Comprehensive geriatric assessment

Abstract

To learn the meaning of comprehensive geriatric assessment (CGA), its domains and commonly used assessment instruments, as well as its application in clinical programmes.
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Chapter 2. Comprehensive Geriatric Assessment
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CHAPTER 2
comprehensive geriaTric assessmenT
Tak-kwan KONG
CGA in the 1930s on the basis of faith and optimism.
Today, CGA programmes have evolved and been the
subject of scientic scrutiny in the era of evidence-
based medicine. Since the late 1970s, controlled
trials have evaluated the effectiveness of CGA with
consequent publications of positive results in the
1980s.2 A 1993 meta-analysis by Stuck et al3 of 28
controlled trials of CGA programmes that involved
hospital units, hospital consultation teams, in-
home assessment services, outpatient assessment
services, and hospital-home assessment programmes
demonstratedthebenetofCGAintermsofreduced
mortality risk, improved likelihood of living at
home, reduced hospital readmissions, greater chance
of cognitive improvement, and greater chance of
physical function improvement. Since then, major
international conferences have been held to discuss
this new concept of CGA,4 and further controlled
studies and meta-analyses have conrmed the
favourable outcomes.5-10
2.3 Complications and Costs of CGA
Although benecial, there are concerns about
CGA. Complications can occur when it is overused
or abused. An example is delirium as a result of
fragmented and duplicate assessment by different
2.1 Introduction
The simultaneous presence of multiple interacting
problems (physical, psychological, and social) and
the unmet needs of a frail elderly patient require
an assessment more complex than that provided
by a routine medical diagnosis. Comprehensive
geriatric assessment (CGA) is a multidimensional
interdisciplinary diagnostic process intended
to determine a frail elderly person’s medical,
psychosocial, and functional capabilities, and
problems and aid in the development of a coordinated
and integrated plan for management and long-term
follow-up.1 CGA forms the basis of a frail elderly
person’s treatment and rehabilitation plan. The goals
are to reduce pain, improve function, delay death, and
ultimately improve quality of life. In contrast to high
technology, CGA emphasises high touch. It extends
beyond the patient to the individual, from diagnosis
to assessment, and from treatment to management.
CGA, coupled with multidisciplinary care, has
become the cornerstone of geriatric medicine and
geriatric care systems.
2.2 Evidence of the Effectiveness of CGA
Early pioneers of geriatric medicine such as Marjory
Warren and Lionel Cosin introduced the concept of
OBJECTIVE
To learn the meaning of comprehensive geriatric assessment (CGA), its domains and commonly used
assessment instruments, as well as its application in clinical programmes.
KEY POINTS
• CGAis a diagnostic process of gettingto knowan elderlyindividual inall dimensions;it isthe
cornerstone of geriatric medicine.
• Key domains in the assessment of elderly patients include physical health, functional capacity,
mental function, socioeconomic resources, and environmental resources.
• Usefulinformationcanbeacquiredfrombothelderlypatientsandtheirfamily/friend/caregiver.
• When caring for a frail old person with multiple illnesses, multiple medications and complex
needs, we have to ask the right questions. Instead of asking just where they should go and who is
responsible, we should work together and ask who are they, and how we can help satisfy their needs.
• Dualsensoryimpairmentinvisionandhearingisassociatedwithcognitiveandfunctionaldecline
and increased mortality.
• Toidentifyearlycognitiveimpairment,acombinationofpatient-basedandinformant-basedscreens
are the most appropriate approach.
2.1

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professions.11 CGA should be performed in the
clinical setting with due regard to the patient’s
tolerance and well-being with appropriate clinical
interpretation of the assessment results. Another
concern, notably from hospital management, is the
costs associated with the involvement of multiple
disciplines. Wieland12 reviewed 19 randomised
controlled trials that reported the cost endpoints in
CGA, and concluded that CGA was cost-efcient
(less cost for same outcome or same cost for better
outcome) for the majority, and cost-effective for a
few. A related issue is not to invest in programmes
that are not effective. It is therefore important to
observe the organisational elements of CGA that are
associated with effective programmes, as concluded
from previous meta-analysis and reviews of CGA
(Table 2.1).2,12
CGA programmes can fail if they target individuals
whoaretoohealthytoderivebenetoriftheyfailto
identify the frail. To be effective, assessment must be
linked with management, called Geriatric Evaluation
and Management in the US. Returning elderly patient
to a previous care environment may not be feasible if
iatrogenicproblemsareidentiedduringassessment.
The three essential components of an effective CGA
programme are therefore:
• identifyingortargetingafrailelderlyindividual;
• assessment of the individual and consequent
recommendations for care; and
• implementation of the recommendations by a
geriatrician and / or interdisciplinary team
2.4 CGA Programmes
2.4.1 CGA within the Hospital
In-patient CGA programmes have been developed
for both the acute and the post-acute setting.
An acute care for the elderly unit is designed to
cater for the special needs of acutely ill elderly
inpatients, combining CGA with interventions such
as interdisciplinary care for geriatric syndromes in
an age-friendly environment, as well as discharge
planning and support. CGA programmes in the post-
acute environment focus on the continuation of post-
acute care and rehabilitation of elderly inpatients by
an interdisciplinary team. The interdisciplinary team
conference is crucial to the success of an inpatient
CGA programme. Meta-analyses have demonstrated
the effectiveness of such programmes in both the
acute and post-acute rehabilitation setting.5-7 A 2011
Cochrane meta-analysis of 22 trials involving 10 315
participants in six countries concluded that inpatient
CGA programmes increased a patient’s likelihood of
being alive and resident in their own home following
an emergency admission to hospital, especially if they
were cared for on a ward that performed CGA, and
were also associated with a potential cost reduction
compared with general medical care.8
2.4.2 CGA and the Hospital-home
Transition
CGA that targets elderly patients at high risk of
recurrent heart failure after hospital discharge,
combined with post-discharge follow-up at the
hospital and at home has been shown to reduce
hospital readmissions, improve quality of life, and
reduce net cost.9,13
2.4.3 CGA in the Community
In Hong Kong, CGA in the community is performed
by geriatric day hospitals (GDHs) and community
geriatric assessment teams (CGATs). Stroke patients
are the major users of GDHs. Physical function in
terms of self-care, mobility, and household function
has been shown to improve following discharge from
a GDH.14 CGATs were established in Hong Kong in
1994 to enhance and preserve the health and quality
of life of elderly persons in the community by timely
assessment and appropriate management. At its
inception, CGAT services included assessment prior
to admission to subvented care homes or hospitals,
outreach geriatric clinics for care homes, hospital
discharge support services, and geriatric home care.
