Comprehensive Geriatric
Assessment (CGA)/ Pengkajian
Paripurna Pasien Geriatri (P3G)
Czeresna Heriawan Soejono
DR.Dr. SpPD, KGer, MEpid, FACP, FINASIM
Patient Examination
• Diagnosis
– Medical
– Surgery
• Therapy/ Management
– Medical
– Surgery
Diagnosis
• Collect the data
– History
– Physical Examination
– Laboratory test
– Other tests
• Analyze the data
• Synthesis Diagnosis
History
• Chief complain
• Present illness history
– Clinical history of the disease/ symptom
– Changes in ADL
• Riwayat Penyakit Dahulu
– Penyakit dahulu
– Riwayat perawatan
– Riwayat operasi
History
• Chief complain
• Present illness history
– Clinical history of the disease/ symptom
– Changes in ADL
• Past history
– Past illness history
– History of hospitalization
– History of surgery
• Family history (history of illness in the family)
• Allergy history; Medication consumed
• Social history; religious & leisure time activities
• Financial analysis
• Nutritional analysis
• House analysis
• Genogram
• System Anamnesis
• Anamnesis of Emotional Condition
• Anamnesis of Cognitive Status
Conventional Anamnesis vs CGA
• Chief complain • Chief complain
• Present illness history • Present illness history + ADL
• Past illness history • Past illness history
• Family history • Family history + Genogram
• Allergy history • Allergy history; Medication
• Social history • Social history
• Financial, nutritional, & house
analysis
• System Anamnesis
• Emotional Condition
• Cognitive Status
ADL (Barthel Index)
Ability or inability to perform ADLs as a measurement of
functional status of a person
Basic ADLs consist of self-care tasks
• Bowels (Ability to control defecation) 2
• Bladder (Ability to control micturition) 2
• Grooming 1
• Toilet use 2
• Feeding 2
• Transfer 3
• Mobility = ambulation 3
• Dressing 2
• Go up & down stairs 2
• Bathing 1
Basic ADL Score
20 : Independent 5- 8 : Severe dependent
12-19 : Mild dependent 0- 4 : Total dependent
9-11 : Moderate dependent
Lawton IADL Scale
Instrumental ADLs let an individual live independently in a
community
• Ability to use telephone
• Mode of transportation
• Shopping
• Food preparation
• House keeping
• Responsibility for own medications
• Laundry
• Ability to handle finances
1 = independent 2 = needs help 3 = dependent
Emotional Condition
• Sad face
• Speak slowly
• Reluctant to answer questions
• Loss of interest or pleasure
• Loss of desire
• Loss of appetite
• Reluctant to consume medications
Instrument for screening GDS 15
Geriatric Depression Scale (GDS) -15
Please choose the best answer for how you have felt over the past week
Present question VERBALLY.
DO NOT show to patient
Scores:
5-9 high possibility of depression
> 10 depression
AMT
• Age ............................... years old 1
• Time 1
• Address 1
• Year 1
• Name of this place 1
• Identification of other people (doctor, nurse, etc) 1
• Year of Indonesia Independence Day 1
• Name of Indonesia current president 1
• Patient’s or the last child’s year of birth 1
• Count backwards (20 to 1) 1
Affect : good; labile; depressed; agitated; nervous
AMT Score
0-3 : severe cognitive impairment
4-7 : Moderate cognitive impairment
8-10 : Normal
MMSE (mini mental state examination)
• Orientation
• Registration
• Attention
• Calculation
• Recall
• Language
• Executive
• Visuo-spatial
Physical Examination (PE)
• Consciousness
• Vital Signs (lie down and sitting position BP!!)
• System physical examination
• MMT/manual muscle test (motoric/ muscle strength)
• Coordination
• Cranial nerves I – XII
• Sensorium
• Balance
• ADL:
ADL
• Transfer
• Sitting balance
• Standing balance
• Balance while ambulation/ mobilization
• Need to use walking aid?
– Stick/ staff
– Tripot/ quadripot
– Walker
– Wheel chair
System Physical Examination
• All system, including teeth and oral cavity
• Musculoskeletal
– ROM
– Muscle hypo/ atrophy
– Deformity?
