Age and Ageing 2022; 51: 1–9 © The Author(s) 2022.

thor(s) 2022. Published by Oxford University Press on behalf of the British Geriatrics
https://doi.org/10.1093/ageing/afac104 Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.

SYSTEMATIC REVIEW

Comprehensive geriatric assessment in older

people: an umbrella review of health outcomes
Nicola Veronese1 , Carlo Custodero2 , Jacopo Demurtas3 , Lee Smith4 , Mario Barbagallo1 ,
Stefania Maggi5 , Alberto Cella6 , Nicola Vanacore7 , Pierangelo Lora Aprile8 , Luigi Ferrucci9 ,

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Alberto Pilotto2,6 , The Special Interest Group in Systematic Reviews of the European Geriatric
Medicine Society (EuGMS), The Special Interest Group in Meta-analyses and Comprehensive
Geriatric Assessment of the European Geriatric Medicine Society (EuGMS)
1
Geriatrics Section, Department of Internal Medicine, University of Palermo, Palermo, Italy
2
Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, Bari, Italy
3
Clinical and Experimental Medicine PhD Program, Università di Modena e Reggio Emilia, Modena, Italy
4
The Cambridge Centre for Sport and Exercise Sciences, Anglia Ruskin University, Cambridge, UK
5
Institute of Neuroscience, Aging Branch, CNR, Padua, Italy
6
Department Geriatric Care, Orthogeriatrics and Rehabilitation, E.O. Ospedali Galliera, Genova, Italy
7
National Center for Disease Prevention and Health Promotion, Italian National Institute of Health, Rome, Italy
8
Italian College of General Practitioners and Primary Care, Florence, Italy
9
Intramural Research Program, National Institute on Aging, National Institute of Health, MD, USA

Address correspondence to: Nicola Veronese. Geriatric Unit, Department of Internal Medicine and Geriatrics, University of
Palermo, via del Vespro, 141, 90127, Palermo, Italy. Tel/fax: 00390916554018. Email: nicola.veronese@unipa.it

Abstract
Background: Comprehensive geriatric assessment (CGA) has been in use for the last three decades. However, some doubts
remain regarding its clinical use. Therefore, we aimed to capture the breadth of outcomes reported and assess the strength of
evidence of the use of comprehensive geriatric assessment (CGA) for health outcomes in older persons.
Methods: Umbrella review of systematic reviews of the use of CGA in older adults searching in Pubmed, Embase, Scopus,
Cochrane library and CINHAL until 05 November 2021. All possible health outcomes were eligible. Two independent
reviewers extracted key data. The grading of evidence was carried out using the GRADE for intervention studies, whilst data
regarding systematic reviews were reported as narrative findings.
Results: Among 1,683 papers, 31 systematic reviews (19 with meta-analysis) were considered, including 279,744 subjects.
Overall, 13/53 outcomes were statistically significant (P < 0.05). There was high certainty of evidence that CGA reduces
nursing home admission (risk ratio [RR] = 0.86; 95% confidence interval [CI]: 0.75–0.89), risk of falls (RR = 0.51; 95%CI:
0.29–0.89), and pressure sores (RR = 0.46; 95%CI: 0.24–0.89) in hospital medical setting; decreases the risk of delirium
(OR = 0.71; 95%CI: 0.54–0.92) in hip fracture; decreases the risk of physical frailty in community-dwelling older adults
(RR = 0.77; 95%CI: 0.64–0.93). Systematic reviews without meta-analysis indicate that CGA improves clinical outcomes in
oncology, haematology, and in emergency department.
Conclusions: CGA seems to be beneficial in the hospital medical setting for multiple health outcomes, with a high certainty
of evidence. The evidence of benefits is less strong for the use of CGA in other settings.

Keywords: comprehensive geriatric assessment, older people, umbrella review, systematic review

Key Points
• Comprehensive geriatric assessment is available to geriatricians and other medical and non-medical figures from three
decades, but it is still poorly used.

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N. Veronese et al.

• Our umbrella review including systematic reviews regarding comprehensive geriatric assessment in older people supported
the use of this approach across several settings and clinical situations, even if supported by different degrees of evidence and
strength.
• A solid literature supports the use of comprehensive geriatric assessment in hospital medical setting for multiple health
outcomes, with a high certainty of evidence, whilst the evidence of benefits is less strong for the use of this approach in
other settings.

Background Table 1 for systematic reviews with or without meta-analysis

in older people using CGA versus standard/usual care or
Comprehensive geriatric assessment (CGA) may be con- using CGA-based tools for predicting health outcomes of
sidered as a multidisciplinary diagnostic process aimed at interest.

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identifying medical, psychosocial, and functional needs of
older people that guide the development of a coordinated
plan to manage the health complexity and to maximise Study selection
overall health in older persons [1, 2]. Overall, CGA is usually For the aims of this work, we included: (i) systematic reviews
initiated through a referral by the primary care physician or with or without meta-analysis that evaluated observational
by clinicians working in the hospital setting. For this reason, studies with longitudinal (prospective or retrospective)
CGA may be different according to the different settings of design reporting on health outcomes in subjects receiving
care and may impact on different outcomes [3]. CGA, for a given condition, in older people; (ii) systematic
CGA has been studied for approximately three decades reviews with or without meta-analysis that evaluated
[1]. Evidence from randomised controlled trials (RCTs) and intervention studies, i.e. RCTs comparing CGA versus
meta-research has suggested that CGA significantly improves standard/usual care or no intervention, for a given condition,
several outcomes in older patients across different conditions in older people. We excluded systematic reviews of cross-
and settings [4]. For example, home CGA programs and sectional studies, narrative reviews without a formal search
CGA performed in the hospital have been shown to be of the literature, conference abstracts, meta-analyses that
consistently beneficial for several health outcomes [5], but reported less than two studies for a single outcome, and
results on the effectiveness of post-hospital discharge CGA letters to the editor. When more than one systematic review
programs, outpatient CGA consultation, and CGA-based on the same research question was available that used similar
inpatient geriatric consultation services are conflicting [5]. study design (observational or RCTs), the one with the
It has been widely recognised that the effectiveness of CGA largest number of studies was selected.
programs may vary in different settings or specific clinical
conditions suggesting CGA programs should be tailored to
Data extraction
the specific purposes that they are for, such as preoperative
assessment [6], admittance or discharged from emergency Two reviewers (JD, CC) independently screened title/ab-
departments [7], orthogeriatric units [8] or evaluation of stracts for eligibility, and when a consensus was not reached
patients with specific medical conditions such as cancer. [9] a third senior reviewer (NV) was consulted. The full texts
Since the body of research on this topic is rapidly of potentially eligible articles were retrieved, and two inves-
expanding, we aimed to summarise the current knowledge of tigators (JD, CC) independently scrutinised each study for
CGA using an umbrella review methodology to capture the eligibility. When consensus was not reached, a third senior
breadth of outcomes reported and globally assess strength of reviewer was consulted (NV).
evidence that CGA can improve multiple health outcomes The following information for each eligible work were
in older persons. extracted: first author name; publication year; number of
included studies and number of participants: study pop-
ulation; type of effect size used; study design (RCT or
Materials and methods observational); type of CGA by model/setting of delivery
(e.g. geriatric ward, geriatric consultation team, acute geri-
The Preferred Reporting Items for Systematic Reviews and atric care unit, emergency department interventions, pre-
Meta-analyses (PRISMA) recommendations guidelines were or perioperative CGA in non-orthopaedic surgical ward,
used to guide this umbrella review [10]. The full protocol is geriatric trauma consultation, geriatric rehabilitation team,
available in PROSPERO (CRD42021246239). orthogeriatric care, multidimensional preventive home visit
program); setting; number of participants with (cases) and
Data sources and searches without (controls) events in observational studies and people
We searched Pubmed, Embase, Scopus, Cochrane library randomised to CGA or usual/standard care in RCTs. We also
and CINHAL from database inception until 05 November extracted the study-specific estimated relative risk for health
2021, with the search strategies reported in Supplementary outcomes (risk ratio, RR; odds ratio, OR; mean difference,

2
 Table 1. GRADE assessment of significant associations of randomised controlled trials of comprehensive geriatric assessment
Certainty assessment Summary of findings

Participants Risk of bias Inconsistency Indirectness Imprecision Publication Overall Study event rates (%) Relative effect Anticipated absolute effects
(studies) bias certainty of (95% CI)
evidence

