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Geriatric Assessment

junaidi . ar
Dept. of Internal Medicine

Objectives

Understand that geriatric patients have


multiple problems that often require a
multidisciplinary approach
Understand the benefits of geriatric
assessment
Be able to identify which persons benefit
the most from geriatric assessment
Know how to identify functional
impairments in an elderly person

Geriatric Medicine

What is geriatric medicine?

Geriatric Medicine

Definition:

Comprehensive assessment and management


of the older patient with chronic disability,
multiple medical and social problems

Goal:

Optimize function
Multiple disciplines involved physician,
nursing, rehabilitation medicine, social work

Geriatric Medicine

Why are we concerned?

Geriatric Medicine

Elderly people are subject to


deteriorating function, diverse
diseases and environmental
challenges that can lead to the
development of frailty and the
inability to live independently

Demography

1900 people > 65: 4% population


2000
: 12%
2030
: 20%

Total number of elderly was 3.1 million in


1900/ by 2000 it was 35 million

Life expectancy:

75 years at birth
82 years at 65

Demography

Aging of the population has


heightened demand for
comprehensive health services
Persons > 65 account for 1/3 health
expenditures
More

frequent and more prolonged


hospitalization
85% at least one chronic illness/30% 3
or more

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2005 Elsevier

Disease and disability are common at


advanced age but it is unclear whether
the continued growth of the older
population will lead to increased numbers
of debilitated elderly requiring extensive
medical/social support

Disease prevention and health promotion


might be developed to delay the onset of
chronic illness and disability

Aging

Processes occurring during the


postmaturational life span that
progressively decreases the ability
of an organism to adapt to
environmental change and increases
likelihood of dying
Includes

alterations in biochemistry,
decrease in physiologic capacity and
increased disease susceptibility

Theories of Aging

Two representative categories of aging


theory
Oxidative

stress
Genetically regulated aging

Oxidative Stress

Normal metabolism generates


oxygen free radicals that lead to
cumulative damage of DNA,
proteins and lipids over time
Supported

by observation that low


levels of oxygen free radicals or
overexpression of protective
antioxidant enzymes leads to longer
lifespan in some species

Oxidative Stress

Aging may occur as result of


cumulative mutations in DNA or
errors in transcription or translation
May occur as result of oxidative
damage or spontaneoulsy
Insufficient to explain all age related
physiologic changes

Genetically Regulated

Programmed control aging process


Telomere attrition
Telomeres

are redundant DNA


sequences at ends of chromosomes
essential for mitosis
Certain cell lines have less activity of
telomerase over time
Further cell division no longer possible

Normal Aging

Physiologic functioning is highly


variable among older individuals
Aging

populations without disease on


average are characterized by
physiologic decline
Often difficult to distinguish normal
aging from disease associated with the
aging process

Normal Aging

Normal aging (absence of disease)


often classified into two categories:
Usual
Aging

accompanied by typical
nonpathologic losses of physiologic
function

Successful
Physiologic

decline during aging is


minimal/absent

Normal Aging

Physiologic losses have been attributed to


modifying effects of extrinsic variables

Diet
Exercise
Psychosocial factors

Need for further research into strategies


by which life-style modifications might
reduce morbidity

An 85 year old man is admitted to the hospital


with dehydration, fever and marked
disorientation. He is presumed to have fallen,
because he was found lying on the floor in his
bedroom. He had been discharged from a
rehabilitation hospital 2 months ago, after
recovering from an acute CVA. At that time he
was able to ambulate with a walker, and do
basic self-care.
He is febrile and tachypneic and has dry
mucous membranes. Chest x-ray is consistent
with a left lower lobe pneumonia.

Atypical Presentation of Illness

Age and other factors affect signs


and symptoms of illness in older
people

Factors That Influence


Response

Age-associated changes in physiologic function


(Host factors)

Alterations of perception to pain


Absence of signs or symptoms seen in younger
patients

Burden of Co-morbid disease

Acute illness in one system may stress reduced


reserve capacity of another

Produces unrelated signs and symptoms that can


distract from correct etiology

Urosepsis presenting as delirium in a person with


cognitive impairment

Factors That Influence Response

Treatment of Disease
Treatment

of one illness may unmask


previously undiagnosed pathologic
condition

Urinary outlet obstruction may become


apparent when pharmacologic agent with
anticholinergic properties is given and
provokes urinary retention

Treatment of Disease

Signs and symptoms may appear


straightforward, further evaluation to
uncover an occult contributing disease is
appropriate
Certain nonspecific syndromes require more
thorough investigation

Failure to thrive
Acute change in appetite
Decline in self-care capacity
Onset of falls
Change in intellectual function
New onset of incontinence

