Geriatric MEDICAL CONSULTS
What is Geriatric Care? Geriatrics is a health discipline encompassing psycho-social, economic, historical, and physiological factors for adults 65 and older. Geriatrics medicine focuses on two principal goals: preserving or improving quality of life and fostering independence or control over life as long as possible.
Who are Geriatricians? Geriatricians are physicians trained in the aging process. They evaluate and manage medical, social, and emotional needs of older adults. Their focus is in diagnosis, treatment, and prevention of disease and disability in older adults. They are specialized in geriatric assessment and rehabilitation, preventive medicine, management of patients in long-term care settings, and psycho-social, ethical, legal, and economic issues pertinent to geriatric patients. They give special attention to patients suffering from frailty, falls, incontinence, cerebrovascular disease, dementia, sensory impairment and other cognitive and affective changes that occur with aging.
What is Comprehensive Geriatric Consult (CGC) or Assessment (GCA)? CGC is comprised of a multidisciplinary diagnostic and treatment process that identifies medical, psycho-social, and functional limitations of an elderly person. It requires evaluation of physical, cognitive, affective, social, financial, environmental, and spiritual components that influence an older adult's health. The elderly person’s primary care/hospital physician can send a referral to a geriatrician and request a CGC if she/he believes that based on the patient’s medical history (age; medical conditions such as heart failure or cancer; psycho-social disorders such as depression or isolation; specific geriatric conditions such as dementia, falls, or functional disability; high health care utilization; and changes in living situation such as from independent living to nursing home or assisted living), the patient would health-wise benefit from such assessment .
Comprehensive Geriatric Assessment will focus on medical history, social history, and review of systems and includes the following components:
Who are Geriatricians? Geriatricians are physicians trained in the aging process. They evaluate and manage medical, social, and emotional needs of older adults. Their focus is in diagnosis, treatment, and prevention of disease and disability in older adults. They are specialized in geriatric assessment and rehabilitation, preventive medicine, management of patients in long-term care settings, and psycho-social, ethical, legal, and economic issues pertinent to geriatric patients. They give special attention to patients suffering from frailty, falls, incontinence, cerebrovascular disease, dementia, sensory impairment and other cognitive and affective changes that occur with aging.
What is Comprehensive Geriatric Consult (CGC) or Assessment (GCA)? CGC is comprised of a multidisciplinary diagnostic and treatment process that identifies medical, psycho-social, and functional limitations of an elderly person. It requires evaluation of physical, cognitive, affective, social, financial, environmental, and spiritual components that influence an older adult's health. The elderly person’s primary care/hospital physician can send a referral to a geriatrician and request a CGC if she/he believes that based on the patient’s medical history (age; medical conditions such as heart failure or cancer; psycho-social disorders such as depression or isolation; specific geriatric conditions such as dementia, falls, or functional disability; high health care utilization; and changes in living situation such as from independent living to nursing home or assisted living), the patient would health-wise benefit from such assessment .
Comprehensive Geriatric Assessment will focus on medical history, social history, and review of systems and includes the following components:
- Functional capacity
- Fall risk
- Cognition
- Mood
- Pain
- Vision & hearing
- Medication (Polypharmacy & drug cascade)
- Social support
- Financial concerns
- Goals of care
- Advanced care preferences
- Nutrition/weight change
- Urinary/ fecal continence
- Sexual function
- Dentition
- Living situation
- Assessment of Driving-Related Skills
- Spirituality
- Durable power of attorney for healthcare
What is Palliative Consult? Palliative care is specialized medical care for people suffering from advanced, life threatening, or chronic illnesses such as cancer, cardiac disease such as congestive heart failure, chronic obstructive pulmonary disease, kidney failure, Alzheimer’s, Parkinson’s, etc. It focuses on providing patients with relief from the symptoms and stress of a serious illness and can be provided along with curative treatment. Palliative care helps patients deal with pain, fatigue, nausea, loss of appetite, depression, difficulty sleeping, delirium, shortness of breath, and to build tolerance to medical treatment. The goal of receiving a Palliative Consult is to improve quality of life for both the patient and the family. It involves pain and symptom management, as well as assessing the psychosocial, emotional and spiritual needs of patients and their loved ones.
Palliative Consult includes the following components:
What is Mental Competency/Capacity Examination? Mental Capacity describes a person’s ability to make a clear decision such as a financial or a health care one. An individual who has decision making capacity can demonstrate the ability to understand the risks and benefits of a proposed intervention and communicate a choice. For example, in a medical context, capacity refers to the ability to utilize information about an illness and proposed treatment options to make a choice that is congruent with one’s own values and preferences.
