Alberto Pilotto Finbarr C. Martin Editors

In this context, the emergence of a comprehensive geriatric assessment (CGA) as the best approach to the care of older adults was a crucial milestone that initiated the geometric expansion of research in clinical geriatrics over the past four decades. The operational idea that this complexity can be addressed through comprehensive geriatric assessment was proposed by Warren in the late 1930s [4].

The Explosion of Interest for GCA

The idea that improving medical outcomes and quality of life in older people requires a multidisciplinary approach that cannot be limited to disease management originated and developed in the health care system of the United Kingdom, the first country to formally establish the notion of geriatric medicine as a. specialty.

The Essence of CGA

For example, the use of some form of CGA used to assess surgical risk or to assess the potential benefit of cancer chemotherapy in elderly patients has shown significant benefits compared to more traditional approaches [15, 16]. Aggregate results derived from CGA allow for the stratification of elderly patients in groups of homogeneous complexity and provide an understanding, in control studies, of how interventions originally developed in relatively healthy patients work when administered to debilitated elderly patients.

CGA as a Proxy Measure of Phenotypic Aging

On the other hand, because our understanding of the underlying cause of this 'accelerated aging' remains hidden in most cases, there is very little we can do to stop or reverse it. A caveat to this interpretation is that aging is ubiquitous and likely affects many aspects of human anatomy, physiology, and biology that CGA does not even consider.

What Is Missing?

Fried's definition of frailty has generated some of the most important research on aging in the last two decades, but again, and similar to CGA, most of this literature has focused on predictive validity and evidence that frailty is a multisystem consequence. dysregulation of various homeostatic mechanisms [21]. There is still a lack of evidence that interventions that significantly change important outcomes can be implemented after frailty is diagnosed, and this missing link is probably the most important reason why, as with CGA, translating the concept of frailty into clinical practice has been so difficult.

Biological Aging

Such homeostatic mechanisms are the instruments of resilience and become less and less effective with age. However, after development, when genetic control is less stringent, the variance of the phenotype increases geometrically and there may be a significant discrepancy between chronological and phenotypic age.

Fig. 1.1 Metrics of aging. Chronologic age is a linear function of time with no heterogeneity across individuals

The Future of CGA

Wellens NIH, Deschodt M, Flamaing J et al (2011) First-generation versus third-generation comprehensive geriatric assessment instruments in the acute hospital setting: a comparison of the minimal geriatric screening instruments (MGST) and the interRAI acute care (interRAI AC) . Fried LP, Tangen CM, Walston J et al (2001) Frailty in older adults: evidence for a phenotype.

The Different Domains

Introduction
Physical Health

Vision
Hearing
Multimorbidity and Polypharmacy
Nutritional Status
Balance and Falling

Functional Status
Psychological Health .1 Cognitive Status

Mood

Socioenvironmental Status

Finally, assessment of alcohol use should be performed in all patients as part of the assessment of nutritional status. Kaufman DW, Kelly JP, Rosenberg L et al (2002) Recent patterns of medication use in the United States adult outpatient population: the Slone survey.

Fig. 2.1 Main determinants of health status of older people

The Patient, the Multidisciplinary Team and the Assessment

Introduction
Who Needs CGA?
The Purposes of Assessment
Assessment Tools
Measurement and Scaling
Choosing the Appropriate Type of Assessment Scale
Clinical Prediction Tools
The Clinical Team
Team Building and Team Working

Design the service according to the required resources and skills – assess (changing) needs over time. A numerical difference of a unit does not mean a consistent difference in the amount of estimated issue.