Hazards of Bed Rest

Imposition of bed rest has been


shown to have physiologic and
psychologic hazards
Elderly

persons have less physiologic

reserve
More prone to the adverse effects of
bed rest

Hazards of Bed Rest

Physiologic Consequences
Cardiac

output declines/Pulmonary
volumes decline
Urinary concentrating ability decreases

Calcium and nitrogen loss can exceed intake

Decrease

in muscle strength/ Decrease in


endurance
Skin breakdown/Pressure sores
Increased risk for DVT
Central nervous system function altered

Emotional lability; poor short-term memory

Hazards of Bed Rest

Prevention
Passive

range of motion exercises


Assumption of upright posture several
minutes/day
Frequent changes of position
Routine orders for hospitalized patients
to be out of bed for meals and daily
ambulation

Comprehensive Geriatric
Assessment

NIH Consensus Conference:


The multiple problems of older persons are
uncovered, described and explained, if
possible, and the resources and strengths
of the person are catalogued, the need for
services assessed, and a coordinated care
plan developed to focus interventions on
the persons problems.

Benefits of Comprehensive Geriatric


Assessment

May reveal previously undetected medical or


psychiatric diagnoses that need evaluation or
treatment

Identification of functional deficits predicts


need for social and environmental
interventions

Improve use of community services/more


appropriate placement

Benefits of Comprehensive Geriatric


Assessment

Improves function
Repetition of functional assessment may
be used to gauge impact of therapy
More appropriate medication use
May decrease number of acute care days

Functional Status

The capacity of an individual to


function in multiple domains
(physical, mental, social, emotional)
and at multiple levels (organ
function, function of person as
whole, function of person in society)

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2005 Elsevier

Who should be evaluated?

Three patient categories


1.

2.

3.

Healthy elderly persons living in


the community
Frail elderly persons living in the
community
Institutionalized or severely
impaired elderly persons

Patients who benefit most

Frail because of age


Decrease in functional status
Change in mental status- cognition/affect
Multiple medical problems
Multiple psychosocial problems
Take multiple medications
New onset urinary or fecal incontinence
Involuntary weight loss
Frequent falls
One or more sensory impairments
Disruptive behavior or personality changes

Multi-Disciplinary Team Approach

Interdisciplinary team to make


assessments and develop a diagnosis and
treatment plan
Each member of team sees every patient
Team Members: physician, nurse, social
worker, physical and occupational therapy,
psychology, rehabilitation medicine,
audiology, clinical pharmacy and nutrition

Multi-Disciplinary Team Approach

Model has been limited


Shortage

of health care professionals


trained in geriatric medicine
Poor reimbursement

Methods have been developed to


administer functional status
assessments in physician offices

Components of CGA

Complete History and Physical


Laboratory as indicated
Prevention Screening

Geriatric Syndromes

1.

Common problems that have been identified as


warranting special attention in elderly

Cognitive Disorders
Dementia/Delirium

2.
3.
4.
5.
6.

Polypharmacy
Falls/Gait Instability
Urinary Incontinence
Depression
Malnutrition

Components of CGA

Set of assessment protocols that


focus on screening for physical and
psychosocial impairments and
disabilities

Components of CGA

Measures to evaluate disability and


functional status
Activities

of Daily Living
Instrumental Activities of Daily Living

Consideration of living situation


adequacy and safety
Discussion with patient/family
regarding preferences for future
medical care

Screening Assessments Used in


Comprehensive Geriatric
Assessment

A 72 year old man is brought to your office by


his son because he is unable to handle his
financial affairs. The patient is a retired
accountant and has enjoyed good health.
He has some insight into his mental
problems. He is taking no medication.
Since his wife died 6 months ago, he has
lived alone
Physical examination reveals blood pressure of
180/100 and a left carotid artery bruit. The
rest of the exam and lab work is
unremarkable. MRI of the head is
unremarkable.

