Geriatric Assessment and Health Maintenance Flashcards
Are there enough geriatricians to deliver care to the growing number of older adults?
No – there has been a steady decrease since 2000
Goals of a CGA
Provide an all-round evaluation.
Establish appropriate management for medical problems.
Improve the quality of life for frail elders.
Delay or prevent disability.
Delay or prevent institutionalization.
What is a CGA?
A multi-dimensional and multi-disciplinary process as well as integrated plan of care to determine the medical, psychological, functional and social capabilities of “frail” older adults
Why is a CGA important?
increases life expectancy
What does a CGA allow you to screen for?
Age-related increase in morbidity
Age-related increase in use of medications
Age-related decline in physical function
Age-related decline in mental function
What is a CGA particularly useful?
Particularly useful in evaluating elder adults with multiple complex medical problems.
What are the Geriatric Target Conditions?
Dementia or delirium End-of-life care Falls or mobility disorders Malnutrition Pressure ulcers Urinary incontinence
What encompasses the cross cutting conditions?
Continuity of care Hospital care Medication use Pain management Screening and prevention
What are the steps of a CGA?
- Targeting appropriate patients
- Assessing patients and developing recommendations
- Implementing recommendation
Who needs a geriatric assessment?
all older person
What are the applying criteria for a geriatric assessment?
too sick to benefit
appropriate and will benefit
too well to benefit
Appropriate placement?
???
What are the characteristics of a pt that is too sick to benefit?
Critically ill or medically unstable
Terminally ill
Disorders with no effective treatment
What are the characteristics of a pt that is appropriate and will benefit?
Multiple interacting bio-psychological problems that are amenable to treatment
Disorders that require rehabilitation therapy
What are the characteristics of a pt that is too well to benefit?
One or a few medical conditions
Needing prevention measures only
What are the components of a CGA?
medical functional (physical) cognitive mood nutritional assessment other geriatric syndromes access to care and other facilities elderly saftey and security
What is involved with the medical portion of a CGA?
Medical problems
Medications – prescription
Medications – over the counter
What goes into the functional portion of a CGA?
Activities of daily living Instrumental activities of daily living Other functional status (Mobility) --Gait – Type of gait and gait speed --Balance --Strength – upper extremity strength, lower extremity strength
What is involved in the component of access to care and other facilities?
transportation
financial factors
What are the other geriatric syndromes to look at?
urinary incontinence
falls
frailty
sleep disorders
What is the medical component of the CGA?
Individualize treatment plan with the objective of improving functional status and quality of life
What are the types of treatment goals?
Cure
Prevention of complication
Control of symptoms and prevention of side effects of medications
Improve functional status
Assess (analyze) the risk-benefit ratio of treatment
What medications do we get from the patient?
get detailed list of all medications: Prescription medications Non-prescription medications including herbs, etc. Non-daily medications Ointments/creams/gels
What does the beers list help us with?
Useful to avoid using inappropriate drugs
What are the beers criteria?
Medications generally considered inappropriate when given to elderly people.
Medications listed tend to cause side effects in the elderly due to the physiologic changes of aging.
What do we look at when assessing the functional status?
Activities of Daily Living (ADLs) Instrumental Activities of Daily Living (IADLs) Mobility, Strength and Vision: --Gait --Balance --Strength --Vision
What are the ADLs?
bathing dressing transferring walking eating grooming
How do we judge the ADLs and IADLs?
if they are independent, require assistance, or are dependent
What are the IADLs?
use of the phone transportation shopping meal preparation shopping meal preparation house work medical management management of finances
What is the prevalence of functional blindness (20/200)?
71-74 years 1%
>90 years 17%
NH patients 17%
What is the prevalence of functional visual impairment?
71-74 years 7%
>90 years 39%
NH patients 19%
What do we do to assess visual impairment?
annual eye examination
screening test
What is the prevelance of hearing impairment?
65-74 years = 24%
>75 years = 40%
What percent of those >85 years are deaf in at least one ear?
30
What can we do to assess hearing impairment?
audioscope
whisper test
What is an audioscope?
A handheld otoscope with a built-in audiometer
What is the definition of mobility?
Purposeful movement from one place to another independently.
Important items in mobility evaluation include:
Balance
Muscle strength
Gait speed
How do we assess gate speed? What does this determine?
(in meters or feet per second) - Slow gait speed predicts several adverse events including falls, disability, hospitalization and decreased survival.
What is the speed to safely cross a traffic light?
1.2 m/sec
What are tests that assess and screen for balance?
Tandem walk
Berg Balance Scale – may take longer time.
What does a Berg balance scale do?
Developed to measure balance among older people with impairment in balance function by assessing the performance of functional tasks. It is a valid instrument used for evaluation of the effectiveness of interventions and for quantitative descriptions of function in clinical practice and research.
What is the chair stand test?
- Observe is the patient is able to stand up from a sitting position without the support of his/her arms.
2a. If they are not able to stand up, STOP.
