Comprehensive Geriatric Assessment Sumit. CHOpptx.pptx

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1. Comprehensive Geriatric Assessment 1

2. Learning Objectives Understand about Comprehensive geriatric assessment (CGA). Role of CHO and Staff Nurse in CGA. Components/Domains that come under Comprehensive Assessment of Elderly. [ Refer to MODULE Staff Nurse pg - 21- 31 CHO pg 21-29 ] Also refer to annexures of this modules June 24, 2024 2

3. Comprehensive geriatric assessment (CGA) CGA is a multi-disciplinary process where the information captured is used as a basis to plan care and treatment. It includes short term and long-term goals, follow up and rehabilitative services. June 24, 2024 3

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5. Role of ASHA Completion of Community based assessment checklist (CBAC) for all the elderly for each village in the SHC-HWC area will be done by the ASHA. The section B3 is specific to the elderly . June 24, 2024 5

6. Section B3of CBAC June 24, 2024 6 B3: Elderly Specific (60 years and above) Y/N Y/N Do you feel unsteady while standing or walking? Do you need help from others to perform everyday activities such as eating, getting dressed, grooming, bathing, walking, or using the toilet? Are you suffering from any physical disability that restricts your movement? Do you forget names of your near ones or your own home address?

7. Flow of Events June 24, 2024 7 ASHA - identify any elderly in need of comprehensive assessment if the answer to any of the questions in Part B3 of the CBAC is ‘ Yes ’. MPW (M/F)- preliminary assessments of these identified elderly individuals CHO- comprehensive geriatric assessment . If required - refer elderly individuals who need specialized management to the Medical Officer or Specialist

8. Comprehensive Assessment of Elderly 1. Socio-demographic assessment- Information about socio-demographic and socio-economic details of the person. Why do CHO/ Staff Nurse have to know about socio-demographic information/ socio-economic status ? June 24, 2024 8

9. Comprehensive Geriatric Assessment Tool June 24, 2024 9 Name: ________________ Age (In Completed Years): ________________ Sex: 1. Male 2. Female 3. Others 4. Marital Status: Never Married 2. Currently Married 3. Divorced 4. Separated 5. Widowed

10. Comprehensive Geriatric Assessment Tool June 24, 2024 10 5. Who is Head of the family? 1. Myself 2. W ife 3. Son 4.Daughter in law 5. Others 6. Education: 1. Illiterate 2. Just literate (knows to read and write but nil education 3. Primary school (5 th completed 4. Middle school (8 th completed) 5. High school(10 th completed 6. Senior secondary (12 th completed 7. Graduate 8. Post-graduate

11. Comprehensive Geriatric Assessment Tool June 24, 2024 11 7. Occupation: 1. Not working; 2. Working (Specify) ____ 8. Religion: 1. Hindu 2. Muslim 3. Christian 4. Sikh 5. Others (Specify)__ 9. What kind of locality is your house in? 1. Urban (Specify) ______ 2. Rural (Specify) ______

12. Comprehensive Geriatric Assessment Tool June 24, 2024 12 10. Type of Family: 1. Single 2. Nuclear 3. Joint 4. Elderly homes 11. Total Family income per month? /Rs. ____ 1. Total number of family members? ________ 2. Per capita Income per month: Rs________

13. Comprehensive Geriatric Assessment Tool June 24, 2024 13 3. Socio-economic status: (according to B.G. Prasad scale) _ Per Capita monthly income (2020) 1.Upper (Rs 7533 and above) 2.Upper Middle (3766- 7532) 3.Lower Middle (2260-3765) 4.Upper Lower (1130- 2259) 5.Lower (1129 and below)

14. Comprehensive Geriatric Assessment Tool June 24, 2024 14 12. Comorbidity Profile: Disease Duration of Disease (Months) Receiving Treatment? 1.Yes/ 2.No If Yes, Since When? (Months) If No , Reasons Diabetes Mellitus Hypertension Others (specify)

15. Comprehensive Geriatric Assessment Tool June 24, 2024 15 13. Smoking: 1. Smoker (All current smokers and those who quit smoking less than 1 year before the assessment) 2. Non smoker 14. Have you ever consumed alcohol in any form ? 1. Yes 2. No 3. Occasionally 14.A. If yes -Duration (in years):

16. Comprehensive Geriatric Assessment Tool June 24, 2024 16 15. Diet preference: 1. Vegetarian 2. Mixed Diet 3. Egg vegetarian 16. Intravenous Drug Use? 1. Yes 2. No 17. Present Complaints of: _________________________________________ 18. History of Presenting Illness: _________________________________________

