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+++++++++++++++++++++ + +++ +SENioR HEALTH +++ +++++++++++++++++++++ Geriatric evaluation and Management in the 21st Century by barbara messinger-rapport, mD, phD T HE FIELd oF geriatrics developed to apply our understanding of aging principles to internal and family medicine, acknowledging that older adults can be more complicated than young and middle-aged adults. A problem such as a mood disorder, recurrent falls or urinary incontinence, for example, can often be attributed to one particular disease process in a young person. In an older adult, such a problem, or syndrome, is unlikely to resolve unless several aspects of aging are acknowledged and addressed. The purpose of geriatric assessment clinics has been, and often still is, to identify and address geriatric syndromes. Traditional geriatric assessment can take hours: the patient and caregiver(s) are evaluated by a gerontologically trained nurse and social worker as well as a physician, physical therapist, psychologist, pharmacist and other specialists. New medical conditions may be identified, medication suggested, and therapy recommended. Comprehensive testing and follow-up may be needed to formulate a diagnosis and plan of care. One could argue that the traditional geriatric assessment is an anachronism in the 21st Century. + Baby boomers are aging successfully, staying mentally and physically active longer. + Smart home technology assists adult aging in place. + State governments are recognizing value in subsidizing services to keep elders at home (less expensive than nursing home care). + Interested elders who can afford them reside in continuing care communities that tailor care as needed. Primary care physicians (PCPs) are more intensely trained in geriatrics. Hospitals are incorporating geriatric principles of hospitalization in "huddles," nutrition stations, attention to delirium, co-management of hip fracture patients, and 24-hour family visitation, among many interventions. Physicians in outpatient and inpatient settings take much better care of older adults than they did even 10 years ago. 30 | Cleveland/Akron/Canton MD News ■ mdNEWS.Com ■ NovEmBEr /dECEmBEr A new understanding of geriatrics has evolved. Geriatrics now really means care of the old-old, those who are greater than 75 to 80 years of age. Accordingly, a new clinical approach to geriatric evaluation and management (GEM) has been developed. A trained nurse or medical assistant evaluates the patient for cognitive or mood impairments. Simultaneously, the family or informant (assuming this individual initiated the evaluation) is queried regarding goals of the visit and specific medical and psychosocial concerns. Typically, the initial assessment takes one to two hours. To conclude the visit, the physician usually presents a tentative diagnosis and plan to the patient and family. Testing, therapy evaluations or subspecialty referrals may be recommended. If dementia is the diagnosis, the disease is identified and appropriate treatment outlined. Community resources to help family deal with associated issues are often recommended. A follow-up visit with a mid-level professional (advanced practice nurse or nurse practitioner, typically) in four to six weeks helps the patient and/or family understand the diagnosis and allows fine-tuning of the plan to include new information such as lab, imaging, counseling from resources such as the Alzheimer Association, etc. Follow-up visits may occur approximately every six months, depending on evolving concerns. The GEM clinic does not generally assume the primary care of the patient. GEM providers work with the PCP to place medical conditions such as hypertension or diabetes in perspective with the patient's life expectancy, disabilities and personal healthcare goals. Geriatric management and assessment clinics have proven successful in dealing with quality of life for patients and caregiver(s) who attend appointments, and in identifying caregivers' stress, as well. Much different than past geriatric assessment programs, GEM programs address the needs of the old-old in the 21st century. Dr. Barbara Messinger-Rapport is the Director of the Center for Geriatric Medicine and Section Head of Geriatric Medicine for the Department of Internal Medicine at Cleveland Clinic. ■