Chapter 2: Management of geriatric diseases and geriatric syndrome using comprehensive geriatric assessment (<scp>CGA</scp>): English translation of the Japanese <scp>CGA</scp>‐based healthcare guidelines 2024

Is CGA effective in frail older adults? Statement: CGA is proposed to be performed on frail older adults. Strength of evidence D. Degree of recommendation 2 (weak) (agreement rate: 100%). In this systematic review, intervention outcomes through Comprehensive Geriatric Assessment (CGA) for frail older individuals were identified as follows: improvement in the decline of independence (e.g., new certification for care needs, institutionalizations), reduction in the incidence of emergency hospitalizations, reduction in the incidence of falls and fractures, reduction in mortality, and increased costs. No randomized controlled trials (RCTs) were identified regarding the decrease in the incidence of falls and fractures, but several RCTs were found for other outcomes. However, the results were inconsistent. Some reports showed positive effects, whereas others did not, leading to insufficient evidence overall. Initially, “malnutrition” was included in the outcome of the clinical question (CQ) and statement, but no relevant literature was selected during the review process, making the examination of the effect of CGA interventions on malnutrition in older people impossible. Additionally, frailty was defined inconsistently; of the 11 extracted articles, two utilized the phenotype model,1, 2 one used both the phenotype and cumulative deficit models,3 and the remaining utilized the original methods. Three RCTs examined the effect of CGA intervention on the decline in independence, of which two were on outpatients, and one was on older inpatients. The two outpatient studies evaluated basic activities of daily living (BADL), but intervention effects were not significant.4, 5 By contrast, a study that included older people aged ≥75 years who were hospitalized in internal medicine wards for acute illness reported a positive result. The participants were divided into two groups: one group that received CGA intervention in a Geriatric Evaluation and Management Unit (GEMU) and one group that received regular treatment in a general medical ward and investigated the effect of CGA. Thus, although BADL was not evaluated, the rate of living in their own home was significantly higher in the GEMU group at 3 months after discharge (64% vs. 80%) in the GEMU group (P = 0.005) and at 6 months (60% vs. 72%) in the GEMU group (P = 0.04).6 In another interventional study with CGA in hospitalized patients, ADLs improved with the intervention. However, it could not be included in the analysis with the outcome of “improvement in the decline of independence” because of a lack of data on the places of care before and after admission and discharge.7 Four RCTs have reported the effects of CGA on emergency hospitalization, two of which were performed in outpatients and the other two in hospitalized patients. No significant effects were found between the intervention and control groups in the four studies: a study before surgery for colorectal cancer,8 a study for older patients with hematologic malignancies (leukemia, malignant lymphoma, etc.),3 a longitudinal comparison in patients attending clinics with or without CGA,4 and a 6-month follow-up study comparing a group receiving CGA intervention at GEMU and a group receiving regular care at MW.6 Regarding the effect of CGA on reducing mortality, eight interventional studies were conducted in outpatient and inpatient settings, but seven did not show significant effects.1, 3-5, 8-10 In one study of older patients hospitalized for internal medicine, partial effects were observed, with significantly reduced mortality rates at 3 and 6 months in the intervention group, but the significance disappeared at 12 months.11 Three reports on the effect of CGA interventions on costs were conducted, two of which did not find any economic benefits from CGA.9, 10 In one report, a positive effect was found on the costs of 12-month multidisciplinary CGA interventions in community-dwelling frail older people aged 70 years. The intervention group was more cost-effective than the control group receiving regular medical care and local services, and the effect was stronger in the very frail subpopulation.2 Regarding the effect of CGA interventions, many studies did not show significant benefits in terms of the outcomes of “improvement in the decline of independence,” “reduced incidence of emergency hospitalization,” “reduced incidence of falls and fractures,” “reduced mortality,” and “increased costs.” Because of the various methods of interventions, subjects, and research designs in the included studies, conducting an integrated meta-analysis was impossible. Further research is warranted. In preparing the recommendations for this CQ, we emphasized on improving the decline in independent function (new nursing care certification, admission to a facility), reducing the incidence of emergency