Developing a Delphi Consensus on the Domains and Conduct of Brief Geriatric Assessments in Singapore

Delphi Consensus on Brief Geriatric Assessments

Article information

Ann Geriatr Med Res. 2025;29(2):177-184

Publication date (electronic) : 2025 February 19

doi : https://doi.org/10.4235/agmr.24.0198

, Penny Lun ¹, Lay Khoon Lau ¹, Woan Shin Tan ¹, Edward Tan ¹, Wee Shiong Lim ²^,³, Reshma Aziz Merchant ⁴^,⁵, Laura Tay ⁶, Yew Yoong Ding ¹^,³

¹Geriatric Education and Research Institute Limited, Singapore

²Institute of Geriatrics and Active Ageing, Tan Tock Seng Hospital, Singapore

³Department of Geriatric Medicine, Tan Tock Seng Hospital, Singapore

⁴Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

⁵Division of Geriatric Medicine, Department of Medicine, National University Hospital, Singapore

⁶Department of General Medicine, Sengkang General Hospital, Singapore

Corresponding Author: Jonathan Gao, PhD Geriatric Education and Research Institute Limited, 2 Yishun Central 2, Singapore 768024 E-mail: gao.jonathan.s@geri.com.sg

This study was presented at Singapore Health & Biomedical Congress 2024 on October 10, 2024 in Singapore.

Received 2024 December 26; Revised 2025 February 11; Accepted 2025 February 13.

Abstract

Background

Comprehensive geriatric assessment (CGA) is a process supporting a multidimensional assessment of the health and well-being of older adults and leads to the development of long-term personalized care plans. CGA is resource intensive, hence shorter forms such as brief geriatric assessments (BGA) could be alternatives. However, little is known about BGA’s implementability in community and primary care settings. To understand the core requirements for BGA in Singapore’s community and primary care settings, an electronic two-round Delphi study with Singaporean clinical experts was conducted.

Methods

Statements were informed by a previous scoping review and three study advisors. Statements related to target population, essential domains and sub-domains, and approach to BGA administration and implementation. Sixteen participants identified as experts in geriatric or family medicine were invited. Consensus was defined a priori as 75% agreement and an interquartile range of ≤1.

Results

Fifteen participants responded, and 45/72 and 11/31 statements reached consensus in Round 1 and Round 2, respectively. Round 2 contained statements that did not reach consensus and were modified or added based on feedback. Participants agreed on targeting selected older adults for BGA to identify geriatric syndromes; physical, psychological, function, mobility/balance, and social status as domains to assess for BGA; and healthcare professionals administering BGA.

Conclusion

Results suggest using BGA to identify high-risk older adults for CGA, potentially saving resources. Additional research is needed to determine identification of older adults for BGA, and feasibility of interventions for older adults after a BGA.

Keywords: Aged; Frailty; Geriatric assessment; Health services for the aged

INTRODUCTION

The world’s population is ageing, with the number of older adults expected to double by 2050.1) Geriatric syndromes are clinical conditions in older adults caused by multiple underlying factors with high prevalence.2) A study of 11 European countries reported an average of two geriatric syndromes per older adult.3) In United States, prevalence of geriatric syndromes range from 28.1% for dementia to 42.9% for sarcopenia.4) However, these syndromes were not always identified by physicians5) or recognized as problems by older adults.6)

Geriatric syndromes can be an important clinical indicator. Older adults with such syndromes have increased odds of cardiovascular conditions or diabetes,7) and being prescribed potentially inappropriate medication.8) Geriatric syndromes were also linked with hospitalization and institutionalization for older adults.9,10) Therefore, early detection and intervention of geriatric syndromes could be beneficial.

