Comprehensive geriatric assessment


Comprehensive geriatric assessment 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 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

s 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 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

Each of these domains is assessed assess different domains. The physician assesses physical and mental health; the pharmacist may undertake a medication review ; 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 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 cancer treatment for older people, and in primary care. 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 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, 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.