Comprehensive assessment involves looking not only at disease states as a standard medical assessment would do, or at functional ability as a standard rehabilitation assessment might do, but at a range of domains. By assessing each of these domains of health, a comprehensive assessment can be made, and the full biopsychosocial nature of the individual’s problems can be identified. This process can be supported by using standardised scales and tools, or full formal assessment schemes such as the ‘interrai’ assessment tools (www.interrai.org). Using standardised scales can encourage consistent practice, help to ensure safety (e.g. pressure injury risk screening) and enable detection of serial changes, but they can also be time-consuming and clinically constraining. Clinicians undertaking CGA should consider the extent to which standardised approaches are helpful in their setting . Core components of CGA that should be considered during the assessment process are outlined in Table 4.1.
Functional status: Functional status relates to the ability to perform activities necessary or desirable in daily life. It is directly influenced by health conditions, particularly in the context of an older person’s environment and social support network. Changes in functional status (e.g. not being able to bathe independently) should prompt further diagnostic evaluation and intervention. Measurement of functional status can be valuable in monitoring response to treatment and can provide prognostic information that assists in long-term care planning. With respect to the impact of functional status on activities of daily living (ADLs), an older person’s functional status can be assessed at three levels: (1) basic activities of daily living (BADLs), (2) instrumental or intermediate activities of daily living (IADLs) and (3) advanced activities of daily living (AADLs). BADLs consider self-care tasks which include; bathing, dressing, toileting and maintaining continence, grooming, feeding and transferring. IADLs consider the ability to maintain an independent household which includes shopping for groceries, driving or using public transportation, using the telephone, performing housework, home maintenance, preparing meals, doing laundry, taking medication and handling finances.
In addition to considering ADLs, gait speed alone predicts functional decline and early mortality in older adults. Assessment of gait speed is the domain of the physiotherapist within the team and may identify patients who need further evaluation, such as those at increased risk of falls. Assessing gait speed may also help identify frail patients who might not benefit from treatment of chronic asymptomatic diseases such as hypertension. For example, elevated blood pressure in individuals age 65 and older is associated with increased mortality only in individuals with a walking speed ≥0.8 m/s (measured over 6 m or 20 feet) .
Falls: Approximately one-third of community-dwelling people over 65 years and one-half of those over 80 years of age fall each year . Those who have fallen or have a gait or balance problem are at higher risk of having a subsequent fall and losing independence. An assessment of fall risk should be integrated into the history and physical examination of all older patients (Chap. 3).
Cognition: The incidence of dementia and delirium increase with age, particularly among those over 85 years; yet many older people with cognitive impairment remain undiagnosed. The value of making an early diagnosis includes the possibility of uncovering treatable conditions. The evaluation of cognitive function can include a thorough history, brief cognition screening, a detailed mental status examination, neuropsychological testing and other tests to evaluate medical conditions that may contribute to cognitive impairment (Chap. 9).
Mood: Depressive illness in older people is a serious health concern leading to unnecessary suffering, impaired functional status, increased mortality and excessive use of healthcare resources (Chap. 9). Depression in later life remains underdiagnosed and inadequately treated. Depression in older adults may present atypically and may be masked in patients with cognitive impairment. Screening is easily administered and likely to identify patients at risk if both of the folowing questions are answered affirmatively:
‘During the past month, have you been bothered by feeling down, depressed, or hopeless?’
‘During the past month, have you been bothered by little interest or pleasure in doing things?’
Polypharmacy: Older people are often prescribed multiple medications by different healthcare providers, placing them at increased risk of drug interactions and adverse medication events. The clinician should review medications at each visit. The best method of detecting potential problems with polypharmacy is to have patients provide all medications (prescription and non-prescription) in their packaging. Alternatively, practitioners should contact the patient’s primary care physician, particularly if the patient cannot remember their medications. As some health systems have moved towards electronic health records and electronic prescribing, the possibility of detecting potential medication errors and interactions has increased. Older people should also be asked about alternative medical therapies by asking about herbal medicine use with the question: ‘What prescription medications, over the counter medicines, vitamins, herbs, or supplements do you use?’
Social and financial support: The existence of a strong social support network in an older person’s life can frequently be the determining factor of whether the patient can remain at home or needs placement in a residential care setting. A brief screen of social support includes taking a social history and determining who would be available to help if they become ill. Early identification of problems with social support can help planning and timely development of resource referrals. For patients with functional impairment, the practitioner should ascertain who the person has available to help with ADLs. It is also important to assess the financial situation of a functionally impaired older adult; some may qualify for state or local benefits, depending upon their income. Occasionally, there are other benefits such as long-term care insurance or veteran’s benefits that can help in paying for caregivers and prevent the need for institutionalisation.
The gathering of information is more complex than it seems , particularly collecting accurate baseline information from patients who may have cognitive difficulties, espeically if the environment is noisy such as in the ED or busy trauma unit, in the presence of pain or opioid analgesia use or anaesthesia. In the first few hours following admission, the patient is more likely to recall the history of the injury due to more recent recall, but this period is also very stressful. Collecting detailed and accurate information needs specialised skills in communication and an expert understanding of the process of assessment.