CASE SHEET FORMAT

HISTORY TAKING

Name:

Hospital number:

Age:

Sex:

Date of examination:

Address/contact:

Name/relationship of contact person:

Contact address/number:

Problem list Duration

Past medical history:

Medical condition Duration

Vision impaired

Hearing impaired

Cancer

OA

Thyroid

Family History:

Hypertension

Diabetes

Heart disease

Dementia

Cancer

Social Assessment:

Married: Yes No

Spouse living: Yes No

Living with:

No. of children

How often do you see them?

Who assists you?

Is it sufficient? Yes No

Native language

Type of house Independent Apartment

Stairs Present Absent

Personal History:

Do you exercise daily? Yes No

If yes, minutes/day?

What type?

Weight loss/gain (3 kg) Yes No

Smoker Yes No

Duration

Alcohol Yes No

Duration

Level of Independence (tick one of them) Independent

Dependent

Needs assistance

Caregiver fatigue Yes No

10-minute comprehensive screening

Memory 3 objects named Yes No

Depression Are you often sad/depressed? Yes No

Falls Fallen more than twice in last 1

year

Yes No

Able to walk around chair? Yes No

Urinary incontinence Lost urine/got wet in past 1 year? Yes No

Memory recall One object Two objects Three objects None

Draw the face of

clock

Vision Difficulty in Right Left

reading eye eye

Hearing Right

ear

Left

ear

6, 1, 9 test—Stand behind the patient and say 6, 1 and

9 in normal tone and in whisper

Normally

Softly

Constipation Yes No

Insomnia Yes No

Physical Functional Capacity:

Are you able to …………………………?

Run/walk fast to catch a bus Yes No

Do heavy work at home Yes No

Go shopping for groceries/clothes Yes No

Get to places out of walking distance?(drive/take a bus) Yes No

Bath using shower/bucket Yes No

Put on clothes/footwear Yes No

Basic Activities of Daily Living:

Bath Yes No Transfer Yes No

Dress Yes No Toilet Yes No

Toilet Yes No Feeding Yes No

Montreal cognitive assessment score

Geriatric depression score

Physical Examination:

Height (m)

Weight (kg)

Body mass index (BMI) (W/H

2

)

Pulse

Blood pressure (BP) (sitting/supine)

BP (standing 1 minute/3 minutes)

Anemia Yes/No

Skin Normal/abnormal

Teeth Normal/abnormal

Any other GPE abnormality

Systemic Examination:

Normal/abnormal Describe

Joints

Cervical spine

Thoracic spine

Lumbar spine

RS

CVS

P/A

Neurological examination R L

Muscle strength Upper limb

Shoulder

Elbow

Wrist

Small

muscles of

hand

Lower limb

Hip

Knee

Ankle

Tone (describe) Rigidity/hypotonia/spasticity

Balance Normal/abnormal Sensory

Cerebellar

Vestibular

Gait

Timed up and go test

(seconds)

Current Treatment Details:

………………………………………………………………………..

Polypharmacy: Yes/No

Investigations:

Investigations Date Values

Complete blood picture

Creatinine

Electrolytes, blood sugar

PSA (for males)

Urine routine

Ultrasonography (USG) abdomen and pelvis

DIAGNOSIS FORMAT

Comprehensive Geriatric Assessment Report

Acute Illness

Comorbidity

Geriatric giants

Other age-related problems

Social problems

Economic problems

Prescription modification

Examples:

Acute illness Delirium secondary to hyponatremia

Postoperative fracture neck of femur

Comorbidity Diabetes, hypertension, dyslipidemia.

Geriatric giants Delirium

Incontinence

Other age-related problems Cataract

Stress incontinence

Social problems Stress incontinence

Living alone

Feels lonely

Has no body for emergency help

Economic problems Present, not earning

Prescription modification Avoid diuretics and beta-blockers

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DISCUSSION

Comprehensive geriatric assessment (CGA) (Fig. 8.1) is a

multidimensional, multidisciplinary diagnostic, and therapeutic p

rocess conducted to determine the medical, mental, and functional

problems of older people with frailty so that a coordinated and

integrated plan for treatment and follow-up can be developed.

Factors which make assessment/treatment of elderly different are

as follows:

Individuals become more dissimilar as they grow

Abrupt decline in any system is always due to disease and not due

to normal aging

Multiple pathology

Missing symptoms (e.g. angina in an elderly patient with

osteoarthritis—may not manifest)

Masking symptoms (e.g. history of fall and fracture neck of femur

in an elderly female-masked a coexistent hemiparesis due to an

internal capsule infarct).

When an older person is identified as being at risk of frailty, whether

in an acute hospital, day hospital, community or residential care,

they should be considered for a CGA. CGA should be initiated as

soon as possible after admission to hospital by a skilled, senior

member of the multidisciplinary team, and used to identify reversible

medical problems, target rehabilitation goals, and plan all the

components of discharge and postdischarge support needs.

The CGA multidisciplinary team may include:

Medical, e.g. geriatrician, psychiatry of old age, palliative care

specialist, and general practitioner (GP)

Nursing

Medical social worker

Physiotherapy

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Occupational therapy

Speech and language therapy

Dietetics

Pharmacists

Podiatry.

Benefits of Comprehensive Geriatiric Assessment

Improves diagnostic accuracy

Optimizes medical and rehabilitation treatment

Enhances health and functional outcomes

Informs the development of individualized care plans

Assists in avoiding the potential complications of hospitalization

Facilitates effective discharge planning.

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Fig. 8.1: Components of comprehensive geriatric assessment

(CGA).

The four main dimensions covered in a CGA should include

physical, functional, psychological, and social assessment as

follows:

Four main dimensions

Physical assessment Functional assessment

Presenting complaint

Past medical history

Medication reconciliation and review

Nutritional status

Alcohol

Immunization status

Activities of daily living

Balance

Mobility

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Advanced directives

Psychological assessment Social assessment

Cognition and mood Living arrangements

Social support

Career stress

Financial circumstances

Living environment

Identifying Elderly Patients who Would Benefit from Such an

Assessment

Strongly consider if they have three or more of the “Red Flags” namely

>75 years

Needs help with activities of daily living/instrumental activities for daily living

(ADLs/IADLs) by caregiver

Lives alone

Falls

Delirium/confusion

Incontinence

>2 admissions to acute care hospital/year

“Failure to thrive”

Basic activities of daily living

Basic activities of daily livings (BADLs) are fundamental activities

such as personal cares which are basic to independent living. Loss

of basic ADLs places a heavy burden on the caregivers and is a

marker of complete dependence.

For assessing autonomy in daily activities:

Toileting, self-hygiene, bathing, grooming, dressing, feeding, and

ambulation (stairs too).

For each of the questions, enquire whether the person can

perform it independently, whether he/she needs assistance or

he/she is completely caregiver-dependent.

Instrumental activities of daily living

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Instrumental activities of daily living (IADLs) are complex tasks which

enable an older adult to live independently and safely. They are not

necessary for fundamental existence in the way that basic ADLs are

necessary, but are an indicator of functional independence.

Assessment of IADLs is useful during baseline and follow-up

assessments among older adults. Loss of IADLs may be the first

indication of deterioration in an older adult.

Complex tasks and roles you do at home

Shopping, meal planning and preparation, housekeeping, laundry,

transit, financial management, using a telephone, medication

management, and driving.

Geriatric Giants (Fig. 8.2)

Fig. 8.2: Modern geriatric giants.

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