Comprehensive Geriatric Assessment and Frailty — Clinical Case

DCE Long Case

Patient brief (provided to trainee)

Patient: Mrs Margaret Chen, 84 years old, retired schoolteacher. [1]

Presenting complaint: Progressive functional decline over 6 months, two falls (one with a wrist fracture), weight loss, and low mood, assessed in the geriatric outpatient clinic. [1]

History of the presenting complaint: Mrs Chen's daughter reports a 6-month decline. Her mother has become increasingly slow and cautious on her feet, has had two falls in the past 4 months (the second resulting in a distal radial fracture treated in a plaster), and has given up driving after a minor parking accident 2 months ago. She now needs help with her weekly shopping and her housework. Her appetite has decreased, and she has lost about 5 kg over 6 months. She has become withdrawn and has stopped attending her weekly garden club. She denies chest pain, palpitations, syncope, or focal neurological symptoms. [1]

Past history:

• Hypertension (diagnosed 20 years ago).
• Type 2 diabetes (diagnosed 15 years ago).
• Atrial fibrillation (diagnosed 8 years ago, on warfarin).
• Osteoarthritis (knees and hips).
• Left total hip replacement 8 years ago for osteoarthritis.
• Appendicectomy in her 30s.
• No prior fractures until the recent wrist fracture. [1]

Current medications:

• Warfarin 4 mg daily (INR target 2.0 to 3.0).
• Metformin 1000 mg twice daily.
• Gliclazide 80 mg daily.
• Amlodipine 10 mg daily.
• Oxybutynin 5 mg twice daily (for overactive bladder, started 3 years ago).
• Paracetamol 1 g four times daily.
• Codeine 30 mg as needed (takes two to three daily for joint pain).
• Temazepam 10 mg at night (started after her husband died 2 years ago).
• Omeprazole 20 mg daily. [1]

Social history: Widowed 2 years ago when her husband died of pancreatic cancer. Lives alone in a two-storey, three-bedroom house in an outer suburb. Her older daughter lives locally and visits weekly; her younger daughter lives interstate. She was a primary school teacher, retired at 65. She does not smoke and drinks alcohol rarely. Before this decline she was independent in all activities, walked daily, and attended her garden club and a weekly church group. She has no advance care directive and no appointed substitute decision-maker. [1]

Examination findings (trainee elicits):

• Alert and cooperative. Oriented to person and place but gives the year as 2024. Speech is slow but fluent.
• MoCA: 21 out of 30 (points lost on recall, attention, and executive).
• GDS-15: 7 (positive screen for depression).
• 4AT: 0 (no delirium).
• Blood pressure: 142/78 mmHg lying, 118/66 mmHg standing (24 mmHg systolic drop).
• Pulse: 78, irregularly irregular (atrial fibrillation).
• Bilateral temporal wasting and reduced thenar bulk.
• Grip strength: 14 kg dominant hand (Jamar dynamometer).
• Timed Up and Go: 17 seconds.
• Gait speed over 4 metres: 0.65 m/s. Gait is slow, cautious, with a shortened stride and a wide base.
• Chair stand (5 rises): 16 seconds.
• Katz ADL: 4 out of 6 (needs help with bathing and transferring).
• Lawton IADL: 5 out of 8 (independent in telephone, feeding, medications; needs help with shopping, housework, laundry, transport, finances).
• MNA-SF: 8 out of 14 (at risk of malnutrition).
• Clinical Frailty Scale: 6 (moderately frail). [1]

Investigations:

• Full blood count: normal.
• Urea and electrolytes: sodium 138, potassium 4.2, creatinine 92 micromol/L (eGFR 52).
• Liver function tests: normal.
• HbA1c: 58 mmol/mol.
• TSH: 2.1 (normal).
• B12: 280 pmol/L (normal), folate normal.
• Calcium normal, vitamin D 38 nmol/L (low).
• INR: 2.6.
• DEXA: T-score minus 2.6 at the femoral neck (osteoporosis). Appendicular skeletal muscle mass index 4.9 kg per square metre (low for women, below 5.4).
• CT brain: mild generalised atrophy with a few small white matter changes. No infarct or mass. [1]

