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Comprehensive Geriatric Assessment (CGA)

Last updated 1 Jun 2026 · Geriatric medicine

📋 Key Information Summary

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  • Comprehensive Geriatric Assessment (CGA) is a multidimensional, interdisciplinary diagnostic and therapeutic process used to determine the medical, functional, cognitive, psychological, social and environmental needs of older adults.
  • CGA should be considered for all adults aged ≥65 years presenting with multimorbidity, functional decline, falls, delirium, polypharmacy, or frailty; use the Clinical Frailty Scale (CFS) to guide referral urgency.
  • Functional assessment uses Katz ADL and Lawton IADL scales to quantify independence in basic self-care and higher-order community tasks — results directly guide residential care eligibility (ACAT assessment) and Home Care Package level allocation.
  • Cognitive screening with the MMSE or MoCA, mood screening with the GDS-15, and delirium screening with the 4AT or CAM should be performed systematically on every CGA patient.
  • Delirium is a medical emergency requiring urgent investigation of precipitants (infection, medication, metabolic, pain) — never attribute acute confusion to dementia without formal assessment.
  • Medication review should use the STOPP/START criteria v2 to identify potentially inappropriate medicines and prescribing omissions; deprescribing benzodiazepines, anticholinergics, antipsychotics and NSAIDs is a core CGA intervention.
  • Nutrition screening with the Mini Nutritional Assessment Short Form (MNA-SF) identifies malnutrition risk; unintentional weight loss >5% in 6 months or BMI <22 kg/m² warrants dietitian referral and high-protein oral nutrition supplements.
  • Falls risk assessment is mandatory for every CGA: use the Timed Up and Go (TUG), Functional Reach Test and multifactorial risk review; multifactorial falls prevention programmes reduce fall rates by 20–30%.
  • Social support evaluation, home environment safety assessment (Westmead Home Safety Assessment), and advance care planning are integral CGA components that influence discharge destination and community service referral.
  • CGA must include assessment for Aboriginal and Torres Strait Islander older adults, with awareness that age-related presentations may occur a decade earlier and cultural safety is essential for engagement.
  • CGA is best delivered by an interdisciplinary team (geriatrician, GP, nurse, physiotherapist, occupational therapist, social worker, dietitian, pharmacist) — in Australia, specialist geriatric services are available through public hospital outreach, Transition Care Program (TCP), and My Aged Care system.
  • In-hospital CGA models (Acute Care of the Elderly units, Geriatric Evaluation and Management) reduce mortality, length of stay, and rates of discharge to residential aged care compared with usual care.
  • Advance care planning documentation (Advance Health Directive, Enduring Power of Attorney) should be offered to all older adults and is funded under MBS items 994–996 and chronic disease management plans.

Introduction & Australian Epidemiology

Comprehensive Geriatric Assessment (CGA) is the foundation of modern geriatric medicine. It is defined as a multidimensional, interdisciplinary diagnostic and therapeutic process designed to determine the medical, psychological, functional, social and environmental capabilities and needs of older adults in order to develop a coordinated and integrated plan for treatment and long-term follow-up. CGA goes far beyond a standard medical history and examination by systematically evaluating domains that are often missed in conventional acute or primary care consultations.

CGA guides individualised care planning for older adults with complex needs. It enables identification of reversible conditions, facilitates discharge planning, reduces inappropriate polypharmacy, and improves both survival and quality of life. The geriatric principle of "looking beyond the presenting complaint" is operationalised through CGA — a patient presenting with a fall may have underlying depression, polypharmacy, visual impairment and social isolation, all of which must be addressed for effective management.

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When to trigger a CGA: Consider CGA for all patients aged ≥65 years presenting with any of: functional decline (new ADL dependency), recurrent falls, delirium, polypharmacy (≥5 regular medicines), frailty (CFS ≥5), multimorbidity (≥3 chronic conditions), or discharge planning complexity. CGA is also indicated for patients of any age with geriatric syndromes.

Australian Demographic Context

Australia's population is ageing rapidly. According to the Australian Institute of Health and Welfare (AIHW), in 2023 approximately 17% of Australians were aged 65 and over (4.3 million people), a proportion projected to exceed 23% by 2066. The "oldest old" (aged ≥85 years) represent the fastest-growing demographic segment. Aboriginal and Torres Strait Islander Australians have a younger population age structure, but experience age-related chronic disease burden and geriatric presentations a decade or more earlier than non-Indigenous Australians.

Australian Ageing Metric Value Source
Population aged ≥65 years (2023) ~17% (4.3 million) AIHW, 2023
Projected population aged ≥65 years (2066) ~23–25% Australian Bureau of Statistics
Prevalence of multimorbidity (≥65 years) ~60% AIHW, 2022
Falls rate (aged ≥65 years, past 12 months) ~30% AIHW Injury in Australia
Older Australians receiving Home Care Packages (2023) ~275,000 Dept. Health & Aged Care
Permanent residential aged care residents ~190,000 AIHW, 2023
Dementia prevalence (≥65 years) ~8–10% Dementia Australia

Evidence for CGA Effectiveness

A Cochrane systematic review (Ellis et al., 2017) of 28 trials demonstrated that inpatient CGA (compared with general medical care) reduced the combined outcome of death or functional decline at discharge and follow-up (RR 0.87, 95% CI 0.79–0.95), and increased the likelihood of patients being alive and living at home at 12 months. Acute Care of the Elderly (ACE) unit models and hospital-at-home CGA interventions have shown similar benefits in Australian healthcare settings. In the community, CGA-informed care planning reduces emergency department presentations and delayed hospital transfers.

