14.1 Comprehensive Geriatric Assessment & Frailty Syndromes

Comprehensive Geriatric Assessment & Frailty Syndromes

Gerontological nursing in Singapore operates within a rapidly evolving demographic landscape. As Singapore transitions into a super-aged society—where over 21% of the resident population is aged 65 years or older—registered nurses play a critical role in proactive health screening, chronic disease management, and functional preservation. Guided by the Ministry of Health (MOH) Healthy Ageing Masterplan and the Age Well SG framework, gerontological nursing practice emphasizes early detection of frailty, multidisciplinary intervention, and seamless care transitions across acute hospitals, community hospitals, and primary care settings.

The Framework of Comprehensive Geriatric Assessment (CGA)

The Comprehensive Geriatric Assessment (CGA) is a multidimensional, interprofessional diagnostic process designed to determine an older person's medical, psychological, functional, and socio-environmental capabilities and limitations. Unlike routine medical evaluations, CGA focuses on functional independence and quality of life. In accordance with the Singapore Nursing Board (SNB) Code for Nurses and Midwives (2023), nurses coordinate CGA findings within interprofessional teams to establish tailored care plans.

CGA spans four primary domains:

1. Medical and Physical Domain: Evaluation of multimorbidity, polypharmacy, chronic pain, sensory impairments (presbycusis and presbyopia), nutritional status, urinary or fecal incontinence, and fall history.
2. Functional Domain: Assessment of basic Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) to determine baseline autonomy and support requirements.
3. Cognitive and Psychological Domain: Screening for mood disorders, executive dysfunction, and memory impairment using standardized tools such as the Abbreviated Mental Test (AMT) and Geriatric Depression Scale (GDS-15).
4. Socio-Environmental Domain: Audit of home safety hazards, living arrangements, informal caregiver strain, and social isolation, adhering to the Personal Data Protection Act (PDPA) when communicating with family networks.

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Frailty Screening and Clinical Stratification

Frailty is a multi-system physiological decline characterized by vulnerability to low-level stressors, increased risk of hospitalization, institutionalization, and mortality. In Singapore healthcare institutions, frailty is recognized not as an inevitable consequence of aging, but as a dynamic, potentially reversible geriatric syndrome.

Clinical Frailty Scale (CFS)

The Rockwood Clinical Frailty Scale (CFS) is widely adopted across Singapore acute and community hospitals (such as Tan Tock Seng Hospital, Singapore General Hospital, and Changi General Hospital) for rapid clinical stratification (CFS 1 to 9):

• CFS 1–3 (Fit to Managing Well): Active, independent individuals without significant chronic symptoms. Nursing focus centers on preventive health screening and health promotion.
• CFS 4 (Vulnerable): Not frankly dependent, but disease symptoms limit activities. Often complains of being "slowed down."
• CFS 5 (Mildly Frail): Evident slowness, requiring assistance in high-order IADLs (finance, transportation, heavy housework).
• CFS 6 (Moderately Frail): Requires help with all outside activities and keeping house. Inside, often has problems with stairs, needs help with bathing, and may require minimal help with dressing.
• CFS 7 (Severely Frail): Completely dependent for personal care (basic ADLs) from any cause (physical or cognitive).
• CFS 8 (Very Severely Frail): Completely dependent, approaching end of life. Typically cannot recover even from minor illnesses.
• CFS 9 (Terminally Ill): Approaching end of life with life expectancy <6 months.

Fried Frailty Phenotype

The Fried Frailty Phenotype categorizes individuals based on five physical criteria:

1. Unintentional Weight Loss: Exceeding 4.5 kg or >5% of body weight in the preceding year.
2. Self-Reported Exhaustion: Frequently feeling that everything requires major effort.
3. Muscle Weakness: Low handgrip strength measured by a dynamometer (<28 kg for men, <18 kg for women).
4. Slow Walking Speed: Gait speed >6 seconds to cover 4.5 meters.
5. Low Physical Activity Level: Minimal weekly caloric expenditure.

A score of 0 indicates robust status; 1–2 indicates pre-frailty (a key window for nurse-led lifestyle interventions); and ≥3 indicates established frailty.

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Functional Assessment and Singapore Healthcare Safety Nets

Functional evaluation relies on the Modified Barthel Index (MBI), a 100-point validated scale measuring ten basic ADL components (grooming, bathing, feeding, toilet use, stair climbing, dressing, bowel control, bladder control, ambulation, and wheelchair transfers).

In Singapore, accredited assessors utilize MBI parameters to evaluate claims under CareShield Life and ElderShield—national severe disability insurance schemes. Claim eligibility requires an inability to perform at least three out of six basic ADLs (washing, dressing, feeding, toileting, mobility, and transferring).

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Sarcopenia and Physical Performance Testing

Sarcopenia is defined by the European Working Group on Sarcopenia in Older People (EWGSOP2) as a muscle disease rooted in muscle failure. In Singapore clinical practice, screening begins with the SARC-F questionnaire (Strength, Assistance with walking, Rising from a chair, Climbing stairs, and Falls). A SARC-F score ≥4 triggers physical assessment:

• Calf Circumference: Screen cutoff is <31 cm in males and <30 cm in females.
• Handgrip Strength: Measured via hydraulic dynamometer (<28 kg for males, <18 kg for females).
• Five-Times Sit-to-Stand Test: Taking >15 seconds to complete 5 chair rises indicates low muscle power.
• Timed Up and Go (TUG): Taking >12 seconds to stand from a chair, walk 3 meters, turn, walk back, and sit down signals heightened fall risk and functional impairment.

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Polypharmacy and Medication Management

Polypharmacy (concurrent use of ≥5 medications) and hyperpolypharmacy (≥10 medications) affect over 40% of hospitalized older adults in Singapore. Age-related pharmacodynamic and pharmacokinetic changes—such as reduced renal clearance, reduced hepatic blood flow, increased body fat ratio, and decreased serum albumin—heighten drug sensitivity and adverse drug reactions (ADRs).

Nurses conduct structured medication reconciliations guided by the Beers Criteria and STOPP/START (Screening Tool of Older Persons' Prescriptions / Screening Tool to Alert to Right Treatment) guidelines. Key high-risk drug classes in geriatrics include:

• Anticholinergic Agents: Precipitate urinary retention, acute delirium, dry mouth, and cognitive decline.
• Sedatives and Hypnotics (Benzodiazepines): Significantly increase ataxia, daytime sedation, and fall-related fractures.
• Antihypertensives: Can induce postural hypotension (blood pressure drop ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing).

Fall mitigation strategies employ the Morse Fall Scale and MOH Clinical Practice Guidelines on Fall Prevention, mandating non-slip footwear, clear environmental pathways, hourly rounding bundles, and sensor mat installation for high-risk patients.