Comprehensive geriatric Assessment

A comprehensive geriatric assessment (CGA) is a multidisciplinary process that evaluates an older

person's mental health, medical conditions, functional capacity, and social circumstances.

It is an iterative, collaborative and multidimensional framework and process of assessment used to

assess people living with frailty.

The goal of a CGA is to create a holistic plan for treatment, rehabilitation, and long-term follow-up.

A CGA can help identify a person's care and treatment needs, and can reduce mortality and hospital
length of stay. It can also help increase the number of patients who can return home after
hospitalization.

Assessment can have the following benefits:

 Increased identification of conditions

 Improved functional and mental status (1)

 Reduced mortality (1, 2)

 Decreased use of nursing homes and acute care hospitals (2)

 Greater satisfaction with care

A CGA includes a number of assessments, including:

 General Medical Assessment

 Physical Functioning Assessment

 Psychosocial Assessment

 Social Health Assessment

 Environmental Assessment

 Quality of Life Assessment

 Assessment of Common Symptoms or Problems in Older Adults

 Older persons often have complex, multiple and interdependent problems (multimorbidity),
which make their care more challenging than the care of younger people or those with just
one medical problem.[6]

 The CGA is considered the best way to evaluate the health status and care needs of older
adults.[7]

 The strength of the CGA lies in the fact it is a multidimensional holistic assessment of an
older person that takes into consideration health and well-being.

The CGA allows healthcare practitioners to:

 create a problem list and a plan to address these issues

 o this plan focuses on improving quality of life and an individual's ability to cope -
particular importance is placed on what matters most to the patient[8]

The hallmarks of the CGA are that it:

 emphasises quality of life, functional status, prognosis, and outcome

o has greater depth and breadth than a standard evaluation

 involves many members of the interdisciplinary team and the use of any number of
standardised instruments to evaluate aspects of patient functioning, impairments, and social
supports[9][10]

 these features help differentiate the CGA from standard models of care

The Domains of the CGA

There are five domains at the centre of the CGA, and these form the framework for the assessment:

1. Physical health and nutritional status (e.g. COPD, osteoarthritis, urinary incontinence,
hearing or visual impairments)[11]

2. Mental and emotional health (e.g. depression, cognition, vascular dementia)

3. Functional issues (e.g. unable to shower or do the cleaning on their own)

4. Social issues (e.g. lives alone, family far away)

5. Environmental issues (e.g. stairs to the bedroom [fall risk], poor lighting)
Health care professionals who treat older adults may find the following geriatric assessment tools
helpful in their practice.

Assessment Area Available Tools

 Clinical Dementia Rating Scale

Cognitive Ability  Mini-Mental State Examination, 2nd Edition™

 Criteria for Alzheimer's Disease

 AAA Professional Driving Assessment for Seniors

 AAA Self-Rating Driving Tool for Seniors

Driving  AARP Driver Safety Program

 Brochures from the National Highway Traffic Safety Administration

 Physician's Guide to Assessing and Counseling Older Drivers

 Global Assessment of Functioning (GAF) Scale

Functional Ability
 Karnofsky Performance Status (original scale defined by Karnofsky in 1949)

Mood  Geriatric Depression Scale (other languages)

 Abnormal Involuntary Movement Scales (AIMS) (to check for Parkinsonian side effect
medications)

Neurologic Function  NIH Stroke Scale

 Parkinson's Disease (from the National Parkinson Foundation website)

 Stroke Risk Assessment (from the American Stroke Association)

Overall Health  Ageism (WHO)

 Challenges in Pain Management at the End of Life (American Family Physician, 10/01/
Pain
 Pain Assessment

Palliative/Hospice
 Palliative Care Assessment and Research Tools
Care

 Brief Psychiatric Rating Scale (BPRS)

Psychosis
 Pittsburgh Agitation Scale

The first step in CGA is to identify those individuals who are likely to benefit from this process as well
as the orthogeriatric team approach. Decision-making criteria used to identify patients could include:

 The age of the person and the way in which their ageing process is manifested, e.g. frailty

 Existing medical conditions that are likely to impact on care, recovery and outcomes
  The presence of psychosocial disorders such as depression or social isolation

 Specific ‘geriatric syndrome’ conditions such as dementia, falls, functional disability,

sarcopenia and frailty

 Previous or predicted high need for healthcare use

 Recent change in living situation, e.g. from independent living to assisted living, nursing
home or in-home caregivers

 Major illnesses such as those requiring hospitalisation (such as a fracture) or increased need
for home care resources to manage medical and functional needs.

