Comprehensive geriatric assessment and RACF care in Australian GP

CGA in general practice — a process, not a checklist

Comprehensive geriatric assessment (CGA) is a structured, multidimensional, multidisciplinary evaluation of an older person’s medical, functional, cognitive, psychological, social and spiritual domains, leading to a coordinated, patient-centred care plan. Per the RACGP Aged Care Clinical Guide (Silver Book 5th edition 2024), CGA is not a single instrument — it is an integrated process that the GP operationalises across several mechanisms: the annual 75+ Health Assessment, the GPCCMP care plan, the pharmacist medication review (HMR or RMMR), and the My Aged Care gateway.

In an ageing Australian population, CGA is one of the GP’s most high-yield activities. Ellis et al. (Cochrane 2017) demonstrated that inpatient CGA increases the likelihood of living at home and reduces death or deterioration at 12 months in hospital settings. In general practice, the Australian model of GP-led CGA — supported by geriatrician referral for complex cases — is endorsed by both RACGP and the Australian and New Zealand Society for Geriatric Medicine (ANZSGM).

The annual 75+ Health Assessment (MBS item 705 in-rooms, 707 home visit) is the funded vehicle for GP-led CGA. For Aboriginal and Torres Strait Islander peoples, the ATSI Health Assessment (item 715) applies from age 55, reflecting earlier physiological ageing and higher age-specific multimorbidity burden.

A. Core clinical — the AU general-practice framework

The six domains of CGA

1. Medical — comorbidities, undiagnosed conditions, pain (Abbey Pain Scale in dementia), nutrition (weight trend, MNA-SF, swallowing), continence (urinary and faecal), sensory function (vision — Snellen chart, cataracts, age-related macular degeneration; hearing — whispered voice, audiometry referral), oral health (dentition, dentures, oropharyngeal candidiasis), skin (pressure injury risk via Braden score, lesions, bruising), polypharmacy (STOPP/START 2023), vaccination status (influenza annual; pneumococcal Prevenar 20 at 65; Shingrix shingles vaccine PBS-funded for adults ≥65; COVID boosters), cardiovascular risk.

2. Functional — ADLs (Katz Index: bathing, dressing, toileting, transferring, continence, feeding; Barthel Index); IADLs (Lawton Scale: telephone use, shopping, food preparation, housekeeping, laundry, transport, medications, finance); gait and balance — Timed Up and Go test (TUG ≥12 seconds signals increased falls risk per World Falls Guidelines 2022); gait speed under 0.8 m/s predicts adverse outcomes; five-times-sit-to-stand test. Falls history — more than one fall in the past year triggers multifactorial intervention.

3. Cognitive — screen and distinguish normal ageing, mild cognitive impairment, dementia and delirium. MoCA (Montreal Cognitive Assessment) is the preferred general practice screening tool — score ≥26 is normal; more sensitive to mild cognitive impairment than the MMSE. RUDAS (Rowland Universal Dementia Assessment Scale) is validated for culturally and linguistically diverse populations, less affected by education level and language, and is the preferred tool in multicultural settings. GPCOG is brief, AU-designed, and includes an informant component. Collateral history from a carer, family member or RACF staff is essential. If cognitive concern confirmed, investigate reversible causes: TSH, B12 and folate, syphilis serology (selected), MRI brain for vascular disease, normal pressure hydrocephalus, or mass lesion.

4. Psychological — depression (GDS-15; Cornell Scale for Depression in Dementia if MoCA below 22); anxiety (GAD-7); sleep (insomnia and sleep apnoea — STOP-Bang); behavioural and psychological symptoms of dementia (BPSD); grief, bereavement, loneliness; alcohol (AUDIT-C); suicidality (direct enquiry).

5. Social — living arrangement; support network; financial security (Centrelink Age Pension, DVA, superannuation); housing safety; carer burden (Zarit Burden Interview); transport access; cultural and religious needs; elder abuse screen (EASI 6-question or HS-EAST — embed in every 75+ Health Assessment); mandatory SIRS reporting for RACF residents under the Aged Care Quality and Safety Commission.

6. Spiritual and advance care planning — values, meaning, cultural and religious preferences; ACP discussion — appoint a substitute decision-maker (state-specific: VCAT in Victoria, NCAT in NSW, QCAT in Queensland); complete an Advance Care Directive; document goals of care (resuscitation, hospital transfer, artificial nutrition, antibiotics); preferred place of care and death; upload to My Health Record. Review ACP annually and after any major health event.

Pre-assessment and workflow

A nurse-led pre-assessment (15–30 minutes) optimises the GP consultation time: confirm consent, obtain collateral from family or RACF staff (with consent), reconcile medications using the PBS dispensing record or My Health Record, review recent hospital discharge summaries, and collect baseline observations including lying and standing blood pressure (orthostatic hypotension is under-detected and drives falls).

During the GP assessment, the structured history reviews each domain systematically. The examination should include a lying-to-standing blood pressure at one, three and five minutes (a drop of ≥20/10 mmHg at any time point confirms orthostatic hypotension), TUG, tandem stance, MoCA or RUDAS, GDS-15, oral health inspection, vision and hearing screen, and a systematic polypharmacy review using STOPP/START criteria.

