BBS I: BLOCK 6 , MODULE 2 , CASE 2 (NEW)

THE PHYSIOLOGY OF AGING

● Frequently, the composition of the team is determined by
COMPREHENSIVE GERIATRIC ASSESSMENT
local expertise and availability of resources rather than
● Nature of assessment: multidimensional, multidisciplinary programmatic needs.
● Aim: to evaluate elderly individuals with complex problems
● Implementer: team of health professionals
● Expectation: uncover treatable health problems and lead to DIFFERENCE BETWEEN COMPREHENSIVE GERIATRIC
ASSESSMENT AND STANDARD MEDICAL EVALUATION
better health outcomes
● Core geriatric practice performed by an accredited
Comprehensive Geriatric Standard Medical
geriatrician.
Assessment Evaluation
● This enables a geriatrician to allocate up to 2 hours, with
appropriate remuneration, to conduct a comprehensive case
review and develop a care plan in collaboration with the GP FOCUS AND SCOPE
● CGA is based on the premise that a systematic evaluation
of frail older persons by a team of health professionals may ● It involves a broader ● The primary focus is on
uncover treatable health problems and lead to better health evaluation of the older diagnosing and treating
outcomes. adult's overall health specific medical
● This evaluation typically includes four dimensions: physical status, including physical, conditions or symptoms.
health; functional status; psychological health, including mental, and social aspects. ● The evaluation may be
cognitive and affective status; and socio factors. ● The assessment limited to the presenting
● Early randomized clinical trials provided convincing encompasses various complaint or specific
evidence that such programs conducted in hospital-based domains, such as organ systems.
and rehabilitation units, which typically required several functional status, cognition,
weeks of treatment, could lead to better survival rates, mental health, social
improved functional status, and more desirable placement support, nutritional status,
(eg, home rather than nursing home) following discharge and geriatric syndromes.
from the hospital. ● It aims to identify not only
● Conceptually, CGA is a three-step process: specific medical conditions
○ (1) screening or targeting of appropriate patients but also the overall
○ (2) assessment and development of functional abilities, quality
recommendations, and of life, and potential
○ (3) implementation of recommendations, including geriatric issues that may
physician and patient adherence with impact the person's
recommendations. well-being.

1. Screening or targeting of appropriate patients MULTIDISCIPLINARY APPROACH

● The purpose of the first step, targeting, is to distinguish
older patients who are appropriate and will benefit from
● Involves a multidisciplinary ● Typically conducted by a
CGA, from those who are either too sick or are too well to
team of healthcare primary care physician or
benefit.
professionals with expertise a specialist in a specific
● To date, no easily administered targeting criteria have been
in geriatrics, including medical field, depending
demonstrated and validated to readily identify patients who
geriatricians, nurses, on the presenting
are likely to benefit from CGA in different settings.
physical and occupational complaint or condition.
● Specific strategies used by CGA programs to identify older
therapists, social workers,
persons who are most appropriate for CGA have included
and psychologists.
chronological age, functional disability, physical illness,
● Each team member
geriatric conditions, psychosocial conditions, and previous
contributes their
or predicted high health care utilization.
specialized knowledge to
● All of these criteria have randomized clinical trial support for
assess different aspects of
their effectiveness in identifying older persons likely to
the older adult's health and
benefit from CGA. However, the definitions of these criteria
well-being. This
and the interventions that have followed have varied from
interdisciplinary approach
study to study.
ensures a more
● Most CGA programs exclude patients who are unlikely to
comprehensive evaluation
benefit because of terminal illness, severe dementia,
and a broader perspective
complete functional dependence, and inevitable nursing
on the individual's needs.
home placement.
● Exclusionary criteria have also included identifying older
persons who are “too healthy” to benefit. EMPHASIS ON FUNCTIONAL STATUS AND QUALITY OF LIFE

