Takaisin

Comprehensive geriatric assessment (CGA) for older adults living in community

Näytönastekatsaukset
Hanna Kortejärvi
16.3.2021

Level of evidence: B

Comprehensive geriatric assessment of the older adults appers to improve some dimensions of quality of life, appears to delay the progression of frailty, reduce hospital admissions, and length of hospital stay.

Study «Counsell SR, Callahan CM, Clark DO ym. Geriatric c...»1

Design

Randomized controlled clinical trial, n = 951, USA

Population

Age 65 years or older (mean intervention group age 71.8, SD 5.6, mean control group age 71.6, SD 5.8), an established patient (defined as at least 1 visit to a primary care clinician at the same site within the past 12 months), and with an income less than 200% of the federal poverty level, living in community. Number of patients with multimorbidity not reported.

Exclusion criteria

Residence in a nursing home; living with a study participant already enrolled in the trial; enrolled in another research study; receiving dialysis; severe hearing loss; English language barrier; no access to a telephone; severe cognitive impairment (defined by Short Portable Mental Status Questionnaire score ≤5); without an available caregiver to consent to participate.

Intervention

The Geriatric Resources for Assessment and Care of Elders (GRACE) model of primary care was developed specifically to improve the quality of care for low-income seniors living in community. Patients received 2 years of home-based care management. The GRACE support team consisted of an advanced practise nurse and social worker, who care for low-income older adults, in collaboration with the patient's primary care physician and geriatrician. Interdisciplinary team was led by a geriatrician. The support team met with the patient in the home to conduct an initial comprehensive geriatric assessment. The support team then presented their findings to the larger GRACE interdisciplinary team to develop an individualised care plan. Then the support team met face-to face with the patient's primary care physician to discuss the care plan and make any modifications. The support team then implemented the plan through face-to face and telephone contact with patients, family members, caregivers and healthcare professionals. Each patient received a minimum of 1 home follow-up to review care. Each patient received a minimum of 1 in-home follow-up visit to review the care plan, 1 telephone or face-to face contact per month, and a face-to face home visit after any emergency department visit or hospitalization.

Control

Control (n = 477), usual care

Outcome

– Patient reported health and quality of life was measured by using The Medical Outcomes 36-Item Short-Form (SF-36) and intervention group was favoured as reported in NICE guidelines «National Guideline Centre (UK). Multimorbidity: ...»2 as follows:

– mental component risk difference 2.4 (95% confidence interval (CI) 1.06 to 3.74)

– general health risk difference 2.5 (95% CI 0.06 to 4.94)

– vitality risk difference 5.2 (95% CI 2.55 to 7.85)

– social functioning risk difference 5.3 (95% 1.43 to 9.17)

– mental health risk difference 3.9 (95% CI 1.57 to 6.23)

– Emergency department visits were lower for intervention patients in the second year (848 vs. 1314, P=0.03) «Counsell SR, Callahan CM, Clark DO ym. Geriatric c...»1.

– Hospital admission rates were lower for intervention patients in the second year and 396 vs. 705, P=0.03 «Counsell SR, Callahan CM, Clark DO ym. Geriatric c...»1.

  • Applicability: Good
  • Study quality: Moderate

Study «Liimatta H, Lampela P, Laitinen-Parkkonen P ym. Ef...»3

Design

A randomised controlled trial, n = 422, Finland

Population

Independently home-dwelling older adults 75 years and older, consisting of 211 in the intervention and 211 in the control group. The additional inclusion criteria were not receiving home help or nursing services, Finnish speaking, and living permanently in the Hyvinkää area.

Intervention

The intervention was based on the comprehensive geriatric assessment and consisted of three multiprofessional preventive home visits performed by a nurse, a physiotherapist, and a social worker during a six- to nine-month time period. The nurse visit was the first, followed by the visit from a physiotherapist, and the social worker visit was the last. They had the possibility of consulting with a physician from a geriatric ward if needed. The nurse measured the participants' blood glucose and blood pressure levels and distributed information on the social and health services offered by the municipality, as well as local third-party organizations and voluntary groups. If any concerns regarding participant's health or well-being arose during the assessment, the nurse directed participants to contact their family doctor or other suitable health or social service. The physiotherapist's home visit comprised a structured assessment focusing on the barriers to mobility, fall risk, and home safety. S/he assessed the need for aids and compiled individual exercise instructions based on the test results as well as the participant's motivation and wishes. Participants were given information on the physiotherapy and individual and group exercise services offered by the municipality and local voluntary and third-party organizations. The social worker home visit comprised a structured assessment on social functioning, activities of daily living (ADL), instrumental activities of daily living (IADL), and service needs. The social worker also distributed information on social services, and financial and other benefits provided to older adults, and left contact information when needed. The social worker helped the participant to contact a service provider if other services or a financial need arose during a visit.

Control

Control (n = 211), usual care

Outcome

– Over time, the Health related quality of life (HRQoL) using the 15D score declined significantly slower in the intervention group compared to the control group. At the one-year time point, the difference between changes in the 15D score between groups was 0.015 (95% CI 0.029 to 0.0016; P= 0.028 adjusted for age, sex, and baseline value)

– However, the favorable effect was lost once the visits ended, and at the two-year time point the difference between groups (0.0093) was no longer significant (95% CI 0.031 to 0.013; p=0.41 adjusted for age, sex, and baseline value)

  • Applicability: Good
  • Study quality: High
  • Comment. The level of evidence is downgraded by the lack of randomized trials, and because of that study 3 may have been underpowered to show clinically significant differences.

References

  1. Counsell SR, Callahan CM, Clark DO ym. Geriatric care management for low-income seniors: a randomized controlled trial. JAMA 2007;298:2623-33 «PMID: 18073358»PubMed
  2. National Guideline Centre (UK). Multimorbidity: Assessment, Prioritisation and Management of Care for People with Commonly Occurring Multimorbidity. London: National Institute for Health and Care Excellence (UK) 2016 «PMID: 27683922»PubMed
  3. Liimatta H, Lampela P, Laitinen-Parkkonen P ym. Effects of preventive home visits on health-related quality-of-life and mortality in home-dwelling older adults. Scand J Prim Health Care 2019;37:90-7 «PMID: 30810457»PubMed