BMH Medical Journal

BMH Med. J. 2020; 7(Suppl): Early Online. Geriatrics & Gerontology Initiative: International Workshop on Care of the Elderly

Case Study: An elderly living by herself presented with uncontrolled hypertension with the blood pressure reading of 200/110 mmHg. She was already on treatment with atenolol 50 mg and hydrochlorthiazide 12.5 mg. She had mild cognitive decline and history of frequent falls. She also had mild visual impairment. She had urge incontinence. She was depressed. The physician added 10 mg of amlodipine and the next week she had a fall and fractured her right femur.

This is the common story of an elderly. A Geriatrician would address this case little differently. He will do Comprehensive Geriatric Assessment (CGA) and list her problems and initiate action as under:

	Problem List	Action
1.	Lives alone	Daughter asked to help
2.	Gait and Balance abnormality due to postural hypotension	Stopped diuretic, gait and balance training
3.	Urinary Incontinence	Diuretic withdrawal
4.	Impaired vision	Cataract surgery
5.	Osteoporosis	Bisphosphonates, regular exercise, calcium, vitamin D
6.	Mild dementia	Regular Physical activity
7.	Drug noncompliance	Using pill organizer, label and daughter asked to assist

With these interventions, the elderly lady was no longer giddy and incontinent. Her cognition improved. She was able to do her basic activities of daily living and was able to live independently with the assistance of her daughter.

This is the very purpose of Geriatric Assessment i.e. to keep the elderly functionally independent and improve their quality of life, rather than curing the big list of diseases.

The purpose of this article is to appraise the readers on:

1. Demography of aging in India
2. Common geriatric problems which are missed by routine organ oriented history and physical examination
3. Comprehensive Geriatric Assessment (CGA) - Why and How?

Demography of Ageing and Age related disorders in India

India currently has 100 million elderly people and the percentage of people above 60 is rising rapidly. Of the 100 million:

• 3.7 million suffer from dementia
• 40 million suffer from poor vision
• 1.6 million suffer from stroke annually
• 1 in 3 suffer from arthritis
• 1 in 3 has hypertension
• 1 in 5 has diabetes
• 1 in 5 has auditory problems
• 1 in 4 suffer from depression
• 1 in 10 falls and sustains a fracture
• 1 in 3 suffer from bowel disorder
• Cancer is 10 times more common

Why Comprehensive Geriatric Assessment (CGA)?

1. Geriatric problems like delirium, depression, dementia, imbalance and falls, and urinary incontinence that are commonly missed in routine medical examination. These are referred to as Geriatric giants. They have multifactorial etiology and significantly impair the quality of life. They are potentially treatable conditions, if recognized early. However these conditions need detailed assessment using questionnaire and some tools which are not commonly used by physicians.

2. Geriatric Health testifies WHO definition of health, and it is a product of physical, social and psychological health. These features are rarely assessed by physicians. So only a quarter of health is looked after by physicians. Mood affects cognition are assessed only when they are severely impaired and it may be too late.

3. Physician focuses on diseases with the hope to cure or control diseases. Geriatric assessment focuses on function rather than list of diseases. Activities of daily living are assessed with the goal to make them functional.

4. Geriatric patients have multiple comorbidities, for which physicians send them to multiple specialists for treatment. Geriatrician will manage these problems by taking the help of specialists only for diagnostic or therapeutic procedures.

5. Geriatric care is delivered by a multidisciplinary team comprising of physiotherapist, social worker, psychologist, pharmacist, occupational therapist and a nurse who will comprehensively assess and plan the treatment. Physicians do not have such a team.

6. Geriatrician is able to understand the weak link system and atypical manifestations of disease in elderly. For example delirium may be a manifestation Parkinsonism, urinary incontinence may be a manifestation of urinary infection and cough may be due to an aspiration Pneumonia.

7. Pain and palliative care needs are rarely assessed by physicians and it can be a component of Geriatric assessment in frail elderly patients. Although advanced directives are not valid in India, elderly can document wishes such as organ donation, decisions regarding end of life care etc through a living will which can be a part of CGA.