Targeted investigations (not a blanket panel): FBC, UEC and eGFR, LFT, calcium, TSH, B12 and folate, ferritin, 25-OH vitamin D, HbA1c, ACR, and ECG. DXA (MBS item 12306) if fragility fracture, steroid use, or high FRAX risk. Avoid treating asymptomatic bacteriuria — it is common in older adults and RACF residents and does not benefit from antibiotics per Choosing Wisely Australia.

GPCCMP and allied health coordination

Following the 75+ Health Assessment, a GPCCMP (965 prepare; 967 review) provides the framework for coordinated care, unlocking up to five allied health referrals per year (MBS items 10950–10970) — physiotherapy, occupational therapy, exercise physiology, podiatry, dietetics, social work, speech pathology, and psychology via MHCP.

B. Evidence — the case for structured assessment

CGA effectiveness

Ellis G et al. (Cochrane 2017) systematically reviewed 29 trials of inpatient CGA versus usual care. CGA increased the likelihood of patients being alive and living at home at 12 months (OR 1.25), reduced death or institutionalisation, and produced better functional outcomes. While the evidence is strongest for inpatient settings, GP-led CGA in general practice reduces hospitalisation rates in frail elderly when systematically delivered.

MoCA versus MMSE

Nasreddine et al. (JAGS 2005) demonstrated MoCA’s substantially superior sensitivity for mild cognitive impairment (90% vs 18% for MMSE at respective standard cut-offs) with comparable specificity. MoCA is now the Australian general practice standard for cognitive screening. MMSE is retained where serial scoring continuity with prior assessments is required.

Advance care planning

Detering et al. (BMJ 2010) conducted an Australian RCT of facilitated ACP versus usual care in hospitalised older adults. Facilitated ACP significantly improved goal-concordant care, patient and family satisfaction, and reduced PTSD, anxiety and depression in bereaved family members. ACP is most effective when conducted while patients retain decision-making capacity — ideally as part of routine 75+ Health Assessment rather than at the point of crisis.

Dementia risk modification

The Lancet Commission on Dementia Prevention (Livingston et al. 2024) estimated that 45% of dementia cases are potentially preventable through addressing modifiable risk factors — including low education, hypertension, obesity, hearing loss, depression, physical inactivity, diabetes, smoking, social isolation, excessive alcohol, traumatic brain injury, air pollution, high LDL cholesterol, and vision impairment. Systematic addressing of these factors at the 75+ Health Assessment represents the most evidence-based approach to dementia prevention.

C. Elder abuse and RACF care

Elder abuse in the community

The National Elder Abuse Prevalence Study (AIFS 2021) found approximately 14.8% of community-dwelling older Australians experienced elder abuse in the past year, with psychological abuse most prevalent, followed by financial, neglect, physical, and sexual. Risk factors: cognitive impairment, social isolation, financial dependence of the carer on the older person, and carer substance use or mental illness.

Screen at every 75+ Health Assessment using the EASI 6-question tool. Where elder abuse is identified: believe and document; assess safety; offer support; refer to 1800 ELDERHelp (1800 353 374) or state elder abuse services. For patients with preserved capacity who decline intervention, respect autonomy, document clearly, and maintain safety-netting.

RACF care and the SIRS

The Aged Care Quality and Safety Commission Standards 2026 govern all RACF providers. The Serious Incident Response Scheme (SIRS) mandates that RACF staff and providers report abuse, neglect, financial coercion, unexplained injury, missing residents, unexpected death, and psychological or sexual misconduct to the Commission. As a GP providing care to RACF residents, familiarise yourself with SIRS and support appropriate reporting when you become aware of a notifiable incident.

GP attendance MBS items for RACF: 20 (brief), 35 (standard), 43 (long), 51 (prolonged). RMMR (item 903) — pharmacist-led residential medication management review — is PBS-funded annually and should be triggered for all RACF patients, or earlier after any significant clinical change.

For BPSD (behavioural and psychological symptoms of dementia): non-pharmacological approaches first; contact DBMAS / SBRT (1800 699 799) for specialist behaviour support. Risperidone is the only PBS-listed antipsychotic for BPSD; it is Authority Required, ≤12 weeks duration, with mandatory three-monthly review and a trial taper.

D. Australian operations

MBS items

• 75+ Health Assessment: 705 (in-rooms ≥30 min) / 707 (home visit) — annual entitlement
• ATSI Health Assessment from age 55: 715
• 45–49 Health Assessment: 701 / 703 — earlier identification
• GPCCMP: 965 (prepare) / 967 (review 3-monthly)
• Allied health under GPCCMP: 10950–10970 — 5 services/year
• MHCP: 2715 / 2717 — depression, anxiety, BPSD
• HMR (community): 900 / RMMR (RACF): 903 — pharmacist medication review
• DXA bone density: 12306
• RACF attendance: 20 / 35 / 43 / 51
• ACAT-related GP attendance: 92024
• Geriatrician referral: 110 / 116
• Case conference: 735 / 739 / 743

My Aged Care navigation

My Aged Care 1800 200 422 is the single national entry point. Entry-level support (domestic assistance, meals, transport, social support, allied health, personal care) is accessed via CHSP through a Regional Assessment Service (RAS) — no comprehensive ACAT assessment is required. Home Care Packages Levels 1–4 (providing approximately $10,000–$60,000 per year in subsidised support) require an ACAT face-to-face comprehensive assessment. Apply early: Level 3 and 4 wait times commonly run six to twelve months. Bridge with CHSP services while awaiting package commencement. The Support at Home program (replacing HCP and CHSP from 1 July 2025) restructures the funding into classified levels under a single program. For permanent RACF placement, ACAT approves eligibility.

