Joseph T. Freeman Award Lecture: Comprehensive Geriatric Assessment: From Miracle to Reality

THANK you very much for this great honor. I am really pleased to have been selected by my colleagues for this award and to join a long list of past Freeman awardees, many of whom were my own wonderful mentors and senior faculty members, such as David Solomon and John Beck, as well as noted friends and colleagues, including Frank Williams, Bob Butler, Jack Rowe, Chris Cassel, Knight Steel, Evan Calkins, Reubin Andres, Richard Besdine, Isadore Rossman, Lissy Jarvik, Harvey Cohen, Bill Hazzard, Mary Tinetti, and Bob Luchi. (Maybe I magically thought by dropping their names, some of their wisdom and poise might rub off on my own words today!) Who was Dr. Joseph Freeman? He was a past president of the Gerontological Society of America (GSA) and an internist with a pioneering interest in the health problems of older adults. He authored some of the earliest geriatrics textbooks, including Clinical Principles and Drugs in the Aging in 1963 and Clinical Features of the Older Patient in 1965. He chaired the internal medicine section of the first White House Conference on Aging in 1961, and was on the faculty of the Medical College of Pennsylvania for over 20 years. The Clinical Medicine Section of GSA established the Freeman Award lectureship in 1977 with an endowment to honor Dr. Freeman. Dr. Freeman lived several more years and was actually able to attend some of these lectures. He practiced medicine until his death in 1989 at age 81. My topic today is “Comprehensive Geriatric Assessment: From Miracle to Reality.” I'll try to give an overview of the concept of comprehensive geriatric assessment (CGA), its history as a central guiding principle of geriatrics, its rationale, and research evidence for its effectiveness—spanning the earliest single-site trials to the more recent multi-site trials. In the process, I'll try to give my perspective on some of the key aspects of CGA and why the effectiveness data seems to have varied between trials and over the years. My hope is that key elements will emerge that are signals to guide future development. Recognition of these elements will insure the continued usefulness and cost effectiveness of CGA as an important tool for improving care of frail elders. I was really fortunate to have entered geriatric medicine on the ground floor (or maybe the second floor), at a time when there was almost a limitless amount to discover and study. The field was new, and the potential areas of research were just beginning to be scoped out and studied rigorously. People thought I was somewhat weird to be going into geriatrics then. After all, who would want to specialize in people who were often felt to be the “least desirable” of patients—patients with short life expectancies, little disposable income, often demanding and difficult to communicate with, and usually with difficult-to-understand complex and interacting medical problems? Well, people probably still think that I'm weird, but the field of geriatrics has matured and become at least almost respectable. It has become eminently clear that our field has developed a truly scientific and effective way for treating complex elderly patients that improves their outcomes and increases their quantity and quality of life. When I entered geriatrics back in 1979 after my Robert Wood Johnson fellowship, my first boss was Itamar Abrass, who put me in charge of a brand new inpatient geriatrics unit at the Sepulveda Veterans Administration (VA) hospital—we called it the geriatric evaluation unit (GEU). I worked there together with our first fellows (many of whom have gone on to major leadership careers in geriatric medicine) and with rotating attending coverage from senior geriatric faculty members such as Dave Solomon, John Beck, Bob Kane, and John Morley. The Sepulveda GEU was based on similar units existing in the United Kingdom where complex older patients could be assessed, treated, and given rehabilitation in a specialized clinical and educational setting. These units were widely used, but never tested for their effectiveness. Most physicians in the U.K. felt that geriatric units were important and effective, but without data, it seemed that the concept would be a hard sell in mainstream U.S. medicine. An exception to the general reluctance in the United States to consider geriatrics services was the VA where the geriatric imperative was appearing well before it had begun to in the rest of the medical care establishment. The VA anticipated the premature graying of its population and, under the leadership of Drs. Paul Haber and Ralph Goldman, established the system of Geriatric Research, Education and Clinical Centers (GRECCs) in the mid-1970s to create a cadre of clinicians, educators, and researchers ready to face the onslaught of older veterans. (As an aside, this is another example of the foresight and largely unsung creativity of the VA—analogous to its more recent outstanding and innovative computerized medical record systems, quality assurance programs, and multi-branched research programs—indicating how the VA has anticipated the special needs of its economically and physically challenged patient population.) Before going on to