Journal of Gerontological Nursing

Feature Article 

Development of a Comprehensive Geriatric Assessment Led by Geriatric Nurse Consultants: A Feasibility Study

Rebecca L. Trotta, PhD, RN; Aditi D. Rao, PhD, RN; Robin M. Hermann, MSN, CCRP; Marie P. Boltz, PhD, RN, GNP-BC, FGSA, FAAN

Abstract

Hospitalized older adults are at high risk for complications, leading to negative outcomes such as longer lengths of stay, hospital readmissions, and functional and cognitive decline. Comprehensive Geriatric Assessment (CGA) models are effective in mitigating these syndromes but are not widespread. Nurses with expertise in gerontology who can provide consultation and care coordination can improve care processes and clinical outcomes. This pilot study capitalized on the role of the geriatric nurse consultant (GNC) to develop, implement, and test the feasibility, acceptability, and utility of a GNC–led CGA. Through repeated applications with hospitalized patients, this study demonstrated that GNCs could complete a CGA and identify clinically actionable findings. This study also uncovered clinical geriatric concerns that would not have otherwise been identified via traditional nursing assessments. The results highlight contribution of a GNC–led CGA as a mechanism to support care process improvements to address common geriatric concerns in the acute care setting. [Journal of Gerontological Nursing, 44(12), 25–34.]

Abstract

Hospitalized older adults are at high risk for complications, leading to negative outcomes such as longer lengths of stay, hospital readmissions, and functional and cognitive decline. Comprehensive Geriatric Assessment (CGA) models are effective in mitigating these syndromes but are not widespread. Nurses with expertise in gerontology who can provide consultation and care coordination can improve care processes and clinical outcomes. This pilot study capitalized on the role of the geriatric nurse consultant (GNC) to develop, implement, and test the feasibility, acceptability, and utility of a GNC–led CGA. Through repeated applications with hospitalized patients, this study demonstrated that GNCs could complete a CGA and identify clinically actionable findings. This study also uncovered clinical geriatric concerns that would not have otherwise been identified via traditional nursing assessments. The results highlight contribution of a GNC–led CGA as a mechanism to support care process improvements to address common geriatric concerns in the acute care setting. [Journal of Gerontological Nursing, 44(12), 25–34.]

An acute care hospital stay continues to be a life-changing event for many older adults, often resulting in complications that are unrelated to the reason for admission (Wier et al., 2009). The acute illness or injury is superimposed on age-related changes and other baseline vulnerabilities, which can include one or more of the following: impaired function, sensory loss, the presence of comorbidities, complicated medication regimes, and complex social situations (Creditor, 1993; Smith & Cotter, 2016). As a result, older adults are at risk for hospital-acquired complications, including the new onset or exacerbation of delirium (Inouye, Studenski, Tinetti, & Kuchel, 2007), functional decline (Boltz, Resnick, Capezuti, Shuluk, & Secic, 2012; Covinsky et al., 2003; Kortebein, Ferrando, Lombeida, Wolfe, & Evans, 2007), pressure injuries (Baumgarten et al., 2006), adverse medication events (Goodman, Villarreal, & Jones, 2011), and falls (Oliver, Healey, & Haines, 2010). These geriatric syndromes increase the likelihood that upon discharge from the hospital older adults will be readmitted, be relocated to a nursing home, and experience protracted functional decline, as well as higher rates of mortality (Anpalahan & Gibson, 2008; Goodman et al., 2011).

The atypical presentation of older adults and the likelihood of multiple overlapping problems create a complex challenge to the clinical care team. The coexisting medical, functional, psychological, and social needs of acutely ill older adults warrant a comprehensive assessment. Comprehensive geriatric assessment (CGA) is a mechanism to facilitate coordination of an integrated, interdisciplinary plan of care for initial treatment and long-term follow up (Stuck, Siu, Wieland, Adams, & Rubenstein, 1993).

