Comprehensive geriatric assessment for older adultsBMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d6799 (Published 27 October 2011) Cite this as: BMJ 2011;343:d6799
All rapid responses
There is little doubt that the comprehensive geriatric assessment (CGA) is the optimal tool for ensuring the highest standard of holistic care for frail, elderly patients. Ellis et al (BMJ, 2011) concluded that the CGA improves elderly patient outcomes compared to usual care following emergency admission (1). The editorial ‘Comprehensive geriatric assessment for older adults’ (BMJ, 2011) stated that the CGA “should become standard practice” (2), a view held by the rapid responders and countless other clinicians.
A group of fourth year medical students at Cardiff University recently carried out a prospective case note review on the implementation of basic components of the CGA as outlined by Wieland and Hirth (Cancer Control, 2003) (3). We would like to offer our findings to your discussion on the use of the CGA.
By 2050 it is estimated that 22-46% of the population will be aged 65 and over (4). Individuals in this age group have a higher risk of mortality and morbidity (5) and are responsible for the largest increase in hospital admissions in the UK (4). It is therefore necessary to manage this increasing population in an efficient multidisciplinary context. Numerous studies have shown that the CGA is effective in assessing this populations needs, which is a pre-requisite to better management (1).
The study aimed to determine the degree of implementation of key aspects of the CGA (medical, functional, environmental, psychological and social assessments), and to compare implementation rates between general and care of the elderly (COTE) wards. A pro-forma was used to conduct a prospective review of patient notes belonging to 183 inpatients over the age of 65 years who had been admitted to general (n=89) and COTE (n=94) wards for longer than 5 days across three health boards in Wales.
Medical assessments were generally well implemented: patients had problem lists and co-morbidities recorded (98.9%), medication reviews (86.9%), management plans (98.4%), pressure sore assessments (81.4%) and were asked about pain (87.4%). Nutritional assessments however were only carried out in 74.3% of all patients with significant discrepancies between health boards (P<0.001). Mobility and exercise status was assessed by a physiotherapist in 94.5% of patients on COTE wards compared to 81.4% on general wards. Patient function was assessed by an occupational therapist in 47.5% of all patients; of these, 88.5% went on to have their activities of daily living and instrumental activities of daily living assessed. However, this aspect of the CGA is usually assessed prior to discharge and thus it is difficult to comment on the significance of this finding. Continence needs were questioned in 73.8% of patients, of which, 40.7% went on to be formally assessed. A mental status (cognitive) test was carried out in 35.0% of all patients and significantly more frequently in patients on COTE than general wards (45.7% c.f. 26.6%, p=0.002). Living arrangements prior to admission (i.e. community/nursing home) were documented in all patients, and support services (i.e. formal care/informal care/no care) in 98.4% of patients. A formal care provision assessment was recorded in 35.5% of patient notes: this assessment is also usually carried out prior to discharge.
Overall, implementation of the CGA was more consistent on COTE than general wards but this was statistically significant only in certain areas. Of note, nutritional assessment, functional assessment by an occupational therapist, cognitive assessment and formal care provision assessment were poorly documented. Limitations to this audit include inconsistencies between auditors and a relatively small sample number. Ideally further work should be undertaken to corroborate these results.
Notwithstanding the limitations of our study, we agree fully with the statement that the CGA should become standard practice. Further education of healthcare professionals and students alongside use of the ‘acute care toolkit 3’(6) in the acute medical setting may enable comprehensive assessment to be properly implemented.
Competing interests: No competing interests
Comprehensive geriatric assessment for older adults: patient-centred rather than standard procedures in primary care.
The purpose of a comprehensive geriatric assessment for older patients is the same in general practice as in secondary care: to determine individual medical, psychosocial, functional, and environmental resources and problems to create a holistic care plan. The overall aim is to foster older patients’ ability of living independently at home.
