Comprehensive Geriatric Assessment

Darryl Wieland, PhD, MPH; Victor Hirth, MD, MHA

Disclosures

Cancer Control. 2003;10(6) 

In This Article

History of Comprehensive Geriatric Assessment

The roots of modern CGA practice go back approximately 70 years and are conventionally traced to the work of Marjory Warren in the United Kingdom.[15,16] Warren created a specialized geriatric assessment unit in a large chronic disease hospital (a "workhouse infirmary"). The hospital had been filled with elderly patients who were neglected and bedridden. By systematically evaluating these patients, Warren was able to determine who might benefit by medical and rehabilitation efforts. She remobilized a majority of these patients and in many cases discharged them to their homes. These experiences led her to become a leading proponent of comprehensive assessment of elderly prior to their placement in chronic hospital or nursing-home facilities. Since then, the concepts and practice of CGA have evolved to amalgamate the traditional medical history and physical with functional evaluation and treatment derived from the rehabilitation disciplines, social work assessment, and other aspects of psychometric measurement from the behavioral and social sciences ( Table 1 ).

CGA is now applied internationally and has a central position in systems of geriatric care rather than only at the point of entry into institutional long-term care. In the United States, CGA was a defining feature of programs begun in the 1970s in some Veterans Administration hospitals (now Department of Veterans Affairs [VA] medical centers). Geriatric evaluation units (now called geriatric evaluation and management [GEM] units) were established, first in inpatient bed sections and later in ambulatory care, to identify, assess, and treat frail and disabled older veterans in the system who were at risk for institutionalization and failing to benefit from usual care.[17] An influential early controlled trial suggested the GEM approach was highly cost effective, leading the VA to adopt it system-wide.[18] By the mid 1990s, over three quarters of the 172 VA medical centers reported having a GEM program.[19]

Outside of the VA medical centers, hospital GEM units have floundered due to funding issues, difficulty in maintaining interdisciplinary teams, and lack of sufficiently trained physicians to run these units.[20] Nonetheless, CGA has become part of geriatric primary care and inpatient consultation services. Standardized packages such as the Minimum Data Set (MDS) embody the first stages of CGA and are at least intended to facilitate the CGA process (eg, RAI-Home Care Assessment Manual[21]). Presently, however, the US healthcare system is not focused on detecting and referring frail elderly patients for further evaluation, and many experience the deficiencies of usual care, most notably but not solely at point of transition between different parts of the system. Even where adopted in the United States (eg, the MDS resident assessment system for nursing homes), standardized clinical assessment systems are not widely used to plan and manage care.

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