Comprehensive
Geriatric Assessment
John E Morley
St Louis University
St Louis VAMC GRECC
“Old age is like a plane
flying through a storm.
Once you are aboard there is
nothing you can do about it.”
- Golda Meier
Typical medical
evaluation
and intervention:
• 85 year old woman has
uncontrolled hypertension
on one blood pressure
medication (185/80)
• Plan: Add a second blood
pressure medication
Typical medical
evaluation
and intervention:
2 weeks later….
Comprehensive
Geriatric Assessment
• 85 year old woman has uncontrolled
hypertension on one blood pressure
medication
1.
2.
3.
4.
5.
6.
7.
8.
Lives alone
Gait and balance abnormality
Osteoporosis
Mild memory impairment
Incontinent of urine
Vision impairment
OTC meds
Difficulty with cleaning
Comprehensive
Geriatric Assessment
•
85 year old woman has uncontrolled hypertension
on one blood pressure medication
1.
2.
3.
4.
5.
6.
7.
8.
Lives alone (daughter will help with meds)
Gait and balance abnormality (home therapy)
Osteoporosis (treated)
Mild memory impairment (eval for dementia)
Incontinent of urine (treated)
Vision impairment (fix or find glasses, ophtho. appt)
OTC meds (discard)
Difficulty with cleaning (Home OT-eval fall risk)
Comprehensive
Geriatric Assessment
• 85 year old woman had
uncontrolled hypertension on
one blood pressure medication
(2nd visit):
• Daughter came, helping with meds, BP fine
• Gait and balance is better-no falls
• No longer rushing to the bathroom (not
incontinent)
• Discussion about dementia and best
options to keep her living independently
Comprehensive
Geriatric Assessment
(CGA)
• Older patients may have
multiple problems, that
interact
• Looks at these interactions
(i.e. whole patient)
• Identifies current and
potential problems
Comprehensive
Geriatric Assessment
• GEMU
1.68 (1.17 - 2.41)
• Hospital
1.49 (1.12-1.98)
• Home assessment 1.20 (1.05 – 1.37)
LIVING AT HOME
Comprehensive geriatric assessment: a meta-analysis of controlled trials
Stuck et al, Lancet 342:1032, 1993
Comprehensive
Geriatric Assessment
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7 or more medicines
Fatigue
Cannot climb stairs or walk one block
Sadness
Memory problems
Weight loss
Falls
Urinary incontinence
Uncontrolled pain
Help with managing money or shopping
Unhappy with physicians treatment
The I’s of Geriatrics
The Modern Geriatric Giants
Instability (frailty)
Incontinene
Intellectual impairment
Iatrogenesis
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Inanition (malnutrition)
Impoverishment
Lawton’s IADLs
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Telephone
Shopping
Food Preparation
Housekeeping
Laundry
Transportation
Taking medicine
Managing Money
Status Post Fall
is a
Delirium Equivalent
Vowel test
Confusion Assessment Methodology
Families and physicians fail to recognize
dementia.
Mini-Mental Status Examination
Folstein et al. 1975
1.
Educationally dependent
2.
Both false positives and false negatives
3.
Minimal testing of visuospatial system
1.0
1.0
0.9
0.9
0.8
0.8
0.7
0.7
0.6
0.6
Sensitivity
Sensitivity
ROCs For SLUMS &MMSE
for MCI > HS Education
0.5
0.4
0.5
0.4
0.3
0.3
Area Under Curve = 64.3%
0.2
Area Under Curve = 94.1%
0.2
0.1
0.1
0.0
0.0
0.0
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
0.1
0.2
0.3
0.4
1-Specificity
SLUMS
0.5
0.6
1-Specificity
MMSE
0.7
0.8
0.9
1.0
Depression
• Are you sad?
