Comprehensive Geriatric Assessment (GCA) is a multi-dimensional and multi-disciplinary screening exercise to arrive at a comprehensive understanding of the health and social care needs of an older adult. This understanding helps plan and intervene in various aspects, clinical and non-clinical, thus ensuring a quality of life best suited to the older adult.
21 May, 2022
Dr Marjory Warren is the co-founder of the Medical Society for the Care of the Elderly (renamed the British Geriatrics Society) along with other physicians and credited with the formalisation of geriatrics as a medical speciality within the National Health Service (NHS) in the UK.
In two seminal papers in the 1940s, in the British Medical Journal and the Lancet, Warren advocated the creation of a medical specialty of geriatrics, the provision of special geriatric units in general hospitals, and the teaching of medical students in the care of elderly people by senior doctors with specialist interest and experience in geriatrics.
You can read more about Dr Warren, considered the mother of modern geriatric medicine, on the BGS website.
Since then, the field of geriatric has evolved to become multi-disciplinary and many countries around the world today recognize the need to strengthen adult care in the context of longevity, i.e., increased lifespans of general population. For context, the average lifespan of Indians has risen by 10 years in the last two decades, and a 2021 Silver Angels essay titled Future of Ageing: An India Perspective looks at the evolution of policies towards increasing quality of life of older adults and seniors.
A recent study led by Professor Santosh Salagre at KEM Hospital Mumbai, mentions that India, home to over 100 million adults over the age of 60 years, produces 20 geriatricians annually due to limited availability of post-graduate seats, and has limited functioning geriatric departments under public healthcare.
The nation-wide web survey carried out as part of this study covered 800 medical interns and professionals, and looked for knowledge, attitude and practices and perceived needs regarding specialised geriatric healthcare. It also consolidated views towards geriatric medicine as a career option among medical interns (MBBS students).
- Insufficient knowledge (48.5% of professionals) regarding any specialised branch of geriatric healthcare was found.
- Only 9.0% medical professionals performed ‘Comprehensive Geriatric Assessment’.
- 96% professionals and 92% interns felt the need for specialised geriatric services throughout India with majority feeling the need for specialised OPDs.
- 32.7% of interns were willing to opt for post-graduation in Geriatrics, if given a choice and those with any specialised geriatric facility available at their institute were more willing.
- More than 85% professionals and interns had affirmative attitudes towards the possible benefits of specialised healthcare.
A 2016 summary note prepared at the Royal College of Physicians of Ireland expands key aspects of a Comprehensive Geriatric Assessment (CGA) and considers,
– the four main dimensions (physical, functional, psychosocial and social assessments),
– the elements that should be part of such assessments (gait/balance, cognitive, nutrition, etc.),
– the composition of the multi-disciplinary team (medical, nursing, health and social care professionals) and,
– benefits from such assessments (improved diagnostic accuracy, individualised care plans, reduction in potential hospitalization, etc.).
A previous study led by Professor Santosh looked at the burden of undiagnosed medical problems of the elderly by Comprehensive Geriatric Assessment (GCA) screening in the context of the Indian healthcare systems.
- An assessment chart with ten common problems associated with older adults along with the diagnostics tests relevant and cut-off values for positive and negative screening were prepared.
- The study participants were recruited from seven out-patient departments (medical, surgical, orthopaedic, ophthalmic, ENT, gynaecological and general) at KMS Hospital and excluded patients, and those with pre-existing diagnoses of severe psychiatric disorders.
- The sample constituted 262 patients with a mean age of ~68 years with ~62% of them educated to the primary level or lower.
The study (by Salagre et al) showed a high prevalence of problems going undiagnosed ranging from 58% to 95% across various OPDs with depression, cognitive impairment, malnutrition, dependency and functional impairment showing high prevalence among study participants.
Professor Y Sathyanarayana Raju, Chief of Geriatric Medicine at the Nizam’s Institute of Medical Sciences in Hyderabad, in his editorial note for the Jan 2022 issue of the Journal of Association of Physicians of India (JAPI), in which both studies were published, explains CGA as follows.
Geriatric assessment screening is a holistic multidisciplinary approach, that constitutes a different paradigm from a standard medical evaluation of adults. It is helpful in identifying not only medical issues, but also to multiple determinants of health like psychosocial, and functional limitations in the elderly. CGA aims at improving the quality of life in the older patient and is used in various hospital settings including intensive care units.
In his editorial, Professor Raju also provides a comparative summary along with two other studies, one undertaken at AIIMS Delhi and the other in rural Bangalore, and argues for the need to carry out more studies to gather evidence to support the need to make CGA a standard part of adult care.
This 2011 study published in the British Medical Journal analyses meta-data from randomized controlled trials (RCTs) of such assessments, and found a clear and significant improvement in the odds of a patient being alive and in their own home if they receive coordinated specialist services rather than conventional care in a hospital setting. In another controlled study that adapted CGA across 19 primary care centers in Sweden with individual follow-ups over a two-year period, it was observed that the introduction of CGA can reduce the need for hospital care days in a high-risk population of older adults.
Given the increasing lifespan of general population, and the fact that India is projected to have a significant population of older adults, and particularly those with high-risk of comorbidity and other ailments, Comprehensive Geriatric Assessment (CGA) adapted to primary care settings and also offered in tertiary settings can help detect undiagnosed problems early, intervene as needed and ensure a higher quality of life across various stages. Experts have argued for increasing the number of post-graduate seats in geriatrics across medical institutes, more exposure to older patients during undergraduate studies, better career pathways and options for interns, etc on one end and also the introduction of multi-disciplinary care models in hospital settings. This article helps highlight some of the research and evidence around CGAs and why it is important to take a critical look at screening of older adults in its current form (OPDs focused on primary issue), and evolve a more suitable format that is affordable and allows for early detection/prevention.
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