Australian CGA Service Models

  • Geriatric Evaluation and Management (GEM) units: Inpatient subacute units available in all Australian state/territory public hospitals, funded under state health budgets.
  • Consultation-Liaison Geriatrics: Hospital-based inpatient consultative CGA services.
  • Outpatient & community geriatrics: Hospital-based geriatric outpatient clinics; Transition Care Program (TCP) providing up to 12 weeks of restorative care post-hospital (MBS Item 143).
  • ACAT (Aged Care Assessment Team): Multi-disciplinary teams that assess eligibility for residential aged care, Transition Care, and Home Care Packages — mandated CGA-based assessment through My Aged Care.
  • General Practice: GP Management Plans (GPMP, MBS Item 721) and Team Care Arrangements (TCA, MBS Item 723) enable CGA-based chronic disease management; GP Chronic Condition Health Assessment (MBS Item 701) is available for Aboriginal and Torres Strait Islander peoples.

Functional Assessment (ADL/IADL)

Functional assessment is the cornerstone of CGA and directly determines a patient's ability to live independently. It evaluates the ability to perform activities essential for self-care and community living. Functional decline is often the presenting symptom of an acute or chronic illness in older adults and is a stronger predictor of mortality and healthcare utilisation than many diagnoses.

Basic Activities of Daily Living (ADL)

Basic ADLs assess fundamental self-care tasks. The Katz Index of Independence in Activities of Daily Living is the most widely used and validated tool, scoring six activities on a binary (independent/dependent) scale:

ADL Domain (Katz Index) Description Key Observation Points
Bathing Ability to wash, shower or bathe Note: can reach all body parts; fear of falls in bathroom
Dressing Ability to select clothing and put on/take off garments Check fine motor tasks (buttons, zips), balance during dressing
Toileting Getting to/from toilet, managing clothing, cleaning self Transfers; use of aids; incontinence assessment
Transferring Moving in/out of bed or chair Sit-to-stand; bed mobility; assistive devices
Continence Complete control of urination and bowel movements Distinguish stress, urge, functional and overflow incontinence
Feeding Ability to get food from plate to mouth Note dysphagia, use of modified utensils

A Katz ADL score of 6 indicates full independence; scores ≤4 are associated with significant care needs. In Australia, ACAT assessments use ADL dependency as a key criterion for residential aged care eligibility and Home Care Package level allocation (Levels 1–4).

Instrumental Activities of Daily Living (IADL)

IADLs assess more complex tasks required for independent community living. The Lawton IADL Scale evaluates eight domains (note: different scoring scales for men and women, reflecting historical gendered roles — clinicians should apply the full scale to all patients regardless of gender in modern practice):

  • Using the telephone — can the person look up numbers, dial, and take messages?
  • Shopping — can the person manage a shopping list, travel to shops, make purchases and return home?
  • Food preparation — can the person plan, prepare and serve meals?
  • Housekeeping — can the person perform light and heavy housework?
  • Laundry — can the person wash, dry, fold and put away clothing?
  • Transportation — can the person drive, use public transport or arrange transport?
  • Medication management — can the person self-administer medications at correct times and doses?
  • Finances — can the person manage a budget, pay bills, and handle banking?
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Medication management failure is a red flag: Inability to manage medications independently is one of the strongest predictors of adverse drug events, hospital readmission and loss of independent living. This domain alone often drives the decision for Home Care Package Level 3 or 4, or residential aged care.

Additional Functional Measures

Essential Timed Up and Go (TUG) Test Time to rise from chair, walk 3 metres, turn, walk back and sit. >12 seconds indicates increased falls risk. Requires metronome or stopwatch. No special equipment needed.
Essential Functional Reach Test Maximal forward reach in standing without losing balance. <15 cm indicates high falls risk. Performed at bedside.
Available Hand grip dynamometry Measures grip strength using a Jamar dynamometer. Low grip strength is diagnostic criterion for sarcopenia (men <27 kg; women <16 kg, EWGSOP2). Available in most physiotherapy departments.
Available Short Physical Performance Battery (SPPB) Combines balance testing, 4-metre walk speed, and repeated chair stands. Score ≤9/12 indicates physical performance impairment. Validated in Australian populations.
Available Gait speed (4-metre walk test) Normal gait speed ≥0.8 m/s. Gait speed <0.6 m/s is associated with increased hospitalisation, falls and mortality. Simple, reliable, and the "sixth vital sign".

Interpreting Functional Assessment

Functional decline in an older adult should never be attributed to "normal ageing" without thorough evaluation. Acute functional decline — especially when rapid — is a hallmark of delirium, occult infection, medication adverse effects, or acute cardiovascular events. Subacute progressive decline suggests dementia, depression, worsening chronic disease, social isolation, or malignancy. A structured functional assessment should always be paired with cognitive, mood and delirium screening to complete the CGA picture.

Cognition, Mood and Delirium Screening

Cognitive, mood and delirium screening form a critical triad within CGA. These three domains are closely interrelated: delirium can be mistaken for dementia, depression can mimic both, and they frequently coexist. Systematic screening using validated tools is essential to avoid diagnostic error and guide appropriate management.

