Chapter 1: Effectiveness of each element of the comprehensive geriatric assessment (<scp>CGA</scp>): English translation of the Japanese <scp>CGA</scp>‐based healthcare guidelines 2024

Is screening with the comprehensive geriatric assessment (CGA) useful in older adults? Screening with the CGA is recommended for older adults. Strength of evidence: B. Degree of recommendation: 1 (strong; agreement rate: 100%). Of the literature included in the systematic review, six were randomized controlled trials (RCTs). The CGA is a multidimensional assessment of the medical and functioning of older adults, which identifies current life problems and the risk of developing problems. The CGA plays a screening role; however, simple screening tools such as the Kihon checklist, CGA7, and Dementia Assessment Sheet in Community-based Integrated Care System–21 items (DASC-21) are also used in clinical practice and are part of the CGA. In a systematic review, the usefulness of CGA in the outpatient, inpatient, and home settings was investigated, emphasizing on “reduced mortality,” “reduced length of stay,” “improved polypharmacy,” and “increased costs.” Six reports of RCTs assessed outcomes, randomly assigned with or without the CGA and CGA-based interventions. For the CGA of outpatients, a Swedish study comparing CGA-based care with usual care in outpatients aged ≥75 years was selected. In that study, the CGA contributed to longer survival (hazard ratio [HR], 1.49 [95% CI, 1.05–2.12]) and shorter hospital stay (15.1 vs. 21.0 days; P = 0.01) 36 months after intervention, with no increase in costs.1 Moreover, the CGA may improve outcomes after an emergency department visit. In an Australian study comparing the CGA with or without continuous care intervention in patients aged ≥75 years returning home from an emergency department visit, the CGA group had lower overall hospital admissions in the first 30 days (16.5% vs. 22.2%; P = 0.048) and emergency admissions over 18 months (44.4% vs. 54.3%; P = 0.007) than the usual care group (control group), whereas no difference in mortality was noted.2 For inpatient CGA, a Swedish study compared acute care in a CGA care unit with that in a usual care unit for patients aged ≥75 years demonstrating frailty. The study found that patients receiving care in a CGA care unit had a slightly lower health-related quality of life (QOL) and a significantly lower mortality rate at 3 months (HR, 0.55 [95% CI, 0.32–0.96]), and the medical and nursing costs for hospital admissions or hospital visits did not increase.3 In a UK study examining the usefulness of preoperative CGA during hospital admission, preoperative CGA in patients aged 65 years undergoing vascular surgery was associated with shorter hospital stays (geometric mean ratio, 0.60 [95% CI, 0.46–0.79]) and a lower incidence of postoperative complications such as delirium.4 A German study examining CGA's effectiveness in home medical care also found a significant mortality reduction in the group with the CGA and information sharing with the family doctor (odds ratio [OR], 0.78 [95% CI, 0.67–0.91]), supporting positive results for the CGA in all healthcare settings, including primary care.5 Indirectly, the provision of CGA-based home care was reported to have reduced healthcare costs.6 Two Japanese retrospective cohort studies have investigated the usefulness of inpatient CGA, and one Canadian retrospective study investigated the usefulness of preoperative CGA. Both Japanese studies included patients aged >65 years who were admitted with stroke, and in one study, the CGA was significantly associated with lower in-hospital mortality (intervention group, 3.6%; nonintervention group, 4.1%; P < 0.001) and lower long-term hospitalization rate (intervention group, 8.7%; nonintervention group, 10.1%; P < 0.001).7 Another Japanese study of patients who were able to take medications internally similarly showed that the CGA was significantly associated with lower polypharmacy rates at discharge (intervention group, 32.9%; nonintervention group, 34.3%; P < 0.001) and lower number of prescribed drugs (3.76 vs. 3.84; P < 0.001).8 In a study of preoperative CGA, the CGA was significantly associated with lower mortality (HR, 0.81 [95% CI, 0.68–0.95]); however, the length of hospital stay was not significantly different, and healthcare costs only slightly increased (OR, 1.03 [95% CI, 1.01–1.05]).9 Systematic reviews by the Cochrane Collaboration have examined the effectiveness of the CGA in inpatients, patients undergoing surgery, and community-dwelling older adults exhibiting frailty 10–13. These studies have reported reduced/nonsignificant mortality in the CGA group, reduced risk of unscheduled hospital admissions, and a slight reduction in the length of stay (high to moderate certainty of evidence), whereas the evidence proposes that the CGA may slightly increase healthcare costs (low certainty of evidence). However, performing direct comparisons of medical and long-term care costs between studies is difficult because of differences in the systems in each country. Accordingly, the strength of the evidence is “B” for improvement in mortality, length of hospital stay, and polypharmacy because many studies have found a common direction, regardless of the setting where the CGA is performed. Further studies using CGA tools and including Japanese older adults are warranted to increase the accuracy and quality of the evidence. The following were considered important in developing recommendations for this CQ: reduction in mortality for outpatients, inpatients, and institutionalized patients, reduction in the length of stay, improvement in polypharmacy, and increase in costs. Is ADL assessment useful in older adults? ADL assessments are recommended for older adults. Strength of evidence: C. Degree of recommendation: 1 (strong; agreement rate, 90%). Ten studies were included in the systematic review (one review, two RCTs, four cohort studies, one cross-sectional study, and two other observational studies [one subanalysis and one database study]). The CGA is a multidimensional