Comprehensive Geriatric Assessment

From Research to Practice

Department of Medicine & Geriatrics
Princess Margaret Hospital
Dr. T. K. Kong 江德坤醫生
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 Unwanted Elderly in Unwanted Institutions
‘Eventide’: a painting of a workhouse by Hubert von Herkomer in 1878
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Comprehensive Geriatric Assessment

Its Origin
Br Med J, 25 December 1943
Care of Chronic Sick: a case for treating chronic
sick in blocks in a general hospital

Volume 247, Issue 6406, 8 June 1946, Pages 841-876

Care of the Chronic Aged Sick

Marjory Warren (1897 - 1960)

Mother of Geriatrics
 Pathologies
Comprehensive Geriatric Assessment

(multiple)
(multiple)
Knowing The Frail Elderly Person

Ageing

Drugs
Physical

support
Mental

Social
health
health
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Comprehensive Geriatric
Assessment As Cornerstone
of Geriatric Medicine

• Beyond patient … to
person (holistic
approach)
• Beyond disease
(diagnostic label) …to
illness (physical, mental
& social well being)
• Beyond treatment …to
management (defining
needs, goal-setting,
intervention, teamwork,
care planning)
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Comprehensive Geriatric Assessment

Its Effectiveness

ORGINAL ARTICLE
Volume 311:1664-1670 December 27, 1984 Number 26
Effectiveness of a geriatric evaluation unit. A randomized clinical trial
LZ Rubenstein, KR Josephson, GD Wieland, PA English, JA Sayre, and RL Kane

Abstract
We randomly assigned frail elderly inpatients with a high probability of nursing-home placement
to an innovative geriatric evaluation unit intended to provide improved diagnostic assessment,
therapy, rehabilitation, and placement. Patients randomly assigned to the experimental (n = 63)
and control (n = 60) groups were equivalent at entry. At one year, patients who had been
assigned to the geriatric unit had much lower mortality than controls (23.8 vs. 48.3 per cent, P
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The Evidence for Benefit of CGA

Volume 342, Number 8878, Saturday 23 October 1993

• Reduced risk of mortality

• Improved likelihood of living at
home
• Reduced hospital readmissions
• Greater chance of cognitive
improvement
• Greater chance of physical
function improvement
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Improvement in Physical Function of

Stroke Patients at Exit from GDH
39 Self-care 24 Mobility 18 Household function
p < 0.000 p < 0.000 p < 0.0005
35 31.35
28.94 20 15 13.68
30 16.06 11.68
25 15 13.09
Score

10
20
15 10

10 5
5
5
0 0 0
Initial Discharge Initial Discharge Initial Discharge
n = 436 n = 436 n = 28
Kong TK, Lum CM, Mo KK. Development of a hierarchical activities of daily living scale for
Chinese stroke patients in geriatric day hospitals. Aging Clin Exp Res 1995; 7:173-178.
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Community Geriatric Assessment Team

(CGAT)
Mission

• To enhance and preserve health and quality of life

of elderly persons in the community by timely
assessment and appropriate management

Services
• Pre-admission assessment
– Subvented care homes
– Hospital infirmary
• Outreach geriatric clinics to care homes
• Hospital discharge support services
• Geriatric home care
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Effectiveness of CGAT in Reducing Hospital

Utilization by Care Home Residents:
A & E Attendance
Overall (n=67 homes) CGAT (n=41 homes) No CGAT (n=26 homes)
30 50%

Percentage of Care Homes

Number of Care Homes

40%

20
30%

20%
10
p = 0.01 10% p = 0.01
14.0 17.4 14.0 17.4

0 0%
0 5 10 15 20 25 30 35 0 5 10 15 20 25 30 35

A & E Attendance A & E Attendance

(per 100 residents per month) (per 100 residents per month)

Survey data (Nov 2004 – Jan 2005) for Princess Margaret Hospital
from Hospital Authority, Hong Kong
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Effectiveness of CGAT in Reducing Hospital

Utilization by Care Home Residents:
Hospital Admissions
Overall (n=67 homes) CGAT (n=41 homes) No CGAT (n=26 homes)
30 50%

Percentage of Care Homes

Number of Care Homes

40%

20
30%

20%
10
p = 0.015 10% p = 0.015
13.7 17.0 13.7 17.0

0 0%
0 5 10 15 20 25 30 35 0 5 10 15 20 25 30 35

Hospital Admissions Hospital Admissions

(per 100 residents per month) (per 100 residents per month)

Survey data (Nov 2004 – Jan 2005) for Princess Margaret Hospital
from Hospital Authority, Hong Kong
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Effectiveness of CGAT in Reducing Hospital