2. Assessment and development of recommendations ● Places a strong emphasis ● While functional status
● The second step of CGA, the assessment process itself, on evaluating functional and quality of life may be
continues to be highly variable across programs. abilities and the impact of considered, they are not
● The types of healthcare professionals included in the health conditions on the always the primary focus.
assessment team, the content of information collected, and individual's daily life. The primary emphasis is
the types and intensity of services provided have differed in ● It assesses activities of on diagnosing and treating
studies of the effectiveness of CGA. daily living (ADLs) and specific medical
● In many settings, the CGA process relies on a core team instrumental activities of conditions.
consisting of a physician, nurse, and social worker and, daily living (IADLs) to
when appropriate, draws upon an extended team of various determine the person's
combinations of physical and occupational therapists, level of independence and
nutritionists, pharmacists, psychiatrists, psychologists, need for assistance.
dentists, audiologists, podiatrists, and opticians. ● The goal is to optimize
● Although these professionals are usually on staff in hospital functional abilities and
settings and are available in the community, access to and enhance quality of life by
reimbursement for these services have limited the addressing any
effectiveness of the CGA process. impairments or limitations.
LONG-TERM CARE PLANNING 5. Mobility Gait and Quantification of gait, · Tinetti Mobility
Balance balance and risk of Assessment
falls · Get up and go
● Recognizes the importance ● Often focused on test
of long-term care planning immediate management
and addresses the social, and treatment of acute or 6.Nutritional Current nutritional · Nutritional
psychological, and practical chronic conditions, with Adequacy status and risk of Screening Checklist
aspects of aging. less emphasis on malnutrition · Mini-nutritional
● It considers factors such as long-term care planning or Assessement
social support, caregiver addressing non-medical
burden, housing aspects.
arrangements, and
advance care planning.
● The assessment helps in
developing a personalized 7. Special Senses Hearing and vision · Whispered Voice
care plan that considers the impairments Test or Hearing
individual's preferences, Handicap Inventory
values, and goals for future · Snellen chart or
care. Vision Function
Questionnaire

● Overall, a comprehensive geriatric assessment provides a

more comprehensive, person-centered, and
multidimensional evaluation of older adults compared to a
standard medical evaluation.
● It takes into account the broader context of aging, including 8. Oral Health Impairments of oral · Geriatric Oral
functional abilities, mental health, social support, and quality health Health Assessment
of life, to optimize care and enhance well-being in older Index
individuals.
● CGA places a greater emphasis on assessing:
○ Function
ELEMENTS OF CGA AND THEIR SCREENING STRATEGIES
○ Quality of life
○ Non-medical domains Detailed Problem List
● It is a diagnostic process which includes evaluation and
● Based on history, PE, and appropriate testing
management
● Screening methods: History, PE
● KEY ELEMENT: a focus on function
● Immunization status
○ Measures of function are often essential in
determining overall health, well-being and need for
health and social services Assessment of Vision
● Visual impairment is a common and often underreported
Principal Domains Assessed problem in the older population.
● Each of the four major eye diseases (cataract, age-related
Dimension Basic context Specific examples
macular degeneration, diabetic retinopathy, and glaucoma)
increases in prevalence with age.
● Moreover, presbyopia is virtually universal and the vast
1. Functional majority of older persons require eyeglasses.
● Visual impairment has been associated with increased risk
of falls, functional and cognitive decline, immobility, and
Basic ADL (activities of Strengths and · Katz (ADL) depression.
daily living) limitations in · Lawton Personal
● The high rates of vision disorders and their associated
self-care,basic Self-Maintenance
mobility and Scale sequalea, the brevity of the screening process, and the
incontinence · Barthel Index treatments available for visual impairment justify screening
for visual impairment.
● However, the revised 2009 USPSTF guidelines conclude
that evidence is insufficient to determine whether screening
older adults for vision impairment improves functional
outcomes.

