Mauricio has sent you an UpToDate topic
Mauricio
UpToDate is a clinical information service that has thousands of topics such as this one, designed to give immediate answers to clinical questions. Visit them on the web at www.uptodate.com.
| ©2011 UpToDate ® |
| Comprehensive geriatric assessment | ||
| Authors Katherine T Ward, MD David B Reuben, MD | Section Editor Kenneth E Schmader, MD | Deputy Editor Pracha Eamranond, MD, MPH |
| Last literature review version 19.2: Maio 2011 | This topic last updated: Fevereiro 11, 2011 | ||
INTRODUCTION — Geriatric conditions such as functional impairment and dementia are common and frequently unrecognized or inadequately addressed in older adults. Identifying geriatric conditions by performing a geriatric assessment can help clinicians manage these conditions and prevent or delay their complications.
Although the geriatric assessment is a diagnostic process, the term is often used to include both evaluation and management. Geriatric assessment is sometimes used to refer to evaluation by the individual clinician (usually a primary care clinician or a geriatrician) and at other times is used to refer to a more intensive multidisciplinary program, also known as a comprehensive geriatric assessment (CGA).
This topic will review the indications for CGA, as well as its major components and evidence of its efficacy. General issues of geriatric health maintenance and the assessment of specific geriatric populations are discussed elsewhere. (See "Geriatric health maintenance" and "Comprehensive geriatric assessment for patients with cancer" and "Failure to thrive in elderly adults: Evaluation".)
BACKGROUND — Comprehensive geriatric assessment (CGA) is defined as a multidisciplinary diagnostic and treatment process that identifies medical, psychosocial, and functional limitations of a frail elderly person in order to develop a coordinated plan to maximize overall health with aging [1,2]. The health care of an older adult extends beyond the traditional medical management of illness. It requires evaluation of multiple issues including physical, cognitive, affective, social, financial, environmental, and spiritual components that influence an older adult's health. CGA is based on the premise that a systematic evaluation of frail, older persons by a team of health professionals may identify a variety of treatable health problems and lead to better health outcomes.
CGA programs are usually initiated through a referral by the primary care clinician or by a clinician caring for a patient in the hospital setting. The content of the assessment varies depending on different settings of care (eg, home, clinic, hospital, nursing home). CGA is not available in all settings, due to issues related to the time required for evaluation, need for coordination of multidisciplinary specialties, and lack of reimbursement for some components (eg, outpatient social work, pharmacy, and nutrition).
INDICATIONS FOR REFERRAL — The best evidence for CGA is based on identifying appropriate patients (ie, excluding patients who are either too well or are too sick to derive benefit). No criteria have been validated to readily identify patients who are likely to benefit from CGA. Specific criteria used by CGA programs to identify patients include:
- Age
- Medical comorbidities such as heart failure or cancer
- Psychosocial disorders such as depression or isolation
- Specific geriatric conditions such as dementia, falls, or functional disability
- Previous or predicted high health care utilization
- Consideration of change in living situation (eg, from independent living to assisted living, nursing home, or in-home caregivers)
One outpatient approach would be to refer patients for CGA who are found to have problems in multiple areas during geriatric assessment screens. Major illnesses (eg, those requiring hospitalization or increased home resources to manage medical and functional needs) should also prompt referral for CGA, particularly for functional status, fall risk, cognitive problems, and mood disorders. (See "Geriatric health maintenance" and 'Major components' below.)
An inpatient approach would be to refer elderly patients admitted for a specific medical or surgical reason (eg, fractures, failure to thrive, recurrent pneumonia, pressure sores). Another approach would be to have all patients above a certain age (eg, 85 years) receive preliminary screening to determine whether a full multidisciplinary evaluation is needed.
Most outpatient CGA programs exclude patients who are unlikely to benefit because of terminal illness, severe dementia, complete functional dependence, and inevitable nursing home placement. Exclusionary criteria have also included identifying older persons who are "too healthy" to benefit, such as those who are completely functional without any medical comorbidities.
