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Comprehensive Geriatric Assessment
T.S. Dharmarajan
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Questions and Answers
1. You are asked by a patient who just turned 65 and visits
you for a routine evaluation. After the examination, she
asks you if her visit will be covered by insurance
(Medicare). You uncover no illness. Which one of the following is the correct response to the patient?
A. The visit is a routine one and hence is not covered by
Medicare.
B. The visit is covered by Medicare as this is the patient’s
first visit after she became entitled to Medicare.
C. This and subsequent visits are covered by Medicare.
D. The visit would have been covered provided she had
an illness.
Answer: B
In the United States, Medicare beneficiaries (typically aged
65 or more) have the opportunity for a one-time “Initial
Preventive Physical Examination” (also termed Welcome
to Medicare visit) within 12 months of getting Medicare
benefits. The patient is covered for this visit even in the
absence of an illness. In future, she is covered for any health
disorder under Medicare Part B, which also covers laboratory and other tests. Additionally, she is entitled for an
“Annual Wellness Visit” every year to focus on preventive
services. All health disorders are covered under Medicare
Part B in the office or outpatient setting and by Medicare
Part A for hospital services.
2. At the end of a visit, a 65-year-old just retired male in
good health asks you about preventive services. He has
never taken immunizations in the past 25 years as he
believes his health is good since he is a nonsmoker. The
patient wishes to take the bare number of vaccines as he is
somewhat concerned about getting ill from the injections;
he believes he has no allergies. As a vegetarian, the patient
does not appreciate the taste of eggs. He is married and
periodically visits his son and grandchild. The single best
recommendation at this time is:
A.Influenza, pneumococcal, and tetanus-diphtheriapertussis vaccines.
B.Pneumococcal and tetanus-diphtheria-pertussis vaccines; avoid influenza as he does not like eggs.
C. Influenza and tetanus-diphtheria-pertussis vaccines.
D.Avoid vaccination at this time as his health has been
good in spite of not receiving any vaccines in the past.
Answer: A
Although the patient is in good health thus far, the current
guidelines suggest that at age 65 the patient receive in
addition to the annual influenza vaccine, a one-time pneumococcal vaccine and a tetanus-diphtheria-pertussis
immunization. Influenza is common in older adults and
associated with much morbidity, hospitalizations, and
mortality. The efficacy of a high-dose vaccine introduced
in 2010 containing the same three strains but four times
the antigen to boost immune response is not clear yet.
Disadvantages include local reactions and increased cost.
The revaccination strategy for pneumococcal vaccine is
now clarified to include persons below age 65 with highrisk conditions, if 5 years have elapsed. The vaccine is
safe with little to no reactions; the 23 valent vaccine
covers 75–90% of all pneumococcal disease cases.
Tetanus, diphtheria, pertussis (Tdap) is termed a “family
affair” as household members transmit the majority of
infections to infants; persons over age 65 in contact with
infants and young children should receive a single dose of
Tdap, applicable to our patient with a grandchild. While
egg protein allergy has been considered a contraindication
for influenza vaccine, a dislike for eggs is not a reason;
the 2011 recommendation is that only anaphylaxis to egg
protein is a contraindication. Prior good health is never a
basis to avoid future immunizations; with age, immunity
is likely to wane and susceptibility to infections will
C.S. Pitchumoni and T.S. Dharmarajan (eds.), Geriatric Gastroenterology,
DOI 10.1007/978-1-4419-1623-5_7, © Springer Science+Business Media, LLC 2012
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T.S. Dharmarajan
increase. A better immune antibody response is likely at
age 65 or at earlier age than in later years.
3. Following an evaluation in the office, a 66-year-old anxious male in good health asks for advice. The patient is
obsessed with the topic of cancer (since his friend has
prostate cancer), although not on medications for any
illness. He has never smoked in his life and is willing to
undergo the minimum evaluation to rule out cancer,
provided it is necessary. All through life until retirement,
he has been reluctant to undergo tests for fear that “something
bad will be uncovered.” In addition to routine laboratory
tests, electrocardiogram, and a chest X-ray, you recommend which one of the following at this time?
A.Sonogram of the abdomen for abdominal aorta aneurysm (AAA).
B. Prostate-specific antigen (PSA) and urinalysis.
C. Colorectal cancer screening by colonoscopy.
D. Low-dose CT Scan for lung cancer.
Answer: C
Although guidelines suggest a one-time abdominal ultrasound for AAA screening in males between 65 and 75
years, the recommendation is only for smokers, including
ever smokers (over 100 cigarettes in a lifetime). This patient
is a nonsmoker and hence is not a candidate for the test. The
value of low-dose CT scan and chest radiography in screening for lung cancer has not been substantiated. Colorectal
cancer screening as a modality to prevent and detect cancer
is well established, although the age at which to stop screening is controversial. United States Preventive Services Task
Force (USPSTF) recommends against ever screening those
over 85 years old and against routine screening those >75
years. A 66-year-old in good health would be a candidate
for CRC screening. Screening for prostate cancer is not recommended in those over age 75 years; the recommendation
has now been extended (2011) to all men, with a grade D
recommendation from the USPSTF. However, the decision
to screen may follow a discussion with the patient on risks,
benefits, and alternatives. Other groups differ in recommendations with the American Cancer Society and
American Urological Association recommending PSA
measurements and digital rectal examination in men annually beginning at age 50 years.
4. A 70-year-old female is evaluated in your office. She
weighs 170 lb and has a BMI of 27. Disorders include
well controlled hypertension, hyperlipidemia (on a
statin), and mild osteoarthritis of the knees relieved by
acetaminophen . She has generally been reluctant to
exercise. Your counseling should include which one of
the following?
A. Exercise, of mild-to-moderate intensity for 300 min/week.
B.Dietary restrictions to lower the caloric intake and
lose weight.
C.Moderate intense physical activity, at 150 min/week,
in addition to dietary restrictions, in the absence of
contraindications.
D.No changes to the regimen, as the blood pressure
and cholesterol are well controlled; add NSAIDs for
osteoarthritis.
Answer: C
While caloric restrictions help reduce weight, the
best combination that will help is that of dietary caloric
restriction in conjunction with an increase in physical activity. At all ages, and even in the presence of
comorbidity, some exercise is better than none. As the
exercise is increased in duration, the benefit in reducing
risk of coronary artery disease increases, but the biggest
return is at the lower end of exercise; some physical activity is better than none, and additional benefits occur with
more physical activity. Diet alone helps, but the benefit is
far more when coupled with exercise. Physical activity is
never initiated at 300 min/week; after medical assessment, activity is usually initiated at 10–15 min at a time,
increasing to 30 min daily and further if tolerated, provided there are no contraindications. Analgesics by themselves are not a treatment for osteoarthritis; in this patient
with arthritis, hypertension and hyperlipidemia, all three
disorders will benefit from activity such as walking along
with weight reduction. In fact, the patient’s weight may
have contributed to knee osteoarthritis. NSAIDs may
worsen the hypertension and hence are not first-line longterm therapy. No contraindications to physical activity are
readily apparent in this case.
5. A 70-year-old male is being evaluated by a gastroenterologist for colonoscopy. He is in generally good health
and appears to be cooperative. He has a caring daughter
who understands the indications for the procedure and
recognizes that CRC screening is a well-accepted preventive measure in today’s practice. The gastroenterologist’s
responsibility prior to performing the procedure includes
which one of the following?
A.Proceed with the colonoscopy, as the daughter is caring
and understand the value of CRC screening.
B.Ask the daughter (and the patient) if an Advance
Directive in the form of a living will or health care
proxy is in place; review the document to determine
if there is a designated agent.
C.Decide not to do the colonoscopy as the patient is
already 70 years.
D.As the first step, determine the capacity of the patient to
understand and take decisions regarding his health care.
Answer: D
Prior to any procedure, the first step is to ensure that the
patient has the capacity to understand the reasons for
7 Comprehensive Geriatric Assessment
undergoing any procedure, including the risks, benefits,
and alternatives. It is only after ensuring that the patient
has capacity, one must attempt to obtain an informed consent for the procedure. Regulations demand that we document information on patient preferences. ADs include a
Living Will and a Health Care Proxy, with the latter generally preferred. ADs are valuable resources to health care
professionals when confronted by life-threatening situations and when a decision has to be taken regarding a surgical procedure or gastrointestinal procedure such as
endoscopy. In the absence of capacity and an available
AD, the Family Health Care Decisions Act may be
invoked, to enable decisions to be made by a close relative
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or person. In this case, one may accept the daughter’s
opinion only if the patient is deemed to have no capacity.
Barriers to implementing ADs include attitudes towards
“End of Life” discussions and “time constraints,” while
culture, race, education, and religious beliefs also play a
role. Not performing the colonoscopy is a premature decision; it becomes a consideration when it is determined
that the patient has dementia or an illness with limited life
expectancy. It is proper to also ensure that the daughter is
in fact the agent before accepting her recommendation;
however, determining capacity of the patient is nevertheless the first step.