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 is arguably the single most foundational topic in geriatric medicine for your exams. It answers one deceptively simple question: why do old patients keep bouncing back to hospital, and what do we do about it? The case of Mr Wong — an 84-year-old man admitted three times in quick succession for pneumonia, cough, and dizziness — illustrates that treating the acute disease alone is insufficient. Without assessing cognition, mood, function, falls risk, carer stress, and social support, you miss the real problems. CGA is the "technology of geriatric medicine" — the structured process that uncovers these hidden problems and couples them with targeted interventions.
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)
How it fits into exams: Past papers directly test matching of assessment tools to clinical scenarios (EMQ 2018), distinguishing BADL vs IADL (MCQ 2020), and depression pseudodementia. SAQs ask you to list CGA domains, propose interventions for case vignettes, and explain why CGA reduces mortality and institutionalisation.
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 — An average older person in HK has 2–3 chronic diseases (HT 62.5%, DM 21.7%, arthritis 19.9%) [1]. These diseases interact. Treating one may worsen another (e.g., NSAIDs for arthritis → worsening CHF/CKD).
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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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Atypical presentation — An MI may be painless ("silent MI"). Pneumonia may present as confusion rather than fever. UTI may present as falls rather than dysuria. If you only look for the textbook presentation, you miss the diagnosis.
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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 biological states of vulnerability mean that even minor stressors can cause disproportionate decline.
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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 |
| Frail elderly person | Targeted at those who are biologically aged / frail, not just chronologically old | Fit 80-year-olds don't need full CGA; frail 65-year-olds do |
| 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
- 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 slide shows that normal aging causes gradual decline; dementia causes accelerated decline starting with AADL → IADL → BADL; stroke causes sudden drop in BADL.
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 — severely impaired balance → high fall risk. [1]
Patient rises from an arm chair, walks 3 metres, turns, walks back, and sits down. Timed. < 20 seconds = more independent. > 30 seconds = more dependent. [1]
TUGT Thresholds — Commonly Examined
< 20 sec → likely independent, low fall risk > 30 sec → likely dependent, HIGH fall risk 20–30 sec → grey zone, needs further assessment
Some sources use ≥ 14 seconds as "increased fall risk" (NICE). The GC slide uses < 20 and > 30. Use the GC slide values for the exam.
Mr Wong failed TUGT — confirming deconditioning with high fall risk. [1]
Total score 20. Quick bedside assessment of mobility.
Combines balance and gait subscales. Total score 28. Score < 19 = high fall risk.
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]
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-off varies by education level (e.g., 18 for illiterate, 22 for primary, 24 for secondary+).
- Gold standard screening tool but has ceiling effect — may miss MCI.
Validated for MCI. 30-point, ~10 minutes. Freely accessible at www.mocatest.org. Assesses: visuospatial/executive, naming, memory, attention, language, abstraction, delayed recall, orientation.
Mr Wong: MoCA 5/30 — dementia range. [1]
2018 EMQ Q2: "Assessment of memory and cognitive performance" → Answer: J. Montreal Cognitive Assessment [4]
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.
CDT is excellent for visuospatial and executive function. It can detect frontal/parietal dysfunction that MMSE may miss. The instruction "set the time to 11:10" requires the patient to put the minute hand on the 2 (not 11) — this tests executive function because they must inhibit the prepotent response.
Geriatric Depression Scale (GDS) [1]
Original 30 questions. Shorter version: GDS-15 (15 questions). Cut-off: GDS-30 ≥ 11, GDS-15 ≥ 5. Offers valid assessment even in mild-moderate depression. Test-retest reliability satisfactory.
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 — positive for geriatric depression. [1]
Depression in the Elderly — Pseudodementia
Past paper 2020 Q24: "Which psychiatric condition can mimic dementia and is known as pseudodementia?" → Answer: A. Depressive disorder. Depression in older adults often presents with cognitive complaints (poor concentration, memory difficulties) that can mimic dementia. Key differences: depressive pseudodementia has relatively acute onset, the patient complains of cognitive problems (insight preserved), mood symptoms predominate, and it responds to antidepressant treatment. [5]
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). Quick, practical. CFS ≥ 5 = frail.
- 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).
2018 EMQ Q3: "Assessment of nutritional status of a frail bedbound patient" → Answer: I. Malnutrition Universal Screening Tool (MUST) [4]
Common members: Geriatrician, Nurse, Medical Social Worker (MSW), Physiotherapist (PT), Occupational Therapist (OT), Dietitian, Speech Therapist (ST), 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) |
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
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 | Dementia range | Dementia (previously undiagnosed) |
| Functional | OT: BI 5/20, BADL mostly dependent | Dependent in most BADL | Functional dependence |
| Mood | GDS 11/15 | Positive for depression | Geriatric depression |
| 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 |
1. Pneumonia 2. Carer stress 3. Geriatric depression 4. Dementia 5. Deconditioning with high fall risk 6. Multiple follow-up in different clinics [1]
1. Complete antibiotics 2. Approve high disability allowance 3. Prescribe antidepressant 4. Home visit by OT with home modification 5. ADL training by OT 6. Walking rehabilitation by PT 7. Refer Geriatric Day Hospital upon discharge 8. Long-term follow-up in geriatric clinic [1]
After discharge from FYKH: no hospitalization in next two years. [1]
This is the power of CGA — addressing all domains prevents the revolving door.
