GC038 Comprehensive Geriatric Assessment And Rehabilitation In Older People
Comprehensive Geriatric Assessment is a multidimensional, interdisciplinary diagnostic process used to determine the medical, psychological, functional, and social capabilities and limitations of an older person in order to develop a coordinated and integrated plan for treatment and long-term follow-up, including rehabilitation to optimize overall health and independence.
Comprehensive Geriatric Assessment and Rehabilitation in Older People
This lecture answers one deceptively simple question: why can an older person keep returning to hospital even when the apparent acute illness has been treated? Mr Wong — an 84-year-old man admitted three times in quick succession for fever, cough, and dizziness — illustrates the gap between treating a disease and restoring safe function. Cognition, mood, mobility, medicines, nutrition, caregiver capacity, and the home environment can all determine whether discharge succeeds. CGA is the "technology of geriatric medicine": a structured whole-person assessment coupled to a coordinated plan.
Learning Objectives (from GC038 and CFB MED12):
- Define CGA and explain why it is the cornerstone of geriatric medicine
- List and explain the domains of CGA (physical, mental/cognitive, functional, social, environmental, economic)
- Know the commonly used geriatric assessment instruments and when to apply each
- Understand the multidisciplinary team and each member's role
- Describe the evidence base for CGA (Rubenstein RCT, Ellis BMJ meta-analysis)
- Understand geriatric rehabilitation principles, goal-setting, and settings
- Apply CGA to clinical scenarios (Mr Wong)
Why Do Older People Need a Different Approach?
"Multiple organic, psychological and social problems; functional and physiological capacities diminished; adverse effects of drugs pronounced; physical diseases might present as mental disorder like delirium; atypical presentation in symptoms and signs like silent MI; frail and pre-frail common; sarcopenia." [1]
This slide is the philosophical foundation. Here's the reasoning:
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Multimorbidity — The lecture's 2009 Hong Kong survey reported hypertension 62.5%, diabetes 21.7%, arthritis 19.9%, eye disease 18.0%, hypercholesterolaemia 16.3%, and heart disease 14.5% among respondents [1]. These are historical, survey-specific figures, not current universal prevalence estimates. The enduring point is that conditions and treatments interact (for example, an NSAID may worsen heart failure or kidney disease).
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Reduced physiological reserve — Aging reduces organ reserve (cardiac output, renal GFR, respiratory capacity). The older person sits closer to the cliff edge: a small push (infection, new drug, dehydration) tips them into functional decline.
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Less specific presentation — Acute illness may present with delirium, anorexia, reduced mobility, or a fall rather than a single localising symptom. This should broaden careful assessment, not justify diagnostic shortcuts: a nonspecific symptom alone does not prove pneumonia or symptomatic urinary infection.
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Drug sensitivity — Altered pharmacokinetics (decreased renal clearance, hepatic metabolism, increased body fat) and pharmacodynamics (increased CNS sensitivity) mean drugs cause more adverse effects.
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Frailty and sarcopenia — These are related but distinct states of vulnerability. SARC-F is a case-finding screen; low muscle strength suggests probable sarcopenia, low muscle quantity/quality confirms it, and poor physical performance indicates severe sarcopenia under EWGSOP2 [16].
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Functional decline — The ultimate feared outcome. Hospitalization itself causes disability ("hospitalization-associated disability") — deconditioning, delirium, falls, pressure ulcers, malnutrition. [2]
The Geriatric Giants
The classic "geriatric giants" (Isaacs): Intellectual decline, Instability (falls), Immobility, Incontinence, Iatrogenesis. These are syndromes, not diagnoses — each has multiple interacting causes that CGA aims to uncover. [3]
Comprehensive Geriatric Assessment (CGA) — Definition and Structure
"A multidimensional, interdisciplinary diagnostic process intended to determine a frail elderly person's medical, psychosocial, and functional capacities and problems with the objective of developing an overall plan for treatment and long-term follow-up." — Rubenstein [1]
Break this definition into its components for the exam:
| Component | Meaning | Why It Matters |
|---|---|---|
| Multidimensional | Covers physical, psychological, functional, social, environmental, economic domains | A single-dimension approach misses hidden problems |
| Interdisciplinary | Uses a team of professionals (not just the doctor) | No single discipline can address all domains |
| Diagnostic process | Systematic, not ad hoc — uses validated instruments | Ensures reproducibility, tracks progress |
| Older person with frailty or complexity | Target by need, trajectory, and vulnerability rather than chronological age alone | A fit 80-year-old and a frail 65-year-old may need very different depth of assessment |
| Overall plan for treatment and long-term follow-up | Assessment must be coupled with intervention | Assessment alone without action is pointless |
CGA is the "cornerstone" and "technology" of geriatric medicine. [1]
High Yield: CGA Definition
Examiners love to ask you to define CGA. Include ALL of: multidimensional, interdisciplinary, diagnostic process, frail elderly, medical + psychosocial + functional capacities, plan for treatment AND long-term follow-up. This is the Rubenstein definition.
