老年病学教学课件：老年医学评估

GeriatricAssessment1TeachingPurposeandRequirementsMaster:

ComponentsoftheGeriatricAssessment;Strategicapproachestogeriatricassessmentforthepracticingclinician;Know:Comprehensivegeriatricassessment(CGA);Understand:Whydowegeriatricassessment?2ContentsPart1：

ComponentsoftheGeriatricAssessmentPart2：

StrategicapproachestogeriatricassessmentforthepracticingclinicianPart3：

Comprehensivegeriatricassessment3WhyDoWeGeriatricAssessment?Identifyproblems:symptomunderreporting,functionallossoftenfirstdiseaseindication;Identifyrisks:death,NH,falls,UI,MVA;Identifyresourcesandstrengths;Riskstratificationforinterventions,DxorRx;MonitorRxresponseanddiseaseprogression;SetclinicalobjectivesforRxorrehab;Communicationamongmultipleprofessionals，develop,implementandmonitoranintegratedandcoordinatedcareplan.4ContentsPart1：ComponentsoftheGeriatricAssessmentPart2：

StrategicapproachestogeriatricassessmentforthepracticingclinicianPart3：

Comprehensivegeriatricassessment5ComponentsoftheGeriatricAssessment6AssessmentofFunctionMeasurementoffunctionalstatusisanessentialcomponentoftheassessmentofolderpersons.Thepatient’sabilitytofunctioncanbeviewedasasummarymeasureoftheoverallimpactofhealthconditionsinthecontextofhisorherenvironmentandsocialsupportsystem.Therefore,changesinfunctionalstatusshouldpromptfurtherdiagnosticevaluationandintervention.Measurementoffunctionalstatusisalsovaluableinmonitoringresponsetotreatmentandmayprovideprognosticinformationthatwillhelpplanforlong-termcare.7AssessmentofFunctionPredictiveValueofFunctionFunctionalStatusatAge70AverageLifeExpectancy(years)AnnualHealthCareCosts($)Independent14.3$4600IADLDeficitOnly12.4$8500>1ADLDeficit11.6$14,0008ValidatedScreensforFunctionActivitiesofDailyLiving?Vision:Doyouhavetrouble? Hearing:Audioscope,whisperedvoiceLegstrength,balance:UpandGoTestUrinaryincontinence:Doyouwet;>6days?Nutrition:10lb.wt.Lossin6mo.or<100lbs.?Comprehensiveassessmentifscreenpositive9AssessmentofFunction——DailyLivingActivitiesofDailyLivingcanbeassessedatthreelevels:BADLs:basicactivitiesofdailyliving;IADLs:instrumentalorintermediateactivitiesofdailyliving;3.AADLs:advancedactivitiesofdailyliving.10AssessmentofFunction——DailyLiving1.BADLs:refertoself-caretaskssuchasbathing,dressing,toileting,continence,grooming,feeding,andtransferring.11AssessmentofFunction——DailyLivingLawtonADLScale(range0-6)ToiletingIndependent,noincontinenceAnythingelse10FeedingEatsIndependentlyAnythingelse10DressingDresses,undresses,selectsfromownwardrobeAnythingelse10GroomingAlwaysneat(hair,nails,hands,face,clothing)withoutassistanceAnydependence10WalkingIndependent,distances>1block<1blockorrestrictionsoraid10BathingBathesself(tub,shower,spongebath)aloneAnyassistance1012AssessmentofFunction——DailyLiving2.IADLs:refertotheabilitytomaintainanindependenthouseholdsuchasshoppingforgroceries,drivingorusingpublictransportation,usingthetelephone,mealpreparation,housework,homerepair,laundry,takingmedications,andhandlingfinances.13AssessmentofFunction——DailyLivingLawtonIADLScale(range0-8)TelephoneIndependent,dialsfewnumbers,answersonlyCannotuse10ShoppingIndependentCannot10FoodPrepIndependentNotindependent10HousekeepingIndependent,lightonly,lightbutdirtyhomeCannot10LaundryIndependent,smallitemsonlyCannot10TransportationIndependent,arrangestaxionly,publicassistedCannot,taxiorprivatecaronlywhenassisted10MedicationsTakesdrugsinrightdoseatrighttimeAnyassistance;e.g.,loadingofdailypillboxes10FinancesIndependent;assistancewithbank,bigpurchasesCannot1014AssessmentofFunction——DailyLiving3.AADLs:refertotheabilitytofulfillsocietal,community,andfamilyrolesaswellasparticipateinrecreationaloroccupationaltasks.15AssessmentofFunction——VisionVisualimpairmentisacommonandoftenunder-reportedproblemintheolderpopulation.ThestandardmethodofscreeningforproblemswithvisualacuityistheSnelleneyechart,whichrequiresthepatienttostand20ftfromthechartandreadletters,usingcorrectivelenses.Patientsfailthescreeniftheyareunabletoreadallthelettersonthe20/40linewiththeireyeglasses.16Hearingimpairmentisamongthemostcommonmedicalconditionsreportedbyolderpersons,affectingapproximatelyone-thirdofthose65yearsofageorolder.Screeningforhearinglosscanbeaccomplishedbyseveralmethods.OneofthemostaccurateoftheseistheHearingHandicapInventoryforElders.AssessmentofFunction——Hearing17HearingHandicapInventoryforElders.Methods:Doeshearingmakeyouembarrassedtomeetpeople?Doeshearingmakeyoufrustratedtalkingtoyourfamily?Doyouhavetroublehearingsomeonespeaksinawhisper?Doyoufeelhandicappedbyahearingproblem?Doeshearingcauseaproblemwhenvisitingfriends/relatives?Doeshearingpreventyouattendingreligiousservices?Doeshearingcauseargumentswithfamilymembers?DoeshearingmakeithardtolistentoTVorradio?Doeshearinglimitorhamperyourpersonalorsociallife?Doeshearingcausedifficultyinarestaurantwithfriends?ScoringandInterpretation: YES=4pts.;SOMETIMES=2;NO=0 0-8=normal;10-24=50%impairment;26-40=84%impairment.AssessmentofFunction——Hearing18Malnutritionisaglobaltermthatencompassesmanydifferentnutritionalproblemsthatareassociatedwithdiversehealthconsequences.Bothextremesofbodyweightplaceolderpeopleatriskforsubsequentfunctionalimpairment,morbidity,andmortality.Severalself-administerednutritionalquestionnairesareavailable,mostnotablytheNutritionScreeningInitiative’s10-itemchecklistandtheMini-NutritionalAssessment(MNA).AssessmentofFunction——Nutrition19Urinaryincontinenceiscommon,andisunder-recognized.Womenmaybeembarrassedtoraisetheissue;theyalsomayregarditasanormalaspectofaging.Askingtwoquestionscanscreenforincontinence:(1)“Inthelastyear,haveyoueverlostyoururineandgottenwet?”andifso,(2)“Haveyoulosturineonatleastsixseparatedays?”Inaresearchsetting,thosewhoansweredpositivetobothquestionshadhighrates(79%forwomenand76%formen)ofurinaryincontinenceasdeterminedbyaclinician’sevaluation.AssessmentofFunction——

Urinaryincontinence20Overone-thirdofcommunity-dwellingpersonsoverage65yearsfalleveryyear.Fallsareindependentlyassociatedwithfunctionalandmobilitydecline.Theriskoffallingcanbeassessedbyaskingallolderpatientsiftheyhavefalleninthelastyear,andthenperformingamultifactorialfallsassessmentbytestingbalance,gait,andlowerextremitystrength.Performingamultifactorialassessmentonpatientswhoscreenpositiveforfalls,andthentreatingtheirriskfactorsforfallingcanreducefallsby30%to40%.AssessmentofFunction——

