Comprehensive geriatric assessment

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Comprehensive geriatric assessment
Purposeassess 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. [1] It is also called "multidimensional geriatric assessment." [2]

Contents

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. [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. [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.

Evidence for its benefit

A Cochrane systematic review of studies looking at CGA found 29 relevant randomized controlled trials done in nine countries. [3] They included a total of 13,766 people over 65 who were admitted to hospital, and compared CGA with routine care. [3] 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. [12] It is widely accepted that CGA provides the benefits cited in the introduction above, except for people who are too well, or too frail. [13] 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. [13] 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. [14] 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. [15]

Areas in which it is used

CGA has been shown to be useful for treating people who are hospitalized, [3] in care homes, [16] in case management (in the U.S.), [1] in cancer treatment for older people, [17] and in primary care (i.e. in the general community). [18] 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. [19]

Related Research Articles

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.

<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.

Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides. Vitals and EKG's may be delegated to certified nurses aides or nursing techs. It differs from a medical diagnosis. In some instances, the nursing assessment is very broad in scope and in other cases it may focus on one body system or mental health. Nursing assessment is used to identify current and future patient care needs. It incorporates the recognition of normal versus abnormal body physiology. Prompt recognition of pertinent changes along with the skill of critical thinking allows the nurse to identify and prioritize appropriate interventions. An assessment format may already be in place to be used at specific facilities and in specific circumstances.

<span class="mw-page-title-main">Gerontological nursing</span> Specialty of nursing pertaining to older adults

Gerontological nursing is the specialty of nursing pertaining to older adults. Gerontological nurses work in collaboration with older adults, their families, and communities to support healthy aging, maximum functioning, and quality of life. The term gerontological nursing, which replaced the term geriatric nursing in the 1970s, is seen as being more consistent with the specialty's broader focus on health and wellness, in addition to illness.

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

Frailty is a common and clinically significant grouping of symptoms that occurs in aging and older adults. These symptoms can include decreased physical abilities such as walking, excessive fatigue, and weight and muscle loss leading to declined physical status. In addition, frailty encompasses a decline in both overall physical function and physiologic reserve of organ systems resulting in worse health outcomes for this population. This syndrome is associated with increased risk of heart disease, falls, hospitalization, and death. In addition, it has been shown that adults living with frailty face more anxiety and depression symptoms than those who do not. The presence of frailty varies based on the assessment technique, however it is estimated that 4-16% of the population over 65 years old is living with frailty.

Geriatric medicine, as a speciality, was introduced in Egypt in 1982, and in 1984 a geriatrics and gerontology unit in Ain Shams University Faculty of Medicine was established.

Geriatric oncology is a branch of medicine that is concerned with the diagnosis and treatment of cancer in the elderly, usually defined as aged 65 and older. This fairly young but increasingly important subspecialty incorporates the special needs of the elderly into the treatment of cancer.

Geriatric anesthesia is the branch of medicine that studies anesthesia approach in elderly.

<span class="mw-page-title-main">British Geriatrics Society</span>

The British Geriatrics Society (BGS) is the professional body of specialists in the healthcare of older people in the United Kingdom. Membership is drawn from doctors, nurses, allied health professionals, researchers and others working in the field of geriatric medicine with a particular interest in improving healthcare for older people. It has over 4,000 members worldwide and is the only Society in the UK which draws together experts from all the relevant disciplines in the field. The current President is Professor Adam Gordon.

Guided Care is a model of proactive, comprehensive health care for people with several chronic conditions. A form of medical home, the model has been developed and tested by a multidisciplinary team of experts at the Roger C. Lipitz Center for Integrated Health Care in the Johns Hopkins Bloomberg School of Public Health. Guided Care is provided by physician-nurse teams in primary care practices to the physicians' most complex patients, mainly older adults with chronic conditions and complicated health needs. It is designed to increase patients' quality of care and quality of life, while improving the efficiency of their use of health care resources, thus reducing their overall health care costs.

Albert Siu is a Cuban American internist and geriatrician and the Ellen and Howard C. Katz Chairman and Professor of the Brookdale Department of Geriatrics and Palliative Medicine at Mount Sinai Hospital in New York City. He is also the director of the Geriatric Research, Education, and Clinical Center at the James J. Peters VA Medical Center in The Bronx, a senior associate editor of Health Services Research, a senior fellow of the Brookdale Foundation and a former trustee of the Nathan Cummings Foundation.

