UNIT 2: COMPREHENSIVE GERIATRIC ASSESSMENT 2.1 PHYSICAL EXAMINATION

Comprehensive geriatric assessment (CGA) is a response to the high prevalence in the elderly of needs and problems undiagnosed, reversible dysfunction and unrecognized dependencies. These are beyond the traditional clinical assessment, the history and physical examination. The aging process is a series of events that, if not identified in a timely manner, have devastating effects on the quality of life of the elderly.

It is an interdisciplinary diagnostic process, aimed at identifying problems in medical, psychological, functional, social and family an elderly person as well as their resources, in order to develop a comprehensive plan and track.

Therefore, CGA as a diagnostic method allows for an overview of health of this population.

It allows detecting and quantifying the problems, needs and abilities of the elderly in clinical areas, functional, mental and social to develop a strategy based on them interdisciplinary intervention, treatment and long term follow up. Besides optimize resources in order to achieve the greatest degree of independence and quality of life.

It is considered a cornerstone in the daily practice of geriatric and aims to facilitate the approach to the elderly patient.

A recent meta-analysis concluded that the hospitalized elderly who are underwent VGI decrease the likelihood of functional impairment, to die or be institutionalized. Besides experience an improvement in cognition in a maximum of 12 months compared to other patients with the same characteristics. (Ellis G, 2011).

Furthermore, there is evidence that the approach is more cost effective VGI (cost-effectiveness), compared to the conventional method, there is an improved quality of life, improvement in functional status and improved patient satisfaction in group VGI is performed in the conventional group. (Soejono CH, 2008).

For all this, in practice it is recommended a comprehensive geriatric assessment all patient over 60-65 years at least 1 time per year in primary care.

Furthermore, in clinical practice, geriatric assessment should:
- Carried out respectfully refer the patient by name and make eye contact with him
- Avoid infantilization the elderly
- Do not yell assuming that not hear well
- Use language that older adults understand. Do not talk too much cheese fast


- Focus on the person, recognizing their individuality and heterogeneity of this population

The exploration in elderly person is no different from that made in the adult, takes longer to carry out due to the greater number of exploratory findings. First proceed to the general inspection: appearance, care, grooming, and collaborative exploration. Then determine vital signs: temperature, blood pressure, heart rate and respiratory rate. And we will perform a physical examination following a topographic order:

1. Head. Assessing temporal arteries, mouth (dental status, dentures, oral fungal presence, tumors), cranial nerves, eyes (ectropion / entropion, cataracts).

2. Neck. It is important to explore the existence debocio, lymphadenopathy, raised jugular venous pressure, heartbeat and carotid bruits, cervical rigidity.

3. Thorax. The exploration includes heart and lung auscultation, the presence of chest deformities and scoliosis, and breast tenderness. Abdomen. Follow the classic steps: inspection, palpation, percussion and auscultation.

5. Digital rectal exam to rule out fecal impaction, hemorrhoids or tumors.

6. Tips. Assess the situation vascular and muscular, presence or absence of peripheral pulses, presence of edema and limitations / joint deformities.

7. Neurological. Studying gait, balance, muscle tone, strength and sensitivity. Do not forget to assess the presence of speech disorder, tremor, rigidity, akinesia and frontal release reflexes.

8. Skin. Search trophic lesions, vascular pressure ulcers or signs of ischemia.

Musculoskeletal problems are the most frequent, followed by a decrease in vision and hearing. Presbyopia is present in 1/3 of the population.

It is known that the decrease in visual acuity is a risk factor for falls, depression, isolation and functional dependence (Crews J, 2004, Yueh, 2003)

The causes of impaired visual acuity in the population aged 75 or more is as follows, according to the 2002 NHIS study (JE Crews, 2004)

• Falls (53.4%)

• Glaucoma (10'3%)

• Diabetes (14'9%)

• age-related macular degeneration (8'7%)

Thus in practice an exam recommended annual newspaper optometrist or ophthalmologist for older adults, especially among those with diabetes mellitus, hypertension and glaucoma. (Arseven A, 2005)

Hearing loss in older has a prevalence of 25 to 40% in the group of 65 and increases to 80% in those over 85 years (Crews JE, 2004 and Yueh, 2003)

In practice, to assess hearing test is recommended voice whispered in his ear, is easy to perform and their sensitivity and specificity varies from 70 to 100%. Consists placed behind the patient to whisper about 15 cm and 10 words. If you cannot repeat the 50% of the words, is to be considered as disabling loss of hearing acuity. (Yueh, 2003)

For detection of visual acuity loss may be sufficient to ask:

- Do you have difficulty hearing?

- Do you have difficulty seeing television, read or perform any activities of daily living because of your eyesight?

If the answer to either of the two questions is yes, it will send the patient to a specialist.

These alterations have broad functional implications, psychological and social, to be a prime element in risk of falls and accidents. Also urinary incontinence is present in 1/3 of the population. This increases isolation, feelings of personal humiliation, shame, insecurity, anxiety, depression and sadness, falls, dependency, institutionalization predisposition, infections, nutritional disorders and compromised immune status, making it more susceptible to infections and complications.

It was found that the cause of falls and gait difficulty is multifactorial, with repercussions ranging from physical injuries, fractures, shame, greater social isolation, post fall syndrome, hospitalization, in some cases, death. Also influence on sleep disorders, present in half of the adults studied affects the quality of life, emphasizing depression frequently psychogeriatric disease in this age group, since at this stage of life all is lost.

Depression is often not identified early, present in 1/4 as cognitive status among other changes due to cerebral atrophy and meningeal are decreased intellectual responses and reasoning ability and decrease in analysis and integration of sensory information, leading to decrease in short-term memory and some loss in learning ability, although this is not an exclusive condition of old age, age itself is a risk factor for developing it, its prevalence doubles every five years after age 65, in those over 85 years old has a prevalence of 20 to 50%.

REFERENCES:

• Treaty of geriatrics for residents. Spanish Society of Geriatrics and Gerontology. [Home Site] [accessed May 18, 2013] Available at: http://www.segg.es/tratadogeriatria/main.html

• Clinical Practice Guideline: Assessment Comprehensive Geriatric Gerontological Ambulatory Elderly. Mexico: Ministry of Health, 2011. Available at:http://sgm.issste.gob.mx/medica/medica_documentacion/guias_autorizadas/Geriatr%C3%ADa/IMSS-491-11-valoraci%C3%B3n%20geronto-geriatrica/IMSS-491-11-GER%20Valoraci%C3%B3n%20geronto%20geriatrica.pdf

• N Alma Rosa Cortés, Enrique Villarreal R, Galicia R Liliana, Lydia Martinez G, Vargas D Emma Rosa. Comprehensive geriatric assessment of older adults. Rev. Marrow. Chile [serial on the Internet]. 2011 Jun [cited 2013 May 23], 139 (6): 725-731. Available at: http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872011000600005&lng=es