Comprehensive Geriatric Assessment (CGA)

🧩 What is CGA?

Comprehensive Geriatric Assessment (CGA) is a multidimensional, interdisciplinary diagnostic process that identifies medical, functional, psychological, and social problems in frail older adults, creating a coordinated care plan to improve outcomes.

JAMA Evidence — Why CGA Works

A landmark meta-analysis (Stuck et al., JAMA 1993) of 28 RCTs showed CGA significantly reduces mortality, functional decline, nursing-home admission, and rehospitalisation compared to standard care. Repeated confirmed by Ellis et al., Cochrane 2017 (inpatient CGA units improved living at home at 12 months).

Key Outcomes Improved by CGA

• 22% reduction in mortality at 12 months
• 25% reduction in nursing-home admissions
• Improved functional status and ADL maintenance
• Reduced polypharmacy and medication errors
• Improved delirium recognition and prevention

CGA vs Standard Assessment

Feature	Standard Assess.	CGA
Focus	Presenting complaint	Whole-person domains
Team	Single clinician	MDT
Functional status	Brief/implied	Formal tools (Katz, Barthel)
Cognitive screen	Informal	MMSE/MoCA/4AT
Social factors	Rarely documented	Structured (Zarit, housing)
Medication review	Ad hoc	STOPP/START systematic
Care planning	Medical only	Coordinated MDT plan

👥 CGA Multidisciplinary Team

🩺

Geriatrician

Medical diagnosis, medication optimisation, prognosis

🏥

Nurse

Functional screening, delirium monitoring, care coordination

🏃

Physiotherapist

Gait, balance, mobility, rehabilitation potential

🍽️

Occupational Therapist

ADL/IADL assessment, home adaptation, cognition

🤝

Social Worker

Housing, carer support, safeguarding, discharge planning

💊

Pharmacist

Polypharmacy, STOPP/START, deprescribing, adherence

🥗

Dietitian

Nutritional assessment, MUST score, supplementation

🧠

Psychiatry/Psychology

Depression, anxiety, capacity, behaviour in dementia

🗺️ Six Domains of CGA

Functional

ADLs, IADLs, mobility, falls risk, rehabilitation potential

Cognitive/Psychological

Dementia, delirium, depression, anxiety, capacity

Medical

Comorbidities, nutrition, continence, pain, sensory impairment

Social

Carer support, living situation, financial capacity, safeguarding

Environmental

Home safety, fall hazards, accessibility, transport

Pharmacological

Polypharmacy, STOPP/START, adherence, reconciliation

🎯 Who Benefits from CGA?

Suitable for CGA — Frail Elders

• Multiple comorbidities (≥3 chronic conditions)
• Polypharmacy (≥5 medications)
• Functional decline or recent falls
• Cognitive impairment / dementia
• Complex social circumstances (living alone, carer issues)
• Frequent hospitalisations or ED visits
• Post-acute rehabilitation needs
• Unexplained weight loss or malnutrition risk

Less Benefit from CGA

• Fully independent "fit" elderly with no frailty
• Terminally ill with established palliative plan
• Severe dementia with limited goals

Use Clinical Frailty Scale (CFS 1–3 = fit; 4–6 = frailty spectrum; 7–9 = severe frailty)

Nurse's Role in CGA

Nurses are often first to identify frailty, initiate screening, coordinate MDT communication, monitor delirium, manage falls prevention, and ensure discharge planning includes community support.

🔬 Mini CGA Screening Tool — Interactive

Quick bedside screening for CGA need. Not a replacement for full CGA — use to prioritise referrals.

Timed Up & Go (TUG) — seconds

AMT4 Score (0–4) — Abbreviated Mental Test

Number of Regular Medications

Lives Alone?

Yes No

Hospital Admission in Last 3 Months?

Yes No

Quick Barthel (Mobility Domain)

Quick Barthel (Feeding Domain)

🚶 ADLs — Katz Index of Independence

Six basic self-care activities scored as Independent (1) or Dependent (0). Score 6 = fully independent; 0 = fully dependent.

