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Comprehensive geriatric assessment

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Medical evaluation Medical diagnostic method
Comprehensive geriatric assessment
Synonymsmultidimensional geriatric assessment
Purposeassess health in older patients

Comprehensive geriatric assessment (CGA) is a process used by healthcare practitioners to assess the status of older people who might have frailty in order to optimize their subsequent management. These people often have complex, multiple and interdependent problems (multimorbidity) which make their care more challenging than in younger people, or those with just one medical problem. CGA is the core work of specialists in the care of older people, although many other health care practitioners either have not heard of it, or are not aware of what it actually is.

Older people who receive CGA upon admission to a hospital are more likely to be alive and be back in their own homes during their next follow-up.

History

Geriatricians have focused on holistic assessments of their patients since the early days of the specialty. Dr. Marjorie Warren was the first doctor in the UK to systematically assess older people, categorizing them into those who could be got better with appropriate treatment and then discharged, and those who needed continuing (usually institutional) care. Over the past 30 years, CGA has evolved greatly, becoming much more explicit and better defined, and it has been implemented in a number of ways.

One of the first formal models was the orthogeriatrics service set up in Hastings in the 1960s. The collaboration between Devas, an orthopaedic surgeon, and Irvine, a geriatrician, laid the foundation for a template for managing orthopaedic problems in older patients with concurrent medical problems. Subsequent collaborative models between geriatricians and other specialists have been described, for example managing cancer in people who are older and frail. In acute medicine the involvement of early CGA has been shown to reduce length of stay and improve management of people over the age of 70.

Rationale

Two thirds of older people have two or more long-term medical problems (multimorbidity). This makes determining the cause of any deterioration more difficult, and thus deciding the best treatment plan is also challenging, since it depends on accurately diagnosing the underlying medical problem. CGA is a systematic approach to identifying the problems that are limiting a person's ability to thrive and make the most of their life, in order to try to remedy as many of the problems as possible. The aim is to maximize quality of life.

Assessment domains

  • Physical health issues (e.g. heart failure, osteoarthritis)
  • Mental health issues (e.g. depression, vascular dementia)
  • Functional issues (e.g. unable to shower herself, or do shopping)
  • Social issues (e.g. lives alone, only child lives 200 miles away)
  • Environmental issues (e.g. many rugs in the house , only heating is coal fire)

Each of these domains is assessed (where possible using validated and reliable instruments and then a list of problems is compiled in the patient's record. This potentially allows solutions to be identified for each of the identified problems. However, it is not a simple tick box exercise, but depends to some extent on the expertise of the clinicians involved.

The various members of the geriatric medicine multidisciplinary team (MDT) assess different domains. The physician (usually a geriatrician or GP) assesses physical and mental health; the pharmacist may undertake a medication review (deprescribing; the nurse assesses various aspects of personal care (for example skin integrity and continence); the physiotherapist, balance and mobility; the occupational therapist, activities of daily living; and the social worker, social aspects of the case. Other paramedical health care professionals may be involved as needed, on a case by case basis - for example a speech and language therapist if there are concerns about language or swallowing, a dietician if there are concerns about nutrition, and so on.

Usually, the MDT meet regularly to integrate the information from the various assessments in order to formulate a list of problems and potential solutions. Then, recommendations about how to proceed can be explained to the older person (and to relatives or close friends, if the person wishes) to see what their preferences are. Since the person's condition may change over time, the process is iterative, working towards a final management plan. In the case of hospital in-patients the aim is to devise a robust discharge plan.

Benefits

CGA has been shown to be useful for treating people who are hospitalized, in care homes, in case management (in the U.S.), in cancer treatment for older people, and in primary care (i.e. in the general community). However there is a relative lack of geriatricians with the training and expertise to contribute to a CGA, therefore, a significant proportion of people who are older and frail and who may benefit from CGA do not have access to it.

