Comprehensive geriatric assessment for older people admitted to a surgical service

Gilgamesh Eamer, Amir Taheri, Sidian S Chen, Quinn Daviduck, Thane Chambers, Xinzhe Shi, Rachel G Khadaroo, Gilgamesh Eamer, Amir Taheri, Sidian S Chen, Quinn Daviduck, Thane Chambers, Xinzhe Shi, Rachel G Khadaroo

Abstract

Background: Aging populations are at increased risk of postoperative complications. New methods to provide care for older people recovering from surgery may reduce surgery-related complications. Comprehensive geriatric assessment (CGA) has been shown to improve some outcomes for medical patients, such as enabling them to continue living at home, and has been proposed to have positive impacts for surgical patients. CGA is a coordinated, multidisciplinary collaboration that assesses the medical, psychosocial and functional capabilities and limitations of an older person, with the goal of establishing a treatment plan and long-term follow-up.

Objectives: To assess the effectiveness of CGA interventions compared to standard care on the postoperative outcomes of older people admitted to hospital for surgical care.

Search methods: We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and two clinical trials registers on 13 January 2017. We also searched grey literature for additional citations.

Selection criteria: Randomized trials of people undergoing surgery aged 65 years and over comparing CGA with usual surgical care and reporting any of our primary (mortality and discharge to an increased level of care) or secondary (length of stay, re-admission, total cost and postoperative complication) outcomes. We excluded studies if the participants did not receive a complete CGA, did not undergo surgery, and if the study recruited participants aged less than 65 years or from a setting other than an acute care hospital.

Data collection and analysis: Two review authors independently screened, assessed risk of bias, extracted data and assessed certainty of evidence from identified articles. We expressed dichotomous treatment effects as risk ratio (RR) with 95% confidence intervals and continuous outcomes as mean difference (MD).

Main results: We included eight randomised trials, seven recruited people recovering from a hip fracture (N = 1583) and one elective surgical oncology trial (N = 260), conducted in North America and Europe. For two trials CGA was done pre-operatively and postoperatively for the remaining. Six trials had adequate randomization, five had low risk of performance bias and four had low risk of detection bias. Blinding of participants was not possible. All eight trials had low attrition rates and seven reported all expected outcomes.CGA probably reduces mortality in older people with hip fracture (RR 0.85, 95% CI 0.68 to 1.05; 5 trials, 1316 participants, I² = 0%; moderate-certainty evidence). The intervention reduces discharge to an increased level of care (RR 0.71, 95% CI 0.55 to 0.92; 5 trials, 941 participants, I² = 0%; high-certainty evidence).Length of stay was highly heterogeneous, with mean difference between participants allocated to the intervention and the control groups ranging between -12.8 and 8.3 days. CGA probably leads to slightly reduced length of stay (4 trials, 841 participants, moderate-certainty evidence). The intervention probably makes little or no difference in re-admission rates (RR 1.00, 95% CI 0.76 to 1.32; 3 trials, 741 participants, I² = 37%; moderate-certainty evidence).CGA probably slightly reduces total cost (1 trial, 397 participants, moderate-certainty evidence). The intervention may make little or no difference for major postoperative complications (2 trials, 579 participants, low-certainty evidence) and delirium rates (RR 0.75, 95% CI 0.60 to 0.94, 3 trials, 705 participants, I² = 0%; low-certainty evidence).

Authors' conclusions: There is evidence that CGA can improve outcomes in people with hip fracture. There are not enough studies to determine when CGA is most effective in relation to surgical intervention or if CGA is effective in surgical patients presenting with conditions other than hip fracture.

Conflict of interest statement

Gilgamesh Eamer: none known.

Amir Taheri: none known.

Sidian S Chen: none known.

Quinn Daviduck: none known.

Thane Chambers: none known.

Xinzhe Shi: none known.

