Comprehensive Geriatric Assessment in Surgical Care: A Multidimensional Approach to Optimizing Outcomes in Older Adults

Abstract

The global demographic landscape is witnessing an unprecedented rise in the older adult population, a phenomenon that has profound implications for healthcare systems, particularly in the realm of surgical interventions. Older adults often present with unique and complex health profiles, characterized by multimorbidity, polypharmacy, attenuated physiological reserves, and the insidious presence of frailty. These factors collectively predispose them to a significantly heightened risk of adverse postoperative outcomes, including increased morbidity, prolonged hospitalisation, functional decline, and mortality. In response to this growing challenge, Comprehensive Geriatric Assessment (CGA) has emerged as an indispensable, multidimensional, and interdisciplinary diagnostic and therapeutic process. This detailed report meticulously examines the pivotal role of CGA in systematically identifying frailty, precisely assessing an array of geriatric-specific risk factors, and ultimately enhancing surgical outcomes within the burgeoning geriatric population. Through an exhaustive synthesis of contemporary academic literature and established clinical guidelines, this report elucidates the multifaceted components of CGA, explores its various methodologies of implementation, quantifies its demonstrable impact on a spectrum of postoperative outcomes, and addresses the inherent challenges and future trajectories in its widespread adoption. The report unequivocally underscores the critical necessity of integrating CGA into routine preoperative evaluations and highlights its broader implications for fundamentally transforming and elevating the quality of care delivered to older adults across diverse clinical settings.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

1. Introduction: The Imperative of Geriatric Surgical Optimisation

The 21st century is defined, in part, by a significant demographic shift: the rapid expansion of the aging population. Projections indicate that by 2050, the number of individuals aged 65 and older will reach nearly 1.6 billion globally, representing a substantial proportion of the total population (United Nations, 2019). This demographic revolution is inevitably accompanied by a proportionate increase in the demand for surgical services among older adults. While surgical interventions offer the potential for profound improvements in quality of life, alleviation of symptoms, and even life prolongation, they simultaneously introduce a heightened spectrum of risks for this vulnerable demographic. Unlike younger cohorts, older patients embarking on surgical journeys are frequently navigating a complex interplay of pre-existing chronic conditions (multimorbidity), the concurrent use of multiple medications (polypharmacy), and profound physiological alterations characteristic of the aging process. These age-related changes, encompassing declines in cardiovascular, pulmonary, renal, neurological, and musculoskeletal system reserves, diminish the physiological capacity to withstand the profound stress of surgery and anaesthesia (American College of Surgeons, 2021). Furthermore, a critical, yet often underappreciated, factor complicating surgical outcomes in older adults is the pervasive presence of frailty. Frailty, distinct from chronological age or comorbidity, signifies a state of reduced physiological reserve and increased vulnerability to stressors, profoundly influencing the trajectory of recovery. In light of these intricate challenges, traditional preoperative risk stratification models, primarily focused on isolated organ system function or specific disease states, have proven insufficient for comprehensively identifying and mitigating risks in the geriatric surgical patient. It is within this complex clinical landscape that Comprehensive Geriatric Assessment (CGA) has ascended as a pivotal, person-centred tool. CGA transcends a mere medical evaluation, offering a holistic, multidimensional, and interdisciplinary approach to preoperative assessment. Its fundamental aim is to systematically identify frailty, unearth a constellation of geriatric syndromes, and pinpoint associated risk factors that are often overlooked in standard evaluations. By doing so, CGA facilitates the development of highly individualised care plans designed to optimise surgical planning, enhance intraoperative management, and crucially, improve postoperative recovery and long-term functional independence. This report delves into the intricate details of CGA, asserting its indispensable role in modern geriatric surgical care.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

2. The Concept of Frailty in Older Adults: A State of Enhanced Vulnerability

Frailty represents a dynamic and often progressive clinical syndrome observed in older adults, fundamentally characterised by a decline in the functionality and integrity of multiple physiological systems. This systemic deterioration leads to a diminished capacity to withstand physiological stressors, such as surgery, infection, or trauma, resulting in an increased vulnerability to adverse health outcomes. It is critical to differentiate frailty from chronological age itself or from the mere presence of multiple chronic diseases (comorbidity). While older age and multimorbidity increase the likelihood of frailty, they are not synonymous (Fried et al., 2001). A robust 90-year-old may be less frail than a sedentary 70-year-old with numerous chronic conditions.

2.1 Theoretical Frameworks of Frailty

Two predominant conceptual models underpin the understanding of frailty:

• The Frailty Phenotype Model (Fried’s Phenotype): Proposed by Fried and colleagues, this model conceptualises frailty as a distinct clinical syndrome identifiable by the presence of at least three out of five specific criteria (Fried et al., 2001). These include:

  • Unintentional Weight Loss: A loss of ≥10 lbs (or ≥5% body weight) in the past year, reflecting catabolism and malnutrition.
  • Self-Reported Exhaustion: Often indicated by responses to questions like ‘I felt that everything I did was an effort’ or ‘I could not get going’ on a specified number of days per week.
  • Low Physical Activity: Measured by caloric expenditure or self-reported frequency of physical activity, indicating reduced engagement in daily movement.
  • Slowness: Defined by a measured gait speed over a short distance (e.g., 4 meters), adjusted for height, indicating diminished motor function and balance.
  • Weakness: Quantified by grip strength using a dynamometer, adjusted for sex and body mass index, reflecting reduced muscle power.
    Individuals meeting one or two criteria are often classified as ‘pre-frail’, signifying an increased risk of progressing to full frailty. This phenotype model highlights the physiological decline across multiple systems – notably musculoskeletal, metabolic, and neurological – that underpins frailty.

