Comprehensive geriatric assessment in the acute care hospital and in the ambulatory setting

Comprehensive geriatric assessment (CGA) is defined as a multidimensional medical, functional, psychosocial and environmental evaluation of an older person's problems and resources, linked with an overall plan for treatment and follow-up. It is well established that CGA implemented in specialized geriatric evaluation and management units improves function and survival in frail older patients. The results of new randomized controlled trials, however, show that the application of CGA does not only improve outcomes in selected older persons, but probably in most. A randomized controlled study in unselected older patients admitted to an acute care hospital found that patients function at hospital discharge was improved, and the risk of nursing home admissions decreased, in patients receiving integrated geriatric care as compared to patients receiving the usual acute hospital care. Another trial examined the impact of follow-up geriatric home-visits in patients with unstable cardiac failure discharged from the hospital. This trial found a statistically significant reduction of hospital readmissions and cost savings in the intervention group as compared with controls. A new application for CGA emerges in the preventive arena. Annual comprehensive geriatric assessments with preventive home visits in older people living at home resulted in fewer nursing home admissions and delayed or prevented the onset of disability in the activities of daily living in persons of the intervention group as compared to controls. One of the roles of geriatricians is teaching CGA and conducting further research with a view to refining CGA methodology and its application. Practical application of the principles of geriatric assessment and management, however, should not remain in the hand of specialists alone, but should become an integrated part of primary care medicine in the ambulatory and hospital settings.