Understanding the Comprehensive Geriatric Assessment (CGA)
The Comprehensive Geriatric Assessment (CGA) is a multidimensional and multidisciplinary diagnostic process designed to determine a frail older person's medical, functional, and psychosocial issues. It goes far beyond a standard medical checkup, which primarily focuses on disease management. Instead, CGA evaluates the complex interactions between different health domains to produce a coordinated, integrated plan of care that addresses the person as a whole, not just their individual ailments. The CGA is a dynamic process, not a one-time event, and the summary provides a roadmap for ongoing monitoring and adaptation of the care plan.
The Four Pillars of the Assessment
The CGA is built upon four core areas of evaluation, often described as its pillars. Assessing these areas holistically provides the rich, detailed data necessary for a comprehensive summary.
Physical Health
This pillar involves a thorough review of the older adult’s medical history, current conditions, and overall physical state. Key areas include:
- Review of Comorbidities: Identifying all chronic and acute conditions. The presence of multimorbidity is a common trigger for a CGA.
- Medication Review: Assessing for polypharmacy (the use of multiple medications) and potential inappropriate prescriptions or drug interactions. A pharmacist is often a key member of the team.
- Nutritional Status: Evaluating weight loss, eating habits, and the risk of malnutrition.
- Sensory Impairment: Screening for vision and hearing problems, which can significantly impact communication, safety, and social interaction.
- Gait and Balance: Assessing mobility and fall risk through observations and standardized tests like the Timed Up and Go Test.
Functional Status
This domain evaluates an older person's ability to perform daily tasks, a critical measure of their independence and quality of life. It is divided into two main categories:
- Activities of Daily Living (ADLs): These are fundamental self-care tasks necessary for independent living. They include bathing, dressing, eating, transferring (moving from a bed to a chair), toileting, and continence.
- Instrumental Activities of Daily Living (IADLs): These are more complex tasks that allow for independent living within a community. They include managing finances, using a telephone, preparing meals, managing medication, doing housework, and shopping.
Mental and Cognitive Health
This pillar addresses psychological and cognitive well-being. It is a crucial part of the CGA, as mental health issues and cognitive decline can heavily influence functional capacity and overall health.
- Cognition: Screening for cognitive impairment and dementia using tools like the Mini-Cog or Montreal Cognitive Assessment (MoCA).
- Mood and Anxiety: Assessing for depression and anxiety, which are common in older adults and can be overlooked. The Geriatric Depression Scale is a common tool.
- Emotional Well-being: Discussing fears and emotional concerns that may affect quality of life.
Socioenvironmental Evaluation
This domain looks at the patient's support systems and living conditions, which are vital for long-term health and safety.
- Social Support: Evaluating the availability and adequacy of informal support from family and friends, as well as formal statutory care.
- Living Arrangements: Assessing the safety and convenience of the patient's home environment. This can involve home safety checklists.
- Financial Resources: Considering financial stability and access to resources that might impact care.
The Process of Creating the CGA Summary
The CGA is not a single test but a systematic, multi-step process that culminates in a comprehensive summary and action plan.
- Data Gathering: A multidisciplinary team, including a geriatrician, nurse, social worker, and therapists, collects information across all domains. This can happen over multiple visits to accommodate patient fatigue.
- Team Discussion: The team reviews the gathered data, shares insights, and collaborates on a holistic understanding of the patient's needs and challenges.
- Problem List and Goal Setting: Based on the discussion, the team creates a detailed problem list that goes beyond simple diagnoses. For example, instead of just "arthritis," a problem might be "pain from arthritis limiting daily activities." Realistic, goal-oriented interventions are then developed.
- Care Plan Development: A coordinated treatment plan is created, assigning responsibilities and timelines for interventions. This plan is shared and agreed upon with the patient and family.
- Implementation, Monitoring, and Revision: The plan is put into action, and the patient's status is monitored regularly. As the patient's condition evolves, the plan is reviewed and revised as needed.
CGA vs. Standard Checkup: Key Differences
| Feature | Comprehensive Geriatric Assessment (CGA) | Standard Checkup |
|---|---|---|
| Scope of Evaluation | Multidimensional; covers physical, functional, psychological, and socioenvironmental factors. | Unidimensional; focuses on diagnosis and management of specific diseases. |
| Team Approach | Multidisciplinary team (geriatrician, nurse, social worker, therapists). | Typically a single physician or healthcare provider. |
| Patient Focus | Frail older adults, individuals with multimorbidity, or functional decline. | Generally for all adults for routine screening and monitoring. |
| Outcome | Goal-oriented, integrated care plan to maximize overall well-being and independence. | Disease-specific treatment and follow-up. |
| Emphasis | Maximizing function and quality of life. | Diagnosing and treating illness. |
| Duration | Can occur over multiple visits to accommodate complex needs. | Typically a single, time-limited appointment. |
The Benefits of a Detailed CGA Summary
The summary of a CGA is a powerful tool with significant benefits for the older adult, their family, and the healthcare team. It leads to:
- Improved Diagnostic Accuracy: The multidisciplinary review often reveals problems missed in a standard evaluation.
- Enhanced Functional Outcomes: Tailored interventions improve mobility, balance, and independence, reducing the risk of falls and decline.
- Better Quality of Life: By addressing not just medical issues but also psychosocial and environmental concerns, the CGA improves overall well-being.
- Reduced Hospital Readmissions: Effective care planning and monitoring helps prevent crises that lead to hospitalization.
- Optimized Medication Regimens: Thorough medication review identifies and reduces harmful polypharmacy.
Ethical Considerations in Geriatric Assessment
The process of a CGA involves sensitive issues that require careful ethical consideration. These include:
- Informed Consent: Ensuring the patient fully understands the purpose and scope of the assessment, and consents to the process.
- Balancing Autonomy and Beneficence: Respecting the patient's right to make their own decisions (autonomy) while acting in their best interest (beneficence).
- Capacity Assessment: Carefully evaluating the patient's capacity to make decisions, and involving a surrogate decision-maker when necessary.
- Confidentiality: Maintaining the privacy of the patient's health information across the multiple professionals involved.
- Advance Care Planning: Using the assessment as an opportunity to discuss the patient's wishes for future medical care and establish an advance directive.
Conclusion
In summary, a comprehensive geriatric assessment and its subsequent summary provide a truly holistic, detailed, and actionable overview of an older adult's health. By moving beyond traditional, disease-focused evaluations, this multidisciplinary approach identifies and addresses the complex physical, functional, psychological, and social factors that impact an individual's well-being. The result is not just a list of diagnoses, but a dynamic, goal-oriented care plan that empowers older adults to achieve better health outcomes, greater independence, and a higher quality of life. For further details on how family physicians can incorporate geriatric assessment, visit the American Academy of Family Physicians website.
