1. 10 slides on… Comprehensive Geriatric Assessment for older people with CKD Dr Miles D Witham Clinical Reader in Ageing and Health University of Dundee

2. What is Comprehensive Geriatric Assessment? Multidomain assessment of function, capabilities and resources Physical, cognitive, psychological, social Requires a multidisciplinary team Must lead to actions to improve problems, increase support, ameliorate symptoms, and treat / prevent disease

3. Systematic review data Highly effective 22 trials, 10,000 patients Works best if done by a dedicated team on a specialist ward Cochrane dB SR 2011; CD006211 Ellis et al. BMJ 2011; 343: d6553 DomainOR / SMDNNT Alive in own home at 6 mths1.25 (1.11, 1.42)17 Alive in own home at 12 mths1.16 (1.05, 1.28)13 Institutionalised0.79 (0.69, 0.88)25 Death or functional deterioration0.76 (0.64, 0.90)17 Death at 6 mths0.91 (0.80,1.05)- Cognition improvement (SMD)0.08 (0.01, 0.15)- OR: Odds ratio SMD: Standardised mean difference

4. How does CGA differ from what is done in renal units normally? CGAUsual renal care Renal problems×  Comorbid disease  Geriatric syndromes (e.g. falls, incontinence)  × Cognition  × Depression / anxiety  ?? Physical function  × ? Social function  × ? Diet  Complex discharge planning  End of life care  / × ?? ? = sometimes done; varies between units

5. Who is needed to deliver CGA? A multidisciplinary team. Core members are usually: A geriatrician Nursing staff with expertise in caring for older people Physiotherapist Occupational therapist Plus other members, often including: Dietitian Speech and language therapy Social worker Pharmacist

6. Who should receive CGA? CGA is probably most beneficial to older people who are frail See the presentation on frailty for how you might identify these people Frailty is not the same as multimorbidity (although the two may go hand in hand) Another way to identify those patients who might benefit is those who present with frailty syndromes: Falls Reduced mobility Incontinence Delirium or other cognitive impairment

7. Where should CGA be delivered? The best results in clinical trials come from CGA that is delivered by a specialist team on a specialist ward Roving teams that visit patients on other wards do not work as well Having said this, CGA is a process that should extend beyond hospital, out into the community Assessment might start in hospital, but therapy, rehabilitation, changes to medications, and further assessment might occur after discharge CGA also occurs in:Rehabilitation units Intermediate care Day Hospitals At home (e.g. hospital at home)

8. How might I go about doing this in practice? 1) Assemble a team 2) Gather suitable assessment tools 3) Agree criteria for who to apply CGA to 4) Meet regularly as an MDT to discuss assessment results and make a comprehensive plan 5) Deliver the plan and reassess

9. An example Mrs X has advanced CKD, and is admitted for the third time this year with AKI and falls After supportive treatment by renal team, her AKI resolves Physiotherapist assesses her falls risk (Tinetti score) and physical function Occupational therapist gathers information on her home and current activities of daily living Geriatrician reviews her medications Nursing staff assess cognition using the MoCA (Montreal Cognitive assessment) Social worker gathers information from family on current support and likely future needs

10. At MDT, a plan is made: -Mrs X wants to remain at home, and family happy to support this -PT delivers strength and balance training to reduce falls -OT modifies home environment to reduce falls -Cognitive testing reveals cognitive impairment -Medication reminder system implemented -Geriatrician suggests stopping some medications to reduce falls risk; discussion with renal team and patient about balance between falls risk, risk of precipitating delirium, AKI risk and need to manage CKD -3x/day package of care arranged -Follow up cognitive assessment with geriatrician arranged for a few weeks time (to allow any delirium time to settle) -Social work to reassess care needs at home in 4 weeks time

11. Summary CGA is a powerful, evidence-based approach to improving outcomes in older people Best targeted at those with frailty Requires the right mix of specialists to deliver, facilitated by the right assessment tools Not just an assessment, but an ongoing process