Role of the Comprehensive Geriatric Assessment

Two types of CGA models have been examined in the acute care setting. The first model is offered in a hospital unit, known as acute care for elders (ACE) or geriatric evaluation and management (GEM) (Baztán, Suarez-Garcia, Lopez-Arrieta, Rodriguez-Manas, & Rodriguez-Artalejo, 2009; Van Craen et al., 2010). Care is delivered by a multidisciplinary team and often coordinated by a geriatrician and geriatric nurse practitioner. In the second model, the interdisciplinary geriatric consultation service, an interdisciplinary team visits appropriate patients throughout the hospital, assessing patients and making recommendations (Ellis, Whitehead, Robinson, O'Neill, & Langhorne, 2011). These individuals work together to perform coordinated assessments, discuss findings, make referrals, and develop treatment plans and recommend interventions (Smith & Cotter, 2016). Both models have demonstrated improvements in cognitive recovery, especially in older adults at high risk for cognitive and functional decline. In addition, older adults receiving hospital-based CGA were more likely to be alive and living at home as compared to those not receiving CGA (Ellis et al., 2011).

Given the shortage of geriatricians, as well as other clinicians trained in geriatric care (Institute of Medicine, 2008), a more feasible approach is warranted to support uptake and dissemination of CGAs. Geriatric nurse consultants (GNCs), staff nurses who have received training in the assessment and management of geriatric syndromes and serve as a resource to peers (Boltz et al., 2013), offer a potential alternative to leading CGA-based programs. Nurses are integral to care coordination on acute care units and comprise the workforce with the most direct and sustained contact with patients (U.S. Department of Health and Human Services, Health Resources and Services Administration, 2010). Nurses with expertise in gerontology, strategically positioned to provide unit-based consultation and care coordination, have demonstrated the ability to improve care processes and clinical outcomes (Boltz et al., 2008; Capezuti et al., 2012). It is likely, then, that GNCs can assume a leadership role in the CGA process, conducting assessments and coordinating interprofessional evaluations and implementation (Borenstein et al., 2016).

Purpose

The purpose of the current pilot study was to develop a process for nurses trained as GNCs to administer a CGA in the acute care setting with medical patients. The primary aim of the study was to develop, implement, and test the feasibility and acceptability of the GNC–led CGA on general medical units. The secondary aim was to evaluate the utility of the assessment to yield clinically actionable findings. Preliminary descriptive CGA results are also presented.

Method

Design

This study used an exploratory design employing principles of rapid-cycle quality improvement methodology (Berwick, 1998). Iterative rounds of implementation, evaluation, and revision were used to promote feasibility, acceptability, and utility of a GNC–led CGA. This study was approved by the Institutional Review Board of the University of Pennsylvania.

Setting and Participants

The current study took place on three general medical units at a large urban academic medical center in the northeastern United States. GNCs (N = 30) served as key informants and study participants. To participate as GNCs, nurses needed to have a minimum of 1-year experience on the unit and work at least 32 hours per week. The GNC role was voluntary. Most GNCs were female (83%, n = 25) and Caucasian (80%, n = 24); 13% were African American (n = 4) and 7% were Asian (n = 2). GNCs ranged in age from 23 to 59 (mean age = 33 years) and had an average of 10 years of experience (range = 1 to 38 years). All GNCs were bachelor's-prepared.

Procedures

The study took place over 17 months, beginning with an initial version of the CGA, which was created via literature review and expert consultation with an interdisciplinary team of nurses, nurse practitioners, physicians, clinical nutritionists, therapists, pharmacists, and social workers. These individuals provided guidance on the selection of tools to comprise the CGA and the process by which the results could be used by members of their respective disciplines.

Initial CGA

In addition to demographic information, the initial CGA included instruments to assess patients' sensory and physical function, cognition, nutritional status, social support, medication adherence, and medication profile. A complete list of instruments contained in the initial CGA is provided in Table 1.

Initial Comprehensive Geriatric Assessment Components

Table 1:

Initial Comprehensive Geriatric Assessment Components

Visual acuity was assessed using the hand-held Snellen test (McGraw, Winn, & Whitaker, 1995). Hearing was evaluated with the Whispered Voice Test (Pirozzo, Papinczak, & Glasziou, 2003). Basic activities of daily living (ADL) and instrumental activities of daily living (IADL) were assessed using the Barthel Index and Lawton IADL Scale, respectively, and were evaluated at baseline (report of status 2 weeks prior to admission) as well as current status. The Barthel Index is a 14-item measure of physical function that assesses ability for self-care in ADLs (walking/mobility, transfer ability, stair climbing ability, dressing, bathing, feeding, grooming, toilet use, and bowel and bladder control) (Mahoney & Barthel, 1965). The Lawton IADL Scale assesses independent living skills in eight domains of function: (a) telephone use, (b) shopping, (c) food preparation, (d) housekeeping, (e) laundry, (f) transportation, (g) self-administration of medication, and (h) management of finances (Lawton & Brody, 1969). In addition, the Physical Capability Scale was used to measure 11 basic abilities: following verbal and visual commands; demonstrating full flexion, external, and internal rotation of the upper extremities; pointing and flexing toes; flexing knees and marching; rising from a chair; and standing independently for 1 minute (Resnick, Galik, & Boltz, 2014).

