontol, 1986; 5:161-73.
Depression screening:
Screening for Specific Problems:
Caregiver Stress and Abuse
Caregiver stress highly correlated with increased riskof institutionalization, abuse and neglect.
Education & support of Caregiver is very important.
Clues: Caregiver miss appointments,concerned about medical costs, history of substance abuse, dominates interview,defensive, hostile, dependence on patient for income.
•Q & A: Do you feel Safe at home?
Nutritional Status• MNA: mini‐nutritional assessment
‐30 items‐Association of: anthropometric and dietary parameters, global evaluation and a subjective evaluation of health
‐The first 6 items are enough for screening‐Well validated in USA and Europe (6)‐ Able to classify 75 % of patients‐ Good nutritionnal status >24‐ Denutrition < 17
Rubenstein et al; J Gerontol 96:M366-72,2001
1) My appetite is1. Very poor2. Poor3. Average4. Good5. Very good
2) When I eat, I feel full after1. Eating only a few mouthfuls2. Eating about a third of a plateful3. Eating over half a plateful4. Eating most of the food5. Hardly ever
3) Food tastes1. Very bad2. Bad3. Average4. Good5. Very good
4) Normally I eat1. Less than one full meal a day2. One meal a day3. Two meals a day4. Three meals a day5. More than three meals a day,
including snacks
S.N.A.Q
< 15 predicts significant weight loss within 6 months
SNAQ
Sensitivity(%)
Specificity(%)
5% weight loss
81.3 76.4
10% weight loss
88.2 83.5
Other Tests• Hearing• Vision• Sleep apnea• Advance Directives• Health Promotion• Driving• Guns• Sex (ADAM)
POSTPRANDIAL HYPOTENSION
(“BIG MAC ATTACK”)• VARIABLE• MORE COMMON IN AM• PREVALENCE 26%• falls
syncopestrokemyocardial infarctiondeath
• STIMULATED BYCARBOHYDRATE
• DUE TO CGRP RELEASE
Measure Blood PressureStanding in
ALLOlder Persons
Socio‐environmental Factors
Detailed knowledge of any change in living, who is available at home or in the local community. Inquiring about: stairs, rugs, thresholds, bathing facilities, heating.Home visit is the best methodExtent of Social relationships is a powerful predictor of functional status and mortality.
Berkman LF.Am J Epidem 1986;123:559
CGA: benefits
• ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
Luk et al; HKMJ March 2000
Clinical Case:• K.R, 85 year old Female, living at home by herself, had fallen down the stairs one week ago. Since her fall, she walks slowly while holding her hands to the furniture, doesn’t want to leave the apartment, not eating well and calling anxiously her daughter multiple times per day.
• Her daughter brought to the primary care clinic for evaluation.
• Physical exam practically normal.• How can the family physician evaluate this patient?
Clinical Case
“Get up and go”:test takes 45 sec; difficulty rising of the chair; incapacity of advancement without holding to the furniture.
ADL (5/6): needs aid for toileting and eating. IADL (10/14): (budget management issue…)MMS: 20/30: (short term memory problems, moderate temporo‐spatial disorientation, calculcation problems)
GDS: 8/15MNA: 23/30 Social evaluation: daughter is 55 y o with a husband having lung cancer; can take her home on weekends
• Impression: post‐fall syndrome with depressive symptomatology; Recent loss of autonomy; moderate cognitive problems; De‐nutrition risk.
• Management proposed by the doctor:• Physical therapy at home.• Antidepressant treatment.• Antialzheimer treatment• Visiting nurse at home twice a week (for complete toileting)
• Family intervention on week‐end and for budget management.
• Visiting maid for help in eating• Follow‐up evaluation in 2 months.
Thank youThank you
References:1‐ JKH lukU et al. Using the CGA technique to assess elderly patient;
HMMJ Vol 6 No 1 March 2000.
2‐ Rainfray Muriel et al.: Comprehensive Geriatric assessment: a useful tool for prevention of acute situation in elderly; Ann.Med.Interne,2002;153,6,347‐402.
3‐Saldvedt et al. Reduced mortality in treating acutely sick, frail older patients in a geriatric evaluation and management unit. J.Am.Geriatr.Soc,2002; 50,792‐798.
4‐ Appelgate et al.; 1991;Geriatric evaluation and management: current status and future research directions.J.Am.Geriatr.Soc;39,2S‐7S.
5‐ H‐K kuo et al.The influence of outpatient Geriatric assessment on survival; a meta‐analysis; Arch of Geront and Geriartrics 39 (2004) 245‐254.
• 6‐ Scheikh Ji, Yesavage Ja: Geriatric depression scale (GDS): recent evidence and development of a shorter version.Clin Gerontol, 1986;5:161‐173.
• 7‐ Guigoz et al.: mini‐nutritionnal assessment: a practical assessment tool for grading nutritionnal state of elderly patients. Facts Res Gerontol, 1994:21‐60.
Old age is like a plane flying through a storm.
Once you are aboard, there is nothing you can do about it.”
“
