Comprehensive Health Assesment of a Geriatric Patient Essay
Geriatric patients have delicate health conditions that should always be monitored on a daily basis. Failure to this, they may succumb to diseases, which in the end may lead to further complications. According to Bowers, (2016,) geriatric patients require both physical body and multidimensional assessment. It involves a thorough assessment of the pain, mental condition, social and economic status as well as the physical environment where they are exposed (Bowers, 2016). Their mental status refers to the cognitive functions such as decision-making and planning abilities, language, memory orientation and the ability to visualize their ideas. Comprehensive Health Assesment of a Geriatric Patient Essay. Ward, Reuben, Schmader, & Eamranond, (2016), physical body assessment involves a thorough check up of their body functionality such as the kidneys, eyes, arms, legs among others. Assessment of social and economic status involves their attitude and ability to interact with friends and families where they live (Ward et al. 2016). In additional to this, nutritional assessment should also be conducted since their body functionality, and general health is dependent on their nutrition patterns.
While attending to geriatric patients, several considerations should be in mind of the physician so that they may know the extent of care and attention that the patient requires. Some of these factors include; the patient’s age, their psychological disorder such as hallucinations, depression, and isolation (Bowers, 2016). It is also important to consider patients specific geriatric conditions that have already been identified by physicians such as functional disability, dementia, and falls. Caillet, et al. (2014), state that, this will help the nurse in charge while conducting the assessment to be able to factor out the different characters depicted by these patients. Also, any past health care utilization should be analyzed as well (Caillet, et al. 2014).
A comprehensive Geriatric assessment will only be effective if the process is done with care following the right procedure. Failure to this, a geriatric patient may end up suffering without the physician knowledge.
Assessment helps care planning professionals in examining their client’s life in much detail so that correct diagnosis, suitable treatment post, problem lists, and treatment goals can be developed (Health in All Policies, 2010). Generally, a clinical assessment identifies client or patient’s recent experiences and their physical, psychological, and socio-cultural history to settle on exact treatment needs (Smith & Capon, 2011). Comprehensive Health Assesment of a Geriatric Patient Essay. Assessment can be done in different ways but the most two types of assessment used on the basis of underlying differences are as follows:
Comprehensive assessment is a type of clinical assessment that enables the health professional or treatment provider with the determination of client’s most suitable treatment placement and treatment plan. Comprehensive assessment could be defined as a multidisciplinary investigative and treatment procedure that distinguishes medical, psychosocial, and functional restrictions of an unhealthy person with an aim to formulate a corresponding plan to maximize on the whole health with aging. Usually comprehensive assessment is used for the health care of an older adult as it is far more than the traditional medical management of illness. Providing care to old people need evaluation of number of issues such as physical, affective, social, cognitive, financial, environmental, and spiritual aspects that could be identified effectively with comprehensive assessment (Mazza & Harris, 2010).
Comprehensive assessment relies on the premise that a methodical evaluation of older individuals by a team of health professionals helps in discovering a number of treatable health issues and direct towards effective health outcomes. Comprehensive assessment is generally initiated with a referral by the primary care clinician or from some professional clinician working in hospital.
Every patient could not be referred for comprehensive assessment as there are specific evidences to identify appropriate patients for comprehensive assessment. Although there are no set criteria to refer patients for comprehensive assessment, but some specific points or criteria’ used in this concern are:
Medical comorbidities like heart failure or cancer
Psychosocial disorders like depression or isolation
Specific geriatric conditions like dementia, falls, or functional disability
Earlier or anticipated high health care utilization (Wanberg & Milkman, 2009). Comprehensive Health Assesment of a Geriatric Patient Essay.
Change in living situation
One outpatient approach for referring patients for comprehensive assessment is to refer patients who have problems in various areas, whereas an inpatient approach to refer would be to refer patients for CGA who are found to have problems in multiple areas during geriatric assessment screens. An inpatient approach used to refer patients for comprehensive assessment is to refer patients admitted in hospital or clinical care institute for a specific medical or surgical reason (Phillips, McKeown & Sandford, 2009).
Comprehensive assessment helps clinical care professionals in providing care with the help of six steps that are data collection, team discussion, development of a treatment plan, execution of the treatment plan, monitoring response to the determined treatment plan, and revising the treatment plan. A comprehensive assessment is undertaken with the help of qualified and trained clinicians that in turn assist the treatment provider to determine the most effective treatment placement and treatment plan (Wanberg & Milkman, 2009).
In contrast to comprehensive assessment, risk assessment refers to making decisions on the basis of acquaintance of research evidence, familiarity of the individual service user and their social background, knowledge of the service user’s own experience, and clinical judgement. In risk assessment, the clinician must collect information from two main information sources to direct clinical decisions (O’Connell, Ostaszkiewicz & Hawkins, 2011). Understanding of statistical factors in regard to the increased risk is needed, along with clinical and contextual information specific to patient’ or clinical service user’s present situation. Evidence of known risk factors can be attempted from the clinical data as well as from the patient’s demographic information (Mazza & Harris, 2010).
Demographic information like age, gender or past behaviour may be related to increased risk. Although, all these factors are static, so risk may not be decreased through the modifications in these factors. Dynamic factors on the other hand can be modified like factors related to patient’s mental state or socio-economic conditions etc (Phillips, McKeown & Sandford, 2009). Information collected from dynamic factors is more effective to inform care planning. Comprehensive Health Assesment of a Geriatric Patient Essay. Therefore, in risk assessment information specific to the patient and his/her contextual information need to be incorporated.
The concentration of risk assessment is to guide and support positive approaches to risk management whereas in comprehensive assessment focus is on the development of treatment placement and treatment plan. Risk assessment and its management in clinical care is a step-wise procedure that includes following steps; social and environmental context, defining the risks, distinguish who is at risk, information collection, evaluation of risks, determining which risks factors need to be modified, resource significances, communication, care planning, and review.
A continence assessment is executed by healthcare professionals with an aim to assess an individual ability to control bladder or bowel function and to agree on factors that may be imparting to incontinence. For continence management, it is vital to take continence assessment and it is undertaken in two parts: an interview and a physical assessment. As well, patient may also need to fill a bladder diary before his/her assessment (Chiarelli, 2011). A bladder diary refers to a diary of evidences and what patient was doing at the time evidences took place. A bladder diary serve health professionals with significant clues in regard to the type of incontinence an individual is facing and what are the activities that may be contributing to incontinence.
In the interview portion of the continence assessment, patient could be asked with a series of questions such as prior medical history, medication being taken, overall health, weight, smoking history, history of prostate issues (for men), pregnancy/childbirth history (for women), diabetic, problem with frequent constipation etc. In the physical assessment portion a urinalysis is done to check for kidney or bladder problems, such as infection (Ferrell & Coyle, 2010). At the same time, if needed healthcare professional (generally a nurse continence expert or a doctor) may also carry out a physical exam, together with a vaginal exam for women and a rectal exam for men. Comprehensive Health Assesment of a Geriatric Patient Essay. It is done to evaluate the strength of patient’s pelvic floor muscles (Phillips, McKeown & Sandford, 2009).
Physical assessment makes it easier for healthcare professionals to identify a physical problem due to which incontinence is occurring. A continence assessment is significant to identify the reason of incontinence, and recommend patients in regard to managing incontinence (Chiarelli, 2011).
A continence assessment significantly contributes in a comprehensive health assessment and this could be understood with an example of an old person comprehensive health assessment. Today, old patients have multiple problems like diabetes mellitus, chronic chest conditions etc. For dealing with all these health issues of older people, it is vital to undertake comprehensive health assessment that if also includes a continence assessment would benefit a lot to identify the actual causes of all problems in old aged patients (Miller, 2011).
Diabetes mellitus can result in number of bladder problems, including polyuria, urinary retention and urinary tract infection, so at the time of comprehensive health assessment is a continence assessment is also done it becomes easy to control the health problems and its affects at earlier stage (Chiarelli, 2011). A continence assessment assist health care professional a lot in their comprehensive health assessment as without identifying bladder functioning it is not possible to arrive at suitable treatment plan (Ferrell & Coyle, 2010).
Abnormal Findings and Actions to deal with it:
The prevalence of urinary incontinence heightens with age, so the diagnosis of it on time is essential for women. As the population of US ages, quality care professionals confront increasing number of inconsistence (Massoud, Mahshid & Behrouz, 2011). At the time of performing continence assessment one might expect these three abnormal findings:
Stress Incontinence: It refers to the spontaneous loss of urine throughout an increase of intra-abdominal pressure brought about from activities like coughing, smiling or exercising. The underlying abnormality is generally urethral hyper mobility due to the breakdown of the normal anatomic accompaniments of the urethrovesical junction. Being a planning care professional one can deal with this abnormality with the diagnosis along with various tests to assess the severity of leakage as well as undertaking specialized tests such as urodynamics and cystourethroscopy (Continence Assessment, 2010). Comprehensive Health Assesment of a Geriatric Patient Essay.
Detrusor instability or Detrusor hyperreflexia: These abnormalities are all due to overactive bladder. For dealing with this abnormality, a planning care professional may undertake several simple or complex urodynamic studies to arrive at the definitive diagnosis of Detrusor instability or Detrusor hyperreflexia. As well, some patients may also be treated without experiencing invasive testing. Behavioural therapy could also be used as bladder retraining and biofeedback that tries to re-establish cortical control of the bladder by appropriating the sufferer ignore exigency and void only in retort to cortical signals in waking hours (Ferrell & Coyle, 2010).
Ectopic ureters and diverticulae: Another abnormality that is expected to come up at the tiem of performing continence assessment is ectopic ureters and diverticulae. For dealing with this type of abnormality, a completed history is obtained and a physical examination is performed to initiate treatment. Treatment of women with urinary incontinence secondary to a urinary or gynecologic deformity or lack of continuity usually calls for surgery by an urogynecologist or an urologist (Continence Assessment, 2010).
Comprehensive geriatric assessment (CGA) is a core and an essential part of the comprehensive care of the aging population. CGA uses specific tools to summarize elderly status in several domains that may influence the general health and outcomes of diseases of elderly patients, including assessment of medical, physical, psychological, mental, nutritional, cognitive, social, economic, and environmental status. Here, in this paper, we review different assessment tools used in elderly patients with chronic diseases. The development of comprehensive assessment tools and single assessment tools specially used in a dimension of CGA was discussed. CGA provides substantial insight into the comprehensive management of elderly patients. Developing concise and effective assessment instruments is helpful to carry out CGA widely to create a higher clinical value. Comprehensive Health Assesment of a Geriatric Patient Essay.
Since the 21st century, the aging of the population began to accelerate. Although the aging of the population is still concentrated in developed countries, many developing countries have entered the era of an aging population. The United Nations predict that population aging will occur mainly in developing countries in the next 35 years . The World Health Organization (WHO) categorized 60–74-year-olds as the younger elderly, 75–89-year-olds as the elderly, and ≥90-year-olds as elderly elderly or macrobian elderly, while the National Comprehensive Cancer Network (NCCN) defined the 65–75-year-olds as the younger elderly, 76–85-year-olds as the elderly, and >85-year-olds as the macrobian elderly .
According to the assessment in 2010, the balance of the global burden of disease is gradually tilted to chronic diseases which will be the first burden of the global elderly. The most common chronic illnesses include cardiovascular disease, heart disease, cancer, chronic respiratory diseases, musculoskeletal disorders, pulmonary disease, diabetes, cognitive impairment, and depression, among which cardiovascular disease is a major killer of elderly health, especially ischemic heart disease. As Beard and Bloom [3, 4] make clear in their viewpoint, increased disease burden will be mainly concentrated in those age-related diseases. For example, due to the aging of population, Alzheimer’s disease will further increase the burden on the elderly in the next 30 or 40 years. The latest estimates show that the number of patients with dementia is expected to increase from the current 44 million to 135 million by 2050. Therefore, under the new situation of the elderly increasing demand for health services, it is an inevitable requirement and a challenge to develop some new models and innovative elderly disease control to achieve healthy aging.
Comprehensive Geriatric Assessment (CGA) was proposed by Warren in the late 1930s. The National Institutes of Health (NIH) organized experts in relevant disciplines to develop the standard of CGA in 1987 [5, 6]. CGA provides detailed information on clinical, functional, and cognitive domains of older patients; it concerns the general health of the elderly and multidimensional and comprehensive scientific assessment of health status. CGA is an important way to implement the comprehensive management of aging populations. It integrates physical health, mental health, functional status, social adaptability, and environment conditions and quantifies the elderly overall health objectively. Not only is CGA an assessment, but also it formulates and makes treatment plans that protect the health and functional status of the elderly to maximize their quality of life (QoL). CGA has become an important means of the management of the elderly [7–9]. Comprehensive Health Assesment of a Geriatric Patient Essay.
