Entrustable Professional Activities

EPA 14: Comprehensive geriatric assessment

EPA 14

Comprehensive geriatric assessment

Assess patients using a comprehensive geriatric assessment

This activity requires the ability to:

  • assess the physical, medical, psychological, social, environmental, and functional abilities of patients systematically
  • develop a comprehensive problem list
  • develop a patient-centred care plan based on the findings of the comprehensive geriatric assessment in conjunction with patients, families and carers, and their goals of care
  • monitor the health status of patients and adjust the care plan according to changes in their health status or new information
  • work flexibly across a variety of settings, including inpatient, ambulatory care, residential care facilities, patients’ homes and telehealth

Professional practice framework domain

Medical expertise

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • identify appropriate patients for comprehensive geriatric assessment
  • recognise that comprehensive geriatric assessment can take place in a variety of settings, e.g. inpatient, outpatient, the perioperative setting
  • review patients’ medical records to gather relevant information from previous assessments
  • elicit and synthesise a history from patients, including the following aspects:
    • medical problems
    • social history
    • medication history
    • psychological impact of disease(s)
    • mobility
    • nutrition
    • home environment
    • systems review of common issues affecting older adults e.g. falls, frailty, incontinence
    • ability to carry out activities of daily living
    • legal issues / proxy decision makers
    • vaccination status and advance care planning arrangements
  • complete a full physical examination, including vision, hearing, dental, skin, and genitourinary, balance, and gait assessment
  • discuss patients’ history and other relevant information with family or carers and other specialists involved in care, including general practitioners
  • use appropriate assessments or screening tools, such as:
    • cognitive screening tools
    • depression scales
    • frailty assessment tools
    • activity of daily living tools
    • functional independence measures
  • collaborate with the wider multidisciplinary team in assessments, where appropriate
  • determine whether patients are at a high risk of functional decline, multiple comorbidities, or a moderate to severe degree of disability
  • identify changes in functional status
  • engage patients’ families and carers in short and long-term goal setting
  • develop a holistic care plan which addresses underlying diseases / health conditions, disabilities, social issues, environmental issues, and changes in functional status in conjunction with patients, families, and carers
  • assess and facilitate rehabilitation where appropriate
  • use investigations judiciously with an evidence-based approach and assessment of likely benefits, in consultation with patients, families and carers
  • work with patients, families, and carers to develop strategies to improve quality of life, make home modifications, and manage psychosocial impact of health conditions
  • assess patients’ abilities in personal activities of daily living (pADL) and instrumental activities of daily living (iADL)
  • recognise and address progressive functional decline and limited prognosis, and then discuss, plan, and prioritise patients’ care needs according to their goals of care
  • create or update advance care plans, and plan long-term care

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • discount psychosocial factors of the assessment in favour of medical issues
  • perform an incomplete physical examination
  • gather irrelevant collateral history from patients, families, and carers
  • struggle to identify decline in functional status, or not be able to identify strategies to address
  • inadequately modify approach to the assessment to meet the cognitive or competency level of patients
  • omit patients, their families, and carers in the management plan or in shared decision making
  • devise short-term management plans without considering long-term goals of care
  • document an incomplete assessment, and inadequately liaise with other specialists involved in care

Communication

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • document assessments fully, including recommendations, and liaise with other specialists involved in care as needed
  • explain to patients, families, and carers the reasons for assessment and relevant aspects
  • provide patients, families and carers appropriate information, referrals, and support strategies
  • collect information through observation and open questioning of patients, families, and carers
  • modify communication approach when discussing sensitive topics, such as continence or memory impairment
  • write letters describing patients’ conditions based on the outcomes of comprehensive geriatric assessments

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • inadequately interpret verbal and nonverbal cues
  • inadequately communicate with patients during assessments, particularly when explaining the reason for assessment, process of physical examination, or discussing sensitive topics, such as continence
  • inadequately engage families or carers in discussions or care planning

Quality and safety

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • consider health promotion strategies in assessments, such as:
    • bone protection for patients with frequent falls
    • medication review in patients with polypharmacy
    • cognitive assessment for patients presenting with delirium
    • identify patients at risk of malnutrition
    • identify the pre-frail state and consider appropriate strategies, e.g. exercise
    • screening for cancer and other diseases

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • omit all or some health promotion strategies during assessments

Teaching and learning

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • promote the relevance and importance of the comprehensive geriatric assessment to patients, families, other medical specialists, and multidisciplinary team
  • seek to improve knowledge in areas which may be lacking
  • use available tools / proformas for conducting comprehensive geriatric assessment where appropriate

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • recognise gaps in own knowledge

Research

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • recognise the evidence of utility for comprehensive geriatric assessment, and appreciate the limitations of the assessment in certain settings
  • use an evidence-based medicine approach to management strategies
  • recognise areas in which evidence base is lacking, and adjust treatments accordingly

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • use evidence selectively
  • demonstrate difficultly adjusting management plans based on patient factors

Cultural safety

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • assess patients in a culturally appropriate manner
  • observe cultural practices according to the location of assessments, such as patients’ homes
  • recognise the importance of culture as part of patients’ health and wellbeing
  • recognise the importance of involving family and carers in a culturally appropriate way

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • demonstrate difficulty engaging patients in a culturally appropriate manner, not adjusting communication styles according to the cultural needs of patients, families, and carers

Ethics and professional behaviour

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • discuss patients’ support services and care networks, and provide advice / guidance with medical, legal, and financial concerns, or refer to appropriate services
  • encourage patients, families, and carers to consider advance care planning and identify proxy decision makers, documenting their decisions
  • identify elder abuse, and demonstrate knowledge of appropriate services to refer to
  • recognise carer stress and identify and refer to appropriate resources

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • use an inconsistent approach when conducting a holistic assessment, including not screening for elder abuse, carer stress, and legal issues
  • inadequately consider need for advance care planning, identifying proxy decision makers and documentation of decisions

Judgement and decision making

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • assess information gained during assessments and in formulation of management plans
  • incorporate principles of shared decision making with patients, families, and carers
  • recognise when active treatment of a medical condition may not be in patients’ best interest

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • make decisions that are unsupported by pattern recognition, data, or evidence
  • formulate management plans without regard for patients, family or carers’ wishes or goals of care

Leadership, management, and teamwork

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • conduct regular multidisciplinary team review meetings to discuss patients and share knowledge
  • negotiate with patients, families, carers, and other involved specialists to agree on the actions necessary to achieve goals, and the support required to do so
  • identify when referrals for single specialist assessments are appropriate, e.g. cardiology or gastroenterology

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • attend but not lead the multidisciplinary team review meetings

Health policy, systems, and advocacy

confident
Ready to perform without supervision

Expected behaviours of a trainee who can routinely perform this activity without needing supervision

The trainee will:

  • refer to appropriate and validated templates or tools to collect and document information during assessments
  • be aware of assessment processes for community services from discharge
  • advocate for the place of comprehensive geriatric assessment in the care of older people
  • promote vaccinations as a preventative health strategy

direction
Requires some supervision

Possible behaviours of a trainee who needs some supervision to perform this activity

The trainee may:

  • use validated tools inconsistently to collect and incompletely document information