Understanding the Comprehensive Geriatric Assessment (CGA)
The Comprehensive Geriatric Assessment (CGA) is more than a standard medical exam; it is a systematic, multidisciplinary process that evaluates a frail older person's medical conditions, psychosocial status, and functional capabilities. It is a person-centered approach that aims to improve outcomes and maximize independence. Unlike a typical exam focused on a single ailment, a CGA addresses the full spectrum of an older adult's health, leading to more tailored and effective treatment plans.
Functional Status: The Foundation of Independence
Functional status is a critical indicator of an elderly patient's overall health. It is evaluated by assessing their ability to perform daily tasks and is often divided into two main categories: Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). Any decline in these areas can signal an underlying health issue.
Assessing Activities of Daily Living (ADLs)
- Bathing: The ability to wash and groom oneself.
- Dressing: The ability to select appropriate clothes and put them on.
- Toileting: The ability to use the toilet independently.
- Transferring: The ability to move from a bed to a chair and back.
- Continence: The ability to control bladder and bowel function.
- Feeding: The ability to eat and drink without assistance.
Assessing Instrumental Activities of Daily Living (IADLs)
- Managing Finances: Paying bills and handling money.
- Shopping: Purchasing groceries and necessities.
- Preparing Meals: Planning and cooking meals.
- Housekeeping: Performing light household duties.
- Using a Telephone: Operating a phone to make and receive calls.
- Using Transportation: Driving or using public transit.
Simple observation of how a patient rises from a chair, walks, and performs simple tasks like unbuttoning a shirt can provide invaluable insights into their functional capacity. Standardized tools like the Katz Index for ADLs and the Lawton Scale for IADLs can be used for a more formal evaluation.
Comprehensive Physical Health Examination
A physical examination of an older adult should be sensitive to age-related changes and focus on conditions common in this population. Beyond standard vital signs and organ system checks, special attention should be paid to sensory impairments, nutritional status, and musculoskeletal health.
- Vision Screening: With conditions like cataracts, glaucoma, and macular degeneration being more prevalent, a visual acuity test using a Snellen chart is crucial. Assess for glare sensitivity and night vision issues.
- Hearing Assessment: Age-related hearing loss (presbycusis) is common and can lead to social isolation and cognitive decline. Use a whispered voice test or a screening questionnaire like the Hearing Handicap Inventory for the Elderly to check for deficits.
- Nutrition Evaluation: Up to 15% of community-dwelling older adults may be malnourished. Look for unintended weight loss, poor dentition, and signs of poor nutrient intake. Validated tools like the Mini Nutritional Assessment (MNA) can help identify at-risk patients.
- Musculoskeletal Health: Assess joints for arthritis, examine gait for stability, and check for signs of osteoporosis, particularly in women. Range of motion, muscle strength, and flexibility should all be evaluated.
Cognitive and Mental Health Evaluation
Cognitive decline is not a normal part of aging, though it is more common. Screening for cognitive impairment and mental health disorders is a vital component of the assessment.
Screening for Cognitive Impairment
- Mini-Cog: A quick and easy screening tool involving a three-item recall and a clock-drawing test.
- Montreal Cognitive Assessment (MoCA): A more detailed tool used when cognitive issues are suspected, covering various cognitive domains.
Screening for Mood Disorders
Depression can be underdiagnosed in the elderly and may present with atypical symptoms. Screening tools like the Geriatric Depression Scale (GDS) can aid in early detection and intervention. Anxiety and social isolation should also be considered.
The Dangers of Polypharmacy
Polypharmacy, the use of multiple medications, is a significant issue for older adults, increasing the risk of adverse drug reactions, drug-drug interactions, and falls. A comprehensive medication review is essential.
| Assessment Aspect | Simple Medication Review | Comprehensive Medication Review (CMR) |
|---|---|---|
| Scope | Lists all prescribed and OTC medications. | Evaluates necessity, dosage, effectiveness, and interactions. |
| Goal | Ensures all medications are documented. | Minimizes unnecessary medications (deprescribing) and manages side effects. |
| Process | Primarily patient-driven recall. | Involves pharmacist collaboration and use of screening tools like the Beers Criteria. |
| Timing | Standard part of any visit. | At least annually or after significant health events (e.g., hospitalization). |
Socioenvironmental Evaluation and Fall Prevention
The patient's environment and social support network significantly impact their health outcomes and safety.
- Home Safety Assessment: Evaluate the home for fall hazards, such as loose rugs, poor lighting, and lack of grab bars.
- Social Support: Understand the patient's living situation, caregiver network, and degree of social isolation.
- Fall Risk: Conduct an annual fall risk assessment using tests like the “Timed Up and Go.” For patients at high risk, a multidisciplinary intervention plan is necessary.
A Concluding Thought on Geriatric Assessment
A thorough and compassionate assessment is the cornerstone of quality geriatric care. By moving beyond a problem-centric view to a holistic, multidisciplinary evaluation of medical, functional, cognitive, and social domains, healthcare professionals can significantly enhance an older adult's health, safety, and quality of life. Regular and thoughtful assessments ensure that care plans are personalized and evolve as the patient's needs change. For more details on the geriatric approach, you can consult resources from the American Academy of Family Physicians, including their guidance on office-based assessments: The Geriatric Assessment: An Office-Based Approach.