2b. If they are able to stand up: ask the patient to:
3a. Sit in a chair with back straight and arms over the chest.
3b. Stand up from sitting position as many times as possible in 30 seconds.
What does the chair stand test assess?
lower extremity muscle strength
What is the Timed “Get-Up-and-Go” test?
Can be done during a clinic visit: Ask patient to stand up from a sitting position Walk 10 ft (3 meters) Turn around and walk back to the chair And sit back in the chair
What does the get up and go test assess?
Simple test to evaluate lower extremity strength, balance and walking speed.
What are the rankings of the get up and go test?
Seconds Rating:
29 seconds: Impaired mobility
How do we assess cognitive function?
screening tests
What is the prevelance of dementia?
30%
What comprises most of the dementia cases?
Alzheimer’s disease and vascular dementias comprise >80% of cases
What does the cognitive assessment help determine?
Risk for functional decline, delirium, falls and caregiver stress
What is the mini-cog?
Consists of:
1. 3-items delayed recall – assesses memory.
- Clock drawing test (CDT) - assesses executive function (ability to plan, make decisions, prioritize, trouble shoot, etc).
What are the results of the mini-cog test? What do these results mean?
Recall = 0 -> abnormal Recall = 1-2 clock test = abnormal -> abnormal Recall = 1-2 Clock test = normal -> normal Recall = 3 -> normal
What is the most commonly used instrument for screening cognitive function?
mini-mental state test
What do we have to keep in mind with the mini-mental state test?
Not suitable for making a diagnosis but can be used to indicate the presence of cognitive impairment (such as suspected dementia or following a head injury)
Why is the mini-mental state test preferred?
Fast and More sensitive in detecting cognitive impairment than the use of informal questioning or overall impression of a patient’s orientation
What does the mini-mental status help with?
Provides measures of orientation, registration (immediate memory), short-term memory (but not long-term memory) as well as language functioning.
What is the Folstein Mini-Mental State Examination?
Assesses five different cognitive (mental) functional abilities:
Orientation to time and place
Registration – the ability to repeat named prompts.
Attention Span and Arithmetic (count or spell backwards)
Memory and recall- going back to the named objects in the registration section.
Language- asked to repeat a phrase
points are awarded of 5 pts for each correct answer
What do most people score on the folstein mini-mental?
28 >85 y/o and >12yrs education
29 70-74 y/o and >12yrs education
22 65-69 y/o and 0-4 yrs education
What has to be taken into consideration with the scoring of the folstein mini-mental?
pts education level
What is the scoring of a mini-mental state test?
Scores: 25-30 out of 30 are considered normal 21-24 is considered mild 10-20 as moderate <10 as severe impairment.
When is the mini-mental state test not appropriate?
The MMSE may not be an appropriate assessment if the patient has learning, linguistic/communication or other disabilities (e.g. sensory impairments).
What is depression associated with?
Associated with physical decline of community-dwelling adults and hospitalized patients
What percent of those >65 show depressive symptoms? What percent have a major depressive disorder?
10
1
How do we assess depression in the elderly?
the geriatric depression scale
What do we look for in a Nutritional Assessment?
History of unintentional weight loss Current body mass index Number of meals per day Accessibility of food items Problem with chewing and swallowing
What do we consider unintentional weight loss?
10 pounds in one year
5 pounds in 6 months
T/F: those in the community are more malnourished that those in the hospitals?
False
What are we concerned with if pts are haveing unintetional weight loss?
death
What types of incontinence do we look at?
Urinary and fecal
How do we assess fecal incontinence?
Ask: How often do you have problem with leakage of stool? Never Less than once a month 2 -3 times per month At least once a week Daily
Why are falls more problematic in the elderly?
Slowed reaction time
Impaired protective responses
Comorbid Diseases
What are the main cause of fractures in the elderly?
falls
What else are falls likely to cause?
Second leading cause of brain and spinal cord injury in older adults.
What are the consequences of falls?
Death
Broken bones
20% of restricted activity days (more than any other condition)
Nursing Home Placement
What are we worried even more so about if the pt falls and cant get back up?
Pneumonia
Dehydration
Rhabdo
What are methods of household saftey?
Handrails on both sides of any stairway
Well lit stairways and walkways
No-slip backing on rugs
Hand bars in bath/shower
What are possible sleep/wake problems?
Tend to take longer to fall asleep.
Lower sleep efficiency
More night time awakenings
Wake up earlier
What percent of community dwelling geriatric patients complain of some sort of sleep disorder?
50
What are conditions that affect sleep/wake problems?
Circadian Rhythm Changes Sleep Apnea Medical Illness Multiple Medications Psychiatric Illness Dementia Poor Sleep Hygiene
T/F: There are Multifactorial Causes for Sleep Disorders in the Elderly
True
What is a frailty syndrome?
Collection of symptoms, signs or findings that are commonly found among older adults and predict adverse outcomes which include:
Disability
Institutionalization
Increased mortality.
