Comprehensive Geriatric Assessment

Question 1

What number of people in hospital are over 65?

Answer 1

2/3rd

Question 2

Frailty is not an illness itself, it is what?

Answer 2

A susceptibility state - frail individuals are more at risk of disability and multi-morbidity

Question 3

What does progressive accumulation of damage to a complex system result in?

Answer 3

Aggregate loss of system redundancy

Question 4

What happens as systems age?

Answer 4

The ability of the body to repair minor damages in its redundant state becomes reduced, resulting in more multi-morbidities, disability and medical intervention

Question 5

What does age-related decline lead to?

Answer 5

Impairment of individual organ function
Breakdown of the complex interplay between organ systems (dyshomeostasis)
Increased susceptibility to environmental stress resulting in frailty

Question 6

What is the definition of frailty according to Rockwood?

Answer 6

A reduced ability to withstand illness without loss of function

Question 7

What methods are there to help identify frail people?

Answer 7

Frailty index
Frailty phenotype
Frailty syndromes
HIS ‘Think Frailty’

Question 8

How is frailty identified?

Answer 8

Can use methods such as frailty index, but largely it is something that can be seen on observation and examination

Question 9

3 of the 5 criteria in the frailty phenotype are needed to identify someone as frail, what are these criteria?

Answer 9

Unintentional weight loss
Exhaustion 
Weak grip strength 
Slow walking speed
Low physical activity

Question 10

What are some frailty syndromes?

Answer 10

Falls
Immobility
Delirium
Functional loss

Question 11

What does dyshomeostasis lead to in illness?

Answer 11

Multiple body systems being involved in one illness

Question 12

What are frailty syndromes?

Answer 12

Essentially presentations of system failures

Question 13

What are the criteria of HIS ‘Think Frailty’?

Answer 13

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)

Question 14

Rather than a binary concept, what should frailty be viewed as?

Answer 14

A spectrum, ranging from minimal frailty to severe frailty

Question 15

Repeated insults result in what?

Answer 15

Gradually decompensated frailty

Axis of increasing complexity (i.e. more multi-morbidity and disability)

Question 16

People with physical frailty are often frail in what domains?

Answer 16

Multiple health domains

Question 17

Why can health not be viewed as a binary state?

Answer 17

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

Question 18

What are the health domains?

Answer 18

Medical 
Psychological
Functional 
Behavioural
Nutritional 
Spiritual 
Environmental 
Social 
Societal

Question 19

What does illness in frail people lead to?

Answer 19

Disruption in multiple health domains, which can be triggered by disruption in any health domain

Question 20

How have illness trajectories changed?

Answer 20

Fewer sudden deaths e.g. due to MI, stroke

Increasing frailty and organ failure

Question 21

Why does our healthcare paradigm present challenges for comprehensive geriatric assessment?

Answer 21

It continues to be disease/system specific in research, guidelines, medical education and training, and secondary care

Question 22

What are the problems for the medical health domain?

Answer 22

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

Question 23

How is spiritual care person-centred?

Answer 23

It focuses on what is important to that individual and takes into account what their wishes are for their care

Question 24

What are the factors affecting the psychological health domain?

Answer 24

Mood
Confidence
Cognition

Question 25

What are the factors affecting the functional health domain?

Answer 25

Mobility Activities of daily living Community living skills

Question 26

What are the factors affecting the behavioural health domain?

Answer 26

Behavioural determinants of ill-health e.g. smoking, unhealthy eating Activities/pastimes Occupation

Question 27

What are the factors affecting the environmental health domain?

Answer 27

Housing Heating Sanitation Adaptation

Question 28

What are the factors affecting the social health domain?

Answer 28

Support networks | Potential for abuse

Question 29

What are the factors affecting the societal health domain?

Answer 29

Attitudes to the ageing and elderly Technological advances Political Regulations

Question 30

What is comprehensive geriatric assessment?

Answer 30

The process used to assess and manage illness in older people with frailty

Question 31

What is comprehensive geriatric assessment used for?

Answer 31

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

Question 32

What is the approach of comprehensive geriatric assessment? What are the benefits of this approach?

Answer 32

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

Question 33

What are the key professions involved in comprehensive geriatric assessment?

Answer 33

Geriatrician Occupational therapist Physiotherapist Skilled nurses

Question 34

What other professions are involved in comprehensive geriatric assessment?

Answer 34

``` GP Other doctors Social worker Home care Dietician ```

Question 35

What are the established models of comprehensive geriatric assessment?

Answer 35

Inpatient Intermediate care Hospital at home

Question 36

What does good geriatric care allow?

Answer 36

Early identification of need Early comprehensive geriatric assessment Early provision of appropriate level of care for need

Question 37

What evidence is there supporting the benefit of comprehensive geriatric assessment?

Answer 37

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

Question 38

What are the benefits of hospitalisation?

Answer 38

Access to clinical expertise Access to complex tests and interventions Rapid access to supervised care support

Question 39

What are the risks of hospitalisation?

Answer 39

``` Disorientation and delirium Learned dependency Deconditioning Iatrogenic harm Hospital Acquired Infection ```

Question 40

When should patients be discharged from hospital?

Answer 40

When goals are met, or when risk of staying in hospital outweighs the benefits