Table 3.1 Properties of assessment tools in health and social care

Comprehensive Geriatric Assessment in the Hospital

Introduction

CGA in Hospital

No improvement in survival Rubenstein et al. 1991) [1]Meta-analysis15 RCTs 39% reduction in inpatient mortality from IGCSs and a 37% reduction in inpatient mortality from GEMUs/ACEs Van Craen et al Meta-analysis7 studies (n = 4759 patients) Less functional decline at discharge from the GEMU and a lower rate of institutionalization 1 year after discharge GEMU's geriatric evaluation and management units, RCT randomized controlled trial, IGCS's inpatient geriatric consultation services, ACEs acute care for the elderly, ADL activities of daily living 4 Comprehensive Geriatric Assessment in the Hospital. There was also a reduction in the combined outcome of death or functional decline and an improved cognitive functioning, with wards appearing more effective than mobile units [ 13 , 17 ].

CGA in Posthospital Discharge

Van Craen K et al (2010) Effectiveness of inpatient geriatric evaluation and management units: a systematic review and meta-analysis. Stuck AE, Siu AL, Wieland GD, Adams J, Rubenstein LZ (1993) Comprehensive geriatric assessment: a meta-analysis of controlled trials.

Comprehensive Geriatric Assessment in Long-Term Care and Nursing Homes

Introduction
CGA in Long-Term Care
The Resident Assessment Instruments (RAI)
Other CGA Programs for Nursing Homes
CGA Programs for Patients Admitted to Nursing Homes After Acute Hospitalization
CGA and Quality of Care in Nursing Homes

Hermans K, Spruytte N, Cohen J et al (2014) Palliative care informed in nursing homes through the interRAI palliative care instrument: a study protocol based on the medical research council framework. Hermans K, De Almeida MJ, Spruytte N et al (2014) A comparative analysis of comprehensive geriatric assessments for nursing home residents receiving palliative care: a systematic review.

Table 5.1Principal observational studies and systematic reviews on comprehensive geriatric assessment (CGA) in long-term care, i.e., rehabilitation units and nursing homes Author, year, referenceSettingType of studyNumber of participants/trials with gene

Comprehensive Geriatric Assessment in the Community and in Outpatient

Introduction and General Characteristics
Evidence Supporting HAS/HHAS CGA
Evidence Supporting OAS and CGA Programmes Integrated into Primary Care
Primary Care Physicians and Outpatient CGA
Perspectives in Research on Multifactorial CGA-Based Interventions in Preventing Functional Decline

A cluster randomized controlled trial conducted in 12 general practices in the south of the Netherlands did not provide any evidence of the effectiveness of a proactive primary care approach (home multidimensional assessment with interdisciplinary care based on a tailored treatment plan and regular evaluation and follow-up) among frail older people in relation to disability (primary outcome) or other secondary outcomes (depression, social support interactions, fear of falling and social participation) [24]. Metzelthin SF, Van Rossum E, De Witte LP, Ambergen AW, Hobma SO, Siper W, Kempen GIJM (2013). Ploeg J, Brazil K, Hutchison B, Kaczorowski J, Dalby DM, Goldsmith CH et al (2010) Effect of preventive primary care outreach on health-related quality of life among older adults at risk of functional decline: randomized controlled trial.

Table 6.1 Meta-analyses on CGA in the community and in outpatient consultation Author,

Comprehensive Geriatric Assessment and Personalized Medicine

Introduction
Personalized Medicine and Old Age
Patient-Centred End Points
Multidimensional Prognostic Index and Patient- Centred End Points
Patient-Centred Medicine in Old Age

Direct or indirect effect on patient-centred endpoints Frailty, reduced quality of life and. Patient-centered endpoints may be useful, alone or in combination with disease-specific endpoints, to identify specific pharmacological treatments and monitor their effects in frail older patients. The traditional concept of personalized medicine can still be applied, perhaps in combination with the proposed, modified approach of patient-centered medicine, in older patients.

