Comprehensive Geriatric Assessment and Frailty — Written Clinical Reasoning

SAQ 1 — Frail Older Woman with Functional Decline, Falls, Polypharmacy, and Malnutrition (20 marks, 30 minutes)

Prompt: Using the comprehensive geriatric assessment framework, outline the four-domain assessment findings for this patient, her Clinical Frailty Scale score, the problem list, and the integrated management plan. Justify each decision with reference to evidence and guideline recommendations. [1]

Model Answer

The four-domain CGA findings (4 marks): [1]

This woman requires a full comprehensive geriatric assessment (CGA) — a multidimensional, interdisciplinary diagnostic and therapeutic process. The findings across the four domains are: [1]

Medical domain: She has multiple comorbidities (hypertension, type 2 diabetes with suboptimal control at HbA1c 58 mmol/mol, atrial fibrillation on warfarin, osteoarthritis, previous hip replacement). She has significant polypharmacy — 8 regular medications with a high anticholinergic and sedative burden (oxybutynin, codeine, temazepam). She has orthostatic hypotension (a lying-to-standing drop of 24 mmHg systolic, exceeding the 20 mmHg threshold), which is a major contributor to her falls and is likely driven by the amlodipine, the oxybutynin, and dehydration. She has had a wrist fracture — a fragility fracture that mandates a bone mineral density assessment and osteoporosis treatment. Her BMI is low and she has lost 5 kg (9 percent) in 6 months — a red flag for malnutrition, malignancy, and depression. [1]

Functional domain: She has lost independence in two instrumental ADLs (shopping, housework — Lawton IADL reduced) and has given up driving. Her physical performance is severely impaired: grip strength 14 kg (below the 16 kg threshold for women, indicating probable sarcopenia), Timed Up and Go 17 seconds (abnormal, well above the 12-second threshold), gait speed 0.65 m/s (severely impaired, below 0.8 m/s). Her Katz ADL is likely 4 to 5 — she needs some help with bathing and transferring. [1]

Psychological domain: Her MoCA of 21 indicates cognitive impairment (below the cutoff of 26, consistent with mild cognitive impairment or early dementia). Her GDS-15 of 7 indicates depression (cutoff of 5). The cognitive impairment, depression, and anticholinergic burden (oxybutynin) are interrelated and mutually reinforcing. [1]

Social domain: She lives alone in a two-storey house since her husband's death — a falls hazard (stairs) and an isolation risk. One daughter is interstate. She has no identified advance care directive or substitute decision-maker. She is at high risk of institutionalisation. [1]

Clinical Frailty Scale score (2 marks): [1]

Her CFS is 6 (moderately frail) — she needs help with all outside activities (shopping, transport) and with keeping house, and she needs some help with bathing. This places her firmly in the frail category and predicts significantly worse outcomes after any acute illness or injury. She is not CFS 5 (mildly frail) because she has lost more than high-order IADLs — she has physical performance impairment, cognitive impairment, and nutritional decline. She is not CFS 7 (severely frail) because she is not completely dependent for personal care. [1]

The problem list (4 marks): [1]

1. Moderate frailty (CFS 6) with sarcopenia — confirmed by low grip strength (14 kg) plus low muscle mass (DEXA ASMI 4.9 kg/m², below 5.4 for women), meeting the EWGSOP2 criteria for confirmed sarcopenia (Cruz-Jentoft 2019, PMID 31081853). She also meets 3 to 4 of the Fried criteria (unintentional weight loss, weakness, slow gait, low activity).
2. Falls and fragility fracture — two falls in 4 months, one with a wrist fracture. Contributing factors: orthostatic hypotension, sarcopenia, polypharmacy (sedatives, anticholinergics), visual and environmental hazards.
3. Orthostatic hypotension — 24 mmHg systolic drop, likely driven by amlodipine, oxybutynin, and volume depletion.
4. Polypharmacy with high anticholinergic and sedative burden — oxybutynin (high anticholinergic, worsens cognition), codeine (sedating, constipating, falls risk), temazepam (sedating, falls risk, cognitive impairment), amlodipine (contributes to orthostasis).
5. Cognitive impairment (MoCA 21) — likely mild cognitive impairment or early dementia, worsened by the anticholinergic burden.
6. Depression (GDS-15 of 7) — likely contributing to weight loss, low activity, and cognitive impairment.
7. Malnutrition (MNA-SF 8, 9 percent weight loss in 6 months) — at risk of malnutrition, with probable sarcopenia and vitamin D deficiency to exclude.
8. Suboptimal diabetes control (HbA1c 58 mmol/mol) — needs individualised targets; in a frail older adult, glycaemic targets should be relaxed to avoid hypoglycaemia, which worsens falls risk and cognition.
9. Social isolation and environmental risk — lives alone in a two-storey house, one daughter interstate, no advance care directive. [1]