Rachel G Khadaroo: none known.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

References

References to studies included in this review Hempenius 2013 {published data only}

    1. Hempenius L, Slaets JP, Asselt D, Bock TH, Wiggers T, Leeuwen BL. Long term outcomes of a geriatric liaison intervention in frail elderly cancer patients. PloS One 2016;11(2):e0143364.
    1. Hempenius L, Slaets PJ, Asselt D, Bock GH, Wiggers T, Leeuwen BL. Outcomes of a geriatric liaison intervention to prevent the development of postoperative delirium in frail elderly cancer patients: Report on a multicentre, randomized, controlled trial. PloS One 2013;8(6):e64834. [DOI: 10.1371/journal.pone.0064834]
Hempsall 1990 {published data only}
    1. Hempsall VJ, Robertson DR, Campbell MJ, Briggs RS. Orthopaedic geriatric care ‐ is it effective? A prospective population‐based comparison of outcome in fractured neck of femur. Journal of the Royal College of Physicians of London 1990;24(1):47‐50.
Kennie 1988 {published data only}
    1. Kennie DC, Reid J, Richardson IR, Kiamari AA, Kelt C. Effectiveness of geriatric rehabilitative care after fractures of the proximal femur in elderly women: A randomised clinical trial. BMJ 1988;297(6656):1083‐6.
Marcantonio 2001 {published data only (unpublished sought but not used)}
    1. Marcantonio ER. Systematic review data request [personal communication]. Email to: ER Marcantonio 16 March 2016.
    1. Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: A randomized trial. Journal of the American Geriatrics Society 2001;49(5):516‐22.
Naglie 2002 {published data only}
    1. Naglie G, Tansey C, Kirkland JL, Ogilvie‐Harris DJ, Detsky AS, Etchells E, et al. Interdisciplinary inpatient care for elderly people with hip fracture: A randomized controlled trial. CMAJ : Canadian Medical Association Journal 2002;167(1):25‐32.
Prestmo 2015 {published data only}
    1. Prestmo A, Hagen G, Sletvold O, Helbostad JL, Thingstad P, Taraldsen K, et al. Comprehensive geriatric care for patients with hip fractures: A prospective, randomised, controlled trial. Lancet 2015;385(9978):1623‐33.
    1. Taraldsen K, Thingstad P, Sletvold O, Saltvedt I, Lydersen S, Granat MH, et al. The long‐term effect of being treated in a geriatric ward compared to an orthopaedic ward on six measures of free‐living physical behavior 4 and 12 months after a hip fracture ‐ a randomised controlled trial. BMC Geriatrics 2015;15:160‐7. [DOI: 10.1186/s12877-015-0153-6]
Stenvall 2007 {published data only}
    1. Stenvall M, Berggren M, Lundström M, Gustafson Y, Olofsson B. A multidisciplinary intervention program improved the outcome after hip fracture for people with dementia‐‐subgroup analyses of a randomized controlled trial. Archives of Gerontology and Geriatrics 2012;54(3):e284‐9.
    1. Stenvall M, Olofsson B, Nyberg L, Lundström M, Gustafson Y. Improved performance in activities of daily living and mobility after a multidisciplinary postoperative rehabilitation in older people with femoral neck fracture: A randomized controlled trial with 1‐year follow‐up. Journal of Rehabilitation Medicine 2007;39(3):232‐8. [DOI: 10.2340/16501977-0045]
Vidán 2005 {published data only}
    1. Vidán M, Serra JA, Moreno C, Riquelme G, Ortiz J. Efficacy of a comprehensive geriatric intervention in older patients hospitalized for hip fracture: A randomized, controlled trial. Journal of the American Geriatrics Society 2005;53(9):1476‐82. [DOI: 10.1111/j.1532-5415.2005.53466.x]
References to studies excluded from this review Albrand 2011 {published data only}
    1. Albrand G. Oncogeriatric support for breast cancer. Cahiers de l'Annee Gerontologique 2011;3:26‐32.
Applegate 1990 {published data only}
    1. Applegate WB, Miller ST, Graney MJ, Elam JT, Burns R, Akins DE. A randomized, controlled trial of a geriatric assessment unit in a community rehabilitation hospital. New England Journal of Medicine 1990;322(22):1572‐8. [DOI: 10.1056/nejm199005313222205]
