Comprehensive Geriatric Assessment in the Hospital

Background: An increasing number of older people are being treated in German hospitals. In 2022, more than 35.7 million hospitalized patients in Germany were of age 65 or older. Comprehensive geriatric assessment (CGA) can help to structure and improve the diagnosis and treatment of these patients, many of whom suffer from multimorbidity.

Methods: The guideline group developed this guideline in accordance with the AWMF recommendations. Answers to questions were either evidence-based or consensus-based; the latter were established with a Delphi procedure followed by a consensus conference. The guideline was issued in May 2024.

Results: The guideline contains twelve evidence-based and eight consensus-based recommendations and statements. The strongest evidence for the effectiveness of CGA was found in the wards for acute geriatric medicine, oncology, and orthopedics/trauma surgery, with weaker evidence from emergency departments and general surgery wards. Core elements of the guideline are the specification of a minimum duration of CGA (15 minutes), the definition of minimum requirements (six core dimensions: self-help ability, mobility, cognitive function/delirium, affect, nutrition, social situation), and setting-specific process recommendations. Specific screening instruments to identify patients who stand to benefit from CGA are recommended mainly in the oncological setting (G8 questionnaire).

Conclusion: The German clinical practice guideline on CGA can serve as a guide to personalized geriatric medicine in the hospital. Further complex interventional studies are needed to evaluate the efficacy of CGA in other settings.

Cite this as: Kumlehn B, Brefka S, Kocar T, Verri FM, Wirth R, Denkinger M: Clinical practice guideline: Comprehensive geriatric assessment in the hospital. Dtsch Arztebl Int 2025; 122: 156–62. DOI: 10.3238/arztebl.m2024.0262

It is expected that by 2040 the proportion of older people in the total population will have increased from 19% at present to up to 26%; given the parallel increase in the burden of disease, this trend will have a major impact on the healthcare system (1). More than 35.7 million cases of in-patient treatment were recorded in the age group 65 years or older in Germany in 2022 (2). The high degree of medical, functional, psychological, and social heterogeneity observed in the older population is attributable to differences in the aging process as well as factors such as health behavior and exposure to environmental factors (3, 4). In the 1940s, Dr. Marjory Warren founded modern geriatrics by developing a resource- and function-oriented care approach, thereby enabling the discharge of numerous patients hospitalized over several months (5). This approach served as the starting point for the development of comprehensive geriatric assessment (CGA) which seeks to identify problems both in the inpatient and outpatient settings at an early stage and enable an appropriate response. CGA is a multidimensional process designed to determine and evaluate resources and deficits based on the biopsychosocial model; CGA is considered the gold standard for improving numerous relevant endpoints for older people in acute care hospitals (6). Yet until now, no corresponding S3-level clinical practice guideline has been issued for German-speaking countries. The primary aim of the evidence- and consensus-based (= S3-level) clinical practice guideline “Comprehensive Geriatric Assessment (CGA) in the Hospital” (7) is to improve hospital care and aftercare in geriatric patients usually aged 65 years or older with multimorbidity and limited self-help ability.

Methods

The guideline group consisted of a steering committee (eTable 1) and mandate holders of various scientific medical societies as well as patient representatives (eTable 2). The Guidance Manual and Rules for Guideline Development of the Association of the Scientific Medical Societies in Germany (AWMF, Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften) (8) and the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument (9) served as the methodological basis. (9).

eTable 1

Members of the steering committee

eTable 2

Scientific medical societies and organizations in alphabetical order

The development of the research question is described in the online version (eFigure 1). Figure 1 shows the PRISMA diagram with the results of the comprehensive literature search. Of the altogether 5303 publications screened, 45 were eligible for inclusion. The AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews) tool was used to assess the methodological quality of the included systematic reviews. The guidelines included were assessed using the AGREE II instrument. The quality of evidence and strength of recommendation were rated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The confidence of evidence was assessed in four levels (high, moderate, low, very low) for all relevant endpoints. In addition, the following aspects were considered for determining the strength of recommendation based on the evidence-to-decision (EtD) framework of GRADE (10): benefits and harms, patient values and preferences, resources, equity, acceptability, and feasibility. The methods used to determine the grade of recommendation as well as the evidence-to-decision table can be found in the online version (eFigure 2 and eTable 3).

