www.drjayeshpatidar.blogspot.com 1Geriatric Assessment & Care ManagersA Care Plan is an outcome of a geriatric assessment, and is essentially an action plan forfuture care. A Care Plan lists all identified problems, suggests specific interventions oractions required and makes specific recommendations regarding resources needed toprovide the necessary support services.In This Article:What is geriatric assessment?When is a geriatric assessment neededWho performs a geriatric assessment?Geriatric care managersFinding a geriatric care managerCosts of geriatric care managementReferences and resourcesWhat is geriatric assessment?A geriatric assessment is a comprehensive evaluation designed to optimize an olderpersons ability to enjoy good health, improve their overall quality of life, reduce the needfor hospitalization and/or institutionalization, and enable them to live independently foras long as possible.An assessment consists of the following steps:1. An examination of the older persons current status in terms of:o Their physical, mental, and psycho-social healtho Their ability to function well and to independently perform the basicactivities of daily living such as dressing, bathing meal preparation,medication management, etc.
www.drjayeshpatidar.blogspot.com 2o Their living arrangements, their social network, and their access to supportservices.2. An identification of current problems or anticipated future problems in any ofthese areas.3. The development of a comprehensive "Care Plan" which addresses all problemsidentified, suggests specific interventions or actions required, and makes specificrecommendations regarding resources needed to provide the necessary supportservices.4. The management of a successful linkage between these resources and the olderperson and that persons family so that provision of the necessary services isassured.5. An ongoing monitoring of the extent to which this linkage has, or has not,addressed the problems identified, and the modification of the Care Plan asneeded.When is a geriatric assessment needed?A request for a geriatric assessment would be appropriate when there are persistent orintermittent symptoms such as:memory loss,confusion,or other signs of possible dementia.Often, what looks like Alzheimers or dementia can be the result of medicationinteractions or other medical or psychiatric problems. Because of the thoroughness of thegeriatric assessment, it is one of the best ways to determine what the actual problem andcause is or is not.Who performs a geriatric assessment?A geriatric assessment can be done in many different settings such as:a hospital,a nursing home,an outpatient clinic,a physicians office orthe patients home.It is an assessment that is comprehensive in scope, involving a complete review of thecurrent status of the older person in all of its complex dimensions, and because it is socomprehensive, it can only be successfully conducted by a multi-disciplinary team ofexperts. This team might include:physicians,ancillary personnel,
www.drjayeshpatidar.blogspot.com 3social workers,physical and/or occupational therapists,dieticians, psychologists,pharmacists, andgeriatric nurse practitioners.You can request a referral for a geriatric assessment from a primary care physician. Also,check with any large hospital or university to see whether they have a geriatricassessment unit.Geriatric care managersA geriatric care manager (GCM) is a professional with specialized knowledge andexpertise in senior care issues. Ideally, a GCM holds an advanced degree in gerontology,social work, psychology, nursing, or a related health and human services field.Sometimes called case managers, elder care managers, service coordinators or carecoordinators, GCMs are individuals who evaluate your situation, identify solutions, andwork with you to design a plan for maximizing your elders independence and well being.Geriatric care management usually involves an in-depth assessment, developing a careplan, arranging for services, and following up or monitoring care. While you arentobligated to implement any part of the suggested care plan, geriatric care managers oftensuggest potential alternatives you might not have considered, due to their experience andfamiliarity with community resources. They can also make sure your loved one receivesthe best possible care and any benefits to which they are entitled.Help provided by geriatric care managersGeriatric care managers facilitate the care selection process for family members who liveat a distance from their elderly relatives, as well as for those who live nearby but do notknow how to tap into the appropriate local services.You can hire a care manager for a single, specific task, such as helping you find a dailycaregiver, or to oversee the entire caregiving process. Geriatric care managers can helpfamilies or seniors who are:new to elder care or uncomfortable with elder care decision-making;having difficulty with any aspect of elder care;faced with a sudden decision or major change, such as a health crisis or a changeof residence;dealing with a complex situation such as a psychiatric, cognitive, health, legal, orsocial issue.In addition to helping seniors and their families directly, geriatric care managers can actas your informed connection with a range of other professionals who are part of yourelder care network, including any of the following service providers:
www.drjayeshpatidar.blogspot.com 4Attorneys or trust officers. A care manager can serve as both elder advocate andintermediary with financial and legal advisors. The GCM is often a good sourceof referrals if a family needs services from these professionals.Physicians. The GCM is an ideal liaison between doctors and other healthprofessionals, and the elder patient and family members.Social workers. It is useful for hospital and nursing home social workers anddischarge planners to know that their senior patient will have someone tocoordinate their care and assist them on a long-term basis.Home care companies. The GCM will know local agencies and be able toexplain options, costs, and oversight of home care workers. The care manager canalso assist in dealing with patients social issues, help link to other communityresources, and suggest possible placement options.Residential facilities. The GCM can help identify types of care facilities andassist you in selecting an appropriate one for your situation. The GCM may alsobe able to streamline the transition into or out of a senior community, for both theelderly resident, family members and staff.Finding a geriatric care managerIn addition to the many References and resources available, a good place to start yoursearch for a geriatric care manager is with your family physician. Other sources forreferrals include:your local Area Agency on Aging (call 1-800-677-1116 for the AAA in yourarea)local hospitals and health maintenance organizationssenior or family service organizationssenior centersreligious affiliations including churches and synagoguesYellow Page listings for Senior Citizens Services, Care Management, HomeCare, Home Health Services and similar subject areasMedicaid officesprivate care management companiesWhile geriatric care managers are frequently licensed by the state within their respectivefields of expertise, there are no state or national regulations for professional caremanagers per se. For this reason, anyone can use the title case or care manager.Membership in a professional organization and/or certification in care management aregood indicators of appropriate background. The National Association of ProfessionalGeriatric Care Managers recognizes the following designations for a "Certified CareManager": CMC, CCM, C-ASWCM and C-SWCM. Each of these requires testing andcontinuing education.When interviewing potential geriatric care managers, the NAPGCM suggests asking:Are you a member of a professional care or case management association?
