BMJ 2011;343:d6799 doi: 10.1136/bmj.
d6799
Page 1 of 3
Editorials
EDITORIALS
Comprehensive geriatric assessment for older adults
Should be standard practice, according to a wealth of evidence
1
Andreas E Stuck professor of geriatrics , Steve Iliffe professor of primary care for older people
Geriatrics Department, University of Berne, Inselspital University Hospital, CH-3010 Bern, Switzerland; 2University College London, UCL Royal
Free Campus, London, UK
1
Care of older people differs from care of middle aged adults.
Older people often have more complex multisystem problems,
are at increased risk for morbidity and mortality, and need
comprehensive interventions that take into account the
biopsychosocial components of health. Comprehensive geriatric
assessment is an approach developed for this purpose. It is a
process that determines an older persons medical, psychosocial,
functional, and environmental resources and problems, and it
creates an overall plan for treatment and follow-up.1 It
encompasses linkage of medical and social care around medical
diagnoses and decision making under the leadership of a doctor
trained in geriatric medicine.
Older people admitted to hospital as emergencies are at
especially high risk. In the linked systematic review (doi: 10.
1136/bmj.d6553), Ellis and colleagues performed a
meta-analysis of the comprehensive geriatric assessment of
elderly people admitted to hospital.2 They found that patients
in hospital who received such an assessment were significantly
less likely to die or experience functional deterioration. As a
result, such patients were also less likely to be admitted to an
institution and more likely to be alive in their own homes at
longer term follow-up (median 12 months) compared with those
receiving usual care.
This systematic analysis combined subacute and acute hospital
based assessment programmes (table). Subacute models are
typically for selected older patients in hospital, and they offer
specialised multidisciplinary rehabilitative inpatient care. A
previous systematic review found that general and orthopaedic
geriatric rehabilitation programmes improve functional and
survival outcomes in selected older patients.3
In contrast, acute models typically apply to all patients aged 70
and over admitted for acute hospital care. They include an
interdisciplinary patient centred approach based on an
assessment linked with care protocols and early discharge
planning, in a hospital environment adapted for elderly people
with mobility or orientation problems. A previous systematic
review reported favourable effects of acute care geriatrics,
although conclusions were limited by a low number of studies.4
According to the findings of the linked meta-analysis,2
comprehensive geriatric assessment carried out in dedicated
wards was more beneficial than if implemented by teams liaising
with other specialties. In contrast to widespread belief, ward
based assessment is not only effective for selected older patients
but has beneficial effects in all elderly patients admitted to acute
hospital care.1-4 All ambulatory older patients can benefit from
specific types of programmes based on comprehensive geriatric
assessment (table).5-9 In the subgroup of frail older patients,
coordinated care based on this assessment improves outcomes
and reduces unnecessary hospital admissions.6 In selected people
above the age of 75, preventive home visits based on
comprehensive geriatric assessment can reduce the decline in
functional status and prevent nursing home admission.7 In the
large group of non-disabled people above the age of 65, health
risk appraisal programmes combined with personal
reinforcement have shown favourable effects.8 9 At the other
end of the spectrum, patients in need of palliative care also seem
to benefit from based on comprehensive geriatric assessment
methods.6
This has implications for research. More evidence is needed on
how to optimise the effectiveness and efficiency of these
assessments, including research on how best to approach
individual components of the model (such as falls, pain,
delirium, nutrition) in different settings. This will also require
translational research based on non-randomised study designs,
to evaluate cost and effectiveness of dissemination of evidence.
The clinical implications are clearcomprehensive geriatric
assessment should become standard practice. Clinical expertise
is needed to implement these approaches. Doctors need to be
trained to use the assessment like a laboratory test, linked with
diagnostic and prognostic evaluation and therapeutic action.10
Widespread adoption of comprehensive geriatric assessment
will require system change. Redesigning systems of care to
increase support for clinicians in their work may improve
patients experience and outcomes more than relying on training
alone.11 The process of hospital care needs to be adapted to
include comprehensive geriatric assessment, including geriatric
evaluation and management. System change also means placing
the geriatrician at the centre of clinical management in countries
andreas.stuck@insel.ch
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BMJ 2011;343:d6799 doi: 10.1136/bmj.d6799
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EDITORIALS
where most hospital inpatients are older people with complex
needs. In addition, reimbursement systems that promote
comprehensive care are needed. Previous research suggests that
assessment based interventions may result in additional costs
initially. However, in the longer term comprehensive geriatric
assessment not only improves patient outcomes but may save
costs by reducing hospital readmissions and lowering the need
for long term nursing home care.2 12
Competing interests: All authors have completed the ICMJE uniform
disclosure form at www.icmje.org/coi_disclosure.pdf (available on
request from the corresponding author) and declare: no support from
any organisation for the submitted work; no financial relationships with
any organisations that might have an interest in the submitted work in
the previous three years; no other relationships or activities that could
appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer
reviewed.
