Comprehensive Geriatric Assessment and Medication "Appropriateness".

As a population ages, performing comprehensive geriatric assessment (CGA) is necessary to help clinicians manage older adults' conditions and to prevent or delay complications. CGA is now known as the best method by which to improve care outcomes and quality of life in older adults, and it requires a multidisciplinary approach. The aim of CGA is to identify older adults' needs, develop individual care plans, and improve care outcomes.1 Care outcomes are the results of treatment. They're also a key performance indicator for hospitals. The most common negative key performance indicators related to older adults are a long hospital stay, dying in the hospital, and unplanned readmission.2 The implementation of CGA may help control the care outcomes of older adults, as one of its main functions is to improve these outcomes. However, previous studies have shown inconsistent results related to CGA—although some have indicated that CGA improves care outcomes, others have found that CGA can worsen them. Specifically, many studies have reported that the implementation of the CGA model can reduce lengths of stay, readmission rates, and in-hospital mortality among hospitalized older adults, especially in the geriatric ward.3-6 However, others have reported these three care outcome parameters increased following the implementation of the CGA model.4-7 The reason for these inconsistencies requires further investigation. For example, it's possible that the method of CGA implementation varied among studies. As such, investigation is needed into how CGA is being conducted, especially the completeness of the CGA tool used; this is integral to achieving a comprehensive diagnosis and identifying appropriate interventions. Accordingly, this study was conducted to evaluate the completeness of the CGA tool and its relationship to care outcomes among older adults—especially readmission rates, lengths of hospital stay, and in-hospital mortality. Methods Investigators retrospectively evaluated older adults' medical records in one of the first—and largest—referral hospitals in Indonesia. To evaluate readmission rates, patients' medical records were reviewed for 30 days after discharge from the hospital. Included in this study was a sample of 222 hospitalized adults age 60 years or older who had a minimum of two diseases according to medical diagnosis. Older adults who were admitted or transferred to the ICU and those who were hospitalized for less than 24 hours were excluded from the study. The selection technique applied was stratified random sampling. Multiple logistic regression analyses were used to look for the predictor influence of the dependent variables of 30-day readmission and in-hospital death and examine the predictors of length of stay. Geriatric medical teams for participants performed various assessments to evaluate the completeness of the CGA. The researchers created this completeness evaluation, which comprised 4 domains (physical health, functional status, psychological health, and socioenvironmental status) broken into 21 items. The total completeness score ranged from 0 to 21. The data were then converted into percentages to facilitate analysis and evaluation. This evaluation utilized the observational checklist instrument, which had been tested for validity and reliability. Researchers conducted a pilot study to test this instrument and found it to be valid and reliable. It received a score of 0.89 using the content validity index (CVI). This CVI was reviewed by eight experts from Indonesia and Taiwan, including a geriatrician, a geriatric nurse, and gerontological nursing lecturers. The reliability test used an internal consistency and interrater reliability test. The internal consistency test analyzed by Kuder-Richardson Formula 20 with a result of 0.73 means the instrument is reasonably reliable in producing a consistent score. Results Completeness of CGA The overall average completeness of the CGA performed on the included patients was 68.19% (SD, 7.85). The CGA was more likely to be fully complete when conducted on the geriatric ward (71.99%; SD, 8.54) than on the nongeriatric ward (64.52%; SD, 4.85), with a significant difference (t = −7.99; P = .000). Table 1 presents a description of the CGA's completeness in terms of the total score and the score for each of the four evaluated domains. Table 1: - Description of the completeness of CGA (N = 222) Variables Mean ± SD Median (Range) 95% CI Completeness of CGA 68.19 ± 7.85 66.67 (52.38-85.71) 67.15-69.23 Physical health 84.73 ± 5.39 88.89 (77.78-88.89) 84.02-85.44 Functional status 39.34 ± 12.84 33.33 (33.33-66.67) 37.64-41.04 Psychological health 12.01 ± 25.68 00.00 (00.00-66.67) 8.62-15.41 Socioenvironmental status 86.04 ± 10.16 83.33 (50.00-100) 84.69-87.38 Looking at each domain in greater detail, only socioenvironmental status was completely evaluated by the medical care team. In each of the three other domains, at least one item wasn't examined at all. A detailed description of each item evaluated within the four domains is given below, and the data are presented in Table 2. Table 2: - Data distribution of the completeness of CGA for each item by ward type (N = 222) Type of ward Domain (mean ± SD)/Item, n (%) Nongeriatric (n = 113) Geriatric (n = 109) Total X2/U P Physical health 83.19 ± 5.58 86.34 ± 4.69 84.73 ± 5.39 4410 .000∗ Chief complaint 113 (100) 109 (100) 222 (100) - - Medical history 113 (100) 109 (100) 222 (100) - - Healthy behavior history 55 (48.7) 84 (77.1) 139 (62.6) 19.1 .000∗ Physical assessment 113 (100) 109 (100) 222 (100) - - Multimorbidity 113 (100) 109 (100) 222 (100) - - Polypharmacy 113 (100) 109 (100) 222 (100) - - Nutrition status 113 (100) 109 (100) 222 (100) - - Balance 0 0 0 - - Risk of fall 113 (100) 109 (100) 222 (100) - - Functional status 34.22 ± 5.38 44.65 ± 15.86 39.34 ± 12.84 4231 .000∗ Activity of daily living 113 (100) 109 (100) 222 (100) - - Instrumental of activity daily living 3 (2.7) 37 (33.9) 40 (18) 36.77 .000∗ Mobility 0 0 0 - - Psychological health 1.77 ± 10.77 22.63 ± 31.71 12.01 ± 25.68 4231 .000Re Cognition 3 (2.7) 37 (33.9) 40 (18) 36.77 .000∗ Delirium 0 0 0 - - Mood 3 (2.7) 37 (33.9) 40 (18) 36.77 .000∗ Socioenvironmental status 83.33 ± 9.71 88.84 ± 9.9 86.04 ± 10.16 4512.5 .000∗ Marital status 113 (100) 109 (100) 222 (100) - - Guardian 113 (100) 109 (100) 222 (100) - - Caregiver 106 (93.8) 108 (99.1) 214 (96.4) 4.45 .066 Environmental support 108 (95.6) 108 (99.1) 216 (97.3) 2.59 .213 Financial situation 109 (96.5) 104 (95) 213 (95.9) 0.16 .745 Social activity 16 (14.2) 43 (39.4) 59 (26.6) 18.18 .000∗ ∗Correlation is significant at the alpha level (.05). Care outcomes As shown in Table 3, compared with the older adults on the nongeriatric ward, those on the geriatric ward experienced a lower rate of readmission (4.6% versus 8%) but a higher rate of in-hospital death (13.8% versus 2.7%). In addition, the older adults hospitalized on the geriatric ward stayed in the hospital significantly longer than did the older adults on the nongeriatric ward (U = 4854; P = .006). Table 3: - Care outcomes in relation to ward type Type of ward Care outcomes Total Geriatric Nongeriatric X2/U Score P 30-day readmission, n (%) 0.58 .448 Yes 14 (6.3) 5 (4.6) 9 (8) No 208 (93.7) 104 (95.4) 104 (92) In-hospital death, n (%) 7.76 .005∗ Yes 18 (8.1) 15 (13.8) 3 (2.7) No 204 (91.9) 94 (91.9) 110 (97.3) Length of stay, median (range) 8 (2-62) 10 (2-34) 7 (2-62) 4854 .006∗ ∗Correlation is significant at the alpha level (.05). Completeness of CGA in relation to care outcomes The length of hospital stay care outcome showed different results from the other two outcomes as shown in Table 4. In general, there was a significant relationship between the completeness of the CGA and the length of stay (r = 0.15; P = .028). When evaluating by ward type, a significant relationship between the two parameters was observed for patients on the geriatric ward (r = 0.19; P = .041) but not for those on the nongeriatric ward (r = −0.081; P = .393). In other words, the length of hospital stay was significantly correlated with the completeness of the CGA for the total sample and for the geriatric ward. Both correlations were positive and moderate, meaning that the more complete the CGA was, the longer the hospital stay. Table 4: - Completeness of CGA in relation to care outcomes Completeness of CGA Care Outcomes Total (n = 222) Geriatric (n = 109) Nongeriatric (n = 113) Mean ± SD t/r (P) Mean ± SD t/r (P) Mean ± SD t/r (P) 30-day readmission 1.13 (.272) 0.92 (.361) −0.70 (.483) Yes 66.67 ± 4.94 68.57 ± 7.22 65.61 ± 3.18 No 68.29 ± 8.00 72.16 ± 8.59 64.42 ± 4.97 In-hospital death −0.33 (.739) 0.89 (.372) 0.95 (.346) Yes 68.78 ± 8.68 70.16 ± 8.72 61.90 ± 4.77 No 68.14 ± 7.79 72.29 ± 8.52 64.59 ± 4.85 Length of stay 0.15 (.028)∗ 0.19 (.041)∗ −0.08 (.393) ∗Correlation is significant at the alpha level (.05). Correlation between completeness of CGA and care outcomes, controlling for other variables The multiple logistic regression analysis found no significant results related to readmission. Only the type of ward had a significant influence on in-hospital death (odds ratio [OR] = 7.28; P = .004). This indicates that older adults hospitalized on the geriatric ward had a probability of death that was seven times higher than those hospitalized on the nongeriatric ward. Further, analysis indicated that the only predictor of length of stay was comorbidity. However, upon examining this by ward type, the completeness of the CGA had a significant impact on and predicted length of stay only for patients on the geriatric ward (B = 0.02; t = 2.08; P < .05). This result indicates that every change by one unit in the completeness of the CGA increased the length of stay by 2 days. Study authors hypothesize that when a CGA is more complete, more problems are identified, necessitating further medical treatment; accordingly, providing a comprehensive intervention to manage all the identified problems might result in a longer length of stay.6,8 Discussion Completeness of CGA The completeness of the CGA was defined as how comprehensively the geriatric medical team assessed participants during hospitalization. The analyses conducted in this study indicated that, on average, the reviewed CGAs were only slightly more than 50% complete. Unfortunately, this result can't be compared with other studies because no previous studies have evaluated CGA completeness. Moreover, this result doesn't correspond to the concept of CGA, which is the primary recommended intervention for geriatric wards.4 Although policy requirements are in place regarding the use of CGA as part of the provision of geriatric services, the percentage of CGA completeness on the geriatric ward alone was only about 72%. A comprehensive CGA is vital to establish diagnoses and ensure that the interventions provided are appropriate and in accordance with each patient's needs. The results also showed that CGA wasn't optimally implemented in the hospital setting, as some items were frequently skipped. As such, other medical teams—especially nurses—must contribute to the CGA, as they spend a significant amount of time with patients; their input could reduce missing data, making the CGA more comprehensive and complete, enhancing care outcomes for older adults. Care outcomes 30-day readmission. Based on a review of all the older patients who were readmitted within 30 days after discharge from the hospital, individuals on the nongeriatric ward had twice as many readmissions as did those on the geriatric ward. Previous related studies found that patients who had been treated in the CGA group had fewer readmissions.3,5 In terms of the relationship between the completeness of the CGA and readmission, the total sample score of the average number of older adults who were readmitted was lower than that of patients who didn't require readmission. On the nongeriatric ward, patients who were readmitted had a higher CGA completeness score than those who weren't readmitted. Even though this difference wasn't statistically significant, it's possible that on the geriatric ward, the more complete a CGA is, the more likely it is that a readmission event can be avoided. This result could be explained by the fact that, on the geriatric ward, a predefined CGA intervention package was