www.drjayeshpatidar.blogspot.com 5Are you certified as a care manager? Do you hold other professional licenses orcertifications?How long have you been providing care management services?Are you available for emergencies?Does your company also provide home care services?How will you communicate information to me?Can you provide me with references from past clients?Costs of geriatric care managementPrivate geriatric care managers fees can range from $50 - $200 per hour, depending onwhere you live and what services you need. You may also be charged an intake fee of$50 - $300 for the initial visit, which is when the in-depth assessment takes place.While this may seem costly, bear in mind that a GCM will likely save you money in thelong run, by assessing your precise needs and helping you choose the specific servicesthat will best serve you now. In addition, most people require geriatric care managementonly intermittently once support services are in place. Following the initial assessment,your GCM will help your family carefully estimate the ongoing cost of service delivery.Although geriatric care management fees are not covered by Medicare or Medicaid, someemployers, insurance companies, health plans and financial service providers arebeginning to subsidize or cover these services for their members and clients. Long-termcare insurance is most likely to include care management.If you are unable to afford a private care manager, there are other options. Low-cost orno-cost geriatric care management is often available through a community agency, seniorservices organization or other non-profit agencies; your local Area Agency on Aging (call1-800-677-1116 for the AAA in your area) will be able to refer you to a city, county oragency source.In addition, most states offer a Medicaid waiver program that provides geriatric caremanagement and in-home services for individuals 65 and older, who are eligible for bothnursing home placement and Medicaid. In California, this program is available throughThe Multi-Purpose Senior Services Program (MSSP) throughout the state.References and resources about geriatric assessmentOther related linksThe FHA Physician Referral Service – Provides an online form for you to request a list ofgeriatric specialists in your area. Includes a brief listing of additional resources to assistyou in locating a doctor nearby. (American Geriatrics Society)
www.drjayeshpatidar.blogspot.com 6What Is Geriatrics? – Defines geriatrics and the role of a geriatrician. Describes the teamapproach and who should see a geriatrician. (American Geriatrics Societys Foundationfor Health in Aging)My Parents - How Do I Know If They Need Help? – Provides information on theimportance of geriatric assessments for older parents. (AARP)Talking With Your Doctor: A Guide for Older People – A helpful guide for preparing foryour appointment. Includes tips on questions to ask, preparing a health history, and tipsfor good communication with your doctors. (National Institute on Aging)FAQ: What Does a Geriatric Care Manager Do? – A thorough description of geriatriccare managers, why one uses them, and how to find one in your area. (Geriatric CareManagers of New England)A multidimensional process designed to assess an elderly persons functional ability,physical health, cognitive and mental health, and socioenvironmental situation.Comprehensive geriatric assessment differs from a standard medical evaluation byincluding nonmedical domains, by emphasizing functional ability and quality of life, and,often, by relying on interdisciplinary teams. This assessment aids in the diagnosis ofhealth-related problems, development of plans for treatment and follow-up, coordinationof care, determination of the need for and the site of long-term care, and optimal use ofhealth care resources.Geriatric assessment programs vary widely in purpose, comprehensiveness, staffing,organization, and structural and functional components. Most attempt to target theirservices to high-risk elderly persons and to couple their assessment results with sustainedindividually tailored interventions (eg, rehabilitation, education, counseling, supportiveservices).Comprehensive geriatric assessment of frail or chronically ill patients can improve theircare and clinical outcomes. The possible benefits include greater diagnostic accuracy,improved functional and mental status, reduced mortality, decreased use of nursing homesand acute care hospitals, and greater satisfaction with care. However, the cost ofcomprehensive geriatric assessment programs has limited their use. Although some cost-effectiveness evaluations suggest that these programs can save money, few programsoperate in integrated care systems that can track these savings. Wide use of comprehensivegeriatric assessment programs has thus been slow to develop. An alternative approach is toconduct less extensive assessments in primary care offices or emergency departments.An assessment instrument designed to help primary care physicians, nurses, and otherhealth care practitioners perform practical, efficient assessment is shown in Table 4-1. Itincludes elements from an instrument recommended by the American College ofPhysicians and from instruments validated and field-tested in randomized clinical trials.
www.drjayeshpatidar.blogspot.com 7To identify elderly persons who might benefit from assessment (in a specialcomprehensive geriatric assessment unit or in a primary care setting), some health careorganizations mail multidimensional self-administered health questionnaires to elderlypopulations. Responses are scored according to defined algorithms, and reports of high-risk conditions and behaviors are sent to the patients and their primary care physicians tostimulate more detailed follow-up evaluation and treatment. Other organizations identifycandidates for assessment by interviewing elderly persons in their homes or meeting places(eg, meal sites, senior centers, places of worship). Family members who are concernedabout an elderly relatives health or functional abilities may also arrange referrals forgeriatric assessment.THE 10 MINUTE GERIATRICASSESSMENTFredrick T. Sherman, MD, MScMedical DirectorSENIOR HEALTH PARTNERSMount Sinai School of Medicinewww.geri.comComprehensive Geriatric Assessment American Geriatrics Society (AGS)COMPREHENSIVE GERIATRIC ASSESSMENT POSITION STATEMENT*Last Updated August 26, 2005*BACKGROUNDComprehensive geriatric assessment has been defined by the 1987 National Institutes ofHealth Consensus Conference on Geriatric Assessment Methods for Clinical Decision-making as a "multidisciplinary evaluation in which the multiple problems of olderpersons are uncovered, described, and explained, if possible, and in which the resourcesand strengths of the person are catalogued, need for services assessed, and a coordinatedcare plan developed to focus interventions on the persons problems." Research
www.drjayeshpatidar.blogspot.com 8evaluating comprehensive geriatric assessment (CGA) demonstrates its ability to improvethe health status and quality of life of frail older adults across the spectrum of health caresettings.CGA is a necessary tool to minimize disability and loss of independence in frail elderlypatients. Aging is a process that steadily reduces physiologic reserve and results in adiminished ability to compensate for the toll of illness. Illnesses accumulate with age,increasing in both severity and number. This double burden of physiologic decline anddisease is associated with excess morbidity and resultant disability, i.e., difficulty inperforming simple physical and mental tasks necessary for daily life. CGA is anintervention that seeks to identify and remediate the causes and effects of disability.When remediation is not possible, CGA seeks to slow functional decline and bolsterindependence by mobilizing available medical, psychological and social resources.One of the goals of a responsive health care system is to promote the well-being of thosesuffering from the effects of disability and/or chronic illness. Randomized trials of CGA,applied across multiple health service settings, show it to be a cost-effective interventionthat improves quality of life, quality of health, and quality of social care. Its benefits havebeen most robustly demonstrated when applied in a hospital or rehabilitation unit, but itsvalue is also evident when used in the following settings: after hospital discharge, as anelement of outpatient consultation, in home assessment services, and in continuity care.Despite these benefits, the application of CGA remains underused in the United Statesand its use is limited primarily to academic health centers and Veterans Administrationhospitals that recognize its contribution to quality health care for older adults.POSITIONS1. Comprehensive geriatric assessment has demonstrated usefulness in improvingthe health status of frail, older patients. Therefore, elements of CGA should beincorporated into the care provided to these elderly individuals.Rationale: Not all older persons who might benefit from comprehensive geriatricassessment will receive specialized geriatric asssesment services. Practicingphysicians should be encouraged to apply the elements of geriatric assessment inthe care of older patients, including multidisciplinary teamwork, assessment offunction, and psychosocial assessment. Physicians and other health professionalsorganizations could appropriately take a leadership role in the dissemination ofthis assessment methodology.2. CGA is most effective when targeted toward older adults who are at risk forfunctional decline (physical or mental), hospitalization or nursing homeplacement.Rationale: A targeted population, the frail elderly, is the most likely to benefitfrom CGA. Targeting criteria used in successful trials of CGA suggest thatpersons who have impairments in basic or instrumental activities of daily living,or suffer from a geriatric syndrome (falls, urinary or fecal incontinence, dementia,
www.drjayeshpatidar.blogspot.com 9depression, delirium, or weight loss), or whose health care utilization patternsindicate a high risk of subsequent hospitalization or nursing home placement arethe most likely to benefit from CGA.3. Comprehensive geriatric assessment should be an integral part of the curriculumfor all medical and health professional training programs.Rationale: Routine CGA examines, at the very least, a patients mobility,continence, mental status, nutrition, medications, and personal, family, andcommunity resources. It involves all disciplines responsible for providing care, aswell as the patient and family, in developing an appropriate care plan.Comprehensive geriatric assessment is an effective tool for teaching theintegration of the biological, psychological, social, and environmental aspects ofhealth care, while recognizing the geriatricians special area of expertise.4. Medicare and other insurers should recognize as a reimbursable service orprocedure: 1) comprehensive geriatric assessment of patients who are at risk forfunctional decline (physical or mental), hospitalization or nursing homeplacement, and 2) the support services required for effective application of CGARationale: Comprehensive geriatric assessment requires an interdisciplinary teamto conduct medical, functional and psychosocial assessments, develop a written,comprehensive plan of care, and coordinate the health care providers and familymembers who are responsible for the execution of the plan of care. At the presenttime, Medicare payment policy does not reimburse the work of some necessaryprofessionals (e.g., social work, dietician) in assessment and does not recognizethe work of team conferences. Few professionals can or will provide the service ifit is not adequately reimbursed. Insufficient reimbursement of CGA ultimatelyrestricts the access of frail, older persons to this effective intervention andexacerbates the financial disincentives that aggravate our national shortage ofgeriatricians.REFERENCES1. Boult C. Boult L. Morishita L. Smith SL. Kane RL. Outpatient geriatricevaluation and management. J Am Geriatr Soc. 46(3):296-302, 1998 Mar.2. Boult C. Boult LB. Morishita L. Dowd B. Kane RL. Urdangarin CF.Arandomized clinical trial of outpatient geriatric evaluation and management. J AmGeriatr Soc. 49(4):351-9, 2001 Apr.3. Boult C. Brummel-Smith K. Post-stroke rehabilitation guidelines. The ClinicalPractice Committee of the American Geriatrics Society. J Am Geriatr Soc.45(7):881-3, 1997 Jul.
www.drjayeshpatidar.blogspot.com 104. Boult C. Pualwan TF. Fox PD. Pacala JT. Identification and assessment of high-risk seniors. HMO Workgroup on Care Management. Am J Manage Care.4(8):1137-46, 1998 Aug.