hospitalization, reducing the incidence of falls and fractures, reducing mortality, and reducing costs. Are evaluations with assessment tools for “cognitive function” and “behavioral and psychological symptom (BPSD)” effective in the CGA for older adults with dementia? Statement: The use of assessment tools of cognitive function or BPSD is recommended when performing CGA on older adults with dementia. Strength of evidence C. Degree of recommendation 1 (strong) (agreement rate: 88.9%). In this CQ, the literature was searched in terms of the following outcomes: improved behavioral and psychological symptoms, reduced rates of hospitalization and institutionalization, reduced mortality, appropriateness of management of comorbidities, and reduced medical expenses or patient burden. Only six articles were extracted through a systematic review process, which were studies on the appropriateness of comorbidity management.12-17 Among these, two studies were interventional designs. One study showed that CGA was implemented in 90 hospitalized patients with dementia with eating disorders who received artificial hydration and nutrition, which was compared with a historical control group of 124 patients. The withdrawal rate from artificial hydration and nutrition was significantly higher in the intervention group (51% vs. 34%; P = 0.02), and the survival rate without artificial hydration and nutrition after 1 year was also significantly higher in the intervention group (28% vs. 15%; P = 0.01).12 Another cluster randomized controlled trial implemented CGA with interventions based on patients with dementia living in 24 nursing homes. The intervention group (118 patients) tended to have fewer unmet needs in social, medical, psychological, and environmental aspects, including food, housing, visual and hearing impairments, and intimate relationships, compared with the control (usual care) group (120 patients) (change in the number of unmet needs identified using the scale: −3.1 vs. −0.7), but the difference was not statistically significant due to the large variability between clusters.13 In these two studies, direct comparisons could not be performed due to the differences in terms of target populations, intervention contents, and outcomes. Conversely, all remaining four observational studies showed significant associations between CGA and prognosis or predictability of prognosis based on the CGA results, although with different evaluation tools and outcomes used.14-17 If prognosis can be predicted by using CGA, it is expected to be proactive to anticipated adverse events. No studies quantitatively evaluated the costs or adverse events by assessing cognitive function or behavioral/psychological symptoms in CGA for older people with dementia. In addition, most studies extracted were small-scale, and the overall evidence for this CQ was limited. By contrast, it is commonly performed in clinical settings to assess cognitive function regularly, whether as CGA or not, in continuous medical treatments for patients with dementia. In addition, behavioral and psychological symptom assessments were also conducted when necessary. The effects of medical procedures routinely performed in clinical settings are difficult to evaluate as interventions, which explains why the evidence for this CQ was limited. Although the results of the interventional studies extracted in this CQ were inconsistent, observational studies suggested that including cognitive function or behavioral/psychological symptom evaluations in the CGA for older people with dementia might be beneficial. Although the evidence is limited, there is a high clinical need to evaluate the deterioration of cognitive function or behavioral/psychological symptom severity in older people with dementia. Considering that such assessments are unlikely to lead to adverse events, including cognitive function or behavioral/psychological symptom assessments in CGA for older people with dementia is recommended. In preparing the recommendations for this CQ, emphasized on improving behavioral and psychological symptoms, reducing the rate of hospitalization and admission, reducing mortality, optimizing comorbidity management, and reducing medical costs or patient burden. Is CGA effective for older patients with polypharmacy? Statement: Conducting CGA is proposed for older patients with polypharmacy. Strength of evidence B. Degree of recommendation 2 (weak) (agreement rate: 68.9%). CGA is effective for preventing declines in the quality of life (QOL) and reducing the number of prescribed medications; however, whether CGA is effective for reducing adverse drug events, mortality, hospitalization, or functional decline in older people with polypharmacy is unclear. Because polypharmacy carries a risk of adverse drug events, regular reviews of prescribed medications are required. However, deprescribing may lead to deterioration in patients' health if the highly necessary medications are stopped. Therefore, physicians sometimes find it difficult to determine whether certain medications