Cognitive Screening

Tool Administration Time Score & Interpretation Strengths & Limitations
Mini-Mental State Examination (MMSE) ~10 min Score 0–30. ≥24 = normal; 18–23 = mild impairment; ≤17 = severe. Adjust for education. Widely validated; ceiling effect in mild impairment; now copyright-restricted (PAR Inc).
Montreal Cognitive Assessment (MoCA) ~10–15 min Score 0–30. ≥26 = normal; 18–25 = MCI range; <18 = dementia range. Add 1 point for ≤12 years education. More sensitive for mild cognitive impairment (MCI); free to use (moCA test.org); covers executive function and visuospatial domains.
GPCOG (General Practitioner Assessment of Cognition) ~5 min Patient section 0–9; ≤4 = needs informant section. Designed for primary care. Brief, designed for Australian GP use (developed by Brodaty et al., UNSW); free; includes informant component.
RUDAS (Rowland Universal Dementia Assessment Scale) ~10 min Score 0–30. <23 suggests cognitive impairment. Designed to be culturally fair; validated for use in Aboriginal and Torres Strait Islander and CALD populations in Australia. Free to use.
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Tool selection guidance: Use the MoCA for suspected MCI (sensitivity ~90% vs MMSE ~18% for MCI). Use RUDAS for Aboriginal and Torres Strait Islander patients and those from culturally and linguistically diverse (CALD) backgrounds. Use GPCOG for rapid screening in time-limited GP consultations. Always adjust for education, language, sensory impairment and cultural context.

Mood Screening

Depression is present in approximately 10–15% of community-dwelling older adults, up to 30% of hospitalised older adults, and up to 40% of residential aged care residents. It is frequently under-recognised because older adults more commonly present with somatic complaints, apathy, cognitive complaints ("pseudodementia") and reduced appetite rather than the classic sadness of younger patients.

Tool Details Cut-off
Geriatric Depression Scale (GDS-15) 15 yes/no items specifically developed for older adults; excludes somatic symptoms that overlap with medical comorbidity 0–4 = normal; 5–8 = mild depression; 9–11 = moderate; 12–15 = severe
PHQ-9 9-item Patient Health Questionnaire; commonly used in Australian primary care; may overestimate severity in medically unwell patients 0–4 minimal; 5–9 mild; 10–14 moderate; 15–19 moderately severe; ≥20 severe
K-10 (Kessler Psychological Distress Scale) Validated in Australian populations; used by GPs under Mental Health Treatment Plans (MBS Item 721) 10–19 likely to be well; 20–24 mild; 25–29 moderate; ≥30 severe

Delirium Screening

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Delirium is a medical emergency. It is associated with in-hospital mortality of 25–33%, prolonged hospital stay, accelerated cognitive decline, and increased risk of subsequent dementia. Delirium is present in 10–31% of older hospitalised patients but is missed in up to 60% of cases. Always screen for delirium before attributing confusion to dementia or "old age".
Tool Time Interpretation Notes
4AT <2 min Score 0–12. ≥4 = probable delirium; 1–3 = possible cognitive impairment requiring further assessment. No training required; does not need observation period; suitable for rapid bedside use; recommended by NICE (UK) and widely adopted in Australian hospitals.
CAM (Confusion Assessment Method) 5–10 min Requires (1) acute onset AND fluctuating course AND (2) inattention AND either (3) disorganised thinking OR (4) altered consciousness. Gold standard research tool; requires trained assessor; sensitivity 94%, specificity 89% when used by trained clinicians.
CAM-ICU ~5 min Adapted for intubated/sedated ICU patients using yes/no picture cards. Standard of care in Australian ICUs (ACSQHC Delirium Clinical Care Standard).

Delirium Precipitants — Mnemonic "DELIRIUMS"

  • Drugs (anticholinergics, benzodiazepines, opioids, polypharmacy)
  • Electrolyte imbalance (dehydration, hyponatraemia, hypercalcaemia)
  • Lack of drugs (alcohol/benzodiazepine withdrawal, anticholinesterase withdrawal)
  • Infection (UTI, pneumonia, cellulitis, COVID-19)
  • Reduced sensory input (visual/hearing impairment, unfamiliar environment)
  • Intracranial (stroke, subdural, meningitis)
  • Urinary retention / faecal impaction
  • Myocardial (MI, heart failure, arrhythmia) / Metabolic (hypoglycaemia, hypoxia, hepatic/renal failure)
  • Sleep deprivation / pain / Surgery (post-operative)

Differentiating Delirium, Dementia and Depression

Feature Delirium Dementia Depression
Onset Acute (hours–days) Insidious (months–years) Weeks–months
Course Fluctuating, often worse at night Progressive, stable over 24 hours Diurnal variation (worse mornings)
Consciousness Altered (clouded, hyperalert or lethargic) Clear until late stages Clear
Attention Impaired (hallmark feature) Relatively preserved until late Preserved (may report poor concentration)
Orientation Impaired Impaired (progressive) Preserved
Reversibility Usually reversible (treat cause) Mostly irreversible (except some causes) Treatable
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Dementia and delirium can coexist. A known dementia patient who is acutely more confused than their baseline should be assessed for superimposed delirium. Never assume baseline dementia without checking for reversible precipitants.

Medication Review, Nutrition and Falls Risk

Medication Review

Polypharmacy — defined as the regular use of five or more medicines — affects approximately 40% of older Australians and is associated with increased adverse drug events, falls, delirium, hospital admissions, drug–drug interactions and medication non-adherence. Medication review is a mandatory CGA component. In Australia, Home Medicines Review (HMR, MBS Item 900) and Residential Medication Management Review (RMMR, MBS Item 903) are funded Medicare services conducted by accredited pharmacists on referral from the patient's GP.

