Comprehensive geriatric assessment, rehabilitation and discharge planning

Increasing numbers of people are living with multiple chronic diseases and increasing frailty. Patching up one issue can aggravate another; another may not improve until a further one is addressed. These people need a coordinated multidisciplinary assessment to clarify their diagnoses and management plans, also taking into account patients’ own wishes and their broader social environment and support. This assessment process is known as comprehensive geriatric assessment (CGA), and is associated with improved mortality and reduced risk of institutionalization. CGA requires assessment in a number of domains, which are outlined in the article along with examples of the roles of the different members of the multidisciplinary team. The article also addresses the role of rehabilitation and complex discharge planning.