www.drjayeshpatidar.blogspot.com 1

Geriatric Assessment & Care Managers

A Care Plan is an outcome of a geriatric assessment, and is essentially an action plan for

future care. A Care Plan lists all identified problems, suggests specific interventions or

actions required and makes specific recommendations regarding resources needed to

provide the necessary support services.

In This Article:

What is geriatric assessment?

When is a geriatric assessment needed

Who performs a geriatric assessment?

Geriatric care managers

Finding a geriatric care manager

Costs of geriatric care management

References and resources

What is geriatric assessment?

A geriatric assessment is a comprehensive evaluation designed to optimize an older

person's ability to enjoy good health, improve their overall quality of life, reduce the need

for hospitalization and/or institutionalization, and enable them to live independently for

as long as possible.

An assessment consists of the following steps:

1. An examination of the older person's current status in terms of:

o Their physical, mental, and psycho-social health

o Their ability to function well and to independently perform the basic

activities of daily living such as dressing, bathing meal preparation,

medication management, etc.

www.drjayeshpatidar.blogspot.com 2

o Their living arrangements, their social network, and their access to support

services.

2. An identification of current problems or anticipated future problems in any of

these areas.

3. The development of a comprehensive "Care Plan" which addresses all problems

identified, suggests specific interventions or actions required, and makes specific

recommendations regarding resources needed to provide the necessary support

services.

4. The management of a successful linkage between these resources and the older

person and that person's family so that provision of the necessary services is

assured.

5. An ongoing monitoring of the extent to which this linkage has, or has not,

addressed the problems identified, and the modification of the Care Plan as

needed.

When is a geriatric assessment needed?

A request for a geriatric assessment would be appropriate when there are persistent or

intermittent symptoms such as:

memory loss,

confusion,

or other signs of possible dementia.

Often, what looks like Alzheimer's or dementia can be the result of medication

interactions or other medical or psychiatric problems. Because of the thoroughness of the

geriatric assessment, it is one of the best ways to determine what the actual problem and

cause is or is not.

Who performs a geriatric assessment?

A geriatric assessment can be done in many different settings such as:

a hospital,

a nursing home,

an outpatient clinic,

a physician's office or

the patient's home.

It is an assessment that is comprehensive in scope, involving a complete review of the

current status of the older person in all of its complex dimensions, and because it is so

comprehensive, it can only be successfully conducted by a multi-disciplinary team of

experts. This team might include:

physicians,

ancillary personnel,

www.drjayeshpatidar.blogspot.com 3

social workers,

physical and/or occupational therapists,

dieticians, psychologists,

pharmacists, and

geriatric nurse practitioners.

You can request a referral for a geriatric assessment from a primary care physician. Also,

check with any large hospital or university to see whether they have a geriatric

assessment unit.

Geriatric care managers

A geriatric care manager (GCM) is a professional with specialized knowledge and

expertise in senior care issues. Ideally, a GCM holds an advanced degree in gerontology,

social work, psychology, nursing, or a related health and human services field.

Sometimes called case managers, elder care managers, service coordinators or care

coordinators, GCMs are individuals who evaluate your situation, identify solutions, and

work with you to design a plan for maximizing your elder's independence and well being.

Geriatric care management usually involves an in-depth assessment, developing a care

plan, arranging for services, and following up or monitoring care. While you aren't

obligated to implement any part of the suggested care plan, geriatric care managers often

suggest potential alternatives you might not have considered, due to their experience and

familiarity with community resources. They can also make sure your loved one receives

the best possible care and any benefits to which they are entitled.

Help provided by geriatric care managers

Geriatric care managers facilitate the care selection process for family members who live

at a distance from their elderly relatives, as well as for those who live nearby but do not

know how to tap into the appropriate local services.

You can hire a care manager for a single, specific task, such as helping you find a daily

caregiver, or to oversee the entire caregiving process. Geriatric care managers can help

families or seniors who are:

new to elder care or uncomfortable with elder care decision-making;

having difficulty with any aspect of elder care;

faced with a sudden decision or major change, such as a health crisis or a change

of residence;

dealing with a complex situation such as a psychiatric, cognitive, health, legal, or

social issue.

In addition to helping seniors and their families directly, geriatric care managers can act

as your informed connection with a range of other professionals who are part of your

elder care network, including any of the following service providers:

www.drjayeshpatidar.blogspot.com 4

Attorneys or trust officers. A care manager can serve as both elder advocate and

intermediary with financial and legal advisors. The GCM is often a good source

of referrals if a family needs services from these professionals.

Physicians. The GCM is an ideal liaison between doctors and other health

professionals, and the elder patient and family members.

Social workers. It is useful for hospital and nursing home social workers and

discharge planners to know that their senior patient will have someone to

coordinate their care and assist them on a long-term basis.

Home care companies. The GCM will know local agencies and be able to

explain options, costs, and oversight of home care workers. The care manager can

also assist in dealing with patients' social issues, help link to other community

resources, and suggest possible placement options.

Residential facilities. The GCM can help identify types of care facilities and

assist you in selecting an appropriate one for your situation. The GCM may also

be able to streamline the transition into or out of a senior community, for both the

elderly resident, family members and staff.

Finding a geriatric care manager

In addition to the many References and resources available, a good place to start your

search for a geriatric care manager is with your family physician. Other sources for

referrals include:

your local Area Agency on Aging (call 1-800-677-1116 for the AAA in your

area)

local hospitals and health maintenance organizations

senior or family service organizations

senior centers

religious affiliations including churches and synagogues

Yellow Page listings for Senior Citizens' Services, Care Management, Home

Care, Home Health Services and similar subject areas

Medicaid offices

private care management companies

While geriatric care managers are frequently licensed by the state within their respective

fields of expertise, there are no state or national regulations for professional care

managers per se. For this reason, anyone can use the title case or care manager.

Membership in a professional organization and/or certification in care management are

good indicators of appropriate background. The National Association of Professional

Geriatric Care Managers recognizes the following designations for a "Certified Care

Manager": CMC, CCM, C-ASWCM and C-SWCM. Each of these requires testing and

continuing education.