www.drjayeshpatidar.blogspot.com 11Geriatric Assessment Methods for Clinical Decision MakingNational Institutes of HealthConsensus Development Conference StatementOctober 19-21, 1987This statement is more than five years old and is provided solely for historicalpurposes. Due to the cumulative nature of medical research, new knowledge hasinevitably accumulated in this subject area in the time since the statement wasinitially prepared. Thus some of the material is likely to be out of date, and at worstsimply wrong. For reliable, current information on this and other health topics, werecommend consulting the National Institutes of Healths MedlinePlushttp://www.nlm.nih.gov/medlineplus/.This statement was originally published as: Geriatric Assessment Methods for ClinicalDecision making. NIH Consens Statement 1987 Oct 19-21;6(13):1-21.For making bibliographic reference to the statement in the electronic form displayed here,it is recommended that the following format be used: Geriatric Assessment Methods forClinical Decision making. NIH Consens Statement Online 1987 Oct Online 19-21 [citedyear month day];6(13):1-21.IntroductionThe population of elderly persons in the developed nations is growing with extraordinaryrapidity. Although the majority enjoy good health, many older people suffer frommultiple illnesses and significant disability. Comprehensive assessment methodologies,while not solely applicable to frail elderly persons, are believed to be particularly suitedto their situation. These individuals tend to exhibit great medical complexity andvulnerability; have illnesses with atypical and obscure presentations; suffer majorcognitive, affective, and functional problems; are especially vulnerable to iatrogenesis;are often socially isolated and economically deprived; and are at high risk for prematureor inappropriate institutionalization.To deal with the exceedingly difficult health care issues posed by frail elderly persons,health professionals need to collect, organize, and use a vast array of clinically relevantinformation. This process, comprehensive geriatric assessment, is defined as a
www.drjayeshpatidar.blogspot.com 12multidisciplinary evaluation in which the multiple problems of older persons areuncovered, described, and explained, if possible, and in which the resources and strengthsof the person are catalogued, need for services assessed, and a coordinated care plandeveloped to focus interventions on the persons problems.Comprehensive geriatric assessment generally includes evaluation of the patient inseveral domains, most commonly the physical, mental, social, economic, functional, andenvironmental.The term "functional" is used here in a narrow sense: It means the ability to function inthe arena of everyday living. The panel recognizes that the same word has been used inthe much broader sense of the whole range of functions we have listed just above. Inother words, some use "functional assessment" to mean what we have termed"comprehensive geriatric assessment."When applied to clinical decision making, comprehensive geriatric assessment involvesclinicians from the many health care professions who are necessarily involved in goodgeriatric care. Comprehensive geriatric assessment is only one component of generalgeriatric care. Appropriate geriatric care involves some level of assessment of themultiple domains just cited, but comprehensive geriatric assessment tends to be appliedonly to a subset of older persons who are frail and considered most likely to benefit (seequestion 3). It has been suggested that a new form of comprehensive assessment could bedeveloped to evaluate physical fitness for purposes of monitoring health promotion anddisease prevention in well older persons and another form to guide the humane care ofirreversibly disabled and terminally ill older persons.Between 1973 and 1987, reports have appeared on a significant number of trueexperiments exploring the elements and effectiveness of various approaches to geriatricassessment. The data from these studies, coupled with the growing numbers of frailelderly individuals, the high cost of their health care, the intensity of their distress anddiscomfort, and the great uncertainty as to the best route to wise clinical decision making,led to the current conference. The National Institute on Aging and the Office of MedicalApplications of Research of the National Institutes of Health, in conjunction with theNational Institute of Mental Health, the Veterans Administration, and the Henry J. KaiserFamily Foundation, convened the Consensus Development Conference on GeriatricAssessment Methods for Clinical Decision making on October 19-21, 1987. After a dayand a half of presentations by experts in the field, a consensus panel includingmethodologists and representatives of medicine, nursing, social work, and the publicconsidered the scientific evidence and developed answers to the following centralquestions:1. What are the goals, structure, processes, and elements of geriatric assessment forclinical decision making?2. What are the comparative merits of different methods in carrying out a geriatricassessment?
www.drjayeshpatidar.blogspot.com 133. What is the evidence that a geriatric assessment is effective? If so, in whatsettings, for whom, and for which outcomes?4. Insofar as a geriatric assessment is effective, what linkages to clinicalmanagement systems are required?5. What are the priorities for future research in geriatric assessment?Comprehensive geriatric assessment has been used for many nonclinical purposes,including research, education, health policy, and administration. This report focuses onlyon its use for clinical decision making.What Are the Goals, Structure, Processes, and Elements of Geriatric Assessment forClinical Decision Making?GoalsThe goals of comprehensive geriatric assessment are: (1) to improve diagnostic accuracy,(2) to guide the selection of interventions to restore or preserve health, (3) to recommendan optimal environment for care, (4) to predict outcomes, and (5) to monitor clinicalchange over time.StructureComprehensive geriatric assessment may be done in many institutional settings,including acute care, psychiatric, or rehabilitation hospitals and nursing homes, and inambulatory settings, including outpatient or freestanding clinics, the offices of primarycare physicians, or in the patients home. It often has been applied to elderly persons atcritical transition points in their lives, including actual or threatened decline in health andfunctional status, impending change in living environment, bereavement, or other unusualstress.ProcessesComprehensive geriatric assessment is initiated by a referral from one of a number ofsources (see question 4). In addition to the patient, the process often includes familymembers and other important persons in the individuals environment. It is conducted bya core team that consists, at a minimum, of a physician, nurse, and social worker, eachwith special expertise in caring for older people. Frequently, a psychiatrist is a member ofthe core team. The specific activities and contributions of each team member may varyconsiderably, and flexibility in roles may facilitate the assessment process.The assessment begins with a case-finding approach that utilizes screening instrumentsand techniques. Based on these initial findings, a more detailed assessment is frequentlyundertaken. This in-depth assessment often requires the participation of a number of
www.drjayeshpatidar.blogspot.com 14other professions. These may include audiology, clinical psychology, dentistry, nutrition,occupational therapy, optometry, pharmacy, physical therapy, podiatry, speechpathology, and the clergy. Support from other medical disciplines, such as neurology,ophthalmology, orthopedics, physiatry, surgery, and urology, is commonly needed.Some aspects of geriatric assessment may be provided by self-rating scales completed bythe patient or caregivers. Such information may lead to different insights than thoseobtained through external assessment performed by a member of the health care team.ElementsPhysical HealthA careful history is obtained from the patient and others with significant knowledge ofthe patient. Special attention is directed to the use of prescription and nonprescriptionmedications and clues to the presence of malnutrition, falling, incontinence, andimmobility. Data are gathered on smoking, exercise, alcohol use, immunization status,and sexual function. Also important is information regarding the patients personalstrengths, values, perceived quality of life, acceptability of interventions, and expectedoutcomes from his or her health care.A physical examination is performed with emphasis on identification of specific diseasesor conditions for which curative, restorative, palliative, or preventive treatment may beavailable. Special attention is directed toward visual or hearing impairment, nutritionalstatus, and conditions that may contribute to falling or difficulty in ambulation.Laboratory tests and other diagnostic studies are obtained as indicated.Mental HealthCognitive, behavioral, and emotional status are evaluated. Detection of dementia,delirium, and depression is particularly important. A range of assessment instruments isavailable for these purposes. For some patients a detailed psychiatric interview, aneurobehavior consultation, or comprehensive neuropsychological testing is indicated.Social and Economic StatusEvaluating the social support network includes identifying present and potentialcaregivers and assessing their competence, willingness to provide care, and acceptabilityto the older person. This information may be obtained by questionnaires, structuredinterviews, or other methods. The degree of caregiver stress and the caregivers supportnetwork also are considered.Areas of special importance to the individual, such as cultural, ethnic, and spiritualvalues, are noted. The individuals own assessment of the quality of life is recorded. Theclinician evaluates the economic resources of the elderly person, which often determineaccess to medical and personal care and influence options for living arrangements.
