Gediatric syndrome - Dr Das.pptx

INTRODUCTION
In India
• Elderly population has increased from 24.71 million in 1961 to 104 million in 2011
Constituting 5.6% in 1961 to 8.6% of the total population in 2011.
Older population in India is growing at
• A rate three times higher than the rate of growth of population as a whole
At the country level,
• 27.72% of the older population reported an illness whether chronicor short-term in India
Banerjee, Shreya. "Determinants of rural-urban differential in healthcare utilization among the elderly population in India." BMC Public Health 21.1 (2021): 1-18.

INTRODUCTION
Due to multiple comorbidities and frailty,
• Elderly are at increased risk of adverse outcomes with each clinical insult.
Besides the common comorbidities such as diabetes and hypertension, older patients
can present with atypical presentation too.
Banerjee, Shreya. "Determinants of rural-urban differential in healthcare utilization among the elderly population in India." BMC Public Health 21.1 (2021): 1-18.

WHAT IS GERIATRIC SYNDROME?
Geriatric syndromes are a range of conditions representing multiple organ
impairment in older adults.
Unlike traditional chronic diseases, these syndromes cannot fit into discrete disease
categories and are loosely defined.
• Frailty
• Sarcopenia
• Cognitive impairment
• Urinary incontinence are widely recognized as common examples of geriatric syndromes.
However,
Cheung, J.T.K., Yu, R., Wu, Z. et al. Geriatric syndromes, multimorbidity, and disability overlap and increase healthcare use among older Chinese. BMC Geriatr 18, 147 (2018).
https://doi.org/10.1186/s12877-018-0840-1

WHAT I S DIFFERENCES BETWEEN GERIATIRCAND ADULT
MEDICINES
Geriatric medicine specializes in the health and care of elderly patients.
Geriatricians are doctors trained to care for older adults and address common age-related illnesses.
Internal medicine doctors provide general care for adults of all ages.
Geriatricians help manage chronic conditions and prevent age-related illnesses and injuries.
They offer support and resources for cognitive problems like memory loss.
Geriatricians are recommended for complex health needs.
Internists provide high-quality care for straightforward health needs.
Cheung, J.T.K., Yu, R., Wu, Z. et al. Geriatric syndromes, multimorbidity, and disability overlap and increase healthcare use among older Chinese. BMC Geriatr 18, 147 (2018).
https://doi.org/10.1186/s12877-018-0840-1

GIANTS OF GERIATRICS (ISAACS 1970)
Immobility
Instability
Intellectual
Impairment
Incontinence
Iatrogenesis

GERIATRIC ASSESSMENT
• Functional status
• Objective physical performance
• Comorbid medical conditions
• Cognition
• Nutritional status
• Psychological status
• Social support
The GA evaluates the following domains:
• an independent predictor of morbidity and mortality in older patients with cancer
Each domain is
Mohile, Dale, Hurria and Panel. ASCO Guidelines in Geriatric Oncology. JCO, 2018
Geriatric assessment (GA) is an approach to the evaluation of the older patient, leading to the early identification
and treatment of areas of vulnerability.

OBJECTIVES
Todefine what is a Comprehensive Geriatric Assessment (CGA)
Toidentify the components or domains of the CGA
To identify the target population for doing a CGA
Torecognize the clinical syndromes where a CGA must be done
Toexplain the various models of implementing a CGA
Toshow evidence of benefits of the CGA

WHAT ISTHECOMPREHENSIVEGERIATRIC ASSESSMENT?
• Multidimensional, interdisciplinary diagnostic process
• Develop a coordinated and integrated plan for treatment and long- term follow-up.
• Emphasizes quality of life and functional status, prognosis, and outcome that entails a
workup of more depth and breadth
• Employment of interdisciplinary teams and the use of any number of standardized instruments
• Both a diagnostic and therapeutic process
http://journals.sagepub.com/doi/pdf/10.1177/107327480301000603 https://www.uptodate.com/contents/comprehensive-geriatric-assessment
https://www.bmj.com/content/343/bmj.d6553

WHATARETHE
COMPONENTSOR DOMAINS
OFTHE CGA?