• The Cumulative Deficit Model (Rockwood’s Frailty Index): Developed by Rockwood and Mitnitski, this model posits that frailty arises from the accumulation of deficits across various health domains (e.g., diseases, symptoms, signs, disabilities) (Rockwood & Mitnitski, 2007). The Frailty Index (FI) is calculated as the proportion of deficits present out of a total number of potential deficits (typically 30-70 items). A higher FI score indicates greater frailty. This model provides a continuous measure of frailty and is highly sensitive to changes over time, reflecting an individual’s total burden of health deficits. It emphasizes the concept of ‘homeostenosis’, where the body’s capacity to maintain physiological equilibrium in response to stress progressively narrows with aging and deficit accumulation.

Both models, while distinct in their approach, converge on the idea that frailty is a state of reduced physiological reserve, leading to increased vulnerability.

2.2 Physiological Underpinnings of Frailty

Frailty is not simply the sum of individual diseases; rather, it reflects a complex interplay of interrelated physiological changes at the cellular and systemic levels. Key mechanisms include:

• Sarcopenia: The progressive and generalised loss of skeletal muscle mass and strength with age. Sarcopenia directly contributes to weakness and slowness, increasing the risk of falls and functional decline (Cruz-Jentoft et al., 2010). It impairs metabolic function and reduces protein reserves necessary for healing and recovery post-surgery.
• Chronic Low-Grade Inflammation: Often termed ‘inflammaging’, this refers to a persistent, low-grade inflammatory state observed in older adults, characterised by elevated levels of pro-inflammatory cytokines (e.g., IL-6, TNF-alpha, CRP). This chronic inflammation contributes to muscle wasting, endothelial dysfunction, and impaired immune responses (Michaud et al., 2013).
• Neuroendocrine Dysregulation: Imbalances in hormonal systems, such as reduced growth hormone, IGF-1, and sex steroid levels, as well as dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, contribute to muscle loss, bone demineralisation, and impaired stress response.
• Immunosenescence: Age-related decline in immune system function, leading to reduced vaccine efficacy, increased susceptibility to infections, and impaired wound healing, all of which are critical in the surgical context.
• Mitochondrial Dysfunction: Impaired mitochondrial function in cells leads to reduced energy production, increased oxidative stress, and contributes to cellular damage and functional decline across various organ systems.

These interwoven physiological changes create a synergistic effect, profoundly compromising an older adult’s ability to recover from major physiological insults like surgery.

2.3 Assessment Tools for Frailty

Given the critical impact of frailty, various tools have been developed for its clinical assessment:

• Clinical Frailty Scale (CFS): A rapid, practical tool ranging from 1 (very fit) to 9 (terminally ill), based on clinical judgement after a brief conversation with the patient and/or family about their functional status over the preceding year (Rockwood et al., 2005). It is widely used in acute care settings due to its simplicity and predictive validity.
• Grip Strength: Measured using a handheld dynamometer, it is a robust indicator of overall muscle strength and has strong predictive value for adverse outcomes.
• Gait Speed: Measured over a short distance (e.g., 4 meters), a slow gait speed (<0.8 m/s) is a powerful predictor of functional decline, hospitalisation, and mortality.
• Short Physical Performance Battery (SPPB): A composite measure assessing balance, gait speed, and chair stand performance. It is a reliable predictor of disability and mortality.

Understanding and accurately assessing frailty is paramount, as it directly informs surgical risk assessment, preoperative optimisation strategies, and guides the development of highly individualised management plans.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

3. Comprehensive Geriatric Assessment (CGA): A Holistic Paradigm

Comprehensive Geriatric Assessment (CGA) is defined as a multidimensional, interdisciplinary diagnostic process designed to determine an older person’s medical, psychosocial, and functional capabilities and problems with the aim of developing an overall plan for treatment and long-term follow-up (Rubenstein et al., 1991). Unlike a standard medical examination that often focuses on specific organ systems or diseases, CGA adopts a holistic, person-centred perspective, recognising that an older adult’s health status is a complex interplay of numerous interacting factors. Its origins trace back to the mid-20th century, driven by the recognition that older patients often present with ‘geriatric syndromes’ (e.g., falls, delirium, incontinence), which are multifactorial in origin and require a broader assessment than traditional disease-specific approaches. The primary objective of CGA is to identify and address reversible conditions, optimise functional status, and enhance the overall quality of life, particularly in the context of planned medical or surgical interventions. (en.wikipedia.org)

3.1 Core Components of CGA

The robustness and utility of CGA stem from its systematic evaluation across several critical domains:

3.1.1 Medical Assessment

This domain extends beyond a typical review of systems, delving deeply into the physiological and pathological landscape unique to older adults. Key aspects include:

• Chronic Diseases and Multimorbidity: Detailed inventory and assessment of all existing chronic conditions (e.g., cardiovascular disease, diabetes, chronic kidney disease, chronic obstructive pulmonary disease, arthritis, neurological disorders). Understanding the cumulative burden of these diseases and their potential interactions is crucial.
• Polypharmacy and Medication Review: Older adults frequently take multiple medications, increasing the risk of adverse drug reactions, drug-drug interactions, and medication-related geriatric syndromes (e.g., delirium, falls, constipation). A thorough medication reconciliation involves reviewing all prescription and over-the-counter medications, supplements, and herbal remedies, assessing their necessity, dosage, potential side effects, and adherence. Tools like the Beers Criteria or STOPP/START criteria can guide the identification of potentially inappropriate medications (American Geriatrics Society, 2019).
• Geriatric Syndromes Identification: Active screening for common geriatric syndromes that are often overlooked or misattributed:
  • Falls Risk: Assessment of fall history, balance, gait stability, fear of falling, and contributing factors (e.g., polypharmacy, orthostatic hypotension, sensory impairment, environmental hazards).
  • Delirium Risk: Baseline cognitive status, history of delirium, and risk factors (e.g., infection, dehydration, severe pain, psychoactive medications).
  • Urinary Incontinence: Type and severity, impact on quality of life, and potential reversible causes.
  • Pressure Ulcers: Skin integrity assessment, nutritional status, and mobility levels.
  • Malnutrition: Screening for unintentional weight loss, poor appetite, difficulty eating/swallowing (dysphagia), and overall nutritional status using tools like the Mini Nutritional Assessment (MNA) or Nutrition Risk Screening (NRS-2002).
• Pain Assessment: Systematic evaluation of chronic and acute pain, its impact on function and mood, and adequacy of pain management, considering age-related changes in pain perception and metabolism of analgesics.
• Sensory Impairment: Screening for vision (e.g., cataracts, glaucoma, macular degeneration) and hearing loss, as these can significantly impact communication, mobility, and cognitive function, particularly during hospitalisation.
• Oral Health: Assessment of dental status, presence of dentures, and any oral discomfort that might affect nutrition.

