GRON 3112

Basic Care in Gerontology

Week 6
11 Oct 2022
Basic Health Assessment
Comprehensive Geriatric Assessment
Mr. CP Chiu
Content
• Basic Health Assessment
• 1.1 Anthropometric measurements
• 1.2 Vital signs
• 1.3 Biochemical measurements

• 2. Comprehensive Geriatric Assessment (CGA)

• Physical
• Socioeconomic / Environmental
• Functional
• Mobility / Balance
• Psychological / mental
• Medication Review
1.1 Anthropometric measurements
• Body Mass Index (BMI)
• Most commonly used methods to assess whether an adult is underweight or overweight.
• BMI = Weight (kilograms) / Height (metre) 2

• Weight measurement
• Equipment: Weight balance / scale
• Unit: kilograms (kg)

• Height measurement
• Equipment: Measuring tape
• Unit: meter (m)

BMI, kg/m2
Underweight < 18.5
Normal range 18.5-22.9
Overweight 23-24.9
Obese ≥ 25
• Limitation: Does not distinguish between weight associated with muscle or fat in an individual.

(CHP, 2019)
1.1 Anthropometric measurements
• Waist Circumference
• Measurement of central obesity
• Abdominal fat accumulation would be a more
sensitive indicator of cardiovascular and chronic
disease risk.
• Equipment: Measuring tape
Sex Waist Circumference, cm
Male <90 (~36 inches)
Female <80 (~32 inches)

(Photo credit: CHP) (CHP, 2021)

1.2 Vital signs
• Vital signs are measurement of the body’s most basic functions.
• Useful in detecting or monitoring medical problems.

• 4 main vital signs:

• 1. Blood pressure (BP)
• 2. Pulse Rate (P)
• 3. Temperature (Temp)
• 4. Respiration Rate (RR)

• Additional: Oxygen saturation (SpO2)

1.2 Vital signs
• 1. Blood Pressure
• Cardiovascular System = Heart + Blood vessels + Blood

• Heart pumps blood

• Arteries: Transport blood away from the heart to the
organs for oxygen and nutrients.

• Blood vessels and blood pressure

• Blood pressure is the force exerted by blood upon the (Nelson & Greene,
walls of the artery / arteries of the systemic 2021. From Betts et
al., 2013. Licensed
circulation. under CC BY 4.0)
(Marieb, 2004)
1.2 Vital signs
• Systolic and Diastolic blood pressure
• Systolic blood pressure (SBP) is the pressure
exerted upon the walls of blood vessels when the
heart contracts.
• Diastolic blood pressure (DBP) is the one when the
heart relaxes.
• BP is measured in millimeters of mercury (mmHg).

• Measurement: Digital blood pressure monitor or

sphygmomanometer (traditional name)
(Health Bureau, 2022)
1.2 Vital signs
• Before taking BP:
• Consider the time and place to measure blood pressure, and body conditions

• Measure blood pressure at around the same time each day.

• Ensure the environment is quiet with least distraction.

• Do not exercise, smoke or consume foods or drinks containing caffeine (such

as tea or coffee) at least 30 minutes before measurement.

• Rest and relax for 5 minutes.

(CHP, 2013)
1.2 Vital signs
• Key points in measuring BP:
• Make sure the arm is supported on a tabletop at an even level with your heart.

• The lower border of the cuff should be 2 cm above the pit of elbow (~ 2 finger-breadths).

• Make sure the tubing is placed at the centre of your arm, facing the front and that the sensor is
correctly placed.

• Tightness of the cuff: Should be able to just slip two fingertips beneath the cuff, near its edge at
the top end.

• During measurement, stay relaxed, keeping still and quiet.

• After completing the measurement, release the cuff completely.

(CHP, 2013)
• Ideal situation: Take the average value of the last 2 readings.
 1.2 Vital signs
Blood pressure level (mmHg)

BP categories SBP DBP Recommendations

Optimal <120 <80 Recheck in 2 years

(Once a year for people > 75)

Normal 120-129 80-84 Recheck in 1 year

High normal 130-139 85-89 Recheck in 6 months

Hypertension ≥ 140 ≥ 90 Consult family doctor

SBP is persistently ≥ 140 mmHg or
DPB is persistently ≥ 90 mmHg

( Health Bureau, 2022)

 9 Pulse Sites
1.2 Vital signs
• 2. Pulse Rate
(Common site for pulse counting)
• Each time the heart ejects blood forcefully into the
circulation, the arteries must expand and then recoil
to accommodate the surge of blood moving through (BP measurement)
them. This expansion and recoiling of the arterial wall
(Common site for pulse counting)
is called the pulse.