Instrumental ADL Strengths and · Lawton (IADL) Snellen Eye Chart

limitations in · OARS, IADL ● The standard method of screening for problems with visual
shopping cooking, acuity is the Snellen eye chart, which requires the patient
household activities, to stand 20 ft from the chart and read letters, using
finances
corrective lenses.
● Patients fail the screen if they are unable to read all the
letters on the 20/40 line with their eyeglasses (best
2. Social Activities Strengths and · Lubben Social corrected vision).
and Supports limitations in social Network Scale
network and · OARS, Social Assessment of Hearing (Whisper Test)
community activities Resources ● Hearing impairment is among the most common medical
conditions reported by older persons, affecting
3.Mental Health Degree of anxiety, · Geriatric approximately one-third of those 65 years or older.
Affective depression, Depression Scale ● Hearing impairment is associated with reduced cognitive,
happiness · Zung Depression emotional, social, and physical function, as well as
Scale increased hospitalizations, and the use of amplification
devices has led to improved functional status and quality of
life of older persons.
4.Mental Health Degree of alertness, · Folstein ● Screening for hearing loss can be accomplished by several
Cognitive orientation Mini-mental State
methods. The most accurate of these is the Welch Allyn
concentration, · Kahn Mental
mental task capacity Status Questionnaire AudioScope 3, a handheld otoscope with a built-in
audiometer.
Whisper Test Functional Status Assessment
● One alternative is the whispered voice test, which is
administered by whispering three to six random words Katz Index of Independence in Activities of Daily Living
(numbers, words, or letters) at a set distance (6, 8, 12, or 24 ● The Index ranks adequacy of performance in the six
in) from the person’s ear and then asking the patient to functions of bathing, dressing, toileting, transferring,
repeat the words. continence, and feeding. This has a perfect score of 6 with 0
○ The examiner should be behind the person to prevent as the patient being very dependent and 6 which means that
speech reading and the opposite ear should be the patient is very independent.
covered or occluded during the examination. ● The activities are usually divided into three performance
○ Patients fail the screen if they are unable to repeat levels:
half of the whispered words correctly. ○ Able to do without assistance
○ Needing some assistance
Medication Review and Reconciliation ○ Dependence
● Hospital admission is an important time for medication
review. Lawton Instrumental Activities of Daily Living Scale (ADL)
● Clarification of the patient’s medications, often ● The Lawton Instrumental Activities of Daily Living Scale
prescribed by multiple physicians, and identification of (IADL) is an appropriate instrument to assess independent
potential ADEs are two important aspects of medication living skills (Lawton & Brody, 1969). These skills are
review. considered more complex than the basic activities of daily
● ADEs might include amplified side effects, drug-drug or living as measured by the Katz Index of ADLs (See Try this:
drug-disease interactions, and errors in drug administration. Katz Index of ADLs).
● ADEs may lead to hospital admission and are more ● There are eight domains of function measured with the
common as the number of medications and comorbid Lawton IADL scale which are: ability to use telephone,
illnesses increase. shopping, food preparation, housekeeping, laundry, mode of
● While age alone is not an independent predictor of ADEs, transportation, responsibility for own medications, and ability
older patients are more likely to have multiple comorbid to handle finances. A summary score ranges from 0 (low
conditions and be on multiple medications. function, dependent) to 8 (high function, independent).
● Regulatory bodies, such as the Joint Commission, require
that all institutions have a process in place to reconcile
Advanced Activities of Daily Living
medication lists.
● The medication reconciliation that occurs at the time of ● Refer to the ability to fulfill societal, community, and family
hospital admission is the first step in the management of roles as well as participate in recreational or occupational
multiple medications that will continue throughout the tasks.
hospital stay ● These advanced activities vary considerably from
● Aspects of medication reconciliation can be aided by individual to individual but may be valuable in monitoring
computerized physician order entry systems and clinical functional status prior to the development of disability
pharmacists. ● Examples are those elderly who works as Barangay Health
● How: Workers and those who are actively participating in church
○ Instruct patient to bring in all current medicines for services and programs
review and compare with chart
○ Balance guidelines for chronic disease management Urinary Incontinence Assessment
with the individual’s goals of care, as well as risk ● Urinary incontinence is often multifactorial:
factors for adverse drug events such as cognitive ○ Lower urinary tract abnormality
impairment, frailty, renal, discontinuation of the ○ Changes in neurological control of voiding
suspected agent ○ Multimorbidity
○ Confirm the patient understand their meds and is ○ Functional impairment
taking them correctly ● Screening for IU is recognized as an indicator of quality of
care
Nutrition Assessment ○ Screening can be done with two questions:
● Poor nutritional status is common among hospitalized ■ In the past year, have you ever lost your urine
older patients. Studies have estimated that up to 50% of all and gotten wet?
hospitalized older patients are nutritionally at risk and up to ■ Have you lost urine on at least six separate
25% meet criteria for malnutrition. days?
● Among hospitalized older patients, poor nutritional status is ○ Yes answer to both questions had high rates of UI
associated with worse clinical outcomes. ● Its assessment involves evaluating and diagnosing the
● During the hospitalization, nutritionally at-risk patients are underlying causes and contributing factors of urinary
more likely to suffer from hospital-acquired complications, incontinence.
