Comprehensive Geriatric Assessment (CGA)
The gold standard for the management of frailty in older people is the process of care known as Comprehensive Geriatric Assessment (CGA). It involves an holistic, multidimensional, interdisciplinary assessment of an individual by a number of specialists of many disciplines in older people’s health and has been demonstrated to be associated with improved outcomes in a variety of settings 16.
CGA is a clinical management strategy which will give a framework for the delivery of interventions which address relevant and appropriate issues for an individual patient. After CGA it will be possible to use the Rockwood Clinical Frailty index to demonstrate the level of frailty of the individual 7. However, it is not a rapid process. The initial assessment and care planning for a full CGA is likely to take at least 1.5 hours of professional time, plus the necessary time for care plan negotiation and documentation (likely total of 2.5 hours, plus there is a need for ongoing review). Therefore it is simply not feasible for everyone with frailty (from mild up to severe life limiting frailty) to undergo a full multidisciplinary review with geriatrician involvement. Nevertheless, all patients with frailty will benefit from a holistic medical review (see detail below) based on the principles of CGA. Some people will need to be referred to a Geriatrician for support with diagnosis, intervention or care planning and others will also need to be referred to other specialists in the community such as an Old Age Psychiatrist, therapists, specialist nurses, dieticians and podiatrists.
Whatever level of input is needed for an individual, the resulting process of assessment, individual care and support planning (see detail below) and regular review is vital to provide an evidence based management plan for frailty.
The processes outlined in this section are described as a flow chart in figure 1 above.
Further notes on CGA:
Comprehensive Geriatric Assessment (CGA), also known in some countries as Geriatric Evaluation and Management (GEM), involves a holistic, multidimensional, interdisciplinary assessment of an individual by a number of specialists of many disciplines in older people’s health.
CGA typically results in the formulation of a list of needs and issues to tackle, together with an individualised care and support plan, tailored to an individual’s needs, wants and priorities.
It is usual to describe the domains which comprise ‘multidimensional assessment’ as follows:
- Physical Symptoms ( which must include pain) and the underlying illnesses and diseases
- Mental Health Symptoms (including memory, mood and poor organisation) and the underlying illnesses and diseases
- Level of function in daily activity, both for personal care (washing, dressing, grooming continence and mobility) and for life functions (communication, cooking, shopping using the phone etc.)
- Social Support Networks currently available, both informal (family, friends and neighbours) and formal ( social services carers, meals, day care). It needs to include the social dynamic between the individual and his/her family and carers (whilst trying to avoid too much judgement)
- Living Environment – state of housing, facilities and comfort. Ability and tendency to use technology. Availability and ability to use local transport
- Level of Participation and individual concerns, i.e. degree to which the person has active roles and things they have determined are of significance to them (possessions, people, activities, functions, memories). Will also include particular anxieties, for example fear of ‘cancer’ or ‘dementia’. Knowledge of these will help frame the developing care and support plan
- The compensatory mechanisms and resourcefulness which the individual uses to respond to having frailty. Knowing this will allow the care and support plan to incorporate strategies to enhance this resilience
Extensive research has shown that CGA in hospital increases independence (individuals are more likely to go home after this process compared to standard medical care) and reduces mortality. A recent Cochrane review showed that those who underwent CGA on a ward had a 30% higher chance (OR 1.31 CI 1.15 – 1.49) of being alive and being in their own home at 6 months. This equates to a Number needed to treat of 13.16
However, despite considerable evidence for CGA in community settings in the US17, there is less evidence to support CGA in community settings in the UK because the research has not been done. Nonetheless a recent review18 showed that CGA in the community which focussed on older people identified with frailty could reduce hospital admissions.
The BGS believes that it is highly likely that CGA in any setting will be an effective intervention for an older person identified as having frailty. In the community there may need to be local flexibility in terms of what constitutes an interdisciplinary team and how the medical input is provided – neverthelss, the principle stands. The resulting individualised care and support plan must include information for older people and their carers about how and when to seek further advice and possibly information which defines advance planning for end of life care.
Readers who would like to learn more about Comprehensive Geriatric Assessment are advised to read ‘Comprehensive Geriatric Assessment- a guide for the non specialist’. Welsh TJ.;Gordon AL.; and Gladman JR. Int J Clin Pract2013 doi: 10.1111/ijcp. 12313.