The effectiveness of CGAT in supporting frail elders
in the community is evidenced by the lower hospital
utilisation by care homes with CGAT support in
terms of accident and emergency (A&E) department
attendance, total hospital admissions, and total
hospital bed-days, with relative reductions of 24%,
24%,and43%,respectively(Figure2.1).15
2.4.4 CGA at the Hospital Interface: Gate-
keeping Versus Goal-keeping in Caring for
the Frail Old
For the frail old with multiple problems, the
question is often asked, “where should s/he go,
whose responsibility is this?” In a time of rationing
and rationalisation, modern healthcare tends to
answer with gate-keeping that is primarily resource-
driven, leaving less room for goal-keeping that is
needs-led (Figure 2.2a). This was aptly described
by the Canadian geriatrician, Professor Kenneth
Rockwood,16 “Modern health care needs to reconcile
itself to complex patients. There are many wrong
ways to address this, each of which has the following
•Targeting the frail
• Interdisciplinaryteamstructure
•Comprehensive / multidimensional geriatric assessment
•Management with clinical control of treatments and care
•Long-term follow-up
Table 2.1 Organisational elements of comprehensive geriatric
assessment associated with effective programmes2,12

Chapter 2. Comprehensive Geriatric Assessment
/ 17
in common: instead of getting to grips with how
service is provided, they want the frail old people to
go away, to some more appropriate place.”
Nevertheless there is evidence that with CGA and
effective organisational elements mentioned above,
goal-keeping can be harmonised with gate-keeping,
whereby goal-keeping can lead to gate-keeping with
a reduction in resource utilisation, and gate-keeping
can result in goal-keeping with attention to the needs
of elders (Figure 2.2b). Evidence to support such
cost-effective CGA programmes has been shown
in a number of settings. First, CGA prior to entry
into a care home has enabled detection of treatable
previously undiagnosed illnesses, improved physical
function, alleviation of the need for care home
placement, and reduced total health and social
costs.17,18 As of 2014, 6.1% of elders aged >65 years
in Hong Kong were resident in a care home. Timely
introduction of specialist assessment prior to care
home entry locally may help to reduce this relatively
high institutional rate with important implications
for quality and costs of elderly healthcare. Second, the
benetofCGAhasbeenshownatA&Edepartments.
Attention has been drawn to the problems of A&E
in managing frail elders.19,20 Studies of CGA at A&E
have shown enhanced function and reduced use
of care homes without increased cost.21-23 Studies
of patients who present to A&E following fall
also highlight the importance of CGA in this area,
with reduced serious injury and subsequent bed-
day utilisation.24-26 Third, it has been shown that
CGA reduces serious adverse drug reactions while
reducing suboptimal prescribing.27 Inappropriate
medication and adverse drug reactions are important
causes of hospital admission of elders.28,29 Thus CGA
that targets polypharmacy can be both goal-keeping
in improving the medical care of elders and gate-
keeping in reducing iatrogenic hospitalisations.
2.5 CGA Domains and Instruments
The World Health Organization and the British
Geriatrics Society have recommended the following
domains for comprehensive assessment of elderly
patients: physical health; functional capacity; mental
function; social resources; economic resources; and
environmental resources.30,31 A number of validated
instruments for geriatric assessment have been
developed and published since the 1960s on these
various domains (Table 2.232-91).
2.3
Figure 2.1 Effectiveness of community geriatric assessment team (CGAT) in reducing hospital utilisation by care home residents,
basedonsurveydata(November2004toJanuary2005)forPrincessMargaretHospitalfromHospitalAuthority,HongKong15
Abbreviations: A&E = accident and emergency department; RR = relative risk
Figure 2.2 (a) Gate-keeping and goal-keeping dichotomy
and (b) their harmonisation through comprehensive geriatric
assessment
30
20
10
0
30
20
10
0
30
20
10
0
No.ofcarehomes
0 5 10 15 20 25 30 35 0 5 10 15 20 25 30 35 0 50 100 150 200 250 300 350 400 450
A&E attendance
(per 100 residents per month)
Overall
(n=67 homes)
With CGAT
(n=41 homes)
Without CGAT
(n-26 homes)
(p=0.01, RR=24%)
Mean
With CGAT
14.0
Without CGAT
17.4
Hospital admissions
(per 100 residents per month)
(p=0.015, RR=24%)
With CGAT
13.7
Without CGAT
17.0
Hospital bed-days
(per 100 residents per month)
(p=0.008, RR=43%)
With CGAT
118
Without CGAT
169
Needs-led
Needs-led Goal-keeping
Goal-keeping
Resource-driven
Resource-driven
Gate-keeping
Gate-keeping
(a) (b)

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The Royal College of Physicians and the British
Geriatrics Society have recommended standardised
assessment scales for use in geriatric practice to
facilitate 75-plus screening, clinical and research
communication, and case-mix comparison: the
Barthel ADL index, the Abbreviated Mental Test
(AMT) score, the Geriatric Depression Scale, the
Philadelphia Geriatric Center Morale Scale, and a
social support checklist.92
Over the years, CGA has evolved from a selection of
single-domain, individually validated measures (the
‘rst generation’ of assessment instruments) to the
‘second generation’ omni-comprehensive assessment
instruments developed for a specic healthcare
environment (e.g. Minimum Data Set–Nursing Home)
in the 1990s to the ‘third generation’ of standardised
communication system in transitional care in the
2000s based on a common set of standardised
assessment items in addition to a limited number of
setting-specicitems,e.g.interRAIHC (home care),
interRAI LTCF (long-term care facility), and interRAI
AC (acute care).93,94 The third-generation instruments
share core elements of information and are intended
for elderly patients in all healthcare environments
and to improve information transfer in transitional
care. These instruments use the same philosophy of
assessment to facilitate clinical communication both
between different caregiving professionals and across
acute, post-acute, and long-term care settings. They
aim to enhance interdisciplinary care planning and
continuity of care with effective use of information
technology.93
2.6 Visual Assessment
Assessment of vision is especially important in
old age because impairment is common, strongly
associated with falls and fractures, adversely affects
communication and medication handling; and yet is
often remediable through surgery or prescription of
spectacles.
