7. CGA in Primary Care Settings: Creating a problem list

The Problem List should be developed in collaboration with a patient and/or caregiver and be individualised and patient-centric, reflecting patients’ concerns and those of their families. The creation of the list in full will help in the generation of the care plan. 

The Problem List process is particularly helpful for structuring an approach to:

• Older patients with complex, multiple comorbid conditions
• Those older people with conditions in need of collaboration between primary and specialist care
• Those older  people in need of collaboration between different services
• Those with multiple needs (e.g. socioeconomic, health, safeguarding), often identifying interactive problems. 

It can be initiated in any setting, at any stage of a frailty presentation, but it is important to recognise that problems and goals noted at the point of an acute illness or decompensation may differ from the list produced once the patient is stable and at home. Thus the Problem list and Goals may change/evolve over time. 

In frailty, there can be more than one problem as patients often have varied and multiple problems (on average six), but the Problem List should help to identify all acute, subacute or chronic problems which may interact. The Problem List should also help with prioritisation so that acute and more serious problems (from the patient’s point of view) are dealt with first. 

However, setting goals and prioritising them may be difficult for various reasons, for example in a patient of advanced age with poor functional status, with dementia or  with multiple interacting acute and chronic conditions, thereby turning the problems into ‘works in progress’, and underlining the need for continuing assessment.

When creating the Problem List, difficulties can arise in reaching the appropriate decision about which investigations/actions are necessary, or whether enough is being done for the patient. An important aspect of such decisions is to focus on the assessment of patients’ competence or capacity. This will determine whether and how the other aspects of assessment/management/treatments are undertaken.

A summary sheet can be used to record an holistic assessment which will facilitate the generation of a Problem List.

Using tests to manage problems

Unless tests are clearly inappropriate, or the patient has refused them, the majority of older patients presenting with new health or functional problems should be investigated as guided by the signs/symptoms  of ill health. Investigations should initially be confined to those that are simple, inexpensive, easily performed and not distressing and those for which the results are almost instantly available, resulting in high yield. 

Such tests include:

• Urea (be aware that middle range can represent severe dehydration in older patients),
• Creatinine ( be aware that low muscle bulk can mask poor renal function and that there are limitations of the Cockcroft-Gault equation for calculating eGFR in older patients when diagnosing and staging kidney disease, this overdiagnosing Chronic Kidney Disease (CKD)).
• Electrolytes (be aware sodium <125mM/L can cause confusion and tiredness; sodium <115mM/L can cause seizure, coma, death). Be aware that rate of change is important also. Some people run a chronically low sodium of around 125 which is unlikely to be causing symptoms.
• Glucose (be aware of higher risk of hypoglycaemia in older patients, due to the age-associated decrease in the autonomic response to hypoglycaemia).
• Liver Function Tests (be aware that Paget’s disease should only be considered if elevated alkaline phosphatase in otherwise normal liver function tests. It could also be elevated for weeks after a sustained fracture).
• Calcium, C Reactive Protein (CRP), Thyroid Function Tests (be aware of sick euthyroid syndrome during acute illness. Also, if a hypothyroid older patient is successfully treated, but clinically not feeling better, consider further tests for concomitant autoimmune conditions like pernicious anaemia, Addison’s disease), 
• Chest Radiography (CXR), 
• Electrocardiograph,
• Urinalysis (asymptomatic bacteria does not necessarily indicate urinary infection but new onset incontinence should be investigated with urine culture).  
• Full Blood Count. Haemoglobin (Hb) levels gradually decline from the age of 60. Around 20 per cent of older patients are anaemic due to disease, and they may also suffer from marrow suppression (myelodysplasia). Also, fluid overload can cause a fall of Hb level as can fluids in a previously dry patient. Further discussion and decision about investigating an older patient with anaemia should depend on clinical problems, symptoms, past medical history, severity of anaemia, particularly the rate of Hb fall (a recent significant change should usually mean urgent investigation), and MCV results (micro-, macro- or anaemia of chronic disease-normocytic, normochromic), where the investigations should not depend only on the absolute level of Hb. Be aware that some older patients suffering with malabsorption (e.g. due to coeliac disease with low iron, folate, B12) could have a dimorphic blood picture thus appearing to have a normal mean cell volume (MCV) – this means checking haematinic levels is always useful in any anaemia. In patients with a normal MCV whose haematinic levels are within the normal range anaemia of chronic disease is the most likely cause. The most common cause of this is chronic kidney disease, but pay attention to wounds of any type, including leg ulcers, chronic inflammatory disease and mailgnancy. It may be appropriate to consider further tests such as blood film, TFT, urine analysis, LFT, bone profile, immunoglobulins and – in men – PSA.
• Erythrocyte Sedimentation Rate (ESR) can be useful for monitoring/screening some conditions in older people. It is usually very high (>90mm/hr) in the following conditions: giant cell arteritis, metastatic cancer, chronic infection and paraproteinaemias. However, in patients older than 70 years, values of up to 35 mm/hr for female and 30 mm/hr for male patients can be normal. 

Decisions about any further investigations should usually not be rushed at the first presentation/assessment and without the available results of the initial investigations. Often a short period of observation may be necessary, particularly for ascertaining the patient’s ability to consent and to tolerate further investigations, and her or his suitability for the treatment. 

Moving on to further tests

Ordering further investigations without careful weighing pro- and contra- arguments for each decision in a frail, older patient, with multiple comorbidities, may result in distressing, time-consuming, expensive, unnecessary and even harmful investigations/assessments. For example non-intentional weight loss of 5% in a period of one month or 10% over 6 months in an older patient is usually worrying, but the general rule for ordering further investigations should be the consideration of investigations that will alter management of the patient. This does not necessarily mean offering a curative procedure such as a surgical intervention – it could simply mean establishing suitability for palliative radiation.  Another focus of the investigation/assessment could be the determination of prognosis and its consequence for the patient: good or bad (e.g. reassuring the patient and family or focusing them on advanced planning).  It is important to determine what the focus of the investigations is – prior to referral for the tests.  

It should be borne in mind that several tests are usually not well-tolerated or are difficult to perform in older patients: 24-hour ECG tape (in a confused patient and often in someone who is not confused but poorly mobile), Exercise Tolerance Test (e.g. poor mobility), Bowel preparation and Colonoscopy (e.g. risk of dehydration and perforation).