3.1.2 Functional Assessment

This domain evaluates an individual’s capacity to perform activities essential for independent living, providing insights into their baseline functional status and potential for recovery. Key measures include:

• Activities of Daily Living (ADLs): Basic self-care tasks essential for fundamental functioning. These include bathing, dressing, toileting, transferring (moving in/out of bed or chair), continence, and feeding. Tools like the Katz ADL Index are commonly used (Katz et al., 1963).
• Instrumental Activities of Daily Living (IADLs): More complex activities necessary for independent living within a community. These include managing finances, preparing meals, shopping, using the telephone, doing housework, and managing medications. The Lawton IADL Scale is a widely recognised assessment tool (Lawton & Brody, 1969).
• Mobility and Balance: Beyond gait speed, assessment of balance (e.g., tandem stand, single-leg stand), walking endurance, and overall physical mobility. Tools like the Timed Up and Go (TUG) test, which measures the time taken to rise from a chair, walk 3 meters, turn around, return, and sit down, provide quick and reliable indicators of mobility and fall risk.
• Advanced Activities of Daily Living (AADLs): Highly complex activities that involve social, occupational, and recreational pursuits, reflecting higher levels of independent function.

3.1.3 Cognitive Assessment

Recognising that cognitive impairment is highly prevalent in older adults and a significant predictor of adverse surgical outcomes (e.g., postoperative delirium), this domain is crucial:

• Screening for Cognitive Impairment: Use of validated screening tools to identify potential dementia, mild cognitive impairment (MCI), or a predisposition to delirium. Common tools include the Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), or the 4-A’s Test (4AT) (Pendlebury et al., 2013; Bellelli et al., 2014).
• Delirium Risk Stratification: Identification of pre-existing risk factors for delirium, such as baseline cognitive impairment, history of previous delirium, severe illness, visual/hearing impairment, polypharmacy, and alcohol abuse.
• Impact on Decision-Making: Evaluation of the patient’s capacity for informed consent regarding surgical procedures and understanding of postoperative care instructions.

3.1.4 Psychological Assessment

Psychological well-being profoundly impacts recovery and quality of life. This domain focuses on:

• Mood Disorders: Screening for depression (e.g., using the Geriatric Depression Scale [GDS] or PHQ-9) and anxiety (e.g., GAD-7), which are common in older adults and can significantly impair recovery, increase pain perception, and reduce adherence to treatment plans (Yesavage et al., 1982).
• Coping Mechanisms: Understanding the patient’s psychological resilience and coping strategies in the face of illness and surgery.
• Fear and Anxiety related to Surgery: Addressing specific concerns about the procedure, pain, recovery, and potential loss of independence.

3.1.5 Social Assessment

An individual’s social context heavily influences their ability to recover and maintain independence post-surgery:

• Social Support Systems: Evaluation of the availability and quality of formal and informal caregivers (family, friends, community services). Assessing caregiver burden is also vital, as stressed caregivers may not be able to provide adequate post-discharge support.
• Living Conditions: Understanding the patient’s home environment, including accessibility (stairs, bathroom layout), safety hazards, and suitability for recovery.
• Financial Stability and Resources: Assessing financial capacity to cover medical expenses, medications, and potential home modifications or support services.
• Transportation Access: Ability to attend follow-up appointments and procure necessary services.
• Advance Care Planning (ACP): Discussions about the patient’s wishes for future medical care, including resuscitation preferences, intubation, and feeding tubes, and the designation of a durable power of attorney for healthcare. This ensures that care aligns with patient values and preferences, especially in scenarios of unexpected decline. (en.wikipedia.org)

By integrating findings from these diverse domains, CGA creates a comprehensive, holistic portrait of the older adult, enabling clinicians to move beyond a disease-centric view to a person-centred understanding of their unique strengths, vulnerabilities, and needs.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

4. Methodologies in Conducting CGA: A Structured and Collaborative Process

The effective implementation of CGA is not a singular event but rather a systematic, multi-step process that demands a structured approach and often involves a multidisciplinary team. The methodology typically encompasses screening, comprehensive evaluation, intervention planning, and ongoing follow-up.

4.1 Models of CGA Delivery

CGA can be delivered in various settings, each with its own advantages and limitations:

• Inpatient CGA: Often implemented for older adults admitted for acute medical conditions or planned surgical procedures. Dedicated geriatric wards or geriatric consultation services provide this. The focus here is on preventing hospital-associated complications (e.g., delirium, falls, functional decline) and facilitating safe discharge planning.
• Outpatient/Pre-admission Clinic CGA: Increasingly common in elective surgery pathways. Patients undergo CGA weeks or days before surgery, allowing ample time for pre-optimisation interventions. This model is proactive and aims to mitigate risks before the surgical stressor occurs.
• Community-based CGA: For older adults living at home, often performed by community nurses or geriatric teams to prevent hospital admissions, manage chronic conditions, and support independent living.
• Geriatric Co-management Models: In this model, a geriatrician or geriatric team collaborates directly with surgical teams, offering expertise in assessing and managing older surgical patients throughout their perioperative journey (from pre-op to discharge and beyond). This fosters shared decision-making and ensures geriatric principles are embedded in surgical care.