With With Risk with Risk difference with

usual/standard comprehensive usual/standard comprehensive geriatric
care geriatric care assessment
assessment
........................................................................................................................
Surgery setting
Mortality at 12 months in older adults in surgical ward (emergency surgery) 
4,458 Not serious Seriousa Not serious Not serious None  523/2,932 206/1,526 RR 0.70 178 per 1,000 54 fewer per 1,000
(4 RCTs) MODERATE (17.8%) (13.5%) (0.54 to 0.90) (from 82 fewer to 18 fewer)
Reduction in time to surgery in older adults in surgical ward (emergency surgery) 
1,107 Not serious Seriousa Not serious Not serious Publication  252/536 390/571 RR 0.60 470 per 1,000 188 fewer per 1,000
(3 RCTs) bias strongly LOW (47.0%) (68.3%) (0.50 to 0.73) (from 235 fewer to 127 fewer)
b
suspected
Delirium in older adults hospitalised under nonorthopedic surgical teams for operative or nonoperativemanagement
1,139 Seriousc Not serious Not serious Not serious None  90/536 49/603 (8.1%) RR 0.52 168 per 1,000 81 fewer per 1,000
(5 RCTs) MODERATE (16.8%) (0.37 to 0.92) (from 106 fewer to 13 fewer)
Length of stay (days) in older adults hospitalised under nonorthopedic surgical teams for operative or nonoperative
 management
617 Seriousc Not serious Not serious Not serious None  264 353 - - MD 1.98 days lower
(3 RCTs) MODERATE (3.09 lower to 0.88 lower)
Orthopaedics
Mobility in older adults with hip fracture trauma 
982 Not serious Seriousa Not serious Not serious None  495 487 - - SMD 0.32 SD higher
(6 RCTs) MODERATE (0.12 higher to 0.52 higher)
Delirium in older adults with hip fracture trauma 
1,443 Not serious Not serious Not serious Not serious None 313/667 283/776 OR 0.71 469 per 1,000 84 fewer per 1,000
(6 RCTs) HIGH (46.9%) (36.5%) (0.54 to 0.92) (from 146 fewer to 21 fewer)
ADL in older adults with hip fracture trauma 
d a
1,291 Very serious Serious Not serious Not serious None  648 643 - - SMD 0.26 SD higher
(5 RCTs) VERY LOW (0.04 higher to 0.49 higher)
Mortality in older adults with hip fracture trauma 
2088 Very seriousd Not serious Not serious Not serious None  125/1,047 91/1,041 OR 0.73 119 per 1,000 29 fewer per 1,000
(8 RCTs) LOW (11.9%) (8.7%) (0.54 to 0.98) (from 51 fewer to 2 fewer)
Hospital
Institutionalisation in older adults admitted to hospital at discharge 
4,459 Not serious Not serious Not serious Not serious None 674/2,300 579/2,159 RR 0.86 293 per 1,000 41 fewer per 1,000
(12 RCTs) HIGH (29.3%) (26.8%) (0.75 to 0.99) (from 73 fewer to 3 fewer)
Discharge at home in older adults admitted to hospital 
a
6,799 Not serious Serious Not serious Not serious None  1,852/3,301 2,079/3,498 RR 1.060 561 per 1,000 34 more per 1,000
(16 RCTs) MODERATE (56.1%) (59.4%) (1.009 to 1.100) (from 5 more to 56 more)
Falls in older adults admitted to hospital for acute medical condition or injury 
658 Not serious Not serious Not serious Not serious None 40/469 (8.5%) 14/189 (7.4%) RR 0.51 85 per 1,000 41 fewer per 1,000
(3 RCTs) HIGH (0.29–0.89) (from 61 fewer to 9 fewer)
Pressure sores in older adults admitted to hospital for acute medical condition or injury 
658 Not serious Not serious Not serious Not serious None 36/469 (7.7%) 16/189 (8.5%) RR 0.46 77 per 1,000 41 fewer per 1,000
(3 RCTs) HIGH (0.24–0.89) (from 58 fewer to 8 fewer)
Institutionalisation in older adults admitted to hospital at 3 and 6 months 
6,285 Not serious Not serious Not serious Not serious None 568/3,061 481/3,224 RR 0.80 186 per 1,000 37 fewer per 1,000
(14 RCTs) HIGH (18.6%) (14.9%) (0.71–0.89) (from 54 fewer to 20 fewer)
Non-hospital setting
Physical frailty in community-dwelling older adults 
786 Not serious Not serious Not serious Not serious None 133/351 135/435 RR 0.77 379 per 1,000 87 fewer per 1,000
(3 RCTs) HIGH (37.9%) (31.0%) (0.64 to 0.93) (from 136 fewer to 27 fewer)

CI, confidence interval; RR, risk ratio; MD, mean difference; SMD, standardised mean difference; OR, odds ratio. a I2 between 50% and 75%. b Egger’s test (P-value) < 0.05. c Between 10% and 30% of RCTs with a

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UR CGA

high RoB. d Risk of bias present in more than 30% of the RCTs.

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N. Veronese et al.

Figure 1. PRISMA flow-chart. Downloaded from https://academic.oup.com/ageing/article/51/5/afac104/6581610 by guest on 12 June 2023

MD; standardised mean difference, SMD) and 95% confi- Data synthesis and analysis
dence intervals (CIs). We finally extracted the data for the For each meta-analysis, we estimated the summary effect
Assessment of Multiple Systematic Reviews (AMSTAR)-2 size and its 95% confidence interval (CI) by using the
tool. [11] random-effects DerSimonian and Laird (DL). [13] We also
estimated the prediction interval (PIs) and its 95% CI, which
further accounts for between-study effects and estimates the
Quality assessment certainty of the association if a new study addresses that
Two reviewers (CC, JD) assessed the methodological quality same association [14, 15]. Between-study inconsistency was
of the included meta-analyses using AMSTAR-2 [11, 12] estimated with the I2 metric, with values between 50% and
that ranks the quality of a systematic review from critically 75% indicative of high heterogeneity and ≥75% indicating
low to high according to sixteen predefined grades. very large heterogeneity [16]. We calculated the evidence of
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Table 2. Summary of Findings of the Systematic Reviews (Without Meta-analysis) included of the randomised controlled
trials
Author, year Sample size Surgery Orthopaedics Hospital Non-hospital
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Boult (2009) 5,925 Not available Not available Not available Increase of quality of care in 4/4
RCTs included, quality of life,
use of health care
Daniels (2020) 1,143 Reduction of length of Not available Not available Not available
stay in 2/4 RCTs
Garrad (2019) 1,643 Not available Not available Not available No effect of CGA on mortality
and hospital/ED admission
Marino (2018) 3,382 Not available Not available Not available Reduction of ED/hospital
admission in 3/4 studies included
McCusker (2006) 6,606 Not available Not available Little effect on ED utilisation for Reduction of ED/hospital
hospital-based interventions admission in outpatient and/or