When interviewing potential geriatric care managers, the NAPGCM suggests asking:

Are you a member of a professional care or case management association?

www.drjayeshpatidar.blogspot.com 5

Are you certified as a care manager? Do you hold other professional licenses or

certifications?

How long have you been providing care management services?

Are you available for emergencies?

Does your company also provide home care services?

How will you communicate information to me?

Can you provide me with references from past clients?

Costs of geriatric care management

Private geriatric care managers' fees can range from $50 - $200 per hour, depending on

where you live and what services you need. You may also be charged an intake fee of

$50 - $300 for the initial visit, which is when the in-depth assessment takes place.

While this may seem costly, bear in mind that a GCM will likely save you money in the

long run, by assessing your precise needs and helping you choose the specific services

that will best serve you now. In addition, most people require geriatric care management

only intermittently once support services are in place. Following the initial assessment,

your GCM will help your family carefully estimate the ongoing cost of service delivery.

Although geriatric care management fees are not covered by Medicare or Medicaid, some

employers, insurance companies, health plans and financial service providers are

beginning to subsidize or cover these services for their members and clients. Long-term

care insurance is most likely to include care management.

If you are unable to afford a private care manager, there are other options. Low-cost or

no-cost geriatric care management is often available through a community agency, senior

services organization or other non-profit agencies; your local Area Agency on Aging (call

1-800-677-1116 for the AAA in your area) will be able to refer you to a city, county or

agency source.

In addition, most states offer a Medicaid waiver program that provides geriatric care

management and in-home services for individuals 65 and older, who are eligible for both

nursing home placement and Medicaid. In California, this program is available through

The Multi-Purpose Senior Services Program (MSSP) throughout the state.

References and resources about geriatric assessment

Other related links

The FHA Physician Referral Service – Provides an online form for you to request a list of

geriatric specialists in your area. Includes a brief listing of additional resources to assist

you in locating a doctor nearby. (American Geriatrics Society)

www.drjayeshpatidar.blogspot.com 6

What Is Geriatrics? – Defines geriatrics and the role of a geriatrician. Describes the team

approach and who should see a geriatrician. (American Geriatrics Society's Foundation

for Health in Aging)

My Parents - How Do I Know If They Need Help? – Provides information on the

importance of geriatric assessments for older parents. (AARP)

Talking With Your Doctor: A Guide for Older People – A helpful guide for preparing for

your appointment. Includes tips on questions to ask, preparing a health history, and tips

for good communication with your doctors. (National Institute on Aging)

FAQ: What Does a Geriatric Care Manager Do? – A thorough description of geriatric

care managers, why one uses them, and how to find one in your area. (Geriatric Care

Managers of New England)

A multidimensional process designed to assess an elderly person's functional ability,

physical health, cognitive and mental health, and socioenvironmental situation.

Comprehensive geriatric assessment differs from a standard medical evaluation by

including nonmedical domains, by emphasizing functional ability and quality of life, and,

often, by relying on interdisciplinary teams. This assessment aids in the diagnosis of

health-related problems, development of plans for treatment and follow-up, coordination

of care, determination of the need for and the site of long-term care, and optimal use of

health care resources.

Geriatric assessment programs vary widely in purpose, comprehensiveness, staffing,

organization, and structural and functional components. Most attempt to target their

services to high-risk elderly persons and to couple their assessment results with sustained

individually tailored interventions (eg, rehabilitation, education, counseling, supportive

services).

Comprehensive geriatric assessment of frail or chronically ill patients can improve their

care and clinical outcomes. The possible benefits include greater diagnostic accuracy,

improved functional and mental status, reduced mortality, decreased use of nursing homes

and acute care hospitals, and greater satisfaction with care. However, the cost of

comprehensive geriatric assessment programs has limited their use. Although some cost-

effectiveness evaluations suggest that these programs can save money, few programs

operate in integrated care systems that can track these savings. Wide use of comprehensive

geriatric assessment programs has thus been slow to develop. An alternative approach is to

conduct less extensive assessments in primary care offices or emergency departments.

An assessment instrument designed to help primary care physicians, nurses, and other

health care practitioners perform practical, efficient assessment is shown in Table 4-1. It

includes elements from an instrument recommended by the American College of

Physicians and from instruments validated and field-tested in randomized clinical trials.

www.drjayeshpatidar.blogspot.com 7

To identify elderly persons who might benefit from assessment (in a special

comprehensive geriatric assessment unit or in a primary care setting), some health care

organizations mail multidimensional self-administered health questionnaires to elderly

populations. Responses are scored according to defined algorithms, and reports of high-

risk conditions and behaviors are sent to the patients and their primary care physicians to

stimulate more detailed follow-up evaluation and treatment. Other organizations identify

candidates for assessment by interviewing elderly persons in their homes or meeting places

(eg, meal sites, senior centers, places of worship). Family members who are concerned

about an elderly relative's health or functional abilities may also arrange referrals for

geriatric assessment.

THE 10 MINUTE GERIATRIC

ASSESSMENT

Fredrick T. Sherman, MD, MSc

Medical Director

SENIOR HEALTH PARTNERS

Mount Sinai School of Medicine

www.geri.com

Comprehensive Geriatric Assessment American Geriatrics Society (AGS)

COMPREHENSIVE GERIATRIC ASSESSMENT POSITION STATEMENT

*Last Updated August 26, 2005*

BACKGROUND

Comprehensive geriatric assessment has been defined by the 1987 National Institutes of

Health Consensus Conference on Geriatric Assessment Methods for Clinical Decision-

making as 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." Research

www.drjayeshpatidar.blogspot.com 8

evaluating comprehensive geriatric assessment (CGA) demonstrates its ability to improve

the health status and quality of life of frail older adults across the spectrum of health care

settings.

CGA is a necessary tool to minimize disability and loss of independence in frail elderly

patients. Aging is a process that steadily reduces physiologic reserve and results in a

diminished ability to compensate for the toll of illness. Illnesses accumulate with age,

increasing in both severity and number. This double burden of physiologic decline and

disease is associated with excess morbidity and resultant disability, i.e., difficulty in

performing simple physical and mental tasks necessary for daily life. CGA is an

intervention that seeks to identify and remediate the causes and effects of disability.

