Comprehensive Geriatric Assessment and Frailty Viva

Long Case Viva Defence

Candidate's opening statement (model answer)

"Mrs Margaret Chen is an 84-year-old retired schoolteacher presenting with a 6-month decline in function, two falls (one resulting in a wrist fracture), progressive difficulty with shopping and housework, weight loss, and low mood. She lives alone in a two-storey house since her husband died 2 years ago. ^[1]

Her past history includes hypertension, type 2 diabetes, atrial fibrillation on warfarin, osteoarthritis, and a previous left hip replacement 8 years ago. Her medications are warfarin, metformin, gliclazide, amlodipine, oxybutynin, paracetamol, codeine, temazepam, and omeprazole — eight regular medications with a high anticholinergic and sedative burden. ^[1]

On her comprehensive geriatric assessment, she is oriented to person and place but not the full date, her MoCA is 21 out of 30, her grip strength is 14 kg, her Timed Up and Go is 17 seconds, her gait speed is 0.65 m/s, her GDS-15 is 7, her MNA-SF is 8, and her DEXA appendicular skeletal muscle mass index is 4.9. She has lost 5 kg in 6 months. Her Clinical Frailty Scale score is 6 (moderately frail). ^[1]

Her main problems are:

1. Moderate frailty (CFS 6) with confirmed sarcopenia (low grip strength plus low muscle mass by EWGSOP2)
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)
7. Suboptimal glycaemic control needing individualised targets
8. 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 to conduct a structured medication review and deprescribe — I will stop the oxybutynin and switch to mirabegron, withdraw the temazepam gradually, minimise and stop the codeine, and review the amlodipine for the orthostasis. I will arrange a multifactorial falls assessment and intervention, start a progressive resistance exercise and protein supplementation programme for the sarcopenia, treat the depression with an SSRI, investigate the cognitive impairment with an MRI and a B12, folate, and TSH, start osteoporosis treatment given the fragility fracture, arrange a home safety assessment and community services, and initiate advance care planning. I will review at 3 months with repeat measures to track the frailty reversal. The framework is comprehensive geriatric assessment, and the evidence (Ellis 2017, PMID 28898390) is that CGA with an interdisciplinary team and ongoing follow-up improves survival and function in this patient group." ^[1]

Examiner probing questions and model answers

Q1: "You mentioned stopping the oxybutynin. Explain why this is your priority, and what would you use instead?" ^[1]

"Oxybutynin is a potent antimuscarinic anticholinergic with high blood-brain barrier penetration — it directly blocks central acetylcholine at muscarinic receptors, worsening cognition and opposing the mechanism of any cholinesterase inhibitor I might consider. It is among the highest-anticholinergic-burden drugs in common use, and it is also contributing to her orthostatic hypotension. Reducing anticholinergic burden is one of the most effective and safest interventions I can make — the evidence is that higher anticholinergic burden is associated with faster cognitive decline, increased falls, and increased mortality in older adults. For her bladder symptoms, I would switch to mirabegron, a beta-3 adrenergic agonist that relaxes the detrusor without anticholinergic activity, or manage with timed voiding, fluid management, and bladder training. If an antimuscarinic is essential, I would choose one with lower central penetration, such as trospium, but the principle is to minimise the anticholinergic burden. This is my priority because it improves her cognition, reduces her falls risk, and removes a drug-drug interaction — a single intervention that addresses three of her problems." ^[1]

Q2: "How would you assess and manage her sarcopenia specifically?" ^[1]

"Her sarcopenia is confirmed by the EWGSOP2 criteria (Cruz-Jentoft 2019, PMID 31081853) — she has low muscle strength (grip 14 kg, below the 16 kg threshold for women) plus low muscle quantity (DEXA appendicular skeletal muscle mass index 4.9, below the 5.5 threshold for women). She also has low gait speed (0.65 m/s), which classifies her as having severe sarcopenia. The management is non-pharmacological and evidence-based: progressive resistance exercise training is the single most effective intervention — two to three sessions per week of progressive resistance targeting the major muscle groups has been shown to increase muscle mass, strength, and function in adults into their 90s. I would combine this with dietary protein at 1.2 to 1.5 grams per kilogram per day — about 60 to 70 grams per day for her 48 kg body weight — distributed across meals, and oral nutritional supplements given her MNA-SF of 8 and her weight loss. I would check and correct vitamin D deficiency with 1000 IU daily. I would address the contributing factors — the depression, the polypharmacy, the deconditioning from her falls, and her social isolation. No pharmacological agent is yet approved for sarcopenia, though selective androgen receptor modulators and myostatin inhibitors are under investigation. The key message is that sarcopenia is reversible with targeted exercise and nutrition at any age." ^[1]

