BMJ

Comprehensive geriatric assessment for older adults: Should be standard practice, according to a
wealth of evidence
Author(s): Andreas E Stuck and Steve Iliffe
Source: BMJ: British Medical Journal, Vol. 343, No. 7832 (19 November 2011), pp. 1029-1030
Published by: BMJ
Stable URL: http://www.jstor.org/stable/41333296
Accessed: 21-10-2015 01:22 UTC

REFERENCES
Linked references are available on JSTOR for this article:
http://www.jstor.org/stable/41333296?seq=1&cid=pdf-reference#references_tab_contents

You may need to log in to JSTOR to access the linked references.

Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at http://www.jstor.org/page/
info/about/policies/terms.jsp

JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content
in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship.
For more information about JSTOR, please contact support@jstor.org.

BMJ is collaborating with JSTOR to digitize, preserve and extend access to BMJ: British Medical Journal.

http://www.jstor.org

This content downloaded from 190.80.117.170 on Wed, 21 Oct 2015 01:22:51 UTC
All use subject to JSTOR Terms and Conditions
bmj.com
review:
©Clinical Cognitiveassessment ofolderpeople{BMJ201 l;343:d5042)
OCIinicalreview: and
Assessing helping carers
ofolderpeople{BMJ 2011;343:d5202)
OCIinicalreview:
Fallassessment inolderpeople(BMJ2011;343: d5153)
OCIinicalreview:
Functionalassessment inolderpeople{BMJ2011;343: d4681)

Comprehensive geriatric assessment for older adults

Should be standard practice, according to a wealth of evidence

AndreasEStuck Geriatrics weresignificantly

ofgeriatrics,
professor lesslikely todieorexperi- carried outindedicated wardswasmoreben-
Department, ofBerne,
University Universityence functional
Inselspital deterioration. As a result, eficialthanifimplemented byteamsliaising
CH-3010
Hospital, Switzerland
Bern, suchpatients werealsolesslikely tobeadmit- withotherspecialties.In contrast towide-
andreas.stuck@insel.ch tedtoaninstitution andmorelikely tobealive spreadbelief, wardbasedassessment is not
Stevelliffe ofprimary
professor care
forolder
people, intheirownhomesat
London,UCL Free term
longer follow-up only effectiveforselected olderpatients has
but
University
College Royal Campus,
London,UK (median 12 months) compared with those beneficialeffectsin all elderlypatients admit-
receivingusualcare. tedtoacutehospitalcare.14Allambulatory
Careofolderpeoplediffers fromcareofmiddle Thissystematic analysiscombined subacute olderpatients canbenefit from specifictypes of
agedadults. Olderpeopleoften havemore com- and acutehospitalbased assessmentpro- programmes basedoncomprehensive geriatric
areat increased grammes (table).Subacutemodelsaretypi- assessment 9
plexmultisystem problems, (table).5Inthesubgroup offrail
riskformorbidity and mortality, and need callyforselected olderpatients inhospital,and olderpatients, coordinated carebasedonthis
comprehensive interventions thattakeinto theyoffer specialised multidisciplinary reha- assessment improves outcomes andreduces
accountthebiopsychosocial components of bilitativeinpatient care.Aprevious systematicunnecessary hospital admissions.6 Inselected
health.Comprehensive geriatricassessment is reviewfoundthatgeneraland orthopaedic peopleabovetheageof75,preventive home
anapproach developed forthispurpose.Itisa geriatric rehabilitation programmes improve visitsbasedoncomprehensive geriatricassess-
process thatdetermines anolderperson's med- functional andsurvival outcomes inselected ment canreduce thedeclineinfunctional sta-
ical,psychosocial, functional, andenviron- olderpatients.3 tusandprevent nursing home admission.7 In
mental resources andproblems, anditcreates In contrast, acutemodelstypically apply thelargegroupofnon-disabled peopleabove
anoverall planfortreatment andfollow-up.1 It toall patientsaged70 andoveradmitted for theageof65,health riskappraisal programmes
encompasses linkage ofmedical andsocialcare acutehospital care.Theyincludean interdis-combined withpersonalreinforcement have
aroundmedicaldiagnoses anddecisionmak- ciplinary centred basedon shownfavourable effects.8 9Attheotherend
patient approach
ingundertheleadership ofa doctortrainedin an assessment linked withcareprotocols and ofthespectrum, patients inneedofpalliative
geriatricmedicine. earlydischarge in a
planning, hospital environ- carealso seem to benefit from basedoncom-
Olderpeopleadmitted tohospitalas emer- mentadaptedforelderly peoplewithmobilityprehensive geriatricassessment methods.6
gencies areatespecially Inthelinked ororientation
highrisk.. problems. Aprevious systematic Thishasimplications forresearch.Moreevi-
systematic review, Ellisandcolleaguesper- review reported favourable ofacutecare denceis neededonhowtooptimise
effects theeffec-
formed a meta-analysis ofthecomprehensivegeriatrics, although conclusions werelimited tiveness andefficiency oftheseassessments,
geriatricassessment of elderlypeople admit- bya low number of studies.4 including research on how besttoapproach
tedtohospital.2 They found that patientsin tothe
According findings ofthelinked meta- individual components themodel(such
of
hospitalwhoreceivedsuchan assessment analysis,2 comprehensive assessment as falls,pain,delirium,
geriatric nutrition)indifferent

