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Comprehensive Geriatric Assessment (CGA)

CGA in Primary Care Settings. British Geriatrics Society. British Geriatrics Society. 28 January 2019

CGA Specific presentations Mobility and balance, Bone health, Falls, Depression, Confusion/delirium, Mental capacity, Urinary incontinence, Weight loss and nutrition, End of life care

CGA Toolkit for Primary Care Practitioners (pdf)


Definition

Comprehensive Geriatric Assessment (CGA), or
Comprehensive older age assessment (COAA), or
Geriatric Evaluation Management and Treatment (GEMT)

is a process of integrated care comprising a number of steps:

  1. Multidimensional holistic assessment

  2. Creation of a problem list to address issues

  3. Intervention

  4. Regular planned review

Why is it done?

Evidence shows that CGA is effective in secondary care :

  • reducing mortality

  • improving independence for older people 

  • reducing hospital admission and readmission

  • reduce the impact of frailty

  • reverse the progression of frailty

The evidence base for primary care care is not yet as strong. A systematic review by Garrard et al (2019) concluded potential benefits

  • cost-effecttiveness

  • improved medication adherence

  • reduced hospital admission rate

  • effect on mortality outcomes were inconsistent


When is CGA done?

  1. Presenting with frailty syndromes – i.e. falls, confusion, reduced mobility and increasing incontinence
    even if these appear to be due to a reversible cause – such as a new medication or minor infection

  2. When a GP or community team learns of an incident which implies frailty- for example if an ambulance is called after a fall

  3. Discharged from hospital after presenting with a frailty syndrome (fall, reduced mobility, delirium etc) even if another diagnosis has been offered as the cause.

  4. In care homes - most residents of care homes will have frailty.

Several tools for risk stratification and for frailty ‘screening’ are available and more are being developed, such as Electronic frailty index eFI which is embedded in System one and EMIS.

Who may be involved?

  • General practitioner

  • Community geriatrician (if available)

  • Community nursing team (including community matrons, dedicated nurses from the CCG, district nurses)

  • Physiotherapists

  • Occupational therapists

  • Community psychiatric nurses CPN

  • Pharmacists


The elements of the CGA process

CGA comprises interdisciplinary and interagency working in a number of domains:

  1. Physical assessment
    Sensory loss
    Feet and footwear
    Gait and balance:
    Timed up and Go Test (TUGT), number of steps to turn 180 degrees
    Lying and standing BP (at 0, 1min, 3min)
    Cognition and mood
    Functional ability
    Pain/joints
    Weight and nutrition
    PR and genitalia

  2. Functional, social and environmental assessment  
    Mobility
    Activities of daily living,
    Nottingham Extended ADL Scale,
    Barthel Index,
    BGS Social & Environment Questionnaires   
    Driving
    Timed up and Go Test (TUGT) 

3. Psychological components: Mood and Cognition

Cognition:
Useful screening question for patient/carers:

“Has the person been more forgetful in the last 12 months to the extent it has affected their daily life? For example, difficulty using the phone, managing shopping lists, using money, managing their medication, driving, etc.

Mood

Screen for low mood, depression and suicide risk

Geriatric Depression Score

Cognitive assessment
in Primary Care

Abbreviated mental test score (AMTS)


General practitioner assessment of cognition (GPCOG) GP-Cog test

Mini-cog

Cognitive assessment
in Memory Clinics

Addenbrookes cognitive examination-III (ACE-III)

Montreal Cognitive Assessment (MoCA)

Cognitive assessment in acute care (delirium and dementia co-exist)

Confusion Assessment Method (CAM) for delirium

Abbreviated mental test score (AMTS)

6-Item cognitive impairment test (6CIT)

General practitioner assessment of cognition (GPCOG)

Cognitive assessment
in care homes

Abbreviated mental test score (AMTS)

6-Item cognitive impairment test (6CIT)

General practitioner assessment of cognition (GPCOG)

Montreal Cognitive Assessment (MoCA)

Alzheimer’s Society Practical Toolkit for clinicians

4. Medication Review


STOPP/START criteria for potentially inappropriate prescribing in older people: LINK

The Medication Appropriateness Index: LINK

7-Steps Scottish Polypharmacy guidance: LINK

5. Creating a Problem List

Consider baseline tests and further specialist tests (e.g. 24hr ECG or colonoscopy etc).
Baseline tests:
Full Blood Count
Urea Creatinine (Chronic Kidney Disease (CKD)
Electrolytes (be aware sodium <125mM/L can cause confusion and tiredness)
Glucose
Liver Function Tests (ALP elevated with Paget’s disease or post-fracture)
Calcium
C Reactive Protein (CRP) ESR
Thyroid Function Tests
PSA
Urinalysis
Chest Radiography (CXR)
Electrocardiograph


What should a care plan include?

The diagram below summarises nine key areas that ought to be included at the end point of the CGA process as the individualised care plan for a frail older person.