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IM25.1-22 | Geriatrics — Assignment
CLINICAL SCENARIO
This assignment asks you to perform and document a simulated Comprehensive Geriatric Assessment (CGA) for a fictional multimorbid elderly patient presented to you below, and to develop an integrated management plan. You will identify the geriatric syndromes present, systematically assess all five CGA domains using validated tools, review the medication list for inappropriate prescriptions, and formulate a problem-prioritised multidisciplinary management plan. You will also address one ethical issue raised by the case. The case is designed to reflect the complexity of a typical geriatric inpatient in an Indian teaching hospital.
Instructions
Write a structured report in the five sections below. Use professional clinical language and named validated tools throughout. Your management plan must be specific — avoid vague statements like 'manage medically'; instead state the intervention, goal, and responsible team member. Do not copy SDL text verbatim. Word limit: 1,300–1,700 words.
Length: 1,300–1,700 words across all sections
What to Submit
Case Vignette (READ CAREFULLY before writing)
Guidance: Mr Rajan Kumar, 78 years old, is admitted from his home in Chennai via the emergency department after his daughter found him confused and on the floor near his bed at 7 am. He lives with his daughter (a working professional, aged 45) and her family. His wife passed away 14 months ago. He has type 2 diabetes mellitus (on metformin 1 g BD, glibenclamide 5 mg BD, and sitagliptin), hypertension (on amlodipine 5 mg, telmisartan 40 mg, and indapamide), knee osteoarthritis (on diclofenac 75 mg BD and omeprazole 20 mg), insomnia (on nitrazepam 10 mg at night), and a recent DEXA-confirmed diagnosis of osteoporosis (T-score -2.7). His daughter reports he has been increasingly forgetful for 6 months, repeating questions, occasionally not recognising familiar neighbours, and refusing to eat properly for 3 weeks. His recent eGFR is 44 mL/min. On examination: confused (MMSE 19/30), malnourished (BMI 17.5 kg/m2, serum albumin 25 g/L), BP 148/92 lying and 118/74 standing (postural hypotension), pulse 86 irregular (probable AF), bruises in multiple stages on both forearms with no clear explanation from either the patient or daughter, and TUG test 18 seconds. ECG shows AF. Blood glucose 4.1 mmol/L. Urinalysis: pyuria, bacteriuria.
Section 1: Geriatric Syndromes — Identification and Pathophysiology
Guidance: Identify ALL relevant geriatric syndromes present in this patient. For each syndrome: (a) name it, (b) state the clinical evidence from the vignette that supports its presence, and (c) explain the pathophysiological basis in terms of age-related changes. Address the four classic geriatric giants (the four Is) explicitly. Approximately 300 words.
Section 2: Comprehensive Geriatric Assessment — Five Domains
Guidance: Perform a structured CGA across all five domains. For each domain: name the domain, state what specific assessment you would perform, name the validated tool you would use, and document the findings from the case vignette (or state what additional information you would gather). Domains: (1) Medical (comorbidities, medications, acute illness), (2) Functional (ADL/IADL — use Barthel Index for ADL; Lawton IADL scale), (3) Cognitive (use MMSE findings already given; note any need for MoCA), (4) Psychological (GDS-15 for depression; note delirium vs dementia differentiation), (5) Social and Environmental (family support, home safety, financial, elder abuse risk). Approximately 350 words.
Section 3: Medication Review — Beers/STOPP-START Analysis
Guidance: Review the full medication list given in the vignette. Identify at least THREE inappropriate medications using the Beers Criteria or STOPP criteria. For each: (a) name the drug, (b) state the specific harm in this patient (with reference to his clinical context — renal function, fall risk, cognitive status, cardiac status), and (c) propose a safe alternative or state why stopping is indicated. Then apply the START criteria: identify at least ONE clinically indicated medication that is missing from his chart. Approximately 250 words.