should be deprescribed. Only one interventional study was found after we examined through a systematic review whether CGA is effective in changes of the status of polypharmacy, or improvement of prognosis/preventing functional decline in patients with polypharmacy.18 In this study, 84 family physicians in Norway were divided into CGA and non-CGA practice groups, and the prognosis and medication changes of their older patients (355 in total) were evaluated after 16 weeks. The subjects were community-dwelling patients aged 70 years who were regularly prescribed seven or more medications, and patients with serious diseases were excluded. The primary outcome was QOL after 16 weeks (15D: score range, 0–1; higher scores indicate better QOL; clinically significant changes are ≥0.015 points). The decline in QOL was suppressed in the CGA group (CGA group: 0.698 ± 0.164 points, nonpractice group: 0.655 ± 0.184 points, difference between groups: 0.045 [95% CI: 0.004–0.086]; P < 0.03). By contrast, the secondary outcome measures of mortality and hospitalization rates and changes in physical and cognitive functions were not significantly different. Most patients in the CGA group had changes in their medications, and only 1.2% of the CGA group (35.4% of the nonpractice group) had no changes in their medications at 16 weeks. The Medication Appropriateness Index (a 10-item assessment with a maximum score of 18 points, with higher scores being appropriate) showed that the appropriateness of prescriptions improved in the CGA practice group (6.6 ± 7.1 and 0.1 ± 4.3 points in the CGA practice and nonpractitioner groups, respectively).18 Few studies have evaluated the medication number or prognosis in subjects with polypharmacy with or without specific diseases. However, the abovementioned study showed suppression in the decline in QOL in patients with polypharmacy, demonstrating the effectiveness of reviewing medications. Therefore, although the evidence is weak, the practice of CGA for older people with polypharmacy is recommended. We extracted only one reference, and no significant differences were found in mortality, hospitalization, or changes in physical function/cognitive function. However, these outcome items were considered important because maintenance of QOL and optimization of medication were achieved. Is CGA effective for older patients with multimorbidity? Statement: Performing CGA is recommended for older patients with multimorbidity. Strength of evidence B. Degree of recommendation 1 (strong) (agreement rate: 77.8%). Implementing CGA in older people with multimorbidity reduces mortality, rehospitalization, and functional decline without increasing costs. Generally, older people have multimorbidity, defined as having multiple diseases and/or health problems. Although medical professionals see older people with multimorbidity daily, guidelines for specific diseases have not yet fully established management in patients with multimorbidity. Two studies recommended the use of CGA to manage patients with multimorbidity. A RCTs19 was conducted in Sweden targeting older patients aged ≥75 years with three or more diseases and who had been hospitalized three or more times in the previous year. Patients (208 and 174 in the intervention and control groups, respectively) were assigned to either a group with or without CGA. Although the rate of rehospitalization within 36 months was not significantly different, the number of survival days during the period increased (hazard ratio: 1.49 [95% CI: 1.05–2.12]; P = 0.026), and the length of hospital stay reduced (CGA group: 15.1 days [SD: 18.4], control group: 21.0 days [SD: 25.0]; P = 0.01) in the CGA group. However, no difference was found in expenses (P = 0.43). In another study from the same trial,1 the outcome was the combined rate of frailty and death within 24 months, which was significantly lower in the CGA group (P = 0.002), and the proportion of prefrailty was also significantly lower in the CGA group (P = 0.004). Thus, CGA for older people with multimorbidity may positively affect the length of hospitalization, survival, and maintenance of ADL without increasing costs. Moreover, the implementation of CGA is recommended for patients with multimorbidity. Although we only extracted two articles, the multifaceted effects, such as length of hospital stay, mortality rate, and onset of frailty, should be confirmed, as well as costs and adverse events. Is it effective to use CGA in the management of older patients with DM? Statement: CGA is proposed in the management of older patients with DM. Strength of evidence D. Degree of recommendation 2 (weak) (agreement rate: 100%). Only one randomized controlled trial (RCT) evaluated the effectiveness of CGA in older people with diabetes mellitus (DM). It was conducted at a single facility in Taiwan for patients aged years after surgery for = for specific care and for study showed that performing CGA for in older patients with improved the of in and compared with the non-CGA group, that CGA may be effective for