Comprehensive geriatric assessment in elderly

1. COMPREHENSIVE GERIATRIC
ASSESSMENT
Dr. Divyamol Sasidharan
Senior Resident
Dept. of Geriatrics
AIMS, Kochi

4. What is CGA???
A multidisciplinary
diagnostic and treatment process that identifies
medical, psychosocial, and functional limitations
of a frail older person in order to develop
a coordinated plan to
maximize overall health
with aging

5. 3 step process:
1) Targeting appropriate patients
2) Assessing patients and developing
recommendations
3) Implementing recommendations

6. AIM
Restoration of health function
Independence where possible
Amelioration of disability and distress

7. Multi-disciplinary team
Family doctor
Nurses
Speech therapist
Dietician
Physiotherapist
Occupational therapist
Pharmacist
Community
supportFamily
Geriatrician
Multi-disciplinary team
Psychologist
Social worker

8. Target population
• Age
• Multiple medical co morbidities eg: heart
failure, cancer
• Psychosocial disorder : depression, isolation
• Specific geriatric conditions : dementia, falls,
functional disability

9. Target population
• Previous or predicted high health care
utilisation
• Considering of change in living situation
from independent living to assisted, nursing
home or in home care givers

10. Target population
• Too Sick to Benefit
: Critically ill or medically unstable
: Terminally ill
: Disorders with no effective treatment
• Too Well to Benefit
: One or a few medical conditions
: Needing prevention measures only

11. Target population
• Appropriate and Will Benefit
: Multiple interacting biopsychological problems
that are amenable to treatment
: Disorders that require rehabilitation therapy

12. FRAME WORK
1) Data-gathering
2) Discussion among the team, increasingly
including the patient and/or caregiver as a
member of the team
3) Development, with the patient and/or caregiver,
of a treatment plan
4) Implementation of the treatment plan
5) Monitoring response to the treatment plan
6) Revising the treatment plan

14. ADDITIONAL FACTORS:
Nutrition/ weight change
Urinary incontinence
Sexual Function
Vision/ hearing
Dentition
Living Situation
Spirituality

15. Efficacy
• Multiple meta-analyses have found home
assessments to be consistently effective in
reducing functional decline as well as overall
mortality
1. Stuck AE, Egger M, Hammer A, et al. Home visits to prevent nursing home admission and functional decline in elderly
people: systematic review and meta-regression analysis. JAMA 2002; 287:1022.
2. Elkan R, Kendrick D, Dewey M, et al. Effectiveness of home based support for older people: systematic review and
meta-analysis. BMJ 2001; 323:719.
3. Huss A, Stuck AE, Rubenstein LZ, et al. Multidimensional preventive home visit programs for community-dwelling
older adults: a systematic review and meta-analysis of randomized controlled trials. J Gerontol A Biol Sci Med Sci 2008;
63:298.
Stuck AE, Siu AL, Wieland GD, et al. Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet
1993; 342:1032.

16. • 17 randomized trials evaluating geriatric
rehabilitative units (within an acute care
hospital or a rehabilitation hospital) found that
inpatient multidisciplinary programs were
associated with improvement in all outcomes
at discharge, including better functional status
(OR 1.75, 95% CI 1.31-2.35), decreased nursing
home admission (relative risk [RR] 0.64, 0.51-
0.81), and reduced mortality (RR 0.72, 0.55-
0.95).
Bachmann S, Finger C, Huss A, et al. Inpatient rehabilitation specifically designed for geriatric patients:
systematic review and meta-analysis of randomised controlled trials. BMJ 2010; 340:c1718.

17. • A meta-analysis of 22 randomized trials of
inpatient CGA by mobile teams or in
designated wards found that patients who
received CGA were more likely to be alive and
in their own homes at the end of the
scheduled follow-up (OR 1.1, 95% CI 1.05-
1.28) and less likely to be living in residential
care (OR 0.78, 95% CI 0.69-0.88), compared
with usual care
Ellis G, Whitehead MA, Robinson D, et al. Comprehensive geriatric assessment for older adults
admitted to hospital: meta-analysis of randomised controlled trials. BMJ 2011; 343:d6553.

