Comprehensive geriatric assessment

Medical evaluation Medical diagnostic method

Comprehensive geriatric assessment
Purpose	assess health in older patients

Comprehensive geriatric assessment (CGA) is a process used by healthcare practitioners to assess the status of people who are frail and older 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. It is also called "multidimensional geriatric assessment."

The use of CGA improves the outcomes for people who are older and frail. For example, people who undergo CGA whilst in hospital are more likely to 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.

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. 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.

Evidence for its benefit

A Cochrane systematic review of studies looking at CGA found 29 relevant randomized controlled trials done in nine countries. They included a total of 13,766 people over 65 who were admitted to hospital, and compared CGA with routine care. This provides a fairly powerful body of evidence on which to base clinical practice, and is the basis for National Institute for Health and Care Excellence (NICE) recommending its use in older people with complex needs admitted to hospital. It is widely accepted that CGA provides the benefits cited in the introduction above, except for people who are too well, or too frail. There is also evidence of its benefit with respect to functional status, social activity, satisfaction with life and health, and mood when used in primary care. However, the evidence for its use in the community was low quality, and the NICE recommended further research in specific groups of people, before making strong recommendations for its use. A subsequent systematic review of its use in primary care showed mixed results, with improved adherence to medication modifications, but no survival or functional outcome benefits, although interventions were acceptable and potentially cost-effective.

Areas in which it is used

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). 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.

References

^ 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.
Rubenstein, Laurence Z.; Stuck, Andreas E. (2012). "Multidimensional Geriatric Assessment". Pathy's Principles and Practice of Geriatric Medicine. pp. 1375–1386. doi:10.1002/9781119952930.ch112. ISBN 9781119952930. S2CID 196340690.
^ "Comprehensive geriatric assessment for older adults admitted to hospital", Cochrane, 12 September 2017. Retrieved 4 October 2018.
^ 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.
Devas, Michael (1974). "Geriatric orthopaedics". Br Med J. 1 (5900): 190–192. doi:10.1136/bmj.1.5900.190. PMC 1633029. PMID 4811849.
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.
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.
"Multimorbidity – the biggest clinical challenge facing the NHS?", NHS England, 25 November 2016. Retrieved 4 October 2018.
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.
Rubenstein, Laurence; Rubenstein, Lisa (2017). "Multidimensional Geriatric Assessment". Brocklehurst's Textbook of Geriatric Medicine and Gerontology (8th ed.). Philadelphia: Elsevier. p. 216. ISBN 9780702061851.
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.
"Multimorbidity: clinical assessment and management | Guidance and guidelines". NICE. 21 September 2016. Retrieved 25 November 2018.
^ 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.
"Multimorbidity: clinical assessment and management". NICE. Retrieved 25 November 2018.
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.
"Does Comprehensive Geriatric Assessment have a role in Care Homes?", Gordon, Adam L. PhD Thesis. 2012. Retrieved 9 October 2018.
"Practice Guideline: Comprehensive Geriatric Assessment (CGA) in oncological patients" (PDF). International Society of Geriatric Oncology. Retrieved 25 November 2018.
"Comprehensive Geriatric Assessment Toolkit for Primary Care Practitioners", BGS, 4 February 2016. Retrieved 9 October 2018.
"Comprehensive Geriatric Assessment Position Statement", American Geriatrics Society, 5 September 2008. Retrieved 9 October 2018.

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