4.2 The Multidisciplinary Team (MDT) Approach

A hallmark of effective CGA is its reliance on an interdisciplinary team. While the specific composition may vary, core members typically include:

• Geriatrician: Specialises in the care of older adults, overseeing the overall assessment, diagnosis, and management plan.
• Geriatric Nurse: Conducts initial screening, performs detailed functional and cognitive assessments, monitors progress, and provides patient and family education.
• Social Worker: Assesses social support, living conditions, financial concerns, caregiver burden, and facilitates access to community resources.
• Physical Therapist (PT): Evaluates mobility, balance, gait, strength, and develops exercise programmes for prehabilitation and rehabilitation.
• Occupational Therapist (OT): Assesses ADL and IADL performance, identifies environmental barriers, and recommends adaptive equipment or home modifications.
• Pharmacist: Reviews medication regimens, identifies polypharmacy and potential adverse drug reactions, and makes recommendations for deprescribing or optimising drug therapy.
• Dietitian/Nutritionist: Assesses nutritional status, identifies malnutrition or risk, and develops tailored dietary plans.
• Other Specialists: Depending on patient needs, this may include a neuropsychologist, speech therapist, palliative care specialist, or spiritual counsellor.

The MDT meets regularly to discuss individual patient findings, synthesise information, develop a unified problem list, and formulate an integrated, personalised care plan. This collaborative synergy ensures a holistic perspective and avoids fragmented care.

4.3 Key Methodological Steps

4.3.1 Screening and Triage

Given that full CGA is resource-intensive, initial screening is often employed to identify older adults who would most benefit from a comprehensive assessment. This often involves:

• Age Threshold: Typically, all patients aged 65, 70, or 75 and older are screened, depending on local policy.
• Frailty Screening: Use of brief, validated tools like the Clinical Frailty Scale (CFS), PRISMA-7, or ISAR (Identification of Seniors At Risk) to quickly identify frail or at-risk individuals (de Witte et al., 2013).
• Geriatric Syndrome Screening: Simple questions or tools to identify issues such as falls history, cognitive impairment (e.g., 6-CIT, Mini-Cog), or nutritional risk (e.g., Malnutrition Universal Screening Tool [MUST]).

Patients identified as frail or at high risk for geriatric syndromes are then referred for full CGA.

4.3.2 Comprehensive Evaluation

This is the core of CGA, where detailed assessments are conducted in each of the medical, functional, cognitive, psychological, and social domains. This involves:

• Standardised Tools: Utilisation of validated assessment instruments (e.g., Katz ADL, Lawton IADL, GDS, MMSE, MNA) to ensure consistent and reproducible data collection.
• Patient and Caregiver Interviews: Gathering information directly from the patient and, crucially, from family members or informal caregivers, who can often provide invaluable insights into baseline function, daily challenges, and personal preferences.
• Physical Examination: A thorough physical examination, with particular attention to geriatric-specific findings (e.g., sarcopenia, balance issues, sensory deficits).
• Laboratory and Imaging Studies: Targeted investigations based on clinical findings (e.g., complete blood count, electrolytes, renal function, thyroid function, vitamin B12, vitamin D levels).

4.3.3 Intervention Planning and Implementation

Based on the comprehensive findings, the MDT collaborates to develop an individualised care plan. This involves:

• Prioritisation of Problems: Identifying the most pressing and modifiable problems identified during the assessment.
• Goal Setting: Establishing realistic, patient-centred goals, often involving shared decision-making with the patient and family.
• Tailored Interventions: Implementing specific interventions to address identified deficits:
  • Prehabilitation: A multimodal programme implemented before surgery to optimise physiological reserve. This typically includes exercise (aerobic, resistance, balance), nutritional optimisation (protein supplementation), psychological support, and anaemia correction (CRH, 2021).
  • Medication Optimisation: Deprescribing inappropriate medications, simplifying drug regimens, and adjusting dosages.
  • Nutritional Support: Oral nutritional supplements, dietary modifications, or consideration of enteral feeding if severe malnutrition is present.
  • Physical Therapy/Occupational Therapy: Prescribing exercises to improve strength, balance, and endurance; providing assistive devices; and recommending home modifications.
  • Cognitive Stimulation: For individuals with mild cognitive impairment, strategies to maintain cognitive function and reduce delirium risk.
  • Psychological Support: Referral for counselling or pharmacotherapy for depression/anxiety.
  • Social Support Activation: Connecting patients with community resources, arranging home care services, or providing caregiver support.
  • Advance Care Planning: Documenting patient wishes and preferences for future care.

4.3.4 Follow-Up and Monitoring

CGA is an iterative process. Regular follow-up is essential to monitor the effectiveness of interventions, adjust care plans as needed, and ensure continuity of care, especially during transitions (e.g., from hospital to home, or to rehabilitation facilities).

4.4 Training and Competency

Successful CGA implementation hinges on well-trained clinicians. Ongoing education in geriatric principles, the nuances of geriatric syndromes, and proficiency in using validated assessment tools are vital. Training programmes should extend beyond geriatric specialists to encompass surgeons, anaesthesiologists, nurses, and allied health professionals, fostering a shared understanding and collaborative approach to geriatric surgical care.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

5. Impact of CGA on Surgical Outcomes: A Paradigm Shift in Perioperative Care

The most compelling evidence for the value of CGA lies in its demonstrated ability to significantly improve a broad spectrum of surgical outcomes in older adults. By proactively identifying and addressing multifactorial risks, CGA transforms the perioperative landscape, moving beyond reactive management of complications to proactive optimisation.

