The geriatric assessment

The Geriatric Assessment: A Complete GuideAbhishek Achar, OMS-III

Two AssessmentsGeriatric Health

Maintenance

• Primary care setting• Routine Health Maintenance• Identifies indicators of quality

of life• Screening • Preventative Interventions• Whole Health Management

Comprehensive Geriatric Assessment (CGA)

• Allied Health assessment• Identifies common and

frequently unrecognized impairments in older adults• CHF• Depression, Isolation,

Dementia• Functional Instability, Falls• Predicted High Healthcare

Utilization

Geriatric Health Maintenance• Patient centered complete and through History

and Physical• Preventative Measures• Primary Prevention• Secondary Prevention• Tertiary Prevention

• Whole Health Management• Medications• Driving• Financial and Social Support• Abuse• Advance Care Directives

Preventative Measures• Primary Prevention

To avert the development of disease

• Encourage Physical Activity and counsel against Alcohol and Tobacco• Discuss prophylactic Aspirin in CV Risk patients• Immunizations• Influenza – Annually • Pneumococcal – >65y.o. (PPSV23)• Herpes Zoster – >60y.o.

GERIATRIC HEATH MAINTENANCE

Preventative Measures• Secondary Prevention

Early detection and treatment of asymptomatic disease

• Cancer Screenings• Prostate – Between 50-69y.o.• Colorectal – Between 50-75y.o. (85y.o. for High Risk

patients)• Breast – Controversial Guidelines• Typically every 1-2 years for females with ≥4 years life

expectancies.

• Cervical – Between 21-65y.o. with adequate recent screening.• Three consecutive negative cytology test OR• Two consecutive negative Pap in the last 10 years• May start screening women under 21 who are sexually

activeGERIATRIC HEATH MAINTENANCE

Preventative Measures• Secondary Prevention

Early detection and treatment of asymptomatic disease

• Blood Pressure Screening• Lipid Screening • Osteoporosis (DEXA)• Routine Bone Density

(DEXA) • Women ≥65y.o.• High Risk Women ≥60y.o.

• Abdominal Aortic Aneurysms• One-time Abdominal US• Men ≥65y.o. who have

smoked or have AAA in PFHx


Preventative Measures• Tertiary Prevention

Identification of disease to prevent further morbidity or functional decline

• Functional• Focused on activities of daily living

• Cognitive• Targeted screening in patients with• Memory complaints• New functional impairment

• Vision• Decreased visual acuity increases fall and mortality risk• General Ophthalmologic Exam every 1-2 years

• Depression• "Over the past two weeks have you felt down, depressed, or

hopeless?" • "Over the past two weeks have you felt little interest or pleasure

in doing things?"


Preventative Measures• Tertiary Prevention

Identification of disease to prevent further morbidity or functional decline

• Hearing• 3rd most common ailment (HTN, Arthritis)• Associated with depression, social isolation, functional decline• Whisper test almost as effective as formal studies

• Nutrition• Routine Nutritional Assessments necessary• Vit B12, Vit D, Calcium typically low

• Mobility/Falls• ~30% of noninstitutionalized older adults fall every year. • 5% of falls result in fracture/hospitalization

• Regular assessments necessary• Circumstances of falls, orthostatic vitals, visual acuity, cognitive testing, gait,

balance, iatrogenic causes

• Incontinence• Major psychosocial impact• Routine targeted H/P with Urine/Blood testing indicated


Whole Health Management• Medications• Multiple medication increase the risk of Drug-Drug

interactions• Maintain up-to-date medications (including

OTC/herbal)• Annual comprehensive reviews

• Assess for duplications, drug-drug contraindications, affordability

• Altered pharmacokinetics/dynamics increase risk of ADR• Assess specific classes associated with ADR• Warfarin, Analgesics (NSAIDs), Antihypertensives (ACE-

I, Diuretics), Insulin, hypoglycemic agents (Nitro), psychotropics


Whole Health Management• Driving• Should be discussed in patients with • Dementia• Decline in visual, hearing, and psychomotor skills

• Reporting laws exist and vary state to state

• Abuse• Reported in 3-8% of older population• Suspicion raised if patient presents with contusions, burns,

bite marks, genital or rectal trauma, pressure ulcers, or a BMI <17.5 without clinical explanation

• Advance Care Directives• Discussion is appropriate during Health Maintenance Exam

focusing on preventative planning


Comprehensive Geriatric Assessment• Intensive Multidisciplinary Diagnostic and Treatment

Program • Differing from the Primary Care Clinician’s Geriatric Health

Maintenance

• Maximizes health with disease and aging• Initiated through referral by PCP

Comprehensive Geriatric Assessment• Indications for referral • Age• Major Comorbidities • CHF, Cancer, DQs, Surgery, etc

• Psychosocial Disorders • Depression, Social Isolation

• Unstable Geriatric Conditions • Dementia, Falls, Functional

Disability• Predicted high health care

utilization• Change in living situation

Comprehensive Geriatric Assessment

Comprehensive Geriatric Assessment• Major Components of the CGA• Functional capacity• Fall risk• Cognition• Mood• Polypharmacy• Social support• Financial concerns• Goals of care• Advanced care preferences


Components of the CGA

• Basic Activities of Daily Life• Bathing• Dressing• Toileting• Maintaining continence• Grooming• Feeding• Transferring

• Instrumental Activities of Daily Life• Shopping for groceries• Driving or using public

transportation• Using the telephone• Performing housework• Doing home repair• Preparing meals• Doing laundry• Taking medications• Handling finances


• Functional capacity• Ability to perform activities necessary AND desirable in

daily life• In the context of living environment and social network

Components of the CGA• Fall risk• Assessment integrated into H/P of all geriatric patients

• Cognition• Assessment integrated into H/P of all geriatric patients

• Mood• Assessment integrated into H/P of all geriatric patients

• Polypharmacy• Clinician review recommended on every visit


Components of the CGA• Social support and Financial concerns• Brief screening of SoHx indicated• Screen caregivers periodically for depression burnout• Refer to counseling or support groups

• Goals of care• Typical CGA patients have limited ability to return to fully

healthy/independent lifestyles• Social and Functional goals typically assume priority over

healthcare.

• Advanced care preferences• Assessment integrated into H/P of all geriatric patients


References• UpToDate• Medscape

Fin!

Health & Medicine

The geriatric assessment