A brain storming session to address important point in CGA and health promotion

1. Health promotion and
CGA
Professor Doha Rasheedy

2. Q1
An 80-year-old man, who is diabetic smoker,
has moderate to severe cognitive impairment.
Family is seeking medical advice because his
cousin who is 60-year-old was discovered to
have colon cancer recently.
• Which of the following should you
recommend?
A.Fecal occult blood
B.Colonoscope
C.No testing
D.Fecal DNA
• CT colonogram

3. Q2
An 80-year-old man, who is diabetic smoker,
has severe cognitive impairment. With altered
bowel habit, significant weight loss
• Which of the following should you
recommend?
A.Fecal occult blood
B.Colonoscope
C.No testing
D.Fecal DNA
E.CT colonogram
•

4. Q3
An 60-year-old man, who is diabetic smoker, With altered bowel habit,
significant weight loss
• Which of the following should you recommend?
A. Fecal occult blood
B. Colonoscope
C. No testing
D. Fecal DNA
E. CT colonogram

5. Q4
An 60-year-old man, who is diabetic smoker,
otherwise he has no relevant history.
• Which of the following should you
recommend?
A.CT chest
B.Colonoscope
C.No testing
D.Pelviabdominal CT
E.Coronary angiography

6. Q5
A 60-year-old woman, widow for 10 years, comes to the office for a
routine visit. She is in good health. Which of the following should you
recommend?
A. Barium enema
B. Pap smear
C. Carcinoembryonic Antigen
D. Mamography
E. No testing

7. Q6
A 60-year-old woman, married, comes to the
office for a routine visit. She is in good health.
Which of the following should you
recommend?
A.Barium enema
B.Pap smear
C.Carcinoembryonic Antigen
D.CT lung
E.No testing

8. Q7
A 80-year-old woman, married, comes to the
office for a routine visit. She is in good health.
Which of the following should you
recommend?
A.Barium enema
B.Pap smear
C.Carcinoembryonic Antigen
D.CT lung
E.No testing

9. Q8
A 60-year-old man with lymphoma presented
for your clinic for health promotion
counseling. Which one is a contraindicated
approach?
A.Pnemococcal vaccine
B.Influenza vaccine
C.Herpes Zoster vaccine
D.Booster dose for tetanus vaccine
E.Chemoprophylaxis

10. Why CGA needed?

11. A 75-year-old man with previously
well-controlled DM and HTN
presents with elevated HbA1c (9.2%)
and BP (160/90 mmHg).

12. •A 75-year-old man with previously well-controlled
DM and HTN presents with elevated HbA1c (9.2%)
and BP (160/90 mmHg). He admits he has been
rationing his medications due to the high cost of
co-pays after losing his Medicare Part D subsidy.
•CGA Insights:
•- Social/Economic Assessment: Identified inability
to afford medications.
•- Intervention: Connected to a social worker for
medication assistance programs, switched to
lower-cost generics, and enrolled in a patient
assistance program.

13. A 75-year-old man with previously well-controlled DM and HTN
presents with elevated HbA1c (9.2%) and BP (160/90 mmHg). He
reports feeling overwhelmed since his wife’s death 4 months ago,
skipping meals, and forgetting medications.
• CGA Insights:
• - Psychological Assessment: Screen for depression (positive for
depressive symptoms).
• - Functional Assessment: Decline in IADLs (e.g., meal
preparation).
• - Intervention: Bereavement counseling, simplified medication
regimen (blister pack), and home health aide for meal support.
• - Why CGA Matters: Holistic approach addresses emotional and
functional decline.

14. •A 75-year-old man with previously well-controlled
DM and HTN presents with elevated HbA1c (9.2%)
and BP (160/90 mmHg). His daughter notes he
forgets to take pills or double-doses. MMSE reveals
mild cognitive impairment (score 20/30).
•CGA Insights:
•- Cognitive Assessment: Uncovered memory deficits
impacting adherence.
•- Safety Assessment: Risk of hypoglycemia from
erratic insulin use.
•- Intervention: Transitioned to supervised
medication administration (family caregiver + pill
organizer), deprescribed non-essential drugs.
•- Why CGA Matters: Detects cognitive issues early to
prevent harm.

15. • A 75-year-old man with previously well-
controlled DM and HTN presents with
elevated HbA1c (9.2%) and BP (160/90
mmHg). He was stable until 6 months
ago when he required repeated oral
steroids for COPD flares.
•CGA Insights:
•- Medical Complexity: Steroids worsened
glucose and fluid retention.
•- Medication Review: Identified drug-
disease interaction (steroids + DM/HTN).
•- Intervention: Adjusted DM regimen
(added basal insulin), monitored BP closely,
and explored steroid-sparing COPD
therapies (e.g., LAMA/LABA).
•- Why CGA Matters: Manages
polypharmacy and prioritizes alternatives.