particularly infection. ● It includes gathering information about the patient's medical
● Compared with patients with good nutritional status, poor history, symptoms, and lifestyle.
nutritional status is associated with longer length of stay, ● Physical examinations are conducted to assess bladder
higher readmission rates, increased likelihood of being function and pelvic floor muscle strength.
discharged to an extended care facility, and higher ● Neurological function is evaluated to identify any
mortality rates. neurological disorders contributing to urinary incontinence.
● Given the prevalence and importance of poor nutritional ● Medication review is performed to identify any drugs that
status in the older hospitalized patient, the Joint may be causing or exacerbating the condition.
Commission mandates nutritional screening in this ● Diagnostic tests such as urine analysis, bladder diary,
population. urodynamic studies, and imaging studies may be
● Several screening tools have been developed including the conducted.
Chandra scale, the Nutrition Screening Initiative, and the ● The assessment helps determine the type and severity of
Mini Nutritional Assessment. urinary incontinence and develop an appropriate treatment
● The Mini Nutritional Assessment has been shown to be plan.
predictive for in-hospital mortality, longer length of stay, and ● Tailored treatment strategies and interventions can be
greater likelihood of being discharged to a long-term care implemented based on the assessment findings.
facility. ● The goal is to improve the individual's quality of life by
● The use of the MNA can help detect risk of malnutrition addressing the specific needs associated with urinary
while albumin and BMI are still in the normal range. incontinence.
● Although the validity of these instruments has been
questioned, they are being increasingly used in
community-based screening programs.
Urinary incontinence assessment involves several ● Predominant problem lies outside the lower urinary tract, but
important considerations: lower urinary tract abnormalities may also be present.
● Many individuals with urinary incontinence do not freely
report their condition, but they are more likely to disclose it
when asked by their physician.
● Healthcare providers should screen for urinary incontinence
and identify risk factors during evaluations.
● The initial evaluation aims to identify reversible causes of
incontinence, classify the type of incontinence, and
determine the need for surgical intervention.
● Gathering a detailed medical history, including voiding and
incontinence characteristics, concurrent medical problems,
and quality of life assessment, is crucial.
● Special attention should be given to factors such as quantity Two-Question Screen
of urine loss, duration of the problem, frequency, urgency, ● two questions that can be used as a quick screening
stream strength, and associated symptoms. assessment for urinary incontinence:
● Medication history and the evaluation of previous treatment 1. Do you experience any involuntary leakage of urine?
attempts are important in formulating a treatment plan. 2. How often do you experience urine leakage?
● Keeping an incontinence diary helps in understanding ● These questions can help identify individuals who may be
patterns and assessing treatment outcomes. experiencing urinary incontinence and further assessment
● Physical examinations, including abdominal, neurological, or evaluation can be recommended based on their
rectal, and pelvic exams, provide valuable information. responses.
● Diagnostic tests like urinalysis, cytology, and imaging may
be necessary to rule out infections or other underlying Assessment of Cognition and Mental Health
conditions.
● Identification of cognitive concerns is the first step in
● Post-void residual measurement is effective in diagnosing
evaluation.
urine stasis and overflow incontinence.
● Early cognitive changes may not be apparent in some
● Referral for urodynamic studies may be considered when
patients due to factors like poor insight or cultural views.
the type of incontinence remains uncertain or for specific
● Routine screening for dementia in older adults is
cases.
controversial.
● Medicare Annual Wellness Visit requires cognitive
Type of Incontinence
assessment.
Urge Incontinence
● Self-reported memory concerns or screening questions can
● Common in adults over 65 years, accounting for up to 70%
help identify patients needing evaluation.
of incontinence cases.
● Gathering information from the patient and an informant is
● Characterized by an insuppressible urge to void and loss of
important.
urine.
● Reversible causes of cognitive dysfunction should be
● Associated with neurological disorders like stroke, spinal
addressed, such as medication review and evaluation of
stenosis, Parkinson's disease, or dementia.
depression, anxiety, hearing loss, and vascular risk factors.
● Terms such as "overactive bladder," "detrusor
● Safety assessment is crucial, including medication
hyperreflexia," and "detrusor instability" are sometimes used
management, driving, and susceptibility to scams.
interchangeably.
● Past medical history and medication review are essential for
● Involuntary detrusor contractions may or may not be
assessing cognitive effects.
present.
● Various cognitive screening tools are available, such as
● In some cases, incomplete bladder emptying occurs due to
MMSE, MoCA, and SLUMS.
involuntary contractions (detrusor hyperactivity with
● Laboratory tests can assist in identifying contributing factors
impaired contractility).
to cognitive decline.
● Proper diagnosis is crucial for effective treatment.
● Neuroimaging, such as CT or MRI scans, is recommended
for patients with cognitive impairment.
Stress Incontinence
● Additional tests like EEG or PET imaging may be
● More common in women than men and occurs with
considered in specific cases.
increased intra-abdominal pressure.
● Genetic testing for APOE ε4 genotype is not recommended
● Involuntary loss of urine in small amounts during activities
in routine practice.
like coughing, sneezing, lifting, or laughing.
● Clinical judgment and integration of information are key in
● Bladder outlet support tissue incompetence is the underlying
the evaluation process.
cause.
● Clinician should assess when there is suspicion of
● Risk factors include vaginal childbirth, hysterectomy, lack of
impairment
estrogen, and obesity.
● Screening tools:
● Severe cases can lead to significant urine loss with minimal
○ Mini Mental Status Examination
strain.
○ Montreal Cognitive Assessment (MoCA) test
● These are not diagnostic for dementia and normal results do
Overflow Incontinence
not exclude the possibility of this disorder. Patients who
● Failure to properly empty the bladder is the key
have abnormal findings on the cognitive screening tests
characteristic.
should receive more in depth cognitive evaluation
● Can result from increased bladder outflow resistance, poorly
● Among hospitalized patients, mental status should be
contractile bladder, or both.
assessed at the time of hospital admission and then
● Causes include prostatic enlargement, urethral stricture,
periodically because older persons are especially prone to
neuropathic bladder due to diabetes, and other factors.
develop delirium during the hospital stay. Abnormal findings
● Build-up of intra-vesicular pressure in an overdistended
on the mental status examination in hospitalized patients
bladder leads to urine leakage.
must be interpreted in the context of change from baseline
● Symptoms include urinary frequency, hesitancy, urgency,
and the clinical situation
weak urine stream, and postvoid dribbling.
● May mimic stress incontinence, but with the distinguishing
sign of an uncomfortably distended bladder. Mini Mental Status Montreal Cognitive
Examination Assessment
Functional Incontinence
● Occurs when a patient is unable or unwilling to access toilet
The Mini Mental Status The Montreal Cognitive
facilities in time to void.
Examination (MMSE) is Assessment (MoCA) is a widely
● Factors include musculoskeletal problems, neurological
a commonly used used screening tool for
issues, advanced dementia, psychological problems,
screening tool for assessing cognitive function. It is
physical restraints, and frailty.
assessing cognitive designed to detect mild cognitive
● Iatrogenic causes can include medication use or restrictions
function in individuals. It impairment (MCI) and early
on mobility.
 is a brief questionnaire stages of dementia, particularly
consisting of a series of Alzheimer's disease. The
questions and tasks that MoCA evaluates various
evaluate various cognitive domains, including
cognitive domains, attention and concentration,
including orientation, executive functions, memory,
memory, attention, language, visuospatial
language, and abilities, and orientation.
visuospatial skills. The
MMSE assesses an The MoCA consists of a series of
individual's ability to tasks and questions that assess
follow instructions, recall different cognitive functions.
information, perform These tasks may include drawing
simple calculations, specific shapes, naming animals,
name objects, repeat recalling words, serial
phrases, and copy a subtraction, and performing
drawing. trail-making and clock-drawing
tasks, among others. The
The maximum score on maximum score on the MoCA is
the MMSE is 30, with 30, with higher scores indicating
higher scores indicating better cognitive function.
better cognitive function.
The test typically takes Compared to the Mini Mental
about 10-15 minutes to Status Examination (MMSE), the
administer and is widely MoCA provides a more detailed
used in clinical settings, assessment of cognitive abilities
research studies, and and is considered more sensitive
screenings for cognitive in detecting mild cognitive
impairment or dementia. impairment. It takes
While the MMSE can approximately 10-15 minutes to
provide a snapshot of administer and is commonly
cognitive abilities, it used in clinical settings, research Montreal Cognitive Assessment (MoCA)
should not be used as a studies, and screenings for ● The Montreal Cognitive Assessment (MoCA) is a useful
sole diagnostic tool but cognitive impairment or cognitive screener in older adults, with scores of less than
rather as part of a dementia. 21 indicating clinically significant impairment.
comprehensive As with any screening tool, the ● Developed by Dr. Ziad Nasreddine in the 1990s, the MOCA
evaluation that includes MoCA should not be used as a Test helps detect mild cognitive impairment and other
a detailed medical sole diagnostic tool but as part of conditions that can affect cognitive functioning.
history, physical a comprehensive evaluation that ○ It assesses different cognitive domains: attention and
examination, and other includes a thorough medical concentration, executive functions, memory, language,
assessments. history, physical examination, visuoconstructional skills, conceptual thinking,
and other assessments. calculations, and orientation.
● It consists of questions and tasks that test a person's
short-term memory, orientation to time and place, language,
abstraction capabilities, attention span, problem-solving,
Mini Mental Status Examination (MMSE) and visual-spatial abilities. Administered by healthcare
● Remains the most widely used instrument with a high sensitivity professionals, it typically takes about 10 to 15 minutes and
and specificity for separating moderate dementia from normal has a maximum score of 30.
cognition ● A score of 26 or above is considered normal.
● tests the domains of memory, attention, construction, language,
and orientation Affective Assessment
● Focuses on the cognitive aspect alone. ● Major depression and other affective disorders are common
● Scores on the MMSE range from 0 to 30. Patients with mild among older adults and are likely underdiagnosed, as
dementia usually score from 20 to 23; those with moderate symptoms may be underreported, present atypically, or be
disease score from 10 to 19; and those with severe disease masked by cognitive impairment or other neurologic
score < 10. diseases such as Parkinson disease.
● Educational levels can affect MMSE performance, and ● Given their association with increased disability, health care
information about literacy and education should be obtained. utilization, morbidity, and mortality, and decreased quality of
life, clinical detection and treatment of affective disorders is
paramount.