17. Comprehensive Geriatric Assessment Tool June 24, 2024 17 19. Examinations: A) GENERAL PHYSICAL EXAMINATION : Oral Examination: Ophthalmic Examination: Ear Examination: Musculoskeletal Examination: Other Systems (If Required): B) INVESTIGATIONS : Hemoglobin 2. Serum cholesterol 3. Blood Sugar: 4. Blood Pressure

18. 2. Physical health assessment- a. Oral health assessment b. Assessment of eyes and ears c. Assessment of cardiovascular disease risk d. Assessment of musculoskeletal system June 24, 2024 18

19. Comprehensive Assessment of Elderly... a. Oral health assessment: Screen- common oral cancers and precancerous lesions (oral ulceration, red or white patches). Ask for denture use- cause oral ulcers. Look for dental caries (blackish discoloration of teeth), tooth and gum lesions- refer to Dental specialist in HWC-PHC (inform CHO). Assess- substance use like Tobacco (smokeless and smoking), alcohol and other medication abuses- counselling. June 24, 2024 19

20. Comprehensive Assessment of Elderly... b. Assessment of eyes and ears: Age-related diseases of eyes and ears like cataract, presbyopia and hearing loss. Screen for difficulty in vision and hearing and examination of eyes and ears should be done. June 24, 2024 20

21. Comprehensive Assessment of Elderly... Role of ASHA for addressing Loss of Hearing and Vision: 1. Fill out the assessment of difficulty in hearing/ seeing/ reading in the Community Based Assessment Checklist. 2. Empathise with the elderly and assure them about sensory losses being normal during ageing. 3. Mobilise the elderly and family members to visit the nearby health and wellness centre for getting checked from CHO and further provision of any assistive device if needed. June 24, 2024 21

22. Comprehensive Assessment of Elderly... c. Assessment of cardiovascular disease risk: Higher risk of heart diseases- if not treated early- can develop serious consequences like heart failure and heart attacks. Cardiovascular risk is predicted by the CHO/MO using WHO/ISH chart. High risk of CVD risk prediction- referred to Medical officer at HWC-PHC by the CHO. June 24, 2024 22

23. Comprehensive Assessment of Elderly... At the Community level, you can screen elderly individuals for certain symptoms and signs which are suggestive of cardiovascular disease. You will ask for: Breathlessness on lying down Breathlessness which makes the person wake up at night Dizziness on suddenly standing up Any episode of syncope (fainting) in last 3 months Chest pain Palpitation (the person can feel his/her own heart beating fast or pounding) June 24, 2024 23

24. Comprehensive Assessment of Elderly... You will look for: Swelling of feet/hands Fast breathing at rest (>20 breaths in a minute) You will measure: BP Pulse rate Non-Communicable disease management: managed under supervision of Medical Officer at PHC. June 24, 2024 24

25. Cardiovascular WHO/ ISH Charts The tool predicts risk by including domains of age more than 40 years, S ex, Systolic Blood pressure, Smoking status, S tatus of Diabetic Mellitus and B lood cholesterol levels. June 24, 2024 25

26. Cardiovascular WHO/ ISH Charts - Interpretation The patients under high risk of CVD risk prediction should be referred to Medical officer at HWC-PHC and P atient is followed up for cardiovascular investigations and treatment status. pressure, blood cholesterol and blood sugar. The risk prediction charts are a simple way of calculating the approximate combined risk due to all these risk factors. It is expressed as a 10-year risk of developing a heart attack or stroke. June 24, 2024 26

27. Using these new risk prediction charts, an individual can be classified in a category of high risk (maroon and red), medium risk (orange and yellow), or low risk (green) for heart attack or stroke in the following ten years. If an individual has high cardiovascular risk, the guidelines recommend more intensive treatment, often including drugs -- this is because the individual's risk has to be lowered urgently to prevent a heart attack or stroke. On the other hand, if the risk is low, the interventions may be more conservative ones like counselling for change in behavior e.g. smoking cessation or increased physical activity June 24, 2024 27

28. WHO/ISH have devised two sets of risk prediction charts— with and without blood cholesterol. The former requires data on sex (male/female), age (measured in single years), systolic blood pressure (in mmHg), total serum cholesterol (in mmol/l), current smoking status (yes/no) and diabetes status (yes/no) For individuals with missing cholesterol data we used the no-cholesterol charts June 24, 2024 28

