CGA

Introduction

Comprehensive Geriatric Assessment (CGA) is widely used in the management and assessment of older people living with frailty, however optimal ways of delivering CGA are not well understood. Gait and balance impairments, common in those living with frailty, are assessed in CGA. Advancements in digital technology provide opportunities to improve patient outcomes by digital monitoring, rather than observation-based assessments - which may be less accurate. As part of the Digital and Remote Enhancements for the Assessment and Management of older people living with frailty (DREAM) study, the aim of this review was to identify devices to assess gait and balance remotely, to enhance CGA

Methods

Searches were conducted across six databases. Papers published since 2008 were included if: participants were over 65; evaluated gait or balance using wearable technology suitable for community use; presented data on validity, reliability, or acceptability of the device.

Results

Of 6,203 papers identified, 48 papers were included evaluating 49 devices. 35 evaluations assessed gait, 7 assessed balance, and 7 assessed gait and balance. The most common modality was a single sensor (n= 30) on a participants’ back (n=22). Seven studies assessed more than one aspect of validity, but the majority examined criterion validity (n=35) and reliability (n=12). Good-excellent agreement between the wearable and a comparable method of analysing gait/balance was found in 15 studies.  Devices could distinguish between healthy populations and those with Parkinson’s disease (n=8), cognitive impairment (n=4), falls (n=4), mobility disability (n=3) and frailty (n=3).

Conclusion

Wearable technologies offer accurate and reliable assessment of gait and balance that could be used to enhance CGA. These tools could be applied remotely in domiciliary settings, freeing up healthcare professionals to focus on other components of CGA, such as ensuring the delivery of interventions to address identified gait and balance impairment. 

Introduction
The Assessment and Rehabilitation Centre (ARC) in Edinburgh sees around 600 new patients a year who are beginning to demonstrate signs of frailty, principally around mobility and balance. When taking a comprehensive geriatric assessment, we commonly identify concerns around cognition. We noted in some cases people were already waiting to be seen by the Memory Clinic Services, the current wait for which is approximately 10 months. We decided to see what ARC could do to help.
Method
From within existing resources, alongside the Psychiatry of Older Age (POA) Team, the ARC multi-disciplinary team coproduced a pathway that involved an initial assessment comprising identification of potentially cognitively frail patients, taking a corroborative history, performing cognitive and imaging investigations. Each step was added to a shared spreadsheet enabling us to chart progress of diagnostic information steps.
Then once assessment complete, a POA colleague reviewed the evidence and made a diagnosis with treatment recommendations.  The ARC team then discusses the outcome with the patient and their family, arranges a medication tolerance follow-up in ARC, then refers onward for ongoing community support.
Results
Between March 2023 and 2024, 52 patients completed the Memory MDT process, 34 (65%) of which were diagnosed with a dementia, 20 (33%) of which were started on dementia medication. 16 were removed from the Memory service waiting list (2.5%) and a further 18 avoided the need to be referred.
Conclusion
We identified a group of patients with a common underlying pathology that had resulted in them being referred to multiple specialities.  By arranging our services around this vulnerable patient group rather than the other way around, we reduced their need for multiple hospital attendances and freed up resource in the memory service. Work is underway to spread and scale up.

Introduction:

It is very often observed in clinical practice that older patients with frailty stay in the A&E for long periods under the Therapy Assisted Discharge Service (TADS) team without an appropriate referral to the medical/Frailty team. There are many potential risks identified such as missed opportunity for early geriatrician/frailty input, incomplete clinical assessment, missed opportunity for CGA, critical medications omitted, missed VTE assessment, and delay in receiving care.

Methodology:

A retrospective study of 50 patients was conducted through EPR notes at East Kent Hospitals University NHS Foundation Trust.  We collected data from the A&E list daily for patients >75 years old with Rockwood scores 5 or more, who have been in A&E for >12 hours under TADS/A&E without referral to any specialty. We also looked for referrals to the medical/Frailty team, Comprehensive Geriatric assessment (CGA), regular medicine prescription, advanced care plan, successful discharge, and percentage of patients readmitted in 7 days. Following the first cycle, awareness was raised through meeting with the TADS team, educating front-door doctors to refer patients to the Frailty/Medical team within <12 hours who met the inclusion criteria. 