ASSESSMENT TEAM — The range of health care professionals working in the assessment team varies based on the services provided by individual CGA programs. In many settings, the CGA process relies on a core team consisting of a physician, nurse, and social worker and, when appropriate, draws upon an extended team of physical and occupational therapists, nutritionists, pharmacists, psychiatrists, psychologists, dentists, audiologists, podiatrists, and opticians. Although these professionals are usually on staff in the hospital setting and are also available in the community, access to and reimbursement for these services have limited the availability of CGA programs. Increasingly, CGA programs are moving towards a "virtual team" concept in which members are included as needed, assessments are conducted at different locations on different days, and team communication is completed via telephone or electronically.
Traditionally, the various components of the evaluation are completed by different members of the team, with considerable variability in the assessments. The medical assessment of older persons may be conducted by a physician (usually a geriatrician), nurse practitioner, or physician's assistant. The core team (geriatrician, nurse, social worker) may conduct only brief initial assessments or screens for some dimensions. These may be subsequently augmented with more in-depth evaluations by additional professionals. As an example, a dietitian may be needed to assess dietary intake and provide recommendations on optimizing nutrition, or an audiologist may need to conduct a more extensive assessment of hearing loss and evaluate an older person for a hearing aid.
CONDUCTING THE ASSESSMENT
Framework — Conceptually, CGA involves several processes of care which are shared over several providers in the assessment team. The overall care rendered by CGA teams can be divided into six steps:
- Data gathering
- Discussion among the team
- Development of a treatment plan
- Implementation of the treatment plan
- Monitoring response to the treatment plan
- Revising the treatment plan
Each of these steps is essential if the process is to be successful at achieving maximal health and functional benefits.
Several different models for CGA have been implemented in various health care settings. An increasing number of CGA programs are relying on post-discharge assessment due to the decrease in length of hospital stay. Furthermore, while most of the early CGA programs focused on restorative or rehabilitative goals (tertiary prevention), many newer programs are aimed at primary and secondary prevention. (See "Geriatric health maintenance", section on 'Classification of preventive measures'.)
Assessment tools — Although the amount of potentially important information may seem overwhelming, formal assessment tools and shortcuts can reduce this burden on the clinician performing the initial CGA [3]. A pre-visit questionnaire sent to the patient or caregiver prior to the initial assessment can be a timesaving method to gather a large amount of information [4] (table 1) and (table 2).
These questionnaires can be used to gather information about general history (eg, past medical history, medications, social history), as well as gather information specific to CGA, such as:
- Ability to perform functional tasks and need for assistance
- Fall history
- Sources of social support, particularly family or friends
- Depressive symptoms
- Vision or hearing difficulties
- Whether the patient has specified a durable power of attorney
Office staff can be trained to administer screening instruments to both save time and help the clinician to hone in on specific disabilities that need more detailed evaluation.
MAJOR COMPONENTS — Core components of CGA that should be evaluated during the assessment process are as follows:
- Functional capacity
- Fall risk
- Cognition
- Mood
- Polypharmacy
- Social support
- Financial concerns
- Advanced care preferences
Additional components may also include evaluation of the following:
- Nutrition/weight change
- Urinary continence
- Sexual function
- Vision/hearing
- Dentition
- Living situation
- Spirituality
This section will focus on the core components of CGA. Although other aspects of the geriatric assessment are usually addressed during the CGA (eg, vision/hearing, nutrition), these components are discussed separately. (See "Geriatric health maintenance".)
Functional status — Functional status refers to the ability to perform activities necessary or desirable in daily life. Functional status is directly influenced by health conditions, particularly in the context of an elder's environment and social support network. Changes in functional status (eg, not being able to bathe independently) should prompt further diagnostic evaluation and intervention. Measurement of functional status can be valuable in monitoring response to treatment and can provide prognostic information that assists in long-term care planning.
Activities of daily living — An older adult's functional status can be assessed at three levels: basic activities of daily living (BADLs), instrumental or intermediate activities of daily living (IADLs), and advanced activities of daily living (AADLs).
BADLs refer to self-care tasks which include:
- Bathing
- Dressing
- Toileting
- Maintaining continence
- Grooming
- Feeding
- Transferring
IADLs refer to the ability to maintain an independent household which include:
- Shopping for groceries
- Driving or using public transportation
- Using the telephone
- Performing housework
- Doing home repair
- Preparing meals
- Doing laundry
- Taking medications
- Handling finances
AADLs vary considerably from individual to individual. These advanced activities include the ability to fulfill societal, community, and family roles as well as participate in recreational or occupational tasks.
