How to Applicate Comprehensive Geriatric Assessment

in Geriatric Rehabilitation

Wanarani Aries

Department of Physical Medicine and Rehabilitation, Dr. Cipto Mangunkusumo General Hospital,

Faculty of Medicine, University of Indonesia, Jakarta, Indonesia

kolit.rehabmedikrscm@gmail.com

Keywords: CGA, Geriatric Patients, Functional Status, Interdiscpline Approach

Abstract: Comprehensive Geriatric Assessment (CGA) is a multidimensional, multidisciplinary diagnostic instrument

designed to collect data on the medical, psychosocial-economy, enviromental, spiritual and places high

value on functional status. Measurement of functional is an essential components, and the patient’s ability to

function can be viewed as a summary measure of the overall impact of elderly health conditions. This

geriatric models of assessment used in patient first visit to assess geriatric patients who have complicated

condition and need special approach. CGA has several essential aspects of evaluating elderly patients, so it

is known for it’s costly and time consuming. This caused by difficulties in taking histories of geriatric

patients, and systematically reviewing the patients. CGA aimed to integrates the functional and medical

goals of care, allowing physicians to improve clinical outcomes and patients satisfaction. This tools can be

used in primary care (e.g puskesmas), clinic, hospital, long term care or home, and as a strategy to make

evaluation process more efficient. Prognosis is focused on medical and function information. CGA can be

applied in 4 step process, used by individual clinician but more refers to an interdisciplinary team.

1 INTRODUCTION

The population of elderly, or defined by aged 60

years old or older is increasing along with the life

expectancy. Between 2015 and 2050, the proportion

of the world's population over 60 years will nearly

double from 12% to 22%. In 2050, 80% of older

people will be living in low and middle income

countries, and the pace of population ageing is much

faster than in the past (World Health Organization,

2018). In Indonesia, the number of elderly is

increasing, from 18 million people (7.56%) in 2010

to 25.9 million people (9.7%) in 2019, and expected

to continue increasing in 2035 to 48.2 million people

(15.77%) (Kementerian Kesehatan RI, 2019). This

condition cause a face major challenges to ensure

their well-being in comprehensive aspect.

Ageing is the natural process of life, results from

the impact of the accumulation of a wide variety of

molecular and cellular damage over time. Later, it

leads to a gradual decrease in physical and mental

capacity, a growing risk of disease, and ultimately,

death. This gradual decrease could potentially

increasing disability that occur over the course of

time in health. Disability can have a negative impact

on mobility, self-care, and pain. This condition

requires the role of rehabilitation, aimed to focus on

recovery of self-care ability, mobility, and its

requires a longer period of time to achieve.

2 DISCUSSION

2.1 Comprehensive Geriatric

Assessment (CGA)

Based on complicated condition generally described

above, the elderly need special approach and the

CGA is a multidimensional, multidisciplinary

diagnostic instrument designed to collect data on the

medical, psychosocial-economy, enviromental,

spiritual and places high value on functional status.

This tool has several essential aspects of evaluating

geriatric patient, so its consist of several instrument.

CGA assess patient’s functional status, using ICF

(International Classification of Functioning,

Disability and Health), which can be viewed as a

Aries, W.

How to Applicate Comprehensive Geriatric Assessment in Geriatric Rehabilitation.

DOI: 10.5220/0009062100480053

In Proceedings of the 11th National Congress and the 18th Annual Scientiﬁc Meeting of Indonesian Physical Medicine and Rehabilitation Association (KONAS XI and PIT XVIII PERDOSRI

2019), pages 48-53

ISBN: 978-989-758-409-1

summary measure of the overall impact of elderly

health conditions.

This assesment aimed to integrates the functional

and medical goals of care, allowing physicians to

improve clinical outcomes and patients satisfaction,

and as a strategy to make evaluation process more

efficient. CGA can be used at patient first visit in

primary care (e.g puskesmas), clinic, hospital, long

term care, or home, done in 4 step process by

individual clinician but more refers to an

interdisciplinary team. Because of its comprehensive

method, systematically reviewing the patients, and

difficulties in taking histories of geriatric patients, it

is known for it’s costly and time consuming. The

prognosis of this assesment focused on medical and

function information.

2.2 Review of CGA

Aging, is an inevitable and extremely complex,

multifactorial process, is characterized by the

progressive degeneration of organ systems and

tissues. It is largely determined by genetics, and

influenced by a wide range of environmental factors,

such as diet, exercise, exposure to microorganisms,

pollutants, and radiation. Gender also plays a part

and, in most developed countries, women typically

outlive men by 7–10 years. Recent research has also

reported that childhood personality and education, as

well as behavioral factors, also contribute to

longevity (Nigam et al, 2012).

