Importance of CGA in improving services for acute care for frail older people - D Thompson & S Conroy

Urgent care demand is rising faster than any predictions. Results of the older people benchmarking study found a 22% increase overall in ED attendances comparing 2005 to 2013, including a 50% increase in ED attendances for people aged 60-79 and a 55% increase in people over 80. It is clear that age is one factor driving the increase in demand for emergency services.

Older people accessing urgent care tend to have multiple comorbidities, which adds complexity to the clinical assessment. In addition, multiple comorbidities drive polypharmacy, which itself is associated with increased use of urgent care due to drug-disease or drug-drug interactions, as well as adverse events. With the increasing prevalence of cognitive and sensory impairment in older people confounding initial clinical assessments, it is clear that urgent care systems will need to adapt if they are to continue to operate effectively.

Evolution, improvement and then standardisation of processes and sharing of best practice are key to improving the quality of care for frail older people. A key recommendation of the Silver Book (http://www.bgs.org.uk/campaigns/silverb/silver_book_complete.pdf) is that the presence of one or more frailty markers  in patients should trigger the process of Comprehensive Geriatric Assessment (CGA).

CGA is defined as ‘a multidimensional, interdisciplinary diagnostic process to determine the medical, psychological, and functional capabilities of a frail older person in order to develop a coordinated and integrated plan for treatment and long-term follow-up’.

While integrating standard medical diagnostic evaluation, CGA emphasises quality of life and functional status, prognosis, and outcome; team and standardised assessment tools are commonly used. A typical team might include some or all of:

• A geriatrician
• A nurse specialist
• An occupational therapist
• A physiotherapist
• A pharmacist
• Plus others as needed (speech and language therapy, dietetics).

CGA leads to better outcomes, including reduced long term care, greater patient satisfaction and lower costs. This approach is fully supported by the Royal College of Physicians that have also produced guidance.

Additional guidance has been published this year from work led by Professor David Oliver for the Kings Fund that describes a goal for acute care as ‘acute hospital care must meet the needs of older patients with complex co-morbidities, frailty and dementia. Services should provide adequate access to specialist input, minimise harms and ward moves, and provide care that is compassionate and person-centred’. This can be accessed at http://www.kingsfund.org.uk/publications/making-our-health-and-care-systems-fit-ageing-population