Comprehensive Geriatric Assessment Flashcards
1
Q
How many people in the history of the world who have ever lived to age 65 are alive TODAY
A
2/3
2
Q
By 2050 people age 65 and older will equal ??? percent of the population?
A
20%
3
Q
What is estimated need for geriatricians?
A
20,000 +
4
Q
What is the actual amount of geriatricians?
A
7, 600 -
5
Q
What is a geriatrician?
A
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
6
Q
What does a geriatric syndrome consist of ?
A
multiple etiological factors
Interacting physiologic pathways
Unified manifestation
7
Q
What is homeostenosis?
A
The ability to maintain homeostenosis in our body begins to go down.
8
Q
When disease severity begin to increase, what happens to compensatory mechanisms?
A
Decreases
9
Q
What is the goal of comprehensive geriatric assessment?
A
develop coordinated and integrated plan for long term care and follow up
10
Q
What should be done for a “ too well to benefit” patient?
A
promote health
maintain functional independence
Emphasize self care practices
Identify early dysfunction in the home environment
11
Q
What should be done for a “appropriate geriatric pt”
A
recovery of health and education
Prevention of disability
Maintain home environment
monitor environment functional status to asses effectiveness of intervention
12
Q
What should be done for “too sick to benefit”
A
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
13
Q
What are the 5Ms of geriatrics?
A
Matters Most Mind Mobility Medications Multi- complexity
14
Q
Maintaining the ability to walk/and or maintain balance
A
Mobility
15
Q
The single best predictor of institutionalization?
A
impaired functional staus
16
Q
Self- reported function is an accurate predictor of ??
A
health risks and costs
17
Q
Pre admission ADLs are the highest in?
A
eating
18
Q
Discharge ADLs lost are the highest in?
A
eating
19
Q
What are 5 reasons for IADL losses?
A
Cognitive impairment Physical impairment Psychological factors Inadequate caregiver/ social support Unfriendly environment
20
Q
What is the goal of targeting medications?
A
reducing polypharmacy
de-prescribing
prescribing txt exactly for an older person needs
helping build awareness of harmful medication effects
21
Q
What 4 things makes medication use so challenging in older adults?
A
low representation in research
Health system factor that compound complexity
Polypharmacy
Physiologic changes (PK.PD)
22
Q
How the body reacts to a medication?
A
Pharmacokinetics
23
Q
How the medication reacts to the body?
A
Pharmacodynamics
24
Q
In the elderly effects of drugs at similar concentrations are ??
A
more pronounced
25
How many meds are considered polypharmacy?
>5
26
What are 5 problems of polypharmacy?
```
disability
frailty
drug-drug interactions
impaired cognition
slowed gait speed
```
27
The elderly account for ?? percent of drug costs in the US?
33%
28
The average elderly person is on ?? of prescription drugs and ?? OTC drugs at any given time
4. 5 prescription drugs
| 3. 5 OTC
29
What is deprescribing?
Planned or supervised process of DOSE REDUCTION or STOPPING MEDICATION(S) that may be causing HARM or NO LONGER PROVIDING BENEFIT
30
What are the 5 steps to deprescribing protocol?
1. Reconcile all medications
2. Consider risks/ benefits of use
3. Assess eligibility
4. Prioritize
5. Implement and monitor deprescribing
31
What are 4 medication assessment tools?
American Geriatrics Society Beers Criteria
Medication Appropriateness Index
Anticholinergic Risk scale
STOPP and START
32
What are things you should consider in priority?
```
benefit vs harm
easiest to discontinue
patient "buy-in"
complex regimens
cost
```
33
What are some anticipated barriers?
rebound s/s
withdrawal s/s
patient attachment
patient/provider relationship
34
Stopping a medication should be done with the ....
same considerations as starting one
35
Maintaining mental activity, helping treat and prevent delirium
Mind
36
T/F Dementia is normal aging?
FALSE
37
What is the life expectancy after symptoms of dementia begin?
8-10yrs
38
How is dementia diagnosed?
Decline in at least 2 areas + a decline in functional status PLUS evidence of both (family complaint, neuropsych testing)
39
What is the most common type of dementia?
Alzheimers disease
40
What are the 3 stages of dementia?
preclinical, mild cognitive impairment, dementia
41
What are 3 ways to screen for cognitive impairment?
Mini Cog (repeat 3 words, clock draw, recall 3 words)
42
What patients should be screened for dementia?
When there are concerns from patient, family, caregivers
43
What should be ruled out in evaluation for dementia?
