The Gold Standard: Comprehensive Geriatric Assessment (CGA)
For an older adult patient, a routine physical assessment is often insufficient. The most complete and recommended method is the Comprehensive Geriatric Assessment (CGA). This is not a single test but a systematic, multi-dimensional, and interdisciplinary process designed to evaluate a frail older person's medical conditions, functional capabilities, cognitive and mental health, and social circumstances. The goal is to develop a coordinated care plan that maximizes overall health and quality of life.
Unlike traditional assessments that often focus on a single presenting complaint, the CGA recognizes that an older adult's health concerns are interconnected. A new medication, for example, could affect mobility, which in turn impacts social engagement and mood. By addressing all these factors together, nurses and the healthcare team can create a more effective, holistic, and person-centered plan of care.
Key Components of the CGA
Physical and Medical Status
A thorough medical history and physical examination form the foundation of any assessment, but in the CGA, certain topics are given special focus due to their higher prevalence and impact in older adults. These include:
- Sensory Impairment: Vision and hearing decline can significantly impact quality of life and functional independence. Nurses should perform or screen for these impairments, being mindful of potential issues like cataracts, glaucoma, and presbyopia.
- Nutrition and Weight: Malnutrition can be both a cause and a consequence of poor health. Nurses assess for unintentional weight loss or gain and use screening tools like the Mini Nutritional Assessment (MNA) to identify at-risk patients.
- Continence: Urinary or fecal incontinence is not a normal part of aging but a treatable condition that can lead to social isolation and health complications. The assessment should investigate the type of incontinence to guide treatment.
Functional Ability and Mobility
Functional status is a cornerstone of the CGA, assessing a person's ability to perform tasks required for living independently. It is typically divided into two categories:
- Activities of Daily Living (ADLs): Basic self-care tasks like bathing, dressing, eating, and toileting. The Katz Index is a common tool used to assess ADL independence.
- Instrumental Activities of Daily Living (IADLs): More complex tasks necessary for independent living, such as managing finances, preparing meals, and using transportation. The Lawton IADL scale can be used to evaluate these skills.
Mobility and fall risk are also crucial. The Timed Up and Go (TUG) test is a simple and effective screening tool where the patient is timed walking a short distance. A slow time indicates a higher risk of falls and need for further evaluation.
Cognitive and Mental Health
Older adults are at higher risk for cognitive impairment, delirium, and depression. A CGA includes screening for these conditions using validated tools.
- Cognition: The Mini-Cog test is a fast and reliable screening tool for dementia and cognitive impairment. Other options include the Saint Louis University Mental Status (SLUMS) exam.
- Mood: The Geriatric Depression Scale (GDS) is specifically designed for older adults and can help identify depressive symptoms that are often mistaken for normal aging.
Psychosocial and Environmental Factors
The patient's overall well-being is heavily influenced by their social and environmental context. This aspect of the assessment considers:
- Social Support: Identifying family, friends, or caregivers who can assist the patient. Also important is understanding the patient's level of social engagement and potential for isolation.
- Living Environment: Assessing home safety for fall hazards and ensuring the environment is conducive to the patient's level of function.
- What Matters Most: Involving the patient in discussions about their goals, values, and priorities is a critical part of the CGA, encapsulated by frameworks like the 'Geriatric 5Ms'.
Nursing Assessment Tools vs. Comprehensive Assessment
| Assessment Aspect | Standard Nursing Assessment (Example) | Comprehensive Geriatric Assessment (CGA) |
|---|---|---|
| Focus | Typically problem-driven and organ-system focused. | Holistic, multidimensional, and interdisciplinary approach. |
| Cognition | May include basic orientation questions (e.g., “Do you know where you are?”). | Uses validated tools like the Mini-Cog or SLUMS to screen for early impairment. |
| Functional Status | Informal observation of mobility. | Uses standardized scales (e.g., Katz ADL, Lawton IADL) and objective tests (e.g., Timed Up and Go). |
| Medication Review | Asks for a list of prescribed medications. | Thoroughly reviews all medications (prescribed, OTC, supplements) to identify polypharmacy and inappropriate prescriptions. |
| Psychosocial | Asks general questions about social support. | Assesses social networks, caregiver burden, environment, and financial status, and prioritizes patient goals. |
The Nurse's Role in Applying the CGA
A complete assessment of an older adult is not a one-time event but an ongoing process. Nurses are often at the center of this, initiating the assessment and integrating information from various sources.
Communication is Key
Effective communication is paramount. Nurses should:
- Speak plainly and clearly, facing the patient to aid with potential hearing loss.
- Minimize distractions in the room.
- Provide written instructions or summaries of care, as remembering details can be difficult.
- Engage family members or caregivers, but always respect the patient's privacy and autonomy.
The Multidisciplinary Team
The nurse plays a central role in a larger multidisciplinary team that may include physicians, social workers, pharmacists, and physical therapists. The nurse's detailed assessment provides the foundation upon which the entire team can build a coordinated care plan. By sharing observations and using standardized tools, the nurse helps ensure all members of the team have a complete and accurate picture of the patient's needs.
For more detailed information on specific geriatric assessment tools, the Geriatric Assessment Tool Kit from the University of Missouri is an authoritative resource that can help nurses in their practice.
Conclusion: Beyond the Standard
The method a nurse should use to obtain a complete assessment of an older adult patient is the Comprehensive Geriatric Assessment. This holistic and systematic process moves beyond traditional medical evaluation to encompass a patient's physical, functional, cognitive, psychosocial, and environmental health. By integrating standardized tools, effective communication, and collaboration with a multidisciplinary team, nurses can gain a truly complete picture, leading to improved health outcomes and enhanced quality of life for older adults.
