CGA

Question 1

What is a CGA?

Answer 1

A process of care comprising a number of steps
Multidimensional holistic assessment of an older person that leads to a formulation of a plan to address issues which are of concern to the older person, family and carers.
Interventions arranged to support plan
Progress reviewed and original plan reassessed at appropriate intervals

Question 2

Why is it done?

Answer 2

It is effective at reducing mortality and improving independence
Reduce hospital admissions
Reduce risk of readmission in those recently discharged
Identify areas for improvement to reduce frailty

Question 3

Who is usually in the best position to coordinate CGA?

Answer 3

GP - especially if known patent for a long time and involved in other aspects of their care
Well placed to handle medication review

Question 4

How is CGA done?

Answer 4

Interdisciplinary team working together

Generation of problem list - identify issues and how they have changed over time in a number of domains

Question 5

What domains are considered in a CGA?

Answer 5

Physical 
Socioeconomic 
Functional 
Mental 
Environmental 
Mobility / balance 
Medication review

Question 6

What quick screens for sensory problems can be done?

Answer 6

Whispering numbers in the ear and requesting there repetition
Cupping hearing aid to check for feedback noise
Gross visual testing - number of fingers, read a line from book

Question 7

In terms of feet and footwear what should be checked?

Answer 7

Choice of footwear
Condition of skin and nails 
Oedema 
Ulcers
Peripheral sensory testing 
Perfusion - temperature, capillary refill time, pulses

Question 8

In terms of gait and balance what should be checked?

Answer 8

Timed up and go test
Number of steps to turn 180 degrees
Formal balance scoring

Question 9

How should a lying and standing BP be performed?

Answer 9

Patient lie flat for at least 5 mins
Check BP when standing immediately
After 1 minute check again
After further 3 minutes check again

Question 10

What constitutes postural hypotension?

Answer 10

A drop in systolic BP of more than 20 mmHg

Question 11

Even if there is no drop in BP, can some patients still have symptoms of postural hypotension?

Answer 11

Yes - may need more formal testing

Question 12

How can weight and nutrition be assessed?

Answer 12

Check and record weight consistently 
Poor fitting clothes 
Loose skin 
General condition of hair and nails 
Oral health including checking for dentures

Question 13

Why should PR and genitalia examination be done?

Answer 13

Constipation often missed - can cause appetite reduction, abdominal pain, acute deterioration, nausea, overflow diarrhoea

Assess prostate size, haemorrhoids, bleeding or rectal masses

Question 14

What are some normal age related changes?

Answer 14

Uneven colouration of skin 
Skin thinning 
Decreased or absent ankle reflexes 
Loss of vibration sense in toes 
Subtle changes in eye movement

Question 15

What is the questioning model of assessment?

Answer 15

Asking a series of pre determined questions

Assessor sets the agenda and seen as expert

Question 16

What is the exchange model of assessment?

Answer 16

Shared enterprise
Individual as the expert on their own situation
Individual states own wishes and needs

Question 17

What should be included in a social assessment?

Answer 17

Who does patient live with
What informal support is available - family, friends, neighbours, groups
How often is support available
What formal support is involved - care home, district nurse, social worker, voluntary sector, meals on wheels, age UK befriender
Does patient go out and about - do they have access to own vehicle and any concerns about driving
Are they a carer
Do they receive carer’s allowance
Any pets
Have they had a social services needs based assessment
Are they eligible for Continuing Health Care funding
Are they in receipt of disability allowance, income support, housing benefit, pension credit, mobility allowance
Any capacity concerns
Safeguarding issues including DOLS
Power of attorney - health and/ or finances
Has a will been made and is there a funeral plan
Nature of home circumstances - rented, owned, residential, nursing
Stairs
Availability of toilet - upstairs or down, commode
Equipment - hoist, pressure mattress, hospital bed
Is there a telephone
Cooking facilities
Damp concerns
Hearing and lighting
Smoke detector working
Pendant alarm

Question 18

What are the 2 components of functional assessment?