• Skin & integument
– Decubitus ulcer
– Hematom
Nutritional Status
• Anamnesis of dietary and fluid intake
• Anthropometric measurement
– Body height/ Knee height
– Body weight
– Body mass index
– Mid-arm circumference; Skin fold; Calf circumference
• Clinical assessment: Mini Nutritional Assessment
(MNA)
• Biochemical data: Haemoglobin, Albumin
Knee height formula
BH (♂) = 59,01 + (2,08 x KH)
BH (♀) = 75,00 + (1,91 x KH) – (0,17 x Age)
Biochemical At Risk Level
Parameters
Serum albumin < 3.5 g/dL
Total lymphocyte <1500 cells/mm3
count
Serum transferrin <140 mg/dL
Serum pre- <17 mg/dL
albumin
Total iron-binding <250 mcg/dL
capacity
Serum cholesterol <150 mg/dL
Mini Nutritional Assessment (MNA)
Diagnosis/ problems:
• Physical, BIOLOGIC
• FUNCTIONAL
• PSYCHOLOGIC
• COGNITIVE
• PSYCHOSOCIAL
THE MANAGEMENT....also:
• Physical, BIOLOGIC
• FUNCTIONAL
• PSYCHOLOGIC
• COGNITIVE
• PSYCHOSOCIAL
PSYCHO-
Physical
COGNITIVE
BIOLOGIC
SOCIAL
FUNCTIONAL
SUMMARY
• Characteristics of Geriatric Patient:
– Multipathology
– Decreased reserved/ physiological capacity
– Atypical presentation of illness
– Decreased functional status
– Malnutrition
Multipathology
• Require multidiscipline team
• Who work interdiscipline
MEDICAL REHABILITATION
INTERNAL MEDICINE
PSYCHIATRY
MEDICAL REHABILITATION
INTERNAL MEDICINE
PSYCHIATRY
INTERNAL MEDICINE PATIENT
Decreased reserved/ physiological
capacity
• Deteriorate easily
• Longer time to improve/ heal/ be cured
• Longer time to recover
---that’s why require:
• Health Promotion, Disease Prevention
– Early detection
– Immunization (influenza, pneumonia)
• Medical Rehabilitation Program
– Help to accelerate the healing process (e.g. ...?)
– Help to accelerate the recovery (e.g. ...?)
---that’s why require:
• Health Promotion, Disease Prevention
– Early detection
– Immunization (influenza, pneumonia)
• Medical Rehabilitation Program
– Help to accelerate the healing process (e.g. ...?)
– Help to accelerate the recovery (e.g. ...?)
Atypical presentation of illness
• The symptoms frequently atypical
– Do not remember
– Unable to express
– Afraid
Thus, need to be systematic
• System Anamnesis • System Physical
– Cardiovascular Examination
– Respiration – Cardiovascular
– Musculoskeletal – Respiration
– Haematologic – Musculoskeletal
– Nephrologic – Haematologic
– Endocrinologic – Nephrologic
– GIT – Endocrinologic
– Hepatobilier – GIT
– Hepatobilier
Decreased Functional Status
• Ability to do basic daily activity decrease, due
to e.g. :
– Multiple illness
– meanwhile the reserved/ physiological capacity
already decreased
---thus require:
• Functional status assessment:
– ADL
– IADL
– Katz
– UNFPA
– etc
• sebenarnya memberikan panduan: are we
on the right track?
---thus require:
• Functional status assessment:
– ADL
– IADL
– Katz
– UNFPA
– etc
think beyond …
actually it gives us guidance: are we on the right track?
Malnutrition
• Increase morbidity
• Decelerate healing process
• Decelerate recovery
• Increase mortality
---thus require...
