Comprehensive Geriatric Assessment: From Miracle to Reality

THANK you very much for this great honor. I am really pleased to have been selected by my colleagues for this award and to join a long list of past Freeman awardees, many of whom were my own wonderful mentors and senior faculty members, such as David Solomon and John Beck, as well as noted friends and colleagues, including Frank Williams, Bob Butler, Jack Rowe, Chris Cassel, Knight Steel, Evan Calkins, Reubin Andres, Richard Besdine, Isadore Rossman, Lissy Jarvik, Harvey Cohen, Bill Hazzard, Mary Tinetti, and Bob Luchi. (Maybe I magically thought by dropping their names, some of their wisdom and poise might rub off on my own words today!) Who was Dr. Joseph Freeman? He was a past president of the Gerontological Society of America (GSA) and an internist with a pioneering interest in the health problems of older adults. He authored some of the earliest geriatrics textbooks, including Clinical Principles and Drugs in the Aging in 1963 and Clinical Features of the Older Patient in 1965. He chaired the internal medicine section of the first White House Conference on Aging in 1961, and was on the faculty of the Medical College of Pennsylvania for over 20 years. The Clinical Medicine Section of GSA established the Freeman Award lectureship in 1977 with an endowment to honor Dr. Freeman. Dr. Freeman lived several more years and was actually able to attend some of these lectures. He practiced medicine until his death in 1989 at age 81. My topic today is ‘‘Comprehensive Geriatric Assessment: From Miracle to Reality.’’ I’ll try to give an overview of the concept of comprehensive geriatric assessment (CGA), its history as a central guiding principle of geriatrics, its rationale, and research evidence for its effectiveness— spanning the earliest single-site trials to the more recent multi-site trials. In the process, I’ll try to give my perspective on some of the key aspects of CGA and why the effectiveness data seems to have varied between trials and over the years. My hope is that key elements will emerge that are signals to guide future development. Recognition of these elements will insure the continued usefulness and cost effectiveness of CGA as an important tool for improving care of frail elders. I was really fortunate to have entered geriatric medicine on the ground floor (or maybe the second floor), at a time when there was almost a limitless amount to discover and study. The field was new, and the potential areas of research were just beginning to be scoped out and studied rigorously. People thought I was somewhat weird to be going into geriatrics then. After all, who would want to specialize in people who were often felt to be the ‘‘least desirable’’ of patients—patients with short life expectancies, little disposable income, often demanding and difficult to communicate with, and usually with difficult-to-understand complex and interacting medical problems? Well, people probably still think that I’m weird, but the field of geriatrics has matured and become at least almost respectable. It has become eminently clear that our field has developed a truly scientific and effective way for treating complex elderly patients that improves their outcomes and increases their quantity and quality of life. When I entered geriatrics back in 1979 after my Robert Wood Johnson fellowship, my first boss was Itamar Abrass, who put me in charge of a brand new inpatient geriatrics unit at the Sepulveda Veterans Administration (VA) hospital—we called it the geriatric evaluation unit (GEU). I worked there together with our first fellows (many of whom have gone on to major leadership careers in geriatric medicine) and with rotating attending coverage from senior geriatric faculty members such as Dave Solomon, John Beck, Bob Kane, and John Morley. The Sepulveda GEU was based on similar units existing in the United Kingdom where complex older patients could be assessed, treated, and given rehabilitation in a specialized clinical and educational setting. These units were widely used, but never tested for their effectiveness. Most physicians in the U.K. felt that geriatric units were important and effective, but without data, it seemed that the concept would be a hard sell in mainstream U.S. medicine. An exception to the general reluctance in the United States to consider geriatrics services was the VA where the geriatric imperative was appearing well before it had begun to in the rest of themedical care establishment. TheVA anticipated the