5.1 Reduction in Postoperative Complications

CGA’s greatest impact is arguably its efficacy in mitigating the incidence and severity of various postoperative complications that disproportionately affect older adults.

• Postoperative Delirium (POD): This acute confusional state is one of the most common and devastating complications in older surgical patients, associated with increased mortality, longer hospital stays, and accelerated cognitive decline (Inouye et al., 2014). A systematic review and meta-analysis by Chen et al. (2024) specifically highlighted that CGA-informed interventions, such as medication optimisation (e.g., avoiding anticholinergics), early mobilisation, pain management, and addressing sensory impairments, significantly reduced the incidence of POD among older surgical patients (Chen et al., 2024). CGA’s emphasis on baseline cognitive assessment allows for early identification of at-risk individuals, enabling targeted preventive strategies.
• Postoperative Functional Decline: Many older adults experience a decline in their ability to perform ADLs and IADLs post-surgery, often failing to return to their baseline functional status. This can lead to increased dependency, need for institutionalisation, and reduced quality of life. CGA, particularly when coupled with prehabilitation programmes, strengthens patients before surgery, enhancing their resilience. Studies have shown an association between CGA and better postoperative functional status and a decreased need for long-term care facilities or nursing home placement (Geriatric Assessment in Surgical Oncology, 2015; Chen et al., 2024). By identifying specific functional deficits pre-operatively (e.g., poor balance, weakness), targeted physical therapy and occupational therapy interventions can be initiated.
• Reduced Morbidity (e.g., Pulmonary, Cardiac, Infectious Complications): CGA’s holistic approach allows for the identification and optimisation of co-morbidities that predispose older patients to complications. For instance, nutritional assessment can identify malnutrition, leading to nutritional supplementation that reduces wound healing issues and infections. Cardiovascular optimisation reduces cardiac events. Pulmonary physiotherapy and smoking cessation advice can lower rates of pneumonia and other respiratory complications (Fried et al., 2014).
• Falls: Both pre-existing fall risk factors and hospital-induced factors (e.g., delirium, polypharmacy, deconditioning) contribute to falls during hospitalisation. CGA identifies these risks pre-operatively, allowing for environmental modifications, medication adjustments, and balance training, thereby reducing inpatient fall rates and associated injuries.

5.2 Improved Functional Recovery and Quality of Life

Beyond merely surviving surgery, the ultimate goal for older adults is to maintain or regain their independence and quality of life. CGA contributes significantly to this aim:

• Faster Return to Baseline Function: By addressing deficits in strength, nutrition, and mobility pre-emptively, CGA, especially through prehabilitation, enhances the patient’s physiological reserve. This allows them to recover more quickly from the surgical insult and regain their pre-morbid functional status (Gillis et al., 2014).
• Reduced Need for Institutionalisation: A critical outcome for older adults is the ability to return home and live independently. CGA’s focus on comprehensive discharge planning, social support assessment, and functional optimisation directly reduces the likelihood of discharge to a rehabilitation facility or nursing home, promoting direct discharge to home (Geriatric Assessment in Surgical Oncology, 2015).
• Enhanced Patient and Caregiver Satisfaction: By involving patients and families in shared decision-making and ensuring comprehensive support, CGA contributes to higher satisfaction with care and improved peace of mind for both patients and their caregivers.

5.3 Enhanced Shared Decision-Making and Risk Stratification

CGA provides a nuanced and comprehensive understanding of an older patient’s risk profile that extends far beyond traditional surgical risk scores (e.g., American Society of Anesthesiologists [ASA] physical status classification). While ASA scores are useful, they do not capture the complexity of frailty, cognitive impairment, or social vulnerabilities. CGA fills this gap:

• Informed Surgical Decisions: By identifying frailty and other geriatric risk factors, CGA empowers both clinicians and patients to engage in truly informed shared decision-making (The Effect of Comprehensive Geriatric Assessment on Treatment Decisions, 2024). This may lead to:
  • Selection of Less Invasive Procedures: For frail patients, a less invasive surgical approach (e.g., laparoscopic vs. open surgery, transcatheter aortic valve implantation [TAVI] vs. surgical aortic valve replacement) might be preferred, reducing surgical stress and recovery time.
  • Consideration of Alternative Treatments: In highly frail or cognitively impaired individuals, non-surgical management, palliative care, or even deferral of surgery might be deemed more appropriate, aligning care with patient values and prognosis.
  • Optimisation Before Surgery: If surgery proceeds, CGA guides pre-operative optimisation strategies, allowing time to address modifiable risks (e.g., improving nutritional status, managing anaemia, adjusting medications).
• Personalised Prognostication: CGA data can be used to provide more accurate and personalised prognoses to patients and families regarding their likely surgical outcomes, recovery trajectory, and potential for long-term independence. This facilitates realistic expectations and planning (Kristjansson et al., 2023).

5.4 Reduced Length of Hospital Stay and Readmissions

While not always the primary endpoint, the reduction in hospital length of stay (LOS) and readmission rates is a significant economic and logistical benefit of CGA. By preventing complications, promoting faster recovery, and ensuring robust discharge planning, CGA can streamline the patient’s journey (Formosa et al., 2025).

• Shorter LOS: Fewer complications mean less need for extended inpatient care. Early identification of discharge needs (e.g., home modifications, equipment) and seamless transition planning also contribute to timely discharge.
• Lower Readmission Rates: Comprehensive planning, addressing underlying deficits, and ensuring adequate post-discharge support reduce the likelihood of complications or functional decline leading to re-hospitalisation.