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(excluding ED-based primary care or home care
interventions) settings
Neyens (2011) 3,759 Not available Not available Not available Reduction of falls in 4/8 RCTs
in nursing home residents
RCT: randomised controlled trial; CGA: comprehensive geriatric assessment; ED: emergency department.

small-study effects (i.e. whether small studies inflated effect Findings from the randomised controlled trials
sizes). We used the regression asymmetry test [17], using a P- As reported in Supplementary Table 3, the 53 outcomes
value <0.10 with more conservative effects in larger studies included a median of six RCTs (range: 3–21) with a
as indicative of small-study effects [18]. Furthermore, we median of 2,088 older participants (range: 355–14,597)
assessed if the largest study in each meta-analysis in terms for a total of 182,214 older people. Altogether, about half
of participants was statistically significant, using a P-value of the outcomes were studied in hospital setting (26/53),
<0.05. 10/53 in orthopaedics, nine in surgery setting, five among
Finally, we applied the excess of significance test [19]. The community-dwellers, three in outpatients. Regarding the
larger the difference between observed (O) and expected (E) type of CGA used, the majority (18/53) used CGA-
number of studies, the higher the degree of excess signifi- ward. Among the outcomes investigated, mortality was
cance. Because of the limited statistical power of this test, a the most common explored (14/53), followed by disability
lenient significance threshold (P < 0.10) was adopted [20]. (8/53), and by hospitalisation/re-hospitalisation (4/53)
All analyses were conducted with STATA 13.0 (Stata (Supplementary Table 3).
Corp LP, College station, TX, USA). Overall, 13/53 (=25%) of the outcomes included
reported that CGA is statistically significantly superior to
Grading the evidence usual/standard care in RCTs. Table 1 shows the GRADE
assessment of RCTs of CGA, divided by setting. In
When the P-value for the random effect was <0.05, we eval- emergency surgery setting, the use of CGA was associated
uated the evidence derived from RCTs using the GRADE with lower mortality risk at 12 months (RR = 0.70;
(Grading of Recommendations, Assessment, Development 95%CI: 0.54–0.90; moderate strength) and a lower time
and Evaluation) assessment [21]. We also considered 95% to surgery (RR = 0.60; 95%CI: 0.50–0.73; low strength).
PI (excluding the null or not), the presence of large hetero- In older adults admitted to a surgical service (excluding
geneity (I2 > 50%), small study effects (P < 0.10), and excess orthopaedic ward), there was moderate strength of evidence
significance (P < 0.10) as possible indicators of other biases that perioperative CGA can significantly reduce delirium
in the available evidence. Findings of the systematic reviews compared to usual/standard care (RR = 0.52; 95%CI:
without meta-analysis were reported descriptively. 0.37–0.92) and length of stay in hospital of approximately
2 days (MD = −1.98; 95%CI: −3.09 to −0.88). In older
patients with hip fracture following a trauma, CGA signif-
Results icantly reduced the risk of delirium (OR = 0.71; 95%CI:
0.54–0.92; high strength), prevented mobility decline
Literature review (SMD = 0.32; 95%CI: 0.12–0.52; moderate strength),
As shown in Figure , we identified 1,815 unique manuscripts reduced mortality (OR = 0.73; 95%CI: 0.54–0.98; low
across all searched databases. After excluding 1,679 abstracts, strength) and disability in activities of daily living [ADL]
136 full texts were examined and a total of 31 system- (SMD = 0.26; 95%CI: 0.04–0.49; very low strength)
atic reviews were considered eligible, 19 including a meta- compared to usual/standard care. In older adults admitted
analysis. References of the included works are reported in to hospital for acute medical condition or injury, with a high
Supplementary Table 2. certainty of evidence, CGA significantly reduced nursing

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N. Veronese et al.

Table 3. Summary of Findings of the Systematic Reviews (Without Meta-analysis) included of the observational studies
Author (year) Sample size Surgery Orthopaedics Hospital Non-hospital

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Caillet (2014) 12,900 Optimal prediction of Not available Not available Not available
mortality with
CGA-based tools and
domains
De Almeida (2015) 58,244 Not available Not available Not available CGA captures needs of
older patients
Graf (2011) 2,476 Not available Not available Good discrimination of adverse Not available
outcomes in ED
Lin (2016) 815 Optimal prediction of Not available Not available Not available
mortality with
CGA-based tools

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Scheepers (2020) 212 Not available Not available CGA may help identify higher Not available
risk of non-completion of
chemotherapy for frail people
Terret (2015) 425 Not available Not available CGA may help identify higher Not available
risk of death for frail people and
fit patients for curative therapy
CGA: comprehensive geriatric assessment; ED: emergency department.

