Comprehensive geriatric assessment & acute illness

Question 1

What is the geriatric process ?

Answer 1

• Comprehensive Geriatric Assessment
• Creation of a problem list (more than a just a list of differential diagnoses for one problem)
• Agree objectives of care
• Develop Individual Management Plan
• Regular Review

Question 2

What is a comprehensive geriatric assessment (GCA) ?

Answer 2

A multidimensional interdisiplinary diagnostic process focused on determining a frail older persons medical, psychological and functional capability in order to develop a co-ordinated and intergrated plan for treatment

Question 3

What does a GCA comprised of?

Answer 3

4 main domains - Medical, psychological, functioning& social/environment under each of the following domains the following is assessed:

• Medical - Problem list, Co-morbid conditions and disease severity, Medication review, Nutritional status
• Psychological - Mental status/cognitive function, Mood/depression testing
• Functioning - Basic ADLs (activities of daily living), Extended ADLs, Activity/exercise status, Gait and balance
• Social/environment - Informal needs and assets, Social circle, Care resource eligibility & resources, Safety

Question 4

What are some of the problems in an elderly person which may be included in a problem list ?

Answer 4

• Off legs (poor mobility)
• Falls
• Confusion
• Frailty
• Continence issues
• Polypharmacy
• Syndromes

Question 5

What are the benefits shown by doing CGA’s?

Answer 5

• Reduces mortality at 6 months
• Improves function
• Improves cognition
• Reduces need for nursing home care (NNT=33)
• Reduces subsequent hospital admission

Question 6

Appreicate these points

Answer 6

• Comprehensive geriatric assessment is the founding skills of geriatric medicine
• Ward based CGA should be considered the evidence based standard of care for frail older inpatients
• Many MDT members contribute to CGA, communication and teamwork are key

Question 7

How can acute illness in older people vary from in younger people ?

Answer 7

• Atypical or masked presentations may delay diagnosis or lead to the wrong diagnosis
• Pathophysiology response varies
• Immune response may vary with disease/drugs/nutrition
• Co-morbid conditions increase need to be co-managed
• Investigations and management need to be tailored to individual
• Medication always need to be reviewed and any new medications need to be justified and proporionate

Question 8

How does the presentation of MI sometimes differ in older people compared to younger ?

Answer 8

Young people: Chest pain

Older people: 1/3rd have no chest pain but may present with:

• Collapse
• Delirium
• Dizziness
• Breathlessness

Question 9

How might the investigation/management of MI in older people differ from younger people ?

Answer 9

Investigations:

• both will get blood tests, ECGs and CXRs

Young person:

• Would get Angiogram straight away, usually normal echo

Older person:

• Might not be able to lie flat, may be confused and not able to tolerate angiogram, echo may be abnormal

Management:

• Both will get an antiplatelet, statin

Young person:

• Dual antiplatelets, high dose statin, quick titration of beta blocker

Older person:

• Need to be wary Side effects from antiplatelets, statins, etc i.e. bleeding and muscle weakness

Question 10

How can the presentation of sepsis differ in older people from younger people ?

Answer 10

• BP may drop early (esp in those on antihypertensives)
• Temperature often low, not high
• Tachycardic response may be absent
• Delirium may be a prominent feature
• CRP and WCC may not rise (or not much)
• Fluid balance may be hard
• Antibiotics should be targeted as higher risk C.diff