1. Multidisciplinary approach 2. Utilization of one or more set of measuring instruments 3. Use of interdisciplinary team to pool expertise 4. Attempt to couple assessment with intervention programme (rehabilitation, counselling, placement) 5. Flexibility is the rule — geared towards the need of a particular setting, purpose, and society
Assessment Is Not the Endpoint
Scales make findings visible and trackable, but CGA is not a battery of scores. A useful CGA turns the history, collateral information, examination, medicines review, function, goals, and context into a prioritised problem list, a named plan, and follow-up. WHO ICOPE similarly uses four linked steps: basic assessment, in-depth assessment, a personalised care plan, then implementation and monitoring [14].
- Diagnostic work-up → develop plan of therapy
- Monitoring of progress → track response to rehabilitation
- Screening → early detection of potential disability
- Determining level/setting of long-term care → home vs residential care vs nursing home
- Education and research
Domains of CGA (WHO Framework) [1]
Physical health | Mental function (cognitive and psychiatric symptoms) | Functional (ADL and instrumental ADL) | Social resources | Environmental resources | Economic resources
Standard medical assessment of active and chronic diseases, medication review, nutrition, continence, sensory function (vision, hearing), pain, skin integrity.
Two sub-domains:
- Cognitive: Is there dementia or delirium? (AMT, MMSE, MoCA, Clock Drawing Test)
- Psychiatric: Is there depression? (GDS) Other psychiatric problems?
This is what makes geriatric medicine unique — function is the outcome that matters most. Three levels:
Level of function vs Age graph:
- AADL (Advanced ADL) — e.g., playing violin, travelling — lost first in dementia/aging
- IADL (Instrumental ADL) — e.g., shopping, cooking, managing money, transport, housework — lost next
- BADL (Basic ADL) — e.g., bathing, dressing, feeding, toileting, transferring — lost last [1]
The image makes trajectory the diagnostic clue: normal ageing is drawn as gradual change; dementia progressively affects AADL → IADL → BADL; stroke causes an abrupt fall across functional domains followed by variable recovery or a new plateau. Always ask about baseline, time course, reversible contributors, and the person's own target—not merely today's score.
Exam Trap: BADL vs IADL
Past paper 2020 Q23 asks: "Which of the following is counted as an instrumental activity of daily living? A. Bathing, B. Eating, C. Preparing meals, D. Toileting." Answer: C. Preparing meals. Bathing, eating, and toileting are all BADL. Remember: IADLs are the things you need to live independently in the community — they require more cognitive and organizational ability.
Living situation, carer availability, carer stress, social isolation, support networks.
Home safety (stairs, lighting, bathroom rails, floor surfaces), accessibility.
Financial support, disability allowance, community resources.
Geriatric Assessment Instruments — The Toolbox
Functional Assessment Tools
Barthel Index (20-point or 100-point scale) — measures BADL
| Item | Scoring (0–2 or 0–3) |
|---|---|
| Bowels | 0 = incontinent, 1 = occasional accident, 2 = continent |
| Bladder | 0 = incontinent/catheterised, 1 = occasional accident, 2 = continent |
| Grooming | 0 = needs help, 1 = independent |
| Toilet use | 0 = dependent, 1 = needs some help, 2 = independent |
| Feeding | 0 = unable, 1 = needs help cutting, 2 = independent |
| Transfer | 0 = unable, 1 = major help, 2 = minor help, 3 = independent |
| Mobility | 0 = immobile, 1 = wheelchair independent, 2 = walks with help, 3 = independent |
| Dressing | 0 = dependent, 1 = needs help, 2 = independent |
| Stairs | 0 = unable, 1 = needs help, 2 = independent |
| Bathing | 0 = dependent, 1 = independent |
Total: 20 points. Higher = more independent. BI of 20 = fully independent in BADL.
In the Mr Wong case, BI was 5/20 — mostly dependent in BADL. [1]
2018 EMQ Q1: "Assessment of patient's level of independence" → Answer: A. Barthel Index [4]
Barthel Index — Know This Cold
The BI is the most commonly used BADL tool in HK geriatric practice. It's a 10-item, 20-point scale. Know the items (mnemonic: Bowels, Bladder, Grooming, Toilet, Feeding, Transfer, Mobility, Dressing, Stairs, Bathing — "BB GT FT MDS B"). Know that it assesses BASIC ADL, NOT instrumental ADL.
Another BADL tool (bathing, dressing, toileting, transferring, continence, feeding). Less commonly used in HK than Barthel but know it exists.
Total 126 points. Used in TWH Stroke Unit and FYKH GDH/MMRC rehab cases.
| Category | Items | Max Score |
|---|---|---|
| Self-care | Eating, grooming, bathing, toileting, upper/lower body dressing | 42 |
| Sphincter control | Bladder and bowel management | 14 |
| Transfer | Bed/chair/wheelchair, toilet, tub/shower | 21 |
| Locomotion | Walk/wheelchair, stairs | 14 |
| Communication | Comprehension, expression | 14 |
| Social cognition | Social interaction, problem solving, memory | 21 |
FIM is more comprehensive than Barthel because it includes communication and social cognition — important for stroke rehabilitation. Each item is scored 1-7 (1 = total assistance, 7 = complete independence).
Reuben and Solomon. Includes recreational, occupational, community service functions. E.g., playing a musical instrument, volunteering.
Can you: (1) get to places out of walking distance, (2) go shopping, (3) prepare your own meals, (4) do housework, (5) handle your own money? Each scored 1 (without help) or 0 (with help).
The full Lawton IADL Scale has 8 items (adds telephone use, medication management, laundry).
Motor Function / Mobility Tools
Total 56 points. Assesses: getting out of chair, sitting unsupported, standing balance (feet together, apart, eyes closed), turning, reaching forward, picking up object from floor, tandem/single leg stance, dynamic weight shifting.
In Mr Wong's case: BBS 12/56 — markedly impaired balance and a strong reason for supervised mobility assessment and falls intervention. A BBS score alone does not predict whether an individual will fall. [1,15]
Patient rises from an arm chair, walks 3 metres, turns, walks back, and sits down. Record the time and observe the transfer, posture, stride, turning, balance, symptoms, and use of the usual walking aid. [1,15]
TUG: Preserve the Slide, Avoid the Clinical Trap
The historical slide labels < 20 seconds as more independent and > 30 seconds as more dependent. These describe mobility/dependence in the cited teaching context; they are not validated universal "low-risk/high-risk" fall cut-offs. Current NICE guidance says TUG and other gait/balance tests help clinicians observe impairment but do not predict an individual's fall risk. A fall history, frailty, medicines, orthostatic symptoms, vision, continence, cognition, footwear, environment, and gait/balance all belong in a comprehensive assessment [15].
Mr Wong could not complete the TUG safely; together with his BBS, need for contact assistance, illness, and functional history, this supports deconditioning and a multifactorial falls assessment. [1]
Total score 20. Quick bedside assessment of mobility.
Combines balance and gait subscales (total 28). Historical cut-offs are setting-dependent; use the result to characterise impairments and guide intervention rather than as a stand-alone fall prediction rule [15].
Cognitive Assessment Tools
10 questions: Age, Time (nearest hour), Address for recall (42 West Street), Year, Name of institution, Recognition of 2 persons, Date of birth, Year of First World War, Name of present monarch, Count backward 20 to 1. Scoring: 0–3 severe impairment, 4–7 moderate impairment, 8–10 normal.
Mr Wong: AMT 3/10 — severe cognitive impairment. [1]
Several original AMT items are culturally and historically dependent (for example, an old address, wartime date, or monarch). Use a validated local-language/adapted version, check hearing, vision, language, education, and acute illness, and interpret the result as a screen, not a dementia diagnosis.
AMT — Quick Bedside Screen
AMT is a 10-item bedside screen taking 2–3 minutes. It's good for detecting moderate-severe cognitive impairment but NOT sensitive for mild cognitive impairment (MCI). For MCI, use MoCA.
- 30 points. Assesses orientation, registration, attention/calculation, recall, language, visuospatial.
- Cut-offs and norms vary by language, culture, age, and education; use a locally validated version.
- It is a copyrighted structured screen with ceiling and floor effects. It is neither a stand-alone diagnosis nor a universal "gold standard."