The Get Up and Go Test evaluated balance function on a 5-point scale, requiring patients to rise from a chair, walk 10 feet, return, and sit back down (walking aids/equipment may be used) (Mathias, Nayak, & Isaacs, 1986). Grip strength measured the amount of static force that the hand can squeeze around a dynamometer, measured in kilograms, calculated as mean of three trials of grip strength for each hand (Roberts et al., 2011).

The Mini-Cog (three-item recall test for memory and a scored clock-drawing test) was used to screen for cognitive impairment (Borson, Scanlan, Chen, & Ganguli, 2003). The Confusion Assessment Method (CAM) was used to assess for delirium. The CAM includes four features found to have the greatest ability to distinguish delirium from other types of cognitive impairment: (a) acute onset and fluctuating course, (b) inattention, (c) disorganized thinking, and (d) altered level of consciousness (Inouye et al., 1990).

The Patient Health Questionnaire-2 (PHQ-2) was used to screen for depression. This tool comprises two questions that inquire about depressed mood and anhedonia (Kroenke, Spitzer, & Williams, 2003). The Mini-Nutritional Assessment (MNA) comprises six questions scored on a Likert scale (Vellas et al., 1999). The MNA assessed changes in food intake, recent weight loss, current mobility status, recent psychological distress or acute disease, current neuropsychological problems (dementia/depression), and body mass index. The Enriched Social Support Inventory (ESSI), a seven-item measure, was used to evaluate the availability of support from any network member, plus a single item inquiring about the existence of a marital partner (Mitchell et al., 2003). The Medication Management Assessment was used to assess patients' medication adherence practices at home.

Finally, medications were evaluated to identify potentially inappropriate medications (PIMs) using the 2015 American Geriatrics Society (AGS) Beers Criteria (AGS, 2015). There is sufficient evidence for the reliability and validity of all measures for use in older adults.

Preparation of GNCs to Administer the CGA

To prepare for their role, GNCs first received basic gerontological nursing training via the NICHE Geriatric Resource Nurse online modules (20 hours) (Capezuti et al., 2012). Upon completion of these modules, GNCs received certificates from NICHE as Geriatric Resource Nurses, which was foundational to their preparation. In addition, they received 22 hours of didactic and interactive education on geriatric assessment, evidence-based management of common geriatric syndromes, and the process for CGA administration in the clinical setting. Upon completion of training, a competency evaluation was conducted with each GNC to validate skill and knowledge in administration of the CGA. Study directors were also available to answer GNCs' questions and provide one-on-one support regarding CGA administration and interpretation of results.

Implementation of the CGA

Each of the three study units had one budgeted full-time position (40 hours per week) for a GNC, which was filled by the pool of 30 GNCs on a rotating basis Monday through Friday from 7:00 a.m. to 3:30 p.m. Therefore, each GNC enacted the consultative role approximately two shifts per month, with hours dedicated solely to the consultative role. When GNCs were not acting as consultants, they functioned as staff nurses on the study units. The study researchers elected to train and facilitate a large number of GNCs in this role to support extensive gerontological competence, rather than concentrating this expertise in a smaller number of nurses.

Each morning, GNCs received a list of patients admitted to the medical units within the past 24 hours who were 65 and older. GNCs conducted the CGA and developed a plan to address the needs according to CGA findings. GNCs also conducted follow-up visits on patients seen by other GNCs on previous days to facilitate implementation of interventions initiated on previous days. Therefore, GNCs typically saw one new patient and conducted approximately two to six follow-up visits, depending on census, in an 8-hour day.