assessment of diseases and functioning in older adults, and ADL (basic and instrumental ADLs) assessment is considered important as a function of daily living. ADL assessment is also included in the screening using the Kihon checklist, CGA, CGA7, and DASC-21. In this systematic review, the usefulness or harmfulness of ADL (basic and instrumental ADLs) assessment in outpatients, inpatients, and institutionalized older adults was investigated, emphasizing on the items of “reduction in mortality,” “increase in institutionalization,” “increase in costs,” and “optimization of care services.” No studies have assessed these outcomes by random assignment with or without the CGA. Conversely, a cohort study analyzed whether the CGA contributes to increased costs.1 This study examined the cost-effectiveness of the CGA over 3 months in older inpatients of an acute care hospital. The CGA group was significantly more cost-effective than the non-CGA group in primary, hospital, and local authority care levels in a multivariate analysis.14 Although ADL (basic and instrumental ADLs) assessment in older adults is related to the CGA content and may be effective in the care for older adults, assisted living, and care prevention, very few studies have examined these issues. Thus, more accurate and higher quality studies including Japanese older adults are essential. The following were considered important in developing recommendations for this CQ: reducing mortality for outpatients, inpatients, and institutionalized older adults, increasing institutionalization, increasing costs, and optimizing care services. Is it useful to assess the CGA in older adults using cognitive assessment tools? The usage of a cognitive assessment tool when performing the CGA is recommended in older adults. Strength of evidence: C. Degree of recommendation: 1 (strong; agreement rate, 88.9%). Only 14 studies from the systematic review addressed the outcomes of improving the diagnosis rate of dementia and mild cognitive impairment, optimizing comorbidity management, and increasing costs using the CGA as a cognitive assessment tool. These studies included one interventional study with an outcome of improving dementia diagnostic rates15 and 13 observational studies on optimizing comorbidity management.16-28 The intervention study was an RCT in the Netherlands that compared usual care at home with a geriatric assessment program (intervention based on a referral from a family doctor, with a specialist nurse for older adults visiting participants' homes and delivering the CGA and CGA-based interventions) to older adults who did not have dementia at the start of the study. It reported a significant increase in the rate of dementia diagnosis with the intervention, with 29% of the participants in the intervention group and 9% in the control group having a new diagnosis of dementia after 6 months of followup (P = 0.02) among 113 participants.15 Conversely, no studies have examined the improvement in the diagnosis rate of mild cognitive impairment. Most observational studies on the optimization of comorbidity management have conducted the CGA, which includes the assessment of cognitive function, before events such as hospitalization or surgery, and evaluated whether the CGA results or CGA-based interventions were associated with prognosis after the event or whether the CGA was predictive of prognosis. Although a meta-analysis could not performed because of differences in the study design and outcomes, 10 out of 13 studies reported the usefulness of the CGA.16-25 Thus, the CGA may lead to more appropriate interventions, and prognostic predictions based on the CGA results will guide in making more appropriate decisions on hospitalization, surgical indications, and proactive responses to adverse events. An observational study showed that the DASC-8, a tool used in the CGA, can help identify diabetes treatment goals in older patients with diabetes, and its use is expected to optimize diabetes management.25 No study has quantitatively evaluated the costs and adverse events of including a cognitive function assessment tool in the CGA. The cognitive function assessment included in the CGA is quick and easy to perform and does not impose a significant burden on patients. In addition, the CGA is used as a screening tool in clinical practice; a positive result required a detailed assessment using standard methods, resulting in a low risk of unnecessary interventions due to false positives, and the potential harm from including cognitive function assessment in the CGA is considered limited. The quality of the evidence is not high because most of the studies extracted analyzed small samples and lacked sufficient adjustment for confounding factors. Despite the limited evidence from interventional studies, the inclusion of cognitive assessment tools in the CGA is common in clinical practice because of the high prevalence of dementia in older adults, and conducting large-scale interventional studies on whether to include cognitive assessment tools in the CGA would be difficult. In conclusion, the inclusion of cognitive assessment in the CGA is likely to be more beneficial than harmful. In addition, such inclusion is recommended because of the social need, not only at the individual level, to conduct CGA as a screening tool to facilitate the early diagnosis of dementia. The following were considered important in developing recommendations for this CQ: improving the diagnosis rate of dementia, improving the diagnosis rate of mild cognitive impairment, optimizing comorbidity management, and increasing costs. Is depression assessment useful in older adults with physical disease? Which depression scales are useful? Depression assessment is recommended for older adults with physical disease. The geriatric depression scale (GDS)-15 is recommended. Strength of evidence: C. Degree of recommendation: 1 (strong; agreement rate, 80%). The comorbidity of depression in older adults with physical illness is associated with a poorer prognosis for physical illness. For example, the comorbidity of depression