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Introduction Non-emergency settings Emergency units and acute medical units References
Introduction
Comprehensive Geriatric Assessment (CGA) is a hospital service model led by geriatricians, for older patients.1 It was initiated in 1977 in a large teaching hospital in Edinburgh. Patients over 65 years admitted to the hospital were assessed by a designated junior medical team. A reduction in the length of stay for that group from 25 days to 16 days was observed. The geriatric team worked closely with other disciplines to provide the best care in a timely fashion. A study concluded that earlier and better care for the elderly patients can be delivered by CGA without the need to transfer them to geriatric units. The reasons for this success were attributed to early assessments of complex social issues, communications with physiotherapists and advance discharge planning. The researchers concluded that the single most important factors to the success is the ability of consultant geriatricians to decide upon a safe or appropriate time to discharge a patient after he or she has regained a certain degree of independency.2
Target groups
CGA is multidisciplinary assessment of older people3-5 covering different aspects of the patient, including physical, psychological, social and aspects related to functional ability.6,7
Elements
These are variable according to hospital site capacity and demand. Healthcare teams require holistic assessments of old adult patients. In addition to their medical issues, healthcare teams must also assess patients’ pre-morbid functional capacities; cognitive assessment; comorbidity; hydration and nutritional status; falls and socioeconomic status.8
Where
CGA can be performed equally appropriately in acute medical wards as in designated geriatric wards.3
Who
Almost all the studies among this field report that geriatricians are an essential component in designated teams as team leaders for assessment, intervention and the provision of essential care.6 Other important groups are as follows: trained nurses, social workers, physiotherapists and occupational therapists. This multidisciplinary approach is the core of the CGA assessment to develop a plan of care. In order to reach and incorporate a plan, it is required to have regular meetings (at least once weekly) among all professional groups.3
Outcomes:
For the purpose of evaluation effectiveness of geriatric outreach teams, the author of this paper will analyse the outcome of CGA on acute medical admission and emergency wards and on €œgeneral€ acute medical and surgical wards.
Non-emergency settings
The research of Stuck and colleagues9 in evaluating the effects of CGA revealed that 33 patients needed to be treated to keep one patient at his or her own home. However, this is only if CGA is applied in elderly care wards. According to meta-analysis reviews,3 mortality rate is improved when applying CGA in the short-term, but not after one year. A similar finding was reported in a randomised controlled trail- RCT at Southern California Kaiser Permanente health maintenance organisation.6 The RCT showed that CGA added no health benefit as consultative care. Patient’s input with regard to their satisfaction was collected by questionnaires,5 and were not in support of CGA in the general hospital’s wards.
An old person may benefit from CGA to provide continued management in hospitals and in the community.6 Bakker and colleagues’10 meta-analysis reviews concluded there was a variation in positive outcomes across studies as researchers applied different models and approaches in their assessments. The difficulties in applying GCA primarily have to do with lack of consensus procedures in approaching old people in acute medical wards within NHS with complex medical, functional and social issues. This is due to different demands from one trust to another.10
There is a noticeable variation in socio-demographics across the country. It is observed that the failure of CGA in secondary care was due to poor implementation for geriatric recommendations, either because of other specialists not accepting the care of elderly doctors’ suggestions, or lack of appropriate resources to implement them.6,9 On the other hand, there were stronger evidences of better care provided by specialty care of elderly units rather than liaison outreach service.3 Therefore, transferring older people with complex discharge from various subspecialties to designated geriatric wards will provide better outcomes.
There is also more robust evidence on the benefits of geriatric programmes targeting specific symptoms or complications such as delirium in patients who underwent surgical intervention.12-16
Emergency units and acute medical units
Acute medical admission was established in most NHS trusts to provide rapid access and care for adult patients with medical conditions rather than conventional emergency medicine to allocate appropriate resources. This is to triage patients for those in need of urgent care, as well as to provide further hospital treatment as required and maximise discharge rates for those who can continue management in the community.
However, it has been noted that higher rates of re-admission and mortality are among older people in those who were discharged within three days.17 Harari and colleagues’18 study assessed old adult length of stay before and after intervention of OPAL – Older People Assessment and Liaison team. OPAL consists of small unit of specialist nurse or therapist and a geriatrician screening of all old-adult un-elective admissions within 24 hours for five days a week. Cases are matched to age, gender, pre-morbid status and main presentation.
The researchers compared high-risk patient groups, 48 cases before introducing OPAL and 49 cases post-OPAL. There was better care provided to patients whilst in the hospital and followed up in appropriate clinics, eg. appropriately assessing fallers according to NICE and BGS guidelines, and referring them to fall-clinics for continued management. The same results were obtained for other geriatric symptoms such as urinary incontinence and dementia.18
Despite the positive results of this study, it has been limited by its methodology and unknown rate for readmission or failed discharges. The meta-analysis17 revealed limited RCT studies with regard to this subject, and no robust evidences, in five relatively small trials, those acute geriatric teams can make a difference in the mortality, morbidity or functional capacity of their patients.
Geriatric outreach teams, in an American study, failed to produce significant positive differences in the views and responses of patients/relatives in regards to that quality of care.5 Despite the difficulties in applying CGA, there is a positive view among geriatricians to establish such service in acute trusts. In assessing geriatricians’ opinions, there is strong feeling that CGA has a benefit on patients’ health-outcome and can reduce patients’ journey in hospital, improve patients’ care and facilitate coordination among health allies in secondary care and in the community.19 The primary issue, in the opinion of clinicians, is the lack of specific pathways for older people. There are also further concerns with the lack of communication with social services, especially during out-of-hours.
