Authors: Dong-Ying Bao, Lin-Yan Wu, Qi-Yan Cheng
Categories: Retrospective Cohort Study, Compliance, Comprehensive geriatric assessment, Diabetes, Hypertension, Nursing, Quality of life
Source: World Journal of Clinical Cases
The Comprehensive Geriatric Assessment (CGA) was introduced late in China and is primarily used for investigating and evaluating health problems in older adults in outpatient and community settings. However, there are few reports on its application in hospitalized patients, especially older patients with diabetes and hypertension.
To explore the nursing effect of CGA in hospitalized older patients with diabetes and hypertension.
We performed a retrospective single-center analysis of patients with comorbid diabetes mellitus and hypertension who were hospitalized and treated in the Jiangyin Hospital of Traditional Chinese Medicine between September 2020 and June 2022. Among the 80 patients included, 40 received CGA nursing interventions (study group), while the remaining 40 received routine nursing care (control group). The study group's comprehensive approach included creating personalized CGA profiles, multidisciplinary assessments, and targeted interventions in areas, such as nutrition, medication adherence, exercise, and mental health. However, the control group received standard nursing care, including general and medical history collection, fall prevention measures, and regular patient monitoring. After 6 months of nursing care implementation, we evaluated the effectiveness of the interventions, including assessments of blood glucose levels fasting blood glucose, 2-h postprandial blood glucose, and glycated hemoglobin, type A1c (HbA1c); blood pressure indicators such as diastolic blood pressure (DBP) and systolic blood pressure (SBP); quality of life as measured by the 36-item Short Form Survey (SF-36) questionnaire; and treatment adherence.
After 6 months, the nursing outcomes indicated that patients who underwent CGA nursing interventions experienced a significant decrease in blood glucose indicators, such as fasting blood glucose, 2-h postprandial blood glucose, and HbA1c, as well as blood pressure indicators, including DBP and SBP, compared with the control group (P < 0.05). Quality of life assessments, including physical health, emotion, physical function, overall health, and mental health, showed marked improvements compared to the control group (P < 0.05). In the study group, 38 patients adhered to the clinical treatment requirements, whereas only 32 in the control group adhered to the clinical treatment requirements. The probability of treatment adherence among patients receiving CGA nursing interventions was higher than that among patients receiving standard care (95% vs 80%, P < 0.05).
The CGA nursing intervention significantly improved glycemic control, blood pressure management, and quality of life in hospitalized older patients with diabetes and hypertension, compared to routine care.
Keywords: Comprehensive geriatric assessment, Diabetes, Hypertension, Nursing, Quality of life, Compliance
Core Tip: This is a retrospective single-center study introduces the novel application of the Comprehensive Geriatric Assessment (CGA) in older patients with diabetes and hypertension. Our findings demonstrate that CGA-based interventions significantly improve glycemic control, blood pressure, quality of life, and treatment adherence, offering a promising strategy for holistic care in this demographic.
With declining fertility rates and increased life expectancy, the global population is aging rapidly. China's seventh national census data show a sustained rise in the number of older adults over recent decades[1]. This demographic shift raises concerns about the health of older individuals. The combination of age-related frailty and chronic diseases increases the risk of adverse health outcomes in older adults[2]. Aging is typically associated with a decline in physical function and changes in dietary habits, resulting in an increasing prevalence of age-related diseases[3]. This issue is not limited to medicine and is increasingly becoming a financial burden on the healthcare economy[4]. Diabetes and hypertension are important components of geriatrics, and they have similar etiology and often occur at the same time. Patients with diabetes and hypertension are usually older, less educated compliant with medication, and have limitations in various functional areas, such as motor function, cognition, mood and nutrition levels, resulting in increased difficulty in disease care[5]. Traditionally, healthcare models have focused primarily on managing the disease. However, this study introduces a more comprehensive evaluation method. In addition, the disease management of diabetes and hypertension is not completely disease-oriented, but rather focused on functional status. Therefore, older patients need a nursing method covering social and psychological factors, such as daily activities and participation[6].The Comprehensive Geriatric Assessment (CGA) is committed to assessing potential problems related to patients' physical functioning, psychology, cognition, and social support from a multidimensional perspective. It facilitates the implementation of targeted nursing interventions[7]. CGA can provide considerable benefits to patients at a low cost, including shortening hospitalization time, reducing mortality and hospitalization rates, and improving cognitive levels and quality of life[2]. The CGA enables personalized medical care that aligns with the unique requirements and available resources of each patient. For example, previous studies have demonstrated that this assessment technique positively impacts the functional capabilities and longevity of older adults[8]. Research on CGA in China began late and has primarily been used in outpatient and community settings to assess the health problems of older adults. However, there are limited reports on its application in hospitalized patients, especially among older patients with diabetes and hypertension. Therefore, this study aimed to analyze the effects of an intervention using a comprehensive assessment of the older population.
