Comprehensive geriatric assessment for older adults

Care of older people differs from care of middle aged adults. Older people often have more complex multisystem problems, are at increased risk for morbidity and mortality, and need comprehensive interventions that take into account the biopsychosocial components of health. Comprehensive geriatric assessment is an approach developed for this purpose. It is a process that determines an older person’s medical, psychosocial, functional, and environmental resources and problems, and it creates an overall plan for treatment and follow-up.1 It encompasses linkage of medical and social care around medical diagnoses and decision making under the leadership of a doctor trained in geriatric medicine.

Older people admitted to hospital as emergencies are at especially high risk. In the linked systematic review (doi: 10.1136/bmj.d6553), Ellis and colleagues performed a meta-analysis of the comprehensive geriatric assessment of elderly people admitted to hospital.2 They found that patients in hospital who received such an assessment were significantly less likely to die or experience functional deterioration. As a result, such patients were also less likely to be admitted to an institution and more likely to be alive in their own homes at longer term follow-up (median 12 months) compared with those receiving usual care.

This systematic analysis combined subacute and acute hospital based assessment programmes (table⇓). Subacute models are typically for selected older patients in hospital, and they offer specialised multidisciplinary rehabilitative inpatient care. A previous systematic review found that general and orthopaedic geriatric rehabilitation programmes improve functional and survival outcomes in selected older patients.3

In contrast, acute models typically apply to all patients aged 70 and over admitted for acute hospital care. They include an interdisciplinary patient centred approach based on an assessment linked with care protocols and early discharge planning, in a hospital environment adapted for elderly people with mobility or orientation problems. A previous systematic review reported favourable effects of acute care geriatrics, although conclusions were limited by a low number of studies.4

According to the findings of the linked meta-analysis,2 comprehensive geriatric assessment carried out in dedicated wards was more beneficial than if implemented by teams liaising with other specialties. In contrast to widespread belief, ward based assessment is not only effective for selected older patients but has beneficial effects in all elderly patients admitted to acute hospital care.1 2 3 4 All ambulatory older patients can benefit from specific types of programmes based on comprehensive geriatric assessment (table⇑).5 6 7 8 9 In the subgroup of frail older patients, coordinated care based on this assessment improves outcomes and reduces unnecessary hospital admissions.6 In selected people above the age of 75, preventive home visits based on comprehensive geriatric assessment can reduce the decline in functional status and prevent nursing home admission.7 In the large group of non-disabled people above the age of 65, health risk appraisal programmes combined with personal reinforcement have shown favourable effects.8 9 At the other end of the spectrum, patients in need of palliative care also seem to benefit from based on comprehensive geriatric assessment methods.6

This has implications for research. More evidence is needed on how to optimise the effectiveness and efficiency of these assessments, including research on how best to approach individual components of the model (such as falls, pain, delirium, nutrition) in different settings. This will also require translational research based on non-randomised study designs, to evaluate cost and effectiveness of dissemination of evidence.

The clinical implications are clear—comprehensive geriatric assessment should become standard practice. Clinical expertise is needed to implement these approaches. Doctors need to be trained to use the assessment like a laboratory test, linked with diagnostic and prognostic evaluation and therapeutic action.10

Widespread adoption of comprehensive geriatric assessment will require system change. Redesigning systems of care to increase support for clinicians in their work may improve patients’ experience and outcomes more than relying on training alone.11 The process of hospital care needs to be adapted to include comprehensive geriatric assessment, including geriatric evaluation and management. System change also means placing the geriatrician at the centre of clinical management in countries where most hospital inpatients are older people with complex needs. In addition, reimbursement systems that promote comprehensive care are needed. Previous research suggests that assessment based interventions may result in additional costs initially. However, in the longer term comprehensive geriatric assessment not only improves patient outcomes but may save costs by reducing hospital readmissions and lowering the need for long term nursing home care.2 12