The importance of a comprehensive geriatric assessment for older people admitted onto a virtual ward

The purpose of completing a comprehensive geriatric assessment (CGA) is to provide a holistic assessment of patients who are frail or are vulnerable adults, in order to deliver measurable health improvements to the older person and reduce hospital admissions (Welsh et al, 2014). In an ever-ageing population – with currently over 12 million people in the UK over the age of 65 and close to 15 000 aged over 100 – the need for CGAs has never been greater (Welsh et al, 2014; Age UK, 2019; Office for National Statistics, 2019).

Virtual wards are a relatively new approach in health care and there has been a drive for these in the NHS in England since the COVID-19 pandemic (NHS England, 2022a). COVID-19 virtual wards showed that they could be implemented safely and quickly while reducing hospital admissions by up to 50% (Thornton, 2020; NHS England Transformation Directorate, 2023). Recent pressures to develop transformational change within the NHS have led to the development of virtual wards or ‘hospital at home’ services for frail older people and people with long-term health conditions (British Geriatrics Society, 2022).

The British Geriatrics Society (2022) and NHS England (2022b) discussed different models when developing a virtual ward using face-to-face assessments, remote monitoring and advice services to provide a person-centred, effective, and safe hospital care at home service following a CGA. Following on from the NHS England/NHS Improvement (2020) Urgent Community Response paper on the development of rapid response teams (RRT) in the community, integrated care systems (ICSs) – the new bodies responsible for commissioning healthcare services – are taking steps to transform services so they are fulfilling the principles required to establish a virtual ward supported by an RRT (British Geriatrics Society, 2022). An RRT consists of a full multidisciplinary team of consultant practitioners, advanced practitioners, senior nurses, nursing associates, physiotherapists, occupational therapists, social workers, social care officers, pharmacists, support workers, and night sitters to provide a holistic service to patients in the community providing a 2-hour urgent response (NHS England/NHS Improvement, 2020).

A qualitative paper by Mäkelä et al (2020) not only highlighted how a CGA for the older person on a virtual ward can facilitate long-term strategies to meet the personal, social, and service needs of the patient following discharge from the virtual ward but also discussed the underpinning principles of a CGA for patients on a virtual ward.

Case study

The theoretical, composite case presented here is that of Mrs Smith, a 78-year-old female, who was widowed and lived alone. The RRT had received a referral from the North-West Ambulance Service (NWAS). The paramedic felt that she would be a suitable candidate to be admitted onto the virtual ward as she was showing signs of delirium and possibly required hospital treatment, due to her acute confusion he felt that a hospital admission might disorientate Mrs Smith further and delay her recovery time (Røsvik and Rokstad, 2020; Scerri et al, 2020).

Mrs Smith's presenting complaint was delirium secondary to a urinary tract infection (UTI). She was showing signs of acute confusion, mild fever, new incontinence, and an offensive smell of urine in the house had been noted. However, the latter should not be used as a diagnosing symptom for a UTI (Age UK, 2021). Mrs Smith had reduced mobility and a Rockwood Clinical Frailty Scale score of 6. The referral from NWAS to the RRT was received as part of the step-up pathway onto the virtual ward. The observations reported by the paramedic were: temperature 37.9C, blood pressure 108/78 mmHg, peripheral oxygen saturation Sp02 99% on room air, respiratory rate 20 breaths per minute, pulse 92 beats per minute and she was acutely confused. Her score for the National Early Warning Score 2 (NEWS2) was 6 – this is an early warning score designed to help identify the acutely unwell patient (Smith et al, 2019). Mrs Smith had a past medical history of hypertension, depression, osteoarthritis to both knees and chronic kidney disease (CKD) stage 3. Her current prescribed medications were ramipril 10 mg once daily, citalopram 20 mg once daily and paracetamol 1000 mg up to four times a day when required, with no over-the-counter remedies.

Frailty

Junius-Walker et al (2018) defined frailty as:

‘A health condition of decreased functional reserves leading to a vulnerable state with the inherited risks of a multitude of adverse outcomes.’