Bai 2003 {published data only}
    1. Bai B, Wang KZ, Liu WK, Song JH, Chen JC. Comprehensive treatment for old patients with hip fractures. Zhonghua Chuang Shang za Zhi [Chinese Journal of Traumatology] 2003;6(5):297‐301.
Barber 2012 {published data only}
    1. Barber J, Fox J, Doran H. The impact of a geriatrician on surgical wards. Age and Ageing 2012;41(Suppl 1):ii32. [DOI: 10.1093/ageing/afs112]
Björkelund 2010 {published data only}
    1. Björkelund KB, Hommel A, Thorngren KG, Gustafson L, Larsson S, Lundberg D. Reducing delirium in elderly patients with hip fracture: a multi‐factorial intervention study. Acta Anaesthesiologica Scandinavica 2010;54(6):678‐88. [DOI: 10.1111/j.1399-6576.2010.02232.x]
Day 2001 {published data only}
    1. Day GA, Swanson C, Yelland C, Broome J, Dimitri K, Massey L, et al. Surgical outcomes of a randomized prospective trial involving patients with a proximal femoral fracture. Australian and New Zealand Journal of Surgery 2001;71(1):11‐4. [DOI: 10.1046/j.1440-1622.2001.02019.x]
Fisher 2006 {published data only}
    1. Fisher AA, Davis MW, Rubenach SE, Sivakumaran S, Smith PN, Budge MM. Outcomes for older patients with hip fractures: The impact of orthopedic and geriatric medicine cocare. Journal of Orthopaedic Trauma 2006;20(3):172‐8.
Fukuse 2005 {published data only}
    1. Fukuse T, Satoda N, Hijiya K, Fujinaga T. Importance of a comprehensive geriatric assessment in prediction of complications following thoracic surgery in elderly patients. Chest 2005;127(3):886‐91.
Galvard 1995 {published data only}
    1. Galvard H, Samuelsson SM. Orthopedic or geriatric rehabilitation of hip fracture patients: A prospective, randomized, clinically controlled study in Malmo, Sweden. Aging‐Clinical and Experimental Research 1995;7(1):11‐6.
Ho 2009 {published data only}
    1. Ho WW, Kwan Dai DL, Liu KW, Chow KM, Lau E, Woo J, et al. To investigate the effect and cost‐effectiveness of implementing an orthogeriatric intervention for elderly patients with acute hip fracture: the experience in Hong Kong. Journal of the American Geriatrics Society 2009;57(11):2153‐4. [DOI: 10.1111/j.1532-5415.2009.02529.x]
Huddleston 2004 {published data only}
    1. Huddleston JM, Long KH, Naessens JM, Vanness D, Larson D, Trousdale R, et al. Medical and surgical comanagement after elective hip and knee arthroplasty: A randomized, controlled trial. Annals of Internal Medicine 2004;141(1):28‐38.
Huusko 2002 {published data only}
    1. Huusko TM, Karppi P, Avikainen V, Kautiainen H, Sulkava R. Intensive geriatric rehabilitation of hip fracture patients: a randomized, controlled trial. Acta Orthopaedica Scandinavica 2002;73(4):425‐31. [DOI: 10.1080/00016470216324]
Kimura 2013 {published data only}
    1. Kimura S, Lynch S, Lui DF, Butler A, Ramotshabi K, Hsu M, et al. Orthogeriatric involvement in the management of hip fracture improves functional outcome post operatively: Comprehesive Orthogeriatric Assessment Services for Trauma (COAST) trial. Irish Journal of Medical Science 2013;182:S59. [DOI: 10.1007/s11845-013-0908-z]
Leung 2010 {published data only}
    1. Leung A, Fong C, Mac KC, Ting C, Franklyn K, Gudjuhar A. Utility of an ortho‐geriatric service: Hip fracture patient outcomes across three Melbourne metropolitan hospitals. Internal Medicine Journal 2010;40(Suppl 1):131. [DOI: 10.1111/j.1445-5994.2010.02187.x]
Lundström 2007 {published data only}
    1. Lundström M, Olofsson B, Stenvall M, Karlsson S, Nyberg L, Englund U, et al. Postoperative delirium in old patients with femoral neck fracture: A randomized intervention study. Aging Clinical and Experimental Research 2007;19(3):178‐86.
Miura 2009 {published data only}
    1. Miura LN, Dipiero AR, Homer LD. Effects of a geriatrician‐led hip fracture program: Improvements in clinical and economic outcomes. Journal of the American Geriatrics Society 2009;57(1):159‐67. [DOI: 10.1111/j.1532-5415.2008.02069.x]
