The geriatric assessment
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The Geriatric Assessment: A Complete GuideAbhishek Achar, OMS-III
Two AssessmentsGeriatric Health
Maintenance
• Primary care setting• Routine Health Maintenance• Identifies indicators of quality
of life• Screening • Preventative Interventions• Whole Health Management
Comprehensive Geriatric Assessment (CGA)
• Allied Health assessment• Identifies common and
frequently unrecognized impairments in older adults• CHF• Depression, Isolation,
Dementia• Functional Instability, Falls• Predicted High Healthcare
Utilization
Geriatric Health Maintenance• Patient centered complete and through History
and Physical• Preventative Measures• Primary Prevention• Secondary Prevention• Tertiary Prevention
• Whole Health Management• Medications• Driving• Financial and Social Support• Abuse• Advance Care Directives
Preventative Measures• Primary Prevention
To avert the development of disease
• Encourage Physical Activity and counsel against Alcohol and Tobacco• Discuss prophylactic Aspirin in CV Risk patients• Immunizations• Influenza – Annually • Pneumococcal – >65y.o. (PPSV23)• Herpes Zoster – >60y.o.
GERIATRIC HEATH MAINTENANCE
Preventative Measures• Secondary Prevention
Early detection and treatment of asymptomatic disease
• Cancer Screenings• Prostate – Between 50-69y.o.• Colorectal – Between 50-75y.o. (85y.o. for High Risk
patients)• Breast – Controversial Guidelines• Typically every 1-2 years for females with ≥4 years life
expectancies.
• Cervical – Between 21-65y.o. with adequate recent screening.• Three consecutive negative cytology test OR• Two consecutive negative Pap in the last 10 years• May start screening women under 21 who are sexually
activeGERIATRIC HEATH MAINTENANCE
Preventative Measures• Secondary Prevention
Early detection and treatment of asymptomatic disease
• Blood Pressure Screening• Lipid Screening • Osteoporosis (DEXA)• Routine Bone Density
(DEXA) • Women ≥65y.o.• High Risk Women ≥60y.o.
• Abdominal Aortic Aneurysms• One-time Abdominal US• Men ≥65y.o. who have
smoked or have AAA in PFHx
GERIATRIC HEATH MAINTENANCE
Preventative Measures• Tertiary Prevention
Identification of disease to prevent further morbidity or functional decline
• Functional• Focused on activities of daily living
• Cognitive• Targeted screening in patients with• Memory complaints• New functional impairment
• Vision• Decreased visual acuity increases fall and mortality risk• General Ophthalmologic Exam every 1-2 years
• Depression• "Over the past two weeks have you felt down, depressed, or
hopeless?" • "Over the past two weeks have you felt little interest or pleasure
in doing things?"
GERIATRIC HEATH MAINTENANCE
Preventative Measures• Tertiary Prevention
Identification of disease to prevent further morbidity or functional decline
• Hearing• 3rd most common ailment (HTN, Arthritis)• Associated with depression, social isolation, functional decline• Whisper test almost as effective as formal studies
• Nutrition• Routine Nutritional Assessments necessary• Vit B12, Vit D, Calcium typically low
• Mobility/Falls• ~30% of noninstitutionalized older adults fall every year. • 5% of falls result in fracture/hospitalization
• Regular assessments necessary• Circumstances of falls, orthostatic vitals, visual acuity, cognitive testing, gait,
balance, iatrogenic causes
• Incontinence• Major psychosocial impact• Routine targeted H/P with Urine/Blood testing indicated
GERIATRIC HEATH MAINTENANCE
Whole Health Management• Medications• Multiple medication increase the risk of Drug-Drug
interactions• Maintain up-to-date medications (including
OTC/herbal)• Annual comprehensive reviews
• Assess for duplications, drug-drug contraindications, affordability
• Altered pharmacokinetics/dynamics increase risk of ADR• Assess specific classes associated with ADR• Warfarin, Analgesics (NSAIDs), Antihypertensives (ACE-
I, Diuretics), Insulin, hypoglycemic agents (Nitro), psychotropics
GERIATRIC HEATH MAINTENANCE
Whole Health Management• Driving• Should be discussed in patients with • Dementia• Decline in visual, hearing, and psychomotor skills
• Reporting laws exist and vary state to state
• Abuse• Reported in 3-8% of older population• Suspicion raised if patient presents with contusions, burns,
bite marks, genital or rectal trauma, pressure ulcers, or a BMI <17.5 without clinical explanation
• Advance Care Directives• Discussion is appropriate during Health Maintenance Exam
focusing on preventative planning
GERIATRIC HEATH MAINTENANCE
Comprehensive Geriatric Assessment• Intensive Multidisciplinary Diagnostic and Treatment
Program • Differing from the Primary Care Clinician’s Geriatric Health
Maintenance
• Maximizes health with disease and aging• Initiated through referral by PCP
Comprehensive Geriatric Assessment• Indications for referral • Age• Major Comorbidities • CHF, Cancer, DQs, Surgery, etc
• Psychosocial Disorders • Depression, Social Isolation
• Unstable Geriatric Conditions • Dementia, Falls, Functional
Disability• Predicted high health care
utilization• Change in living situation
Comprehensive Geriatric Assessment
Comprehensive Geriatric Assessment• Major Components of the CGA• Functional capacity• Fall risk• Cognition• Mood• Polypharmacy• Social support• Financial concerns• Goals of care• Advanced care preferences
Comprehensive Geriatric Assessment
Components of the CGA
• Basic Activities of Daily Life• Bathing• Dressing• Toileting• Maintaining continence• Grooming• Feeding• Transferring
• Instrumental Activities of Daily Life• Shopping for groceries• Driving or using public
transportation• Using the telephone• Performing housework• Doing home repair• Preparing meals• Doing laundry• Taking medications• Handling finances
Comprehensive Geriatric Assessment
• Functional capacity• Ability to perform activities necessary AND desirable in
daily life• In the context of living environment and social network
Components of the CGA• Fall risk• Assessment integrated into H/P of all geriatric patients
• Cognition• Assessment integrated into H/P of all geriatric patients
• Mood• Assessment integrated into H/P of all geriatric patients
• Polypharmacy• Clinician review recommended on every visit
Comprehensive Geriatric Assessment
Components of the CGA• Social support and Financial concerns• Brief screening of SoHx indicated• Screen caregivers periodically for depression burnout• Refer to counseling or support groups
• Goals of care• Typical CGA patients have limited ability to return to fully
healthy/independent lifestyles• Social and Functional goals typically assume priority over
healthcare.
• Advanced care preferences• Assessment integrated into H/P of all geriatric patients
Comprehensive Geriatric Assessment
References• UpToDate• Medscape
Fin!