www.drjayeshpatidar.blogspot.com 15Functional StatusThere are several components to a comprehensive assessment of an older persons abilityto function. Physical functioning usually is measured by the ability to accomplish basicactivities of daily living (ADL), including bathing, dressing, toileting, transferring,continence, and feeding.Other components of functional well-being are behavioral and social activities thatrequire a higher level of cognition and judgment than physical activities. Theseinstrumental activities of daily living (IADL) include preparation of meals, shopping,light housework, financial management, medication management, use of transportation,and use of the telephone.Functional status (ADL and IADL) is probably most accurately evaluated by directobservation of the patient by family or health professionals in the home or a simulatedhomelike environment. However, surprisingly accurate information is also obtained bystandardized questionnaire or self-report.Environmental CharacteristicsEvaluating the patients physical environment is essential. Home visits and questionnairesare used to determine the safety, physical barriers, and layout of the home as well asaccess to services, such as shopping, pharmacy, transportation, and recreation.Development and Implementation of a Care PlanComprehensive geriatric assessment is a dynamic, ongoing process. After the initialassessment, the team generates a comprehensive list of the patients needs and strengths,usually at a multidisciplinary case conference. Recommendations are integrated into anindividualized plan of interventions and desired outcomes. The preferences of the patientand family must be especially carefully considered at this stage in the process. If theassessment takes place in an inpatient facility, treatment and rehabilitation are ofteninitiated in that facility, sometimes directly by members of the team on a specialized unit.In consultative models, the teams recommendations are transmitted to the appropriateprimary care providers. Regardless of the site of assessment or the primary responsibilityfor implementation of the recommended regimen, periodic reassessment and appropriatemodification of the care plan are central elements of the process of comprehensivegeriatric assessment.What Are the Comparative Merits of Different Methods in Carrying Out aGeriatric Assessment?Many assessment methods for specific domains have undergone rigorous validation, andthe criteria for acceptance of a given method have been carefully defined. However, indomains in which there are multiple validated instruments to measure the same function,
www.drjayeshpatidar.blogspot.com 16there have not yet been studies that directly compare one method to another. As a result,identification of the single best instrument in each domain is not possible at this time.One of the first steps in establishing a program of geriatric assessment is deciding upon astandardized approach to data collection. Before choosing from among the differentmethods, clinicians should consider some of the following issues.In the context of comprehensive geriatric assessment, there is a role for both structuredand unstructured methods of data gathering. There are several merits of a structuredapproach. Precision, reproducibility, and freedom from bias are enhanced by usingstandardized validated questions and requiring the respondent to choose from a limitednumber of answers. The task of data collection is more easily delegated if the format isstandardized. Standardized data collection methods help in clinical decision making andprospective evaluation of the efficacy of interventions. On the other hand, merits ofunstructured methods include flexibility of the testing procedure, ability to probeproblems in detail, and the opportunity for synthesis of findings to develop a globalimpression.A number of assessment instruments have been shown individually to have goodreliability and validity. A reliable instrument is internally consistent and provides thesame evaluation of the patient when used by different raters. A valid instrument measurescorrectly the domain being investigated. In addition to quantitatively measured validityand reliability, an instrument should have face validity (i.e., on the "face of it" theinstrument appears to measure the domain correctly). Although some characteristics ofpatients who will benefit from a given type of assessment have been identified, there areno validated instruments for predicting benefit.One approach to developing a comprehensive geriatric assessment program is to selectone of several multidimensional instruments designed to address all major domains ofgeriatric assessment. Alternatively, specific assessment instruments developed for eachdomain can be combined to accomplish a comprehensive assessment. There is noevidence that either approach is superior to the other.Desirable characteristics of instruments for case finding are efficiency, simplicity,flexibility for use under a variety of circumstances, and portability. Case-finding requiresless sophistication from the examiner than in-depth assessment and is relativelyinexpensive. There are reliable and valid instruments with which to assess mentalfunction, socioeconomic status, and ADL. Each instrument has a specific range ofusefulness. For example, assessment of ADL reliably detects advanced degrees offunctional impairment but is quite unlikely to detect minimal departures from normalcy.In-depth geriatric assessment methods need to have high predictive value, detect smallchanges in function, identify potentially remediable problems, and efficiently predictpatient outcomes. Special expertise is often required to carry out an in-depth assessment.Three additional issues should be addressed. First, in-depth assessments (and consequentinterventions) must take patients values into account. Second, comprehensive assessment
www.drjayeshpatidar.blogspot.com 17methods should accurately reflect change in patient status over time. Most existingmethods do not meet this need. Finally, while it is possible to educate a variety of healthcare professionals to carry out various aspects of comprehensive assessment, experienceand leadership are required in the individual or individuals responsible for supervising theassessment effort.What Is the Evidence That a Geriatric Assessment Is Effective? If So, in WhatSettings, for Whom, and for Which Outcomes?Accumulated evidence indicates with moderate-to-high confidence that comprehensivegeriatric assessment is effective when coupled with ongoing implementation of theresulting care plan.The settings in which effectiveness has been convincingly demonstrated are thecombined geriatric assessment and rehabilitation unit and the inpatient geriatricassessment unit. There is less consistent evidence regarding the effectiveness ofcomprehensive geriatric assessment in the home, ambulatory setting, and the hospitalinpatient consultation service.As practiced, comprehensive geriatric assessment has been demonstrated to be effectivefor a variety of desirable outcomes. Studies to test effectiveness have varied in designfrom descriptive (before versus after) to match control to the most persuasive form,randomized controlled trials.Outcomes favorably affected by comprehensive geriatric assessment, as demonstrated byrandomized controlled trials, have included improved diagnostic accuracy, prolongedsurvival, reduced annual medical care costs, reduced use of acute hospitals, and reducednursing home use. These have been most consistently demonstrated. Less consistentlyreported benefits include increased use of health and social services delivered in thehome, reduced medications, and improved placement location, affect and cognition, andfunctional status. Other outcomes of great importance (e.g., quality of life) have not beenstudied adequately.Two aspects of comprehensive geriatric assessment appear to be of central importance.The first of these is targeting of the process to those persons most likely to benefit, afeature of most successful programs and one strongly endorsed by experienced programleaders. In the inpatient setting, targeting has focused on patients over age 75 and thosewith potentially reversible disabilities. This target group may account for as much as 10to 25 percent of hospitalized elderly patients. Most studies demonstrating effectivenesshave excluded groups whom the investigators thought least likely to benefit, notablypersons who are fully independent and those with end-stage disease or disability. Severalprograms have focused on elderly persons at points of transition or instability, as citedunder question 1.