Comprehensive
Geriatric
Assessment
MEDICAL
HISTORY
Physical
Functional
Behavioral
Emotional
Environmental
Spiritual
Social

GERIATRIC ASSESSMENT GUIDES CLINICAL CARE
Mohile et al. JCO, 2018; Mohile et al. JAMA Onc, 2019

1. Functional Status
2. Physical Health
1. Vision impairment
2. Hearing loss
3. Nutrition status
4. Fall prevention
5. Urinary Incontinence
6. Osteoporosis and arthritis
3. Polypharmacy and Medication
Reconciliation
4. Cognitive Assessment
1. Dementia
2. Sleep and Insomnia
3. Mood disorder
ISSUES OF CONCERN
Issues of concern in geriatric assessment can be broadly divided into the following 4 classes:
Ghimire, Kiran, and Ranjan Dahal. "Geriatric Care Special Needs Assessment." (2021).

FUNCTIONAL STATUS
Functional status assessment evaluates one's ability to live independently.
It comprises basic activities of daily living (BADL) and instrumental activities of daily living (IADL).
BADL includes self-care activities like feeding, dressing, bathing, etc.
IADL includes activities for independent living such as medication management, shopping, cooking, etc.
Katz index assesses BADL, while the Lawton scale measures IADL.
Open-ended questions can also provide information about functional status.
Changes in functional status should prompt further evaluation due to its direct connection to physical health.
Validated tools like theVulnerable Elders Scale-13 and Clinical Frailty Scale measure functional ability.
Gait speed is proposed as a screening tool for functional status.
Higher gait speed is associated with better survival in pooled analysis.

PHYSICAL HEALTH
• Screening for diseases like diabetes, hypertension, and cancer should be based on patient
preferences, life expectancy, and co-morbid conditions.
• Vaccines such as influenza, pneumococcal, herpes zoster, and tetanus should be routinely
recommended for older patients.
Preventative Health
• Geriatric assessment should include detailed medical history and physical examination.
• Specific focus should be given to problems common in the elderly: vision, hearing, nutrition, fall
prevention, urinary incontinence, osteoporosis, and preventative health.

PHYSICAL HEALTH
• Hearing loss is the third most common condition in older patients and is associated with
functional decline, poor cognition, and depression.
• Routine screening is not recommended, but decline in function should prompt assessment.
• Patients who fail the screening test should be referred to an otolaryngologist for a possible
hearing aid.
Hearing
• Malnutrition affects up to 15% of the elderly population and is associated with physical decline,
poor cognition, and increased mortality.
• Clinical assessment and validated tools can be used for nutritional assessment.
• At-risk patients should undergo further evaluation and receive appropriate treatment.
Nutrition

PHYSICAL HEALTH
• Falls are common in older adults and can lead to physical and social limitations.
• Screening for falls and instability is recommended annually.
• High-risk patients benefit from a multidisciplinary approach to prevent falls.
Falls
• Urinary incontinence affects a significant percentage of older patients and can lead to
isolation and functional disability.
• Types of urinary incontinence include stress, urge, overflow, mixed, and functional.
• Evaluation includes medical history, self-voiding diary, and conservative treatments.
Urinary Incontinence

PHYSICAL HEALTH
• Osteoporosis screening is recommended for women over.
• Prevention includes early diagnosis, nutritional supplements, and fall prevention.
• Osteoarthritis is a major cause of disability and pain in older patients.
• Diagnosis involves ruling out other conditions and may require additional tests.
• Medication and joint replacement surgery can help manage symptoms and improve quality of
life.
Osteoporosis and Arthritis
• Visual impairment affects functional status and is associated with falls, cognitive decline, and
depression in the elderly.
• Common causes of visual impairment include cataracts, glaucoma, and macular degeneration.
• Visual screening is not recommended by the USPSTF, but decline in function should prompt
assessment.
Vision

POLYPHARMACY
Patients older than 65 account for over 30% of all prescribed medication in the U.S.
Polypharmacy in the elderly is
• Influenced by multiple factors, including comorbidities, multiple specialties involved in their care,
hospitalization and care transitions, self-medication, prescription cascade, and cognitive decline.
Taking multiple medications can lead to serious adverse effects due to the drugs themselves, drug-drug
interactions, and drug-disease interactions.