Based on management model for service delivery,

elderly can be stratified into one of three strata:

robust; frail; and complex care needs. Spoorenberg

et al, 2013). Frailty is a geriatric syndrome

characterized by impaired performance and reduced

functional reserve across multiple physiologic

systems, and associated with increase vulnerability

adverse health outcomes from even minor stressor

(Sloane and Cesari, 2018). Frailty often overlapping

with sarcopenia, which is a term of the loss of

muscle function as well as the loss of muscle mass

that occurs with ageing. It is a common and

increasingly condition associated with subsequent

disability and morbidity (Dodds and Sayer, 2016).

The utilization of CGA can be used in the three

groups above, especially for screening in elderly, so

frailty can be prevented or reversed. By reversing

frailty through exercise intervention, elderly patients

can be remain physically independent and non-frail

throughout a longer period of their life (Pilotto,

2018).

2.3 Geriatric Health Problem

Multiple pathology process occur in elderly and play

important role in declining physical function. It is

clear that the loss in physical function is inevitable

in elderly, but the effects of age are highly

individual and age alone is a poor index of physical

function. Age is associated with increased

prevalence of disease conditions that are impossible

to ignore as a strong contributor to occurrence of

disability (Manini, 2011). Measurement of disability

are able to capture the impact of the presence and

severity of multiple pathologies, including physical,

cognitive, and psychological conditions, as well as

the potential synergistic effects of these conditions

on overall health status (Halter et al, 2017).

Balance and gait are important considerations in

the health of elderly subjects. Decline of sensory

systems in elderly adults has been implicated in the

reduced ability of older adults to adapt to changes in

their environment and maintain balance; the visual

system is particularly important in maintaining

postural stability. It is estimated that 13% of adults

self‐report imbalance from ages 65 to 69 and this

proportion increases to 46% in those aged 85 and

older. Furthermore, impairments of balance and gait

have been implicated in increased risks of falls. In

adults aged 65 and older, the estimated annual

prevalence of falls is 28% (Nigam et al, 2012). Falls

are associated with significant morbidity and

mortality in the elderly because they are the most

common cause of accidental death and nonfatal

accidental injury, accounting for 55.8% of accidental

deaths in those 65 and older (Osoba et al. 2019).

2.4 Comprehensive Management In

Geriatric Health Problem

The elderly population constitutes a significant

challenge for health authorities worldwide as with

advancing age multiple chronic diseases are

associated. As a result of which elderly people tend

to take multiple medications in a day that can be

referred to as polypharmacy. Elderly people are at a

greater risk for adverse drug reactions (ADRs)

because of the metabolic changes and reduced drug

clearance associated with ageing; this risk is

furthermore exacerbated by increasing the number

of drugs used. Polypharmacy may also lead to

decreased medication compliance, poor quality of

life, and unnecessary drug expenses (Dagli and

Sharma, 2014).

How to Applicate Comprehensive Geriatric Assessment in Geriatric Rehabilitation

As we know before, old age often goes hand in

hand with increasingly complex and often

interrelated problems, they need social support.

Social support has been recognized as an important

social determinant of health because it assists

individuals in reaching their physical and emotional

needs, and it reduces the effects of stressful events

on their quality of life

Social support consists of

addressing tangible needs, such as assistance with

transportation, home and personal care, as well as

emotional support such as being listened to,

understood, and comforted. This support can be done

either by family, neighbor, or other people as their

caregiver (Dai et al, 2016).

Caregivers assist the daily care needs of the care

receiver using activities of daily living (ADLs) and

instrumental activities of daily living (IADLs)

scoring. Caregiver as an individual who provides

direct care to children, elderly people, or the

chronically ill. Stress is defined as “a physical,

chemical, or emotional factor that causes bodily or

mental tension and may be a factor in disease

causation. Caregiver divided by two groups, consist

of formal and informal. Formal caregivers are

volunteers or paid employees connected to the social

service or healthcare systems. The term informal

caregiver refers to family members and friends, who

are the primary sources of care (Llanque et al, 2016).

Elderly well-being, is not just focused on disease

or curing the disease, because majority of geriatric

patients have chronic illness. Therefore, the need of

“care” become necessary to improve or maintain the

physical and cognitif function. The role of CGA

takes places to assess the functional status of the

geriatric patients as a central focus and optimize care

outcomes. This tools also used to construct the

planning of treatment such listing the comprehensive

and inclusive of functional problem for appropriate

targetting of interventions. The functionl status is

measured before and after treatment to determine the

effectiveness and efficiency of care and utilized the

necessity level of care (Pilotto, 2018).