However we have experienced that it is less important which instruments and pathways are used to uncover health problems, but what care and treatment decisions ensue. An older patient who has undergone a comprehensive assessment reveals on average 12 health problems in general practice (1,2). This synopsis of health issues confounds the general practitioner (GP) more than his patient. In our experience, doctors feel overburdened by the multitude of issues and tend to limit themselves to medical conditions with specified pathways. Even then they realize that evidence based treatments for single diseases interact and may lead to patient harm when added together. Hence treatments must be carefully selected; they need to be prioritised in consultation with the patient. This explains why it is imprudent to standardise assessment procedures like a ‘laboratory test, linked with diagnostic and prognostic evaluation and therapeutic action’. If we act in this way, we follow a disease management approach and loose sight of holistic care, which older patients with complex needs require.
What was also missing in the editorial is patient involvement. We as doctors must be careful to act in the best interest of the patient – and this should mean sharing decision-making on any treatments and priorities to be set. The doctor’s assumption on what is important for the patient is not sufficient, since patients and doctors hardly agree on what constitute priority problems for further attention. The GPs focus on the disease, patients on illness and the effect on everyday life (3,4). Consequently geriatric assessment and successive actions entail becoming acquainted with each others’ perspectives and entail negotiating to an equitable conclusion.
We agree that geriatric assessment should become standard practice in general practice as well. Currently many GPs can barely be convinced that assessments are feasible and lead to positive patient outcomes. Ellis et al. have published an impressive confirmation on the patient benefit from assessments for the hospital setting (5). Beswick’s et al. meta-analysis has shown this already in 2008 for the primary care setting (6). However the interventions were heterogeneous and particular to the respective health systems.
It presents a major challenge to increase the acceptance of general practitioners for comprehensive assessments. GPs need support through training and system delivery reforms for an effective transfer into practice. They should be able to dedicate time to patients with complex needs and be financially rewarded. Successful implementation also requires doctors reconsidering values and principles in the care of older patients. Instead of focussing on illness and cure, we should focus on health needs; comprehensive, continuous and person-centred care should replace episodic curative care)(7).
Much remains to be done. Future studies should tackle conditions of successfully implementing assessment into primary care. They should also seek for approaches on how to deliver patient-centred holistic care from which treatment through protocols can follow.
1. Mueller CA, Klaaßen-Mielcke R, Penner E, Junius-Walker U, Hummers-Pradier E, Theile G. Disclosure of new health problems and intervention planning using a geriatric assessment in a primary care setting. Croat Med J 2010;51:493-500.
2. Piccoliori G, Gerolimon E, Abholz HH. Geriatric Assessement in der Hausarztpraxis - Eine Studie der Südtiroler Akademie für Allgemeinmedizin. Z Allg Med 2005(81):491-498.
3. Minaire, P. Disease, illness and health: theoretical models of the disablement process. Bulletin of the World Health Organization 1992, 70 (3): 373-379.
4. Junius-Walker U, Stolberg D, Steinke P, Theile G, Hummers-Pradier E, Dierks ML. Health and treatment priorities of older patients and their general practitioners: a cross-sectional study. Qual Prim Care. 2011;19(2):67-76
5. Ellis G, Whitehead MA, O'Neil D, Langhorne P, Robinson D. Comprehensive geriatric assessment for older adults admitted to hospital. Intervention review. Cochrane Database of Systematic Reviews 2011.
6. Beswick AD, Rees K, Dieppe P, Ayis S, Gooberman-Hill R, Horwood J, et al. Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis. Lancet 2008 01.03.2008;371:725-735.