If a person lacks capacity, he/she has an impairment or disturbance in the functioning of the mind or the brain that leaves the person unable to make a decision. If a person has been diagnosed with a medical condition such as dementia causing an impairment to the performance of their mind or brain; or if the person’s family member or healthcare provider have concerns about a person’s mental capacity; or if a person’s behavior raise doubt as to whether he/she has the capacity to make a decision, she/he can be referred to a geriatrician who can assess the person’s mental capacity.
It is crucial to assess a person’s capacity accurately; otherwise, a person might be denied the right to make a decision. Therefore, the correct test and the right interpretation of the results by the geriatrician are of essence when determining mental capacity. Mental capacity is best determined by a face-to-face interview between the geriatrician and the patient. The goal of the interview is to evaluate four decision-making abilities: the ability to Understand information about treatment; the ability to Appreciate how that information applies to their situation; the ability to Reason with that information; and the ability to make a Choice.
These abilities can be determined by different tests, the most common being MacCAT-T (MacArthur Competency Assessment Tool for Treatment) and ACED (Assessment of Capacity for Everyday Decision). When conducting the test the geriatrician scores the patient’s answer as adequate (2 points), marginal (1 point), or inadequate (0 points). A summary score is then generated for each decisional ability. A skilled geriatrician should then be able to interpret the scores on an individual basis keeping in mind factors such as the patient’s medical history and judgment status and not solely based on the scores attained.
What is Evaluation of Memory & Cognitive Functions? Cognitive functions encompass learning and memory, language, executive function, complex attention, perceptual-motor, and social cognition. Cognitive disorders (amnesia, dementia and delirium) are mental health disorders that primarily affect one or more cognitive domains. Dementia is more common in the elderly and is associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities. Dementia could be caused by genetic factors or by trauma. The most common types of Dementia are:
Delirium is caused by a combination of factors (such as medical conditions and medication toxicity) that trigger a malfunction in brain activity. Conditions that increase the risk of delirium include:
Cognitive evaluation is a part of the Annual Wellness Exam for Medicare beneficiaries. Individuals with memory concerns, cognitive complaints, personality change, depression, deterioration of chronic disease without explanation, and those suffering from falls or balance issues should undergo cognitive evaluation.
Palliative Consult includes the following components:
- Managing pain
- Managing physical symptoms
- Managing emotional symptoms
- Facilitating medical decision-making
- Navigating advanced care planning
- Facilitating community supports
- Family support including education and support
What is Mental Competency/Capacity Examination? Mental Capacity describes a person’s ability to make a clear decision such as a financial or a health care one. An individual who has decision making capacity can demonstrate the ability to understand the risks and benefits of a proposed intervention and communicate a choice. For example, in a medical context, capacity refers to the ability to utilize information about an illness and proposed treatment options to make a choice that is congruent with one’s own values and preferences.
If a person lacks capacity, he/she has an impairment or disturbance in the functioning of the mind or the brain that leaves the person unable to make a decision. If a person has been diagnosed with a medical condition such as dementia causing an impairment to the performance of their mind or brain; or if the person’s family member or healthcare provider have concerns about a person’s mental capacity; or if a person’s behavior raise doubt as to whether he/she has the capacity to make a decision, she/he can be referred to a geriatrician who can assess the person’s mental capacity.
It is crucial to assess a person’s capacity accurately; otherwise, a person might be denied the right to make a decision. Therefore, the correct test and the right interpretation of the results by the geriatrician are of essence when determining mental capacity. Mental capacity is best determined by a face-to-face interview between the geriatrician and the patient. The goal of the interview is to evaluate four decision-making abilities: the ability to Understand information about treatment; the ability to Appreciate how that information applies to their situation; the ability to Reason with that information; and the ability to make a Choice.
These abilities can be determined by different tests, the most common being MacCAT-T (MacArthur Competency Assessment Tool for Treatment) and ACED (Assessment of Capacity for Everyday Decision). When conducting the test the geriatrician scores the patient’s answer as adequate (2 points), marginal (1 point), or inadequate (0 points). A summary score is then generated for each decisional ability. A skilled geriatrician should then be able to interpret the scores on an individual basis keeping in mind factors such as the patient’s medical history and judgment status and not solely based on the scores attained.
What is Evaluation of Memory & Cognitive Functions? Cognitive functions encompass learning and memory, language, executive function, complex attention, perceptual-motor, and social cognition. Cognitive disorders (amnesia, dementia and delirium) are mental health disorders that primarily affect one or more cognitive domains. Dementia is more common in the elderly and is associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities. Dementia could be caused by genetic factors or by trauma. The most common types of Dementia are:
- Alzheimer disease (AD)- AD is the most common form of dementia in the elderly. In 2012, approximately 5.2 million Americans (65 years or older) had AD. This number is expected to reach 6.7 million by 2025. The exact cause of Alzheimer's disease is not known but scientists believe that it results from a combination of genetic, lifestyle and environmental factors that affect the brain over time.