BalanceandGaitImpairmentsandFalling21Evidence-BasedInterventionsforFallsExerciseorphysicaltherapyModificationofhomehazardsMedicationwithdrawaloradjustmentNutritionalorvitaminsupplementationReferralforcorrectionofvisualdeficiencyCardiacpacemakerforsyncope-associatedfallsMultidisciplinary,multifactorial,health,andenvironmentalrisk-factorscreeningandinterventionCognitive-behavioralinterventionSystemΔtopreventfallsinhigh-riskhospitalpatientsEducationofphysiciansinCTAssessmentofFunction——

BalanceandGaitImpairmentsandFallingTinettiMetal.NEJM.2008;359:25222CognitiveAssessmentBecausetheprevalenceofAlzheimer’sdisease,otherdementias,andcognitiveimpairment,risesconsiderablywithadvancingage,theyieldofscreeningforcognitiveimpairmentincreaseswithage.MINI-COGASSESSMENT:Combines3-itemrecalltestwithaclock-drawingtest(CDT);about3min,noequipment,littleeffectofeducationorlanguage.23MINI-COGASSESSMENT

Method：1.Instructpatienttolistencarefullytoremember3(unrelated)words,thenrepeatbacktoyou(tobesurethepatientheardthem)2.Instructthepatienttodrawthefaceofaclock(blankpageorwithcirclealreadyonit.3.Afterpatientputsnumbersonclockface,askpt.todrawhandsofclocktoread8:20.Nofurtherinstructionstobegiven.Ifafter3min,theCDTisnotfinished,gotonextstep.4.Askpt.torepeatthe3previouslypresentedwords.Scoring:1pointforeachrecalledwordafterCDT;0–3forrecall.2pointsfornormalCDT(allnumbersdepictedonce,incorrectorderandposition,handsshowrequestedtime),0forabnormalCDT.AddrecallandCDTscorestogetMini-CogScore-0-5.

Interpretation:3ormorenormal,2orlessabnormal24AffectiveAssessmentAlthoughmajordepressionisnomorecommonamongtheelderlythantheyoungerpopulation,depressionandotheraffectivedisordersarecommonandcauseconsiderablemorbidity.PatientHealthQuestionnaire-9(PHQ-9)hasincreasinglybeenusedtodetectandmonitordepressionsymptoms.ThePHQ-9isabriefpatient-administereddepressionscale,andprovidesareliableandvalidmeasureofdepressionseverity.25PatientHealthQuestionnaire-9(PHQ-9)Method：Choosebestanswerforhowyoufeltoverthepastweek.1.Areyoubasicallysatisfiedwithyourlife?yes/no

2.Haveyoudroppedmanyofyouractivitiesandinterests?yes/no3.Doyoufeelthatyourlifeisempty?yes/no

4.Doyouoftengetbored?yes/no

5.Areyouingoodspiritsmostofthetime?yes/no

6.Areyouafraidthatsomethingbadisgoingtohappentoyou?yes/no

7.Doyoufeelhappymostofthetime?yes/no8.Doyouoftenfeelhelpless?yes/no26PatientHealthQuestionnaire-9(PHQ-9)9.Doyouprefertostayathome,ratherthangoingoutanddoingnewthings?yes/no10.Doyoufeelyouhavemoreproblemswithmemorythanmost?yes/no11.Doyouthinkitiswonderfultobealivenow?yes/no12.Doyoufeelprettyworthlessthewayyouarenow?y/n13.Doyoufeelfullofenergy?yes/no

14.Doyoufeelthatyoursituationishopeless?yes/no15.Doyouthinkmostpeoplearebetteroffthanyou?yes/noScoringandInterpretation:1pointforeachblackanswer;>5suggestsdepression27AssessmentofSocialSupportThecompositionoftheolderpatient’ssocialsupportstructurecanbeassessedbyaskingafewquestionswhenobtainingthesocialhistory.Earlyidentificationofproblemswithsocialsupportmaypromptplanningtodevelopresourcesshouldthenecessityarise.28EconomicAssessmentAlthoughsomecliniciansfeeluncomfortableinassessingtheeconomicstatusoftheirpatients,insurancestatusisroutinelycollectedbyofficestaff.Forthefrailandfunctionallyimpaired,physiciansmayneedtobegindiscussionsofplanningtomobilizesavingsandotherresourcestoprovidepersonalattendantcare.29EnvironmentalAssessmentEnvironmentalassessmentencompassestwodimensions：1.Thesafetyofthehomeenvironment2.Theadequacyofthepatient’saccesstoneededpersonalandmedicalservices.30ContentsPart1：ComponentsoftheGeriatricAssessmentPart2：StrategicapproachestogeriatricassessmentforthepracticingclinicianPart3：

Comprehensivegeriatricassessment31AStrategicApproachtoGeriatricAssessmentPrevisitquestionnaires：canbecompletedbythepatientorproxybeforetheclinicalencounter.Thesequestionnairestypicallygatherinformationonpastmedicalhistory,medications,preventivemeasures,andfunctionalstatus,includinginformationonwhohelpswhenthepatientisfunctionallydependent.Asaresult,theycanmarkedlyreducethetimeneededtoconductaninitialassessmentandcanensureaconsistentlevelofcomprehensivenessforeverypatient.Byincludingvalidatedscreeninginstruments,theycanalsobeusedtocase-findindividualswithcommongeriatricsyndromes.32AStrategicApproachtoGeriatricAssessmentTodelegatetheadministrationofscreeninginstrumentsformanyoftheimportantgeriatricproblemstotrainedofficestaff.Thus,theclinicianmayspendashortperiodoftimereviewingtheresultsofthesescreensandthendecidewhichdimensions,ifany,needgreaterevaluation.Thismethodmaybetheonlywaytofeasiblyensurethatolderpatients’diversehealthneedsareaddressedcomprehensively.33AStrategicApproachtoGeriatricAssessmentAthirdapproachhasbeentointegratescreeningforgeriatricconditionsintotheofficeworkflowandthenusestructuredclinicalvisitnotestoguidemoredetailedassessmentandguidethecliniciantowardappropriatemanagementsteps.Thisapproachhasbeendemonstratedtoimprovethequalityofcareforfallsandurinaryincontinence.34ContentsPart1：ComponentsoftheGeriatricAssessmentPart2：StrategicapproachestogeriatricassessmentforthepracticingclinicianPart3：Comprehensivegeriatricassessment35ComprehensiveGeriatricAssessmentComprehensivegeriatricassessment(CGA)isbasedonthepremisethatasystematicevaluationoffrailolderpersonsbyateamofhealthprofessionalsmayuncovertreatablehealthproblemsandleadtobetterhealthoutcomes.36ComprehensiveGeriatricAssessmentComprehensivegeriatricassessment(CGA)typicallyincludesfourdimensions:physicalhealth;functionalstatus;psychologicalhealth,includingcognitiveandaffectivestatus;socioenvironmentalfactors.37ComprehensiveGeriatricAssessmentCGAisathree-stepprocess:(1)screeningortargetingofappropriatepatients,(2)assessmentanddevelopmentofrecommendations,(3)implementationofrecommendations,includingphysicianandpatientadherencewithrecommendations.Eachofthesestepsisessentialiftheprocessistobesuccessfulatachievinghealthandfunctionalbenefits.38ComprehensiveGeriatricAssessmentThegoalofscreeningortargetingofappropriatepatientsistodistinguishelderlypatientswhoareappropriateandwillbenefitfromCGA,fromthosewhoareeithertoosickoraretoowelltobenefit.SpecificstrategiesusedbyCGAprogramstoidentifyolderpersonswhoaremostappropriateforCGAhaveincludedchronologicalage,functionaldisability,physicalillness,geriatricconditions,psychosocialconditions,andpreviousorpredictedhighhealthcareutilization.39ComprehensiveGeriatricAssessmentThesecondstepofCGA,theassessmentprocessitself,continuestobehighlyvariableacrossprograms.Thetypesofhealthcareprofessionalsincludedintheassessmentteam,thecontentofinformationcollected,andthetypesandintensityofservicesprovidedhavedifferedinstudiesoftheeffectivenessofCGA.40ComprehensiveGeriatricAssessmentTheCGAprocessreliesonacoreteamconsistingofaphysician,nurse,andsocialworker