LESSON 3: Comprehensive Geriatric Assessment

Week 3

I. MAIN TOPIC : A. Components of Comprehensive Geriatric Assessment

B. Members of the CGA multidisciplinary core team
C. Role of the nurse in Comprehensive Geriatric Assessment

II. SUB – TOPICS : 1. Physical Assessment

2. Functional Assessment
3. Communication Assessment

4. Psychological Assessment

III. LEARNING OUTCOMES:

At the end of the lesson, that student will be able to:

1. Describe the components of Comprehensive Geriatric Assessment.

2. Apply a holistic approach to patients and focus on the older person’s quality of
life.
3. Develop knowledge of the roles of the nurse in the comprehensive assessment
of older people.

IV. PRE – ASSESSMENT

1. Watch the following video:

A formulated geriatric assessment and the role of nurses

https://youtu.be/YfebCGp0JOU
https://youtu.be/-eHPugoC5sE
2. Output of Group Activity: Dated September 18,2020

Interview of an older person directed to assessing physical function and the patient’s
capacities at home

V. DISCUSSION:
Comprehensive Geriatric Assessment (CGA)
 Is a “multi-dimensional, interdisciplinary diagnostic process to determine the
medical, psychological and functional capabilities of a frail older person in order
to develop a coordinated and integrated plan for treatment and long-term follow-
up” (Rubenstein, L.Z., et al., 1991).

Overview
 Population ageing is accelerating rapidly worldwide, presenting unique challenges
to provide sustainable health and social services.
 Physical, psychological and socioeconomic factors interact to influence the health
and functional status of older people.
 Strategies are required to consistently assess health and social care needs in order
to provide services in a timely manner and in the most appropriate setting, while
utilizing available resources as efficiently as possible.
 CGA is an approach developed for this purpose and has become an increasingly
important cornerstone of modern geriatric care.

A. COMPONENTS OF COMPREHENSIVE GERIATRIC ASSESSMENT

1. Physical Assessment
 Focused examination of the systems primarily involved in exercise.
 Heart and peripheral vasculature - to garner information about aerobic exercise
capacity as well as identifying pathologies that may limit aerobic exercise
tolerance such as peripheral vascular disease.
 Underlying cardiovascular disease may also be identified such as uncontrolled
hypertension, unstable angina, third degree heart block or acute heart failure
which would be contraindicated to exercise initiation in older adult.
 The respiratory system - to identify any pulmonary disorders such as chronic
bronchitis, emphysema or restrictive lung diseases.
 The musculoskeletal examination involves examination of the axial and
appendicular skeleton, with an attention to posture, muscle bulk, joint range of
motion and strength testing.
  Neurological testing - vision assessment, sensation, proprioception and a mini-
mental examination.
1.1. Musculoskeletal disorders/bone health/sarcopenia
1.2. Falls and syncope
1.3. Pain
1.4. Recent/recurrent infections
1.5. Elimination patterns/continence status
1.6. Skin problems
1.7. Impaired vision/hearing
1.8. Previous fractures
1.9. Previous/recent hospitalization
1.10. Alcohol
1.11. Stroke

2. Functional Assessment
Definition: Functional impairment - difficulty performing, or requiring the assistance of another
person to perform, one or more of the following Activities of Daily Living (ADL):
ADL impairment is a stronger predictor of hospital outcomes (functional decline, length of
stay, institutionalization, and death) than admitting diagnoses, Diagnosis Related Group, and
other physiologic indices of illness burden. ADL impairment is also a risk factor for nursing
home placement, emergency room visits, and death among community-dwelling adults.
2.1. Basic Activities of Daily Living- ADLs are the essential elements of self-care.
Inability to independently perform even one activity may indicate a need for supportive services.
 Dressing, Eating, Toilet use, Bathing, Personal Hygiene, Mobility in bed, Locomotion
inside and outside home
2. 2. Instrumental Activities of Daily Living- IADLs are associated with independent
living in the community and provide a basis for considering the type of services necessary in
maintaining independence.
 Meal Preparation, Housework, managing medications, Managing finances, Phone use,
Shopping,
Transportation
 2.3. Activity/Exercise Status- An exercise-focused physical examination allows the
physician to identify conditions that may impact exercise in the elderly but also can be used to
track the beneficial changes of an exercise program.
 Mobility-ambulation/transfer, Activity levels, Endurance, fall & history
2.4. Gait and Balance- non-institutionalized older adults may have difficulty walking or
require the assistance of another person or special equipment to walk. Walking disability
increases with age., such as in older adults with diseases such as arthritis.
 Assistive devices, Gait/ Balance Analysis

