Comprehensive Geriatric Assessment

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

Disclosures

Cancer Control. 2003;10(6) 

In This Article

Components of Comprehensive Geriatric Assessment

Table 2 provides a list of basic components usually included in a CGA. While the detailed elements vary, virtually all CGAs -- whether relatively simple multidimensional assessments for screening purposes or fully elaborated team assessments -- include medical, psychological, social, and environmental components, as well as functional components (at the level of activities of daily living [ADLs] and instrumental activities of daily living [IADLs]). Table 2 also provides examples of elements that may be contained in more or less extensive assessments. These are discussed in more depth after first reviewing the various ways in which a CGA is initiated in the system of care.

A CGA can be effective only if there is a process for identifying elderly patients who may benefit from it. In most cases, they are elderly individuals who are frail and disabled or have multiple interacting comorbid conditions, as opposed to relatively healthy older people (including those whose health conditions are addressable by usual medical approaches) and those with serious focal chronic conditions for whom disease management by primary care with input by other subspecialists is appropriate. Examples include an older patient who appears to be on a rapid downward trajectory toward nursing home placement and a previously functional senior who is requiring increasing assistance to accomplish daily tasks.

Although no "gold standard" has been developed that accurately and reliably identifies frail or pre-frail seniors, a number of clinical screening tests applicable to frail patients are now available. The timed "up and go,"[22] a test of one-leg standing balance,[23] and brief screening questionnaires,[24] among others, are useful. Due to the lack of a validated test battery for the frailty syndrome, geriatricians have often been left with forming a "gestalt" of which patients are frail or pre-frail. Community screening and casefinding have been implemented in some Medicare managed care organizations via enrollment and periodic questionnaire (eg, the Probability of Repeated Admission [PRAPlus[25] ), in care management demonstrations in the VA system,[26] and in the senior "health check" program required of general practitioners in the United Kingdom in their elderly practice panels in the National Health Service,[27] to name a few. Multidimensional screening in hospitals and other settings has also been used in targeting at-risk patients for CGA.[28] Generally, screening is performed to identify patients with new or troublesome functional deficits or with challenging geriatric problems (falls, cognitive status changes, incontinence) and to refer them for CGA in the most appropriate setting.

The scope of the CGA per se is dependent on the care setting and resources available. In institution-based programs or intensive community-based models like the Program of All-Inclusive Care for the Elderly (PACE),[8] an interdisciplinary team divides the responsibilities for assessment components. Results are reported at the team meeting, during which an interdiscipli-nary problem list and care plan are developed.[1,2,3,4] Hospital GEM units or PACE sites may involve many different disciplines, given the complexity of care plans and the high prevalence of incipient disability and geriatric syndromes in the overall caseload. Smaller teams, usually composed of a geriatrician, social worker, and nurse, can perform CGA in clinic or practice settings when the problem mix and caseload allow. Such smaller teams form the core of geriatric primary care practices in the United States[29] and a variety of prevention-oriented programs of in-home geriatric assessment.[30] Physicians alone can perform many aspects of a CGA,[31] although this is often not practical given the limited time available and the workload issues of instituting a complex care plan. Still, if appropriately focused on a defined set of geriatric problems and linked to the necessary care management resources, a small team or physician CGA can also be beneficial.

As stated above, the medical aspect of CGA, like the other components, varies with the setting of the encounter ( Table 2 ). In the acute hospital, day hospital, or nursing home, the geriatrician either alone or with other physicians may be involved with evaluation and management of acute or subacute problems or surgical procedures. Otherwise, in the CGA process, the geriatrician will focus on developing a list of complex clinical problems with a prioritization so that the most serious are dealt with first.[32] Thus, there is no routine format for the medical history or physical examination: the focus will be driven with the input of patients, families, and caregivers on the major complaints as well as the findings of other members of the team concerning the health and functioning of the patient. Development of the prioritized problem list, as important as it is, is not the only goal of the medical encounter in the CGA process. Other objectives are counseling for disease prevention and health promotion, determining immunizations, screening for asymptomatic conditions that are prevalent in elderly patients, assessing medication burden, screening for other substance abuse, and ascertaining social and psychological problems. A general review of the geriatrician's approach has been provided by Applegate.[32]