Candidate's long-case presentation (SASPOP)

"Mrs Margaret Chen is an 84-year-old retired schoolteacher presenting with a 6-month decline in function, two falls with one fragility wrist fracture, weight loss, and low mood. [1]

Her past history includes hypertension, type 2 diabetes, atrial fibrillation on warfarin, osteoarthritis, and a previous left hip replacement. Her medications are warfarin, metformin, gliclazide, amlodipine, oxybutynin, paracetamol, codeine, temazepam, and omeprazole — eight regular medications with a high anticholinergic and sedative burden. [1]

She lives alone in a two-storey house since her husband died 2 years ago. Her older daughter visits weekly; her younger daughter is interstate. She has no advance care directive. [1]

On examination she has atrial fibrillation, orthostatic hypotension (a 24 mmHg systolic drop), bilateral temporal wasting, a MoCA of 21, a GDS-15 of 7, a grip strength of 14 kg, a Timed Up and Go of 17 seconds, a gait speed of 0.65 m/s, and a Katz ADL of 4. Her DEXA shows osteoporosis (T-score minus 2.6) and an appendicular skeletal muscle mass index of 4.9. Her vitamin D is low at 38. [1]

Her main problems are:

1. Moderate frailty (Clinical Frailty Scale 6) with confirmed sarcopenia by EWGSOP2 (low grip strength plus low muscle mass)
2. Falls and a fragility wrist fracture, with orthostatic hypotension, sarcopenia, and polypharmacy as contributors
3. Polypharmacy with high anticholinergic and sedative burden — oxybutynin, codeine, temazepam, amlodipine
4. Cognitive impairment (MoCA 21), worsened by the anticholinergic burden
5. Depression (GDS-15 of 7)
6. Malnutrition (MNA-SF of 8, 9 percent weight loss in 6 months) and vitamin D deficiency
7. Osteoporosis (T-score minus 2.6, fragility fracture) needing secondary fracture prevention
8. Suboptimal glycaemic control needing individualised targets
9. Social isolation and environmental falls risk — lives alone in a two-storey house, one daughter interstate, no advance care directive [1]

My integrated plan is a structured medication review — I will stop the oxybutynin and switch to mirabegron, withdraw the temazepam gradually, minimise and stop the codeine, and reduce the amlodipine for the orthostasis. I will start a multifactorial falls prevention programme — exercise, home safety, vision check, and vitamin D. I will address the sarcopenia with progressive resistance exercise and dietary protein at 1.2 to 1.5 grams per kilogram per day with oral nutritional supplements, and correct the vitamin D deficiency with 1000 IU daily. I will treat the depression with citalopram 10 mg daily. I will investigate the cognitive impairment with an MRI and repeat the MoCA after the medication changes. I will start osteoporosis treatment with alendronate, calcium, and vitamin D given the fragility fracture. I will arrange a home safety assessment by an occupational therapist, community home care services, and a personal alarm. I will initiate advance care planning — values, goals, the appointment of an enduring guardian and power of attorney while she retains capacity. I will review at 3 months with repeat measures to track the frailty reversal. The framework is comprehensive geriatric assessment, and the evidence is that CGA with interdisciplinary follow-up improves survival and function in this patient group." [1]

Discussion questions

Q1: "How would you prioritise these nine problems, and what is the single most impactful intervention?" [1]