Comprehensive geriatric assessment (CGA) is a multidisciplinary diagnostic process assessing older adults’ medical, psychological, and functional capabilities to develop a customized treatment and follow-up plan.11) CGA can be used to identify and manage geriatric syndromes, leading to beneficial outcomes.12) The relevance of follow-up interventions to older adults after CGA reportedly reduced frailty13) and risk of malnutrition,14) as well as improved quality of life.15) The review and changes to older adults’ medication regimen after CGA also reduced polypharmacy.16,17)

However, CGA can be time consuming, leading to attempts of shorter versions such as brief geriatric assessments (BGA).4,18,19) Some BGA were intended as rapid needs assessment followed by targeted investigations and/or early interventions,20,21) while other BGA identified older adults with care needs requiring follow-ups like CGA.22,23)

In Singapore, time constraints with CGA emerged as an issue for a frailty management program targeting frail older adults in community and primary care settings.24) While BGA was suggested as an alternative, there were uncertainties on the target population and essential domains (e.g., physical, mental) to assess.25) Studies on BGA also needed to cater to their own context and resource availability, leading to wide heterogeneity.

The Delphi method can gather informed consensus on topics with ambiguous evidence.26) It was used to identify core requirements for frailty screening in an emergency department,27) along with malnutrition management28) and sarcopenia diagnosis guidelines29) for geriatric patients. Local clinical experts were therefore engaged via the Delphi method to contextualize evidence on BGA to Singapore. This consensus study aims to identify the target population and essential domains for a BGA, as well as the appropriateness, feasibility and implementability of BGA in Singapore’s community and primary care settings.

In Singapore’s context, community setting refers to community care providers such as active ageing centers. Currently, there are 208 active ageing centers delivering services complementing primary care, such as monitoring older adults’ medication compliance to ensure adherence to their prescribed health plan.30) Primary care refers to the 23 public clinics providing government subsidized care and 1,800 privately run general practitioners clinics.31) Their role includes handling patients’ acute or chronic conditions and engaging patients in preventive measures.

MATERIALS AND METHODS

This Delphi study is the second of a three-phase project on BGA. The first phase was a scoping review of international literature on BGA implementation in community and primary care settings, domains assessed, and reported outcomes.25) Review findings guided this Delphi study. The third phase engages stakeholders from Singapore’s community and primary care settings to discuss the feasibility and implementability of BGA. This Delphi study followed the CREDES (Conducting and REporting DElphi Studies) guidance.32)

Formulation of Statements

Scoping review findings are as follows.25) First, commonly assessed domains were physical health, psychological/cognition, functional, and mobility/balance. Second, mode of administration includes healthcare professionals, trained volunteers, and self-administration. Third, duration of BGA ranged from less than 5 minutes to 20 minutes. Fourth, except for improved identification of older adults with higher or unexpressed needs, no other significant changes were observed.

These findings guided the initial draft of Delphi statements. For example, the use of trained volunteers to administer BGA prompted a statement regarding its feasibility in Singapore. This was followed by a consultation with three study advisors, who are lead or adjunct scientists with a national research institute focusing on ageing research. The advisors are also senior consultants or the head of Geriatric Medicine departments of public hospitals in Singapore and hold professorships with local universities. They were chosen due to their involvement and extensive experience in practice, education, and research on geriatric medicine. The draft statements were edited based on their feedback and questions were also anchored on the need for BGA to be within 15 minutes to ensure consistency among participants. The statements were also piloted with two additional senior consultants, resulting in minor revisions. The finalized version contained 72 statements.

Delphi Panel

A condensed set of experts is recommended for specialized clinical topics,33) with 12 participants deemed sufficient for reliable consensus.34) We aimed to complete the Delphi with a minimum of 12 participants. Considering a 25% attrition rate from a previous study,35) a purposive sample of 16 doctors were invited via email. The invitees are consultants, senior consultants, or heads of service in Geriatric Medicine departments of public hospitals in Singapore, or doctors in family medicine focusing on geriatric issues at public clinics in Singapore.