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Potentially Inappropriate Medicines (PIMs) in older Australians: The most commonly prescribed PIMs include proton pump inhibitors beyond recommended duration, long-acting benzodiazepines (diazepam, nitrazepam), first-generation antihistamines, anticholinergic medicines, NSAIDs (particularly with concurrent anticoagulants or in CKD), and antipsychotics in dementia without a documented behaviour management plan.

STOPP/START Criteria v2

The Screening Tool of Older Persons' Prescriptions (STOPP) and Screening Tool to Alert to Right Treatment (START) criteria are the most widely used explicit criteria for identifying potentially inappropriate prescribing in older adults. Version 2 (O'Mahony et al., 2015) includes 80 criteria across organ systems. Key Australian applications include:

STOPP — Key "Stop" Criteria
  • Long-acting benzodiazepines (diazepam, nitrazepam) — falls risk, cognitive impairment
  • Anticholinergics with concurrent dementia or delirium
  • NSAIDs with heart failure (NYHA III–IV) or CKD stage ≥3b
  • Proton pump inhibitors beyond 8 weeks without documented indication
  • Antipsychotics in dementia without documented behavioural disturbance
  • Dipyridamole as monotherapy (lack of efficacy)
  • Metformin if eGFR <30 mL/min/1.73 m²
START — Key "Start" Criteria
  • Statin therapy in diabetes with ≥1 cardiovascular risk factor
  • ACE inhibitor or ARB in heart failure with reduced EF
  • Anticoagulation in non-valvular atrial fibrillation (CHA₂DS₂-VASc ≥2)
  • Vitamin D supplementation in older adults with falls risk or housebound
  • Bisphosphonate or denosumab if osteoporotic fracture and no contraindication
  • Laxatives when prescribing opioids regularly
  • SSRI for major depression (not TCAs as first-line)

Deprescribing Medications

Deprescribing is the planned and supervised process of dose reduction or stopping of medication that might be causing harm or is no longer of benefit. It is a core geriatric medicine skill. Common deprescribing targets include:

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Benzodiazepines
Diazepam (Valium®), Temazepam (Temaze®) · Deprescribing target
Risk Falls, fractures, cognitive impairment, delirium, dependence. Associated with 40% increased fall risk in meta-analysis.
Deprescribing approach Gradual dose reduction over 4–8 weeks (reduce by 10–25% every 1–2 weeks). Switch to short-acting (temazepam) first if on long-acting. Consider melatonin (PBS Authority Required) or psychological interventions for insomnia.
PBS status ✔ PBS General Benefit (for both diazepam and temazepam)
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Proton Pump Inhibitors
Omeprazole (Losec®), Pantoprazole (Somac®) · Deprescribing target
Risk Clostridioides difficile infection, hypomagnesaemia, osteoporosis, B12 deficiency, community-acquired pneumonia with long-term use.
Deprescribing approach Step-down to half dose for 2–4 weeks then cease, or switch to PRN H₂RA (famotidine 20 mg nocte). Reassess indication; most patients on PPI >8 weeks without documented indication.
PBS status ✔ PBS General Benefit
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Antipsychotics in Dementia
Risperidone (Risperdal®), Quetiapine (Seroquel®) · Deprescribing target
Risk Stroke (RR ~3), falls, sedation, extrapyramidal effects, mortality. Increased mortality risk in elderly with dementia (FDA/EMA black box warning).
Deprescribing approach Implement non-pharmacological behaviour management first (ABC approach, environmental modification). If behavioural interventions fail, attempt gradual dose reduction over 4–12 weeks. Risperidone is the only antipsychotic with limited PBS authority for aggression in dementia (≤12 weeks only).
PBS status ⚠ PBS Authority Required (risperidone for dementia-related psychosis, ≤12 weeks)

Nutrition Assessment

Malnutrition affects approximately 20% of older Australians in the community and up to 50% in residential aged care and hospital settings. It is an independent predictor of mortality, infection, pressure injuries, poor wound healing, sarcopenia and prolonged hospital stays. Early identification and intervention are essential components of CGA.

Essential Mini Nutritional Assessment Short Form (MNA-SF) Six-item screening tool (food intake, weight loss, mobility, psychological stress, neuropsychological problems, BMI). Score 0–14. ≥12 = normal; 8–11 = at risk; 0–7 = malnourished. The MNA-SF is recommended by the Australasian Society for Parenteral and Enteral Nutrition (AuSPEN) and validated in Australian populations.
Essential Malnutrition Screening Tool (MST) Two-item screening (unintentional weight loss, appetite). Score 0–5. ≥2 = at risk. Quick and easy for hospital admission screening. Validated in Australian hospitals and mandated by NSQHS Standards.
Available Subjective Global Assessment (SGA) Clinician-rated assessment (A = well nourished, B = moderately malnourished, C = severely malnourished). More comprehensive than screening tools; requires dietitian or trained clinician.