Selected
comprehensive assessment
geriatric basedprogrammes
with effects
favourable to
according
results
ofsystematic orindividual
analyses randomised
controlled
trials
Setting Patient
group Programme
description
Hospital2 atacute
Patients care admission
hospital Acute
care
for
the unit4*
elderly
Patients inacute
staying care selected
hospital for Inpatient rehabilitation;
geriatric
subacute
subsequent care orthopaedic rehabilitation3*
geriatric
Ambulatory Patients
admittedtoemergency
department emersenCy
department16"1
care
Interdisciplinary
primary
models; assessment
outpatient and
Patients
withchronic
conditions , geriatric and
evaluationmanagement
programmes;
proactive
ambulatory
rehabilitation
programmes6*
inend
Patients oflife
situation Palliative
care
programmes6t '>
<
Older
non-disabled
people inthe
living community
<x
'Favourable
effects ofsystematic
toresults
according analysis.
tFavourable
effects torandomised
according controlled
trials. CO
<
LU
2

119NOVEMBER
BMJ 2011
1VOLUME
343 1029

This content downloaded from 190.80.117.170 on Wed, 21 Oct 2015 01:22:51 UTC
All use subject to JSTOR Terms and Conditions
Doctorsneed to be trainedto use geriatricassessment like
a laboratorytest,linkedwithdiagnosticand prognostic
evaluationand therapeuticaction

settings. Thiswillalso requiretranslational comprehensive geriatric assessment notonly 6 Boult C,Green AF,Boult
LB,Pacala
JT,
Snyder C,Leff
B.
researchbased on non-randomised outcomes butmaysavecosts Successful
modelsof care
comprehensive forolder
adults
study improves patient with
chronicconditions:
evidence
for
theInstitute
of
designs, to evaluate cost and effectivenessof byreducing hospital readmissions and lowering Medicine's for
"retooling anagingAmerica" .J
report Am
dissemination ofevidence. theneedforlongterm nursing homecare.212 GeriatrSoc
2009;57:2328-37.
Theclinical implications areclear-compre- Competing All
interests: authorshave completed theICMjE 7 Multidimensional
Stuck
Huss'A, AE,RubensteinLZ, M,
Egger
assessment:
geriatric backtothe
KM.
Clough-Gorr
future.
hensivegeriatric assessment shouldbecome uniform
disclosure
formatwww.icmje.org/coi_disclosure. Multidimensional homevisit for
onrequest
(available
pdf fromthecorresponding author)and preventive programs
standard practice. Clinicalexpertise is needed declare:
nosupport from forthe submitted communitydwellingolder
adults:
asystematicreview
and
anyorganisation ofrandomized
meta-analysis controlled
trials
[published
toimplement theseapproaches. Doctors need work;nofinancial with
relationships any organisationsthat correction ABiol
Gerontol
'n-.J MedSci2009-M-318].J
tobetrained tousetheassessment have
might
likea labora- three aninterest
inthesubmittedwork inthe previous Gerontol ABiolMed Sci2008:63:298-307.
years;noother oractivities
relationships that could 8 Rand Health
Corporation: Risk and
Appraisals
torytest,linked with diagnostic andprognosticappear tohave influenced
thesubmittedwork. Medicare.Evidence andevidence-based
report
evaluation andtherapeutic action.10 Provenanceandpeer review:
Commissioned; notexternally recommendations. 2000. USDepartmentofHealth
Widespread adoption ofcomprehensive reviewed.
geri- peer andHuman Services,
www.rand.org/pubs/reprints/
atricassessment 1 StuckAE.Siu AL,WielandGD,Adams Rubenstein
J, LZ. RP1225.html.
willrequire system change. U,Anders
Comprehensive assessment:
geriatric ameta-analysisof 9 Dapp JAM,vonRenteln-Kruse
W, MinderCE,
Redesigning systems ofcaretoincreasesup- controlled
trials.
Z.o/?cef
1993;342:1032-6. Meier-BaumgartnerHP,Swift etal.Arandomized
CG,
portforclinicians intheir workmayimprove 2 Ellis G,WhiteheadMA, RobinsonD,O'NeillD,Langhorne trial ofeffectsofhealthrisk combined
appraisal
P.Comprehensive assessment
geriatric for olderadults withgroup sessionsorhome visits
onpreventive
patients'experience and outcomes more than admittedtohospital: ofrandomised behaviorsinolderadults. ABiol
JGerontol SciMedSci
meta-analysis
relyingontraining alone.11Theprocess ofhospi- controlled
trials.
BMJ201l;343:d6553. 2011;66:591-8.
talcareneedstobeadapted toinclude compre- 3 Gorr
Bachmann C,Huss
S,Finger A,EggerM, StuckAE, Clough-10 Ward Reuben
KT, DB.Comprehensivegeriatric
KM. rehabilitation
Inpatient designed
specifically for assessment.Schmader KE,ed.UpToDate 2011.www.
hensive geriatricassessment, including geriatric geriatric patients: review
systematic and of
meta-analysis uptodate.com/contents/comprehensive-geri
evaluation andmanagement. System change randomised controlled
trials
[publishedcorrection
in:BMJ assessment?source=search_result&search=ge
alsomeansplacing thegeriatrician 2010;340:Cl718.].
atthecen- 4 Baztan BMJ2010;340:Cl718. ssessment&selectedTitle=l%7E46.
Suarez-Garcia
JJ, FM, J,
Lopez-Arrieta 11
Rodriguez- Bergeson SC,Dean JD.Asystemsapproach topatient-
treofclinical management incountries where Mafias F.Effectiveness
L,Rodriguez-Artalejo ofacute centered
care.JAMA 2006;296:2848-51.
mosthospital inpatients areolderpeoplewith units
geriatric onfunctional
decline, athome,
living 12 StuckAE,Aronow HU, Steiner
A,Alessi
CA, Bula Gold
CJ,
andcase fatality
among older admitted
patients to MN,etal.Atrialofannualin-homecomprehensive
complex needs. In addition, reimbursement foracutemedical
disorders: assessments
geriatric for
elderly
people inthe
living
hospital BMJ
meta-analysis.
systems thatpromote comprehensive careare 2009;338:b50. community. NEnglJMed 1995;333:1184-9.
needed. Previous research suggests thatassess- 5 Graf CE, D,Giannelli
Zekry S,Michel]P,
ChevalleyT.
Efficiency
Cite
this
as:BMJ 2011;343:d6799
and ofthe
applicability comprehensive assessment
geriatric doi:
10.1
1
mentbasedinterventions mayresultinaddi- intheemergency asystematic
department: review.
Aging 36/bmj.d6799
tionalcostsinitially.However, inthelonger term Clin
Exp Res2010; online
published 5October. ORESEARCH, p1034

