Chapter 3: Utilization of comprehensive geriatric assessment (<scp>CGA</scp>) in healthcare and caregiving settings by related professionals: English translation of the Japanese <scp>CGA</scp>‐based healthcare guidelines 2024

Is comprehensive geriatric assessment (CGA) effective in nursing (nursing department) older adults? CGA implementation in nursing (nursing department) is recommended for older adults. Strength of evidence: A. Degree of recommendation: 1 (strong) (agreement rate: 100%). A systematic literature search resulted in the extraction of 20 papers, of which 14 were high-quality studies (including 11 randomized controlled trials [RCTs]) (Fig. S1). There were five outcome items: mortality rate, activities of daily living (ADL), quality of life (QOL), hospitalization/institutionalization rate, and medical expenses. There were five high-quality RCTs with mortality rate as an outcome. In Spain, 620 older adult outpatients were randomized to a usual nursing care or CGA and multidisciplinary nursing care group. The combined outcome of mortality rate and hospitalization/institutionalization rate was lower in the intervention group than in the usual care group after 18 months, but this difference was not statistically significant. However, a subgroup analysis of older adults at high risk of frailty revealed that the intervention group had a significantly lower incidence rate (intervention group: 16.3% vs. control group: 28.4%; P = 0.028).1 A Swiss study on 2284 community-dwelling older adults randomly allocated to a usual care group or a CGA and multidisciplinary nursing care group for 2 years showed a decreased mortality rate in the CGA group compared with the usual group after 8 years.2 In Sweden, a multidisciplinary team including nurses evaluated the mortality rate in 382 older adult outpatients receiving either usual care or CGA and multidisciplinary care. Although there was no significant difference in the mortality rate between the two groups after 2 years, there was a significant reduction after 3 years.3 A meta-analysis of four RCTs, including the abovementioned reports, revealed a significantly reduced mortality rate in the CGA group (risk ratio: 0.78, 95% confidence interval [CI]: [0.64–0.94]) (Fig. 1).1, 4-6 The other RCT also demonstrated a significant reduction in the mortality rate in the CGA group.2 There were two high-quality RCTs with ADL as an outcome. In Sweden, nurses used a CGA and multidisciplinary care approach for 64 older adults hospitalized with a hip fracture in an orthopedic ward at a university hospital. Compared with the usual care group, ADL was restored in a larger proportion of the CGA group 12 months after surgery. The CGA group also showed a significant reduction in falls during hospitalization, postoperative delirium, and malnutrition compared with the usual care group.7 In another Swedish study, 161 older adults discharged after visits to the hospital emergency department received either usual care or CGA and multidisciplinary care from a team comprising geriatricians, nurses, physical therapists, and occupational therapists. Compared with the usual care group, ADL was restored after 1 year in the CGA group.8 A meta-analysis of two RCTs revealed that ADL was significantly restored in the CGA group (odds ratio: 2.88, 95% CI: 1.60–5.18) (Fig. 2).8, 9 The remaining RCT also demonstrated significant improvement in ADL in the CGA group.7 There were two high-quality RCTs with QOL as an outcome. In Canada, a multidisciplinary team of nurses, geriatricians, physical therapists, occupational therapists, speech therapists, and dietitians performed usual care or CGA and multidisciplinary care for 182 community-dwelling frail older adults. Compared with the usual care group, goal attainment scaling scores improved after 3, 6, and 12 months in the CGA group.10 In Australia, a multidisciplinary team of physicians and nurses performed usual care or CGA and multidisciplinary care for 116 older adults residing in a care facility. After 6 months, the CGA group showed higher satisfaction with the care provided than the usual care group.11 The abovementioned Australian study11 was one of two high-quality RCTs where the hospitalization/institutionalization rate was an outcome. The Australian study reported that the hospitalization rate within 6 months was similar between the usual care group and the CGA group. However, the number of outpatient visits within 6 months was significantly less in the CGA group compared with the usual care group.11 The second study was performed in Sweden, where a multidisciplinary team of physicians, nurses, case managers, physical therapists, occupational therapists, and dietitians performed either usual care or CGA and multidisciplinary care for 382 older adult outpatients. However, after 2 years, there was no significant difference in the institutionalization rates between the CGA and the usual care groups.6 There were three high-quality RCTs where the outcome was healthcare costs. In Australia, a multidisciplinary team of geriatricians, physiatrists, dietitians, and nurses performed usual care or CGA and multidisciplinary care for 241 community-dwelling frail older adults (according