18. COMPONENTS OF CGA

19. FUNCTIONAL ASSESSMENT

20. Why care about function ?
73
19
84
36
93
46
92
47
92
56
94
72
0
10
20
30
40
50
60
70
80
90
100
%Independent
Bathing Dressing Transferring Walking Toiletting Eating
Pre-Admission and Discharge ADLs of
Patients With Functional Decline
During Index Hospitalization
Pre-
Admission
ADLs
Discharge
ADLs

21. Functional domain
KATZ INDEX of ACTIVITIES OF DAILY LIVING
 Independant
 Assistance
 Dependant

22. Functional domain
INSTRUMENTAL ACTIVITIES OF DAILY LIVING
 Independant
 Assistance
 Dependant

23. Functional domain
Advanced Activities of Daily Living
Ability to fulfill societal, community and
family roles and participate in recreational or
occupational tasks

24. • Data from: Saliba D, Elliott M, Rubenstein LZ, et al. The Vulnerable Elders Survey: a tool for identifying vulnerable older people in
the community. J Am Geriatr Soc 2001; 49:1691.

25. FALLS/ IMBALANCE
Approximately
1/3rd community-dwelling persons age 65 years
1/2 of those over 80 years of age fall/year.
1/5th of the elderly in Ernakulam fall/year.
 higher risk of having a subsequent fall and
losing independence

26. Screening for fall/ risk for falling
• History of falls in prior 12 months
• Presents with acute fall
• Difficulty with walking or balance
.
The Prevention of Falls in Older Persons: Clinical Practice Guideline(http://www.medcats.com/FALLS/frameset.htm)
from the American Geriatrics Society. For more information visit the AGS online at www.americangeriatrics.org

28. Functional domain
GET UP AND GO TEST:
• Only valid in patients not using an assistive
device
• Get up and walk 10ft, and return to chair
Seconds Rating
<10 freely mobile
<20 mostly independent
20-29 variable mobility
>30 assisted mobility

29. Functional domain
• Sensitivity 88%
• Specificity 94%
• Time to complete <1 minute
• Requires no special equipment
Cassel, C. Geriatric Medicine: An Evidence-Based Approach, 4th edition, Instruments
to Assess Functional Status, p. 186.

30. Gait Speed
• Gait speed alone predicts functional decline
and early mortality in older adults
• Eg. elevated blood pressure in individuals age
≥ 65yrs was associated with increased
mortality only in individuals with a walking
speed ≥0.8 meters/second (measured over 6
meters or 20 feet)
1. Studenski S, Perera S, Patel K, et al. Gait speed and survival in older adults. JAMA 2011; 305:50.
2. Odden MC, Peralta CA, Haan MN, Covinsky KE. Rethinking the association of high blood pressure with mortality in
elderly adults: the impact of frailty. Arch Intern Med 2012; 172:1162.

31. COGNITIVE ASSESSMENT
• MMSE
• MINI COG – 3 ITEM RECALL, CLOCK DRAW
• CAM

32. AFFECTIVE ASSESSMENT
• GDS
• Do you often feel sad or depressed?

33. POLYPHARMACY

34. VISUAL IMPAIRMENT
• PRESBYOPIA
• Cataract, Age related macular degeneration,
DR, glaucoma
• FALLS, FUNCTIONAL AND COGNITIVE DECLINE,
IMMOBILITY, DEPRESSION

35. HEARING IMPAIRMENT
• PRESBYCUSIS
• Reduced cognitive, emotional, social and
physical function
• WHISPERED VOICE TEST

36. MALNUTRITION/ WEIGHT LOSS
• UNDERWEIGHT/ OBESITY
• Mini nutritional assessment

38. URINARY INCONTINENCE

39. SOCIAL SUPPORT

40. ECONOMIC ASSESSMENT

41. ENVIRONMENTAL ASSESSMENT
• Safety of home environment
• Adequacy of access to needed personal and
medical services

42. SPIRITUALITY

43. Advanced directive
• CPR ?
• Artificial feeding
NG tube
IV
• Ventilators?
• Medications
Antibiotics, Antidiabetics,
Antihypertensive

44. Advanced directive
• Catheters
• Comfort medications
Pain
Dyspnoea
Secretions
Enema

45. NEWER APPLICATIONS OF CGA
• cancer patients undergoing chemotherapy [1]
• considerations of surgery, or transcatheter
aortic valve replacement for patients with
aortic stenosis [2]
• postoperative mortality risk [3].
1. Kalsi T, Babic-Illman G, Ross PJ, et al. The impact of comprehensive geriatric assessment interventions on tolerance to
chemotherapy in older people. Br J Cancer 2015; 112:1435.
2. Boureau AS, Trochu JN, Colliard C, et al. Determinants in treatment decision-making in older patients with symptomatic
severe aortic stenosis. Maturitas 2015; 82:128.
3. Kim SW, Han HS, Jung HW, et al. Multidimensional frailty score for the prediction of postoperative mortality risk. JAMA
Surg 2014; 149:633.

46. Conclusion
• Multi disciplinary approach
• Targeted population
• High efficacy
• Can be brought to practice easily
• Essential part of geriatric care