POLYPHARMACY
Polypharmacy increases the risk of iatrogenic illness, poor medication compliance, falls, decreased quality of
life, increased hospitalization, and even death.
Commonly prescribed drugs like aspirin, warfarin, oral hypoglycemic agents, insulin, and digoxin are
associated with significant hospitalizations due to adverse drug effects.
Regular medication reconciliation should be conducted at least annually and after each care transition to
ensure the necessity of the medications being taken.
The American Geriatric Society's Beers criteria provide a list of potentially inappropriate medications that
should be avoided in the elderly, serving as a reference for physicians.

COGNITIVEASSESSMENT
•Many older patients present to primary care providers with complaints of memory problems, highlighting the need for early detection and intervention.
•Early detection allows for identification of reversible causes, initiation of appropriate pharmacological interventions, and future planning for patients and caregivers.
•Primary care providers should have a low threshold to screen for cognitive decline in elderly patients.
•Various validated tools can be used to screen for cognitive decline, including the Mini-Mental State Exam (MMSE), Montreal Cognitive Assessment (MoCA) test, and Mini-Cog.
•The Mini-Cog is particularly useful in multi-lingual patients due to its simplicity and minimal language interpretation requirements.
Prevalence of mild cognitive impairment (MCI) and dementia increases with age.
Dementia: 5-7% prevalence; MCI: about 4 times more common than dementia.
Older patients at increased risk due to age, comorbidities, and other factors.
Early detection helps identify reversible causes, initiate timely interventions, and plan for the future.
Primary care providers should screen elderly patients for cognitive decline.
Validated tools for screening include MMSE, MoCA, and Mini-Cog.
Mini-Cog is suitable for multi-lingual patients due to its simplicity.

COGNITIVEASSESSMENT
• Insomnia is common in older patients and is associated with fatigue, falls, poor quality of life,
and mortality.
• Quality of sleep decreases with aging.
• Sleep disorders can be primary or secondary to other factors.
• Assessment should include evaluation for secondary causes.
• Non-pharmacological interventions are the first-line treatment for insomnia.
Sleep

COGNITIVEASSESSMENT
• Depression often starts in individuals aged 60 or older.
• Depression is associated with decreased cognition, functioning, self-care, and independence.
• Older patients with depression have a higher mortality rate, including a higher suicide rate.
• Treatment options include psychotherapy and antidepressant medications.
• Screening for depression is recommended for all adults.
• The PHQ-2 is a validated screening tool, followed by the PHQ-9 for diagnosis in the elderly.
Depression

CLINICAL SIGNIFICANCE
• Aging can lead to rapid deterioration in older patients.
• New signs or symptoms in the elderly can be caused by adverse medication effects.
• Medication reconciliation and avoidance of polypharmacy are important in every visit or
transition of care.
Medication Reconciliation and Polypharmacy
• Falls are a major cause of disability and morbidity in the elderly.
• Assessing for falls and discussing prevention strategies is important in each visit.
Falls Prevention
• Vision and hearing impairment can lead to functional decline and be mistaken for mood
changes or cognitive impairment.
• Assessment of vision and hearing impairment is crucial for patients with suspicious symptoms.
Sensory Issues

CLINICAL SIGNIFICANCE
• Urinary incontinence, osteoporosis, and arthritis can limit mobility and lead to functional decline.
• Detailed history and appropriate treatment are important for diagnosing and managing urinary
incontinence.
• Nutritional support, preventative health measures, safe medication use, and surgical options can improve
the health of patients with osteoporosis and arthritis.
Urinary Incontinence,Osteoporosis, andArthritis
• Early recognition of cognitive decline, including dementia, insomnia, and mood disorders, is crucial.
• Early intervention with behavioral and medical therapy can potentially reverse or slow disease progression.
Cognitive Decline
• Older patients make up a significant portion of healthcare consumers.
• Standardized tools can help address multiple issues in older patients.
• Regularly addressing these issues during clinic visits can improve outcomes for this vulnerable population.
Addressing Issues in Older Patients