Table 7.1 Factors limiting the routine use of personalized medicine in older patients

CGA and Clinical Decision-Making

The Multidimensional Prognostic Index

Frailty and Prognosis in Clinical Decisions in Older Adults
Frailty and Medications
Role of CGA in Prognosis
The CGA-Based Multidimensional Prognostic Index (MPI)

Practical Notes

The Role of MPI in Clinical Decision-Making
Future Directions

Pilotto A, Sancarlo D, Panza F, Paris F, D'Onofrio G, Cascavilla L et al. older patients with dementia. Pilotto A, Addante F, Franceschi M, Leandro G, Rengo G, D'Ambrosio LP et al (2010) Multidimensional prognostic index based on a comprehensive geriatric assessment predicts short-term mortality in older patients with heart failure. Pilotto A, Sancarlo D, Aucella F, Fontana A, Addante F, Copetti M et al (2012) Addition of the multidimensional prognostic index to the estimated glomerular filtration rate improves prediction of long-term all-cause mortality in older patients with chronic kidney disease.

Table 8.1Clinical studies of development and validation of the multidimensional prognostic index (MPI) and predictive values against different disease- specific prognostic indices DiseaseSetting, patients numberAccuracy AUC (95% CI) C-index risk: OR or HR

Comprehensive Geriatric Assessment in the Emergency Department

Introduction

Routes into Hospital
Paramedic-Led Responses
Community Team-Led Responses

Inside the Emergency Department

Identifying Older People with Frailty in Urgent Care
Clinical Evaluation
Falls
Pain
Sepsis

Why CGA in the ED?
What Does Ideal CGA in the ED Look Like?

Environment
Patient Centred
Patient Identification
Multidimensional Assessment
Development of a Coordinated and Integrated Plan for Treatment
Reducing Iatrogenesis
Early Discharge Planning
Follow-Up

How Can CGA Be Delivered in the ED?
Summary

In the following section, the ideal CGA service in the ED setting will be described. Ellis G, Jamieson CA, Alcorn M et al (2012) An acute care unit for the elderly (ACE) in the emergency department. Conroy SP, Ansari K, Williams M et al (2014) A controlled evaluation of comprehensive geriatric assessment in the emergency department: the 'Emergency Frailty Unit'.

Fig. 9.1 Box and whisker plot for the time taken to complete four commonly used risk stratifica- stratifica-tion tools in the ED

Comprehensive Geriatric Assessment in Cancer Patients

Introduction
Domains and Tools Used for CGA of Cancer Patients
How to Identify Older Cancer Patients Who May Benefit from a CGA
CGA as a Decision Support in Geriatric Oncology
Clinical Relevance of CGA to Detect Health Problems in Oncology
Clinical Relevance of CGA to Organize an Individualized Geriatric Intervention Program and Follow-Up
The Prognostic Value of CGA for Predicting

Few studies have described interventions implemented on the basis of CGA results in older cancer patients. Wildiers H, Heeren P, Puts M et al (2014) International Society of geriatric oncology consensus on geriatric assessment in elderly patients with cancer. Decoster L, Van Puyvelde K, Mohile S et al (2015) Screening tools for multidimensional health problems warranting a geriatric assessment in older cancer patients: an update of SIOG recommendations.

Table 10.1 Domains and tools most frequently used for CGA of older cancer patients [3–7, 9–11]

Comprehensive Geriatric Assessment in Orthogeriatrics

Introduction
Hip Fracture in Older Adults: The Paradigm of Frailty In adults or young adults, an osteoporotic or traumatic fracture is usually associated
The Comprehensive Geriatric Assessment Approach in Orthogeriatric Care
Orthogeriatric Models of Integrated Care: Optimal Setting and Care Organization
Conclusions: What’s Next?

Giusti A, Barone A, Razzano A et al (2015) Optimal setting and organization of care in the management of older adults with hip fracture: a narrative review. Barone A, Giusti A, Pizzonia M et al (2006) A comprehensive geriatric intervention reduces short- and long-term mortality in older people with hip fracture. Sletvold O, Helbostad JL, Thingstad P et al (2011) Effect of in-hospital comprehensive geriatric assessment (CGA) in older people with hip fracture.

