Object
Title: Analysis of the possibility of using comprehensive geriatric assessment in primary health care
Abstract:
Introduction The aging of societies in highly developed and developing countries is a huge economic, social and medical challenge. At the end of 2021, when the population in Poland consisted of 37.9 million people, almost 7.2 million of them were people aged 65 and over. One of the methods used in the care of older people is the comprehensive geriatric assessment (CGA). It is a commonly used tool in modern geriatric practice. CGA is defined as a complex diagnostic and therapeutic process that enables the recognition of medical, psychosocial and functional capabilities and limitations of an older patient. Thanks to the CGA, it is possible to determine the senior's treatment and rehabilitation priorities with his family and the patient himself. Many studies have shown that performing CGA can measurably improve the general condition of patients, which leads to better prognosis, improving the quality of life (QoL) of patients and keeping them in the best condition and functional autonomy. Studies have shown that its use in the assessment of senior patients is associated with a reduction in mortality,a reduction in the number of hospitalizations and an improvement in functional status. Objective In this study, the possibility of using elements of CGA in patients over 64 years of age was analysed in primary health care setting. The research objectives were: (1) to assess in the ; older patients the prevalence and severity of: mood and cognitive disorders, malnutrition, functional limitations, risk of falls, insomnia and frailty syndrome; (2) to assess the QoL in seniors; (3) to determine whether the senior caregiver's judgment about the geriatric patient's functioning status is correct; (4) to establish whether there are associations between CGA scores and selected social, demographic and medical factors; (5) to determine in which geriatric patients it would be most appropriate to perform the elements of CGA. Material and method A cross-sectional, observational study was conducted from April 2018 to April 2019 in 15 randomly selected primary care clinics cooperating with the Department of Family Medicine of the Jagiellonian University Medical College. Patients over 64 years of age participated in it. They filled in an authors’ questionnaire concerning basic data about them (e.g. age, gender, marital status) and medical information (e.g. health condition, smoking, use of health care), containing 20 questions. Then, the elements of the CGA were performed in the patients, with the use of eight scales commonly used in geriatrics: the Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL), the Mini-Mental State Assessment (MMSE), the Geriatric Depression Scale (GDS), Timed Up and Go Test (TT), Mini Nutritional Assessment Short For ; m (MNA), Clinical Frailty Scale (CFS) and Athens Insomnia Scale (AIS). The last step was to determine the level of QoL with the use of the EQ-5D-5L questionnaire. In addition, patients indicated whether they had caregivers. Caregivers filled in an authors’ questionnaire in which they specified how, in their opinion, a given patient functions in the domains assessed during the CGA. Moreover, the form included questions about the relationship of caregivers with the health care services. Results The study involved 438 patients aged between 65 and 96 years (mean 75.6±7.9 years); 63% of the respondents were women. For the purpose of the analysis, the patients participating in the study were divided by age into the following subgroups: 65-74 years, 75-84 years, ≥85 years, which included 50%, 31% and 19% of the subjects, respectively. The most frequently identified deficits concerned the occurrence of depressive symptoms, frailty and insomnia. Mild depressive disorders were suspected in 17%, 32% and 40%, respectively, and severe depressive disorders in 3%, 8% and 9% of the respondents, in particular age subgroups. Frailty symptoms were detected in 12%, 43% and 72% of patients, respectively. Insomnia was suspected in 10%, 17% and 24% of the participants in each age subgroup, respectively. Male gender was associated with a lower risk of depressive symptoms [OR=0.6 (0.39-0.92); p=0. ; 02] and falls [OR=0.63 (0.41-0.95); p=0.03]. City dwellers had a lower risk of disability related to daily activities [OR=0.24 (0.11-0.54); p<0.001] and depression [OR=0.65 (0.42-0.99); p=0.04]. Being in a partnership or marriage was associated with a lower risk of functional disability [OR=0.38 (0.21-0.68); p<0.001], falls [OR=0.43 (0.29-0.64); p<0.001] and frailty syndrome [OR=0.39 (0.26-0.58); p<0.001], depressiveness [OR=0.45 (0.3-0.69); p<0.001] and cognitive impairment [OR=0.42 (0.26-0.68); p<0.001]. In the QoL assessment performed with the EQ-5D-5L tool, the most common problem reported by seniors was pain and discomfort. 21% of respondents declared no limitations in the five assessed areas that comprised to QoL. The average subjective assessment of health-related QoL indicated by the study participants on the visual-analogue scale (VAS) was 62.36±18.98 points, and the median (Q1-Q3) was 60 (50-80) points out of 100 possible. Younger and physically active patients (p<0.001) and those living with relatives (p=0.01) scored higher on the EQ-5D-5L VAS. Seniors with more than three chronic diseases had a lower QoL than their healthier coevals (p<0.001). Patients with declared lower QoL, assessed with the EQ-5D-5L VAS scale, obtained worse scores in the scales used to assess mood, the presence of frailty and the risk of falls, and insomnia. Out of the 438 examined geriatric ; patients, 258 (59%) had a caregiver. The mean age of the caregiver was 59.37±0.5 years, and the median (Q1-Q3) was 76 (69-94) years. Most of them were women (n=182, 70%). Mostly, the patients' partners were the caregivers of the patients; the second largest group of caregivers were the children of the respondents. Patients using the help of caregivers were older (p=0.001), less educated and more often lived in rural areas (p<0.001) compared to people who did not use the care of others. Seniors with caregivers had higher scores in some areas of the CGA, i.e. in CFS (p=0.008) and in AIS (p=0.049). It was shown that these people obtained lower results in the ADL and IADL scales (in both cases p<0.001), which indicates the presence of difficulties in everyday functioning. In terms of the agreement between the opinion of caregivers of the seniors and the screening assessment in the areas included in the CGA, it was shown that caregivers correctly identified deficits in basic and complex activities of daily living. At the same time, they had problems with identifying the presence of cognitive disorders and depression. Conclusions 1. In older patients under the care of family physicians, geriatric screening tests reveal abnormalities that may be overlooked in everyday clinical practice. The most common of these are depressive disorders, frailty and insomnia. These data indicate th ; e legitimacy of carrying out diagnostics of the above-mentioned problems by general practitioners. 2. The number of geriatric problems identified in the CGA increases with age. In the youngest age group (people aged 65-74), the results of most tests were within normal range, therefore, from the population and systemic point of view, it is more beneficial to perform CGA in the oldest group of patients. 3. Female gender is associated with a higher risk of depressive disorders and falls, and residents of rural areas have a higher risk of limitations related to daily activities and depression. These differences should be taken into account by general practitioners who may adjust the CGA range to individual patients. 4. The level of QoL of older patients coming to general practitioners decreases with age, mainly in the areas of pain and mobility. Lower QoL of patients is associated with deficits and problems identified within the CGA. Taking this relationship into account, family physicians should extend geriatric diagnostics, especially among patients with reduced QoL. 5. Caregivers of geriatric patients in primary health care setting are usually members of their families, often also in old age. They can determine whether the patients are disabled and malnourished, which means that in these areas the information obtained from them can play an important role for medical professi ; onals. However, caregivers are not able to correctly assess depressive disorders and insomnia, which determines the need for routine diagnostics in these areas. 6. Due to the lack of information on proper care among caregivers of the older people and the desire to obtain it from medical professionals, family doctors, apart from working with the patients themselves, should provide seniors’ families with the necessary knowledge on this subject.
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Rada Dyscypliny Nauki medyczne
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Tomasik, Tomasz ; Piotrowicz, Karolina
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Jun 28, 2024
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May 22, 2024
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http://dl.cm-uj.krakow.pl:8080/publication/5112
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