The Comprehensive Geriatric Assessment and the ... 190914 Polidori.pdf · if the same applied to drugs they ... in which care is coordinated efficiently and effectively and linked

Universität zu Köln

Lehrstuhl für Geriatrie

Klinik für Geriatrie am St. Marien-Hospital

M. Cristina Polidori MD PhD FRCPDepartment of Geriatrics

University of Cologne, Medical Faculty

Cologne, Germany

The Comprehensive Geriatric Assessmentand the Personalized Medicine –

A Global Perspective

10th International Congress of the European Geriatric Medicine Society

September 19th, 2014Rotterdam, The Netherlands




The Comprehensive Geriatric Assessmentand the Personalized Medicine : Life expectancy at birth

Data Source: United Nations Department of Economic and Social Affairs, Population Division

Oldest age at which at least 50% of the birth

cohort is still alive in eight countries

Children

borne 2000

Children

borne 2007

Canada 102 104

Denmark 99 101

France 102 104

Germany 99 102

Italy 102 104

Japan 104 107

UK 100 103

USA 101 104

Christensen, Lancet 2009




Christensen, Lancet 2009

Fratiglioni et al, in progress




The Comprehensive Geriatric Assessmentand the Personalized Medicine :

Prevalence of chronic disorders by age and gender

The Comprehensive Geriatric Assessmentand the Personalized Medicine :

ADL disability by multimorbidity status and age




Fratiglioni et al, in progress

0

10

20

30

40

50

60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100

Age (decade)

% w

ith d

rug

pres

crip

tion

The Comprehensive Geriatric Assessmentand the Personalized Medicine:

The response to Multimorbidity is up-to-date Multitherapy




Courtesy Dr Howard L. McLeodMedical Director, DeBartolo FamilyPersonalized Medicine InstituteSenior Member, Division of Population Sciences

“A surgeon who uses the wrong side of the scalpel cuts his own fingers and not the patient;if the same applied to drugs they would have been investigated very carefully a long time ago”Rudolph BucheimBeitrage zur Arzneimittellehre, 1849





The response to Multimorbidity is up-to-date Multitherapy




Gelegen et al (2006) Am J Physiol Endocrinol Metab, Liao et al (2010) Aging Cell, Liao et al (2013) Exp Gerontol

The Comprehensive Geriatric Assessmentand the Personalized Medicine : Caloric and Dietary restriction ?





What if the response to Multimorbidity were Prevention




The Comprehensive Geriatric Assessmentand the Personalized Medicine : Phersu

The 6 characteristics of optimal quality of care for a pat ient facing frailty

• Extensive knowledge of the aging process, of prognostic indicators, and the multiple geriatric syndromes• Proactive and anticipatory care that is longitudinal• A well-functioning practice structure with a multidisciplinary team or network, in which care is coordinated efficiently and effectively and linked to community resources• Personal interaction with the relationship grounded in good communication skills and clearsense of the patient‘s values, goals, and preferences• Practices that manage care across diverse settings to ensure safe transitions and continuity• Health care institutions, especially hospitals,that incorporate acute care of the elderly units,Early mobilization, careful attention to drug interactions, and other best practicesto reduce the grave risk they currently pose to frail, elderly individuals

Cassell, Policy for an ageing society. JAMA 2009 (302) 2701-2702




The Comprehensive Geriatric Assessmentand the Personalized Medicine : the CGA

„Multidimensional interdisciplinarydiagnostic process focused on determininga frail older person‘smedical, psychological and functional capabilityin order to developa coordinated and integrated plan for treatment and long-term follow-up“

Rubinstein et al., J Am Geriatr Soc 2011




The Comprehensive Geriatric Assessmentis both a diagnostic and therapeutic process

Ellis et al. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ 2011

Description and preliminary observations of a cognitive health multidomainintervention program including nutritional counseling established in 2011 in

a memory outpatient clinic in Cologne, Germany

The Comprehensive Geriatric Assessmentand the Personalized Medicine : the Cologne experience




•All subjects consecutively visiting the Unit for Cognitive Frailty of the NeuroMed neurological outpatient Clinic in Cologne, Germany for neuropsychological evaluation

•All patients participating in phase II to IV clinical trials in AD as well those < 70 y/oare excluded from the present analysis

•As of January 2007, 254 patients were seen for neuropsychological assessment: 47 AD and mixed dementia patients , 71 MCI patients , and 146 subjects with subjective cognitive impairment ( SCI)

Polidori, J Alzheimer’s Dis 2014







•Follow-up ranging from twice / year for dementia to once every 18 months for SCI

•Basic neuropsychological evaluation : MMSE, Clock Drawing Test, DemTect

•Advanced neuropsychological evaluation : ADAS-Cog, RBANS, CogState, NPI, CDR

•Individualized multidomain counseling(IMC, based upon the concept of personalized multidisciplinary approach, JAMA 2009)





• 2011 begin of IMC based on CGA including information on lifestyle

• Questions on the previous 3-month physical activity level, leisure and cognitive activity level, a food-frequency questionnaire as well as any medical actions taken in the previous 12 weeks. Patients and/or proxy respondents undergo the individualized assessment of modifiable AD risk factors, i.e., those related to the cardiovascular system as well as those related to lifestyle habits.

• In the same session, a tailored neuropsychological evaluation is performed








• On the basis of patients’ profile, subjects and relatives are encouraged to:

1) be aware and keep under control any anamnestic or newly identified cardiovascular symptomsand comorbidities including hypertension,hypercholesterolemia, heart failure, hyperglycemia/diabetes, and atherosclerosis, with the help of the GPs;

2) improve and maintain physical activity at a level of moderate intensity physical activity: this home-based program has been shown to be logistically and financially more practical for those subjects who choose activities that require classes or a centered venue. Structured aerobic exercise may include walking, swimming, playing tennis, biking;

3) Improve and maintain mental activity without artificial training by daily activitiesindividually experienced as being intrinsically enjoyable such as crossword puzzles, challenging reading, card games, chess; improve and maintain social activities at a levelfulfilling the desire to feel generative, such as attending concerts, art expositions, meetings with friends and family, volunteering in socially productive initiatives;

and 4) improve and maintain healthy nutrition by adhering to a Mediterranean diet profile.






2007-2010 2011-April 2014

Total 134, 52.8% Total 124, 47.2%

MCI+AD 66 MCI+AD 42

>> No dementia 68 >> SCI 78, X2 5.26, p < 0.022

IMC associated with cognitivestability in 108 MCI+AD , X2 8.499, p = 0.004

IMC associated with %increaseantioxidant micronutrients, p < 0.02

IMC associated with bothmicronutrient increase and cognitivestability at FU (f-test up to 15.2)






The Comprehensive Geriatric Assessmentand the Personalized Medicine : the Cologne experience a

possible everyday-experience in every geriatric setting?

“Using the case of Mr. Z., Reuben examines the patient-care encounter and the analytical and interpersonal processes that the physician must

undertake. For most [US] physicians, both specialists and generalists, this story is likely unfamiliar, and physicians may be hardly be able to imagine

themselves or colleagues conducting the kind of extensive evaluation described. Patients would flock to this comprehensive yet individualized

care”

Cassell, Policy for an ageing society. JAMA 2009 (302) 2701-2702)

Documents

The Comprehensive Geriatric Assessment and the ... 190914 Polidori.pdf · if the same applied to drugs they ... in which care is coordinated efficiently and effectively and linked