Monica_HW1

Monica_HW1

by Monica Ospina Romero -

The use of comprehensive geriatric assessment (CGA) for older persons with fragility.

Older people are at higher risk of acquired disability, cognitive decline, or admission to residential care as a consequence of illness or its treatment. They also have more complex needs because of the coexisting medical, functional, psychological, and social conditions. Comprehensive geriatric assessment is a proposed solution to improve care in older adults. This approach is defined as a multidisciplinary diagnostic and treatment process that identifies medical, psychosocial, and functional limitations of a frail older person in order to develop a coordinated plan to maximize overall health with aging1. This model has the most robust evidence in the hospital setting. A large meta-analysis published in 1993 demonstrated that CGA was superior to general medical care in reducing mortality and preventing institutionalization of older adults admitted to hospital1. Further, other meta-analysis and Cochrane reviews support this evidence2. CGA is not universally distributed in the hospital setting despite the clear evidence from the meta-analysis showing its benefits. In contrast, the data are conflicting in outpatient geriatric consultation but CGA is a complex intervention that is highly dependent upon the context in which is put into practice3. Studies have showed that cost-effectiveness of this program for ambulatory patients compares favorably to other common medical interventions4. I would like to understand the barriers to implement this practice in the hospital setting as well as how can we adapt this program to the primary care context.

 

1.       Stuck AE, Siu AL, Wieland GD et al. Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet 1993; 342: 1032–6.

2.       Ellis G, Whitehead MA, O’Neill D et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev 2011; CD006211.

3.       Gladman JR, Conroy SP, Ranhoff AH et al. New horizons in the implementation and research of comprehensive geriatric assessment: knowing, doing, and the know-do gap. Age Ageing. 2016 Mar;45(2):194-200

4.       Keeler EB, Robalino DA, Frank JC et al. Costeffectiveness of outpatient geriatric assessment with an intervention to increase adherence. Med Care. 1999;37(12):1199–206.

 


Re: Monica_HW1

by Lea Vella -

This is a great topic!  I can imagine that the implementation barriers are going to be very different for primary care vs. hospital settings (i.e., different compensation structures, staff resources, work cultures). There may be some interesting parallels to the implementation of high need/high cost care teams (see work by Donna Zulman), or even in the integrated pain care settings. Looking forward to seeing how your project progresses!

Re: Monica_HW1

by Monica Ospina Romero -

Thanks Lea for your comment, it is encouraging to find that other researchers think this is a relevant topic. I think I am inclined to work in the primary care setting and it is very interesting your suggestion of using as example the implementation of other high cost/need care team model. I will review the work of Donna Zulman!

Re: Monica_HW1

by Timothy -

Hi Monica,

Two questions - first, can you provide a bit more concrete information as to what "comprehensive geriatric assessment" entails - who conducts it, what resources does it take, what are the concrete benefits?  this may help get at the barriers to utilization.

Secondly, CGA seems like a long-term goal process,  whereas hospital care is often short-term goal directed process i.e. what does it take to get the patient out of hospital as safely and quickly as possible...what is the focus of CGA in the acute setting? Does it related to delirium or other conditions for which older adults are at particularly high risk during hospitalization? Or is it more related to a discharge planning / preventing readmission medium-term set of goals?

Tim


Re: Monica_HW1

by Monica Ospina Romero -

Hi Tim,

Thanks for your interest in my topic. CGA is conducted by a multidisciplinary team, but the range of health care professional participating varies based on the services provided by the different CGA programs. The team is usually integrated by a clinician, nurse, social worker, and when appropriate, physical therapist, nutritionist, pharmacist, psychiatrist, dentist, podiatrist, or optician. One important barrier is coordinating this multidisciplinary evaluation and implementing care recommendations. Hospitals sometimes have an inpatient consultation program, others have a acute geriatric care units that have shown the most robust evidence for benefit. The main goal with CGA in hospital care is to increase the likelihood of a patient returning home and avoiding admission to residential care, death, functional deterioration.