The use of CGA improves the medical outcomes for older people. For example, people who undergo CGA upon admission to a hospital are more likely to be alive and remain in their own home (and less likely to be admitted to a nursing home) up to a year after discharge from hospital when compared with people who received standard medical treatment.

CGAs for older people with frailty who do not live in a long-term care institution could improve medication adherence, patient functioning, quality of care, and reduce the risk of unplanned hospital admissions. At the same time CGA for this demographic seems to have no impact on death or nursing home admissions.

When used in primary care, CGA can lead to an improved adherence to medication modifications and may also have a positive effect on outcomes with respect to functional status, social activity, satisfaction with life and health, and mood.

References

  1. ^ Welsh, T. J.; Gordon, A. L.; Gladman, J. R. (2014). "Comprehensive geriatric assessment - a guide for the non-specialist". International Journal of Clinical Practice. 68 (3): 290–293. doi:10.1111/ijcp.12313. PMC 4282277. PMID 24118661.
  2. ^ "Comprehensive geriatric assessment for older adults admitted to hospital", Cochrane, 12 September 2017. Retrieved 4 October 2018.
  3. ^ Arakelyan, Stella; Mikula-Noble, Nataysia; Ho, Leonard; Lone, Nazir; Anand, Atul; Lyall, Marcus J; Mercer, Stewart W; Guthrie, Bruce (November 2023). "Effectiveness of holistic assessment-based interventions for adults with multiple long-term conditions and frailty: an umbrella review of systematic reviews". The Lancet Healthy Longevity. 4 (11): e629 – e644. doi:10.1016/S2666-7568(23)00190-3. PMID 37924844.
  4. ^ Barton, A. (2003). "History of the development of geriatric medicine in the UK". Postgraduate Medical Journal. 79 (930): 229–234. doi:10.1136/pmj.79.930.229. PMC 1742667. PMID 12743345.
  5. Devas, Michael (1974). "Geriatric orthopaedics". Br Med J. 1 (5900): 190–192. doi:10.1136/bmj.1.5900.190. PMC 1633029. PMID 4811849.
  6. Caillet, Philippe; Laurent, Marie; Bastuji-Garin, Sylvie; Liuu, Evelyne; Culine, Stephane; Lagrange, Jean-Leon; Canoui-Poitrine, Florence; Paillaud, Elena (2014). "Optimal management of elderly cancer patients: usefulness of the Comprehensive Geriatric Assessment". Clin Interv Aging. 9: 1645–1660. doi:10.2147/CIA.S57849. PMC 4189720. PMID 25302022.
  7. Harari, D.; Martin, F. C.; Buttery, A.; O'Neill, S.; Hopper, A. (2007). "The older persons' assessment and liaison team 'OPAL': Evaluation of comprehensive geriatric assessment in acute medical inpatients". Age and Ageing. 36 (6): 670–675. doi:10.1093/ageing/afm089. PMID 17656421.
  8. "Multimorbidity – the biggest clinical challenge facing the NHS?", NHS England, 25 November 2016. Retrieved 4 October 2018.
  9. Pilotti, Alberto; Panza, Francesco (2018). "Comprehensive geriatric assessment: evidence". In Michel, J-P; Beattie, BL; Martin, FC; Walston, JD (eds.). Oxford Textbook of Geriatric Medicine. Oxford: Oxford University Press. p. 117. ISBN 9780198701590.
  10. Rubenstein, Laurence; Rubenstein, Lisa (2017). "Multidimensional Geriatric Assessment". Brocklehurst's Textbook of Geriatric Medicine and Gerontology (8th ed.). Philadelphia: Elsevier. p. 216. ISBN 9780702061851.
  11. Busby-Whitehead, J; Arenson, C; Reichel, W, eds. (2017). Reichel's care of the elderly : clinical aspects of aging (Seventh ed.). Cambridge, UK: Cambridge University Press. p. 28. ISBN 9781107054943.
  12. "Does Comprehensive Geriatric Assessment have a role in Care Homes?", Gordon, Adam L. PhD Thesis. 2012. Retrieved 9 October 2018.
  13. "Practice Guideline: Comprehensive Geriatric Assessment (CGA) in oncological patients" (PDF). International Society of Geriatric Oncology. Retrieved 25 November 2018.
  14. "Comprehensive Geriatric Assessment Toolkit for Primary Care Practitioners", BGS, 4 February 2016. Retrieved 9 October 2018.
  15. "Comprehensive Geriatric Assessment Position Statement", American Geriatrics Society, 5 September 2008. Retrieved 9 October 2018.
  16. Ellis, Graham; Gardner, Mike; Tsiachristas, Apostolos; Langhorne, Peter; Burke, Orlaith; Harwood, Rowan H; Conroy, Simon P; Kircher, Tilo; Somme, Dominique; Saltvedt, Ingvild; Wald, Heidi; O'Neill, Desmond; Robinson, David; Shepperd, Sasha (2017-09-12). Cochrane Effective Practice and Organisation of Care Group (ed.). "Comprehensive geriatric assessment for older adults admitted to hospital". Cochrane Database of Systematic Reviews. 2017 (9). doi:10.1002/14651858.CD006211.pub3. PMC 6484374. PMID 28898390.
  17. ^ Briggs, Robert; McDonough, Anna; Ellis, Graham; Bennett, Kathleen; O'Neill, Desmond; Robinson, David (2022-05-06). Cochrane Effective Practice and Organisation of Care Group (ed.). "Comprehensive Geriatric Assessment for community-dwelling, high-risk, frail, older people". Cochrane Database of Systematic Reviews. 2022 (5). doi:10.1002/14651858.CD012705.pub2. PMC 9074104. PMID 35521829.
  18. Imison, Candace (24 October 2024). "Frailty: research shows how to improve care". NIHR Evidence. National Institute for Health and Care Research. doi:10.3310/nihrevidence_64717.
  19. Garrard, James W.; Cox, Natalie J.; Dodds, Richard M.; Roberts, Helen C.; Sayer, Avan A. (1 February 2020). "Comprehensive geriatric assessment in primary care: a systematic review". Aging Clinical and Experimental Research. 32 (2): 197–205. doi:10.1007/s40520-019-01183-w. PMC 7033083. PMID 30968287. S2CID 106409868.
  20. Busby-Whitehead, J; Arenson, C; Reichel, W, eds. (2017). Reichel's care of the elderly : clinical aspects of aging (Seventh ed.). Cambridge, UK: Cambridge University Press. p. 29. ISBN 9781107054943.

