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      Comprehensive geriatric assessment in primary care: a systematic review

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          Abstract

          Background

          Comprehensive geriatric assessment (CGA) involves the multidimensional assessment and management of an older person. It is well described in hospital and home-based settings. A novel approach could be to perform CGA within primary healthcare, the initial community located healthcare setting for patients, improving accessibility to a co-located multidisciplinary team.

          Aim

          To appraise the evidence on CGA implemented within the primary care practice.

          Methods

          The review followed PRISMA recommendations. Eligible studies reported CGA on persons aged ≥ 65 in a primary care practice. Studies focusing on a single condition were excluded. Searches were run in five databases; reference lists and publications were screened. Two researchers independently screened for eligibility and assessed study quality. All study outcomes were reviewed.

          Results

          The authors screened 9003 titles, 145 abstracts and 97 full texts. Four studies were included. Limited study bias was observed. Studies were heterogeneous in design and reported outcomes. CGAs were led by a geriatrician ( n = 3) or nurse practitioner ( n = 1), with varied length and extent of follow-up (12–48 months). Post-intervention hospital admission rates showed mixed results, with improved adherence to medication modifications. No improvement in survival or functional outcomes was observed. Interventions were widely accepted and potentially cost-effective.

          Discussion

          The four studies demonstrated that CGA was acceptable and provided variable outcome benefit. Further research is needed to identify the most effective strategy for implementing CGA in primary care. Particular questions include identification of patients suitable for CGA within primary care CGA, a consensus list of outcome measures, and the role of different healthcare professionals in delivering CGA.

          Electronic supplementary material

          The online version of this article (10.1007/s40520-019-01183-w) contains supplementary material, which is available to authorized users.

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          Most cited references15

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          Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials

          Graham Ellis, Martin A Whitehead, David Robinson … (2011)
          Objective To evaluate the effectiveness of comprehensive geriatric assessment in hospital for older adults admitted as an emergency. Search strategy We searched the EPOC Register, Cochrane’s Controlled Trials Register, the Database of Abstracts of Reviews of Effects (DARE), Medline, Embase, CINAHL, AARP Ageline, and handsearched high yield journals. Selection criteria Randomised controlled trials of comprehensive geriatric assessment (whether by mobile teams or in designated wards) compared with usual care. Comprehensive geriatric assessment is a multidimensional interdisciplinary diagnostic process used to determine the medical, psychological, and functional capabilities of a frail elderly person to develop a coordinated and integrated plan for treatment and long term follow-up. Data collection and analysis Three independent reviewers assessed eligibility and trial quality and extracted published data. Two additional reviewers moderated. Results Twenty two trials evaluating 10 315 participants in six countries were identified. For the primary outcome “living at home,” patients who underwent comprehensive geriatric assessment were more likely to be alive and in their own homes at the end of scheduled follow-up (odds ratio 1.16 (95% confidence interval 1.05 to 1.28; P=0.003; number needed to treat 33) at a median follow-up of 12 months versus 1.25 (1.11 to 1.42; P<0.001; number needed to treat 17) at a median follow-up of six months) compared with patients who received general medical care. In addition, patients were less likely to be living in residential care (0.78, 0.69 to 0.88; P<0.001). Subgroup interaction suggested differences between the subgroups “wards” and “teams” in favour of wards. Patients were also less likely to die or experience deterioration (0.76, 0.64 to 0.90; P=0.001) and were more likely to experience improved cognition (standardised mean difference 0.08, 0.01 to 0.15; P=0.02) in the comprehensive geriatric assessment group. Conclusions Comprehensive geriatric assessment increases patients’ likelihood of being alive and in their own homes after an emergency admission to hospital. This seems to be especially true for trials of wards designated for comprehensive geriatric assessment and is associated with a potential cost reduction compared with general medical care.
          Article 0 comments Cited 261 times – based on 0 reviews     Review now
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            Effectiveness of home based support for older people: systematic review and meta-analysis.

