Comprehensive

Geriatric
Assesment

Pembimbing : Dr. Med. Sc. Irma Ruslina Defi,dr.,

SpKFR(K)
Comprehensive geriatric assessment

• Geriatric assessment is a broad term used to describe the

health evaluation of the older patient, which emphasizes
components and outcomes different from that of the
standard medical evaluation

• This approach recognizes that the health status of older

persons is dependent upon influences beyond the
manifestations of their medical conditions:
•Social
•Psychological
•Mental health, and
•Environmental factors.
Comprehensive geriatric assessment

• Comprehensive geriatric assessment has been shown

to improve both mortality and the chances of
remaining in the community.

• The challenge is to use it efficiently

• Complex patients and those facing major long-

term care decisions are strong candidates, but
studies have also shown benefit for persons
presumably at low risk.
 Components of Comprehensive
Geriatric Assessment

The key elements of the process of care rendered by CGA teams

can be divided into six steps :
1. Data gathering
2. Discussion among the team
3. Development of treatment plan
4. Implementation of treatment plan
5. monitoring response to the treatment plan
6. revising the treatment plan.
GERIATRIC • Traditional medical assessment alone is often not
enough to evaluate the older population with
ASSESSMENT (GA) BY multiple comorbidities.
THE INDIVIDUAL • Out of this recognized need, the geriatric
CLINICIAN assessment has been developed, which
emphasizes a broader approach to evaluating
contributors to health in older persons.
• Geriatric assessment uses specific tools to help
determine patient’s status across several different
dimensions, including assessment of medical,
cognitive, affective, social, economic,
environmental, spiritual, and functional status.
 Holistic 360 degree assessment
• This helps to gain a
complete picture of the
patient.
• For example, it may
uncover previously
undiagnosed cognitive
impairment, treatable
reasons for impaired
mobility, inappropriate
prescribing, or care needs
that have not been
addressed.
 Domain CGA

• By assessing each of these domains of health

 the full bio-psycho-social nature of the
individual’s problems can be identified.
• Some clinicians formalise this process by
the use of standardised scales and tools
• Using standardised scales can encourage
consistent practice, help to ensure safety
(e.g., pressure sore risk screening) and
enable detection of serial changes
• BUT, it is time consuming and
clinically constraining
GERIATRI 1. Hearing impairment
C 2. Vision impairment
ASSESSME 3. Functional decline
NT (GA)
4. Falls
BY THE
INDIVIDU 5. Urinary incontinence
AL 6. Cognitive impairment
CLINICIAN 7. Depression
8. Malnutrition
9. Spiritual, economic, and social
assessment.
GERIATRI
C • GA can provide substantial insight into the
comprehensive care of older persons, from those who
ASSESSME are healthy and high-functioning to those with
significant impairments and multiple comorbidities.
NT (GA)
• Functioning is the end result of the various efforts of the
BY THE geriatric approach to care.
INDIVIDU • Optimizing function necessitates integrating efforts on
AL several fronts.
CLINICIAN • It is helpful to think of functioning as an equation:
 1. Hearing Impairment Tools

• Hearing impairment affects up to one-third of persons

aged >65 years.
• Independently, it is associated with reduced cognitive and
physical function, and reduced social involvement.
• It is also often under-recognized and therefore
undertreated, and again often not selfreported by patients
Geriatric Assessment Tools. Sonja L. Rosen, MD and David B. Reuben, MD. Mt Sinai J Med 78:489–497, 2011.
The welch allyn audioscope 3
• The most accurate Screening is the Welch Allyn AudioScope 3
• Patients fail the screen if they are unable to hear either the 1000- or
2000-Hz frequency in both ears or both the 1000- and 2000-Hz
frequencies in one ear, indicating the need for formal audiometric
testing.
Whispered voice test