3. Communication Assessment
 Good communication is at the heart of assessment: listening carefully and
understanding what is said, what is felt and what is helpful are essential skills for
an assessor, as is the ability to explain clearly what you are doing and why.
 Good communication skills are particularly important in these situations, and
when the older person may be anxious, inhibited, depressed or confused, or have
impaired memory or speech.

Take note of the following:

 Aphasia- Multi-modal language disorders affecting a person’s ability to

understand and produce spoken and written language.

 Dysarthria- Speech disorders that are due to disturbances in muscular

control of the speech mechanism.

 Dyspraxia of speech- Speech disorders that represent a disruption to the

selection, programming and online control of the movements for speech.

 Voice Disorders (Dysphonia)- Assessment for abnormality of pitch,

volume, resonance and/or quality, and/or a voice that is inappropriate for
the age, gender or culture of the speaker.

 Cognitive-Linguistic Disorders- Communication assessment is required

in order to aid differential diagnosis, establish a baseline for monitoring
change.
4. Psychological Assessment
 Unrecognized cognitive impairment is a risk factor for:
 medication non-adherence
 poor compliance with behavioral recommendations
 difficulty navigating the health care system
 Caregiver stress.
 The most common causes of cognitive impairment in elderly patients are:
 dementia
 depression
 delirium

 Patients with suspected cognitive impairment should be screened for delirium and
depression.
 Delirium is a disorder of attention, and should be considered in patients
with waxing and waning attention or level of consciousness. Delirium is
commonly a side effect of medications, and often unrecognized by
clinicians.

The following are important parameters:

 Cognition- Deficits in cognitive domains including short term

memory, language, executive functioning, orientation and
attention.

 Mood/depression testing- Mood symptoms and disorders

including anxiety or depressions taking timelines into account and
identifying baseline Requirement for therapeutic support to deal
with loss, separation, grief and bereavement.

 Health behaviors- Addiction behaviors; substance misuse;

dual/multi addictive behaviors; self-neglect; ability to manage care
plan and problem solving.

B. MEMBERS OF THE CGA MULTIDISCIPLINARY CORE TEAM

 Experienced individuals drawn from medical, nursing and associated health
professions. They should be responsible for the coordinated assessment,
discussion and recommendation or implementation of treatment plans.
 The members of the multidisciplinary team may include:
Medical – e.g. Geriatrician, Psychiatrist of Later Life, Palliative Care Specialist, GP
Nursing
Medical social worker
Physiotherapy
Occupational therapy
Speech and Language therapy
Dietetics
Pharmacists
Psychology
Podiatry

1. Appropriate Settings for Comprehensive Geriatric Assessment

1.1. Comprehensive Geriatric Assessment in Acute Medical Units- At risk older

people who would most likely benefit from CGA may be identified in the AMU and a
plan put in place to carry out CGA in the most appropriate setting.

1.2. Comprehensive Geriatric Assessment in the Ambulatory Geriatric Day

Hospital- the Ambulatory Geriatric Day Hospital is particularly suited to CGA of the
older person with physical and cognitive co-morbidities which may require multiple
visits to complete the assessment.

C. ROLE OF THE NURSE IN COMPREHENSIVE GERIATRIC ASSESSMENT

 The nurse plans and provides care using professional knowledge, skill and
expertise in person-centered holistic care. Nursing care is based on a holistic
framework guided by an appropriate model of nursing to assess, identify needs,
plan, implement and evaluate change in patient status.