Utilization by Care Home Residents:
In-patient Bed-days
Overall (n=67 homes) CGAT (n=41 homes) No CGAT (n=26 homes)
30

Percentage of Care Homes

50%
Number of Care Homes

40%
20
30%

10 20%
p = 0.008 p = 0.008
10%
118 169 118 169

0 0%
0 50 100 150 200 250 300 350 400 450 0 50 100 150 200 250 300 350 400 450

Bed-days Bed-days
(per 100 residents per month) (per 100 residents per month)

Survey data (Nov 2004 – Jan 2005) for Princess Margaret Hospital
from Hospital Authority, Hong Kong
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Comprehensive Geriatric
Assessment Technology:
Complications

Delirium from fragmented

and duplicate assessment
by different members
Rozzini R et al. Delirium induced by
neuropsychological tests. J Am
Geriatr Soc 1989; 37(7): 666.
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Comprehensive Geriatric Assessment

Technology: Cost
Review of 19 RCTs
reporting cost endpoints
in CGA
• Cost-efficient
– Less cost for same outcome
– Same cost for better outcome
• Cost-effective
– E.g. less cost per QALY

Wieland D. The effectiveness and

costs of comprehensive geriatric
evaluation and management.
Critical Reviews in
Oncology/Hematology. 2003; 48(2):
227-237.
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Organizational Elements of CGA

Associated with Effective Programs
• Targeting the frail
• Interdisciplinary team structure
• Comprehensive/multidimensional geriatric
assessment
• Management with clinical control of treatments
and care
• Long-term follow-up
Stuck AE, Siu AL, Wieland GD, Adams J, Rubenstein LZ. Comprehensive geriatric
assessment: a meta-analysis of controlled trials. Lancet 1993;342:1032–6. 6.
Wieland D, Rubenstein LZ. What do we know about targeting in
geriatric evaluation and management (GEM) programs? Aging Clin
Exp Res 1996;8:297–311.
Wieland D. The effectiveness and costs of comprehensive geriatric evaluation and
management. Critical Reviews in Oncology/Hematology. 2003; 48(2): 227-237.
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Gate-keeping & Goal-keeping Dichotomy

“ Modern health care needs to

reconcile itself to complex
patients. There are many
wrong ways to address this,
Goal-keeping
Gate-keeping each of which has the
Needs led following in common: instead
Resource of getting to grips with how
driven service is provided, they want
the frail old people to go away,
to some more appropriate
place. ”
Professor Kenneth Rockwood
Age Ageing 2004; 33: 429-430
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The Yin-Yang of Assessment

Harmonizing goal-keeping with

Goal-keeping gate-keeping through
Needs led comprehensive geriatric
Gate-keeping assessment coupled with
Resource driven effective organizational
elements
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The Yin-Yang of Assessment

Entry to Care Homes
Volume 312, Issue 8081, 15 July 1978, P 141-143
Care of the Elderly
function MEDICAL SCREENING OF OLD PEOPLE
ACCEPTED FOR RESIDENTIAL CARE
JC Brocklehurst, MH Carty, JT Leeming, J Robinson

Goal-keeping Age and Ageing 2004; 33:25-34

Needs led The value of specialist clinical assessment of
Gate-keeping older people prior to entry to care homes
Resource driven DAVID CHALLIS, PAUL CLARKSON, JANINE
WILLIAMSON, JANE HUGHES, DAN VENABLES, ALISTAIR
BURNS, ASHLEY WEINBERG

institutionalization Age and Ageing 2004; 33:3-4

Assess first, admit second
TONY LUXTON

BENEFITS: identify undiagnosed conditions, physical function, caregiver stress

COSTS: use of A&E/care home, health cost(sig.), social & health costs(non-sig.)
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Placement after Pre-admission Assessment

by CGAT of PMH (1994-1995)
% with % requiring
alternate specialist
placements advice/care
Assessment for:
Infirmary care 24.9 14.3
Care & Attention Home 26.0 33.5
Hostel care 9.0 27.2
(meal section & self care)
Overall 24.5 (113/461) 21.0 (97/461)

Rafferty et al * 7.0 15.0

*Rafferty J, Smith RG, Williamson J. Medical Assessment of Elderly
Persons prior to a move to residential care - a review of 7 years’
experience in Edinburgh. Age Ageing 1987; 16:10-12.
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Growth of Care Home Residents

Percentage of 65+ population

60 7.0%

residing in care homes

Residents (in thousands)