Re: Monica_HW1

by Todd -


Hi Monica,


Sounds like a great project! In order to hone in on the implementation gap you may want to consider defining more specifically the patient population. For instance, by hospitalization indication or emergency status:

1) Here is a review article on the use of CGA for surgical admissions.

Eamer G, Taheri A, Chen SS, Daviduck Q, Chambers T, Shi X, Khadaroo RG. Comprehensive geriatric assessment for older people admitted to a surgical service. The Cochrane Library. 2018 Jan 1.

2) Here are two review articles on the use of CGA for cancer patients.

Extermann M, Aapro M, Bernabei R, Cohen HJ, Droz JP, Lichtman S, Mor V, Monfardini S, Repetto L, Sørbye L, Topinkova E. Use of comprehensive geriatric assessment in older cancer patients:: Recommendations from the task force on CGA of the International Society of Geriatric Oncology (SIOG). Critical reviews in oncology/hematology. 2005 Sep 1;55(3):241-52.

Puts MT, Hardt J, Monette J, Girre V, Springall E, Alibhai SM. Use of geriatric assessment for older adults in the oncology setting: a systematic review. Journal of the National Cancer Institute. 2012 Aug 7;104(15):1134-64.

3) Here is a review article on the use of CGA with ED discharge.

Caplan GA, Williams AJ, Daly B, Abraham K. A randomized, controlled trial of comprehensive geriatric assessment and multidisciplinary intervention after discharge of elderly from the emergency department—the DEED II study. Journal of the American Geriatrics Society. 2004 Sep 1;52(9):1417-23.

Also, the NEJM article below appears to outline the opposing literature which may demonstrate why the CGA has been around for 20+ years and yet is not adopted in many settings. Likewise, "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).” (Ward KT, Reuben DB. Comprehensive geriatric assessment. In: UpToDate, Schmader KE (Ed), UpToDate, Waltham, MA. Accessed 04/10/18.)

Reuben DB, Borok GM, Wolde-Tsadik G, Ershoff DH, Fishman LK, Ambrosini VL, Liu Y, Rubenstein LZ, Beck JC. A randomized trial of comprehensive geriatric assessment in the care of hospitalized patients. New England Journal of Medicine. 1995 May 18;332(20):1345-50. 

Best,

Todd 

Re: Monica_HW1

by Monica Ospina Romero -

Hi Todd,

Thanks for this post full of details, this is certainly very relevant information for what I am planning for my research. I agree with you I need to narrow down my population.

Thank you!

Monica

Re: Monica_HW1

by Eduardo Rodriguez Almaraz -

HI Monica - I think this is a very important questions that you're addressing. To my knowledge fragility is one of the most important issues that geriatricians deal with in the day to day practice, but there are limited tools to intervene once is detected. I think it is challenging for clinicians because is not a condition that can be solved by just one member of the care team but, as you very well pointed out, it is a multidisciplinary effort. 

I have a couple questions regarding your implementation. Is the CGA a score that is yield at the time of evaluation and you are provided with an intervention plan based on that score?

and if so, what happens if a person scores lower in the psycho-social aspect but higher in the functional aspect? Is this tool capable to discriminate between domains?

 

Re: Monica_HW1

by Rashed -

Dear Monica, 

Thank you for sharing this--I think you definitely highlighted a significant gap regarding the evidence-based CGA for older people with fragility. 

It is especially interesting that evidence emerged as early as 1993 yet this gap still exists. I was wondering, have you had the chance to look for/or did you find any more recent meta-analyses or systematic reviews with an update on the utilization of CGA?

You mentioned a very critical question regarding the adaptation of this assessment in primary care settings. Unfortunately, evaluating the efficacy of any intervention is only one step towards its actual implementation, and challenges in various fields revolve around identifying ways or mechanisms to adopt evidence-based interventions. In the field of psychology, there have been some efforts to promote translational science/implementation science as an actual occupation because actually implementing evidence-based practice is a beast by itself that requires a lot of time and effort. Thus, implementation or translational scientists often create manuals/guidelines and simultaneously go into clinical settings to aid in the adoption of evidence-based practice. I was curious...is there some sort of implementation of CGA manual/guideline? Are there people willing to intervene in primary care contexts?