Comprehensive geriatric assessment (CGA) Mieke Deschodt, RN, PhD Lucky you, getting older in Europe - Multiplier event IC Dien Oostduinkerke, 5 June 2018 @mieke_deschodt
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Outline Comprehensive geriatric assessment (CGA) 1. Do we need CGA? 2. What is CGA? 3. CGA as core intervention of models of care 4. The role of the nurse in CGA-based models of care 3
4 1. Do we need CGA?
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Population is ageing Absolute number Proportion 6
7 Characteristics of ageing
The aging phenotype 8 Ferrucci L, et al. Public Health Reviews 2010;32:475 88.
Gerontology geriatrics Gerontology = the study of the ageing process itself Comprehensive Geriatric Assessment Geriatrics = medical gerontology - Multimorbidity - Polypharmacy - Functional disabilities 9
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11 2. What is CGA?
Comprehensive The geriatric patient geriatric assessment (CGA) a multidimensional interdisciplinary diagnostic process focused on determining a frail elderly person s medical, psychosocial and functional capabilities in order to develop a coordinated and integrated plan for treatment and long-term follow-up (Rubenstein et al., 1999) PSYCHOLOGIST/ PSYCHIATRIST COGNITIVE GERIATRIC NURSE GERIATRICIAN MEDICAL SOCIAL SOCIAL WORKER PHYSIO- THERAPIST FUNCTIONAL OCCUPATIONAL THERAPIST 12 DIETICIAN
Comprehensive geriatric assessment Targeting the appropriate patients Assessment and formulating recommendations Implementation of recommendations Follow-up A. Screening tools OR B. Predefined populations Medical/clinical evaluation Functional status Cognition Nutrition Social aspects Individual care plan and delivery of the recommended treatments based on evidencebased guidelines Reassessment: Did the interventions work? Are additional interventions needed? 13 (Adapted from Deschodt et al. Doctoral thesis, 2013)
PubMed search (30 May 2018) 200 180 160 140 120 100 80 60 40 20 0 Comprehensive geriatric assessment n = 1617 1980 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 14
Target group Patients - with an average age 75 years - who need a specific approach for the following reasons: a frailty profile active multi-pathology a limited homeostasis atypical clinical appearances of diseases disturbed pharmaco-kinetics risk for functional decline or malnutrition trend to be inactive and bedridden - with an increased risk for institutionalization, dependency in activities of daily living or psychosocial problems. 15
1. Detection of high-risk patients Screening tools need to be short and valid High sensitivity If the patient has a geriatric risk profile (e.g. risk for functional decline, readmission), what is the chance that the patient will have a postive screening result? Minimum of falls negative results (1- sensitivity) High negative predictive value If the test is negative, what is the chance that the patient will not have a geriatric risk profile? 16
Screening tools: hospital ISAR (McCusker et al. 1999) Since the illness that brought you to the hospital, have you needed more help than usual to take care of yourself? Before the illness that brought you to the hospital, did you need someone to help you on a regular basis? Hospitalized 1 nights during the past 6 months? Flemish TRST (Mion et al. 2001; Braes et al. 2009) Lives alone or no caregiver available Difficulty with walking or fall in the last 6 months Use of the emergency department or has been hospitalized within last 3 months > 3 medications 5 different medications VIP (Vandewoude et al. 2008) Lives alone Needs help with bathing and dressing Serious memory problems Cognitive impairment Does not use telephone or dials a few well-known numbers Vision problems Systematic screening detects the majority of patients at high risk who might benefit from CGA increases awareness of characteristics of geriatric risk profiles BUT Positive screening should lead to more detailed comprehensive geriatric assessment in order to filter out the high number of falsepositives. 17 (Deschodt et al. Ageing Clin Exp Res 2011)
Screening tools: community and nursing home Groningen Frailty Indicator 18 (Peters et al. J Am Med Dir Assoc 2012)
Comprehensive geriatric assessment Pain MEDICAL Nutrition Medical history and clinical assessment Medication - Potentially Inappropriate Medication (PIMs) Charlson Comorbidity Index 19
Comprehensive geriatric assessment FUNCTIONAL Gait speed Activities of daily living (ADL) IADL Pressure ulcers Falls Hearing Vision 20
Comprehensive geriatric assessment PSYCHOLOGICAL Cognitive Decline - Dementia Delirium Depression 21
What questions should I ask? 1. What is the nature of the change in behavior/cognition? 2. When was the change in behavior/cognition first observed? 3. What is the course of the change? 4. Any change in performance of ADLs/IADLs? 5. Any recent changes in health status, mood, life situation? Screening test for cognitive/behavioral changes Mini-Cog Geriatric Depression Scale (GDS-15, GDS-30) Confusion Assessment Method (CAM) 22