Domain Instrument / test
Physical health
Vision Snellen Visual Acuity Test, visual function assessment instruments32-36, Melbourne Edge Test,37
visualeld,Albert’slinecancellationtestforvisualneglect38,39
Hearing ScreeningVersionofHearingHandicapInventoryfortheElderly(HHIE-S),40-42 Whispered voice
test43
Swallowing Water swallow test44,45 (see Chapter 43)
Nutrition MiniNutritionalAssessment(MNA)46,47[seeChapter30],SimpliedNutritionalAssessment
Questionnaire(SNAQ)48
Medication GerontoNetADRriskscore,49 Medication appropriateness index,50 Morisky 8-item medication
adherence scale51 (see Chapter 15)
Comorbid conditions and
disease severity
CharlsonComorbidityIndex,52CumulativeIllnessRatingScale–Geriatrics(CIRS-G)53,54
Functional capacity
Basicactivitiesofdailyliving
(ADL)
Katzindex,Barthelindex,Functionalindependencemeasure(FIM)(seeChapter4)
Instrumentalactivitiesofdaily
living(IADL)
Lawton’sIADL55
Balanceandmobility Get-up and go,56TimedUp&Go,57BergBalanceScale,58 Functional Reach Test59 (see Chapter 20)
Frailty “FRAIL”QuestionnaireScreeningTool,60 Canadian Study of Health and Aging Clinical Frailty
Scale61,62
Sarcopenia SARC-F screen for sarcopenia63
Mental function
Cognition Clock drawing test,64-66 Executive clock drawing task (CLOX),67-69 Mini-Cog,70SaintLouisUniversity
MentalStatus(SLUMS)examination,71 Rapid Cognitive Screen (RCS)72
Mini-Mental State Examination (MMSE),73 Chinese version of the Mini-Mental State Examination
(CMMSE)74,75
Abbreviated Mental Test (AMT)76,77
Addenbrooke’s Cognitive Examination Revised (ACE-R)78
Montreal Cognitive Assessment (MoCA)79-83
Ascertain Dementia 8 (AD8),84,85 Chinese AD8 (cAD8)86
InformantQuestionnaireonCognitiveDeclineintheElderly(IQCODE)87
Confusion Confusion assessment method (CAM)88 (see Chapter 24)
Mood / anxiety / fears Geriatric Depression Scale (GDS)89 (see Chapter 25)
Socioeconomic resources Social network and support checklist (see Chapter 16)
Eligibility for care resources / disability allowances
Environmental resources Checklist for positive environment (age-friendly,90 supportive [therapeutic, prosthetic], accessible,
adaptable, comfortable, safe91), negative environment (iatrogenic, barriers, hazards), transport
facilities, accessibility to local resources
Table 2.2 Domains and instruments of comprehensive geriatric assessment32-91

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Assessment of vision begins with taking a history:
questions about function (can you feed yourself?
dress? handle / inject medication? read? watch
television? cook? sew? shopping? drive?); use of aids
(spectacles and why? magnifying glass?); accident,
falls, and near-falls (bump to one side?); and risk
factors (diabetes, stroke, hypertension, steroid,
smoking, alcohol). Examination includes response to
hand shaking, test of newspaper reading, inspecting
spectacles, visual acuity and contrast sensitivity
testing, fundoscopy, visual eld examination, and
tests of perceptual neglect.
Visual acuity is the ability to see detail at a distance.
This is recorded as a Snellen fraction when the person
being assessed reads down the Snellen chart of a
series of letters or letters and numbers that reduce in
size from the top to the bottom. The Snellen fraction
records the ability to identify a letter of a certain size
ataspecieddistance.Therstnumberornumerator
of the Snellen fraction is the testing distance (standard
is 20 feet or 6 m). During the visual acuity test, one
eye is covered and the vision of each eye is recorded
separately, as well as both eyes together. When the
person is unable to correctly identify more than
half the letters on a line, the previous line will be
recorded as the visual acuity. The second number or
denominator of the Snellen fraction represents the
distance that the average eye can see the letters on
a certain line of the eye chart. A Snellen fraction of
20/40 or its metric equivalent 6/12 means that the
eye being tested can see at 20 feet (6 m) the smallest
letter that can be seen by the average eye at 40 feet
(12 m). Visual acuity worse than 20/400 or 6/120
isrecordedascount ngers (atacertain number of
feet), hand motion (at a certain number of feet), light
perception, or no light perception.
Impaired vision is considered present when the level
of vision is below that which the individual requires
for his or her everyday tasks. A common cut-off point
is binocular visual acuity of 6/12 or 6/18 as used in
the Medical Research Council study. Legal blindness
is taken as 6/60. The common causes of impaired
vision are refractive errors, cataract, glaucoma,
macular degeneration, and stroke.
Visual function assessment instruments have been
developed to measure a patient’s vision capability that
maynotbereectedbytestingvisualacuityalone.32
These consist of questions to assess visual perception
(activity limitation, near vision, intermediate vision,
and distance vision), sensory adaptation (light / dark
adaptation, visual search, colour discrimination, and
glare disability), peripheral vision, depth perception,
social functioning, role limitations, dependency,
and mental health. Chinese versions of such visual
function assessment instruments that deal with daily
vision-dependent activities and associated everyday
problems relevant to Chinese culture have been
developed and used.33-36
Edges in the environment, such as steps and pavement,
are naturally occurring visual stimuli of functional
signicance. An impaired ability to perceive edges
will disadvantage elderly persons, especially those
with slow reaction times, muscle weakness, or
reduced peripheral sensation, and increase their fall
risk.95 Edge contrast sensitivity can be assessed by
the Melbourne Edge Test that contains 20 circular test
patches of 25 mm diameter, with a series of edges of
reducing contrast and variable orientation.37
Visual eld is assessed by confrontation and
perimetry. Visual eld loss is present in 1 in every
20 community-dwelling elderly people, increased in
incidence 5-fold between 55-80 years of age, and is
associated with impaired daily functioning and fall
risk.96,97 Glaucoma, stroke, cataract, and age-related
macula degeneration are common causes of visual
eldlossinoldage.52,53,98
Perceptual neglect or hemi-neglect is a defect in the
detection, orientation, or response to stimuli (visual,
auditory, or tactile) from spatial regions on the side
contralateral to the side of cerebral damage, and the
decitcannotbeattributabletomalfunctioninmore
basic sensory or motor systems. Perceptual neglect
hasbeenfoundin49%ofnon-dominanthemisphere
strokesand 25% of dominant hemispherestrokesin
the early stages.32 It can readily be diagnosed from
the characteristic sitting posture of slumping to one
side diagonally, leaving behind an exposed triangle
(‘inverted triangle sign’) on the back of the chair,
with the trunk and head rotated away from the side
of weakness, and conjugate eye deviation away from
the side of weakness (Plate 2.1). Visual neglect can be
assessed by the Albert’s line cancellation test,38,39 in
which the patient is asked to cross out lines ruled on
a sheet of paper; the central line being crossed by the
examiner as a demonstration (see Learning Manual).