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 is the landmark trial that proved CGA works. The mortality curve diverges early and continues to separate over 12 months.
Rubenstein 1984 — Exam Favourite
Know these numbers: mortality halved (24% vs 48%), nursing home admission halved (13% vs 30%). This is the study most likely to be cited in SAQs asking you to justify CGA.
Meta-analysis of RCTs: CGA (ward-based model) favours intervention for the outcomes of "being alive and in their own homes." The forest plot on the slide shows the pooled effect favouring CGA.
- 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 rehab initiated within 48 hours (e.g., stroke) |
| 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 |
Stroke Rehabilitation:
- Initiated within 48 hours
- 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 (DEXA, bisphosphonates, calcium + vitamin D, falls prevention)
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-based multicomponent interventions (orientation, early mobilisation, hydration, sleep hygiene, medication review, sensory aids) reduce delirium incidence by 30-40% (Hospital Elder Life Program — HELP).
Falls assessment is embedded within CGA. The MMAI (Multidisciplinary Multifactorial Assessment and Intervention) approach includes: visual correction, medication review, balance training, home hazard modification, vitamin D + calcium, hip protectors.
Restraints — A Common Exam Trap
Restraints do NOT reduce falls. They INCREASE injury severity if a fall occurs, and they INCREASE risk of delirium, pressure ulcers, functional decline, agitation, and death. The answer in exams is always: "Physical restraints should be avoided." [11]
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.
Likely Exam Questions
- Which tool best assesses level of independence in BADL? → Barthel Index (not Lawton IADL, not BBS, not MoCA)
- Which of the following is an IADL? → Preparing meals (not bathing, eating, toileting)
- TUGT > 30 seconds indicates? → High fall risk / dependent
- GDS-15 cut-off for depression? → ≥ 5
- AMT 3/10 indicates? → Severe cognitive impairment
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"An 82-year-old woman is admitted for the third time in 2 months with falls. List the domains of CGA and one assessment tool for each."
- Physical: medication review
- Cognitive: AMT or MoCA
- Mood: GDS
- Functional: Barthel Index (BADL), Lawton (IADL)
- Mobility: TUGT, BBS
- Social: MSW assessment
- Environmental: OT home visit
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"Describe the evidence for CGA effectiveness. Cite one study." → Rubenstein 1984 NEJM RCT: GEU vs control. At 1 year: mortality 24% vs 48%, nursing home admission 13% vs 30%.
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"List 4 members of the MDT and their roles." → Geriatrician (medical assessment), PT (mobility/balance), OT (ADL/home modification), MSW (social support/placement).
"Mr Chan, 79, admitted with confusion. PMH: DM, HT. He lives alone. After treating UTI, he is still unsteady and confused. Outline your CGA approach."
- Cognitive: AMT → score likely low → MMSE/MoCA to confirm dementia vs resolving delirium
- Mood: GDS → screen for depression (pseudodementia)
- Functional: Barthel → was he independent premorbidly? → assess current function
- Mobility: TUGT, BBS → fall risk
- Social: lives alone → can he return home safely? → MSW
- Environmental: OT home visit
- Medical: medication review, nutritional assessment, continence assessment
- Plan: MDT goal-setting, rehab program, discharge planning
| 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 |
| 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 |
| Cut-off | ≥ 5 | N/A for GDS comparison | ≥ 10 |
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: Rubenstein 1984 RCT — mortality halved (24% vs 48%), nursing home admission halved (13% vs 30%). Ellis 2011 BMJ meta-analysis — ward-based CGA favours being alive and at home. Mr Wong case: revolving-door admissions resolved by CGA revealing depression, dementia, deconditioning, carer stress — targeted interventions led to no hospitalization for 2 years. IADL = cooking, shopping, transport, housework, money (NOT bathing, eating, toileting — those are BADL). TUGT: < 20s independent, > 30s dependent. GDS-15 cut-off: ≥ 5. AMT: 0–3 severe, 4–7 moderate, 8–10 normal.
Active Recall - Comprehensive Geriatric Assessment
[1] Lecture slides: GC 038. Comprehensive geriatric assessment and rehabilitation in older people.pdf (slides 1–39) [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) [5] Past papers: 2020 Fourth Summative Assessment MCQ paper.pdf (Q23, Q24) [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
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.