with type 2 diabetes increases mortality,29 whereas the comorbidity of depression with cancer shortens survival.30 Depression in older adults is often foregrounded by physical symptoms, making it difficult to diagnose depression and pointing to the need for regular assessment.30 However, studies have been scarce, so a systematic review only included four studies: three studies31-33 examining reductions in mortality and hospitalization/readmission rates and one study34 showing improvement in polypharmacy. The strength of evidence for the reduction in mortality and hospitalization/readmission rates was graded C because only one of the three studies reported significant results. Regarding the balance of benefits and harms, the degree of certainty of the balance is high because the undesirable effects of depression assessment, such as patient burden, are considered small compared with the benefits, such as reduced mortality and hospitalization/readmission rates and improved polypharmacy. The intention of patients (family members) regarding the depression assessment was not considered to vary significantly. However, with regard to costs, a study of older patients aged 70 years with proximal femoral fractures reported that comprehensive care for older adults was significantly more expensive than usual orthopedic care.35 Although only two of the four factors affecting the strength of the recommendation were applicable, if depression is overlooked in older adults with physical illness without assessment for depression, the harm to the patient is likely to be significant; therefore, depression assessment is considered useful and thus “recommended.” No studies on the usefulness of the scale employed were extracted; however, the GDS-15 was widely used in the selected literature and other literature, which proposes that the GDS-15 may be useful. The following were considered important in developing recommendations for this CQ: reduction in mortality and hospital admission/readmission rates that could be identified as outcomes. A study on improving polypharmacy was used as a reference for the recommendations. Is it useful to assess motivation in older adults with possible apathy? Which measures of motivation are useful? We propose to assess motivation in older adults with possible apathy. In Japan, the vitality index is often used as an assessment scale; however, evidence for its usefulness is insufficient. Strength of evidence: C. Degree of recommendation: 2 (weak; agreement rate, 100%). Apathy is often observed in organic brain syndromes such as vascular disease and dementia. It is the most frequent behavioral and psychological symptom of dementia in Alzheimer's disease and other dementias, and its intensity increases with disease progression.36 Acute care hospitals prioritizes treatment of the physical disease; thus, support for apathy prevention is insufficient, and even if the physical illness improves, the deterioration of apathy often leads to prolonged hospitalization or discharge to an institution.37 Therefore, nursing support based on comprehensive assessment, including motivation assessment, is necessary for acute care hospitals.38 Because low-activity delirium is often observed in older adults, apathy should be carefully differentiated from delirium.39 However, very few studies have examined the effects of motivation assessment in older adults. Only one study38 showed significant results in improving physical and motor function, and no studies have reported on reducing hospitalization rates, improving rehabilitation effectiveness, or improving frailty. Accordingly, the level of evidence was set at C. However, no studies have reported increased patient burden, including costs. The degree of certainty of balance is considered high because of the small undesirable effects associated with motivation assessment such as patient burden. The intentions of patients and their family members regarding the assessment were not considered to vary significantly. Thus, the assessment of motivation may be useful in patients with possible apathy and is weakly recommended. Although vitality index was used in the extracted literature, the apathy evaluation scale is widely used worldwide. Accordingly, a decision on a useful scale for motivation (apathy) is reserved at present. The following were considered important in developing recommendations for this CQ: physical and motor function that could be identified as an outcome. Is it advisable to assess the QOL in older adult care? Only two studies have examined the significance of QOL assessment in the CGA: a before-and-after study and a non-RCT. Both studies have shown some benefits; however, the evidence is insufficient. Although few studies have verified the effectiveness of QOL assessment in older adult care, it may be useful, and further studies are expected in the future. Only two studies have examined the significance of QOL assessment in the CGA. One was a before-and-after comparative study examining the effects of a multifaceted intervention consisting of the CGA, QOL assessment, and nurse-led telephone counseling in patients with cancer aged >70 years. Although some QOL domains (mobility/role and fatigue/pain) worsened, the overall QOL was improved or maintained in 72% of the patients.40 The other was a non-RCT, examining the effects of a nonindividualized intervention based on QOL assessment in community-dwelling participants aged 60 years with no physical or cognitive impairment. The intervention group showed no difference in the overall QOL compared with the control group; however, differences were noted in some QOL domains, such as mental health, physical function, and overall sense of wellbeing.41 Although the inclusion of QOL assessment in the CGA could be beneficial, we cannot assess whether it is beneficial at present. Thus, more studies are needed because patient-reported outcomes have become more important in recent years. Are interventions based on the assessment of social factors useful in older adults? We propose an intervention based on the assessment of