Comprehensive Geriatric Assessment Flashcards
What is comprehensive geriatric assessment?
Multidisciplinary evaluation in which the multiple problems of older persons are uncovered, described and explained, if possible, and in which the resources and strengths of the person are catalogued, need for services assessed and a coordinated care plan developed to focus interventions on the person’s problems.
Comprehensive Geriatric Assessment advised for older adults with high risk of adverse events to guide treatment
Multidisciplinary diagnostic and treatment process aimed at maximizing overall health
Medical
Psychosocial
Functional
Increased focus on sub-specialties
Oncology, cardiology, trauma
Discuss function as it related to CGA?
Number and severity of medical illnesses does not necessarily correlate with level of functional impairment
Decreased functional status is linked with increased risks for falls, institutionalization, and loss of independence
While screening tests for both cognitive and motor function elicit useful information, daily life involves significant DUAL TASKING
Describe interdisciplinary team
Social work, gerontologic nurse practitioner and/or a geriatrician
Patient accompanied by their support team
“Virtual Team”
Specialist teams as needed to assess condition and make recommendations for specific issue
Who is part of the virtual team?
Neurology Psychiatry Physiatry Pharmacy Dietary Podiatry Dentistry Audiology ENT Physical Therapy Occupational Therapy Speech-Language Pathology
Discuss special considerations related to cardiology
Risk of mortality doubles in individuals with CVD and frailty
Functional assessments such as gait speed useful across stable disease processes and pre-operatively
Pre-operative planning of treatment course
Describe special considerations related to trauma/emergency
No single risk factor or tool accurately predicts risk for adverse outcomes in older ED patients
Risk stratification for improved resource allocation
Triage Risk Screening Tool (TRST)
Predicts risk of repeat ED/hospital visits
Not recommended to be used alone in risk stratification
Describe special considerations related to oncology
Assisting with treatment decisions Treatment is associated with significant toxicity Timing Addressing ageism Prehab
Treatment Choice Specific Tools
https: //www.moffitt.org/eforms/crashscoreform/
http: //www.mycarg.org/Chemo_Toxicity_Calculator
How do you structure a Comprehensive Geriatric Assessment?
Setting Goals of provider Goals of patient Goals of patient support team Time Incorporates Flexibility, compassion, patience, cultural dexterity, follow up
Structuring a Geriatric Assessment
Stratify risk (fit, vulnerable, or frail)
Foster well-being throughout selected treatment by identifying geriatric syndromes
Create an individualized care plan that addresses treatment, prevention, and management of identified syndromes
Plan for outcomes of treatment (optimizing survivorship and/or end-of-life planning)
What is important in structuring post acute care?
Where is new baseline? Matching needs to available supports within the context of individual priorities
What is important in structuring inpatient trauma care?
minimizing iatrogenesis and supporting holistic care
CAM (confusion assessment method)
Minicog
Triage Risk Screening Tool (TRST)
What is important in structuring outpatient consults care?
referred by specialists, typically related to concerns for cognitive impairment
MoCA, SLUMS, MMSE, GDS (geriatric depression scale)
What are benefits of assessment tools?
Provides a framework for assessment
Standardizes assessment across clinicians
Tracks condition over time for a single patient
Risk stratification
What precautions should you be aware of with assessment tools?
Assessment tools DO NOT replace clinical judgement
Is the scale validated and reliable?
What population was this tool designed for?
What is the Fulmer SPICES tool?
Sleep Disorders
Problems with Eating or Feeding
Incontinence
Confusion
Evidence for Falls
Skin Breakdown
How do you assess frailty?
Accumulation of deficits versus a biologic reduction in physiologic reserve
Scales often geared toward a specific population
Physical Frailty Phenotype (PFP) most widely researched
Examples: Palliative Performance Scale, Vulnerable Elderly Survey – 13 (VES-13), Groningen Frailty Index (GFI) Weight loss of 10 pounds or more Weakness measured by grip strength Self reported exhaustion Gait Speed Physical activity
Frail: more than 3 positive flags
Variable cut offs based on weight and gender
Describe the vulnerable elderly score
13-item self report tool
Can be done in person or over the phone and is not setting specific
Age, self-reported health, ADLs and IADLs
Cut off score 3 or more points
Individuals scoring greater than 3 had 4-fold increased risk of death or functional decline
How can you assess fall risk?
Validated in specific populations
The yellow sock problem
Community: Fall Risk Assessment Screening Tool (FRAST), Timed Up and Go
Home Care: Missouri Alliance for Home Care (MAHC-10) Fall Risk Assessment
Inpatient: Morse Fall Scale Model and Heindrich II Fall Risk Model
Describe the mini nutritional assessment and what other considerations?
Used across settings
Also to consider: Where and how food obtained Chewing and swallowing Companionship 1. food intake decline in past 3 months 2. weight loss 3. what is mobility? 4. suffered psych distress or acute disease? 5. neuropsych problems? 6. BMI 7. calf circumference
MMSE
69-91% sensitive 87-99% specific 15 items out of 30 points cut off >/=25 measures severity of dementia
MOCA
100% sensitive 87% specific 12 items, 30 points cutoff >/= 26 detects MCI
SLUMS
Sensitive 92-95% Specificity 76-81% 11 items, 30 points >/= 27 not copyrighted
Mini cog
Mini Cog screens executive, visual perception, construction, language, attention, and memory domains of cognition in 3 minutes
1: State 3 unrelated words and ask individual to remember them. Repeat up to 3 times to register the words
2: Clock Draw Test (2 points)
3: Repeat 3 word (3 points)
Score of 2 or less screens positive for dementia
How can you screen for delirium?
Confusion Assessment Method (CAM)
1: Acute or Fluctuating Course
2: Inattention
3: Disorganized Thinking
and/or
4: Altered Level of Consciousness
Is there evidence of an acute change in mental status from the patient’s baseline? Did the (abnormal) behavior fluctuate during the day, that is, tend to come and go, or increase and decrease in severity?
Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said?
Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?
Overall, how would you rate this patient’s level of consciousness? (alert [normal]), vigilant [hyperalert], lethargic [drowsy, easily aroused], stupor [difficult to arouse], or coma [unarousable])
Describe the geriatric assessment scale
a score > 5 suggests depression
describe how you felt over past week
Describe gait speed
”6th Vital Sign” Walkway of 5-10 meters Acceleration phase (3 meters) Straight path Instruct individual to walk a safe speed without running Ideal 1 meter/second or faster
Describe interventions to improve function
MULTIPLE interventions and resources available to maximize patient function
Plan must be individualized for each patient
Goal to achieve and maintain HEALTH, HAPPINESS, and SAFETY! Personalized care planning Take away before you add interventions Guiding expectations Advance Care Planning Appropriate Referrals Follow Up
What is included in ROS
HPI sleep nutrition continence/bowels sensory impairment ADLs/functional status falls/mobility cognition mood goals of care/medical decision-making
PE
VS
general
Skin
HEENT
neck/lymph
REsp
CV/PV
GI
GU
MS
N
Cogn
Psych
Capacity {ACE}Objective labs
Labs
CMP, magnesium, Calcium, phosphate, CBC (should already be done recently)
pre-albumin, albumin, TSH, B12, Vitamin D, Folate, (LDL), RPR, (if concern), urinalysis (if concern)