This single-centered, retrospective study investigated older patients with diabetes and hypertension who were hospitalized in the Jiangyin Hospital of Traditional Chinese Medicine between September 2020 and June 2022. Participants were aged ≥ 60 years, with diabetes and hypertension diagnosed according to the 2019 World Health Organization criteria. Older patients with severe communication disorders, such as Alzheimer's disease, were excluded, as well as those critically ill who were long-term bedridden, including patients in intensive care units, those with advanced cancer, and unaccompanied patients. Finally, 80 patients were included in the 40 in the study group and 40 in the control group. Figure 1 illustrates the participation process in the study, detailing the number of patients deemed qualified, excluded, or enrolled.
Figure 1 Study flow chart.
After admission, the patients received routine nursing care, which included the collection of their general and medical histories. Moreover, routine care, such as fall prevention measures and regular patient monitoring, was provided.
Pre-preparation: A multidisciplinary CGA intervention team with extensive clinical experience was established, consisting of a head nurse (responsible for coordinating nursing interventions), four registered nurses (responsible for implementing specific nursing interventions), a clinical pharmacist (responsible for guiding rational drug use), a nutritionist (responsible for formulating a nutrition intervention plan), a psychological consultant (responsible for psychological nursing interventions of patients), and two chief physicians (responsible for supervising the entire nursing process and evaluating nursing results). A personal CGA profile was created to collect general patient information (e.g., sex, age, disease course), clinical data, and scale assessment results. This profile was used to collect dynamic information about a patient’s illness and set care goals. Before implementing the CGA evaluation, we trained team members, introduced the use of CGA profiles, and assigned responsibilities. Patients are required to complete the profile within two days of admission.
CGA: Multiple scales are used to evaluate patients' mental states, physical capabilities, nutritional status, cognitive function, and sleep quality, allowing for the identification of changes, analysis of causes, and development of appropriate interventions, including the Modified Barthel Index (MBI), Geriatric Depression Scale (GDS), Hamilton Anxiety Scale (HAMA), Mini Nutritional Assessment Scale (MNA), Montreal Cognitive Assessment (MoCA) and Pittsburgh Sleep Quality Index (PSQI). See Table 1[9-15].
**Nursing ** Monitoring of blood glucose and blood pressure, hierarchical patient management, and the implementation of individualized blood glucose and blood pressure monitoring were included in the nursing intervention. The objectives for blood glucose fluctuation control are outlined in Table 2, with the standard for blood pressure control set at diastolic blood pressure (DBP) ≤ 90 mmHg and systolic blood pressure (SBP) ≤ 140 mmHg. On-site training on the use of blood glucose meters and sphygmomanometers was conducted. Continuous glucose monitoring was selected based on factors such as the patient's blood glucose level, cognitive status, physical mobility, and economic status.
Regarding diet control, nutritionists developed individualized diets according to the patient’s condition and personal preferences. The rational distribution of the proportions of nutrition and salt intake was strictly limited (< 6 g/d), and smoking cessation and reduced alcohol consumption were ensured. In addition, the order of food consumption was adjusted to optimize the intake of protein, fat, and carbohydrates. Patients with a history of imbalanced dietary habits required additional vitamins and minerals.
Drug use Medication information was recorded in each patient’s file, and patients were instructed to strictly adhere to the prescribed timing and dosage instructions. Patients and their families received training in insulin injection techniques for cases requiring medication. Regular monitoring of vital signs was emphasized to ensure proper medication management.
Physical Before formulating a physical exercise program for patients, a risk assessment was performed based on the patient's medical history, family history, physical activity level, and relevant medical examination results. The primary forms of exercise included aerobic activities such as brisk walking, badminton, and Tai Chi. Patients exercised 5–7 d per week, with each session lasting 20–30 min, ideally scheduled 1 h after each meal.