to the Cardiovascular Health Study criteria). The intervention group was more cost-effective after 1 year compared with the usual care group, and this was particularly pronounced in those with severe frailty.12 In Sweden, a multidisciplinary team of physicians, nurses, case managers, physical therapists, occupational therapists, and dietitians performed usual care or CGA and multidisciplinary care for 382 older adult outpatients. Compared with the usual care group, the CGA group showed increased survival and reduced hospitalization rates at 2 and 3 years, without substantially increasing costs.3, 6 Furthermore, there was an increase of 0.54 quality-adjusted life years, and the incremental cost-effectiveness ratio was €46000.13 However, although such cost-effectiveness is considered reasonable in Sweden, the cost-effectiveness of CGA in Japan remains unclear. To summarize, the 14 high-quality reports retrieved in the systematic literature search, including 11 RCTs, showed that a CGA nursing (nursing department) approach for older adults improved mortality rate, ADL, QOL, and healthcare costs, but evidence of its impact on hospitalization/institutionalization rates was insufficient. Although the outcomes differed, two reports indicated that CGA effectiveness was positively correlated with increased frailty. Furthermore, studies with longer follow-up periods were more likely to demonstrate CGA effectiveness, suggesting that its benefits may be more apparent in the long-term prognosis of frail older adults. There were seven studies with potential bias concerns (worsening outcomes, 1; unchanged outcomes, 3; and improved outcomes, 3). In conclusion, CGA is effective in nursing (nursing department) older adults, and its implementation is recommended. Additionally, an assessment of the balance between benefits and harms showed that CGA was not harmful, and the likelihood of CGA increasing patient burden or resulting in functional impairment is considered low. However, there are no reports discussing qualitative concerns about the potential harms of CGA, including the impact on patients due to the burden placed on healthcare providers when performing CGA. Thus, there is insufficient evidence to evaluate the balance between the benefits and harms of CGA. The following factors were considered important in developing recommendations for this CQ: reduced inpatient, outpatient, and institutionalized patient mortality; reduced length of hospitalization; improved polypharmacy; and increased costs. Is CGA effective for the provision of care for older adults by care workers (e.g., care managers and certified care workers)? None. In this FRQ, the roles considered care work included care managers, certified care workers, registered care workers, and similar positions. There were five outcome items: mortality rate, ADL, QOL, hospitalization/institutionalization rate, and medical expenses. A systematic literature search did not yield any appropriate publications (Fig. S2). This was likely primarily due to the limited number of research reports in the caregiving field and differences in care systems across countries and regions. Moreover, there are no positions in other countries that are fully equivalent to the roles of care managers and certified care workers in Japan. The contents of the RCTs extracted up to the secondary screening stage are discussed below. In Japan, a multidisciplinary team of public health nurses, social workers, and care managers performed usual care or CGA and multidisciplinary care for 360 frail older adults who were capable of walking. Compared with the usual care group, ADL was restored after 1 year in the intervention group, although the difference was not statistically significant.14 Some countries have the profession of a case manager, and their role is similar to that of care managers in Japan. In Sweden, a multidisciplinary team of case managers and nurses performed usual care and CGA and multidisciplinary care for 161 community-dwelling older adults aged ≥80 years or frail older adults aged 65–79 years. Compared with the usual care group, ADL was improved in the CGA group at both the 3-month and 1-year follow-ups.8 In contrast, a study in the Netherlands where case managers performed usual care or CGA and multidisciplinary care for 1456 community-dwelling older adults did not report differences in QOL between the two groups.15 In some countries, municipal care managers or social workers may engage in roles similar to care managers in Japan. In Sweden, a multidisciplinary team including municipal care managers performed usual care or CGA and multidisciplinary care for 382 older adult outpatients. The hospitalization and mortality rates after 3 years were reduced in the CGA group compared with the usual care group, without increased medical costs.3 In Finland, a multidisciplinary team including social workers performed usual care or CGA and multidisciplinary care for 422 community-dwelling older adults. CGA reduced the decline in QOL after 2 years without increased medical costs.16 All of the abovementioned studies are small-scale and have risks of bias. Additionally, the systems of caregiving professions differ among