A 30-point cognitive screen taking about 10 minutes. It samples visuospatial/executive function, naming, memory, attention, language, abstraction, delayed recall, and orientation.
Mr Wong: MoCA 5/30 — a profoundly abnormal screen in this context, but not by itself proof of dementia or its subtype. [1,17]
2018 EMQ Q2: "Assessment of memory and cognitive performance" → Answer: J. Montreal Cognitive Assessment [4]
Use the official version and instructions. Current MoCA policy permits administration for total-score screening by a clinician following the official instructions, while domain-level interpretation requires official training/certification [21].
Patient draws a clock face, numbers, and hands showing 11:10. Scoring: Closed circle (1), Numbers in order (1), 12 numbers (1), Correctly positioned (1), Hands at designated time (1). Normal = 4–5.
The slide's example drawings show different error patterns—number crowding, poor spatial planning, perseveration, and incorrect hand setting. CDT samples visuospatial and executive performance, but scoring systems vary and it is not diagnostic alone.
Low Cognitive Score During Acute Illness
Before labelling dementia, establish the baseline and trajectory with collateral history, look for fluctuation/inattention, and assess reversible contributors such as delirium, depression, medicines with anticholinergic burden, sensory impairment, metabolic illness, and language barriers. NICE recommends the 4AT when delirium indicators are present and a clinician with relevant expertise to make the final diagnosis [18]. Dementia assessment requires history, functional impact, examination, appropriate investigations, cognitive testing, and—when suspicion persists—specialist assessment [17].
Geriatric Depression Scale (GDS) [1]
Original 30 questions. Shorter version: GDS-15 (15 questions). The lecture uses GDS-30 ≥11 and GDS-15 ≥5 as positive screening thresholds.
GDS-15 sample items: "Have you dropped many activities and interests?", "Do you feel your life is empty?", "Do you often feel helpless?", "Do you feel pretty worthless?", "Do you feel your situation is hopeless?"
Mr Wong: GDS 11/15 — a strongly positive depression screen requiring a clinical interview, assessment of suicide/self-harm risk, differential diagnosis, and an individualised treatment plan. The threshold can vary with version and setting [1,19].
Depression with Cognitive Symptoms
Past paper 2020 Q24 uses the older term "pseudodementia" for depressive disorder. Clinically, avoid treating it as a clean either/or distinction: depression can cause cognitive symptoms, coexist with dementia, or be an early feature of neurodegenerative disease. Onset, insight, effort, and response to treatment are clues—not definitive separators. Assess cognition longitudinally while treating depression and excluding delirium and other causes [17,19].
The lecture lists four frailty tools:
- Fried's Phenotypic Frailty — 5 criteria: unintentional weight loss, self-reported exhaustion, low energy expenditure, slow gait speed, weak grip strength. ≥ 3 = frail, 1–2 = pre-frail, 0 = robust.
- Frailty Index (Rockwood) — Deficit accumulation model. Count deficits/total items assessed. Higher ratio = more frail.
- Rockwood Clinical Frailty Scale (CFS) — 9-point pictorial scale (1 = very fit, 9 = terminally ill). Score usual baseline function rather than transient acute-illness disability, and do not use it as a stand-alone rationing or falls-prediction tool.
- Morley's FRAIL Scale — Fatigue, Resistance (climbing 1 flight of stairs), Ambulation (walking 1 block), Illness ( ≥ 5), Loss of weight ( > 5% in 6 months). ≥ 3 = frail.
SARC-F questionnaire (Strength, Assistance walking, Rise from chair, Climb stairs, Falls) is a case-finding screen, not confirmation of sarcopenia [16].
2018 EMQ Q3: "Assessment of nutritional status of a frail bedbound patient" → Answer: I. Malnutrition Universal Screening Tool (MUST) [4]
The lecture's patient-centred team graphic includes a geriatrician, nurses, medical social worker (MSW), physiotherapist (PT), occupational therapist (OT), dietitian, speech therapist (ST), and podiatrist.