Delphi Process & Consensus

Participants rated statements on a scale of 1 (strongly disagree) to 7 (strongly agree) and could also provide comments in text boxes. Consensus was defined a priori, combining the common definition of level of agreement, and dispersion of responses based on interquartile range for additional robustness.33,36) Consensus is achieved if 75% of respondents disagreed (rating of 1 and 2) or agreed (rating of 6 and 7) with a statement, and if the interquartile range of the response is 1 or less. Based on participants’ feedback, non-consensus statements in Round 1 were edited, and new statements were added for Round 2. Participants had to respond to both rounds. Non-respondents in Round 1 were not invited to Round 2. The study was conducted electronically via email.

Data Analysis

Participants’ quantitative responses were entered into an Excel spreadsheet to calculate the percentage of agreement/disagreement and interquartile range for each statement. Qualitative responses in text boxes were read and discussed among the study team to understand the quantitative results. Findings were also discussed with the study advisors before the results synthesis.

RESULTS

Response rate for Round 1 and Round 2 were 94% (15/16) and 100% (15/15), respectively. Consensus were achieved for 45/72 (62.5%) and 11/31 (35.4%) statements in Round 1 and Round 2, respectively. Based on feedback from Round 1, one new statement was added while two original statements were split and modified. Overall, four statements were added. Hence, Round 2 had 31 statements instead of 27. A flowchart of the Delphi process is in Fig. 1. The list of statements that achieved consensus is in Supplementary Table S1, while the list of non-consensus statements is in Supplementary Table S2.

Fig. 1.

Delphi flowchart.

Target Population

Participants agreed on using BGA to detect geriatric syndromes for older adults in community and primary care, specifically targeting those showing geriatric syndromes or with mild to moderate frailty. There was no consensus on targeting all older adults aged 75 and above in these settings. Participants questioned the efficiency and the healthcare system’s capacity to cope with the influx of referrals from these broad screenings. There was no consensus on targeting older adults receiving regular primary care services or living alone.

Domains and Sub-domains for BGA

Participants agreed that BGA in community settings should assess physical health, psychological/mental health, functional abilities, mobility/balance, and social situation. Participants also agreed that these domains, together with medication use, should be part of BGA in primary care settings. There was also consensus on the sub-domains for each domain (e.g., visual & hearing impairment for the domain of physical health). Information on domains and sub-domains is in Supplementary Table S3. There was no consensus on assessing comorbidity for the physical health domain in community-based settings. One participant felt that comorbidity assessments would prolong the BGA without adding significant value, while another expressed concerns about the accuracy of older adults’ self-reports.

Approach to a BGA

Administration of BGA by healthcare professionals was agreed as feasible. There was no consensus on administration by trained non-healthcare professionals or self-administration by older adults. One participant highlighted potential difficulties in maintaining competency standards for trained non-healthcare professionals, while another expressed concerns on the validity of self-administration.

For mode of data collection, participants agreed that self-reporting based on older adults’ own subjective perception, such as how an older adult is feeling, should be accompanied by objective assessments. Conversely, self-administered tools collecting objective (e.g., older adults’ height or number of times they can perform an action) and subjective measurements should be accompanied by an informant report. Validity issues with self-reporting and self-administering were highlighted by participants.

Participants agreed that a positive BGA result (i.e., geriatric syndromes detected) should lead to a CGA referral. There was no consensus on recommending follow-up interventions without CGA for cases with a single identified geriatric syndrome. One participant questioned the likelihood of identifying only a single geriatric syndrome. Two participants commented that intervening without CGA depends on the geriatric syndrome identified. Another suggested that assessments and interventions can be conducted as needed, instead of expecting all assessments to be completed before intervening. The need for a clear care pathway and adequate resources to support older adults in follow-up interventions without a CGA was emphasized by a participant.

DISCUSSION

This study builds on a scoping review to develop expert consensus on domains to assess and implementation considerations for BGA in Singapore’s community and primary care settings. Participants agreed on (1) targeting selected older adults for BGA to identify geriatric syndromes, (2) the domains and sub-domains, (3) CGA following a positive BGA result, and (4) having healthcare professionals administer BGA. This study contributes by providing preliminary clarity and guidance on using BGA in community and primary care settings in Singapore.