implemented that included multidimensional assessment, multidisciplinary specialty expertise, geriatric meetings, care plans focused on patient-centered goals based on CGA results, the implementation of care plans by geriatric nurse specialists, and a continuous review of progress and care planning.4 In-hospital death. The rate of in-hospital death on the geriatric ward was about five times greater than that on the nongeriatric ward. Considering that the CGA was applied on the geriatric ward in the hospital analyzed in this study, this result was quite surprising. Nevertheless, the characteristics of patients on the geriatric ward—for example, being older and having more diseases—could be the reason why the mortality was higher. These results are also in line with a previous study, which showed that more older adults died on the geriatric ward than on the general ward.7 The relationship between the in-hospital mortality and the completeness of the CGA wasn't statistically significant. However, the mean CGA completeness score for older adults who didn't die in the hospital tended to be higher than that for patients who did, for both wards. This result is consistent with previous research, which stated that CGA can reduce mortality among hospitalized older adults.3,4,6 Length of stay. Length of hospital stay wasn't significantly related to age but was significantly related to comorbidities and ward type. The more illnesses a patient had, the longer their hospital stay. Further, older adults on the geriatric ward with more illnesses also stayed in the hospital longer than did those on the nongeriatric ward. This aligns with a previous study indicating that prolonged hospital stays often occur in older adults because of the higher incidence of complications, such as multimorbidity.9 The completeness of the CGA had a significant relationship with length of stay. For the total sample and on the geriatric ward, the relationship was positive and moderate or typical. This means that the more complete the CGA was, the longer the patient stayed in the hospital. This positive relationship is supported by previous studies.5-7 Limitations This study only evaluated the assessment part of the CGA, although there are three steps in the CGA process and six key features of CGA. The assessment part is the first stage. For effective implementation to improve care outcomes, the entire process and all of the key features need to be completed, although this wasn't the subject of the present study. Second, this study excluded older adults who were transferred to the ICU, High Care Unit, and Intensive Coronory Care Unit while they were hospitalized. This exclusion criterion was designed to control the condition of the older adults in both wards, so they were similar in acuity. However, this means the results underestimate the possibility that the older adults could die in the hospital, thus influencing mortality data. Third, the data for readmission were measured only by counting the rate of participants readmitted to the same hospital. Investigators didn't collect the reason for the readmission nor account for the possibility of patients being readmitted to another hospital. This could underestimate the readmission rate of the older patients. Fourth, the independent variables were few: age, comorbidity, ward type, and the completeness of CGA. The complex care outcomes of older adults might be influenced by many other factors, such as healthcare and patient factors, that warrant further investigation. Finally, these study results can only be generalized to similar settings and populations. Further revision of the 21-item evaluation for the CGA should be investigated in future studies. Implications for nurse leaders Nurse leaders, especially in geriatric settings, should understand that the CGA may not be optimally implemented in a hospital setting, and note which items aren't frequently assessed. The domains of functional status and psychological health in particular had a low completion rate. Although the entire team is responsible for addressing this concern, the nurse leader must identify and educate those who don't regularly complete full and complete evaluations. Involving nurses in the completion of the CGA would lead to more comprehensive assessments that ultimately improve care outcomes for older adults. These authors also challenge nurse leaders to get involved with policymaking to provide regulations for all medical teams that treat older adults, particularly in relation to geriatric assessments including the CGA. Getting to 100% The average CGA completeness score in this study was 68.19%, and the completeness rate in the geriatric ward was significantly higher than in the nongeriatric ward. There were three items that weren't documented in this study population: balance in the physical domain, mobility in the functional domain, and delirium in the psychological domain; these items should be emphasized for staff because they're important parameters in assessing the condition of hospitalized older adults. Of the four CGA domains, psychological health had the lowest average completeness rate, whereas socioenvironmental status had the highest average score. The overall evaluation showed that the CGA assessment wasn't optimally performed, even in the geriatric ward where it was the policy to do so. The 30-day readmission rate was 6.3%; more patients who were readmitted came from the nongeriatric ward compared with the geriatric ward, although this finding wasn't statistically significant. Similarly, the CGA completeness score of patients who weren't readmitted after 30 days was slightly higher than those who were readmitted, but again, this finding didn't reach statistical significance. In-hospital mortality was 8.1%, and older adults in the geriatric ward had significantly more deaths than those in the nongeriatric ward. However, those patients in both wards who survived had a more complete CGA. The median length of stay was 8 days (range, 2 to 62 days) and the length of stay in the geriatric ward was significantly longer than in the nongeriatric ward. Ultimately, the more complete the CGA, the longer the patient's length of stay.

