Identifying individuals who are frail or at risk of poor health outcomes, followed by appropriate evaluation and intervention is the cornerstone of geriatric medicine and quality care for the ever-growing elderly population. However, in older adults, clinical decision making, including diagnosis, treatment, and outcome selection may be challenging. The complexity is due to the interplay of multisystemic effects of the ageing process with multimorbidity and polytherapy and the contribution of psychological, social, economic and environmental factors as key determinants of the health status.
Many models of care and multiple instruments have been
developed over the last 40 years. The majority of CGA tools include similar
measurable dimensions that can be grouped into physical health, functional
status, psychological health and socio-environmental status.
1. Physical Health
CGA does not substitute the traditional clinical workup
based on patient’s medical history and clinical examination. But clinicians
need to extend beyond standard evaluation and focus on a systematic search for
specific conditions that are common among older people. This is because older
patients fail to report conditions such as visual and hearing impairment and
frequent falls. The dimensions assessed as part of physical health include
vision, hearing, multimorbidity, polypharmacy, nutrition and balance.
·
Vision
One in three older adults aged 65 years and
above have vision-reducing eye disease. The prevalent conditions with
increasing age are presbyopia, cataract, macular degeneration, glaucoma and
diabetic retinopathy. Many older adults do not report visual loss assuming it
to be a normal part of ageing. Intact vision is essential to maintain
functional independence, and impaired vision is associated with mobility
restriction, recurrent falls, increased risk of delirium etc.
Simple questions to screen for visual
impairment:
o
Do you have trouble recognizing faces?
o
Do you have problems reading a book or a
newspaper?
o
Do you have problems watching television?
A positive response should prompt
further detailed evaluation, including assessing visual acuity using a Snellen
chart and ophthalmologic reference. Correction of visual impairment using
spectacles, cataract surgery can improve the quality of life of these
individuals.
·
Hearing
After hypertension and arthritis,
presbycusis is the third most common chronic condition in older adults. Hearing
impairment can significantly impact the functional abilities and reduce
participation in social activities. Individuals with hearing impairment are
also at an increased risk for cognitive decline (dementia). Health care
providers must screen for hearing loss as most older adults don’t self-report
decreased hearing.
Screening questions include:
o
Do you feel you have a hearing deficit?
o
Do you have trouble speaking over the telephone?
People who give a positive answer
to screening questions should be referred for audiology examination.
Rectification of hearing impairment by removing ear wax, or using hearing aids
(when indicated) can improve their participation in social life.
·
Multimorbidity and Polypharmacy
Presence of two or more long term
conditions is called as multimorbidity. Multimorbidity becomes more common as
people age. Two-thirds of people aged 65 years and above have multimorbidity.
And the Longitudinal Ageing Study in India (LASI) reported that cardiovascular
diseases, diabetes mellitus and respiratory diseases contribute to a significant
share of chronic health conditions.
But the presence of two illnesses may not
be of much significance. For example, a person with well-controlled
hypertension and mild osteoarthritis will also be considered to have multimorbidity
(by definition). Still, it is not relevant as his/her condition is well
controlled and not requiring much medical attention. Many tools have been
developed, such as the cumulative illness rating scale and the Charlson
comorbidity index, to assess multimorbidity severity. Presence of
multimorbidity matters when associated with disability, reduced quality of
life, higher mortality and increased health service utilization, including
emergency hospital visits.
Multimorbidity is associated with polypharmacy,
increased treatment burden and higher rates of adverse drug events. Older
adults take more medications than other age groups. Severe adverse drug
reactions may lead to hospital admissions, delirium precipitation, functional
decline and increased mortality. Self-management of drugs and correct adherence
by the patient is a demanding task requiring good cognitive performance.
Medication assessment, reconciliation and comprehensive medication review are a
cornerstone of geriatric evaluation and patient safety.
The clinician needs to determine what medications
that patient is taking and how he/she takes them. For this process, called “medication
reconciliation”, multiple pieces of information from the patient, caregiver and
medical record should be gathered. After establishing the medication, its safety
and appropriateness are assessed. Beers criteria and the STOPP and START
criteria help clinicians identify potentially inappropriate medications and the
right treatment for a specific patient. By following these essential steps, the
pill-burden and use of improper prescriptions can be reduced.
Next week I will describe the assessment of nutritional
status, balance and functional status.