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Mini-Cog Very brief cognitive screening instrument 3-item recall test + clock-drawing test Twice as fast than MMSE Less affected by ethnicity, language, education, socioeconomic status 1. Remember the following words: Apple Table Penny 2. Inside the cirkel draw in the hours of the clock and set the hands to ten past eleven) 3. Repeat the three words I asked you to remember 24
25 Cognition: clock-drawing test Cognition: clock-drawing test
Mini-Cog: interpretation MINI-COG Recall = 0 Recall = 3 Recall = 1-2 Clock abnormal DEMENTIA? Clock normal NO DEMENTIA 26 (Borson S. Int J Geriatr Psych 2000)
Confusion Assessment Method (CAM) Validated screening tool for delirium: Sensitivity 94-100%; Specificity 90-95% Takes about 5 mins Does not asess severity of delirium 1. Acute onset and fluctuating course 2. Inattention 3. Disorganized thinking 4. Altered level of consciousness Diagnosis requires presence of 1 + 2 + (3 or 4) 27 (Inouye SK et al. Ann Intern Med 1990)
Depression: GDS-15 Choose the best answer for how you have felt over the past week: 1. Are you basically satisfied with your life? YES / NO 2. Have you dropped many of your activities and interests? YES / NO 3. Do you feel that your life is empty? YES / NO 4. Do you often get bored? YES / NO 5. Are you in good spirits most of the time? YES / NO 6. Are you afraid that something bad is going to happen to you? YES / NO 7. Do you feel happy most of the time? YES / NO 8. Do you often feel helpless? YES / NO 9. Do you prefer to stay at home, rather than going out and doing new things? YES / NO 10. Do you feel you have more problems with memory than most? YES / NO 11. Do you think it is wonderful to be alive now? YES / NO 12. Do you feel pretty worthless the way you are now? YES / NO 13. Do you feel full of energy? YES / NO 14. Do you feel that your situation is hopeless? YES / NO 15. Do you think that most people are better off than you are? YES / NO 0-4 = not indicative for depression >5 : follow-up assessment >10 = always indicative for depression 28 (Yesavage JA, et al. J Psychiatr Res. 1982)
Comprehensive geriatric assessment SOCIAL Living situation Advanced Care Planning Patient goals Finances Caregiver burden 29
Comprehensive geriatric assessment Targeting the appropriate patients Assessment and formulating recommendations Implementation of recommendations Follow-up A. Screening tools OR B. Predefined populations Medical/clinical evaluation Functional status Cognition Nutrition Social aspects Individual care plan and delivery of the recommended treatments based on evidencebased guidelines Reassessment: Did the interventions work? Additional interventions needed? 30 (Adapted from Deschodt et al. Doctoral thesis, 2013)
3. CGA as core intervention of models of care 31
CGA-based models of care for older people Hospital Acute geriatric units Geriatric consultation teams Geriatric co-management Community 32
Acute geriatric units Scope Acute and sub-acute episodes for which specialized input is required. Organizational aspects Interprofessional care and organisation Team organisation comprehensive assessment standardised assessment tools at least weekly multidisciplinary meetings protocolised care specialised ward environment 33 (Ellis et al. Cochrane Database Syst. Rev. 2017)
Acute geriatric units: evidence base Reduction in mortality (Rubenstein et al. 1991; Stuck et al. 1993; Ellis & Langhorne 2004; Ellis et al. 2017) More patients living alone at home (Stuck et al. 1993; Ellis & Langhorne 2004; Ellis et al. 2017) Improved physical function (Stuck et al. 1993; Baztan et al. 2009; Van Craen et al. 2010) Less new nursing home admissions (Van Craen et al. 2010) Based on 6 meta-analyses the acute geriatric ward is an evidence-based model of care or the gold standard for elderly inpatient care 34
Acute geriatric units Demand versus supply 35
When there is no acute geriatric unit... Challenge = complex care needs of frail older adults IADL impairment 83% Functional decline 39% Frailty 56% Polypharmacy 61% Mobility difficulty 59% Caregiver burden 53% Malnutrition 52% complications length of stay readmission mortality nursing home admissions 36 (Deschodt et al. IJNS 2012; Deschodt et al. KCE Reports 245, 2015; Milisen et al. 2006; Covinsky et al. JAMA 2013; Inouye et al. Lancet 2014; Benbassat et al. Arch Intern Med 2000; Askari et al. Plos One 2011)
Internal geriatric consultation teams Aim to share the core geriatric principles and multidisciplinary expertise to all medical staff and care teams and for all hospitalized persons with a geriatric profile who are admitted at non-geriatric units. Roles of IGCT Evaluation of patients that were flagged as being at risk by a validated screening tool Multidisciplinary CGA Formulation of recommendations to the care team, the treating physician and the GP Dissemination of the geriatric approach in the hospital No direct patient care Team meetings 37 (Braes et al. 2009; Deschodt et al. IJNS 2011)