Purpose: To examine factors associated with changes in mobility and living arrangements in a comprehensive geriatric outpatient assessment after hip fracture. Method: Population-based prospective data on 887 consecutive hip fracture patients aged 65 years and older. The domains of the geriatric assessment were the independent and changes in mobility level and living arrangements 4 months postoperatively the outcome variables. Results: Of the survivors, 499 (73%) attended the assessment. The mobility level had declined in 39% of the attendees and 38% of them had moved to more supported living arrangements 4 months after the hip fracture. In the age-adjusted univariate logistic regression analyses, almost all the domains of the comprehensive geriatric assessment were significantly associated with both outcomes. In the forward stepwise multivariate analysis, disability in activities of daily living, poor performance in Timed Up and Go and comorbidity as measured by the American Society of Anesthesiologists scores remained significantly associated with the outcomes. Conclusions: While comorbidity and disability in activities of daily living and mobility are the major indicators of poor outcomes of mobility and living arrangements after hip fracture, all the domains in the comprehensive geriatric assessment deserve attention during hip fracture care and rehabilitation.Implications for RehabilitationIn almost half of the patients the mobility level and living arrangements had deteriorated 4 months after the hip fracture, suggesting an urgent need for more effective postoperative rehabilitation.Almost all the domains of the comprehensive geriatric assessment were associated with poor outcomes and require equal attention during the acute and postacute phases of hip fracture care and in the course of rehabilitation.A geriatric outpatient assessment a few months after the hip fracture provides a check-point for the outcomes and an opportunity to target interventions at different domains of the comprehensive assessment.