| Member | Key Role in CGA |
|---|---|
| Geriatrician | Medical assessment, diagnosis, medication review, coordination |
| Nurse | ADL assessment, skin/wound care, continence, medication administration, patient education |
| MSW | Social assessment, carer support, financial assistance (e.g., disability allowance), placement |
| PT | Mobility, balance, gait training, falls prevention, exercise programmes |
| OT | ADL training, cognitive assessment (AMT, MoCA), home visits, environmental modification, assistive devices |
| Dietitian | Nutritional assessment, dietary planning |
| ST | Swallowing assessment (bedside, FEES, VFSS), communication rehabilitation |
| Podiatrist | Foot care (especially diabetic foot, nail problems) |
| Pharmacist | Medicines reconciliation, interactions, adherence, deprescribing and safer regimens |
| Psychologist / old-age psychiatry | Diagnostic assessment and treatment of mood, behaviour and cognition when indicated |
The exact membership depends on the setting and the person's goals. Primary care, orthotics/prosthetics, rehabilitation assistants, community nursing, and voluntary-sector services may also contribute. The older person and family/caregiver are partners in goal-setting, not merely recipients of the team's decisions. The final Chinese slide makes this explicit: geriatric care should support and teach caregivers as well as treat the patient [1].
Why Instruments Are Necessary [1]
1. Make assessment easy to perform and teach 2. More reliable 3. Facilitate transmission of standardized clinical information between health providers — smooth teamwork, meaningful and valid data 4. Therapeutic progress can be measured over time
Standardised instruments improve communication and make change measurable. They do not replace clinical judgement, collateral history, direct observation, or a shared plan; a statistically different score may still be clinically meaningless, while a small change may matter greatly to the patient.
The Case of Mr Wong — Applying CGA [1]
This case perfectly illustrates the lecture's key message:
- 84M, lives with family, walks with quadripod, PMH: HT, DM, CHF
- Admitted for fever → treated as pneumonia → antibiotics → fever resolved D2 → discharged
- Cough → CXR same → treated as "unresolved pneumonia" → same antibiotics → discharged D2
- Dizziness
What went wrong? Each admission treated the acute problem in isolation without looking at the whole person. The revolving door admissions are a red flag for unaddressed geriatric issues.
| Domain | Assessment | Finding | Problem Identified |
|---|---|---|---|
| Motor/mobility | PT: walk with frame + contact assist, failed TUGT, BBS 12/56 | Severely impaired mobility and balance | Deconditioning with high fall risk |
| Cognitive | OT: AMT 3/10, MoCA 5/30 | Severe cognitive impairment on screening | Possible delirium and/or major neurocognitive disorder; establish baseline and investigate |
| Functional | OT: BI 5/20, BADL mostly dependent | Dependent in most BADL | Functional dependence |
| Mood | GDS 11/15 | Strongly positive depression screen | Possible depressive disorder; interview and assess risk |
| Social | MSW: lives with wife and daughter | Difficult to care for due to high fall risk + ADL dependence | Carer stress |
| Medical | As above | Pneumonia + multiple clinic follow-ups | Pneumonia, polypharmacy risk |
The slide labels pneumonia, carer stress, geriatric depression, dementia, deconditioning/high falls risk, and fragmented follow-up [1]. In current practice, keep depression and dementia provisional until confirmed. Also revisit whether infection persists, reconcile medicines, look for delirium and orthostatic hypotension, assess nutrition/continence/sensory impairment, and clarify the patient's baseline function and goals.
The lecture plan was to complete antibiotics, arrange disability allowance, prescribe an antidepressant, conduct an OT home visit and modifications, provide ADL and walking rehabilitation, refer to geriatric day hospital, and arrange long-term geriatric follow-up [1]. Modernise that into a sequence:
- Reassess the acute diagnosis, response, microbiology and continued need/duration of antibiotics.
- Reconcile and optimise medicines; assess hydration, orthostatic blood pressure, pain, nutrition, continence, vision/hearing, and delirium.
- Confirm cognitive and mood diagnoses after collateral history and appropriate work-up; if depression is diagnosed, choose treatment collaboratively and monitor adverse effects, sodium, falls, and suicide risk [19].
- Begin task-specific, progressive PT/OT rehabilitation using the required assistance and equipment; train transfers, gait, balance and ADLs.
- Conduct home/environment assessment, provide equipment and caregiver training, and agree a safe discharge plan.
- Coordinate community/day-hospital rehabilitation, benefits/social support, follow-up ownership, and contingency plans.
After discharge from FYKH: no hospitalization in next two years. [1]
This is an illustrative success, not proof that CGA alone caused the outcome. Its teaching value is that recurrent admissions should trigger a wider problem list and coordinated intervention.
Evidence Base for CGA
RCT: excluded too well, too ill (terminal disease/severe dementia). Randomized to Geriatric Evaluation Unit (GEU, n=60) vs control (n=63). GEU staffed by geriatrician, SW, geriatric nurses, supported by PT, OT, psychologist, dietitian. At 1 year, intervention group had:
- Lower mortality: 23.8% vs 48% (p < 0.005)
- Less likely discharged to nursing homes: 12.7% vs 30% (p < 0.05)
- Less acute hospital stay
- More likely to improve in morale and functional status
- Less direct cost of institutional care
This small landmark trial showed a large benefit in its selected population; it did not by itself "prove" that every CGA model reduces mortality. The slide's cumulative mortality curves separate over follow-up, with the control curve rising more steeply than the geriatric-unit curve. Read the graph as a visualisation of this trial's result, not a current universal effect size.
Rubenstein 1984 — Exam Favourite
The lecture-reported figures are mortality 23.8% vs 48% and nursing-home discharge 12.7% vs 30%. Quote the study and its small sample if asked, then distinguish this historical RCT from the later pooled evidence.
Meta-analysis of RCTs: CGA (ward-based model) favours intervention for the outcome "being alive and in their own homes."
How to read the slide's forest plot: each square is a trial estimate, square size reflects weight, and the horizontal line is its 95% confidence interval. The vertical line is no difference. Values to the right favour intervention; the pooled diamond for the ward model is entirely to that side (fixed-effect OR 1.22, 95% CI 1.10–1.35 on the slide). Individual trials can cross no effect even when the pooled estimate does not.
The updated review included 29 trials and 13,766 participants. Compared with usual inpatient care, CGA:
- increased the likelihood of being alive and at home at 3–12 months (RR 1.06, 95% CI 1.01–1.10; high-certainty);
- reduced nursing-home admission (RR 0.80, 95% CI 0.72–0.89; high-certainty);
- made little or no difference to mortality (RR 1.00, 95% CI 0.93–1.07) or dependence (RR 0.97, 95% CI 0.89–1.04);
- had uncertain cost-effectiveness.
Therefore, the best contemporary one-line claim is more patients alive in their own homes, not "CGA halves mortality."
- Stuck et al. 1993 (Lancet): Meta-analysis of controlled trials showing CGA improves survival and function
- Baztán et al. 2009 (BMJ): Acute geriatric units reduce functional decline, increase living at home
- Bachmann et al. 2010 (BMJ): Inpatient geriatric rehabilitation specifically designed for geriatric patients → systematic review supports benefit
Geriatric Rehabilitation
| Level | Definition | Example |
|---|---|---|
| Impairment | Problem in body function/structure | Hemiplegia, aphasia |
| Activity limitation | Difficulty executing a task | Cannot walk, cannot dress |
| Participation restriction | Problem with involvement in life situations | Cannot go to community centre, cannot work |
| Contextual factors | Environmental (physical, social) and personal | Stairs at home (barrier), family support (facilitator) |
Rehabilitation aims to maximise function, minimise activity limitation, and reduce participation restriction.
- Multidisciplinary/interdisciplinary team approach with patient and carer involvement
- Simultaneous management of multiple conditions — can't just rehab the stroke if depression, pain, and delirium are untreated
- Understanding frailty, variability, and inactivity — frail patients have less reserve and may need modified exercise
- Maintenance of good health and residual function complemented with environmental management and carer support
- Exercise and nutrition are critical components of treatment for frailty [6]
Goals are constrained by:
- Premorbid functional level (what the patient could do before the illness)
- Severity of concomitant diseases and impairments
- Family/carer support availability
- Safety considerations
Realistic Goal Setting
A common mistake is having either excessively high or excessively low expectations. Low expectations from patients, families, or healthcare staff lead to suboptimal rehabilitation. Conversely, unrealistic expectations need management. Always set goals collaboratively with the patient and family.
| Setting | Description |
|---|---|
| Acute hospital | Early assessment, prevention of avoidable deconditioning, and rehabilitation once medically safe |
| Convalescent hospital | Continued rehab after acute phase (Mr Wong's case) |
| Geriatric Day Hospital (GDH) | Outpatient rehab programme; patients attend during the day |
| Community | Home-based rehab, community outreach |
| Long-term care facility | Maintenance rehab in residential/nursing home |
The montage is clinically informative rather than decorative. It shows:
- task-specific upper-limb/hand practice and cognitive–perceptual assessment;
- hoist-assisted transfer practice when manual transfer is unsafe;
- supported standing and gait with the correct walking aid and assistance level;
- parallel-bar, balance, obstacle and functional mobility training;
- repeated reassessment, equipment adjustment, and caregiver instruction.