When remediation is not possible, CGA seeks to slow functional decline and bolster

independence by mobilizing available medical, psychological and social resources.

One of the goals of a responsive health care system is to promote the well-being of those

suffering from the effects of disability and/or chronic illness. Randomized trials of CGA,

applied across multiple health service settings, show it to be a cost-effective intervention

that improves quality of life, quality of health, and quality of social care. Its benefits have

been most robustly demonstrated when applied in a hospital or rehabilitation unit, but its

value is also evident when used in the following settings: after hospital discharge, as an

element of outpatient consultation, in home assessment services, and in continuity care.

Despite these benefits, the application of CGA remains underused in the United States

and its use is limited primarily to academic health centers and Veterans Administration

hospitals that recognize its contribution to quality health care for older adults.

POSITIONS

1. Comprehensive geriatric assessment has demonstrated usefulness in improving

the health status of frail, older patients. Therefore, elements of CGA should be

incorporated into the care provided to these elderly individuals.

Rationale: Not all older persons who might benefit from comprehensive geriatric

assessment will receive specialized geriatric asssesment services. Practicing

physicians should be encouraged to apply the elements of geriatric assessment in

the care of older patients, including multidisciplinary teamwork, assessment of

function, and psychosocial assessment. Physicians' and other health professionals'

organizations could appropriately take a leadership role in the dissemination of

this assessment methodology.

2. CGA is most effective when targeted toward older adults who are at risk for

functional decline (physical or mental), hospitalization or nursing home

placement.

Rationale: A targeted population, the frail elderly, is the most likely to benefit

from CGA. Targeting criteria used in successful trials of CGA suggest that

persons who have impairments in basic or instrumental activities of daily living,

or suffer from a geriatric syndrome (falls, urinary or fecal incontinence, dementia,

www.drjayeshpatidar.blogspot.com 9

depression, delirium, or weight loss), or whose health care utilization patterns

indicate a high risk of subsequent hospitalization or nursing home placement are

the most likely to benefit from CGA.

3. Comprehensive geriatric assessment should be an integral part of the curriculum

for all medical and health professional training programs.

Rationale: Routine CGA examines, at the very least, a patient's mobility,

continence, mental status, nutrition, medications, and personal, family, and

community resources. It involves all disciplines responsible for providing care, as

well as the patient and family, in developing an appropriate care plan.

Comprehensive geriatric assessment is an effective tool for teaching the

integration of the biological, psychological, social, and environmental aspects of

health care, while recognizing the geriatrician's special area of expertise.

4. Medicare and other insurers should recognize as a reimbursable service or

procedure: 1) comprehensive geriatric assessment of patients who are at risk for

functional decline (physical or mental), hospitalization or nursing home

placement, and 2) the support services required for effective application of CGA

Rationale: Comprehensive geriatric assessment requires an interdisciplinary team

to conduct medical, functional and psychosocial assessments, develop a written,

comprehensive plan of care, and coordinate the health care providers and family

members who are responsible for the execution of the plan of care. At the present

time, Medicare payment policy does not reimburse the work of some necessary

professionals (e.g., social work, dietician) in assessment and does not recognize

the work of team conferences. Few professionals can or will provide the service if

it is not adequately reimbursed. Insufficient reimbursement of CGA ultimately

restricts the access of frail, older persons to this effective intervention and

exacerbates the financial disincentives that aggravate our national shortage of

geriatricians.

REFERENCES

1. Boult C. Boult L. Morishita L. Smith SL. Kane RL. Outpatient geriatric

evaluation and management. J Am Geriatr Soc. 46(3):296-302, 1998 Mar.

2. Boult C. Boult LB. Morishita L. Dowd B. Kane RL. Urdangarin CF.A

randomized clinical trial of outpatient geriatric evaluation and management. J Am

Geriatr Soc. 49(4):351-9, 2001 Apr.

3. Boult C. Brummel-Smith K. Post-stroke rehabilitation guidelines. The Clinical

Practice Committee of the American Geriatrics Society. J Am Geriatr Soc.

45(7):881-3, 1997 Jul.

www.drjayeshpatidar.blogspot.com 10

4. Boult C. Pualwan TF. Fox PD. Pacala JT. Identification and assessment of high-

risk seniors. HMO Workgroup on Care Management. Am J Manage Care.

4(8):1137-46, 1998 Aug.

www.drjayeshpatidar.blogspot.com 11

Geriatric Assessment Methods for Clinical Decision Making National Institutes of Health

Consensus Development Conference Statement

October 19-21, 1987

This statement is more than five years old and is provided solely for historical

purposes. Due to the cumulative nature of medical research, new knowledge has

inevitably accumulated in this subject area in the time since the statement was

initially prepared. Thus some of the material is likely to be out of date, and at worst

simply wrong. For reliable, current information on this and other health topics, we

recommend consulting the National Institutes of Health's MedlinePlus

http://www.nlm.nih.gov/medlineplus/.

This statement was originally published as: Geriatric Assessment Methods for Clinical

Decision making. NIH Consens Statement 1987 Oct 19-21;6(13):1-21.

For making bibliographic reference to the statement in the electronic form displayed here,

it is recommended that the following format be used: Geriatric Assessment Methods for

Clinical Decision making. NIH Consens Statement Online 1987 Oct Online 19-21 [cited

year month day];6(13):1-21.

Introduction

The population of elderly persons in the developed nations is growing with extraordinary

rapidity. Although the majority enjoy good health, many older people suffer from

multiple illnesses and significant disability. Comprehensive assessment methodologies,

while not solely applicable to frail elderly persons, are believed to be particularly suited

to their situation. These individuals tend to exhibit great medical complexity and

vulnerability; have illnesses with atypical and obscure presentations; suffer major

cognitive, affective, and functional problems; are especially vulnerable to iatrogenesis;

are often socially isolated and economically deprived; and are at high risk for premature

or inappropriate institutionalization.

To deal with the exceedingly difficult health care issues posed by frail elderly persons,

health professionals need to collect, organize, and use a vast array of clinically relevant

information. This process, comprehensive geriatric assessment, is defined as a

www.drjayeshpatidar.blogspot.com 12

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.