Section 4: Integrated Multidisciplinary Management Plan
Guidance: Formulate a problem-prioritised management plan. Organise by priority: (1) acute problems to address in the first 24-48 hours, and (2) medium-term and discharge/rehabilitation plan. For each problem: state the goal, the intervention, the responsible MDT member, and the timeframe. Your plan should address: acute infection (UTI and delirium precipitant), postural hypotension, glycaemic control (with attention to the low blood glucose), AF management, osteoporosis and falls prevention, nutritional rehabilitation, cognitive assessment (delirium vs early dementia), and preparation for safe discharge. Approximately 400 words.
Section 5: Ethical and Social Considerations
Guidance: Select ONE of the following ethical/social issues raised by this case and address it in depth: (a) The unexplained forearm bruising — what does this suggest, how would you screen for elder abuse, and what are your obligations under Indian law (Maintenance and Welfare of Parents and Senior Citizens Act 2007)? OR (b) Capacity and consent — the patient is confused. How would you assess whether he currently has decision-making capacity? What is the legal and ethical framework for making decisions on his behalf if capacity is impaired? Reference the Mental Healthcare Act 2017 as relevant. Approximately 200 words.
Grading Rubric — Comprehensive Geriatric Assessment Report Rubric
| Criterion | Points | Full-marks descriptor |
|---|---|---|
| Geriatric Syndromes Identification (Section 1): Accurately identifies the geriatric giants and atypical presentations present in the case; explains the pathophysiological basis for each syndrome identified; addresses the four Is (immobility, instability/falls, incontinence, intellectual impairment) as applicable. | 20 pts | All relevant geriatric syndromes correctly identified with accurate pathophysiological explanations; atypical presentations recognised and explained with reference to age-related changes; all applicable geriatric giants addressed. |
| Comprehensive Geriatric Assessment (Section 2): Systematically applies CGA across all five domains (medical, functional, cognitive, psychological, social/environmental); uses appropriate validated tools (MMSE/MoCA, GDS-15, Barthel/IADL, TUG, MNA) for each domain; findings presented in an organised, domain-structured format. | 25 pts | All five CGA domains covered systematically; appropriate validated tool named and applied for each domain; findings clearly linked to the management plan; demonstrates understanding of CGA as a multidimensional, interdisciplinary process. |
| Polypharmacy and Medication Review (Section 3): Identifies inappropriate medications using Beers Criteria or STOPP/START principles; states the specific harm of each flagged medication; proposes safe alternatives with justification; applies START criteria to identify clinically indicated medications that are missing. | 20 pts | At least three inappropriate medications identified with specific harm stated; appropriate alternative proposed for each; at least one omission identified via START criteria; medication review demonstrates understanding of renal, cardiac, and fall-risk implications. |
| Integrated Management Plan (Section 4): Formulates a problem-prioritised, multidisciplinary management plan addressing medical, functional, nutritional, psychological, and social needs; plan is specific and measurable with stated goals; addresses short-term (acute) and long-term (rehabilitation/prevention) priorities. | 25 pts | Management plan is problem-prioritised with specific, measurable goals; addresses at least five clinical domains; names appropriate MDT members for each goal; short-term and long-term priorities clearly delineated; plan is coherent and integrative. |
| Ethical and Social Considerations (Section 5): Addresses at least one ethical issue relevant to the case (capacity, advance care planning, autonomy, elder abuse screening); demonstrates understanding of the patient's social context and its impact on health; incorporates relevant Indian social and legal frameworks. | 10 pts | Ethical issue clearly identified and correctly reasoned; capacity assessment principles applied; social context integrated into the management plan; reference to relevant Indian legislation (Mental Healthcare Act 2017 / Maintenance and Welfare Act 2007 as applicable). |
PEER REVIEW
Review your peer's CGA report using the rubric provided. For each section, assign a score and write one specific, constructive comment. Specifically check: (1) In Section 1, are all four geriatric giants addressed? (2) In Section 2, are validated tools named correctly for each domain — not just mentioned generically? (3) In Section 3, is glibenclamide identified as the most urgently dangerous medication in the context of eGFR 44 and blood glucose 4.1? (4) In Section 4, is the management plan specific and prioritised, with named MDT members? (5) In Section 5, does the student take a clear position on the ethical issue chosen? Complete your review within 72 hours.