CGA/Role of geriatrician Flashcards
5 outcomes to measure effectiveness of ACE unit
Functional disability/BADL*
LTC admission*
Cost of hospitalization
Length of stay
Readmission to hospital
Other: restrained patients, satisfaction*, falls, delirium, pressure ulcers
5 ACE unit principles
- Prepared environment
- Patient centered bedside care*
- Comprehensive discharge planning
- Medical care review*
- Early rehabilitation*
* more important as per JAGS 2013 review
ACE unit vs. ACE order set JAGS 2022 Norman and Sinha
ACE more likely to be discharged home
In hospital mortality lower but non significant
JAGS 2012 Systematic review for ACE
Significant: less falls, delirium, functional decline, discharge to LTC, shorter LOS, lower costs
Trend: pressure ulcers
No difference: functional decline b/w hospital admission, mortality, hospital admissions
Topics for health promotion
- Healthy eating
- Physical activity
- Falls prevention
- Tobacco control
- Social connectedness
10 reasons to refer to geriatric consult team
- Delirium
- Dementia
- Falls
- Fracture
- Polypharmacy
- Frailty
- Mood
- Urinary incontinence
- Parkinsonism
- Sleep
Other: driving, capacity
ACE Unit which patients benefit
> 70 yo
General medicine patients
Community dwellers
Who is needed for ACE unit?
- RN for patient entered care
- PT/OT for early rehab
- SW for discharge planning
- Geriatrician for medical care review
Positive outcomes found for geriatric day hospital
Cochrane 2015
Only significant findings is for GDH vs. no care did show improvement for ADL deterioration and composite of death/poor outcome (institutional, dependency, dec physical function)
2020 study
Difference in fear of falling, functional exercise capacity and balance
No difference in caregiver stress
What is the definition of a CGA?
Multidimensional, interdisciplinary diagnostic process to determine medical, psychosocial and functional capabilities of frail elderly person to develop integrated treatment plan
Core components of CGA
Medical/surgical history
Social History
Functional history (Katz, Lawton)
Physical assessment (Tinetti, Get up and go, gait speed)
Cognition (MMSE, MOCA, CAM)
Mood/mental health (GDS, Cornell, PHQ-9)
Falls
Sleep
Pain
Nutrition (mini nutritional assessment)
Continence
Polypharmacy
Cochrane 2022 Outcomes of CGA community dwelling, high risk, frail
Little to no difference in mortality
Little to no difference nursing home
May decrease risk of unplanned hospital admission (14 months)
Effect on ED visits uncertain
5 primary prevention programs in elderly
- Vaccinations
Herpes - 2 doses once 50+
Flu - annual
PNA - 1 dose once 65+ or in LTC - Physical fitness
- Good nutritional status
- Smoking cessation
- Reduce alcohol intake
5 secondary prevention programs in elderly
- FRAX for females 65+
- HTN - BP at all appropriate GP visits
- Breast cancer - mammogram q2-3 years 50-74
- Diabetes A1c q3-5 years if high risk
- Lung cancer - low dose CT x 3 between 55-74 if 30 pyx and quit <15 years ago
Cochrane 2017 review CGA for patients admitted to hospital
- Increased likelihood patients will be alive and in their own home 3-12 mos
- Less likely to be admitted to nursing home 3-12 mos
- Little or no difference mortality 3-12 mos
- Little or no difference in dependence
- No meaningful conclusions for cognitive function, LOS, cost and QALY
4 Ms of Age Friendly health system
- Mobility
- Medication
- Mentation
- Matters Most
Steps to integrate 4 Ms into care
- Understand current state
- Describe care consistent with 4Ms
- Design/adapt workflow
- Provide care
- Study performance
- Improve and sustain care
5 outcomes in Cochrane 2018 review on CGA for surgical service
Improved
1. Reduce mortality
2. Reduce discharge to inc level of care
3. Reduce LOS
4. Reduce total cost
No difference
1. Readmission rates
2. Major post op complications
3. Delirium rates
9 outcomes for CGA
- Admission to LTC
- Mortality
- Hospital admission
- ED visits
- Delirium
- Falls
- Pressure sores
- LOS
- Cost
Age/Ageing 2022 CGA review
- Hospital: reduce nursing home, reduce risk of falls, reduce pressure sores
- Hip fracture reduce delirium
- Community: decrease risk of physical frailty
- Improve clinical outcomes in oncology, hematology and ED
Review of all evidence
ACE 2012 JAGS
- Improved: falls, delirium, functional dependence, LTC, COS, LOS
- Trend: pressure injuries
- No evidence: hospital admission, func decline b/w admissions, mortality
GDH
- Fear of falling
- Functional exercise capacity
- Balance
CGA – Community Cochrane 2022
- Little to no difference: mortality, LTC
- Unsure: ED visit
- Maybe: unplanned hospital admissions
CGA – Hospital Cochrane 2017
- Improve: less likely LTC 3-12 mos, more likely alive and in home 3-12 mos
- Little to no difference: mortality, dependence
- Unsure: LOS, COS, Cognition, QALY
CGA – Surgical Cochrane 2018
- Improve: LOS, COS, mortality, discharge to LTC
- Little to no difference: readmission, post op delirium, complications
CGA – Multiple Age/Ageing 2022
- Hospital: fall, pressure injury, LTC
- Hip fracture – reduce delirium
- Community – reduce physical frailty
- Outcomes in onc, heme, ED
