Comprehensive geriatric assessment

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Comprehensive geriatric assessment
Synonyms multidimensional geriatric assessment, geriatric evaluation management and treatment, comprehensive older age 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. [1]

Contents

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. [2] [3]

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. [4] 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. [5] 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. [4] Subsequent collaborative models between geriatricians and other specialists have been described, for example managing cancer in people who are older and frail. [6] 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. [7]

Rationale

Two thirds of older people have two or more long-term medical problems (multimorbidity). [8] 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. [9]

Assessment domains

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. [10] 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. [11] 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, [2] in care homes, [12] in case management (in the U.S.), [1] in cancer treatment for older people, [13] and in primary care (i.e. in the general community). [14] 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. [15]

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. [2] [3] [16]

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. [3] [17] At the same time CGA for this demographic seems to have no impact on death or nursing home admissions. [17] [18]

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. [19] [20] However, those who undergo a CGA on admission are more likely to survive and be discharged to their homes. [21] [22]

When used in primary care, CGA can lead to an improved adherence to medication modifications [23] and may also have a positive effect on outcomes with respect to functional status, social activity, satisfaction with life and health, and mood. [24]

Related Research Articles

Evidence-based medicine (EBM) is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. ... [It] means integrating individual clinical expertise with the best available external clinical evidence from systematic research." The aim of EBM is to integrate the experience of the clinician, the values of the patient, and the best available scientific information to guide decision-making about clinical management. The term was originally used to describe an approach to teaching the practice of medicine and improving decisions by individual physicians about individual patients.

<span class="mw-page-title-main">Dementia</span> Long-term brain disorders causing impaired memory, thinking and behavior

Dementia is a syndrome associated with many neurodegenerative diseases, characterized by a general decline in cognitive abilities that affects a person's ability to perform everyday activities. This typically involves problems with memory, thinking, behavior, and motor control. Aside from memory impairment and a disruption in thought patterns, the most common symptoms of dementia include emotional problems, difficulties with language, and decreased motivation. The symptoms may be described as occurring in a continuum over several stages. Dementia ultimately has a significant effect on the individual, their caregivers, and their social relationships in general. A diagnosis of dementia requires the observation of a change from a person's usual mental functioning and a greater cognitive decline than might be caused by the normal aging process.

<span class="mw-page-title-main">Pneumonia</span> Inflammation of the alveoli of the lungs

Pneumonia is an inflammatory condition of the lung primarily affecting the small air sacs known as alveoli. Symptoms typically include some combination of productive or dry cough, chest pain, fever, and difficulty breathing. The severity of the condition is variable.

Delirium is a specific state of acute confusion attributable to the direct physiological consequence of a medical condition, effects of a psychoactive substance, or multiple causes, which usually develops over the course of hours to days. As a syndrome, delirium presents with disturbances in attention, awareness, and higher-order cognition. People with delirium may experience other neuropsychiatric disturbances including changes in psychomotor activity, disrupted sleep-wake cycle, emotional disturbances, disturbances of consciousness, or, altered state of consciousness, as well as perceptual disturbances, although these features are not required for diagnosis.

In medicine, comorbidity refers to the simultaneous presence of two or more medical conditions in a patient; often co-occurring with a primary condition. It originates from the Latin term morbus prefixed with co- ("together") and suffixed with -ity. Comorbidity includes all additional ailments a patient may experience alongside their primary diagnosis, which can be either physiological or psychological in nature. In the context of mental health, comorbidity frequently refers to the concurrent existence of mental disorders, for example, the co-occurrence of depressive and anxiety disorders. The concept of multimorbidity is related to comorbidity but is different in its definition and approach, focusing on the presence of multiple diseases or conditions in a patient without the need to specify one as primary.

Palliative care is an interdisciplinary medical caregiving approach aimed at optimising quality of life and mitigating or reducing suffering among people with serious, complex, and often terminal illnesses. Within the published literature, many definitions of palliative care exist.

<span class="mw-page-title-main">Geriatrics</span> Specialty that focuses on health care of elderly people

Geriatrics, or geriatric medicine, is a medical specialty focused on providing care for the unique health needs of the elderly. The term geriatrics originates from the Greek γέρων geron meaning "old man", and ιατρός iatros meaning "healer". It aims to promote health by preventing, diagnosing and treating disease in older adults. There is no defined age at which patients may be under the care of a geriatrician, or geriatric physician, a physician who specializes in the care of older people. Rather, this decision is guided by individual patient need and the caregiving structures available to them. This care may benefit those who are managing multiple chronic conditions or experiencing significant age-related complications that threaten quality of daily life. Geriatric care may be indicated if caregiving responsibilities become increasingly stressful or medically complex for family and caregivers to manage independently.

<span class="mw-page-title-main">Polypharmacy</span> Use of five or more medications daily

Polypharmacy (polypragmasia) is an umbrella term to describe the simultaneous use of multiple medicines by a patient for their conditions. The term polypharmacy is often defined as regularly taking five or more medicines but there is no standard definition and the term has also been used in the context of when a person is prescribed 2 or more medications at the same time. Polypharmacy may be the consequence of having multiple long-term conditions, also known as multimorbidity and is more common in people who are older. In some cases, an excessive number of medications at the same time is worrisome, especially for people who are older with many chronic health conditions, because this increases the risk of an adverse event in that population. In many cases, polypharmacy cannot be avoided, but 'appropriate polypharmacy' practices are encouraged to decrease the risk of adverse effects. Appropriate polypharmacy is defined as the practice of prescribing for a person who has multiple conditions or complex health needs by ensuring that medications prescribed are optimized and follow 'best evidence' practices.