Further reading

  • Michel J-P, Beattie BL, Martin FC, Walston J. (eds) (2017, 3rd ed.). Oxford Textbook of Geriatric Medicine OUP Oxford. ISBN 9780198701590 (chapters 16 - Comprehensive Geriatric Assessment: Evidence, & 17 - Comprehensive Geriatric Assessment: The Specific Assessment Technology of InterRAI)
  • Sinclair AJ, Morley JE, Vellas B. (eds) (2012, 5th ed.) Pathy's Principles and Practice of Geriatric Medicine ISBN 9780470683934 (chapter 112 - Multidimensional Geriatric Assessment)
  • Fillit HM, and Rockwood K, Young JB. (eds) (2016, 8th ed.) Brocklehurst's Textbook of Geriatric Medicine and Gerontology ISBN 9780702061851 (chapters 34 - Multidimensional Geriatric Assessment, & 38 - Measuring Outcomes of Multidimensional Geriatric Assessment Programs)
  • Busby-Whitehead J, Arenson C, Reichel W. (eds) (2016, 7th ed) Reichel's Care of the Elderly ISBN 9781107054943 (chapter 3 - Comprehensive Geriatric Assessment)
  • Woodford H, George J. (2013, 1st ed.) Acute Medicine in the Frail Elderly ISBN 9781908911582 (p 41 - Comprehensive Geriatric Assessment)

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