Figure 1

PRISMA flowchart of the literature search

eFigure 1

PICOS schema

eFigure 2

Evidence and evidence-to-decision assessment using GRADE

eTable 3

Evidence-to-decision assessment of 20 recommendations and statements

After a multistage Delphi process, a structured consensus conference under the neutral moderation of the AWMF, external review, and approval by the issuing medical societies/organizations, the guideline was published on 21 May 2024.

Results

When determining the strength of recommendation (for an EtD assessment overview see also eFigure 2), an advantage in conducting CGA compared to standard care was found across all 20 recommendations and statements of the guideline (eTable 3).

General recommendations and statements

The six general recommendations and statements are listed in Table 1 and will be discussed below based on the clinically relevant questions.

Table 1

General recommendations and statements

What is CGA and what is its purpose?

Multidimensionality, interprofessionality and the need for an adequately accurate assessment based on the biopsychosocial model are considered the main features of CGA (Table 1) (general statement no. 1) (11). In contrast to qualitative screening approaches, CGA assesses and quantifies deficits, needs and resources in the functional and psychosocial domains of the person and goes beyond individual diseases and organ dysfunctions. The comprehensive assessment and holistic view allow individualized treatment planning and prognostication (12). Not all patients benefit to the same extent. Mainly in orthogeriatrics, a benefit of CGA is noted particularly in persons with moderately increased vulnerability and higher premorbid functional ability (13, 14).

The first general recommendation (Table 1, no. 2) advises implementing a screening tool that can identify geriatric patients with complex treatment requirements where treatment can be improved with the help of CGA (grade of recommendation A). Examples of use of these tools include older persons prior to systemic cancer treatment, elective surgical procedures or, as prescribed in the structural criteria for the treatment of hip fractures, also in emergency departments. Suitable screening instruments are listed in Figure 2. Depending on the setting, more appropriate instruments can be used, such as the Identification of Seniors at Risk (ISAR) test in the emergency department (15) or the Geriatric-8 (G8) questionnaire in oncology (16), while patients in geriatric wards do not require any screening prior to CGA.

Figure 2

Screening CGA algorithm

Which professions/persons are involved in performing CGA?

The interprofessional geriatric treatment team called for in the second general recommendation (Table 1, no. 3) reflects good clinical practice; interprofessionality is assumed in most of the evidence reviewed (6, 16, 17, 18, 19, 20). CGA performed in this manner proved effective mainly in that it led to improvements in the investigated endpoints of mortality, institutionalization rate, delirium, functionality, length of stay, and activities of daily living (ADL). Since this is to be regarded as indirect evidence, the levels of evidence were reduced by one level in each case (overall low level of evidence) and the grade of recommendation was lowered to B. In the oncology setting in particular, a key element of CGA is the involvement of patients and caregivers (including relatives) in the assessment process (16, 18). The second general statement (Table 1, no. 4) refers to the possibility of improving the quality of life (QoL) of older patients and their caregivers by involving the caregivers in the CGA process; this improvement is partly attributable to a reduced burden on the caregivers (21, 22).

Which dimensions are relevant for CGA?

The third general statement (Table 1, no. 5) lists six essential and some optional CGA dimensions, which can be supplemented by additional dimensions, depending on the setting and question to be addressed. The essential dimensions—self-help ability, mobility, cognitive function, including delirium, affect, nutrition, and social situation—are derived from the reviewed evidence (6, 23) and the German OPS catalog 2024 (24), the Dutch CGA guideline (25), and the Integrated Care for Older People (ICOPE) recommendations of the WHO (26).

What is the optimum duration of a geriatric assessment?

The majority of studies showing beneficial effects of CGA-based interventions use assessment instruments that require a minimum total time of 15 minutes as specified in the third general recommendation (Table 1, no. 6) (examples are provided in Table 3). There are no comparative studies with different assessment durations or cut-offs. All of the studies with information or recommendations on the assessment duration are from the oncology setting. As with the interprofessional team approach, CGA carried out within the specified duration proved to be effective with regard to the endpoints treatment toxicity and secondary dose reduction (27) which is to be regarded as indirect evidence. For this reason, the levels of evidence of the endpoints were downgraded to overall low and the grade of recommendation was reduced to B.

