Review: comprehensive geriatric assessment increases a patient's likelihood of being alive and in their own home at up to 12 months
- Correspondence to Marie Boltz
College of Nursing, New York University, 726 Broadway, New York 10003, USA;
Implications for research and practice
■ Comprehensive geriatric assessment (CGA) is associated with improved functional and mortality outcomes for hospitalised older adults.
■ The benefits of CGA are more predominate in dedicated wards, as compared with CGA mobile teams.
■ Future research should focus on methods of identifying older adults most likely to benefit from CGA and delineating the roles of acute and stepdown models of CGA.
As the number of older adults continues to rise at an unprecedented rate globally, older patients represent the core consumer of acute care services. The physical, psychological and social complexity of the critically ill older adults' demand a multi-disciplinary, function-focused approach to assessment and clinical management. CGAs provide this approach through mobile multi-disciplinary teams or through dedicated geographic units.
Data were sourced by handsearching high-yield journals and from searching the following databases: Cochrane Effective Practice and Organisation of Care Group Register, the Cochrane Central Register of Controlled Trials (to April 2010), the Database of Abstracts of Reviews of Effects, MEDLINE (1966 to April 2010); EMBASE (1980 to April 2010); CINAHL (1982 to April 2010); and AARP Ageline (from 1978 to April 2010). The searches identified randomised controlled trials and cluster randomised trials comparing CGA (whether by mobile teams or in designated wards) to usual care provided to adults aged 65 years or older who were admitted to hospital care as an emergency with medical, psychological, functional or social problems. Methodological quality of individual studies was assessed based on quality of randomisation procedure, concealment of treatment allocation and blinding of participants.
The primary outcome measure was living at home (the odds of someone being alive and in their own home at a point in time) and the secondary outcome measures included death, institutionalisation, dependence, death or dependence, activities of daily living, cognitive status, readmission, length of stay and resource use. A subgroup analysis compared ward versus team, ward and team by admission criteria (ie, age alone versus age plus other criteria), timing of admission and outpatient follow-up versus none.
A total of 22 trials evaluating 10 315 participants in six countries were identified. Patients in receipt of CGA were more likely to be alive and in their own homes at up to 6 months (OR 1.25, 95% CI 1.11 to 1.42, p=0.0002) and at the end of scheduled follow-up (median 12 months) (OR 1.16, 95% CI 1.05 to 1.28, p=0.003) when compared with general medical care. In addition, patients were less likely to be institutionalised (OR 0.79, 95% CI 0.69 to 0.88, p <0.0001). They were less likely to die or deteriorate (OR 0.76, 95% CI 0.64 to 0.90, p=0.001), and were more likely to experience improved cognition in the CGA group (OR 1.11, 95% CI 0.20 to 2.01, p=0.02). Subgroup interaction in the primary outcomes suggests that the effects of CGA are primarily the result of CGA wards.
Hospitalisation for older adults is often a life-altering event. The interaction of baseline vulnerabilities (age-related changes, multiple co-morbidities, the acute illness itself), as well as the non-elder friendly hospital environment, place them at increased risk for cognitive and functional decline, longer lengths of stay, postacute institutionalisation and mortality, and unplanned readmissions.1,–,3 Over the past three decades, there has been increasing emphasis on developing and testing models of care that seek to improve both the outcomes and experiences of the hospital stay for older persons. The vigorous systematic review by Ellis et al, though admittedly limited by variations in study measures and sample sizes, reports what intuitively makes sense to gerontological clinicians. Multi-disciplinary care in specially prepared environments, provided by clinicians trained in geriatrics, increases the chance for better patient outcomes.
The findings also raise important questions about the impact of CGA in shaping overall improvement in geriatric acute care. As the authors point out, research has not defined the characteristics of older adults most likely to benefit from CGA. Additionally, there is a lack of standardisation of CGA protocol in areas of assessment tools, staff qualifications and training, quality metrics and environmental modifications. Thus, replicability is a challenge, perhaps limiting dissemination of the CGA model.
An even more significant challenge is the fact that the CGA ward is limited in its capacity to meet the needs of the majority of hospitalised older patients. A designated unit does not address the needs of older patients hospital-wide, including those in medical, surgical, critical care and emergency departments. It is time to use the lessons learnt about CGA and focus on dissemination of CGA principles to all units that serve older adults.