Comprehensive Geriatric Assessment and Its Clinical Impact in Oncology

Objective To investigate the impact of comprehensive geriatric assessment(CGA)on treatment outcomes of chronic heart failure(CHF)complicated with emotional disorders in the elderly. Methods A total of 216 CHF patients with emotional disorders at Henan Provincial People’s Hospital were recruited from September 2017 to March 2019 and were randomly divided into a CGA group and a control group with 108 cases in each group.The control group was given standard drug treatment and psychological counseling, whereas individualized treatment was given to participants in the CGA group in compliance with CGA guidelines.The clinical effects after intervention for 8 weeks in the two groups were examined, using measures such as Hamilton Depression Rating Scale for Depression(HAMD)-24, Hamilton Anxiety Scale(HAMA)-14, amino-terminal pro-brain natriuretic peptide(NT-proBNP), the 6 minute walk test(6MWT)and left ventricular ejection fraction(LVEF). The changes of cognitive status, nutritional status, fall risk and other indicators in patients were comprehensively assessed and statistically analyzed. Results Compared with pre-treatment data, 8 weeks of treatment for both the control group and the CGA group resulted in decreased HAMD-24 scores(Control group: 31.78±9.08, 23.69±10.16; CGA group: 32.09±8.98, 15.35±7.91; P<0.05), HAMA-14 scores(Control group: 22.38±7.09, 15.28±6.54; CGA group: 21.99±8.12, 10.48±6.82; P<0.05)and NT-proBNP levels[Control group: (4672±392)ng/L, (3279±282)ng/L; CGA group: (4861±378)ng/L, (2387±215)ng/L; P<0.05], and increased LVEF(%)[Control group(34.5±6.2)%, (39.8±7.5)%; CGA group(35.1±3.9)%, (42.5±6.1)%; P<0.05]and 6MWT scores[Control group(298±79±7.5)m, (358±102)m; CGA group(305±98)m, (402±178)m; P<0.05], with more marked changes in all the measures in the CGA group than in the control group(P<0.05). Conclusions The early application of CGA can improve the condition and prognosis in elderly heart failure patients complicated with emotional disorders. Key words: Geriatric comprehensive assessment; Heart failure; Mood disorders

796 Background: Comprehensive geriatric assessment (CGA) is recommended to inform treatment decisions in older patients with cancer. Patients ≥ 70 years are referred to the Geriatric Oncology and Liaison (GOAL) clinic in University Hospital Waterford, for a pre-treatment CGA, which includes assessment of mobility, cognitive, nutritional, functional, and psychological status, along with comprehensive geriatric pharmacological assessment. Informed treatment recommendations are made using CGA outcomes and risk assessed using the Cancer and Aging Research Group toxicity calculator. Limited information exists on treatment decisions based on age subgroups within the geriatric oncology population. Methods: Data from patients with gastrointestinal (GI) malignancies attending the GOAL clinic over a 3-year period to September 2022 were included. Patients ≥ 70 years with a G-8 (screening tool) score ≤14, and all patients aged ≥ 80 underwent CGA. An age-based subgroup analysis (&lt; 80 vs ≥ 80) of systemic anti-cancer therapy (SACT) decisions was performed using the Chi-square test. Results: In total, 206 patients with GI malignancies were assessed, comprising 67 (33%) patients with gastroesophageal cancer, 40 (19%) with pancreaticobiliary and 92 (45%) with colorectal cancer. 40% of patients were ≥ 80 years (n = 83). The majority of patients had stage III/IV disease (82%, n = 168). Across all groups, 58% (n = 120) of patients were treated with SACT, comprising 70% of those &lt; 80 (n = 86) and 41% (n= 34) of those ≥ 80. Across all stages (I-IV), patients ≥ 80 years were less likely to be treated with SACT compared to patients &lt; 80 years (p &lt; 0.01). There was no significant difference between age groups when comparing treatment intent (curative vs palliative) (p = 0.15). There was no significant difference between age groups for baseline dose reductions vs full dose (p = 0.18). Patients ≥ 80 years were less likely to receive polychemotherapy regimens in comparison with the &lt; 80 subgroup (p &lt; 0.01). Conclusions: Older patients with GI malignancies are a heterogeneous population. In the setting of a CGA, patients ≥ 80 years are less likely to receive SACT across any stage group, and are more likely to receive monochemotherapy regimens. The use of CGA ensures a considered and personalised approach to identify older adults most likely to benefit from active treatment and those where best supportive care alone is more appropriate.