Scales that measure functional status at each of these levels have been developed and validated. The Vulnerable Elders Scale-13 (VES-13) is a 13-item screening tool that is based upon age, self-rated health, and the ability to perform functional and physical activities [5-7]. It identifies populations of community-dwelling elders at increased risk for functional decline or death over a five year period (table 3). The VES-13 can be self-administered or administered by nonmedical personnel over the telephone or at an office visit in less than five minutes.
Questions that ask about specific BADL and IADL functions have also been incorporated into a variety of more generic, health-related quality-of-life instruments (eg, the Medical Outcomes Study Short-form and its shorter version, the SF-12) [6,8,9]. Some AADLs (eg, exercise and leisure time physical activity) can be ascertained by using standardized instruments. However, given the broad nature of AADLs, open-ended questions asking how one's day is spent might provide a better assessment of function in healthier older persons.
Adults over age 70 are more likely to have motor vehicle accidents, as well as increased associated mortality. The patient's ability and safety to drive a car should also be evaluated in the functional assessment. (See "Approach to the evaluation of older drivers".)
In addition, measurement of gait speed predicts functional decline and early mortality in older adults [10]. Assessing gait speed in clinical practice may identify patients who need further evaluation, such as those at increased risk of falls.
Falls/imbalance — Approximately one-third of community-dwelling persons age 65 years and one-half of those over 80 years of age fall each year. Patients who have fallen or have a gait or balance problem are at higher risk of having a subsequent fall and losing independence. An assessment of fall risk should be integrated into the history and physical examination of all geriatric patients (algorithm 1). (See "Falls in older persons: Risk factors and patient evaluation", section on 'Falls risk assessment' and "Gait disorders of elderly patients".)
Cognition — The incidence of dementia increases with age, particularly among those over 85 years, yet many patients with cognitive impairment remain undiagnosed. The value of making an early diagnosis includes the possibility of uncovering treatable conditions. The evaluation of cognitive function can include a thorough history, brief cognition screens, a detailed mental status examination, neuropsychologic testing, tests to evaluate medical conditions that may contribute to cognitive impairment (eg, B12, TSH), depression assessment, and/or radiographic imaging (CT or MRI). (See "Evaluation of cognitive impairment and dementia".)
Mood disorders — Depressive illness in the elder population is a serious health concern leading to unnecessary suffering, impaired functional status, increased mortality, and excessive use of health care resources. (See "Diagnosis and management of late-life depression".)
Late-life depression remains underdiagnosed and inadequately treated. Depression in the elderly may present atypically, and may be masked in patients with cognitive impairment. A two question screener is easily administered and likely to identify patients at risk if both questions are answered affirmatively [11]. The questions are:
"During the past month, have you been bothered by feeling down, depressed or hopeless?"
"During the past month, have you been bothered by little interest or pleasure in doing things?"
This two-question screen is sensitive, but not specific (table 4). It may be best used in tandem with a second screen such as the Patient Health Questionnaire-9 (PHQ-9) [12]. The PHQ-9 has increasingly been used to detect and monitor depression symptoms among elder adults (table 5) [13]. The PHQ-9 provides a reliable and valid measure of depression severity.
A variety of other screens for depression are available and each has its advantages and disadvantages [14].
Polypharmacy — Older persons are often prescribed multiple medications by different health care providers, putting them at increased risk for drug-drug interactions and adverse drug events. The clinician should review the patient's medications at each visit. The best method of detecting potential problems with polypharmacy is to have patients bring in all of his/her medications (prescription and nonprescription) in their bottles. Entering the medication list electronically can help to detect potential medication errors. (See "Drug prescribing for older adults" and "Medical care of the nursing home patient in the United States", section on 'Prevention of adverse drug events'.)
Elder patients should also be asked about alternative medical therapy. As an example, asking about herb use can be done with: "What prescription medications, over the counter medicines, vitamins, herbs, or supplements do you use?" (see "Overview of herbal medicine and dietary supplements").
Social and financial support — The existence of a strong social support network in an elder's life can frequently be the determining factor of whether the patient can remain at home or needs placement in an institution. A brief screen of social support includes taking a social history and determining who would be available to the elder to help if he or she becomes ill. Early identification of problems with social support can help planning and timely development of resource referrals. For patients with functional impairment, the clinician should ascertain who the person has available to help with activities of daily living. (See 'Activities of daily living' above.)
