Issue link: https://viewer.e-digitaledition.com/i/89851
+++++++++++++++++++++++++++++++++++++++++++++++++++++ +++ +++ +++++++++++++++++++++++++++++++++++++++++++++++++++++ CLINICAL SECTION: CARING FOR OLDER ADULTS + + The Power of a Comprehensive By Maryjo L. Cleveland, MD I RECENTLY SAW AN 84-year-old woman we'll call Mrs. Smith. Her only complaint was "I just don't feel as good as I used to". She was unable to articulate any more clearly specific symptoms. Her medical review of sys- tems was essentially negative--no chest pain, shortness of breath, nausea, etc. At a typical office visit, where the next patient is already waiting for you, the next step is either an antidepressant or a flurry of laboratory tests. Is there a better way? There is — the Comprehensive Geriatric Assessment (CGA). At its core, the CGA is a structured approach to the common medical prob- lems, medications, functional limitations and social changes that face the older patient. It also involves a physical exam that adds a cognitive and mood assess- ment. Mrs. Smith knows very well what is bothering her. But her perception is that it's all normal. That it's not worth your time. That nothing can be done. But that is precisely where she is wrong. Mrs. Smith's geriatric review of sys- tems reveals that her appetite is poor; in fact she has lost 6 pounds since her last visit. She is having trouble sleeping, partly because she has to urinate 3 times per night. During the day she has to rush to the bathroom and sometimes doesn't make it. She hates wearing pads. She is constipated. Her memory is fine but her mood may be a little down. She has Geriatric Assessment chronic pain in her knees and fingers from arthritis. She has fallen twice in the last month. Her functional assessment reveals that she is independent in all Activities of Daily Living but she has a few minor problems with Instrumental Activities of Daily Living. She is only driving in the daytime due to glare from oncoming cars. She has no trouble managing her finances but the pain in her fingers makes it difficult to open her pill bottles and cook like she used to. Her medication review reveals that she takes amlodipine 10 mg daily for hypertension and alendronate 70 mg weekly for osteoporosis. Her over the counter meds include calcium/vit d, daily doses of ibuprofen 200-600 mg for pain and diphenhydramine 25 mg for sleep. Her physical exam is normal except for bilateral cataracts, changes from OA in her hands, 1+ edema bilaterally and bp of 146/92. Folstein MiniMental Status Exam is 27/30. Geriatric Depression Scale is 5/15. Now, instead of a flurry of lab orders, you have a problem list. It includes weight loss, osteoarthritis, hypertension, falls, depression, urinary incontinence, constipation, cataracts, insomnia, edema. Each of these problems can now be addressed individually with a specific plan, pharmacologic or nonpharmaco- logic intervention or a referral. My interventions with Mrs. Smith included replacing her amlodipine (likely causing edema) with lisinopril. She stopped taking ibuprofen (likely worsening her blood pressure) and started taking scheduled Tylenol. She stopped diphenhydramine (potentially causing her fall) and replaced it with mirtazapine (which is likely to help her mood, sleep and appetite). She was referred to ophthalmology for cataract removal and to urogynecology where she underwent a minor surgical procedure to manage her incontinence. Her daughter used our "home safety checklist" to review the home for potential hazards including inadequate lighting, throw rugs and lack of hand rails. Four months later, Mrs. Smith returned to the office. Her numbers and symptoms had all improved significantly. The important part was that she said "I feel like myself again". You see, the power of a Comprehensive Geriatric Assessment is not actually in the interventions — not the referrals, not the medications. It is in the asking. It is in helping patients understand that you care about the little things that add up to profoundly affect their quality of life. As I tell my colleagues, it's not rocket science. It's much more important than that. Dr. Maryjo L. Cleveland is medical director, Center for Senior Health, Summa Health System in Akron. s NOVEMBER-DECEMBER 2012 s MDNEWS.COM s MD NEWS Cleveland/Akron/Canton | 21