In essence, CGA transforms the approach to geriatric surgery from one of risk acceptance to one of risk mitigation and proactive optimisation, leading to more favourable and patient-centred outcomes.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

6. Broader Applications of CGA Beyond Surgical Settings: A Pillar of Geriatric Care

While its impact in the surgical context is profound, the principles and methodologies of Comprehensive Geriatric Assessment extend far beyond the operating theatre. CGA serves as a foundational pillar in various facets of geriatric care, providing a holistic framework for managing the complex health needs of older adults and promoting healthy aging.

6.1 Chronic Disease Management and Multimorbidity

Older adults frequently live with multiple chronic conditions (multimorbidity), which often interact in complex ways, leading to cumulative symptoms, functional decline, and increased healthcare utilisation. CGA is uniquely positioned to manage this complexity:

• Integrated Care Planning: Instead of managing each disease in isolation, CGA encourages an integrated approach. It identifies how different conditions impact each other and how they collectively affect a patient’s function, cognition, and quality of life. For example, uncontrolled diabetes might exacerbate peripheral neuropathy, contributing to falls; or heart failure might limit participation in physical activity, contributing to sarcopenia.
• Polypharmacy Management: As detailed earlier, CGA’s meticulous medication review is critical for older adults with multimorbidity. It allows for the identification of medication redundancies, interactions, and inappropriate prescriptions, leading to deprescribing and simplification of regimens. This reduces the risk of adverse drug events and improves medication adherence (American Geriatrics Society, 2019).
• Identification of Therapeutic Targets: CGA helps prioritise therapeutic interventions based on patient goals and overall burden, rather than solely focusing on disease-specific guidelines which may be unsuited for complex older patients (e.g., aggressive blood pressure targets may increase fall risk in frail individuals).

6.2 Preventive Care and Health Promotion

CGA is a powerful tool for proactive prevention and health promotion by identifying modifiable risk factors for future health issues:

• Falls Prevention: Beyond the surgical context, CGA systematically screens for fall risk factors (e.g., poor balance, muscle weakness, polypharmacy, visual impairment, environmental hazards). This leads to targeted interventions such as exercise programs, home safety assessments, medication adjustments, and vision correction, significantly reducing fall incidence in the community.
• Malnutrition Prevention: Early identification of nutritional deficiencies or risk of malnutrition allows for dietary counselling, nutritional supplementation, and addressing underlying causes (e.g., poor oral health, dysphagia, social isolation affecting meal preparation).
• Delirium Prevention in Acute Settings: In hospitalised older adults, CGA principles guide proactive measures to prevent delirium, even when not undergoing surgery. These include promoting sleep, maintaining hydration, early mobilisation, reorientation, and sensory aids.
• Cognitive Health Promotion: Early detection of mild cognitive impairment or early-stage dementia allows for interventions such as cognitive stimulation, management of cardiovascular risk factors, and lifestyle modifications that may slow cognitive decline.

6.3 Geriatric Rehabilitation

Following acute illness, injury (e.g., hip fracture), or stroke, older adults often require intensive rehabilitation. CGA principles are fundamental to designing effective rehabilitation programmes:

• Tailored Rehabilitation Goals: CGA helps assess baseline function, cognitive status, and social support, which are critical for setting realistic and achievable rehabilitation goals.
• Addressing Barriers to Rehabilitation: It identifies factors that might impede rehabilitation progress, such as depression, pain, poor nutrition, or lack of motivation, allowing the rehabilitation team to address these issues holistically.
• Optimising Discharge Planning: Ensures that patients are discharged to the most appropriate setting with necessary support and follow-up to maximise long-term functional recovery.

6.4 Palliative and End-of-Life Care Planning

CGA facilitates sensitive and critical discussions about goals of care and advance directives, ensuring that medical interventions align with the patient’s values, preferences, and prognosis. This is particularly relevant for older adults with life-limiting illnesses or advanced frailty.

• Clarifying Patient Values: CGA encourages open dialogue about what matters most to the patient in terms of quality of life, independence, and preferred care settings.
• Advance Care Planning (ACP): Helps patients document their wishes regarding medical treatments (e.g., CPR, mechanical ventilation, feeding tubes) and designate a healthcare power of attorney. This ensures that their autonomy is respected even if they lose capacity.
• Symptom Management: A comprehensive assessment of pain, nausea, dyspnoea, and other distressing symptoms allows for effective palliative symptom management.
• Supporting Caregivers: CGA considers the needs of family caregivers, offering support, education, and resources as they navigate the complexities of end-of-life care.

6.5 Long-Term Care Planning

For older adults experiencing progressive decline, CGA helps determine the most appropriate long-term care setting and support services:

• Needs Assessment: Comprehensive evaluation identifies the level of assistance required for ADLs and IADLs, medical needs, cognitive status, and social support.
• Resource Navigation: Social workers within the CGA team can guide families through the complexities of accessing home care services, assisted living facilities, or skilled nursing facilities, ensuring a safe and supportive environment for the patient.

In essence, CGA provides a robust, evidence-based framework for person-centred care that enhances the well-being and independence of older adults across the entire spectrum of healthcare, from acute interventions to chronic disease management and end-of-life planning. Its principles are foundational to a truly geriatrically informed healthcare system.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

7. Challenges and Limitations of CGA: Navigating Implementation Barriers

Despite the compelling evidence supporting the efficacy of Comprehensive Geriatric Assessment, its widespread and consistent implementation across all healthcare settings, particularly in the perioperative context, faces several significant challenges and inherent limitations. Addressing these is crucial for maximising the full potential of CGA.

