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Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly

Making it Happen

Development of a More Substantial System

Making It Happen

The following sample case studies illustrate the journey of implementation of a more CGA based, proactive, personalised care of the elderly in a GP practice.

The 3 case studies are composites of real GP practice experiences and illustrate the :

  1. Early stage of implementation

  2. Development of a more substantial system

  3. Advanced implementation

More System

2. Development of a more substantial system



Success of early stage of implementation.

Dr. Murphy was greatly encouraged by the success of the implementation of a CGA based proactive and personalised care of  Mary O'Connell.

The system was applied to several other elderly individuals in the practice.

Dr. Murphy found the work done by the nurses extremely useful and was happy to be able to thus spend more time discussing issues with the patients, concentrating on the clinical examinations and decisions arising.

The nurses reported great satisfaction in the provision of care. They all valued the clear protocols to be followed and the tailored for purpose resources available.

The positive feedback from specialists consulted was most gratifying.

As was the case with Mary, every patient was highly pleased with the care provided.

Word of mouth led to a significant number of new patients of all ages transferring to the practice.

Cosequently Dr Murphy decided to expand the system to the care of the 12 residents under his care in 2 local residential nursing homes.




Nurse Cathy visited the nursing homes on 3 separate occasions in order to perform

for all 12 nursing home residents

In both nursing homes Nurse Cathy also

  • Explained the scope of CGA based proactive and personalised care of  the elderly, and how this was implemented in Dr. Murphy's practice

  • Requested the nursing home collect AGEDAT-G1 baseline data for all patients

    • i.e. Complete all sections except 4-Psychological, 6-Advance Care Planning, and 7-Problem list (to be completed by Dr)

  • Requested the nursing home provide for each paient

    • Urine stix analysis

    • A set of fresh observations

  • Requested laboratory workup for each patient

    • Blood screen

      • FBC

      • ESR

      • LFT

      • TFT

      • glu + HbA1c

      • FSH

      • Renal screen with eGFR

      • Bone screen with Ca+ uncuffed and Vitamin D

      • Coeliac screen with Bence Jones protein and Mg+

      • Lipids

      • B12 and folate

    • Stool screen

      • Fecal occult blood

      • Calprotectin




Nurse review

Nurse Cathy entered all information gathered in the work-up above and entered it into each patient's AGEDAT-G1 record


Dr Review

It was Dr. Murphy's long standing arrangement to regularly attend each nursing home once every week.

Utilising the routine weekly scheduled visits, and basing the required actions on a review of the information gathered in the initial work-up, it took 2 months for Dr. Murphy to complete the AGEDAT-G1 record for each of the 12 patients.

This included :

  • Reviewing the work-up data collected for each patient and

  • Performing the required portions of the Physical Examination

  • Performing a Medication Review for each patient

  • Request nursing home staff obtain

    • Further laboratory blood tests for 2 patients arising from physical examination findings and review of initial work-up lab. results

    • CXR for 4 patients

    • Barthel Index scoring for 8 patients whose Edmonton scale score indicated moderate or severe Frailty

    • Frequency and Volume chart for 1 female patient who complained of increased frequency in the absence of a UTI

    • International Prostate Symptom Score (IPSS) for 1 male patient who reported increased nocturnal voiding in the absence of a UTI

    • Epworth Sleepiness scale for 2 patients who staff reported as being unusually sleepy and snoring loudly in recent weeks

    • Advance Care Plan Statement from 3 patients able to comply

    • DNACPR document signed by relatives of 2 demented patients, where no such record was found to be held by the nursing home

  • Request Nurse Cathy attend the nursing home to perform

    • QFracture score for 3 patients whose FRAX score was in the low bone mass range

    • DOLOPLUS-2 scale assessment for 1 patient because of poorly controlled pain and dementia

    • MoCA evaluation for 2 patients whose mental status had markedly deteriorated in recent months

  • Referral of

    • 2 patients to dietician because of low BMI, and 1 because of high BMI

    • 3 patients to podiatrist


Nurse visits


2 Domiciliary visits were required for Nurse Cathy to perform the

  • 3 Q-Fracture score calculations requested by Dr Murphy

  • 1 DOLOPLUS-2 scale assessment requested by Dr Murphy

  • 1 MoCA evaluation

which were requested by Dr Murphy

Patient allocation to appropriate register

scheduled appointments as required by each register's protocol

Dr. completion of AGEDAT-G1 record

Utilising the routine weekly scheduled visits, it took 1 month for Dr. Murphy to

  • Process the results of the various tests he had requested be performed by the Nursing Home Staff and by Nurse Cathy,

  • Prescribe appropiate medication

  • Refer x patients along the way

    • 1 to Psychiatrist (re-evaluation of dementia medication)

    • 1 to ENT surgeon (investigation of excessive snoring)

    • 1 to Urologist (suspected residual volume and/or bladder pathology)

  • Update the AGEDAT-G1 record for each of the 12 patients accordingly



4 monthly and annual interventions were scheduled as per

  • AGEDAT-G1 requirements

  • requirements of registers on which several of the patients were placed



Nursing home

  • The staff at both nursing homes were very pleased with Dr. Murphy's care plan, and co-operated enthusiastically with the required interventions.