            K Brummell, D Kendrick, Stephen Hewitt … (2001)
            To evaluate the effectiveness of home visiting programmes that offer health promotion and preventive care to older people. Systematic review and meta-analysis of 15 studies of home visiting. older people living at home, including frail older people at risk of adverse outcomes. Mortality, admission to hospital, admission to institutional care, functional status, health status. Home visiting was associated with a significant reduction in mortality. The pooled odds ratio for eight studies that assessed mortality in members of the general elderly population was 0.76 (95% confidence interval 0.64 to 0.89). Five studies of home visiting to frail older people who were at risk of adverse outcomes also showed a significant reduction in mortality (0.72; 0.54 to 0.97). Home visiting was associated with a significant reduction in admissions to long term institutional care in members of the general elderly population (0.65; 0.46 to 0.91). For three studies of home visiting to frail, "at risk" older people, the pooled odds ratio was 0.55 (0.35 to 0.88). Meta-analysis of six studies of home visiting to members of the general elderly population showed no significant reduction in admissions to hospital (odds ratio 0.95; 0.80 to 1.09). Three studies showed no significant effect on health (standardised effect size 0.06; -0.07 to 0.18). Four studies showed no effect on activities of daily living (0.05; -0.07 to 0.17). Home visits to older people can reduce mortality and admission to long term institutional care.
            Article 0 comments Cited 78 times – based on 0 reviews     Review now
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              Screening for Frailty in Canada's Health Care System: A Time for Action.

              William J. Lahey, Samir Sinha, Paige Moorhouse (2016)
              As Canada's population ages, frailty - with its increased risk of functional decline, deterioration in health status, and death - will become increasingly common. The physiology of frailty reflects its multisystem, multi-organ origins. About a quarter of Canadians over age 65 are frail, increasing to over half in those older than 85. Our health care system is organized around single-organ systems, impairing our ability to effectively treat people having multiple disorders and functional limitations. To address frailty, we must recognize when it occurs, increase awareness of its significance, develop holistic models of care, and generate better evidence for its treatment. Recognizing how frailty impacts lifespan will allow for integration of care goals into treatment options. Different settings in the Canadian health care system will require different strategies and tools to assess frailty. Given the magnitude of challenges frailty poses for the health care system as currently organized, policy changes will be essential.
              Article 0 comments Cited 43 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                James W. Garrard:
                ORCID: http://orcid.org/0000-0003-2771-0099
                james.garrard@rdm.ox.ac.uk
                Journal
                Journal ID (nlm-ta): Aging Clin Exp Res
                Journal ID (iso-abbrev): Aging Clin Exp Res
                Title: Aging Clinical and Experimental Research
                Publisher: Springer International Publishing (Cham )
                ISSN (Print): 1594-0667
                ISSN (Electronic): 1720-8319
                Publication date (Electronic): 9 April 2019
                Publication date PMC-release: 9 April 2019
                Publication date (Print): 2020
                Volume: 32
                Issue: 2
                Pages: 197-205
                Affiliations
                [1 ]GRID grid.4991.5, ISNI 0000 0004 1936 8948, Radcliffe Department of Medicine, , University of Oxford, ; Oxford, OX1 2JD UK
                [2 ]GRID grid.5491.9, ISNI 0000 0004 1936 9297, Academic Geriatric Medicine, Faculty of Medicine, , University of Southampton, ; Southampton, UK
                [3 ]GRID grid.430506.4, NIHR Southampton Biomedical Research Centre, , University Hospital Southampton NHS Foundation Trust and University of Southampton, ; Southampton, UK
                [4 ]GRID grid.430506.4, University Hospital Southampton NHS Foundation Trust, ; Southampton, UK
                [5 ]GRID grid.1006.7, ISNI 0000 0001 0462 7212, AGE Research Group, Institute of Neuroscience, , Newcastle University, ; Newcastle upon Tyne, UK
                [6 ]GRID grid.420004.2, ISNI 0000 0004 0444 2244, NIHR Newcastle Biomedical Research Centre, , Newcastle upon Tyne Hospitals NHS Foundation Trust and Newcastle University, ; Newcastle upon Tyne, UK
                [7 ]GRID grid.5491.9, ISNI 0000 0004 1936 9297, National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Wessex, , University of Southampton, ; Southampton, UK
                Author information
                http://orcid.org/0000-0003-2771-0099
                http://orcid.org/0000-0002-4297-1206
                http://orcid.org/0000-0003-4968-7678
                http://orcid.org/0000-0002-5291-1880
                http://orcid.org/0000-0003-1283-6457
                Article
                Publisher ID: 1183
                DOI: 10.1007/s40520-019-01183-w
                PMC ID: 7033083
                PubMed ID: 30968287
                SO-VID: 38fd9d6d-fd97-46fb-97f5-0dcdd786eece
                Copyright © © The Author(s) 2019
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                History
                Date received : 11 March 2019
                Date accepted : 23 March 2019
                Categories
                Subject: Review
                Custom metadata
                issue-copyright-statement © Springer Nature Switzerland AG 2020

                Keywords: comprehensive geriatric assessment,older people,primary care
                Data availability:
                Keywords: comprehensive geriatric assessment, older people, primary care

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