1
2
3
Stuck AE, Siu AL, Wieland GD, Adams J, Rubenstein LZ. Comprehensive geriatric
assessment: a meta-analysis of controlled trials. Lancet 1993;342:1032-6.
Ellis G, Whitehead MA, Robinson D, ONeill D, Langhorne P. Comprehensive geriatric
assessment for older adults admitted to hospital: meta-analysis of randomised controlled
trials. BMJ 2011;343:d6553.
Bachmann S, Finger C, Huss A, Egger M, Stuck AE, Clough-Gorr KM. Inpatient
rehabilitation specifically designed for geriatric patients: systematic review and
5
6
7
8
9
10
11
12
meta-analysis of randomised controlled trials [published correction in: BMJ
2010;340:c1718.]. BMJ 2010;340:c1718.
Baztn JJ, Surez-Garcia FM, Lpez-Arrieta J, Rodriguez-Maas L, Rodriguez-Artalejo
F. 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.
Graf CE, Zekry D, Giannelli S, Michel JP, Chevalley T. Efficiency and applicability of the
comprehensive geriatric assessment in the emergency department: a systematic review.
Aging Clin Exp Res 2010; published online 5 October.
Boult C, Green AF, Boult LB, Pacala JT, Snyder C, Leff B. Successful models of
comprehensive care for older adults with chronic conditions: evidence for the Institute of
Medicines retooling for an aging America report. J Am Geriatr Soc 2009;57:2328-37.
Huss A, Stuck AE, Rubenstein LZ, Egger M, Clough-Gorr KM. Multidimensional geriatric
assessment: back to the future. Multidimensional preventive home visit programs for
community dwelling older adults: a systematic review and meta-analysis of randomized
controlled trials [published correction in: J Gerontol A Biol Med Sci 2009;64:318]. J Gerontol
A Biol Med Sci 2008:63:298-307.
Rand Corporation: Health Risk Appraisals and Medicare. Evidence report and
evidence-based recommendations. 2000. US Department of Health and Human Services.
www.rand.org/pubs/reprints/RP1225.html.
Dapp U, Anders JAM, von Renteln-Kruse W, Minder CE, Meier-Baumgartner HP, Swift
CG, et al. A randomized trial of effects of health risk appraisal combined with group
sessions or home visits on preventive behaviors in older adults. J Gerontol A Biol Sci Med
Sci 2011;66:591-8.
Ward KT, Reuben DB. Comprehensive geriatric assessment. Schmader KE, ed. UpToDate
2011. www.uptodate.com/contents/comprehensive-geriatric-assessment?source=search_
result&search=geriatric+assessment&selectedTitle=1%7E46.
Bergeson SC, Dean JD. A systems approach to patient-centered care. JAMA
2006;296:2848-51.
Stuck AE, Aronow HU, Steiner A, Alessi CA, Bla CJ, Gold MN, et al. A trial of annual
in-home comprehensive geriatric assessments for elderly people living in the community.
N Engl J Med 1995;333:1184-9.
Cite this as: BMJ 2011;343:d6799
BMJ Publishing Group Ltd 2011
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BMJ 2011;343:d6799 doi: 10.1136/bmj.d6799
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EDITORIALS
Table
Table 1| Selected comprehensive geriatric assessment based programmes with favourable effects according to results of systematic
analyses or individual randomised controlled trials
Setting
Hospital
Patient group
Programme description
Patients at acute care hospital admission
Acute care for the elderly unit4*
Patients staying in acute care hospital selected for subsequent Inpatient geriatric rehabilitation; orthopaedic geriatric rehabilitation3*
subacute care
Ambulatory
Patients admitted to emergency department
Short assessment in emergency department5
Patients with chronic conditions
Interdisciplinary primary care models; outpatient assessment and geriatric
evaluation and management programmes; proactive ambulatory rehabilitation
programmes6*
Patients in end of life situation
Palliative care programmes6
Older non-disabled people living in the community
Preventive home visits7*; health risk appraisal for older people8
*Favourable effects according to results of systematic analysis.
Favourable effects according to randomised controlled trials.
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