"reversible contributors"
44
What things make up the evaluation of dementia?
```
History
Function
Cognition
Mood
Labs and imaging
```
45
What assessment can be used to r/o cognition?
Mini mental state exam
| Montreal Cognitive Assessment (MoCA)
46
What assessment can be used to r/o mood?
Geriatric Depression Scale
| Zarit Burden interview for caregivers
47
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
48
What are 3 types of imaging to consider in brain imaging?
CT non-contrast (go to)
MRI
PET
49
What are 2 medications for dementia?
Acetylcholinesterase inhibitors
| NMDA antagonists
50
What med should be started in the early/mild dementia?
AChl
51
What med should be started in middle/moderate dementia?
Start AChI + NMDA antagonist
52
MMSE: 26-21, MoCA 16-9
Early/mild dementia
53
MMSE: 20-10, MoCA 14-4
Middle/ moderate
54
MMSE: 9-0, MoCA 0-3
Late/severe
55
What med should be started in late/severe dementia?
Start AChI + NMDA antagonist
56
What are the side effects of AChI?
GI upset, nausea, vomiting, diarrhea
Bradycardia
Insomnia
57
What are the side effects of NMDA antagonist
GI upset
Dizziness
Confusion
58
Disturbance in mental abilities that results in decreased awareness of environment and confused thinking
Delirium
59
What are 3 differences in dementia vs delirium?
sudden onset
fluctuating course
can improve
60
What are 3 types of delirium?
hyperactive- least common were
hypoactive
mixed
61
What is the mortality rate for delirium?
VERY HIGH! 1 month 14%
62
What criteria is used to access for delirium?
Confusion Assessment Method (CAM)
63
What criteria is used to access for depression?
Geriatric depression scale
64
Helping older adults manage a variety of health conditions?
Multi-complexity
65
Recommendations for colonoscopy in 76-85yrs old?
should be an individual one, taking into account the patients overall health and prior screening history
66
Coordinating advanced care planning, helping manage goals of care?
Matters Most
67
What is lagtime to benefit?
time between the preventative intervention to when improved health outcomes are seen
68
What is a good resource for cancer screening?
ePrognosis
69
What 4 things do CAM test for?
Acute Onset and Fluctuating Course
Inattention
Disorganized Thinking
Altered Level of Consciousness
70
Diagnosing Delirium requires what 2 things?
Acute Onset and fluctuating Course AND
| Inattention
71
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
```
72
What is NOT affected by the normal aging process?
Absorption
73
What can alter drug absorption?
Antacids
| Iron
74
What diseases can effect absorption?
lack of intrinsic factor (B12 absorption)
| Delayed gastric emptying
75
Less water = decrease volume of distribution =
higher concentration of water soluble drugs
76
More fat = increase volume of distribution =
prolonged action of fat soluble drugs (increase half life)
77
Lower serum proteins =
increases the concentration of unbound/ active drugs
78
Phase I metabolism is ??
slowed
79
Two drugs effected by Phase I metabolism?
Warfarin and phenytoin
80
What occurs in phase I reaction?
Oxidation, reduction, dealkylation
81
What occurs in phase II reaction
Conjugation, acetylation, methylation
82
Which phase is unchanged?
Phase II
83
What may NOT be an accurate reflection of renal clearance in elderly patients
Serum creatinine
84
What makes it difficult to predict drug metabolism or drug effects in older adults?
clinical trials exclusion
85
What are 6 medications that commonly account for ADEs in older adults?
```
Cardio
Psychotropic
Antibx
Anticoag
Non-opioid analgesics (NSAIDS)
Anti-seizure
```
86
What are the 7 risk factor for ADEs?
```
> 6 chronic disease
> 12 doses/day
> 9 MEDICATIONS
Low BMI (< 22Kg)
Age > 85
Creatinine clearance < 50kml/min
History of prior ADE
```
87
a-adrenergic activity causes?
urine retention and raises blood pressure
88
a-adrenergic antagonist causes?
decrease in urinary retention and lowers bp
89
Associated with significant morbidity and mortality in older adults?
Falls and hip fractures
90
What should be done rather than treating an ADE with another medication?
Consider discontinuing or dose reducing
91
What is Beers Criteria?
A list of potentially` inappropriate mediations
92
What does Beers not account for?
Complexity of the entire medication regimen
93
Dry mouth, urinary retention, constipation, confusion, deliurium?
anticholinergic meds
94
How to prescribe meds to the elderly?
start one medication at a time
| Start low dose and increase gradually
95
What are the 4 principles to prescribing?
