Comprehensive Geriatric Assessment and Frailty — Clinical Case

DCE Long Case

Patient brief (provided to trainee)

Patient: Mrs Margaret Chen, 84 years old, retired schoolteacher. [1]

Presenting complaint: Progressive functional decline over 6 months, two falls (one with a wrist fracture), weight loss, and low mood, assessed in the geriatric outpatient clinic. [1]

History of the presenting complaint: Mrs Chen's daughter reports a 6-month decline. Her mother has become increasingly slow and cautious on her feet, has had two falls in the past 4 months (the second resulting in a distal radial fracture treated in a plaster), and has given up driving after a minor parking accident 2 months ago. She now needs help with her weekly shopping and her housework. Her appetite has decreased, and she has lost about 5 kg over 6 months. She has become withdrawn and has stopped attending her weekly garden club. She denies chest pain, palpitations, syncope, or focal neurological symptoms. [1]

Past history:

• Hypertension (diagnosed 20 years ago).
• Type 2 diabetes (diagnosed 15 years ago).
• Atrial fibrillation (diagnosed 8 years ago, on warfarin).
• Osteoarthritis (knees and hips).
• Left total hip replacement 8 years ago for osteoarthritis.
• Appendicectomy in her 30s.
• No prior fractures until the recent wrist fracture. [1]

Current medications:

• Warfarin 4 mg daily (INR target 2.0 to 3.0).
• Metformin 1000 mg twice daily.
• Gliclazide 80 mg daily.
• Amlodipine 10 mg daily.
• Oxybutynin 5 mg twice daily (for overactive bladder, started 3 years ago).
• Paracetamol 1 g four times daily.
• Codeine 30 mg as needed (takes two to three daily for joint pain).
• Temazepam 10 mg at night (started after her husband died 2 years ago).
• Omeprazole 20 mg daily. [1]

Social history: Widowed 2 years ago when her husband died of pancreatic cancer. Lives alone in a two-storey, three-bedroom house in an outer suburb. Her older daughter lives locally and visits weekly; her younger daughter lives interstate. She was a primary school teacher, retired at 65. She does not smoke and drinks alcohol rarely. Before this decline she was independent in all activities, walked daily, and attended her garden club and a weekly church group. She has no advance care directive and no appointed substitute decision-maker. [1]

Examination findings (trainee elicits):

• Alert and cooperative. Oriented to person and place but gives the year as 2024. Speech is slow but fluent.
• MoCA: 21 out of 30 (points lost on recall, attention, and executive).
• GDS-15: 7 (positive screen for depression).
• 4AT: 0 (no delirium).
• Blood pressure: 142/78 mmHg lying, 118/66 mmHg standing (24 mmHg systolic drop).
• Pulse: 78, irregularly irregular (atrial fibrillation).
• Bilateral temporal wasting and reduced thenar bulk.
• Grip strength: 14 kg dominant hand (Jamar dynamometer).
• Timed Up and Go: 17 seconds.
• Gait speed over 4 metres: 0.65 m/s. Gait is slow, cautious, with a shortened stride and a wide base.
• Chair stand (5 rises): 16 seconds.
• Katz ADL: 4 out of 6 (needs help with bathing and transferring).
• Lawton IADL: 5 out of 8 (independent in telephone, feeding, medications; needs help with shopping, housework, laundry, transport, finances).
• MNA-SF: 8 out of 14 (at risk of malnutrition).
• Clinical Frailty Scale: 6 (moderately frail). [1]

Investigations:

• Full blood count: normal.
• Urea and electrolytes: sodium 138, potassium 4.2, creatinine 92 micromol/L (eGFR 52).
• Liver function tests: normal.
• HbA1c: 58 mmol/mol.
• TSH: 2.1 (normal).
• B12: 280 pmol/L (normal), folate normal.
• Calcium normal, vitamin D 38 nmol/L (low).
• INR: 2.6.
• DEXA: T-score minus 2.6 at the femoral neck (osteoporosis). Appendicular skeletal muscle mass index 4.9 kg per square metre (low for women, below 5.4).
• CT brain: mild generalised atrophy with a few small white matter changes. No infarct or mass. [1]

Candidate's long-case presentation (SASPOP)

"Mrs Margaret Chen is an 84-year-old retired schoolteacher presenting with a 6-month decline in function, two falls with one fragility wrist fracture, weight loss, and low mood. [1]

