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Dolores Buscemi, MD
Dept. of Internal Medicine
Objectives
Goal:
Optimize function
Multiple disciplines involved – physician,
Life expectancy:
75 years at birth
82 years at 65
Demography
Aging of the population has
heightened demand for
comprehensive health services
Persons > 65 account for 1/3 health
expenditures
More frequent and more prolonged
hospitalization
85% at least one chronic illness/30% 3
or more
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© 2005 Elsevier
Disease and disability are common at
advanced age but it is unclear whether
the continued growth of the older
population will lead to increased numbers
of debilitated elderly requiring extensive
medical/social support
Oxidative stress
Genetically regulated aging
Oxidative Stress
Normal metabolism generates
oxygen – free radicals that lead to
cumulative damage of DNA,
proteins and lipids over time
Supported by observation that low
levels of oxygen free radicals or
overexpression of protective
antioxidant enzymes leads to longer
lifespan in some species
Oxidative Stress
Aging may occur as result of
cumulative mutations in DNA or
errors in transcription or translation
May occur as result of oxidative
damage or spontaneoulsy
Insufficient to explain all age related
physiologic changes
Genetically Regulated
Programmed control aging process
Telomere attrition
Telomeres are redundant DNA
sequences at ends of chromosomes
essential for mitosis
Certain cell lines have less activity of
telomerase over time
Further cell division no longer possible
Normal Aging
Physiologic functioning is highly
variable among older individuals
Aging populations without disease on
average are characterized by
physiologic decline
Often difficult to distinguish “normal
aging” from disease associated with the
aging process
Normal Aging
Normal aging (absence of disease)
often classified into two categories:
Usual
Aging accompanied by typical
nonpathologic losses of physiologic
function
Successful
Physiologic decline during aging is
minimal/absent
Normal Aging
Physiologic losses have been attributed to
modifying effects of extrinsic variables
Diet
Exercise
Psychosocial factors
Need for further research into strategies
by which life-style modifications might
reduce morbidity
An 85 year old man is admitted to the hospital
with dehydration, fever and marked
disorientation. He is presumed to have fallen,
because he was found lying on the floor in his
bedroom. He had been discharged from a
rehabilitation hospital 2 months ago, after
recovering from an acute CVA. At that time he
was able to ambulate with a walker, and do
basic self-care.
He is febrile and tachypneic and has dry
mucous membranes. Chest x-ray is consistent
with a left lower lobe pneumonia.
Atypical Presentation of Illness
Improves function
Repetition of functional assessment may
be used to gauge impact of therapy
More appropriate medication use
May decrease number of acute care days
Functional Status
The capacity of an individual to
function in multiple domains
(physical, mental, social, emotional)
and at multiple levels (organ
function, function of person as
whole, function of person in society)
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© 2005 Elsevier
Who should be evaluated?
Three patient categories
3. Cognitive Disorders
Dementia/Delirium
Polypharmacy
Falls/Gait Instability
Urinary Incontinence
Depression
Malnutrition
Components of CGA
Anxiety
Hostility
Psychosis
Behavioral Problems
An 85 year old woman comes to your office
for the first time because she ahs lost 9.1 kg
in the last 6 months. She has no appetite
and foods taste different to her. A careful
history fails to identify a likely cause for
weight loss. She has HTN and OA.
Step height
Step continuity
Step symmetry
Walking stance
Path deviation
Hearing impairment
65-74y/o 25%
>85y/o 50%
Visual Impairment
Methods available for office
screening have limitations
Sensitivity/Specificityhave not been
established in older adults
Limitations in diagnostic accuracy of
glaucoma screening by primary care
physician
Visual Impairment
Screening should be performed
using Snellen test
Specific questions about functional
disability that might be due to poor
vision
Referral to Ophthalmologist if
needed
Hearing Impairment
Hand held audioscope
Performed in 90 seconds
94% sensitive, 72% specific
Physical exam techniques such as
whispered voice or finger rub can be used
Accuracy of tests may be enhanced if
combined with short questionnaire on
functional disability associated with
hearing impairment
Functional Assessment
Complement to screening for
specific impairments
Helpwith determining overall health
and well being
Guide to treatment plan
Help to plan long-term care services
Monitor effectiveness of
interventions
Functional Assessment
Choice between methods and
instruments to measure function
depends on frailty of patient
population, time available for
assessment and intended use of
information
Activities of Daily Living
One of the original methods and in
wide use today
Focuses on basic activities
Bathing Transferring
Dressing Continence
Toileting Feeding
Instrumental Activities of Daily
Living
Shopping
Using the telephone
Handling finances
Housekeeping
Using transportation
Food preparation
Taking medication
Assessment of Home Safety
Throughout the interior several
common features
Scatterrugs, adequate lighting, enough
room for easy mobility, emergency
telephone numbers posted
Kitchen
Bathroom
Outside the home
Assessment of Social Support
Assess the patient’s emotional
support
Identify actual/potential caregivers
Ask who would be available in an
emergency
Social information and background
may help assess coping ability
Long Term Options/Placement
Support for remaining in the home
Home health
Provider service
Day care
Nursing home
Conclusions
Value of CGA has been evaluated in the
inpatient and outpatient settings
Demonstrated to improve medical care
provided to frail elderly
Controlled studies have shown improved
patient outcomes
No study has shown worse outcomes
Inpatient units may improve survival
Conclusions
CGA should be targeted to patients
with potentially improvable function
Optimal targeting criteria have not
been established
May be that a patient without
potential for improved function
might benefit from depression
screening, medication review
Conclusions
Comprehensive Geriatric
Assessment has been advanced as a
means to more effectively diagnose
and manage complex medical
problems of frail elderly