CGA Flashcards by Roshan Patel

What is the purpose of the comprehensive geriatric assessment?

Hollistic management of older person
Reduce mortality and improve independence
Can reduce hospital admissions
Can be done by any member of the heath and social team

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What are the stages of a comprehensive geriatric assessment?

Assessment
Creating a problems list
Personalised care plan
Intervention
Regular planned review

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What assessments are done in a comprehensive geriatric assessment?

Physical
Socioeconomoc/environmental
Functional
Mobility/balance
Psychological
Medication review

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What are the general considerations in physical assessment of an elderly patient?

Opportunistically assess gait and balance

Prioritise parts of examination as it can be tiring

May be limitations to posture and mobility so group examinations by position rather than system

Check capacity for non-concordant patients

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What should be assessed within a physical exam in a comprehensive geriatric assessment?

Sensory loss - hearing, vision, feet
Gait and balance
Lying and standing BP
Cognition and mood
Skin
Functional ability
Pain
Weight and nutrition
PR/genitalia exam
Continence

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What changes are considered normal as a patient ages?

Skin changes - wrinkles, uneven colouration

Neurological - reduced ankle reflex, loss of vibration sense in toes

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What would you consider abnormal on a blood pressure measurement for an elderly person?

Systolic <90

Drop >20 when standing

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What are the 2 models of assessing an elderly patients social wellbeing?

Questioning model - assessor set agenda

Exchange model - patient is expert

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Why are social and financial situations important for patient wellbeing?

Impact attendance and compliance to healthcare

Psychological wellbeing

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What is assessed in the social assessment of the comprehensive geriatric assessment?

Living - who with? pets?
Financial - income support? Carer allowance? CHC funding?
Support - informal, formal, carers? how often?
Mobility - how often? how?
Other - power of attorney? capacity? care plan?

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What is assessed in the environmental assessment of the comprehensive geriatric assessment?

Nature of home circumstance
Specific information - buzzer, access to home
Stairs - rails, lift?
Toilet facilities - comode? where?
Room to room analysis
Telephone
Cooking facilities - who does shopping?
Heating and lighting
Risks

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What factors are encompassed within functional assessment of comprehensive geriatric assessment?

ADL
Mobility
Technology use - telecare?
Sensory loss - coping mechanisms?

What can and what does the patient do
How recently has function changed

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What can sudden loss of function indicate in an elderly patient?

Acute illness

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What tools are used to assess functional ability in elderly patients?

Barthel index
Nottingham extended ADL scale
Timed up and go test

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Why is maximising an elderly patients mobility and balance so important?

Improve quality of life

Decrease need for health and social care - major risk factor for falls

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Why is a diagnosis of gait and balance disturbance important before making physio referral?

Relevant referrals can be made
Guide patient expectation
Can’t control pain in arthritis so cant do certain physio exercises

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What are the steps in assessing a patients gait and balance?

History
Referral to specialist
Watch patient walk - ideally when unaware

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How do elderly patients tend to walk and what does this mean?

Shorter steps

More difficult to get up and do steps
Tendency to fall backwards

What walking tests can be done to assess gait and balance?

Time up and go - 8-11s
180 degrees turn test - number of steps
Gait speed
Chair stand

What are the parts of the psychological assessment in the comprehensive geriatric assessment?

Mood

Cognition

Why is mood assessment important in the elderly and what should be done?

5-10% of >65yo depressed but often under recognised and attributed to other conditions

Results in increased mortality and poorer outcomes

Do geriatric depression score

What screening questions should be asked to assess an elderly patients mood?

How often have they felt down In the last month
Ever sit and cry for no reason?
Worry about future?
Anhedonia?
Lonely?

Ask questions when alone ideally

What are the risk factors for suicide in the elderly?

Male
Social isolation/bereavement
Hx of attempt/plan
Chronic illness
Drug/alcohol
Sleep disorder

Why is cognition assessed in elderly patients?

Look for dementia and delirium

How is cognition assessed in elderly patients?

Screening question about forgetfulness GP-Cog MMSE AMTS

What is involved in a medication review?

``` Full medication history Compliance Does the drug work Side effects Medical history Drug-drug interactions ``` STOP START

What is the NO TEARS tool for medication review?

``` Need and indication Open questions Tests and monitoring Evidence and guidelines Adverse effects Reduction Simplification and switches ```

What is the STOP START tool?

Document with various medications which should be commenced/stopped for patients >65yo with certain conditions

How should a problem list be collated?

Develop in collaboration with patient Acute, subacute and chronic problems Tests and investigations if they alter the management plant

What is care planning?

Conversation with patient to discuss priorities of treatment to create a holistic support plan Identify best treatment and agree actions of both parties Continuous process Document needs, wishes and treatment plan

Why do we want to use care planning?

Currently we are reactive and disease focussed in our approach. We provide fragmented care. Care plans allow us to create a holistic management plan which is proactive and aims to prevent further hospitalisation. It aims to best use limited resources

What are the 9 key areas in a care plan?

``` Personal details Views of patient and carer Views of professionals Care and support arrangements Medication Hx Identify goals End of Life Named contact Action plan ```

What are the stages of a care plan?

1 Prepare 2 Discuss 3 Document - goals and normal observations 4 Review

What is an escalation plan (integrated care)?

Plan for what should be done if things deteriorate

What is the issue with prescribing in the elderly population?

Age related organ changes alter drug pharmacokinetics Multiple co-morbidities lead to cautions, CI and drug-drug interactions

What are the aims of a medication review?

In agreement with patient on necessary medications Optimise impact of medication Reduce ADRs Reduce waste

What is the process for a medication review?

``` List of medications Assess compliance - do they take them all Are they working? Side effects? Over the counter medications? Drug-drug interactions ```

What must be considered when prescribing new medications in the frail population?

``` Is it needed? Start on lowest dose Make instructions on usage clear Dosette boxes? Involve pharmacist ```

Give examples of drug classes that can lead to elderly patients being hospitalised

``` NSAID's Diuretics ACE-Inhibitors B-Blocker Warfarin Clopidogrel Antidepressants Opiates Prednisolone ```

What anti-depressants should be avoided in the elderly?

Amitriptyline - postural hypo Serotenergic meds - agitation and seretonin syndrome

What diabetic meds should be avoided in the elderly?

Long acting - risk of hypoglycaemia

Why should you be wary when prescribing hyponotics in the elderly?

Can cause daytime drowsiness and unsteadiness --> falls Benzo's addictive Sleep hygiene and non-pharmacological used first

What key questions should be considered when making a care plan?

What is important to you? What elements of care do you want? What elements of care do you not want? Who is going to speak for you?

Why is care planning used?

Current methods are reactive and disease focussed Care planning aims to be proactive - preventative and holistic with best use of resources