Target Population

Older adults showing potential geriatric syndromes should be targeted for a BGA to detect geriatric syndromes. For example, an older adult who keeps bumping into things and does not always respond when addressed could be seen as showing signs of hearing and visual impairment. A BGA could confirm the impairment or determine if the issues are caused by other geriatric syndromes such as cognitive impairment. Statements targeting broader groups such as those: (1) aged 75 and above, (2) receiving regular primary care services, or (3) living alone did not achieve consensus. The cost and consequences of broad screening underlined participants’ preference for a targeted approach, which aligns with the targeted frailty37,38) and cognitive screening38) recommendations by national organizations in other countries.

Domains and Sub-domains for BGA

Participants agreed that BGA in community settings should assess physical health, psychological/mental health, functional abilities, mobility/balance, and social situation, while BGA in primary care should also include medication use. This difference arose from a deliberate omission of a statement on medication assessment in the community, as suggested by all three study advisors as community assessors may not have the prerequisite background. Participants’ consensuses almost mirrored the scoping review.25) Most BGA identified assessed physical health, psychological/mental health, functional abilities, and mobility/balance. However, social situation was the least assessed domain.25) This may reflect a recent emphasis on social connection in Singapore’s Ministry of Health action plan for older adults,39) prompting participants to include social situation assessment.

For each domain, participants agreed on a comprehensive list of sub-domains to assess, including frailty, incontinence, visual and hearing impairment, weight loss, cognitive function, mood, activities of daily living, fall history, and caregiver presence. This list differed from the BGA identified in the scoping review. For example, the Rapid Geriatric Assessment assessed frailty, sarcopenia, anorexia of aging, and mild cognitive impairment or dementia,40) while the Brief Risk Identification of Geriatric Health Tool assessed activities of daily living, cognitive impairment, and fall history.41) Even the more comprehensive BGA were missing sub-domains participants agreed on, such as behavioural problems, gait disturbances, and pain.42) This discrepancy may stem from participants underestimating the time required to assess all suggested sub-domains.

Approach to a BGA

Participants agreed on the feasibility of healthcare professionals administering BGA. This is consistent with the scoping review, where majority of BGA were administered by healthcare professionals.25) Conversely, the statement on BGA administration by non-healthcare professionals only came close to consensus, even though several BGA identified in the scoping review did so.42) One participant’s concern on maintaining trained volunteers’ competency standards to a similar level to healthcare professionals could explain the non-consensus. Previous research showed mixed results regarding assessments by laypeople versus professionals. While excellent inter-rater reliability was observed for Timed Up and Go tests conducted by caregivers and student physiotherapists,43) low inter-rater reliability was observed for nutritional screening conducted by trained volunteers and a dietician.44) Differences were also noted in assessments of neuropsychiatric symptoms between clinicians and caregivers.45) Timed Up and Go test measures performance while assessments of neuropsychiatric symptoms and nutrition involve subjective judgements whereby domain expertise is likely to play a bigger role. Delphi consensus are informative, but does not mean that a “correct” answer has been found.32) The use of trained non-healthcare professionals for BGA remains a possibility. One suggestion is that they could handle performance assessments while healthcare professionals manage more complex subjective evaluations.

Participants agreed on either a combination of self-administered tools and informant reports, or a combination of self-reporting questions and objective assessments for data collection. Concerns on the validity of self-reporting BGA led researchers to add objective measures.46) Other studies on self-administered or self-reporting tools cite the cost of using a healthcare professional as a reason for their research and have reported promising results.47,48) A comparison of self-administered and healthcare professional administered BGA found that the self-administered version performed well on questions about falls, fatigue, weight loss, and multimorbidity.47) Areas for improvement, such as clarifying ambiguous wording, were also identified. Further research could explore improved versions of these tools to assess whether healthcare professional administration or supplementary assessments are still necessary.