- Vascular dementia (VD)- VD is the second most common type of dementia. It occurs as a result of brain damage due to reduced or blocked blood flow in blood vessels leading to brain. Blood vessel problems may be caused by stroke or infection of a heart valve called endocarditis.
- Lewy body dementia (LBD)- LBD affects approximately 10 percent of people with dementia. Lewy bodies are abnormal clumps of protein that have been found in the brains of people with LBD, Alzheimer's disease and Parkinson's disease. Symptoms of LBD are similar to those of the Alzheimer’s disease. However, people with LBD suffer from visual hallucinations, tremor and rigidity, fluctuations between confusion and clear thinking, and rapid eye movement sleep behavior disorder that involves acting out dreams.
- Frontotemporal dementia (FTD)- FTD involves the degeneration (breakdown) of nerve cells in the frontal and temporal lobes of the brain. These areas are associated with personality, behavior and language. FTD tends to occur at a younger age (between the ages of 50-70) than does Alzheimer's disease. People suffering from FTD have difficulty with thinking, concentration, and language. Other symptoms include movement problems and inappropriate behaviors.
Delirium is caused by a combination of factors (such as medical conditions and medication toxicity) that trigger a malfunction in brain activity. Conditions that increase the risk of delirium include:
- Dehydration
- Infections (such as urinary tract infection or pneumonia)
- Fever
- Dementia
- Older age
- Previous delirium episodes
- Visual or hearing impairment
- Poor nutrition
- Severe, chronic or terminal illness
- Multiple medical problems or procedures
- Treatment with multiple drugs
- Alcohol or drug abuse or withdrawal
- A number of medications (such as pain, sleep, allergy, asthma, anti-anxiety, anti depression, mood-disorder, or Parkinson’s disease medications)
- Polypharmacy (taking too many medications)
Cognitive evaluation is a part of the Annual Wellness Exam for Medicare beneficiaries. Individuals with memory concerns, cognitive complaints, personality change, depression, deterioration of chronic disease without explanation, and those suffering from falls or balance issues should undergo cognitive evaluation.
What are Mood & Behavioral Disorders in the Aging Population? Mood and Behavioral disorders have a high prevalence in the aging population (20 percent of adults aged 55 or older have experienced some type of mental health concern). Although the rate of mood and behavioral disorders tends to increase with age, they are not a normal part of growing older. Mood and behavioral disorders include depression, anxiety, psychosis, aggression, agitation, sleep disturbances, restlessness, wandering, hallucination, delusion, hypo/hyper-sexuality, bipolar disorder, etc. They occur in 90% of patients suffering from dementia. They cause immense patient suffering as well as caregiver/family stress and can result in institutionalization, hospitalization, and early death. As such, prevention, early diagnosis, and treatment of behavioral disturbances are of essence. Mood and behavioral disorders could be the result of medical illnesses, physical disability, dementia, polypharmacy, drug cascade, pain, personal needs, loss of a loved one, alcohol or substance abuse, malnutrition or a poor diet, and environmental factors (such as moving into assisted living). Many mood and behavioral disorders can be prevented in the elderly by avoiding inappropriate medications and educating patient, family, caregivers, and health care providers. Caregivers/family members should consult a geriatrician or a family physician if they observed the following warning signs, which could indicate a mental health concern in their elderly loved ones:
Elder Abuse Assessment- Elder mistreatment, which includes physical abuse, neglect, financial exploitation, sexual abuse, and emotional mistreatment, places the victim’s health, safety, emotional well-being, and ability to engage in daily life activities at risk. Victims of elder abuse have a significantly higher level of psychological distress and health care problems including increased bone or joint problems, digestive problems, depression or anxiety, chronic pain, high blood pressure, and heart problems. Elders who experience abuse have a 300% higher risk of death.
Elder abuse occurs in private homes as well as in institutional settings like nursing homes and other types of long term care facilities. Female elders are abused at a higher rate than males. Research indicates that people with dementia are at a greater risk of elder abuse than those without. The vast majority of abusers are family members (approximately 90%). Other abusers include service providers, care assistants and strangers. Elder abuse is experienced by one out of every ten people ages 60 and older and for every one case of elder abuse that is detected or reported, it is estimated that approximately 23 cases remain unreported. The elderly rarely report abuse because of fear of retaliation or lack of physical and/or cognitive ability to report it. Perpetrators often limit the victim’s access to the outside world (eg, deny the victim visitors and telephone calls). Social isolation of the elderly victim often makes detection difficult. Geriatricians are well trained in detecting the signs of elder abuse. Trusted family members of the patient, adult protective services, or law enforcement agencies who suspect elder abuse need to encourage the patient to undergo an evaluation by a geriatrician.