ANSWERS TO ENDGAMES,p 1086 Forlonganswers

gototheEducation
channel
onbmj.com

CASE REPORT
swjs^Qu^j^s:;;-7}
A patientwithbilateralshoulder and pelvicgirdleaching :■
1Theclinical presentation-severebilateral
achingandstiffnessof(sub)acuteonset
theshoulders
involving andpelvic inanelderly
girdle (>65years),
patient withnobenefit
oftreatment witha non-steroidal
anti-inflammatory
drug- suggests a diagnosisof
polymyalgia rheumatica. ! ON EXAMINATIONQUESTION j
2Thecausesofpolymyalgia rheumaticaareunknown. However, environmentaland
geneticfactorsarethought tocontribute
todiseasesusceptibility
andseverity. | Peutz-Jegherssyndrome
3 Other medicalconditionscanpresentwithsimilar BandEarecorrect,
| Answers while
A,C,andDareincorrect.
j
(serious) symptoms, sothe
differential iswide-for
diagnosis example,autoimmune conditions(rheumatoid arthritis,
ankylosing ormyositis),
spondylitis, infectious
diseases(viral
syndromes, tuberculosis, ANATOMY QUIZ
orosteomyelitis),
endocrine disorders orhypo(para)thyroidism),
(hyper(para)thyroidism
andmalignant disorders
(lymphoma, leukaemia,ormyeloma). Magnetic resonance angiogramofthe
4 Polymyalgiarheumatica usually
responds to
rapidly a moderate doseofprednisolone brain
15 mgdaily, butlongterm treatmentisneeded. A:Internal
carotid
artery
5Asmall number ofreports havedescribedanassociation
between fluvaccineand B:Middle
cerebral
artery
polymyalgia rheumatica.Genetic
variantsoftheHLA complex havebeensuggested to C:Anterior
cerebral
artery
playa roleinthisphenomenon, butthisdoesnotmean that
fluvaccinationisthecauseof D:Posterior
communicating
artery
polymyalgia rheumaticainourpatient. E:Posterior
cerebral
artery

1030 119NOVEMBER
BMJ 2011
1VOLUME
343

This content downloaded from 190.80.117.170 on Wed, 21 Oct 2015 01:22:51 UTC
All use subject to JSTOR Terms and Conditions