The integrated management plan (8 marks): [1]

Medication review and deprescribing (the most impactful single intervention):

• Stop oxybutynin — it is a potent antimuscarinic with high central anticholinergic burden, directly worsening cognition and opposing any benefit, and contributing to orthostasis. Switch to mirabegron (a beta-3 agonist without anticholinergic activity) or manage with timed voiding and bladder training. This is the single highest-yield deprescribing decision.
• Stop temazepam — benzodiazepines increase falls, fractures, and cognitive impairment in older adults. Withdraw gradually (reduce by 25 percent per week over 4 weeks) to avoid withdrawal. Replace with non-pharmacological sleep strategies (sleep hygiene, melatonin if needed).
• Minimise and eventually stop codeine — it is sedating, constipating, and a falls risk. Switch to regular paracetamol and topical NSAIDs for osteoarthritis, and consider a physiotherapy and exercise programme.
• Review amlodipine — reduce or stop to address the orthostatic hypotension. The target blood pressure in a frail older adult with orthostasis should prioritise standing over sitting pressures.
• Relax glycaemic targets — in a frail 84-year-old, an HbA1c target of 58 to 64 mmol/mol is reasonable to avoid hypoglycaemia. Consider simplifying the diabetic regimen. [1]

Falls prevention: A structured multifactorial falls assessment and intervention — medication review (above), a strength and balance exercise programme (Otago or Tai Chi), a home safety assessment by an occupational therapist (addressing the stairs, rugs, lighting, bathroom rails), vision assessment and correction, podiatry, and a vitamin D supplement (1000 IU daily) if deficient. [1]

Sarcopenia and nutrition: The cornerstone is progressive resistance exercise (2 to 3 sessions per week, targeting the major muscle groups) combined with dietary protein at 1.2 to 1.5 g/kg/day (60 to 70 g per day for this 48 kg woman, distributed across meals), and oral nutritional supplements given her MNA-SF of 8 and her weight loss. Refer to a dietitian. Check and correct vitamin D deficiency. [1]

Cognitive impairment: Arrange an MRI brain to characterise the atrophy and exclude reversible structural causes. Check B12, folate, and TSH. Address the anticholinergic burden (stop oxybutynin). Reassess the MoCA after the medication changes, the depression treatment, and the nutrition improvement — some of the cognitive impairment may be reversible. Consider a cholinesterase inhibitor if the diagnosis is confirmed as mild to moderate Alzheimer disease. [1]

Depression: Start an SSRI (citalopram 10 mg daily, the first-line antidepressant in older adults with a favourable side-effect profile). Treat the depression — it will improve her appetite, activity, and cognition and is a key part of the frailty reversal. [1]

Osteoporosis: Given the fragility wrist fracture, arrange a bone mineral density (DEXA) and start antiresorptive therapy (alendronate 70 mg weekly with calcium and vitamin D supplementation) unless contraindicated. [1]

Social and environmental: Arrange a home safety assessment (OT), consider a ground-floor relocation or a stair lift, arrange community home care services (shopping, cleaning, medication supervision), and offer a personal alarm. Initiate an advance care planning conversation — values, goals, preferred place of care, the appointment of an enduring guardian and power of attorney while she retains the capacity to participate. Offer her daughter (locally) a carer assessment and support. [1]

Frailty reversal and follow-up: The integrated goal is to improve her frailty status — there is good evidence that targeted exercise, nutrition, and medication review can move patients from CFS 6 toward CFS 4 or 5. Arrange a CGA follow-up at 3 months with a repeat MoCA, grip strength, gait speed, MNA-SF, and weight. The CGA is a process, not a single visit — the benefit depends on ongoing follow-up (Ellis 2017, PMID 28898390). [1]

Communication (2 marks): [1]

I would explain the concept of frailty to her and her daughter — a treatable vulnerability, not an inevitable consequence of ageing — and set realistic expectations: the medication changes and the exercise and nutrition programme can improve her strength, balance, mood, and function, reduce her falls risk, and potentially improve her cognition. I would conduct the advance care planning conversation with empathy and respect for her autonomy, ensuring she is at the centre of the decisions. The family should be involved with her consent, and the local daughter should be offered a carer assessment and education about the management plan. [1]

SAQ 2 — Hip Fracture and the Orthogeriatric CGA Model (10 marks, 15 minutes)

Prompt: A 79-year-old man with a known Clinical Frailty Scale of 6 is admitted with a fragility fracture of the right femoral neck after a fall. He has atrial fibrillation (on apixaban), hypertension, moderate dementia (MoCA 16), and chronic kidney disease stage 3. Outline the role of comprehensive geriatric assessment and the orthogeriatric model in his perioperative management, including the immediate assessment, the perioperative plan, and the rehabilitation and longer-term strategy. [1]

Model Answer

The orthogeriatric model and the role of CGA (2 marks): [1]