Less is more!
Think drugs!
Start low and go Slow
Assess adherence
96
Belief that each of us has the right to die pain free and with dignity, and that our loved ones will receive the necessary support allow us to do so
Hospice
97
What are the 8 domains of palliative care?
```
interdisciplinary team
physical
psychological and psychiatric
social
spiritual, religious, existential
cultural
imminently dying
legal ethical
```
98
Who needs palliative care?
Patients of all ages suffering from a Serious, life-limiting illness
99
Hospice focuses on ?? not ??
caring not curing
100
What are the 4 domains of hospice care?
physical, social, spiritual, psychological
101
Who is eligible for hospice services?
Patients of any age, religion, race or illness, regardless of health insurane
102
Where is hospice care largely delivered?
At home (98%)
103
What does Medicare cover in hospice benefits?
routine home care
general inpatient care
continuous home care
inpatient respite care
104
What are the 4 general referral criteria for hospice?
Prognosis < 6mo
End stage illness
Life threatening illness
Terminal cancer willing to forgo further palliative txt
105
When is palliative care most beneficial?
when started at diagnosis
106
Those who received PC at time of diagnosis experienced?
better symptom control
improved quality of life
less aggressive interventions
LIVED LONGER
107
When does palliative care stop?
DOESN'T continues through disease until death
108
Who provides palliative care?
All HEALTH CARE PROFESSIONALS
109
What is prognostication?
provides information to set patient goals, priorities, and expectations of care
110
What 4 things make up total pain?
physical
spiritual
psychological
social
111
What is FICA used for?
spiritual assessment tool
112
F in (FICA)?
Faith, Belief, Meaning
113
I in (FICA)
Importance and influence
114
C in (FICA)
Community
115
A in (FICA)
Address/ Action in Care
116
What are palliative care physicians primary task?
helping patients choose the best interventions to meet their needs in specific situations and then providing pts with the best possible care
117
What does prognostication conversation help improve?
QOL
Decreases aggressive medical care at death
earlier hospice referral
improved bereavement for family
118
What are two components of prognostication?
Forseeing- formulating the prediction
| Fortelling- communicating the prediction
119
Assess a patient's understanding of information?
Ask-tell-Ask
120
What does SPIKES stand for?
```
S- Setting
P- Perception
I- Invitation
K- Knowledge
E- Emotions
S- Strategy/Summary
```
121
What does NURSE stand for?
```
N- Name the emotion
U- Understand
R- Respect
S- Support
E- Explore
```
122
What 4 phrases to avoid?
There is nothing more we can do for you
Would you like us to do everything possible
Withdrawal of care
It is futile
123
The movement of a patient from one setting of care to another
Transitions of care
124
Changes in the level, location, or providers of care as patients move within the healthcare system
Transitions of care
125
What is the key problem in TOC?
Information is often not available to those who need it when they need it
126
Who is at a risk for complicated care transition?
Older adults
127
8 P's
```
Problems w/ meds
Psychological
Principal diagnosis
Physical limitations
Poor health literacy
Patient support
Prior hospitalization
Palliative care
```
128
What 3 P's are not included?
Lack of Primary care
Public support used by pt
Poor mobility status
129
Best for older adults who require only intermittent skilled services?
home health care
130
Medicare requires that older adults who receive home health care be ??
homebound
131
Medicare covers up to how many days of skilled nursing care?
100 days after a hospital stay
132
What does a safe transition include?
communication and coordination of care
133
What is the requirement for acute rehabilitation?
must be able to participate in 3 hrs per day of intense therapy
134
What is the most common type of nursing homes?
For profit (68%)
135
Provide only personal assistance that can be performed by someone with little or no medical training?
Assisted Living Facilites
136
Custodial Care?
assisted living or nursing home
137
What is the least common type of nursing home?
Government nursing home
138
What is considered a lower quality nursing home?
For profit, large population funded by Medicaid
139
Most common condition in nursing homes?
Dementia (46%)
140
More than 60% of nursing home residents are on?
psychoactive meds
141
What does skilled nursing facility include?
full staff, skilled needs, short period, wound care
142
No governed by the government, no onsite RN?
Assisted living facilites
143
If nursing home is mostly funded by Medicaid its probably?
lower quality
144
Who makes up 80% of nursing home population?
Long-stay residents (>90days)
145
What is more important than a diagnosis?