www.drjayeshpatidar.blogspot.com 18The role of targeting in comprehensive geriatric assessment conducted outside thehospital setting is less clear. Certain U.S. studies have failed to demonstrate favorableoutcomes in ambulatory settings. This result may be attributable to ineffective targeting.However, two European studies of randomly selected, community-dwelling personsreported efficacy of comprehensive geriatric assessment without targeting other than foradvanced age, suggesting the possibility of expanding the use of these techniques to abroader population in this country.The second important aspect of comprehensive geriatric assessment appears to be the linkbetween assessment and followup services (also discussed under question 4). Successfulprograms have been able to assure adoption of treatment recommendations reachedduring the initial assessment. In some programs, the assessment team has assumed directcontrol over treatment of the patients, while in others the followup has involved activeand ongoing consultation and communication with primary care providers. The failure toprovide sufficient linkage between assessment and followup may provide anotherexplanation for negative results reported in certain studies. In addition, these negativeresults may be due to an insufficiently comprehensive assessment or intervention (e.g.,failure to include medical evaluation) or to the use of instruments insensitive to changesthat actually may have occurred.Additional elements of the comprehensive geriatric assessment to which effectiveness hasbeen attributed by developers of successful programs deserve attention. Such elementsinclude focus upon content areas in which geriatric expertise is acknowledged:malnutrition, mental impairment, immobility, iatrogenesis (notably polypharmacy),impaired homeostasis, and incontinence. Furthermore, the effectiveness of thecomprehensive geriatric assessment appears to be more than the sum of its parts, perhapsbecause of the integrative nature of the process and the multidisciplinary discussion thattranslates the information gathered into a rational plan of care. Finally, it has also beensuggested that the effectiveness of comprehensive geriatric assessment is at least partlyattributable to the enthusiasm and caring attitude of those who have developed theseprograms.Insofar as a Geriatric Assessment Is Effective, What Linkages to ClinicalManagement Systems Are Required?Comprehensive geriatric assessment programs should not be viewed as operatingindependently from other elements of the health care system. Geriatric assessment is adynamic process responsive to the changes in health status that occur over time.Therefore, a method for assessing effectiveness of interventions over time and fordetecting new problems must be provided. A broad approach is needed to ensure thatcommunity case-finding identifies the at-risk population and links comprehensivegeriatric assessment to subsequent provision of services.In the absence of a community case-finding program, patients are referred forcomprehensive geriatric assessment from a variety of sources, most commonly relatives
www.drjayeshpatidar.blogspot.com 19and community service agencies. Less common sources of referral are the patientsthemselves, friends, and physicians. Health maintenance organizations and othermanaged care organizations, as well as nursing homes, may be increasingly importantreferral sources in the future.Ongoing monitoring of the implementation of recommendations made duringcomprehensive geriatric assessment is believed to be central to the success of the careplan. The role of linkages to clinical management systems in the effectiveness ofcomprehensive geriatric assessment has not been directly tested. However, continuingpersonal contact of hospital geriatric assessment consultants with the patients and theirprimary providers does appear to facilitate the implementation of recommendations. Casemanagement as a process to provide linkages is available in many communities, and itsrole in ensuring followup of recommendations requires further investigation. Clearly, theavailability of a wide array of social services is a requirement for successfulimplementation of a comprehensive geriatric care plan.What Are the Priorities for Future Research in Geriatric Assessment?Although past research on comprehensive geriatric assessment has provided muchvaluable information, many questions remain unanswered. Existing studies havedemonstrated that effective services can be provided, but these services consist ofcombinations of activities that have been selected on an empiric basis. Future researchcan define more carefully which elements of these packages--perhaps all of them--contribute importantly to achieving the observed results. Earlier studies have been site-specific and have incompletely assessed the range of patients who might benefit fromthese activities. Finally, important measurement problems persist. Thus, key future stepsin research include the following:Conduct multicenter, randomized controlled trials of comprehensive geriatricassessment, including both academic and nonacademic settings, addressing theabove-cited gaps in our knowledge.Extend the use of randomized controlled trials of comprehensive geriatricassessment to other outcomes, particularly quality of life, effect on family, andcost-effectiveness.Extend the use of randomized controlled trials of comprehensive geriatricassessment to other settings, particularly the home and the nursing home.Determine the most effective means for targeting of comprehensive geriatricassessments in a broad patient population.Use controlled trials of comprehensive geriatric assessment to evaluate the effectof different combinations of personnel, instruments, and interventions.Compare the effects of assessment with and without various methods forcoordinated implementation of the care plan.Develop new assessment tools for measuring levels of and changes in functionalstatus, particularly for those with mild-to-moderate levels of impairment.Directly compare instruments that assess information within the same domain.
www.drjayeshpatidar.blogspot.com 20Develop data bases with which to establish patterns of changing function,especially in persons who spend time in long-term care institutions.ConclusionsThe settings, uses, processes, personnel, and component domains of comprehensivegeriatric assessment have been defined with sufficient clarity to provide guidelines forestablishment of new assessment programs.Accumulated evidence indicates with moderate-to-high confidence that comprehensivegeriatric assessment is effective when coupled with ongoing implementation of theresulting care plan.Effectiveness has been most convincingly demonstrated in two inpatient settings, thegeriatric assessment unit and the combined geriatric assessment-rehabilitation unit.The most consistently demonstrated favorable outcomes of comprehensive geriatricassessment have been prolonged survival, reduced annual medical care costs, andreduced use of acute hospitals and nursing homes.Although the evidence allows for alternative interpretation, it is probable that carefulselection of patients has contributed importantly to the ability to demonstrate benefit fromcomprehensive geriatric assessment.In view of the seemingly indispensable role of monitoring and implementation of the careplan in achieving desired outcomes, ongoing health care should be linked systematicallyto the process of comprehensive geriatric assessment.Consensus Development PanelDavid H. Solomon, M.D.Panel and Conference ChairpersonProfessor of MedicineAssociate DirectorMulticampus Division of Geriatric MedicineUniversity of California at Los Angeles School ofMedicineLos Angeles, California A. Sue Brown, M.S.W.AdministratorLong-Term Care AdministrationDistrict of Columbia Department of Human ServicesCommission of Public HealthWashington, D.C.