Geriatric Depression Scale (GDS)

● A variety of other screens for depression, including the
Geriatric Depression Scale, which has 5-, 15-, and 30-item
versions, are available and each has its advantages and
disadvantages.
● Scoring: 15-22 mild depression; >22 severe depression
 Environmental Assessment
● Concerned with the patient’s innate ability and environment
to perform daily tasks
● Environmental assessment encompasses two dimensions,
the safety of the home environment and the adequacy of
the patient’s access to needed personal and medical
services. Particularly among frail individuals and those with
mobility and balance problems, the home environment
should be assessed for safety.
● Older persons who begin to develop IADL dependencies
should be evaluated for the geographic proximity of
necessary services such as grocery shopping and banking,
their need for use of such services, and their ability to use
these services in their current living situations.
● Environmental prescription should also include alterations in
the physical environment
● Increasingly, some of these services are available online
though many older persons, particularly those who are frail,
do not feel comfortable using the Internet to purchase
services. Older drivers are at increased risk for motor
vehicle accidents secondary to functional impairments,
medications, and medical conditions.

Fall Risk Assessment

● A fall is “an event which results in a person coming to rest
inadvertently on the ground or floor or other lower level.”
● Screening:
Frailty
○ Inquire about ≥ 2 falls within the last year
● Dysregulation of multiple physiologic systems reaches ○ Ask about difficulty with walking or balance
threshold → increases vulnerability
● Increased risk for falls, fracture, hospitalization, surgical Timed Up-And-Go Test
cases, disability/dependency, and mortality ● The timed “up and go” test is a timed measure of the
patients’ ability to rise arm chair, walk 3 m (10 ft), turn, walk
Clinical Frailty Scale back, and sit down again
● Effective and rapid way to assess frailty. It uses criteria such ○ those who take longer than 12 seconds to complete
as activity levels, ADL/IADL, dependence, and life the test should receive further evaluation and are
expectancy more likely to have recurrent falls
○ Gait speed is also a helpful marker for recurrent falls
Assessment of Social Support ■ Patients who take more than 13 seconds to
● The composition of the older patient’s social support walk 10 m are more likely to have recurrent falls
structure can be assessed by asking a few questions about ● The short physical performance battery incorporates; chair
relationships such as family, friends, neighbors, and stands; side-by-side, semi-tandem, and full-tandem stance;
caregivers when obtaining the social history. The quality of and gait speed to calculate a summary score that assesses
these relationships should also be determined. quadriceps strength, balance, and gait speed. (Hazzards)
● For very frail older persons, the availability of assistance ● The Timed Up and Go Test (TUG) measures the time taken
from family and friends is frequently the determining factor for a person to rise from a chair, walk 3 m at normal pace
of whether a functionally dependent older person remains at with their usual assistive device, turn, return to the chair,
home or is institutionalized. and sit down. The TUG has shown some predictive value in
● If dependency is noted during functional assessment, then prospective and retrospective studies, and a time of 12 or
the clinician should inquire as to who provides help for more seconds to complete the tests indicates impaired
specific BADL and IADL functions and whether these functioning in community-living older people. (Step-Up
persons are paid or voluntary help. Geriatrics)
● Even in healthier older persons, it is often valuable to raise
the question of who would be available to help if the patient Spirituality
becomes ill. ● Spirituality, whether affiliated with a formal religious
● Early identification of problems with social support may denomination or nonreligious intangible elements, has
prompt planning to develop resources should the necessity increasingly been recognized as an important influence on
arise. health and quality of life.
● For vulnerable older adults, clinicians should be mindful of ● Frequent attendance of religious services has been
signs of elder abuse, neglect, or exploitation, and if associated with lower health care utilization and mortality
suspected, are mandated to report cases to Adult Protective rates.
Services. ● Formal instruments for assessing spirituality have been
developed, such as the FICA tool for spiritual
Economic Assessment assessment, but these are not widely used in clinical
● Many older adults live on fixed incomes, and the rising costs practice.
of medical expenses coupled with that of paid caregivers ● Simply asking older persons whether religion or spirituality is
and residential facilities can cause financial hardship that important to them may provide insights that may facilitate
may manifest as medication nonadherence, weight loss, or their care.
the appearance of self-neglect. ● Especially in hospital settings, involvement of pastoral care