• Peripheral pulse: Pulse located away from the heart

(e.g. neck, wrist and foot).

(Nelson & Greene, 2021. From Betts et al., 2013. Licensed under CC BY 4.0)
1.2 Vital signs
• Assessing the pulse
• By palpation for 1 min.
• The middle 2 or 3 fingertips with moderate pressure are used.

• Both the rate, rhythm and the strength are important.

• Normal range of rate: 60-100 BPM (Beat Per Minute)
• < 60 BPM: Bradycardia (Brady- = Slow); >100 BPM: Tachycardia (Tachy- = Fast)

• Rhythm: Pattern of the beats and the intervals between the beats.
• Regular or irregular (arrhythmia/dysrhythmia). When a irregular rhythm is detected, the apical
pulse should be assessed.

• Strength: The pulse strength indicates the strength of ventricular contraction and cardiac output.
If the pulse is strong, then systolic pressure is high. If it is weak, systolic pressure has fallen, and
medical intervention may be warranted.

(Nelson & Greene, 2021. From Betts et al., 2013. Licensed under CC BY 4.0)
1.2 Vital signs
• 3. Temperature
• Normal body temperature can range from 36.5-37.2 degrees C (°C) for a
healthy adult.
• Fever, refer to the type of measurement
• Hypothermia (<35.0°C)

(Photo credit: MDD)

1.2 Vital signs
• 3. Temperature
• Types of thermometer:
• Mercury / Alcohol in glass
• Electronic (Digital)
• Infrared

(Photo credit: MDD)

1.2 Vital signs
• 3. Temperature
• A person's body temperature can be taken in any of the following ways:

(Photo credit: MDD)

1.2 Vital signs
• 3. Temperature
• Measurement methods and specific precaution

(Photo credit: MDD)

1.2 Vital signs
• 4. Respiration Rate (RR)
• Number of breaths a person takes per minute.
• The rate is usually measured when a person is at rest.

• Counting the number of breaths for one minute by counting how many times
the chest rises.

• Normal range (at rest): 12-16 breaths per minute.

• May increase with fever and other medical conditions. When checking
respiration, it is important to also note whether a person has any difficulty
breathing.

(Johns Hopkins Medicine)

1.2 Vital signs
• Additional: Oxygen saturation by pulse oximetry
• Pulse oximetry: Measure the oxygen level (oxygen saturation, SpO2) of the blood.
How well oxygen is being sent to parts of your body furthest from your heart, such
as the arms and legs.

• Normal rang: 95-100%

• Specify the condition in measurement: RA (Room Air) or O2 in L/min on oxygen
therapy etc…)

• To check the health of a person with condition that affects blood oxygen levels, e.g.:
• Heart diseases
• COPD / asthma
• Lung cancer / pneumonia
• Anemia (Johns Hopkins Medicine)
 1.3 Biochemical measurements
• Blood glucose level by POCT (Point-of-care testing)
• Purpose: Basic health checking
• -Regular monitoring for clients with diabetes mellitus (DM)
• -Emergency health assessment (e.g. hypoglycemia, when blood
glucose level < 4 mmol/L)

• Types of Blood glucose:

• –Fasting blood sugar: No food intake for ≥ 8 hours
• –Random blood sugar: Fixed times of the day or random time
1.3 Biochemical measurements
• Random blood glucose test and reference value
Blood glucose level (mmol/L)
Normal blood glucose Fasting (no food intake for ≥8 hrs): Below 6.1
Impaired fasting glucose Fasting: 6.1-6.9 and
2hrs after meal: <7.8
Impaired glucose tolerance Fasting: <7 and
2hrs after meal: 7.8-11.0
Diabetes Fasting: ≥7 or
2hrs after meal: ≥ 11

Self-monitoring of blood glucose by DM patient

(Health Bureau, 2022)

1.3 Biochemical measurements
• Blood cholesterol level by POCT (Point-of-care testing)
• Purpose: Basic health checking
• -Regular monitoring for clients with lipid disorder

• Types of Blood cholesterol:

• Fasting blood cholesterol: No food intake for ≥ 8 hours
 1.3 Biochemical measurements
• Desirable levels of cholesterol and lipoproteins
Type of blood cholesterol Desirable levels (mmol/L)
Total cholesterol (TC) < 5.2
LDL (LDL) cholesterol < 3.4 (Below 2.6 is more desirable)
HDL (HDL) cholesterol >1.0 (1.6 or above is more desirable)
Triglycerides (TG) < 1.7

• Blood lipid disorder can be:

• TC ↑
• LDL cholesterol ↑
• HDL cholesterol ↓
• TG ↑
• Even a combination of these conditions (CHP, 2021)
2. Comprehensive Geriatric Assessment (CGA)

(BGS, 2019)
 2. Comprehensive Geriatric Assessment (CGA)
• Comprehensive Geriatric Assessment (CGA) is a process of caring.
• 1. Initially, a multidimensional holistic assessment of an older person.

• 2. Formulation of a plan with treatment goal to address issues which are of concern to the older
person, their family and carers when relevant.
• Interventions are then arranged in support of the plan.
• Progress is reviewed and the original plan reassessed at appropriate intervals.

• Can be performed anywhere, either in the older person’s home, in a special clinic set up for the
purpose in a leisure centre, day centre or hospital outpatient department.

• Multi-disciplinary team approach

• Shared decision (BGS, 2019)
• Collaboration between patient/family/carers and members of the team throughout the process
• Older person and their family will own this process and regard the resulting care plan as their own.
Effectiveness of CGA
• 1. In community settings, reduce hospital admission and reduce the
risk of readmission in those recently discharged.

• 2. CGA is also a vital part of the management strategy for older

people suspected of having frailty in order to identify areas for
improvement and support to reduce the impact of frailty.

• 3. A recent study showed that comprehensive assessment and

individualised care planning can reverse the progression of frailty.

(BGS, 2019)
1. Physical assessment
• There is no well-validated screening tool for general physical
examination.

• Incorporates all the typical aspects of clinical examination.

• Specific examinations that may be more relevant in older people.

• The physical examination will guide which areas require more in-
depth or systematised assessment.
(BGS, 2019)
1. Physical assessment
• Some examples of specific examinations
• 1. Weight and nutrition
• Check and record weight / BMI consistently.
• Observation of oral health (including checking of dentures).
• Screening of malnutrition.
• Tool: Mini Nutrition Assessment , MNA-SF
 Mini Nutrition Assessment , MNA-SF
• English version: mna-mini-
english.pdf (mna-
elderly.com)

• Chinese version: mna-

mini-chinese.pdf (mna-
elderly.com)

• https://www.mna-
elderly.com/mna-forms

(NNI, 2021)
Mini Nutrition Assessment, MNA-SF
• mna-guide-english-sf.pdf
(mna-elderly.com)

(NNI, 2021)
 1. Physical assessment
• 2. Pain / joints

• Many older patients will deny pain or be unable to express it.

• Observation during movement or change in posture may yield clues that
mobility or function may be limited by pain.

• Using alternative words when assessing movement (e.g. “stiffness”) may

elucidate further.

• Examination of joints commonly affected by osteoarthritis such as the fingers

and knees with functional observation and checking of range of movement.
(BGS, 2019)
 1. Physical assessment
• 3. Rectal examinations
• Constipation is often missed, and can cause chronic reduction in
appetite or recurrent abdominal pain.
• Faecal incontinence can result from rectal problems.
• A rectal examination also assess for prostate size/shape, haemorrhoids,
bleeding or rectal masses.

(BGS, 2019)
(Photo credit: National Cancer Institute)
2. Socioeconomic and environmental
assessment
• Social and financial circumstances have a direct impact on physical
and mental wellbeing.

• The influence patients’ ability and inclination to comply with medical

advice and the frequency of attendance in health care services.

• Domain of social worker.

(BGS, 2019)
 Social and environmental questionnaire
Social questionnaire (abstract)
Does the patient live alone? If no, who do they live with? Lives alone
Lives with ???
What informal support is available? Family, Friends, Neighbours, Clubs/societies,
community group, Voluntary
Does the patient get out and about? Yes – independently
Yes – with some difficulty
Yes – but with great difficulty
No – completely housebound

Are they eligible for care funding?

Are they in receipt of: Disability living allowance / Income support /
Housing benefit / Pension credit

Link: BGS, BGS Social & Environment Questionnaires | British Geriatrics Society
 Social and environmental questionnaire
Environment questionnaire (abstract)

What is the nature of the home circumstances? Owner / Rented private / Nursing home /Residential home
Other (please specify)

Does the accommodation have stairs? No stairs / Stairs without difficulty /Not safe on the stairs

Is there a telephone? No / Landline with cable / Mobile

Equipment in situ [drop down menu to be created, Commode / Hoist / Pressure mattress / Hospital bed
e.g. stair lift, commode, hoist, pressure mattress,
pressure cushion, syringe driver etc]

Is there a working smoke detector?

