Systematic integrative review explores the enablers and challenges of conducting Comprehensive Geriatric Assessment in the community

RESEARCH HIGHLIGHT

As Singapore shifts to community care to support ageing-in-place, GERI researchers take a closer look at community-based Comprehensive Geriatric Assessment and provide recommendations for its implementation beyond the hospital setting.

As a person ages, their biological, psychological and social needs become more complex. If these needs are not assessed and identified, they may go unaddressed and thus, unmet. Enter: Comprehensive Geriatric Assessment (CGA), which differs from a typical medical evaluation. CGA is the holistic assessment of different aspects of older adults in order to develop personalised care plans for them. These aspects include their physical and mental health, ability to do daily activities or tasks, or functional ability, and whether their social needs are met.

Thus far, research has focused on the effects of CGA conducted in the hospital setting, CGA led by geriatricians, or CGA for older adults with specific health conditions, like frailty or cancer. To address these knowledge gaps, GERI researchers carried out a systematic integrative review on the effects of delivering CGA to community-dwelling older adults, including at their homes and in primary care.

Published in BMC Geriatrics, this study is the first of its kind to narratively synthesise evidence on health outcomes from quantitative research and the barriers and facilitators from qualitative research on conducting CGA for community-dwelling older adults.

"By 2026, Singapore will become 'super-aged'. The population's demand for hospital and long-term care will grow. Shifting to community-based interventions can form part of a sustainable path forward to help older adults age-in-place," said Dr Tan Woan Shin, Joint Faculty, GERI and Deputy Director, Health Services & Outcomes Research at the National Healthcare Group. Dr Tan is the Principal Investigator and senior author of the study.

For their study approach, the researchers chose to depart from the conventional systematic review. "Instead of examining either quantitative or qualitative findings in a single systematic review, we conducted a systematic integrative review to analyse both types of results. This allowed us to paint a fuller picture of the effects of community-based CGA and the challenges and enablers of conducting it," said Dr Grace Sum, Research Fellow, GERI and lead author of the study.

The research team searched medical and social sciences online databases across two decades. The search strategy involved using keywords and Medical Subject Headings. Precise inclusion and exclusion criteria were applied to select the records. Data extraction and quality evaluation of the included articles were conducted.

Health outcomes that were examined included functional ability, frailty and falls, mental health, cognition, nutrition, chronic condition management, self-rated health, and quality of life. The team analysed qualitative findings by developing themes inductively and linking similar concepts across studies. After screening the titles and abstracts of 14,151 articles and reviewing 203 full text articles, the team included 43 articles for analysis.

Findings on the effects of community-based CGA on health outcomes were mixed. Some studies showed that CGA had positive effects, while others reported no effects on health outcomes. "Inconsistent findings could be due to differences in study designs, health and social care domains that were assessed, assessment tools used, and the health status of the participants in the study," explained Dr Sum.

"Importantly, what makes CGA effective are the actions that come after it, including the development of a personalised care plan for older persons and linkage to health and social care services that target their specific needs," added Dr Sum.

Barriers to implementation included the lack of partnership among various healthcare providers and the lack of buy-in from older adults on the value of preventive care. On the other hand, patients appreciated the convenience of receiving CGA at home whilst healthcare staff felt that community-based CGA improved care coordination and provided patient education. These perceived benefits could facilitate the implementation of CGA in the community.

On the direction that future research could take, Dr Tan commented, "Current results from the wider literature do not yet inform us on which approach is more cost-efficient to conduct community-based CGA and which groups of older adults are likely to reap more benefits. Given that CGA is an investment on the part of all providers involved, as it is time-consuming and resource-intensive, more research is needed on these areas."

The team also outlined several recommendations for policymakers and practitioners on implementing CGA in the community.

"While different stakeholders have a common goal of delivering better care to older persons, successful collaboration could still be challenging. Thus, clear operating procedures and delegation of roles are recommended to facilitate the forging of partnerships and minimise duplication of work and miscommunication," shared Dr Sum.

"Regardless of age, we all strive for and value independence. Healthcare professionals could improve older adults' acceptance of CGA by focusing on the value of prevention in supporting them to maintain their level of independence and sense of self-worth," added Dr Tan.

The full study can be accessed here.

Reference:  Sum, G.; Nicholas, S.O.; Nai, Z.L.; Ding Y.Y.; Tan W.S. "Health outcomes and implementation barriers and facilitators of comprehensive geriatric assessment in community settings: a systematic integrative review." [PROSPERO registration no.: CRD42021229953]. BMC Geriatr 22, 379 (2022).