Comprehensive geriatric assessment generally includes evaluation of the patient in

several domains, most commonly the physical, mental, social, economic, functional, and

environmental.

The term "functional" is used here in a narrow sense: It means the ability to function in

the arena of everyday living. The panel recognizes that the same word has been used in

the much broader sense of the whole range of functions we have listed just above. In

other words, some use "functional assessment" to mean what we have termed

"comprehensive geriatric assessment."

When applied to clinical decision making, comprehensive geriatric assessment involves

clinicians from the many health care professions who are necessarily involved in good

geriatric care. Comprehensive geriatric assessment is only one component of general

geriatric care. Appropriate geriatric care involves some level of assessment of the

multiple domains just cited, but comprehensive geriatric assessment tends to be applied

only to a subset of older persons who are frail and considered most likely to benefit (see

question 3). It has been suggested that a new form of comprehensive assessment could be

developed to evaluate physical fitness for purposes of monitoring health promotion and

disease prevention in well older persons and another form to guide the humane care of

irreversibly disabled and terminally ill older persons.

Between 1973 and 1987, reports have appeared on a significant number of true

experiments exploring the elements and effectiveness of various approaches to geriatric

assessment. The data from these studies, coupled with the growing numbers of frail

elderly individuals, the high cost of their health care, the intensity of their distress and

discomfort, and the great uncertainty as to the best route to wise clinical decision making,

led to the current conference. The National Institute on Aging and the Office of Medical

Applications of Research of the National Institutes of Health, in conjunction with the

National Institute of Mental Health, the Veterans Administration, and the Henry J. Kaiser

Family Foundation, convened the Consensus Development Conference on Geriatric

Assessment Methods for Clinical Decision making on October 19-21, 1987. After a day

and a half of presentations by experts in the field, a consensus panel including

methodologists and representatives of medicine, nursing, social work, and the public

considered the scientific evidence and developed answers to the following central

questions:

1. What are the goals, structure, processes, and elements of geriatric assessment for

clinical decision making?

2. What are the comparative merits of different methods in carrying out a geriatric

assessment?

www.drjayeshpatidar.blogspot.com 13

3. What is the evidence that a geriatric assessment is effective? If so, in what

settings, for whom, and for which outcomes?

4. Insofar as a geriatric assessment is effective, what linkages to clinical

management systems are required?

5. What are the priorities for future research in geriatric assessment?

Comprehensive geriatric assessment has been used for many nonclinical purposes,

including research, education, health policy, and administration. This report focuses only

on its use for clinical decision making.

What Are the Goals, Structure, Processes, and Elements of Geriatric Assessment for

Clinical Decision Making?

Goals

The goals of comprehensive geriatric assessment are: (1) to improve diagnostic accuracy,

(2) to guide the selection of interventions to restore or preserve health, (3) to recommend

an optimal environment for care, (4) to predict outcomes, and (5) to monitor clinical

change over time.

Structure

Comprehensive geriatric assessment may be done in many institutional settings,

including acute care, psychiatric, or rehabilitation hospitals and nursing homes, and in

ambulatory settings, including outpatient or freestanding clinics, the offices of primary

care physicians, or in the patient's home. It often has been applied to elderly persons at

critical transition points in their lives, including actual or threatened decline in health and

functional status, impending change in living environment, bereavement, or other unusual

stress.

Processes

Comprehensive geriatric assessment is initiated by a referral from one of a number of

sources (see question 4). In addition to the patient, the process often includes family

members and other important persons in the individual's environment. It is conducted by

a core team that consists, at a minimum, of a physician, nurse, and social worker, each

with special expertise in caring for older people. Frequently, a psychiatrist is a member of

the core team. The specific activities and contributions of each team member may vary

considerably, and flexibility in roles may facilitate the assessment process.

The assessment begins with a case-finding approach that utilizes screening instruments

and techniques. Based on these initial findings, a more detailed assessment is frequently

undertaken. This in-depth assessment often requires the participation of a number of

www.drjayeshpatidar.blogspot.com 14

other professions. These may include audiology, clinical psychology, dentistry, nutrition,

occupational therapy, optometry, pharmacy, physical therapy, podiatry, speech

pathology, and the clergy. Support from other medical disciplines, such as neurology,

ophthalmology, orthopedics, physiatry, surgery, and urology, is commonly needed.

Some aspects of geriatric assessment may be provided by self-rating scales completed by

the patient or caregivers. Such information may lead to different insights than those

obtained through external assessment performed by a member of the health care team.

Elements

Physical Health

A careful history is obtained from the patient and others with significant knowledge of

the patient. Special attention is directed to the use of prescription and nonprescription

medications and clues to the presence of malnutrition, falling, incontinence, and

immobility. Data are gathered on smoking, exercise, alcohol use, immunization status,

and sexual function. Also important is information regarding the patient's personal

strengths, values, perceived quality of life, acceptability of interventions, and expected

outcomes from his or her health care.

A physical examination is performed with emphasis on identification of specific diseases

or conditions for which curative, restorative, palliative, or preventive treatment may be

available. Special attention is directed toward visual or hearing impairment, nutritional

status, and conditions that may contribute to falling or difficulty in ambulation.

Laboratory tests and other diagnostic studies are obtained as indicated.

Mental Health

Cognitive, behavioral, and emotional status are evaluated. Detection of dementia,

delirium, and depression is particularly important. A range of assessment instruments is

available for these purposes. For some patients a detailed psychiatric interview, a

neurobehavior consultation, or comprehensive neuropsychological testing is indicated.

Social and Economic Status

Evaluating the social support network includes identifying present and potential

caregivers and assessing their competence, willingness to provide care, and acceptability

to the older person. This information may be obtained by questionnaires, structured

interviews, or other methods. The degree of caregiver stress and the caregiver's support

network also are considered.

Areas of special importance to the individual, such as cultural, ethnic, and spiritual

values, are noted. The individual's own assessment of the quality of life is recorded. The

clinician evaluates the economic resources of the elderly person, which often determine

access to medical and personal care and influence options for living arrangements.

www.drjayeshpatidar.blogspot.com 15

Functional Status

There are several components to a comprehensive assessment of an older person's ability

to function. Physical functioning usually is measured by the ability to accomplish basic

activities of daily living (ADL), including bathing, dressing, toileting, transferring,

continence, and feeding.

