Challenging Patient: Older patient with multiple co-morbidities
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Challenging Patient: Older patient with multiple co-morbidities Comprehensive Geriatric Assessment and the Patient-Centered Clinical Method
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Challenging Patient: Older patient with multiple co-morbidities. Comprehensive Geriatric Assessment and the Patient-Centered Clinical Method. Objectives. Describe the effectiveness of CGA Select and use an assessment tool Describe interventions to address functional impairment - PowerPoint PPT Presentation
Transcript of Challenging Patient: Older patient with multiple co-morbidities
Challenging Patient:Older patient with multiple co-
morbiditiesComprehensive Geriatric Assessment and the
Patient-Centered Clinical Method
ObjectivesDescribe the effectiveness of CGASelect and use an assessment toolDescribe interventions to address functional
impairmentConsider patient and family goals when
developing management plan
Comprehensive Geriatric Assessment: a Meta-analysis of Controlled Trials
Mortality 0.86 (0.75-0.98)Living at home 1.26 (1.1-1.44)Hospital admissions 0.88 (0.79-0.98)Physical Fxn better 1.10 (0.89-1.36)Cognitive Fxn 1.41 (1.12-1.77)
Stuck et al, Lancet, 1993:23;1032-1036
What is CGA? a multidisciplinary evaluation in which the multiple
problems of older persons are uncovered, described, and explained, if possible, and in which the resources and strengths of the person are catalogued, need for services assessed, and a coordinated care plan developed to focus interventions on the person’s problems.
The Black Box of CGA
What happens in the black box?Multidisciplinary teamThorough medical evaluation
Medical conditionsMedication
Assess multiple functional domainsValidated instruments
What comes out of the box?General medical problems
Depression
Incontinence
Musculoskeletal problems
Hypertension
Functional impairment
Falls, vision and hearing
Patient-Centered Clinical Method
History
Physical
Lab
Feelings
Ideas
Function
Expectations
1 – Exploring both disease and illness experience Cues and prompts
2 – Understanding the whole person
Disease
Illness
Person
Proximal Context
Distal Context3 – Finding Common Ground Problems Goals Roles
Mutual decisions
4 – Incorporating prevention and health promotion
6 – Being realistic
5 – Enhancing the patient-physician relationship
Patient-Centered Medicine: Transforming the Clinical Method, Stewart, M. et al, 2003
Make it work in practiceThe right patientThe right tools, administered the right wayThe right peopleCommon, prioritized goalsFollow-up
Targeting
Target - at risk for declineAge ≥ 75Fxn: ≥ 1 ADL def; falls; poor healthUtil: ≥ 1 hosp admission; ≥ 6 visits; ≥ 5
prescription medsMed: CAD, DM, Depression, UISocial: Absence of a caregiverSelf-reported task modification
Domains of function
The Right Instrument
Characteristics of Functional Assessment InstrumentsDiagnostic characteristics
ValiditySensitivity (NPV)/Specificity (PPV)Ceiling/Floor
ReliabilityEase of administration
Who provides data? Self-report Caregiver report Physical performance test
Sensitivity to change
The right people
