Critical Reviews in Oncology/Hematology 59 (2006) 205–210

The abbreviated comprehensive geriatric assessment (aCGA) for use in

the older cancer patient as a prescreen: Scoring and interpretation
Janine A. Overcash a,∗, Jason Beckstead a,1, Linda Moody a,b, Martine Extermann b,2, Sara Cobb a
a College of Nursing, University of South Florida, 12901 Bruce B. Downs Blvd., MDC 22, Tampa, FL 33612-4766, United States
b University of South Florida, Senior Adult Oncology Program, H. Lee Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, United States

Accepted 13 April 2006

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
1.1. Time savings for the clinician and the patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
1.2. The comprehensive geriatric assessment (CGA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
1.3. Screening and prescreening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
1.4. Adherence to recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
2.1. Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
2.2. The aCGA prescreen instrument . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
2.3. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Reviewers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Biography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210

Abstract

The abbreviated CGA (aCGA) can be used as a prescreening assessment to identify patients who would most benefit from the complete CGA.
Objective: To develop cutpoints for scoring the aCGA that are consistent with existing limitations as revealed by the full CGA.
Design/setting: A retrospective chart review of patients at the H. Lee Moffitt Cancer Center.
Participants: Over 500 charts between 1995 and 2001 were reviewed on cancer patients 70 and over.
Measurements: Each of the four domains: functional status (activities of daily living (ADL), instrumental activities of daily living (IADL),
depression, using the geriatric depression scale (GDS), and cognition using the mini-mental state examination (MMSE)) are scored separately.
Results: For the depression domain, a score of 2 or more toward depression indicates that the entire GDS be administered. For the MMSE,
a score of 6 or lower indicates necessity of the entire MMSE. For the ADL/IADL, any deficit on either scale (needs assistance or complete
assistance) requires further clinical evaluation using the entire instruments.
Conclusions: These guidelines provide the clinician with parameters to target patients most likely to benefit from more intensive geriatric
evaluation.
© 2006 Elsevier Ireland Ltd. All rights reserved.

Keywords: Comprehensive geriatric assessment (CGA); Elderly assessment; functional status; Depression; Dementia

∗ Corresponding author. Tel.: +1 813 974 2191/258 8131; fax: +1 813 974 5418.
E-mail addresses: jovercas@hsc.usf.edu (J.A. Overcash), jbeckste@hsc.usf.edu (J. Beckstead), extermann@moffitt.usf.edu (M. Extermann).
1 Tel.: +1 813 974 2191/258 8131; fax: +1 813 974 5418.
2 Tel.: +1 813 979 3822; fax: +1 813 972 8468.

