Comprehensive and age-appropriate evaluation during hospital stay is best for older patients

Older people rushed to the emergency room are more likely to be living at home up to a year later if they receive a comprehensive and age-appropriate evaluation during their hospital stay.

That's the finding of a new review of recent studies that evaluate the usefulness of a comprehensive geriatric assessment, or CGA. "Rather than a single assessment, a CGA is a thorough examination of an older person's medical background and psychological and functional capabilities, combined with a multidisciplinary treatment plan," said Graham Ellis, M.D., lead review author and a geriatrician at Monklands Hospital in Airdrie, Scotland.

Conducted by a team of health care workers who specialize in geriatric care, Ellis and colleagues said, a thorough assessment could save lives and spare older patients further deterioration and colleagues.

"There is a clear and significant improvement in the chances of a patient being alive and in their own home at up to a year after an emergency hospital admission if they receive coordinated specialist services," Ellis said.

The review appears in the latest issue of The Cochrane Library, a publication of the Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

Emergency hospital admissions are on the rise worldwide, a trend that is growing fastest among people over 65. The Cochrane researchers analyzed 22 studies involving more than 10,000 patients admitted to emergency rooms in the United States, Sweden, Australia, Canada, Germany and Norway.

Those who received comprehensive geriatric assessments during their stay were more likely to live in their own homes and even experience improved cognition than were those who received general medical care. Yet, these effects were most clearly visible following patient admission to hospital wards dedicated to geriatric care, rather than simply being visited in general wards by geriatric specialists.

"This effect is very similar to the differences observed between stroke wards and stroke teams," Ellis said. "A dedicated ward with more time focused exclusively on older peoples' care allows greater learning within the team, fostering the development of greater skills and expertise."

Outside of a dedicated geriatric ward, he added, a comprehensive geriatric assessment team might have less influence over other physicians and nurses who are directly involved in a patient's care. "As a consequence, recommendations for treatment and therapy are not always carried through," Ellis said.

The researchers suggest that the significant benefits of these assessments — and the relatively low financial costs of specialist wards — should encourage hospitals to reorganize their geriatric services.

Other researchers have found ways to use the comprehensive geriatric assessments outside of a hospital setting, which could save even more money in the long term. The GRACE project, administered and tested by Indiana University, the Regenstrief Institute and Wishard Health Services across the United States, connects older, low-income patients with a multidisciplinary geriatric health care team via home visits by a nurse practitioner and social worker.

The GRACE program has been shown to lower hospital admission rates and improve the quality of life even for older adults with multiple chronic diseases, said Steven Counsell, M.D., the program's lead researcher and a geriatric professor at Indiana University School of Medicine.

"We have found a strategy to do that for a very vulnerable growing population in a way that shows cost savings over time," Counsell said, "and has the added benefit of providing services that these seniors desperately need but can't get elsewhere."