Key Facts

CGA is one of the most evidence-based interventions in medicine for improving outcomes in frail older adults. It is both an assessment tool and a management framework.

Epidemiology

• Approximately 30-50% of hospital inpatients >65 would benefit from CGA
• Acute frailty units using CGA have improved outcomes compared to standard care
• CGA is recommended by NICE for all frail older people admitted to hospital

Aetiology

CGA addresses the multifactorial nature of illness and decline in older adults, recognising that a single disease model is inadequate.

Pathophysiology

• Frail older adults have reduced physiological reserve
• Acute illness causes disproportionate functional decline
• Multiple interacting problems (medical, cognitive, psychological, social) require a holistic approach
• CGA identifies these interactions and creates an integrated management plan

Indications for CGA

• Frail older adults (CFS ≥5)
• Multiple comorbidities
• Functional decline
• Recurrent admissions
• Complex discharge planning
• Cognitive impairment with comorbidities
• Falls and mobility problems
• Polypharmacy

CGA Process

1. Multidomain assessment by MDT
2. Problem identification across all domains
3. Goal-setting with patient and family
4. Creation of integrated care plan
5. Implementation
6. Regular review and adaptation

Red Flags Triggering CGA

• Functional decline not explained by acute illness alone
• Delirium
• Recurrent falls
• New incontinence
• Significant weight loss
• Carer breakdown
• Discharge to higher level of care being considered

Bedside

• Medical: comprehensive medical history, medication reconciliation
• Functional: ADLs (Barthel Index), IADLs (Lawton Scale), mobility (TUG, gait speed)
• Cognitive: 4AT (delirium), AMT-10, MoCA/ACE-III (dementia)
• Psychological: GDS-15 (depression), GAD-7 (anxiety)
• Nutritional: MUST score, weight, BMI, dietary history
• Social: living situation, carers, social support, advance care planning
• Environmental: home safety assessment

Bloods

• FBC, U&Es, LFTs, TFTs, calcium, vitamin D, B12, folate, ferritin
• HbA1c, albumin, CRP
• Medication levels where appropriate

Imaging

• As directed by CGA findings

Special Tests

• Medication review (STOPP/START)
• Swallow assessment if dysphagia
• Continence assessment
• Tissue viability assessment
• Carer strain assessment

Non-pharmacological

• Personalised care plan based on CGA findings and patient goals
• Rehabilitation: physiotherapy (strength, balance), OT (functional goals, ADLs)
• Cognitive stimulation: for dementia/delirium prevention
• Nutritional optimisation: dietitian input, supplementation
• Social prescribing: address isolation, community activities
• Discharge planning: start from admission; MDT assessment of safe discharge
• Follow-up: community geriatric teams, GP care plan

Pharmacological

• Medication optimisation: STOPP/START criteria, deprescribing
• Treat identified conditions: heart failure, infection, depression, pain
• Preventive measures: vitamin D, vaccination, bone protection

Surgical/Interventional

• CGA informs surgical risk assessment in older adults
• Proactive geriatric liaison in surgical patients (hip fracture, emergency surgery)
• Perioperative CGA reduces post-operative complications

Referral Criteria

• All frail older adults admitted to hospital
• Complex community patients with functional decline
• Pre-operative assessment for frail surgical patients
• Recurrent admissions
• Complex discharge planning

• CGA in hospital: NNT 13 to prevent one death or institutional placement at 12 months
• CGA reduces mortality: OR 0.76 (95% CI 0.64-0.90)
• CGA reduces institutionalisation: OR 0.80
• Outcomes best when delivered by a dedicated geriatric MDT on a specialist unit
• CGA in the community also improves outcomes (reduces hospital admissions)
• Goal attainment is associated with improved patient satisfaction and quality of life

CGA Domains and Assessment Tools

Evidence for CGA