Caregivers should be screened periodically for symptoms of depression or caregiver burnout and, if present, referred for counseling or support groups. Elder mistreatment should be considered in any geriatric assessment, particularly if the patient presents with contusions, burns, bite marks, genital or rectal trauma, pressure ulcers, or malnutrition with no clinical explanation. (See "Elder mistreatment: Abuse, neglect, and financial exploitation".)
The financial situation of a functionally impaired older adult is important to assess. Elders may qualify for state or local benefits, depending upon their income. Older patients occasionally have other benefits such as long-term care insurance or veteran's benefits that can help in paying for caregivers or prevent the need for institutionalization.
Advanced care preferences — Clinicians should begin discussions with all patients about preferences for specific treatments while the patient still has the cognitive capacity to make these decisions. Advance directives help guide therapy if a patient is unable to speak for himself or herself. Included in that discussion should be appointing a durable power of attorney (also known as a health care proxy) to serve as a surrogate in the event of personal incapacity. Once the power of attorney is determined, it is important that clinicians have a discussion with the power of attorney to help understand the patient's advanced care preferences. Establishing advanced directives, living wills, and power of attorney are vital to caring optimally for the geriatric population. (See "Ethical issues near the end of life".)
EFFICACY — Most meta-analyses have found that CGA leads to improved detection and documentation of geriatric problems [1,15-19]. However, the ability of CGA to improve outcomes (eg, decreased hospitalization, nursing home admission, and mortality) depends on specific CGA models and the settings where they have been implemented.
Several meta-analyses of randomized trials have evaluated five models of CGA [1,15-19]:
- Home geriatric assessment
- Acute geriatric care units
- Post-hospital discharge
- Outpatient consultation
- Inpatient consultation
Home geriatric assessment and acute geriatric care units have been shown to be consistently beneficial for several health outcomes. In contrast, the data are conflicting for post-hospital discharge, outpatient geriatric consultation, and inpatient geriatric consultation services.
Home assessment — Home geriatric assessment programs focus primarily on preventive rather than rehabilitative services. Although home assessment programs vary, most programs include a visiting nurse trained in geriatric care, as well as a physical therapist, social worker, psychologist, and specialty referrals when appropriate. In addition to home visits, telephone follow-up is routinely performed. Patients assessed at home are usually followed for at least one year.
Multiple meta-analyses have found home assessments to be consistently effective in reducing functional decline as well as overall mortality [1,16-18]. As an example, a meta-analysis of 21 randomized trials found that multidimensional home visit programs were effective in reducing functional decline if a clinical examination was conducted (OR 0.64, CI 0.48-0.87) and in reducing mortality in patients age ≤77 years old (OR 0.74, 95% CI 0.58-0.94) [18]. However, the home visits did not significantly prevent nursing home admissions (OR 0.86, CI 0.68-1.10). Like other meta-analyses for home assessments, this study was limited by heterogeneity across studies for all outcomes.
Acute geriatric care units — Several inpatient geriatric unit approaches have been developed in a variety of clinical settings. Within the Department of Veterans Affairs Hospitals, these are usually referred to as Geriatric Evaluation and Management Units (GEMUs). In academic and private sector hospitals, they are usually labeled Acute Care of the Elderly (ACE) units. ACE units initially included structural modifications to promote mobility and simulate living conditions at home in preparation for a return to independence. More recently, however, ACE units are located on conventional hospital wards as designated geriatric units and tend to focus exclusively on processes of care.
GEMUs are hospital wards that care for frail elderly patients through the multidisciplinary team approach. GEMUs have two main advantages over inpatient CGA consultation models. First, physicians staffing the unit generally assume primary care of the patient, thus facilitating the implementation of recommendations. Second, the availability and experience of a dedicated team of providers (eg, nurses and therapists) increase the consistency and geriatric orientation of hospital care.
