Comprehensive Geriatric Assessment Flashcards
How many people in the history of the world who have ever lived to age 65 are alive TODAY
2/3
By 2050 people age 65 and older will equal ??? percent of the population?
20%
What is estimated need for geriatricians?
20,000 +
What is the actual amount of geriatricians?
7, 600 -
What is a geriatrician?
a physician that is well grounded in internal medicine, and be experienced in neurology, psychiatry, and rehabilitation medicine. And possible additional role as organizer and coordinator of health services for old people
What does a geriatric syndrome consist of ?
multiple etiological factors
Interacting physiologic pathways
Unified manifestation
What is homeostenosis?
The ability to maintain homeostenosis in our body begins to go down.
When disease severity begin to increase, what happens to compensatory mechanisms?
Decreases
What is the goal of comprehensive geriatric assessment?
develop coordinated and integrated plan for long term care and follow up
What should be done for a “ too well to benefit” patient?
promote health
maintain functional independence
Emphasize self care practices
Identify early dysfunction in the home environment
What should be done for a “appropriate geriatric pt”
recovery of health and education
Prevention of disability
Maintain home environment
monitor environment functional status to asses effectiveness of intervention
What should be done for “too sick to benefit”
supportive care during a time of dependence and decline
Respect dignity during a period of expected decline
Monitoring of function, caregiver support, and the home environment
What are the 5Ms of geriatrics?
Matters Most Mind Mobility Medications Multi- complexity
Maintaining the ability to walk/and or maintain balance
Mobility
The single best predictor of institutionalization?
impaired functional staus
Self- reported function is an accurate predictor of ??
health risks and costs
Pre admission ADLs are the highest in?
eating
Discharge ADLs lost are the highest in?
eating
What are 5 reasons for IADL losses?
Cognitive impairment Physical impairment Psychological factors Inadequate caregiver/ social support Unfriendly environment
What is the goal of targeting medications?
reducing polypharmacy
de-prescribing
prescribing txt exactly for an older person needs
helping build awareness of harmful medication effects
What 4 things makes medication use so challenging in older adults?
low representation in research
Health system factor that compound complexity
Polypharmacy
Physiologic changes (PK.PD)
How the body reacts to a medication?
Pharmacokinetics
How the medication reacts to the body?
Pharmacodynamics
In the elderly effects of drugs at similar concentrations are ??
more pronounced
How many meds are considered polypharmacy?
> 5
What are 5 problems of polypharmacy?
disability frailty drug-drug interactions impaired cognition slowed gait speed
The elderly account for ?? percent of drug costs in the US?
33%
The average elderly person is on ?? of prescription drugs and ?? OTC drugs at any given time
- 5 prescription drugs
3. 5 OTC
What is deprescribing?
Planned or supervised process of DOSE REDUCTION or STOPPING MEDICATION(S) that may be causing HARM or NO LONGER PROVIDING BENEFIT
What are the 5 steps to deprescribing protocol?
- Reconcile all medications
- Consider risks/ benefits of use
- Assess eligibility
- Prioritize
- Implement and monitor deprescribing
What are 4 medication assessment tools?
American Geriatrics Society Beers Criteria
Medication Appropriateness Index
Anticholinergic Risk scale
STOPP and START
What are things you should consider in priority?
benefit vs harm easiest to discontinue patient "buy-in" complex regimens cost
What are some anticipated barriers?
rebound s/s
withdrawal s/s
patient attachment
patient/provider relationship
Stopping a medication should be done with the ….
same considerations as starting one
Maintaining mental activity, helping treat and prevent delirium
Mind
T/F Dementia is normal aging?
FALSE
What is the life expectancy after symptoms of dementia begin?
8-10yrs
How is dementia diagnosed?
Decline in at least 2 areas + a decline in functional status PLUS evidence of both (family complaint, neuropsych testing)
What is the most common type of dementia?
Alzheimers disease
What are the 3 stages of dementia?
preclinical, mild cognitive impairment, dementia
What are 3 ways to screen for cognitive impairment?
Mini Cog (repeat 3 words, clock draw, recall 3 words)
What patients should be screened for dementia?
When there are concerns from patient, family, caregivers
What should be ruled out in evaluation for dementia?
“reversible contributors”
What things make up the evaluation of dementia?
History Function Cognition Mood Labs and imaging
What assessment can be used to r/o cognition?
Mini mental state exam
Montreal Cognitive Assessment (MoCA)
What assessment can be used to r/o mood?
Geriatric Depression Scale
Zarit Burden interview for caregivers
Brain imaging should be considered in ?
onset occurs at age <65 years
Neurologic signs are asymmetric or focal
Clinical picture suggests normal pressure hydrocephalus
Patient has had recent fall or other head trauma
What are 3 types of imaging to consider in brain imaging?
CT non-contrast (go to)
MRI
PET
What are 2 medications for dementia?
Acetylcholinesterase inhibitors
NMDA antagonists
What med should be started in the early/mild dementia?
AChl
What med should be started in middle/moderate dementia?
Start AChI + NMDA antagonist
MMSE: 26-21, MoCA 16-9
Early/mild dementia
MMSE: 20-10, MoCA 14-4
Middle/ moderate
MMSE: 9-0, MoCA 0-3
Late/severe
What med should be started in late/severe dementia?
Start AChI + NMDA antagonist
What are the side effects of AChI?
GI upset, nausea, vomiting, diarrhea
Bradycardia
Insomnia
What are the side effects of NMDA antagonist
GI upset
Dizziness
Confusion
Disturbance in mental abilities that results in decreased awareness of environment and confused thinking
Delirium
What are 3 differences in dementia vs delirium?
sudden onset
fluctuating course
can improve
What are 3 types of delirium?
hyperactive- least common were
hypoactive
mixed
What is the mortality rate for delirium?
VERY HIGH! 1 month 14%
What criteria is used to access for delirium?
Confusion Assessment Method (CAM)
What criteria is used to access for depression?
Geriatric depression scale
Helping older adults manage a variety of health conditions?
Multi-complexity
Recommendations for colonoscopy in 76-85yrs old?
should be an individual one, taking into account the patients overall health and prior screening history
Coordinating advanced care planning, helping manage goals of care?
Matters Most
What is lagtime to benefit?
time between the preventative intervention to when improved health outcomes are seen
What is a good resource for cancer screening?
ePrognosis
What 4 things do CAM test for?
Acute Onset and Fluctuating Course
Inattention
Disorganized Thinking
Altered Level of Consciousness
Diagnosing Delirium requires what 2 things?
Acute Onset and fluctuating Course AND
Inattention
What are 6 physiologic changes associated with normal aging?
Less water More fat Less muscle mass Slowed hepatic metabolism Decreased renal excretion Decreased responsiveness and sensitivity of baroreceptor reflex
What is NOT affected by the normal aging process?
Absorption
What can alter drug absorption?
Antacids
Iron
What diseases can effect absorption?
lack of intrinsic factor (B12 absorption)
Delayed gastric emptying
Less water = decrease volume of distribution =
higher concentration of water soluble drugs
More fat = increase volume of distribution =
prolonged action of fat soluble drugs (increase half life)
Lower serum proteins =
increases the concentration of unbound/ active drugs
Phase I metabolism is ??
slowed
Two drugs effected by Phase I metabolism?
Warfarin and phenytoin
What occurs in phase I reaction?
Oxidation, reduction, dealkylation
What occurs in phase II reaction
Conjugation, acetylation, methylation