www.drjayeshpatidar.blogspot.com 21Geriatric Assessment ProgramA n n o u n c e m e n t sAn important resource for seniors and their caregivers.For more information, call 302-477-3300.Aging is a natural part of life to be respected and celebrated.Yet, with it comes many new challenges—physical andemotional—impacting seniors and their caregivers.If you are over 65, or are caring for someone who is over 65,Christiana Care’s Outpatient Geriatric Assessment Programis an important resource for you. Based on information wegather from thorough evaluations, our uniquely qualified,board-certified geriatrician (a doctor who specializes ingeriatric medicine) and geriatric team can help you betterunderstand, adjust to and embrace the physical and mentalchanges associated with aging.Our in-depth Geriatric Assessment gives doctors an overallpicture of a senior’s health status, including his or her:Physical condition.Psychological assessment – including memory lossand depression.Social well-being – including support networks for those who live alone.Our comprehensive physical assessment includes:Detailed review of all medications, prescribed and over-the-counter, to assesspossible side-effects or drug interactions that could contribute to the challenges ofaging.Eye exam.Hearing assessment withreferral toa full audiologicalevaluation, when appropriate.The GertiatricAssessment Programteam can help you betterunderstand, adjust to andembrace the physical andmental changes associatedwith aging.
www.drjayeshpatidar.blogspot.com 22Aging impacts more than just the bodyAlong with performing a thorough physical examination, our geriatric specialists willspend a significant amount of time —often as many as two to three hours—to get toknow the senior patient and make recommendations regarding support services, such ashome nursing care, meal delivery, personal and household services, or even assistedliving, that may ease some of the challenges of aging, particularly for seniors who livealone.As part of the assessment, our geriatric physician may recommend a home visit toevaluate safety issues – particularly fall hazards and nutritional needs. They will take thetime to thoroughly discuss options for support services, assisted living, long-term careand decisions regarding nursing home care.What about Alzheimer’s care?About 80 percent of the seniors we see for geriatric assessments have serious memoryproblems, or dementia. Approximately 70 to 75 percent of all dementias are Alzheimer’scases. Christiana Care’s geriatric specialists are trained to recognize and evaluatememory disorders and recommend appropriate medical and support services throughoutthe community.Care for the caregiver, tooThe challenges of aging affect those who care for seniors, too. In fact, many caregivers,themselves, develop physical problems because of the stress they are under while takingcare of their loved ones. If caring for a senior is taking its toll on you, please call us todayto learn about resources available to help you.Time to ask questionsOne of the things seniors and their caregivers appreciate most about our GeriatricAssessment Program is the opportunity to spend time with the doctor asking questionsand discussing any number of issues relating to aging. Christiana Care’s geriatric teambelieves that communication is key to helping all involved learn about and appropriatelyaddress any challenges affecting the senior patient.Keeping your doctor informedChristiana Care’s Outpatient Geriatric Assessment Program is not intended to replace thesenior’s relationship with his or her primary care physician. Instead, it is a service toenhance the care already being provided. To ensure continuity of care and opencommunication, Christiana Care’s geriatric specialists will provide a complete report ofthe physical and psychosocial assessment to the senior’s primary care physician.Together, the primary care physician and geriatric physician will consult onrecommended approaches to addressing the senior’s aging challenges.
www.drjayeshpatidar.blogspot.com 23Medicare coverageChristiana Care’s Outpatient Geriatric Assessment Program is covered by Medicare andmost insurance plans. No referral is required.How to reach usChristiana Care’s Outpatient Geriatric Assessments are performed at Christiana Care’sFoulk Road Family Medicine Center, 1401 Foulk Road, Wilmington, Delaware (acrossfrom Brandywine High School).For more information, or to make an appointment for a Geriatric AssessmentGeriatricsUT Southwestern Medical Center combines attentive and compassionate care with state-of-the-artmedical resources to create one of the nation’s leading health-care programs for older adults. OurGeriatrics Program offers expert diagnosis by specialists who care about the needs of patients andfamilies. Our geriatricians are specially trained to prevent and manage older adults’ unique and, oftentimes, multiple health concerns. They develop care plans that address the special health care needs ofolder adults.At UT Southwestern Medical Center, our geriatrics specialists focus on the complete individual,including social and psychological issues as well as medical conditions. We offer three geriatricprograms:Geriatric primary care – Our physicians provide long-term primary care for patients 65 years ofage and older.Comprehensive geriatric assessment - We evaluate older adults with complex medical andsocial conditions, including mobility issues, osteoporosis, urinary incontinence, rehabilitationneeds, dementia, Alzheimer’s disease and psychological disorders. We also analyze thepatient’s current medications to determine whether they are clinically warranted and interactsafely. This complete and coordinated evaluation occurs in one clinical setting and is performedby a team that includes a geriatrician, a geriatric nurse practitioner and a social worker whospecializes in geriatrics. Each member of the team separately assesses the patient, and then theyconfer to create the best guidance for future care.Senior HouseCalls Program – We provide primary medical care to home-bound individuals 70years of age and older. Health care is provided in the older adult’s home where medical staffcan best integrate the efforts of family members and community resources such as traditionalhome-based health care.Our geriatric specialists provide both primary care services and comprehensive geriatric assessmentsfor patients and their families.Patients with Alzheimer’s disease, Parkinson’s disease and other neurological conditions can also beseen by our neurosciences service. Patients with psychological disorders can also be seen by our mental