A possible solution is to recruit small floating units led by therapists or nurses with special interest in the care of elderly to identify requirements for their care and alert appropriate disciplines: doctors, physiotherapists, occupational therapists or social workers5 in various medical, surgical and emergency medicine wards. The parameters that can predict increased length of stay or raise care concern are non- mechanical falls, dementia, impaired mobility, delirium, bladder or faecal incontinence and poor functional capacities that make it unsafe to discharge patients to their own environments.18-20
It has become a requirement within NHS hospitals to apply for CGA, as suggested by the RCP.21 This is to be applied in acute medical and surgical wards, outpatient clinics, rehabilitation wards and in community. This is also to create collaborative teams integrating the assessments of elderly patients with better efficiency by establishing stronger collaboration of service.22
With regard to the DoH proposal, Common Assessment Framework for adult- CAF aims to provide holistic approaches by various specialists through the most efficient methods. The CAF process starts with patient consent for assessment and for information to be shared with different department. Multi-strategy assessments are under continued evaluation, aiming to put patients’ needs in the centre of care and provide complete holistic assessments; this will reduce costs by preventing duplications, inappropriate referrals and better communication methods.23 CAF proposed to provide great benefits in many aspects however the evidence is scarce in research and service surveys.24
Based on the above, there is no clear evidence of additional benefits when applying CGA in Acute Medical Units. Furthermore, it is more important to concentrate on acute medical issues rather than comorbidity. This evidence is supported by a retrospective study conducted in Ireland.25 The outcome results highly dependent on patients’ presentation, severity and complications in acute settings. Other chronic diseases have less of an effect on the mortality rate of older people in Accident & Emergency and Acute Medical Units. In another two RCTs,6,26 there were positive outcomes in favour of intervention groups in sustaining functional abilities for the patients in geriatric wards. This dedicated team for adjusting the environment of patients in acute medical wards can improve functional abilities of patients.
There is no requirement for additional pathways for elderly patients in emergency units. However, having a consultative service to advise the best discharge planning for those deemed to have no acute medical problems is valuable. This will have a better outcome in terms of the functional capacities of the patients.27
Further service surveys are essential to evaluate the productivity of CGA and compliance of the hospital with current guidelines. Based on BGS, the outcome measures should focus on; length of stay, re-admission within a month, mortality rate and patient stratification.17
Dr Kawa Amin, Consultant Geriatrician
First published November 2013
References
1. Conroy, S. & Cooper, N (2010). €œ Executive Summary€. BGS
2. Burley, L., Currie, C., and Smith, R. (1979). €œContribution from geriatric medicine within acute medical wards€. BMJ, 2:90-92
3. Ellis, G., and Langhorne, P. (2005). €œComprehensive geriatric assessment for older hospital patients€. British Medical Bulletin, 71: 45-59
5. Arbaje, A., Maron, D., Yu, Q., et al. (2010). €œThe geriatric floating interdisciplinary transition team€. Journal of the American Geriatrics Society. 58:364€“370
6. Reuben, B., Borok, M., Wolde-Tsadik, G., et al. (1995). €œA randomized trial of comprehensive geriatric assessment in the care of hospitalized patients€. New England Journal Medicine 332:1345€“1350.
7. Royal College of Physicians (2008) €œConsultant physicians working with patients. The duties, responsibilities and practice of physicians in medicine, geriatric medicine€. RCP publication
8. Robinson, L. (2010). €œInterface Geriatrics: New models of care are needed for the 21st century population€. News, the newspaper for of the royal college of general practitioner. May 2010.
9. Stuck, E., Siu, L., Wieland, D., et al. (1993). €œComprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet, 342:1032€“1036
10. Bakker, F., Robben, S., and Rikkert, M. (2010). €œEffects of hospital-wide interventions to improve care for frail older inpatients: a systematic review€. BMJ Quality Safety doi:10.1136/bmjqs.2010.047183
19. Amin, K. (2011). €œService Survey Questionnaire€.
17. Conroy, S., Stevens, T., Parker, S., et al. (2011). €œA systemic review of comprehensive geriatric assessment to improve outcomes for frail older people being rapidly discharged from acute hospital: interface geriatrics€. Age and ageing, 40: 436- 443
18. Harari, D., Martin, F., Buttery, A., et al. (2007). €œThe older persons’ assessment and liaison team €˜OPAL’: evaluation of comprehensive geriatric assessment in acute medical inpatients€. Age Ageing 36: 670-675
20. Campbell, S., Seymour, G., Primrose, W., et al. (2005). €œA multi-centre European study of factors affecting the discharge destination of older people admitted to hospital: analysis of in-hospital data from the ACMEplus project€. Age and Ageing, 34:467-475
22. DoH, white paper (2010). €œEquity and Excellence: Liberating the NHS€. Series number cm 7881: page 61.
23. DoH (2009). €œCommon Assessment Framework for Adult: A consultation on proposal to improve information sharing around multidisciplinary assessment and care planning€. DoH publications.
24. Clarkson, P., Brand, C., Hughes, J., et al (2011). €œIntegrating assessments of older people: examining evidence and impact from RCT€. Age and Ageing 40:388-408.
25. Byrne, D., Chung, S., Bennett, K., et al. (2010). €œAge and outcome in acute emergency medical admissions€. Age and ageing, 39:694-698
26. Landefeld, S., Palmer, M., Kresevic, M., et al.(1995). €œA randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients€. New England Journal Medicine, 332:1338-1344
27. Cunliffe, A., Gladman, J., Husbands, S., et al. (2004). €œSooner and healthier: a randomised controlled trial and interview study of an early discharge rehabilitation service for older people€. Age and ageing 33:246-252