countries. Therefore, we concluded that none of the identified literature was suitable for this FRQ, and the recommendation was deemed as “none.” Research advances in the caregiving field are expected, and these findings will be used to make recommendations for this FRQ in the future. Furthermore, CQ settings and search strategies need to be developed to accommodate the diverse caregiving systems across different countries and regions. Is the use of CGA effective for medication management in older adults? Although the quality of pharmacotherapy is expected to improve with the use of CGA for medication management in older adults, evidence supporting this expectation is insufficient. The systematic literature search only yielded one observational study (Fig. S3). Thus, evidence of the impact of CGA on medication management in older adults was limited. However, the identified study reported that CGA resulted in prescription optimization, and medication adherence remained relatively high (72% at 6 months, slightly declining to 65% at 12 months).17 Although the quality of evidence was low, CGA implementation may contribute to pharmacotherapy optimization in older adults. Medication management using CGA is crucial for optimizing pharmacotherapy and patient education and is expected to improve the quality of pharmacotherapy in older adults. However, the lack of studies in this area means that further research is necessary. Is the use of CGA by pharmacists effective for performing medication reviews in older adults? It is recommended that pharmacists use CGA to perform medication reviews in older adults. Strength of evidence: C. Degree of recommendation: 2 (weak) (agreement rate: 100%). In this CQ, there were four outcomes: risk of emergency hospitalization, cost, adherence, and drug-related issues. There was only one RCT extracted from the systematic literature search,18 and the results suggested that pharmacist interventions using CGA improved the appropriateness of pharmacotherapy in terms of increased rehospitalizations and adverse effects (Fig. S4). The extracted RCT18 targeted older adults aged ≥80 years in an emergency medical ward and compared 182 patients in the pharmacist intervention group with 186 patients in the nonintervention group. The intervention included the following: (1) medication adjustments upon admission and discharge, (2) medication review and identification of medication-related issues, (3) follow-up after medication changes, (4) patient education, (5) notification of primary care physicians regarding initial treatment plans, and (6) patient follow-up calls after discharge. The impact of these pharmacist interventions on pharmacotherapy appropriateness and clinical outcomes (rehospitalizations) was evaluated using the medication appropriateness index (MAI), screening tool of older persons' potentially inappropriate prescriptions (STOPP), and screening tool to alert doctors to the right treatment at both patient admission and discharge. The intervention group showed a higher proportion of improvements in MAI and STOPP and a lower proportion of deterioration compared with the nonintervention group. Concerning the association with medication-related rehospitalizations, the risk increased by 9% for each 1-point increase in the MAI score. Furthermore, each 1-point increase in STOPP increased the risk of rehospitalization by 34%. However, although higher MAI and STOPP scores at discharge were associated with an increased rate of medication-related rehospitalizations, the association with the total number of hospital revisits during the 12-month follow-up period was not statistically significant. This study also confirmed that pharmacist intervention improved prescription appropriateness, although details regarding undesirable effects and adverse events related to the interventions were unclear. Based on these findings, we recommend that pharmacists use CGA to perform medication reviews. The strength of the evidence is rated as “C,” and the overall assessment suggests that the proposal of this intervention is warranted. The following were considered important in developing recommendations for this CQ: improved MAI for older adults and reduced medication-related rehospitalizations and issues. Is CGA effective for the rehabilitation of older adults? CGA is recommended for the rehabilitation of older adults. Strength of evidence: B. Degree of recommendation: 2 (weak) (agreement rate: 80%). Rehabilitation for older adults requires the identification of age-specific diseases and disabilities and the provision of comprehensive treatment and care individually tailored to the patient's background. Two RCTs were extracted from the systematic literature search for the formulation of this statement (Fig. S5).19, 20 The target patients in both RCTs were older adults with hip fractures. Patients receiving team care based on CGA were compared with those receiving standard orthopedic treatment only. Neither of the studies showed differences in mortality rates between the two groups (Fig. 3). Prestmo et al. evaluated physical function using the short physical performance battery (SPPB), reporting that the group undergoing CGA-based rehabilitation