Areas of Assessment That Team Members May Choose to Assess Depending on Patient Needs

 Current symptoms and illnesses and their functional impact

 Current medications, their indications and effects

 Relevant past illnesses

 Recent and impending life changes

 Objective measure of overall personal and social functionality

 Current and future living environment and its appropriateness to function and prognosis

 Family situation and availability

 Current caregiver network including its deficiencies and potential

 Objective measure of cognitive status

 Objective assessment of mobility and balance

 Rehabilitative status and prognosis if ill or disabled

 Current emotional health and substance abuse

 Nutritional status and needs

 Disease risk factors, screening status and health promotion activities

 Services required and received

Conceptually, CGA involves several processes of care that are shared over several members of the
assessment team (Box 4.2).

Box 4.2: Elements of Comprehensive Geriatric Care

 Data gathering

 Biopsychosocial assessment

 Discussions among the team

 Patient and/or caregiver as a member of the team involvement

 Treatment and nursing plan development, with the patient and/or caregiver
  Implementation of the treatment and nursing plan

 Monitoring response to the treatment and nursing plan

 Revising the treatment and nursing plan

Summary of Key Points

 Timely and comprehensive assessment is essential in understanding the needs of older

people and ensuring that their needs are met through care and treatment

 CGA is a person-centred, holistic, multidisciplinary process that helps to assess the frail older
person so that their medical conditions, mental health, functional capacity and social
circumstances can be considered in detail and from which patients with fragility fractures can
benefit significantly

 The process should begin on admission and be followed through to post-discharge care in
primary and residential care settings: it is not a one-off process but should be subjected to
constant review and evaluation

 The CGA process should, as a minimum, consider the domains of physical health and medical
conditions, mental health and psychological status, functioning, social circumstances and
environment so that MDT care and treatment can be based on the needs generated by these

 Assessment tools need to be developed, or adapted, to meet the needs of this

interdisciplinary process and can include existing assessment and screening tools.
Interdisciplinary team collaboration will be needed in making this process work in the best
interests of patients with fragility fractures.

 Domains and suggested items for comprehensive geriatric assessment (BGS 2010)

Domain Suggested items for assessment

Physical health and medical Comorbid conditions and disease severity

conditions Medical review
Nutritional status
Polypharmacy
Urinary continence
Sexual function
Vision/hearing
Dentition

Mental health and psychological Cognition

status Mood and anxiety
Fears
Goals of care
Advance care preferences
 Domain Suggested items for assessment

Spirituality

Functioning Functional capacity: core functions such as mobility and

balance, fall risk
Activities of daily living
Life roles that are important to the patient

Social circumstances Social support and networks:

Informal support available from family
Wider network of friends and contacts
Statutory care
Financial concerns and poverty

Environment Living situation: housing, comfort, facilities and safety

Use or potential use of ‘telehealth’ technology
Transport facilities
Accessibility to local resources

Dimensions of Comprehensive Geriatric Assessment

Comprehensive assessment involves looking not only at disease states as a standard medical
assessment would do, or at functional ability as a standard rehabilitation assessment might do, but at
a range of domains. By assessing each of these domains of health, a comprehensive assessment can
be made, and the full biopsychosocial nature of the individual’s problems can be identified. This
process can be supported by using standardised scales and tools, or full formal assessment schemes
such as the ‘interrai’ assessment tools (www.interrai.org). Using standardised scales can encourage
consistent practice, help to ensure safety (e.g. pressure injury risk screening) and enable detection of
serial changes, but they can also be time-consuming and clinically constraining. Clinicians
undertaking CGA should consider the extent to which standardised approaches are helpful in their
setting [12]. Core components of CGA that should be considered during the assessment process are
outlined in Table 4.1.
Table 4.1

Domains and suggested items for comprehensive geriatric assessment (BGS 2010)

Functional status: Functional status relates to the ability to perform activities necessary or desirable
in daily life. It is directly influenced by health conditions, particularly in the context of an older
person’s environment and social support network. Changes in functional status (e.g. not being able
to bathe independently) should prompt further diagnostic evaluation and intervention.
Measurement of functional status can be valuable in monitoring response to treatment and can
provide prognostic information that assists in long-term care planning. With respect to the impact of
functional status on activities of daily living (ADLs), an older person’s functional status can be
assessed at three levels: (1) basic activities of daily living (BADLs), (2) instrumental or intermediate
activities of daily living (IADLs) and (3) advanced activities of daily living (AADLs). BADLs consider self-
care tasks which include; bathing, dressing, toileting and maintaining continence, grooming, feeding
and transferring. IADLs consider the ability to maintain an independent household which includes
shopping for groceries, driving or using public transportation, using the telephone, performing
housework, home maintenance, preparing meals, doing laundry, taking medication and handling
finances.

