What is the evidence supporting comprehensive geriatric assessment in elderly patients with complex medical conditions?

Evidence Supporting Comprehensive Geriatric Assessment in Elderly Patients with Complex Medical Conditions

Comprehensive Geriatric Assessment (CGA) significantly improves health outcomes for elderly patients with complex medical conditions by reducing unplanned hospital admissions and increasing the likelihood of patients remaining in their own homes rather than being admitted to nursing facilities.

What is Comprehensive Geriatric Assessment?

CGA is a multidimensional, multidisciplinary diagnostic and therapeutic process designed to determine the medical, psychological, functional, and social capabilities of older adults to develop a coordinated and integrated plan for treatment and follow-up 1. It goes beyond standard medical assessment by:

• Evaluating multiple domains of health and function
• Involving a multidisciplinary team approach
• Developing targeted interventions for identified issues
• Providing ongoing monitoring and management

Key Components of CGA

The most recent evidence supports using the Geriatric 5Ms framework to guide comprehensive assessment 2, 3:

1. Mind: Assessment of cognitive function, mood, and mental health

   • Screening for cognitive impairment or dementia should be performed at initial visit, annually, and as appropriate for adults 65+ 2
   • Evaluation of depression, anxiety, and other psychological conditions

2. Mobility: Evaluation of physical function and fall risk

   • Assessment of basic activities of daily living (ADLs): dressing, eating, ambulation, toileting, bathing 2
   • Assessment of instrumental activities of daily living (IADLs): shopping, meal preparation, cleaning, medication management, finances, communication, transportation 2

3. Medications: Review of all medications

   • Evaluation of polypharmacy, which contributes to increased chemotherapy toxicity in cancer patients 2
   • Identification of potentially inappropriate medications, especially those with anticholinergic properties 4

4. What Matters Most: Person-centered care priorities

   • Advanced care planning and end-of-life discussions
   • Goals of care and treatment preferences
   • Quality of life priorities

5. Multicomplexity: Assessment of comorbidities and social determinants

   • Evaluation of multiple chronic conditions and their interactions
   • Assessment of social support, economic security, housing, and other social determinants 2

Evidence Supporting CGA Effectiveness

Hospital-Based CGA

High-certainty evidence shows that inpatient CGA:

• Increases the likelihood that patients will be alive and in their own homes at 3-12 months follow-up (RR 1.06,95% CI 1.01-1.10) 5
• Decreases the likelihood of nursing home admission at 3-12 months follow-up (RR 0.80,95% CI 0.72-0.89) 5
• Shows little or no difference in mortality at 3-12 months follow-up (RR 1.00,95% CI 0.93-1.07) 5

Community-Based CGA

For community-dwelling frail older adults:

• May decrease the risk of unplanned hospital admissions (RR 0.83,95% CI 0.70-0.99) 1
• Results in little or no difference in nursing home admissions (RR 0.93,95% CI 0.76-1.14) 1
• Has uncertain effects on emergency department visits and serious adverse events 1

CGA in Oncology

In elderly cancer patients, CGA:

• Adds substantial information on functional assessment beyond performance status alone 2
• Identifies limitations in ADLs (9.3%) and IADLs (37.7%) even in patients with good performance status 2
• Components of CGA (comorbidities, functional status, geriatric syndromes, nutritional status) are associated with cancer treatment decisions and survival 2

Implementation of CGA

The most effective CGA implementation involves:

1. Team-Based Approach:

   • Physician, social worker, and family members/caregivers as key contributors 3
   • Additional expertise from physical therapists, occupational therapists, nurses, speech-language pathologists, dietitians, audiologists, and pharmacists as needed 3

2. Setting:

   • Evidence suggests that both home-based and hospital-based CGA programs consistently show benefits for health outcomes 6
   • CGA can be performed in primary care settings, though more research is needed to identify the most effective implementation strategies 7

3. Assessment Tools:

   • Validated questionnaires and assessment tools can simplify data gathering 3
   • Tools should assess functional status, frailty, mobility, fall risk, nutritional status, polypharmacy, and cognition 3

Common Pitfalls and Caveats

1. Focusing on chronological age alone: Aging is highly individualized, and CGA should be used to assess biological rather than chronological age 2

2. Incomplete assessment: Failing to address all domains of CGA may miss important issues affecting health outcomes

3. Lack of follow-through: CGA is not just assessment but should lead to targeted interventions and ongoing management

4. Resource constraints: Full CGA is time and resource-intensive; adapted versions may be more practical for everyday clinical practice 2

5. Failure to involve caregivers: Family members or caregivers provide crucial information, especially when cognitive issues or mood disorders are present 3

Conclusion

CGA represents a critical approach to caring for elderly patients with complex medical conditions. The evidence strongly supports its use in both hospital and community settings to improve patient outcomes, particularly in reducing unplanned hospitalizations and nursing home admissions. Healthcare systems should implement CGA using the Geriatric 5Ms framework, with appropriate adaptations based on available resources and specific patient populations.