Guest editorial: Caring for older adults, Part 1: The value of geriatric assessment

Dr Roger Y. Wong

The comprehensive geriatric assessment (CGA) is not a novel concept and its value has been well documented in the medical literature.[1,2] Proven benefits for patients include the preservation of physical function, maintenance of community living status, and shorter stays and fewer iatrogenic adverse events during hospitalization, while possible benefits for the health care system include cost containment.[3,4] CGA has been successfully applied in the acute care setting[4,5] as well as in the ambulatory care setting,[6-8] where effective assessment has been associated with survival benefit in older adults.[6]

It is both appropriate and timely for this two-part theme issue on caring for older adults to discuss CGA, which can be applied pragmatically to manage a number of common clinical scenarios in a busy clinician’s practice. While most people in British Columbia and Canada will age with few chronic health conditions or with a chronic health condition that causes no functional deficits, a small cohort of frail older adults will have a chronic health condition or multiple conditions that result in functional deficits involving physical and cognitive domains. The vulnerable clinical state of these frail older adults is associated with adverse clinical outcomes and increased utilization of health care services,[9] both of which may be addressed in part by appropriate assessment.

Although reports have confirmed the value of key components of CGA (Table),[10-12] it can be challenging to conduct an assessment in the time available during any single clinical encounter in a busy practice. One possible solution is to complete the assessment over a number of consecutive encounters. Another is to involve a multidisciplinary team in community care or acute care that includes nursing, physiotherapy, occupational therapy, pharmacy, social work, and nutrition services.

Using a systematic and structured approach supported by the best available evidence in the medical literature, the CGA can help identify clinically likely geriatric syndromes, each of which may involve a collection of symptoms and signs to be considered in the differential diagnosis. The relationship between CGA findings and the final diagnosis, however, is often nonlinear, and we should bear in mind that an atypical presentation of a common condition is by far more likely than a typical presentation of an uncommon health condition. We should also remember that CGA findings are often the result of multiple factors, and that the ultimate objective is to determine if these factors are potentially reversible so that interventions and treatment goals can be considered jointly by the patient and the clinician.

The use of comprehensive geriatric assessment features in all of the articles that follow. First, Kenneth Madden describes a systemic approach to distinguishing between neuroautonomic and cardiac causes of syncope, a common presenting complaint in older adults. Second, Martha Spencer, Kathy McManus, and Johanne Sabourin discuss the role of a multidisciplinary team in managing urinary and fecal incontinence in older adults. This is another common presenting complaint and, unfortunately, one that is not thoroughly understood by many clinicians. Third, Joshua Budlovsky and Larry Dian use a case-based approach to consider a number of clinical questions in osteoporosis management. Bone health in older adults remains a hot research topic, both in terms of basic science and new clinical trial findings. Fourth and finally, Amanda Hill and Walid Alkeridy explore preoperative decision making in the context of older patients, who can face unique risks when undergoing surgery. The authors describe how functional capacity and frailty can be incorporated in risk assessment tools for determining the appropriate level of surgical intervention in older adults.

These articles all show how comprehensive geriatric assessment can be a powerful tool for improving health care for older adults. In Part 2 of the theme issue we will look at how CGA can be deployed when complex interactions occur with common geriatric syndromes known as the four Ds: dementia, delirium, depression, and drug-related problems. 
—Roger Y. Wong, MD, FRCPC, FACP, FCAHS
Executive Associate Dean, Education 
Faculty of Medicine, University of British Columbia
Clinical Professor, Division of Geriatric Medicine
Department of Medicine, University of British Columbia

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This article has been peer reviewed.

References

1.    Stuck A, Siu A, Wieland G, et al. Comprehensive geriatric assessment: A meta-analysis of controlled trials. Lancet 1993;342(8878):1032-1036.
2.    Stuck AE, Aronow HU, Steiner A, et al. Trial of annual in-home comprehensive geriatric assessments for elderly people living in the community. N Engl J Med 1995;333:1184-1189.
3.    Ellis G, Whitehead MA, Robinson D, et al. Comprehensive geriatric assessment for older adults admitted to hospital: Meta-analysis of randomised controlled trials. BMJ 2011;343:d6553.
4.    Fox MT, Persaud M, Maimets I, et al. Effectiveness of acute geriatric unit care using acute care for elders components: A systematic review and meta-analysis. J Am Geriatr Soc 2012;60:2237-2245.
5.    Baztan JJ, Suarez-Garcia FM, Lopez-Arrieta J, et al. Effectiveness of acute geriatric units on functional decline, living at home, and case fatality among older patients admitted to hospital for acute medical disorders: Meta-analysis. BMJ 2009;338:b50.
6.    Ekdahl AW, Alwin J, Eckerblad J, et al. Long-term evaluation of the ambulatory geriatric assessment: A frailty intervention trial (AGe-FIT): Clinical outcomes and total costs after 36 months. J Am Med Dir Assoc 2016;17:263-268. 
7.    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. J Am Geriatr Soc 2004;52:1417-1423.
8.    Monteserin R, Brotons C, Moral I, et al. Effectiveness of a geriatric intervention in primary care: A randomized clinical trial. Fam Pract 2010;27:239-245. 
9.    Morley JE, Vellas B, van Kan GA, et al. Frailty consensus: A call to action. J Am Med Dir Assoc 2013;14:392-297.
10.    Wong RY. Routine use of comprehensive geriatric assessment needed in outpatient practice. Geriatr Aging 1999;2:10 and 22. 
11.    Wong RY. Cardiac clinical examination changes with age of patient. Geriatr Aging 1998;1:9 and 21.
12.    Wong RY. Assessment of mobility impairment. Geriatr Aging 2005;8:60-63.