Bathing
Independent if bathes self completely or requires help with 1 body part only

Dressing
Independent including buttons, zips — excludes tying shoelaces

Toileting
Independent in going to toilet, undressing, cleaning, re-dressing

Transferring
Moves in/out of bed and chair without assist (may use device)

Continence
Fully controls urination and defaecation

Feeding
Self-feeds from plate — excludes cutting meat or buttering bread

Katz Score Interpretation

6 = Full independence
4 = Moderate independence
2 or less = Severe functional impairment → immediate OT/PT referral

Decline in Katz score over time = functional decline marker — document at each admission

Nursing Action Points

• Assess on admission and discharge (change = rehabilitation signal)
• Document in patient record with date
• Score ≤2: refer to OT for home assessment
• Compare to pre-morbid function — "What was patient doing 3 months ago?"

🏠 IADLs — Lawton Scale (8 Domains)

Instrumental ADLs — higher-order activities needed for independent community living. Max 8 (women) / 5 (men — excludes cooking, housekeeping, laundry).

Ability to use telephone
Shopping (food and clothes)
Food preparation (cooking)
Housekeeping
Laundry
Mode of transportation (driving/bus)
Responsibility for own medications
Ability to handle finances

Clinical Relevance

IADL impairment often precedes ADL decline. Early IADL loss (especially finances, medications) is a warning sign of mild cognitive impairment. Refer to Social Worker if IADL score ≤4 in community-dwelling elderly.

📊 Barthel Index (0–20 Scoring)

Activity	Assisted	Independent
Feeding	5	10
Bathing	—	5
Grooming	—	5
Dressing	5	10
Bowel control	5	10
Bladder control	5	10
Toilet use	5	10
Transfers (chair/bed)	5–10	15
Mobility on level surface	5–10	15
Stairs	5	10

0–8

Total dependence — high nursing care needs

9–11

Severe dependence

12–15

Moderate dependence

16–19

Slight dependence

Full independence

⏱️ Timed Up & Go (TUG) Test

Patient rises from standard chair, walks 3 metres, turns, returns and sits. No assistance, usual footwear.

<12

Normal — low fall risk in community elderly

12–20

Borderline — increased fall risk, physiotherapy referral

>20

High fall risk — multifactorial falls assessment required, RED FLAG

RED FLAG: TUG >30 seconds

Suggests significant mobility impairment. Urgent physiotherapy and occupational therapy assessment. Environmental modification needed.

⚠️ Falls Risk — FRAT Tool

Falls Risk Assessment Tool — 4 key risk factors in elderly

Recent fall — fall in last 12 months (highest predictor)
Medications — ≥4 meds or high-risk drugs (sedatives, antihypertensives)
Psychological — depression, cognitive impairment, fear of falling
Cognitive status — confusion, dementia

Handgrip Strength

Measured with dynamometer. Low grip strength = sarcopenia marker and falls risk. Threshold: <27 kg (men), <16 kg (women). Refer to dietitian and physiotherapy.

🧠 MMSE — Mini-Mental State Examination (0–30)

Domain	Max Score
Orientation to time (year/season/date/day/month)	5
Orientation to place (country/county/town/hospital/ward)	5
Registration (3 objects — repeat immediately)	3
Attention & calculation (Serial 7s or WORLD backwards)	5
Recall (3 objects after delay)	3
Naming (watch, pencil)	2
Repetition ("No ifs, ands or buts")	1
3-stage command	3
Reading ("Close your eyes")	1
Writing (sentence)	1
Copying (pentagon)	1

27–30

Normal cognition

24–26

Mild cognitive impairment — monitor, repeat

18–23

Mild dementia

10–17

Moderate dementia

<10

Severe dementia — capacity concerns

Arabic MMSE Validation

The Arabic MMSE has been validated for GCC populations (Al-Ghamdi et al.). Adjust for education level — cut-off may be lower in illiterate patients. MMSE is copyrighted — MoCA freely available at mocatest.org.

🎯 MoCA — Montreal Cognitive Assessment

More sensitive than MMSE for MCI. 30 points. Available in Arabic. Free at mocatest.org. Takes ~10 min.

Visuospatial/Executive — Trail B, clock, cube (5 pts)
Naming — 3 animals (3 pts)
Memory — 5 words, delayed recall (5 pts)
Attention — digit span, serial 7s, tap test (6 pts)
Language — sentence repeat, fluency (3 pts)
Abstraction — similarities (2 pts)
Orientation (6 pts)

≥26

Normal (add 1 pt if <12 yrs education)

18–25

Mild cognitive impairment

<18

Moderate–severe cognitive impairment

⚡ AMT4 — 4-Question Rapid Screen

Abbreviated Mental Test 4 — bedside screening in 1 minute. Score 0–4.