Cognitive Impairment

Dementia is common but often goes


unrecognized
Some cases are potentially treatable
or reversible
Important to identify patients with
impairment, even if not treatable, in
order to plan for future care

Cognitive Impairment

Prevalence of cognitive impairment


varies greatly by age and clinical
setting
Community

dwelling patients

> 65 y/o have 10% Alzheimers rate


> 85 y/o have 47% rate

Prevalence

much greater in
institutionalized settings

Cognitive Impairment

Extensive screening batteries for


cognitive impairment have been
developed
Most widely used is the Mini-Mental
State Examination (MMSE)
Takes

about 5-10 minutes to administer

Folstein Mini-Mental Status


Exam

ORIENTATION
Ask for year, season,
date, day, month
Ask for state, county,
town, place,street
REGISTRATION
Name three unrelated
objects. Ask patient to
repeat
ATTENTION/
CALCULATION
- Subtract 7 from
100,repeat 5 times

RECALL
Recall three previous
objects
LANGUAGE
Show wrist watch and
ask what it is
Ask to repeat no, ifs
ands or buts
On blank piece of paper
print Close your eyes
and ask patient to do it
Give patient a blank
piece of paper and ask
him to write a sentence

TOTAL SCORE 30; SCORE < 20


PROBABLE DEFICIENCY

Cognitive Impairment

Positive result indicated need for


further evaluation
Can use for monitoring by repeating
screen at later date and see if
improvement or deterioration takes
place

Depression

Common disorder in the elderly


Under diagnosed
Impairments range from depressive
symptoms to major depression

Depression-Screening

Geriatric Depression Scale


Designed

specifically for frail older

patients
Series of 30 YES/NO questions covering
symptoms and manifestations of
depression
Takes 10-15 minutes to administer
Score > 14 greatly increases
probability of depression
Score < 9 greatly decreases probability

Geriatric Depression Scale


Are you basically satisfied with your life? Yes/NO
Have you dropped many of your interests?
YES/No
Do you feel your life is empty? YES/No
Do you often feel bored? YES/No
Are you in good spirits most of the time? Yes/NO
Afraid something bad is going to happen?
YES/No
Do you feel happy most of the time?
Yes/NO
Do you often feel helpless?
YES/No
Do you prefer to stay at home? YES/No
Do you feel you have memory problems? YES/No
Do you think it is wonderful to be alive? Yes/NO
Do you feel worthless? YES/No
Do you feel full of energy?
Yes/NO
Do you feel your situation is hopeless?
YES/No
Do you think most people are better off than you?

YES/No

Depression- Screening

Demented patients frequently suffer


from depression
Measures have been developed to
screen for depression without
reliance on patient self-report
Caregiver

asked questions about


presence of a number of
symptoms/manifestations of depression

Depression

Should be aware of other problems


causing cognitive impairment
Delirium
Anxiety
Hostility
Psychosis
Behavioral

Problems

An 85 year old woman comes to your office


for the first time because she ahs lost 9.1 kg
in the last 6 months. She has no appetite
and foods taste different to her. A careful
history fails to identify a likely cause for
weight loss. She has and OA.
Physical exam shows a markedly
underweight and frail woman. Her gait is
slow and she has difficulty getting out of a
chair without assistance.

Musculoskeletal Impairment and


Immobility

Unsteadiness
Abnormality sitting or getting up from a
chair
Turning or walking with difficulty
Step height

Impairments in these areas increase the


risk of falling in older persons
Often undetected in a standard history and
physical

Screening Tests

Upper extremity mobility


Manual dexterity
Lower extremity mobility

Evaluations of Balance and Gait

Balance Measures
Sitting

balance (leaning vs steady)


Ability to rise from chair
Immediate standing balance
Standing balance (wide based, narrow
based or assisted)
Sternal nudge
Standing balance w/ eyes closed

BALANCE SCORE ___/16 < 10 =


HIGH FALL RISK

Evaluations of Balance and Gait

Gait Observations
Initiation

of gait
Step length
Step height
Step continuity
Step symmetry
Walking stance
Amount of trunk sway
Path deviation
GAIT SCORE ___/12 < 9 = HIGH
FALL RISK

Malnutrition

Increased risk for poor nutritional


status because of chronic disease,
poverty, social isolation, cognitive
impairment and functional disability
Associated with impaired wound
healing, increased surgical
complications and increased
mortality

Indicators

Body weight < 100 pounds highly


sensitive
Can

also occur patients > 100 pounds

Historical clues
Involuntary

weight loss of 10% body fat

Physical Exam
Glossitis,

loss of subcutaneous fat, muscle


wasting, edema

Lab
Serum

albumin

DETERMINE Checklist

Tool developed by Nutrition Screening


Initiative
Based on warning signs described by the
word

Disease, Eating poorly, Tooth loss/mouth pain,


Economic hardship, Reduced social contact,
Multiple Medicines, Involuntary weight loss/gain,
Needs assistance in self-care, Elderly years >80

Score

0-2
3-5
>6

Good
Moderate risk
High risk

Visual and Hearing Impairment

Visual impairment
13%

Hearing impairment
65-74y/o
>85y/o

25%
50%

Visual Impairment

Methods available for office


screening have limitations
Sensitivity/Specificity

have not been


established in older adults
Limitations in diagnostic accuracy of
glaucoma screening by primary care
physician