The impact of comprehensive geriatric assessment on final treatment decisions

With changing world demographics, increasing numbers of older patients present with complex surgical diseases and will require surgical management, mainly in the emergency setting.Ageing is associated with multimorbidity and frailty, both of which are independent predictors of adverse outcomes.Screening surgical patients for frailty, using specific tools, can lead to targeted interventions that reduce perioperative complications and length of hospital stay.In the last 10 years, perioperative models of care incorporating Comprehensive Geriatric Assessment and optimisation methodology have been implemented for elective surgical procedures.In the emergency setting, surgeons are required to make critical, time-sensitive decisions, often with limited information and high responsibility. A comprehensive geriatric multidisciplinary assessment could support them in practice to improve the management of geriatric surgical patients.We aim to report the last evidence about the comprehensive geriatric assessment for geriatric surgical patients, including its implementation in the emergency setting through a focused narrative review.Graphical

At times, comprehensive geriatric assessment (CGA) appears to be a black box. The patient enters from one side, frail and with unknown and unaddressed medical needs. After undergoing the assessment process and suggested therapeutic interventions, the patient emerges functionally improved. It may be blasphemous to compare the only "technology" that geriatrics will probably ever have to a black box. But it is an appropriate metaphor about the process of geriatric assessment, whether conducted within the realm of a specialized unit or in a clinic. It is generally unclear which part of the process is responsible for improved outcomes. Therefore, the entire process of CGA is applied to each patient. The article by Naughton and colleagues1 in this issue of the Journal presents the results of a randomized trial in which the intervention should be commended for its simplicity. The assessment process used in the study removed most of the trappings of specialized units and has reduced geriatric assessment to its essence; the evaluation and management of chronically ill and functionally frail older adults by a geriatrician and a social worker. Naughton et al have given us a starting point for the next generation of trials of CGA. We already understand a great deal about CGA and where it appears to be effective. A recent meta-analysis of 28 controlled trials examined the impact of five different models of CGA on patient outcomes. Different types of CGA have different effects on patient outcomes. For example, inpatient Geriatric Evaluation and Management Units (GEMUs) have the greatest effect on reducing mortality, while outpatient interventions have failed to demonstrate an impact on mortality. However, all types of CGA have been shown to increase the likelihood of a patient living at home. Finally, there is convincing evidence that CGA with continued long term management appears to be more effective in maintaining the positive effects of the intervention. There is an even greater amount of information that we do not know about CGA. For example, what is the optimum number and composition of an assessment team to maximize patient outcomes? Does every team need a physician, nurse practitioner, social worker, and a cadre of therapists to evaluate each patient? Could complex patients first be screened by a trained health professional with triage to other health professionals as appropriate? There are a large number of screening instruments available to assess such important domains of the frail elderly as cognitive status, gait, and balance. A structured approach to the assessment process is important to its success. But how are these instruments utilized in clinical practice, and who is the best professional to administer them to the patient? This most recent study allows us to shed some light into the black box and the process of geriatric assessment. It is important to understand that the complexity of patient medical problems will vary according to where CGA is delivered; therefore, not only the intervention components, but also the assessment goals and outcomes are different for each type of CGA. In this study, the assessment was designed to efficiently manage the acute care hospitalization. The geriatrician-led intervention was efficient; it produced the same or similar clinical patient outcomes at a lower cost. The intervention team focused on those functional needs and limitations of the acutely ill patients that would interfere with hospital discharge. The intervention was not a predetermined mix of services, but individually tailored to meet patient needs. Instead of applying all parts of CGA to all patients, the patient undergoing assessment should be exposed to increasingly finer filters to detect impairment and make the appropriate interventions. This study utilized this principle in the initial assessment of the patient. Because of this fundamental change in structure, the intervention was not a costly add-on for the hospital; rather it was a value-added intervention for the patient. If CGA is to survive under our evolving system of health care reimbursement, it has to be value-added; CGA must produce the same or better patient outcomes, compared with usual clinical care, at the same cost. When appropriately utilized for the right group of patients, CGA is an effective clinical intervention. However, as objective clinicians and researchers, we cannot afford to have CGA provide excellent care at higher costs. If we do, CGA will probably cease to exist as a clinical intervention. The next phase of evaluation of CGA should not be where to put the box, but what is inside of it. What components of the assessment process lead to improved patient outcomes, and who is best trained to provide each component? If CGA is to evolve and become a powerful clinical tool, we must focus on creating the most efficient and effective models for delivering assessment services. Achievement of that goal will improve health care delivery for frail older adults.