Regarding psychological intervention, nursing staff assisted patients in regulating negative moods, promoting relaxation, and improving sleep quality by encouraging interpersonal communication. Patients' families were also informed to provide additional spiritual support and attend to their needs and desires. Furthermore, enhancing patients' understanding of their conditions through disease education helped foster a positive attitude toward treatment and care by dispelling misconceptions.
Evaluation of the intervention The results were divided into three A (met the standard), B (partially met the standard), and C (did not meet the standard). Re-evaluation could only be stopped and the study’s operational process could proceed after each nursing problem met the standard (Figure 2).
Figure 2 Technical Roadmap. CGA: Comprehensive Geriatric Assessment; MBI: Modified Barthel Index; GDS: Geriatric Depression Scale; HAMA: Hamilton Anxiety Scale; MNA: Mini Nutrition Assessment Scale; MoCA: Montreal Cognitive Assessment; PSQI: Pittsburgh Sleep Quality Index.
We compared fasting blood glucose (FBG), 2 h postprandial blood glucose (2hPBG), HbA1c, and blood pressure (DBP and SBP) before and after the intervention. Using the 36-item Short Form Survey (SF-36) for quality of life assessment, the patients' physical, emotional, mental, and overall health, as well as physiological function, were evaluated before and after the intervention. Furthermore, treatment compliance in the two groups was compared before and after the intervention.
Statistical software SPSS 21.0 (IBM, United States) was used for all analyses. Measurement data were expressed as the mean ± SD for the Student's t-test, while count data were expressed as percentages for the chi-squared test. P < 0.05 indicates statistical significance.
In the study group, there were 19 men and 21 women with an average age of 70.35 ± 4.26 years (62–78), an average diabetes duration of 9.13 ± 2.26 years (3–13), and an average hypertension duration of 5.30 ± 1.09 years (2–7). In the control group, there were 22 men and 18 women with an average age of 71.20 ± 4.18 years (60–81), an average diabetes duration of 8.80 ± 2.24 years (5–13), and an average hypertension duration of 5.28 ± 0.72 years (4–7). The differences in sex ratio, age, and disease duration between the two groups were not statistically significant (P > 0.05) (Table 3).
Before the intervention, there were no statistically significant differences in FBG, 2hPBG, or HbA1c levels between the two groups (P > 0.05). After the intervention, these indicators significantly decreased in both groups. However, compared with the control group, the improvements in these three indicators were more pronounced in the study group after the intervention, with the differences being statistically significant (P < 0.05) (Table 4).
In the context of blood pressure assessment before the intervention, there was no significant difference in DBP or SBP between the two groups (P > 0.05). After the intervention, a significant reduction in blood pressure metrics was observed in both groups (P < 0.05). The decrease in these indicators was more pronounced among patients in the study group compared to the control group (P < 0.05) (Table 5).
The SF-36 questionnaire was used to assess multidimensional changes in patient's health status, including physical, emotional, social, and mental well-being, before and after nursing interventions. Initially, there were no significant differences in scores across various domains, such as physical, emotional, mental, and overall health, as well as physical function, between the two groups (P > 0.05). However, post-intervention, the study group demonstrated higher scores in these domains compared to the control group, with the most significant difference observed in the physical function domain (P < 0.05) (Table 6).
After the intervention, the treatment compliance rate was 80.0% in the control group (32 cases of compliance and 8 of non-compliance) and 95.0% in the study group (38 cases of compliance and two cases of non-compliance). There was a statistically significant difference between the two groups (χ^2^ = 4.114, P = 0.043).
The growing older population will exert substantial pressure on social security and pension service systems in the future. Nevertheless, we are committed to studying the healthcare needs of older adults, especially those with diabetes and hypertension. Building upon the outcomes of comprehensive assessments of older individuals, targeted intervention care should be implemented to address patients’ health needs, including physical health, psychological well-being, nutritional diet, safety, and health education. Targeted care provided by primary healthcare teams, based on a comprehensive assessment of older individuals’ health, can potentially improve their health and quality of life, especially those of advanced age[16].
Diabetes and hypertension are commonly encountered metabolic diseases among older adults, both of which can accelerate the progression of atherosclerosis, impair vascular function, and increase the risk of adverse cardiovascular events. These conditions are closely related to patients' dietary habits, level of physical activity, and psychological well-being[17]. Patients often require long-term medication to regulate their blood glucose and blood pressure levels. Factors such as misconceptions about their conditions, limited self-management skills, and poor treatment compliance can adversely affect the effectiveness of therapy[18]. Therefore, implementing comprehensive nursing interventions in hospitals is essential to enhance patient treatment outcomes.