No consistent impact on clinical outcomes Reasons for non-effect Lack of adherence to the team s recommendations Lack of control over care Interventions on patient level only Not as proactive as intended Implications for general practice How to increase adherence rates? Co-management instead of consultation? 38
Consultation versus co-management Type of interaction Goals To enhance patient care... Focus Responsibility for clinical outcomes Clinical consultation... Or improve skills of confidence of consultee Consultant may or may not see patient directly Degree of focus on consultee s skill is negotiated with consultee Remains with consultee, who is free to accept or reject the advice of consultant Co-management... through availability of two or more professionals working together to optimize outcomes Both professionals see patients directly and coordinate their care with one another Shared Shared responsibility and decision making between treating physician and geriatrician Geriatrician provides complementary medical care Prevention and management of geriatric-oriented problems (Deschodt et al. KCE report 2015; Kammerlander, 2010) GERIATRIC CO-MANAGEMENT 39 (Barron AM, White PA. (2005) Consultation. In: Advanced practice nursing. An integrative approach. 3 rd ed. Hamric AB, Spross JA, Hanson CM. (eds). Missouri, United States. Elsevier Saunders)
Geriatric co-management has been described thoroughly (44 papers), but limited valid evaluation (12 prospective controlled trials) Potential effect of co-management on in-hospital outcomes Length of stay Inhospital and 6-month mortality In-hospital complications 40
G-COACH program CGA within 24h of admission on cardiology ward by geriatric nurse G-COACH team = Geriatric nurse specialist, geriatrician, cardiologist, nursing staff, physiotherapist, occupational therapist, social worker Implementation & coordination of interdisciplinary care plan Low risk Medium risk Proactive consultation Prevent functional decline Co-management by geriatric nurse and cardiology team Goals of care Bedside education Protocols for geriatric problems Early rehabilitation Early discharge planning Acute problem Treat acute geriatric problems Co-management by geriatrician and cardiologist Diagnostic & therapeutic interventions Medication review 41 More information: https://gbiomed.kuleuven.be/english/research/50000625/50000630/researchprojects/gcoach
Implementation of a community-based care program for home-dwelling seniors citizens NOT AT RISK SCREENING Proactive risk prediction of older adults e.g. patients discharged from hospital after unplanned hospital admission at risk for readmission e.g. patients identified by PCP as being at risk for functional decline or social problems Groningen Frailty Indicator 4 ASSESSMENT Comprehensive Geriatric Assessment by the independent Advanced Practice Nurse (APN) in the Informations- und Beratungsstelle or at home Health promotion and frailty prevention Information about ageingrelated questions, promotion of physical activity, vaccine campaigns INTEGRATED CARE PLAN Individualized integrated care plan discussed with general practitioner & others; Care coordination by APN in collaboration with all social and health care providers in the care region FOLLOW-UP Evidence-based protocols for identified geriatric syndromes and social problems, referral to community care services, coordination of transitions, education and support of patient and informal caregivers 42
In nursing homes ASSESSMENT INTEGRATED CARE PLAN FOLLOW-UP 43
4. The role of the nurse in CGA-based models of care 44
Nurse Geriatrics : Geriatrician / GP Social assistent You never stand alone Physiotherapist Occupational therapist Dietician 45
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Workforce: nurses Table: Nurse-patient ratio CGA takes time and is not only about assessment 47 (Aiken et al. IJNS 2013 - RN4cast study)
NICHE: Nurses Improving Care for Healthsystem Elders Mission = to educate nurses with the knowledge and skills to provide best practice care and to position nurses as change agents in the settings in which they work to improve the quality of care delivered to older adults. (Fulmer T, et al. Geriatr Nurs. 2002) 48
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Key points Comprehensive geriatric assessment = cornerstone of geriatric care Target the at-risk patients by using screening tools or specify your at-risk population Assessment by a multidisciplinary care team Make sure the recommendations get implemented Provide follow-up Nurse as coordinator of care in CGA-based models of care Acute geriatric wards = gold standard for geriatric care Consultation teams = no consistent effects, but... Geriatric co-management = promising effects, but... 50
Contact: mieke.deschodt@kuleuven.be