• by whispering 3-6 random words (numbers,

words, or letters)
• at a set distance (6, 8, 12, or 24 inches) from
the person’s ear
• and then asking the patient to repeat the
words.
• Patients fail the screen if they are unable to
repeat half of the whispered words correctly
Hearing Handicap Inventory for the Elderly Screening Version
 2. Visual
Impairment
• Four major eye diseases : cataract, age-related
macular degeneration, diabetic retinopathy, and
glaucoma.
• Most older persons have presbyopia and require
corrective lenses.
• Visual impairment has been associated with increased
risk of falls, functional and cognitive decline, immobility,
and depression.
• The standard method of screening for problems with visual
acuity is the Snellen eye chart
• Unable to read letters on the 20/40 line with their
eyeglasses on, and should then be referred for further
evaluation by an ophthalmologist
TOOLS
Snellen’s Visual Acuity Chart
(2 and 6 meters)
Portable Eye Examination Kit
(PEEK)
Vision Functioning
Questionnaire (VFQ 25)
Activities of Daily Vision
Scale
Cut off score 90 points
14-ITEM VISUAL
FUNCTIONING INDEX (VF-
14)
Sensitivity Specificity
85% for distant 96% and 84% for
vision and 100% for distant and near
near vision vision
85% 98% Time: 70-80 seconds
12,2% 98,7% six items: watch TV, walk outdoors, read
newspapers and books, read telephone book,
engage in hobby, and manage household.
Score: 0-1
• correlation between visual loss and ADVS score,
was -0.37 (P < 0.001)
• useful tool to assess fall risk in older adults
with vision impairment, especially in those
persons with glaucoma, diabetic retinopathy,
and/or cataracts
weakly correlated with visual acuity in the • 14 item
better eye (VA 20/40) (r 0.27), • Score 0-4.
more strongly correlated with the patients’ • SCORE: Total score x
selfassessment of the overall trouble that 25
they were having with their vision (r 0.45)
and their overall satisfaction with their
current vision (r 0.34).
 Activity of Daily Vision
Scale
Cut off: 90
point

Subscale:
 VF-14

Scoring
• An item is not included in scoring if the person does
not do the activity for some reason other than their
vision.
• Scores on all activities that the person performed or
did not perform because of vision were then
averaged, yielding a value from 0 to 4.
• This value was multiplied by 25, giving a final score
from 0 to 100.
• a score of 100 indicates able to do all applicable
activities
• a score of 0 indicates unable to do all applicable
activities because of vision
 3. Functional Performance
Functional status can be assessed at three levels:
1. Basic activities of daily living (BADLs) :
bathing, dressing, toileting, continence,
grooming, feeding, and transferring.
2. Onstrumental or intermediate activities of daily living
(IADLs): refer to the ability to maintain an independent
household (shopping for groceries, driving or using public
transportation, using the telephone, meal preparation,
housework, home repair, laundry, taking medications, and
handling finances)
3. Advanced activities of daily living (AADLs) : to
fulfill societal, community, and family roles as well
as participate in recreational or occupational tasks.
 4. Cognitive impairment

• Detection of cognitive impairments early can identify treatable

conditions, such as ischemic brain disease, when risk factors can be
then better controlled, helping to prevent progression of disease.
• Detection of Alzheimer’s disease can lead to appropriate
pharmacologic treatment and improvements in patient safety by
garnering appropriate resources to assist with ADLs and IADLs.
• Early detection may also help facilitate long-term planning, including
identifying preferences for care and sources of financial and caregiver
support that will be important as the disease progresses.
 Modified Mini-Mental State
(MMMS, or 3MS)

• same items as the MMSE from which it was derived, but

includes four additional items,
• long term memory (recall of date and place of birth),
• verbal fluency (naming animals),
• abstract thinking
• the recall of the three words an additional time
 5. Malnutrition
• The term ‘‘malnutrition’’ has been used to refer to a wide
spectrum of deficiencies (eg, proteinenergy, vitamins) and
excesses (eg, obesity, hypervitaminosis)
• Weight loss has commonly been used to define
undernutrition and also predicts increased mortality.
• Measuring albumin and prealbumin, though not a specific indicator
of malnutrition, can also be helpful in assessing prognosis.
• Albumin is also affected by inflammatory states related to
concomitant illness, stress, and traumatic or surgical conditions.
 Sensitivity specificity