Nutritional Interventions in CGA

  • Dietitian referral — available in public hospitals and community via Medicare-funded chronic disease management (CDM) plans (up to 5 allied health visits per year, MBS Item 10950).
  • High-protein oral nutritional supplements (ONS): e.g., Ensure Plus® (1.5 kcal/mL, 15 g protein per 230 mL) or Novasource Renal® for CKD patients. PBS listing for ONS is limited; generally funded through hospital, RACF, or Home Care Package budgets rather than PBS.
  • Vitamin D supplementation: Cholecalciferol (vitamin D₃) 1000–2000 IU daily is recommended for all older adults with limited sun exposure, falls risk or osteoporosis. Calcitriol (1,25-dihydroxyvitamin D) is available on PBS for patients with renal osteodystrophy.
  • Texture-modified diets per Speech Pathologist assessment — follow the Australian Standardised Terminology and Definitions for Texture Modified Foods and Fluids (IDDSI framework adopted nationally).
  • Multidisciplinary mealtime assistance — food-first approach, protected mealtimes, and social dining are evidence-based strategies in hospital and RACF settings.

Falls Risk Assessment

Falls are the leading cause of injury-related hospitalisation and death in older Australians. One in three adults aged ≥65 years falls each year, and falls are the most common reason for ambulance attendance in this age group. In 2021–22, there were approximately 263,000 fall-related hospitalisations in Australians aged 65 and over. Falls risk assessment and multifactorial falls prevention are core CGA responsibilities.

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Lie-down fractures: Hip fractures in older adults carry a one-year mortality of 20–30%. Of those who survive, only 50% return to pre-fracture functional level. Every fall in an older person should be treated as a serious event requiring comprehensive assessment.

Multifactorial Falls Risk Factors

Category Modifiable Risk Factors Interventions
Medications Benzodiazepines, antidepressants (SSRIs, TCAs), antipsychotics, opioids, antihypertensives (especially polypharmacy), diuretics Deprescribing; review postural BP; medication timing optimisation
Gait/balance Impaired balance, muscle weakness, gait disorder, neuropathy Physiotherapy; strength and balance exercise programmes (e.g., Otago Exercise Programme — delivered by physiotherapist, 3×/week, reduces falls by 35%)
Vision Visual acuity <6/12, cataracts, bifocals/multifocals, macular degeneration Optometry referral (Medicare-funded); single-lens distance glasses for walking; cataract surgery referral
Cardiovascular Orthostatic hypotension, carotid sinus hypersensitivity, arrhythmia Active stand test; 24-hour BP monitoring; cardiology referral if recurrent unexplained falls
Environment Loose rugs, poor lighting, stairs without handrails, wet bathrooms OT home safety assessment (funded under Home Care Package or via hospital outreach); minor home modifications (Medicare-funded via CDMA for Aboriginal and Torres Strait Islander patients)
Footwear Slippers, high heels, loose-fitting shoes, walking barefoot Podiatry assessment; supportive, well-fitting shoes with non-slip soles
Continence Urge incontinence, nocturia, rushing to toilet Bladder training, pelvic floor exercises, review diuretic timing, bedside commode
Cognition Dementia, delirium, impaired executive function Environmental modification; supervised activity; dual-task training

Vitamin D and Falls Prevention

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Cholecalciferol (Vitamin D₃)
Ostelin®, various generics · Nutritional supplement
Adult dose 1000–2000 IU (25–50 micrograms) PO daily for falls prevention in older adults with vitamin D insufficiency (<50 nmol/L) or falls risk
Evidence Cochrane review (2019): vitamin D reduces falls rate in people with low serum 25(OH)D (<25 nmol/L) — NNT 10. No benefit in vitamin D-replete individuals.
Notes Available OTC at pharmacies; calciferol 25,000 IU monthly injection (Stoss therapy) available for non-adherent patients. Do NOT use calcitriol (1,25-dihydroxyvitamin D) for falls prevention — it does not reduce falls and increases hypercalcaemia risk.
PBS status ✘ Not PBS listed (available OTC; hospital/clinic-funded). Calcitriol is PBS-listed for renal osteodystrophy only.

Social Support, Environment and Care Planning

The social, environmental and care planning domains of CGA are often the determinants of where and how an older person will live after their assessment. A medically optimised patient cannot be safely discharged to an unsafe home, and conversely, a well-supported older person can remain at home despite significant medical complexity. This section addresses the three interconnected pillars of social assessment, environmental evaluation and advance care planning.

Social Support Assessment

Social isolation and loneliness are associated with a 26% increased risk of all-cause mortality (Holt-Lunstad et al., 2015), equivalent to smoking 15 cigarettes per day. Social determinants must be systematically assessed as part of CGA.

Essential Social history and support network mapping Document: living arrangements (alone, with spouse, with family, RACF); informal carer availability and carer burden (use Zarit Burden Interview); proximity of family/friends; community group participation; cultural and language needs.
Available Lubben Social Network Scale (LSNS-6) Six-item validated tool measuring social isolation in older adults. Score <12 indicates social isolation risk. Free to use.
Available Zarit Burden Interview (ZBI) 22-item carer burden scale. Score 0–88. 0–20 = no burden; 21–40 = mild; 41–60 = moderate; 61–88 = severe. Essential for supporting carers — referrals to Carers Australia, My Aged Care for carer respite.
Available Elder Abuse screening Screen for financial, emotional, physical, neglect and sexual abuse. Use the Elder Abuse Suspicion Index (EASI) or direct questioning. Reporting obligations vary by state — contact the relevant Adult Safeguarding Unit or Elder Abuse Helpline (1800 ELDERHelp / 1800 353 374).

Home Environment Assessment

Environmental hazards contribute to approximately 40–50% of falls in older adults. A home safety assessment is a core CGA intervention, ideally performed by an occupational therapist using a standardised tool.