home admission at discharge (RR = 0.86; 95%CI: 0.75– by chronic conditions, whilst the effect on hospital/e-
0.89), the risk of falls (RR = 0.51; 95%CI: 0.29–0.89) and mergency department admission, use and costs of health
pressure sores (RR = 0.46; 95%CI: 0.24–0.89) (Table 1). services was less clear. In 3,759 nursing home residents,
Moreover, CGA increased the probability to be discharged CGA decreased the risk of falls in 4/8 RCTs included.
at home after a hospitalisation (RR = 1.06; 95%CI: 1.009– When considering CGA-based tools, the CGA may help
1.10) even if supported by a moderate strength of evidence the clinician to better tailor therapy and reduce mortality in
according to the GRADE. Finally, in community-dwelling 425 patients affected by non-Hodgkin lymphoma. Similarly,
older adults, CGA reduced the risk of physical frailty CGA-based tools reduced the risk of mortality in older
(RR = 0.77; 95%CI: 0.64–0.93; high strength). patients undergoing surgery and with solid tumour cancer.
Supplementary Table 3 reports the ancillary analyses for
the 53 outcomes of the RCTs included in our analyses.
Heterogeneity was low in 24/53 (I2 < 50%), high in 18/53
(I2 between 50 and 75%) and very high in 11/53 outcomes. Discussion
Small study effect, as p-value of the Egger’s test <0.10, was
present in 13/53 of the outcomes included, whereas the In this umbrella review, including 31 systematic reviews and
excess significance bias was present in 10/53 outcomes. The approximately 300,000 older participants, we found data on
largest study reported statistically significant results in 14/53 the effectiveness of CGA across different settings and condi-
outcomes. The prediction intervals included the null values tions and towards multiple outcomes. Focusing on interven-
in all the outcomes evaluated. tion studies we studied of the effect of CGA on 53 different
Supplementary Table 4 reports the quality assessment outcomes including information on ‘hard outcomes’ such as
made according to the AMSTAR2. Overall, among the 19 mortality, risk of hospitalisation and admission to nursing
meta-analyses included, two were rated as of high quality, home. Systematic reviews without meta-analysis completed
four of medium, seven low quality and the others very this picture also giving information regarding the use of
low. Among the 12 systematic reviews included only one CGA-based tools, particularly in patients affected by cancer.
was rated high, two systematic reviews scored low, whereas In the meta-analyses of the RCTs, we found high cer-
the others were deemed to be critically low, as shown in tainty of the evidence regarding the importance of CGA in
Supplementary Table 4. reducing nursing home admission, risk of falls and pressure
sores in hospital setting. These findings indicate that all older
patients admitted to hospital should be evaluated through
Findings from the narrative systematic reviews the CGA not only for decreasing the institutionalisation, but
Overall, 12 systematic reviews without a formal meta- also for decreasing other outcomes, such as falls and pressure
analysis for a total of 97,530 participants were included sores, that can further increase the length of stay in hospital.
(Table 2 for intervention studies, Table 3 for observational These findings are of clinical importance since CGA reduced
studies; other information in Supplementary Table 5). In the risk of nursing home admission, falls, and pressure sores
systematic reviews of RCTs, CGA seems to lead to an of about 41 units for every 1,000 older patients evaluated,
improvement in quality of care in older outpatients affected when compared to usual/standard care, indicating that in

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 UR CGA

hospital setting CGA is a highly beneficial intervention for outcomes. On the contrary, a previous umbrella review on
older patients. the same topic summarised CGA intervention definitions
Moreover, our works indicated that in older patients and benefits, only from systematic reviews and meta-analysis
affected by hip fracture, CGA significantly prevented delir- including interventional studies carried out in hospital set-
ium. Delirium is amog the most frequent complication in ting [5]. Another review of reviews was more broadly focused
people undergoing surgery for a hip fracture, being asso- on different elements of the integrated care approach for
ciated with higher rates of disability and cognitive recov- older people and among others also CGA, but did not
ery, and a prolonged hospital stay with consequent higher analyse effect on clinical outcomes [28]. Both these works,
mortality rates and treatment costs [22]. Moreover, there even if important, only provided a narrative synthesis of the
is an increasing evidence that episodes of delirium may evidence and thus not performing any evaluation of their
increase the risk of dementia after hospital discharge [23, 24]. strength.
Therefore, to reduce the rate of delirium in older patients We believe that our umbrella review can add some novel
affected by a hip fracture is a priority also from a public findings to the discussion regarding the importance of CGA