7. The World Health Report 2008 - Primary Health Care. Now More Than Ever. World Health Organization 2008.
Competing interests: No competing interests
Comprehensive geriatric assessment(CGA), when introduced by Marjory Warren in 1930(1), revealed utility in systematic evaluation and intervention, in frail elderly patients within a hospital setting. The 22 RCTs selected by Ellis et al(2) for meta-analysis exhibit striking differences in methodology of intervention and measurement. Though the meta-analysis suggests that CGA organised on “wards” rather than “teams” show overall benefit in predetermined subgroup analysis, evidence from well-designed observational cohort studies(3) excluded from the analysis have not been taken into account. RCTs may not prove to be optimal in studying how to best implement evidence-based practice, nor effectively evaluate complex interventions such as CGA(4) .Heterogeneity in definitions, measurement and intervention further detract from drawing firm conclusions. The publication of the SQUIRE Guidelines(5) for describing quality improvement interventions is a step in the right direction.
A concerted effort to define who would most benefit from CGA would help elucidate the ambiguity in this area, and therefore direct resources to high-risk groups, as well as help target system-wide quality improvement. Timeliness of assessment in relation to outcome in the acute/post-acute setting, and redundancies between the various validated risk prediction scores (i.e. the ability of one score to predict the outcome of another) are areas of much needed further study. Quality improvement tools such as Care Bundles, that reduce variation and improve consistency in health-care provision, should also be considered.
As such, this systematic review and meta-analysis is a welcome addition to the growing evidence of systematic multicomponent assessment and intervention for complex needs elderly patients admitted to hospital.
1. Warren MW. Care of the chronic aged sick. Lancet 1946;1(6406):841.
2. Ellis G, Whitehead MA, Robinson D, O’Neill D, Langhorne P. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ: British Medical Journal 2011;343.
3. Harari D, Martin FC, Buttery A, O'Neill S, Hopper A. The older persons' assessment and liaison team 'OPAL': evaluation of comprehensive geriatric assessment in acute medical inpatients. Age Ageing 2007;36(6):670-5.
4. Bakker FC, Robben SH, Olde Rikkert MG. Effects of hospital-wide interventions to improve care for frail older inpatients: a systematic review. BMJ Qual Saf 2011;20(8):680-91.
5. Davidoff F, Batalden P, Stevens D, Ogrinc G, Mooney S. Publication guidelines for quality improvement in health care: evolution of the SQUIRE project. Quality and Safety in Health Care 2008;17(Suppl 1):i3.
Competing interests: JTYS has a Clinical Quality Improvement and Research Fellowship funded by RCPL
Let us start by congratulating you for writing the inspiring editorial “Comprehensive geriatric assessment for older adults” published in BMJ, issue 343.
We applaud the vision that Comprehensive Geriatric Assessment (CGA) is a useful instrument in taking care of our elderly population. It is a vision we also share, since we are developing a webbased CGA agenda for GPs (general practitioners) in Belgium. In the light of our work, we would like to highlight some aspects stated in your article, as well as providing some complementary statements.
We decisively agree with the conclusion that CGA should become standard practice. When an older person is admitted to the hospital, performing a CGA will be beneficial. But why not take CGA to the level of the general practitioner? At the primary care level, CGA is the perfect instrument to accomplish primary prevention, hence preventing early hospital admission. Elder patients visit their general practitioner at a regular basis, promoting CGA to be integrated in daily care. GPs can perform CGA as a process of permanent evaluation instead of a one-time examination. Furthermore, the general practitioner usually has a long-term relationship with the patient, creating a special bonding. This may lead to a more confidential conversation.
Performing CGA at the primary care level enables to reach the ‘healthy elderly’. In our opinion it is important to perform a general examination before the self reliance has failed. We envision to detect potential needs before they create a real problem. In that way we can intervene in an even earlier stage and hopefully prevent hospitalization. We hope that if we talk about these matters in an early phase, patients will be more likely to visit their general practitioner in case of a rising problem.
Concerning the topics of a CGA program; we think advanced life care planning is of great importance. It’s important to know what the elderly and their family want for the future. For example: what do they want when a severe problem arises? Who will take care of them when it’s getting hard to stay home? How do they feel about going to a nursing home?
It is of great interest for us to know other opinions about a CGA agenda for the general practitioner. Should we use the same questionnaires and which topics are the most important for the primary care setting?
Competing interests: No competing interests