Other components of functional well-being are behavioral and social activities that

require a higher level of cognition and judgment than physical activities. These

instrumental activities of daily living (IADL) include preparation of meals, shopping,

light housework, financial management, medication management, use of transportation,

and use of the telephone.

Functional status (ADL and IADL) is probably most accurately evaluated by direct

observation of the patient by family or health professionals in the home or a simulated

homelike environment. However, surprisingly accurate information is also obtained by

standardized questionnaire or self-report.

Environmental Characteristics

Evaluating the patient's physical environment is essential. Home visits and questionnaires

are used to determine the safety, physical barriers, and layout of the home as well as

access to services, such as shopping, pharmacy, transportation, and recreation.

Development and Implementation of a Care Plan

Comprehensive geriatric assessment is a dynamic, ongoing process. After the initial

assessment, the team generates a comprehensive list of the patient's needs and strengths,

usually at a multidisciplinary case conference. Recommendations are integrated into an

individualized plan of interventions and desired outcomes. The preferences of the patient

and family must be especially carefully considered at this stage in the process. If the

assessment takes place in an inpatient facility, treatment and rehabilitation are often

initiated in that facility, sometimes directly by members of the team on a specialized unit.

In consultative models, the team's recommendations are transmitted to the appropriate

primary care providers. Regardless of the site of assessment or the primary responsibility

for implementation of the recommended regimen, periodic reassessment and appropriate

modification of the care plan are central elements of the process of comprehensive

geriatric assessment.

What Are the Comparative Merits of Different Methods in Carrying Out a

Geriatric Assessment?

Many assessment methods for specific domains have undergone rigorous validation, and

the criteria for acceptance of a given method have been carefully defined. However, in

domains in which there are multiple validated instruments to measure the same function,

www.drjayeshpatidar.blogspot.com 16

there have not yet been studies that directly compare one method to another. As a result,

identification of the single best instrument in each domain is not possible at this time.

One of the first steps in establishing a program of geriatric assessment is deciding upon a

standardized approach to data collection. Before choosing from among the different

methods, clinicians should consider some of the following issues.

In the context of comprehensive geriatric assessment, there is a role for both structured

and unstructured methods of data gathering. There are several merits of a structured

approach. Precision, reproducibility, and freedom from bias are enhanced by using

standardized validated questions and requiring the respondent to choose from a limited

number of answers. The task of data collection is more easily delegated if the format is

standardized. Standardized data collection methods help in clinical decision making and

prospective evaluation of the efficacy of interventions. On the other hand, merits of

unstructured methods include flexibility of the testing procedure, ability to probe

problems in detail, and the opportunity for synthesis of findings to develop a global

impression.

A number of assessment instruments have been shown individually to have good

reliability and validity. A reliable instrument is internally consistent and provides the

same evaluation of the patient when used by different raters. A valid instrument measures

correctly the domain being investigated. In addition to quantitatively measured validity

and reliability, an instrument should have face validity (i.e., on the "face of it" the

instrument appears to measure the domain correctly). Although some characteristics of

patients who will benefit from a given type of assessment have been identified, there are

no validated instruments for predicting benefit.

One approach to developing a comprehensive geriatric assessment program is to select

one of several multidimensional instruments designed to address all major domains of

geriatric assessment. Alternatively, specific assessment instruments developed for each

domain can be combined to accomplish a comprehensive assessment. There is no

evidence that either approach is superior to the other.

Desirable characteristics of instruments for case finding are efficiency, simplicity,

flexibility for use under a variety of circumstances, and portability. Case-finding requires

less sophistication from the examiner than in-depth assessment and is relatively

inexpensive. There are reliable and valid instruments with which to assess mental

function, socioeconomic status, and ADL. Each instrument has a specific range of

usefulness. For example, assessment of ADL reliably detects advanced degrees of

functional impairment but is quite unlikely to detect minimal departures from normalcy.

In-depth geriatric assessment methods need to have high predictive value, detect small

changes in function, identify potentially remediable problems, and efficiently predict

patient outcomes. Special expertise is often required to carry out an in-depth assessment.

Three additional issues should be addressed. First, in-depth assessments (and consequent

interventions) must take patients' values into account. Second, comprehensive assessment

www.drjayeshpatidar.blogspot.com 17

methods should accurately reflect change in patient status over time. Most existing

methods do not meet this need. Finally, while it is possible to educate a variety of health

care professionals to carry out various aspects of comprehensive assessment, experience

and leadership are required in the individual or individuals responsible for supervising the

assessment effort.

What Is the Evidence That a Geriatric Assessment Is Effective? If So, in What

Settings, for Whom, and for Which Outcomes?

Accumulated evidence indicates with moderate-to-high confidence that comprehensive

geriatric assessment is effective when coupled with ongoing implementation of the

resulting care plan.

The settings in which effectiveness has been convincingly demonstrated are the

combined geriatric assessment and rehabilitation unit and the inpatient geriatric

assessment unit. There is less consistent evidence regarding the effectiveness of

comprehensive geriatric assessment in the home, ambulatory setting, and the hospital

inpatient consultation service.

As practiced, comprehensive geriatric assessment has been demonstrated to be effective

for a variety of desirable outcomes. Studies to test effectiveness have varied in design

from descriptive (before versus after) to match control to the most persuasive form,

randomized controlled trials.

Outcomes favorably affected by comprehensive geriatric assessment, as demonstrated by

randomized controlled trials, have included improved diagnostic accuracy, prolonged

survival, reduced annual medical care costs, reduced use of acute hospitals, and reduced

nursing home use. These have been most consistently demonstrated. Less consistently

reported benefits include increased use of health and social services delivered in the

home, reduced medications, and improved placement location, affect and cognition, and

functional status. Other outcomes of great importance (e.g., quality of life) have not been

studied adequately.

Two aspects of comprehensive geriatric assessment appear to be of central importance.

