10.3 Geriatric Syndromes, Frailty & Comprehensive Care
Key Takeaways
- Comprehensive Geriatric Assessment (CGA) is a multidimensional, interdisciplinary diagnostic and therapeutic process that reduces 1-year nursing home placement by 25% and increases the likelihood of a patient remaining alive and in their own home (OR 1.20).
- Delirium is an acute, fluctuating syndrome of inattention and cognitive dysfunction; the 4AT tool (scores 0-12, with ≥ 4 indicating probable delirium) and the Confusion Assessment Method (CAM) algorithm provide rapid bedside diagnostic validation.
- Frailty is a state of vulnerability to low-force stressors characterized by diminished physiological reserve; the Clinical Frailty Scale (CFS 1-9) stratifies individuals from 1 (Very Fit) to 9 (Terminally Ill), guiding proportionated intervention and acute escalation decisions.
- Polypharmacy (≥ 5 medications) and hyperpolypharmacy (≥ 10 medications) increase adverse drug reaction risk exponentially; application of STOPP/START criteria version 3 systematically identifies potentially inappropriate medications and omitted evidence-based indications.
10.3 Geriatric Syndromes, Frailty & Comprehensive Care
Comprehensive Geriatric Assessment & Frailty Models
Comprehensive Geriatric Assessment (CGA) is defined as a multidimensional, interdisciplinary diagnostic and therapeutic process designed to determine an older person's medical, psychological, functional, and social capabilities. The core goal of CGA is to formulate an integrated plan for treatment, rehabilitation, and long-term follow-up. High-quality trial evidence demonstrates that acute CGA units reduce 1-year nursing home admissions by $25%$ and significantly increase the likelihood of a patient remaining alive and living in their own home at 1 year (OR 1.20).
CGA systematically evaluates five clinical domains:
- Physical/Medical: Chronic co-morbidities, polypharmacy, nutritional status, vision, hearing, and pain.
- Functional Capacity: Basic Activities of Daily Living (BADLs: dressing, bathing, toileting, feeding, mobility) and Instrumental Activities of Daily Living (IADLs: managing finances, shopping, cooking, telephone use, medication administration).
- Mental/Cognitive: Screening for delirium, dementia, and depression.
- Social Domain: Informal caregiver network, social support structures, and financial vulnerability.
- Environmental Domain: Home safety, trip hazards, access to emergency call systems.
Frailty Stratification Models
Frailty is a vulnerability state resulting from age-related decline in physiological reserve across multiple organ systems, compromising the body's ability to withstand stress. Two distinct frailty frameworks dominate clinical practice:
- Fried Phenotype Model (Physical Frailty): Defines frailty by the presence of $\ge 3$ of 5 physical criteria: unintentional weight loss ($> 4.5\text{ kg}$ in 1 year), self-reported exhaustion, muscle weakness (reduced handgrip strength), slow walking speed ($> 6-7\text{ seconds}$ for 4 meters), and low physical activity.
- Rockwood Deficit Accumulation Model: Quantifies frailty as a cumulative index of medical, functional, and social deficits, leading to the Clinical Frailty Scale (CFS).
| CFS Score | Classification | Clinical Description & Operational Markers |
|---|---|---|
| CFS 1 | Very Fit | Robust, active, energetic, exercise regularly; among the fittest for their age. |
| CFS 2 | Well | No active disease symptoms; fit, but exercise less regularly than CFS 1. |
| CFS 3 | Managing Well | Medical problems well controlled; not actively fit, but independent in BADLs & IADLs. |
| CFS 4 | Vulnerable | Symptoms limit activities; complain of being "slowed up"; independent, but IADLs restricted. |
| CFS 5 | Mildly Frail | Evident slowing; need help with complex IADLs (finances, heavy housework, medications). |
| CFS 6 | Moderately Frail | Need help with all outdoor activities & housework; need help with bathing/dressing (BADLs). |
| CFS 7 | Severely Frail | Completely dependent for personal care (BADLs); seem unstable; low risk of death within 6 months. |
| CFS 8 | Very Severely Frail | Completely dependent; approaching end of life; cannot recover from minor illnesses. |
| CFS 9 | Terminally Ill | Approaching end of life (life expectancy $< 6\text{ months}$); not otherwise evidently frail. |
Clinical Exam Pearl: The Clinical Frailty Scale assesses the patient's baseline functional state two weeks prior to the acute presentation. Acute illness (such as delirium or sepsis) causes transient functional decline; using the acute state overestimates baseline frailty and leads to inappropriate treatment withholding.
Delirium: Neurobiology, Assessment & Management
Delirium is an acute, fluctuating syndrome characterized by disturbance of attention, awareness, and cognition. It affects up to $30%$ of older medical inpatients and is independently associated with increased mortality, prolonged hospital stay, and institutionalisation. The neurobiology involves central cholinergic failure, dopaminergic excess, and neuroinflammation triggered by peripheral cytokines crossing a compromised blood-brain barrier.
Motor Subtypes of Delirium
- Hyperactive ($15%$): Agitation, restlessness, hallucinations, wandering, and hypervigilance. Easily recognized but less common.
- Hypoactive ($25%$): Lethargy, somnolence, reduced motor activity, and withdrawal. Frequently missed or misdiagnosed as depression/dementia; carries the worst overall prognosis.
- Mixed ($50%$): Fluctuating features alternating between hyperactive and hypoactive states.
| Parameter | Delirium | Dementia | Depression |
|---|---|---|---|
| Onset | Acute (hours to days) | Insidious (months to years) | Variable (weeks to months) |
| Course | Fluctuating over 24 hours | Progressive, stable day-to-day | Diurnal variation (worse in morning) |
| Attention | Severely impaired | Intact until advanced stages | Usually intact |
| Consciousness | Altered / Clouded | Clear until end-stage | Unimpaired |
| Reversibility | Usually reversible | Irreversible / Progressive | Reversible with treatment |
Diagnostic Algorithms: CAM & 4AT
The Confusion Assessment Method (CAM) requires:
- Feature 1: Acute onset and fluctuating course AND
- Feature 2: Inattention AND EITHER
- Feature 3: Disorganized thinking OR
- Feature 4: Altered level of consciousness
The 4AT is a validated, rapid 2-minute screening tool scoring 0 to 12:
- Alertness: Normal (0), Mild sleepiness (0), Clearly abnormal (4).
- AMT4 (Age, DOB, Place, Current Year): 0 errors (0), 1 error (1), 2+ errors/untestable (2).
- Attention (Months backward from Dec): 7+ correct (0), Starts but $< 7$ correct (1), Untestable (2).
- Acute change or fluctuating course: Absent (0), Present (4). A score $\ge 4$ indicates probable delirium $\pm$ cognitive impairment.
Management Principles
First-line management is strictly non-pharmacological, addressing underlying causes using the PINCH ME framework (Pain, Infection, Nutrition/Constipation, Catheter/Hydration, Hypoxia, Medication, Environment). Ensure adequate lighting, clear communication, orientation clocks, and family presence.
Pharmacological sedation should be avoided whenever possible. Low-dose oral Haloperidol ($0.5-1.0\text{ mg}$) or Quetiapine ($12.5-25\text{ mg}$) is strictly reserved as a last resort for severe agitation causing distress or immediate danger to self or others. Haloperidol is contraindicated in Parkinson's disease and Lewy body dementia (where quetiapine or lorazepam is preferred).
Falls, Syncope & Orthostatic Hypotension
Falls affect one-third of adults aged $> 65$ annually. A multifactorial falls risk assessment includes detailed gait evaluation, visual testing, neurological exam, environmental survey, and bone health stratification (FRAX score, DEXA scan, calcium/vitamin D supplementation, and bisphosphonates for T-score $\le -2.5$).