Results:

After interventions, we demonstrated an improved result compared to the initial cycle. We achieved patient referral to Medics/ Frailty from 45 to 59% within 12 hours, Comprehensive Geriatric assessment (CGA) done 15% to 45%, medications charted within 12 hours 50% to 75%, advanced care plan 45 to 64%, successful discharge 38% to 60%. Interestingly, there was a significantly reduced percentage of patients re-admitted within 7 days which is 30% to 10%.

Conclusion:

It is unsafe to admit older patients with frailty under the A&E/TADS for more than 12 hours without any referrals to the medical or Frailty team because of many potential risks. Following a limited awareness campaign, we witnessed some improvement in some of the standards. However, there are still areas of potential improvement. To attain 100% compliance with the first recommendations of this QIP, a re-audit with increased awareness and actions is planned in a few months.

Reference:

https://www.england.nhs.uk/urgent-emergency-care/same-day-emergency-care/acute-frailty/

In 2022 we had a unique opportunity to develop a Geriatric service in Totnes Community Hospital after a long-standing GP led service provision ended. Given the fact that the majority of patients in the Community Hospitals were over the age of 65 and many had multiple co-morbidities or presented with a frailty syndrome, it was felt that the Geriatric department was the most suitable specialty to take over the service provision. Method Over a period of 12 months, we have gradually introduced key aspects from the Comprehensive Geriatric Assessment (CGA) to the care of our patients. Every new patient had a CGA on admission, completed by the clerking doctor with support from the MDT. We have concentrated on identifying and managing falls risk, bowel and bladder care, bone protection assessment and reviewing inappropriate polypharmacy. Through collaboration with our community pharmacist and nursing staff we have introduced additional medication administration services to include intravenous bisphosphonates, monofer infusions, medical hyperkalaemia management and intravenous electrolyte replacements. For our frailer patients we looked at prioritising care in the community, and closer to their home and family. Where appropriate and safe, we kept the patients in the community hospital for both acute illness and end-of-life care, instead of re-admitting them back to the acute hospital. Conclusion Over the year we have trained, upskilled and supported our nursing staff in managing and treating more acutely unwell and complex patients, so that we can provide more comprehensive and holistic care to our frailer patients in a community setting. We have prevented numerous re-admissions back to the acute hospital by being able to provide increased level of medical care. This was particularly important for the many patients with advanced dementia and delirium. The current model of care is still ongoing and continuing to develop.

Introduction

Older people living with frailty are core users of health and social care. Services attuned to the needs of people with frailty afford better outcomes, help avoid harm and improve the experience for people and those who care for them. Such services can also help with flow and capacity. The Glasgow Royal Infirmary (GRI) Team aimed to advance services in order to enhance the quality and provision of care for older people with frailty.

Methods

As part of the Health Improvement Scotland Focus on Frailty Programme, the GRI Team developed processes for early identification of people living with frailty, using an electronic Frailty Assessment Tool. Processes were designed to streamline patients with frailty to specialist areas of care in order to initiate early Comprehensive Geriatric Assessment (CGA). A Frailty Assessment Proforma was created to swiftly identify the priorities, concerns and goals of patients and carers and to gather key collateral information promptly. Daily CGA Huddles were commenced which include participants from various different health and social care services. Work is now being done towards the development of a dedicated Frailty Assessment Area and a trial of Rapid Access appointments at the Assessment and Rehabilitation Centres is being undertaken.

Results

There has been an improvement in frailty identification. 79% patients over the age of 75 years, who are admitted through the Acute Medical Receiving Unit, are being screened for frailty. There has been improvement noted in terms of access and time to a specialty bed. Further, there has been a reduction in length of stay for people with frailty, coupled with a reduction in readmissions at 7 and 30 days.