16. Importance
of CGA
CGA uncovers hidden contributors (financial,
emotional, cognitive, or iatrogenic).
Tailored interventions (social support, simplified
regimens, caregiver involvement).
Prevents "clinical inertia" by addressing root
causes, not just lab values.
CGA is essential for elderly patients with
sudden deterioration—it goes beyond the
disease to treat the person.

17. Risk stratification and guiding
management decisions in elderly
patients with complex needs

18. Frailty and
Fall Risk in a
Patient with
Osteoporosi
s
An 83-year-old woman with osteoporosis, HTN, and a
recent wrist fracture presents for follow-up. She
reports unsteadiness but denies falls. Her BP is
controlled, but she has lost 8 kg in 6 months.
•CGA Findings:
•- Physical Frailty: Slow gait speed (5 seconds for 4
meters), weak grip strength.
•- Nutritional Assessment: Low albumin, poor oral
intake (loneliness, difficulty cooking).
•- Fall Risk: Timed Up-and-Go (TUG) test >15 seconds
(high risk).
•- Polypharmacy: On sedating antihypertensives (e.g.,
clonidine).
•

19. Risk Stratification:
• High risk for recurrent fractures, functional
decline, and hospitalizations.
CGA-Driven Management:
• 1. Deprescribe sedating medications; switch to
safer antihypertensives (e.g., amlodipine).
• 2. Physical therapy for balance training +
home safety evaluation.
• 3. Nutritional support (Meals on Wheels,
protein supplementation).
• 4. Bone health: Dual-task exercise (strength +
balance), reassess bisphosphonate use.

20. Cognitive
Impairment
and
Anticoagulatio
n in Atrial
Fibrillation
•An 88-year-old man with atrial fibrillation
(CHADS-VASc 5) and mild dementia (MMSE
22/30) presents with frequent bruising. His
daughter worries about falls but fears stroke
if anticoagulants are stopped.
CGA Findings:
•- Cognitive Assessment: Forgets doses,
takes double medications occasionally.
•- Functional Status: Needs reminders for
IADLs (e.g., medication management).
•- Social Support: Daughter is primary
caregiver but works full-time.
•- Bleeding Risk: HAS-BLED score 3 (high
risk).

21. Risk Stratification: - High risk for both stroke (untreated AF) and
bleeding (cognitive impairment + falls).
CGA-Driven Management:
• 1. Switched to DOAC (apixaban) for lower bleeding risk vs. warfarin.
• 2. Medication supervision: Pill dispenser with alarms + caregiver support.
• 3. Fall prevention: Home modifications (remove rugs), PT for strength.
• 4. Advanced care planning: Discussed goals of care (weighing stroke risk vs. QoL).
Why CGA Matters: Balanced thromboembolic and bleeding risks
while preserving autonomy and safety.

22. Multimorbidity
and End-of-Life
Prioritization in
Heart Failure
•A 90-year-old with HFrEF (NYHA Class III), DM,
CKD stage 4, and recurrent hospitalizations
presents with fatigue. He values independence
but struggles with daily activities.
•
•CGA Findings:
•- Severe Functional Decline: ADL dependencies
(needs help bathing, dressing).
•- Symptom Burden: High fatigue, dyspnea at
rest.
•- Prognosis: Estimated 1-year mortality >50%
(via “Surprise Question”).
•- Social Isolation: Lives alone; family visits
weekly.

23. Risk Stratification:
• Very high risk for mortality and further functional decline.
CGA-Driven Management:
• 1. Palliative care referral: Focused on symptom relief (e.g., low-dose opioids for dyspnea).
• 2. Deprescribing: Stopped statins and tight glycemic control (shifted to HbA1c <8%).
• 3. Home health aide: For ADL support and safety monitoring.
• 4. Advance directives: Documented preferences (e.g., no ICU admissions).
Why CGA Matters: Shifted focus from disease-centric to goal-concordant
care, improving quality of life.

24. CGA-Based
Risk
Stratification:
1. Frailty & Function: Guides rehab potential vs.
palliative needs.
2. Cognitive Status: Determines medication
safety/supervision.
3. Social Support: Identifies gaps requiring
caregiver or community resources.
4. Prognosis: Informs deprescribing and
advanced care planning.
5. CGA transforms vague "high-risk" labels into
actionable, personalized plans

25. Thank you