2.5 Geriatric Rehabilitation

The most important point for geriatric rehabilitation

is maintaining the continuity of care by tracked the

patients through the system over time, and use the

care management for those with greated degrees of

disablement or handicap patient to receive additional

support. Several benefits are achieved by using CGA.

First benefit is aspect of care process, physician

could find a new diagnoses or problems uncovered

by the instrument. Second is patient outcomes, when

intervention done according problem discovered by

CGA, the score of functional status, affective, and

cognitive function could improving, and further

resulting in prolonged survival of the patients. The

third is using the nursing home, CGA can improved

placement, and reducing mean days in nursing home.

The last is health care use and costs, by improving

the use of home health care, so the using of hospital

services (mean days and hospital rates) and medical

care cost can be reduced (Pilotto, 2018).

2.6 Application CGA in Geriatric

Rehabilitation

A hallmark of geriatrics is emphasis on the

functional ability of older patients. This approach

recognizes that although individual diseases are

important and that our system of modern medicine is

oriented toward the diagnosis and treatment of

specific diseases, the consequences of single and

multiple diseases can be understood best by

evaluating the functional status of the patient (Halter

et al, 2017).

Nowadays, WHO using ICD (International

Classification of Diseases) model for approaching

diagnosis and treatment of the disease. As noted

above, functional status play very important role,

assessing the patient should also use the model of

ICF which as an integrative model of functioning

and environmental factors. This assessment could

become a comprehensive one covers the need of

“cure” and “care” in elderly, and noted that the

functional status is the end result of various efforts

of geriatric approach to care (Pilotto, 2018).

Clinical practice in order to structure the clinical

description and assesment of functioning, apply the

ICF Core Sets. This should be use in practical for

everyday use by presenting the most relevant

categories (health condition, condition group, and

healthcare context). Items of the Geriatric ICF Core

Set (GeriatrICS) grouped into clusters of health

related problems as experienced by community-

dwellling elderly in frail group devided into mental

function, physical health, mobility, personal care,

nutrition, and support (Spoorenberg et al, 2019).

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

Table 1: Areas of Concern Based on the Geriatric ICF

Core Set (GeriatrICS) (Spoorenberg et al, 2019)

Cluster

GeriatrICS Item (ICF

Category)

Mental Functions

b144 Memory functions

b152 Emotional functions

Physical Health

b210 Seeing functions

b230 Hearing functions

b410 Heart functions

b420 Blood pressure

functions

b525 Defecation

functions

b620 Urination functions

b810 Protective functions

of the skin

Mobility

b240 Sensations

associated with hearing

and vestibular function

b455 Exercise tolerance

functions

b710 Mobility of joint

functions

b730 Muscle power

functions

d410 Changing basic

body position

d450 Walking

d470 Using transportation

Personal Care

d510 Washing oneself

d520 Caring for body

parts

d540 Dressing

Nutrition

b530 Weight maintenance

functions

d550 Eating

d560 Drinking

Support

d760 Family relationships

e310 Immediate family

e320 Friends

e325 Acquaintances,

peers, colleagues,

neighbors and community

members

e570 Social security

services, systems and

policies

e575 General social

support services, systems

and policies

e580 Health services,

systems and policies

CGA as tools used for this comprehensive

assesment done by 4 step, with SOAP (Subject,

Object, Assessment, and Plan) which familiar in

daily clinical practice. This step used to approach to

organizing patient information and collect subjective

and objective database. Later, this data integrate into

assessment and following with discharge planning

and create a care plan (Pilotto, 2018).

Table 2: SOAP model in CGA

Step

Content

Step 1

Subjective and

Objective Database

Chief complaint

Biomedical data impact to

physical & mental function

Assess impact of each

medication effect to function

Psychological data effect to

function

Summary scales of function

Physical examination

Step 2

Assessment

Overview

Areas of concern

Prognosis of function

Step 3

Discharge Planning

Care Plan

Step 4

Checklist

2.7 Assesing of the CGA

The first step of assessing CGA is subjective and

objective database by viewing from both patient’s

and family or caregiver’s word, and finding the

specific functional losses of geriatric patients.

Biomedical data collect the history of medical

diagnosis and history of medication, with a

statement of duration and impact on patient’s

physical and mental function (include appetite,

sexual, performance, constipation, and incontinence).

Another aspect is nutritional data, includding any

changes in weight, appetite, the way of feeding and

swallowing problems (Pilotto, 2018).