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health perspective [25] and in this sense CGA seems to be in daily clinical practice. In particular, we think that to
highly effective when compared to usual/standard care as judge several outcomes at high certainty of evidence can
the evidence supporting this finding is not affected by any encourage the use of CGA in these specific areas and settings
bias. Furthermore, 84 fewer patients out of 1,000 patients (such as hospital or orthogeriatrics). At the same time, our
affected by hip fracture and treated with CGA experienced umbrella review indicates some promising areas of research,
delirium. Moreover, even if supported by a lower certainty of e.g. oncology, in which the use of CGA could be strenght-
evidence, CGA seems to be beneficial in improving mobility, ened. Finally, some important topics in geriatric medicine
disability and mortality in patients with a hip fracture further are still not covered by scientific literature regarding CGA,
supporting the benefits of an integrated care of geriatrics and i.e. palliative care. Despite the fact that CGA has been
orthopaedics, i.e. orthogeriatric model [26]. used from three decades and, as reported in our umbrella
In the surgery setting, CGA was useful in decreasing review, a large literature exists regarding its positive effects,
the risk of mortality at 12 months and time to surgery this intervention is still under-used worldwide, probably
in emergency, even if this evidence is supported by a high suggesting that some obstacles are still present. A number
heterogeneity of the findings. Moreover, the finding that of barriers to the implementation of CGA includes the lack
CGA can decrease the length of stay in general surgery by of guidelines, professional and patients’ factors, need for
approximately 2 days is of interest, but again the poor quality professional interactions, capacity for organisational change
of the RCTs included in this investigation did not permit to as well as social, political and legal factors and economic
have firm conclusions regarding this outcome. aspects [29]. In this regard, for overcoming these barriers,
Finally, meta-analyses of the RCTs, suggested that CGA a better approach to research, clinical activity and teaching
is able to significantly reduce physical frailty in community- might be performed and encouraged by geriatricians, also in
dwelling older adults with a high certainty of evidence, fur- concerted actions of other health professionel interested in
ther suggesting that CGA could be beneficial not only in the CGA [30].
hospital setting, but also in primary care settings [27]. How- The findings of our umbrella review must be considered
ever, among the 53 outcomes included, only five included within its limitations. First, the RCTs included in the sys-
community-dwellers thus further research is needed in this tematic reviews with meta-analyses of CGA intervention
setting taking hard outcomes such as mortality, nursing are probably underpowered since small study effect and
home admission and hospitalisation as endpoints. excess significance bias was present in about 1/4 of outcomes
Narrative systematic reviews completed the picture of included. Moreover, different definitions of CGA may influ-
CGA giving some information regarding CGA-based tools ence our results in terms of clinical heterogeneity: we tried to
in populations different from those treated in RCTs, such overcome this limitation using a stringent value of I2 < 50%
as outpatients having cancer. A strong limitation of this for detecting this issue and for giving high certainty of
evidence is that the quality assessment of this kind of evidence according to the GRADE. Similarly, the prediction
works is not possible and, therefore, we cannot distinguish intervals included the null value in all outcomes investi-
high quality evidence from lower grades. Altogether these gated, suggesting that further research is needed. Second,
findings suggest that CGA can be used for evaluating older it is known that meta-analyses have important limitations
patients having solid tumour or haematological cancers and [31] and their results may also depend on choices made
undergoing treatments typical of these conditions, such about what estimates to select from each individual study
as chemotherapy or radiotherapy and finally indicating and how to report them in the meta-analysis (e.g. in our
the role of CGA in personalised medicine in older umbrella review several meta-analyses did not report infor-
patients [9]. mation regarding the type of CGA used) [31]. Further-
Our review is unique since it is the first comprehensive more, applying the criteria suggested by the AMSTAR-2,
literature review of the evidence on use of CGA in dif- we observed that several systematic reviews had low/critically
ferent settings (i.e. hospital, outpatients, community) and low rating, mainly owing to not reporting of funding and not
its effectiveness for prevention of several relevant clinical pre-registering protocols. Moreover, most studies on CGA

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N. Veronese et al.

focused on mortality, but the need for more studies investi- Orla, Soulis George, Tampaki Maria, Tenkattelaar Natasia,
gating patient-centered outcomes is urgent. Perhaps among Thiem Ulrich, Topinkova Eva, Tromp Jorien, Van Beek
limitations or opportunities for future research. Finally, even Michiel, Van Heijningen Lars, Vandeelen Bob, Vanderhulst
if the GRADE is the preferred method for assessing the Heleen, Vankova Hana, Verissimo Rafaela, Vonk Merel,
certainty of evidence, this assessment does not mean auto- Vrabie Calin, Wearing Paul, Weiss Michael, Welmer Anna-
matically the definition of a recommendation, such as a in Karin, Werle Berenice, Ylmaz Ozlem, Shoaib Muhammad
guideline. Zaidi, Zamfir Mihaela, Zanom Ilo, Zuidhof Jen.
2: The Special Interest Group in Systematic Reviews
and Meta-analyses of the European Geriatric Medicine
Conclusions Society (EuGMS): Nicola Veronese, Lee Smith (coordi-
nators); Alves Mariana, Avcy Suna, Bahat-Ozturk Gulis-
In this umbrella review including 19 independent meta- tan, Balci Cafer, Beaudart Charlotte, Bruyère Olivier,
analyses and 53 outcomes, we found that CGA could be Cherubini Antonio, Da Cruz Alves Mariana, Firth Joseph,
beneficial in the hospital setting with a high certainty of