social factors as part of the CGA in older adults. Strength of evidence: C. Degree of recommendation: 2 (weak; agreement rate, 100%). Three RCTs42-44 and three observational studies45-47 were selected to develop this statement. RCTs have shown that interventions based on the assessment of social factors*1, particularly the CGA, are effective in improving the ADL performance of older adults with frailty. In one study, 15.4% of older adults with frailty who the intervention showed an improvement in ADL compared with in the control However, in two other studies, the of the intervention and significance were Therefore, interventions not have an on all older adults, and the effects may vary on the content and of the intervention and of the older adults. a study found an increase in the life of and an cost-effectiveness ratio of Although the is in the cost-effectiveness in is The three RCTs did not on the of the interventions on the and social support for older adults, and whether interventions based on the assessment of social factors should be considered when interventions for older adults is The and of the intervention be and when interventions based on the assessment of social the appropriate intervention be selected to the and of the older Conversely, observational studies have shown that social interventions such as have reduced the rate of hospital visits by regard to reduced mortality, a study of 10 aged ≥75 years in the UK found that with low social had a higher risk of higher than however, this was not by the of cognitive In addition, a Swedish study of participants aged years showed that the CGA in primary care was cost-effective compared with usual care at months Accordingly, we propose an intervention based on the assessment of social factors as part of the CGA in older adults. factors an individual their or including with family and social level, use of social and is a of QOL and the length of as a number that measures the of a medical It is a of QOL and QOL The following were considered important in developing recommendations for this CQ: improving increasing costs, and improving as a result of interventions based on social factors. Is the frailty assessment useful in older adults? We propose to perform a frailty assessment for older adults. Strength of evidence: C. Degree of recommendation: 2 (weak; agreement rate, 90%). In this systematic review, the usefulness of frailty assessment was investigated with on care management of and costs.” No studies have assessed these outcomes, randomly assigned with or without a frailty Conversely, one retrospective cohort study analyzed older adults two who frailty assessment and who did The participants were community-dwelling older adults aged 65 years in the of who were not for long-term were to whether or not had a frailty assessment using the Kihon The of new long-term care and were observed over the first years after in the first were the two of older adults no significant difference was found in the of new long-term care and however, among the older adults aged ≥75 the of new long-term care was significantly lower in the evaluation group = than in the group = < and was significantly lower in the group than in the group = A was also conducted for the four including with and without the older adults aged ≥75 the incidence of new long-term care was significantly lower in the group who a frailty assessment and a In the group who did not of these the incidence of the new need for long-term care had an of [95% CI, In the group who only frailty assessment, it had an of [95% CI, and in the group who only for and and number of impairment, cognitive impairment, and it had an of [95% CI, The between frailty assessment and prognosis has been for assessment studies have an not only with reduced also with and Therefore, the prognosis be by frailty assessment, and treatment be selected based on this assessment can be effective if it is to appropriate and However, few studies have verified these with a high degree of Thus, more in of accuracy and is necessary in the future. The following were considered important in developing recommendations for this CQ: optimizing care improving optimizing management of and increasing costs. Is the assessment useful in older adults? We propose to perform a assessment for older adults. Strength of evidence: C. Degree of recommendation: 2 (weak; 80%). Because of the potential for in older adults, screening with or of having from a is recommended for all older screening is effective when it is to the assessment of individual problems and In this systematic review, the usefulness of assessment was examined in of the of care and however, no studies have evaluated assessment as an outcome by randomly whether or not it was performed. Conversely, one before-and-after study compared the benefits of a clinical screening and management and the effects on healthcare screening was conducted using the screening with interventions to the risk of A of management clinical with screening were to older adults aged 65 years a and hospital admissions, length of stay, number of visits to the number of visits by medical and medical costs were analyzed during the first 6 months after the of the clinical The mean of the patients was and based on the results of were = = and = management was to the and counseling and by a whereas were recommended for the The results showed that the of a management was associated with hospital admissions, shorter hospital visits to and associated with management were more than by the reduced use of services. This that a of management with the improvement of patient healthcare and reducing costs. However, this is a evaluation after the of the and a before-and-after comparative The assessment of older adults may be useful in with The following were considered important in developing recommendations for this CQ: optimizing care improving improving increasing costs, and increased costs were considered We and for their to this study. This the of 1 of the Japanese from from and from and from Japan, and from and from and from and The other no of