Does Comprehensive Geriatric Assessment Really Make a Difference to Patients?
Yes. Studies have compared CGA to usual or standard models of medical care as employed for less complex patients, typified by focus on single conditions (rather than as a result of a broad assessment), often by a single clinician (rather than involving a team), and without an iterative, case-managed plan based on the assessment and involving a team. In these studies, CGA showed significant benefits both in terms of increased independence and a reduction in mortality. Stuck and colleagues demonstrated reduced mortality from inpatient CGA at 6 months OR 0.73 (CI: 0.61–0.88). Similarly, the 2011 Cochrane review conducted by Ellis and colleagues demonstrated a significant reduction in death or functional decline OR 0.76 (CI: 0.64–0.90) at 6 months. The review also found that those who underwent CGA on a ward had a higher chance of being alive and being in their own home at 6 months OR 1.31 (CI: 1.15–1.49) this equates to a number needed to treat of 13 to avoid one death or admission to residential care.
Accurate assessment is the first step to appropriate management and to avoiding over and under-prescribing. Multimorbidity rises with age, resulting in complex clinical pictures which require a thorough response to avoid causing more harm. Polypharmacy, prescribing errors, adverse drug events, hospital acquired infections, venous thromboembolism, pressure ulceration – all associated with medical intervention – all become more common the older that patients get. However, medication appropriateness indices remind us that harm comes not only from the prescription of unnecessary medications but also the omission of those which evidence-based practice would support. The 2009 RCP national continence audit suggested significant failures in both asking about and attaching a diagnosis to incontinent elders. The 2011 RCP inpatient falls audit suggested that 47% of high-risk patients could have had their bone heath assessed but did not. CGA ensures that a thorough medication review is carried out and patients' regimens are tailored to their needs.