Conclusion

Frailty attuned acute services help patients receive timely, specialist care. They help reduce time spent in hospital and readmissions which, in turn, can contribute to improved flow and capacity.

There is a 35-week waiting time to be seen in a gastroenterology clinic for investigations such as UGI endoscopy and colonoscopy for a condition such as low Hb, weight loss, dysphagia and so on. Most of the time without adequate initial workup and ruling out iron-deficient anaemia and differentials as per the British Gastroenterology Society. The hospital is witnessing an exponential influx of patients, reflecting in long waiting times to accommodate clinic patients.

The current established low Hb referral pathway via GP to gastroenterologists does not consider the co-morbidities and frailty. Hence the main aim of the pilot project is to create parameters and filter patients who are 75 and above with co-morbidities and 85 and above, who would benefit from a comprehensive review, whose outcome might involve invasive gastroenterology investigation. The patients will be able to address their GI problems and other concerns where a Geriatrician will provide the expertise in a personalised care plan.  The Gastroenterology triaging secretaries will filter the suitable patients based on established parameters following referred to an Elderly Care consultant in comprehensive assessment clinics. In the clinic, the patient will have a thorough workup for causes of low Hb or GI causes, assess the level of frailty, and discuss with the patient if they want to go for invasive investigations or manage their condition conservatively. The project will provide holistic, patient-centred care and prevent delays in care plans.

Furthermore, help conserve endoscopy resources where the patient chooses not to have further invasive procedures—resulting in overall patient satisfaction.

Background and Objectives: Polypharmacy is common in frail older adults who often live with multiple co-morbidities. This polypharmacy can carry a significant anticholinergic burden. Frail older adults are particularly sensitive to the anticholinergic side effects of medications which can include constipation, urinary retention and dry mouth. Medications with a high anticholinergic burden scores have also been evidenced to contribute to an increased frequency of falls, cognitive decline and increased mortality. For frail older adults, a medication review, considering anticholinergic burden, is therefore an essential part of Comprehensive Geriatric Assessment. A local frailty census was completed for all medical inpatients over the age of 65 years old and as part of this anticholinergic burden scores were collated.

Materials and Methods: As part of this whole hospital frailty census, an anticholinergic burden score (ACB) was calculated for 77 inpatients. This was calculated using the Anticholinergic Cognitive Burden Scales and Anticholinergic Burden scores.

Results: The average age of the patients was 80.19 (± 9.35). 80.01% of patients were taking one or more medications with an anticholinergic burden. Of those, 40.25% had a significant ACB score of 3 or more (3-8). The patients with the highest ACB scores were those with multi-morbidity, an already established diagnosis of dementia and patients with recurrent falls.

Conclusions: The ACB score for patients included within this frailty census appeared to correlate with certain co-morbidities as would be expected from the known complications associated with these medications in frail older adults. The proportion of our inpatients with a significant ACB score informs us that we need to develop a more robust approach to delivering polypharmacy reviews as part of Comprehensive Geriatric Assessment within our hospital and will help us to inform future service planning and delivery.

Introduction

Information-sharing between primary and secondary care is vital for patient safety and reducing duplication. The Electronic Discharge Summary (EDS) enables this but is often incomplete due to time pressures and poor team continuity. Information from the Comprehensive Geriatric Assessment (CGA) by the Perioperative care of Older People undergoing Surgery (POPS) team is often omitted, leading to queries from primary care colleagues and duplication of work on readmission to hospital.

Methods

Eight core CGA components were determined for inclusion in the EDS. Twenty EDS were reviewed to for each PDSA cycle to assess compliance. Various strategies were trialled to increase compliance including junior doctor education (attendance at induction plus separate teaching), a checklist poster, the POPS team directly entering information into the EDS and a separate CGA summary.

Results

Baseline data demonstrated poor compliance with core CGA components (mean 25%, range 0-62.5%). PDSA 1 demonstrated improvement after junior doctor education and introduction of a checklist poster (mean 35%, range 12.5-87.5%). Mean compliance increased to 53% during PDSA 2 with the POPS team directly entering information into the EDS, but with continued wide variation (range 12.5 – 100%). The introduction of a POPS CGA summary to complement the EDS in PDSA 3 increased compliance with reduced variation in practice (mean 99%, range 87.5-100%).