29. CARDIOVASCULAR RISK ASSESSMENT: (WHO/ISH)- Risk level <10% 2. 10-19% 3. 20-29% 4. 30-39% 5. ≥40% June 24, 2024 29

30. CARDIOVASCULAR RISK ASSESSMENT: (WHO/ISH)- Risk level June 24, 2024 30

31. CARDIOVASCULAR RISK ASSESSMENT: (WHO/ISH)- Risk level June 24, 2024 31

32. CARDIOVASCULAR RISK ASSESSMENT: (WHO/ISH)- Risk level June 24, 2024 32

33. How to implement the tool: Charts are useful for stratifying risk for people with blood pressure <160/100 mm Hg or blood cholesterol < 8 mmol/l or uncomplicated diabetes.   For example, by using the charts, person X and person Y, who have similar blood pressures and blood cholesterol levels, can be correctly assessed for their risk of developing a heart attack or a stroke as follows: June 24, 2024 33

34. June 24, 2024 34 Person Y needs intensive lifestyle interventions and drug treatment to prevent a heart attack or stroke. Person X needs lifestyle interventions and may need drug treatment if risk persists at follow up.  

35. Comprehensive Assessment of Elderly... 3. Mental Health Assessment: a. Assessment of depression- Depression is assessed by ‘’Geriatric Depression Scale (GDS)- 15 item”. The patients will be categorized into Normal, mild, moderate or severe depressives based on the scores obtained. Elder Abuse- suspected with the standard questionnaire “EASI- Elder Abuse Suspicion Index”. June 24, 2024 35

36. Interpretation of GDS Of the 15 items, 10 indicated the presence of depression when answered positively, while the rest (question numbers 1, 5, 7, 11, 13) indicated depression when answered negatively. Scores of 0-4 are considered normal, depending on age, education, and complaints; 5-8 indicate mild depression; 9-11 indicate moderate depression; and 12-15 indicate severe depression. June 24, 2024 37

37. Comprehensive Assessment of Elderly... b. Cognitive assessment - Cognitive function may decline as a result of certain risk factors (e.g. hypertension, elevated cholesterol, cardiac arrhythmias). Adversely impact the physical functioning and quality of life of older adults. June 24, 2024 38

38. Comprehensive Assessment of Elderly... Role of ASHA in addressing Depression, Anxiety and memory problems in elderly: 1. Forming elderly support groups where elderly would get to interact with their peers. 2. Conducting wellness activities for the support groups or encouraging them for conducting wellness activities themselves. 3. Communicating with the elderly about how they feel and how they have been for the past few days during the home visits. 4. Completing the individual assessment (Part D: PHQ2). *If the total score is more than 3, CHO should be informed. June 24, 2024 39

39. Comprehensive Assessment of Elderly... 4. Nutritional Assessment: Assessed using Mini Nutritional Assessment Scale (MNA) Based on food intake, weight loss, mobility, neurological problems, stress, Body Mass Index (BMI) and calf circumference. Blood Haemoglobin is also checked in addition to this scale to correlate with the Nutritional status. June 24, 2024 40

40. NUTRITIONAL ASSESSMENT: (MINI NUTRITIONAL ASSESSMENT SCALE) June 24, 2024 41 A. Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties? 0 = severe decrease in food intake 1 = moderate decrease in food intake 2 = no decrease in food intake

41. NUTRITIONAL ASSESSMENT: (MINI NUTRITIONAL ASSESSMENT SCALE) June 24, 2024 42 B. Weight loss during the last 3 months 0 = weight loss greater than 3kg (6.6lbs) 1 = does not know 2 = weight loss between 1 and 3kg (2.2 and 6.6 lbs) 3 = no weight loss

42. NUTRITIONAL ASSESSMENT: (MINI NUTRITIONAL ASSESSMENT SCALE) June 24, 2024 43 C. Mobility 0 = bed or chair bound 1 = able to get out of bed / chair but does not go out 2 = goes out D. Has suffered psychological stress or acute disease in the past 3 months? 0 = yes 2 = no

43. NUTRITIONAL ASSESSMENT: (MINI NUTRITIONAL ASSESSMENT SCALE) June 24, 2024 44 E. Neuropsychological problems 0 = severe dementia or depression 1 = mild dementia 2 = no psychological problems

44. NUTRITIONAL ASSESSMENT: (MINI NUTRITIONAL ASSESSMENT SCALE) June 24, 2024 45 F1. Body Mass Index (BMI) = weight in kg / (height in m) 2 0 = BMI less than 19 1 = BMI 19 to less than 21 2 = BMI 21 to less than 23 3 = BMI 23 or greater IF BMI IS NOT AVAILABLE, REPLACE QUESTION F1 WITH QUESTION F2. DO NOT ANSWER QUESTION F2 IF QUESTION F1 IS ALREADY COMPLETED.

