We limited the search to reviews published from to February Searches were restricted by the level of evidence systematic review and meta-analysis, or other evidence syntheses , and in English.
Data was extracted from the included reviews not the primary studies included in the reviews using the standardised JBI data extraction tool.
Reviewers discussed and piloted its use. Separate evidence tables were created for the definitions and key elements of CGA, the setting and staff, the key participants, outcome measures and costs, then used to produce summary tables and develop a narrative overview of the evidence.
We screened 1, titles and evaluated abstracts for eligibility, full articles were reviewed for relevance and 24 included in a final quality and relevance check. Thirteen reviews, reported in 15 papers [ 1 — 3 , 10 — 21 ] were selected for review. The most recently conducted trial included in the reviews was reported in , all other trials were reported between and A total of 95 original articles were cited times.
And 26 original articles were cited more than once a table of citation counts for these articles is included as an Appendix. The most highly cited articles included Landefield [ 22 ], Asplund [ 23 ] 7 citations each and Counsell [ 24 ] 6 citations. Removing all except one of the reviews [ 2 , 13 ] which cited these three most highly cited papers did not significantly affect our conclusions with regard to the population characteristics, intervention definition, settings and comparisons and clinical outcomes.
Some health economics detail was lost in this sensitivity analysis. All of the reviews included participants over 65 years of age. In most studies frailty was not explicitly identified as a characteristic of CGA recipients, however, one review [ 23 ], which included the majority of the most highly cited trials attempted to stratify trials by frailty.
Some reviews included the presence of a specific diagnosis, such as cancer or hip fracture Table 1. Table 1. CGA description and definition and components, participants and types of admissions. The bulk of the reviews used essentially the same body of literature extending back to to examine some aspect of CGA in the hospital setting.
Reviews citing literature which was predominantly outside of this highly cited core included a review of interface care [ 12 ], gerontologically informed nursing assessment and referral [ 14 ], and multidisciplinary team interventions [ 21 ].
Resource use and costs were considered in four reviews. Patient related outcomes such as health related quality of life, wellbeing or participation were not usually reported Table 2. Table 2. Outcomes described in reviews of CGA for hospital inpatients. Relatively few studies look at costs. None took a broader view to include direct costs staff and resources , subsequent costs such as community health and social care costs , costs to patients and wider society.
Further, the multiple intervention configurations which broadly deliver CGA, were mostly not standardised. One exception was the review by Fox et al. Two studies [ 1 , 2 ] concluded that many of the hospital based services showed a reduction in costs associated with CGA. In a review of trials of various ACE model components, there was little cost evidence available to differentiate and compare relative effectiveness between components of the ACE model. These reviews concerned the provision of CGA in older patients who were hospital inpatients.
The main target group in this context were older people with acute illness. There was a degree of consistency between the reviews on the definition of CGA which importantly includes both assessment of needs in multiple domains, and the development of a plan to meet those needs. The most consistently reported assessment domains were medical, psychological, social and functional. The settings included dedicated inpatient wards, but also services which delivered CGA across the hospital, at the interface between acute and community care, and by nurse led and multidisciplinary teams.
Death, disability and institutionalisation were the key outcomes for recipients and reduced length of stay and readmissions were the key operational goals. The impact of frailty as a determinant of CGA outcome was not widely examined in these reviews.
The one review that attempted this concluded that for frail patients, ward based CGA may reduce institutionalisation rates. There has only been limited economic evaluation which suggests that CGA may save on hospital costs.
The main strength of and umbrella review is provide a broad overview in a specific topic area. The corresponding weakness may be a paucity of detail relevant to a particular service or context. Such detail is available in the primary reviews and trials that are included in the overview.
While largely of good methodological quality by standard critical appraisal criteria see Appendix , most of the included reviews did not include a robust assessment of sources of bias. Further, while it has been suggested that umbrella review methodology may reduce the bias associated with excluding non-English language articles, it is not completely eliminated and remains a concern [ 25 ]. More work needs to be done on targeting and identifying beneficiaries of CGA.