Older people with frailty are less likely to recover from stressful events such as hospital admissions, accidents such as falls and physical illness (NHS England, 2023). In England 50% of the population over the age of 65 have a form of frailty (British Medical Association (BMA), 2022). Older frail people are at a greater risk of hospitalisation, care home admission, disabilities, and death (Kinsella, 2018), which highlights the need for the correct identification of an older person with frailty at the earliest opportunity to improve patient outcomes (BMA, 2022; NHS England, 2023). With this information in mind, there is a need for a transformational change from hospital admissions to virtual ward or hospital at home services within the community to improve patient outcomes and provide the best quality of patient care (British Geriatrics Society, 2022; NHS England, 2023).

Frailty has been an evolving concept for two decades with extensive research into the subject. Over this time there has been a move away from the ‘unmeasured heterogeneity of ageing’ (Rockwood and Howlett, 2018). Before frailty emerged as a concept a person's chronological age was considered to target care of the older person, but, the ageing process is variable between people (Looman et al, 2018). ‘Frailty’ was introduced to help assess the different domains of functioning and early identification of health risks in the older person (Looman et al, 2018).

There are multiple frailty scoring tools that are available to help determine a person's level of frailty. Fried et al (2001) developed the frailty phenotype model with five characteristics that identify a person with possible pre-frailty and clinical frailty, with the aim of standardising frailty with a pre-defined set of criteria that explores the clinical phenotype. The phenotype model requires a face-to-face assessment and a patient's underlying medical conditions can alter the patient's frailty score, reducing the model's reliability, and it may not be possible to conduct a suitable assessment within the virtual ward setting (Fried et al, 2001).

Other models such as the Cumulative Deficit Model (CDM) and the Rockwood Clinical Frailty Scale are widely used. The CDM looks at the patient's physical and mental health and social factors, it lists 70 variable symptoms, the more symptoms identified from the table the higher the frailty score (Rockwood and Mitnitski, 2007). As a patient's symptoms can vary daily, there is a need for routine screening to maintain a clear accurate frailty score for the patient. A negative aspect of the CDM is that it does not have a clear frailty classification, unlike the phenotype model (Ritt et al, 2015). On the other hand, Looman et al (2018) suggested a standard ‘frail older person’ does not exist and that the term actually covers a diverse group, meaning more specific identification is needed.

Clegg et al (2013) suggested the phenotype model and CDM were preferable models for clinicians. However, the standardised model of choice within acute services and primary care is currently the Rockwood Clinical Frailty Scale (Church et al, 2020; Northern Care Alliance, 2022). The scale originally had 7 classifications (Rockwood et al, 2005), the updated version consists of 9 classifications from 1: very fit to 9: terminally ill, and includes a scoring criterion for people with dementia (Rockwood et al, 2007). The scale focuses on the person's abilities to manage activities of daily living or if the person depends on others to complete tasks and activities. Even though there are clear classifications within the scale (https://tinyurl.com/96c8zyhf), it is based on the clinician's perception of the patient's abilities when scoring their frailty, and as a result may not provide consistent scoring between different clinicians and services. This needs to be considered when patients are referred to a service with a frailty score already calculated (Moreno-Ariño et al, 2020).

The Rockwood Clinical Frailty Scale is a tool that can be used to help predict a patient's illness trajectory and aid the clinician in discussing with the patient – and possibly friends, family and carers – which treatment pathway to follow, whether that is palliative or restorative (Voumard et al, 2018; Elliott et al, 2021). Elliott et al's (2021) study highlighted that the greater a person's frailty score, the higher the prevalence of palliative treatment plans being developed (rather than restorative plans) due to the poor illness trajectory of the frail older person.

When Mrs Smith was referred to the RRT by the ambulance service the paramedic's handover noted that she had a Rockwood Clinical Frailty Scale score of 6, identifying that Mrs Smith was moderately frail and required full support with outdoor activities, help with personal care and dressing, and that extra support with household jobs was required. From the paramedic's referral Mrs Smith seemed an ideal candidate to be brought onto the virtual ward, possibly speeding up her recovery time and improving her experience of care, and also reducing her mortality risk by receiving hospital at home care (British Geriatrics Society, 2022; NHS England, 2023).

