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Файл:Comprehensive geriatric assessment from theory to practice. Study aid
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most of these people prefer to stay at home. Of course, such patients
require a special approach, including the assessment of their status. Thanks
to this research, a special service for the intermediate stage of care for the
elderly was created in the Netherlands, using doctors and general
practitioners. The problems of an elderly person were assessed in a
complex way: histories of life and illness; assessment of the function of
vision, hearing; ability to communicate, self-care and mobility, including
issues such as financial management, such as independence; security in
everyday life; physical condition and mental health. On the basis of a
comprehensive assessment, special measures were planned and carried out
to maintain the health of the elderly. Working with patients, nurses
constantly consulted with geriatricians and general practitioners. This
model has demonstrated clinical and cost effectiveness.
Another similar clinical model has been studied and tested in the
Guided Care study. This is primary care for older patients, reinforced by a
specially trained nurse trained in geriatrics, working in conjunction with a
general practitioner and in his team. This team can provide a wide variety
of services specifically for the elderly. The skills acquired by a nurse
during training include a comprehensive assessment of the state of health,
and an assessment of the quality of care, and the ability to prepare relatives
for care; management of long-term care situations for chronically ill
patients, evidence-based care and treatment planning, monthly review of
the condition of the patient and those who care for him, the ability to
communicate with social services and planning services of this kind, i.e.
almost the entire range of medical and social needs for an elderly
chronically ill patient living at home. After 6 months, it turned out that the
wards of these nurses were twice as good as participants from the control
group in assessing both their condition and the quality of care they
received. A year later, not only a general improvement in well-being was
noted, but also an improvement in the skills of using medications,
satisfaction with their condition. While research is ongoing. The example
of the two described studies suggests that special services, or workers who
need to be trained, trained, prepared, are needed to work with elderly and
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fragile patients at home. It is clear that a general practitioner, even with
two nurses, will not be able to perform such a task. However, the selection
of those who need special supervision and support from the population of
elderly patients can be undertaken at the stage of primary care.
Thus, the first step in working with the elderly population should be
to identify the group most in need of assistance and rehabilitation, i.e.
those who are called fragile, or frail in English. According to modern
concepts, fragility syndrome has certain visible external features, in
particular, several important features describe the “fragile phenotype”:
loss of strength, slowing down in movement, loss of body weight. More
recent publications and studies have refined the definition of this syndrome
by adding imbalances, poor nutritional status, decreased exercise tolerance
resulting in fatigue, weakness, and, in some cases, cognitive decline.
Currently, gerontologists and geriatricians are intensively studying such a
variant of aging as fragility. Fragility, or frailty in English, is defined as
the inability of an elderly person's body to find resources to withstand
stress, as a condition preceding disability, loss of self-care ability, and
even death. The increased interest in this phenomenon is due to the fact
that fragility is reversible. If it is recognized in time, then it is possible to
restore a person's quality of life, increase his strength and reduce
vulnerability, vulnerability to external factors.
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4. COMPREHENSIVE GERIATRIC ASSESSMENT:
CONCEPT, PURPOSE, METHODS
The standard medical model of care for the elderly (60–74 years old)
and senile (75–89 years old) people focuses only on one-sided nosological
diagnosis. However, a simple statement of the state of health does not say
anything about how it affects the life of an elderly person. The influence of
socio-economic status, quality of life, functional activity, premorbid
personal characteristics, mental health, compensatory resources on
objective and subjective indicators of physical health is not taken into
account. The presence of coping strategies (emotionally or problemoriented) for solving health problems in later ages is not taken into
account. In this regard, in foreign geriatric practice, and recently in Russia,
it has become widespread comprehensive geriatric assessment of the
condition of elderly and senile people. A comprehensive geriatric
assessment is a multidimensional, multidisciplinary diagnostic assessment
of older adults using clinical scales, structured questionnaires, and
quantitative tests. With the help of a comprehensive geriatric assessment,
the most significant deviations in the viability of the organism and the state
of health of an aging person are revealed.
