Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly
Toolkit History : July 2014
Dr. Angelo Grazioli,
Mullingar, Republic of Ireland
Why and how this toolkit came about
Before I formally took over the geriatric care lead in a busy 5 doctor GP practice, visits to the nursing homes followed a pattern familiar to most Irish GP's and, I am sure, GP's in many other settings also.
I would rush in and out of the nursing home for a total of 30 to 40 minutes actual on-site clinical time, which with travel time would pretty much take up my entire lunch hour, or take a few extra hours out of my evening.
Back To : Toolkit History
Very little time would be available to ponder the intricacies of poly-pharmacy and co-morbidity, and virtually no time at all to sit and chat , formally assess mental status, diet, interaction with different
other residents, etc.
Q scores, FRAX, egfr etc. would be calculated back at the surgery when time allowed, and be factored into the treatment plan at the next brief nursing home visit.
The overdependence on night-cover medical services, emergency department and outpatient department hospital referrals seemed regrettable but unavoidable.
Back at the surgery the awareness of incomplete care for the community based elderly patient persisted, and made me feel uncomfortable and dissatisfied.
The old dears would take up to 20% of the consultation time just to get from the waiting room to the consulting room, and from chair to couch. Twice the time needed to obtain a history and examination would leave no time for niceties such as TUG test, Clock test, MMSE, drug review etc.
At least these home based individuals could attend the surgery multiple times for the extensive appropriate monitoring care not required by most of the younger patients, but even so, the scheduling depended more on my awareness and mood at the time than on a systematic proven protocol.
Record keeping problems bedevilled geriatric care for both nursing home and community based individuals.
The electronic medical record system provided a religiously maintained front page record of medical conditions, surgical interventions and major special investigations past and present. However, key information would be buried in the SOAP records, and the specialist reports on file, dating back several years.
Frustration and time wasted when planning and executing the required geriatric monitoring and care, ran high.
Something had to be done to maintain the required standard of excellence in care and avoid the myriad of possible omissions and errors courted by the system.
The evidence based literature is crystal clear :
- Geriatrics as a distinct field of study and practice is a relatively young discipline
- the Comprehensive Geriatric Assessment is central to quality geriatrics practice
- the GP is uniquely placed to manage the multidisciplinary effort required
I eagerly searched the literature for a readymade kit of information, protocols, and ready to use forms and templates to get me going.
I was surprised to discover that such a toolkit did not exist.
Some books provided a good theoretical framework but no practical tools.
Some published papers presented excellent protocols and recommendations, but in fragmented fashion, addressing one aspect only, with little attention to integration into the big picture, and very little attention to the difficulties of implementation into a busy GP practice.
The toolkits available were developed by specific organisations to meet their very specific needs such as ED triage, pre-op screening, hospital discharge or nursing home admission.
There was no option but to develop my own toolkit.
It seemed worthwhile, in doing so, to document and publish the effort, the evidence, the validated tools, the references, and my original developed templates, so that my colleagues elsewhere would not have to do it all over again for themselves.
This Comprehensive Geriatric Assessment Toolkit is the result.
It is not offered as THE way to implement a CGA in GP practice.
It is offered as a solid structured base for the GP to adapt to a personalised plan of action for better geriatric care in his/her unique practice setting.
Hopefully, in time, feedback from GPs in different settings will contribute valued improvements and additions to the toolkit, making it even more practical and useful.