At the heart of the CGA is a review of patient functioning, as reflected most commonly in terms of measures of ADLs and IADLs. The basic ADLs are composed of self-care activities of dressing, bathing, transferring to and from chair, bed, and standing position, going to the toilet, and eating. In addition to the required daily activities, IADLs include activities that one may do for oneself or may customarily be done other members of the household (eg, housework or other domestic chores, managing money, using the telephone, shopping). In many cases, particularly in ambulatory clinical settings, patients and/or family caregivers are asked to report on these items by filling out questionnaires. Elsewhere, functioning may receive more extensive clinical evaluation by nurses or occupational therapists. Many potentially useful approaches to functional assessment are available, but selection of a single or set of approaches must be made with care.[1,2,3,4,5,6] Given the central importance of mobility to executing most functional activities and the high incidence and often harmful consequences of falls in older patients, assessment of exercise practice and activity status, as well as gait and balance, has become an important aspect of functional assessment in most settings.[33]

Two chief streams of useful information flow from the functional assessment component in the CGA. One involves the capacity or incapacity of the patient to perform the specific tasks, wherein incapacity may suggest underlying impairments in organ systems or specific disease processes. In this regard, the nearly ubiquitous screens for cognitive impairment and depression that form the core of the psychological assessment component are helpful ( Table 2 ). The second stream of information involves the nature and degree of help needed for specific tasks to be accomplished. This aspect of the functional assessment draws in additional information from the social and environmental components. The strength of the patient's social support network, the kind and amount of familial help available, aspects of the home environment, and financial ability to secure paid personal care assistance -- to name but a few considerations -- all inform the functional prognosis and influence the choice of clinical goals and management approaches.

The care plan is formulated only after the data (ie, information from the standardized clinical measures, laboratory tests results, as well as focused clinical impressions) are gathered from all components of the CGA. An often-underappreciated trait of CGA is that the process is not a three-step sequential procedure of completing the comprehensive assessment, reading the "results," and applying sets of protocols to produce a relatively fixed plan of care. Over the long-term, given the age, health, and functional status of these patients, there is rarely a plan of geriatric care composed entirely of final therapeutic formulations. The assessment has no value it does not yield a care plan, and the care plan has no value if not implemented. The literature on CGA effectiveness suggests that greater benefits tend to be seen where the team/providers performing the assessment are also delivering and managing the care. Individual assessments, care plans, and interventions themselves are best seen as works in progress, feeding back on one another.

Programmatic formats and settings in which CGA is performed follow a continuum from community locations (including homes and physician practices), through specialized clinics and hospital services of various kinds, to long-term institutional and communitybased rehabilitation and care venues. The resources for CGA and intervention tend to increase along this program continuum, following the increasing burdens of clinical complexity, illness acuity, psychosocial problems, and disability in the patients who tend to enter them through their usual screening or targeting procedures. For example, the hospital is the point of encounter for frail elders who are at particular risk from both their acute illness and the usual hospital procedures. Early identification of these frail, disabled, and clinically complex patients -- either in the emergency department[34] or soon post-admission -- can lead to a more extensive CGA, more effective rehabilitative team intervention, and better post-discharge management.[35] Further, it can be a routine feature of step-down GEM units or of specialized hospital units combining geriatric assessment and management with other subspecialty care (eg, geriatric cardiology, geropsychiatry, stroke units, gero-orthopedic units,[38] and, more recently, geriatric oncology services).[3,39] In contrast, most CGAs in outpatient settings -- given patients' generally moderate illness acuity and clinical complexity -- do not require intensive physician and nurse monitoring of inpatient settings or the range of technological resources. Specialized programs such as outpatient GEM clinics and day hospital programs can provide adequate interdisciplinary team assessments, intervention, and monitoring for many.[40,41,42,43]

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