The Albert’s test score is the percentage of lines left
uncrossed and is an important prognostic factor in
determining both mortality and functional recovery
from stroke.32 Patients with hemi-neglect are prone to
fall and injuries on the side of neglect and may ignore
half a plateful of food (Plate 2.1). Caregivers need to be
taught to recognise and appreciate the consequences
anddistressforpatientswiththisperceptualdecit.
2.7 Hearing Assessment
Assessment of hearing in old age is important
because impairment is common and disabling; it
adversely affects communication; impairs physical,
cognitive, and social function; is associated with
mood disturbances and behaviour disorders; and
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yet often can be improved by amplication, use of
appropriate hearing aids, and aural rehabilitation
(see Chapter 28).
Assessment of hearing starts with taking a history:
questions about function (hear door / telephone
bell? hear telephone conversation? visit friends?
accused of turning radio / television up too loud?
accused of being stupid?); use of aids (hearing
aids / ampliers?); and risk factors (chronic noise
exposure, diabetes, hypertension, ototoxic drugs,
alcohol). The Screening Version of Hearing Handicap
Inventory for the Elderly (HHIE-S)40,41 is a validated
self-administered 10-item questionnaire designed to
detect emotional and social problems associated with
impairedhearing (Table2.3).AHHIE-S score of >8
hasa sensitivity of72%, specicity of77%, positive
predictive value of 58%, and negative predictive
value of 86% for detecting impaired hearing in
elderly persons. With a HHIE-S score of >24, the
corresponding values become 41%, 92%, 67%, and
78%.41 The HHIE-S has been translated and adapted
for other languages, including Chinese42 (Table 2.3).
Examination includes screening hearing tests,
otoscopy to identify impacted ear wax, eardrum
perforation or other abnormalities, and audiometry.
Tuning fork tests are used to distinguish conductive
from sensorineural hearing loss. Vision should also be
assessed since hearing and vision impairment often
coexist in elderly persons. Loss of visual clues in a
hearing-impaired elderly person will further impair
speech, and dual sensory impairment is associated
with cognitive and functional decline and increased
mortality.99,100
A simple hearing test is the whispered voice test.43
A tester stands behind (to prevent lip reading) and
to the side of the seated patient, at arm’s length (0.6
m) from the patient’s non-test ear that is masked by
gently occluding and rubbing the external auditory
canal, and whispers sets of three random numbers
(e.g. 6, 1, 9). The patient is asked to repeat the
sequence.Ifthepatientcannotrepeatbackover50%
Abbreviations: [E] = emotional handicap question（情緒問題）; [S] = social handicap question（情景問題）
* Scores(range,0-40):0=“no（不是）”response;2=“sometimes（有時）”;4=“yes（是）”
Question Score*
1. [E]
Doesahearingproblemcauseyoutofeelembarrassedwhenyoumeetnewpeople?
聽力問題使您在遇見陌生人時感到窘迫嗎？
2. [E]
Doesahearingproblemcauseyoutofeelfrustratedwhentalkingtomembersofyourfamily?
聽力問題使您在與家人交談時感到沮喪嗎？
3. [S]
Doyouhavedifcultyhearingwhensomeonespeaksinawhisper?
有人跟您細聲說話時是否會感到費勁？
4. [E]
Doyoufeelhandicappedbyahearingproblem?
聽力問題會使您感到障礙或不方便嗎？
5. [S]
Doesahearingproblemcauseyoudifcultywhenvisitingfriends,relativesorneighbours?
聽力問題會使您在拜訪親朋好友時遇到困難嗎？
6. [S]
Doesahearingproblemcauseyoutoattendreligiousserviceslessoftenthanyouwouldlike?
聽力問題會使您參加活動的次數比以前少嗎？
7. [E]
Doesahearingproblemcauseyoutohaveargumentswithyourfamily?
聽力問題會導致您與家人爭吵嗎?
8. [S]
Doesahearingproblemcauseyoudifcultywhenlisteningtotelevisionorradio?
聽力問題會使您在看電視或聽廣播時感到困難嗎？
9. [E]
Doyoufeelthatanydifcultywithyourhearinglimitsorhampersyourpersonalorsociallife?
您是否感到聽力問題影響您個人或社會生活？
10. [S]
Doesahearingproblemcauseyoudifcultywheninarestaurantwithrelativesorfriends?
聽力問題使您在餐館與親友交談時遇到困難嗎？
Total score:
Table 2.3 ScreeningVersionoftheHearingHandicapInventoryfortheElderly(HHIE-S)40,41 and its Chinese translation42

Chapter 2. Comprehensive Geriatric Assessment
/ 212.7
of the test items over a minimum of two sets, s/he
is assumed to have hearing impairment that requires
further audiometric assessment.
An audioscope is an instrument that serves as both
an otoscope and simplied audiometer. It delivers
pure tone frequencies at 20, 25, and 40 decibels at
500, 1000, 2000, and 4000 Hz. Critical frequencies for
speech reception are 500, 1000, 2000, 3000 Hz. In the
American Speech-Language-Hearing Association
guidelines, 25 dB is the standard screening level used
for adults. To use the audioscope, the tester selects
the largest ear speculum needed to achieve a seal
within the external auditory canal, obtains a clear
view of the tympanic membrane, and removes any
impacted ear wax before testing. The tonal sequence
is then initiated with the patient indicating by raising
a nger that s/he has heard the tone. The tester
records whether the tone is heard at each frequency
for each ear. When tested in the physicians’ ofces
and a hearing centre, the sensitivity of the audioscope
was94% in both locations, whileits specicitywas
90%inthehearingcentreand72%inthephysicians’
ofces.41 A better test accuracy was obtained when
the HHIE-S test was combined with an audioscope
test.41
2.8 Cognitive Assessment
Cognitive impairment occurs along a continuum from
ageing-related cognitive decline to mild cognitive
impairment (MCI) with intact daily function to
dementia that affects daily function. Cognitive
impairmentisageriatricgiantwithsignicantimpact
on the patient, their family and friends, and clinicians.
