1. Comprehensive Geriatric Assessment (CGA)  Physical health.  Mental health  Functional status  Social functioning  Environment.

2. Comprehensive Geriatric Assessment focuses on elderly individuals with complex problems functional status and quality of life interdisciplinary team of providers

3. Teams :  Physician geriatrician (internal medicine or family practice)  Nursing professional  Social worker Can be enriched by collegues from: - Geriatric psychiatry, neurology, podiatry, pharmacy, palliative care, sleep disorders, rehabilitation, dentistry, continence, and/or spiritual counselors.

4. Benefits of CGA  Decreased nursing facility admission  Decreased medication use  Decreased mortality  Decreased annual medical care costs  Increase diagnostic accuracy  Improved independence

5. "Five I's of Geriatrics" intellectual impairment immobility Instability incontinence iatrogenic disorders

6. nutrition vulnerable to inadequate nutrition limited dentition ill-fitting dentures loneliness, depression. Drugs prevalent medical conditions including constipation,congestive heart failure, cancer and dementia. Conversely, an elder is at increased risk of obesity by inactivity.

7. Social Living arrangements financial security transportation crime access to medical services risk factors for injury social networks death of a spouse or detachment

8. Components of Basic ADL Assessment Basic ToiletingFeedingDressingGroomingAmbulationBathing

9. Components of Instrumental ADL IADL Telephone use Shopping Food Preparation HousekeepingLaundryTransportationFinancesMedication

10. Environmental Identify SAFETY RISKS (home visit) – lighting, loose mats, handrails, stairs, showers/bath, kitchen storage Communication – telephone, alarms Good Surveillance system – frequent visits from Dr, Community nurses, social workers etc Nutrition PREVENTIVE REHABILITATION – for all illness

11. Medical history  Patient profile: current residence (house, apartment, nursing facility)  Medication review  Family history  Social history  Past history (prosthetic valves, artificial joints, metal plates or screws)  Review of systems (special attention to alterations in memory, weight change, falls, sleep problems, sensory losses, urinary incontinence, information about bowel habits, dietary history)

12. habits

13. Review of systems vision Loss of near vision (presbyopia) Loss of central vision Loss of peripheral vision Glare from lights at night Eye pain common with age macular degeneration glaucoma, stroke cataracts glaucoma, temporal arteritis

14. auditory Hearing loss Loss of high-frequency range (presbycussis) acoustic neuroma, wax,Paget's disease, drug-induced ototoxicity/common with age

15. GIT Constipation Fecal incontinence hypothyroidism, dehydration,hypokale mia, colorectal cancer,inadequate fiber, inactivity. drugs,fecal impaction, rectal carcinoma

16. Laboratory tests Serum cholesterol Blood glucose – glucose intolerance increases with aging. Heamoglobin. Vitamin B12 Thyroid function tests

17. Effect of medical & nursing care HOSPITALISATION Clinical IatrogenesisFunctional Iatrogenesis Side effects of: Medical intervention Diagnostic intervention Therapeutic intervention Side effects of: The process of These Interventions >50% of patients over 70 years experience a decline in Physical and/or Cognitive function Unrelated to the admitting diagnosis

18. Hospitalization Excess Bed rest Immobility Falls Incontinence Delirium Anorexia Additional Interventions Restraints Psychotropics NG feeds Catheters Additional Complications Pressure sores Delirium Agitation DVT & PE Aspiration Pneumonia UTI’s Bacteraemia Depression Disruptive behaviour FUNCTIONAL LOSS

19. Remember the caregiver! 80% of care of elderly is informal & unpaid Education & support of caregiver may be critical part of keeping your patient at home and safe

20. Abuse and Neglect: Caregiver Risk Factors and Clues Caregiver does not come to appointments Is concerned about medical costs History of substance abuse, mental health problems, conflicts with patient Dominates interview, won’t leave, won’t let patient talk Defensive, hostile, or indifferent Dependence on patient for income/housing

21. Advance directive Instructions given by patients for their future treatment should they become incompetent to consent to, or refuse, such treatment

22. Advance directives Living will Enduring power of attorney Suggested Reading: McQuoid-Mason, D. Advance Directives and the National Health Act. SAMJ 2006, 96, 12: 1236-1238

23. Prevention

24. Prevention Works for Older Adults Longer life Reduced disability  Later onset  Fewer years of disability prior to death  Fewer falls Improved mental health  Positive effect on depressive symptoms  Possible delays in loss of cognitive function Lower health care costs www.healthyagingprograms.org/content.asp?sectionid=85&ElementID=304

25. Preventive Interventions Screening Immunizations counseling.

26. screening Alcohol misuse Blood pressure Breast Cervical Colorectal Depression Obesity Osteoporosis Smoking Diabetes dyslipideamia

28. Immunizations Influenza Influenza infections cause substantial morbidity and mortality among older persons: Annual influenza vaccination for all those aged 65 and older is widely recommended Pneumococcal

29. chemoprophylaxis Aspirin- patients at increased cardiovascular risk

30. “Honest doc--if I had known I was gonna to live this long, I’d have taken better care of myself.”