Question

conduct a Comprehensive geriatric assessment

Answer 1

Comprehensive Geriatric Assessment (CGA) is an organized evaluation method to multidisciplinary assessment of the elderly.

The overall care rendered by CGA teams can be divided into six steps:

• Data-gathering
• Discussion among the team, increasingly including the patient and/or caregiver as a member of the team
• Development, with the patient and/or caregiver, of a treatment plan
• Implementation of the treatment plan
• Monitoring response to the treatment plan
• Revising the treatment plan

1) Assessment tools

Although the amount of potentially important information may seem overwhelming, formal assessment tools and shortcuts can reduce this burden on the clinician performing the initial CGA. A pre-visit questionnaire sent to the patient or caregiver prior to the initial assessment can be a timesaving method to gather a large amount of information. These questionnaires can also be completed through secure portals of electronic health records.

These questionnaires can be used to gather information about general history as well as gather information specific to CGA, such as:

• Ability to perform functional tasks and need for assistance
• Fall history
• Urinary and/or fecal incontinence
• Pain
• Sources of social support, particularly family or friends
• Depressive symptoms
• Vision or hearing difficulties
• Whether the patient has specified a durable power of attorney for health care

2) MAJOR COMPONENTS

Core components of comprehensive geriatric assessment (CGA) that should be evaluated during the assessment process are as follows:

• Functional capacity
• Fall risk
• Cognition
• Mood
• Polypharmacy
• Social support
• Financial concerns
• Goals of care
• Advance care preferences

Additional components may also include evaluation of the following:

• Nutrition/weight change
• Urinary continence
• Sexual function
• Vision/hearing
• Dentition
• Living situation
• Spirituality

a) Functional status

• Functional status refers to the ability to perform activities necessary or desirable in daily life.
• Functional status is directly influenced by health conditions, particularly in the context of an elder's environment and social support network.
• Changes in functional status 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.

b) Activities of daily living

An older adult's functional status can be assessed at three levels:

i) Basic activities of daily living (BADLs)

ii) Instrumental or intermediate activities of daily living (IADLs)

iii) Advanced activities of daily living (AADLs).

i) BADLs refer to self-care tasks which include:

• Bathing
• Dressing
• Toileting
• Maintaining continence
• Grooming
• Feeding
• Transferring

ii) IADLs refer to the ability to maintain an independent household which include:

• Shopping for groceries
• Driving or using public transportation
• Using the telephone
• Performing housework
• Doing home repair
• Preparing meals
• Doing laundry
• Taking medications
• Handling finances

iii) Other possible IADLs that reflect the increased reliance on technology, which have not been validated, include:

• Ability to use a cellphone or smartphone
• Ability to use the internet
• Ability to keep a schedule of activities

c) Gait speed

• In addition to measures of ADLs, gait speed alone predicts functional decline and early mortality in older adults
• Assessing gait speed in clinical practice may identify patients who need further evaluation, such as those at increased risk of falls.
• Additionally, assessing gait speed may help identify frail patients who might not benefit from treatment of chronic asymptomatic diseases such as hypertension.

d) Falls/imbalance

• Approximately one-third of community-dwelling persons age 65 years and one-half of those over 80 years of age fall each year.
• Patients 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 geriatric patients.

e) Cognition

• The incidence of dementia increases with age, particularly among those over 85 years, yet many patients 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 and brief cognition screens.
• If these raise suspicion for cognitive impairment, additional evaluation is indicated, which may include detailed mental status examination, neuropsychologic testing, tests to evaluate medical conditions that may contribute to cognitive impairment.

f) Mood disorders

Depressive illness in the elder population is a serious health concern leading to unnecessary suffering, impaired functional status, increased mortality, and excessive use of health care resources.

g) Polypharmacy

• Older persons are often prescribed multiple medications by different health care providers, putting them at increased risk for drug-drug interactions and adverse drug events.
• The clinician should review the patient's medications at each visit.
• The best method of detecting potential problems with polypharmacy is to have patients bring in all of his/her medications (prescription and nonprescription) in their bottles.
• Discrepancies between what is documented in the medical record and what the patient is actually taking must be reconciled.
• As health systems have moved towards electronic health records and e-prescribing, the potential to detect potential medication errors and interactions has increased substantially.
• Although this can improve safety, record-generated messages about unimportant or rare interactions may lead to "reminder fatigue."

h) Social and financial support

• The existence of a strong social support network in an elder's life can frequently be the determining factor of whether the patient can remain at home or needs placement in an institution.
• A brief screen of social support includes taking a social history and determining who would be available to the elder to help if he or she becomes ill.
• Early identification of problems with social support can help planning and timely development of resource referrals.
• For patients with functional impairment, the clinician should ascertain who the person has available to help with activities of daily living.

i) Goals of care

• Most older adult patients who are appropriate for CGA have limited potential to return to fully healthy and independent lives. Hence, choices must be made about what outcomes are most important for them and their families.
• Goals of care often differ from advance care preferences that focus on future states of health that would be acceptable, determination of surrogates to make decisions, and medical treatments.
• Generally, advance directives are framed in the context of future deterioration in health status.

j) Advance care preferences

• Clinicians should begin discussions with all patients about preferences for specific treatments while the patient still has the cognitive capacity to make these decisions.
• These discussions should include preparation for in-the-moment decision-making, which includes choosing an appropriate decision-maker, clarifying and articulating patients’ values over time, and thinking about factors other than the patient's stated preferences in surrogate decision-making.
• Advance directives help guide therapy if a patient is unable to speak for him or herself and are vital to caring optimally for the geriatric population.