Comprehensive geriatric assessment

A CGA is a multidimensional holistic assessment and is seen as the gold standard for the older person over the age of 65 (Lee et al, 2020). It follows five domains that needs to be considered as part of the assessment: physical medical conditions, mental health conditions, functioning, social circumstances, and the patient's environment (Welsh et al, 2014; Parker et al, 2018) (Table 1). Ward and Reuben (2022) highlighted the advantages and disadvantages of a CGA being conducted for the older person in different settings. A CGA completed within a person's home or on an acute geriatric care unit has been shown to reduce the overall mortality and reduce functional decline in the frail older person (Ward and Reuben, 2022). However, CGAs conducted as part of a post-hospital discharge, outpatient consultations and inpatient consultations have shown little or no benefit for mortality rates in the frail older person (Ward and Reuben, 2022).

For a CGA to be effective in the community a full multidisciplinary team, such as a community RRT, is required to provide a holistic service for the older person (Ward and Reuben, 2022). It is for this reason that the British Geriatrics Society (2022) and NHS England (2022a) recommend that hospital at home services or virtual wards should be provided by community RRTs. Evidence suggests that using the CGA in the community can reduced hospital admissions, reduce the risk of readmission to hospital, promote independence and reduced mortality (Rubenstein, 2015; British Geriatrics Society, 2019). The Getting It Right First Time Programme advises the older person admitted onto a virtual ward with a Rockwood Clinical Frailty Scale score of 5 and above should receive a CGA, NEWS2 score, delirium screen, nutritional assessment, medication optimisation and a clear ongoing care plan for the patient (Hopper, 2021).

Physical and mental health conditions

First, a full medical history was required from Mrs Smith to start her CGA of her physical medical conditions and severity of her disease progression. She had a diagnosis of CKD, depression, hypertension, and osteoarthritis of both knees. A discussion with Mrs Smith had identified she appeared acutely confused, and a ‘4 As test’ (4AT) rapid delirium screen (https://www.the4at.com) as recommended in the National Institute for Health and Care Excellence (NICE) (2023) guideline, confirmed this acute delirium. To help with the CGA, a patient transfer of care (TOC) summary record was requested from Mrs Smith's GP as she lived alone and her next of kin was not available at that time to assist during the CGA. It is crucial that a concise history is obtained when conducting a CGA and even more so when a patient's mental capacity may be diminished due to an acute episode of delirium (Lamont et al, 2016; British Geriatrics Society, 2019).

Mrs Smith had symptoms of new incontinence, mild fever, frequency, dysuria on micturition and reduced mobility. As she was showing new signs of lower urinary tract symptoms (LUTS) and delirium a UTI was the most likely diagnosis (Age UK, 2021). Delirium is defined as an acute disturbance of cognition, awareness and attention of a patient, which can be fatal to the older person (Inouye et al, 2014). There are three subtypes of delirium (NICE, 2023):

• Hyperactive delirium with symptoms of agitation, inappropriate behaviour and hallucinations
• Hypoactive delirium with symptoms of lethargy, reduced appetite and concentration
• Mixed delirium with symptoms of both hyperactive and hypoactive delirium.

Mrs Smith was showing signs of hypoactive delirium and three out of the five ‘geriatric giants’ associated with increased mortality and morbidity: confusion, incontinence, and impaired homeostasis (the other two giants are falls and iatrogenic disorders) (Hughes, 2018). Patients with delirium have longer stays in hospital and delirium symptoms can be exacerbated in unfamiliar setting, giving a negative prognosis for the patient (Tripathi and Vibha, 2009; NICE, 2023). Therefore, a delirium screen was extremely important for Mrs Smith's prognosis on the virtual ward as she displayed potential reversible causes of delirium, which needed to be investigated.