The first of these is targeting of the process to those persons most likely to benefit, a

feature of most successful programs and one strongly endorsed by experienced program

leaders. In the inpatient setting, targeting has focused on patients over age 75 and those

with potentially reversible disabilities. This target group may account for as much as 10

to 25 percent of hospitalized elderly patients. Most studies demonstrating effectiveness

have excluded groups whom the investigators thought least likely to benefit, notably

persons who are fully independent and those with end-stage disease or disability. Several

programs have focused on elderly persons at points of transition or instability, as cited

under question 1.

www.drjayeshpatidar.blogspot.com 18

The role of targeting in comprehensive geriatric assessment conducted outside the

hospital setting is less clear. Certain U.S. studies have failed to demonstrate favorable

outcomes in ambulatory settings. This result may be attributable to ineffective targeting.

However, two European studies of randomly selected, community-dwelling persons

reported efficacy of comprehensive geriatric assessment without targeting other than for

advanced age, suggesting the possibility of expanding the use of these techniques to a

broader population in this country.

The second important aspect of comprehensive geriatric assessment appears to be the link

between assessment and followup services (also discussed under question 4). Successful

programs have been able to assure adoption of treatment recommendations reached

during the initial assessment. In some programs, the assessment team has assumed direct

control over treatment of the patients, while in others the followup has involved active

and ongoing consultation and communication with primary care providers. The failure to

provide sufficient linkage between assessment and followup may provide another

explanation for negative results reported in certain studies. In addition, these negative

results may be due to an insufficiently comprehensive assessment or intervention (e.g.,

failure to include medical evaluation) or to the use of instruments insensitive to changes

that actually may have occurred.

Additional elements of the comprehensive geriatric assessment to which effectiveness has

been attributed by developers of successful programs deserve attention. Such elements

include focus upon content areas in which geriatric expertise is acknowledged:

malnutrition, mental impairment, immobility, iatrogenesis (notably polypharmacy),

impaired homeostasis, and incontinence. Furthermore, the effectiveness of the

comprehensive geriatric assessment appears to be more than the sum of its parts, perhaps

because of the integrative nature of the process and the multidisciplinary discussion that

translates the information gathered into a rational plan of care. Finally, it has also been

suggested that the effectiveness of comprehensive geriatric assessment is at least partly

attributable to the enthusiasm and caring attitude of those who have developed these

programs.

Insofar as a Geriatric Assessment Is Effective, What Linkages to Clinical

Management Systems Are Required?

Comprehensive geriatric assessment programs should not be viewed as operating

independently from other elements of the health care system. Geriatric assessment is a

dynamic process responsive to the changes in health status that occur over time.

Therefore, a method for assessing effectiveness of interventions over time and for

detecting new problems must be provided. A broad approach is needed to ensure that

community case-finding identifies the at-risk population and links comprehensive

geriatric assessment to subsequent provision of services.

In the absence of a community case-finding program, patients are referred for

comprehensive geriatric assessment from a variety of sources, most commonly relatives

www.drjayeshpatidar.blogspot.com 19

and community service agencies. Less common sources of referral are the patients

themselves, friends, and physicians. Health maintenance organizations and other

managed care organizations, as well as nursing homes, may be increasingly important

referral sources in the future.

Ongoing monitoring of the implementation of recommendations made during

comprehensive geriatric assessment is believed to be central to the success of the care

plan. The role of linkages to clinical management systems in the effectiveness of

comprehensive geriatric assessment has not been directly tested. However, continuing

personal contact of hospital geriatric assessment consultants with the patients and their

primary providers does appear to facilitate the implementation of recommendations. Case

management as a process to provide linkages is available in many communities, and its

role in ensuring followup of recommendations requires further investigation. Clearly, the

availability of a wide array of social services is a requirement for successful

implementation of a comprehensive geriatric care plan.

What Are the Priorities for Future Research in Geriatric Assessment?

Although past research on comprehensive geriatric assessment has provided much

valuable information, many questions remain unanswered. Existing studies have

demonstrated that effective services can be provided, but these services consist of

combinations of activities that have been selected on an empiric basis. Future research

can define more carefully which elements of these packages--perhaps all of them--

contribute importantly to achieving the observed results. Earlier studies have been site-

specific and have incompletely assessed the range of patients who might benefit from

these activities. Finally, important measurement problems persist. Thus, key future steps

in research include the following:

Conduct multicenter, randomized controlled trials of comprehensive geriatric

assessment, including both academic and nonacademic settings, addressing the

above-cited gaps in our knowledge.

Extend the use of randomized controlled trials of comprehensive geriatric

assessment to other outcomes, particularly quality of life, effect on family, and

cost-effectiveness.

Extend the use of randomized controlled trials of comprehensive geriatric

assessment to other settings, particularly the home and the nursing home.

Determine the most effective means for targeting of comprehensive geriatric

assessments in a broad patient population.

Use controlled trials of comprehensive geriatric assessment to evaluate the effect

of different combinations of personnel, instruments, and interventions.

Compare the effects of assessment with and without various methods for

coordinated implementation of the care plan.

Develop new assessment tools for measuring levels of and changes in functional

status, particularly for those with mild-to-moderate levels of impairment.

Directly compare instruments that assess information within the same domain.

www.drjayeshpatidar.blogspot.com 20

Develop data bases with which to establish patterns of changing function,

especially in persons who spend time in long-term care institutions.

Conclusions

The settings, uses, processes, personnel, and component domains of comprehensive

geriatric assessment have been defined with sufficient clarity to provide guidelines for

establishment of new assessment programs.

Accumulated evidence indicates with moderate-to-high confidence that comprehensive

geriatric assessment is effective when coupled with ongoing implementation of the

resulting care plan.

Effectiveness has been most convincingly demonstrated in two inpatient settings, the

geriatric assessment unit and the combined geriatric assessment-rehabilitation unit.

The most consistently demonstrated favorable outcomes of comprehensive geriatric

assessment have been prolonged survival, reduced annual medical care costs, and

reduced use of acute hospitals and nursing homes.

Although the evidence allows for alternative interpretation, it is probable that careful

selection of patients has contributed importantly to the ability to demonstrate benefit from

comprehensive geriatric assessment.