This patient should be managed under an orthogeriatric model — co-management by orthopaedic surgery and geriatric medicine, with a comprehensive geriatric assessment within 24 to 48 hours of admission. The orthogeriatric model has strong evidence for reduced 30-day and 1-year mortality, reduced length of stay, reduced complications (delirium, pressure injuries, pneumonia, venous thromboembolism), and improved return to independent mobility after hip fracture. The 2017 Cochrane meta-analysis (Ellis 2017, PMID 28898390) supports CGA in the inpatient setting, and the orthogeriatric pathway is the strongest-evidence application of CGA in surgical patients. Every patient over 65 with a fragility fracture should receive this model. [1]

Immediate assessment and perioperative plan (4 marks): [1]

Immediate CGA (within 24 hours):

• Establish the baseline — from the family or the GP, establish his pre-fracture function, cognition, mobility, and living situation. He was CFS 6 (moderately frail, needing help with outside activities and housework) with moderate dementia.
• Screen for delirium — perform the 4AT on admission. Hip fracture patients are at extremely high risk of delirium (30 to 50 percent), and delirium predicts worse outcomes. Implement a delirium prevention bundle (orientation, hydration, sensory correction, sleep hygiene, minimising sedatives, early mobilisation).
• Medication review — the apixaban needs perioperative management (it is typically withheld and surgery timed to allow safe anaesthesia; the orthogeriatric and anaesthetic teams coordinate the timing). Review all medications for interactions, anticholinergic burden, and falls-contributing drugs.
• Optimise for surgery — address the orthostatic hypotension, the fluid balance, the renal function, the glycaemic control, and the analgesia. Early surgery (within 24 to 48 hours) is associated with reduced mortality and complications in hip fracture patients and should be the goal unless there are reversible contraindications.
• Assess and manage pain — regional analgesia (fascia iliaca block) is preferred to reduce opioid use, which worsens delirium. [1]

Perioperative complications prevention:

• Delirium prevention — the multicomponent bundle (HELP or similar): orientation cues, hydration, correction of sensory impairment, sleep enhancement, early mobilisation, minimising catheters and restraints, and avoiding anticholinergics and sedatives.
• Pressure injury prevention — pressure-relieving mattress, regular repositioning, skin assessment.
• Venous thromboembolism prophylaxis — mechanical and pharmacological, coordinated with the apixaban timing.
• Infection prevention — early mobilisation, chest physiotherapy, urinary catheter avoidance.
• Nutritional support — early dietitian referral, oral nutritional supplements given the pre-existing malnutrition risk and the hypermetabolic state of fracture and surgery. [1]

Rehabilitation and longer-term strategy (4 marks): [1]

Early and structured rehabilitation:

• Early mobilisation — within 24 hours of surgery, if medically stable, with physiotherapy. Early mobilisation reduces complications, improves outcomes, and is a core component of the orthogeriatric pathway.
• Multidisciplinary rehabilitation — physiotherapy (mobility, strength, balance), occupational therapy (ADL retraining, home assessment), and the geriatric team (medical optimisation, delirium and pain management).
• Weight-bearing as tolerated — for most hip fracture fixations, full weight-bearing is encouraged from the first postoperative day unless the surgical team specifies otherwise. [1]

Secondary fracture prevention:

• Osteoporosis assessment and treatment — DEXA and start antiresorptive therapy (alendronate or zoledronic acid). This is a fragility fracture, and secondary prevention is a standard of care.
• Falls assessment — once recovered, a full multifactorial falls assessment to address the modifiable contributors (medications, vision, home hazards, sarcopenia, orthostasis).
• Vitamin D and calcium supplementation. [1]

Discharge planning and community support:

• Discharge destination — based on the pre-fracture function, the rehabilitation progress, and the social support. Options include return home with a community home care package, a period of subacute rehabilitation (GEM or rehabilitation ward), or a transition to residential care. The goal is to return him to his pre-fracture baseline (or as close to it as possible), not to use the fracture as a trigger for premature institutionalisation.
• Community package — home care services (shopping, cleaning, medication supervision), a personal alarm, carer support for his family.
• Advance care planning — given his moderate dementia and his frailty, this admission is an opportunity to clarify his goals of care, to appoint or confirm a substitute decision-maker, and to document his preferences for future acute events. [1]

The communication: I would explain to his family that the orthogeriatric model gives him the best chance of a good recovery — the surgery, the early mobilisation, the delirium prevention, and the structured rehabilitation are all evidence-based. I would set realistic expectations given his pre-existing frailty and dementia: the goal is to return him to his pre-fracture function, to prevent complications, and to set up the secondary prevention (osteoporosis treatment and falls reduction). I would address the advance care planning with sensitivity — this is a patient with moderate dementia and frailty, and the family should be prepared for the possibility of future decline. [1]