The Foundation of Comprehensive Geriatric Assessment (CGA)
A comprehensive geriatric assessment (CGA) is more than just a typical medical evaluation; it is a multidimensional, interdisciplinary diagnostic process that identifies medical, psychosocial, and functional strengths and limitations of an older person. The goal is to develop a coordinated plan for treatment and long-term follow-up. This systematic approach can uncover unrecognized health issues and lead to interventions that improve quality of life and independence. Instead of focusing on isolated symptoms, a CGA examines how various factors interact and impact a person’s overall health and independence.
Functional Status: Activities of Daily Living (ADLs) and Instrumental ADLs (IADLs)
Functional status is a cornerstone of geriatric assessment, measuring a person's ability to perform daily tasks independently. A decline in this area is often one of the first signs of an underlying health problem. The assessment is typically divided into two categories:
- Activities of Daily Living (ADLs): These are basic self-care tasks essential for survival and independent living. They include bathing, dressing, eating, transferring (moving from a bed to a chair), toileting, and continence. Observation is a simple way to gauge these abilities, such as watching a person unbutton their shirt or get up from a chair. Standardized tools like the Katz ADL scale can provide a more formal measure.
- Instrumental Activities of Daily Living (IADLs): These are more complex skills needed to live independently within a community. They involve using the telephone, shopping, preparing meals, housekeeping, managing medications, and handling finances. A deficit in IADLs often signals a need for support before a decline in ADLs becomes apparent. The Lawton IADL scale is a common tool for this assessment.
Physical Health and Management of Chronic Conditions
Older adults often live with multiple chronic illnesses, a condition known as multimorbidity. Assessing physical health involves a detailed medical history and a physical exam focused on age-specific concerns.
Sensory Impairments
Loss of vision and hearing are common and can significantly impact functional ability, mood, and social engagement. Screening for these impairments is crucial. For example, a whispered voice test can screen for hearing loss, and basic vision charts can check for visual acuity.
Nutritional Status
Malnutrition is a common problem among older adults, often linked to decreased appetite, depression, dental problems, and social isolation. Weight changes, dental health, and eating habits should be monitored. Tools like the Mini Nutritional Assessment (MNA) can quickly identify those at risk. Addressing nutritional needs can prevent physical decline and improve overall outcomes.
Fall Risk and Mobility
Falls are a leading cause of injury and hospitalization for older adults. Assessing balance and gait is critical. The Timed Up and Go (TUG) test, where a person is timed as they rise from a chair, walk 10 feet, turn, walk back, and sit down, is a simple and effective screening tool. Environmental modifications, medication review, and exercise can all help reduce fall risk.
Polypharmacy and Medication Management
Taking multiple medications (polypharmacy) increases the risk of drug interactions and side effects, which can contribute to falls, cognitive issues, and other health problems. An annual medication review is essential to identify and potentially discontinue unnecessary or inappropriate medications, using resources like the Beers Criteria.
Cognitive and Mental Health Evaluation
Cognitive impairment and mental health issues are not a normal part of aging and should be carefully assessed. They can dramatically affect a person’s independence and well-being.
Cognitive Function
Cognitive screening is important to detect early signs of dementia or other issues. Simple tools can be used in a short time. The Mini-Cog test, which combines a three-item word recall and a clock-drawing test, is highly effective. For more in-depth assessment, the Montreal Cognitive Assessment (MoCA) evaluates multiple cognitive domains.
Mental Health
Depression and anxiety are significant concerns. They are often underdiagnosed because older adults may present with physical symptoms rather than emotional ones. The Geriatric Depression Scale (GDS) is a validated and straightforward tool for screening. Assessing for social isolation and loneliness is also important, as these are major risk factors for poor mental health outcomes.
Social and Environmental Context
An individual's health is deeply intertwined with their living conditions and social support. These factors are known as the social determinants of health and have a significant impact on aging.
Social Support Network
Understanding who is involved in an older person's life—family, friends, or caregivers—is essential. Social isolation can lead to adverse health outcomes, while strong social connections can be protective. Assessing social and community context can reveal important information about a person's quality of life and support system.
Environmental Safety
The home environment can be a source of risk or a facilitator of independence. A home safety assessment can identify hazards like cluttered walkways, poor lighting, or loose rugs that increase fall risk. Modifications can make a significant difference in a person’s safety and autonomy. Reliable transportation, access to nutritious food, and a safe neighborhood are also crucial components to consider.
Comparing Geriatric Assessment Tools
Geriatric assessment is not a one-size-fits-all process. The tools used depend on the specific domain being evaluated. Here is a comparison of some common screening tools mentioned in comprehensive geriatric assessment guidelines.
| Tool | Primary Purpose | Domains Assessed | Typical User | Strengths |
|---|---|---|---|---|
| Katz ADL Index | Measures basic functional independence | Bathing, Dressing, Toileting, Transferring, Continence, Feeding | Clinician, Caregiver | Quick, clear, focused on basic needs |
| Lawton IADL Scale | Measures complex functional independence | Using telephone, Shopping, Meal prep, Housekeeping, Transportation, Finances, Medication management | Clinician, Trained Staff | Assesses higher-level functions, identifies early decline |
| Mini-Cog | Screens for cognitive impairment | Memory recall, Visuospatial skills | Clinician, Trained Staff | Fast (5 mins), easy to administer, no copyright fees |
| Mini Nutritional Assessment (MNA) | Screens for malnutrition risk | Food intake, Weight loss, Mobility, Psychological stress, BMI | Clinician, Caregiver | Quick, non-invasive, validated |
| Geriatric Depression Scale (GDS) | Screens for depression | Mood and affect questions | Patient, Clinician | Simple yes/no format, easy for older adults to use |
Conclusion
In summary, understanding the important factors to consider when assessing an older person means adopting a comprehensive perspective that goes beyond traditional medical evaluations. A true understanding of an individual's health requires looking at their functional capabilities, the entirety of their physical and mental health concerns, and their social and environmental context. This multi-faceted approach, often led by an interdisciplinary team, not only identifies existing problems but also anticipates future needs, allowing for proactive care and interventions. The goal is to maximize an older adult’s independence, well-being, and overall quality of life by addressing all aspects of their health.
For more detailed information on comprehensive geriatric assessment for primary care, consult the official AAFP Geriatric Assessment Guide.
