LAUSR

The traditional disease-oriented model of medicine focuses on the theory that organor system-based pathologies cause disease and, thus, treatment is focused on eliminating the underlying pathology. However, the disease model does not account for complexity of patients that are more often being seen in modern medical settings [1]. Due to increasing life expectancy, health care systems are progressively facing growing populations of older patients, who often have non-disease specific problems such as multimorbidity, frailty, polypharmacy, and disability [2,3]. The comprehensive geriatric assessment (CGA) and Management is an approach that aims to overcome some of the limitations of the disease-oriented model. Generally defined, CGA is a multi-dimensional multi-disciplinary diagnostic process focused on assessing an older person's medical, psychological and functional capability in order to develop a coordinated and integrated plan for treatment and long-term follow-up focused on the individual's needs. This assessment is followed by the development of a care plan, based upon the comprehensive assessment. The care plan must state explicitly what goals are being aimed for, who is responsible for achieving them and a timeline for review of progress. There are several benefits related to this approach. First, this assessment specifically examines a wider range of problematic areas of the patient, including co-morbidities, potential polypharmacy, and quality of life, as well as physical and cognitive functioning, that might not always be considered during a disease-oriented medical assessment [4]. Second, it allows for more specific, individualized care planning for the patient, resulting in better overall quality of care [5,6]. A systematic review concluded that the CGA approach in inpatients was associated with a reduction in short-term mortality, improvement in physical and cognitive functioning, and also increased the chance of patients retuning to live at home [7]. Zintchouk et al.'s randomized control study published in this issue of the European Journal of Internal Medicine provides an important contribution to the evidence [8]. They identified several benefits of the CGA when administered in an inpatient community rehabilitation unit. First, during the rehabilitation period, the number of daytime GP consultations and visits or phone and email consultations was lower in the intervention (CGA) group compared to those in the control group who did not undergo CGA. Second, more participants in the intervention group improved their overall quality of life over 90 day follow-up. Despite the benefits of CGA, the process could be improved. For example, specific patients should be targeted, in whom the effects of this comprehensive assessment and follow-up may be required more. Persons with multimorbidity [9] or frailty [10] may be suitable patients who would benefit from CGA. Patients presenting with complex conditions such as frailty often have particular clinical needs that are often not being properly addressed, requiring an adaptation of traditional care organization and services. For example, frail patients are significantly less to adhere to pharmacological treatments [11]. This is further complicated by the fact that many patients with chronic diseases such as chronic obstructive pulmonary disease [12] or chronic kidney disease [13] also present with frailty, and vice versa. Interesting, Zintchouk et al.'s study did highlight some differences in outcomes depending on certain patient characteristics. The sub-analysis performed showed that in persons with low to moderate comorbidity participants who underwent CGA had greater 90 day improvement in ADL and overall quality of life than the control group who had no CGA, yet in persons with high comorbidity there was no difference in ADL or overall quality of life improvement between the CGA/no CGA group. This underlines the need of better defining the ideal target population that can get benefit from this approach. Despite there being evidence that CGA in certain patients can improve outcomes, there are currently a number of limitations of the process. The first major issue is that there is a lack of standardization in the assessment. The first assessment tools generally focused on single domains, such as cognitive functioning or mood, and lacked comprehensiveness and standardization. More recently, InterRAI [14], a scientific not-for-profit corporation, has developed a range of validated and standardized setting-specific instruments (i.e., home care, long term care etc.) for older patients. These tools, such as the InterRAI Home Care instrument, are internationally validated comprehensive geriatric assessments. They include common items that have the same scorings and definition, and provide ways not just to standardize assessment but also to standardize data collection and comparison, using international data sharing. Second, there is a lack of standardization in the care approach [7]. A systematic review of CGA