7.1 Resource Intensity and Feasibility

One of the most frequently cited barriers to CGA implementation is its inherently resource-intensive nature:

• Time Commitment: A thorough, multidimensional CGA can be time-consuming, potentially taking several hours for an initial assessment, depending on the complexity of the patient and the number of disciplines involved. In busy clinical environments with high patient throughput, allocating this dedicated time can be difficult.
• Personnel Requirements: Effective CGA necessitates a skilled multidisciplinary team, including geriatricians, geriatric nurses, social workers, physical therapists, occupational therapists, and pharmacists. The availability of such specialised personnel is often limited, particularly in rural or underserved areas, and within non-geriatric departments (e.g., surgical wards).
• Financial Costs: Investing in dedicated CGA clinics, additional personnel, and training programmes incurs significant upfront costs. While studies suggest long-term cost-effectiveness through reduced complications and readmissions, securing initial funding can be a hurdle for healthcare institutions.
• Space and Infrastructure: Dedicated space for comprehensive assessments, including areas for physical performance tests (e.g., gait speed, TUG), may not be readily available in all clinical settings.

7.2 Variability in Implementation and Standardisation

Currently, there is considerable variability in how CGA is defined, what components are included, which tools are used, and how it is implemented across different institutions and countries. This lack of standardisation poses several problems:

• Inconsistency in Quality: The effectiveness of CGA can vary greatly depending on the expertise of the team, the depth of the assessment, and the fidelity to evidence-based interventions. This variability makes it challenging to compare outcomes across studies and generalise findings.
• Lack of Consensus on Core Components: While broad domains are agreed upon, the specific assessment tools (e.g., which cognitive test, which frailty scale) and the threshold for ‘abnormality’ can differ, leading to different patient classifications and intervention pathways.
• Integration into Workflow: Integrating a comprehensive assessment process into existing surgical pre-assessment clinics or inpatient workflows can be challenging. It requires significant organisational change, interdepartmental collaboration, and adaptation of electronic health records (EHRs) to capture and utilise CGA data effectively.
• Training Gaps: While the need for training is acknowledged, consistent and high-quality training programmes for all healthcare professionals involved in geriatric care are not universally available, leading to skill deficits and inconsistent application of CGA principles.

7.3 Evidence Gaps and Need for Further Research

While robust evidence supports CGA’s benefits, certain areas require further high-quality research:

• Cost-Effectiveness Studies: Although intuitively CGA appears cost-effective in the long run, more rigorous economic evaluations are needed to demonstrate its financial benefits across diverse healthcare systems and patient populations, particularly for specific surgical specialties (e.g., emergency surgery, complex cancer surgery).
• Tailored CGA for Specific Sub-populations: The optimal CGA components and intensity may vary for different surgical procedures (e.g., cardiac vs. orthopaedic surgery) or specific patient groups (e.g., oncology patients, patients with advanced dementia). More research is needed to refine tailored CGA protocols.
• Optimal Timing and Duration of Interventions: While prehabilitation is promising, the ideal timing, intensity, and duration of pre-surgical interventions informed by CGA findings are still areas of active research.
• Long-Term Outcomes: More longitudinal studies are needed to understand the very long-term impact of CGA on quality of life, institutionalisation rates, and survival beyond the immediate postoperative period.
• Feasibility in Emergency Surgery: Implementing full CGA in emergency surgical scenarios, where time is of the essence, presents significant practical challenges. Research is needed on abbreviated or ‘flash’ CGA models for this context.

7.4 Patient Engagement and Communication

Engaging older patients and their families in the CGA process and subsequent care planning can present challenges:

• Cognitive Impairment: Patients with significant cognitive impairment may struggle to participate fully in assessments or understand complex treatment plans, necessitating greater reliance on proxy informants and ethical considerations regarding informed consent.
• Health Literacy and Preferences: Some older adults may have low health literacy or differing preferences regarding invasive procedures or life-sustaining treatments, requiring sensitive communication and shared decision-making strategies.
• Fatigue and Burden: The sheer volume of questions and assessments during a comprehensive CGA can be fatiguing for frail older individuals.

7.5 Ethical Considerations

CGA can raise ethical dilemmas, particularly regarding balancing patient autonomy with beneficence:

• Informed Consent: How to ensure truly informed consent for complex surgical procedures, especially when cognitive impairment is present or surgical risks are very high due to frailty.
• Shared Decision-Making: The ethical imperative to provide comprehensive information about risks and benefits, including the option of not having surgery, and to genuinely incorporate patient values and preferences into the decision-making process.
• Resource Allocation: In systems with finite resources, the comprehensive nature of CGA might raise questions about equitable access to such intensive assessments.

Addressing these challenges requires a concerted effort from policymakers, healthcare leaders, clinicians, and researchers to develop standardised protocols, invest in infrastructure and training, and generate robust evidence for tailored and cost-effective CGA models.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

8. Future Directions: Innovating and Expanding CGA’s Reach

The evolving landscape of healthcare, coupled with technological advancements and a deeper understanding of geriatric physiology, points towards several promising future directions for Comprehensive Geriatric Assessment. These advancements aim to overcome current limitations, enhance efficiency, and broaden the impact of CGA.

8.1 Standardization and Development of Universal Protocols

To address the current variability in CGA implementation, a critical future direction is the development of universally accepted, evidence-based guidelines and standardised protocols. This includes:

• Consensus on Core Outcome Sets: Establishing an international consensus on a minimum set of core domains and outcome measures for CGA in different clinical contexts (e.g., elective surgery, emergency care, community settings). This would facilitate consistency in assessment and allow for meaningful comparison of research findings and clinical effectiveness across institutions.
• Standardised Tools and Training: Promoting the widespread adoption of a limited number of validated, user-friendly assessment tools and ensuring consistent training in their application and interpretation for all healthcare professionals involved in geriatric care.
• Modular CGA Approaches: Developing adaptable CGA modules that can be tailored in intensity and depth depending on the patient’s context (e.g., abbreviated CGA for emergency surgery, full CGA for elective procedures) while maintaining core principles.