Conclusions

Sharing information gleaned from a CGA was marginally improved with education, but is challenging due to the rotational nature of staff completing the EDS. The improvement seen with the POPS team entering EDS information was limited by the lack of 7-day working and the ‘locking’ of the completed EDS by the parent team. A separate CGA summary markedly improves information-sharing, with reduced variation in practice. This has benefitted primary and secondary care colleagues, as well as the POPS team when patients are readmitted or attend clinic.

Introduction: In the cancer setting, Comprehensive Geriatric Assessment (CGA) reduces chemotherapy toxicity, improves QOL and increases advance directive completion (ASCO 2020: The Geriatric Assessment Comes of Age; Soto-Perez-de-Celis et al; The Oncologist). We wanted to look at whether CGA improved symptomatology, as patients attending our oncogeriatric clinic complained of a range of symptoms, related to their cancer, as well as other co-morbidities and frailty.

Methods: We retrospectively analysed follow up clinic letters of patients who had attended the oncogeriatric clinic, between June 2022 and June 2023. We used a Lirkert scale, to see whether symptoms they had complained of had 1 – got worse, 2 – stayed the same, 3 – improved or 4 – resolved.

Results: 32 patients with a wide range of malignancies were included. 59 patients were excluded because they: died before the 2nd appointment, did not require a second appointment, had their second appointment outside the analysis window, DNA or in 1 case the follow up letter could not be found. On average each patient complained of 3 symptoms. 30 different symptoms were noted (2 excluded as there was no mention of them in the 2nd visit.) The top presentations were pain, constipation, low mood, breathlessness, reduced mobility, falls and dizziness. 68% of the symptoms complained of showed improvement – including all the top presentations. The average score on the Lirkert scale was 2.76 78% of patients had shown improvement or resolution in at least some of their symptoms.

Conclusions: Our retrospective review shows that older, cancer patients, have a high burden of varied symptomatology, because of their cancer, co-morbidities and frailty. Attendance at an oncogeriatric clinic results in improvement in the symptom burden for the majority of older adults, and an improvement in some symptoms, whether they are related to cancer, or other frailty syndromes.

Background: North Middlesex University Hospital runs an outpatient frailty service offering Comprehensive Geriatric Assessment. There is a daily ‘hot slot’ for patients who may otherwise require unplanned admission if not seen within seven days. Aim was to improve slot utilisation from 50 to 100%, with appropriate admission avoidance referrals by June 2023. Empty slots result in an inefficient use of resources, increased workload in other departments and reduced opportunity for patients to benefit from the service. 

Methods: We audited hot slots in November and December 2022, marking slots as ‘filled’ or ‘unfilled’. In January 2023 we established a clear referral process for hot slots, implemented an education programme to increase awareness of the availability and referral criteria, and increased Consultant availability in the department. We then re-audited the hot slots from February to April 2023 and analysed data, conducted statistical testing and produced visual representation of the data.  

Results: After exclusion of periods where hot slots were closed (n=13) including industrial action, bank holidays and times with below minimum staffing; 82 slots were audited, pre-intervention (n=39) and post-intervention (n=43). The utilisation of hot slots increased from 51% pre-intervention to 86% post-intervention. Fisher's exact test showed statistical significance (p<0.0007). Intervention did not improve appropriate use of hot slots (41% to 35%). 

Conclusions: Interventions increased utilisation of hot slots but fell short of the targeted 100% utilisation rate. We plan to make the hot slot available exclusively to the Geriatric Emergency Medicine (GEM) team for one week in August to assess whether this increases utilisation of the hot slot. We intend to further analyse the data to review the appropriateness of referrals and help identify other ways to improve this. We anticipate our service will expand frailty frontline provision plans to help meet rising need for urgent outpatient frailty care.