Multidimensional geriatric assessment: back to the future.

CYCLING of events, modes, and cultural movements pervades history and art. Almost every time a new idea emerges, we are prompt to spot the roots of its inspiration in the past. Theories and practices once widely popular fade for decades until they are rediscovered, almost always with a different flavor or viewed from a different angle. Of course, because of improved experience, knowledge, and technology, the old and pale idea often turns into a modern and glamorous motif. Geriatric medicine is no exception: We can trace the origin of Comprehensive Geriatric Assessment (CGA) to the experience of the Sepulveda Geriatric Evaluation Unit (1), perhaps the single most important experiment in modern geriatrics conducted well over two decades ago. The demonstration that CGA conducted by an interdisciplinary team on a subacute hospital ward could yield large improvements in outcomes of frail elderly patients, including increased survival, improved functioning, and decreased nursing home placement became almost a mantra in every scientific meeting, and caused a burst of enthusiasm and optimism for the prosperity and growth of geriatric medicine as a science and a specialty. The effect in geriatrics was akin to dropping a large rock into a small pond. Among the ripples propagated were 1) a new focus on classification, identification and intervention in older persons whose decline could be prevented, delayed, or reversed; 2) invigorated attention to development and application of multidimensional health status measures relevant for older persons generally and in specific clinical contexts; and 3) improved scientific standards for the conduct of clinical and health services research in geriatrics toward improving the evidence base for clinical care. We will not expand further on details, our readers know quite well what GCA represents, and the history and accomplishments of CGA programs have been extensively reviewed (2). It is fair to say that, in spite of these successes, the implementation of CGA in clinical practice was at best patchy and not long-lived. It would be easy to conclude that, because the early enthusiasm surrounding CGA has largely dissipated after a few years, it was perhaps unwarranted. In reality, the implementation of CGA faced different challenges. First, some of the numerous subsequent self-identified studies have been negative. At the same time, there have been few attempts to ‘‘replicate’’ successful CGA trials: The health systems contexts, the interventional elements, and patients themselves are so complex that individual trials—while able to attain internal validity—are hardly ever reproducible or their findings generalizable. This has been a major limitation for systematic reviews and for development of multicenter randomized trials (3–5). Thus, the messages became mixed, at best. Moreover, geriatricians and allied health professionals with specialized training became more and more rare, and payment for health care continued to skew to acute and procedural medical care not well suited to frail elderly or older patients with multiple morbidities (6). Nowadays, in the U.S., units like the one at Sepulveda exist only in the Veterans Affairs (VA) system—most of those in modified form—and geriatric interdisciplinary team care is seldom encountered except in the VA and in settings such as the Program for All-Inclusive Care of the Elderly (PACE). Fortunately, enough of the principles of CGA, including the use of problem lists and care plans that involve multiple providers/disciplines and reach out to family and community resources, remained as an unconscious legacy—beyond our shores and even beyond geriatrics. The time is ripe now to reexamine this legacy at work in current research, and revisit multidimensional geriatric assessment (MGA) in the special section of the present issue. The studies collected herein show the continuing themes and increasing diversity of CGA/MGA research. Four reports describe three randomized controlled trials (7–10). Two of these studies had the added objective of formal costeffectiveness analysis, which, in time of economic recession, is an element essential to implementation and has been rare in this literature (7–9). Echoing past experiences, the first of these two Dutch home visit trials showed positive effects on functional status and mental well-being and indicated that the program was cost effective (7,8), while the other showed none of the hypothesized impacts on healthcare utilization or associated costs (9). These and many other trials are included in an updated systematic review of geriatric preventive home visit programs, also in this issue (11). While the common concern of home visit programs is the identification of at-risk older persons in their homes, prevention of functional deterioration, and preservation of the community tenure, the systematic review reveals heterogeneity of both programs and effects characterizing even this narrowly defined program type. Importantly, in