CGA

Question 1

What is CGA?

Answer 1

A process to assess and manage disruption to health in older people with frailty

“A multidimensional interdisciplinary diagnostic process focused on determining a frail elderly person’s medical, psychological and functional capability in order to develop a co-ordinated and integrated plan for treatment and long term follow up”
Rubenstein, 1991

Question 2

What is ageing?

Answer 2

Progressive accumulation of damage to a complex system resulting in aggregate loss of system redundancy

Loss of redundancy leads to frailty

Question 3

What does loss of system redundancy lead to?

Answer 3

Decreased resilience to overcome environmental stress-leads to increased risk of system failure

Our aging strategy is that we have high levels of redundancy and low levels of repair

Question 4

What are the effects of ageing (senescence) and how does it lead to frailty?

Answer 4

Age related decline leads to:
- Impairment of individual organ function
- Breakdown of the complex interplay between organ systems (dyshomeostasis)

This leads to
Increased susceptibility to environmental stress= FRAILTY

Question 5

What is frailty a state of?

Answer 5

A state of susceptibility to acquiring disease and susceptibility to functional decline in the context of disease

Question 6

Is multimorbidity the norm?

Answer 6

Multimorbidity-idea of having more than one chronic diseases is the norm for people who access health care and it gets worse as you get older

Question 7

If you are old + multimorbid does it mean you are frail?

Answer 7

NOOO

Question 8

How do we identify someone as ‘frail’?

Answer 8

Use the frailty index

• More points the more frail you are

Question 9

The frailty phenotype applies in Fried at al model if have 3 of what 5 criteria?

Answer 9

Unintentional weight loss
Exhaustion
Weak grip strength
Slow walking speed
Low physical activity

Special cut offs for each of these things

Question 10

What is the spectrum view of frailty?

Answer 10

Spectrum between minimal and severe frailty

Some people can improve, get less frail or improve their resilience, improve their health

Question 11

What is the clinical frailty scale?

Answer 11

1-9

From very fit to terminally ill

(scoring frailty in people with dementia differs-degree of frailty corresponds to the degree of dementia)

Question 12

In what conditions to people tend to present with frailty syndromes?

Answer 12

Falls
Immobility
Delirium
Functional decline

These are system failure presentations

Decompensated frailty syndromes – often present with multiple frailty syndromes at once

Environmental stress leading to breakdown of the whole system

Question 13

What characterises a system failure?

Answer 13

System failure leads to fault-delirium-functional decline

Question 14

What does taking a functional Hx show?

Answer 14

Ability to live a life independently

• What did you do to get up and go into work today?-asks about ability to do these things

Question 15

What are the ADLs?

Answer 15

Transfers
Mobility
Toileting
Washing
Dressing
Meal preparation
Feeding

Question 16

What do system failure presentations cause?

Answer 16

Decompensated frailty syndromes

Question 17

What is the role of the doctor in a person’s story?

Answer 17

Take the story where the person wants their plot to go- or help give it a happy ending (good palliative care)

Goal and focus is the life and not the disease

Goal centredness
Person centredness
Wellbeing
Realistic Medicine

Question 18

What is goal centredness in CGA?

Answer 18

The right thing to do=We do what the person wants, not what the doctor wants

The easy thing to do:
Multimorbidity
Conflicting ‘disease priorities’
Polypharmacy

Question 19

What is health realistically?

Answer 19

A dynamic process rather than a binary state

Health isn’t solely the concept of disease or this narrow medical view

Question 20

What does illness in frail people lead to and what can it be triggered by?

Answer 20

Leads to disruption in multiple health domains

Can be triggered by disruption in any health domain

Question 21

What is the difference between pathological and physiological?

Answer 21

Pathological – ‘disease’
Physiological – ‘normal ageing’

Reversible
Non-reversible

Multiple concomitant problems
Iatrogenic harm

Few things in med are ‘curable’

Aim to preserve function in chronic disease – organ function or overall function- and looking to reduce exacerbations

Infection and iatrogenic harm can be cured

Question 22

What does spiritual care mean?

Answer 22

Person centred care

Acknowledge persons meaning

Question 23

What psychological issues should be addressed commonly when thinking about frailty and ageing?

Answer 23

Mood:
Low mood
Anxiety

Confidence:
‘fear of falling syndrome’

Cognition:
Delirium
Dementia

Question 24

What functional issues should be addressed?

Answer 24

Mobility:
Transfers
Mobilising

Activities of Daily Living

Community living skills-higher level function that you need to do to exist in the society

Question 25

What behaviours should be looked at in a CGA?

Answer 25

Behavioural determinants of ill health-Unhealthy eating/smoking/drinking Activities/Pastimes Occupation

Question 26

What nutritional aspects should be thought about and what screening tool can be used?

Answer 26

Poor nutrition leads to ill health Ill health leads to poor nutrition MUST screening tool

Question 27

What environmental factors and social factors should be addressed?

Answer 27

Environmental: Housing Heating Sanitation Adaptation Social: Support networks - Practical/emotional - Formal/informal Potential for abuse (Financial, Physical, Sexual, Neglect)

Question 28

What are some societal issues with views on ageing?

Answer 28

Attitudes to ageing/the aged - Asset vs. burden - Paternalism Technological advance-Enabling vs. disabling Political/Regulations - Money (eg. Winter heating allowance/pensions) - Accessibility (eg. Free bus passes/Disabled access)

Question 29

What is crucial about CGA?

Answer 29

- Goal centredness - Multidimensional/'holistic' approach

Question 30

How does CGA work as an inpatient?

Answer 30

MDT assessment - Form a combined view - Importance of goal directedness - Come up with a plan-out of hosp and maintenance of future health or palliative - Discharge planning

Question 31

If someone cannot be made better when can they be discharged from hospital?

Answer 31

Hosp benefits: Access to clinical expertise Access to complex tests and interventions Rapid access to supervised care support Risks of Hosp: Disorientation and delirium Learned dependency Deconditioning-particularly if immobile-rapidly lose muscle strength and develop all the complications of immobility Iatrogenic harm Hospital Acquired Infection Optimal discharge based on individual assessment (when risk outweighs benefit) or simply discharge when goals are met

Question 32

What is the evidence for CGA?

Answer 32

Compared to standard medical care this has better outcomes for older people with frailty

Question 33

What are the geriatric giants now known as frailty syndromes?

Answer 33

- Instability - Immobility - Incontinence - (cognitive) Impairment

Question 34

What are some reasons that patients may fall?

Answer 34

Poor footwear Intoxication Degenerative brain conditions Meds Postural instability Cognitive impairment Urinary urgency

Question 35

What are reasons that a patient may not be able to walk?

Answer 35

Loss of muscle mass-sarcopenia SOB Pain Postural instability

Question 36

What are some reasons for incontinence?

Answer 36

Weakened pelvic floor Infection Constipation-faecal incontinence due to overflow Caffeine

Question 37

Reasons for a patient being cognitively impaired?

Answer 37

- Collateral Hx - Dementia - Delirium SDH Intoxication Brain disease Constipation

Question 38

What Hx & examinations are recommended in a geriatric patient?

Answer 38

Hx: - Collateral Hx - GP, care home - Meds - Social Hx Exam: Resp/CVS/Abdo Neurology - Focused neurological examination Gait Lying and Standing BP Look at the skin Incontinent? PR +/- external PV-Look for prolapse