A Fall in the Night: High-fidelity simulation exploring comprehensive geriatric assessment (CGA) principles ‘out-of-hours’

Introduction:
High-fidelity simulation provides a safe scaffold for developing clinical skills within an out-of-hours context. Night-shifts introduce compounding human and system factors that disproportionately affect care of frail older patients. Delirium and inpatient falls are common high-risk overnight presentations, yet recognition of frailty syndromes and the need for comprehensive geriatric assessment (CGA) is frequently missed1,2. System-wide approaches to frailty education include multimedia resources and clinical champions; however simulation-based training for is often poorly described3,4. Heterogeneity in education and subjective definitions of CGA further contribute to inconsistent practice4. We developed a night-time simulation within the foundation programme to improve resident confidence managing falls and emphasise holistic, risk-focused care at all times.

Method:
Foundation doctors underwent a high-fidelity, ward-based night-time simulation featuring an older patient with established delirium who sustains an unwitnessed fall. The scenario incorporated low lighting, limited staff and a patient actor. Participants conducted a structured post-fall assessment, identified reversible causes of delirium, managed agitation using least restrictive strategies, and engaged with immediate falls prevention. Facilitated debriefs focused on CGA principles, clinical reasoning, patient safety, multidisciplinary working, and the impact of human factors in an out-of-hours context. Evaluation included pre- and post-simulation questionnaires assessing confidence and perceived competence in CGA use; alongside structured observation of clinical decision-making and thematic analysis of the debrief. Further data collection is ongoing.

Results:
Early findings demonstrate improved confidence in CGA implementation, reduced intention to prescribe sedatives reflexively, and increased recognition of multifactorial precipitants of acute frailty syndromes. Qualitative debrief analysis highlighted enhanced risk perception and the importance of early holistic assessment.

Conclusion:
This project supports early recognition and application of CGA principles within the falls protocol despite overnight barriers to multidisciplinary care. Simulation provides an effective, standardised, and scalable method for experiential frailty education aligned with NICE Falls guideline update and postgraduate medical education priorities5,6.

References:

1. Comprehensive Geriatric Assessment (CGA) Hub | British Geriatrics Society. British Geriatrics Society. Published 2018. https://www.bgs.org.uk/CGA
2. He S, Rolls K, Stott K, et al. Does delirium prevention reduce risk of in‐patient falls among older adults? A systematic review and trial sequential meta‐analysis. Australasian Journal on Ageing. 2022;41(3). doi:https://doi.org/10.1111/ajag.13051
3. A System Wide Approach to Raising Frailty Awareness Through Tier 1 Training | British Geriatrics Society. British Geriatrics Society. Published 2024. Accessed January 16, 2026. https://www.bgs.org.uk/a-system-wide-approach-to-raising-frailty-awareness-through-tier-1-training
4. Polidori MC, Roller-Wirnsberger RE. Chances and challenges of comprehensive geriatric assessment training for healthcare providers. Geriatric Care. 2018;4:7853. doi:10.4081/gc.2018.7853.
5. Braude P, Reedy G, Dasgupta D, Dimmock V, Jaye P, Birns J. Evaluation of a simulation training programme for geriatric medicine. Age and Ageing. 2015;44(4):677-682. doi:https://doi.org/10.1093/ageing/afv049
6. NICE. Overview | Falls: Assessment and Prevention in Older People and in People 50 and over at Higher Risk | Guidance | NICE. Nice.org.uk. Published April 29, 2025. https://www.nice.org.uk/guidance/ng249