James Lister Newman was a New Zealand geriatrician and advocate for the elderly, a medical superintendent at Cornwall and Green Lane Hospitals in Auckland, and writer of the Family Doctor column in The New Zealand Herald.

<span class="mw-page-title-main">Herzog Hospital</span> Hospital in West Jerusalem

Herzog Hospital is a geriatric-psychiatric hospital in West Jerusalem. It is the third largest hospital in the city. Herzog Hospital specializes in nursing care for the elderly. The director-general of the hospital is Jacob Haviv.

The John A. Hartford Foundation is a private United States–based philanthropy whose current mission is to improve the care of older adults. For many years, it made grants for research and education in geriatric medicine, nursing and social work. It now focuses on three priority areas: creating age-friendly health systems, supporting family caregivers and improving serious illness, and end-of-life care.

David Oliver is a British physician specialising in the geriatric medicine and acute general internal medicine. He was President of the British Geriatrics Society from 2014 to 2016. He is Visiting Professor of Medicine for Older People in the School of Community and Health Sciences at City University London and a King's Fund Senior Visiting Fellow. He was formerly the UK Department of Health National Clinical Director for Older People's Services from 2009 to 2013. He is a researcher, writer, teacher and lecturer on services for older people and a regular blogger, columnist and media commentator. He was elected as Clinical Vice President of the Royal College of Physicians, London. In April 2022 he was elected as president of the Royal College of Physicians but withdrew in July 2022 after he had contracted Covid 19 and "no longer felt able to do it justice".

<span class="mw-page-title-main">Marjory Warren</span>

Marjory Winsome Warren is one of the first geriatricians and considered the mother of modern geriatric medicine.

A day hospital is an outpatient facility where patients attend for assessment, treatment or rehabilitation during the day and then return home or spend the night at a different facility. Day hospitals are becoming a new trend in healthcare. The number of surgical procedures carried out on a same-day basis has markedly increased in EU countries and USA. New medical technologies such as less invasive surgeries and better anesthetics have made this development possible. These innovations improve patient safety and health outcomes. Shortening the length of stay in hospital reduces the cost per intervention and increases the number of procedures performed. Less hospital beds are necessary, and they are often replaced by day hospital chairs that enable admission and preparation of the patient before surgery and recovery after surgery.

Goal-oriented health care, also known as goal-directed health care, goal-oriented medical care, and patient priorities care, is a form of health care delivery that is based on achieving individualized goals that are created through collaborative conversations between patients and providers in health care settings. It is a form of Patient Centered Care/Person-Centered Care as the goals are unique to the individual patient and direct the plan of care. This is in contrast to problem-oriented or disease-driven care where the focus is on correcting biological abnormalities. This philosophy of practice is become attractive in the medical community especially in primary care practices worldwide.

Paula Ann Rochon is a Canadian geriatrician. She is the Retired Teachers of Ontario/ERO Chair in Geriatric Medicine at the University of Toronto.

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. ↑ 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.
  3. 1 2 3 4 "Comprehensive geriatric assessment for older adults admitted to hospital", Cochrane, 12 September 2017. Retrieved 4 October 2018.
  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. ↑ "Multimorbidity: clinical assessment and management | Guidance and guidelines". NICE. 21 September 2016. Retrieved 25 November 2018.
  13. 1 2 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.
  14. ↑ "Multimorbidity: clinical assessment and management". NICE. Retrieved 25 November 2018.
  15. ↑ 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.
  16. ↑ "Does Comprehensive Geriatric Assessment have a role in Care Homes?", Gordon, Adam L. PhD Thesis. 2012. Retrieved 9 October 2018.
  17. ↑ "Practice Guideline: Comprehensive Geriatric Assessment (CGA) in oncological patients" (PDF). International Society of Geriatric Oncology. Retrieved 25 November 2018.
  18. ↑ "Comprehensive Geriatric Assessment Toolkit for Primary Care Practitioners", BGS, 4 February 2016. Retrieved 9 October 2018.
  19. ↑ "Comprehensive Geriatric Assessment Position Statement", American Geriatrics Society, 5 September 2008. Retrieved 9 October 2018.

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