Challenging Patient: Older patient with multiple co-morbidities

1. Challenging Patient:Older patient with multiple co-morbidities Comprehensive Geriatric Assessment and the Patient-Centered Clinical Method

2. Objectives • Describe the effectiveness of CGA • Select and use an assessment tool • Describe interventions to address functional impairment • Consider patient and family goals when developing management plan

3. Comprehensive Geriatric Assessment: a Meta-analysis of Controlled Trials • Mortality 0.86 (0.75-0.98) • Living at home 1.26 (1.1-1.44) • Hospital admissions 0.88 (0.79-0.98) • Physical Fxn better 1.10 (0.89-1.36) • Cognitive Fxn 1.41 (1.12-1.77) Stuck et al, Lancet, 1993:23;1032-1036

4. What is CGA? a multidisciplinary evaluation in which the multiple problems of older persons are uncovered, described, and explained, if possible, and in which the resources and strengths of the person are catalogued, need for services assessed, and a coordinated care plan developed to focus interventions on the person’s problems.

5. CGA The Black Box of CGA

6. What happens in the black box? • Multidisciplinary team • Thorough medical evaluation • Medical conditions • Medication • Assess multiple functional domains • Validated instruments

7. CGA What comes out of the box? General medical problems Depression Incontinence Musculoskeletal problems Hypertension Functional impairment Falls, vision and hearing

8. 2 –Understanding the whole person 1 –Exploring both disease and illness experience Cues and prompts Disease Person Feelings History Ideas Illness Physical Function Lab Expectations Proximal Context 3 – Finding Common Ground Problems Goals Roles Distal Context 4 – Incorporating prevention and health promotion Mutual decisions 6 – Being realistic 5 – Enhancing the patient-physician relationship Patient-Centered Clinical Method Patient-Centered Medicine: Transforming the Clinical Method, Stewart, M. et al, 2003

9. Make it work in practice • The right patient • The right tools, administered the right way • The right people • Common, prioritized goals • Follow-up

10. Targeting

11. Target - at risk for decline • Age ≥ 75 • Fxn: ≥ 1 ADL def; falls; poor health • Util: ≥ 1 hosp admission; ≥ 6 visits; ≥ 5 prescription meds • Med: CAD, DM, Depression, UI • Social: Absence of a caregiver • Self-reported task modification

12. Domains of function

13. The Right Instrument

14. Characteristics of Functional Assessment Instruments • Diagnostic characteristics • Validity • Sensitivity (NPV)/Specificity (PPV) • Ceiling/Floor • Reliability • Ease of administration • Who provides data? • Self-report • Caregiver report • Physical performance test • Sensitivity to change

15. The right people