Mini Nutritional <70% >70%

Assessment- Short

Form (MNA-SF),

Mini Nutritional 90% 87%

Assessment (MNA)

Malnutrition 90% 73% Dibandingkan

Universal Screening dengan MNA

Tool (MUST)
 6. Urinary incontinence
• Common, especially among older women
• Urinary incontinence has been associated with depressive symptoms in older adults.
Moreover, effective treatments are available for incontinence. As a result, screening
for urinary incontinence has increasingly been recognized as an indicator of quality of
care.
• Urinary incontinence is associated with a low quality of life in adults, especially
women.
• Although urinary incontinence is not a lifethreatening problem, the symptoms of
incontinence can cause considerable impairment, leading to a reduced quality of life
• Screening : Asking two questions can screen for incontinence: (1) “In the last year, have
you ever lost your urine and gotten wet?” and if so, (2) “Have you lost urine on at least
six separate days?”
 Urinary Incontinence
2. The 3IQ questionnaire to distinguish
between urinary stress and urge incontinence
in primary care settings

This questionnaire has been validated in studies that show it to be reasonably accurate in categorizing
urinary incontinence in middle-aged to older women.20 It has a sensitivity of 0.86 and 0.75, and a
specificity of 0.60 and 0.77, for cla ssifying stress and urge incontinence, respectively
 positive negative sensitivity specificity
likelihood likelihood
“Do you have a strong and sudden urge to ratio ratio
0.48 Urge continence
4.2 void that makes you leak before reaching
the toilet?”
“Is your incontinence caused by coughing, 0.39 stress incontinence
2.2 sneezing, lifting, walking, or running?”
Incontinence Questionnaire Urinary 88.3% 65.9% 92.1% 55.6%
Incontinence – Short Form. (ICIQ-UI
SF Domain Short form
Tools
Incontinence Impact Purposeof urinary
impact • physical activity, IIQ-7
Questionnaire (IIQ) incontinence on activities and • social relationships
emotions Self-administered questions • Travel
• Emotional health
Urogenital meant to complement the • symptoms related to stress UDI-6
Distress Inventory IIQ assess the degree to urinary incontinence
(UDI) which symptoms associated • Detrusor overactivity
19 questions with incontinence ar • bladder outlet obstruction
troubling.
 7. Mental Health
• Depression in older people has a prevalence of 5-10 per cent in those aged over
65, but is frequently under-recognised.
• It is associated with increased risk of dementia, medical comorbidities,
mortality, and significant impact on quality of life
• Older people under-report symptoms of depression, and may attribute them to the
effects of ageing. Somatic symptoms are more common than in younger people
with depression.
• However, people are often embarrassed to admit these things in front of others
and it is usually more fruitful to ask these questions during the physical
examination when perhaps family and carers are not in the room.
• Older adults with depression are at higher risk of completed suicide than younger people, so specific
enquiry into suicidal thoughts should always be made. Risk factors for suicide in older people include:
• Older age, male gender.
• Social isolation and or bereavement.
• History of attempts and or evidence of planning.
• Chronic painful illness or disability.
• Drug or alcohol use

Simple screening questions which might help include:

◦ During the last month, have you often been bothered by feeling down, depressed or hopeless?
◦ Do you ever sit and cry for no reason?
◦ Do you worry about the future and what it might hold?
◦ During the last month, have you often been bothered by having little interest or pleasure in doing
things?
◦ Do you feel lonely?
PHQ-
9
 Anxiety