What year is it? (1 pt)

What is your age? (1 pt)

What is this place / where are we? (1 pt)

What is your date of birth? (1 pt)

AMT4 ≤ 3 — RED FLAG

Score ≤3 suggests cognitive impairment. Proceed to 4AT delirium tool. Determine if acute (delirium) vs chronic (dementia). Check reversible causes: infection, medication, metabolic.

🔴 4AT Delirium Tool (0–12)

Validated delirium assessment tool. Takes <2 minutes. Score ≥4 = possible delirium. Free at the4AT.com.

Alertness — 0=normal; 4=severely drowsy/agitated

AMT4

AMT4 — 0=4 correct; 1=3 correct; 2=≤2 correct

Attention (months backwards) — 0=7+; 1=start but <7; 2=refuses/fails

Acute change / fluctuation — 0=no; 4=yes

Delirium unlikely (not excluded if clinical concern)

1–3

Cognitive impairment likely — but not delirium criteria

≥4

Possible/probable delirium — initiate delirium protocol

Delirium — Urgent Actions

• Identify and treat precipitating cause (sepsis, urinary retention, constipation, metabolic, medication)
• Avoid antipsychotics as first-line
• Non-pharmacological: reorientation, clock, familiar faces, hearing aid, glasses, mobilise, sleep hygiene
• Nurse-to-patient ratio critical in delirium

🔺 Delirium vs Dementia vs Depression — 3D Differentiation

Feature	Delirium	Dementia	Depression
Onset	Acute (hours–days)	Insidious (months–years)	Weeks–months
Course	Fluctuating	Progressive, stable	Diurnal variation
Consciousness	Reduced/altered	Preserved early	Preserved
Attention	Severely impaired	Variably impaired	Mildly impaired
Memory	Impaired (immediate)	Long-term early	Forgetfulness subjective
Psychosis	Common (vivid hallucinations)	Late feature	Mood-congruent
Reversibility	Usually reversible	Irreversible	Treatable
Priority action	Find medical cause urgently	Plan, support, safety	GDS-15 / PHQ-9, antidepressants

😔 Depression Screening — GDS-15 & PHQ-9

Geriatric Depression Scale (GDS-15) preferred in elderly — yes/no format, avoids somatic items.

0–4

Normal — no depression

5–8

Mild depression — counselling, review

9–11

Moderate depression — GP/psychiatry referral

12–15

Severe depression — urgent psychiatric review

⚖️ Capacity Assessment in Cognitively Impaired

Mental capacity is decision-specific and time-specific. Always assume capacity unless evidence otherwise.

Understand — can they understand information given?
Retain — can they hold the information long enough?
Weigh up — can they use information to decide?
Communicate — can they communicate their decision?

GCC Context

In GCC, family often act as proxy decision-makers for incapacitated elders. Document family consultations. Respect Islamic ethical principles — sanctity of life, beneficence, avoiding harm.

💊 Polypharmacy — Definitions & Burden

Polypharmacy

≥5 regular medications simultaneously. Present in up to 40% of elderly over 65.

Problematic Polypharmacy

Prescribing that introduces risks that outweigh benefits; inappropriate drug combinations; prescribing cascade.

Hyperpoly-pharmacy

≥10 regular medications. Associated with 300% increased risk of adverse drug reactions.

RED FLAG: ≥10 Medications

Automatic pharmacist referral required. High risk of drug–drug interactions, anticholinergic burden, falls, confusion, renal injury, and nutritional deficiencies (e.g. metformin → B12 deficiency).

🔍 STOPP/START Criteria — Version 3 (2023)

STOPP — Screening Tool of Older Persons' Prescriptions (Drugs to STOP)

Drug Class	Reason to Stop
Benzodiazepines	Falls, sedation, cognitive impairment, dependence
Anticholinergics	Confusion, constipation, urinary retention, falls
NSAIDs (long-term)	GI bleed, renal impairment, fluid retention, hypertension
First-gen antihistamines	Sedation, anticholinergic effects (chlorphenamine)
Tricyclic antidepressants	Cardiac arrhythmia, falls, anticholinergic burden
Antipsychotics (in dementia)	Stroke risk, accelerated cognitive decline, falls
PPIs >8 weeks (without indication)	C. difficile, fractures, B12 deficiency, hypomagnesaemia
Alpha-blockers (female)	Orthostatic hypotension, urinary incontinence