45. NUTRITIONAL ASSESSMENT: (MINI NUTRITIONAL ASSESSMENT SCALE) June 24, 2024 46 F2. Calf circumference (CC) in cm 0 = CC less than 31, 3 = CC 31 or greater Note: Malnutrition Indicator Score - 12-14 points: Normal nutritional status; 8-11 points: At risk of malnutrition; 0-7 points: Malnourished

46. Comprehensive Assessment of Elderly... Role of ASHA in addressing Nutrition in elderly: 1. Notify the CHO if malnutrition is suspected in elderly individual. 2. Utilize patient support groups for discussing nutritional provisions for the elderly. Exchange of recipes of local foods suitable for elderly can be facilitated on these groups. 3. Suggest the family and caregivers about soft, chewable foods for the elderly. 4. Talking to the elderly about lack of appetite being normal, listening to them compassionately about changed food habits. June 24, 2024 47

47. What is role of CHO/ Staff nurse? June 24, 2024 48

48. Video –WHO Integrated Care https://youtu.be/q2SdjlFQn3I

49. Group Work Participants are divided in five groups Each group is allocated one case study They discuss role of HWC team (including CHO, staff nurse, ANM, ASHA) based on identified problem areas in case/ family Discuss possible assessments- CGA Time allocated is five minutes for discussion One participant per group discuss the group activity June 24, 2024 50

50. Case Scenario 1 Mr. Radhey sham , 70 year old, assessed at a point of care by a CHO at HWC. He is non smoker, weighs 49 kg and is 162.5 cm tall. He was put earlier on oral hypoglycaemics, but is non adherent to medicines. He had two consecutive 5minute BP readings 137/87 mm Hg and 138/84 mm Hg. He went earlier to DH for his blood investigations- RBS – 250 mg/dl, Total CHL- 221 mg/ dl, LDL- 204 mg/dl, HDL- 30 mg/dl, TGL- 208 mg/dl Serum Creatinine- 2.2 mg/dl Hb 9.8 mg/dl Discuss care plan and role of CHO in this case. Do appropriate risk assessment in this case. June 24, 2024 51

51. Case Scenario 2 Mrs. Savithri , 68 years had a major abdomen surgery four months back in view of a cancer in gall bladder. She was very active before that but after surgery, prefers to be in bed. She can get up out of her bed but remains confined to her room. She worries that she will not be able to recover and lacks will to do any work. She stays with her son’s family and maintain good relationships. They are concerned about her. She has reduced appetite and has been reducing weight more than 3 kgs in last three months. On oral examination she has teeth, though had carries in few teeth and has poor oral hygiene. On examination- her weight was 40 kg, height 150 cm, Pulse 85/ min, afebrile, BP 98/62 mm of Hg, GDS score – 7 As a CHO/ Staff nurse, do a nutritional assessment, and comprehensively assess the situation, based on scenario presented. June 24, 2024 52

52. Case Scenario 3 An 85 year retired old school teacher Mr. Ganesh, presented with complaints of pain in his right knee since 8 years. He said that 2 years back while he was visiting a temple with his family he suddenly lost consciousness and had to be taken to an emergency room at district hospital. After evaluation ,he was told , to have no major problem and was sent home. He said that he hasn’t gone out of his house for the past 2 years, as he felt dizzy and felt he might fall and lose consciousness again. He is a smoker, diabetic and on oral hypoglycaemics. He said his wife expired , 1 year back and he said he was waiting for his time to come. His children were well settled. He was living with his eldest son and their family. His BP was 124/88 mm of Hg. Discuss role of HWC team in this case

53. Case Scenario 4 On a visit to houses in the village, MPW (F) Susheela talked to Mrs. Shakuntala, 73 year old woman having hypertension and hypothyroidism . She was taking medicines, but was found to be worried. Her husband Mr. Suresh, was chronically ill with cancer and had difficulty in walking. He used to fall frequently , and while taking care of him, Mr. Suresh fell down on her. Her right ankle and foot was paining too much. There was swelling also and Mrs. Shakuntala had difficulty in walking. Nobody else lived with them. Discuss the role of HWC team in this case June 24, 2024 54

54. Case Scenario 5 Sohan lives in Nawabganj village with his wife Parwati , his only son Ramu and Ramu’s wife Radha. He is 72 years of age and in good health. He runs a local shop and quite popular in his village. He was living happily with his family but then suddenly he lost his wife in an accident. After that his life has changed a lot, now he has no interest in life. Though the behaviour of his son and daughter in law towards him is good but still he feels lonely and prefers staying home. He has also lost interest in many activities which he used to enjoy earlier. At times he feels emptiness in his life and gets bored. Ramu thinks his father is sad due to his mother's death and things will be better after sometime. Meanwhile ASHA informs you about Sohan , You visit his home and assess Sohan for depression . Discuss role of HWC team in this case. Apply GDS and comment on whether depression exists or not June 24, 2024 55

55. THANK YOU June 24, 2024 56