• The detection of anxiety in older adults is also complicated by the high frequency of
medical disorders in this age group.
• Prevalence: 80% and 86% of adults aged 65 and older have at least one significant
medical condition
• Symptoms:muscle tension, hypervigilance, and difficulties related to sleep) to a medical
problem than to anxiety
• many symptoms of anxiety may be overlooked or wrongly attributed to a medical illness.
• Many physical conditions :
• cardiovascular disease
• respiratory disease
• Hyperthyroidism
• pulmonary difficulties
• Additionally, anxiety symptoms can occur as side effects of medication that is being used
to treat a medical condition
 ANXIETY CORELATION (DSM) RELIABILITY
Beck Anxiety
Inventory
• 21-item self-report
• four-point scale
TOOLS
• 0–9 (normal anxiety)
• 10–18 (mild to moderate
relatively high (r:0.56–
0.65)
adequate
(r:0.64–0.75)
• to measure the severity of anxiety)
anxiety • 19–29 (moderate to
• to distinguish anxiety severe anxiety),
from depression • 30–63 (severe
anxiety
Penn State • 16-item self-report • Score 16-80 Moderate to high Moderate to high
Worry • five-point scale • cut-off score of 50 r:0.54–0.78 (r:0.54–0.78)
Questionnaire • to evaluate pathological
worry
Geriatric 20–50 min. eight syndrome high (r:0.76–0.78) Inconsistent
Mental Status Score: 0 (no symptoms) to 5 clusters: organicity, R:0.49 to 0.75
Examination (very severely affected). schizophrenia and related
paranoia,
mania, depression,
hypochondrias, phobias,
and
obsessional and anxiety
neurosis
 8. Risk of Falls
• Falls are 2nd only to traffic accidents as the leading cause of injury related deaths among
the elderly worldwide

• Falls are major cause of both death and injury in people over 65 years of age
• WHO: 28–35% of the population over age 65 fall each year agerelated increase in fall risk
• Falls cause 20–30% of mild-to-severe injuries, and >50% of those involve treatment
requiring hospitalization

• Falls can limit daily activities and induce post-fall syndromes, such as dependence, loss of
autonomy, immobilization, and depression

• Falls can occur in any setting; hence, fall prevention should start by considering
environmental conditions and factoring them into the fall risk assessment
• Assessment tools for fall risks should accurately discriminate fallers from non-fallers in
practice  fall prevention strategy
The functional goals of the balance system includes:
1.Maintenance of a specific postural alignment, such as sitting or
standing,
2.Facilitation of voluntary movement, such as the movement
transitions between postures, and
3.Reactions that recover equilibrium to external disturbances, such
as a trip, slip, or push.
Tools

•The fall risk assessment tools currently used

for the elderly did not show sufficiently high
predictive validity for differentiating high and
low fall risks.
•The Berg Balance scale and Mobility
Interaction Fall chart showed stable and high
specificity
•We concluded that rather than a single
measure, two assessment tools used together
would better evaluate the characteristics of
falls by the elderly that can occur due to a
multitude of factors and maximize the
advantages of each for predicting the
occurrence of falls.
 9. Assessment of Social Support

• For very frail older persons, the availability of assistance from family and friends is
frequently the determining factor of whether a functionally dependent older person
remains at home or is institutionalized.
• If dependency is noted during functional assessment, then the clinician should
inquire as to who provides help for specific BADL and IADL functions and whether
these persons are paid or voluntary help
• Even in healthier older persons, it is often valuable to raise the
question of who would be available to help if the patient
becomes ill
 10. Economic Assessment
The patient’s income can also be assessed and eligibility for state or
local benefits (e.g., In Home Supportive Services through Medicaid) to
provide services for the functionally impaired can be determined

11. Environmental Assessment

Environmental assessment encompasses two dimensions:
1. the safety of the home environment
2. the adequacy of the patient’s access to needed personal and
medical services.
 13. Functional Decline
•Functional limitations  defined as a restriction or lack of ability to perform an action)
lie proximal on the pathway to disability
•Performance measures objectively assess these limitations  Low scores on these tests
may indicate a preclinical precursor state prior to the onset of disability.
•For older adults with chronic disease, with little or no disability, physical performance
measures can signal early functional decline even before it is reported by the patient or
noticed by the doctor.
•It is at these early stages of decline that interventions are valuable to prevent
established disability.
•Measuring disability and functional limitations, using performance measures as well as
self- reported measures, all add to our understanding of an older adult’s function.
TERIMAKASIH