Comprehensive Geriatric Assessment

Original Editor - Lucinda hampton Top Contributors - Mariam Hashem, Lucinda hampton, Kim Jackson, Jess Bell, Scott Buxton, Olajumoke Ogunleye, Aminat Abolade and Robin Tacchetti

Purpose

Comprehensive geriatric assessment (CGA) is an iterative collaborative framework and process of assessment used to assess people living with frailty. These people often have complex, multiple and interdependent problems (multimorbidity) which make their care more challenging than in younger people, or those with just one medical problem.. 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 wellbeing. A plan is then formulated to address issues which are of concern to the older person (and family/carers if relevant) and arranges interventions according to the plan and then reviews the impact. The CGA differs from a standard evaluation as it emphasizes quality of life and functional status, prognosis, and outcome, entailing greater depth and breadth. The hallmarks of CGA are the employment of interdisciplinary teams and the use of any number of standardized instruments to evaluate aspects of patient functioning, impairments, and social supports.

The Centre of The CGA

There are five domains at the centre of the CGA which form the framework for the assessment. By ensuring each domain is considered during each assessment the patient and their needs are considered as a whole. The benefits gained by performing the CGA are only realised when all of the domains are covered.

1. Physical health (e.g. COAD, osteoarthritis)
2. Mental health (e.g. depression, vascular dementia)
3. Functional (e.g. unable to shower herself, or do cleaning)
4. Social (e.g. lives alone, family far away)
5. Environmental (e.g. stairs to bedroom [fall risk],poor lighting)

From the assessment, using validated and reliable outcome measures, a list of problems is formulated and recorded. This allows problems identified to then be addressed. This problem solving draws on the expertise of the multidisciplinary (MDT) team.

Each expert in multidisciplinary team (MDT) assess their domain. The physician (usually a geriatrician or GP) assesses physical and mental health; the pharmacist may undertake a medication review; the nurse assesses various aspects of personal care (for example hygiene and continence); the physiotherapist, balance and mobility; the occupational therapist, activities of daily living; and the social worker, social aspects of the case. If needed others may be involved in the MDT assessment eg speech therapist, dietician.

This is not to say that different professions can assess different domains, it is about considering who is best places and best equipped to do the best thing for the patient at that time.

Physiotherapists' Role in the CGA

The Physiotherapists involvement in the delivery of a CGA can be incredibly varied and ultimately depends on your speciality, which setting you work in and the reasons for the patient being referred to you.

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.

Activities of daily living —including: basic activities of daily living (BADLs) eg bathing, dressing, instrumental or intermediate activities of daily living (IADLs) eg shopping, telephoning, taking medicine , and advanced activities of daily living (AADLs) eg being able to partake in social activities.

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.

Falls/balance — 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.

Outcome Measures

Examples of outcome measures that could be employed include

• Patient Specific Functional Scale
• Barthel index
• Katz ADL
• FIM
• Elderly Mobility Scale
• BOOMER
• Romberg test
• TUG
• Functional Reach
• 10 metre walk test

Evidence

A 2017 Cochrane review found that older people are more likely to be alive and in their own homes at follow-up if they received CGA on admission to hospital.

A 2017 study on physical fitness of the frail elderly is enhanced by use of a CGA.It found that in their acute care a CGA unit showed superior results (cf conventional care) in terms of preserving physical fitness at 3 months follow-up. CGA management may positively influence outcomes of great importance for these patients, such as mobility, strength, and endurance.