SOME OFTHE OTHER ISSUES OF CONCERN INCLUDE
Elder mistreatment
Driving safety Home safety

HOME SAFETY
Unintentional injuries are a leading cause of death in older adults, with falls being the primary contributor.
Decline in overall health and isolation increase the risk of accidents at home.
Discussing preventive measures like proper lighting, handrails, and walking assistance devices can help prevent falls.
CDC's checklist for home fall prevention provides valuable guidance.

DRIVING SAFETY
Aging affects visual, motor, and cognitive abilities, which can impact driving skills.
Retiring from driving can be emotionally challenging for older individuals.
Individualized assessments, including tests for visual acuity, neck mobility, and reaction time, along with a multidisciplinary
approach, can evaluate and improve driving function.
If driving risks are high, discussing alternative transportation and mobility options with patients and caregivers is important.

ELDER MISTREATMENT
Elder mistreatment, including abuse and neglect, is prevalent but often underreported.
Signs of mistreatment include unusual bruising, burns, bite marks, genital trauma, pressure ulcers, low
BMI, and frequent ER visits.
Screening for mistreatment and involving a social worker for further evaluation is necessary.

COMPREHENSIVEGERIATRIC
ASSESSMENT

COMPREHENSIVE
HEALTH CARE
FOR ELDERLY
Cardiovascular
RiskAssessment
Nutritional
Assessment
Mental Health
Assessment
Non
Communicable
disease
management
Oral assessment
Ophthalmic
Assessment

RISK ASSESSMENT: ROLE OF ASHA
Completion of community based assessment checklist
(CBAC) for all
• The elderly for each village in the SHC-HWC area will be done by ASHA
• The section B# is specific to the elderly (persons 60 years and above)

COMPREHENSIVEGERIATRICASSESSMENTWHO DOESWHAT?

o
o
COMPREHENSIVEGERIATRIC ASSESSMENTTOOLKIT

Vision
Ask:“ Do you have If, Yes, TestVision
difficulty reading using - Snellen’s/ or
doing any of Finger
Counting
your daily activities
because of your
eyesight?" (even with
wearing glasses)
Right eye Left eye
If visual
impairment
present, refer to
medical
officer/specialist
for further
Assessment
Hearing Right ear Left ear If hearing
6,1,9 test (Stand behind the
patient
Normally impairment present, refer
and speak softly and then
in normal voice - 6,1, 9 and
check for hearing)
Softly
to medical
officer/specialist
for further
assessment
Have you noticed a change
in your weight over
the past 6 months?
Yes No If YES, Increase= -----kg or Decrease =----kg
Constipation Yes No Refer to medical
Insomnia Yes No officer for further assessment
B. SCREENING FOR OTHER AGE- RELATED PROBLEMS

Activities Points (0 or 1) Independence (1 point)
NO supervision, direction or personal assistance
Dependence (0 point)
WITH supervision, direction, personal assistance or total
care
Bathing (1 POINT) Bathes self completely or needs help in bathing
only a single part of the body such as the back, genital area or
disabled extremity.
(0 POINTS) Needs help with bathing more than one part
of the body, getting in or out
Dressing (1 POINT) Gets clothes from closets and drawers and puts on
clothes and outer garments complete with fasteners. May
have help tying shoes.
(0 POINTS) Needs help with dressing self or needs to be
completely dressed.
Toileting (1 POINT) Goes to toilet, gets on and off, arranges
clothes, cleans genital area without help
(0 POINTS) Needs help
transferring to the
toilet, cleaning self or
uses bedpan or
commode
Transferring (1 POINT) Moves in and out of bed or chair
unassisted. Mechanical transferring aides are
acceptable
(0 POINTS) Needs help in moving from bed to chair
or requires a complete transfer.
Continence (1 POINT) Exercises complete selfcontrol over urination and
defecation
(0 POINTS) Is partially or totally incontinent of bowel or
bladder.
Feeding (1 POINT) Gets food from plate into mouth without
help. Preparation of food may be done by another
person.
(0 POINTS) Needs partial or total help with feeding
or requires parenteral feeding