"I would prioritise the problems in order of the immediate risk to her safety and the reversibility of the intervention. The top priority is the falls risk — she has had two falls, one with a fracture, and the next fall could be a hip fracture with catastrophic consequences. The most impactful single intervention is the medication review and deprescribing — specifically, stopping the oxybutynin, withdrawing the temazepam, minimising the codeine, and reducing the amlodipine for the orthostatic hypotension. These four changes address the falls risk (reducing orthostasis, sedation, and central nervous system depression), the cognitive impairment (reducing anticholinergic burden), and the polypharmacy simultaneously. The second priority is the sarcopenia and the falls prevention programme — progressive resistance exercise, protein, and vitamin D — because these are the evidence-based interventions that can improve her strength, balance, and function and reduce the falls risk. The third priority is the osteoporosis treatment — she has a fragility fracture and osteoporosis on DEXA, and the bisphosphonate reduces the risk of the next fracture. The fourth is the depression and the cognitive assessment, the fifth is the glycaemic control (relaxed targets for a frail older adult), and the sixth is the advance care planning and the social support package. The key insight is that the problems are interrelated — the medication review improves the falls risk, the cognition, and the orthostasis in a single step, and the exercise and nutrition programme addresses the sarcopenia, the falls, the depression, and the cognitive function. This is the principle of the integrated CGA plan." [1]

Q2: "How would you manage her atrial fibrillation and anticoagulation given her falls?" [1]

"Her stroke risk is high — her CHA2DS2-VASc is at least 7 (female sex, age over 75, hypertension, diabetes), giving an annual stroke risk of around 10 percent or more. Her bleeding risk is also elevated, but the evidence is clear that in atrial fibrillation, the stroke risk almost always exceeds the bleeding risk, even in frail older adults, and anticoagulation prevents more strokes than it causes serious bleeds. The annual risk of a fall-related intracranial haemorrhage in an anticoagulated older adult is about 1 percent — far below the stroke risk. My approach would be to switch her from warfarin to apixaban 2.5 mg twice daily (she meets the dose-reduction criteria of age 80 or over and weight 60 kg or under) — the direct oral anticoagulants have a lower risk of intracranial haemorrhage than warfarin and do not require INR monitoring. I would not stop the anticoagulation because of her falls — instead, I would reduce the falls risk through the medication review, the exercise programme, and the home safety assessment, which together reduce the bleeding risk. The decision is shared with her and her family, and I would explain the balance of risk and benefit honestly — but the evidence-based recommendation is to continue anticoagulation." [1]

Q3: "She has a MoCA of 21. How would you assess whether this is dementia, and what reversible causes would you exclude?" [1]

"The MoCA of 21 indicates cognitive impairment, but a single score does not diagnose dementia. The diagnosis requires a progressive decline from a documented baseline, confirmed by a collateral history, across multiple cognitive domains, with functional impact. I would first establish the baseline and the trajectory — her daughter reports a 6-month functional decline, but the cognitive timeline is less clear. I would seek a collateral history from both daughters and from the GP. I would exclude the reversible contributors: the B12, folate, and TSH are normal, which excludes B12 deficiency, folate deficiency, and hypothyroidism. The anticholinergic burden from the oxybutynin is a significant reversible contributor — stopping it may improve the cognition. The depression (GDS-15 of 7) can produce pseudodementia — treating it with an SSRI and reassessing the cognition is essential. The orthostatic hypotension and the polypharmacy may be contributing. The CT brain shows mild atrophy and a few white matter changes — the white matter changes suggest a vascular component, which fits her hypertension, diabetes, and atrial fibrillation. I would arrange an MRI to characterise the atrophy pattern and the vascular burden more precisely. After the medication review (stopping oxybutynin, withdrawing temazepam, minimising codeine) and the treatment of the depression, I would reassess the MoCA at 3 months. If it remains low and the collateral history confirms a progressive decline, the diagnosis is likely mixed Alzheimer and vascular mild cognitive impairment or early dementia, and I would consider a cholinesterase inhibitor. The key point is that a MoCA score is a starting point, not a diagnosis — the trajectory and the exclusion of reversible causes are what settle it." [1]

Q4: "How would you set up her community support, and what is the plan if she continues to decline?" [1]

