Health outcomes and implementation barriers and facilitators of comprehensive geriatric assessment in community settings: a systematic integrative review [PROSPERO registration no.: CRD42021229953]

Abstract

Background Comprehensive geriatric assessment (CGA) addresses the bio-psycho-social needs of older adults through multidimensional assessments and management. Synthesising evidence on quantitative health outcomes and implementation barriers and facilitators would inform practice and policy on CGA for community-dwelling older adults. Methods We systematically searched four medical and social sciences electronic databases for quantitative, qualitative, and mixed methods studies published from 1 January 2000 to 31 October 2020. Due to heterogeneity of articles, we narratively reviewed the synthesis of evidence on health outcomes and implementation barriers and facilitators. Results We screened 14,151 titles and abstracts and 203 full text articles, and included 43 selected articles. Study designs included controlled intervention studies (n = 31), pre-post studies without controls (n = 4), case-control (n = 1), qualitative methods (n = 3), and mixed methods (n = 4). A majority of articles studied populations aged ≥75 years (n = 18, 42%). CGAs were most frequently conducted in the home (n = 25, 58%) and primary care settings (n = 8, 19%). CGAs were conducted by nurses in most studies (n = 22, 51%). There was evidence of improved functional status (5 of 19 RCTs, 2 of 3 pre-post), frailty and fall outcomes (3 of 6 RCTs, 1 of 1 pre-post), mental health outcomes (3 of 6 RCTs, 2 of 2 pre-post), self-rated health (1 of 6 RCTs, 1 of 1 pre-post), and quality of life (4 of 17 RCTs, 3 of 3 pre-post). Barriers to implementation of CGAs involved a lack of partnership alignment and feedback, poor acceptance of preventive work, and challenges faced by providers in operationalising and optimising CGAs. The perceived benefits of CGA that served to facilitate its implementation included the use of highly skilled staff to provide holistic assessments and patient education, and the resultant improvements in care coordination and convenience to the patients, particularly where home-based assessments and management were performed. Conclusion There is mixed evidence on the quantitative health outcomes of CGA on community-dwelling older adults. While there is perceived positive value from CGA when carried out by highly skilled staff, barriers such as bringing providers into a partnership, greater acceptance of preventive care, and operational issues could impede its implementation.

The relevance of geriatric assessments on the association between chronic kidney disease stages and mortality among older people: a secondary analysis of a multicentre cohort study

“…Although nephrologists and geriatricians recognised the relevance of geriatric assessment in older CKD patients [ 35 ], current evidence regarding its use in primary care (i.e. the presumable setting for community-dwelling older people with mild-to-moderate CKD) is mixed and barriers to implementation still need to be overcome and warrant further investigations [ 36 ].…”

GP-led adapted comprehensive geriatric assessment for frail older people: a multi-methods evaluation of the ‘Living Well Assessment’ quality improvement project in Scotland

“…A Cochrane review found low-certainty evidence that CGA in a community setting increases the likelihood of frail older people being able to remain at home and reduces the risk of unplanned hospital admission (12) but all the trials were geriatrican raher than GP-led . Another systematc review in community settings reported improvement in function, quality of life and mental health outcomes following CGA for older frail people (19). Most CGAs were conducted by geriatrician or geriatric nurses (12,19) (20).…”

“…Primary care (13) provides an ideal setting for routinely identifying high-risk patients (14), but there is no established model of frailty assessment and management (15) and limited evidence of effectiveness or cost effectiveness of community-based CGA (12,(15)(16)(17), even though an adapted CGA for use within general practice is recommended by the British Geriatrics Society (18). Barriers to implementation need further investigation (19). Research on community-based CGA shows wide variation in who conducts the assessment, including geriatric specialists (19,20), nurses, physiotherapists and social workers (19,21,22).…”

“…Barriers to implementation need further investigation (19). Research on community-based CGA shows wide variation in who conducts the assessment, including geriatric specialists (19,20), nurses, physiotherapists and social workers (19,21,22). There are very few studies that have evaluated CGA delivered by general practitioners (GPs) (19).…”

Development and validation of retrospective electronic frailty index using operational data of aged care homes

“…Home-based CGA is an alternative to clinical CGA for the elderly in RACs for their care management to improve their quality of life [ 10 ]. There are many barriers and challenges to the implementation of CGAs in community settings [ 11 ], but in the context of early identification of health risks, it is difficult to identify the time for CGA to meet the needs of individuals as the health status could change rapidly and unexpectedly in the elderly [ 12 ]. Regardless of the challenges and limitations, CGA is a gold standard for the management of frailty [ 8 , 13 ].…”