In view of the seemingly indispensable role of monitoring and implementation of the care

plan in achieving desired outcomes, ongoing health care should be linked systematically

to the process of comprehensive geriatric assessment.

Consensus Development Panel

David H. Solomon, M.D. Panel and Conference Chairperson

Professor of Medicine

Associate Director

Multicampus Division of Geriatric Medicine

University of California at Los Angeles School of

Medicine

Los Angeles, California A. Sue Brown, M.S.W.

Administrator

Long-Term Care Administration

District of Columbia Department of Human Services

Commission of Public Health

Washington, D.C.

www.drjayeshpatidar.blogspot.com 21

Geriatric Assessment Program

A n n o u n c e m e n t s

An important resource for seniors and their caregivers.

For more information, call 302-477-3300.

Aging is a natural part of life to be respected and celebrated.

Yet, with it comes many new challenges—physical and

emotional—impacting seniors and their caregivers.

If you are over 65, or are caring for someone who is over 65,

Christiana Care’s Outpatient Geriatric Assessment Program

is an important resource for you. Based on information we

gather from thorough evaluations, our uniquely qualified,

board-certified geriatrician (a doctor who specializes in

geriatric medicine) and geriatric team can help you better

understand, adjust to and embrace the physical and mental

changes associated with aging.

Our in-depth Geriatric Assessment gives doctors an overall

picture of a senior’s health status, including his or her:

Physical condition.

Psychological assessment – including memory loss

and depression.

Social well-being – including support networks for those who live alone.

Our comprehensive physical assessment includes:

Detailed review of all medications, prescribed and over-the-counter, to assess

possible side-effects or drug interactions that could contribute to the challenges of

aging.

Eye exam.

Hearing assessment with

referral toa full audiological

evaluation, when appropriate.

The Gertiatric

Assessment Program

team can help you better

understand, adjust to and

embrace the physical and

mental changes associated

with aging.

www.drjayeshpatidar.blogspot.com 22

Aging impacts more than just the body

Along with performing a thorough physical examination, our geriatric specialists will

spend a significant amount of time —often as many as two to three hours—to get to

know the senior patient and make recommendations regarding support services, such as

home nursing care, meal delivery, personal and household services, or even assisted

living, that may ease some of the challenges of aging, particularly for seniors who live

alone.

As part of the assessment, our geriatric physician may recommend a home visit to

evaluate safety issues – particularly fall hazards and nutritional needs. They will take the

time to thoroughly discuss options for support services, assisted living, long-term care

and decisions regarding nursing home care.

What about Alzheimer’s care?

About 80 percent of the seniors we see for geriatric assessments have serious memory

problems, or dementia. Approximately 70 to 75 percent of all dementias are Alzheimer’s

cases. Christiana Care’s geriatric specialists are trained to recognize and evaluate

memory disorders and recommend appropriate medical and support services throughout

the community.

Care for the caregiver, too The challenges of aging affect those who care for seniors, too. In fact, many caregivers,

themselves, develop physical problems because of the stress they are under while taking

care of their loved ones. If caring for a senior is taking its toll on you, please call us today

to learn about resources available to help you.

Time to ask questions One of the things seniors and their caregivers appreciate most about our Geriatric

Assessment Program is the opportunity to spend time with the doctor asking questions

and discussing any number of issues relating to aging. Christiana Care’s geriatric team

believes that communication is key to helping all involved learn about and appropriately

address any challenges affecting the senior patient.

Keeping your doctor informed Christiana Care’s Outpatient Geriatric Assessment Program is not intended to replace the

senior’s relationship with his or her primary care physician. Instead, it is a service to

enhance the care already being provided. To ensure continuity of care and open

communication, Christiana Care’s geriatric specialists will provide a complete report of

the physical and psychosocial assessment to the senior’s primary care physician.

Together, the primary care physician and geriatric physician will consult on

recommended approaches to addressing the senior’s aging challenges.

www.drjayeshpatidar.blogspot.com 23

Medicare coverage

Christiana Care’s Outpatient Geriatric Assessment Program is covered by Medicare and

most insurance plans. No referral is required.

How to reach us

Christiana Care’s Outpatient Geriatric Assessments are performed at Christiana Care’s

Foulk Road Family Medicine Center, 1401 Foulk Road, Wilmington, Delaware (across

from Brandywine High School).

For more information, or to make an appointment for a Geriatric Assessment

Geriatrics

UT Southwestern Medical Center combines attentive and compassionate care with state-of-the-art

medical resources to create one of the nation’s leading health-care programs for older adults. Our

Geriatrics Program offers expert diagnosis by specialists who care about the needs of patients and

families. Our geriatricians are specially trained to prevent and manage older adults’ unique and, often

times, multiple health concerns. They develop care plans that address the special health care needs of

older adults.

At UT Southwestern Medical Center, our geriatrics specialists focus on the complete individual,

including social and psychological issues as well as medical conditions. We offer three geriatric

programs:

Geriatric primary care – Our physicians provide long-term primary care for patients 65 years of

age and older.

Comprehensive geriatric assessment - We evaluate older adults with complex medical and

social conditions, including mobility issues, osteoporosis, urinary incontinence, rehabilitation

needs, dementia, Alzheimer’s disease and psychological disorders. We also analyze the

patient’s current medications to determine whether they are clinically warranted and interact

safely. This complete and coordinated evaluation occurs in one clinical setting and is performed

by a team that includes a geriatrician, a geriatric nurse practitioner and a social worker who

specializes in geriatrics. Each member of the team separately assesses the patient, and then they

confer to create the best guidance for future care.

Senior HouseCalls Program – We provide primary medical care to home-bound individuals 70

years of age and older. Health care is provided in the older adult’s home where medical staff

can best integrate the efforts of family members and community resources such as traditional

home-based health care.

Our geriatric specialists provide both primary care services and comprehensive geriatric assessments

for patients and their families.

Patients with Alzheimer’s disease, Parkinson’s disease and other neurological conditions can also be

seen by our neurosciences service. Patients with psychological disorders can also be seen by our mental

www.drjayeshpatidar.blogspot.com 24

health service. Patients with urinary incontinence can also be seen by our urology service.