8.2 Integration with Technology and Digital Health

Technology holds immense potential to enhance the efficiency, accessibility, and analytical capabilities of CGA:

• Electronic Health Record (EHR) Integration: Seamless integration of CGA data into EHRs would allow for real-time data capture, automated risk stratification, decision support alerts for clinicians, and population-level analysis. Structured data entry forms for CGA components can improve consistency.
• Telemedicine and Remote CGA: Leveraging telehealth platforms can extend the reach of CGA, particularly for patients in rural areas or those with mobility limitations. Remote assessments, including virtual consultations, remote monitoring of physical activity, and digital cognitive tests, can make CGA more accessible and convenient.
• Artificial Intelligence (AI) and Machine Learning (ML): AI and ML algorithms can be trained on large datasets to:
  • Automate Frailty and Risk Prediction: Identify frail individuals or those at high risk for adverse outcomes from routine clinical data (e.g., EHR data, claims data), potentially streamlining the screening process and targeting CGA resources more effectively.
  • Personalised Intervention Recommendations: Suggest tailored prehabilitation programmes or medication adjustments based on individual patient profiles and predicted responses.
  • Predictive Analytics: Forecast length of stay, risk of readmission, or likelihood of functional decline, enabling proactive discharge planning and resource allocation.
• Wearable Devices and Remote Monitoring: Integration of data from wearables (e.g., smartwatches, accelerometers) can provide objective measures of physical activity, sleep patterns, and heart rate variability, offering insights into physiological reserve and response to interventions, complementing traditional assessments.

8.3 Enhanced Education and Training Across Disciplines

Building a geriatrically-competent healthcare workforce is paramount. Future efforts must focus on:

• Curriculum Integration: Embedding comprehensive geriatric principles and CGA methodologies into the curricula of medical schools, nursing programmes, and allied health professions.
• Interprofessional Education: Fostering collaborative learning opportunities where surgeons, anaesthesiologists, geriatricians, nurses, and allied health professionals train together, promoting a shared understanding of geriatric care and strengthening interdisciplinary teamwork.
• Continuing Professional Development: Offering accessible, ongoing training and certification in CGA for experienced clinicians, ensuring competency in new tools and approaches.

8.4 Implementation Science and Research

Beyond demonstrating efficacy, future research needs to focus on how to effectively integrate CGA into routine clinical practice in diverse settings:

• Context-Specific Models: Research into optimal CGA models for various surgical specialties (e.g., orthopaedics, cardiac, general surgery, oncology) and acute vs. elective settings.
• Economic Impact: Robust studies on the long-term cost-effectiveness and return on investment of CGA in different healthcare systems.
• Patient and Caregiver Perspectives: Research exploring patient and caregiver experiences with CGA, identifying barriers to engagement, and understanding their preferences for shared decision-making.
• Sustainability: Developing and evaluating sustainable models for CGA delivery that are scalable and integrated into existing healthcare funding structures.

8.5 Focus on Prehabilitation and Post-Acute Care Transitions

Future efforts will continue to refine and expand the role of prehabilitation and strengthen the transition from acute care:

• Tailored Prehabilitation: More personalised prehabilitation programmes based on specific deficits identified by CGA, incorporating exercise, nutrition, psychological support, and medication optimisation.
• Post-Acute Care Continuum: Strengthening the links between acute hospital care and post-discharge support (e.g., home healthcare, rehabilitation facilities, community services) to ensure continuity of care and prevent readmissions.

The future of CGA is poised for significant innovation, driven by a blend of technological advancements, refined protocols, and a commitment to interdisciplinary collaboration, ultimately aiming to provide truly person-centred, high-quality care for the aging surgical population.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

9. Conclusion: CGA as the Standard of Care for Older Surgical Patients

The global demographic shift has fundamentally reshaped the surgical landscape, presenting an imperative to adapt perioperative care to the unique and often complex needs of older adults. This report has meticulously detailed how Comprehensive Geriatric Assessment (CGA), a multidimensional and interdisciplinary diagnostic and therapeutic process, stands as a critical and indispensable tool in this adaptation. By moving beyond traditional organ-centric assessments, CGA provides a holistic understanding of an older patient’s medical conditions, functional capabilities, cognitive status, psychological well-being, and social support systems. Its systematic approach is crucial for identifying frailty – a distinct state of vulnerability that significantly heightens the risk of adverse postoperative outcomes, including delirium, functional decline, and prolonged hospitalisation.

The evidence overwhelmingly demonstrates that the implementation of CGA in the preoperative setting leads to a myriad of tangible benefits. It facilitates a profound reduction in postoperative complications, significantly improves functional recovery rates, and enhances the overall quality of life for older surgical patients. Furthermore, CGA empowers truly informed shared decision-making, allowing clinicians and patients to collaboratively select the most appropriate surgical approach or, when necessary, explore viable alternative treatments. The broader applications of CGA extend far beyond the operating room, serving as a foundational methodology for chronic disease management, preventive care, geriatric rehabilitation, and compassionate end-of-life planning.

However, the full realisation of CGA’s potential is contingent upon addressing inherent challenges, notably its resource intensity, the existing variability in its implementation, and the need for further robust research to optimise its application across diverse clinical contexts. Looking ahead, the future of CGA is bright, with promising avenues in standardisation, integration with cutting-edge technologies like AI and telemedicine, and expanded education for healthcare professionals. These innovations hold the key to enhancing the efficiency, accessibility, and effectiveness of CGA.

In summation, Comprehensive Geriatric Assessment is not merely an optional addition to perioperative care; it is rapidly becoming the gold standard for optimising surgical outcomes in older adults. Its widespread and consistent implementation is essential for delivering person-centred, high-quality care that respects the unique needs and maximizes the resilience of our aging population, ensuring that longevity is accompanied by vitality and dignity.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

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