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 at the same time. Multimorbidity can have a significant impact on people's health and wellbeing. It also poses a complex challenge to healthcare systems which are traditionally focused on individual diseases. Multiple long-term conditions can affect people of any age, but they are more common in older age, affecting more than half of people over 65 years old.

<span class="mw-page-title-main">Frailty syndrome</span> Weakness in elderly person

Frailty or frailty syndrome refers to a state of health in which older adults gradually lose their bodies' in-built reserves and functioning. This makes them more vulnerable, less able to recover and even apparently minor events can have drastic impacts on their physical and mental health.

As populations age, caring for people with dementia has become more common. Elderly caregiving may consist of formal care and informal care. Formal care involves the services of community and medical partners, while informal care involves the support of family, friends, and local communities. In most mild-to-medium cases of dementia, the caregiver is a spouse or an adult child. Over a period of time, more professional care in the form of nursing and other supportive care may be required medically, whether at home or in a long-term care facility. There is evidence to show that case management can improve care for individuals with dementia and the experience of their caregivers. Furthermore, case management may reduce overall costs and institutional care in the medium term. Millions of people living in the United States take care of a friend or family member with Alzheimer’s disease or a related dementia.

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<span class="mw-page-title-main">Falls in older adults</span> Age-related health problem

Falls in older adults are a significant cause of morbidity and mortality and are a major class of preventable injuries. Falling is one of the most common accidents that cause a loss in the quality of life for older adults, and is usually precipitated by a loss of balance and weakness in the legs. The cause of falling in old age is often multifactorial and may require a multidisciplinary approach both to treat any injuries sustained and to prevent future falls. Falls include dropping from a standing position or from exposed positions such as those on ladders or stepladders. The severity of injury is generally related to the height of the fall. The state of the ground surface onto which the victim falls is also important, harder surfaces causing more severe injury. Falls can be prevented by ensuring that carpets are tacked down, that objects like electric cords are not in one's path, that hearing and vision are optimized, dizziness is minimized, alcohol intake is moderated and that shoes have low heels or rubber soles.

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<span class="mw-page-title-main">Deprescribing</span> Process to taper or stop medications

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 health and care goals over time, as well as polypharmacy and adverse effects. Deprescribing can improve adherence, cost, and health outcomes but may have adverse drug withdrawal effects. More specifically, deprescribing is the planned and supervised process of intentionally stopping a medication or reducing its dose to improve the person's health or reduce the risk of adverse side effects. Deprescribing is usually done because the drug may be causing harm, may no longer be helping the patient, or may be inappropriate for the individual patient's current situation. Deprescribing can help correct polypharmacy and prescription cascade.

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References

  1. 1 2 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. 1 2 3 "Comprehensive geriatric assessment for older adults admitted to hospital", Cochrane, 12 September 2017. Retrieved 4 October 2018.
  3. 1 2 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. hdl: 20.500.11820/26646baa-3aa1-4b09-bffb-d8bce4632bdc . PMID   37924844.
  4. 1 2 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. 1 2 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. ↑ Boucher, Emily L.; Gan, Jasmine M.; Rothwell, Peter M.; Shepperd, Sasha; Pendlebury, Sarah T. (21 April 2023). "Prevalence and outcomes of frailty in unplanned hospital admissions: a systematic review and meta-analysis of hospital-wide and general (internal) medicine cohorts". eClinicalMedicine. 59: 101947. doi:10.1016/j.eclinm.2023.101947. PMC   10149337 . PMID   37138587.
  20. ↑ 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.
  21. ↑ Gardner, Mike; Shepperd, Sasha; Godfrey, Mary; Mäkelä, Petra; Tsiachristas, Apostolos; Singh-Mehta, Amina; Ellis, Graham; Khanna, Pradeep; Langhorne, Peter; Makin, Stephen; Stott, David J (March 2019). "Comprehensive Geriatric Assessment in hospital and hospital-at-home settings: a mixed-methods study". Health Services and Delivery Research. 7 (10): 1–206. doi:10.3310/hsdr07100. ISSN   2050-4349.
  22. ↑ Conroy, Simon Paul; Bardsley, Martin; Smith, Paul; Neuburger, Jenny; Keeble, Eilís; Arora, Sandeepa; Kraindler, Joshua; Ariti, Cono; Sherlaw-Johnson, Chris; Street, Andrew; Roberts, Helen; Kennedy, Sheila; Martin, Graham; Phelps, Kay; Regen, Emma (April 2019). "Comprehensive geriatric assessment for frail older people in acute hospitals: the HoW-CGA mixed-methods study". Health Services and Delivery Research. 7 (15): 1–174. doi:10.3310/hsdr07150. ISSN   2050-4349.
  23. ↑ 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.
  24. ↑ 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.

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