Visual Impairment

Screening should be performed


using Snellen test
Specific questions about functional
disability that might be due to poor
vision
Referral to Ophthalmologist if
needed

Hearing Impairment

Hand held audioscope

Performed in 90 seconds
94% sensitive, 72% specific

Physical exam techniques such as


whispered voice or finger rub can be used
Accuracy of tests may be enhanced if
combined with short questionnaire on
functional disability associated with
hearing impairment

Functional Assessment

Complement to screening for


specific impairments
Help

with determining overall health


and well being

Guide to treatment plan


Help to plan long-term care services
Monitor effectiveness of
interventions

Functional Assessment

Choice between methods and


instruments to measure function
depends on frailty of patient
population, time available for
assessment and intended use of
information

Activities of Daily Living

One of the original methods and in


wide use today
Focuses on basic activities
Bathing
Dressing
Toileting

Transferring
Continence
Feeding

Instrumental Activities of Daily


Living

Focus on more complex activities important for


independent living in the community
Shopping
Using the telephone
Handling finances
Housekeeping
Using transportation
Food preparation
Taking medication

Assessment of Home Safety

Throughout the interior several


common features
Scatter

rugs, adequate lighting, enough


room for easy mobility, emergency
telephone numbers posted

Kitchen
Bathroom
Outside the home

Assessment of Social Support

Assess the patients emotional


support
Identify actual/potential caregivers
Ask who would be available in an
emergency
Social information and background
may help assess coping ability

Long Term Options/Placement

Support for remaining in the home


Home

health
Provider service
Day care

If unable to remain in the home


Assisted

living facility
Subsidized senior apartments
Nursing home

Conclusions

Value of CGA has been evaluated in the


inpatient and outpatient settings
Demonstrated to improve medical care
provided to frail elderly
Controlled studies have shown improved
patient outcomes
No study has shown worse outcomes
Inpatient units may improve survival

Conclusions

CGA should be targeted to patients


with potentially improvable function
Optimal targeting criteria have not
been established
May be that a patient without
potential for improved function
might benefit from depression
screening, medication review

Conclusions
Comprehensive Geriatric
Assessment has been advanced as a
means to more effectively diagnose
and manage complex medical
problems of frail elderly

Asesmen geriatri

Suatu analisa multidisiplin yang


dilakukan seorang geriatris atau tim
interdisipliner geriatri atas seorang
penderita usia lanjut untuk
mengetahui kapabilitas medis,
fungsional, psiko sosial agar dapat
dilakukan penatalaksanaan
menyeluruh dan berkesinambungan
.

Tujuan :

Untuk memperbaiki kualitas hidup


lansia.

Kualitas dipengaruhi oleh status


kesehatan , faktor sosial ekonomi ,
dan lingkungan

Quality of life

Health status
Physical,sosial,mental healhty

Disease status
Physiological measuress
Sign and sympioms
Prognosis

Socioeconomy status
Environment

Fungtional status
Daily activities
Achievement
Disabilities

Kapasitas fungsional : ADL


Interaksi dimensi dimensi asesmen geriatri
Cognitive

environment

economic

medical

Fungtionsl
Status

Affective

Social support

spirituality

Dalam Pelaksanaan
Skala asesmen kuantitatif

Panduan evaluasi

Membantu diagnosa

/form
Interpretasi /
keterbatasan

Asesmen fungsional

Gg beragam sebab potensial,


perubahan menua
ADL
IADL
25% lansia butuh bantuan orang
lain

Asesmen medis

1. masalah mobilitas dan


keseimbangan.
The timed up & go test dan the
performance oriented of balance
2. gg penglihatan
3. gg dengar
4. malnutrisi
5. Polifarmasi
6. inkontenensia

Asesmen Kognitif

Dimensia

MMSE Mini mental state exam


Clock drawing test

Asesmen Afektif

Depresi
10 - 15% R jalan
20% r inap
GDS geriatric depression scale

Asesmen sosial

Dukungan terhadap Caregiver


/perumat
Abuse and neglect
The burden interview

Asesmen lingkungan

Keamanan lingkungan rumah


Kemudahan akses
Pemakaian piranti adaptif

Asesmen Ekonomi

Sumber daya penghasilan


Emosional

Asesmen spiritual

Agama !

Kesimpulan

Asesmen G merupakan tata cara


evaluasi yg komperhensif atas
status kesehatan lansia
Kepekaan perhatian terhadap lansia
Kewaspadaan aspek aspek unik
permasalahan medis
Ber-interaksi
Kesabaran
Prespektif cara pandang dewasa
dan lansia .