Comprehensive Geriatric Assessment (CGA), Frailty & Function

Comprehensive Geriatric Assessment (CGA), Frailty & Function

Principles of Comprehensive Geriatric Assessment (CGA)

Geriatric care requires shifting from a disease-centric diagnostic model to a holistic, functional paradigm. The Comprehensive Geriatric Assessment (CGA) is a multidimensional diagnostic process evaluating an older adult's functional capability, physical health, cognitive/psychological well-being, and social/environmental support. The CGA formulates an integrated plan for therapy, rehabilitation, and long-term follow-up.

The Five Core Domains of CGA

1. Medical Domain: Evaluates chronic disease burden, multimorbidity, polypharmacy (utilizing the AGS Beers Criteria 2023 update), sensory impairments, nutritional status, and geriatric syndromes (incontinence, pain).
2. Functional Domain: Evaluates basic self-care capabilities and complex instrumental tasks necessary for independent living.
3. Cognitive Domain: Assesses executive function, memory, attention, and screens for dementia, mild cognitive impairment (MCI), and delirium.
4. Psychological Domain: Evaluates mood disorders, late-life depression, anxiety, and coping mechanisms.
5. Environmental and Social Domain: Assesses home safety, architectural hazards, financial security, caregiver stress, and community support.

Functional Assessment: ADLs, IADLs & Physical Performance

Functional status is the most powerful predictor of health outcomes, hospitalization, and mortality in older adults. Functional decline is often the initial presentation of an acute medical illness.

Basic Activities of Daily Living (ADLs) & The Katz Index

ADLs represent basic physical self-care tasks. The Katz Index of Independence in Activities of Daily Living assesses 6 core functions:

1. Bathing: Washing oneself independently in tub or shower.
2. Dressing: Selecting clothing and dressing independently.
3. Toileting: Getting to/from toilet, cleaning oneself, adjusting clothes.
4. Transferring: Moving independently into and out of bed or chair.
5. Continence: Complete voluntary bowel and bladder control.
6. Feeding: Getting food from plate to mouth independently.

Scoring: 1 point per independent task (0 to 6). Score 6 = full independence; 4 = moderate impairment; $\le 2$ = severe dependency.

Instrumental Activities of Daily Living (IADLs) & The Lawton Scale

IADLs involve complex cognitive skills required for independent community living. The Lawton Instrumental Activities of Daily Living Scale evaluates 8 domains:

1. Telephone Use: Dialing numbers and answering calls.
2. Shopping: Purchasing food and necessities independently.
3. Food Preparation: Planning, cooking, and serving meals.
4. Housekeeping: Maintaining a clean home.
5. Laundry: Washing and drying clothing.
6. Transportation: Driving or navigating public transit.
7. Medication Management: Taking correct doses at scheduled times.
8. Financial Management: Budgeting, writing checks, paying bills.

Clinical Pearl: Loss of IADLs precedes loss of ADLs. Because tasks like managing medications or finances require high-level executive functioning, a decline on the Lawton Scale is often the earliest indicator of mild cognitive impairment or early dementia.

Performance-Based Mobility Measures

• Timed Up and Go (TUG) Test: The patient rises from a chair, walks 3 meters (10 feet), turns, walks back, and sits down.
  • Interpretation: Completion time $> 12$ seconds identifies high fall risk.
• 4-Meter Gait Speed Test: Gait speed $< 0.8\text{ m/s}$ indicates physical frailty, mobility limitation, and increased mortality risk.
• Short Physical Performance Battery (SPPB): Combines balance, gait speed, and chair stands. Score $< 10$ indicates vulnerability.

Frailty Syndromes, Sarcopenia & Clinical Stratification

Frailty is a biological syndrome of decreased physiological reserve resulting from multi-system dysregulation.

The Fried Frailty Phenotype

Diagnoses frailty based on the presence of 3 or more of 5 criteria:

1. Unintentional Weight Loss: Loss of $\ge 10$ lbs (or $\ge 5%$) in the past year.
2. Self-Reported Exhaustion: Increased effort required for daily tasks.
3. Low Physical Activity: Low weekly energy expenditure.
4. Slowness: Slow walking speed over 15 feet.
5. Weakness: Low handgrip strength measured via dynamometer.

Categorization: 0 criteria = Robust; 1-2 = Pre-Frail; $\ge 3$ = Frail.

Sarcopenia Assessment

Sarcopenia is the progressive loss of skeletal muscle mass and strength. Screening utilizes the SARC-F questionnaire. Confirmation involves grip strength ($< 27\text{ kg}$ in men, $< 16\text{ kg}$ in women) and DXA scan for appendicular lean muscle mass.

Cognitive & Psychological Screening Tools

Mini-Cog Screening Tool

A 3-minute screening instrument combining:

1. Three-Item Recall: Clinician presents 3 non-related words.
2. Clock Drawing Test (CDT): Patient draws clock face, numbers, and hands set to 10 past 11.
3. Recall Verification: Patient recalls the 3 words.

Scoring: 1 point per recalled word (0-3); CDT rated Normal (2 points) or Abnormal (0 points). Score 0 to 2 indicates high likelihood of cognitive impairment.

Montreal Cognitive Assessment (MoCA)

A 30-point screening tool sensitive for Mild Cognitive Impairment (MCI). Score $< 26 / 30$ suggests cognitive impairment (add 1 point if education $\le 12$ years).

Geriatric Depression Scale (GDS-15)

A 15-item self-report tool excluding somatic symptoms. Score $\ge 5$ indicates clinical depression.

CDC STEADI Fall Prevention & Elder Abuse Screening

CDC STEADI Framework

1. Screening (Three Key Questions):

   • "Have you fallen in the past year?"
   • "Do you feel unsteady when standing or walking?"
   • "Do you worry about falling?"

2. Multifactorial Assessment & Interventions:

   • Medication Reconciliation: Deprescribe psychoactive medications.
   • Orthostatic Blood Pressure: Check BP supine and at 1 and 3 min standing. Systolic drop $\ge 20\text{ mmHg}$ or Diastolic drop $\ge 10\text{ mmHg}$ defines orthostatic hypotension.
   • Home Safety & Physical Therapy: Refer to occupational therapy for home safety and physical therapy for gait/balance training (Tai Chi).
   • Vitamin D: Recommend 800-1000 IU daily for deficient older adults at fall risk.

Elder Maltreatment & Caregiver Strain

APRNs are mandatory reporters for suspected elder abuse (physical, emotional, sexual, financial exploitation, neglect). Assess caregiver stress using the Zarit Burden Interview (ZBI) to prevent caregiver burnout and elder neglect.