Geriatric Evaluation and Management (GEM) services provides care in which the primary clinical purpose or treatment goal is improving the functioning of a person with multidimensional needs. These needs are associated with medical conditions related to ageing. They include falls, incontinence, reduced mobility, delirium and depression.
The person may have complex psychosocial problems and is usually (but not always) an older person. GEM is always managed by a clinician with special expertise in GEM.
GEM incorporates an individualised multidisciplinary management plan that is documented in the person’s medical record. The plan includes negotiated goals within indicative timeframes and documented assessment of functional ability.
The GEM patient
GEM patients are generally older and frailer people. They tend to have multi-morbidity that needs to be considered when developing their treatment regime.
Younger patients can be cared for in GEM, especially where there are clinical issues generally associated with ageing or disabilities. There may be complex social issues that require a multidisciplinary approach to assessment and planning.
GEM patients present with a diverse range of primary diagnoses. However, orthopaedic and neurological conditions account for around 30 per cent of all GEM admissions. A further 30 per cent present with general medical conditions, cardiac or pulmonary diseases.
A review of diagnostic related groups identifies a wide range of conditions, the more prevalent being:
- dementia and delirium
- rehabilitation
- injuries (commonly related to falls)
- infections (especially of the genitor-urinary tract and respiratory-related)
- cardio-pulmonary failure and unstable angina
- disorders of the nervous system disease
- other factors influencing health
- chronic obstructive airways disease
- gastro-intestinal disorders.
Elements of the service model
The GEM service model provides specialist assessment and management by an interdisciplinary team comprising medical, nursing and allied health. Direct care and all assessment and planning occurs within GEM.
Key members of the health team conduct initial assessments. Their expertise includes medical, nursing, physiotherapy, social work and occupational therapy. Other allied health professionals are referred in when specific issues are identified. Given the complexity of the cohort, access to the full range of allied health is generally required, including psychology and neuropsychology.
A formal assessment of functional ability, both on admission and discharge, is required. The Functional Independence MeasureTM (FIM) is currently mandated by the department for assessment of all GEM episodes.
All GEM patients’ cognition should be assessed on admission and whenever there is evidence of change during the admission.
Comprehensive geriatric assessment
The GEM patient group is made up of people who have complex and multiple medical, functional, and often cognitive, conditions requiring a comprehensive geriatric assessment (CGA).
A CGA will identify pre-hospital function and issues such as malnutrition, depression, cognition and ability to manage daily living activities in addition to current level of functioning.
The aim of a CGA is to maintain or restore function, minimise risks associated with impaired function, manage common geriatric conditions (such as falls and immobility, incontinence and cognitive impairment) and optimise community living arrangements.
A CGA always acknowledges the older person’s personal preferences and engages with family and carers when developing the care plan. Determining pre-morbid function is essential in the planning of care to identify early any issues around the discharge destination.
The plan of care needs to be routinely reviewed by the treatment team to determine the patient’s progress against the set goals.
Key features of a CGA
The key features of a comprehensive geriatric assessment are:
- team-based interdisciplinary assessment and planning
- geriatric medical input
- focus on the older person’s medical, psychological, functional and social capabilities
- coordinated and integrated treatment plan and longer term care planning
- focus on restoration of function or compensation for lost function
- person-centred and goal-orientated approach.
Setting of service
Geriatric evaluation and management can be provided in a variety of settings. These include dedicated inpatient beds, the community, the patient’s own home or in another setting such as residential care.
Consideration should always be given to providing care for the vulnerable older person in the least restrictive setting that will promote independence and reduce the risk of functional decline and adverse events often associated with admission to hospital. For appropriate patients, this means getting them home earlier supported by a GEM service model, including from an emergency department, acute ward or short stay unit.
Health services are able to provide admitted GEM care in settings outside of the hospital including in a patient's own home. Commonly referred to as GEM in the Home, such a service must fulfil the same criteria for admission as any other admitted patient, as well as all reporting and clinical governance expectations as for GEM provided in a hospital bed.
The physical environment
The environment in which geriatric evaluation and management operate should be one that is designed to encourage independence and promote an interdisciplinary team approach. It should also take into consideration:
- the older person’s needs - their strengths and abilities should be fostered while they are also protected against harm
- the need for interactions between family and carers to be enhanced - private spaces and communal areas should be available
- how the environment supports people with cognitive impairment - Improving Care for older people: A policy for health services (2003) and Improving the environment for older people in health services: An audit tool (2006) provide the policy framework and a practical tool for developing an environment that is safe and functional for both patients and staff providing care.