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Goisser Sabine, Hursitoglu Mehmet, Hurst Christopher,
the evidence and with a less strong certainty in surgery, Kemmler Wolfgang, Kiesswetter Eva, Kotsani Marina,
orthopaedics and primary care settings. In older patients Koyanagi Ai, Locquet Médéa, Marengoni Alessandra, Nida,
affected by cancer the use of CGA-based tools seems to Mahwish, Obretin Florian Alexandru, O’Hanlon Shane,
be promising, but further intervention research is urgently Okpe Andrew, Pedone Claudio, Petrovic Mirko, Pizzol
needed. Overall, our findings support the use of CGA in Damiano, Prokopidis Konstantinos, Rempe Hanna, Sanchez
clinical practice, also encouraging new research in different Rodrigues Dolores, Schoene Daniel, Schwingshackl Lukas,
directions in which the geriatrician could be useful for Shenkin Susan, Solmi Marco, Soysal Pinar, Stubbs Brendon,
tailored and personalised medicine. Thompson Trevor, Torbahn Gabriel, Unim Brigid.
Supplementary Data: Supplementary data mentioned in Declaration of Conflicts of Interest: None.
the text are available to subscribers in Age and Aging online.
Declaration of Sources of Funding: None.
Acknowledgement: We wish to acknowledge two collabo-
rative groups:
1: The Special Interest Group in Comprehensive Geriatric
Assessment of the European Geriatric Medicine Society References
(EuGMS): Alberto Pilotto, Maria Cristina Polidori (coor-
dinators); Alves Mariana, Benzinger Petra, Berg Nicolas, 1. Pilotto A, Cella A, Pilotto A et al. Three decades of compre-
Brach Julie, Cardoso Irwin, Cella Alberto, Chefi Ben, Ciurea hensive geriatric assessment: evidence coming from different
Annette, Cornejo Lingan Ana Maria, Cotobal Rodeles healthcare settings and specific clinical conditions. J Am Med
Santiago, Cruz-Jentoft Alfonso, Curiale Vito, Custodero Dir Assoc 2017; 18: 192.e1–11.
Carlo, Danielova Libuse, Davies Franco, De Groot Aafke, 2. Pilotto A. Chapter 16 Comprehensive Geriatric Assessment:
De Groot Cathrine, De Lepeleire Jan, De Vries Benjamin, evidence. In: Michel JP, Beattie BL, Martin FC, Walston JD
Decock Anne-marie, Denkinger Michael, Dikmeer Ayse, Editors. Oxford Textbook of Geriatric Medicine, 3rd Edition.
Dini Simone, Durand Amaury, Fatin Ami, Fernandes Oxford University Press, 2017; pp. 117–26.
3. Devons CA. Comprehensive geriatric assessment: making the
Marilia, Ferrara Nicola, Francis Bahaa, Fratiglioni Laura,
most of the aging years. Curr Opin Clin Nutr Metab Care
Freiberger Ellen, Galvin Rose, Garmendia Blanca, Gillain 2002; 5: 19–24.
Sophie, Gomez Pavon Javier, Goudzwaard J.A., Greco 4. Pilotto A, Panza F. Comprehensive geriatric assessment: evi-
Antonio, Gruner Heidi, Gunther Bernd, Happe Lisa, dence. Oxford Textbook of Geriatric Medicine. In: Michel JP,
Hermush Vered, Huibregtse Bimmel Jan-Kees, Indiano Beattie BL, Martin FC, Walston JD (Ed). 2017; 3: 117–26.
Ilaria, Isaak Julia, Jaramillo Javier, Kerminen Hanna, 5. Parker S, McCue P, Phelps K et al. What is comprehensive
Laocha Aoife Ni, Lau Sandra, Lozano Isabel, Madeira geriatric assessment (CGA)? An umbrella review. Age Ageing
Sarmento Ana Teresa, Mangoni Arduino, Marques da 2018; 47: 149–55.
Silva Pedro, Mars Patricia, Matejovska-Kubesova Hana, 6. Kim K-i, Park K-H, Koo K-H, Han H-S, Kim C-H. Com-
Mattace Raso Francesco, Moeskops Simone, Molnar prehensive geriatric assessment can predict postoperative mor-
Andrea, Musacchio Clarissa, Nagaratnam Kiruba, Nieminen bidity and mortality in elderly patients undergoing elective
surgery. Arch Gerontol Geriatr 2013; 56: 507–12.
Uomo, O’Connor Margaret, Özge Kayhan Koçak Fatma,
7. Conroy SP, Ansari K, Williams M et al. A controlled evalua-
Paccalin Marc, Palikhe Anil, Pavic Tajana, Per Nordnes tion of comprehensive geriatric assessment in the emergency
Raymond, Platon Izabela, Polinder Harmke, Prada Gabriel, department: the ‘emergency frailty unit’. Age Ageing 2014;
Ragnheim Ragnhild, Ramsawak Lisa, Rewiuk Krzysztof, 43: 109–14.
Rodrigues Carlos, Roller-Wirnsberger Regina, Rossinen 8. Giusti A, Kammerlander C. Comprehensive geriatric assess-
Juhani, Ruotolo Giovanni, Ruppe Georg, Ryan Dan, Sabba ment in orthogeriatrics. In: Pilotto A, Martin F, eds.
Carlo, Sanchez Elisabet, Savas Sumru, Schmid Veronika, Comprehensive Geriatric Assessment. Cham: Springer Inter-
Schroderus Kaisa, Siegrist Monica, Smedberg Daniel, Smit national, 2018; 123–32.

8
 UR CGA

9. Extermann M, Hurria A. Comprehensive geriatric assess- strength of recommendations. BMJ 2008; 336: 924.
ment for older patients with cancer. J Clin Oncol 2007; 25: https://doi.org/10.1136/bmj.39489.470347.AD.
1824–31. 22. Caplan GA, Teodorczuk A, Streatfeild J, Agar MR. The
10. Liberati A, Altman DG, Tetzlaff J et al. The PRISMA state- financial and social costs of delirium. Eur Geriatric Med 2020;
ment for reporting systematic reviews and meta-analyses of 11: 105–12.
studies that evaluate health care interventions: explanation 23. Witlox J, Eurelings LS, de Jonghe JF, Kalisvaart KJ, Eike-
and elaboration. J Clin Epidemiol 2009; 62: e1–34. lenboom P, van Gool WA. Delirium in elderly patients
11. Shea BJ, Reeves BC, Wells G et al. AMSTAR 2: a critical and the risk of postdischarge mortality, institutionaliza-
appraisal tool for systematic reviews that include randomised tion, and dementia: a meta-analysis. JAMA 2010; 304:
or non-randomised studies of healthcare interventions, or 443–51.
both. BMJ 2017; 358: j4008. 24. Morandi A, Davis D, Bellelli G et al. The diagnosis of delirium
12. Shea BJ, Grimshaw JM, Wells GA et al. Development of superimposed on dementia: an emerging challenge. J Am Med
AMSTAR: a measurement tool to assess the methodological Dir Assoc 2017; 18: 12–8.
quality of systematic reviews. BMC Med Res Methodol 2007; 25. Khachaturian AS, Hayden KM, Devlin JW et al. Inter-

Downloaded from https://academic.oup.com/ageing/article/51/5/afac104/6581610 by guest on 12 June 2023

7: 10. https://doi.org/10.1186/1471-2288-7-10. national drive to illuminate delirium: a developing public
13. Lau J, Ioannidis JP, Schmid CH. Quantitative synthesis in health blueprint for action. Alzheimers Dement 2020; 16:
systematic reviews. Ann Intern Med 1997; 127: 820–6. 711–25.
14. IntHout J, Ioannidis JPA, Rovers MM, Goeman 26. Kammerlander C, Roth T, Friedman S et al. Ortho-geriatric
JJ. Plea for routinely presenting prediction intervals service—a literature review comparing different models.
in meta-analysis. BMJ Open 2016; 6: e010247. Osteoporos Int 2010; 21: 637–46.
https://doi.org/10.1136/bmjopen-2015-010247. 27. Garrard JW, Cox NJ, Dodds RM, Roberts HC, Sayer AA.
15. Higgins JP, Thompson SG, Spiegelhalter DJ. A re-evaluation Comprehensive geriatric assessment in primary care: a system-
of random-effects meta-analysis. J R Stat Soc Ser A Stat Soc atic review. Aging Clin Exp Res 2020; 32: 197–205.
2009; 172: 137–59. 28. Briggs AM, Valentijn PP, Thiyagarajan JA, de Carvalho IA.
16. Higgins JP, Thompson SG. Quantifying heterogeneity in a Elements of integrated care approaches for older people: a
meta-analysis. Stat Med 2002; 21: 1539–58. review of reviews. BMJ Open 2018; 8: e021194.
17. Egger M, Davey Smith G, Schneider M, Minder C. Bias in 29. Gladman JR, Conroy SP, Ranhoff AH, Gordon AL. New
meta-analysis detected by a simple, graphical test. BMJ 1997; horizons in the implementation and research of comprehen-
315: 629–34. sive geriatric assessment: knowing, doing and the ’know-do’
18. Carvalho AF, Kohler CA, Brunoni AR et al. Bias in periph- gap. Age Ageing 2016; 45: 194–200.
eral depression biomarkers. Psychother Psychosom 2016; 85: 30. Polidori MC, Roller-Wirnsberger RE. Chances and challenges
81–90. of comprehensive geriatric assessment training for healthcare
19. Ioannidis JP, Trikalinos TA. An exploratory test for an excess providers. Geriatr Care 2018; 4: 79–83.
of significant findings. Clin Trials 2007; 4: 245–53. 31. Ioannidis JP. The mass production of redundant, misleading,
20. Ioannidis JP. Clarifications on the application and interpre- and conflicted systematic reviews and meta-analyses. Milbank
tation of the test for excess significance and its extensions. J Q 2016; 94: 485–51.
Math Psychol 2013; 57: 184–7.
21. Guyatt GH, Oxman AD, Vist GE et al. GRADE: an
emerging consensus on rating quality of evidence and Received 6 January 2022; editorial decision 8 April 2022