Early detection of impaired cognition allows for
diagnosis, appropriate treatment, and support.
Cognitive assessment is commonly used to screen for
cognitive impairment; obtain differential diagnoses
of its cause; rate its severity; monitor change; and
make decisions about competency, management, and
placement.
With a view towards better care from geriatricians
for patients with cognitive impairment, the British
Geriatrics Society produced a consensus document
in 2005 that recommended use of Mini-Mental
State Examination (MMSE)73 and an executive clock
drawing task (CLOX1)67 as the two initial screening
tests in a cognitive screening algorithm.101 Patients
with abnormalities in either one of these tests were
further evaluated by two additional cognitive
tests: the Confusion Assessment Method88 and the
Informant Questionnaire on Cognitive Decline in
the Elderly (IQCODE)87 to screen for delirium and
dementia, respectively.
In recognition of the importance of the maintenance
of cognitive or brain health to both the individual and
society, the International Association of Gerontology
and Geriatrics and its Global Aging Research
Network convened an expert consensus panel in 2015
and published a consensus paper that recommended
a combination of validated, brief (3-7 mins) patient-
based and informant-based screens as the most
appropriate approach to the identication of early
cognitive impairment.102
2.8.1 Clock Drawing Test
The clock drawing test (CDT) is a simple and quick
test designed originally as a measure of visuospatial
ability and attention in hemi-neglect patients, and
to screen for constructional apraxia.103 The CDT is
now also recognised as a test for executive and other
cognitive functions.64 The test requires the patient
to draw a clock face on a piece of paper with or
without the arms set at a specied time. The CDT
is commonly used together with the MMSE. These
two cognitive tests are complementary to each other,
with the CDT more suited for screening executive
and visuo-constructional functions, and the MMSE
more suited for orientation, memory, and language
functions.64,104 There are many versions of the CDT
that differ in instruction, scoring, and ease of use.
Despite the different scoring protocols, study has
shown that they all correlate well with the severity
of global cognitive impairment, although particular
scoring methods may be better suited to assess
vascular dementia than Alzheimer’s disease and
vice versa.74 A comprehensive review of the multiple
clock drawing scoring systems revealed that no CDT
was consistently superior in terms of predictive
validity for dementia screening, and concluded that a
qualitative assessment of ‘normal’ versus ‘abnormal’
by ‘eyeballing’ the clocks may be sufcient for use
of CDT as a dementia screening instrument in a
primary / general medicine / community setting.105
A CDT adapted for use among elderly Chinese in
Hong Kong has been designed (ll inside a pre-
drawn circle of 2.5” diameter the numbers of a clock
face with arms indicating the 3 o’clock position) and
proved to be a valid measure to screen for dementia,
even for illiterate individuals traditionally thought to
be non-compliant with tests that required writing or
drawing.65,66
The CLOX designed by Royall et al67 is used to elicit
executive impairment and discriminate it from
non-executive constructional failure (Table 2.4).
The CLOX is divided into an unprompted drawing
task(withspeciedtime of 1:45)thatissensitive to
executive control (CLOX1) and a copied version
that is not (CLOX2). Points are awarded based on
the answers to a set of 15 questions (e.g. does the
gureresemblea clock?). Maximumscoresfor both
the drawing task (CLOX 1) and the copying task
(CLOX 2) are 15 points each. A lower score indicates

HKGS Curriculum in Geriatric Medicine (2nd Edition)
/ 222.8
Executive clock drawing task (CLOX1 and CLOX2)
STEP 1 (CLOX1 unprompted executive clock drawing task):
Turnthisformoveronalight-colouredsurfacesothatthecirclebelowisvisible.Havethepatientdrawaclockontheback.Instruct
him/herto“請你畫一個鐘，顯示1:45。將手臂和數目字放在面上邊，以至連一個細路都識睇。”“drawmeaclockthatsays1:45.Set
thehandsandnumbersonthefacesothatachildcouldreadthem.”Repeattheinstructionsuntiltheyareclearlyunderstood.Once
the subject begins to draw, no further assistance is allowed. Score this clock in the CLOX1 column.
STEP 2 (CLOX2 non-executive clock copying task):
Returntothissideandletthesubjectobserveyoudrawaclockinthecirclebelow.Place12,6,3,and9rst.Setthehandsagainto
“1:45”.Makethehandsintoarrows.Invitethesubjecttocopyyourclockinthelowerrightcorner.Scorethisclock(CLOX2).
Organisational element CLOX1 CLOX2
Q1 Doesgureresembleaclock? Q1=1 point Q1=1 point
Q2 Outercirclepresent? Q2=1 point Q2=1 point
Q3 Diameter>1inch? Q3=1 point Q3=1 point
Q4 Allnumbersinsidethecircle? Q4=1 point Q4=1 point
Q5 12,6,3and9placedrst? Q5=1 point Q5=1 point
Q6 Spacingintact?(symmetryoneithersideofthe12-6axis?)Ifyes,
skip next.
Q6=2 point Q6=2 point
Q7 Ifspacingerrorsarepresent,aretheresignsofcorrectionorerasure? Q7=1 point Q7=1 point
Q8 OnlyArabicnumerals? Q8=1 point Q8=1 point
Q9 Onlynumbers1-12amongtheArabicnumerals? Q9=1 point Q9=1 point
Q10 Sequence1-12intact?Noomissionsorintrusions Q10=1 point Q10=1 point
Q11 Onlytwohandspresent? Q11=1 point Q11=1 point
Q12 Allhandsrepresentedasarrows? Q12=1 point Q12=1 point
Q13 Hourhandbetween1and2o’clock? Q13=1 point Q13=1 point
Q14 Minutehandlongerthanhour? Q14=1 point Q14=1 point
Q15 Noneofthefollowing:
(1) handpointingto4or5o’clock?
(2) ‘1:45’present?
(3) intrusionsfrom‘hand’or‘face’present?
(4) anyletters,wordsorpictures?
(5) anyintrusionfromcirclebelow?
