Overview: English translation of the Japanese comprehensive geriatric assessment-based healthcare guidelines 2024

Abstract

The Comprehensive Geriatric Assessment (CGA) is a multidimensional and multidisciplinary evaluation of the medical status, activities of daily living (ADL), instrumental ADL (IADL), cognitive function, mood, motivation, quality of life (QOL), and social background of older adults. Table 1 shows the components of the CGA and its main tools. Further details are provided in Chapter 1. Although the CGA effectively predicts the future course of older adults, the primary aim is not to evaluate the current status or predict prognosis. The main objective of the CGA is to provide personalized medical care by developing holistic management plans and targeted interventions based on comprehensive assessments. This guideline emphasizes combining the CGA with subsequent interventions.¹

This guideline evaluates the effectiveness of the CGA based on evidence from the literature. The use and benefits of the CGA are described using case studies in this section.

Case 1 was a patient with a history of diabetes and multiple comorbidities (Table 2). Most of his personal care was performed by his wife; thus, no major problems were apparent in his life. However, his wife reported that he had been tripping and occasionally falling and was becoming increasingly forgetful. The CGA results revealed that he walked with a cane but maintained most of his basic ADLs, including walking on level ground. However, the patient's instrumental ADLs were impaired, especially medication management. Cognitive function was also impaired. In particular, time orientation and short-term memory scores indicated mild dementia. An investigation of his living conditions revealed impaired lower limb muscle strength and poor vision, which made obstacles difficult to see, leading to falls. His medication adherence was poor, consistently taking only about half of his prescribed medications. This poor medication adherence may have contributed to his poor glycemic control. The patient's wife was asked to assist him with his medications, as cognitive decline likely caused his poor medication adherence. To address the risk of falls, the patient's medications were reviewed. Antiplatelet therapy was discontinued, the doses of antihypertensives were reduced, and the overall medication regimen was simplified. A thorough examination for dementia was scheduled. We suggested that the patient apply for long-term care insurance to introduce preventive care services and home renovation to prevent falls. The results of the CGA can be referenced to prepare the primary care physician's statement document, called “Shujii-ikensho,” which is required for certifying long-term care needs. In this case, the CGA provided information that contributed to understanding the patient's condition and living conditions. The CGA also facilitated the initiation of appropriate measures to improve disease management.

Case 2 was a patient with multiple compression fractures of the thoracolumbar spine due to osteoporosis, osteoarthritis of the knees, and chronic lower back pain, which limited her mobility and physical activity (Table 3). The patient stayed home most of the time, which contributed to constipation, insomnia, anorexia, and weight loss. These conditions are associated with frailty. The CGA evaluation revealed that the patient had decreased mobility in basic ADL and problems with defecation, including occasional fecal incontinence, possibly due to laxative use. Although her instrumental ADLs were mostly maintained, the reduced mobility prevented the patient from shopping. The patient could cook but found cooking burdensome; thus, the patient often relied on ready-made dishes and prepackaged bento meals. The patient sometimes skipped meals due to her lack of appetite. Her cognitive function was intact, but her Geriatric Depression Scale score was 12, indicating a depressive mood. Her social background included visits from her daughter once or twice a week to help with shopping and cleaning. Although she was certified as “requiring assistance level 2,” she did not utilize any care services. Recreational activities and rehabilitation were needed to improve her depression and physical function. We proposed the use of daycare services and daily life support by a home helper, working through her care manager. The potential use of pharmacotherapy for depression was also considered as a future treatment option.

Information provided by the CGA allowed her care manager to immediately understand the situation and respond to the patient's needs. Medical and lifestyle problems can be identified easily from the CGA, leading to appropriate intervention. Moreover, unlike blood tests or diagnostic imaging, the CGA serves as a shared tool that can be easily understood by both healthcare and social care professionals.

What if CGA had not been performed in these cases? The symptoms may have been regarded as age-related or disease-related issues, leading physicians to observe the situation without appropriate intervention. Even if tests or symptomatic treatments against complaints were performed, the outcomes may have been less favorable than the outcomes achieved through the CGA. Here, what is a “good outcome” for the older adults? A good outcome during the care of an older adult is not solely defined by reduced mortality, which is often considered the gold standard in adult medicine. Healthy longevity and quality of life are also emphasized when assessing good outcomes for older adults. The use of Quality-Adjusted Life Years is becoming an international standard for evaluating the outcomes and cost-effectiveness of drugs and medical products.² According to a survey on prioritizing outcomes in geriatric medicine,³ “Reduction in mortality” was ranked as the least important outcome of the 12 items by both healthcare providers and recipients. “Improvement in quality of life,” “Recovery of physical functions,” “Reduction in caregiver burden,” “Maintenance of mobility,” and “Improvement in mental status” were considered more important. In this guideline, the outcomes for each clinical question were based on these priorities, and systematic reviews to determine the usefulness of the CGA were conducted. If these outcomes are deemed important, they must be evaluated in clinical and care settings, making CGA a highly significant tool for systematic assessment.

The history of the CGA is summarized in Table 4.^{4, 5} Marjory Warren from the United Kingdom, known as “the mother of geriatrics,” was one of the first geriatricians. Warren laid the foundation for the CGA.⁶ In 1935, Warren divided older patients in the workhouse into categories based on the degree of disability and provided the necessary nursing care, rehabilitation, and medical care to these patients. This approach was successful and eventually evolved into the CGA. In 1984, Laurence Z. Rubenstein, known as “the father of geriatrics,” et al. at the University of California, Los Angeles, demonstrated through a randomized controlled trial (RCT) that the CGA improved the prognoses of inpatients.⁷ In 1993, a meta-analysis of RCTs showed that using the CGA improved life expectancy, physical function, and cognitive function.⁸ A recent meta-analysis also demonstrated that implementation of the CGA improved geriatric syndromes and shortened hospital stays.⁹ However, it is important to note that these results were not solely achieved through the CGA; they were the result of a multidisciplinary team approach that included geriatricians.

In Japan, Toshio Ozawa of Kochi Medical University introduced the CGA into clinical research in 1990, and Kozo Matsubayashi reported the results, which have been widely recognized both nationally and internationally. Subsequently, the CGA was introduced at the Tokyo Metropolitan Institute for Geriatrics and Gerontology, the Department of Geriatrics at the University of Tokyo, the National Center for Geriatrics and Gerontology, and other medical facilities. However, the CGA was not widely implemented in Japan. The long-term care insurance system was introduced in 2000, “The Guideline for Comprehensive Geriatric Assessment” summarizing the evidence and practices of the CGA was published in 2003, and an additional reimbursement for the CGA was introduced in 2008, leading to nationwide implementation of the CGA. A primary care physician's document, known as the “Shujii-ikensho,” is required for long-term care insurance certification. Primary care physicians must assess the patient's daily living functions and specify the necessary care services to complete this document; therefore, most physicians perform at least some parts of the CGA. Hospitals are required to have at least one physician who has completed a training program on the CGA to qualify for additional reimbursement. The Japan Geriatrics Society has successfully certified thousands of physicians through its workshops and training programs.

Several retrospective cohort studies using propensity score matching demonstrated the beneficial effects of CGA. Associations between CGA and lower inpatient mortality, shorter hospital stays, and improved polypharmacy have been reported in stroke patients ≥65 years old.^{10, 11} The implementation of the CGA is steadily increasing in Japan, and further promotion of the CGA based on this guideline should be achieved. In addition, the concept, definition, and evaluation tools associated with CGA should continue to evolve, i.e., the guidelines should be continuously updated to reflect these advancements.

SO received lecture fee from Daiichi Sankyo. MA received research funding from Astellas Pharma, Bayer Yakuhin, Chugai Pharmaceutical, Daiichi Sankyo, Eisai, Merck & Co., Fukuda Lifetech, Kracie, Mitsubishi-Tanabe Pharma, Ono Pharmaceutical, Takeda, and Tsumura, manuscript fee from Daiichi Sankyo, and lecture fees from Daiichi Sankyo, Merck & Co., Toa Eiyo, and Towa Pharmaceutical. The other authors declare no conflict of interest.