Components Of Comprehensive Geriatric Assessment Research Articles

Comorbidity and prognostic indices do not improve the 5-year mortality prediction of components of comprehensive geriatric assessment in hospitalized older patients.

BackgroundAdvancing age is associated with increased vulnerability to chronic health problems. Identifying factors that predict oldest-old status is vital for developing effective clinical interventions and public health strategies.MethodsObservational prospective study of patients aged 75 years and older consecutively admitted to an Acute Geriatric Ward of a tertiary hospital. After a comprehensive geriatric assessment all patients were assessed for five comorbidity indices and two prognostic models. Univariate and multivariate logistic regression models were fitted to assess the association between each score and 5-year mortality. The ability of each score to predict mortality was assessed using the area under the receiver operating characteristic curve.Results122 patients were enrolled. All patients were followed up for five years. 90 (74%) of them died during the study period. In the logistic regression analyses, apart from age, cognitive impairment and Barthel Index, three indices were identified as statistically associated with 5-year mortality: the Geriatric Index of Comorbidity and the two prognostic indices. The multivariate model that combined age, sex, cognitive impairment and Barthel showed a good discriminate ability (AUC = 0.79), and it did not improve substantially after adding individually any of the indices.ConclusionsSome prognostic models and the Geriatric Index of Comorbidity are better than other widely used indices such as the Charlson Index in predicting 5-year mortality in hospitalized older patients, however, none of these indices is superior to some components of comprehensive geriatric assessment.

Prospective registry of symptomatic severe aortic stenosis in octogenarians: a need for intervention

OBJECTIVE: To study the factors associated with choice of therapy and prognosis in octogenarians with severe symptomatic aortic stenosis (AS). STUDY DESIGN: Prospective, observational, multicenter registry. Centralized follow-up included survival status and, if possible, mode of death and Katz index. SETTING: Transnational registry in Spain. SUBJECTS: We included 928 patients aged ≥80 years with severe symptomatic AS. INTERVENTIONS: Aortic-valve replacement (AVR), transcatheter aortic-valve implantation (TAVI) or conservative therapy. MAIN OUTCOME MEASURES: All-cause death. RESULTS: Mean age was 84.2 ± 3.5 years, and only 49.0% were independent (Katz index A). The most frequent planned management was conservative therapy in 423 (46%) patients, followed by TAVI in 261 (28%) and AVR in 244 (26%). The main reason against recommending AVR in 684 patients was high surgical risk [322 (47.1%)], other medical motives [193 (28.2%)], patient refusal [134 (19.6%)] and family refusal in the case of incompetent patients [35 (5.1%)]. The mean time from treatment decision to AVR was 4.8 ± 4.6 months and to TAVI 2.1 ± 3.2 months, P < 0.001. During follow-up (11.2-38.9 months), 357 patients (38.5%) died. Survival rates at 6, 12, 18 and 24 months were 81.8%, 72.6%, 64.1% and 57.3%, respectively. Planned intervention, adjusted for multiple propensity score, was associated with lower mortality when compared with planned conservative treatment: TAVI Hazard ratio (HR) 0.68 (95% confidence interval [CI] 0.49-0.93; P = 0.016) and AVR HR 0.56 (95% CI 0.39-0.8; P = 0.002). CONCLUSION: Octogenarians with symptomatic severe AS are frequently managed conservatively. Planned conservative management is associated with a poor prognosis.

Comprehensive geriatric assessment (CGA) in men age 70 or over with localized prostate cancer.

184 Background: There has been a four-fold increase in incidence of prostate cancer (PC) in men age 70 or older in England in the last 30 years. Which treatment (surgery, radiotherapy, or surveillance) is right for which patient depends on a number of factors including the risk of death from competing causes and fitness for the proposed treatment. Objective assessments such as those included in a Comprehensive Geriatric Assessment (CGA) might be helpful in this regard. The primary objective of this study is to describe CGA scores of a cohort of older men with PC. The secondary objectives are to examine if a single score (the Vulnerable Elders Survey [VES-13]), is a suitable screening test for a full CGA and to assess whether scores predict radiotherapy toxicity. Methods: Patients age 70 and older with localised PC completed a CGA prior to commencement of radical radiotherapy. The CGA assessed WHO performance status (PS), activities of daily living (ADL), instrumental activities of daily living (IADL), Charlson co-morbidity index, number of medications, mini-nutritional assessment (MNA), social network index (SNI), G8 score, and VES-13. Participants had acute radiotherapy toxicity assessed 12 weeks post-treatment completion. Results: As of September 2013, 100 patients had been recruited. Median age was 74.5 (range 70 to 82). Ninety five percent of patients had a PS less than two. Using the VES-13 tool, 5.2% scored greater than two. 22.6% scored less than 14 on G8 scoring. Additionally, 13.5% were not fully independent on ADLs, 4.2% were not fully independent on IADLs, 32.3% scored greater than one on the Charlson Index, 12.3% had a history of depression or dementia, and 52.9% were on more than three prescription medications. Fourteen percent were at risk of malnutrition and 2.3% were malnourished according to MNA scores, 25.0% had SNI scores less than three and 9.3% of patients had fallen at least once in the preceding three months. Twelve week follow-up data regarding acute radiotherapy toxicity is currently being collected; these will be correlated with the CGA components and presented at the 2014 ASCO Genitourinary Cancers Symposium. Conclusions: These data demonstrate that many older men with localised prostate cancer are vulnerable according to a CGA. Correlations observed between radiotherapy toxicity and CGA scores would have important implications for therapeutic decisions.