Essential Westmead Home Safety Assessment (WeHSA) Standardised OT assessment tool developed in Australia (Clemson et al., 1999). Identifies environmental hazards in all areas of the home. Scored checklist with hazard rating. Validated and shown to reduce falls when combined with home modifications (RR 0.64, Cochrane Review).
Available Check Your Home safety checklist (NSW Health) Self-completion checklist available in multiple languages. Suitable for initial community screening. Can be completed by patient or carer prior to OT assessment.

Key Environmental Modifications

  • Lighting: Night-lights in hallways and bathroom; adequate task lighting; sensor lights on stairs
  • Flooring: Remove loose rugs and mats; secure carpet edges; non-slip surfaces in wet areas
  • Bathroom: Grab rails (shower and toilet); non-slip mat in shower/bath; raised toilet seat; shower chair if needed
  • Stairs: Handrails on both sides; contrasting colour on stair edges; avoid storage on stairs
  • Kitchen: Frequently used items at waist height; stable step-stool with handrail; kettle tipper
  • External: Clear pathways; handrails at entrance; secure garden paths; adequate exterior lighting
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Funding for home modifications in Australia: Minor modifications (grab rails, ramps, handrails) can be funded through Home Care Packages (Level 1–4), state-based Commonwealth Home Support Programme (CHSP) grants, or the NDIS (if under 65 years). Major modifications (bathroom renovations, stairlifts) may require Home Care Package Level 3–4 funding or state-based programs. Aboriginal and Torres Strait Islander patients may access the Indigenous Australians Health Programme (IAHP) for housing and safety assessments.

Advance Care Planning (ACP)

Advance care planning is a process of discussion and documentation about an individual's values, goals and preferences for future medical treatment. ACP is an integral part of CGA and should be offered to all older adults, particularly those with multimorbidity, frailty, life-limiting illness, or cognitive impairment (while they still have capacity). In Australia, ACP is supported by the National Framework for Advance Care Planning (2021).

ACP Document Description Legal Status
Advance Health Directive (AHD) Written statement of treatment preferences for future healthcare when the person lacks decision-making capacity Legally binding in all Australian states/territories (name varies: Advance Care Directive in SA, Advance Personal Plan in NT, Advance Health Directive in WA/QLD)
Enduring Power of Attorney (EPOA) / Enduring Guardian Appoints a substitute decision-maker for health and/or financial matters if the person loses capacity Legally binding; must be made while person has capacity; varies by state/territory (e.g., Enduring Power of Guardianship in VIC/SA)
Resuscitation plan / Goals of care Clinician-initiated plan documenting the agreed approach to CPR, ICU admission, and escalation limits based on patient preferences and clinical futility Not a statutory document but carries clinical and ethical weight; endorsed by the Australasian Society for Parenteral and Enteral Nutrition and Resuscitation Council of Australia

MBS Items for ACP

  • MBS Item 994: Health assessment for patients aged 75 years and older (annual) — includes ACP discussion
  • MBS Item 721/723: GP Management Plans and Team Care Arrangements — can incorporate ACP goals
  • MBS Item 701: Aboriginal and Torres Strait Islander health assessment — incorporates culturally appropriate ACP

Aged Care Pathway — The My Aged Care System

CGA findings directly determine eligibility and level of support within Australia's aged care system. Key pathways include:

  • Commonwealth Home Support Programme (CHSP): Entry-level support for those needing minimal assistance (meals, transport, social support, minor home modifications). Accessed via My Aged Care portal.
  • Home Care Packages (HCP): Levels 1–4 (basic to high care needs) providing coordinated package of care and support services. ACAT/SDA assessment determines level. Wait times can be significant; interim support via CHSP.
  • Transition Care Program (TCP): Up to 12 weeks of restorative care post-hospital to prevent premature residential care admission.
  • Residential Aged Care (RAC): Permanent or respite care in an aged care facility. Requires ACAT approval. The Aged Care Quality Standards (2019) mandate person-centred care aligned with CGA principles.
  • Residential Aged Care Funding — AN-ACC (Australian National Aged Care Classification): Since October 2022, AN-ACC replaced ACFI as the funding model, using a resident classification based on functional capacity, cognition, behaviour and care needs — all CGA domains.

Special Populations

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The Oldest Old (≥85 Years)

The "oldest old" are the fastest-growing population segment in Australia and have the highest prevalence of frailty, falls, dementia, sensory impairment and polypharmacy.
Atypical presentations of illness are the norm — falls, functional decline, delirium and incontinence may be the sole manifestations of acute coronary syndrome, pneumonia or urinary tract infection.
CGA is particularly beneficial in this group: in-hospital CGA reduces mortality by up to 25% and increases the proportion living at home at 12 months.
Consider conservative management pathways where appropriate; discuss goals of care early. Avoid over-investigation where results will not change management.
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Chronic Kidney Disease (CKD)

CKD prevalence exceeds 30% in Australians aged ≥65 years. GFR estimation (CKD-EPI) should use the creatinine-based equation without race coefficient (consistent with Australasian Creatinine Consensus).
Adjust medications for renal function: reduce gabapentin dose in CKD (starting dose 100 mg OD if eGFR <30); avoid metformin if eGFR <30; dose-adjust direct oral anticoagulants (DOACs) per product information and PBS authority criteria.
Renal disease contributes to accelerated sarcopenia, anaemia (check ferritin, iron studies), metabolic bone disease, malnutrition and uraemic delirium — all CGA-relevant domains.
Nephrology referral pathway (eGFR <30 or rapidly declining eGFR) should be included in CGA care plan; conservative kidney management may be appropriate for frail elderly patients who decline dialysis.
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Immunocompromised Older Adults