1040-8428/$ – see front matter © 2006 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.critrevonc.2006.04.003
206 J.A. Overcash et al. / Critical Reviews in Oncology/Hematology 59 (2006) 205–210
1. Introduction
The comprehensive geriatric assessment (CGA) has been
shown to be an effective screening tool for inpatient [1] and
outpatient geriatric care [2,3], as well as preoperative and
postoperative settings [4,5], emergency treatment [6] and
long-term care [7]. For many years, it has been demon-
strated that the use of the CGA is important in the care of
the older person [1,8–11]. A limitation of the CGA is the
amount of time required for administration. The abbreviated
comprehensive geriatric assessment (aCGA) [12] provides a
prescreening mechanism to help the clinician direct compre-
hensive screening efforts to those seniors who may be more
likely to require further assessment. The purpose of this paper
is to offer scoring guidelines for clinicians using the aCGA
for the care of the older cancer patient.
1.1. Time savings for the clinician and the patient
While attention is given to the amount of time the clinician
may save using the aCGA, the patient and support person’s
time related inconvenience are also relevant [12]. Respondent
burden applies to the time and effort required of patients who
complete a health screening questionnaire or endure a lengthy
health assessment [13]. Some older patients with cancer may
be in poor health with less functional reserve and therefore an
extensive screening process may be overwhelming and phys-
ically taxing. A preliminary survey (n = 300) conducted at the
H. Lee Moffitt Cancer Center and Research Institute Senior
Adult Oncology Program (SAOP) included general screen-
ing with the mini-mental state examination (MMSE) [14] for
cognitive limitations, along with four other health assessment
instruments. The survey found only 8.7% of seniors with can-
cer screened positive for dementia. Depending on the patient
and clinician interaction, the MMSE alone may often take
10 min to complete. With such a low incidence of patients
who screen positive for dementia, many clinics may not allo-
cate the required time and resources to conduct the MMSE.
The aCGA, along with cutpoints, will help the patient and
clinician expedite the screening process.
1.2. The comprehensive geriatric assessment (CGA)
The CGA has been found beneficial for assessment of
life expectancy, prediction of treatment tolerance and def-
inition of frailty for older cancer patients [15]. In 2000,
Balducci and Yates [16] developed general guidelines for
the management of older patients with cancer. The CGA as
described in those guidelines consists of multiple domains
(functional, emotional, social, etc.) that provide the clinician
with a broad picture of patient health and social support out-
side the clinic or hospital. Such an assessment may require
either several visits by the patient, or a lengthy single visit.
Mann et al. [17] reported that CGA screening took an average
of 31 min in an ambulatory care setting. Several investigators
have called for development of a prescreening instrument that
could identify seniors who would benefit from a full CGA
[18,19].
The aCGA is used in the process of prescreening and
is not diagnostic. Some types of geriatric assessment, con-
sisting of psychosocial, pharmacological, spiritual, and other
domains, act as baseline for overall care of the older person
and not entirely a screening mechanism. This research seeks
to understand ways of more rapid assessment in older persons
for outpatient clinical use. Due to financial and operational
constraints evident in outpatient geriatric healthcare in the
new millennium of the United States, efficiency and produc-
tivity are issues central to healthcare providers. The aCGA
is unlike the CGA discussed in the 1987 National Institutes
of Health Consensus Conference [20] and the National Com-
prehensive Cancer Network [21] in that the aCGA is used to
screen for a few limitations in only four domains.
1.3. Screening and prescreening
According to the National Cancer Institute, screening
refers to conducting an assessment for disease when no signs
or symptoms are evident [22]. Prescreening is a process in
which a brief assessment is conducted to help the clinician
understand if further screening or evaluation is needed. Pre-
screening is a brief evaluation that is not intended to replace,
but to optimize screening efforts. In the area of oncology,
prescreening techniques are used to assess for indications of
malignancy that require further screening [23,24]. In general
geriatric care, prescreening is also used to concentrate social
services on patients who would most benefit [25] and to tar-
get at-risk elders in need of further general medical workup
[26,27].
1.4. Adherence to recommendations
Many tertiary cancer centers see patients less often then
required for the treatment of depression and/or cognition lim-
itations and recommendations for referrals to other providers
are necessary. As with outpatient geriatric assessment, adher-
ence of the patient and caregiver to healthcare recommen-
dations may be difficult to control [13]. One manner of
increasing the likelihood that a recommendation for refer-
ral will be implemented is a physician to physician phone
call to discuss findings and interventions [28]. Communica-
tion and collaboration with other providers outside the cancer
center are important to the care of the older cancer patient and
vital for control of some of the non-cancer related limitations
detected by the CGA.
2. Methods
2.1. Participants
Participants (n = 500) were aged 70 and over, with any
diagnosis of cancer, receiving care at the H. Lee Moffitt Can-
 J.A. Overcash et al. / Critical Reviews in Oncology/Hematology 59 (2006) 205–210 207

cer Center and Research Institute by the SAOP. Participants Table 3

completed the entire CGA (GDS, MMSE, IADL and the Cutpoints for scoring of the GDS aspect of the aCGA
ADL) as part of their initial clinical assessment. Approval Possible GDS cutpoints Specificity Sensitivity
from the Institutional Review Board was granted from the of aCGA prescreen
University and data were retrieved from the patient record. 0 1.000 0.524
Characteristics of this sample are summarized in Table 1. 1 0.962 0.690
2 0.895 0.810
3 0.808 0.929
2.2. The aCGA prescreen instrument 4 0.606 1.000