Q3: "What is the evidence that comprehensive geriatric assessment actually works, and what determines whether it succeeds?" ^[1]

"The strongest evidence is the 2017 Cochrane systematic review by Ellis and colleagues (PMID 28898390), which pooled 29 randomised trials with over 13,000 participants. It found that older adults who received CGA were more likely to be alive and in their own homes at 3 to 12 months follow-up (risk ratio 1.06, 95% CI 1.01 to 1.10), and less likely to be admitted to a residential care facility (risk ratio 0.80, 95% CI 0.72 to 0.89). The critical determinant of success is the model of delivery. CGA delivered on a dedicated geriatric evaluation and management unit — where the geriatric team controls the admission and the care plan — showed consistent and significant benefits. CGA delivered by a consultation team, where a geriatric team advises the primary treating team but does not control the care, showed less certain benefit — that subgroup comparison was underpowered. The reason is that CGA is a therapeutic process, not just a diagnostic assessment — the benefit comes from the interdisciplinary team meeting, the integrated plan, and the ongoing follow-up. If the assessment is filed and ignored, there is no benefit. For this patient, I would deliver the CGA in a model where I have direct control of the care plan and the follow-up — ideally the geriatric outpatient clinic with a community outreach component, or a GEM admission if she decompensates." ^[1]

Q4: "She has atrial fibrillation and is on warfarin. Given her falls and her frailty, how do you balance stroke prevention against bleeding risk?" ^[1]

"This is a classic shared decision in frailty medicine. Her stroke risk is high — she has atrial fibrillation, hypertension, diabetes, and she is over 75 (her CHA2DS2-VASc is at least 6). Her bleeding risk is also high — she is 84, she has chronic kidney disease stage 3 if present, and she has fallen twice (one with a fracture). The key point is that the stroke risk in atrial fibrillation almost always exceeds the bleeding risk, even in frail older adults, and anticoagulation reduces stroke more than it increases serious bleeding. The modern approach is to switch her from warfarin to a direct oral anticoagulant — apixaban or rivaroxaban — which has a lower risk of intracranial haemorrhage than warfarin, does not require INR monitoring, and has more predictable pharmacokinetics. Apixaban 2.5 mg twice daily is appropriate if she meets two of the dose-reduction criteria (age 80 or over, weight 60 kg or under, creatinine 133 micromol per litre or over) — she meets age and weight. I would not stop the anticoagulation solely because of her falls — the annual risk of a fall-related intracranial haemorrhage in an anticoagulated older adult is about 1 percent, while the annual risk of a stroke in an untreated patient with her CHA2DS2-VASc is approaching 10 percent per year. The falls reduction programme, the medication review, and the osteoporosis treatment reduce the bleeding risk. The decision is made with the patient and the family, weighing the values and preferences, but the evidence-based recommendation is to continue anticoagulation." ^[1]

Q5: "How would you approach the advance care planning conversation with her?" ^[1]

"Advance care planning should begin while she retains the capacity to participate, and her MoCA of 21 suggests she does retain capacity for these decisions — capacity is decision-specific and time-specific, and the functional test is whether she can understand, retain, weigh, and communicate the relevant information. I would begin the conversation by asking what matters most to her as her health changes — her values, her goals, and her preferences for future care. I would explore her understanding of her conditions and her prognosis — she has moderate frailty and cognitive impairment, and her trajectory is one of gradual decline with an increased risk of acute events. I would ask about her preferred place of care and place of death, and about the interventions she would or would not want in specific scenarios (cardiopulmonary resuscitation, hospitalisation, artificial nutrition, ICU). I would help her appoint a substitute decision-maker — an enduring guardian for health and lifestyle decisions and an enduring power of attorney for financial decisions — while she retains capacity, and I would document the conversation in an advance care directive. I would revisit the plan at each subsequent visit and at any transition (a hospital admission, a new diagnosis, a significant functional decline). The conversation is not about withdrawing care — it is about ensuring that the care she receives aligns with her values, and that her family and her treating team know her preferences if she loses the capacity to express them." ^[1]