● Although some clinicians feel uncomfortable assessing the may be valuable in supporting the patient and in framing
economic status of their patients, inquiring about financial medical decisions in the context of the patient’s personal
stress may prompt referral to social work or other agencies belief system.
and help prevent the associated poor health outcomes.
● Furthermore, insurance status is routinely collected by office Advance Directives
staff and a patient’s income can be assessed and eligibility ● An Advance Health Care Directive enables patients to make sure
determined for state or local benefits (eg, In-Home that their health care wishes are known in advance and
Supportive Services through Medicaid). For the frail and considered if for any reason they are unable to speak for
functionally impaired older adult, clinicians should partner themselves.
with patients and families to provide anticipatory guidance ● It also allows a patient to appoint a Durable Power of
regarding the resources that may be required to pay for care Attorney, or health care proxy, who will have legal
at home or in a residential facility. authority to make healthcare decisions in the event that
 patient is incapacitated or whereupon the patient grants ● Sometimes additional information will need to be obtained
such authority. before final recommendations can be made. The team then
● Discussions of advance directives are especially important identifies problems that need action and might be
for older patients and should be initiated early on, to discuss responsive to treatment.
the patients’ goals and preferences for care should they
experience progressive cognitive impairment or acute Development of the Treatment Plan
illness. ● Algorithm: integrative approach to decision-making
● Physicians can assist patients by focusing on patients’ 1. Patient goals and preferences
overall goals of care, rather than specific detailed 2. Life expectancy
interventions, and incorporating these goals into the 3. Disease management and Quality of life improvement
patients’ current clinical situation. 4. Symptom management
● A particularly important time to discuss such preferences is ○ Results to: Evaluate geriatric syndromes, Assist
prior to surgery because of the possibility of surgical patient prioritization treatment options,
complications or postoperative delirium, which may preclude Individualized treatment plan
discussions following the procedure.
● Such discussions should be revisited any time there are ● Based on this discussion, the team develops an initial
significant changes in a patient’s medical condition and a treatment plan and goals for the patient. Whenever possible,
better understanding about prognosis becomes available, as the patient and, as appropriate, family members should be
patients often revise their thoughts about the burdens and included in the development of the treatment plan.
benefits of treatment. ● Through techniques such as motivational interviewing,
● Cultural differences regarding preferences for advance patients can be asked to identify their priorities and
directives and end-of-life care should be recognized and readiness to make changes. Based on these, care plans
respected. can be created with patients as active partners.
● Overall, patients are receptive and grateful for discussion of ● Some CGA programs use protocols that are triggered by
their goals and preferences for care, and increasingly specific geriatric conditions, whereas others rely on the
advanced directive counseling discussions have been experience and clinical judgment of the team.
incentivized and recognized in quality- of-care measures, ○ If the number of recommendations resulting from CGA
with various tools being developed to support advanced is large, it is necessary to prioritize recommendations.
care planning in practice. ○ CGA teams should advise primary care physicians
and patients to focus on the major recommendations,
COMPONENTS OF CGA those that are most likely to produce the desired
Data Gathering outcomes.
● Includes an evaluation of an older individual’s functional ○ The urgency of recommendations must also be
status, medical conditions (comorbidities), cognition, determined. Although some recommendations may
nutritional status, psychological state, and social support, as need to be implemented immediately to confer
well as a review of the patient’s medications and problems short-term benefit such as stopping a medication that
● In early studies of CGA, the data-gathering process simply may be the cause of delirium, many more may be
identified the members of the team and mentioned that each better implemented once the patient is stable.
conducted an evaluation. ● At the time of the assessment, a plan for implementation of
● Such descriptions are problematic because of the variability each recommendation must be developed. It needs to be
of evaluations among health professionals. determined who will assume responsibility for initiation and
○ A formal training process can reduce this variability, completion of the recommendation. Similarly, the team must
but a popular approach is to standardize the establish a plan for monitoring the patient’s progress as