Table 3

Examples of commonly used geriatric assessment instruments

eFigure 3 provides a checklist with the essential and optional dimensions as well as the professional groups involved.

eFigure 3

Checklist: Dimensions and Occupational Groups

Setting-specific recommendations and statements

Setting: Emergency Department

Older people often present to the emergency departments of hospitals for acute illnesses. In Germany, the proportion of over-70-year-olds in the emergency departments is about 30% (28). According to a systematic review, the mortality within a period of three months after the visit to the emergency department is about 10% on average (29). Thus, it is crucial to detect vulnerable patients early on so that health and social problems can be identified and targeted treatment initiated (30). Yet conducting CGA in the emergency department (ED) remains a challenge, given that the lack of planning, the frequent absence of caregivers and the acute nature of illnesses seen in the emergency department setting often make it difficult to perform a structured assessment. However, if CGA is indicated, the later conduct of the assessment can already be planned in the ED. The three consensus-based recommendations (twice grade of recommendation B, once grade of recommendation 0, see Table 2) focus on carrying out at least one screening in the emergency department with the dimensions of cognition (dementia, delirium), self-help ability and mobility (risk of falling), as well as checking medication and asking patients about their values and preferences. Information about the premorbid functional status and, for example, the question whether preference is given to living the longest possible life or to living an independent life can have a significant impact on treatment planning from maximum care through to a palliative approach.

Table 2

Setting-specific recommendations and statements

Setting: Oncology

With increasing age, the incidence of most cancers also increases. About half of cancer patients are 65 years or older (31). However, the fact that geriatric patients are usually considerably underrepresented in clinical trials (32) makes selecting an appropriate hemato-oncological treatment regimen and deciding on dose intensity more difficult. As a result, older people with cancer often experience over- or under-treatment which can lead to increased complication, morbidity and mortality rates (33). On the basis of the available evidence (very low quality of evidence), two recommendations (grade of recommendation B) and a statement were developed (Table 2). The guideline recommends screening of older cancer patients using the G8 questionnaire that can be completed in a few minutes and covers items such as food intake, mobility, psychosocial aspects, and polypharmacy; in patients with a G8 score of 14 or more points, the screening is followed by CGA. In all geriatric patients and all patients aged 70 years or older, CGA should always be performed before initiating systemic cancer therapy. Whilst the level of evidence is very low, partly due to a lack of meta-analyses, there is some evidence pointing to improvements in numerous endpoints (such as treatment completion, quality of life, disease burden). After CGA, a statistically significant and clinically very relevant absolute reduction in treatment toxicity by 13% is observed; CGA does not seem to cause a delay in treatment initiation (27).

Setting: Orthogeriatrics

More than 50% of all surgical procedures are performed on persons aged 65 or older (17). The most common reason for admission to an orthogeriatric ward is fall-related hip fracture in an older person with osteoporosis (34). In Germany, the incidence of hip fractures is approximately 130 per 100 000 population per year (35), with women being more frequently affected than men. Postoperative complications occur in about one third (33.6%) of patients (36). In Germany, geriatric trauma centers (ATZ, Alterstraumatologisches Zentrum) were introduced in 2014 to enable the provision of interprofessional and interdisciplinary care for older persons after accidents or falls, taking factors specific to older patients, such as pre-existing health problems, mobility and living conditions, into account. A large epidemiological study conducted in Germany found a decrease in the adjusted 30-day mortality by 22% (absolute risk reduction of 2.48%; number needed to treat: 40) in patients admitted to hospitals with orthogeriatric co-management (37).

The four recommendations received three times the grade of recommendation B and once the grade of recommendation 0 (Table 2). The guideline recommends screening patients aged 70 and older with hip fractures in the emergency department and initiating CGA in case of abnormal screening results—because CGA can lead to improvements in the endpoints institutionalization rate, functional ability and complication rate (including delirium) (evidence level low in each case), which could explain the above-mentioned effect on mortality—as well as perioperative orthogeriatric co-management. In case of other fractures and orthopedic conditions, geriatric patients can also benefit from CGA (evidence level very low in each case).

Setting: General and visceral surgery

In general and visceral surgery, the number of geriatric cases is also increasing. In 2019, bowel surgery in patients aged 60 or older ranked first with 285 200 procedures. Next was bile duct surgery with 216 100 endoscopic procedures. Total hip replacement surgery just reached third place with 204 900 procedures (38). The guideline contains one evidence-based statement (level of evidence very low) and one consensus-based recommendation (grade of recommendation B) for this setting (Table 2). A CGA-adapted treatment strategy can reduce the risk of postoperative delirium and shorten the length of hospital stay (19). An assessment should be made based on a screening CGA algorithm in order to determine the indication for surgery as well as operability (Figure 2).

