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
Universität zu Köln
Lehrstuhl für Geriatrie
Klinik für Geriatrie am St. Marien-Hospital
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
Universität zu Köln
Lehrstuhl für Geriatrie
Klinik für Geriatrie am St. Marien-Hospital
Christensen, Lancet 2009
Fratiglioni et al, in progress
Universität zu Köln
Lehrstuhl für Geriatrie
Klinik für Geriatrie am St. Marien-Hospital
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
Universität zu Köln
Lehrstuhl für Geriatrie
Klinik für Geriatrie am St. Marien-Hospital
Fratiglioni et al, in progress
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ith d
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The Comprehensive Geriatric Assessmentand the Personalized Medicine:
The response to Multimorbidity is up-to-date Multitherapy
Universität zu Köln
Lehrstuhl für Geriatrie
Klinik für Geriatrie am St. Marien-Hospital
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
Universität zu Köln
Lehrstuhl für Geriatrie
Klinik für Geriatrie am St. Marien-Hospital
The Comprehensive Geriatric Assessmentand the Personalized Medicine:
The response to Multimorbidity is up-to-date Multitherapy
Universität zu Köln
Lehrstuhl für Geriatrie
Klinik für Geriatrie am St. Marien-Hospital
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 ?
Universität zu Köln
Lehrstuhl für Geriatrie
Klinik für Geriatrie am St. Marien-Hospital
The Comprehensive Geriatric Assessmentand the Personalized Medicine:
What if the response to Multimorbidity were Prevention
Universität zu Köln
Lehrstuhl für Geriatrie
Klinik für Geriatrie am St. Marien-Hospital
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
Universität zu Köln
Lehrstuhl für Geriatrie
Klinik für Geriatrie am St. Marien-Hospital
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
Universität zu Köln
Lehrstuhl für Geriatrie
Klinik für Geriatrie am St. Marien-Hospital
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
Universität zu Köln
Lehrstuhl für Geriatrie
Klinik für Geriatrie am St. Marien-Hospital
•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
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
Universität zu Köln
Lehrstuhl für Geriatrie
Klinik für Geriatrie am St. Marien-Hospital
•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)
Polidori, J Alzheimer’s Dis 2014
Universität zu Köln
Lehrstuhl für Geriatrie
Klinik für Geriatrie am St. Marien-Hospital
• 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
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
Polidori, J Alzheimer’s Dis 2014
Universität zu Köln
Lehrstuhl für Geriatrie
Klinik für Geriatrie am St. Marien-Hospital
• 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.
The Comprehensive Geriatric Assessmentand the Personalized Medicine : the Cologne experience
Polidori, J Alzheimer’s Dis 2014
Universität zu Köln
Lehrstuhl für Geriatrie
Klinik für Geriatrie am St. Marien-Hospital
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
Polidori, J Alzheimer’s Dis 2014
Universität zu Köln
Lehrstuhl für Geriatrie
Klinik für Geriatrie am St. Marien-Hospital
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)