The aCGA is composed of items from the geriatric

depression scale (GDS) [29], mini-mental state examination
(MMSE) [14], activities of daily living (ADL) [30], and the
independent activities of daily living (IADL) [31]. Examining
item-to-total correlations allowed the selection of those items
that accounted for the highest contribution of the total score
for that particular scale (Table 2). Cronbach’s alpha coeffi-
cient indexing the internal consistency of multi-item scales,
were calculated on both abbreviated and entire full-length
scales (Table 2). The alphas were 0.90 on the entire IADL
and 0.93 on the abbreviated IADL. The MMSE alphas were
0.65–0.70 for the entire and abbreviated scales, respectively.
Scores on the abbreviated and corresponding entire scales
were highly correlated. For further information on the aCGA
prescreen, see Overcash et al. [12].
2.3. Analysis
Each of the domains (functional, emotional, cognitive)
represented in the aCGA (ADL, IADL, GDS, and MMSE)
are scored separately with individual cutpoints. The estab-
lishment of the scoring guidelines was constructed using
specificity and sensitivity analysis methods relevant to diag-
nostic test theory. Receiver operating characteristic (ROC)
curves were calculated to select cutpoints that maximized
specificity and sensitivity relative to the cutpoint on the full
Table 1
Demographics of the sample surveyed for construction of the aCGA
Sex 76% women, 24% men
Age Range 70–92 (mean age 73)
Martial status 53% married, 47% widowed or single
Ethnicity Anglo 95%, Black and Hispanic 5%
Tumor site Breast cancer 42.9%, colon cancer 12%, lymphoma
10%, prostate cancer 10%, leukemia 8%, head and neck
2%, carcinoid 2%, cervical cancer 1%, hepatic cancer
2%, cancer of unknown origin 2%, pancreatic cancer
3%, gastric cancer 2% and esophageal cancer 2%
instrument. ROC curves represent a method of displaying
sensitivity and specificity [32]. The closer the ROC curve is
toward the upper left corner of the graph, the more accurate
the test is that is being measured.
3. Results
For scores on the depression aspect of the aCGA pre-
screen, two of the four items positive for depression indicate
the use of the full GDS (Table 3). The items included in this
domain are: (1) Do you feel that your life is empty? (2) Do
you feel happy most of the time? (3) Do you feel helpless?
(4) Do you feel pretty worthless the way you are now? The
scores range from 0 possible points on the depression items
to a high score of 4 points. A cutpoint of two items that score
positive for depression offers a specificity of 0.895 and a sen-
sitivity of 0.810. Fig. 1 shows the curve close to the upper
left corner of the graph.
The ADL measure is represented by three items from
the six original total items [21] (bathing, transferring and
continence). Each item was characterized by receiving no
assistance, some assistance or more extensive assistance. If
one item requires any amount of assistance, the patient should
then be screened using the entire ADL instrument. Because
of the clinical implications of functional status, it is important
to address any limitation a patient may have. For exam-
ple, if a patient requires minimal assistance bathing, then

Table 2
Characteristics of CGA and aCGA
Instruments Entire scales Abbreviated Correlations of
scales entire and
abbreviated scales
# items Alpha # items Alpha
ADL 6 0.81 3 0.84 0.93
IADL 10 0.90 4 0.93 0.96
MMSE 10 0.65 4 0.70 0.84
GDS 15 0.77 4 0.70 0.86
Fig. 1. ROC curve depicting item specificity of the GDS.
208 J.A. Overcash et al. / Critical Reviews in Oncology/Hematology 59 (2006) 205–210

Table 4
Cutpoints for scoring of the MMSE aspect of the aCGA
Possible MMSE cutpoints Specificity 1-spec Sensitivity
on the aCGA prescreen
0 1.000 0.000 0.048
1 1.000 0.000 0.095
2 1.000 0.000 0.202
3 1.000 0.000 0.512
4 0.969 0.031 0.595
5 0.957 0.043 0.774
6 0.913 0.087 0.821
7 0.836 0.164 0.905
8 0.713 0.287 1.000

4. Discussion
Fig. 2. ROC curve depicting item specificity of the MMSE.
These guidelines provide the clinician cutpoints for the
aCGA prescreen. The individual domain scores enable the
an intervention for assistance must be established. Due to
clinician to make decisions about more in depth assessments,
the clinical implications of the functional status instruments,
and to exclude the patient from undergoing a complete geri-
ROC curves and sensitivity and specificity calculations were
atric assessment unnecessarily. The aCGA is designed to
not performed.
indicate when patients should be assessed with the ADL,
The IADL includes the items of grocery shopping, meal
IADL, GDS and MMSE instruments based on the cutpoint
preparation, housework and laundry [22]. As with the ADL
scores. The items that make up the aCGA were selected from
domain, if any of the items indicate the need for assistance,
the complete versions of the IADL, ADL, GDS and MMSE
then the complete IADL should be administered.
measurement tools to indicate the appropriateness of the com-
The items reflecting dementia were selected from the
plete screening.
MMSE [20] were: attention and calculation, reading, writ-
The aCGA was not administered as a standalone measure
ing and coping. The highest possible score on the demen-
and therefore it was not possible to provide information on
tia aspect of the aCGA prescreen is “8” which indicates
the amount of time needed for its administration. It is possible
no dementia. A score of 6 or lower indicates screening
to illustrate the potential time savings with an example:
with the entire MMSE (Table 4). A clinical cutpoint of
6 would indicate screening with the entire MMSE instru- Suppose 100 patients were administered the complete CGA
ment. Sensitivity and specificity are 0.913 and 0.821 and with each assessment requiring 30 min [17]. Furthermore,
the ROC curve is close to the upper left corner of the graph assume that 10 patients in this group screen positive for lim-
(Fig. 2). itations. The amount of clinician time necessary to identify

Fig. 3. Model of time savings using the aCGA.