CGA is widely used to diagnose and treat geriatric diseases. This model is patient-centered and comprehensively and systematically evaluates older patients from multidimensional levels of physical condition, cognitive ability, psychological state, and social support, which facilitates the development of individualized intervention programs[19]. In addition, CGA has demonstrated positive impacts in various areas, such as cancer treatment, where it aids in identifying patients at high risk of mortality and functional decline[20]. Regarding chronic kidney disease in the elderly, Chen et al[21] used CGA to comprehensively evaluate the levels of renal function, cognition, emotional state, nutritional status, and social support in different stages of the disease and guided patients’ health care. O'Shaughnessy et al[22] reported that CGA in the emergency department could lead to improved outcomes by reducing the negative impacts of potentially preventable hospital admissions.
The CGA aims to identify existing and potential clinical problems in patients, propose treatments to either maintain or improve functional status, and maximize or maintain the quality of life for older individuals. For example, Vu et al[23] developed a CGA questionnaire for diabetes management, including cognitive impairment, depression, urinary incontinence, dependence on daily living activities and instrumental activities, fall risk, hearing loss, visual acuity, polypharmacy, malnutrition, and the presence of multiple geriatric conditions. However, targeted nursing interventions were not provided. The CGA conducted in this study involves a multilevel assessment focusing mainly on the following medical assessment (MBI score), functional assessment (MNA score), psychological assessment (GDS score, HAMA score, PSQI score), and social assessment (MoCA score). Nursing interventions were carried out according to the assessment, including blood glucose and blood pressure monitoring, dietary control, medication guidance, physical exercise, and psychological intervention. Before the intervention, there was no statistically significant difference in FBG, 2hPBG, and HbA1c levels between the two groups. However, after the intervention, these indicators were significantly decreased in both groups, especially in the study group. Concerning blood pressure indicators, there was no significant difference in DBP and SBP between the two groups before intervention. After the intervention, the blood pressure indexes of the two groups decreased significantly, with a more pronounced decrease observed in the study group. Using the SF-36 questionnaire, the researchers assessed changes in the health status of patients in multiple dimensions, such as physical, emotional, social, and mental well-being before and after receiving nursing interventions. At the beginning of the intervention, there was no significant difference in the scores of physical, emotional, mental, and overall health and physical function between the two groups but after the intervention, the scores of the study group in these fields were generally higher than those of the control group, especially in physical function. Furthermore, the treatment compliance rate of the control group after the intervention was 80.0%, while that of the study group reached 95.0%, which indicated that the study group performed better in treatment compliance. Overall, CGA-guided interventions help patients maintain normal blood glucose and blood pressure levels, improve their quality of life, and improve treatment compliance.
However, this study had limitations. First, this was a retrospective study which may have resulted in selection bias and incomplete record-keeping, limiting the generalizability of the results. Second, this study had a relatively small sample size, and the inclusion of patients from a single medical institution may have limited the broad applicability of the findings. Therefore, future research should consider adopting a prospective randomized controlled trial design conducted across multiple centers to enhance the external validity and robustness of the evidence.
The CGA nursing intervention significantly improved glycemic control, blood pressure management, and quality of life in hospitalized older patients with diabetes and hypertension, compared to routine care. The enhanced treatment adherence observed in the CGA group suggests that this model can potentially elevate the standard of care for geriatric patients. Therefore, CGA should be considered for broader implementation in similar patient populations to further optimize health outcomes.
Dong-Ying Bao, Department of Cardiology, Jiangyin Hospital of Traditional Chinese Medicine, Jiangyin 214400, Jiangsu Province, China.
Lin-Yan Wu, Department of Cardiology, Jiangyin Hospital of Traditional Chinese Medicine, Jiangyin 214400, Jiangsu Province, China.
Qi-Yan Cheng, Department of Endocrinology, Jiangyin Hospital of Traditional Chinese Medicine, Jiangyin 214400, Jiangsu Province, China. cqy17768@163.com.
The data used for this study can be obtained from the corresponding author upon request.
The data used for this study can be obtained from the corresponding author upon request.