Fig. 11.1 (A–D) Orthogeriatric models of integrated care for the management of older adults presenting with hip fracture

Comprehensive Geriatric Assessment in Patients with Organ Failure

Cardiovascular Diseases
Chronic Kidney Disease
Respiratory Disorders
Gastrointestinal Disorders

Upper Gastrointestinal Bleeding
Liver Cirrhosis

Pilotto A, Addante F, Franceschi M et al (2010) A multidimensional prognostic index (MPI) based on a comprehensive geriatric assessment predicts short-term mortality in elderly patients with heart failure. Pilotto A, Sancarlo D, Aucella F et al (2012) Addition of multidimensional prognostic index to estimated glomerular filtration rate improves prediction of long-term all-cause mortality in elderly patients with chronic kidney disease. Pilotto A, Addante F, D'Onofrio G et al (2007) Utility of comprehensive geriatric evaluation in elderly patients with upper gastrointestinal bleeding: a two-year follow-up study.

Table 12.1 Usefulness of CGA in patients with organ failure

Comprehensive Geriatric Assessment in Perioperative Medicine

Perioperative Medicine in Older People
Comprehensive Geriatric Assessment in Perioperative Medicine
Comprehensive Geriatric Assessment in the Preoperative Setting
Comprehensive Geriatric Assessment to Facilitate Shared Decision-Making
Comprehensive Geriatric Assessment in the Postoperative Setting
The Evidence for Comprehensive Geriatric Assessment in Perioperative Care
Establishing Comprehensive Geriatric Assessment in Routine Perioperative Care

Performing effective comprehensive geriatric assessment in the preoperative setting requires a thorough knowledge of frequently occurring postoperative complications and the risk factors for the development of these adverse events. The established methodology of comprehensive geriatric assessment uses tools to objectively help describe different aspects of health status. Application of comprehensive geriatric assessment in the postoperative setting will vary depending on whether the patient is presented electively or as an emergency.

Comprehensive Geriatric Assessment in Patients with Cognitive Decline

Burden of Dementia in Advanced age and Multidimensional Aspects
Identification of Cognitively Impaired Patients by Means of CGA
CGA in Dementia and Clinical Decision-Making

Drug Treatments in Dementia: The Role of CGA

Future Perspective: The Key Role of CGA to Prevent Dementia

Improving clinical therapeutic decision-making in demented patients according to their prognosis (Figure 14.1). The use of CGA makes it possible to identify sources and problems in several personal areas that could negatively affect the progression of cognitive impairment (Figure 14.2), but there is a lack of systematic data on the real effect of CGA in dementia. population. Pilotto A, Polidori MC, Veronese N et al on behalf of the MPI_Age study group (2017) Association of antidementia medication and mortality in frail elderly patients with dementia living in the community: the role of mortality risk assessment.

Fig. 14.1 The CGA in older patients without dementia or seeking medical advice for cognitive complaints

Teaching CGA

Introduction
Background on Education and Training
Competencies and Learning Theories
How to Plan and Design Teaching CGA

Several of the core competencies described in the two catalogs above are critical to optimal clinical performance in elderly patients and are necessary skills for performing and interpreting a comprehensive geriatric assessment (CGA), the cornerstone of geriatric medicine. This means that when conceptualizing the curriculum for teaching in CGA, colleagues should consider how the learning outcomes of students and residents should be assessed. In addition to the use of scales, the complexity of the patient and the interpretation of CGA results should be clear to the students.

Fig. 15.1 Pathway for the measurement of effectiveness of training. (Adapted with permission from Spilsbury [11]

Index

See Geriatric Depression Scale (GDS) Geriatric Anxiety Inventory (GAI), 21 Geriatric Anxiety Scale S (GA), 21 Geriatric Depression Scale (GDS), 21 Geriatric Assessment and Management Units.