START — Screening Tool to Alert to Right Treatment (Drugs to START)

Indication	Drug to Start
Osteoporosis	Bisphosphonate + vitamin D + calcium
AF (no contraindication)	Anticoagulation (DOAC preferred in elderly)
Heart failure (EF <40%)	ACE-i/ARNI + beta-blocker + SGLT2-inhibitor
Depression (moderate–severe)	SSRI (avoid TCA)
Diabetes (high CV risk)	SGLT2-inhibitor or GLP-1 agonist
Vitamin D deficiency	Vitamin D3 supplementation (esp. GCC)
Influenza / pneumococcal	Annual vaccine in elderly ≥65

🚫 Beers Criteria (AGS 2023)

American Geriatrics Society criteria for Potentially Inappropriate Medications (PIMs) in adults ≥65.

Diphenhydramine — avoid in elderly (anticholinergic)
Meperidine / pethidine — neurotoxic in elderly, use alternatives
Digoxin >0.125 mg/day — narrow therapeutic index, toxicity risk
Glibenclamide (glyburide) — prolonged hypoglycaemia, prefer glipizide
Nifedipine short-acting — hypotension, MI risk
Muscle relaxants (carisoprodol) — CNS effects, falls
Sliding scale insulin — hypoglycaemia without benefit
Nitrofurantoin (CrCl <30) — ineffective and toxic

🧮 Anticholinergic Burden (ACB Score)

Cumulative anticholinergic drug burden. ACB score ≥3 associated with cognitive impairment and falls.

Score	Drug Examples
3	Amitriptyline, oxybutynin, chlorphenamine, promethazine
2	Carbamazepine, olanzapine, quetiapine
1	Furosemide, nifedipine, ranitidine, prednisolone

ACB Action

Total ACB ≥3: review and reduce. Replace oxybutynin with mirabegron for OAB. Replace amitriptyline with SSRI for depression in elderly.

🔻 Deprescribing Principles

Prioritise medications most likely to cause harm
Taper slowly — avoid withdrawal syndromes (opioids, benzodiazepines, beta-blockers, SSRIs)
Involve patient/family in shared decision-making
Use Medication Appropriateness Index (MAI)
Review at each admission — aim for least number of drugs
Document reason for stopping — aids future prescribers

NSAIDs in Elderly — Specific Warning

Renal: AKI risk — monitor creatinine in first 2 weeks
GI: Peptic ulcer / upper GI bleed — use with PPI if unavoidable
Cardiac: Fluid retention, hypertension, heart failure exacerbation
Cardiovascular: Diclofenac — highest CV risk among NSAIDs

Prefer paracetamol (1 g QDS) or topical NSAID for musculoskeletal pain in elderly.

⬇️ Falls-Causing Medications

Drug Class	Mechanism	Action
Sedatives / hypnotics (benzodiazepines, Z-drugs)	Sedation, slowed reaction time	Taper and stop; CBT-I for insomnia
Antihypertensives (esp. alpha-blockers)	Orthostatic hypotension	Postural BP check; reduce dose; review indication
Opioids (morphine, codeine)	Sedation, dizziness, constipation	Minimise dose; consider non-opioid alternatives
Diuretics (furosemide, thiazides)	Postural hypotension, electrolyte disturbance	Review dose; monitor U&E; educate on rising slowly
Antidepressants (TCAs, SSRIs)	Orthostatic hypotension, hyponatraemia	Prefer SSRI over TCA; monitor Na+
Antipsychotics	Sedation, parkinsonism, orthostasis	Minimise; use lowest dose; regular review
Antiepileptics (carbamazepine, valproate)	Sedation, ataxia, dizziness	Review levels; lowest effective dose

🏡 Social History Assessment

Key Social History Questions

Living situation: House, flat, single-story? Own or rented?
Lives alone or with others? (major safety factor)
Primary carer: Spouse, child, domestic worker, professional?
Carer availability: Hours per day, nights?
Informal support: Neighbours, friends, community?
Financial situation: Pension, savings, benefits eligible?
Driving: Still driving? Safety?
Hobbies and activities: Social engagement, isolation?
Recent bereavements or life stressors?