In addition to considering ADLs, gait speed alone predicts functional decline and early mortality in
older adults. Assessment of gait speed is the domain of the physiotherapist within the team and may
identify patients who need further evaluation, such as those at increased risk of falls. Assessing gait
speed may also help identify frail patients who might not benefit from treatment of chronic
asymptomatic diseases such as hypertension. For example, elevated blood pressure in individuals age
65 and older is associated with increased mortality only in individuals with a walking speed ≥0.8 m/s
(measured over 6 m or 20 feet) [13].

Falls: Approximately one-third of community-dwelling people over 65 years and one-half of those
over 80 years of age fall each year [14]. Those who have fallen or have a gait or balance problem are
at higher risk of having a subsequent fall and losing independence. An assessment of fall risk should
be integrated into the history and physical examination of all older patients (Chap. 3).

Cognition: The incidence of dementia and delirium increase with age, particularly among those over
85 years; yet many older people with cognitive impairment remain undiagnosed. The value of
making an early diagnosis includes the possibility of uncovering treatable conditions. The evaluation
of cognitive function can include a thorough history, brief cognition screening, a detailed mental
status examination, neuropsychological testing and other tests to evaluate medical conditions that
may contribute to cognitive impairment (Chap. 9).

Mood: Depressive illness in older people is a serious health concern leading to unnecessary suffering,
impaired functional status, increased mortality and excessive use of healthcare resources (Chap. 9).
Depression in later life remains underdiagnosed and inadequately treated. Depression in older adults
may present atypically and may be masked in patients with cognitive impairment. Screening is easily
administered and likely to identify patients at risk if both of the folowing questions are answered
affirmatively:

1.

‘During the past month, have you been bothered by feeling down, depressed, or hopeless?’

2.

‘During the past month, have you been bothered by little interest or pleasure in doing things?’

Polypharmacy: Older people are often prescribed multiple medications by different healthcare
providers, placing them at increased risk of drug interactions and adverse medication events. The
clinician should review medications at each visit. The best method of detecting potential problems
with polypharmacy is to have patients provide all medications (prescription and non-prescription) in
their packaging. Alternatively, practitioners should contact the patient’s primary care physician,
particularly if the patient cannot remember their medications. As some health systems have moved
towards electronic health records and electronic prescribing, the possibility of detecting potential
medication errors and interactions has increased. Older people should also be asked about
alternative medical therapies by asking about herbal medicine use with the question: ‘What
prescription medications, over the counter medicines, vitamins, herbs, or supplements do you use?’

Social and financial support: The existence of a strong social support network in an older person’s life
can frequently be the determining factor of whether the patient can remain at home or needs
placement in a residential care setting. A brief screen of social support includes taking a social history
and determining who would be available to help if they become ill. Early identification of problems
with social support can help planning and timely development of resource referrals. For patients with
functional impairment, the practitioner should ascertain who the person has available to help with
ADLs. It is also important to assess the financial situation of a functionally impaired older adult; some
may qualify for state or local benefits, depending upon their income. Occasionally, there are other
benefits such as long-term care insurance or veteran’s benefits that can help in paying for caregivers
and prevent the need for institutionalisation.

The gathering of information is more complex than it seems [7], particularly collecting accurate
baseline information from patients who may have cognitive difficulties, espeically if the environment
is noisy such as in the ED or busy trauma unit, in the presence of pain or opioid analgesia use or
anaesthesia. In the first few hours following admission, the patient is more likely to recall the history
of the injury due to more recent recall, but this period is also very stressful. Collecting detailed and
accurate information needs specialised skills in communication and an expert understanding of the
process of assessment.

Table

Close

A Geriatric Assessment Instrument

 Domain (1) Item

Daily functional Degree of difficulty eating, dressing, bathing, transferring between bed and chair, using the toilet
ability Degree of difficulty preparing meals, doing housework, taking medications, going on errands (eg,

Use of personal devices (eg, cane, walker, wheelchair, oxygen)

Assistive devices
Use of environmental devices (eg, grab bars, shower bench, hospital bed)

Use of paid caregivers (eg, nurses, aides)

Caregivers
Use of unpaid caregivers (eg, family members, friends, volunteers)

Name of prescription medications used

Medications
Name of nonprescription medications used

Height, weight
Nutrition
Stability of weight (eg, "Has the patient lost 4.54 kg [10 lb] in the past 6 months without trying?")

Regularity of blood pressure measurements, guaiac test for occult blood in stool, sigmoidoscopy
hormone assessment, and dental care
Preventive measures
Intake of calcium and vitamin D

Regularity of exercise

AYUSH

10-minute Comprehensive Screening (to be filled by SN) A: Screening for geriatric syndromes An
elderly undergoes screening for depression, risk of falls, urinary incontinence and memory recall B.
Screen for other age-related problems SN undertakes the screening with respect to vision, hearing,
change in weight, constipation and insomnia. C. Functional Assessment An elderly will be assessed
based on assessment tool on activities of daily living and categorizing into dependent and
independent patients.
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