What CAN the patient do!
146
What are icebergs?
unreported symptoms that people contribute to old age
147
Why are generalist important in geriatric care?
because they are the "jack of all trades"
148
What are the 4 domains in a assessment?
Mental, physical, functional, and social economic
149
Why is it always important to take time with the geriatric patient?
to form bonds
150
What are 3 barriers to care?
Sensory deficits
Cognitive Impairment
Passive patients
151
What is the highest chronic condition in medicare beneficiaries?
High blood pressure
152
Presence of 3 of more of what makes up frailty?
```
Weight loss
Exhaustion
Slow walking speed
Low physical activity
Weak grip strength
```
153
What 3 things do some experts suggest adding to the frailty list?
cognition
depressed mood
pain
154
T/F Frailty is not synonymous with age or disease?
true
155
What improves clinical outcomes and alleviates or slows frailty progression?
early identification and focused interventions
156
What is loss of resiliency?
systems no longer can compensate for one another
157
What is impaired energy pathway?
more energy is needed to maintain homeostasis
158
What does models of frailty mean?
goal is to predict poor clinical outcome
159
What does FRAIL stand for?
```
Fatigue
Resistance
Ambulation
Illnesses (>5)
Loss weight (>5%)
```
160
What is the perfect tool for frailty?
There is NONE!
161
What are 3 treatment options for frailty?
treat the whole pt
dx frailty and knowing the patient meets criteria
Patients greatly benefit from multidisciplinary care
162
What relationship has been well established with frailty?
Death
163
What plays a unique role in mistreatment?
primary care
164
How many Americans age 65 have been a victim of elder mistreatment or neglect?
1-2 million
165
Who are the most common perpetrators
Family members (adult children) (46%)
166
Who are the least common perpetrators?
grandchildren
167
What elderly category is most likely to be abused?
dementia
168
What age is most at risk for elder abuse
advanced age (>80)
169
What are 4 risk factors for elder mistreatment?
advanced age
dependent on ADL
Dementia
Combative behavior
170
What 3 risk factors for perpetrators?
depression/mental illness
alcohol/drug dependence
financial dependence
171
Those >85y show what percent of frailty?
70%
172
Women are 1.7x likely to have?
arthritis or depression
173
Men are 1.3x likely to have?
ischemic heart disease
174
Primary Frailty?
without disease
175
Secondary Frailty?
with disease
176
What does STEADI stand for?
```
Stopping
Elderly
Accidents
Deaths and
Injuries
```
177
Who should be asked about falls?
all adults OVER 70
178
What are 5 modifiable risk factors for a fall?
```
Polypharmacy
Orthostasis
Gait and balance
Vision impairment
Environmental Hazards
```
179
What does a "long lie" predict?
lasting decline in functional status
180
What is a predictor of long lie?
cognitive impairment
181
T/F 90% of hip fractures are caused by falls
True
182
What is the leading cause of accidental death in adults over 65?
Falls
183
Who should be screened for falls?
all older adults
184
What screening is done for a single fall?
check of balance or gait distrubance
185
What screening is done for recurrent falls?
A complete assessment
| determine fall risk
186
What are 3 balance assessment tools?
Romberg Test
Functional Reach
Pull Test
187
High steps, foot slapping, foot drop, dragging toe
Neuropath gait
188
Hypokinetic, stooped, shuffling, en bloc turning, tremor
Parkinsonian gait
189
Shortened stance compared to limp
Antalgic
190
What predicts survival?
gait speed
191
A gait of <10sec ?
high mobility
192
A gait >30sec?
low mobility and high fall risk
193
Get up and go test used for?
gait speed
194
What are intrinsic risk factors for falling?
```
>80
previous falls
visual impairment
pain
diabetes
```
195
What is the biggest relative risk for falls?
muscle weakness
196
What medication group causes the greatest falls?
Antidepressants
197
What are extrinsic risk factors for falling?
low lightning
throw rugs
clutter
198
What daily intake of Vitamin D should be part of fall prevention?
800 IU daily
199
What 2 of 4 areas of exercise must be effective to reduce falls?
strength, balance, flexibility, endurance
200
What shoe is recommend?
high box, low heal, thin sole
201
T/F Nonsurgical vision correction reduces falls?
FALSE (may increase risk)
202
Vision intervention that decreases falls?
expedited first cataract surgery
203
What amount of time spent on the floor has poor outcomes?
>1hr
204
Who should perform home safety assessment?
OT
