Comprehensive Geriatric Assessment — What It Is and Its Usefulness in Clinical Practice

Comprehensive geriatric assessment (CGA), also called multidimensional geriatric assessment, is a diagnostic process, usually interdisciplinary, that determines an older person's medical, psychosocial, functional and environmental resources and problems.

Its stated objective is to develop an overall plan for treatment and long-term follow-up. An assessment without a linked care plan is NOT a CGA — a favourite examination point.

It differs from a standard medical evaluation in three ways: it targets older people with complex problems, it emphasises functional status and quality of life, and it uses interdisciplinary teams with quantitative scales.

A purely psychosocial or environmental home visit without a medical evaluation also does not qualify as CGA, because multidimensionality is incomplete.

Historical origin: Dr Marjory Warren, London infirmary, late 1930s. Through evaluation, mobilisation and rehabilitation she got long-bedfast patients out of bed and home, and advocated assessment and rehabilitation before any long-term institutionalisation. Rationale — Why in the Elderly? (five textbook reasons)

Multi-morbidity and complexity — systematic assessment helps set priorities among multiple conditions.

Unrecognised problems — many problems are never reported, often because they are falsely thought to be non-modifiable effects of ageing.

Chronic conditions — a diagnosis without information on functional relevance is of limited therapeutic value.

Social and environmental interaction — home layout and social network determine whether a person can stay at home.

Functional status — the main goal of geriatric medicine is to prevent or delay functional decline; benefit is greatest when intervention occurs early in the path from robustness to frailty to disability.

CGA begins with a functional status "review of systems" built on three measures: frailty, basic ADLs, and IADLs.

Principle of hierarchy / parsimony: if a patient is severely ADL-dependent, do not assess frailty; if the patient is robust or pre-frail, do not assess basic ADLs.

Frailty is measured by two models — the phenotype model (Fried phenotype, Frailty Trait Scale, FRAIL index) and the cumulative deficit model (Frailty Index, Clinical Frailty Scale).

Dimensions and tools (Table 96.1): BADL — Katz, Barthel, Lawton PSMS; IADL — Lawton, OARS; Social — Lubben Social Network Scale; Affective — Geriatric Depression Scale, Zung; Cognitive — MMSE (Folstein), Kahn MSQ; Gait and balance — Tinetti, Get-Up-and-Go; Nutrition — MNA; Senses — whispered voice test, Snellen; Oral — GOHAI.

Two screens are mandatory in any older person with functional disability: cognitive impairment and depression.

Step 1 — set priorities: work first on the problem that most bothers the patient, or the problem on which resolution of others depends (alcoholism, depression).

Step 2 — task and symptom analysis: define the exact nature of the impairment and correlate it with new drugs or dose changes (including over-the-counter), change in living conditions, and intercurrent acute illness. Then examination, laboratory tests, therapist and social-work input, and a long-term follow-up / case-management plan.

Settings: home (preventive visits), office and outpatient clinic, day hospital, acute care for the elderly (ACE) unit, post-acute rehabilitation unit, nursing home (Resident Assessment Instrument), and hospital-at-home programmes. Inpatient and day-hospital settings give intensity and speed for the frail; outpatient settings are cheaper.

Team (minimum): physician, nurse, social worker, physiotherapist, occupational therapist; optimally dietician, pharmacist, ethicist, home-care specialist. The interdisciplinary team conference is critical — present in most successful trials; teams mature through forming, storming, norming, performing.

Proven benefits: CGA improves function and survival while reducing healthcare utilisation and costs. Supporting data: Improved diagnostic accuracy — 1 to more than 4 new diagnoses per patient. 1993 Stuck/Rubenstein meta-analysis (28 trials, ~10,000 patients): mortality down 22% (hospital-based, 12 months) and 14% (all programmes); living at home up 47% (hospital-based) and 26% (all); readmissions down 12%; cognitive improvement up 47%; physical function up 72% on hospital units. 2011 Cochrane meta-analysis: inpatient CGA increases the likelihood of being alive and in one's own home, with potential cost reduction. Better prescribing — CGA reduces unnecessary and inappropriate medication use. Targeting matters: best results when patients are at high risk of deterioration yet retain rehabilitation potential — exclude those "too well or too ill." Programmes with hands-on care and/or long-term follow-up outperform purely consultative programmes. Weak areas: outpatient CGA showed no mortality benefit in one meta-analysis; preventive home visits are not recommended routinely (benefit only with CGA-based extended follow-up in relatively well elders; number needed to visit about 40 to prevent one nursing-home admission). Oncology (SIOG task force): CGA detects many problems missed by regular assessment and is associated with fewer treatment side effects.

German DGG S3 Guideline on CGA in Hospital (2024) — the first S3-level CGA guideline. Twelve evidence-based and eight consensus-based recommendations. Strongest evidence in acute geriatric, oncology and orthopaedic/trauma wards; weaker in emergency departments and general surgery. Core elements: minimum CGA duration of 15 minutes and six core dimensions — self-help ability, mobility, cognitive function/delirium, affect, nutrition and social situation; the G8 questionnaire is recommended for screening mainly in oncology.

Italian National CGA Guideline (2024) — 25 scientific societies plus the National Institute of Health, GRADE methodology. Sixteen recommendations from 117 studies across primary care, clinics, emergency departments, hospital wards and nursing homes. CGA reduces hospitalisation, mortality, institutionalisation and delirium risk, improves prescribing appropriateness, and maintains functional activities. The Multidimensional Prognostic Index (MPI) is specifically recommended to predict negative outcomes.

Japanese CGA-Based Healthcare Guidelines 2024. The main objective of CGA is stated to be personalised care through holistic management plans and targeted interventions — not merely status evaluation or prognostication.

ASCO Geriatric Oncology Guideline Update (2023). Geriatric assessment should be used in all patients over 65 with cancer; all older adults with GA-identified deficits should receive GA-guided management, and the Practical Geriatric Assessment (PGA) is the recommended tool. Evidence base: GAP70+ and GAIN trials.

ASCO Global (Resource-Stratified) Geriatric Assessment Guideline (2025) — adapts the 2023 guideline for resource-limited settings using ADAPTE methodology. Directly relevant to Indian practice.

Cochrane 2022 — Community CGA. Twenty-one studies, 7,893 participants, 10 countries, evaluating domiciliary CGA and CGA in general practice, with outcomes of death, nursing-home admission, unplanned hospital admission and emergency visits.

Meta-analysis of CGA in acute hospitalisation (2025) — CGA may improve short-term survival and reduce readmission rates after acute hospitalisation.

Perioperative CGA is now mainstream. The 2023 World Society of Emergency Surgery guidelines advocate frailty assessment and multidisciplinary geriatric-surgical management in older trauma patients; the UK NELA Best Practice Tariff (April 2023) mandates perioperative team involvement in frailer laparotomy patients. CGA outperforms traditional preoperative risk models in predicting postoperative delirium, infection and prolonged stay.

Indian context. Evidence is predominantly from high-income countries and hospitalised patients; research on CGA in primary care and community settings in low- and middle-income countries is lacking. Under NPHCE, community services are delivered by ASHA workers with clinics at PHCs, but implementation is inconsistent. Short culturally adapted tools such as EHSAS are being validated for rural India because full CGA is impractical with the available workforce.