What are Commonly used frailty markers?
slow walking speed, decreased muscle strength,
decreased energy expenditure (physical activity),
unintentional weight loss, fatigue.
What factors affect access to care and other facilities?
transportation
Financial Factors
Economic factors may impact nutritional status, medication availability, etc.
What are types of elderly mistreatment?
Physical Abuse Neglect Financial or Material Abuse Psychological Verbal
What are the generally accepted criteria for decision-making?
- The condition must have a significant effect on health.
- Acceptable methods of preventive intervention must be available for the condition.
- The intervention must be effective in preserving health for primary prevention (counseling, chemoprevention, immunizations).
- For other preventive services or interventions:
- —Must be period before patient is aware of the condition (seriousness or implications) during which it can be detected.
- —Tests must be available.
- —Preventive services/treatment must have greater effectiveness than after condition is delayed. - The benefits of preventive service or treatment must outweigh any negative effects.
- A comparison of the cost and benefits must be conducted.
What is the risk benefit ratio for the selected heath maintenance procedure: BP
Low Risk
What is the risk benefit ratio for the selected heath maintenance procedure: Blood sugar
Low Risk
What is the risk benefit ratio for the selected heath maintenance procedure: Blood cholestrol
Low Risk
What is the risk benefit ratio for the selected heath maintenance procedure: osteoporosis
US Preventive Services Task Force – no age limit.
Benefit may emerge 18-24 months after treatment is started.
What is the risk benefit ratio for the selected heath maintenance procedure: prostate cancer
Favorable if life expectancy is >10 years
US Preventive Services Task Force does not recommend screening for those >=75 years old.
What is the risk benefit ratio for the selected heath maintenance procedure: breast cancer
US Preventive Services Task Force recommend screening for women up to age 74 years. Favorable if life expectancy is >5 years
What is the risk benefit ratio for the selected heath maintenance procedure: colon cancer
Colonoscopy; favorable if life expectancy is >7-10 years.
What is the risk benefit ratio for the selected heath maintenance procedure: influenza vaccine
Low Risk; Immunize
What is the risk benefit ratio for the selected heath maintenance procedure: pneumonia vaccine
Low Risk; Immunize annually.
What is the risk benefit ratio for the selected heath maintenance procedure: zoster vaccine
Reduce herpes zoster incidence by 53% and post herpetic neuralgia by 65%.
What is the risk benefit ratio for the selected heath maintenance procedure: tetanus-diphtheria
qT boostter q 10 yrs
What are major modifiable risk factors for Cardiovascular and Cerebrovascular Disease?
HTN Smoking Inactivity Hypercholesterolemia (screening questionable/not cost effective) Obesity DM
What is smoking responsible with CV problems?
Responsible for up to 30% of MIs and CVAs.
Stopping smoking reduces CV mortality within 1 year.
What effect does exercise have on CV problems?
Regular exercise should be recommended
Associated with reduced CV mortality
Positive CV effects include reduced BP, lipids, obesity and DM
What role does estrogen have on Cardiovascular and Cerebrovascular Disease?
Postmenopausal estrogen associated with CAD and a 50% reduction in risk of death in women.
What role does asprin have on Cardiovascular and Cerebrovascular Disease?
ASA (81 mg) on a daily basis is recommended (in absence of contraindications) for stroke and CV risk reduction.
What is the association of fat intake with CV problems?
Reduced fat intake (with exception of olive oil, fatty fish, many types of nuts) appears to have protective effects.
What is the association between alcohol intake and CV problems?
Avoiding excess EtOH consumption may prevent HTN (moderate amounts appear to reduce events).
What is the second leading cause of death in the elderly?
cancer
How does the prevalence of BRCA change with age?
Incidence increases with age (more aggressive forms in younger).
What is the treatment of BRCA?
Treatment with Lumpectomy and Tamoxifen well tolerated & effective.
What is the association of cervical cancer with the elderly population?
Comparatively rare in the elderly.
Patients with a history of normal PAP smears do not PAP screening beyond 65 BUT those without previous screening should have 2 normal PAPs before discontinuing.
What is the association of colon cancer with the elderly population?
Risk of CC increases with age.
DREs and FOBTs alone are not effective as screens.
Regular use of ____________ is associated with reduced cancer risk.
Regular use of ASA associated with reduced cancer risk.
Should we recommend screenings for cervical cancer in the elderly?
recommended against screening in those >75
What is the association of prostate cancer with the elderly population?
common in older men and often asymptomatic.
Should we screen for prostate cancer in the elderly?
recommended against in those >75
What increases the risk of oral cancer?
Tobacco and EtOH increase risk.
What improves the out come of oral cancers?
Oral cancer treatment at an early stage improves outcomes.
What should we recommend to an elderly patient for a decrease in skin cancer?
sunscreen
In general should we recommend the screening of cancers in the elderly?
No, except in the lungs. still screen if they have a history of smoking.