www.drjayeshpatidar.blogspot.com 24health service. Patients with urinary incontinence can also be seen by our urology service.PROGRAMMES FOR CARE OF OLDER PERSONSDemographic ageing is a global phenomenon. With a comparatively young population,India is still poised to become home to the second largest number of older persons in theworld. Projection studies indicate that the number of 60+ in India will increase to 100million in 2013 and to 198 million in 2030. The special features of the elderly populationin India are :- (a) a majority (80%) of them are in the rural areas, thus making servicedelivery a challenge, (b) feminization of the elderly population ( 51% of the elderlypopulation would be women by the year 2016) , (c) increase in the number of the older-old ( persons above 80 years) and (d) a large percentage (30%) of the elderly are belowpoverty line.Social Defence Division provides for the needof older persons through its various programmesand initiatives.National Policy for Older Persons (NPOP) (Complete Policy details)Steps Already Taken For Implementation of NPOPList of Members of the National Council for Older Persons (NCOP)List of Ministries/ Departments of Inter-Ministerial Committee implementingNational Policy on Older Persons.Concessions and facilities given to Senior Citizens by different Ministries/DepartmentsInter-Ministerial CommitteeAnnual Plan of Action 2005-06 for implementation by various Ministries/Departments concerned with the welfare of Older PersonsSchemesAn Integrated Programme for Older Persons.Scheme of Assistance to Panchayati Raj Institutions/Voluntary Organisations/SelfHelp Groups for Construction of Old age homes/multi service centers for olderpersons.Important Documents and Downloadable Formats
www.drjayeshpatidar.blogspot.com 25National Policy for Older Persons2. The National Policy for Older Persons (NPOP) was announced in January, 1999,with the primary objective viz. to encourage individuals to make provision fortheir own as well as their spouse’s old age; to encourage families to take care oftheir older family members; to enable and support voluntary and non-governmental organizations to supplement the care provided by the family; toprovide care and protection to the vulnerable elderly people, to provide healthcare facility to the elderly; to promote research and training facilities to traingeriatric care givers and organizers of services for the elderly; and to createawareness regarding elderly persons to develop themselves into fully independentcitizens.Steps already taken for implementation of NPOP3. The Government has constituted a National Council for Older Persons(NCOP) under the Chairmanship of Hon’ble Minister for Social Justice andEmpowerment to advise and aid the Government on policies and programmes forolder persons and also to provide feedback to the Government on theimplementation of the National Policy on Older Persons as well as on specificprogramme initiatives for older persons. The NCOP is the highest body to adviceand coordinate with the Government in the formulation and implementation ofpolicy and programmes for the welfare of the aged.3. The National Council for Older Persons has been re-constituted in 2005.Presently, it has 37 members.The given areas of concern have been emphasizedwhich include:-a. Uniform age of 60+ for extending facilities/ benefits to senior citizens;b. Financial security to the elderly population by: (1) Proposing tax benefits andhigher interest rates for senior citizens (2) Promotion of long term savings in bothrural and urban areas (3) Increased coverage and revision of old age pensionschemes for the destitute elderly and (4) Prompt settlement of pension, providentfund, gratuity and other retirement benefits;c. Health care and nutritional needs of the elderly populations by: (1) Strengtheningof primary health care system to enable it to meet the health care needs of olderpersons; (2) Training and orientation to medical and para medical personnel inhealth care of the elderly. (3) Promotion of the concept of healthy ageing. (4)Assistance to societies for production and distribution of material on geriatriccare. (5) Provision of separate queues and reservation of beds for elderly patients.d. Food security and shelter by : (1) Coverage under the Antyodaya Scheme to beincreased with emphasis on provisions for the benefit of older persons especiallythe destitute and marginalized sections. (2) Earmarking ten percent ofhouses/house sites for allotment to older persons. (3) Barrier-free environment forthe disabled and elderly persons etc.e. Meeting the education, training and information needs of older persons.
www.drjayeshpatidar.blogspot.com 26f. Identification of the most vulnerable among the older persons and working fortheir welfare.g. Realizing the crucial role by the media in highlighting the situation of olderpersons and emphasising their continued role in Societyh. Protection of life and property of the elderly population.Inter-Ministrial CommitteeThe Ministry has also set up Inter-Ministerial Committee (IMC) headed by Secretary (SJ& E) for ensuring speedy implementation of the decisions taken in the meeting of theNational Council for Older Persons and also to review the progress of plan of action forimplementation by the concerned Ministries/Departments as in many cases, the activitieshave to be initiated by the other Ministries/ Departments and, therefore, a combinedeffort by all the Ministries/ Departments is required to implement the National Policy onOlder Persons. The Inter-Ministerial Committee comprises of twenty -twoMinistries/Departments and representatives of State Governments and UTAdministrations. The Inter-Ministerial Committee is responsible for the implementationof the action points as described.SCHEMES :-An Integrated Programme for Older PersonsScheme of Assistance to Panchayati Raj Institutions/ Voluntary Organisations/Self Help Groups for Construction of old age homes/multi service centres forolder persons9. An Integrated Programme for Older Persons Under this Scheme financialassistance up to 90% of the project cost is provided to NGOs for establishing andmaintaining old age homes, day care centres, mobile medicare units and toprovide non-institutional services to older persons. The scheme has been madeflexible so as to meet the diverse needs of older persons including reinforcementand strengthening of the family, awareness generation on issues pertaining toolder persons, popularisation of the concept of life long preparation for old age,facilitating productive ageing, etc. The budget allocation during 2005-2006 wasRs.19.80 crores which was revised and the RE was Rs. 14.00 crores, againstwhich the expenditure was Rs.14.00 crores. The budget allocation for the year2006-07 is kept at Rs.28 crore.10. Scheme of Assistance to Panchayati Raj Institutions/VoluntaryOrganisations/Self Help Groups for Construction of old age homes/multiservice centres for older persons This scheme provides for one timeconstruction grant for old age homes/multi service centers. The registeredsocieties, public trust, Charitable Companies or registered Self-help Groups ofOlder Persons in addition to Panchayati Raj Institutions are eligible to get theassistance under this scheme. Against the budget allocation during 2005-06 ofRs.67 laskh, the expenditure was Rs. 47 lakh.