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1. Background
In the 1940s Marjory Warren in the West Middlesex Hospital, was able to disseminate the benefits of comprehensive assessment of older people. The hospital where she worked had been filled with elderly patients who were neglected and bedridden.

By systematically evaluating these patients, she was able to determine who might benefit from medical rehabilitation and intervention. She was able to mobilise these patients and, in many cases, discharge them back to their own homes. She therefore can be regarded as the founder of modern hospital geriatric medicine.

2. Barriers to implementation

The important recent concentration on the acute aspects of care in hospital can lead to decreased opportunities for frail older people to receive beneficial rehabilitation (see good practice guide) and comprehensive assessment.

Short-term benefits may result in expensive institutionalisation with older people losing control over their lives, over their function and over their environment.

The British Geriatrics Society (BGS) has considerable concerns that the introduction of payment by results may threaten the treatment of these frail older people by accelerating discharge from hospital at the expense of comprehensive assessment.

3. What is comprehensive assessment for frail older people?

The BGS recognises this as a multidimensional interdisciplinary diagnostic process focused on determining a frail older person’s medical, psychological and functional capability in order to develop a co-ordinated and integrated plan for treatment and long term follow up (see Table 1).

Table 1. – Components of Comprehensive Geriatric Assessment (2)

 4. Who should do it?

The BGS on the basis of the evidence (1) recommends that the multi-disciplinary team responsible for comprehensive assessment should consist of:

• An accredited senior specialist physician in medical care of older people
• A co-ordinating specialist nurse with experience,
• A senior social worker, or a specialist nurse who is also a care manager with direct access to care services
• Dedicated appropriate therapists.
  

5.  Who benefits from comprehensive assessment?

Frail older people are the group who benefit most from this type of assessment.

Frailty represents a state of r educed homeostasis and resistance to stress that leads to increased vulnerability and risk for adverse outcomes such as the progression of disease, falls, disability, and premature death. A multi-centre project on frailty has been set up: www.frail-fragile.ca

The BGS recommends that appropriate screening, such as the single assessment process, should be used to identify older frail people who need comprehensive assessment (see Table 2).

The BGS recommends that frail older people being admitted to hospital require effective services, which must include access to comprehensive assessment which should not be confused with the single assessment process.

6. Markers of frailty (3)

Two or more of the following are markers of frailty:

• Inability to perform one or more basic ADL in the three days prior to admission
• A stroke in the past three months
• Depression
• Dementia
• A history of falls
• One or more unplanned admissions in the past three months
• Difficulty in walking
• Malnutrition
• Prolonged bed rest
• Incontinence

7. What are the benefits of comprehensive assessment for frail older people?

“In patient comprehensive assessment of frail older people may reduce short-term mortality and increases the chances of living at home at home at 1 year”(1). An improvement in physical function is demonstrable at 6 months. Reduction in hospital readmissions and placement in care homes as well as improvement in quality of life and in cognition is shown at 12 months (1). These have all been recognised as important markers of effective care for older frail people.

The BGS emphasises that the benefits are greatest in dedicated management units for older frail people. (A geriatric evaluation and management unit is a ward that admits frail older inpatients for a process of multidisciplinary assessment review and therapy). It can include wards for acutely ill older people and rehabilitation wards. Studies show that thirty-three patients needed to be treated for one extra alive in their own homes.

8. How can good results be achieved?

The BGS stresses the importance of a diagnostic, dynamic, multidisciplinary approach for successful comprehensive assessment.

The BGS emphasises the importance of regular review of individual patients. Without this approach older, frail people will continue to receive a poor deal.

Comprehensive assessment of frail older people should not be confused with the single assessment process.

The BGS recommends that Comprehensive assessments enable older frail people to achieve their maximum potential through a careful process of diagnosis, identification of reversible disease, improvement of compliance and reduction of adverse drug reactions.

The BGS believes that encouraging old people, to get out of bed, to mobilise, and to regain their function continues to be of significant importance in 2005.

The BGS recommends that the team must communicate well with the patient, by setting goals and objectives with them, the family, and with one another.

The BGS recommends that team meetings need to take place frequently and that Case conferences should be held with the patients and their families allowing the older frail patient to regain control over their environment, their body and their health.

9. How should it be delivered?

Comprehensive assessment for frail older people should be delivered by multi-disciplinary teams, which must include senior physicians and nurses with expertise in older people.

Effective teams have to include designated case managers, who could be nurses, but who have the ability to access social care fast. This prevents time-consuming work liasing with numerous social service providers as well as a fragmented care approach.

10.Where should it be delivered?

The BGS recommends, based on the evidence, that teams should be ward based but peripatetic services should be available for patients receiving care from other specialities.

11. Future research

The BGS recommends that there should be research funding to identify the key components of comprehensive assessment.

Table 2. – Diverse Goals and Objectives of “ Assessment” in Geriatrics (2)

References:

1. Comprehensive geriatric assessment for older hospital patients
   Ellis and Langhorne Br Med Bull.2005; 71: 45-59
2. Comprehensive geriatric assessment
   Wieland W and Hirth V. Cancer Control 2003 Nov-Dec: 10(6): 454-62.
3. The RACP Annual Scientific Meeting May 2004 "Caring for the Older patient "How should we treat older patients? Professor Len Gray The University of Queensland Academic Unit in Geriatric Medicine.

Jackie Morris
for the Policy Committee
June 2005