Her past history includes hypertension, type 2 diabetes, atrial fibrillation on warfarin, osteoarthritis, and a previous left hip replacement. Her medications are warfarin, metformin, gliclazide, amlodipine, oxybutynin, paracetamol, codeine, temazepam, and omeprazole — eight regular medications with a high anticholinergic and sedative burden. [1]

She lives alone in a two-storey house since her husband died 2 years ago. Her older daughter visits weekly; her younger daughter is interstate. She has no advance care directive. [1]

On examination she has atrial fibrillation, orthostatic hypotension (a 24 mmHg systolic drop), bilateral temporal wasting, a MoCA of 21, a GDS-15 of 7, a grip strength of 14 kg, a Timed Up and Go of 17 seconds, a gait speed of 0.65 m/s, and a Katz ADL of 4. Her DEXA shows osteoporosis (T-score minus 2.6) and an appendicular skeletal muscle mass index of 4.9. Her vitamin D is low at 38. [1]

Her main problems are:

1. Moderate frailty (Clinical Frailty Scale 6) with confirmed sarcopenia by EWGSOP2 (low grip strength plus low muscle mass)
2. Falls and a fragility wrist fracture, with orthostatic hypotension, sarcopenia, and polypharmacy as contributors
3. Polypharmacy with high anticholinergic and sedative burden — oxybutynin, codeine, temazepam, amlodipine
4. Cognitive impairment (MoCA 21), worsened by the anticholinergic burden
5. Depression (GDS-15 of 7)
6. Malnutrition (MNA-SF of 8, 9 percent weight loss in 6 months) and vitamin D deficiency
7. Osteoporosis (T-score minus 2.6, fragility fracture) needing secondary fracture prevention
8. Suboptimal glycaemic control needing individualised targets
9. Social isolation and environmental falls risk — lives alone in a two-storey house, one daughter interstate, no advance care directive [1]

My integrated plan is a structured medication review — I will stop the oxybutynin and switch to mirabegron, withdraw the temazepam gradually, minimise and stop the codeine, and reduce the amlodipine for the orthostasis. I will start a multifactorial falls prevention programme — exercise, home safety, vision check, and vitamin D. I will address the sarcopenia with progressive resistance exercise and dietary protein at 1.2 to 1.5 grams per kilogram per day with oral nutritional supplements, and correct the vitamin D deficiency with 1000 IU daily. I will treat the depression with citalopram 10 mg daily. I will investigate the cognitive impairment with an MRI and repeat the MoCA after the medication changes. I will start osteoporosis treatment with alendronate, calcium, and vitamin D given the fragility fracture. I will arrange a home safety assessment by an occupational therapist, community home care services, and a personal alarm. I will initiate advance care planning — values, goals, the appointment of an enduring guardian and power of attorney while she retains capacity. I will review at 3 months with repeat measures to track the frailty reversal. The framework is comprehensive geriatric assessment, and the evidence is that CGA with interdisciplinary follow-up improves survival and function in this patient group." [1]

Discussion questions

Q1: "How would you prioritise these nine problems, and what is the single most impactful intervention?" [1]

"I would prioritise the problems in order of the immediate risk to her safety and the reversibility of the intervention. The top priority is the falls risk — she has had two falls, one with a fracture, and the next fall could be a hip fracture with catastrophic consequences. The most impactful single intervention is the medication review and deprescribing — specifically, stopping the oxybutynin, withdrawing the temazepam, minimising the codeine, and reducing the amlodipine for the orthostatic hypotension. These four changes address the falls risk (reducing orthostasis, sedation, and central nervous system depression), the cognitive impairment (reducing anticholinergic burden), and the polypharmacy simultaneously. The second priority is the sarcopenia and the falls prevention programme — progressive resistance exercise, protein, and vitamin D — because these are the evidence-based interventions that can improve her strength, balance, and function and reduce the falls risk. The third priority is the osteoporosis treatment — she has a fragility fracture and osteoporosis on DEXA, and the bisphosphonate reduces the risk of the next fracture. The fourth is the depression and the cognitive assessment, the fifth is the glycaemic control (relaxed targets for a frail older adult), and the sixth is the advance care planning and the social support package. The key insight is that the problems are interrelated — the medication review improves the falls risk, the cognition, and the orthostasis in a single step, and the exercise and nutrition programme addresses the sarcopenia, the falls, the depression, and the cognitive function. This is the principle of the integrated CGA plan." [1]