"The community package should be comprehensive and tailored to her needs. I would arrange a home safety assessment by an occupational therapist — to address the stairs (consider a stair lift or a ground-floor bedroom conversion), the bathroom (grab rails, a shower chair, a non-slip mat), the lighting, the rugs and cords, and the kitchen access. I would arrange a community home care package for assistance with shopping, cleaning, meal preparation, and medication supervision — at a level appropriate to her needs (a Home Care Package at level 2 or 3 in the Australian system). I would provide a personal alarm (a pendant or wristband with a fall detector) and register her with her local council for aged care services. I would refer her to a community geriatric or aged care assessment team (ACAT in Australia) for an ongoing assessment and care coordination. I would offer her locally-living daughter a carer assessment, education about the management plan, and access to respite and carer support services. I would encourage the garden club and the church group as social and cognitive engagement — social isolation is a modifiable risk factor for cognitive decline and frailty. If she continues to decline despite the interventions, I would revisit the goals of care with her and her family — whether the aim is to remain at home with increasing support, to move to a single-level dwelling or a ground-floor unit, or to consider a transition to residential care. I would ensure the advance care directive is in place, the substitute decision-maker is appointed, and the preferred place of care and place of death are documented. The plan is dynamic — it is reviewed at each visit and adjusted as her needs change." [1]

DCE Short Case — Functional Assessment

Examiner instruction: "This 80-year-old man on the ward has mobility problems after a recent illness. Please assess his function." [1]

Systematic examination routine

1. Prepare — confirm identity, introduce, explain, ensure comfort, ensure glasses and hearing aids are on, ensure the walking aid is available, establish the baseline from the notes or the nursing staff.
2. Observe — posture, muscle bulk (temporal wasting, thenar wasting), the use of the arms to push up from the chair.
3. Timed Up and Go — explain and time the rise, the 3-metre walk, the turn, the walk back, and the sit. Observe the stride length, the step height, the turn stability, and any freezing.
4. Gait speed — time over 4 metres at the usual pace.
5. Grip strength — dynamometer in both hands, best of three attempts.
6. Chair stand — time five rises from a chair without using the arms.
7. Functional inquiry — ask explicitly about each Katz ADL and each Lawton IADL. Document the scores.
8. Falls and continence — falls in the past year, injuries, frequency, urinary and faecal continence.
9. Brief cognitive and mood screen — clock-drawing, a mood question, if time permits.
10. Clinical Frailty Scale — assign the score based on the overall function.
11. Focused examination — cardiovascular (orthostatic blood pressure, pulse), neurological (parkinsonism, neuropathy, focal signs), musculoskeletal (joint deformity, range of motion). [1]

Key signs this patient demonstrates

• Bilateral temporal wasting and reduced thenar bulk — suggesting sarcopenia.
• Pushes up with his arms to rise from the chair — lower limb weakness.
• Timed Up and Go: 16 seconds (abnormal, over 12 seconds).
• Gait: slow, cautious, shortened stride, wide base, stable turn. Gait speed 0.65 m/s (abnormal, below 0.8 m/s).
• Grip strength: 22 kg dominant hand (low, below 27 kg for men).
• Chair stand: 16 seconds (abnormal, over 15 seconds).
• Katz ADL: 4 out of 6 (needs help with bathing and toileting).
• Lawton IADL: 5 out of 8 (needs help with shopping, housework, transport).
• One fall in the past 3 months.
• Clinical Frailty Scale: 6 (moderately frail). [1]

Presentation template

"I performed a functional assessment on this 80-year-old man. He has bilateral temporal wasting and reduced thenar bulk, suggesting sarcopenia. He pushes up with his arms to rise from the chair. His Timed Up and Go is 16 seconds — abnormal, over the 12-second threshold. His gait speed over 4 metres is 0.65 m/s — abnormal, below 0.8 m/s. His gait is slow and cautious with a shortened stride and a wide base but a stable turn. His grip strength is 22 kg in the dominant hand — low, below the 27 kg threshold for men, suggesting probable sarcopenia. His chair stand for five rises is 16 seconds — abnormal, over 15 seconds. He is independent in four of six basic ADLs (Katz 4 — needs help with bathing and toileting) and has lost independence in three IADLs (Lawton 5 out of 8 — needs help with shopping, housework, and transport). He has fallen once in the past 3 months. His Clinical Frailty Scale score is 6 — moderately frail. [1]