To identify a differential diagnosis of delirium the mnemonic DELIRIUMS, developed by Flaherty and Morley (2004) to recognise the treatable causes of delirium, has been used in conjunction with the Greater Manchester Health and Social Care Partnership (GMHSCP) pathway for identifying and managing delirium in the community (GMHSCP, 2021) (Table 2). There are alternative algorithms that can be used, such as HIDEMAP and PINCHME when ruling out other causes of delirium (Public Health England, 2020; NICE 2023). Following the delirium pathway and taking a full history of symptoms had identified that Mrs Smith had a reversible cause to her delirium, namely a UTI. A mid-stream urine sample was obtained and sent to the laboratory to confirm the diagnosis. As Mrs Smith was over the age of 65 a urinalysis dipstick was an unreliable diagnostic tool due to the prevalence of asymptomatic bacteriuria in the older person without infection (Rousham et al, 2019; Joseph, 2020). Due to the over-prescribing of antibiotics for UTIs in the frail older person it is important that patients are displaying new LUTS before commencing treatment, if there are no new LUTS then an alternative cause of the delirium needs to be considered (Hartman et al, 2022).

Using the Public Health England (2020) quick reference flowchart for the older person with a suspected UTI allows the clinician to rule out differential diagnoses with life-threatening symptoms that require urgent attention, such as sepsis or pyelonephritis. Prompt treatment of these via the virtual ward has been shown to improve patient outcomes, and this is helped by the RRT multidisciplinary approach to a patient's health and social care needs (British Geriatrics Society, 2022). The older person with a cognitive decline due to illness has a poor illness trajectory after an episode of delirium, which highlights the importance of early recognition, diagnosis, and treatment of delirium and UTIs in the community (Tsui et al, 2022; NICE, 2023).

It was thought that having a UTI had caused Mrs Smith to have urinary incontinence, but there are multiple causes and types of urinary incontinence (Blundell and Gordon, 2015). Incontinence is a common distressing complaint in the older person with women having a higher prevalence than men (Goepel et al, 2010; Orell et al, 2013). The effects of incontinence on the older person can cause further risks to a patient such as falls, malnutrition, isolation from others and the feeling of embarrassment (Blundell and Gordon, 2015; Age UK, 2021). A full incontinence assessment would be required if Mrs Smith's symptoms did not resolve once the infection was treated and a referral to the community incontinence team would be required (Orell et al, 2013).

Part of a CGA is assessment of a patient's nutritional status. Malnutrition costs healthcare services across the UK over £20 billion a year with only 31% of older people eating a healthy balanced diet (Age UK, 2019; British Dietetic Association, 2020). Malnutrition can go undetected in the older person due to social isolation in the community, the recent COVID-19 pandemic produced a rise in malnourished older people due to this (British Dietetic Association, 2020). Older people are more vulnerable to acute illnesses, medication issues and malnutrition due to age-related changes to homeostasis, metabolism, gut function, and food absorption (Blundell and Gordon, 2015). The effects of malnourishment can be detrimental to an older person's health such as fatigue, increased falls risk and a reduced ability to fight infections (British Dietetic Association, 2020).

On assessment Mrs Smith weighed 46 kg and was 1.6 m tall, giving her a body mass index (BMI) of 17, identifying she was underweight (Gadzik, 2006). Reviewing recent weights documented on her TOC form and using the Malnutrition Universal Screening Tool (MUST) she had a MUST score of 2 (Murphy et al, 2018). With Mrs Smith's reduced mobility, depression and not taking sufficient nutrients could reduce her ability to fight infection therefore oral nutritional supplements were required to help improve her prognosis and outcome (British Dietetic Association, 2020). Following the local community nutrition support pathway for adults gives clear prescribing guidance on oral nutritional supplements and when reassessment is required, onward referral to a dietitian is also required if supplementation is commenced and the patient was at high risk of malnourishment (Bury Local Care Organisation, 2021).

Functioning, social and environment

As part of the CGA Mrs Smith's function was assessed, which identified chronic inflammation caused by osteoarthritis of the knees, reduced muscle weakness, strength and power of the limbs with reduced mobility due to infection. She was showing symptoms of sarcopenia (Xie et al, 2020). Sarcopenia carries an increased risk of disability and even death and is classed as a new ‘geriatric syndrome’ therefore a plan of exercise to improve resistance and strength training was required to reduce mortality rates (Zhang et al, 2018; Xie et al, 2020). To help assess Mrs Smith's dependency in conducting her activities of daily living the Barthel Index was used during the CGA (Sinoff and Ore, 1997; British Geriatrics Society, 2019). Further assessment of Mrs Smith's balance and gait was required therefore the RRT physiotherapist was requested to carry out a full functionality assessment including a falls risk assessment (Raîche et al, 2000; Cattelani et al, 2015).

