It has been observed that chronologically we all age at the same speed, but the rate of biological ageing is heterogeneous across individuals. The research focus has been identifying the individuals who accumulate multiple comorbidities and have an excess risk of physical and cognitive frailty due to accelerated ageing. The initial work in this area recognized that the typical medical approach to diagnose and treat based on specific diseases is not sufficient.
What do we mean by this?
If a person has diabetes, a physician will assess a few
physical and laboratory parameters. Measure blood pressure to screen for
hypertension, a fundoscopy for retinopathy (disease of the retina), a
monofilament test to screen for neuropathy, fasting and post food blood glucose
levels, serum creatinine and spot urine protein and creatinine to look for
nephropathy (disease of the kidney), serum cholesterol levels etc. These tests
look at specific parameters that revolve around diabetes and are very important
in delivering optimum medical care of diabetes. These assessments do not
comment on the health, functional status and quality of life of older persons,
which is of immense importance.
To assess and manage older people's unmet needs,
geriatricians have developed and used the Comprehensive Geriatric Assessment
(CGA). Larry Rubenstein defined is as a
multidimensional, interdisciplinary diagnostic process focused on determining a
frail older person’s medical, psychological and functional capability to
develop a coordinated and integrated plan for treatment and long-term
follow-up. Let me try to break down each term.
Multidimensional: The unidimensional approach was
disease-oriented. It included diagnosing an illness, identifying its severity
and prescribing medications to treat the disease. Though suitable in younger
adults who often have one condition, this approach does not work well for frail
older adults with multimorbidity. It has been identified that there is a loss
of harmonic interaction between multiple domains which include a functional,
cognitive, psychological and socio-economic domain that ultimately leads to
illness. Hence an assessment of older adult needs to be multidimensional.
Interdisciplinary: This term refers to a process of
care that integrates the specialized knowledge of multiple disciplines. The
complexities of the care needs of older adults require the expertise of various
disciplines. For example, a 70-year-old male, a case of hypertension, diabetes
presenting with recurrent falls was assessed by a geriatrician, physiotherapist
and clinical pharmacist. They found that the factors contributing to his falls
were his benign prostatic hypertrophy (BPH) and a diuretic (given for his BP)
he took at night, which made him wake up multiple times at night. A sedative
prescribed to him for his sleep disturbance (which was because of frequent
urination). The interdisciplinary team is not restricted to the members
mentioned above. It can include a neuropsychologist (in case of declining
memory), a dietitian, an occupational therapist, an orthopaedician (in case of
fragility fracture) etc.
Diagnostic process: performing a CGA is to identify
the problems in various domains that affect the patients and their illness.
Frail older person: This answers the question “Who
should undergo a comprehensive assessment?”. An older adult who is healthy,
with no comorbidities and fully independent should not undergo comprehensive
assessment as he/she might not benefit from such an extensive evaluation. Similarly,
it is not beneficial to assess older patients suffering from acute illness such
as pneumonia, acute heart failure, fracture etc. The ideal candidate who would
benefit is a frail older person.
Medical, psychological and functional capacity: The focus
of CGA is not a particular disease, but the person in entirety. The assessment
involves identifying all the comorbidities (diabetes, hypertension, osteoarthritis
etc.), geriatric syndromes (urinary incontinence, mobility issues, polypharmacy,
visual and hearing impairments etc.), cognitive and psychological capacity (cognitive
reserve, depression, anxiety etc.), functional capacity (ability to perform activities
of daily living) along with other domains.
Develop a coordinated and integrated plan: After an
extensive assessment, it is essential to list the problems and develop a
treatment plan. The management usually includes a multidisciplinary team (geriatrician,
physiotherapist, nutritionist, occupational therapist etc.). The management
plan contains medications for the management of comorbidities, assistive
devices (such as spectacles, hearing aid, walking stick etc.), environmental modifications
(appropriate lighting, railings) and support from the family member. Hence it
is important to involve family members during assessment and planning management.
Long-term follow-up: Unlike acute illnesses that
resolve completely with appropriate medications, older adults' needs are
complex. A care plan made will not be suitable for the same person after a few
years. A long term follow-up with a re-evaluation of the situation and development
of management plans is a continuous process.
The benefits of CGA has been demonstrated in multiple
studies across multiple settings. I will describe the various domains and their
use in different locations in the upcoming parts
