Comprehensive Geriatric Assessment Flashcards
What number of people in hospital are over 65?
2/3rd
Frailty is not an illness itself, it is what?
A susceptibility state - frail individuals are more at risk of disability and multi-morbidity
What does progressive accumulation of damage to a complex system result in?
Aggregate loss of system redundancy
What happens as systems age?
The ability of the body to repair minor damages in its redundant state becomes reduced, resulting in more multi-morbidities, disability and medical intervention
What does age-related decline lead to?
Impairment of individual organ function
Breakdown of the complex interplay between organ systems (dyshomeostasis)
Increased susceptibility to environmental stress resulting in frailty
What is the definition of frailty according to Rockwood?
A reduced ability to withstand illness without loss of function
What methods are there to help identify frail people?
Frailty index
Frailty phenotype
Frailty syndromes
HIS ‘Think Frailty’
How is frailty identified?
Can use methods such as frailty index, but largely it is something that can be seen on observation and examination
3 of the 5 criteria in the frailty phenotype are needed to identify someone as frail, what are these criteria?
Unintentional weight loss Exhaustion Weak grip strength Slow walking speed Low physical activity
What are some frailty syndromes?
Falls
Immobility
Delirium
Functional loss
What does dyshomeostasis lead to in illness?
Multiple body systems being involved in one illness
What are frailty syndromes?
Essentially presentations of system failures
What are the criteria of HIS ‘Think Frailty’?
Functional impairment in context of significant multiple conditions (new or pre-existing)
Resident in a care home
Acute confusion, diagnosis of dementia or history of chronic confusion
Immobility or falls in last 3 months
List of six or more medicines (poly pharmacy)
Rather than a binary concept, what should frailty be viewed as?
A spectrum, ranging from minimal frailty to severe frailty
Repeated insults result in what?
Gradually decompensated frailty
Axis of increasing complexity (i.e. more multi-morbidity and disability)
People with physical frailty are often frail in what domains?
Multiple health domains
Why can health not be viewed as a binary state?
It is a dynamic process - changes from hour-to-hour, day-to-day, complete physical, social and mental well-being is almost always not achievable
What are the health domains?
Medical Psychological Functional Behavioural Nutritional Spiritual Environmental Social Societal
What does illness in frail people lead to?
Disruption in multiple health domains, which can be triggered by disruption in any health domain
How have illness trajectories changed?
Fewer sudden deaths e.g. due to MI, stroke
Increasing frailty and organ failure
Why does our healthcare paradigm present challenges for comprehensive geriatric assessment?
It continues to be disease/system specific in research, guidelines, medical education and training, and secondary care
What are the problems for the medical health domain?
Pathological Physiological Reversible or irreversible Multiple concomitant problems Iatrogenic harm Majority of modern medicine treats/ameliorates chronic disease or acute exacerbations of chronic disease Few things in medicine are truly curable
How is spiritual care person-centred?
It focuses on what is important to that individual and takes into account what their wishes are for their care
What are the factors affecting the psychological health domain?
Mood
Confidence
Cognition
What are the factors affecting the functional health domain?
Mobility
Activities of daily living
Community living skills
What are the factors affecting the behavioural health domain?
Behavioural determinants of ill-health e.g. smoking, unhealthy eating
Activities/pastimes
Occupation
What are the factors affecting the environmental health domain?
Housing
Heating
Sanitation
Adaptation
What are the factors affecting the social health domain?
Support networks
Potential for abuse
What are the factors affecting the societal health domain?
Attitudes to the ageing and elderly
Technological advances
Political
Regulations
What is comprehensive geriatric assessment?
The process used to assess and manage illness in older people with frailty
What is comprehensive geriatric assessment used for?
To;
Determine what the problem are - where multiple medical problems present at once and where multiple health domains are affected
Determine what can be reversed and what can be made better
Produce a management plan
What is the approach of comprehensive geriatric assessment? What are the benefits of this approach?
Goal-centred rather than problem-centred
Preserves autonomy
Means we do what the patient wants, not what the doctor wants
Effective way of dealing with multi-morbidity and competing clinical priorities
What are the key professions involved in comprehensive geriatric assessment?
Geriatrician
Occupational therapist
Physiotherapist
Skilled nurses
What other professions are involved in comprehensive geriatric assessment?
GP Other doctors Social worker Home care Dietician
What are the established models of comprehensive geriatric assessment?
Inpatient
Intermediate care
Hospital at home
What does good geriatric care allow?
Early identification of need
Early comprehensive geriatric assessment
Early provision of appropriate level of care for need
What evidence is there supporting the benefit of comprehensive geriatric assessment?
Ellis et al Comprehensive Geriatric Assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials
More likely to be alive and living at home at:
• 6 months OR 1.25, p < 0.001, NNT 17
• 12 months OR 1.16, p = 0.003, NNT 33
Less likely to be living in residential care
• OR 0.78, p < 0.001
CGA is proven to improve health outcomes in frail older people. The earlier in an illness trajectory a frail person undergoes CGA, the better the outcomes are likely to be
What are the benefits of hospitalisation?
Access to clinical expertise
Access to complex tests and interventions
Rapid access to supervised care support
What are the risks of hospitalisation?
Disorientation and delirium Learned dependency Deconditioning Iatrogenic harm Hospital Acquired Infection
When should patients be discharged from hospital?
When goals are met, or when risk of staying in hospital outweighs the benefits
