Introduction

Although the majority of older people have a positive view of their health status and are free from disability, the proportion with more intensive care and assistance needs rises with age (Australian Institute of Health and Welfare [AIHW] 2007). Traditional health care service provision, which is largely task-oriented and procedurally based, is not always well suited to meet the needs of older people (Hickman et al 2007). Frail, older people with multiple problems and comorbidities, particularly those not under the direct care of geriatric services, are at risk of adverse outcomes. Appropriate assessment is required to address the complexities of health needs. Hence, the cornerstone of contemporary care of older people is assessment (Dorevitch et al 2004). The World Health Organization (WHO) defines health as ‘… a state of complete physical, mental and social well-being, and not merely the absence of diseases or infirmity’ (WHO 1946). If indeed health is viewed as a multi-dimensional construct, then it follows that assessing health status should address the physical, social, psychological and other dimensions as well as the medical.

Person-centred care is considered the optimum way of delivering health care and has been defined simply as ‘valuing people as individuals’ (Winefield et al 1996). Yet, there has been limited discussion of person-centred assessment. Given that ‘assessment sets the scene and the approach to an episode of care and the working relationship that follows’ (Dewing & Pritchard 2000), person-centred comprehensive assessment would be a crucial step to delivering person-centred care. The older person should be the focal point of the assessment in a partnership that is both respectful and reciprocal, and should feel empowered by the process (Heath 2000). It is the significance of the relationships between health care professionals and the older person, as well as the relationships between health care professionals themselves, that is often overlooked as a result of misconceptions about the concept of person-centredness. ‘Robust assessment processes, which are shared across professionals, reflect person-centred care principles’ (Meyer & Sturdy 2004). So the culture and philosophy of the team that underpins the context of assessment should be given consideration.

The importance of an interdisciplinary approach to comprehensive geriatric assessment

In health terms, comprehensive assessment is the detailed evaluation of health status. This involves a more detailed review than screening and leads directly to diagnostic conclusions and assignment to intervention strategies. It is important to understand that comprehensive assessment is a process that identifies both residual functional capacities and limitations of function in order to plan and deliver the most appropriate care. Furthermore, it represents a critical information-gathering phase, without which effective decisions regarding health-promoting interventions cannot be made, or the monitoring of changes in health status cannot be undertaken (Dorevitch et al 2004). Comprehensive geriatric assessment (CGA) has been defined as ‘a multidimensional, interdisciplinary, diagnostic process to identify care needs, plan care, and improve outcomes of frail older people’ (Rubenstein 2004).

Although interdisciplinary teams have evolved from multidisciplinary teams, they are indeed different. Where ‘… multidisciplinary teams create discipline-specific care plans and implement them simultaneously without explicit regard to their interaction,’ an interdisciplinary approach is one in which ‘team members from different disciplines collectively set goals and share resources and responsibilities’ (Beers & Berkow 2000). A number of barriers to multidisciplinary teamwork have been identified that include differing perceptions of teamwork, different levels of skills that impact on how teams function, the dominance of medical power impacting on team interactions, and conflict arising from the tension between role boundaries and perceived control (Atwal & Caldwell 2006; Jones 2006). The latter is of particular importance because the hierarchical structure of a multidisciplinary team can frequently undermine its effectiveness. Along with the structural differentiation, the need for shared meaning is accentuated when looking at the differences between multidisciplinary and interdisciplinary because a lack of shared meanings alienates direct caregiving nursing staff whose cooperation is important but whose participation and membership is excluded (Cott 1998). Given that follow-up, implementation of assessment recommendations, and patient adherence to recommendations are likely to be factors impacting on the effectiveness of CGA (Bogardus et al 2004; Reuben et al 1995; Wolfs et al 2007), an approach that alienates front line care staff is problematic.

An interdisciplinary approach, on the other hand, specifically refers to integration through active coordination. Therefore, interdisciplinary comprehensive assessment is more than sharing information across disciplines involved in the process of assessment. As a result of a much higher level of collaboration, an assumed equality across the team fosters a shared responsibility for effectiveness and team functioning to maximise the care outcomes for the older person (Zeiss & Thompson 2003). Interdisciplinary geriatric assessment and intervention is a proven model for the care of frail older people that is appropriate across community and institutional settings (Fenton et al 2006). Specifically, interdisciplinary team approaches to assessment and care have been shown to facilitate adherence to recommendations, prevent functional decline, and decrease hospitalisations and nursing home placement (Boult et al 2001; Counsell et al 2000; Landefeld et al 1995; Reuben et al 1999; Sommers et al 2000). Payne et al (2002) note, ‘Patients require alliances and effective partnerships across professional boundaries to support continuity of care and adequate information transfer.’ The implications, then, for comprehensive geriatric assessment are clear; an interdisciplinary approach to assessment provides important alliances and partnerships that underpin person-centred care plans and maximise health outcomes.

What is the value of comprehensive geriatric assessment?

The CGA programs across a range of care settings have been shown to play an important role in improving the quality of life (QoL) for older people and their informal caregivers (Aminzadeh et al 2005; Ellis & Langhorne 2004). For example, in the acute hospital setting poor outcomes can be a result of three main factors: ‘age-related physiological changes that afford less resiliency in responding to acute illness; diseases that precipitated hospitalisation, pre-existing comorbidities and newly acquired disorders; and the health care delivery system that renders care’ (Reuben 2000). In-patient CGA has the potential to reduce short-term mortality, increase the chances of living at home at 1 year, and improve physical and cognitive function (Ellis & Langhorne 2004). In appropriate cases CGA can lead to improved patient outcomes including better diagnostic accuracy and treatment planning, reduced need for long-term residential care, improved physical and mental functioning, prolonged inpatient survival, and reduced health care costs (Rubenstein & Wieland 1989; Scanlan 2005). Reduced medication use and improved QoL and mental health, improved client/carer satisfaction, and a reduction in carer burden have also been identified as positive benefits stemming from comprehensive assessment (Dorevitch 2004). Therefore, prompt and early assessment is critical in identifying and preventing complications amongst many older persons and, in turn, affects quality care.