Q15=1 point Q15=1 point
Total / 15 / 15
For Caucasians, CLOX1 score of <10 indicates executive dysfunction ± constructional dyspraxia, CLOX2 score of <12 indicates
constructional / visuospatial dyspraxia (Royall 199867)
For Chinese in Hong Kong, CLOX1 score of <7 (1 standard deviation below mean) or CLOX2 score of <11 (1 standard deviation
below mean) indicates cognitive dysfunction (Wong 200468)
Table 2.4 The executive clock drawing task (CLOX)67 and its Chinese translation68

Chapter 2. Comprehensive Geriatric Assessment
/ 232.9
impairment, with a cut-off score of 10/15 for the
drawing task and 12/15 for the copying task. The
CLOX has been translated into Chinese (Table 2.4)
and was found to correlate strongly with MMSE
when tested among elderly Chinese in Hong Kong,
although performance depended on education with
a lower cut-off score of 7/15 and 11/15 for CLOX1
and CLOX2, respectively among Chinese subjects.68
Nonetheless when the Chinese version of CLOX was
tested in Chinese elderly patients with subcortical
ischaemic vascular disease against more formal
executive measures than that used by Royall et al,67
it performed poorly as a screening test for executive
dysfunction.68 A study of the same Chinese version
of CLOX among Singaporean Chinese, however,
supported CLOX as a valid cognitive screen with
adequate psychometric properties, and its use as an
adjunct in differentiating Alzheimer’s disease from
dementiawithavascularelement, in which decits
in executive control function are more prominent.69
The CDT has been incorporated as a component of
other cognitive screening tests, e.g. Mini-Cog,70 Saint
Louis University Mental Status examination (http://
aging.slu.edu/index.php?page=multi-language-
slums),71 and Rapid Cognitive Screen.72 The Mini-
Cog was developed as a brief 5-point cognitive test
to discriminate dementia from non-dementia among
multilingual elderly persons with diverse educational
status by combining a delayed three-item recall (0-3
points) with a clock drawing test (0 or 2 points) as
recall distractor.70 A score of 0-2 indicated a positive
screen for dementia.
2.8.2 MMSE
The MMSE was rst described by Folstein et al in
1975 as a “practical method for grading the cognitive
state”.73 It was called “mini” because it “concentrates
only on the cognitive aspects of mental functions,
and excludes questions concerning mood, abnormal
mental experiences and the form of thinking.” The
MMSE consists of 19 tests of 11 domains covering
orientation to time and place (10 points), registration
of three words (3 points), attention or calculation
tested by serial sevens or spelling (5 points), recall of
three words (3 points), verbal and written language
including naming, repetition, comprehension (8
points), and visual construction (1 point). Folstein et
al73suggestedacut-offscoreof≤23(outofamaximum
score of 30) for the presence of dementia in persons
with at least 8 years of education. Numerous other
cut-offs have been calculated from receiver operating
characteristic curve analysis of specic populations
together with adjustments for age and education.106
The norms declined with advancing age, especially
for less educated women. Given any age and gender,
the norms were higher for individuals with a higher
education level.106
A meta-analysis of 34 dementia studies and ve
MCI studies was conducted to evaluate the accuracy
and clinical utility of MMSE as a cognitive test
in high and low prevalence settings (Table 2.5).107
The study concluded that MMSE has some value
both in specialist and non-specialist settings but
in two different capacities. In specialist settings
such as memory clinics it was reasonably effective
in identifying dementia but could not be relied
upon alone if a result was negative (patient scored
above threshold) and should not be used alone
for diagnosing MCI. Conversely, in non-specialist
settings such as primary care, the only value of
the MMSE was in excluding dementia in someone
worried about their memory, while a positive result
(scoring under threshold) could be explained mostly
by non-dementia conditions.107 MMSE cannot serve
as a substitute for systematic evaluation that includes
history taking, examination, and laboratory tests.
The MMSE is affected by educational background,
language and communication disorders, and sensory
loss. Limitations of the MMSE include its non-linearity,
aooreffectinadvanceddementia(ascoreof0does
not mean an absolute absence of cognition), a ceiling
effect in very mild disease (a score of 30 does not
always mean normal cognitive function), and a lack
of sensitivity for frontal / executive or visuospatial
functions. The pentagon task of the MMSE does not
assess executive function as it simply requires the
patient to copy the image.108 Thus MMSE may have a
limited ability to detect early stage of dementia with
executive dysfunction, e.g. vascular dementia.108 The
MMSE has been standardised with clear guidance for
its administration, scoring and time allowed for each
of the components, with resultant reduction in inter-
rater variability and administration time.109
A Cantonese version of MMSE has been validated
Setting Sensitivity (%) Specicity (%) Positive predictive value (%) Negative predictive value (%)
Memory clinic 79.8 81.3 86.3 73.0
Mixed specialist hospital 71.1 95.6 94.2 76.4
Non-clinicalcommunity 85.1 85.5 34.5 98.5
Primary care 78.4 87.8 53.6 95.7
Table 2.5 Accuracy of the Mini-Mental State Examination as a cognitive test for dementia in various prevalence settings107

HKGS Curriculum in Geriatric Medicine (2nd Edition)
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as an instrument to detect cognitive impairment in
a local Chinese population in Hong Kong; a cut-off
score of 19-20 is recommended as an indication for
further evaluation of cognitive impairment74; further
studies suggested that the optimal cut-off point was
≤18forilliteratesubjects,≤20forthosewith1-2years
of schooling, and ≤22 for those with >2 years of
schooling.75
The second edition of the MMSE (MMSE-2) was
developed in 2012 under the copyright of the
Psychological Assessment Resources (http://www.
minimental.com/), with a 30-point standard version
equivalent to the original MMSE; a 16-point brief
version for rapid cognitive screening; and a 90-point
expanded version enhanced with two new tasks
(story memory and processing speed) to increase
sensitivity for milder forms of cognitive impairment,
includingsubcorticaldementia.AsimpliedChinese
translation of MMSE-2 is available.
2.8.3 AMT
Based on a study in 21 geriatric departments in the
UK sponsored by the Royal College of Physicians
of London, Hodkinson76 shortened the Blessed,
Tomlinson, and Roth’s mental test110 from 26
questions to 10. He noted that the AMT gave
comparable results to the full mental test and could
replace it where the test was used to recognise
cognitive impairment due to delirium or dementia.76
The shorter test also achieved far more consistent
cooperation by patients being tested. Validation study
of the AMT in the UK recommended a cut-off score
of 8 (<8 suggesting abnormal cognitive function)
withasensitivity of 91% and specicityof75%.111 A
modied local Chinese version of AMT (Table 2.6),
which was validated in a local Chinese population,
is commonly used in Hong Kong.77 The cut-off of 6
yielded a sensitivity of 96% and specicity of 94%
in differentiating normal versus abnormal cognitive
function (e.g. delirium, dementia) in local elderly
patients.77 The lower AMT cut-off of 6 for the local
Chinese population has been attributed to a lower
education level.