Age-related immunosenescence affects vaccine responses, infection susceptibility and atypical presentations. The Australian National Immunisation Program (NIP) funds pneumococcal (PCV20 or PPSV23), influenza (annually, high-dose or adjuvanted for ≥65), shingles (Shingrix®, 2 doses for ≥65), and COVID-19 boosters for older adults.
Iatrogenic immunosuppression (corticosteroids, methotrexate, biologics, chemotherapy) further increases infection risk; ensure Pneumocystis prophylaxis, hepatitis B reactivation screening, and latent TB screening where indicated.
Infection in immunocompromised older adults frequently presents as delirium, falls or functional decline rather than fever or focal symptoms — maintain a low threshold for investigation.
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Hepatic Impairment

Drug metabolism is impaired with hepatic dysfunction; dose-reduce or avoid benzodiazepines (lorazepam, oxazepam are preferred if needed, as they undergo glucuronidation only), opioids, warfarin and statins in significant liver disease.
Hepatic encephalopathy can mimic or precipitate delirium — assess with serum ammonia if suspected, and manage precipitants (constipation, infection, GI bleeding, electrolyte disturbance).
The Child-Pugh and MELD scores guide medication safety; CGA care plans should include hepatology input for patients with chronic liver disease.
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Residential Aged Care Residents

RACF residents are the frakest cohort in the health system: average CFS 6–7, median 8 medications, 50% prevalence of dementia, and 40% malnutrition prevalence.
CGA in RACFs should be performed at admission and reviewed at minimum every 3 months, or after any acute event. The Aged Care Quality Standards (Standard 2: Ongoing Assessment and Planning with Consumers) mandate individualised, comprehensive assessment.
Telehealth geriatrician review (funded by Medicare for residential aged care, MBS items 99202–99215) improves access to specialist CGA in rural and remote RACFs.
Medication review (RMMR, MBS Item 903) is available for all RACF residents on initial admission and every 24 months thereafter, or when clinically indicated.
Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Australians experience age-related chronic disease burden, frailty, falls and geriatric presentations approximately 10–15 years earlier than non-Indigenous Australians. The "proportion of life lived with disability" is significantly higher. CGA must be culturally safe, trauma-informed, and adapted to the unique social, cultural and environmental contexts of First Nations peoples. The following considerations are essential:

Earlier onset of geriatric syndromes
Age-related decline, frailty, falls, cognitive impairment and multimorbidity commonly present from age 50–55 years in Aboriginal and Torres Strait Islander Australians. CGA should be considered for Indigenous patients presenting with geriatric syndromes from age 50 onwards, and certainly by age 55–60. Use of the RUDAS (rather than MMSE or MoCA) is recommended for cognitive screening due to its cultural fairness.
Remote and rural access
Approximately 38% of Aboriginal and Torres Strait Islander people live in remote or very remote areas. Geriatric specialist services are concentrated in metropolitan and major regional centres. Telehealth geriatric CGA (MBS telehealth items) is essential for remote communities. Aboriginal Community Controlled Health Services (ACCHS) are the primary point of healthcare delivery in many communities and should be integrated into CGA models.
Cultural safety and communication
CGA must be delivered in a culturally safe environment with appropriate acknowledgement of Country, use of Aboriginal Health Workers/Practitioners (AHW/Ps) as cultural brokers, and awareness of communication styles (avoid direct questioning where culturally inappropriate; use yarning-based assessment approaches). Many CGA tools (including the Lawton IADL scale) assume Western living contexts and may need adaptation for community-based living arrangements common in remote communities.
Social determinants and environmental factors
Housing overcrowding, food insecurity (limited access to affordable nutritious food in remote communities), limited access to clean water in some communities, transport barriers, and socioeconomic disadvantage are significantly more prevalent. Falls risk assessment must account for unpaved surfaces, overcrowded housing, and lack of standard home modification infrastructure. The Indigenous Australians Health Programme (IAHP) and Close the Gap programs provide targeted funding for some environmental modifications.
Dementia and cognitive impairment
Aboriginal and Torres Strait Islander Australians have 3–5 times the dementia prevalence of non-Indigenous Australians, with onset at younger ages. Vascular dementia and early-onset Alzheimer's are more common. Use the RUDAS for screening. Dementia Australia and Dementia Training Australia provide culturally adapted resources. The Koori Dementia Care Project (Victoria) offers culturally specific support models.
Advance care planning and end-of-life care
ACP must be culturally adapted: consider kinship systems, the role of Elders in decision-making, sorry business (bereavement) practices, and preference for dying on Country. Many Indigenous Australians may prefer that end-of-life discussions occur in specific community settings or involve particular family members. Palliative Care Australia's "Roadmap for Change" highlights the need for culturally appropriate end-of-life care pathways for First Nations peoples.
Medication access and PBS considerations
Remote pharmacies may have limited formulary; Remote Area Aboriginal Health Services can supply PBS medicines under Section 100 (s100) arrangements without co-payment. Closing the Gap PBS co-payment measure (effective 1 July 2023) provides PBS medicines at no cost for eligible Indigenous Australians with chronic disease through Continuous Medication Management (CMM) — an important consideration for deprescribing and polypharmacy reduction in CGA.
MBS items and funding
MBS Item 701 (Aboriginal and Torres Strait Islander health assessment) is a comprehensive health check that can serve as a gateway CGA and is available to all Indigenous Australians without co-payment. MBS Item 715 enables chronic disease management planning. These items, combined with GPMP/TCA (Items 721/723), enable a funded multidisciplinary CGA pathway in primary care.