specifics of what we found on our unit and subsequent research, let's back up just a bit to define a few aspects of comprehensive geriatric assessment. CGA has been defined in both long and short definitions. A brief definition that I favor, which seems to capture the major elements with a minimum of words is: CGA is a multi-dimensional, interdisciplinary, diagnostic process to identify care needs, plan care, and improve outcomes of frail older people. The major purposes of CGA are to improve diagnostic accuracy, optimize medical treatment, improve medical outcomes (including functional status and quality of life), optimize living location, minimize unnecessary service use, and arrange long-term case management. CGA has a number of major measurable dimensions, usually grouped into the four domains of physical health (including the traditional history, physical examination, laboratory data and problem list, disease-specific severity indicators, and preventive health practices), functional status (including activities of daily living [ADL], instrumental activities of daily living [IADL], and other functional scales such as mobility and quality of life), psychological health (including mainly cognitive and affective status), and socioenvironmental parameters (such as social networks and supports, and environmental safety, adequacy, and needs). CGA can be performed in a number of places (such as hospital, home, and nursing home) and with varying program types and levels of intensity (such as hospital GEUs, hospital acute care for elderly [ACE] units, hospital consultation teams, outpatient brief screening assessment programs, or intensive in-home assessment and case management programs). But wherever it is performed, CGA is at the hub of the geriatric care system, serving as a common language, a set of guideposts, a method of gate-keeping, and in fact the foundation for everything we do in geriatrics. Historically, CGA programs have gone through three main phases of development. The mid-1930s through about 1975 was the phase of early conceptualization and model development. The beginning of this period saw the development of geriatric assessment concepts in workhouse infirmaries of the U.K. when Marjory Warren and other pioneering physicians with interests in geriatrics discovered that most of these long institutionalized and mostly bedfast patients had multiple undiagnosed conditions that could be treated and rehabilitated, often raising their levels of independence and in many cases returning them to the community. Their papers relating these experiences were glowing, but all were descriptive and anecdotal. When the British National Health Service was founded in 1948, geriatric medicine was accorded full specialty status, so impressive were the reports of the pioneering geriatricians, and geriatrics units were mandated in each health district in the country. This period also saw the founding and initial development of the geriatric and gerontological societies, all of which advocated research on and improved care for older adults. The end of this first period saw the first major development in geriatrics in the U.S., the establishment of the system of VA GRECCs, to be centers of excellence for research, education, and clinical demonstration programs in geriatric medicine. From 1975 through about 1995 was the period of refinement and testing of clinical geriatric models, specifically those based on CGA. An extended series of randomized controlled trials (RCTs) were performed, culminating in a formal meta-analysis of 28 RCTs in 1993. Major policy statements from professional societies, task force white papers, and consensus reports were produced, extolling the importance of CGA as a major and effective central part of geriatric care. These included the consensus development conferences from the National Institutes of Health in 1983 and 1987 (1); the specialty white papers produced independently by the American Geriatrics Society, the American College of Physicians, and the Society for General Internal Medicine all in 1988; and the International State of the Art conferences in Sweden (2) and Italy (3), in 1988 and 1994, respectively. From 1995 to the present day has been the period of mainstream integration and consolidation. Principles of geriatrics have entered the mainstream of health care, thanks to a substantial extent to the diligent efforts of geriatricians and geriatric educators, and the standard of care for older adults has shown consistent improvement. Models of chronic disease care management have emerged, largely based on CGA principles. Uniform patient care databases have emerged, such as the Minimum Data Set and Resident Assessment Inventory. Multi-site “effectiveness” trials of CGA programs have been performed to test the results of the single-site trials, and these have raised new questions of the optimal roles and sites for CGA programs and which patients are most likely to benefit. But returning to the narrative, why should we do CGA? Among the main reasons has been the presence of much undiscovered treatable disease and disability among the older population, large amounts of premature and otherwise avoidable nursing home admissions, a widespread neglect of rehabilitation needs, rampant