Assessment

Comprehensive Geriatric Assessment (CGA) is the term most commonly used to refer to the specialized process by which the health of some elderly people is assessed. CGA has four characteristics:

1. It is multi-factorial, encompassing items traditionally regarded both as "medical" and "social."
2. Its emphasis is on the functional ability of the person being assessed.
3. It includes an inventory of both assets and deficits.
4. It is action oriented, that is, it provides the basis for the subsequent management plan for the patient who is being assessed.

To consider this process in more detail, we can examine each of the items identified in the opening sentence: Some people, are assessed, by a specialized process. CGA is not meant for all elderly people, only some. Two features identify those individuals who might benefit from CGA: the person should have compromised function; and, they should have more than one thing wrong. Compromised function is key: people who are engaged in all activities in which they would like to be engaged, at a level that is fully satisfying for them, normally do not require CGA, even if they might have one or more medical illnesses, such as high blood pressure or osteoarthritis. But when elderly people find that they can no longer can perform certain activities necessary for them to remain independent, including things like looking after their household or getting dressed, then they become potential candidates for CGA. The other criterion for a person to become a candidate for CGA is to have more than one active medical problem that in some way is gives rise to, or appears to give rise to, the problem with function. To say that an elderly person has compromised function and multiple medical problems is another way of saying that that person is frail.

People with multiple problems require assessment of those problems. This assessment is in contrast to the usual medical approach, which begins with a diagnosis of the medical problem. Diagnosis is the process whereby clues from talking to (called taking the history) and examining the patient yield a pattern that is recognizable as having a single cause. Although more than one problem can be active at once, the traditional emphasis in medical diagnosis is on distilling many symptoms (what the patient tells the physician) and signs (what the physician finds on the examination) into a single cause, called the diagnosis.

The first practitioners of geriatric medicine recognized that this approach, while essential in sorting out the medical problems of frail elderly people, was inadequate in meeting their health needs. For example, many frail elderly people who are medically ill also are deconditioned—that is, they are weaker, especially in the shoulders and hips, more prone to fall, and more prone to abnormalities of fluid balance—but deconditioning is not a traditional medical diagnosis. Knowing how intensively to rehabilitate someone who is deconditioned in a hospital requires some understanding of their home circumstances: Will they have to climb stairs at home? Is there someone readily available to help? Is that person able and willing to help? Such practical methods fall outside the traditional domains of medical diagnoses, and their systematic inventory is what underlies the "assessment" process. Many authors believe that the term "assessment" has too narrow a focus, and that a proper assessment should not only give rise to a plan for addressing the problems thus identified, but should also include the management of the problems themselves, at least after they are stabilized. As a consequence, the term geriatric evaluation and management is sometimes preferred to describe what traditionally has been known as CGA.

The specialized nature of CGA lies in the systematic approach to a patient's problems. Although variation exists among practices, most methods of CGA include, in addition to an evaluation of the patient's medical diagnosis, an assessment of the following domains:

1. Cognitive function. Problems that give rise to impairment of thinking, language, memory, and other aspects of cognition include syndromes such as dementia, delirium, and depression. Typically, cognition is screened using a brief instrument such as the Mini-Mental State Examination (MMSE). The MMSE tests several aspects of cognition, including memory, attention, concentration, orientation, language, and visual-spatial function. If this screening test detects an abnormality, then a more detailed evaluation is required.
2. Emotion. The domain of emotion includes a screening of mood, to look for signs of depression, as well as an evaluation of common problems such as anxiety, or disorders of the mental state such as delusions or hallucinations. In addition, health attitudes are assessed, including the level of motivation, which is particularly important for patients who are being screened for participation in a rehabilitation program.
3. Communication. Communication assessment typically includes a screening of vision, hearing, speech, and language.
4. Mobility. The assessment of mobility that is, the ability to move about in bed, transfer in and or of bed, and walk is particularly important, as it is necessary for independence. In addition, because so many older people have atypical presentations of their illness, careful evaluation of their mobility as it first declines and then gets better allows clinicians to readily determine whether their patients are improving or getting worse. Given that many frail elderly people do not demonstrate the usual signs of sickness as they become ill (for example, they may not show an elevated temperature or white cell count when they have an infection), having a ready means to track illness progression and recovery is of great practical benefit, and careful assessment of mobility and balance allows this to be done.
5. Balance. The assessment of balance is distinct from the assessment of mobility. Again, its importance lies both in its intrinsic value in relation to independence and in its value of improving or worsening health in the setting of acute illness.
6. Bowel function. Bowel function is typically assessed by inquiring about the patient's bowel habit and by physical assessment, which should include a rectal examination.
7. Bladder function. It is important to understand whether an older person is having difficulty with urination. In men, this often reflects disease of prostate. In either sex, the presence of urinary incontinence is of particular importance. As with problems in mobility and balance, the significance lies not just in the incontinence per se, but in incontinence as a sign of illness, within the genitourinary system and elsewhere.
8. Nutrition. Interestingly, nutrition is often neglected in the traditional medical examination. It is important to assess the patient's weight and to note the presence of weight loss, and the time over which this weight loss has occurred. Routine laboratory investigations also offer some insight into an elderly person's nutritional status.
9. Daily activities. In some ways this is at the heart of the assessment. It is extremely important to know whether older people are capable of fully caring for themselves in their particular setting. These activities traditionally are divided into "instrumental" activities of daily living, such as using a telephone, or doing shopping, caring for finances, and administering medications, and "personal" activities of daily living, such as bathing, dressing, or eating. Understanding where problems exist and how they presently are dealt with is essential to knowing how an illness impacts on an older person.
10. Social situation. In addition to inquiring about the usual living circumstances, and whether there is a caregiver, the part of the assessment concerning social situation is the most distinct from the traditional medical examination. While it is clear that the patient enjoys primacy in the physician-patient relationship, it is also the case that the needs of the caregiver cannot be ignored. Indeed, where an older person is dependent in essential activities of daily living, the caregiver becomes the most important asset to the maintenance of independence. It is therefore essential to understand how caregivers feel about their caring role, and whether, and under what circumstances, they can see themselves continuing in it.

The efficacy of CGA has been formally tested in a number of randomized, controlled trials, so that it now forms part of evidence-based medicine. These trials have shown that, compared with usual care, elderly people—especially those who are frail—achieve many important health outcomes when provided with CGA-based care. For example, they are more likely to be discharged from the hospital without delay, more likely to be functional when discharged and up to a year later, less likely to go to a nursing home, and less likely to die within two years of follow-up.

A thorough CGA, including the standard history and physical examination, typically takes between an hour and an hour and a half to complete, and it can take even longer. This is more than twice the length of many initial consultations with a clinician, and so a CGA requires special effort and commitment on everyone's part. Nevertheless, it represents a reasonable way to come to grips with the needs particularly of frail older people, and in consequence to set appropriate and achievable goals to maintain independence, or to otherwise intervene for the benefit of the patient.