50 6.0%
Overall Overall
Private 5.0% Private
40 Subvented Subvented
4.0%
30
3.0%
20
2.0%
10 1.0%
0 0.0%
2000 2001 2002 2003 2004 2000 2001 2002 2003 2004
Data derived from Social Welfare and Statistical Departments, Hong Kong
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The Yin-Yang of Assessment

A&E Journal of the American Geriatrics Society
October 2001 - Volume 49 Issue 10 Page 1390-1392
Older persons in the emergency medical care system
Sanders AB

Ann Emerg Med 2003;41:45-56

iatrogenesis Cost-Effectiveness of a Brief Two-Stage Emergency
Department Intervention for High-Risk Elders:
Results of a Quasi-Randomized Controlled Trial
McCusker J, Jacobs P, Dendukuri N, et al.
Goal-keeping
Journal of the American Geriatrics Society
Needs led September 2004 - Volume 52 Issue 9 Page 1417-1423
Gate-keeping A Randomized, Controlled Trial of Comprehensive
Geriatric Assessment and Multidisciplinary Intervention
Resource driven After Discharge of Elderly from the Emergency
Department - The DEED II Study
Caplan GA, Williams AJ, Daly B, Abraham K

hospitalization Age and Ageing 2005; 34:6-7

Accident, emergency, or what?
COLIN CURRIE

BENEFITS: survival, functional decline, physical & mental function

COSTS: use of care home, admission (Em/El), cost similar to conventional care
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Assessment of Fall Presenting to

A&E
Volume 353, Issue 9147, 9 January 1999, P 93-97
Prevention of falls in the elderly trial (PROFET): a
randomised controlled trial
injury Close J, Ellis M, Hooper R, et al.

Age and Ageing 2005; 34:162-168

Goal-keeping Patients with recurrent falls attending
Accident & Emergency benefit from
Needs led multifactorial intervention—a randomised
Gate-keeping controlled trial.
Resource driven Davison J, Bond J, Dawson P, Steen IN, Kenny RA

Age and Ageing 2005; 34:98-100

hospitalization Prevention of falls—a time to
translate evidence into practice
JACQUELINE C. T. CLOSE

BENEFITS: serious injury

COSTS: subsequent bed day utilization
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An 84-year-old woman presenting

to A&E twice for fall 2 & 3 wks ago

Living alone
Escorted to geriatric clinic by helper
Just discharged 4 wks ago for CHF, old
myocardial infarction
C/o distressing backache
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An 84-year-old woman presenting

to A&E twice for fall 2 & 3 wks ago

Living alone
Osteoporotic collapse of multiple thoracic
and lumbar vertebral bodies
Hx of bilateral salpingoophorectomy for
ovarian cysts at age 72
Functionally dependent on neighbours
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A 71-year-old man referred from

A&E for reduced memory for 2
wks in 8/2004
Accompanied by wife
Seen 3mths later (24/11/04) in Geriatric Clinic
C/o recurrent falls, dizziness and fear-of-
further falls (3Fs) since 8/2004
Attended A&E 27/8/04 for dizziness
Since then attended A&E for 3 more falls: on
18/9/04, 22/10/04, and 4/11/04; the last fall
being associated with head injury
Stopped going out for past 2 weeks, stayed in
bed and feel tired most of the time
Past investigations: 2 holters, CT brain
Medication: Methyldopa 250mg bd, lisinopril
5mg daily, minipress 1mg bd
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The Yin-Yang of Assessment

Polypharmacy
Age and Ageing 1992; 21:294-300
Inappropriate medication is a major cause of adverse
drug reaction in elderly patients
adverse drug Lindley CM, Tully MP, Paramosthy V, Tallis RC
reactions
Journal of the American Geriatrics Society
December 2002 - Volume 50 Issue 12 Page 1919-2107
Goal-keeping Adverse Drug Reactions as Cause of Hospital
Admissions: Results from the Italian Group of
Needs led Pharmacoepidemiology in the Elderly (GIFA)
Gate-keeping Graziano Onder, Claudio Pedone, Francesco Landi, et al.
Resource driven
Am J Med 2004; 116:394-401
Effects of geriatric evaluation and management on
adverse drug reactions and suboptimal prescribing in
polypharmacy the frail elderly

Schmader KE, Hanlon JT, Pieper CF, et al

BENEFITS: serious adverse drug reactions

COSTS: suboptimal prescribing (polypharmacy, inappropriate use, underuse)
 At Hospital
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 At Care Home
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 Polypharmacy in a 67-year-old

Steroid
man with digital gangrene

(immunosuppressed
Dx: fungal infective

by steroid for gout)

endocarditis
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 the questions to health care,
“Research seldom answers

but insights often”

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