Comprehensive Geriatric Assessment in Older Adults

Introduction to Geriatric Evaluation

• The American Geriatrics Society recommends that all individuals aged 65 and older should undergo a systematic geriatric evaluation during routine assessments, including essential domains such as physical and cognitive function, emotional health, comorbidities, polypharmacy, nutrition, and social support 1
• The European Society for Clinical Nutrition and Metabolism suggests that geriatric evaluation should be performed systematically in all older patients, regardless of the specific diagnosis, and even in those who are overweight or obese 2
• This approach allows for the early identification of vulnerabilities that are not detected during routine medical evaluations, with a strength of evidence level of high 3, 1

Essential Domains to Evaluate

1. Malnutrition Screening

• The European Society for Clinical Nutrition and Metabolism recommends systematic screening for malnutrition using a validated tool such as the Mini Nutritional Assessment-Short Form (MNA-SF), every 3 to 6 months in outpatient practice, with a moderate level of evidence 2, 4
• Inquire about unintentional weight loss and assess dietary intake over several days, with a low level of evidence 2
• For this 85-year-old patient, liberalize dietary restrictions (low-sodium, low-cholesterol diets) to reduce the risk of malnutrition and functional decline, with a moderate level of evidence 2

2. Cognitive Evaluation

• The American College of Physicians recommends evaluating cognitive function as soon as impairment is suspected, based on direct observation, patient report, or family concerns, with a high level of evidence 5
• The Mini-Mental State Examination (MMSE) remains the most studied tool, but its interpretation should take into account age and education level, with a moderate level of evidence 5
• For patients with diagnosed dementia, use specific tools like the Edinburgh Feeding Evaluation in Dementia Questionnaire (EdFED-Q) to identify feeding problems, with a low level of evidence 4

3. Medication Review

• The American Geriatrics Society recommends systematic review of all medications to identify polypharmacy and potentially inappropriate medications, with a high level of evidence 1
• Avoid medications with strong anticholinergic properties (diphenhydramine, cyclobenzaprine, oxybutynin) that worsen cognition, with a moderate level of evidence 6

4. Risk of Falls

• The American Geriatrics Society recommends asking a single screening question: "Have you fallen in the past year?" and evaluating mobility and balance if the answer is positive, with a moderate level of evidence 1

5. Emotional State

• The American Psychiatric Association recommends screening for depression using the Patient Health Questionnaire-2 (PHQ-2), with a moderate level of evidence 6
• Reserve selective serotonin reuptake inhibitors (SSRIs) for moderate to severe depression, due to the increased risk of cognitive decline in older adults, with a high level of evidence 6

6. Physical Function and Autonomy

• The American Geriatrics Society recommends evaluating activities of daily living (ADLs) and instrumental activities of daily living (IADLs), with a moderate level of evidence 1

7. Sensory Status

• The American Academy of Ophthalmology and the American Academy of Audiology recommend evaluating vision and hearing, although systematic screening in asymptomatic individuals is not formally recommended, with a low level of evidence 1
• Sensory deficits are common and impact quality of life, with a moderate level of evidence 1

Oncological Screening: Individualized Approach

Colorectal Cancer

• The American Cancer Society recommends that systematic screening for colorectal cancer is generally not recommended at 85 years of age, with a high level of evidence 7, 8, 9
• Exceptions include patients who have never been screened before and are in good health with a life expectancy of more than 10 years, with a moderate level of evidence 8, 9

Interventions Based on Evaluation

• The American Geriatrics Society recommends that any positive evaluation should be followed by targeted interventions, appropriate advice, and/or referrals to specialists, with a high level of evidence 1, 2
• Develop an individualized nutritional care plan in an interdisciplinary team if malnutrition is detected, with a moderate level of evidence 2
• Promote adapted physical activity, including muscle strengthening, cardiovascular exercises, and balance exercises, with a moderate level of evidence 10

Frequency of Re-Evaluation

• The European Society for Clinical Nutrition and Metabolism recommends repeating screening every 3 to 6 months for patients in stable condition in outpatient practice, with a moderate level of evidence 2, 4
• Re-evaluate more frequently in case of changes in overall health, feeding abilities, or behavior, with a low level of evidence 4

Comprehensive Geriatric Assessment for Patients with GAF 65

Essential Domains to Evaluate

• The American Geriatrics Society recommends that all patients age 65 and older require systematic evaluation across six high-priority domains known to be associated with outcomes, including physical function, cognitive function, emotional health, comorbid conditions, polypharmacy, and social support 11, 12
• The assessment of comorbid conditions is crucial, as it may impact treatment tolerance and outcomes, according to the American College of Physicians 12
• Evaluating available social support systems and caregiver resources is essential, as recommended by the American Geriatrics Society 12

Treatment Plan Implementation

• The American Society of Clinical Oncology suggests using GA results to inform treatment decision-making, including adjusting cancer treatment intensity based on identified vulnerabilities and modifying medication regimens to reduce polypharmacy 11, 13, 14
• Targeted interventions, such as providing appropriate counseling and referrals to specialists, can address impairments, as recommended by the American Geriatrics Society 12
• Recent high-quality RCTs, such as the GAP701 trial, demonstrate that GA-guided management significantly improves clinical outcomes, including fewer grade 3-5 toxic effects and improved quality of life 13, 14, 15, 16

Evidence for GAM Effectiveness

• The GAP701 trial showed that patients receiving GA-guided management had significantly fewer grade 3-5 toxic effects (51% vs 71%; RR 0.74, P=0.0001) and fewer falls (12% vs 21%; P=0.0035) 13, 14
• The INTEGRATE trial demonstrated improved quality of life over 24 weeks (P=0.039) and significantly lower healthcare utilization with GA-guided management 14, 15, 16