The ABCD of the comprehensive geriatric assessment

The concept of the “ABCD of CGA” would result in varying assessments depending on the environment and needs of the patient

The comprehensive geriatric assessment (CGA) is considered the gold standard assessment tool for evaluating and providing care to at‐risk and frail older patients. The key elements of the CGA include a multidimensional approach with a coordinated multidisciplinary assessment to identify medical, psychosocial, environmental and functional concerns. The information gathered is used to inform and formulate a detailed and individualised care plan with identified goals focusing on restoring or maintaining function with clear follow‐up.1,2,3

The concept of the geriatric evaluation was developed in the 1930s by British geriatrician Marjory Warren, who recognised that older patients with multiple comorbidities and poor functional status often lacked diagnoses and clear management plans. Warren advocated for specialised and coordinated care, which is the basis of CGA, demonstrating many older patients previously considered dependent on care could be discharged home.1,4

In today’s health care system, increasing rates of hospitalisation with longer lengths of stay and poorer outcomes have been noted in the frail, older population compared with other demographics. The CGA encompasses a holistic approach of the frail older patient with an emphasis on function and quality of life and promotes the use of quantitative assessment tools with early involvement of the multidisciplinary team. Increasingly, a multidisciplinary team approach and assessment of different domains has been adopted into standard care; however, this is often not formally a CGA, which requires definition and specifics that are yet to be properly determined. We propose a new concept of the “ABCD (abbreviated, brief, comprehensive, detailed) of CGA” with varying models of CGA depending on the setting and needs of the patient.

The core components of the CGA are functional status, including cognition, mobility, comorbidities with a focus on the geriatric syndromes, polypharmacy, mood, nutrition, visual and hearing impairment, living environment, social network, finances, support and care needs, goals of care, and advanced care planning.2,5

The evidence supporting the use of CGA is strong and noted in a variety of clinical settings.

Within the geriatric evaluation and management unit setting, the use of CGA has shown multiple benefits:

• increased likelihood of discharge home;5,6,7
• reduction in discharges to residential aged care facilities;5,6
• improvement in functional status;5,7
• greater functional independence on discharge;5
• cognitive improvement;5,6,7
• reduction in mortality;5,7
• reduction in re-hospitalisation and shorter hospital stays;5 and
• greater satisfaction among patients, families and medical and nursing staff.5

The use of CGA within acute care of the elderly units is one of the defining features separating these units from other acute medical units, with the demonstrated benefit of increased likelihood of living at home and a reduction in functional decline at discharge.8

More recently, the use of CGA in the emergency department (ED) setting has been considered in a cohort study conducted in United Kingdom investigating the impact of using CGA in the ED. The CGA was integrated to the ED with an on‐site consultant geriatrician present 7 days a week sharing decision making and with the implementation of a standardised integrated proforma with care pathways and joint education between staff. These changes were associated with a statistically significant reduction in admissions and in the readmission rate, thus demonstrating early intervention is beneficial for patients and hospitals.9

Although the benefits of CGA have been clearly demonstrated, it is not always feasible or beneficial to implement a full comprehensive assessment in all situations due to constraints, including time and resources. Contributing to the difficulty is the definition of the CGA which remains broad and ill‐defined, making it difficult for the user to adopt across various settings. Hence, we propose the concept of the “ABCD of CGA” to establish varying models and intensity of CGA depending on the need. This concept would result in targeted domains in the rapid assessment environment of the ED and a more comprehensive assessment over time in the more subacute environment of the Geriatric Evaluation and Management unit (Box). It is important to understand that CGA does not change management but directs management depending on the CGA findings and the clinical environment.

The next step for this concept would be the development of standardised CGA tools for use in identified settings for specific purposes. Should this concept be accepted, further work would need to be done to validate the four different approaches. Once determined, this would enable common language and understanding with the ability to compare CGA use in various research and clinical settings, including across primary to tertiary care.

Box – Varying models of comprehensive geriatric assessment using the ABCD concept

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