4. CGA in Primary Care Settings: Functional and social assessment
Functional, social and environmental assessments as part of Comprehensive Geriatric Assessment are important as they add context to the other components of the assessment. To understand what value an environmental assessment holds you must also understand how the person functions within that environment. Likewise social and financial circumstances have a direct impact on physical and mental wellbeing. Here we examine both assessments as part of CGA within primary care, including the questions to ask and steps to take.
Functional assessment can encompass multiple factors like mobility, activities of daily living and the ability to interact with technologies used for telecare. Another factor impacting on function, is sensory loss, as someone with poor vision or hearing can still be as functional as anyone else but with very different coping strategies. On initial assessment it may appear as though this person’s functional ability is diminished, but in reality it is only different.
Functional assessment and associated trajectories can also inform decisions and treatment options outside of a full CGA. For example, being able to map functional ability in terms of a progressive decline may aid decisions around elective orthopaedic surgery. Likewise, sudden loss in function may indicate acute illness and guide towards active investigation and management; a slow-sustained loss of function may steer the patient to a more supportive care environment.
There are two components of a functional assessment:
- What can and what does the person actually do?
- How recently has it changed?
The first of these components can be relatively easy: one simply needs to ask the questions and tools are available which offer prompts as to the activities needed.
Tools for functional assessment
Most General Practice IT systems have templates for assessment tools, these can be very useful and quick to use. However, because they are embedded with the primary care system, they may not be easily shareable.
Nurses, social workers, physiotherapists and occupational therapists will all be familiar with the Barthel Index as a measure of function. Although it has been around since the 1960’s, the Barthel Index has remained relatively unchanged; it is not complex and it is easy to understand the meaning of any outcomes. Particularly helpful is the ability to map a trajectory using Barthel, as baseline scores can be recorded and reassessment is relatively quick once you are familiar with the tool. There is good parity between patient self reports, professional assessment and family opinion. Given its widespread use, simplicity and accessibility it remains probably one of the most useful functional assessment tools today.
One of the problems with Barthel is its so-called ceiling effect. This means that because it measures very basic function in terms of daily life, one can score quite well on the Barthel and yet still be pretty dependent on others for daily life – for example cooking, laundry, cleaning and shopping.
Hence the development of other tools, for example the Nottingham Extended ADL Scale, which asks about those components of function which enable social participation.
The Timed up and Go Test (TUGT) can also be a good indicator of overall function, combining an assessment of physical ability – being able to indeed ‘get up and go’ but also a test of cognition relating specifically to following instructions and carrying them out successfully. For more details about this see mobility and balance.
Assessing the timescale of change
Most of these tests do rely on the assessor knowing what was happening previously in order to measure any decline or improvement. While reliant on this factor, the tests are not presented to record and display this. If previous records are not available it is always worth asking “how has this changed in recent weeks?” The patient or their primary care giver will then be prompted, in an open manner, to elaborate. This will add depth to what you assess and better aid decision making and planning.
Knowing the patient well can be the most effective test of function, and GP and Community based staff have the advantage of interacting with patients outside of traditional clinical areas.
Subtly we see the changes in functional ability arise, often over longer time periods. A patient may stop driving one year, stop walking to the surgery the next and within a few years may be house-bound. Identifying these step changes and understanding the multifactorial causes is a vital part of the challenge that is CGA. Evidence shows us that intervening at these times of step changes can help to slow a loss of function and with the right therapies, exercise and goal setting, we can see some reversal and ultimately the patient may regain some physical function.
Social and environmental assessment
Social and financial circumstances have a direct impact on physical and mental wellbeing. They influence patients’ ability and inclination to comply with medical advice and the frequency of attendance in primary care and the emergency department. Most health care consultations are done out of the patient’s home and without the next of kin or informal carers present. It is vitally important that health care professionals are aware of a patient’s social situation and support structures in order to best tailor their advice and support.
We human beings are social beings….. We survive here in dependence on others. …there is hardly a moment of our lives when we do not benefit from others’ activities….most of our happiness arises in the context of our relationships with others.”
Dalai Lama XIV
Social Assessment has historically been the domain of Social Workers. Health Care professionals have tended to ask a few perfunctory questions and move on. How often have you seen a social history comprising one word “married’? We need to be more mindful of patients’ social circumstances and the effects they have on their mental and physical wellbeing, compliance with advice and frequency of contact with the health services. GPs are constrained by time and may not be the best people to collate social and financial information about a patient. This can easily be done by the patient themselves, a well-informed carer, a nurse or health care assistant or indeed a social worker working as part of the Multidisciplinary team. There are good examples of the voluntary care sector undertaking Easy Care assessments of patients to feed back to primary care.
There are a huge number of different ‘social assessments’ quoted in the literature but they are difficult to access and some are copyrighted. They all ask essentially the same questions which have been collated in the BGS ‘Social Questionnaire’ and ‘Environment Questionnaire.’ Feel free to adopt and adapt to your requirements.
Different models of assessment
The medical profession is very wedded to the idea of assessment as asking a series of pre-determined questions – the so called ‘Questioning Model’ – whilst Social Care organisations have increasingly adopted an assessment of the individuals' needs and wishes using the patient as the driver for the exchange – the ‘Exchange Model’ . Social work and nursing assessment practice emphasises the importance of independence and quality of life when establishing needs and thus is a person-centred activity.
Questioning Model: in the context of the questioning model, the assessor sets this agenda and is seen as the expert.
Exchange Model: the assessment process is embarked upon as a shared enterprise and the individual is respected as the expert on his/her own situation.
See also Collin C, Wade DT, Davies S, Horne V (1988), The Barthel ADL Index: a reliability study, Int Disabil Stud. 10(2):61-3.
For those concerned about older people's safety when driving: