Comprehensive Geriatric Assessment: assuring appropriate treatment and improving quality of life.

The Comprehensive Geriatric Assessment (CGA) is an effort by an interdisciplinary team of professionals whose goal is to advocate for elder patients and help restore them to optimum health and functionality. This article presents an analytic look at this powerful and underused tool.

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Years ago, I read the following statistic: "In 1901, there were more blacksmiths than physicians in the United States." Although the source is long gone from my files, I continue to use the comparison to remind myself and others how often we miss the medical mark on assessing and treating our elders' needs. I suspect that in 2002, more than a century later, there still may be more blacksmiths in the United States than there are geriatric physicians--and that's where the problems begin.

Imagine that your seventy-five year-old parent or client visits her regular physician with a bruised knee. Her physician is dedicated and caring, but is not a geriatric specialist. The physician will probably examine the seventy-five year-old woman in the same manner he would examine a forty-five year-old with the same symptoms: he will X-ray her knee, smile, and tell her, "Good news, Mrs. Jones, it's just a bruise. Nothing is torn or broken."

Without special training, and with the time limitations most physicians now impose on their patients, his next step will likely be to quickly write two prescriptions and tell her, "These will reduce the inflammation and ease your pain. If you don't feel better in five or six days, call me." The physician will move on to his next patient, pleased that his patient wasn't seriously hurt and content in the knowledge that he has sent her home to heal just as he has done with hundreds of other patients. But has he?

In reality, his lack of understanding of the process of aging may have actually increased her risk for further injury. It may be unnecessary to investigate the cause of a forty-five year-old patient's bruised knee, but it is vitally important to detect, assess, and treat the root cause of an elder's symptoms and to evaluate the potential risks the patient faces because of the problem. In many cases, adding two more medications to the four to six medications the seventy-five year-old may already take will create its own risk potential. Increasing medication intake to six to eight per day may significantly add to the possibility of an adverse drug reaction, which may increase the patient's risk of falls and hip fractures, have a serious impact on cognitive function, or even result in death. At least 25% of older adults living independently take the wrong prescription medicines, placing them at risk for adverse effects such as nervousness, confusion, memory loss, and depression. (1) Researchers estimate that 23.5% of all older persons in community settings received at least one potentially inappropriate drug--one-fifth of these used two or more harmful drugs and some used as many as five. (2) These two preceding estimates consider only the prescribing of potentially dangerous drugs, not harmful interactions. Consequently, their conclusions represent just the tip of the iceberg. (3)

Think back to the seventy-five year-old client who visited her physician for assistance with her bruised knee. A skilled geriatric physician would try to relax the seventy-five-year-old patient, see to her comfort, and then begin trying to determine whether her bruised knee might have been caused by a decline in her vision that might have caused her to bump into furniture. In the future, her poor vision might also cause her to miss a step and fall down a flight of stairs and could easily lead to life-altering or deadly consequences when she gets in her car to drive home from the doctor's office. The client could also have bruised her knee because of shuffling steps (rather than lifting feet up and putting them down). Shuffling steps can be an indication of Parkinson's or Alzheimer's disease. Or, she might have become dizzy and fallen from adverse medication reactions, low blood pressure, a heart attack, or a mini-stroke.

The truth is, most of the time we never know if Mrs. Smith's bruised knee might have been caused by a simple everyday accident, self-neglect, or physical abuse. Elderly patients who might be successfully treated and returned to a reasonable quality of life are instead inaccurately diagnosed, chronically overmedicated, and habitually inappropriately placed in Alzheimer's facilities or other types of nursing homes--without ever having had access to the restorative care that might help them regain their dignity and quality of life.

In the current medical climate, the comprehensive geriatric assessment may be the only tool that allows professionals the time to search out the information that is necessary for appropriate treatment and to effectively combat the erroneous assumption that we should treat illness and disease as a part of growing older. "Age is not an excuse for a lack of medical attention. `At her age, what do you expect?' is not a diagnosis, it is ageism and it's wrong." (4)

Here's a look at the current situation:

Fact: Americans over the age of sixty-five represent over one-half of physician visits annually.

Status: Only a tiny percent of healthcare professionals have any formal geriatric training to provide optimal care for their older patients. (5)

Fact: Adverse Drug Reactions (ADRs) account for up to 140,000 deaths annually in the United States. (6)

Status: Of the nearly 200,000 pharmacists in the United States, only 720 have geriatric training. (7)

Fact: In 2002, Medicare reduced fees paid for each medical service by 5.4%; fees are scheduled for a total reduction of 17% from 2002 to 2005. (8)

Status: By 2004 the United States is expected to have as few as 6,100 physicians (out of 650,000 currently licensed) certified in geriatric …