PROGRAMMES FOR CARE OF OLDER PERSONS

Demographic ageing is a global phenomenon. With a comparatively young population,

India is still poised to become home to the second largest number of older persons in the

world. Projection studies indicate that the number of 60+ in India will increase to 100

million in 2013 and to 198 million in 2030. The special features of the elderly population

in India are :- (a) a majority (80%) of them are in the rural areas, thus making service

delivery a challenge, (b) feminization of the elderly population ( 51% of the elderly

population would be women by the year 2016) , (c) increase in the number of the older-

old ( persons above 80 years) and (d) a large percentage (30%) of the elderly are below

poverty line.

Social Defence Division provides for the need

of older persons through its various programmes

and initiatives.

National Policy for Older Persons (NPOP) (Complete Policy details)

Steps Already Taken For Implementation of NPOP

List of Members of the National Council for Older Persons (NCOP)

List of Ministries/ Departments of Inter-Ministerial Committee implementing

National Policy on Older Persons.

Concessions and facilities given to Senior Citizens by different Ministries/

Departments

Inter-Ministerial Committee

Annual Plan of Action 2005-06 for implementation by various Ministries/

Departments concerned with the welfare of Older Persons

Schemes

An Integrated Programme for Older Persons.

Scheme of Assistance to Panchayati Raj Institutions/Voluntary Organisations/Self

Help Groups for Construction of Old age homes/multi service centers for older

persons.

Important Documents and Downloadable Formats

www.drjayeshpatidar.blogspot.com 25

National Policy for Older Persons

2. The National Policy for Older Persons (NPOP) was announced in January, 1999,

with the primary objective viz. to encourage individuals to make provision for

their own as well as their spouse’s old age; to encourage families to take care of

their older family members; to enable and support voluntary and non-

governmental organizations to supplement the care provided by the family; to

provide care and protection to the vulnerable elderly people, to provide health

care facility to the elderly; to promote research and training facilities to train

geriatric care givers and organizers of services for the elderly; and to create

awareness regarding elderly persons to develop themselves into fully independent

citizens.

Steps already taken for implementation of NPOP

3. The Government has constituted a National Council for Older Persons

(NCOP) under the Chairmanship of Hon’ble Minister for Social Justice and

Empowerment to advise and aid the Government on policies and programmes for

older persons and also to provide feedback to the Government on the

implementation of the National Policy on Older Persons as well as on specific

programme initiatives for older persons. The NCOP is the highest body to advice

and coordinate with the Government in the formulation and implementation of

policy and programmes for the welfare of the aged.

3. The National Council for Older Persons has been re-constituted in 2005.

Presently, it has 37 members.The given areas of concern have been emphasized

which include:-

a. Uniform age of 60+ for extending facilities/ benefits to senior citizens;

b. Financial security to the elderly population by: (1) Proposing tax benefits and

higher interest rates for senior citizens (2) Promotion of long term savings in both

rural and urban areas (3) Increased coverage and revision of old age pension

schemes for the destitute elderly and (4) Prompt settlement of pension, provident

fund, gratuity and other retirement benefits;

c. Health care and nutritional needs of the elderly populations by: (1) Strengthening

of primary health care system to enable it to meet the health care needs of older

persons; (2) Training and orientation to medical and para medical personnel in

health care of the elderly. (3) Promotion of the concept of healthy ageing. (4)

Assistance to societies for production and distribution of material on geriatric

care. (5) Provision of separate queues and reservation of beds for elderly patients.

d. Food security and shelter by : (1) Coverage under the Antyodaya Scheme to be

increased with emphasis on provisions for the benefit of older persons especially

the destitute and marginalized sections. (2) Earmarking ten percent of

houses/house sites for allotment to older persons. (3) Barrier-free environment for

the disabled and elderly persons etc.

e. Meeting the education, training and information needs of older persons.

www.drjayeshpatidar.blogspot.com 26

f. Identification of the most vulnerable among the older persons and working for

their welfare.

g. Realizing the crucial role by the media in highlighting the situation of older

persons and emphasising their continued role in Society

h. Protection of life and property of the elderly population.

Inter-Ministrial Committee

The Ministry has also set up Inter-Ministerial Committee (IMC) headed by Secretary (SJ

& E) for ensuring speedy implementation of the decisions taken in the meeting of the

National Council for Older Persons and also to review the progress of plan of action for

implementation by the concerned Ministries/Departments as in many cases, the activities

have to be initiated by the other Ministries/ Departments and, therefore, a combined

effort by all the Ministries/ Departments is required to implement the National Policy on

Older Persons. The Inter-Ministerial Committee comprises of twenty -two

Ministries/Departments and representatives of State Governments and UT

Administrations. The Inter-Ministerial Committee is responsible for the implementation

of the action points as described.

SCHEMES :-

An Integrated Programme for Older Persons

Scheme of Assistance to Panchayati Raj Institutions/ Voluntary Organisations/

Self Help Groups for Construction of old age homes/multi service centres for

older persons

9. An Integrated Programme for Older Persons Under this Scheme financial

assistance up to 90% of the project cost is provided to NGOs for establishing and

maintaining old age homes, day care centres, mobile medicare units and to

provide non-institutional services to older persons. The scheme has been made

flexible so as to meet the diverse needs of older persons including reinforcement

and strengthening of the family, awareness generation on issues pertaining to

older persons, popularisation of the concept of life long preparation for old age,

facilitating productive ageing, etc. The budget allocation during 2005-2006 was

Rs.19.80 crores which was revised and the RE was Rs. 14.00 crores, against

which the expenditure was Rs.14.00 crores. The budget allocation for the year

2006-07 is kept at Rs.28 crore.

10. Scheme of Assistance to Panchayati Raj Institutions/Voluntary

Organisations/Self Help Groups for Construction of old age homes/multi

service centres for older persons This scheme provides for one time

construction grant for old age homes/multi service centers. The registered

societies, public trust, Charitable Companies or registered Self-help Groups of

Older Persons in addition to Panchayati Raj Institutions are eligible to get the

assistance under this scheme. Against the budget allocation during 2005-06 of

Rs.67 laskh, the expenditure was Rs. 47 lakh.