PBS

Per PBS: cholinesterase inhibitors (donepezil, rivastigmine, galantamine) — Authority Required for Alzheimer disease (MMSE 10–24); memantine — Authority Required for moderate-severe Alzheimer disease; risperidone for BPSD — Authority Required, ≤12 weeks; calcium, vitamin D, bisphosphonates and denosumab — Authority Required Streamlined for osteoporosis; anticoagulants (apixaban preferred in frail elderly) — Authority Required Streamlined for AF/VTE.

E. Special populations

Aboriginal and Torres Strait Islander peoples: physiological ageing occurs earlier, with higher rates of chronic disease and multimorbidity. ATSI Health Assessment 715 applies from age 55 and is the priority vehicle. Partner with ACCHOs and Aboriginal Health Workers for culturally safe assessment and care navigation. Respect Sorry Business in advance care planning. Use TIS National (131 450) for interpreter services when needed.

Culturally and linguistically diverse (CALD) patients: use RUDAS rather than MoCA or MMSE for cognitive screening — it is less affected by education, language and culture. Arrange professional interpreter (TIS 131 450) rather than using family members for sensitive assessments including ACP, cognitive screening and elder abuse screening. Respect cultural norms around family involvement in medical decision-making.

LGBTIQ+ older adults: chosen family may not have legal recognition as substitute decision-makers unless documented in an Advance Care Directive. Actively include partners of same-sex couples in ACP discussions and ensure documentation reflects the patient’s wishes. Be aware that aged care environments can be unwelcoming for LGBTIQ+ residents — advocate for affirming care.

Driving fitness: cognitive impairment, falls, cardiac conditions, and sedating medications may affect driving safety. Use Austroads Assessing Fitness to Drive 2022 as the reference standard. Occupational therapy driver assessment provides objective evaluation when clinical judgement is uncertain. Mandatory reporting of medically unfit drivers applies in the Northern Territory and South Australia; other states have reporting options.

When to escalate

• Emergency — suspected elder abuse with immediate safety risk; acute delirium requiring hospital-level assessment; acute falls with injury; suspected intracranial pathology
• Urgent — new significant cognitive decline requiring reversible cause investigation; suspected capacity loss requiring formal psychogeriatric assessment; suspected GCA in a patient with PMR and new headache; acute BPSD with risk of harm
• Routine — complex multimorbidity in older adults: geriatrician referral (MBS 110); refractory falls or balance disorder: falls clinic; moderate or severe cognitive impairment: memory clinic or specialist memory service; BPSD: DBMAS (1800 699 799); home care needs: My Aged Care ACAT referral

What this article is and is not

This is general health information based on current Australian guidelines — RACGP Silver Book 5th edition 2024, eTG Aged Care, AMH, ANZSGM position statements, Aged Care Quality and Safety Commission Standards, Aged Care Act 2024, My Aged Care pathway, and key published evidence. It is not personal medical advice and does not substitute for individual clinical assessment and care planning with the patient and their treating team.

For consumer and carer resources: My Aged Care 1800 200 422, Dementia Australia 1800 100 500, Carer Gateway 1800 422 737, 1800 ELDERHelp 1800 353 374, HealthDirect.

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Sources cited

1. RACGP — Aged Care Clinical Guide (Silver Book 5th ed 2024)
2. eTG Aged Care
3. Australian Medicines Handbook — Aged Care Companion
4. ANZSGM position statements
5. My Aged Care 1800 200 422
6. Aged Care Quality and Safety Commission — Strengthened Standards 2026
7. Aged Care Act 2024 and Support at Home program
8. Dementia Australia 1800 100 500
9. DBMAS / SBRT 1800 699 799
10. Carer Gateway 1800 422 737
11. Compass — 1800 ELDERHelp 1800 353 374
12. AIFS — National Elder Abuse Prevalence Study 2021
13. Austroads — Assessing Fitness to Drive 2022
14. Ellis G et al. — CGA in hospital (Cochrane 2017)
15. Nasreddine ZS et al. — MoCA validation (JAGS 2005)
16. Detering KM et al. — ACP in older adults (BMJ 2010)
17. Livingston G et al. — Lancet Commission on Dementia Prevention 2024
18. Montero-Odasso M et al. — World Falls Guidelines (Age and Ageing 2022)
19. GPCOG — gpcog.com.au
20. PBS
21. Choosing Wisely Australia — asymptomatic bacteriuria