2. The Contents of CGA and the Assessment Tools Used in Each Domain
2.1. The Overall Functional Status, including Physical Health, Activities of Daily Living, and Fall Risk Assessment
The World Organization of National Colleges, Academies and Academic Association of General Practitioners/Family Physician (WONCA) considers that separate evaluation could not reflect the actual function of a whole person or his/her activities of daily living, though modern medicine has its own criteria for evaluating the function of each organ system.
The basis of CGA is comprehensive functional assessment, which should include lots of elements, such as the situation of disease of the elderly, hearing, vision, and suffering from urinary incontinence. Frailty is a state of vulnerability to poor resolution of homoeostasis after a stressor event and is a consequence of cumulative decline in many physiological systems during a lifetime. Frailty is an important geriatric syndrome linked to increased mortality, morbidity, and falls risk. A longitudinal assessment for a period of two years by Ng et al.  assessed 1685 Singaporean elderly with Frailty Risk Index (FRI). Weakness, slowness, low physical activity, weight loss, and exhaustion are included in FRI, and evaluation is rated on seven levels (very healthy, healthy, in good health, surface weakness, mild weakness, moderate weakness, and severe weakness) . The results of their study demonstrated that FRI with a certain degree of reliability and validity as a tool is applied in predicting frailty symptoms of the elderly and decline in functional status. A systematic review on the reliability and validity of FRI also proved it .
Currently, functional status was measured by activities of daily living (ADL) and instrumental activities of daily living (IADL) . Barthel’s Index Rating Scale is the most commonly used for ADL with the total score of 100 points, with assessment based on scoring criteria. The Katz Index of Independence in Activities of Daily Living, commonly referred to as the Katz ADL, summarizes overall performance in bathing, dressing, going to toilet, transferring, continence, and feeding. Comprehensive Health Assesment of a Geriatric Patient Essay. Clients scored yes/no for independence in each of the six functions; grading is based on A~G seven functional levels, where higher level indicates lower ADL [14–16]. Function Activity Questionnaire (FAQ) is the preferred rating scale of IADL; the higher the score, the more severe the disorders, with score of more than 5 considered as abnormal. Rapid Disability Rating Scale (RDRs) is also an assessment tool for IADL, which is used for hospitalized and community-dwelling patients, particularly appropriate for elderly patients, but rarely used in clinical practice. The degree of help needs of daily life, degree of disability, and the degree of special issues are taken into account with the highest score of 54, where higher score indicates more severe disability.
In addition, falling fracture always occurs in the patients with balance and gait disorder, with fall rates as high as 50% under the age of more than 80 years, of which more than half of the elderly falls had occurred several times . Fall was the third cause of chronic disability in the elderly which can lead to fractures, soft tissue damage, brain damage, and death .
There are many methods and scales for balance and fall risk assessment, summarized in Table 1. Berg Balance Scale (BBS) is the world’s balance scale for patients with stroke and showed great reliability, validity, and sensitivity in different recovery stages of stroke [19, 20]. BBS assessed balance and fall risk with standing, turning around, standing on one leg, and a total of 14 other actions, with scores ranging from 0 to 56 with the cutoff point as 45, where lower score indicates higher fall risk. According to Pereira’s study , BBS was better than the posturographic Balance Stability System (BSS) in elderly fall risk assessment. Timed Up and Go Test (TUGT)  and Tinetti Gait and Balance Test  are widely used to measure the functional activity of the elderly balance and physical fitness, while the latter can also be used to predict the fall risk by testing the patient’s gait and balance function. The Fall Risk Assessment Scale for the Elderly (FRASE) is correlated with St. Thomas’s Risk Assessment Tool (STRATIFY) ; both of them have the disadvantage of containing only internal fall factors, but STRATIFY is more detailed. The Fall Risk Index (FRI)  is suitable for patients with stroke, and elderly patients with physical and cognitive impairment falls risk assessment usually use the Fall Assessment Tool (FAT), which includes assessment of fall-related environment factors. Therefore, FAT is also suitable for elderly patients newly admitted to assess the fall risk factors due to environmental changes. Comprehensive Health Assesment of a Geriatric Patient Essay.