Setting: Acute geriatrics

In-hospital care for geriatric patients is often provided in specialized geriatric units designed to prevent functional decline and associated complications in older adults admitted to hospital for an acute event (39). Overall, geriatric care in Germany is concentrated in hospitals and rehabilitation facilities, and this trend is increasing. One recommendation (grade of recommendation A) and one statement of this guideline describe the effects of CGA on various endpoints (Table 2). In acute geriatrics, a CGA, covering all treatment-relevant dimensions, should be performed, since this approach can lead to significant improvements in the endpoints living at home (relative risk [RR] 1.06; 95% confidence interval [1.01; 1.10], absolute risk calculated from the meta-analysis 59.4% in the CGA group versus 56.1% with standard care) and risk of institutionalization (RR 0.80 [0.72; 0.89], calculated absolute risk 14.9% in the CGA group versus 18.6% with standard care) and a possible improvement in activities of daily living (level of evidence moderate) (6). The literature search found evidence indicating significant beneficial effects for further endpoints, such as risk of falls (RR 0.51 [0.29; 0.88], calculated absolute risk 5.7% in the CGA group versus 7.7% with standard care) and the risk of delirium (RR 0.73 [0.61; 0.88], calculated absolute risk 19.5% in the CGA group versus 22.7% with standard care) (level of evidence low) (39). CGA-adapted treatment can lead to a slight improvement in the patients’ quality of life (standardized mean difference 0.12; level of evidence very low) (21).

In the long version of this guideline, no specific assessment instruments are mentioned; instead reference is made to the S1-level guideline “Geriatric Assessment Level 2“ (40) and clinical practice guidelines for the respective dimensions. However, examples of assessment instruments and possible interventions to address identified needs are shown in Table 3 to facilitate implementation of the recommendations in everyday clinical practice. Further instrument examples and recommendations can be found in the mentioned guidelines.

Discussion

The evidence search and discussion during the development of this guideline showed that, although it is not clearly defined whether CGA is merely a diagnostic procedure or also comprises a therapeutic intervention, studies demonstrating beneficial effects always include aspects of an interprofessional team, treatment planning, treatment itself, and aftercare. The guideline group agreed on the definition presented in the first General Statement which was largely adopted from Rubenstein (11) and includes treatment planning and follow-up.

The guideline presented here has answered many questions, but has also identified a need for further research. Examples of relevant research questions include:

• Which assessment instruments and which combination of assessment instruments are the most effective for the defined endpoints?
• Is it also possible in other settings, such as cardiology, gastroenterology or neurosurgery, to improve patient management in relation to the defined endpoints by introducing CGA-adapted treatment?
• Is CGA-adapted treatment also effective and cost-effective in view of the relevant endpoints in the outpatient setting (primary care physicians and office-based specialists)?

Acknowledgement

We would like to thank the members of the steering committee and the mandate holders of the participating scientific medical societies and organizations for their valuable and constructive cooperation, especially Dr. Sonja Krupp, Dr. Nina Neuendorff, Prof. Dr. Dr. M. Cristina Polidori, Prof. Dr. Katrin Singler, PD Dr. Valentin Goede, PD Dr. Werner Hofmann, Univ.-Prof. Dr. Bernhard Iglseder, and PD Dr. Thomas Münzer for the text contributions. We would also like to thank Ms. Kathrin Grummich, Freiburg, for her support in developing the search strategy and PD Dr. Dhayana Dallmeier, PhD, for her methodological support. We would like to express our special thanks to the head of AWMF-IMWi, Prof. Dr. Ina Kopp, for her continuous support throughout the development of the guideline.

Conflict of interest statement
The authors declare that no conflict of interests exists.

Funding

The guideline project was funded by the German Geriatric Society (DGG, Deutsche Gesellschaft für Geriatrie), the Institute for Geriatric Research of the Ulm University Hospital and the Geriatric Center Ulm.

Manuscript received on 8 September 2024, revised version accepted on 20 December 2024.

Clinical practice guidelines in the Deutsches Ärzteblatt, as in many other journals, are not subject to a peer review process, since clinical practice (S3 level) guidelines are texts which have already been evaluated, discussed, and broadly agreed upon multiple times by experts (peers).

Translated from the original German by Ralf Thoene, M.D.

Corresponding author
Prof. Dr. med. Michael Denkinger

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