the management of in older patients with DM. However, this study was in terms of the patients with are to have Therefore, the for the of in the older adults in recommended not the implementation of CGA in older patients with with the evidence for hospitalized older patients in not with that CGA a of being and in their own home at to 12 Further research is necessary to whether CGA is effective in the treatment of in the older In preparing recommendations for this CQ, we considered the evidence and with the for in older adults in Is it effective to use CGA to evaluate older adults with or to determine a treatment Statement: CGA is proposed to evaluate older adults with or to determine a treatment Strength of evidence C. Degree of recommendation 2 (weak) (agreement rate: Regarding the effectiveness of using CGA to a treatment for or diseases in the older we articles, of which were examined in in the of three three were studies with the outcome of reduced mortality or events. However, did not outcomes between groups with or without CGA, but examined the associations between CGA evaluation and outcomes. The of evidence was due to the number of and insufficient for However, these studies showed the effectiveness of the CGA Therefore, we to with a recommendation the of CGA to determine the treatment for or diseases. In a study of community-dwelling older people in 11 frail or subjects by CGA had a significantly higher risk for both and that CGA was effective for risk In addition, in a study of patients who or frailty evaluated by CGA was with survival outcomes in the and a study reported that evaluated by CGA was with survival after In this CQ lack and no interventional studies have been but the for improving outcomes was We that CGA be used to evaluate this this CQ in the more and research is to older In preparing recommendations for this CQ, we emphasized improving life preventing preventing dementia and preventing the to a nursing Is a multidisciplinary based on CGA effective for in older Statement: Regarding the effectiveness of a multidisciplinary based on CGA for older patients with no evidence showed direct effects, but a multidisciplinary that the of older patients based on CGA is and we to is the leading of death in and of due to in older adults aged We conducted a literature in the and the to the effectiveness of a multidisciplinary based on CGA for older patients with but no reports were found of RCTs of a multidisciplinary based on CGA to the improvement of in older patients. In an conducted by comparing groups with or without a functional assessment to CGA combined with an eating and assessment mortality, or showed no significant may that including physical and should have an of in older patients to positive outcomes through a However, research is to whether a multidisciplinary using CGA is effective in in older patients. Is CGA effective for in older adults? Statement: Performing CGA is recommended in the management of older patients after Strength of evidence B. Degree of recommendation 1 (strong) (agreement rate: We included three articles in the systematic review two CGA is a multifaceted evaluation of the medical care and in the daily life of older which in including the risk of and falls and the need for medical procedures and We using the In this systematic review, we on the following outcomes in people receiving medical reduction in mortality during the reduction in rate, reduction in rate and in costs. No RCTs with or without CGA evaluated these outcomes. a systematic review by the evaluated the effectiveness of CGA intervention compared with treatment for outcomes in older patients who were hospitalized for various found that older patients who CGA had a lower mortality risk and were more to after discharge to the same before In addition, the medical in the CGA intervention group was lower than in the non-CGA intervention group. a study reported that CGA intervention was with lower mortality in patients with The CGA group had a lower mortality rate than the non-CGA group after for and with a of [95% CI: In addition, patients aged 70 years with were assigned to either a CGA or a hospitalization management group, and their physical function months after surgery was using the physical The CGA group showed improvement in physical function months after surgery compared with the group, that CGA after hospitalization may be effective for with CGA is important for in life such as and risk and the need for medical procedures and care in the but there are studies that have examined the effectiveness of with CGA to the rates of or However, CGA is recommended for the management of patients who surgery for fractures, and the effectiveness of and been for and including that of the older is in the In preparing the recommendations for this CQ, we emphasized on the reduction in mortality, rehospitalization rate, and rate during the as well as the reduction in when patients medical whether or at were by CGA. Is it effective to use CGA to evaluate patients before surgery for or in older