Answer 18

What can and what does the patient do

How recently has it changed

Question 19

What index can be used to measure function?

Answer 19

The Barthel index

Question 20

Why is the Barthel index particularly useful?

Answer 20

Ability to map trajectory

Baseline scores can be recorded and reassessment is relatively quick

Question 21

Impaired gait, balance and strength are key risk factors for…

Answer 21

Falls

Question 22

When doing a mobility and balance assessment what should be considered?

Answer 22

Understand prior levels of mobility
Be specific about the time period of deterioration
Establish what the patient needs to be able to do
Ask about prior intervention for gait and balance problems

Question 23

When establishing current and prior function in walking, balance and associated tasks what questions should be asked?

Answer 23

Can the patient walk outdoors, how far, do they need an aid or someone to go with them
Can the patient walk indoors they need to be able to manage, do they need an aid or anyone to help them?
Have they noticed any changes in their walking pattern?
Have they started to restrict their activity due to reduced confidence?

Question 24

When asking about functional ability what specific questions should you ask?

Answer 24

Difficulty getting up from chair/bed/toilet
Difficulty getting into bed/out of bed/ sleeping in chair
Difficulty with stairs or steps

Question 25

What simply tests can be done to assess walking and balance?

Answer 25

Timed up and go test (stand up from chair, walk 3 m, turn round, walk back and sit down) , if patient needs a walking aid then it is not appropriate

180 degree turn test to measure dynamic balance
Patient stand up from chair and take a step forward and you stand behind them, ask them to turn and face you
- more than five steps suggests an increase risk of falling in following year

Gait speed
Ask patient to walk 4 m, if take more than 5 sec then gait speed is slow

Chair stand
Patients who require use of arms are likely to have lower limb strength impairment

Question 26

Is it true that there is a high prevalence of mental health issues in older people?

Answer 26

Yes - CGA not complete without assessing this

Need to assess mood and cognition

Question 27

Is depression over or under recognised in older people?

Answer 27

Under recognised
Associated with poorer outcomes from physical illness
Somatic symptoms more common

Question 28

When assessing mood in older people, what should be considered?

Answer 28

Psychomotor retardation
Weight loss
Poor sleep
Increasing pain with stable physical issues

Question 29

What are some risk factors for suicide in older people?

Answer 29

Older age, male 
Social isolation or bereavement 
History of attempts or evidence of planning
Chronic painful illness or disability
Drug or alcohol use
Sleep disorders

Question 30

Cognitive decline that is rapid is more likely to be delirium or dementia?

Answer 30

Delirium?

Question 31

When assessing for cognitive decline what simply question can be asked to introduce the subject?

Answer 31

Has the person been more forgetful in the last 12 months to the extent that it has affected their daily life?

Question 32

What is the Mini-Cog test?

Answer 32

An instrument to screen for cognitive impairment in older adults in the primary care setting
3 items for memory
Clock drawing test

Question 33

What is the trail making test?

Answer 33

A test to provide information about visual search speed, scanning, speed of processing, mental flexibility, executive functioning

Sensitive in detecting cognitive impairment associated with dementia

Question 34

Describe the Abbreviated Mental Test (AMT)

Answer 34

Fast screening test
Developed in hospital based care
Can miss executive dysfunction
Not validated for use in primary care

10 questions: age, time, address to recall at end of test, year, name of this place, identification of 2 people, DOB, year of WW1, name of present monarch, count back from 20, address recall

Question 35

A more detailed assessment of cognition can be done with the…

Answer 35

Mini mental state examination or Montreal Cognitive Assessment (MoCA)

MoCA can detect mild cognitive impairment in many conditions

Question 36

Is medication review a component of CGA?

Answer 36

Yes - a core part

Question 37

What should be included in a medication review?

Answer 37

Full medication history
Medication use - in general: are you good at remembering your pills? Can you swallow them ok? What are you most concerned about with your tablets?
- for each tablet: do you take this? How often? What for? Do you think it works? Does it have side effects?

Review for interactions or common side effects
Appropriateness