2.8.4 Montreal Cognitive Assessment
The Montreal Cognitive Assessment (MoCA) is a
cognitive test of 10 items covering the domains of
short-term memory, visuospatial skills, executive
function, phonemic verbal uency, abstraction,
attention, concentration and working memory,
language function, and time orientation (http://
www.mocatest.org). Its nal English version is a
1-page 30-point screening test, with a cut-off score
of <26 considered abnormal and 1 point added for
persons educated ≤12 years.79 Compared with the
MMSE,theMoCAissignicantlybetterfordetecting
MCI, with a sensitivity and specicity of 90% and
87%,respectively.79 Validated Chinese versions with
adjusted cut-offs for use in Hong Kong,80,81 Taiwan,82
and China83 are available. In the Cantonese Chinese
version81 of MoCA, with 2-point added for illiterate
and 1-point for persons educated 1-6 years, a cut-
offof<22/23hasasensitivityof78%andspecicity
of 73% in detecting amnestic MCI, while a cut-off
of 19/20 has a sensitivity of 94% and specicity
of 92% in detecting Alzheimer’s dementia. In the
original 2009 Hong Kong MoCA (HK-MoCA),80 with
1-pointaddedforpersonseducated ≤6 years, a cut-
offof21/22 has asensitivity of 73%and specicity
of75%indifferentiatingpatientswithcerebralsmall
vessel disease (the most common cause of vascular
cognitive impairment) from controls. The HK-MoCA
was subsequently updated to the 2015 version with
age and education corrected normative data of total
score of MoCA (http://www.mocatest.org/wp-
content/uploads/2015/03/HK-MoCA_20151030.
pdf). Cognitive impairment is determined when the
score ≤ age and education corrected percentile cut-
offs at 7th and 2nd percentiles for MCI and dementia,
respectively. A brief version of HK-MOCA, the Hong
Kong version of Montreal Cognitive Assessment —
5-minute protocol (HK-MoCA 5-min), is available for
cognitive screening via telephone.
2.8.5 Informant-based Cognitive
Assessment
In contrast to patient-based mental status tests that
2.10
Question Score
Age (± 5 years) 0/1
Time (to the nearest hour, or am, pm, night) 0/1
(Ask to memorise address for recall at the end of the test: 42 Shanghai Street)
Year (± 1 year) 0/1
Place name 0/1
Recognition of two persons (doctor, nurse) 0/1
Date of birth (date and month) 0/1
Date of Mid-Autumn festival 0/1
NameofpresentChiefExecutiveoftheHongKongSpecialAdministrativeRegionorChineseleader 0/1
Count from 20 to 1 backwards 0/1
Recall address: 42 Shanghai Street 0/1
Table 2.6 Abbreviated Mental Test (Hong Kong version)77

Chapter 2. Comprehensive Geriatric Assessment
/ 25
directly assess the patient’s performance, informant-
based cognitive assessment indirectly assesses the
patient by gathering information about everyday
behaviour and activities from informants (family
or friends). The strengths of this approach are:
change in functioning and time course of decline
can be assessed; less inuenced by education and
premorbid intelligence; less articial and reects
capacity in a natural setting; applicable even when
the patient is non-communicable or uncooperative.112
A weakness is that the indirect assessment is more
inuenced by reporting factors such as bias in
interpretation of the patient’s behaviour; informants’
motivation to provide information; and the quality
of the relationship between the informant and the
patient.112
The Ascertain Dementia 8 (AD8) is a brief (3-min
administration time) informant-based cognitive
screening tool with eight questions that assess
change in memory, temporal orientation, judgement,
and function (Table 2.7).84,85An AD8 score of ≥2 in
a memory clinic setting (dementia prevalence 89%)
hasa sensitivity of92%, specicity of46%, positive
predictive value of 93%, and negative predictive
2.11
1. Veryt—robust,active,energetic,well-motivatedandt;thesepeoplecommonlyexerciseregularlyandareinthettestgroup
for their age. Self-rate health as ‘excellent’
2. Well—withoutactivedisease,butlesstthanpeopleincategory1
3. Well,withtreatedcomorbiddisease—diseasesymptomsarewellcontrolledcomparedwiththoseincategory4
4. Apparentlyvulnerable—althoughnotfranklydependent,thesepeoplecommonlycomplainofbeing‘slowedup’orhavedisease
symptomsorself-ratehealthas“fair”,atbest.Ifcognitivelyimpaired,donotmeetdementiacriteria
5. Mildlyfrail—withlimiteddependenceonothersforinstrumentalactivitiesofdailyliving
6. Moderatelyfrail—helpisneededwithbothinstrumentalandnon-instrumentalactivitiesofdailyliving
7. Severelyfrail—completelydependentonothersfortheactivitiesofdailyliving
8. Terminally ill
AD8 Chinese AD8 Cognitive abilities
asked
Instructionstoinformant:“Remember,‘Yes,achange’
indicates that you think there has been a change in the
last few years caused by cognitive (thinking and memory)
problems.”
填表說明：若您以前無下列問題，但在過去幾年
中有以下的『改變』，請勾選；若無或不確定，
請繼續下一題。一共有八題。
1. Problems with judgement (e.g. falls for scams, bad
nancialdecisions,buysgiftsinappropriateforrecipient)
判斷力上的困難：例如落入圈套或騙局、財路上
不好的決定、買了對受禮者不合宜的禮物。
Judgement
2. Reduced interest in hobbies / activities 對活動和嗜好的興趣降低。 Function
3. Repeats questions, stories, or statements 重複相同問題、故事和陳述。 Memory
4. Trouble learning how to use a tool, appliance, or gadget
(e.g. VCR, computer, microwave, remote control)