A comprehensive geriatric assessment goes beyond the classical
syndromic-nosological concepts described in terms of modern clinical
science in accordance with the nomenclature of diseases.
Comprehensive assessment includes:
• determination of the functional abilities of the body of an aging
person;
• obtaining the most general ideas about the state of physical health;
• study of psychological status and mental health;
• assessment of the impact of environmental factors and social
environment. Specific objectives of a comprehensive geriatric assessment;
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• determination of the physical, mental and social condition of the
patient;
• identifying the ability to daily work activities, household activities,
self-service and independence from others;
• establishment of reversibility or irreversibility of body changes
caused by age and diseases;
• forecasting the nature, features and rates of further changes in the
functional activity and viability of a person.
Such an assessment is carried out with the aim of prolonging
autonomy and increasing the subjective well-being of an elderly and senile
person.
The goals of due diligence are manifold and may require both
immediate and long-term solutions. First of all, this concerns the timely
elimination of reversible involutive pathological changes, the adoption of
measures to stabilize, contain and slow down accelerated aging, as well as
pathological processes caused by diseases associated with old age. The
results of a comprehensive assessment help in the development of
individualized rehabilitation tactics, the restoration of reversibly impaired
functions, and increase the adequacy and timeliness of the provision of
social and medical care.
Modern studies have shown that none of the existing instrumental
indicators, including exercise tolerance, myocardial contractility, and even
the severity of coronary artery stenosis, can in themselves serve as
comprehensive information about a patient.
The following features of a comprehensive geriatric assessment are
distinguished:
It is not a substitute for syndromic nosological diagnostics, but
complements and expands it
Focused on the long-term improvement of the physical condition and
quality of life of the elderly
Aimed at early detection of frailty (“fragility”), which is
accompanied by various geriatric syndromes
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When conducting CGА, emphasis is placed on determining the
degree of impaired functioning in everyday life, the presence of problems
with movement, incontinence, the presence of symptoms of depression,
cognitive impairment, falls, visual impairment, hearing loss.
Particular attention is paid to geriatric problems that the elderly
patient himself may not report. An older person may believe that these
symptoms, such as hearing loss, memory loss, and performance loss, are
normal aspects of aging and cannot be properly assisted to prolong active
longevity.
For evaluation, specially selected tests and scales are used, but they
do not replace a clinical examination by a geriatrician, general practitioner
and other specialized specialists.
Emphasis is placed on examination cognitive functions due to the
prevalence of Alzheimer's disease, vascular and mixed forms of dementia
and other neurodegenerative disorders.
Emphasis is placed on research the presence and severity of
symptoms of depression at later ages. Depression in the elderly may be
atypical and may be masked by physical disorders with cognitive
impairment or neurological disease. A simple question to an older patient,
“Do you feel sad or depressed?” can be used as a screening tool to detect
changes in mental status. This question is sensitive to changes in an older
person's mood, but is best used in conjunction with the Geriatrics
Depression Scale-30.
The features of social activity, the availability of social support,
resources and limitations of an elderly person are taken into account.
The assessment is aimed at developing, together with the elderly
person and his relatives, a treatment plan, an algorithm for supporting his
state of health.
The assessment focuses on adherence to treatment (compliance) and
control over treatment.
A comprehensive geriatric assessment involves a geriatrician, a nurse, a
clinical psychologist and a social worker. Specialists have identified
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diagnostic techniques that allow a clinical psychologist to examine the main
components of a geriatric patient of elderly and senile age.
Various clinical specialties are beginning to adapt frailty assessment
and CGA into their treatment plans. Primarily in disease entities with lifethreatening burden, significant functional decline, or a large amount of
treatment-related stress, frailty assessment and CGA has had impact in
deciding their treatment strategies.
In the area of surgery, frailty is an independent risk factor for
mortality, morbidity, length of stay, and postoperative complication.
Frailty assessment has been most widely used in orthogeriatrics for hip
fracture surgery. FI calculated during routine CGA of post-operative hip
fracture patients, was significantly associated with adverse outcome
including mortality and length of hospital stay. Also, frailty was associated
with increased length of stay, complications after surgery and discharge to
rehabilitation facilities in fracture patients.
To establish treatment and discharge strategies for trauma elderly
patients, the 15-item trauma-specific frailty index (TSFI) was validated
from various centers. This TSFI, which consists of comorbidities, daily
activities, health attitudes, sexual function, and nutrition domains can also
be assessed by the caregiver. It is an independent predictor of unfavorable
discharge if greater than 0.27. Also, to determine frailty for geriatric
patients undergoing emergency general surgery, the 15-variable
Emergency general surgery specific frailty index (EGSFI) was validated in
a prospective cohort. The EGSFI-based frailty status significantly
predicted postoperative complications (odd ratio, 7.3; 95 % confidence
interval, 1.7–19.8), but age was not a relevant factor. In patients
undergoing kidney transplantation, the frailty phenotype showed
significant ability to distinguish patients at high-risk of death or early
readmission. For older patients with end-stage liver disease waiting liver
transplantation, researchers found that the frailty status determined the
deterioration of quality of life rather than severity of liver disease.
Guidelines from American College of Surgeons for Surgery and National
Institute for Health and Care Excellence also emphasized frailty
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assessment in acute care settings or preoperative period as a new screening
criterion for fitness.
Oncology is one of the areas where frailty is most widely integrated
into clinical practice. Previous reports have consistently shown that frailty
status increased the risk of all-cause mortality, postoperative complication,
and chemotherapy-related adverse events. Therefore the US National
Comprehensive Cancer Network, International Society of Geriatric
Oncology and European Organization for Research and Treatment of
Cancer recommend frailty assessment and CGA for older cancer patients
to detect unrecognized health problems and treatment-related risks.
The field of geriatric cardiology is also expanding to offer a CGA
approach within a cardiology practice. A 2011 white paper from the
Journal of the American College of Cardiology acknowledged that
geriatricians provide skills that “augment quality and capacity of cardiac
specialists to meet the needs of their older patients.”
Particularly in
treatment of aortic valve stenosis, the frailty concept is best implemented.
The Placement of Aortic Transcatheter Valves (PARTNER) trial tried to
assess the frailty status in various methods and revealed that TAVR was
superior to SAVR at preventing death, stroke, or rehospitalization in low-
risk patients ≥ 70 years with aortic stenosis.
In the same year, another
research group conducted a prospective cohort study called The Frailty
Assessment Before Cardiac Surgery and Transcatheter Interventions study,
which implemented frailty screening and CGA method to patients
receiving aortic valve replacement and showed frailty trajectories to
predict functional outcomes. Clinical trials on perioperative care and
interventions to optimize functional outcomes are ongoing in the field of
cardiology.
Recently, frailty has been grafted into relatively younger patients.
Rheumatologists constructed a FI based on the deficit-accumulation
concept to patients with systemic lupus erythematosus and validated to
differentiate patients vulnerable to adverse outcomes.
In the UK, electronic frailty index (eFI) was recently developed and
validated using routinely collected primary care electronic health record
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data. The eFI has robust predictive validity for outcomes of mortality,
hospitalization and nursing home admission in older people with different
frail trajectories. Recently the use of eFI has been extended for utilization
in community healthcare services.
In summary, frailty assessment is useful for identification of those at
highest risk for adverse outcomes and for risk stratifications to assist in
clinical decision making. The value of CGA is greater in frail older adults
as CGA identifies the impairments. Before establishing a frailty
assessment and CGA in clinical settings, it is important to design an
assessment system that reflects the clinical course of each disease.
Cautions have been raised against rushing to implement frailty
assessment and CGA in general clinical settings. The most persuasive
evidence of CGA comes from programs that rely on specialized inpatient
units and long hospital stays. A striking, large-scaled, randomized
controlled trial published in the New England Journal of Medicine
revealed that a one-time frailty assessment by a consultative team cannot
improve mortality and functional status for hospitalized patients. They
emphasized that hospitalized frail older patients only benefit from CGA
when optimized management programs are accompanied continuously.