• Beck Depression Inventory
• Yesavage Geriatric Depression
Scale
FRAILTY DEFINITION
OBJECTIVE
Fried et al J Gerontol 56A M146,2001
•Weight Loss(10 lbs in 1 year)
•Exhaustion(self-report)
•Weakness (grip strength;lowest 20%)
•Walking speed(15 feet; slowest 20%)
•Low Physical Activity(Kcals/week;lowest 20%)
Female >
Male
6.9%
FRAILTY
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Fatigue
Resistance (Climb stairs)
Aerobic (Walk one blocK)
Illnesses
Loss of weight
Gait and Balance
• Get up and Go
• One leg stand
• Tinetti Gait and Balance
• Dual Tasking
• Dancing
• Strength (Cybex)
• Muscle Pain (Polymyalgia Rheumatica)
Objective Measures of
Physical Function
• Get-Up-and-Go
• >30 sec fall risk
• 6 Meter walk
• <5.8 sec
• Gait Speed
• >6.0 sec
• 6 Minute Walk
• <300 m mortality
<400 m functional
impairment
Fear of Falling
Measure Blood Pressure
Standing in
ALL
Older Persons
ORTHOSTATIC
HYPOTENSION
POSTPRANDIAL
HYPOTENSION
(“BIG
MAC
ATTACK”)
VARIABLE
•
• MORE COMMON IN AM
• PREVALENCE 26%
•
falls
syncope
stroke
myocardial infarction
death
• STIMULATED BY
CARBOHYDRATE
• DUE TO CGRP RELEASE
PSEUDOHYPERTENSION
OSLER MANEUVER
(Messerli)
PREVALENCE 7.2%
Poor predictive value
Predicts cardiovascular disease
WHITE COAT
HYPERTENSION
PREVALENCE 7.1 TO 21%
No LVH
AMBULATORY MONITORING
BMD
• Done in all women by 50 years
or at menopause
• Done in men by 70 years
• Repeat in 2 year in same season
to see rate of fall
S.N.A.Q
1)
1.
2.
3.
4.
5.
3)
1.
2.
3.
4.
5.
My appetite is
Very poor
Poor
Average
Good
Very good
Food tastes
Very bad
Bad
Average
Good
Very good
< 15 predicts significant
weight loss within 6 months
2)
1.
2.
3.
4.
5.
4)
1.
2.
3.
4.
5.
When I eat, I feel full after
Eating only a few mouthfuls
Eating about a third of a plateful
Eating over half a plateful
Eating most of the food
Hardly ever
Normally I eat
Less than one full meal a day
One meal a day
Two meals a day
Three meals a day
More than three meals a day,
including snacks
SNAQ
Sensitivity
(%)
Specificity
(%)
81.3
76.4
10% weight 88.2
loss
83.5
5% weight
loss
Malnutrition Universal Screening Tool
Weight Loss Score
(unplanned wt loss in 3-6 mo)
BMI Score
BMI >20-0 (>30 obese*)
BMI 18.5-20.0
BMI <18.5
=0
=1
=2
Wt loss <5%
Wt loss 5-10%
Wt loss >10%
=1
=2
Acute Disease Effect
Score
= 0 Add a score of 2 if there has
been or is likely to be no
nutritional intake for >5 days
Add all scores
Overall Risk of Malnutrition and Management Guidelines
0
Low risk
Routine clinical care
•Repeat screening
Hospital – weekly
Care homes-monthly
Community-annually for special
Groups (e.g. those >75yrs)
1
Medium Risk
2 or more
High risk
Observe
Treat*
•Document dietary intake for
3 days if subject in hospital
or care home
•If improved or adequate
intake, little clinical
concern; if no improvement,
clinical concern – follow local
Policy
•Repeat screening
Hopital –Weekly
Care home – at least monthly
Community – at least every ____
•Refer to dietician, nutrition
support team or implement
local policy
•Improve and increase overall
Nutritional intake
•Monitor and review care plan
Hospital – weekly
Care home – monthly
Community – monthly
•Unless detrimental or no benefit
is expected from nutritional
support e.g. imminent death
The Mini-Nutritional Assessment (MNA) Scale
Anthropometric
Parameters
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Weight change
BMI
Arm span
Mid-arm or Calf Circumference
Triceps skinfold
MAMC and MAMA
Waist Circumference
Bioelectrical impedance
Dual photon absorptiometry (DEXA)
CT/MRI
Ultrasound
Underwater weighing
Stable isotopes
Abdominal Adiposity:
The Critical Adipose
Depot
A little poison now and then makes for
agreeable dreams, and much poison in the
end for an agreeable death
Nietzche: Thus Spoke Zorathiestra
Approach to Drug History
1. What is the target problem being treated?
2. Is the drug necessary?
3. Are nonpharmacologic therapies available?
4. Is this the lowest practical dose?
5. Could discontinuing therapy with a medicine help reduce
symptoms?
6. Does this drug have adverse effects that are more likely
to occur in an older patient?
7. Is this the most cost-effective choice?
8. By what criteria, and at what time, will the effects of
therapy be assessed?
Elementary,
My Dear Watson
Other Tests
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Hearing
Vision
Sleep apnea
Advance Directives
Health Promotion
Hallpike-Dix
Driving
Guns
Sex (ADAM)