adults? Statement: Evaluation using CGA before surgery for or in older patients is recommended. Strength of evidence B. Degree of recommendation 1 (strong) (agreement rate: 88.9%). A systematic review was conducted on the of CGA evaluation before surgery for and in older patients. We articles from the and were examined in in the of 11 were observational and interventional studies with improvement in mortality, reduction in the incidence of and of onset of as outcomes. Only one interventional study was found for but the were and the were not Although the evidence had all studies showed the effectiveness of performing CGA evaluation before surgery for and We extracted three and one intervention with improving mortality as the In all studies, risk assessment was performed using CGA and subjects who were considered at high risk using the CGA had a In an interventional study, a multifaceted intervention based on CGA was performed on people aged 70 years and the prognosis was improved compared with the group. We extracted four and one intervention that to the incidence of as an Although of the studies were large in risk was high in patients who had a decline in ADL or cognitive function. In an interventional study, a multifaceted intervention based on CGA was performed on older people before surgery to and the incidence of was We extracted and one interventional that to as an The and subjects of the studies but all showed that CGA evaluations were with the risk of The interventional studies were the same as extracted with mortality as the Moreover, multifaceted interventions based on CGA also the of in patients aged 70 years Thus, although the evidence was not the of the effects was and the evaluation using CGA is considered effective for risk of the extracted studies not only used CGA for risk assessment but also examined the effectiveness of multidisciplinary and multifaceted interventions based on CGA However, this CQ on the significance of assessment using CGA. In the the significance of multifaceted interventions based on CGA results may a new and In preparing recommendations for this CQ, we emphasized on improving survival reducing the incidence of and preventing Is CGA effective in malignant in older Statement: CGA is recommended in the management of older patients with malignant who are for systematic Strength of evidence Degree of recommendation 1 (strong) (agreement rate: 100%). randomized controlled trials (RCTs) examined the effectiveness of performing CGA on patients with malignant Most studies were conducted on patients aged 70 and all studies performed CGA before or after the of systematic In the of clinical older patients are evaluated using an assessment but no intervention is Therefore, studies with only assessments without interventions were also included in the RCTs the effect of the assessment on clinical outcomes this it is of CGA in and We only included one of the RCTs for mortality as the primary In a study comparing a group assigned to treatment based on status and with a group treatment was based on the CGA results in patients with aged years who were to systematic the primary of treatment survival was vs. months [95% CI: P = and the secondary of overall survival was vs. months [95% CI: P = no Conversely, a cluster of patients aged 70 years with who were for systematic compared the group with or without to of CGA results and recommended Although the intervention group had a higher rate of reduction of drug from the vs. the mortality at 1 year was [95% CI: P = studies mortality also showed no improvement in the CGA We found a meta-analysis on adverse events based on the for in patients The study included six with patients The meta-analysis showed that the incidence of or higher adverse events was significantly lower in the CGA group than in the control group care) vs. risk [95% CI: P = We included RCTs with QOL as an but only one study it as a primary The study examined changes in QOL 24 weeks in patients aged 70 years with and large who were for systematic in the CGA or treatment group. The primary was significantly better in the CGA group 24 weeks compared with the treatment group (P = No reports examined the increased on patients. A meta-analysis was conducted to determine whether CGA reduces in patients systematic and The study included four and patients. In the the number of was not significantly different between the CGA and control groups [95% CI: P = Thus, we that CGA be performed in the management of malignant patients for systematic In preparing the recommendations for this CQ, we considered outcomes: survival reduction in adverse events, improvement in increased on patients, and reduction in Among these, the meta-analysis showed that adverse events were significantly we emphasized on the in adverse the outcome We for and of and of of of and for their to this the of 2 of Comprehensive Geriatric < received research from the following and received research from received from received from received from received research from and and from and The other no of