Feedback to Establish the Feasibility, Acceptability, and Utility of the CGA

Information was gathered in real-time as GNCs administered the CGA in clinical practice. Two approaches were used to gather data: (a) observations of CGA implementation with patients, and (b) small group huddles with GNCs to discuss CGA implementation. Project directors conducted the observations and led the huddles with GNCs. Based on feedback and observations, findings were used to refine CGA process (i.e., administering CGA instruments, interpreting results, communicating findings to interprofessional team members, and collaborating on development of a treatment plan). Once the final CGA was established, a standardized competency evaluation was conducted by the project directors to establish mastery of the CGA and interrater reliability. The purpose of this assessment was to ensure that each GNC was administering the CGA in a consistent and complete manner, and that there was concordance with administration among all GNCs. GNCs then received training in communication of CGA results using SBAR (Situation, Background, Assessment, Recommendation) methodology (Thomas, Bertram, & Johnson, 2009) with interprofessional team members. GNCs used evidence-based protocols outlined in the text, Evidence-Based Geriatric Nursing Protocols for Best Practice (Boltz, Capezuti, Fulmer, & Zwicker, 2012), to make recommendations to the patient and the interprofessional team. For example, GNCs frequently referenced the protocol to prevent functional decline in the acute care setting (Boltz, Capezuti, et al., 2012). CGA results were collected over the past 6 months to provide foundational descriptive data on the potential for the CGA to yield clinically actionable findings that can be addressed during an acute hospital stay.

Results

Feasibility, Acceptability, and Utility of the CGA

Table 2 provides a description of the issues identified in implementing the CGA, the type of issue (feasibility, acceptability, and/or utility), and the changes made to the CGA to resolve the issues.

Feasibility, Acceptability, and Utility of the Comprehensive Geriatric Assessment (CGA)

Table 2:

Feasibility, Acceptability, and Utility of the Comprehensive Geriatric Assessment (CGA)

Feasibility. GNCs stated that it was feasible to conduct the CGA, allowing a rest period in some cases for patients. They reported some discomfort in speaking with family members, particularly dealing with family stress/anxiety and lack of knowledge about the CGA process. Thus, scripting and individualized coaching to introduce and administer instruments was provided and integrated into the CGA training process.

GNCs, with input of the inter-professional team, made recommendations to change the order of the CGA instruments, identify cognitive impairment early in the evaluation, and identify the need for a surrogate reporter. They also recommended supplementing assessment of cognition with open-ended questions to engage patients in the assessment and explore patients' perception of their cognitive status, including awareness of potential deficits.

Acceptability. Patients provided input on the acceptability of the assessment. They provided feedback that the assessments of ADLs and IADLs (Barthel Index and Lawton IADL Scale, respectively) were lengthy, and some patients were disinterested in answering all questions. To address this concern, patients were asked to describe their daily routine to provide a meaningful context for the questions about physical function and to develop individualized plans.

Utility. Multiple stakeholders also provided feedback regarding the utility of the CGA items. GNCs recognized that the CAM, when negative, did not proactively identify patients at risk for delirium. Therefore, an assessment of delirium risk factors was added (Inouye, 1998). Members of the interprofessional team questioned the utility of the PHQ-2 on screening for depression, stating it did not identify enough detail to guide a treatment plan. They recommended that the PHQ-9 (Kroenke, Spitzer, & Williams, 2001) be used instead. In the PHQ-9, nine questions address the nine specific symptoms of major depressive disorder scored on a Likert scale. Four unscored questions assess perceived functional status related to work, home, and social life; coping strategies; and desire for additional support and/or resources. Two measures in the initial CGA, the Enriched Social Support Inventory and grip strength, did not demonstrate use for the acute care setting and were therefore eliminated from the CGA.

Preliminary Findings of the Finalized CGA

As shown in Table 3, the final CGA was administered over 6 months to 179 patients on three medical units. Average patient age was 75.7 years; 51% of patients were female, 38.6% were African American, and 52% were Caucasian. Average hospital length of stay was 7.8 days. Patients also had an average of 16 comorbidities and were discharged on an average of 13 medications.

Patient Characteristics (N = 179)

Table 3:

Patient Characteristics (N = 179)

Table 4 shows the order of instruments and content of the final CGA, as well as the preliminary 6-month patient findings. Thirty percent of patients described baseline problems with memory or thinking, and more than one half of patients demonstrated cognitive impairment (55%) and 60% screened positive for depression. In addition, 20% showed signs of delirium. The majority (75%) experienced decline in ADL function from baseline to admission, and risk for or actual malnutrition (90%). Thirty percent claimed inconsistent medication adherence, and 74% were receiving at least one PIM.

Final Comprehensive Geriatric Assessment and Initial Findings

Table 4:

Final Comprehensive Geriatric Assessment and Initial Findings

Discussion

Consistent with other studies, the current project emphasized that nurses who receive gerontological preparation can play an essential role in the assessment of hospitalized older adults when deployed in innovative roles (Boltz et al., 2008; Boltz et al., 2013; Boltz, Resnick, Chippendale, & Galvin, 2014; Capezuti et al., 2012). The current study demonstrated that through repeated applications with hospitalized patients, nurses could complete the CGA and identify clinical findings. This finding is clinically relevant, as issues uncovered by the GNC–led CGA are issues that are not typically measured or addressed in the acute care setting, as the focus of acute care nurse's work is to address the acute admitting problem (e.g., treatment for pneumonia or heart failure). Prevention and management of common geriatric syndromes are not prioritized (Boltz, Resnick, et al., 2012). The CGA provides a mechanism to engage direct care nurses who have received specialized training in gerontological assessment and care planning to detect the risk for actual or potential problems. Moreover, the CGA process used in the current study included the integration of multiple staff nurses, supporting the extensive dissemination of acute care gerontological expertise across three hospital units.

The CGA findings yielded the opportunity for implementation of several evidence-based protocols focused on addressing common geriatric syndromes within the three nursing units where this work was conducted. The high number of patients who screened positive for depression revealed the opportunity to more pointedly address depression in the acute care setting. The number of patients who demonstrated pre-admission functional decline underscores the need for diligent, function-focused care beginning upon admission.

Another notable CGA finding was the high number of patients who showed or were at risk for nutritional compromise. These findings are consistent with other studies (Agarwal et al., 2013; Corkins et al., 2014; Hudson, Chittams, Griffith, & Compher, 2018). Older adults' nutritional status can rapidly decline during hospitalization, and poor nutritional status can compromise outcomes such as mortality, length of stay, hospital readmission, physical ability, and quality of life (Agarwal et al., 2013; Corkins et al., 2014; Gariballa & Forster, 2007; Pedersen, Pedersen, & Damsgaard, 2016; Wakabayashi & Sashika, 2014). With proactive assessment and intervention, however, nutrition can be maintained, and these negative outcomes can be mitigated. Referral to hospital nutritionists is a practice that also demonstrates positive outcomes (Somanchi, Tao, & Mullin, 2011). In addition, family members and patients should have access to nutritious snacks and fluids in the unit kitchens.

The current pilot study also sheds light on important medication issues. First, the use of PIMs raises concern given the strength of the evidence against their use in older adults (AGS, 2015). GNCs are well poised to assess for PIM use in the hospital and lead discussions with providers and pharmacists to implement safer alternatives. Second, patients demonstrated poor medication adherence practices. Approximately 30% of older adults take five or more prescription medications, and many also concurrently take multiple over-the-counter medications (Qato et al., 2008). In addition, poor adherence practices could lead to a host of negative and even dangerous outcomes (Fick, Mion, Beers, & Waller, 2008; Hilmer & Gnjidic, 2009). Through CGA, GNCs can support patients and caregivers in developing strategies to improve adherence practices after discharge.

The impact of the GNC–led CGA on patient, nurse, and organizational outcomes warrants investigation. In addition to addressing the needs of patients and their families, CGA has the potential to improve nurse competency and autonomy, which are associated with improved care delivery and nurse work satisfaction (Boltz et al., 2008; Capezuti et al., 2012). In addition, maximizing nurses' skills to conduct CGAs and synthesize findings into a set of actionable recommendations may improve the efficiency and effectiveness of interprofessional team-based, hospital medical care. Finally, a GNC–led CGA can help promote patient and family engagement in the process, which is associated with improved patient and family outcomes (Boltz et al., 2014).

The role of the GNC and the GNC–led CGA was developed with grant funding, as part of a health system initiative to support atrisk hospitalized older adults. Next steps include evaluating the cost-effectiveness of the CGA, including examining the potential cost-avoidance related to prevention of costly complications as well as improved patient satisfaction. Given that gerontological expertise was developed in 30 nurses, it is important to consider how their expanded knowledge and skill sets may have influenced care delivery in other role functions not related to the CGA, and not yet examined.

Limitations

The current study, by virtue of its pilot nature, was limited in scope and design, and as stated above, evaluation of efficacy. Availability of GNCs was an occasional barrier. For example, a nurse scheduled to function in the GNC role on a given day could be required to assume a patient assignment if needed. In addition, if a GNC was absent from work, his or her position as a GNC on that particular day was not filled by another GNC. Finally, the GNC role was operationalized only on weekdays, which could have impeded consistency, although this was not explicitly evaluated. Despite these barriers, given the program accounted for having three GNCs on a particular day, there was never a day when no GNCs were available. Nonetheless, it was important in demonstrating that specialized geriatric knowledge and skill could be disseminated to multiple staff nurses. Furthermore, it showed that bachelor's-prepared nurses could reliably implement the CGA, an evidence-based approach typically led only by advanced practice nurses or physicians, and participate in driving change to improve geriatric care processes in the hospital setting. Capitalizing on bachelor's-prepared nurses, however, could be a limiting factor with regard to generalizability. Finally, this project underscored the critical role of staff nurses in promoting geriatric evidence-based practice.

Future Research

There are additional areas for future investigation, including examining the populations that would most benefit from the CGA (i.e., specialty units and specific patient populations [e.g., advanced age, nursing home origin, cognitive impairment]). The GNC role may have to be customized to meet the needs and capacity of varying hospitals based on size, resources, patient demographics, and patient acuity. Evaluating the need for ongoing professional development of GNCs and generalizability of the GNC role among nurses who are not bachelor's-prepared are also opportunities for further investigation.

Conclusion

The current feasibility study demonstrated that nurses practicing in the acute care setting can administer a CGA and uncover clinically actionable findings. This study also demonstrated many opportunities to improve evidence-based geriatric care. Despite the noted limitation, the GNC–led CGA process shows promise as an emerging geriatric care model.

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Initial Comprehensive Geriatric Assessment Components

Sensory
  Snellen Test
  Whispered Voice Test
Physical Function
  Barthel Index
  Lawton Instrumental Activities of Daily Living Scale
  Physical Capability Scale
  Get Up and Go Test
  Grip Strength
Cognition
  Mini-Cog
  Confusion Assessment Method
  Patient Health Questionnaire-2
Nutrition
  Mini-Nutritional Assessment
Social Support
  Enriched Social Support Inventory
Medication
  Medication Management Assessment
  American Geriatrics Society 2015 Beers Criteria

Feasibility, Acceptability, and Utility of the Comprehensive Geriatric Assessment (CGA)

Issue/ProblemChanges to the CGA
Feasibility—Geriatric nurse consultants' (GNCs) perceptions of their ability to complete the CGA
GNCs identified the need for more structured questions about cognition and memory in addition to completing the Mini-Cog to give them insight into the patient's potential cognitive limitations.Added the following questions to the cognitive assessment:

Do you feel you have problems with your memory or thinking? If yes, how long have you had these problems?

Has anyone else ever told you they think you have problems with your memory or thinking? If yes, who has told you?

Do you do anything at home to help you with your memory or thinking? If yes, please describe.

In some patients, cognitive impairment was not detected until the end of the CGA.Changed order of assessment instruments to have cognitive questions first.
GNCs expressed discomfort obtaining information from family members, including concern about handling family anxiety and stress.Provided scripting and individualized coaching to introduce and administer instruments.
Acceptability—Patient and GNC perception of the length and pace of administration, and relevance of the CGA instruments
Some patients did not think that the Barthel and Lawton questions were relevant and lost interest in engaging with the GNC.Added open-ended questions regarding daily routine to obtain insight into functional ability and provide a relevant context for Barthel and Lawton questions.
Utility—Ability of the instruments to yield clinically actionable findings
Medical providers reported that the Patient Health Questionnaire-2 (PHQ-2) provided insufficient information about depression from which to act clinically.Replaced the PHQ-2 with the PHQ-9, a more detailed 13-question instrument.
Confusion Assessment Method did not identify risk for delirium in those who screened negative.Added risk assessment for predisposing and precipitating risk factors for delirium. Risk factors include: cognitive impairment, vision/hearing impairment, immobilization, psychoactive medication use, dehydration, and sleep deprivation.
The Enriched Social Support Inventory (ESSI) did not provide meaningful information beyond the basic nursing assessment.The ESSI was eliminated from the CGA.
Grip strength was not deemed actionable—interdisciplinary team did not believe the findings informed care plan development.Grip strength was eliminated from the CGA.

Patient Characteristics (N = 179)

DemographicMean (Range)
Age (years)75.58 (65 to 98)
Hospital length of stay (days)7.78 (1 to 46)
n (%)
Gender
  Female91 (51)
  Male88 (49)
Race
  White93 (51.96)
  Black or African American69 (38.55)
  Asian5 (2.79)
  American Indian or Alaska Native2 (1.12)
  Native Hawaiian or other Pacific Islander1 (0.56)
  Not reported9 (5.03)
Ethnicity
  Non-Hispanic158 (88.27)
  Hispanic5 (2.79)
  Not reported16 (8.94)
Discharge disposition
  Home with home care services85 (47.49)
  Home55 (30.73)
  Skilled nursing facility/long-term care33 (18.44)
  Hospice4 (2.23)
  Rehabilitation center2 (1.12)

Final Comprehensive Geriatric Assessment and Initial Findings

InstrumentMeasureScoringPatient Findings (N= 179)
Cognitive Assessment
  Open-ended questionsPatient perception of cognitionBrief qualitative responses33% described “problems with memory or thinking”
  Mini-CogScreening for cognitive impairmentRange = 0 to 5; 0 to 2 = positive for cognitive impairment, 3 to 5 = negative for cognitive impairmentPositive n= 55 (30.7%)
  Patient Health Questionnaire-9Depression diagnostic assessmentRange = 0 to 27; 1 to 4 = minimal, 5 to 9 = mild, 10 to 14 = moderate, 15 to 19 = moderately severe, and 20 to 27 = severe60% scored ≥10
  Confusion Assessment MethodDeliriumScreen positive (delirium present) or negative20% screened positive for delirium
  Delirium Risk AssessmentDelirium riskRisk factors identified to be addressed with a plan.30% had at least two risk factors: cognitive impairment, vision/hearing impairment, immobilization, psychoactive medication use, dehydration, and sleep deprivation
Functional Assessment
  Barthel IndexFunctional statusRange = 0 to 20; lower score indicates lower functional ability75% had activities of daily living decline from baseline to admission
  Lawton IndexFunctional statusRange = 0 to 8; higher score indicates greater independence with instrumental activities of daily living (IADL)75% had IADL decline from baseline to admission
  Physical Capability ScalePhysical capabilityRange = 0 to 16; higher score indicates greater physical capabilityResults informed mobility plan; all patients deemed appropriate for transfer out of bed to chair
  Get Up and Go TestPhysical function assessmentRange = 1 to 5; 1 = no risk for falling during the test, 5 = severe abnormal fall risk due to staggering/stumblingResults informed mobility plan
Nutritional Assessment
  Mini-Nutritional Assessment–Short FormNutritional status assessmentRange = 0 to 14; 0 to 7 = malnourished, 8 to 11 = at risk of malnutrition, 12 to 14 = normal nutritional status90% were malnourished or at risk for malnourishment
Pharmacotherapy Assessment
  Medication Management AssessmentMedication management and adherenceIdentifies deficits in medication management and adherence practices at home30% reported inconsistent medication adherence and potentially unsafe management practices at home
  Medication Evaluation using 2015 Beers CriteriaPotentially inappropriate medications (PIMs)Number of PIMs present74% received at least one PIM over the course of hospital stay
Authors

Dr. Trotta is Director of Nursing Research and Science, Dr. Rao is Director of Nursing Practice, Mrs. Hermann is Manager of Nursing Research, Hospital of the University of Pennsylvania; Dr. Trotta is also Adjunct Assistant Professor of Nursing, and Dr. Rao is Adjunct Assistant Professor of Nursing, University of Pennsylvania School of Nursing, Philadelphia; and Dr. Boltz is Elouise Ross Eberly and Robert Eberly Professor of Nursing, Penn State College of Nursing, State College, Pennsylvania.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This work was supported by a grant from the Health Resources and Services Administration (UD7HP26041).

Address correspondence to Rebecca L. Trotta, PhD, RN, Director of Nursing Research, Hospital of the University of Pennsylvania, Nursing Administration, Dulles 106, 3400 Spruce Street, Philadelphia, PA 19104; e-mail: Rebecca.Trotta@uphs.upenn.edu.

Received: July 06, 2018
Accepted: October 04, 2018

10.3928/00989134-20181109-03

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