Comparison between Vulnerable Elders Survey-13 and Comprehensive Geriatric Assessment in Predicting Clinical Outcomes in Aggressive Lymphomas

Objective To develop the comprehensive geriatric assessment (CGA) nursing information management system and to explore its application value. Methods CGA and mobile nursing information system were combined to design and develop the CGA nursing information management system. Totally 196 geriatric inpatients admitted in Geriatric Hospital of Nanjing Medical University from April 1st to June 30th, 2018 were selected using convenient sampling. These geriatric patients were managed by the well-trained nursing staff using the system, including CGA at admission and before discharge and continuous CGA. The changes of CGA at admission and discharge were used to assess the clinical application value of the CGA nursing information management system. Results The consistency rate of the implementation of CGA nursing intervention with CGA nursing norms was 67%-91%. The geriatric patients' pain scores at discharge decreased compared with those at admission (P 0.05) . Conclusions The CGA nursing information management system is conductive to the implementation of CGA clinically, the monitoring of the effects of CGA nursing intervention, and the nursing quality control by nursing managers, which is worth promoting clinically and in communities. Key words: Aged; Comprehensive geriatric assessment (CGA); Mobile nursing; Nursing information management system

Comprehensive Geriatric Assessment (CGA) is a multidimensional interdisciplinary diagnostic process focused on determining an older person's medical, psychological and functional capability in order to develop a co-ordinated and integrated care plan. CGA is not limited simply to assessment, but also directs a holistic management plan for older people, which leads to tangible interventions. While there is established evidence that CGA reduces the likelihood of death and disability in acutely unwell older people, the effectiveness of CGA for community-dwelling, frail, older people at risk of poor health outcomes is less clear. To determine the effectiveness of CGA for community-dwelling, frail, older adults at risk of poor health outcomes in terms of mortality, nursing home admission, hospital admission, emergency department visits, serious adverse events, functional status, quality of life and resource use, when compared to usual care. We searched CENTRAL, MEDLINE, Embase, CINAHL, three trials registers (WHO ICTRP, ClinicalTrials.gov and McMaster Aging Portal) and grey literature up to April 2020; we also checked reference lists and contacted study authors. We included randomised trials that compared CGA for community-dwelling, frail, older people at risk of poor healthcare outcomes to usual care in the community. Older people were defined as 'at risk' either by being frail or having another risk factor associated with poor health outcomes. Frailty was defined as a vulnerability to sudden health state changes triggered by relatively minor stressor events, placing the individual at risk of poor health outcomes, and was measured using objective screening tools. Primary outcomes of interest were death, nursing home admission, unplanned hospital admission, emergency department visits and serious adverse events. CGA was delivered by a team with specific gerontological training/expertise in the participant's home (domiciliary Comprehensive Geriatric Assessment (dCGA)) or other sites such as a general practice or community clinic (community Comprehensive Geriatric Assessment (cCGA)). Two review authors independently extracted study characteristics (methods, participants, intervention, outcomes, notes) using standardised data collection forms adapted from the Cochrane Effective Practice and Organisation of Care (EPOC) data collection form. Two review authors independently assessed the risk of bias for each included study and used the GRADE approach to assess the certainty of evidence for outcomes of interest. We included 21 studies involving 7893 participants across 10 countries and four continents. Regarding selection bias, 12/21 studies used random sequence generation, while 9/21 used allocation concealment. In terms of performance bias, none of the studies were able to blind participants and personnel due to the nature of the intervention, while 14/21 had a blinded outcome assessment. Eighteen studies were at low risk of attrition bias, and risk of reporting bias was low in 7/21 studies. Fourteen studies were at low risk of bias in terms of differences of baseline characteristics. Three studies were at low risk of bias across all domains (accepting that it was not possible to blind participants and personnel to the intervention). CGA probably leads to little or no difference in mortality during a median follow-up of 12 months (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.76 to 1.02; 18 studies, 7151 participants (adjusted for clustering); moderate-certainty evidence). CGA results in little or no difference in nursing home admissions during a median follow-up of 12 months (RR 0.93, 95% CI 0.76 to 1.14; 13 studies, 4206 participants (adjusted for clustering); high-certainty evidence). CGA may decrease the risk of unplanned hospital admissions during a median follow-up of 14 months (RR 0.83, 95% CI 0.70 to 0.99; 6 studies, 1716 participants (adjusted for clustering); low-certainty evidence). The effect of CGA on emergency department visits is uncertain and evidence was very low certainty (RR 0.65, 95% CI 0.26 to 1.59; 3 studies, 873 participants (adjusted for clustering)). Only two studies (1380 participants; adjusted for clustering) reported serious adverse events (falls) with no impact on the risk; however, evidence was very low certainty (RR 0.82, 95% CI 0.58 to 1.17). CGA had no impact on death or nursing home admission. There is low-certainty evidence that community-dwelling, frail, older people who undergo CGA may have a reduced risk of unplanned hospital admission. Further studies examining the effect of CGA on emergency department visits and change in function and quality of life using standardised assessments are required.