Orthostatic (Postural) Hypotension (OH) is defined as a sustained drop in blood pressure within 3 minutes of standing from a supine position:
- A drop in Systolic BP $\ge 20\text{ mmHg}$, OR
- A drop in Diastolic BP $\ge 10\text{ mmHg}$ (or $\text{SBP drop} \ge 30\text{ mmHg}$ in underlying hypertension).
Management prioritizes non-pharmacological measures: medication rationalisation (deprescribing diuretics, antihypertensives, vasodilators), increasing fluid ($2-2.5\text{ L/day}$) and salt intake, wearing waist-high compression stockings, and physical counter-pressure maneuvers (leg crossing, squatting). Pharmacological therapy for refractory OH includes fludrocortisone ($50-100\text{ }\mu\text{g/day}$, synthetic mineralocorticoid) or midodrine ($2.5-10\text{ mg}$ TID, selective $\alpha_1$-agonist).
Prescribing Optimisation & STOPP/START Criteria
Polypharmacy ($\ge 5$ drugs) and hyperpolypharmacy ($\ge 10$ drugs) markedly increase adverse drug reactions, drug-drug interactions, and hospital admissions. Age-related altered pharmacokinetics—such as reduced GFR, decreased hepatic CYP450 metabolism, reduced total body water (elevated peak levels of hydrophilic drugs like digoxin), and increased body fat (prolonged half-life of lipophilic drugs like diazepam)—amplify drug toxicity.
The STOPP/START Criteria (Version 3) provides an explicit evidence-based tool for rationalizing medications in adults aged $\ge 65$:
| Domain | STOPP Criteria (Potentially Inappropriate Medications) | START Criteria (Omitted Evidence-Based Therapies) |
|---|---|---|
| Cardiovascular | • Loop diuretics for ankle oedema without clinical HF<br>• Centrally acting antihypertensives (methyldopa, moxonidine)<br>• Aspirin for primary prevention of vascular disease | • ACE inhibitors/ARBs in chronic HF or CKD with proteinuria<br>• Statins in documented coronary or cerebrovascular disease<br>• Anticoagulation (DOACs) for atrial fibrillation |
| Central Nervous | • Long-acting benzodiazepines (nitrazepam, flurazepam) $\rightarrow$ ataxia/falls<br>• Tricyclic antidepressants in patients with dementia/falls<br>• Antipsychotics for non-cognitive behavioural symptoms | • SSRIs for first-line management of severe depression<br>• Acetylcholinesterase inhibitors for mild-moderate Alzheimer's |
| Gastrointestinal | • Full-dose PPIs $> 8\text{ weeks}$ without peptic ulceration or severe GORD | • Fiber supplementation for chronic constipation |
| Musculoskeletal | • Systemic NSAIDs in CKD ($\text{eGFR} < 50$), HF, or hypertension<br>• Long-term systemic corticosteroids without bone protection | • Bone protection (bisphosphonate, Vit D/Calcium) in chronic steroids |
An 82-year-old woman with mild vascular dementia is admitted with a urinary tract infection. On day 2 of admission, she becomes acutely agitated, believes hospital staff are trying to poison her, and attempts to pull out her intravenous cannula. Physical examination is otherwise unchanged. The 4AT score is 7. Which feature of the Confusion Assessment Method (CAM) is mandatory alongside inattention to establish a diagnosis of delirium?
An 85-year-old man who lives independently is evaluated following two falls in the past month. His medications include ramipril 5 mg daily, amlodipine 5 mg daily, bendroflumethiazide 2.5 mg daily, amitriptyline 25 mg at night for neuropathic pain, and lorazepam 1 mg as needed for insomnia. On standing from a seated position, his blood pressure drops from 142/84 mmHg to 110/68 mmHg with a feeling of lightheadedness. According to STOPP/START criteria and falls risk guidelines, which medication intervention is the highest priority?
An 81-year-old man is admitted to the acute medical unit with acute pyelonephritis. He manages his own domestic activities but needs assistance with complex financial affairs and heavy shopping. He walks slowly with a stick but does not require help with personal care. According to the Rockwood Clinical Frailty Scale (CFS), which grade best categorizes his baseline frailty?