在學習如何使用工具、設備和小器具上有困難。
例如：電視、音響、冷氣機、洗衣機、熱水爐
（器）、微波爐、遙控器。
Function
5. Forgets correct month or year 忘記正確的月份和年份。 Temporal orientation
6. Difcultyhandlingcomplicatednancialaffairs(e.g.
balancing checkbook, income taxes, paying bills)
處理複雜的財物上有困難。例如：個人或家庭的
收支平衡、所得稅、繳費單。
Judgment
7. Difcultyrememberingappointments 記住約會的時間有困難。 Memory
8. Consistent problems with thinking and / or memory 有持續的思考和記憶方面的問題。 Memory
Table 2.8 Clinical Frailty Scale62
Table 2.7 Ascertain Dementia 8 (AD8) questions asked of informants84,85 and its Chinese version86*
* TheaboveAD8questionsareaskedofaninformant.Itemsendorsedas“Yes,achange”aresummedtoyieldthetotalAD8score
valueof 43% fordetecting dementia evenat a very
mild stage. The AD8 has been translated into Chinese
in Taiwan and validated.86 At a cut-off of 2, the
ChineseAD8hasasensitivityof97.6%,specicityof
78.1%,positive likelihoodratio of4.5, and negative
likelihood ratio of 0.03 in detecting dementia.86
The IQCODE is a self-administered tool that comprises
26 items completed by an informant familiar with the
patient. The informant rates the patient’s cognitive
function as better or worse than 10 years ago based on a
5-point scale.87 The short form of IQCODE contains 16
items and takes 10-15 minutes to complete. IQCODE
is scored by adding up the score for each question and
then dividing by the number of questions, 26 for the
long IQCODE and 16 for the short IQCODE. The result
is a score that ranges from 1-5; a score of 3 means ‘no
change’, 4 ‘a bit worse’, and 5 ‘much worse’. Balancing
sensitivityandspecicityforscreeningfordementia,
the cut-off for the long IQCODE is 3.27/3.30, while
the cut-off for the short IQCODE is 3.31/3.38. The
IQCODE has been translated into other languages,
including Chinese (http://crahw.anu.edu.au/risk-
assessment-tools/informant-questionnaire-cognitive-
decline-elderly.)

HKGS Curriculum in Geriatric Medicine (2nd Edition)
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2.8.6 Choice of Cognitive Tests
The appropriate choice of a cognitive test depends
both on the time available and the purpose of
assessment. An ideal cognitive screening tool should
be brief and have no copyrighted costs.102,113 Surveys
in the West have shown the MMSE to be the most
commonly used. Nonetheless the MMSE takes on
average 8 (range, 4-21) minutes to perform and the
acquisition of copyright restriction of MMSE by the
Psychological Assessment Resources in 2001 has
increased the need to identify briefer and effective
cognitive tests for use in clinical practice.113,114 A
systematic review and meta-analysis of dementia
screening tests up to 2014 evaluated the diagnostic
performance of all cognitive tests for the detection
of dementia,114 and concluded that the Mini-Cog
test70 and the Addenbrooke’s Cognitive Examination
Revised78 are the best alternative screening tests for
dementia, and the MoCA79 is the best alternative for
MCI.114
2.9 Geriatric Assessment for Geriatric
Syndromes
The Royal College of Physicians advocated early CGA
for frail elderly people.115 Commonly used validated
assessment tools for screening frailty in elderly
persons include the Canadian Study of Health and
Aging (CSHA) Clinical Frailty Scale (Table 2.8)61,62
and the “FRAIL” Questionnaire Screening Tool
(Table 2.9).60 Clinical Frailty Scale is a measure of
frailty based on clinical judgement when interpreting
the results of history taking and clinical examination,
developed in the CSHA. Each one-category increment
ofthescalesignicantlyincreasedthemedium-term
risks of death (21.2% within 70 months) and entry
intoan institution (23.9%).Sarcopenia and fallscan
be identied through the SARC-F questionnaire
(Table 2.10).63 The assessment tools FRAIL (for frailty)
and SARC-F (for sarcopenia and falls) have been
combined with other screening assessment tools
Simplied Nutrition Assessment Questionnaire
≥3=Frailty;1or2=pre-frail
Fatigue:Areyoufatigued?
Resistance:Cannotwalkuponeightofstairs?
Aerobic:Cannotwalkoneblock?
Illnesses:Doyouhavemorethanveillnesses?
Lossofweight:Haveyoulostmorethan5%ofyourweightinthepast6months?
Table 2.9 The“FRAIL”QuestionnaireScreeningTool60
Component Question Scoring*
Strength Howmuchdifcultydoyouhaveinliftingandcarrying10pounds? None=0
Some = 1
A lot or unable = 2
Assistance in walking Howmuchdifcultydoyouhavewalkingacrossaroom? None=0
Some = 1
A lot, use aids, or unable = 2
Rise from a chair Howmuchdifcultydoyouhavetransferringfromachairorbed? None=0
Some = 1
A lot or unable without help = 2
Climb stairs Howmuchdifcultydoyouhaveclimbingaightof10steps? None=0
Some = 1
A lot or unable = 2
Falls Howmanytimeshaveyoufalleninthepastyear? None=0
1-3 Falls = 1
≥4Falls=2
Table 2.10 SARC-F Screen for Sarcopenia63
* Totalscoreof≥4ispredictiveofsarcopeniaandpooroutcomes
* Ascoreof<14mayidentifypersonswithanorexiaandatriskofsignicantweightloss
My appetite is Food tastes When I eat Normally I eat
1. very poor 1. very bad 1.Ifeelfullaftereatingonlyafewmouthfuls 1. less than one meal a day
2. poor 2. bad 2.Ifeelfullaftereatingaboutathirdofameal 2. one meal a day
3. average 3. average 3.Ifeelfullaftereatingoverhalfameal 3. two meals a day
4. good 4. good 4.Ifeelfullaftereatingmostofthemeal 4. three meals a day
5. very good 5. very good 5.Ihardlyeverfeelfull 5. more than three meals a day
Table 2.11 SimpliedNutritionalAssessmentQuestionnaire48*

Chapter 2. Comprehensive Geriatric Assessment
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for anorexia and undernutrition (Table 2.11)48 and
Rapid Cognitive Screen for cognitive dysfunction72
into a Rapid Geriatric Assessment (RGA)116,117
toolkit to quickly screen for the common geriatric
syndromes of frailty, sarcopenia and falls, anorexia
and undernutrition, and intellectual impairment.
The RGA can be completed quickly within 4 minutes,
facilitating early recognition of geriatric syndromes,
diagnosis of underlying causes, and implementation
of intervention and a care plan to reduce disability in
elderly persons.116,117
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