Evaluation of tolerance of Temozolomide in different strategies for management of the older person with glioblastoma

Introduction: The diagnostic value of Comprehensive Geriatric Assessment(CGA) in oncology centres has not yet been established in India. Objectives: To assess whether CGA is feasible,reproducible and comparable in oncology patients in India. Methods: Biopsy proven cancer patients above 65 years,visiting our centres consenting for CGA, not Delirious or suffering from Encephalopathy were included in this analysis.The following components of CGA were assessed: Medical parameters, Nutritional Status, Depression, Neurocognitive functioning, Activities of Daily Living/Instrumental Activities of Daily Living and Quality of Life. A brief self-assembled battery of standardised & culture-fair tests: Mini-mental Status Examination(MMSE), Geriatric Depression Scale(GDS), OARS Activities of Daily Living/Instrumental Activities of Daily Living(ADL/IADL), WHOQuality of Life Scale BREF(WHO-QOL). A trained Psychologist conducted all CGAs with the help of primary oncologist, dietician and occupational therapist.As an exercise, to estimate the feasibility of CGA tools, 1 patient was selected for a detailed CGA(completion time 6 hours). Later, an abbreviated version was developed whereby administration time reduced to 20-30 minutes per CGA and conducted on OPD,IPD and Day Care settings Results: Total N = 46 patients, met our inclusion criteria. Male: Female ratio = 26:20; Age-wise distribution:N65:16,N70-11,N75= 5,N804,N85= 1; Solid Tumors: Lymphoma patients = 38:8. All patients had Performance status of 0,1 7 2(except 1)according to ECOG.18 out of 38 had more than or equal to 2 co-morbidities. Refer the following tables: Interestingly on ADL/IADL scale, Excellent ADL/IADL(n= 11) and Good ADL/IADL(n= 6) whereas mild-moderate impairment in ADL/ IADL(n= 17) and Severely impairment(n= 7), except 1 with complete impairment.On WHO-QOL BREF, on Physical Health Satisfied: Unsatisfied= 11:27; Psychological Health Satisfied:Unsatisfied= 32:6; Social Relationships Satisfied:Unsatisfied= 28:10; Environment Satisfied:Unsatisfied= 27:3 All patients with Severe impairment on any/all areas,had performance status of ≤2 according to oncologist’s review. Conclusion: CGA is a feasible, reproducible procedure involving a multidisciplinary approach. A trained Psychologist is needed as per international standards to administer & interpret psychometric tools used for CGAs.Approx.20% patients had severe impairment in either/ all of the areas, were deemed fit for chemotherapy by the Medical Oncologist.

From the February Issue of JAMDA

The prevalence of anorexia in nursing homes is high even though several possible causes are preventable, according to a longitudinal study that also showed excess mortality among patients with anorexia. “Scientific evidence indicates that a significant number of elderly in nursing homes fail to get proper amounts and types of food necessary to meet essential energy and nutrient needs,” Dr. Francesco Landi, a professor of gerontology and geriatrics at Catholic University of Sacred Heart, Rome, said in an interview. Dr. Landi and his colleagues examined baseline data from 1,904 nursing home residents enrolled in the U.L.I.S.S.E. study to determine the prevalence of anorexia, defined as nutrient intake below 70% of estimated needs. They also looked for factors correlated with anorexia and survival rates. U.L.I.S.S.E. is a prospective, 1-year observational cohort study of the quality of care for older patients in hospitals, in nursing homes, and at their homes in Italy. More than 12% (240) of the patients had anorexia. The risk was nearly double among patients who had behavioral problems, chewing problems, dementia, depression, and constipation, as well as among those taking proton pump inhibitors and opioids. The mortality rate among 1,490 patients scheduled for 1-year follow-ups was double among patients with anorexia. The 271 deaths that occurred included 33.9% of patients with anorexia vs. 15.9% of those without the condition. “Anorexia among elderly is common, under-recognized, and undertreated,” Dr. Landi said. “Mechanisms involved in the age-related physiopathological decline in appetite and food intake are multifactorial and not completely understood.” The researchers cited factors including declining taste and smell that make food no longer enjoyable and medications that may further impair these senses. Dentures or poor dental health can make chewing difficult. Also, loneliness and depression can lead to decreased appetite. Studies have shown that anorexia is prevalent among frail elderly subjects in nursing facilities, and impairments in wound healing, immune response to infections, coagulation capacity, gut function, and muscle mass are correlated with anorexia. “Anorexia needs to be considered as an important geriatric syndrome,” Dr. Landi said. “Anorexia is a clinically relevant problem that impacts morbidity, mortality, and quality of life. Nutritional variables are a cardinal component of comprehensive geriatric assessment. Early recognition and care planning can help to ensure appropriate and timely nutritional intervention.” ▸ Source: Prevalence and Potentially Reversible Factors Associated with Anorexia among Older Nursing Home Residents: Results from the ULISSE Project – Landi et al. A skilled nursing facility is perhaps the most error-prone medical workplace, especially when dealing with new residents, contended Richard W. Miles of Bella Vista, Ariz. The reasons include cognitive errors that result when hospital and nursing home physicians fail to communicate about necessary changes to a patient's treatment plan and when families and patients have low expectations about their care. Citing medical literature and individual physicians' experiences, Dr. Miles said that several other factors are at work, as well. For example, patients and families often mistakenly believe that all community-based physicians are adept in the long-term care setting and that various doctors typically work together to craft a care plan. These same families often enter nursing homes with negative attitudes toward the physician who assumes the patient's care. Dr. Miles said that nursing home physicians can identify and correct their own cognitive errors by recognizing various psychophysical principles. “It is critical that long-term care physicians maintain a zero tolerance for flawed treatments because ‘failure to speak up’ [about another physician's mistake] places the patient at risk, and tolerance has a cumulative effect on local standards of care,” he added. Dr. Miles suggested that training in the cognitive psychology of medical decision making should be a core requirement for becoming a Certified Medical Director. ▸ Source: The Psychophysics of Transition to Long-Term Care – Miles

