1. Comprehensive Geriatric Assessment and the Patient- Centered Clinical Method

2. Objectives Describe the effectiveness of CGA Select and use an assessment tool Describe interventions to address functional impairment Consider patient and family goals when developing management plan

3. Comprehensive Geriatric Assessment: a Meta-analysis of Controlled Trials Mortality0.86 (0.75-0.98) Living at home1.26 (1.1-1.44) Hospital admissions 0.88 (0.79-0.98) Physical Fxn better1.10 (0.89-1.36) Cognitive Fxn1.41 (1.12-1.77) Stuck et al, Lancet, 1993:23;1032-1036

4. What is CGA? a multidisciplinary evaluation in which the multiple problems of older persons are uncovered, described, and explained, if possible, and in which the resources and strengths of the person are catalogued, need for services assessed, and a coordinated care plan developed to focus interventions on the person ’ s problems.

5. The Black Box of CGA

6. What happens in the black box? Multidisciplinary team Thorough medical evaluation Medical conditions Medication Assess multiple functional domains Validated instruments

7. What comes out of the box? General medical problems Depression Incontinence Musculoskeletal problems Hypertension Functional impairment Falls, vision and hearing

8. Patient-Centered Clinical Method History Physical Lab Feelings Ideas Function Expectations 1 – Exploring both disease and illness experience Cues and prompts 2 – Understanding the whole person Disease Illness Person Proximal Context Distal Context 3 – Finding Common Ground Problems Goals Roles Mutual decisions 4 – Incorporating prevention and health promotion 6 – Being realistic 5 – Enhancing the patient- physician relationship Patient-Centered Medicine: Transforming the Clinical Method, Stewart, M. et al, 2003

9. Make it work in practice The right patient The right tools, administered the right way The right people Common, prioritized goals Follow-up

10. Targeting

11. Target - at risk for decline Age ≥ 75 Fxn: ≥ 1 ADL def; falls; poor health Util: ≥ 1 hosp admission; ≥ 6 visits; ≥ 5 prescription meds Med: CAD, DM, Depression, UI Social: Absence of a caregiver Self-reported task modification

12. Domains of function

13. The Right Instrument

14. Characteristics of Functional Assessment Instruments Diagnostic characteristics Validity Sensitivity (NPV)/Specificity (PPV) Ceiling/Floor Reliability Ease of administration Who provides data? Self-report Caregiver report Physical performance test Sensitivity to change

15. The right people