Medication reconciliation as part of a Comprehensive Geriatric Assessment by a specialist pharmacist is a process that has been shown to be beneficial in terms of medication adherence in patients taking oral anticancer medication and potentially cost-effective in cancer patients. Medication review guidelines in older adults with cancer suggest using polypharmacy (≥ 5 medications) as an indication for medication review in older adults with cancer. We present a case where a medication review as part of a Comprehensive Geriatric Assessment in the absence of polypharmacy resulted in two pharmacist interventions when standard care resulted in no intervention. A 71-year-old male prescribed capecitabine for rectal cancer had a medication reconciliation done as standard care before starting an oral anticancer medication. He then proceeded to get a medication review as part of a Comprehensive Geriatric Assessment and was deemed to have a potentially excessive anticholinergic burden and underprescribed gastro protection. This case is interesting as it occurred in a patient who would not have met the current inclusion criteria for a medication review as part of a Comprehensive Geriatric Assessment. As a result of the Comprehensive Geriatric Assessment, a letter was written to the patient's general practitioner, recommending a change to anti-depressant therapy to optimise anticholinergic burden, as well as introducing a proton-pump inhibitor upon completion of the Capecitabine protocol concurrent with radiotherapy, to confer gastro-protection against the antidepressant medication, as per the START criteria. Upon discharge from medical oncology, neither of the changes had been adopted by the patient's general practitioner. This highlights one of the challenges facing clinical pharmacists in an outpatient setting, where evidence-based recommendations are not always implemented as care transitions from tertiary to primary care. Comprehensive Geriatric Assessment is a process that identifies potential issues in older adults with cancer that aren't identified with standard medication review. This is also evident for medication reviews as part of a Comprehensive Geriatric Assessment, and where resources allow, and recommendations are likely to be accepted, it should be offered to all older adults with cancer. Pharmacists are still faced with challenges in implementing recommendations from medication reviews, particularly in healthcare systems where pharmacist prescribing has yet to be introduced.

Comprehensive geriatric assessment (CGA) may benefit frail or chronically ill patients in the emergency department (ED), but take too much time to be performed routinely in ED. An alternative approach is to use first a screening tool to detect high-risk patients and then perform CGA in these patients only. This systematic review focuses on the use and value of CGA in ED for evaluation of older patients and its influence on adverse outcomes. This approach is compared with an alternative one using existing screening tools, validated in ED, to detect high-risk patients needing subsequent CGA. This review ends by suggesting a short assessment of CGA to be used in ED and ways to improve home discharge management from ED. A systematic English Medline literature search was conducted in December 2009, with no date limit with the following Medical Subject Heading (MeSH) terms: "Frail Elderly", "Health Services for Aged", "Community Health Nursing", "Emergency Service, Hospital", "Geriatric Assessment", "Patient Discharge", "Risk Assessment" and "Triage". We selected 8 studies on CGA efficiency and 14 on screening tools. CGA in ED is efficient for decreasing functional decline, ED readmission and possibly nursing home admission in high-risk patients. As CGA takes too much time to be performed routinely in ED, validated screening tools can be applied to detect high-risk patients who will benefit most from CGA. The selected studies demonstrated that screening of high-risk patients is more efficient than age-based screening, and that CGA performed in ED, followed by appropriate interventions, improves outcomes.

Comprehensive Geriatric Assessment in the Older Adult with Cancer: A Review

Objective To evaluate the effectiveness of comprehensive geriatric assessment in hospital for older adults admitted as an emergency.Search strategy We searched the EPOC Register, Cochrane’s Controlled Trials Register, the Database...