Comprehensive Geriatric Assessment in the Emergency Department
Why is this important
For those working in Emergency Departments (EDs), problem identification using a Geriatric Assessment (GA) model allows a more accurate diagnosis (especially the identification of key syndromes such as delirium), which in turn will reduce overall hospital use, improving flow out of the ED. It allows for a more patient centered and often more efficient model of care to be initiated. It can reduce the use of investigations linked to protocol driven care (e.g. automatic CT head scans). It can also provide greater assurance about safer discharge, especially if there are robust community links that can support ongoing care4- 6.
Comprehensive Geriatric Assessment (CGA) improves outcomes for older people in acute specialised geriatric ward settings2.
CGA adapted to the urgent care context is defined as ‘a multidimensional, multidisciplinary process to identify urgent and vital medical, psychological, social and functional needs of an older person in order to develop an integrated co-ordinated acute care plan to meet those needs’1
How do I provide a Holistic CGA in the urgent care setting?
Whilst integrating standard medical diagnostic evaluation, CGA emphasises problem solving, and a patient centred approach with the aim of alleviating distress and restoring independence. This holistic assessment allows a list of problems to be identified and prioritised according to a shared decision-making process involving the clinician and the patient, and/or those close to them.
Typically, CGA involves a team undertaking a multidimensional assessment which should include:
- Diagnoses: There are often multiple interacting comorbidities and associated polypharmacy;
- Psychological function: Especially confusion and mood;
- Physical function: Activities of daily living;
- Environment: in which the individual functions;
- Social support networks: present or required to maintain on-going function;
The team should work within a flattened hierarchy. This facilitates mutual trust and encourages constructive challenge. Typically, CGA involves a team of people from various disciplines (including medicine, physiotherapy, occupational therapy, nursing, social work and clinical pharmacy) working towards a shared common goal and using standardised assessment tools, pathways and documentation.
Facilitating transitions of care to continue the consensus-based treatment plan in the post-ED setting, either in hospital or at home, is crucial to obtain optimal effect.
What can we do?
For older patients with frailty, EDs need to evolve from offering single problem solutions to a more holistic approach. See “Risk Stratification” poster to read more on identifying frailty in the ED. A full CGA often cannot be implemented in the ED setting. It is important to operationalise its key concepts, such as the ‘5Ms of geriatrics’3 in an initial GA:
- Mind: Addressing dementia, delirium & depression
- Mobility: Maintaining mobility and avoiding falls
- Medications: Reducing unhelpful polypharmacy
- Multi-complexity: Addressing the multifaceted needs of older people (medical, psychological, social, functional and environmental)
- Matters most: Ensuring that a person’s individual, personally meaningful health outcomes, goals, and care preferences are reflected in treatment plans
Then use shared decision making to determine what are the patient’s priorities. Work with your interdisciplinary team to work out how and where these can be best met (in hospital or at home or in another care facility).
Toolbox
Information
This education material was developed by the European Task Force for Geriatric Emergency Medicine, which is a collaboration between the European Society for Emergency Medicine (EUSEM) and the European Geriatric Medicine Society (EuGMS). For more information, please visit: geriEMEurope.eu and follow us on Twitter: @geriEMEurope.
References
- Conroy SP, Bardsley M, Smith P, Neuburger J, Keeble E, Arora S, Kraindler J, Ariti C, Sherlaw-Johnson C, Street A, Roberts H, Kennedy S, Martin G, Phelps K, Regen E, Kocman D, McCue P, Fisher E, Parker S. Comprehensive geriatric assessment for frail older people in acute hospitals: the HoW-CGA mixed-methods study. Southampton (UK): NIHR Journals Library; 2019 Apr. PMID: 30986009
- Ellis G, Gardner M, Tsiachristas A, Langhorne P, Burke O, Harwood RH, Conroy SP, Kircher T, Somme D, Saltvedt I, Wald H, O’Neill D, Robinson D, Shepperd S. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev. 2017 Sep 12;9(9):CD006211. doi: 10.1002/14651858.CD006211.pub3. PMID: 28898390; PMCID: PMC6484374.
- Tinetti M, Huang A, Molnar F. The Geriatrics 5M’s: A New Way of Communicating What We Do. J Am Geriatr Soc. 2017 Sep;65(9):2115. doi: 10.1111/jgs.14979. Epub 2017 Jun 6. PMID: 28586122
- Conroy SP, Ansari K, Williams M, Laithwaite E, Teasdale B, Dawson J, Mason S, Banerjee J. A controlled evaluation of comprehensive geriatric assessment in the emergency department: the ‘Emergency Frailty Unit’. Age Ageing. 2014 Jan;43(1):109-14. doi: 10.1093/ageing/aft087. Epub 2013 Jul 23. PMID: 23880143; PMCID: PMC3861335.
- Preston L, van Oppen JD, Conroy SP, Ablard S, Buckley Woods H, Mason SM. Improving outcomes for older people in the emergency department: a review of reviews. Emerg Med J. 2020 Oct 26:emermed-2020-209514. doi: 10.1136/emermed-2020-209514. Epub ahead of print. PMID: 33106287.
- Jay S, Whittaker P, Mcintosh J, Hadden N. Can consultant geriatrician led comprehensive geriatric assessment in the emergency department reduce hospital admission rates? A systematic review. Age Ageing. 2017 May 1;46(3):366-372. doi: 10.1093/ageing/afw231. PMID: 27940568.