 J.A. Overcash et al. / Critical Reviews in Oncology/Hematology 59 (2006) 205–210
these 10 cases would be (100 × 30 min) = 3000 min. We refer
to this process as strategy 1. An alternative strategy, strat-
egy 2, would have these 100 patients be prescreened using
the aCGA; each requiring only 5 min. Recognizing that this
abbreviated assessment may produce some false positives,
say 10, we have 20 patients being identified for further assess-
ment using the full CGA (at 30 min each). Assuming that when
the 20 are assessed with the full CGA the false positives are
ruled out, we end up with 10 patients identified with limita-
tions using strategy 2, with the total amount of clinician time
being (100 × 5 min) + (20 × 30 min) = 1100 min. The poten-
tial savings in terms of clinician time may be estimated as
3000 − 1100 = 1900 min (Fig. 3).
Concerning the functional status (IADL and ADL) portion
of the aCGA, it is important to discuss that clinical application
suggests different scoring criteria as compared to the GDS
and the MMSE. If a senior requires assistance in the func-
tional domain it must be further addressed clinically. Clinical
intervention may be necessary if a person needs assistance
on a task or is completely dependent. The functional status
portion of the aCGA does not have cutpoint scores as do the
MMSE and the GDS.
Limitations of this study are that the data analyzed were
obtained from patient self report and may reflect respondent
bias in expressing feelings and their extent of physical limi-
tations. Moreover, the data were limited to only one clinical
site and the population sampled is not characteristic of the
general population in that only 5% of the participants con-
sidered themselves Black or Hispanic. It may be reasonable
to collect data in populations more representative of the pop-
ulation in the United States concerning the reliability and
validity of the aCGA. The effects of omitted variables (e.g.,
measure of clinician bias, physical performance exam) are
difficult to predict and their omission could lead to misleading
conclusions. The findings from this study may provide use-
ful information to clinicians and researchers, however their
value must be weighed and taken within context.
The conclusion of this research is that the aCGA has
been shown to possess clinical cutpoints useful for determin-
ing further screening on patients with functional, emotional
or cognitive limitations. This research is an initial step in
investigating methods of screening older cancer patients for
comorbidities that may interfere with successful cancer treat-
ment. The next phase of research will investigate the amount
of time required to administer the aCGA requires in a pop-
ulation of older cancer patients. In addition, comparisons of
those senior cancer patients who screen positive on the CGA
and the aCGA will be completed.
Reviewers
Bennett John M., Professor of Medicine Emeritus, Hema-
tology, Oncology Unit, University of Rochester Medical Cen-
ter, 601 Elmwood Avenue, P.O. Box 704, Rochester, NY
14462, USA.
209
Repetto Lazzaro, Dr., Geriatric Oncology Unit, Istituto
Nazionale di Rpose e Cura dell’Anziano, Via Cassia 1167,
IT-00189 Rome, Italy.
Albrand Gilles, Dr., Centre Léon Bérard, Rue Laennec 28,
FR-69008 Lyon, France.
Naeim Arash, Dr., Division of Hematology/Oncology,
David Geffen School of Medicine, University of California-
Los Angeles, 10945 Le Conte Avenue, Suite 2345, P.O. Box
95168, Los Angles, CA 90095-1687, USA.
Acknowledgements
The research was performed as part of the John A. Hartford
Foundation’s Building Academic Geriatric Nursing Capacity
Scholarship Program. Thanks to the Senior Adult Oncol-
ogy Program for your mentorship and research opportunities.
Also thanks to Dr. Lodovico Balducci, Kathy Effingham, Car-
olyn Klein and Jill Blair for your continued support. A sincere
thanks is offered to Dr. Mary Evans for years of mentorship
and research guidance. Dr. Linda Moody is much appreci-
ated for her continued support and guidance. This research
was conducted through the University of South Florida, Col-
lege of Nursing and the H. Lee Moffitt Cancer Center and
Research Institute, Senior Adult Oncology Program. Fund-
ing provided by the John A. Hartford Foundation’s Building
Academic Geriatric Nursing Capacity Scholarship Program.
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Biography
Janine Overcash is currently an assistant professor of nurs-
ing at the University of South Florida. In 2001, she completed
her doctorate in Anthropology at the University of South
Florida that focused on the older cancer women with can-
cer. Janine is also a geriatric nurse practitioner specialized in
the care of the older cancer patient. She has assisted in the
design and management of one of the first geriatric oncology
programs located at the H. Lee Moffitt Cancer Center and
Research Institute in Tampa, Florida. A recent book entitled,
The Older Cancer Patient: A Guide for Nurses and Related
Professionals edited by Janine Overcash and Lodovico Bal-
ducci highlights principles of care of the older person with
cancer and has just received book of the year award by the
American Journal of Nursing. Dr. Overcash is the recipient of
the John A. Hartford Post Doctorate Scholarship for geriatric
nursing. Dr. Overcash continues to perform research dealing
with the older cancer patient and screening for comorbidities
to add to her many publications.