Possible signs of elder abuse include:
What is End-of-Life Care? End-of-life care describe the support and medical care given during the time (which could be for days, weeks, or even months) surrounding death. Comfort care is an essential part of medical care at the end of life. The goal is to prevent or relieve suffering as much as possible while respecting the patients’ wishes. Comfort care includes physical comfort as well as mental, emotional, spiritual and practical support. Geriatricians provide end-of-life care by guiding terminally ill patients or their caregiver(s) to:
- Sadness or depression lasting longer than two weeks
- Social withdrawal
- Loss of interest in things that used to be enjoyable
- Unexplained fatigue or energy loss
- Sleep changes
- Confusion, disorientation, problems with concentration or decision-making
- Appetite increase or decrease
- Changes in weight
- Memory loss, especially recent or short-term memory problems
- Feelings of worthlessness, helplessness, or inappropriate guilt
- Thoughts of suicide
- Physical problems that can’t otherwise be explained
- Changes in appearance or dress
- Problems maintaining the home or yard
- Trouble handling finances or working with numbers
Elder Abuse Assessment- Elder mistreatment, which includes physical abuse, neglect, financial exploitation, sexual abuse, and emotional mistreatment, places the victim’s health, safety, emotional well-being, and ability to engage in daily life activities at risk. Victims of elder abuse have a significantly higher level of psychological distress and health care problems including increased bone or joint problems, digestive problems, depression or anxiety, chronic pain, high blood pressure, and heart problems. Elders who experience abuse have a 300% higher risk of death.
Elder abuse occurs in private homes as well as in institutional settings like nursing homes and other types of long term care facilities. Female elders are abused at a higher rate than males. Research indicates that people with dementia are at a greater risk of elder abuse than those without. The vast majority of abusers are family members (approximately 90%). Other abusers include service providers, care assistants and strangers. Elder abuse is experienced by one out of every ten people ages 60 and older and for every one case of elder abuse that is detected or reported, it is estimated that approximately 23 cases remain unreported. The elderly rarely report abuse because of fear of retaliation or lack of physical and/or cognitive ability to report it. Perpetrators often limit the victim’s access to the outside world (eg, deny the victim visitors and telephone calls). Social isolation of the elderly victim often makes detection difficult. Geriatricians are well trained in detecting the signs of elder abuse. Trusted family members of the patient, adult protective services, or law enforcement agencies who suspect elder abuse need to encourage the patient to undergo an evaluation by a geriatrician.
Possible signs of elder abuse include:
- Behavior signs: Withdrawal by the patient, infantilization of the patient by the caregiver, Caregiver’s insistence on providing the history
- General appearance: Poor hygiene, inappropriate dress
- Physical health: Bruises, pressure ulcers, head and neck injuries, bleeding, infestations, lesions, burns, dehydration
- Chronic disorders: such as hip fractures
- Mental and emotional signs: Depression, anxiety, feeling ashamed or guilt, fearful, angry
- Cognitive impairment: such as dementia
- Functional status: Any physical limitations that impair self-protection
What is End-of-Life Care? End-of-life care describe the support and medical care given during the time (which could be for days, weeks, or even months) surrounding death. Comfort care is an essential part of medical care at the end of life. The goal is to prevent or relieve suffering as much as possible while respecting the patients’ wishes. Comfort care includes physical comfort as well as mental, emotional, spiritual and practical support. Geriatricians provide end-of-life care by guiding terminally ill patients or their caregiver(s) to:
- Make health care decisions: educating patient/caregiver about the likely sequence of events in the late stages of illness and the available end-of-life medical care options ; providing advice to the patient/caregiver about the most suitable health care path
- Plan for end-of-life care: Navigating the patient’s advanced directives (to ensure that an individual’s wishes are followed in the event that he/she is unable to participate in decision-making regarding his/her treatment); providing support for the patient to communicate their beliefs, needs, and wishes; planning and facilitating their care
- Provide necessary medical comfort for the patient: Control their pain; address their breathing difficulties; improve digestive problems (nausea, constipation, vomiting, dysphagia, and loss of appetite); treat or prevent skin problems (such as pressure ulcers), etc.
- Provide mental and emotional comfort to the patients (address depression, delirium, insomnia, and anxiety) and emotional support to their caregivers