• Nutritional status assessment
– Anamnesis dietary intake
– Anthropometric BMI, MAC, CC
– Biochemical data Hb, albumin, prealbumin
– MNA to screen and classify
Nutritional Requirements-(1)
Daily energy requirements per Kg BW generally decrease with age
• Calorie intake / energy intake influenced by energy
requirement
• Energy requirement influenced by basal metabolic
rate, metabolic stage, body temperature and activity
• TEE = BEE + postprandial thermogenesis + EEA
• Energy requirement calorie intake
at risk of developing protein & micronutrient
deficiencies
Nutritional Requirements-(2)
• Energy
Harris-Benedict Equation for Resting Metabolic Rate (RMR)
M: 66.47 + (13.75 x BW) + (5 x BH) – (6.76 x age)
F: 655.1 + (9.56 x BW) + (1.85 x BH) – (4.67 x age)
Total daily energy requirement = RMR x adjustment factor
Stress factor
1.3 for mild; 1.5 for moderate; and 1.7-1.8 for severe illness/ injury
Activity factor
1.2 confined to bed; 1.3 out of bed
Rule of Thumb
Calorie requirement = 25 to 30 kcal/kg Actual BW/day
Unless obese or with edema ideal body weight (IBW)
Nutritional Requirements-(3)
• Including macronutrient (CH, protein, fat), micronutrient (vitamin,
mineral, trace element), and water
• The energy, protein, and fat requirements are determined first
the CH requirements are then calculated by subtracting the
amount of energy supplied by protein and fat from the total energy
requirement
• Because protein requirements represent + 15% of total energy
(During stress: 1.2 - 2 g/kgBW/day 20-30% of total calories)
and fat ideally should be < 30%, CH usually represent 55-70% of
the total
• Water: 30 ml x ABW or 1 ml x kcal fed or 1500 ml x BSA (m2)
CGA / P3G
• Biologic • Curative
• Physical • Promotive
• Psychologic • Preventive
• Cognitive • Rehabilitative
• Functional
• Psychosocial
CGA / P3G
• Multidiscipline TEAM • Impairment
• But the approach MUST BE:
• Disability/
– Unidiscipline X
hendaya
– Paradiscipline X
– Pandiscipline X • Handicap
– Multidiscipline X
– INTERDISCIPLINE
CGA / P3G
• Multidiscipline TEAM • Impairment
• But the approach MUST BE:
• Disability/
– Unidiscipline X
– Paradiscipline X
“hendaya”
– Pandiscipline X • Handicap
– Multidiscipline X
– INTERDISCIPLINE
Impairment, disability, handicap
A disease may create impairment in organ function which can lead
to a reduced ability to perform certain tasks (disability). This
inability may become a handicap when those tasks are necessary
to carry out social activities.
• Impairment
– Impairment in organ function
– Anatomical
• Disability
– Reduced ability to perform certain tasks
• Handicap
– Disturb in the individual social function
CGA / P3G
• Management:
1. Infusion (fluid/ hydration status)
2. Nutrition (food, nutrient)
3. Medications
4. Activity (develop structured program)
5. Psychosocial care (should be optimally
addressed)
CGA / P3G
• Continuum of care
– Hospital based
• Acute care
• Chronic care
• Discharge planning
• Day hospital
– Community based
• Home care
• Hostel
• Panti werdha
• Karang werdha
Home
Continuum of care
Puskesmas
Posyandu
EU
Acute Geriatric
Lansia Ward
CISE Outpatient
clinic Discharge planning
Private
clinic
N/H Day Hospital
…. go home
Chronic Geriatric
Ward
Community
Geriatric
Service Hospital based Geriatric Service
PSYCHO-
Physical
COGNITIVE
BIOLOGIC
SOCIAL
FUNCTIONAL
Anamnesis and
system PE
Clinically, AMT, MMSE,
PSYCHO- GDS
PHYSICAL,
COGNITIVE
BIOLOGIC
SOCIAL
FUNCTIONAL
ADL, IADL Anamnesis, home visit
CGA
I II III IV V VI
Bio/ Physical Curative Multidiscipline Impairment Fluid Hospital
team based
Psycho/ Promotive Uni... X Disability Nutrition Discharge
Cognitive planning
Psychosocial Preventive Para...X Handicap Medications Community
based
Functional Rehabilitative Pan...X Activities
Nutrition INTERDISCIP Psychosocial
LINARY care
APPROACH
CGA
I II III IV V VI
Bio/ Physical Curative Multidiscipline Impairment Fluid Hospital
team based
Psycho/ Promotive Uni... X Disability Nutrition Discharge
Cognitive planning
Psychosocial Preventive Para...X Handicap Medications Community
based
Functional Rehabilitative Pan...X Activities
Nutrition INTERDISCIP Psychosocial
LINARY care
APPROACH
Case
Chief complain:
• Does not want to eat since 3
days before admission
Present illness history:
• Since 1 week before admission,
the patient feels lazy to eat. If
there is no one who ask her to
eat, usually she does not eat.
Her appetite decrease, her fluid
intake also decrease.
• The patient also feels lazy to do
her usual activities, such as
sitting at the porch with her
grandchildren. She spends most
of the time just lying on the
bed.
• Since the last 3 days, her appetite gone, she does
not want to eat at all. She just lying on the bed,
her body becomes weak; she can sit by herself,
but needs help to walk.
• Sometimes she gets fever, cough with whitish
sputum, without dyspneu, palpitation, nor chest
pain. There are no nausea, vomit, abdominal pain,
mastication or swallowing problem, headache, or
slurred speech.
• According to her child, the patient feels very sad
since 2 months ago when her youngest child pass
away.
Thank You
Beautiful young people is a work of NATURE
But beautiful old people is the work of ART / Geriatrics