Aspects to be examined Findings (tick wherever applicable)
Level of consciousness Alert-oriented-cooperative
Build Thin/average/large
Stature Small/average/tall
Nutrition Undernourished/average/obese
Facial Appearance Absence of wrinkling of forehead/deviation of angle mouth
Hair Loss of hair
Colour of hair-white/grey/brownish discolouration
Eyes D
r
o
o
p
i
n
g

Mouth Dryness of lips
S
o
r
e
n
e
s
s
i
n
a
n
g
l
e
o
f
m
o
u
t
h
D

What to look for? Description
Joints 1. Redness
2. Swelling
3. Degree of movements
4. Increased local temperature
5. Tenderness
Cervical Spine 1. Pain
2. Stiffness
3. Tenderness
Thoracic Spine 1. Curvature
2. Scars
3. Discolorations

Drug with dose and schedule Drug with dose and schedule
1.
3.
5.
7.
9.
2. 4.
6. 8.
10.
Polypharmacy (any use of >4 drugs including
over the counter drugs and alternative
medicines)
YES NO

Acute Illness
Comorbidity
Geriatric Giants/Syndromes
Other age-related problem
Social problems
Economic problems
Suggested Prescription modification

Screening
A. Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing
or swallowing difficulties?
1. = severe decrease in food intake
2. = moderate decrease in food intake
3. = no decrease in food intake
B. Weight loss during the last 3 months
1. = weight loss greater than 3 kg (6.6 lbs)
2. = does not know
3. = weight loss between 1 and 3 kg (2.2 and 6.6)
4. = no weight loss

C. Mobility
1. = bed or chair bound
2. = able to get out of bed / chair but does not go out
3. = goes out
D.Has suffered psychological stress or acute disease in the past 3 month?
0 = yes
2 = no
E. Neuropsychological problems
1. = severe dementia or depression
2. = mild dementia
3. = no psychological problems
F.1 Body Mass Index (BMI) (weight in kg) / (height in m)2
1. = BMI less than 19
2. = BMI 19 to less than 21
3. = BMI 21 to less than 23
4. = BMI 23 or greater

IF BMI IS NOT AVAILABLE, REPLACE QUESTION F1WITH QUESTION F2. DO NOT ANSWER QUESTION
F2 IF QUESTION F1 IS ALREADY COMPLETED.
F
2
C
a
l
f
c
i
r
c
u
m
f
e

1 Do you sometimes have trouble making control his/her temper of aggression? Yes/No
2 Do you often feel you are being forced to at out of character or do things you
feel bad about?
Yes/No
3 Do you find it difficult to manage (‘s) behavior? Yes/No
4 Do you sometimes feel that you are forced to be rough with? Yes/No

5 Do you sometimes feel you cant do what is really necessary or what should
be done for?
Yes/No
6 Do you often feel you have to reject or ignore? Yes/No
7 Do you often feel so tired and exhausted that you cannot control meet (‘s) needs? Yes/No
8 Do you often feel you have to yell at? Yes/No
Total Score

Goals of care and advanced directives

GOALS OF CARE AND ADVANCED DIRECTIVES
Goals of care and advance directives should be discussed in ambulatory settings well in advance of health
crises.
Effective communication empowers patients to direct their treatment and cope with serious illness.
Discussions about goals of care should be tailored to individual patients' short and long-term goals.
Advance directives discussions help providers understand patients' wishes and minimize confusion at the end
of life.
These discussions also reduce healthcare costs by avoiding unwanted medical procedures.
Research shows that these discussions improve patients' quality of life and may even increase survival rates
by up to 25%.
Involving patients in these discussions does not increase depression, anxiety, or hopelessness; it improves
their well-being.
Family members also experience reduced stress, anxiety, and depression when goals of care and advance
directives are discussed.

Gediatric syndrome - Dr Das.pptx

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