One meta-analysis of 17 randomized trials evaluating geriatric rehabilitative units (within an acute care hospital or a rehabilitation hospital) found that inpatient multidisciplinary programs were associated with improvement in all outcomes at discharge, including better functional status (OR 1.75, 95% CI 1.31-2.35), decreased nursing home admission (RR 0.64, 0.51-0.81), and reduced mortality (RR 0.72, 0.55-0.95) [19]. This meta-analysis was limited by heterogeneity of interventions across studies. Moreover, due to length of stay (up to three months), such rehabilitative units are rarely available in the United States outside the Department of Veterans Affairs hospitals.
ACE units in acute care hospitals promote mobility and include processes to provide patient-centered care with nursing-initiated protocols. ACE units involve more intensive discharge planning and more detailed education to improve medication compliance, in comparison to usual hospital care. In clinical trials, care in ACE units was associated with greater independence in ADLs at discharge, less frequent discharge to a nursing home, shorter and less expensive hospitalization [20], as well as higher satisfaction rates among patients, family members, physicians, and nurses [21].
Due to the logistical barriers of having dedicated geriatric inpatient units (eg, unfilled beds when the census is light, overflow to other units when the unit is full), some programs have attempted to recreate the core elements of ACE units for hospitalized older persons who are not located on a single unit [22]. Whether these "virtual" units are as effective as ACE units is unknown. The lack of a consistent nursing staff that is trained in the care of older persons may diminish the effectiveness of this model.
Post-hospital discharge — Key elements of post-hospital discharge geriatric assessment include targeting criteria to identify vulnerable patients, a program of multidimensional assessment, comprehensive discharge planning, and home follow-up with nurses with specialized geriatrics training who visit the patients during the hospitalization and at least twice during the weeks following discharge. This intervention usually is initiated one to two days prior to hospital discharge. Similar to the home assessments discussed above, the post-discharge home visits are supplemented by telephone calls and additional visits by physical therapy, occupational therapy, social work, and/or home nursing services when indicated. (See 'Home assessment' above.)
Studies of CGA have found inconsistent benefit for post-hospital discharge programs [1,23-25]. As an example, in a randomized trial of post-hospitalization CGA conducted in the home versus usual care, there was no difference between treatment and control arms in reducing functional decline, readmission rates, or mortality after 60 days [23]. In another randomized trial of comprehensive discharge planning with home follow-up versus usual care, there was no difference in functional status, post-discharge acute care visits, depression, or patient satisfaction after 24 weeks [24]. However, those randomly assigned to the intervention were less likely to be readmitted to the hospital compared to the control group (20 versus 37 percent, respectively). The intervention was also associated with a reduction in cost.
CGA programs for patients discharged to home from the emergency department were found to be effective at reducing emergency room visits and hospital admission [25].
Outpatient consultation — Although meta-analyses have not shown benefit of outpatient CGA consultation [1,15], more complex CGA programs that address adherence to program recommendations and treat patients at higher risk of hospitalization have led to improved outcomes [26,27].
The first meta-analysis to evaluate CGA included four randomized trials and did not demonstrate benefit from outpatient CGA consultation in terms of hospital admission, nursing home placement, or physical/cognitive function [1]. However, one trial from this meta-analysis did not address whether recommendations from CGA were implemented and another trial included patients with poor prognoses, which may limit the generalizability of these data.
Some [26-29], but not all [30], of the subsequent randomized trials have shown some efficacy of outpatient CGA. Representative trials include:
- CGA coupled with an adherence intervention designed to empower the patient and prompt the primary care physician to adhere to CGA recommendations was evaluated in a randomized trial [26]. Among community-dwelling older persons with functional disability, urinary incontinence, falls, or depressive symptoms, those randomly assigned to CGA with adherence intervention had less functional decline, less fatigue, and better social functioning over a 15-month period compared to the control group.
- In a randomized trial evaluating CGA followed by six months of interdisciplinary primary care versus usual primary care in a population at risk for high health care utilization, those randomly assigned to treatment had reduced functional decline, depression, and use of home health services compared to the control group over 15 to 18 months following randomization [27].
- However, in a large, cluster-randomized trial of multidimensional geriatric assessment followed by either geriatric team management or the primary care clinician alone, there were no differences between the groups in hospitalization, admission to other institutions, and quality of life [30].
In a meta-analysis of nine randomized controlled trials (n = 3750) evaluating mortality, there was no benefit of outpatient CGA on survival (RR 0.95, 95% CI 0.82-1.12) [15]. Tests for heterogeneity showed consistency between trial data.