Geriatric evaluation management also has a significant focus on rehabilitation. People need to actively participate in their therapy program and be encouraged to become as physically active as they can.
The ward environment needs to be set up to promote independence, with communal areas for dining and leisure. Patients are expected to be dressed and remain as active as possible during the day. Access to outdoor spaces may be considered therapeutic especially for patients with cognitive impairment.
Location of services
GEM is to be provided at all metropolitan, regional and sub-regional health services. In Planning the future of Victoria’s subacute service system: a capability and access planning framework (2012), a service capability framework defines the scope of practice and expectations for Levels 3, 4 and 5 services that are designated to report GEM or rehabilitation programs.
Geriatric evaluation and management (GEM) services are located across Victoria at the following health services.
Metropolitan:
- Alfred Health
- Austin Health
- Eastern Health
- Melbourne Health
- Mercy Public Hospitals Inc (Werribee)
- Monash Health
- Northern Health
- Peninsula Health
- St. Vincent's Health
- Western Health.
Barwon - South Western Region:
- Barwon Health
- South West Healthcare
- Western District Health Service.
Gippsland Region:
- Latrobe Regional Hospital
- Bass Coast Health
- Bairnsdale Regional Health Service
- Central Gippsland Health Service
- West Gippsland Healthcare Group.
Grampians Region:
- Ballarat Health Services
- Wimmera Health Care Group.
Hume Region:
- Albury Wodonga Health
- Goulburn Valley Health
- Northeast Health Wangaratta.
Loddon Mallee Region:
- Bendigo Health
- Castlemaine Health
- Echuca Regional Health
- Mildura Base Hospital
- Swan Hill District Health
Individuals in the United States are living longer thanks to improvements in medications and surgical intervention, and better awareness of healthy lifestyles. And prolonged life spans mean an increase in the number of geriatric patients. Aging ushers in changes in anatomy, physiology, and overall health, all of which require a more targeted approach to patient care on the part of EMS responders. And no area is more critical than airway management.
Let’s discuss some of the changes that take place in the aging body and how these changes require special consideration during patient care.
General Assessment in the Geriatric Patient – Looks Can Be Deceiving
Patient care always begins with patient assessment. The assessment may be rapid, for instance in cardiac arrest, or prolonged, such as a patient with a suspected hip fracture. But gauging the A-B-Cs and levels of consciousness can be a bit trickier in the geriatric patient. So as you begin your assessment, here are a few things to keep in mind when evaluating the elderly:
- Determining level of consciousness may not be straightforward: confusion may be the norm due to dementia, so involve friends and family when gauging normal mental activity.
- Cardiovascular assessment may be complicated by medications such as beta-blockers or anti-hypertensives, so be sure to obtain a list of the patient’s meds.
- Be alert for pacemakers!
- Volume assessment may also be hampered by the patient’s medications, so be vigilant in cases of suspected shock.
- Delayed capillary refill may be the norm in your elderly patient.
- Temperature regulation may be hampered and slow to respond.
Airway Management in the Elderly
Airway management, like patient assessment, must take into account special considerations in geriatric patients. Here are a few reminders:
- Be alert to the presence of dentures or other dental devices when managing the airway
- Removing dentures may make intubation easier, but may complicate a good mask seal
- Broken teeth are more likely to become obstructions in the elderly
- If your patient normally has a reduced cough reflex, there is a greater chance of aspiration
- Always have suction ready!
- Chest wall stiffness may lead to reduced tidal volume, complicating oxygenation
- Kyphosis may complicate patient positioning, so use extra padding when positioning your patient.
- Nasal tissues are more fragile in the elderly, a condition complicated by the use of anticoagulants, so keep it in mind when considering nasal intubation.
- Hypoxia can progress, even in minor chest injury, so stay vigilant in your assessments.
- Older patients may rely more on diaphragmatic excursion, so be careful not to impede the abdomen when securing your patient on a backboard.
Our Aging Population
According to the Centers for Disease Control’s latest study, by 2050, 20% of the U.S. population will be ages 65 and older. Much of this increase will happen by 2030 as the last of the large baby-boom cohorts reaches age 65, more than double the number of older adults in the United States in 2010. Roughly 10,000 Americans will celebrate their 65th birthday each and every day. What that means for you, the paramedic, is that calls involving geriatric patients will continue to rise.
So be prepared by being aware. Every time you run on an elderly patient, keep in mind their aging bodies present special challenges (just like pediatrics). Maximize your treatment plans by being attuned to their distinct needs and you will be rewarded with more efficient and effective patient care.
Editor's Note: This blog was originally published in January of 2016. It has been re-published with additional up to date content.