The geriatric day-hospital photographs show a coordinated ambulatory MDT rehabilitation service, including transport for people who cannot independently reach outpatient therapy. It is an active bridge between inpatient care and home, not passive placement.
Stroke Rehabilitation:
- Start assessment and rehabilitation early once medically stable; timing and intensity must be individualised rather than applying a rigid "within 48 hours" rule to every patient
- Assess: communication, motor, cognitive, visual/spatial, psychological, sensory deficits
- Trainings: ADL, vocational, cognitive, communication, psychosocial
- Manage complications: hemiplegia, spasticity, dysphagia, seizures, bladder/bowel, depression
- Prevent complications: aspiration pneumonia, contractures, shoulder injury, pressure sores, UTI
Hip Fracture Rehabilitation:
- Orthogeriatric care model (geriatrician + orthopaedic team)
- Early mobilisation post-surgery
- Secondary fracture prevention: assess osteoporosis and future-fall risk, then offer indicated anti-osteoporosis therapy and address calcium/vitamin D deficiency rather than prescribing the same bundle to everyone
A critical concept linked to CGA:
- Hospitalization itself causes functional decline in 30–60% of older adults
- Mechanisms: bed rest (deconditioning), delirium, malnutrition, polypharmacy, restraints, loss of orientation
- CGA-based interventions (early mobilisation, delirium prevention, nutrition support, medication review) can mitigate this
Integration with Related Material
CGA includes medication review — look for potentially inappropriate prescribing using STOPP criteria (drugs to stop) and START criteria (drugs to start that are often omitted, e.g., statins after MI, osteoporosis treatment after fracture).
CGA overlaps heavily with frailty assessment. In fact, CGA is the gold-standard method for identifying frailty. The Clinical Frailty Scale and FRAIL scale are rapid screening tools; CGA is the comprehensive workup.
CGA supports multicomponent prevention: orientation, hydration, pain control, medicines review, early mobility, sleep support, nutrition, oxygenation where needed, and hearing/visual aids. If there is an acute or fluctuating change, use the 4AT and obtain a clinical diagnosis rather than treating a low AMT/MoCA score as dementia [18].
Falls assessment is embedded within CGA. Current management is multifactorial and tailored: fall circumstances, gait/balance, orthostatic cardiovascular assessment, cognition/delirium, vision/hearing, feet/footwear, continence, osteoporosis risk, medicines, and home hazards. Offer progressive strength-and-balance exercise when indicated; arrange OT-led home assessment/modification when appropriate. Vitamin D/calcium or hip protectors are not automatic for every patient.
Restraints Are Not Falls Treatment
Do not use physical restraint as a routine falls-prevention intervention. First identify the cause of unsafe behaviour and use the least restrictive, proportionate approach: treat delirium/pain/retention, provide orientation and sensory aids, optimise supervision and environment, make toileting accessible, and use the correct mobility aid. Any exceptional restriction must follow local legal, capacity, safeguarding, and monitoring requirements.
CGA helps determine the appropriateness of treatment intensity. In advanced dementia or terminal frailty, the goal shifts from cure/rehabilitation to comfort and palliation. CGA findings inform advance care planning discussions.
| Feature | Barthel Index | FIM | Lawton IADL |
|---|---|---|---|
| What it measures | Basic ADL | ADL + communication + cognition | Instrumental ADL |
| Total score | 20 (or 100) | 126 | 8 items (or 5-item version) |
| Used where | Widely (all geriatric settings) | Stroke unit, rehab | Community-dwelling elderly |
| Captures cognitive/communication? | No | Yes | Partly (money management) |
| Feature | AMT | MMSE | MoCA |
|---|---|---|---|
| Items | 10 | 30 | 30 |
| Time | 2–3 min | 10 min | 10 min |
| Best for | Quick bedside screen | Moderate-severe dementia | MCI |
| Weakness | Misses MCI | Ceiling effect, misses MCI | May over-diagnose in low education |
All three are screens, not stand-alone diagnoses; use a validated local-language version and interpret in the context of baseline, education, sensory/language needs, acute illness, and function [17,18].
| Feature | GDS-15 | Hamilton Rating Scale | PHQ-9 |
|---|---|---|---|
| Self-report | Yes | Clinician-rated | Self-report |
| Validated in elderly | Yes (specifically designed) | Not specific to elderly | Not specific to elderly |
| Typical screen threshold | Lecture uses ≥5 | Scale-specific | Often ≥10, setting-dependent |
High Yield Summary
- CGA
- = multidimensional, interdisciplinary diagnostic process for frail elderly, covering 6 domains: physical, mental (cognitive + mood), functional (BADL/IADL), social, environmental, economic.
