Comprehensive geriatric assessment

Start with the person's account of what changed and what matters most. Ask what they could do before the current illness, which activities are now difficult, what outcome would make treatment worthwhile and what they fear losing. Use a trained interpreter, hearing aids, glasses, pain relief and an unhurried environment so communication failure is not mistaken for incapacity or cognitive decline.

Construct a dated acute problem list. Older adults may present with a fall, immobility, poor intake, incontinence or confusion rather than an organ-specific symptom. Examine fully and investigate plausible serious disease while avoiding indiscriminate testing. Record diagnoses, uncertainty, severity, trajectory and which findings are chronic, acute or treatment-related.

Establish baseline function from the period before acute deterioration, commonly about two weeks earlier. Separate basic ADLs such as washing, dressing, toileting, transfers and eating from IADLs such as cooking, shopping, transport, finances and medicine management. Describe assistance, equipment, time, cueing and recent change; a score without context misses the mechanism and discharge requirement.

Assess mobility and falls directly when safe: transfers, gait, walking aid, footwear, postural blood pressure, strength, balance, pain and fear of falling. Review fracture and osteoporosis risk. Physiotherapy identifies capacity and rehabilitation potential; occupational therapy tests meaningful tasks and environmental fit rather than simply confirming that a person walked once on a ward.

Reconcile medicines from at least two sources and include prescribed, over-the-counter, herbal, inhaled, topical and as-required products. For each medicine identify current indication, benefit horizon, adherence, administration help, renal or hepatic suitability and adverse-effect contribution. Deprescribing is a monitored shared decision, not deletion of every preventive drug because the patient is old.

Screen cognition for delirium first, then longer-standing impairment. Obtain collateral about memory, executive function and fluctuation. Assess mood, anxiety, sleep, alcohol, loneliness and grief, recognising that apathy, withdrawal and somatic symptoms may signal depression. Check hearing and vision before interpreting any cognitive score and arrange diagnostic assessment when screening is abnormal.

Nutrition assessment includes weight trajectory, BMI, appetite, swallowing, dentition, ability to obtain and prepare food, feeding assistance and disease-related catabolism. Check continence, constipation, urinary retention and skin integrity. Investigations are hypothesis-led: FBC, renal, liver, glucose, calcium, CRP, urinalysis, ECG and imaging are selected from the acute and chronic problem list rather than ordered as a universal geriatric panel.

Map the social system. Record home layout, heating, stairs, bathroom, alarms, transport, care visits, night support, finances affecting care and who performs each hidden task. Speak with the carer separately when appropriate, ask what support they provide and whether they can and are willing to continue, and offer a carers assessment rather than presuming unlimited family capacity.

Capacity is decision- and time-specific. Support the person to understand, retain, use or weigh and communicate the relevant information. An unwise choice does not prove incapacity. If capacity is absent, identify any valid lasting power of attorney, advance decision and relevant wishes, consult those close to the person and document a proportionate best-interests decision without allowing family preference to become proxy consent.

The case conference prioritises interacting problems. A feasible plan might treat infection, reduce sedative burden, provide strength and transfer practice, change meal support, install equipment and arrange continence review. Set the least restrictive safe destination and document contingency triggers. Discharge summaries state new baseline, outstanding uncertainty, medicine changes with reasons, rehabilitation plan and who will review each item.

Review makes CGA effective. Reassess delirium, function, intake, pain, continence, mood, carer capacity and goals after interventions. If progress stalls, revisit missed disease, adverse medicines, depression, sensory loss, environment and rehabilitation intensity. Functional non-recovery is a clinical signal, not merely a placement problem.

CGA should reduce fragmentation rather than multiply appointments. For severe frailty or multimorbidity, agree one coordinating clinician, align reviews, simplify monitoring and use anticipatory planning. Balance prevention against likely benefit, burden and competing mortality while maintaining vaccination, symptom treatment, dental, sensory and social care that preserves daily life.