Chronic Disease Management, Comprehensive Geriatric Assessment, Older Adults (65 Years and Older)
Conditions
Keywords
Comprehensive Geriatric Assessment, Chronic Disease Management, Older Adults
Brief summary
With the continuous development of China's economy and the improvement of medical standards, the life expectancy of the Chinese population has significantly increased. Against the backdrop of accelerating aging in China, the incidence of age-related chronic non-communicable diseases (NCDs), such as cardiovascular and cerebrovascular diseases and chronic respiratory diseases, has risen remarkably. These diseases are characterized by multiple comorbidities, high disability rates, and high mortality rates, severely compromising the quality of life of older adults, exacerbating family burdens, and straining healthcare systems. This constitutes one of the major challenges faced by aging societies. Therefore, early detection and intervention of chronic diseases in older adults are critical measures to address population aging. Comprehensive geriatric assessment (CGA), a core specialty of geriatric medicine, serves as a fundamental framework for the clinical identification of geriatric syndromes and multidisciplinary management. It is emerging as a key pathway to promote healthy aging. Guided by this premise, this study aims to explore the application value of CGA in managing chronic diseases among older adults, with the goal of achieving full-cycle management for early detection, diagnosis, and treatment of chronic conditions in China's elderly population.
Interventions
DIAGNOSTIC_TESTcomprehensive geriatric assessment
The comprehensive geriatric assessment (CGA) is a multi dimensional diagnostic process used to determine the medi cal, psychological, and functional capabilities of a frail elderly person to develop a coordinated and integrated plan for treat ment and long-term follow-up.
Sponsors
Henan Provincial People's Hospital
Geriatrics Research Institute of Henan Provincial People's Hospital
Beijing Institute of Heart, Lung and Blood Vessel Diseases
Study design
Observational model
COHORT
Time perspective
PROSPECTIVE
Eligibility
Sex/Gender
ALL
Age
60 Years to No maximum
Healthy volunteers
Yes
Inclusion criteria
* 1\. Aged 60 years or older 2. Diagnosed with chronic diseases in the circulatory, respiratory, digestive, nervous, or endocrine systems, consistent with corresponding disease diagnostic criteria; 3. Availability of complete medical records; 4. Clear consciousness and ability to independently answer questions; 5. Signed informed consent form.
Exclusion criteria
* 1\. Presence of any condition/circumstance which in the opinion of the investigator could significantly limit the complete follow up of the patient (e.g. tourist, non-native speaker or does not understand the local language, psychiatric disturbances). 2\. Presence of serious/severe co-morbidities in the opinion of the investigator which may limit short term (i.e. 6 month) life expectancy. 3\. Current participation in a randomised interventional clinical trial.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Major adverse events (MAE) | These data is collected during follow-up visit at 3/6/12/24/36 months after discharge | Major adverse events (MAE) in overall population, defined as composite of all-cause death, Heart Failure hospitalization, recurrent myocardial infarction, stroke, etc. |
Other
| Measure | Time frame | Description |
|---|---|---|
| Gender for each participant | These data is collected from the cases' medical record in an average of 1 month after the sample recruiting | — |
| Height for each participant | These data is collected from the cases' medical record in an average of 1 month after the sample recruiting | — |
| Weight for each participant | These data is collected from the cases' medical record in an average of 1 month after the sample recruiting | — |
| Contact information for each participant | These data is collected from the cases' medical record in an average of 1 month after the sample recruiting | — |
| Past Medical History including disease history, surgical history, and family medical history | These data is collected from the cases' medical record in an average of 1 month after the sample recruiting | — |
| Lifestyle including smoking history and drinking, specify how many years smoking or drinking lasted and detail quantity per day | These data is collected from the cases' medical record in an average of 1 month after the sample recruiting | — |
| blood biochemical index：blood lipid | These data is collected from the cases' medical record in an average of 1 month after the sample recruiting | — |
| blood biochemical index：blood glucose | These data is collected from the cases' medical record in an average of 1 month after the sample recruiting | — |