- Assessment MUST be coupled with intervention.
- Key tools: Barthel Index (BADL), Lawton (IADL), FIM (rehab), AMT/MMSE/MoCA (cognitive), GDS (depression), TUGT/BBS (mobility/falls risk), FRAIL/CFS (frailty).
- MDT: geriatrician, nurse, PT, OT, MSW, dietitian, ST, podiatrist.
- Evidence: the small Rubenstein 1984 RCT reported large mortality and institutionalisation effects; the larger 2017 Cochrane review found more patients alive at home and fewer nursing-home admissions, but little or no mortality difference [13].
- Mr Wong case: recurrent admissions prompted CGA, which revealed severe cognitive/mood screening abnormalities, deconditioning, ADL dependence and caregiver strain. Dementia and depression still require clinical confirmation.
- IADL = cooking, shopping, transport, housework, money (NOT bathing, eating, toileting — those are BADL).
- TUG: the slide's < 20 s / > 30 s values describe relative independence/dependence; TUG observes mobility and does not predict falls by itself [15].
- GDS-15: the slide uses ≥5 as a positive screen, not a diagnosis.
- AMT/MoCA: abnormal scores require context and assessment for delirium, depression, medicines, sensory/language factors, baseline decline and functional impact [17,18].
Active Recall - Comprehensive Geriatric Assessment
[1] Lecture slides: GC 038. Comprehensive geriatric assessment and rehabilitation in older people.pdf (slides 1–40) [2] Lecture slides: Hospitalization-Associated Disability - Covinsky KE 2011 (JAMA).pdf [3] Lecture slides: CFB (MED12) Introduction to Geriatric Medicine.pdf (slides 2, 3, 31, 37) [4] Past papers: 2018 Fourth Summative MCQ.pdf (Q1–Q3, p.35) [6] Medicine lecture slides: HKGS Curriculum in Geriatric Medicine 2nd Ed.pdf (Chapters 1, 2, 4) [7] Senior notes: MBBS Final MB (Medicine) (Felix PY Lai).pdf (Stroke rehabilitation section) [8] Lecture slides: GC 079. Prescribing in older people.pdf; GC 079 (supp-1) STOPP-START criteria 2023.pdf [9] Lecture slides: GC 054. Frailty in the older people.pdf; Frailty in Older Adults - Kim DH 2024 (NEJM).pdf [10] Senior notes: Delirium in Elderly People_Lancet.pdf [11] Senior notes: Maksim Medicine Notes.pdf (Geriatrics section, Falls) [12] Lecture slides: GC 045. End-of-life care for hospitalised older adults.pdf [13] Ellis G, et al. Cochrane Database Syst Rev. 2017;9:CD006211. Comprehensive geriatric assessment for older adults admitted to hospital [14] World Health Organization. 2025. Integrated care for older people (ICOPE): guidance for person-centred assessment and pathways in primary care, 2nd ed [15] NICE NG249. 2025. Falls: assessment and prevention in older people and in people 50 and over at higher risk [16] Cruz-Jentoft AJ, et al. Age Ageing. 2019;48:16–31. Sarcopenia: revised European consensus on definition and diagnosis [17] NICE NG97. Dementia: assessment, management and support for people living with dementia and their carers [18] NICE CG103, updated 2023. Delirium: prevention, diagnosis and management in hospital and long-term care [19] NICE NG222. Depression in adults: treatment and management [20] British Geriatrics Society. Comprehensive Geriatric Assessment Hub [21] MoCA Cognition. Official administration and certification FAQ
GC037 Common Neurological Problems In Older People
Common neurological problems in older people encompass a group of age-related conditions—including dementia, stroke, Parkinson's disease, peripheral neuropathy, and delirium—that result from neurodegenerative, vascular, or metabolic processes and collectively contribute to functional decline and loss of independence in the elderly.
GC039 Confused And Dehydrated: Hypercalcaemia; Hypocalcaemia
Hypercalcaemia and hypocalcaemia are disorders of calcium homeostasis that can present with confusion, dehydration, neuromuscular irritability, or cardiac dysrhythmias depending on whether serum calcium is pathologically elevated or reduced.