1. Physical Assessment
The nurse assesses presenting symptoms, admitting diagnosis and medical
history.
 Assessment is ongoing in order to inform a more focused assessment and plan of
care.
Physical assessment should encompass:
Overall general appearance and demeanor
Oral hygiene and dentition
Skin integrity
Mobility
Foot assessment
Pressure sore risk
Wound assessment
Nutritional status

The nurse is proactive in problem identification and addressing comfort measures:

 Pain assessment is carried out using an appropriate scale which captures
location, frequency, intensity, aggravating and alleviating factors.
 The nurse reviews medication and concordance with treatment plan and
consults with doctor or pharmacist where issues arise.
 Continuity of care facilitates ongoing monitoring and physiological
markers of health status form part of a CGA.

2. Functional Assessment
For all aspects of assessment nurses use a holistic approach with a focus on continuity
of care over a 24-hour period facilitates an in-depth functional assessment. A range of
tools are employed in order to assess function and identify potential risks such as:
Level of independence and ability to attend to own Activities of Daily Living
(ADL)
Falls history
Pressure ulceration present or risk
Aspiration risk
Communication-approaches and queues
Vision, hearing and sensory deficits
 Bladder and bowel function is assessed and may include urine investigations or
bladder scanning.
Palliative care need following a diagnosis of life-limiting disease

3. Psychological
 The nurses’ intuitive skills and ongoing observation of physical cues facilitate
problem identification such as anxiety, withdrawal, apathy and depression
signaling the need for more detailed assessment and appropriate referral.

 Mood and depression should be assessed and evaluated using ongoing

observational skills and the use of a validated screening tool.

 The nurse sensitively assesses patient/family coping strategies, responsibility

of care and potential self-neglect or elder abuse.

 The nurse assesses cognition using validated tools, noting impact on function
and quality of life.

 In the presence of confusion and responsive behaviors, the nurse conducts a

detailed assessment noting potential causes and alleviating and aggravating
factors.

4. Social and Environment

 The nurse assessment captures home circumstances, family support,
accommodation, living arrangements, social supports and other services
(home help, day care, meals on wheels).

 Discussion with the patient and family enables the nurse to assess the older
person’s goals of care, engagement in local community.

VI. LEARNING ACTIVITY:

RLE Class Learning Activity:
1. Reflection exercise: an assessment in hospital
 Edith Robinson is admitted to hospital after falling and breaking her hip. She
is 86 years old and lives alone in the house where she and her husband raised their
four children (an old cottage with several steps in the living area and kitchen). Her
husband died three weeks ago. Her daughter, who found Mrs Robinson lying on the
floor, was not sure how long she had been there.
On admission, Mrs Robinson appears acutely confused. Blood tests revealed
dehydration and anaemia. Her daughter explained that Mrs. Robinson has type 2
diabetes (for which she takes daily metformin), heart failure (for which she takes
blood pressure medication) and osteoporosis (for which she takes calcium tablets).
She also takes laxatives for chronic constipation and pain medication for arthritic
knee pain. Her daughter expresses concern about her mother’s lack of appetite, recent
weight loss and a foot ulcer that is not healing.
Mrs. Robinson is awaiting surgical review and the immediate focus of care is
her hip fracture. Beyond her urgent care, she needs a comprehensive geriatric
assessment (CGA). You are responsible for conducting a CGA for Mrs. Robinson.

You ask yourself the following questions:

1. What are her care needs? How might they be interlinked?

2. How can her care needs be addressed?
3. Which members of the multidisciplinary team need to be involved?
4. What should her care plan include? What are the short- and long-term goals?

VII. EVALUATION/POST ASSESSMENT

1. Send the output from the learning activity through our google class platform.

References:
https://www.cochrane.org/CD006211/EPOC_comprehensive-geriatric...

Ellis, G., et al.,(2011) Comprehensive geriatric assessment for older adults admitted
to hospital. The Cochrane database of systematic reviews, (7): p. CD006211.
Watson KB, Carlson SA, Gunn JP, et al. Physical Inactivity Among Adults Aged 50
Years and Older – United States, 2014. MMWR Morb Mortal Wkly Rep.
2016;65(36):954 958. Published 2016 Sep 16.
https://www.scie.org.uk/publications/guides/guide03/process/comms.asp