A fundamental component of the various successful models to enhance the care of older people has been appropriate assessment with interdisciplinary input (Counsell et al 2000; Harari et al 2007; Inouye et al 2000). Research has shown that shorter length of stay, better maintenance of existing functionality, and fewer hospital readmissions are just some of the benefits experienced by older adults with complex problems if an interdisciplinary geriatric team assesses and actively manages their health care (Harari et al 2007; Landefeld 2003; Shyu et al 2005). Comprehensive assessment is most effective when targeted to older people who are at risk for functional decline (physical or mental), hospitalisation, or residential care placement (American Geriatrics Society 2006a). Not all older people require comprehensive assessment, and screening or targeting those most likely to benefit is common practice. Selection criteria may include the following: advanced age (75 years and over); living alone; recent hospitalisation; multiple comorbidities; polypharmacy; regular use of health services; difficulty managing in the home environment; domiciliary nursing; home care; carer stress; poor balance; falls; confusion; incontinence; limited performance in two or more instrumental activities of daily living; and inability to independently perform personal activities of daily living, bed or chair transfers, or mobilisation (with or without a gait aid).

The structure of a comprehensive assessment

The main reason for carrying out comprehensive assessment of older people is to identify unreported and unmet health care needs that can potentially be positively impacted upon. Comprehensive assessment informs the development of health care plans that are framed in terms of recommended health-promoting interventions that are both acceptable to the patient and their carers and readily accessible. Such assessment demands a detailed and exhaustive evaluation of an older person’s health status. While the format of comprehensive geriatric assessment may vary, there are a number of specific domains under the fundamental dimensions of medical health and physical, psychological and social functioning.

Sources of assessment information

The four main sources of assessment information are patients themselves (‘self-report’), others who know the patient well (‘informant report’), observing the patient undertaking various activities of daily living (‘direct observation’), and various other secondary written sources of information (including hospital records, medical reports, and investigation results). It is likely that the best comprehensive assessments are those that incorporate information collected from all four sources. Each of the four sources of assessment information is associated with potential limitations and pitfalls.

The accuracy of self-report has generally been shown to be superior to that of informants (Dorevitch et al 1992), however it may be compromised by various factors including the following: acute illness; impaired cognition, hearing or communication; limited proficiency with English or other cultural barriers; fear of consequences; or denial as a psychological adaptive mechanism (Dorevitch et al 2004). Even the way the assessor frames the question will impact on the accuracy of the information provided. For example, questions concerning physical function that are framed in terms of ‘performance’ (‘do you…’), rather than ‘capacity’ (‘are you able to…’) can result in answers that seemingly reflect a greater level of dependence than might otherwise be elicited.

Unless there is reason to suspect otherwise, the older person should be assumed to be best placed to provide accurate information about their health status with collateral history sought from other sources if required. Whilst informal or formal community carers may be a useful source of patient-related information, particularly concerning physical function, the accuracy of their information may be adversely affected by such factors as a lack of recent or sufficiently frequent observation of patient performance or by a conscious or subconscious desire to access additional support (Cohen-Mansfield & Jensen 2007; Davis 2001). Permission should be sought from the older person to obtain additional information from other informants such as family, case managers and community or residential aged care providers. Direct observation is really the best source of information about physical function. It is important to recognise that the physical setting in which the observations take place may impact on physical function; what a patient can do in hospital may be quite different from what they can do in their own individualised home environment.

Other sources of information (informant-report, direct observation of physical function, or the use of medical records) should ideally be pursued for corroboration of self-reported information, to fill in any gaps in the assessment, and to gain important carer and service provider perspectives. However, there are situations where they may have to be relied upon as primary sources. Medical records can contain information gathered from the other three sources but it is important to keep in mind that there may be significant imprecision or ambiguity in the way this information was initially recorded.

There is a critical association between assessment and care planning, with the quality of any given care plan being largely a function of the accuracy and comprehensiveness of the assessment that informed it. Inaccurate or incomplete assessment information will inevitably lead to the development of sub-optimal care plans, which in turn will lead to a less favourable impact upon the health of those most likely to benefit — older people with chronic and complex health care needs.

How to conduct a comprehensive assessment

Nolan and Caldock (1996) argue that any framework for assessment should be flexible and able to be adapted to a variety of circumstances, appropriate to the audience it is intended for, capable of balancing and incorporating the views of a number of carers, users and agencies, and able to provide a mechanism for bringing different views together, while recognising the diversity and variation within individual circumstances (Nolan & Caldock 1996). Comprehensive assessment can be conducted using standardised, global assessment tools, structured or semi-structured proformas that incorporate domain-specific instruments and checklists where required, or using an unstructured approach based on the professional expertise of the individual assessor.

The format adopted is likely to depend on:

Selecting the right tools for assessment

The importance of using reliable and valid assessment tools cannot be overstated. The use of tools can facilitate assessment, although, if used inappropriately, can reduce efficiency and undermine the relationship between the assessor and the older person (Osterweil 2003). While a reliance on structured measures alone may not allow for the identification of outstanding needs (Stewart et al 1999), the correct tools can provide a solid foundation of information from which to move forward. As Scanlan (2005) states, ‘Comprehensive assessment requires both simple screening measures to facilitate identification of problem areas and more detailed evaluation tools to guide the development of targeted interventions’.

The importance of using reliable and valid assessment tools cannot be overstated.

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