CGA Flashcards
What is a CGA?
A process of care comprising a number of steps
Multidimensional holistic assessment of an older person that leads to a formulation of a plan to address issues which are of concern to the older person, family and carers.
Interventions arranged to support plan
Progress reviewed and original plan reassessed at appropriate intervals
Why is it done?
It is effective at reducing mortality and improving independence
Reduce hospital admissions
Reduce risk of readmission in those recently discharged
Identify areas for improvement to reduce frailty
Who is usually in the best position to coordinate CGA?
GP - especially if known patent for a long time and involved in other aspects of their care
Well placed to handle medication review
How is CGA done?
Interdisciplinary team working together
Generation of problem list - identify issues and how they have changed over time in a number of domains
What domains are considered in a CGA?
Physical Socioeconomic Functional Mental Environmental Mobility / balance Medication review
What quick screens for sensory problems can be done?
Whispering numbers in the ear and requesting there repetition
Cupping hearing aid to check for feedback noise
Gross visual testing - number of fingers, read a line from book
In terms of feet and footwear what should be checked?
Choice of footwear Condition of skin and nails Oedema Ulcers Peripheral sensory testing Perfusion - temperature, capillary refill time, pulses
In terms of gait and balance what should be checked?
Timed up and go test
Number of steps to turn 180 degrees
Formal balance scoring
How should a lying and standing BP be performed?
Patient lie flat for at least 5 mins
Check BP when standing immediately
After 1 minute check again
After further 3 minutes check again
What constitutes postural hypotension?
A drop in systolic BP of more than 20 mmHg
Even if there is no drop in BP, can some patients still have symptoms of postural hypotension?
Yes - may need more formal testing
How can weight and nutrition be assessed?
Check and record weight consistently Poor fitting clothes Loose skin General condition of hair and nails Oral health including checking for dentures
Why should PR and genitalia examination be done?
Constipation often missed - can cause appetite reduction, abdominal pain, acute deterioration, nausea, overflow diarrhoea
Assess prostate size, haemorrhoids, bleeding or rectal masses
What are some normal age related changes?
Uneven colouration of skin Skin thinning Decreased or absent ankle reflexes Loss of vibration sense in toes Subtle changes in eye movement
What is the questioning model of assessment?
Asking a series of pre determined questions
Assessor sets the agenda and seen as expert
What is the exchange model of assessment?
Shared enterprise
Individual as the expert on their own situation
Individual states own wishes and needs
What should be included in a social assessment?
Who does patient live with
What informal support is available - family, friends, neighbours, groups
How often is support available
What formal support is involved - care home, district nurse, social worker, voluntary sector, meals on wheels, age UK befriender
Does patient go out and about - do they have access to own vehicle and any concerns about driving
Are they a carer
Do they receive carer’s allowance
Any pets
Have they had a social services needs based assessment
Are they eligible for Continuing Health Care funding
Are they in receipt of disability allowance, income support, housing benefit, pension credit, mobility allowance
Any capacity concerns
Safeguarding issues including DOLS
Power of attorney - health and/ or finances
Has a will been made and is there a funeral plan
Nature of home circumstances - rented, owned, residential, nursing
Stairs
Availability of toilet - upstairs or down, commode
Equipment - hoist, pressure mattress, hospital bed
Is there a telephone
Cooking facilities
Damp concerns
Hearing and lighting
Smoke detector working
Pendant alarm
What are the 2 components of functional assessment?
What can and what does the patient do
How recently has it changed
What index can be used to measure function?
The Barthel index
Why is the Barthel index particularly useful?
Ability to map trajectory
Baseline scores can be recorded and reassessment is relatively quick
Impaired gait, balance and strength are key risk factors for…
Falls
When doing a mobility and balance assessment what should be considered?
Understand prior levels of mobility
Be specific about the time period of deterioration
Establish what the patient needs to be able to do
Ask about prior intervention for gait and balance problems
When establishing current and prior function in walking, balance and associated tasks what questions should be asked?
Can the patient walk outdoors, how far, do they need an aid or someone to go with them
Can the patient walk indoors they need to be able to manage, do they need an aid or anyone to help them?
Have they noticed any changes in their walking pattern?
Have they started to restrict their activity due to reduced confidence?
When asking about functional ability what specific questions should you ask?
Difficulty getting up from chair/bed/toilet
Difficulty getting into bed/out of bed/ sleeping in chair
Difficulty with stairs or steps
What simply tests can be done to assess walking and balance?
Timed up and go test (stand up from chair, walk 3 m, turn round, walk back and sit down) , if patient needs a walking aid then it is not appropriate
180 degree turn test to measure dynamic balance
Patient stand up from chair and take a step forward and you stand behind them, ask them to turn and face you
- more than five steps suggests an increase risk of falling in following year
Gait speed
Ask patient to walk 4 m, if take more than 5 sec then gait speed is slow
Chair stand
Patients who require use of arms are likely to have lower limb strength impairment
Is it true that there is a high prevalence of mental health issues in older people?
Yes - CGA not complete without assessing this
Need to assess mood and cognition
Is depression over or under recognised in older people?
Under recognised
Associated with poorer outcomes from physical illness
Somatic symptoms more common
When assessing mood in older people, what should be considered?
Psychomotor retardation
Weight loss
Poor sleep
Increasing pain with stable physical issues
What are some risk factors for suicide in older people?
Older age, male Social isolation or bereavement History of attempts or evidence of planning Chronic painful illness or disability Drug or alcohol use Sleep disorders
Cognitive decline that is rapid is more likely to be delirium or dementia?
Delirium?
When assessing for cognitive decline what simply question can be asked to introduce the subject?
Has the person been more forgetful in the last 12 months to the extent that it has affected their daily life?
What is the Mini-Cog test?
An instrument to screen for cognitive impairment in older adults in the primary care setting
3 items for memory
Clock drawing test
What is the trail making test?
A test to provide information about visual search speed, scanning, speed of processing, mental flexibility, executive functioning
Sensitive in detecting cognitive impairment associated with dementia
Describe the Abbreviated Mental Test (AMT)
Fast screening test
Developed in hospital based care
Can miss executive dysfunction
Not validated for use in primary care
10 questions: age, time, address to recall at end of test, year, name of this place, identification of 2 people, DOB, year of WW1, name of present monarch, count back from 20, address recall
A more detailed assessment of cognition can be done with the…
Mini mental state examination or Montreal Cognitive Assessment (MoCA)
MoCA can detect mild cognitive impairment in many conditions
Is medication review a component of CGA?
Yes - a core part
What should be included in a medication review?
Full medication history
Medication use - in general: are you good at remembering your pills? Can you swallow them ok? What are you most concerned about with your tablets?
- for each tablet: do you take this? How often? What for? Do you think it works? Does it have side effects?
Review for interactions or common side effects
Appropriateness