Living Alone — Risk Assessment

Living alone is an independent risk factor for adverse outcomes after acute illness. Nurse should assess:
• Who to contact in emergency?
• Can patient call for help if they fall?
• Medication compliance without supervision?
• Meals — ability to cook or access food?

GCC Cultural Strength

In GCC, family caregiving is a deeply embedded cultural and religious obligation. Adult children typically care for elderly parents at home. This is a protective factor — but can lead to carer burnout if unrecognised. Assess both patient and carer needs.

😓 Carer Burden — Zarit Scale

Zarit Burden Interview — 22-item scale (0–88) measuring subjective carer burden. Short version = 12 items.

0–20

Little or no burden

21–40

Mild to moderate burden — support needed

41–60

Moderate to severe burden — carer assessment, respite

61–88

Severe burden — urgent intervention, safeguarding concern

High Carer Burden — Actions

• Refer to social worker for carer support services
• Explore respite care options (day centre, short-term residential)
• Carer health assessment — carers often neglect own health
• Provide psychoeducation and coping strategies
• In GCC: consider live-in domestic worker support for family carers

🛡️ Safeguarding Vulnerable Adults

Signs of Elder Abuse / Neglect

Unexplained injuries, bruising, or pressure ulcers
Poor nutrition, dehydration, poor hygiene
Fear or anxiety around carer
Financial irregularities — missing funds, new will, undue influence
Social isolation — carer controlling contact
Delays in seeking medical care
Repeated A&E attendances or unusual injury patterns

Safeguarding Action

• Document findings with clinical objectivity
• Inform nurse in charge / senior clinician immediately
• Complete safeguarding referral per hospital policy
• Do NOT confront suspected abuser directly
• GCC: report to hospital social work, relevant authority (MOCCAE UAE, Ministry of Social Development)
• Patient privacy and dignity must be maintained throughout

🚪 Discharge Planning & Community Resources

Multidisciplinary Discharge Meeting Checklist

Functional status at discharge vs admission (Barthel comparison)
Home safety assessed by OT
Community support packages arranged before discharge
Medication reconciliation completed
Patient and carer education given
Follow-up appointments booked
GP or primary care informed (discharge summary)
Community nursing referral if wound care / medications needed

Community Resources & GCC Services

Day care centres — medical/social attendance, respite for carer
Meals on wheels / food delivery — limited in GCC, largely family provided
Home health nursing — available via DHA, SEHA, PHCC
Intermediate care / step-down — rehabilitation hospitals (e.g. Zayed Military, National Rehabilitation Centre Abu Dhabi)
Telehealth — expanding in KSA (Seha Virtual, MOH app) and UAE (NABIDH)
Elderly residential care — limited; Dar Al-Birr (Dubai), Elder Care (KSA emerging)

🌍 GCC Elderly Demography

Rapid Population Ageing

GCC nationals are ageing rapidly. UAE nationals aged ≥60 expected to reach 15% by 2030. Saudi Arabia has one of the world's fastest-growing elderly populations. Qatar, Kuwait, Bahrain, and Oman face similar trajectories due to improved healthcare and declining mortality.

Expat Elderly Workers

A distinct population: elderly migrant workers (particularly from South Asia) ageing in GCC without citizenship or social safety nets. May lack family support locally. Remittance dependency. High risk of financial exploitation and inadequate end-of-life care. Require culturally sensitive CGA.

Key GCC-Specific Risk Factors

Diabetes prevalence: UAE ~19%, KSA ~18% in adults — highest globally; drives nephropathy, neuropathy, retinopathy in elderly
Hypertension: ~40% prevalence in GCC elderly; poorly controlled
Obesity: Sedentary lifestyle contributes to sarcopenic obesity; functional decline accelerated
Vitamin D deficiency: Paradoxical in sunny region — indoor lifestyle, clothing coverage (abaya/thobe), sun avoidance; affects 70–80% of GCC adults
Frailty onset earlier than in Europe due to comorbidity burden and metabolic disease

☀️ Vitamin D Deficiency in GCC — Clinical Implications

Why Vitamin D Deficiency Occurs in GCC

Sun avoidance due to extreme heat (40–50°C summers)
Traditional clothing covering most skin surface area
Indoor sedentary lifestyle — shopping centres, AC
High melanin skin in South Asian and Arab populations reduces vitamin D synthesis
Low dietary sources (limited fortified foods)

Clinical Consequences in Elderly

• Osteoporosis — hip fracture risk
• Proximal muscle weakness — falls risk
• Impaired immune function
• Possible association with cognitive decline
• Worsens diabetic complications

Action: Check 25-OH vitamin D on all elderly GCC patients. Target ≥50 nmol/L. Supplement 2,000–4,000 IU/day vitamin D3.

