Comprehensive Geriatric Assessment Position Statement

BACKGROUND

Comprehensive geriatric assessment has been defined by the 1987 National Institutes of Health Consensus Conference on Geriatric Assessment Methods for Clinical Decision-making as a “multidisciplinary evaluation in which the multiple problems of older persons are uncovered, described, and explained, if possible, and in which the resources and strengths of the person are catalogued, need for services assessed, and a coordinated care plan developed to focus interventions on the person’s problems.” Research evaluating comprehensive geriatric assessment (CGA) demonstrates its ability to improve the health status and quality of life of frail older adults across the spectrum of health care settings.

CGA is a necessary tool to minimize disability and loss of independence in frail elderly patients. Aging is a process that steadily reduces physiologic reserve and results in a diminished ability to compensate for the toll of illness. Illnesses accumulate with age, increasing in both severity and number. This double burden of physiologic decline and disease is associated with excess morbidity and resultant disability, i.e., difficulty in performing simple physical and mental tasks necessary for daily life. CGA is an intervention that seeks to identify and remediate the causes and effects of disability. When remediation is not possible, CGA seeks to slow functional decline and bolster independence by mobilizing available medical, psychological and social resources.

One of the goals of a responsive health care system is to promote the well-being of those suffering from the effects of disability and/or chronic illness. Randomized trials of CGA, applied across multiple health service settings, show it to be a cost-effective intervention that improves quality of life, quality of health, and quality of social care. Its benefits have been most robustly demonstrated when applied in a hospital or rehabilitation unit, but its value is also evident when used in the following settings: after hospital discharge, as an element of outpatient consultation, in home assessment services, and in continuity care. Despite these benefits, the application of CGA remains underused in the United States and its use is limited primarily to academic health centers and Veterans Administration hospitals that recognize its contribution to quality health care for older adults.

POSITION 1
Comprehensive geriatric assessment has demonstrated usefulness in improving the health status of frail, older patients. Therefore, elements of CGA should be incorporated into the care provided to these elderly individuals.

Rationale: Not all older persons who might benefit from comprehensive geriatric assessment will receive specialized geriatric assessment services. Practicing physicians should be encouraged to apply the elements of geriatric assessment in the care of older patients, including multidisciplinary teamwork, assessment of function, and psychosocial assessment. Physicians’ and other health professionals’ organizations could appropriately take a leadership role in the dissemination of this assessment methodology.

POSITION 2
CGA is most effective when targeted toward older adults who are at risk for functional decline (physical or mental), hospitalization or nursing home placement.

Rationale: A targeted population, the frail elderly, is the most likely to benefit from CGA. Targeting criteria used in successful trials of CGA suggest that persons who have impairments in basic or instrumental activities of daily living, or suffer from a geriatric syndrome (falls, urinary or fecal incontinence, dementia, depression, delirium, or weight loss), or whose health care utilization patterns indicate a high risk of subsequent hospitalization or nursing home placement are the most likely to benefit from CGA.

POSITION 3
Comprehensive geriatric assessment should be an integral part of the curriculum for all medical and health professional training programs.

Rationale: Routine CGA examines, at the very least, a patient’s mobility, continence, mental status, nutrition, medications, and personal, family, and community resources. It involves all disciplines responsible for providing care, as well as the patient and family, in developing an appropriate care plan. Comprehensive geriatric assessment is an effective tool for teaching the integration of the biological, psychological, social, and environmental aspects of health care, while recognizing the geriatrician’s special area of expertise.

POSITION 4
Medicare and other insurers should recognize as a reimbursable service or procedure: 1) comprehensive geriatric assessment of patients who are at risk for functional decline (physical or mental), hospitalization or nursing home placement, and 2) the support services required for effective application of CGA.

Rationale: Comprehensive geriatric assessment requires an interdisciplinary team to conduct medical, functional and psychosocial assessments, develop a written, comprehensive plan of care, and coordinate the health care providers and family members who are responsible for the execution of the plan of care. At the present time, Medicare payment policy does not reimburse the work of some necessary professionals (e.g., social work, dietician) in assessment and does not recognize the work of team conferences. Few professionals can or will provide the service if it is not adequately reimbursed. Insufficient reimbursement of CGA ultimately restricts the access of frail, older persons to this effective intervention and exacerbates the financial disincentives that aggravate our national shortage of geriatricians.

Last updated August 26, 2005.

Developed by the AGS Public Policy Committee. Approved November 1988 by the AGS Board of Directors and revised May 1991. Reviewed April 1993. Reviewed and Updated May 2005 with special thanks to Dr. Paul Mulhausen.

American Geriatrics Society, The Empire State Building, 350 Fifth Avenue, Suite 801, New York, NY 10118. Tel: 212-308-1414; Fax: 212-832-8646; E-mail: info. amger@americangeriatrics.org