📚 References

  1. 1. Ellis G, Gardner M, Tsiachristas A, et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev. 2017;9(9):CD006211. doi:10.1002/14651858.CD006211.pub3
  2. 2. O'Mahony D, O'Sullivan D, Byrne S, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44(2):213-218. doi:10.1093/ageing/afu145
  3. 3. Australian Institute of Health and Welfare (AIHW). Older Australia at a Glance. Canberra: AIHW; 2023. Available from: https://www.aihw.gov.au/reports/older-people/older-australia-at-a-glance
  4. 4. Laver K, Cumming RG, Dyer SM, et al. Clinical practice guidelines for dementia in Australia. Med J Aust. 2016;204(5):191-193. doi:10.5694/mja15.01324
  5. 5. Clemson L, Cumming RG, Kendig H, et al. The effectiveness of a community-based program for reducing the incidence of falls in the elderly: a randomized trial. J Am Geriatr Soc. 2004;52(9):1487-1494. doi:10.1111/j.1532-5415.2004.52411.x
  6. 6. Royal Australian College of General Practitioners (RACGP). Guidelines for Preventive Activities in General Practice. 9th edn (Red Book). Melbourne: RACGP; 2018 (updated 2023).
  7. 7. Morley JE, Vellas B, Abellan van Kan G, et al. Sarcopenia. J Am Med Dir Assoc. 2011;12(4):249-256. doi:10.1016/j.jamda.2011.01.003 (EWGSOP2: Cruz-Jentoft et al., Age Ageing. 2019;48(1):16-31)
  8. 8. Holt-Lunstad J, Smith TB, Baker M, Harris T, Stephenson D. Loneliness and social isolation as risk factors for mortality: a meta-analytic review. Perspect Psychol Sci. 2015;10(2):227-237. doi:10.1177/1745691614568352
  9. 9. Smith T, Gildeh N, Holmes C. The Montreal Cognitive Assessment: validity and utility in a memory clinic setting. Can J Psychiatry. 2007;52(5):329-332. doi:10.1177/070674370705200508
  10. 10. Storey JE, Rowland JT, Basic D, Conforti DA, Dickson HG. The Rowland Universal Dementia Assessment Scale (RUDAS): a multicultural cognitive assessment scale. Int Psychogeriatr. 2004;16(1):13-31. doi:10.1017/S1041610204000043
  11. 11. ACSQHC. Delirium Clinical Care Standard. Sydney: Australian Commission on Safety and Quality in Health Care; 2021. Available from: https://www.safetyandquality.gov.au/standards/clinical-care-standards/delirium
  12. 12. The Royal Australian College of General Practitioners (RACGP). Physical Activity and Exercise in the Prevention and Treatment of Disease (Knowledge Summary). Melbourne: RACGP; 2020. (Otago Exercise Programme evidence review)
  13. 13. Australian Government Department of Health and Aged Care. National Aged Care Mandatory Quality Indicator Program Manual. Version 5.0. Canberra: Commonwealth of Australia; 2023.
  14. 14. Dent E, Morley JE, Cruz-Jentoft AJ, et al. International Clinical Practice Guidelines for Sarcopenia (ICFSR): screening, diagnosis and management. J Nutr Health Aging. 2018;22(10):1148-1161. doi:10.1007/s12603-018-1139-9
  15. 15. Brodaty H, Kemp NM, Low LF. Characteristics of the GPCOG, a screening tool for cognitive impairment. Int J Geriatr Psychiatry. 2004;19(9):870-874. doi:10.1002/gps.1167
  16. 16. Hilmer SN, Gnjidic D, Le Couteur DG. Thinking through the medication list: appropriate prescribing and deprescribing in robust and frail older patients. Aust Fam Physician. 2012;41(12):924-928.
  17. 17. Australian Institute of Health and Welfare (AIHW). Falls in Older Australians 2019–20: Hospitalisations and Deaths. Injury Research and Statistics Series No. 136. Canberra: AIHW; 2023.
for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.
Preventive health
Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction
Paracetamol ± NSAID; manual therapy
2–6 weeks
Provocable on palpation; no red flags
Thoracic compression fracture
Paracetamol; ± calcitonin; DXA + osteoporosis Rx
6–12 weeks healing
Elderly; osteoporosis; acute onset
ACS (posterior MI)
Aspirin 300 mg, GTN, heparin; urgent PCI
Time-critical
ECG, troponin; CV risk factors
Aortic dissection
IV labetalol; urgent CT aortogram; surgery (Type A)
Time-critical
Tearing pain; BP differential >20 mmHg
Vertebral osteomyelitis
IV antibiotics (vancomycin + ceftriaxone initially); ID consult
6 weeks IV antibiotics
Fever, elevated CRP, IV drug use
Biliary colic / cholecystitis
Paracetamol ± morphine; lap cholecystectomy
Surgical within 72 h (cholecystitis)
RUQ/infrascapular; post-prandial; RUQ US

📚 References

  1. 1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
  2. 2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
  3. 3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
  4. 4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
  5. 5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
  6. 6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
  7. 7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
  8. 8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
  9. 9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
  10. 10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
  11. 11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
  12. 12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).