Comprehensive Geriatric Assessment (CGA): Formal and informal caregivers

Many older people living with frailty are reliant upon caregiver support, and CGA must include an assessment of care needs and how they are currently being managed. This includes both formal and informal current care and whether the person’s needs are anticipated to change significantly, to establish appropriate future plans.

When cognition is impaired, it is often caregivers who can provide key information that supports management e.g. clarifying the recent history and functional capabilities aiding in diagnosis and setting appropriate rehabilitation goals.

While the input of formal carers can be relatively easily quantified, the contribution of informal carers can be harder to define. Informal care value has increased by 30% in the last decade and is now valued at £445M per day;¹ this figure is similar to the daily spend across the whole of the NHS. Providing informal care for older adults is widespread; the UK census found that after the age of 50, the average individual will spend more than 5 years providing care,² and data shows that 8% of the UK’s private household population were ‘informal carers’ for someone.³

In addition to providing vital collateral history and insight into a person’s beliefs and wishes, explicitly integrating caregivers in the discharge planning process has been shown to reduce readmissions by 25%.⁴

The care support needs of an individual can vary markedly, and will evolve and change over time. It is also important to note that many caregivers are themselves individuals living with ill health. For this reason, when assessing an older adult with frailty, it is vital to ascertain if they are themselves providing care and support for another, as well as establishing their own care needs.

Impact of caregiver stress and burnout

Consideration of caregiver stress or burden is essential during CGA, and can be defined as the physical, mental and emotional strain experienced by carers as a result of providing care⁵ and there are many factors that influence how much stress is perceived by the individual caregiver. “Stress” is influenced by the nature, intensity and the amount of care required but also by the nature of the previous relationship with the person they are caring for, the carers own health, support networks and resilience, community expectations and societal recognition of the caregiver role.

Higher intensity caregiver roles are linked with worse outcomes for patients and carers and can result in caregiver “burnout”. Where care becomes unsustainable, avoidable harm or hospitalisation can ensue. The monitoring of carer stress is important in the holistic assessment of the domestic situation and can prevent avoidable ill health of both the cared for and the caregiver. Engaging carers in decision making is more likely to lead to successful ongoing care at home and to reduce the subsequent reports of carer stress and potentially “burnout”.

Caregiver stress and burnout can manifest in many ways; for example as sleep disturbance, anxiety, low mood and depression but stress can also lead to resentment and occasionally to harm and abuse. Inquiring and exploring the possibility of caregiver stress needs to be done tactfully. There are a number of standard rating scales that can be employed to screen for Caregiver stress (e.g. Zarit, Caregiver strain index)

Carers may benefit from additional formal care to support their role or a period of respite. It is important to note that impact and emotions will be individual; if an older person with frailty moves into a 24-hour care facility it may be perceived externally as a positive for the caregiver, but there is no guarantee they will find this a less stressful situation.

Supporting carers can provide long term benefits, enhancing the quality of life of carer and the person being cared for.⁶ Caregivers in the UK are entitled to assessments⁷ via local councils to establish how they can be supported in their role, which is a valuable resource to direct to during CGA.

From a health perspective, optimising medical conditions, improving the care environment and providing specialist support can contribute to reducing care dependency. Thorough history taking is key; by understanding the type of care support required, nature of relationships and tensions (where they exist) problems in care provision can be averted and caregiver stress and burnout can be minimised.