The benefits of CGA are conflicting in short-term consultation
settings. CGA by a consultation team with limited follow-up did not
improve health or survival of hospitalized patients. This is because results
of the consultations and geriatric recommendations are not all accepted
and implied causing limited effectiveness of frailty assessments. Therefore
continuous management system beyond simple one-time evaluation,
frailty-targeted intervention programs, and a close inter-department
communication system should be accompanied.
It is known that physical frailty is a manageable condition that can be
targeted for intervention. There are 4 possible treatments that appeared to
have some efficacy in the treatment of frailty:
1) exercise (resistance and aerobic);
2) caloric and protein support;
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3) vitamin D;
4) reduction of polypharmacy.
Exercise in frail individuals increase functional performance,
decrease hospitalizations and falls. Protein-calorie supplementation is
effective in the treatment of weight loss, increase in muscle mass and grip
strength. Vitamin D supplementation is also known to reduce falls, hip
fractures and mortality. Polypharmacy, a possible major contributor to the
pathogenesis of frailty can be reduced to decrease costs and medication
side effects in frail populations.
Multifactorial interventions combining exercise, behavioral therapy,
nutrition, and cognitive training are being developed. Individually tailored
multifactorial interventions was found to improve frailty status and
physical function. Therefore, it is essential to develop and utilize
interventional managements that can aim to reverse or provide support in
areas of impairment identified on CGA.
Some models of interventional frailty management based on CGA in
hospital settings have shown benefits. One of the most successful and
effective model to date is the orthogeriatric model. Various studies
reported that co-management with a geriatrician shows benefit for hip
fracture patients in reducing hospital stay complications, mortality,
readmissions, and delirium. Programmed intervention by geriatricians is
focused on the comorbidity management, review of drug regimens, pain,
nutrition, osteoporosis, prevention of falls, management of delirium,
depression, early mobilization and initiation of rehabilitation. In Korea,
there is a report from a single tertiary hospital that CGA and frailtytargeted intervention programs for hip fracture patients selected under
orthopedic surgeons in the emergency room significantly reduced the
length of stay.
Here are still only a few reports on randomized studies evaluating the
effectiveness of CGA-linked interventions in geriatric oncology. The
examples of interventions involve changes in current chronic medication,
nutritional care, memory evaluation, social support and psychological care.
Further trials on CGA based geriatric interventions are ongoing.
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In older adults admitted to hospital as an emergency, they were
significantly more likely to survive admission and return home, fewer will
die or experience deterioration and more will have improved cognitive
functioning if they undergo CGAs while they are inpatients.
Interventions in community settings
The prevalence of frailty is estimated to be 10 % in community
dwelling older adults and increases up to 60 % in those with advanced
cardiovascular disease. Several randomized controlled trials have tested the
effect of interventions targeting mainly physical inactivity, nutritional
status, depression or falls in community. The Lifestyle Interventions and
Independence for Elders pilot study reported that a 12-month physical
activity intervention was associated with 9 % lower frailty prevalence.
For a recent decade, there have been several frailty-targeted
intervention trials in the community settings in Korea, most of which are
targeted towards vulnerable older adults. A 24-week multicomponent
program for socioeconomically vulnerable older adults that consisted of
group exercise, nutritional supplementation, depression management,
deprescribing medications, and home hazard reductions, sustained
beneficial effects up to 1 year. Therefore CGA based intervention
programs can potentially promote healthy aging in community dwelling
older adults.
Interventions in nursing home settings
Nursing home patients are shown to be very frail. A systemic review
identified 9 studies with a total of 1,373 nursing home patients, and
reported that the prevalence of frail and prefrail were 52.3 % and 40.2 %.
As the Korean society rapidly changes, nursing homes have increasingly
become the site where many of the older adults spend their final years.
According to the Korean Health Insurance Review and Assessment
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