Comprehensive Geriatric Assessment (CGA): Psychological domain

Often during conversations about other aspects of CGA you may pick up on clues that indicate issues with mood or cognition, and it is important to investigate thoroughly so interventions and support can be tailored and implemented as early as possible.

Depression

Depression is more common in people with frailty, and prevalence increases with greater severity of frailty.² There is a reciprocal relationship between depression and frailty – both conditions increase the likelihood of the other, and worsening depression can accelerate cognitive decline and frailty.³

Depression in older people has similar clinical features to younger people but older people are more likely to report physical symptoms of depression e.g. gastrointestinal symptoms, fatigue, poor sleep and weight loss. Anxiety, agitation, hypochondriasis and slowing down of emotional reactions may also predominate.³ Depression in older people may also present with taking less interest in things they previously enjoyed e.g. losing enjoyment from visits from family or friends.

Depression is more likely to have a chronic and relapsing course in older people than young people. About 20% of suicides occur in older people, with a greater proportion of attempts ending in death, compared to younger people.⁴ Risk factors for suicide include being male, being widowed, physical illness, pain, drug or alcohol use and history of attempts or evidence of planning.

Depression can be screened using a number of tools. The two question screener is a useful tool for brevity and ease of use.

1. During the last month, have you often been bothered by feeling down, depressed or hopeless?
2. During the last month, have you been bothered by having little interest or pleasure in doing things?

If the answer to either of these questions is yes, then further assessment must be performed. This can be done by detailed questioning about associated symptoms of depression or using a further assessment tool e.g.

• Geriatric Depression Score
• PHQ-9
• Cornell Scale for Depression in Dementia

Cognition

Cognitive disorders are highly prevalent in people living with frailty. In people living with dementia, they may retain the ability to converse socially for some time, so routine screening is recommended.

The Single Question in Dementia can be useful “Has the person been more forgetful in the last 12 months to the extent that it has affected their daily life?”

Early memory problems may include forgetting events or conversations, repeating questions within a short time period or increasingly misplacing items or getting lost in a way that has become unusual. These early signs along with the loss of the ability to perform more complex tasks like managing finances, or planning a journey may initially be mislabelled as part and parcel of normal ageing. Taking less interest in activities that they used to enjoy can also occur, and in the early stages of dementia can be difficult to distinguish from depression.

If memory problems are present then further information may be gathered with a collateral history or, if time is scarce, questionnaires such as the functional activities questionnaire or IQCODE may be given to families or caregivers.

A validated cognitive assessment tool such as the 6-CIT should be used, although cannot be relied upon solely.

More detailed tools such as the Addenbrooke’s Cognitive Examination may be used by specialists e.g. in memory clinic.

Before a diagnosis of dementia can be considered, reversible causes should be addressed including blood tests (e.g. FBC, U+Es, calcium, LFTs, TFTs, B12, folate) and brain imaging, where appropriate.

Delirium

Delirium can be a frightening experience for people, with long-lasting ramifications. Frailty has been found to be an “independent risk factor for delirium, with an increased chance of 66%”⁵ compared to those without frailty.

Delirium is also difficult to systematically detect without screening. The Single Question in Delirium “Has this person been more confused lately?” should be used, alongside the 4AT, a screening test with excellent sensitivity and specificity, yet takes <2 minutes to perform and does not require training. If delirium is present, then systematically addressing common contributors using the “PINCH ME” mnemonic is recommended: