Janice E. Knoefel, MD, MPH Professor of Medicine & Neurology University of New Mexico Retired - Geriatrics/Extended Care New Mexico Veterans Affairs Healthcare System Albuquerque, NM
Disclosure Statement: Dr. Knoefel has nothing to disclose
Learning Objectives: 1. Understand the principles of Comprehensive Geriatric Assessment 2. Develop strategies to adapt CGA for individual clinical practices
The model, borrowed from traditional rehabilitation by the geriatric community, has developed into the principle of comprehensive geriatric assessment (CGA) Rehabilitation wishes to identify and treat patients who benefit from rehabilitation; the clinician wishes to identify elderly at risk for functional decline and treat appropriately.
Developed in the late 1940s in the United Kingdom as a way to identify seniors in need of services Adapted in the 1970s by US as a way to screen frail seniors who appeared to require nursing home care because of physical or cognitive decline. Many undiagnosed illnesses, 15% mortality at 6 months Initially an inpatient model, now outpatient care
Traditional Rehabilitation Disease -> impairment -> disability -> handicap Example: Degenerative joint disease (DJD) -> pain -> gait disturbance -> unable to access 2nd-floor apartment Interventions: Disease-specific (nonsteroidal anti-inflammatory drugs [NSAIDs], total knee replacement [TKR]) -> impairment management (pain control) -> disability compensation (cane) ->environmental modification (move to 1st-floor apartment)
Clinicians often back into the issue: Patient is failing, family is complaining, something is changing. Why is patient not the same as last year, 2 years ago??undiagnosed new illness?chronic condition worsening?deconditioning,?drug effects,?dementia
: Goals Identify limitations of patient ability to function in daily life. Develop strategies/interventions to improve function. In other words: What cannot be done, why cannot it, what can be done to fix the limitation (patient-based intervention) or change task (environmental remediation)
Dimensions of assessment: Medical, including drug use Functional Physical Cognitive Sensory Psychologic Social
Core team members: Physician/healthcare professional Nurse/nurse practitioner/home care nurse Social worker Makeup of core team members dependent on setting, specific goals of assessment team
Ad hoc team members: Dietitian Pharmacist Rehabilitation therapist(s) Psychologist Dentist Spiritual counselor Audiologist
Consultative versus primary care practice Settings: Outpatient clinic Inpatient unit Home and community Long-term care facility
Components of assessment: Targeting patients likely to benefit Performing the evaluation, making recommendations Implementing recommendations Monitoring outcomes
: Targeting Frail Elders Prevalence of disability increases with age and some have recommended using age as one criteria (ie, all individuals older than 75 years). Investigational criteria use a number of factors: Age, comorbidity, known functional deficits, psychologic and social factors (depression, social isolation), use of health care services
: Targeting Frail Elders Researchers have proposed using hospitalizations or ER visits as a proxy for a high-risk population. Post hoc analysis showed that predictive factors were: Number of medical diagnoses Number of drugs Loss of 2 or more intermediate activities of daily living (IADLs)
: Targeting Frail Elders My criteria: New drug compliance issues Cancellation or no-show for appointments Family members start calling office Family members start to accompany patient to office Unexplained weight loss Change in appearance or behavior
: Targeting New Elders New Medicare approved Welcome to Medicare examination - meant as a screening and preventive examination. This is a one-time comprehensive medical review and physical examination in the first 6 months that patient has Part B Medicare coverage. Good way to get baseline on patients newly eligible for Medicare, however, few meet the frail elderly designation.
: Outcomes Decreased NH admissions Decreased drug use Major and minor new diagnoses Decreased annual medical cost of care Decreased mortality rate, no loss of quality of life (QOL) Increased independent function Increased patient/family satisfaction
Medical assessment: Current condition Medical and surgical history Drugs: Prescriptions, herbal supplements, and over-the-counter (OTC) drugs Allergies Habits: Tobacco, alcohol, diet, exercise Health maintenance: Immunizations; dental, eye and hearing examinations; Fecal Occult Blood; mammogram; Pap test; breast examination Family history
Social assessment: Marital status, family members Educational and occupational history Housing status Financial concerns, income status Hobbies and activities Sexual history Religious preferences
Functional status: Activities of daily living (ADL) Bathing Dressing Personal grooming Eating Transfers Toileting Continence Ambulation
Functional status: IADL Shopping Meal preparation Taking drugs Housekeeping Laundry Transportation Telephone use/communication Managing personal finances
Functional status review counts as review of systems (ROS) Supplement for additional ROS as needed Advance directives Driving: Still driving? Any accidents? Change of driving habits? Gotten lost, lost the car?
Physical examination: Need to include some measure of visual and auditory acuity Cognitive examination: Mini-Mental State Examination (MMSE) Psychiatric examination: Geriatric Depression Scale Performance examination: Get-up-and-go test Neurologic examination: Other measures of balance and gait
Coding: Use evaluation and management (E/M) codes, aim for level 5 History: Chief report, history of present illness Medical and surgical history Drug review Family and social history ROS need to review 10+ systems Examination: Multisystem examination needs to look at 8 of the 12 areas
Decision-making needs to be high complex: 8 or more diagnoses Review management of all diagnoses, but do not need to change if in agreement. Diagnoses include constipation, pain, hearing loss, skin dx, dry eyes, etc. Counseling can upgrade 1 level: Include time in minutes and subject of discussion
Delegate data collection Minimize data recording time Keep information needed for decisionmaking readily available Delegate plan execution
Strategies for Saving Time Previsit questionnaire: Medical history: o Current drugs o Drug allergies o Surgical and medical diagnosis and procedures o Social history o Health maintenance and preventive services Home safety checklist Advance directives
Strategies for Saving Time Specific questions on: Vision Hearing Dentition Falls Urinary incontinence Nutrition Depression symptoms Functional status
Strategies for Saving Time Minimize data recording time: Dictation Templates Word processing programs Computerized medical records
Strategies for Saving Time Keep information needed for decisionmaking readily available: Pocket guides PDA programs Useful books and charts Computer retrieval system
Strategies for Saving Time Delegate plan execution: Network of health professionals Health educators Patient education handouts
Assessing Care of the Vulnerable Elderly Assessing Care of the Vulnerable Elders (ACOVE) http://www.geronet.ucla.edu/centers/ac ove/index.htm Can find: Office forms Physician education Patient education More information and reprints