Further trials are justified and should be stratified by frailty, use patient related outcome measures and collect sufficient economic data to determine cost effectiveness. Such trials will need careful process evaluations embedded within them in line with current research frameworks for the evaluation of complex interventions [ 26 , 27 ]. As elements of CGA become increasingly embedded in general hospital care, with the development of new and emerging settings and services [ 28 ], this review highlights a degree of consistency in definition, essential content, key target group and outcomes of CGA.
We hope that this can be used to inform the development of hospital wide services by developing evidence based implementations and incorporating them into multidimensional assessment processes, which include competence in common clinical syndromes falls, confusion, immobility, continence , multiprofessional co-ordination and management.
Key points Comprehensive Geriatric Assessment CGA is a multidisciplinary process which includes assessment and management of assessed need. Supplementary data mentioned in the text are available to subscribers in Age and Ageing online. Effectiveness of acute geriatric units on functional decline, living at home, and case fatality among older patients admitted to hospital for acute medical disorders: meta-analysis. It supports primary care work with older people, and their families, to help them stay well for longer.
This comprehensive toolkit will be a very helpful resource for primary care teams in Scotland and across the UK. We are delighted to see increasing awareness of the importance of frailty assessment in the community. The entire toolkit can also be downloaded as a complete printable PDF on the sidebar of each page.
He developed the idea for a one-stop shop toolkit freely available online, and created a prototype in An introduction to CGA in primary care settings. In a series. An overview of how Comprehensive Geriatric Assessment CGA is done in the primary care setting, and what to consider when conducting the assessment.
Examination of older patients incorporates all the typical aspects of clinical examination, although there are some general considerations and emphases that should be borne in mind, and specific examinations that may be more relevant in older people. Objectives: our objectives were to describe the key elements, principal measures of outcome and the characteristics of the main beneficiaries of inpatient CGA.
Methods: we used the Joanna Briggs Institute umbrella review method. Results: we screened 1, titles and evaluated abstracts for eligibility, full articles for relevance and included 24 in a final quality and relevance check. Thirteen reviews, reported in 15 papers, were selected for review. Simple tests for walking and balance The following tests are recommended because they are evidence-based, have satisfactory reliability and validity and take less than five minutes.
Timed up and go test This test measures functional mobility in the older population. The patient should sit in a chair of knee height. They should be asked to stand up, walk three metres, turn round, return to the chair and sit down. You should time the patient, starting timing when the patient starts to try and stand up and stopping when the patient is sitting down again.
The patient may not use a walking aid so if they need one then this is not an appropriate test and they already have a mobility problem rendering the test unnecessary. Timed up and go duration increases with worsening mobility. It should not be used in patients who require a walking aid to turn, are not able to fully weight-bear or who cannot follow instructions. A patient should sit in a chair from which they can easily stand up. Backs of chairs or other stable hand-holds should surround the patient in front and to the side forming a square or circle.
The patient should stand up and you should stand behind them. You ask the patient to turn around and face you turn degrees. The patient should not hold on unless they need to, in which case they have failed the test. You should count the number of steps they take. Gait speed Ask a patient to walk a distance of four metres. If they take longer than five seconds then their gait speed can be considered slow i.
Gait speed is correlated with increased risk of falling. Chair stand Ask the patient to sit in a chair which is at knee height. Ask them to stand from the chair. Patients who require use of their arms to stand are likely to have lower limb strength impairment. Lower limb strength impairment is correlated with risk of falls and with poor balance. Onward referral Patients who pass all of these tests but who report worsening quality of mobility or reduced confidence should be referred on to a therapist for more detailed assessment.
In the event of detecting a gait and balance problem the following onward referrals should be considered: Referral to outpatient or ambulatory services for secondary medical opinion if this is needed to reach or confirm the diagnosis and to support with the initial management plan.
Referral to physiotherapy services for: More detailed gait and balance assessment. Strength and balance training. Re-education of walking techniques which may or may not include provision of walking aids. Advice on how to build confidence with walking and balance. Falls prevention advice relating to strength, walking and balance. This could include the provision of aids around the home.
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