Geriatric patients can be classified into 3 categories:

1. Cognitively and functionally fit healthy elderly - may not require detailed CGA
2. Frail elderly with mild cognitive and functional impairment - require detailed CGA
3. Frail elderly with severe cognitive and functional impairment - require detailed CGA

However, to declare any individual as cognitively and functionally fit, a comprehensive assessment is essential.

Benefits of Comprehensive Geriatric Assessment (CGA)

1. CGA is known to reduce mortality and morbidity at multiple settings. Studies have shown that both at nursing homes, home care setting and hospitals those who received CGA are more likely to be alive and independent than those who do not.
2. Our own experience shows that older adults are more satisfied after a CGA than a regular medical examination as all their concerns are addressed.
3. CGA is a single entry point for older adults through which multidisciplinary assessment and care can be delivered. Hence it is less taxing for the elderly.
4. It is cost effective

History of CGA

Marjorie Warren (1897-1960), a British physician is considered as mother of British CGA. She was posted in a ward where all patients who needed long term care were dumped. The ward was like a mental asylum. Marjorie assessed each one of them in depth and planned interventions, after which majority could be discharged.

How do we do CGA and what are the tools available?

WHO Toolkit for CGA is available and accessible to all. Although it is for primary health centers, this toolkit is good enough as we can complete it within 20 minutes in a fit elderly, and may take about 45 minutes for a frail elderly who will have multiple problems.

Part 1: Demographic details, social and environmental history, morbidity list

Part 2: Physician examination and management plan as per routine examination with special reference to older adults

Part 3-7: Toolkits
                Toolkit 1: 10 minute comprehensive assessment
                Toolkit 2: Memory Assessment Toolkit –MMSE,
                Toolkit 3: Detailed assessment of the memory impaired
                Toolkit 4: Geriatric depression scale
                Toolkit 5: Falls assessment
                Toolkit 6: Urinary incontinence
                Toolkit 7: Activities of daily living

In a busy clinic like those in India where 40 to 50 patients have to be seen by a physician, a 10 minute assessment using simple Toolkit 1 and functional assessment is sufficient in the first setting to make a problem list, assess and evaluate. In subsequent visits, we can focus on geriatric giants and their detailed evaluation.

Timed Up and Go test and gait and balance assessment is a valuable tool.

10 Minute assessment has screening questionnaire for hearing, vision, nutrition, 3 object recall for memory, question on whether the person is sad or depressed, whether the person has incontinence, frequent falls, and questions on physical functional capacity.

At the end of the assessment it is better to document issues as follows:

1.	Acute illnesses	Action
2.	Chronic comorbidity	Action
3.	Geriatric Giants	Action
4.	Other age related problems	Action
5.	Social issues	Action
6.	Economic issues	Action
7.	Spiritual issues	Action
8.	Advanced directives	Living will arrangement

Additional things that can be added are pain assessment charts, fitness tests, physical activity questionnaire, food frequency questionnaire and balance scales. However, the frail elderly will find it difficult to go through long interview time.

Enclosed is the sample CGA proforma:

Further reading

1. Age-friendly Primary Health Care (PHC) Centres Toolkit-WHO Publication 2008.

2. Comprehensive Geriatric Assessment toolkit for Primary Care practitioners –Published by British Geriatric Society on 29th January 2019.

3. Ellis G, Whitehead MA, O'Neill D, Langhorne P, Robinson D. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev. 2011;(7):CD006211. Published 2011 Jul 6. doi:10.1002/14651858.CD006211.pub2.

4. Welsh TJ, Gordon AL, Gladman JR. Comprehensive geriatric assessment--a guide for the non-specialist. Int J Clin Pract. 2014;68(3):290–293. doi:10.1111/ijcp.12313.

5. Comprehensive Geriatric Assessment –UpTODATE.

6. Hazard`s Text Book of Geriatric Medicine.

7. Oxford Text Book of Geriatric Medicine.

8. Adhikari P. Tools useful in Geriatric Practice ,Principles and Practice of Geriatric MedicineEd O.P .Sharma 60-64 ,2015 Viva Books,PVt Ltd. New Delhi.

Comprehensive Geriatric Assessment– Common Geriatric Problems