| blood biochemical index：uric acid | These data is collected from the cases' medical record in an average of 1 month after the sample recruiting | — |
| blood biochemical index：urea | These data is collected from the cases' medical record in an average of 1 month after the sample recruiting | — |
| blood biochemical index：creatinine | These data is collected from the cases' medical record in an average of 1 month after the sample recruiting | — |
| blood biochemical index：C reactive protein | These data is collected from the cases' medical record in an average of 1 month after the sample recruiting | — |
| blood biochemical index：D-dimer | These data is collected from the cases' medical record in an average of 1 month after the sample recruiting | — |
| blood biochemical index：NT-proBNP | These data is collected from the cases' medical record in an average of 1 month after the sample recruiting | — |
| Cardiac ultrasound | These data is collected from the cases' medical record in an average of 1 month after the sample recruiting | The whole results of echocardiography report will be recorded. The indicates which can reflect cardiac function including Left ventricular ejection fraction, left ventricular end diastolic diameter, E/A ratio of bicuspid valve will be used to calculate the association with metabolites. |
| Drug treatment | These data is collected from the cases' medical record in an average of 1 month after the sample recruiting | Oral drug therapy, including antiplatelet drugs, antihypertensive drugs, lipid-lowering drugs, etc. |
| Age for each participant | These data is collected from the cases' medical record in an average of 1 month after the sample recruiting | — |
| Comprehensive Geriatric Assessment: Sarcopenia | These data were collected from the comprehensive geriatric assessment process within an average of 1 week after sample recruitment | — |
| Comprehensive Geriatric Assessment: Falls | These data were collected from the comprehensive geriatric assessment process within an average of 1 week after sample recruitment | — |
| Comprehensive Geriatric Assessment: Disability | These data were collected from the comprehensive geriatric assessment process within an average of 1 week after sample recruitment | — |
| Comprehensive Geriatric Assessment: Dysphagia | These data were collected from the comprehensive geriatric assessment process within an average of 1 week after sample recruitment | — |
| Comprehensive Geriatric Assessment: Malnutrition | These data were collected from the comprehensive geriatric assessment process within an average of 1 week after sample recruitment | — |
| Comprehensive Geriatric Assessment: Urinary incontinence | These data were collected from the comprehensive geriatric assessment process within an average of 1 week after sample recruitment | — |
| Comprehensive Geriatric Assessment: Fecal incontinence | These data were collected from the comprehensive geriatric assessment process within an average of 1 week after sample recruitment | — |
| Comprehensive Geriatric Assessment: Constipation | These data were collected from the comprehensive geriatric assessment process within an average of 1 week after sample recruitment | — |
| Comprehensive Geriatric Assessment: Cognitive impairment | These data were collected from the comprehensive geriatric assessment process within an average of 1 week after sample recruitment | — |
| Comprehensive Geriatric Assessment: Anxiety state | These data were collected from the comprehensive geriatric assessment process within an average of 1 week after sample recruitment | — |
| Comprehensive Geriatric Assessment: Depressive state | These data were collected from the comprehensive geriatric assessment process within an average of 1 week after sample recruitment | — |
| Comprehensive Geriatric Assessment: Sleep disorders | These data were collected from the comprehensive geriatric assessment process within an average of 1 week after sample recruitment | — |
| Comprehensive Geriatric Assessment: Pain | These data were collected from the comprehensive geriatric assessment process within an average of 1 week after sample recruitment | — |
| Comprehensive Geriatric Assessment: Social support | These data were collected from the comprehensive geriatric assessment process within an average of 1 week after sample recruitment | — |
| Comprehensive Geriatric Assessment: Home environment | These data were collected from the comprehensive geriatric assessment process within an average of 1 week after sample recruitment | — |
| Comprehensive Geriatric Assessment: Frailty | These data were collected from the comprehensive geriatric assessment process within an average of 1 week after sample recruitment | — |
Contacts
Primary ContactYang Xinying Yang Xinying
Outcome results
None listed