drug-related excesses, and other iatrogenic problems among older people. But the bottom line is that CGA programs improve outcomes. And over the years, many major outcome improvements have been shown to arise from CGA programs, including improved accuracy of diagnosis, better patient functioning and living locations, improved affect and cognitive status, more appropriate medication use, reduced use of hospitals and nursing homes with resultant cost savings, and reduced mortality rates. I'll go into these in more detail now. Let's go back to our original Sepulveda GEU experiences. A very short time after beginning to work on the GEU, it became clear to me that something worthwhile was happening. We kept simple before and after records of diagnoses, medications, physical function, and anticipated versus actual discharge locations in an attempt to understand how our patients were faring. We suspected that the comprehensive assessment, treatment, and rehabilitation by the interdisciplinary team were having some good effects, but such benefits had yet to be shown. After looking at our pre–post data books, it was apparent that, in fact, we were finding lots of previously unmade diagnoses (about 1 major and 3 to 4 minor diagnoses per patient), reducing unnecessary medications, improving physical function as measured by ADL and IADL, and improving discharge location over what had been anticipated. We published these observational findings in 1980 (4). But knowing that pre–post data cannot prove causality, I requested funds (with Itamar's encouragement) from VA Health Services Research and Development Service to undertake an RCT of the unit in which eligible patients would be randomized to either enter the GEU or continue to get their usual hospital care. After completing the first year of follow-up on 123 randomized patients, we were amazed to find that not only did the randomized trial results confirm the pre–post data, in comparison with the control group (i.e., increased diagnoses, improved function, reduced nursing home placement), but new and unanticipated outcomes were shown—notably reduced mortality, reduced rehospitalization rates, reduced cost, and improved high functioning survival—which were findings only a controlled trial could detect. These data were published in 1984 (5) and immediately were greeted with great interest, as well as some skepticism. After all, how could such a simple concept—taking extra time and interest to figure out and manage the special needs of these high-risk patients—produce such dramatic benefits and save money at the same time? Fortunately, it wasn't only our study that showed these benefits. A whole series of controlled trials of CGA programs in a wide variety of settings (hospital, outpatient, home visit) began appearing in print, and most were confirmatory of significant benefits. For example, a little after the Sepulveda GEU trial, Bill Applegate published his controlled trial of a GEU in a private U.S. rehabilitation hospital, and found similar effects outside the VA (6). Not all trials showed the same spectrum of benefits—as might be anticipated, the more intensive and longer-term interventions seemed to provide substantially more benefit than the one-time consultation or outpatient visit programs. The home was another early site for testing CGA, using visiting interdisciplinary For example, about the same time our RCT was study of home for CGA and follow-up with very similar effects on improved reduced and nursing home use, and improved function the years, at least controlled trials were performed and in all the including and the United included hospital inpatient units GEUs, geriatric evaluation and management units, units, geriatric rehabilitation hospital consultation teams, home visit assessment and management programs, and outpatient assessment programs. of the programs varied but the great of them showed major benefits such as improved improved function, reduced nursing home and improved showed significant but all 3 showed some significant patient outcome improvement. In the with and it seemed apparent that, among hospital the programs with benefit were those that more frail patients with complex geriatric problems and those that more care, than simple Among outpatient and home visit the programs with benefit were those that included multiple follow-up and care from the programs, the with patient benefit seemed to be patients most in having clinical control of care than only having multiple follow-up and having a intensity all these were going the concepts of CGA were of in the field were to about the and outcomes of CGA programs. It was very a in geriatric in other as a senior in and In we were fortunate to have the with on his and were able to a number of was a meta-analysis of the CGA study including 28 RCTs grouped general units, hospital consultation teams, home assessment programs, home assessment programs, and outpatient assessment The meta-analysis many of the but was able to do so more types of programs had more benefit than the inpatient units and the home CGA all programs, there was an reduced mortality for patients in the CGA programs, a increased of living at home at a increased of cognitive and a reduced of for was only significant