Mouchoux 2010 {published data only}
    1. Mouchoux C, Duclos A, Krolak‐Salmon P, Rippert P. Methodology for assessing the impact of a multidisciplinary prevention program to prevent postoperative delirium in the elderly. European Geriatric Medicine 2010;1:S63‐4. [DOI: 10.1016/j.eurger.2010.07.008]
Reid 1989 {published data only}
    1. Reid J, Kennie DC. Geriatric rehabilitative care after fractures of the proximal femur: one year follow up of a randomised clinical trial. BMJ 1989;299(6690):25‐6.
Schnell 2010a {published data only}
    1. Schnell S, Friedman SM, Mendelson DA, Bingham KW, Kates SL. The 1‐year mortality of patients treated in a hip fracture program for elders. Geriatric Orthopaedic Surgery & Rehabilitation 2010;1(1):6‐14. [DOI: 10.1177/2151458510378105]
Tackett 2014 {published data only}
    1. Tackett JJ, Rosenthal RA. Proactive delirium management in geriatric surgical patients may increase ability to return patients home from the hospital. Journal of the American College of Surgeons 2014;219(Suppl):e104.
Taraldsen 2014 {published data only}
    1. Taraldsen K, Sletvold O, Thingstad P, Saltvedt I, Granat MH, Lydersen S, et al. Physical behavior and function early after hip fracture surgery in patients receiving comprehensive geriatric care or orthopedic care: A randomized controlled trial. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences 2014;69(3):338‐45. [DOI: 10.1093/gerona/glt097]
Watne 2014 {published data only}
    1. Watne LO, Torbergsen AC, Conroy S, Engedal K, Frihagen F, Hjorthaug GA, et al. The effect of a pre‐ and postoperative orthogeriatric service on cognitive function in patients with hip fracture: Randomized controlled trial (Oslo Orthogeriatric Trial). BMC Medicine 2014;12(1):63. [DOI: 10.1186/1741-7015-12-63]
References to ongoing studies Baroni 2016 {published data only}
    1. Baroni M, Pioli G, Boccardi V, Prenni V, Zengarini E, Conestabile della Staffa M, et al. The orthogeriatric management: An inseparable duo to foster appropriate care. Osteoporosis International 2016;1:S379. [DOI: 10.1007/s00198-016-3530-x]
Brugel 2014 {published data only}
    1. Brugel L, Laurent M, Caillet P, Radenne A, Durand‐Zaleski I, Martin M, et al. Impact of comprehensive geriatric assessment on survival, function, and nutritional status in elderly patients with head and neck cancer: Protocol for a multicentre randomised controlled trial (EGeSOR). BMC Cancer 2014;14(1):427. [DOI: 10.1186/1471-2407-14-427]
Additional references Bettelli 2011
    1. Bettelli G. Preoperative evaluation in geriatric surgery: comorbidity, functional status and pharmacological history. Minerva Anestesiologica 2011;77(6):637‐46. [PUBMED: 21617627]
Buecking 2013
    1. Buecking B, Timmesfeld N, Riem S, Bliemel C, Hartwig E, Friess T, et al. Early orthogeriatric treatment of trauma in the elderly: A systematic review and metaanalysis. Deutsches Arzteblatt International 2013;110(15):255‐62.
Covidence [Computer program]
    1. Veritas Health Innovation. Covidence. Melbourne, Australia: Veritas Health Innovation, accessed 15 May 2016.
Deschodt 2013
    1. Deschodt M, Flamaing J, Haentjens P, Boonen S, Milisen K. Impact of geriatric consultation teams on clinical outcome in acute hospitals: a systematic review and meta‐analysis. BMC Medicine 2013;11:48‐60. [DOI: 10.1186/1741-7015-11-48]
Eamer 2017b
    1. Eamer G, Saravana‐Bawan B, Westhuizen B, Chambers T, Ohinmaa A, Khadaroo RG. Economic evaluations of comprehensive geriatric assessment in surgical patients: A systematic review. Journal of Surgical Research 2017;218:9‐17. [DOI: 10.1016/j.jss.2017.03.041]
Ellis 2017
    1. Ellis G, Gardner M, Tsiachristas A, Langhorne P, Burke O, Harwood RH, et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database of Systematic Reviews 2017, Issue 9. [DOI: 10.1002/14651858.CD006211.pub3]
EPOC 2017a