Factors influencing noncompliance with medication regimens in the elderly

Poor medication compliance is a major issue in the health care of older patients. To identify risk factors for medication noncompliance in the elderly, inpatients aged 65 years and older at Nagoya University Hospital and at Chubu National Hospital underwent a comprehensive geriatric assessment and tests for the assessment of medication compliance. The dependency of medication assistance by a caregiver is associated with low physical function activity, cognitive impairment, depression and communication inability. Medication noncompliance was not associated with the score of any component of comprehensive geriatric assessment. There was a good relationship between patient's knowledge of medications and the frequency of dosage interval, both of which were associated with the score of instrumental ADL, cognitive function and communication ability. The knowledge was also associated with the medication compliance at Nagoya University Hospital but not at Chubu National Hospital. These results may suggest that the elderly patient's understanding of a medication regimen is important but that other factors are also required to maintain their treatment regimen.

Body mass index and mortality among older people living in the community.

To determine if body mass index (BMI = weight/height2), predictive of mortality in seriously ill hospitalized and institutionalized patients, is also predictive of mortality in a longitudinal epidemiologic study. A prospective cohort study. Rovereto, a town in northern Italy. A consecutive sample of 214 patients aged 81.2 +/- 7.3 years receiving community care services. Malnutrition and mortality. According to logistic regression analysis, malnutrition status, expressed by a BMI < 22 Kg/m2, was correlated with dependency in Activity of Daily Living (odds ratio 1.21; 95% confidence interval (CI) 1.01-1.45). Only a low BMI was associated with 1-year survival in Cox regression analysis, after adjusting for potential confounders (relative risk 0.85; 95%CI, 0.74-0.97). A high BMI (>27 Kg/m2) was not significantly related to risk of mortality. Nutrition variables are a cardinal component of comprehensive geriatric assessment. Our results suggest that BMI, a simple anthropometric measure of nutritional status, is an important predictor of mortality among older people living in the community. Even when controlling for clinical and functional variables, a low BMI remained a significant and independent predictor of shortened survival.

Looking inside the black box of comprehensive geriatric assessment: a classification system for problems, recommendations, and implementation strategies.

To develop and test the inter-rater reliability of a coding system for geriatric problems identified through Comprehensive Geriatric Assessment (CGA) of hospitalized older persons, recommendations generated by the assessment, and implementation strategies for these recommendations. Validation study. A health maintenance organization and a geriatrics academic program. A total of 49 hospitalized older persons, who met at least 1 of 13 inclusionary "targeting" criteria, two geriatricians, and one social worker who coded forms. Standardized coding of CGA consultation sheets into (1) geriatric problems identified, (2) recommendations, and (3) implementation strategies; inter-rater reliability testing of coding system using two physicians and a social worker. On average, each assessed patient had 4.8 recommendations. The largest percentages of recommendations were for non-physician referrals (18.2%), advance directives (13.4%), medication adjustments (11.5%), diagnostic evaluation/monitoring (11.5%), and community services (10.9%). The proportions of agreement between raters in coding problems ranged from 0.77 to 0.90, in coding recommendations from 0.69 to 0.86, and in coding implementation strategies from 0.68 to 0.83. A classification system for measuring some components of the process of care of CGA has satisfactory inter-rater reliability, can be adapted for other settings, and may provide valuable insight into determining which components of CGA confer health benefits.