assessment. treatment is being delivered.
○ Standardized assessments can either use
instruments developed specifically for clinical Implementation of the Treatment Plan
purposes or assemble standard instruments that have ● Because of the problem of poor adherence to CGA
previously been studied for validity and reliability. recommendations, the issue of implementation is
○ The advantage of the former is that teams can particularly critical to the success of CGA consultation
customize the information being gathered to best suit programs.
the clinical needs of the program. ● Among inpatient CGA models, poor implementation rates
○ The advantage of the latter is that patients in the may explain some negative trials of hospital consultation
program can be compared to patients in other models of CGA.
programs. ● Failure to implement recommendations is usually
○ Frequently, however, these instruments were attributable to three problems: (1) poor receptivity among
developed for purposes other than to guide clinical primary care physicians whose patients have been
decision making and may provide information that is assessed using consultative models; (2) inadequate
not very helpful in the care of patients. resources to implement recommendations; and (3) poor
continuity or follow- through on recommendations after
Discussion Among Team hospital discharge.
● In ambulatory settings, patient adherence to
recommendations emanating from CGA looms as an even
Core Members Extended Team
larger obstacle to implementation. Patients may simply
choose not to return to see the CGA team (in continuity of
● evaluate all patients ● therapists (e.g., physical, care models) or ignore recommendations in a consultative
● physician (usually a occupational, speech model. Including patients in developing treatment plans can
geriatrician), a nurse therapy), psychologists help engage them in implementing the plan.
(nurse practitioner or or psychiatrists, ● A variety of options for implementation are available ranging
nurse clinical specialist), dietitians, pharmacists, from direct implementation of recommendations by the
and a social worker. and other health team to merely advising physicians and patients by a
professionals (e.g., note in the chart or verbally.
dentists, podiatrists) ● In consultative models of CGA in some ambulatory settings,
patients have been provided with direct advice and
● Following initial data gathering, the team meets to discuss instructions on how to approach their physicians to discuss
the patient’s geriatric needs. CGA recommendations (patient empowerment).
● Although any member of the team could theoretically lead ○ This method, coupled with direct communication to
the conference, the leadership is usually determined by primary care physicians, has resulted in high
local culture. implementation rates of CGA recommendations.
● Each conference typically begins with short Other approaches to improve adherence by primary
discipline-specific presentations followed by interactive care physicians have been by direct telephone
discussions among professionals. contact, letters, faxes, and e-mail.
 Monitoring
● To ensure that recommendations are implemented and to
follow a patient’s progress through the treatment plan,
patients must be monitored directly by the CGA team or by
the primary care physician.
● If the team is to monitor the patient, key issues are how
frequently and for how long this monitoring should occur.
● The more intensively and the longer patients are followed,
the more resource-intensive the consultation becomes.
● In some models (described below), the CGA team may
temporarily assume primary care for several months before
returning the patient to the primary care physician for
ongoing care.

Revising the Treatment Plan

● By monitoring the patient, CGA teams can continually
assess the patient’s progress toward meeting the goals
established by the team. If progress is not proceeding
according to expectations, the team may need to reevaluate
the patient and resume the team discussion.
● Treatment recommendations and implementation plans may
need to be revised.
● Again, engaging the patient is important as readiness to
change or goals may have changed.
● Any modification will require additional monitoring. The
frequency and extensiveness of reevaluations and
additional discussions are important influences on the cost
of CGA consultation.

Benefits of CGA
● The patients who typically benefit the most from a CGA are
the frail elderly and those who experience a nonspecific loss
in physical, cognitive or mobility function. Some indications
are given below:
○ Older than 75
○ Those needing help with daily activities
○ Requiring a caregiver
○ Living alone
○ Having a recent fall
○ Experiencing delirium or confusion
○ Having incontinence
○ Two admissions to an acute care hospital within the
past year

Benefits of a comprehensive assessment include the

following:
1. Identifying and addressing acute problems
2. Optimizing the management of chronic illnesses
3. Optimizing medication regimens
4. Developing a plan to stabilize function
5. Restoring loss of function with the goal of preserving
independence