for patients in the inpatient units After the continued to be on questions relating to what of the were most effective and how the CGA process could be to it intensive and on the between and their and on the common In and there were new of home visit assessment by on the apparent between study and results and the evidence was not hard for by using formal to the data, showed a of our meta-analysis to the new on home visit CGA programs, and performed a to try to find program elements with benefit the presence of the number of follow-up and use of an CGA He found that the number of follow-up in the program was very to the program in reducing nursing home He also found that the effectiveness of the program in reducing functional was very to the presence of an CGA and follow-up These an important CGA programs to be to the patient the CGA several In for frail and high-risk elderly patients, those and those for long-term care, a CGA and follow-up program is For at or for those years and older without chronic a preventive home visit CGA and follow-up program is For at a program of health through care or in with care, is this consistent of data the many benefits of CGA and follow-up programs, the to and general of this has not been a or the has For example, after the first controlled trials were effectiveness of these programs and had begun to the a hospital unit that did that increased of was immediately it could by reduced or nursing home In fact, with the system, multiple to multiple or complex problems were to the than were more The GEU concept still in such as health or the and the VA hard to a GEU or programs in VA medical but unit in the the seemed to put up A for the original unit at Sepulveda was the of 1994, which our Sepulveda inpatient hospital with its on has been that some clinical trials have not shown dramatic benefits. with many research often has and when the evidence seems to the of based on data from multi-site trial results are often The results of the VA trial by Harvey and colleagues, for example, were somewhat In that multi-site almost were to 1 of 4 VA medical centers with established geriatrics programs. either were to the inpatient unit or to usual inpatient care with either usual outpatient follow-up or geriatric the end of the follow-up there were in between (about was a functional for the unit patients and a health in the geriatric follow-up patients, but dramatic before we that CGA is effective, we to the study of all, the have the way care was on the units, the did not until after discharge or not would be on their patients, and well have kept all patients in hospital than would have otherwise to the of patients not optimal outpatient all the sites had geriatrics care and programs for years, and the control group care have been better than at sites without such programs. is something we have over patients in our medical centers are better care than in of diagnostic accuracy, medication use, and general of geriatric medicine and The control group was a bit than in most inpatient trials, which is consistent with this of units at these could this the is in educational in a multi-site trial with central control of patient and data well have the way care was some clinical from work well for trials when there is a to be but not work as well for complex that as it we can a from the as I was by its have been other recent as and more are still published year from of an acute hospital unit showed significant effects on for randomized to the unit My of the many with their variety of program types and is that there are clear reasons why some trials have shown more effects than both to study and to in trials or outcome trials have also from a or of consultation Not all have on what CGA. recent are to the of improving geriatric care which to be in the places most likely to in these types of what have we from these about effective geriatric CGA is an important tool for diagnostic and care on elderly It can be effective in raising the of care, and it has become into everything we do in geriatrics. But it is also important for not to it or to it in such a way as to its on patients who do not We that some of programs are not so effective, to or of these would be consultation that only without substantial care or or outpatient CGA programs with and It is important to the of to the population for most care medicine with to preventive activities (such as and health is probably For and for long-term care, a more CGA and follow-up is important to that their needs are and For programs of in-home CGA and follow-up have been shown to be important to in in improving geriatric effectiveness and cost the to the the CGA to identify the from reduced and nursing home so as to the CGA process, and to an system to that patient are not between the In there are a number of important for research in this These testing of CGA programs in nursing homes or home care for cost from hospital and nursing home and using these funds to CGA testing to use of multiple care the CGA, common computerized databases for CGA that would be care and testing innovative to CGA with the chronic disease care of these activities will to define the optimal roles of geriatric in time to the at the of the Gerontological Society of