showed significantly improved SPPB scores 12 months after discharge compared with the group receiving standard orthopedic treatment alone.19 In contrast, Stenvall et al. assessed physical function based on the degree of maintenance or improvement in walking ability at 12 months post-fracture compared with the pre-fracture status but did not observe any difference between the two groups.20 Similarly, Prestmo et al. reported improvements in ADL in the CGA group at the 12-month evaluation19 while Stenvall et al. found no difference between the groups (Fig. 4).20 In both studies, no differences in rehospitalization rates between the two groups were observed (Fig. 5). Only the study by Prestmo et al. investigated total costs. Their evaluation of 396 patients found no significant difference between the two groups.19 Although the outcomes varied between the two studies, this may be partly attributed to the use of different evaluation methods in each study. The target condition in the extracted literature was proximal femoral fractures. However, there are no studies on the effectiveness of CGA in rehabilitation for other conditions, and further research is expected in the future. The following factors were considered important in developing recommendations for this CQ: reduced mortality for older adults requiring rehabilitation, reduced hospitalization/rehospitalization rates, improved ADL/instrumental ADL, improved physical function, and increased costs/patient burden. Is CGA effective for ACP in older adults with comorbid malignancies or a history of malignancy? The effectiveness of CGA in conducting ACP for older adults with comorbidities or a history of malignancies has not been investigated, making it a topic worthy of future research. ACP is defined as the process whereby appropriate information and explanations are provided by healthcare professionals, such as physicians, in anticipation of end-of-life medical care and support. This enables the patient and their family to engage in detailed conversations with a multidisciplinary team of medical and care professionals, ultimately leading to the patient making informed decisions.21 Because the patient's preferences may change over time, it is imperative that they expresses their wishes whenever they feel the need and that discussions are repeated as necessary. There are no studies on the effectiveness of CGA for conducting ACP for older adults with comorbid malignant tumors or a history of malignant tumors (Fig. S6). An RCT performed in the United States involving 160 patients aged ≥75 years with hematologic malignancy who were ineligible for stem cell transplantation compared a group receiving consultations with a geriatrician and standard care with a group receiving standard care alone.22 The rate of documented end-of-life care preferences (a secondary outcome measure) was approximately three times higher in the intervention group (odds ratio: 3.12, 95% CI: 1.03–9.41) compared with the group receiving only standard care. Although it is not specifically stated that CGA was performed in this study, the results suggest that geriatrician intervention may be beneficial for implementing ACP in patients with malignancies. No studies have investigated the effectiveness of CGA in conducting ACP for older patients with comorbid malignancies or a history of malignancies. Thus, this is a topic for future research. We thank Eriko Koujiya (Osaka University), Tamio Okimoto (Shimane University), Kazuhisa Nakashima (Shimane University), and Hisako Miura (Tohoku University) for their contributions to this study. This manuscript represents the English translation of Chapter 3 of the Japanese Comprehensive Geriatric Assessment-based Healthcare Guidelines 2024 (https://www.jpn-geriat-soc.or.jp/publications/other/cga_guideline2024.html). YT received lecture fees from Astellas Pharma, Daiichi Sankyo, and Merck & Co. YT received research funding from Ono Pharmaceutical and Pfizer Health Research Foundation, as well as lecture fees from AstraZeneca, Bristol-Myers Squibb, Chugai Pharmaceutical, Daiichi Sankyo, Kyowa Kirin, Taiho Pharmaceutical, and Takeda. MA received research funding from Astellas Pharma, Bayer Yakuhin, Chugai Pharmaceutical Co., Daiichi Sankyo, Eisai, Merck & Co., Fukuda Lifetech, Mitsubishi-Tanabe Pharma, Ono Pharmaceutical, Takeda, and Tsumura as well as lecture fees from Daiichi Sankyo, Merck & Co., Toa Eiyo, and Towa Pharmaceutical. All other authors declare no conflict of interest. Figure S1. Process flow for the selection of literature sources for the Chapter 3 CQ III-1 systematic review. Figure S2. Process flow for the selection of literature sources for the Chapter 3 FRQ III-2 systematic review. Figure S3. Process flow for the selection of literature sources for the Chapter 3 FRQ III-3 systematic review. Figure S4. Process flow for the selection of literature sources for the Chapter 3 CQ III-3 systematic review. Figure S5. Process flow for the selection of literature sources for the Chapter 3 CQ III-4 systematic review. Figure S6. Process flow for the selection of literature sources for the Chapter 3 FRQ III-5 systematic review. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.