    1. Effective Practice, Organisation of Care (EPOC). Screening, data extraction and management. Resources for review authors, 2017. Available at: .
EPOC 2017b
    1. Effective Practice, Organisation of Care (EPOC). Suggested risk of bias criteria for EPOC reviews. Resources for review authors, 2017. Available at: .
EPOC 2017c
    1. Cochrane Effective Practice and Organisation of Care (EPOC). EPOC worksheets for preparing a Summary of Findings (SoF) table using GRADE. EPOC Resources for review authors, 2017. Available at: .
Etzioni 2003
    1. Etzioni DA, Liu JH, Maggard MA, Ko CY. The aging population and its impact on the surgery workforce. Annals of Surgery 2003;238(2):170‐7.
Etzioni 2011
    1. Etzioni DA. Quality of care in surgery: the health services research perspective. Surgery 2011;150(5):881‐6.
Frondini 2010
    1. Frondini C, Munardelli M. Comprehensive care of elderly patients with hip fracture: The orthogeriatric model [Ortogeriatria: un nuovo modello di assistenza ai pazienti anziani con frattura di femore e comorbilita]. Italian journal of medicine 2010;4:105‐110.
Geriatric Review Syllabus 2006
    1. Beck JB, American Geriatrics Society. Geriatric Review Syllabus: A Core Curriculum in Geriatric Medicine. 6th Edition. New York, NY: American Geriatrics Society, 2006.
GRADEpro GDT 2015 [Computer program]
    1. McMaster University (developed by Evidence Prime). GRADEpro GDT. Version accessed 15 May 2016. Hamilton (ON): McMaster University (developed by Evidence Prime), 2015.
Grigoryan 2014
    1. Grigoryan KV, Javedan H, Rudolph JL. Ortho‐geriatric care models and outcomes in hip fracture patients: a systematic review and meta‐analysis. Journal of Orthopaedic Trauma 2014;28(3):49‐55.
Guyatt 2008
    1. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck‐Ytter Y, Alonso‐Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ (Clinical research ed.) 2008;336(7650):924‐6.
Higgins 2011
    1. Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from .
Kammerlander 2010
    1. Kammerlander C, Roth T, Friedman SM, Suhm N, Luger TJ, Kammerlander‐Knauer U, et al. Ortho‐geriatric service ‐ a literature review comparing different models. Osteoporosis International 2010;21(Suppl 4):S637‐46.
Lidsky 2012
    1. Lidsky ME, Thacker JK, Lagoo‐Deenadayalan SA, Scarborough JE. Advanced age is an independent predictor for increased morbidity and mortality after emergent surgery for diverticulitis. Surgery 2012;152(3):465‐72.
Rao 1992
    1. Rao JNK, Scott AJ. A simple method for the analysis of clustered binary data. Biometrics 1992;48(2):577‐85.
Review Manager 2014 [Computer program]
    1. Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan 5). Version 5.3. Copenhagen: Nordic Cochrane Centre, The Cochrane Collaboration, 2014.
Rubenstein 1989
    1. Rubenstein L, Wieland D. Comprehensive geriatric assessment. Annual Review of Gerontology and Geriatrics 1989;9:145‐92.
Rubenstein 1991
    1. Rubenstein LZ, Stuck AE, Siu AL, Wieland D. Impact of geriatric evaluation and management programs on defined outcomes: overview of the evidence. Journal of the American Geriatrics Society 1991;39(9 Pt 2):8S‐16S.
Sabharwal 2015
    1. Sabharwal S, Wilson H. Orthogeriatrics in the management of frail older patients with a fragility fracture. Osteoporosis International 2015;26(10):2387‐99.
Turrentine 2006
    1. Turrentine FE, Wang H, Simpson VB, Jones RS. Surgical risk factors, morbidity, and mortality in elderly patients. Journal of the American College of Surgeons 2006;203(6):865‐77.
References to other published versions of this review Eamer 2017a
    1. Eamer G, Taheri A, Chen SS, Daviduck Q, Chambers T, Shi X, et al. Comprehensive geriatric assessment for improving outcomes in elderly patients admitted to a surgical service. Cochrane Database of Systematic Reviews 2017, Issue 1. [DOI: 10.1002/14651858.CD012485]

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe