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 Multimorbidity, also known as multiple long-term conditions (MLTC), means living with two or more chronic illnesses. For example, a person could have diabetes, heart disease and Depression (mood), depression at the same time. Multimorbidity can h ...

) 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."Comprehensive geriatric assessment for older adults admitted to hospital"
Cochrane, 12 September 2017. Retrieved 4 October 2018.

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 Orthopedic surgery or orthopedics ( alternative spelling orthopaedics) is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal ...

, 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 Acute medicine, also known as acute internal medicine (AIM), is a specialty within internal medicine concerned with the immediate and early specialist management of adult patients with a wide range of medical conditions who present in hospital as em ...

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 Heart failure (HF), also known as congestive heart failure (CHF), is a syndrome caused by an impairment in the heart's ability to Cardiac cycle, fill with and pump blood. Although symptoms vary based on which side of the heart is affected, HF ...

osteoarthritis Osteoarthritis is a type of degenerative joint disease that results from breakdown of articular cartilage, joint cartilage and underlying bone. A form of arthritis, it is believed to be the fourth leading cause of disability in the world, affect ...

) * Mental health issues (e.g. depression,

vascular dementia Vascular dementia is dementia caused by a series of strokes. Restricted blood flow due to strokes reduces oxygen and glucose delivery to the brain, causing cell injury and neurological deficits in the affected region. Subtypes of vascular dement ...

) * 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 rip risk 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 A physician, medical practitioner (British English), medical doctor, or simply doctor is a health professional who practices medicine, which is concerned with promoting, maintaining or restoring health through the Medical education, study, Med ...

(usually a geriatrician or GP) assesses physical and mental health; the

pharmacist A pharmacist, also known as a chemist in English in the Commonwealth of Nations, Commonwealth English, is a healthcare professional who is knowledgeable about preparation, mechanism of action, clinical usage and legislation of medications in ...

may undertake a medication review (

deprescribing Deprescribing is a process of tapering or stopping medications to achieve improved health outcomes by reducing exposure to medications that are potentially either harmful or no longer required. Deprescribing is important to consider with changing ...

; the

nurse Nursing is a health care profession that "integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alle ...

assesses various aspects of personal care (for example skin integrity and continence); the

physiotherapist Physical therapy (PT), also known as physiotherapy, is a healthcare profession, as well as the care provided by physical therapists who promote, maintain, or restore health through patient education, physical intervention, disease preventio ...

, balance and mobility; the

occupational therapist Occupational therapists (OTs) are health care professionals specializing in occupational therapy and occupational science. OTs and occupational therapy assistants (OTAs) use evidence-based practice, scientific bases and a Holism, holistic perspec ...

activities of daily living Activities of daily living (ADLs) is a term used in healthcare to refer to an individual's daily self-care activities. Health professionals often use a person's ability or inability to perform ADLs as a measure of their Performance status, functi ...

; and the

social worker Social work is an academic discipline and practice-based profession concerned with meeting the basic needs of individuals, families, groups, communities, and society as a whole to enhance their individual and collective well-being. Social wo ...

, 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 Speech is the use of the human voice as a medium for language. Spoken language combines vowel and consonant sounds to form units of meaning like words, which belong to a language's lexicon. There are many different intentional speech acts, suc ...

if there are concerns about language or swallowing, a

dietician A dietitian, medical dietitian, or dietician is an expert in identifying and treating disease-related malnutrition and in conducting medical nutrition therapy, for example designing an enteral tube feeding regimen or mitigating the effects of ...

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. Older people with moderate or severe frailty who are admitted to a hospital due to an unexpected emergency have an increased risk of a prolonged

length of stay Length of stay (LOS) is the duration of a single episode of hospitalization. patient, Inpatient days are calculated by subtracting day of admission from day of :wikt:discharge, discharge. Analysis A common statistic associated with length of stay ...

, death, and being discharged to a place other than their home. However, those who undergo a CGA on admission are more likely to survive and be discharged to their homes. 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

External links