The Importance of Comprehensive Geriatric Assessment
For older patients with complex health problems, comprehensive geriatric assessment, care coordination, and adherence to the principles of geriatric pharmacology are among the key elements of high-quality healthcare embodied within the principles of geriatric medicine. Geriatric assessment is the logical starting point for such care since it guides and informs all that follows.
Unfortunately, the lack of geriatricians and other geriatrics healthcare providers is an issue for many older patients and for their primary care physicians (PCPs). As the number of older adults rises, this shortfall will become increasingly acute. That’s why it is becoming more important for PCPs and other clinicians who care for older people to familiarize themselves with the goals of geriatric assessment.
Geriatric assessment goes beyond the standard adult comprehensive history and physical examination. It includes a much more extensive evaluation. In addition to the standard elements of a physical examination, there is evaluation of those elements of special significance in older adults—orthostatic vital signs, vision, hearing, gait and balance, cognition, and affect. It should also include an in-depth medication review (covering prescribed and over-the-counter drugs, and vitamins and herbs); a review of immunization status and of difficulties with or dependency in instrumental and basic activities of daily living (ADLs); and an evaluation of living arrangements, social supports and activities, and advance directives.
This kind of assessment usually yields a more complete and relevant list of medical problems (eg, diabetes, hypertension, past strokes, cataracts), functional problems (eg, difficulty walking, a history of falls, the need for assistance with ADLs), and psychosocial issues (eg, the presence of depression, social isolation). These require individualized yet coordinated, integrated plans of care for further evaluation, treatment, referral, and patient and/or caregiver education.
Geriatric assessment and care coordination can be highly effective and also cost effective. Research suggests that geriatric assessment can lead to optimized prescribing; reduce the incidence of adverse drug events, the need for specialty services, diagnostic studies, ER visits, and hospitalizations; and improve outcomes. A 2006 study of nearly 1400 older adults who were hospitalized at 11 VA medical centers found that those randomly assigned to an inpatient geriatric unit where they underwent a comprehensive geriatric assessment fared better than those assigned to usual inpatient care. The former were roughly one-third less likely to need nursing home placement. Though not statistically significant, the mean savings was $1027 for each patient in the geriatric assessment group. Linking geriatric assessment with coordinated care is likely to boost savings further. In Harris County, Texas, the Evercare STAR + PLUS pilot program, which emphasizes care coordination and now serves approximately 65,000 older adults countywide, saved the state government roughly $123 million over two years.
American Geriatrics Society (AGS) publications, such as the Geriatrics Review Syllabus, and educational programs offered by medical schools, Geriatric Education Centers, community and teaching hospitals, regional medical societies, and AGS state affiliates can help PCPs refine their skills in geriatric assessment. (A listing of AGS state affiliates and contacts is at www.americangeriatrics.org/affiliates/current_ags_affiliates.shtml.) I also recommend “Assessing Care of Vulnerable Elders™ Physician Education Program,” a CD-ROM guide to geriatric assessment created by David B. Reuben, MD, Chief of the Division of Geriatrics, and Director of the Multicampus Program in Geriatric Medicine and Gerontology at UCLA. The program, produced by AGS, the RAND Corporation, and Pfizer, focuses on key areas of geriatric assessment such as falls, incontinence, and dementia. (A limited number of the CD-ROMs are available through AGS. To inquire, call  308-1414.)
Comprehensive geriatric assessment is clearly time-consuming for geriatricians and other professionals, and the lack of suitable reimbursement has been the most significant factor limiting its availability. Through the advocacy of the AGS, Congress is now considering much-needed legislation that would fill a major gap in traditional Medicare by covering both geriatric assessments and care coordination for beneficiaries with multiple chronic conditions, such as diabetes and dementia. The legislation, the Geriatric Assessment and Chronic Care Coordination Act (GACCCA), would reimburse more favorably a defined geriatric assessment for such beneficiaries whose medical costs rank in the top 10% of all Medicare beneficiaries. Those who qualify could choose to have the assessment performed by a physician, or by a physician assistant, nurse practitioner, or clinical nurse specialist under the direction of a physician.
Under the GACCCA, beneficiaries who qualify for a geriatric assessment and who would benefit from care coordination could opt for that service, as well, by choosing a chronic care manager. The care manager would have to be a physician, physician assistant, nurse practitioner, clinical nurse specialist, or clinical social worker. If the services were provided by a professional other than a physician, the provider would have to work in collaboration with a physician.
AGS worked closely with legislators sponsoring the bill and continues to advocate for passage of the legislation in Washington. To stay abreast of developments with this important proposal—which should expand the availability of all-important geriatric assessments—and to join AGS advocacy campaigns on its behalf, visit www.healthinaging.org/advocacy.
Dr. Spivak is Associate Clinical Professor of Medicine, Columbia University, New York, NY; Consultant in Geriatric Medicine, Greenwich Hospital, Greenwich, CT; and Medical Director, LifeCare, Inc., Westport, CT.