It is paramount that a patient's mood and cognition is assessed as part of a CGA to provide a holistic assessment, as 1 in 10 older people suffer from a mental health condition (British Geriatrics Society, 2019). The 15-item Geriatric Depression Scale (https://tinyurl.com/54n2psuu) would be used in assessing mental health to help diagnose clinical depression, severity of depression and effectiveness of current treatment (Blundell and Gordon, 2015; British Geriatrics Society, 2019). Assessment of Mrs Smith's mental health identified she had suffered from depression since the death of her husband in 2015, she was taking medication for her depression, which appeared stable with no recent changes to medication or doses.

Depression is the most common mental health complaint in the older person, with bereavement being a leading cause (Age UK, 2019). As Mrs Smith was suffering from acute delirium a full mental health assessment was not feasible however, and was conducted later once her acute delirium had resolved. She was admitted onto the virtual ward for up to 14 days, which allowed time for a further mental health assessment (British Geriatrics Society, 2019; 2022). A mental capacity assessment may be required for set identified tasks, due to these current delirium symptoms (British Geriatrics Society, 2019). If Mrs Smith could not make her own decisions, then a further assessment by the RRT social worker would be requested. She did not have a person granted lasting power of attorney to make decisions for her (Blundell and Gordon, 2015).

Social circumstances and environment are the next domains within the CGA. The older person is 40% more likely to feel socially isolated, they are at a higher risk of dementia due to loneliness and even premature death (Age UK, 2019). Mrs Smith had previously been independent but due to her suffering from several acute issues including delirium she had agreed to social care input via the RRT (British Geriatrics Society, 2022). She did have a good social network of family, friends, and neighbours who helped with her health and social care needs. Later discussion over the telephone with Mrs Smith's next of kin identified they were aware her care needs had increased due to this acute episode; they were close to carer breakdown (the family were reaching the point of crisis and struggling with Mrs Smith's care needs) but wanted Mrs Smith to remain at home. A study by Etkind et al (2020) has highlighted how remaining at home and having family support and care is a high priority for patients. At the time of assessment Mrs Smith did not display any challenging behaviour, however, due to her acute confusion and increased risk of falls the RRT had highlighted concerns for her safety being at home overnight therefore a night sitter was organised to help her remain in her own home (British Geriatrics Society, 2019).

A home environment risk assessment identified various adaptions that could be implemented to help Mrs Smith become more independent during this acute health crisis (Blundell and Gordon, 2015). She lived in a spacious bungalow but had never previously required an occupational therapist assessment. Due to the acute delirium, reduced mobility, and new incontinence Mrs Smith was at an increased risk of falls (British Geriatrics Society, 2019). As an urgent crisis response team, the RRT can request urgent equipment the same day to help a patient remain in their own home and avoid hospital admission therefore an RRT occupational therapist was requested to provide a holistic assessment of Mrs Smith's environmental needs and possible adaptations to help maintain independence (NHS England/NHS Improvement, 2019; NHS England, 2021; British Geriatrics Society, 2022).

Medication review

An important component of a CGA is a medication review. There are multiple validated tools available to help conduct a medication review and optimise the patient's medication (Blundell and Gordon, 2015; British Geriatrics Society, 2019; Northern Care Alliance, 2022). Polypharmacy in the frail older person can be detrimental to their health due to increased adverse drug reactions and age-related changes to the body (Petchey and Gentry, 2019). Some medications are prescribed to treat side effects of other medications in the older person. Using the STOPP/START and NO TEARS tools to help identify high-risk problems will help reduce pill burden and optimise medication therapy (British Geriatrics Society, 2019; Northern Care Alliance, 2022).

