CGA Flashcards
What is CGA?
A process to assess and manage disruption to health in older people with frailty
“A multidimensional interdisciplinary diagnostic process focused on determining a frail elderly person’s medical, psychological and functional capability in order to develop a co-ordinated and integrated plan for treatment and long term follow up”
Rubenstein, 1991
What is ageing?
Progressive accumulation of damage to a complex system resulting in aggregate loss of system redundancy
Loss of redundancy leads to frailty
What does loss of system redundancy lead to?
Decreased resilience to overcome environmental stress-leads to increased risk of system failure
Our aging strategy is that we have high levels of redundancy and low levels of repair
What are the effects of ageing (senescence) and how does it lead to frailty?
Age related decline leads to:
- Impairment of individual organ function
- Breakdown of the complex interplay between organ systems (dyshomeostasis)
This leads to
Increased susceptibility to environmental stress= FRAILTY
What is frailty a state of?
A state of susceptibility to acquiring disease and susceptibility to functional decline in the context of disease
Is multimorbidity the norm?
Multimorbidity-idea of having more than one chronic diseases is the norm for people who access health care and it gets worse as you get older
If you are old + multimorbid does it mean you are frail?
NOOO
How do we identify someone as ‘frail’?
Use the frailty index
- More points the more frail you are
The frailty phenotype applies in Fried at al model if have 3 of what 5 criteria?
Unintentional weight loss
Exhaustion
Weak grip strength
Slow walking speed
Low physical activity
Special cut offs for each of these things
What is the spectrum view of frailty?
Spectrum between minimal and severe frailty
Some people can improve, get less frail or improve their resilience, improve their health
What is the clinical frailty scale?
1-9
From very fit to terminally ill
(scoring frailty in people with dementia differs-degree of frailty corresponds to the degree of dementia)
In what conditions to people tend to present with frailty syndromes?
Falls
Immobility
Delirium
Functional decline
These are system failure presentations
Decompensated frailty syndromes – often present with multiple frailty syndromes at once
Environmental stress leading to breakdown of the whole system
What characterises a system failure?
System failure leads to fault-delirium-functional decline
What does taking a functional Hx show?
Ability to live a life independently
- What did you do to get up and go into work today?-asks about ability to do these things
What are the ADLs?
Transfers
Mobility
Toileting
Washing
Dressing
Meal preparation
Feeding
What do system failure presentations cause?
Decompensated frailty syndromes
What is the role of the doctor in a person’s story?
Take the story where the person wants their plot to go- or help give it a happy ending (good palliative care)
Goal and focus is the life and not the disease
Goal centredness
Person centredness
Wellbeing
Realistic Medicine
What is goal centredness in CGA?
The right thing to do=We do what the person wants, not what the doctor wants
The easy thing to do:
Multimorbidity
Conflicting ‘disease priorities’
Polypharmacy
What is health realistically?
A dynamic process rather than a binary state
Health isn’t solely the concept of disease or this narrow medical view
What does illness in frail people lead to and what can it be triggered by?
Leads to disruption in multiple health domains
Can be triggered by disruption in any health domain
What is the difference between pathological and physiological?
Pathological – ‘disease’
Physiological – ‘normal ageing’
Reversible
Non-reversible
Multiple concomitant problems
Iatrogenic harm
Few things in med are ‘curable’
Aim to preserve function in chronic disease – organ function or overall function- and looking to reduce exacerbations
Infection and iatrogenic harm can be cured
What does spiritual care mean?
Person centred care
Acknowledge persons meaning
What psychological issues should be addressed commonly when thinking about frailty and ageing?
Mood:
Low mood
Anxiety
Confidence:
‘fear of falling syndrome’
Cognition:
Delirium
Dementia
What functional issues should be addressed?
Mobility:
Transfers
Mobilising
Activities of Daily Living
Community living skills-higher level function that you need to do to exist in the society
What behaviours should be looked at in a CGA?
Behavioural determinants of ill health-Unhealthy eating/smoking/drinking
Activities/Pastimes
Occupation
What nutritional aspects should be thought about and what screening tool can be used?
Poor nutrition leads to ill health
Ill health leads to poor nutrition
MUST screening tool
What environmental factors and social factors should be addressed?
Environmental:
Housing
Heating
Sanitation
Adaptation
Social:
Support networks
- Practical/emotional
- Formal/informal
Potential for abuse
(Financial, Physical, Sexual, Neglect)
What are some societal issues with views on ageing?
Attitudes to ageing/the aged
- Asset vs. burden
- Paternalism
Technological advance-Enabling vs. disabling
Political/Regulations
- Money (eg. Winter heating allowance/pensions)
- Accessibility (eg. Free bus passes/Disabled access)
What is crucial about CGA?
- Goal centredness
- Multidimensional/’holistic’ approach
How does CGA work as an inpatient?
MDT assessment
- Form a combined view
- Importance of goal directedness
- Come up with a plan-out of hosp and maintenance of future health or palliative
- Discharge planning
If someone cannot be made better when can they be discharged from hospital?
Hosp benefits:
Access to clinical expertise
Access to complex tests and interventions
Rapid access to supervised care support
Risks of Hosp:
Disorientation and delirium
Learned dependency
Deconditioning-particularly if immobile-rapidly lose muscle strength and develop all the complications of immobility
Iatrogenic harm
Hospital Acquired Infection
Optimal discharge based on individual assessment (when risk outweighs benefit) or simply discharge when goals are met
What is the evidence for CGA?
Compared to standard medical care this has better outcomes for older people with frailty
What are the geriatric giants now known as frailty syndromes?
- Instability
- Immobility
- Incontinence
- (cognitive) Impairment
What are some reasons that patients may fall?
Poor footwear
Intoxication
Degenerative brain conditions
Meds
Postural instability
Cognitive impairment
Urinary urgency
What are reasons that a patient may not be able to walk?
Loss of muscle mass-sarcopenia
SOB
Pain
Postural instability
What are some reasons for incontinence?
Weakened pelvic floor
Infection
Constipation-faecal incontinence due to overflow
Caffeine
Reasons for a patient being cognitively impaired?
- Collateral Hx
- Dementia
- Delirium
SDH
Intoxication
Brain disease
Constipation
What Hx & examinations are recommended in a geriatric patient?
Hx:
- Collateral Hx
- GP, care home
- Meds
- Social Hx
Exam:
Resp/CVS/Abdo
Neurology - Focused neurological examination
Gait
Lying and Standing BP
Look at the skin
Incontinent?
PR +/- external PV-Look for prolapse
