How to use Comprehensive Geriatric Evaluation to Assess

How to use Comprehensive Geriatric Evaluation to Assess Older People with Diabetes Dr. Leocadio Rodríguez Mañas Dr. Marta Castro Rodríguez

WHY TO DO COMPREHENSIVE GERIATRIC ASSESSMENT? Because CGA (Comprehensive Geriatric Assessment) has many benefits: • evaluating the patient’s ability to comply with treatment recommendations and to achieve goals • evaluating the functional, cognitive and mood impact of vascular complications • evaluating the need for support Because functional status is the main predictor of adverse events, mortality and institutionalization in older people and DM has a great impact on it

Impact of DM on functional status 2 years of follow 7. 447 ≥ 70 a. (77± 4, 6) 62, 4% women Good functional status DM Intermedium functional status No DM DM Poor functional status No DM DM No DM Average ± Standard deviation Limitation Total 1, 1 ± , 42 , 96 ± , 43 3, 97±, 83 2, 97±, 82 7, 82±, 86 7, 81± 1, 05 Physical , 73 ± , 26 , 63 ± , 26 2, 22±, 38 1, 83±, 38 3, 15±, 23 3, 12±, 25 BADLs , 14 ± , 11 , 16 ± , 11 , 72 ± , 24 , 46 ± , 24 1, 96±, 41 1, 98±, 49 IADLs , 35 ± , 12 , 29 ± , 13 1, 12±, 26 , 76 ± , 25 2, 73±, 30 2, 75±, 36 Blaum y cols. , JAGS 2003; 51: 745 -753

Accelerated Loss of Skeletal Muscle Strength in Older Adults with Diabetes. The Health, Aging and Body Composition Study cohort of 1, 840 patients aged 70 -79 y Leg and arm muscle mass and strength examined at baseline and after 3 y Compared with nondiabetes, diabetes subjects had greater declines in muscle mass (p<0. 5) and strength (p<0. 001), and poorer muscle quality (p<0. 05); upper limbs showed no real differences Park SW et al, Diabetes Care, 2007 Without diabetes With diabetes 1, 535 305 Model 1 -12. 4 ± 0. 5 -16. 5 ± 1. 2 0. 001 Model 2 -12. 5 ± 0. 5 -16. 2 ± 1. 1 0. 001 Model 3 -12. 5 ± 0. 5 -15. 7 ± 1. 1 0. 008 Model 4 -12. 7 ± 0. 5 -15. 6 ± 1. 2 0. 026 Model 1 -1. 22 ± 0. 07 -1. 57 ± 0. 15 0. 034 Model 2 -1. 20 ± 0. 06 -1. 69 ± 0. 14 0. 001 Model 3 -1. 21 ± 0. 06 -1. 64 ± 0. 14 0. 006 Model 4 -1. 24 ± 0. 06 -1. 64 ± 0. 15 0. 018 n P value Muscle strength (maximal torque, Nm) Muscle quality (specific torque, Nm/kg)

The Italian Longitudinal Study of Ageing (ILSA) Maggi S et al. , Diabetologia 2004 In terms of disability, classical comorbidities only explain 38% of such adverse effects of diabetes in women and 16% in men

Domains/Items to be assessed MEDICAL: • Co-morbid conditions and disease severity • Medication Review • Nutritional status • Frailty FUNCTIONAL CAPACITY: • Basic activities of daily living • Instrumental activities of daily living • Advanced activities of daily living • Gait and balance • Risk of falls/risk of fractures MENTAL HEALTH: • Cognition • Mood SOCIAL CIRCUMSTANCES AND ENVIRONMENT: • Informal support available from family or friends • Social network such a visitors or daytime activities • Eligibility for being offered care resources • Home comfort, facilities and safety • Use or potential use of telehealth technology etc • Transport facilities • Accessibility to local resources

Medical evaluation Co-morbid conditions and disease severity: • Cardiovascular Risk Assessment (Framingham/Score/UKPDS) Only in patients with a life expectancy over 10 years. • Charlson index Medication Review: • Beer criteria Nutritional status: • Mini Nutritional Assessment (MNA) Frailty: • Fried criteria

Comorbidity/Medication Review Charlson Index Table showing one set of drugs as classify by the Beer´s criteria

Nutritional status Mini-Nutritional Assessment (MNA)

FRIED CRITERIA FOR FRAILTY OR PRE-FAIL INDIVIDUALS

WHY TO ASSESS FRAILTY? Mortality in older people with Type 2 DM according to two models of frailty Fried´s model TSHA Frailty score Adjusted by age, sex, comorbidities and disability No frail Pre-frail Frail p=0, 059 p=0, 016 Weeks of follow-up

Functional capacity o Basic activities of daily living (BADL): Barthel and Katz indexes o Instrumental activities of daily living (IADL): Lawton Index o Advanced activities of daily living (AADL) o Gait and balance: Short Physical Performance Battery (SPPB) o Risk of falls/risk of fractures: FRAX