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Review Article
Three Decades of Comprehensive Geriatric Assessment: Evidence Coming From Different Healthcare Settings and Specific Clinical Conditions

https://doi.org/10.1016/j.jamda.2016.11.004Get rights and content

Abstract

Comprehensive geriatric assessment (CGA) is a multidisciplinary diagnostic and treatment process that identifies medical, psychosocial, and functional capabilities of older adults to develop a coordinated plan to maximize overall health with aging. Specific criteria used by CGA programs to evaluate patients include age, medical comorbidities, psychosocial problems, previous or predicted high healthcare utilization, change in living situation, and specific geriatric conditions. However, no universal criteria have been agreed upon to readily identify patients who are likely to benefit from CGA. Evidence from randomized controlled trials and large systematic reviews and meta-analyses suggested that the healthcare setting may modify the effectiveness of CGA programs. Home CGA programs and CGA performed in the hospital were shown to be consistently beneficial for several health outcomes. In contrast, the data are conflicting for posthospital discharge CGA programs, outpatient CGA consultation, and CGA-based inpatient geriatric consultation services. The effectiveness of CGA programs may be modified also by particular settings or specific clinical conditions, with tailored CGA programs in older frail patients evaluated for preoperative assessment, admitted or discharged from emergency departments and orthogeriatric units or with cancer and cognitive impairment. CGA is capable of effectively exploring multiple domains in older age, being the multidimensional and multidisciplinary tool of choice to determine the clinical profile, the pathologic risk and the residual skills as well as the short- and long-term prognosis to facilitate the clinical decision making on the personalized care plan of older persons.

Section snippets

Comprehensive Geriatric Assessment: Definition

The observations of high rates of institutionalization in the frail older population and the inadequacy of provision for readily recognisable and remedial problems in this high-risk group led to the development of one of the cornerstones of modern geriatric care: comprehensive geriatric assessment (CGA).1, 2 The concept is that the early identification of individuals at greatest risk for complications and unfavorable outcomes would enable a more adequate treatment plan and a better allocation

Methods

A literature database search was performed electronically via OVID (MEDLINE and SCOPUS), combining the term “comprehensive geriatric assessment” with the following keywords: “mortality,” “death,” “outcome,” “hospital,” “nursing home,” “randomized controlled trial,” “review,” and “meta-analysis”. The search was restricted to articles published in the English language until June, 2016.

In addition, a manual check on the reference lists in the articles and reviews identified was also conducted to

The Key Components of CGA

CGA is sometimes termed geriatric evaluation and management, particularly when geriatric assessment programs combine geriatric evaluation with management.5 The key components of different models of CGA include a coordinated multidisciplinary assessment, geriatric medicine expertise, identification of medical, physical, social, and psychological problems, and the formation of a plan of care including appropriate rehabilitation.6

The core domains of CGA are functional status, mobility, gait speed,

CGA in Different Healthcare Settings

During the last 30 years, the clinical geriatric models based on CGA have evolved in different healthcare settings to meet differing needs becoming the foundation of “progressive” geriatric care, including acute hospital care, day hospitals, rehabilitation units, nursing homes, and home-care services.8 In progressive geriatric care, CGA is performed at varying levels of intensity in different settings, and its content may vary with the healthcare setting (ie, hospital, posthospital

CGA in Specific Settings or Clinical Conditions

Among innovative approaches to outpatient CGA/OAS, practice redesign approaches focus on specific geriatric conditions for assessment and management by physicians or nurse practitioners. However, a series of particular settings or specific clinical conditions were the object or recent interest for tailored CGA programs in older frail patients (Table 2).

Multidimensional Geriatric Assessment and Clinical Decision Making

A large and increasing body of evidence indicated that the prognosis of older patients was strongly related to the presence of concomitant diseases and to the degree of physical, cognitive, biological, and social impairment.74 CGA, capable of effectively exploring these multiple domains of health, is indeed the multidimensional and multidisciplinary tool of choice to determine the prognosis of the functionally compromised and frail older patient [ie, multidimensional geriatric assessment (MGA)].

Conclusions

A systematic CGA of older adults may identify a variety of treatable health problems and lead to better health outcomes. Healthcare settings or specific clinical conditions may modify the effectiveness of CGA programs. Home and hospital CGA programs were shown to be consistently beneficial for several health outcomes, including mortality, disability, and cognitive functions. Ongoing studies explore the clinical usefulness of CGA programs in older frail patients who are candidates for surgery,

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    This work was supported from the MPI_AGE European project co-funded by the Consumers, Health, Agriculture, and Food Executive Agency (CHAFEA) in the frame of the European Innovation Partnership on Active and Healthy Aging Second Health Program 2008–2013. The contents of this article are the sole responsibility of the above mentioned Authors and can under no circumstances be regarded as reflecting the position of the European Union.

    The authors declare no conflicts of interest.

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