On reviewing each of Mrs Smith's medicines, once the delirium episode had resolved, she was able to discuss what, when and why she was taking each medication, but it had highlighted some concerns. On the GP TOC form her recorded blood pressure had remained low for several months but no change to her ramipril dose was noted. With Mrs Smith being on the virtual ward a medical monitoring device was in situ alerting RRT staff 24 hours a day to her NEWS2 score, therefore a trial without ramipril was commenced (British Geriatrics Society, 2022). As Mrs Smith depression was currently stable and she was still suffering with bereavement no changes to her citalopram regimen were made.

It was previously identified that Mrs Smith was malnourished and underweight. She had been taking paracetamol 1000 mg four times a day, which could cause paracetamol toxicity as according to the British National Formulary (Joint Formulary Committee, 2022) she should only be taking 500 mg four times a day, further diagnostics were requested due to this. Medication that required an immediate start was oral nutritional supplementation, due to malnourishment (Bury Local Care Organisation, 2021). Mrs Smith was not on any medication for bone health therefore once diagnostic blood results were available vitamin D supplements were considered, but not required at this assessment (British Geriatrics Society, 2019). If commencing more than one medication, then this should be introduced individually and, if stopping medication, then it is necessary to reduce them gradually to avoid adverse reactions (Greater Manchester Medicine Management Group, 2023a).

Prioritising problems and care plan

Once the CGA had been conducted a problem list was identified to help prioritise Mrs Smith's problems and develop a patient-centred treatment care plan accordingly (British Geriatrics Society, 2019):

• Acute delirium
• Dehydration
• Malnutrition
• Possible acute kidney injury
• Reduced mobility
• Sarcopenia
• Suspected accidental staggered paracetamol overdose
• Urinary tract infection.

The final part of the CGA was to develop an individualised patient-centred treatment care plan. Mrs Smith was admitted onto the virtual ward for up to 14 days under the RRT, social care input was arranged to aid with personal care, prompt diet and push fluids, plus a night sitter arranged to maintain her safety overnight. Nutritional supplementation and antibiotics were commenced in accordance with symptoms and guidelines with Ethel's CKD stage 3 in mind (Bury Local Care Organisation, 2021; Joint Formulary Committee, 2022; Greater Manchester Medicine Management Group, 2023b). Further assessments from the RRT physiotherapist, OT and a social worker were requested to provide a holistic approach to Mrs Smith's care on the virtual ward. A referral to the community dietitian was also completed and a referral to the incontinence team planned if her symptoms had not resolved while on the virtual ward (Orell et al, 2013; Bury Local Care Organisation, 2021). Further assessments were required around advanced care planning and long-term strategy planning on personal, social, and service needs post-discharge from the virtual ward if required (Makela et al, 2020). On discharge from the virtual ward a discharge summary was completed and sent to her GP updating them of the care received while on the virtual ward and to highlight any further GP actions required

Conclusion

This article has highlighted the importance of conducting a CGA for the older person admitted onto a virtual ward to improve patient satisfaction and improve patient outcomes and illness trajectory. Using the CGA provides a holistic logical approach to a patient case study, as shown here with the discussion of a diagnosis of acute delirium and UTI in the frail older person. The example here shows how an evidence-based patient-centred treatment care plan can be developed for the frail older person on a virtual ward and post-discharge planning considered.

KEY POINTS

• During the COVID-19 pandemic virtual wards reduced hospital admissions by 50%, which has led to transformational changes within the NHS.
• A comprehensive geriatric assessment (CGA) provides a holistic assessment of the older person and highlights an appropriate treatment plan
• Virtual wards/hospital at home services that use the CGA can reduce a patient's risk of mortality and morbidity
• This article discusses the assessment, treatment and management of delirium and urinary tract infection in the older person, in the context of a CGA for a virtual ward

CPD reflective questions

• A comprehensive geriatric assessment (CGA) can be completed in all healthcare settings, how would you incorporate this assessment in your workplace?
• Reflect back on a previous patient encounter, think about how you would have used the CGA in this situation. Would your treatment plan have changed? If not, why not ?
• Dementia and urinary tract infection can significantly affect the older person's ability to complete daily tasks. How would you involve a multidisciplinary team to help you complete a CGA ?