Link: BGS, BGS Social & Environment Questionnaires | British Geriatrics Society
3.Functional assessment
• To identify an older adult's ability to perform self-care, self-maintenance, and
physical activities.
• Functional assessment can encompass multiple factors like mobility and
activities of daily living (ADL).
Activities of daily living (ADL)
 Tools for functional assessment: 1.Barthel Index
• Barthel Index (BI)
• Measure the degree of independence in activities of daily living (ADL).
• Most useful functional assessment tool today.
• Easy to use
• Quick and objective.
• Not only revealing the present disability but also estimating when a
patient will begin to need help.
• To monitor the disease progression and also revise the treatment plan.
Tools for functional assessment:
1. Barthel Index
• Barthel Index
• 10 items (0 or 5 or 10 or 15)
• Total possible scores = 100
• The higher the score, the higher the
independence.

• 0-20: Total dependency

• 21-60: Severe dependency
• 61-90: Moderate dependency
• 91-99: Slight dependency
• 100: Total independency
Tools for functional assessment: 2.IADL Scale
Tools for functional assessment: 2.IADL Scale
• The Lawton Instrumental Activities of Daily Living Scale (IADL)
• To assess independent living skills, these skills are considered more
complex than the basic activities of daily living.

• The instrument is most useful for identifying how a person is

functioning at the present time, and to identify improvement or
deterioration over time.

• 8 domains of function measured.

• Women are scored on all 8 areas of function.
• Historically, for men, the areas of food preparation, housekeeping,
laundering are excluded.

• A summary score ranges from 0 (low function, dependent) to 8 (high

function, independent) for women, and 0- 5 for men.

• The more a patient's abilities are impaired, the more the services will
be necessary to maintain that patient in the community.

(Graf, 2008)
4. Mobility / Balance assessment
• Maximising older people’s walking and balancing abilities improves their quality of
life and reduces their dependence on health and social care.

• Impaired gait, balance and strength are key risk factors for falls and interventions
targeted at improving these have been shown to prevent falls.

• Gait and balance assessment

• Watching the patient walk. If possible, it is better to observe the patient whilst they
are unaware of being watched.
• Watching them walk down the corridor or around their own home is all that is
needed.
(BGS, 2019)
4. Mobility / Balance assessment
• 1. Timed up and go test
• This test measures functional mobility in the older population.

• The patient should sit in a chair of knee height.

• As patient to stand up, walk 3 metres, turn round, return to the chair and sit
down.
• Time the patient, starting timing when the patient starts to try and stand up
and stopping when the patient is sitting down again.

• Normal scores are between 8 and 11 seconds for people between 65 and 99.
If a patient takes more than 12 seconds then their mobility may be considered
impaired.

(BGS, 2019)
4. Mobility / Balance assessment
• 2. Gait speed
• Ask a patient to walk a distance of 4 metres.
• If they take longer than 5 seconds then their gait speed can be considered slow (i.e. less than 0.8
m/s).
• Gait speed is correlated with increased risk of falling.

• 3. 180 degree turn test

• This measures dynamic balance.
• A patient should sit in a chair from which they can easily stand up.
• The patient should stand up and you should stand behind them.
• You ask the patient to turn around and face you (turn 180 degrees).
• The patient should not hold on unless they need to, in which case they have failed the test.
• You should count the number of steps they take. Patients who take 5 or more steps have an increased
relative risk of falling in the following year and might be considered to have balance impairment.

(BGS, 2019)
5. Psychological / mental assessment
• 1. Depression
• Depression in older people has a prevalence of 5-10 per cent in those
aged over 65, but is frequently under-recognised.

• Weight loss, poor sleep or increasing pain with stable physical issues
could well have a depressive illness and this needs to be considered.

• Older adults with depression are at higher risk of completed suicide

than younger people.

(BGS, 2019)
5. Psychological / mental assessment:
Geriatric Depression Score
• Geriatric Depression Scale (GDS)

• 15 items
• Count number of CIRCLE in the form.
• 0-4: Normal
• 5-9: Mild depression
• 10-15: More severe depression

(BMIS, 2022)
5. Psychological / mental assessment
• 2. Cognition
• Use the social aspects of the assessment conversation to judge
whether or not there is a possible issue with cognitive dysfunction.

• Simple screening question: Has the person been more forgetful in the
last 12 months to the extent it has affected their daily life?
• For example, difficulty using the phone, managing shopping lists,
using money, managing their medication etc…

(BGS, 2019)
 5. Psychological / mental assessment:
Montreal Cognitive Assessment (MoCA)
First validated in the setting of MCI, and has subsequently been adopted in numerous other
settings clinically.
Approximately 10 minutes. Free!
1.Attention and concentration
2.Executive functions
3.Memory
4.Language
5.Visuo-constructional Skills
6.Conceptual thinking
7.Calculation
8.Orientation
(Link: https://www.mocatest.org/)
MoCA
• Hong Kong version

(Photo credit: Division of Neurology, CUHK)

6. Medication review
• Older patients with multiple comorbidities can have indications for multiple
medications.
• Review of medications, their indications, side effects, benefits and interactions
can cause significant and rapid improvements in a patient’s condition.

• Schema for a general approach to medication review

• 1 Obtain full medication history
• 2 Review medication use: in general and for each medication
• 3 Review full drug list for pharmacological interactions or common side effects
• 4 Obtain sufficient medical history
• 5 Review each medication
• 6 List and prioritise
(BGS, 2019)
Wrap up
• Basic Health Assessment
• 1.1 Anthropometric measurements: BMI, Waist circumference
• 1.2 Vital signs: BP, P, Temp, & RR. SpO2
• 1.3 Biochemical measurements: Blood glucose level, blood cholesterol

• 2. Comprehensive Geriatric Assessment (CGA)

• 2.1 Physical: Weight & Nutrition, Pain/Joints, Rectal examination
• 2.2 Socioeconomic / Environmental
• 2.3 Functional: Barthel Index & The Lawton IADL
• 2.4 Mobility / Balance: Timed up and go test, gait speed & 180 degree turn
• 2.5 Psychological / mental: Depression and GDS; Cognition & MoCA
• 2.6 Medication Review
Reference
• British Geriatrics Society (BGS). (2019). Comprehensive Geriatric Assessment Toolkit for Primary Care
Practitioners. British Geriatrics Society. https://www.bgs.org.uk/resources/resource-series/comprehensive-
geriatric-assessment-toolkit-for-primary-care-practitioners

• Centre for Health Protection. (2013). How to measure blood pressure using digital monitors script-video.
Department of Health, The government of the Hong Kong Special Administrative Region.
https://www.chp.gov.hk/en/static/29171.html

• Centre for Health Protection. (2019). Non-Communicable Diseases Watch: Blood Lipid Disorders.
Department of Health, The government of the Hong Kong Special Administrative Region.
https://www.chp.gov.hk/files/pdf/ncd_watch_august_2019.pdf

• Centre for Health Protection. (2019). Body Mass Index Chart. Department of Health, The government of the
Hong Kong Special Administrative Region.
https://www.chp.gov.hk/en/resources/e_health_topics/pdfwav_11012.html

• Centre for Health Protection. (2021). Are you obese. Department of Health, The government of the Hong
Kong Special Administrative Region.
https://www.chp.gov.hk/en/resources/e_health_topics/pdfwav_11003.html?page=3
Reference
• Centre for Health Protection. (2021). Cholesterol. Department of Health, The government of the
Hong Kong Special Administrative Region. https://www.chp.gov.hk/files/her/exnnutp036_en.pdf

• Centre for Health Protection. (2022). Diabetes Mellitus. Department of Health, The government
of the Hong Kong Special Administrative Region.
https://www.chp.gov.hk/en/healthtopics/content/25/59.html

• Egton Medical Information Systems (2022). Geriatric Depression Scale (GDS). Geriatric Depression
Scale (GDS) | Doctor | Patient

• Graf C. (2008). The Lawton Instrumental Activities of Daily Living Scale. The American Journal of
Nursing, 108(4): 52-62.

• Health Bureau. (2022). Diabetes and Hypertension Care for Adults in Primary Care Settings. The
Government of the Hong Kong Special Administrative Region.
https://www.healthbureau.gov.hk/pho/files/primary_care_settings_eng.pdf
Reference
• John Hopkins Medicine. Vital signs (Body Temperature, Pulse, Respiration Rate, Blood Pressure).
The John Hopkins University. https://www.hopkinsmedicine.org/health/conditions-and-
diseases/vital-signs-body-temperature-pulse-rate-respiration-rate-blood-pressure

• Marieb, E.N. (2004). Human Anatomy & Physiology. Pearson Education, Inc. Benjamin Cummings.

• Medical Device Division. Proper use of thermometer to measure body temperature. Department
of Health, The government of the Hong Kong Special Administrative Region.
https://www.mdd.gov.hk/filemanager/common/information-publication/thermometer_eng.pdf

• Nelson, A., & Greene, K. (2021). Medical Terminology for Healthcare Professions. University of
West Florida Pressbooks.

• Nestle Nutrition Institute (2021). What is the MNA. https://www.mna-elderly.com/