Psychological data including assessing the

cognitive function (include any episodes of ACS

following medications, hospitalizations, surgery, or

change of living situation). Its also explore the

emotional function, screen for depression, anxiety,

personality, and coping styles. The last is evaluate

the perceptive function (include vision, hearing, and

speech). Social data also assessed, including

individual social skills (include marital history,

issues of physical and emotional intimacy, need for

control, acceptance of help, and presence of

confidant). Identifying family support system,

primary contact (include list of other potential

caretakers and use of existing community resources).

Explore patient’s feeling about medical treatments

How to Applicate Comprehensive Geriatric Assessment in Geriatric Rehabilitation

(such as surgery, hospitalization, NGT, ventilators,

and CPR). Don’t forget to check the document

existence of prior directive (durable power of

attorney, living will, DNR, and Physician Order for

Scope of Treatment (POST). The last is summary

scales of function and physical examination (Pilotto,

2018).

Second step is assessment, integrating the patient

data and organize the problem list. There are 9

areaas of concern such as diagnosis, medication,

nutrition, continence, defecation, cognition, emotion,

mobility, and cooperation with care plan. This care

concern if systematically reviewed in preparing

discharge planning and care plan, lead to improve

health outcomes and satisfaction. This can be used

as a problem checklist to identify areas relevant to

the individual patient and as the goals of care. A

comprehensive view of the complexity ill patient can

be obtained and help the physician to provide

accurate prognostic information to both of patients

and their families (Pilotto, 2018).

The next step is discharge planning and care plan.

The care plan is reconciliation between standards of

medical practice and patient preference. Reconciling

standard medical practice and patient reference is the

most critical step in creating an appropriate and

successful care plan for patients. Physician should

identify reversible or potentially treatable factors in

each area of concern and make treatment

recomendation against the patient’s preference (e.g

no no hospitalization or surgery, no feeding tubes,

no NH placement, no chemotherapy). It is important

to consider individual preferences in each area of

concern. Once recommendation have been

reconciled with the patient’s preferences, common

goals and treatment can proceed (Pilotto, 2018).

Discharge planning is an interdisciplinary

approach to continuity of care; it is a process that

includes identification, assessment, goal setting,

planning, implementation, coordination, and

evaluation and is the quality link between

hospitals, community based services,

nongovernment organizations, and carers. It has five

component, abbreviated as IDEAL, consist of

include, discussion, education, assess, and listen.

Physician should including the patients and family

as a partners in the process of discharge planning.

The next is dicussion should be done with the patient

and family about five key prevent the problem in

house, such as describing how is living at home,

what medication is given, warning the possible

problem, explain the result of examination or

treatment, and make a schedule for the next visit

(Lin et al, 2012).

Throughout the hospital stay and at discharge,

patient and family education is critical in teaching

self-care skills and promoting treatment adherence.

Train and assess the staff on their ability to explain

health information to patients and caregivers and to

use proven teaching methods such as teach-back.

The last is listen to what patients and families have

to say about their needs, concerns, and goals (Lin et

al, 2012).

Outcome measures usually include the following:

length of stay in hospital; readmission rate to

hospital; complication rate; place of discharge;

mortality rate; patient health status; patient

satisfaction; carer satisfaction, both professional and

nonprofessional; psychological health of patient;

psychological health of carers; cost of discharge

planning to the hospital and the community; and use

of medication (Lin et al, 2012).

The last step of CGA is checklist, used to

monitor outcomes of care. The nine areas of concern

provide a comprehensive and convenient checklist

which the physician can monitor the outcomes of

care plan recommendations. Checklist could

reevaluate the patient’s current medical and

functional status. Further, of up-to-date care plans

that reflect new findings can be created (Pilotto,

2018).

CGA may be done by one person or through an

interdiciplinary team approach. Interdiciplinary

approach defined by combining knowledge and

methods from different disciplines, using effective

methods of synthesis (e.g combining of internal

medicine, rehabilitation medicine, and psychiatric).

CGA needs to be providing comprehensive care to

geriatric patients, collaboration and team

communication; well planned team meeting;

pantient specific goals; clearly understood and

agreed by all members (Pilotto, 2018).

3 CONCLUSION

CGA is the comprehensive and multidiciplinary

instrument for assessing geriatric patients, who need

a special approach due to multiple problem

associated with aging. This tools not only focused on

disease itself, but also places high value on

functional status based on ICF model, or using ICF

Core Sets in daily clinical practice. CGA has four

step consist of SOAP model, which is familiar to

physician. CGA and multidisciplinary intervention

can improve health outcomes of older people at risk

of deteriorating health and admission to hospital,

and further maintain the functional status of elderly.

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

Elderly patients can be remain physically

independent through a longer period of their life, and

reducing their morbidity.

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How to Applicate Comprehensive Geriatric Assessment in Geriatric Rehabilitation