Specialized team management — Approaches to outpatient CGA have used some of the more successful components of older models and adapted them to programs within primary care practices:
- Geriatric Resources for Assessment and Care of Elders (GRACE) includes home-based CGA and long-term care management by a nurse practitioner and social worker who collaborate with the primary care clinician and a geriatrics interdisciplinary team. In a randomized trial of low income elderly patients, those randomly assigned to the GRACE intervention had better health-related quality-of-life and fewer emergency department visits compared to those assigned to usual care [31]. Patients at high risk of hospitalization also had fewer admissions by the second year.
- Guided Care integrates an intensively trained nurse into primary care practices to provide geriatric assessment and chronic care management to high-risk patients. In a randomized trial of chronically-ill older patients, those randomly assigned to Guided Care reported improved satisfaction rates and had less health care utilization with lower costs of care compared to those randomly assigned to usual care [32,33].
- Practice redesign approaches (screening, structured visit notes, delegation to office staff, outreach to community resources) focus on specific geriatric conditions for assessment and management by physicians or nurse practitioners. In a randomized trial of patients in community-based practices, patients randomly assigned to practice-based interventions received better quality of care for falls and incontinence compared to those randomly assigned to usual care [28].
Inpatient consultation — A meta-analysis [1] and a subsequent large randomized clinical trial [8] of inpatient consultation found little benefit of inpatient consultation for CGA. Inpatient consultation for CGA has largely been abandoned except in teaching settings.
In contrast, co-management with a geriatrician may be beneficial for hip fracture patients in reducing complications, mortality, readmissions, and delirium [34,35].
SUMMARY AND RECOMMENDATIONS
- CGA is defined as a multidisciplinary diagnostic and treatment process that identifies medical, psychosocial, and functional capabilities of an elderly person in order to develop a coordinated plan to maximize overall health with aging. CGA is based on the premise that a systematic evaluation of frail older persons by a team of health professionals may identify a variety of treatable health problems and lead to better health outcomes. (See 'Background' above.)
- No standard criteria are available to readily identify patients who are likely to benefit from CGA. Specific criteria used by CGA programs to identify patients include:
- Age
- Medical comorbidities
- Psychosocial problems
- Specific geriatric conditions such as functional disability
- Previous or predicted high health care utilization
- Consideration of change in living situation (eg, from independent living to assisted living, nursing home, or in-home caregivers)
- Community-dwelling elderly patients with functional disability, increased fall risk, cognitive decline, depression, or those at high risk for high health care utilization are appropriate candidates for CGA. Follow-up support is needed to ensure implementation of the findings of the CGA. (See 'Indications for referral' above.)
- Inpatients admitted with fractures, failure to thrive, recurrent pneumonia, and pressure sores may benefit from hospitalization on a geriatric unit that provides CGA. Patients age ≥85 years who have geriatric conditions such as dementia or immobility should also be considered for care on these units. (See 'Indications for referral' above.)
- The assessment team usually consists of a physician, nurse, and social worker. Depending on the patient's condition, the team may also include physical and occupational therapists, nutritionists, pharmacists, psychiatrists, psychologists, dentists, audiologists, podiatrists, and opticians. (See 'Assessment team' above.)
- There are several components of CGA that should be evaluated, including:
- Functional capacity
- Fall risk
- Cognition
- Mood
- Polypharmacy
- Nutrition/weight change
- Urinary incontinence
- Sexual function
- Vision/hearing
- Dentition
- Living situation
- Social support
- Financial concerns
- Spirituality
- Advanced care preferences
(See 'Major components' above.)
- Home geriatric assessment and acute geriatric care units have been shown to be effective in improving functional status, preventing institutionalization, and reducing mortality. Studies of CGA have found inconsistent benefit for post-hospital discharge programs, outpatient geriatric consultation, and inpatient geriatric consultation. (See 'Efficacy' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
©2011 UpToDate® custome...@uptodate.com
www.uptodate.com
not an addressee or otherwise authorized to receive this message, you should not use,
copy, disclose or take any action based on this e-mail or any information contained in the
message. If you have received this material in error, please advise the sender immediately
by reply e-mail and delete this message.
Thank you.