The pattern is of moderate frailty with confirmed sarcopenia (low grip strength and impaired physical performance by the EWGSOP2 criteria), functional decline in both basic and instrumental ADLs, and a significantly increased falls risk. My differential for the functional decline includes deconditioning after his recent illness, sarcopenia, osteoarthritis, and a possible contribution from polypharmacy. I would perform a focused cardiovascular and neurological examination for the contributors — orthostatic hypotension, parkinsonism, neuropathy — and a medication review. [1]

My plan is a structured multifactorial assessment and intervention: a falls assessment, a medication review and deprescribing, a progressive resistance exercise and nutrition programme to address the sarcopenia, a DEXA and a vitamin D level to confirm the sarcopenia and the bone health, a home safety assessment, and a community support package. I would reassess at 3 months with the grip strength, the gait speed, the Katz, and the Lawton to track the response." [1]

Discussion

Q: "What is the Clinical Frailty Scale, and why should every older patient have one documented?" [1]

"The Clinical Frailty Scale (Rockwood 2005, PMID 16129869) is a 9-point clinical judgement scale — from 1 (very fit) through 5 (mildly frail), 6 (moderately frail), 7 (severely frail), and 8 (very severely frail) to 9 (terminally ill). It is scored after a brief clinical assessment in under a minute and requires no equipment. The reason every older patient should have a CFS documented within 24 hours of admission is that it predicts mortality, length of stay, institutionalisation, functional decline, delirium, and postoperative complications — more powerfully than age or comorbidity alone. A CFS of 5 or above identifies frailty and should change the care plan: it triggers a CGA, a medication review, a delirium prevention bundle, a falls risk assessment, an early mobilisation plan, and a goals-of-care conversation. In the perioperative setting, the CFS is now used to risk-stratify patients and to guide the consent conversation about the risk-to-benefit ratio of surgery. Without a documented CFS, the frailty is invisible — and invisible frailty is untreated frailty." [1]

Q: "How does the Timed Up and Go compare to other physical performance measures?" [1]

"The Timed Up and Go (TUG) is the highest-yield single physical performance test in geriatric medicine because it integrates several components of mobility in one task — the sit-to-stand (lower limb strength), the gait (stride, speed, balance), the turn (dynamic balance), and the turn-to-sit (controlled lowering). A TUG of 12 seconds or more predicts falls, and a TUG of 20 seconds or more indicates severe mobility limitation. It correlates with the Berg Balance Scale (a 14-item balance assessment) and with gait speed, but it takes a fraction of the time. Gait speed over 4 metres is the other key measure — it is the single most powerful predictor of adverse outcomes in older adults, with the threshold at 0.8 m/s. Grip strength (the Jamar dynamometer) measures upper body strength and is the primary EWGSOP2 parameter for sarcopenia (under 27 kg in men, under 16 kg in women). The chair stand test (five rises) measures lower limb power and is the alternative sarcopenia parameter. In a comprehensive geriatric assessment, I would measure all four — the TUG, the gait speed, the grip strength, and the chair stand — because together they provide a complete picture of the patient's physical performance, their falls risk, their sarcopenia status, and their prognosis." [1]

Q: "What is the single most important message about comprehensive geriatric assessment?" [1]

"That CGA is a therapeutic process that works. The 2017 Cochrane meta-analysis (Ellis, PMID 28898390) of 29 trials with over 13,000 participants showed that older adults who receive CGA are more likely to be alive and in their own homes at follow-up and less likely to be institutionalised. The critical determinant is the delivery model — CGA works when the geriatric team controls the care and provides ongoing follow-up (the GEM ward, the orthogeriatric service, the clinic with direct follow-up), and does not work as a consultation that is filed and ignored. The underlying principle is that frailty is a treatable condition, and the CGA is the structured, interdisciplinary process that identifies the problems and delivers the evidence-based interventions — exercise, nutrition, medication review, the treatment of depression and the reversible contributors, and the social and environmental support — that can improve function, reduce institutionalisation, and keep the older person independent and at home." [1]