.whenappropriate,drawsuponanextendedteamofvariouscombinationsofphysicalandoccupationaltherapists,nutritionists,pharmacists,psychiatrists,psychologists,dentists,audiologists,podiatrists,andopticians.41ComprehensiveGeriatricAssessmentCGAhasbeenimplementedusingmanydifferentmodelsinvarioushealthcaresettings：42ComprehensiveGeriatricAssessmentThekeyelementsoftheprocessofcarerenderedbyCGAteamscanbedividedintosixsteps:(1)datagathering;(2)discussionamongtheteam;(3)developmentofatreatmentplan;(4)implementationofthetreatmentplan;(5)monitoringresponsetothetreatmentplan;(6)revisingthetreatmentplan.143ComprehensiveGeriatricAssessment(1)datagathering：Standardizedassessmentscaneitheruseinstrumentsdevelopedspecificallyforclinicalpurposesorassemblestandardinstrumentsthathavepreviouslybeenstudiedforvalidityandreliability.Theadvantageoftheformeristhatteamscancustomizetheinformationbeinggatheredtobestsuittheclinicalneedsoftheprogram.Theadvantageofthelatteristhatpatientsintheprogramcanbecomparedtopatientsinotherprograms.44ComprehensiveGeriatricAssessment(2)discussionamongtheteam：Followinginitialdatagathering,theteammeetstodiscussthepatient’sgeriatricneeds.Anymemberoftheteamcouldtheoreticallyleadtheconference；Eachconferencetypicallybeginswithshortdiscipline-specificpresentationsfollowedbyinteractivediscussionsamongprofessionals.Theteamthenidentifiesproblemsthatneedactionandmightberesponsivetotreatment.45ComprehensiveGeriatricAssessment(3)developmentofatreatmentplan：Baseduponabovediscussion,theteamdevelopsaninitialtreatmentplanandgoalsforthepatient.CGAteamsshouldadviseprimarycarephysiciansandpatientstofocusonthemajorrecommendations,thosethataremostlikelytoproducethedesiredoutcomes.Theurgencyofrecommendationsmustalsobedetermined.46ComprehensiveGeriatricAssessment(4)implementationofthetreatmentplan：TheissueofimplementationisparticularlycriticaltothesuccessofCGAconsultationprograms.Avarietyofoptionsforimplementationareavailablerangingfromdirectimplementationofrecommendationsbytheteamtomerelyadvisingphysiciansandpatientsbyanoteinthechartorverbally.47ComprehensiveGeriatricAssessment(5)monitoringresponsetothetreatmentplan：Toensurethatrecommendationsareimplementedandtofollowapatient’sprogressthroughthetreatmentplan,patientsmustbemon-itoreddirectlybytheCGAteamorbytheprimarycarephysician.48ComprehensiveGeriatricAssessment(6)revisingthetreatmentplan：Bymonitoringthepatient,CGAteamscancontinuallyassessthepatient’sprogresstowardmeetingthegoalsestablishedbytheteam.Ifprogressisnotproceedingaccordingtoexpectations,theteammayneedtoreevaluatethepatientandresumetheteamdiscussion.49ComprehensiveGeriatricAssessmentEffectivenessofComprehensiveGeriatricAssessmentGeriatricEvaluationandManagementUnitsInpatientConsultationPosthospitalDischargeAssessmentandManagementOutpatientConsultationIn-HomeAssessment50ComprehensiveGeriatricAssessment1.GeriatricEvaluationandManagementUnitsThemeta-analysisindicatedthatthehospitalorrehabilitationunitmodelofCGAhadthestrongestandmostconsistentbenefitsonlivingathomeandfunctionalstatus.51ComprehensiveGeriatricAssessment2.InpatientConsultationlittlebenefit