🧠 Alzheimer's Disease in Arabic-Speaking Patients

Arabic MMSE validated for GCC populations — adjust cut-off for educational attainment
Illiteracy (more common in older generations) can falsely reduce MMSE score — use clock drawing or MoCA where appropriate
MoCA translated into Arabic (Standardised Arabic MoCA — SA-MoCA) at mocatest.org
Culturally sensitive neuropsychological testing: avoid items with Western cultural bias (e.g. "who is the prime minister")
GCC: use "Who is the ruler of [Emirate/Kingdom]?" for orientation questions
Family often the first to report memory concerns — take collateral history from family (محرم / guardian) routinely

Dementia Care in GCC

Alzheimer's Disease International estimates GCC dementia cases will triple by 2050. Memory clinics are developing in UAE (Cleveland Clinic Abu Dhabi, Rashid Hospital Memory Clinic) and KSA (King Faisal Specialist). Key challenge: stigma — families reluctant to label dementia publicly.

Nursing Role in Dementia

• Use simple Arabic phrases for communication
• Involve family in care activities
• Respect prayer times and religious rituals
• Prayer is a meaningful orientation anchor for Muslim patients
• Environment: familiar objects, Quran recitation (where appropriate)

🕌 End-of-Life Care & Islamic Principles

Family Decision-Making

In GCC, end-of-life decisions are predominantly family-led. The senior male family member (usually eldest son or husband) often acts as spokesperson. This is culturally normative and legally complex — ensure any decisions are documented and witnessed. Involve hospital chaplaincy / imam if requested.

Islamic Funeral Preparation

Families typically wish for Islamic funeral rites: ghusl (ritual washing), kafan (shrouding), and burial within 24 hours. Nursing staff should:
• Notify family immediately at time of death
• Avoid unnecessary post-mortem delays where possible
• Follow facility protocol for deceased Muslim patients
• Document patient's religious preferences on admission (RESPECT plan or equivalent)

Islamic Bioethics in Elderly Care

Sanctity of life (حُرمَة الحياة): Life is a trust from Allah — preserve and respect it
Beneficence: Treat with the intention of benefit
Non-maleficence: Excessive/futile treatment causing suffering may be withdrawn after family consensus and scholarly advice
Withdrawal of treatment: Permissible when futile, after Islamic scholar (fatwa) consultation in complex cases
Pain relief: Opioids for comfort in dying are permissible even if they may secondarily hasten death (doctrine of double effect accepted)
DNR discussions: Sensitive — involve family early; use culturally appropriate language

🏛️ National Ageing Strategies — UAE & Saudi Arabia

UAE

UAE National Policy for the Wellbeing of Senior Citizens — comprehensive rights-based framework
Federal Law No. 2 of 2019 concerning the Elderly — establishes rights, healthcare entitlement, transport discounts, priority queuing
Dubai Elderly Care Strategy — home care expansion, memory clinics
Abu Dhabi Department of Health — geriatric care pathway development
Dar Al-Birr Society — non-profit elderly residential care, Dubai
SEHA home health — nursing visits for elderly post-discharge

Saudi Arabia

Vision 2030 — Quality of Life Programme includes active ageing components
Ministry of Human Resources & Social Development — elderly welfare programs
Dar Al-Reaya (Elderly Care Homes) — government-run, limited capacity
SCFHS geriatric medicine subspecialty fellowship expanding
National Dementia Plan in development (MOH KSA)
Family Responsibility Law — adult children legally responsible for elderly parents

Other GCC Countries

Qatar: Ministry of Public Health Elderly Policy, Hamad Medical Corporation geriatric unit, QCHP-regulated nurses.
Oman: MOH Oman National Strategy on Ageing, OMSB geriatric nursing competencies.
Kuwait: MOH Kuwait elderly outreach programmes, Razi Hospital geriatric department.
Bahrain: NHRA regulates elderly care standards, Salmaniya Medical Complex geriatric ward.