Q2: "How would you manage her atrial fibrillation and anticoagulation given her falls?" [1]

"Her stroke risk is high — her CHA2DS2-VASc is at least 7 (female sex, age over 75, hypertension, diabetes), giving an annual stroke risk of around 10 percent or more. Her bleeding risk is also elevated, but the evidence is clear that in atrial fibrillation, the stroke risk almost always exceeds the bleeding risk, even in frail older adults, and anticoagulation prevents more strokes than it causes serious bleeds. The annual risk of a fall-related intracranial haemorrhage in an anticoagulated older adult is about 1 percent — far below the stroke risk. My approach would be to switch her from warfarin to apixaban 2.5 mg twice daily (she meets the dose-reduction criteria of age 80 or over and weight 60 kg or under) — the direct oral anticoagulants have a lower risk of intracranial haemorrhage than warfarin and do not require INR monitoring. I would not stop the anticoagulation because of her falls — instead, I would reduce the falls risk through the medication review, the exercise programme, and the home safety assessment, which together reduce the bleeding risk. The decision is shared with her and her family, and I would explain the balance of risk and benefit honestly — but the evidence-based recommendation is to continue anticoagulation." [1]

Q3: "She has a MoCA of 21. How would you assess whether this is dementia, and what reversible causes would you exclude?" [1]

"The MoCA of 21 indicates cognitive impairment, but a single score does not diagnose dementia. The diagnosis requires a progressive decline from a documented baseline, confirmed by a collateral history, across multiple cognitive domains, with functional impact. I would first establish the baseline and the trajectory — her daughter reports a 6-month functional decline, but the cognitive timeline is less clear. I would seek a collateral history from both daughters and from the GP. I would exclude the reversible contributors: the B12, folate, and TSH are normal, which excludes B12 deficiency, folate deficiency, and hypothyroidism. The anticholinergic burden from the oxybutynin is a significant reversible contributor — stopping it may improve the cognition. The depression (GDS-15 of 7) can produce pseudodementia — treating it with an SSRI and reassessing the cognition is essential. The orthostatic hypotension and the polypharmacy may be contributing. The CT brain shows mild atrophy and a few white matter changes — the white matter changes suggest a vascular component, which fits her hypertension, diabetes, and atrial fibrillation. I would arrange an MRI to characterise the atrophy pattern and the vascular burden more precisely. After the medication review (stopping oxybutynin, withdrawing temazepam, minimising codeine) and the treatment of the depression, I would reassess the MoCA at 3 months. If it remains low and the collateral history confirms a progressive decline, the diagnosis is likely mixed Alzheimer and vascular mild cognitive impairment or early dementia, and I would consider a cholinesterase inhibitor. The key point is that a MoCA score is a starting point, not a diagnosis — the trajectory and the exclusion of reversible causes are what settle it." [1]

Q4: "How would you set up her community support, and what is the plan if she continues to decline?" [1]

"The community package should be comprehensive and tailored to her needs. I would arrange a home safety assessment by an occupational therapist — to address the stairs (consider a stair lift or a ground-floor bedroom conversion), the bathroom (grab rails, a shower chair, a non-slip mat), the lighting, the rugs and cords, and the kitchen access. I would arrange a community home care package for assistance with shopping, cleaning, meal preparation, and medication supervision — at a level appropriate to her needs (a Home Care Package at level 2 or 3 in the Australian system). I would provide a personal alarm (a pendant or wristband with a fall detector) and register her with her local council for aged care services. I would refer her to a community geriatric or aged care assessment team (ACAT in Australia) for an ongoing assessment and care coordination. I would offer her locally-living daughter a carer assessment, education about the management plan, and access to respite and carer support services. I would encourage the garden club and the church group as social and cognitive engagement — social isolation is a modifiable risk factor for cognitive decline and frailty. If she continues to decline despite the interventions, I would revisit the goals of care with her and her family — whether the aim is to remain at home with increasing support, to move to a single-level dwelling or a ground-floor unit, or to consider a transition to residential care. I would ensure the advance care directive is in place, the substitute decision-maker is appointed, and the preferred place of care and place of death are documented. The plan is dynamic — it is reviewed at each visit and adjusted as her needs change." [1]