  • The nursing homes adopted the AGEDAT-G1 format for all Dr. Murphy's patients, and requested 4 monthly updates for their records.

Professional praise

  • HIQA noted the system at their next inspection, and praised the nursing homes and Dr. Murphy for it. HIQA recommended the nursing homes show other attending GPs Dr. Murphy's AGADAT-G1 records, and recommended they adopt a similar system of care.

  • Several specialists who received AGEDAT-G1 format referrals, commented positively about it in their report-back

Improved care

  • Dr. Murphy was pleased to have all required data at hand when performing regular medication reviews

  • Discovering early signs of disease on routine personalised monitoring plans convinced Dr. Murphy of the validity and efficacy of the implemented preventive system of care

  • Dr. Murphy found the personal data collected for AGEDAT-G1 most useful, in that it allowed him to personalise his greetings and small talk with patients .... e.g. by enquiring about a favourite grandchild, commenting on a favourite sport or hobby, mentioning other family members by name etc.  

  • After the 3 months required for the initial work-up and follow-up, Dr murphy was most pleased top find the time spent visiting the nursing home more efficiently utilised, with literally double the amount of work performed in the same amount of time

  • Calls to the nursing home outside of the routine visits all but disappeared, as did callout of the OOH sevice.

Increased clientele

  • In the first 6 months following implementation of the system at the two nursing homes, 8 residents transferred their care to Dr. Murphy, increasing his care from 12 to 20 residents.

  • The families of 4 of the residents tranferred to the practice (7 adults and 6 children)

  • Several individuals personally thanked Dr. Murphy, praising the thoroughness of his care, his personal caring attitude and his propensity to explain disease processes and involve his elderly patients in decision making and management of their health.

Staff satisfaction

  • Dr. Murphy's own staff again expressed enthusiasm for the tools and resources available, and began to contribute suggestions for more of the same, thereby improving team spirit, practice efficiency and patient care


Dr. Murphy's practice was able to provide the care of the patient described above because of the following

  • Practice registers

  • AGEDAT-G1 medical record linked to the practice Electronic Medical Record system

  • Nurse Protocols

  • Protocols for nursing Home
  • Multi Disciplinary Teamwork centred around referrals


Note : Dr. Murphy had personally spoken to all Health Care Professionals to whom patients were referred, and made them aware of the CGA based proactive personalised  approach to their care.

All referrals included an updated copy of the patient's AGEDAT-G1 record



All resources may be accessed directly in the Resources Index

For more information, follow the path to the following appropriate CGA Toolkit Plus pages  :

Edmonton scale

Homepage - Frailty - Edmonton Frail scale

                                 - Read More about Frailty Index - Edmonton Frail Scale App.   


Clock Test

Homepage  - Comprehensive Geriatric Assessment - Medical Assessment - Physical Examination - Clock test

Timed Up and Go test (TUG)

Homepage  - Comprehensive Geriatric Assessment - Medical Assessment - Physical Examination  - TUG


Homepage  - Comprehensive Geriatric Assessment - Medical Assessment - Bone Health Assessment - FRAX



Homepage  - Comprehensive Geriatric Assessment - AGEDAT-G1


Homepage  - Comprehensive Geriatric Assessment - Medical Assessment - Nutrition Assessment - BMI App.

Physical examination

Homepage  - Comprehensive Geriatric Assessment - Medical Assessment - Physical Examination 

Medication Review

​Homepage  - Comprehensive Geriatric Assessment - Medication Review

Barthel Index

​Homepage  - Comprehensive Geriatric Assessment - Assessment of Functioning - Barthel Index

Frequency and Volume Chart

​Homepage  - Geriatric Syndromes - Urinary Incontinence - Frequency and Volume chart

International Prostate Symptom Score (IPSS)

​Homepage  - Geriatric Syndromes - Urinary Incontinence - IPSS

Epworth Sleepiness Scale

​Homepage  - Geriatric Syndromes - Sleep Disorders - Epworth Sleepiness scale


Advance Care Plan

​Homepage  - Advance Care Planning - Advance Statement template (Advance Care Plan)


​Homepage  - Advance Care Planning - DNACPR - DNACPR (England)

QFracture score

Homepage  - Comprehensive Geriatric Assessment - Medical Assessment - Bone Health Assessment - QFracture




​Homepage  - Comprehensive Geriatric Assessment - Medical Assessment - Pain Assessment - Doloplus-2  



​Homepage  - Comprehensive Geriatric Assessment - Psychological Assessment - Cognitive Decline - MoCA

Clock Test
Physical exam
Meds review
Adv Care Plan
Freq+Vol chart
Physical Examination

This case study and these resouces pertain to

the Development of a more substantial system

of a CGA based proactive personalised care system for the elderly

Go To : Advanced implementation

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