Participants agreed that a positive BGA should lead to a CGA referral. There was no consensus on recommending follow-up interventions without a CGA for cases with only one identified geriatric syndrome. Participants expressed the need for a CGA referral as interpreting a positive BGA result can be challenging without further investigation. This aligns with the British Geriatrics Society’s recommendations for a short frailty screening, followed by a CGA for older adults identified with frailty.37) However, referring all positive BGA cases for CGA may create additional burden on healthcare systems. In this study, we were unable to determine the precise conditions where a CGA is unnecessary. Nonetheless, other studies have explored situations where a CGA is warranted, such as the identification of “red flags” based on the Geriatric 5Ms during a brief assessment for older adults visiting an emergency department.49) There is also potential to combine a BGA with management pathways for specific conditions when a CGA could be clinically unnecessary or for cases where older adults are not inclined to proceed with a CGA. For instance, the Rapid Geriatric Assessment was linked with assisted management pathways to screen and manage frailty, sarcopenia, anorexia of aging, and cognitive decline.47) Under the assisted management pathways, an exercise intervention could be recommended to frail or sarcopenic older adults, while cognitive stimulus therapy would be offered to older adults identified with cognitive issues.50) Preliminary research showed positive physical outcomes for sarcopenic older adults and positive cognitive outcomes for older adults with cognitive issues.50)

Implications

Findings indicated that BGA should be targeted at older adults showing potential geriatric syndromes. Healthcare professionals should administer the BGA to assess older adults’ physical health, psychological/mental health, functional abilities, mobility/balance, and social situation in a community setting, while also including medication use in primary care. Detection of geriatric syndromes should lead to a CGA referral. This is a preliminary care process based on the consensuses achieved, and further research is needed to clarify BGA’s role as well as the support needed in the care process.

Participants’ consensuses suggested selective administration of BGA to identify older adults needing CGA. This raises the question on how the target group of older adults (i.e., show signs of geriatric syndromes or mild to moderate frailty) should be identified. Perhaps an even briefer screening tool is needed. Alternatively, greater public education on geriatric syndromes and frailty could prompt family members of older adults to look for the signs and bring their older adults for a BGA.

Strict adherence to the consensus of BGA administration by healthcare professionals may strain the healthcare system. Therefore, using trained personnel or self-assessments should be considered through careful selection of domain-specific instruments that are least susceptible to biased interpretation. Using trained personnel for performance assessments could allow healthcare professionals to work on other tasks requiring their clinical expertise. Alternatively, regular refresher training could address the issue of maintaining standards among non-healthcare professionals.

Limitations

First, a limitation of the Delphi technique is the arbitrariness of the consensus criteria. We used dispersion of responses on top of level of agreement to add robustness to the consensus criteria. Second, a two-round Delphi meant that we were unable to further explore some issues, especially statements close to consensus. Third, we were unable to get participants to prioritize the essential elements of a BGA. This could be due to the use of a Likert scale instead of a ranking system. Alternatively, the 15 minutes time constraint may not have been sufficiently emphasized. It was only indicated at the start of the section and thus could have slipped participants’ mind as they progressed to other pages. Efforts to mitigate the first and second limitations were done via discussions between the study team and study advisors, such as considering statements that came close to consensus.36)

Conclusion

This Delphi study aimed to build expert consensus on domains that are essential for a BGA, and appropriateness, feasibility and implementability of BGA in community and primary care settings in Singapore. Aside from the domains and assessments for a BGA, participants also agreed that (1) administration of BGA should be targeted, (2) BGA should be used to identify those requiring CGA, (3) interventions should only be recommended after a CGA, and (4) BGA should be administered by a healthcare professional. Implications of such recommendations and potential areas for further research were also discussed.

Notes

We would like to thank our Delphi panel experts from the three health clusters (National Health Group, National University Health System, SingHealth) for their time and dedication in this study.

CONFLICT OF INTEREST

The researchers claim no conflicts of interest.

FUNDING

None.

AUTHOR CONTRIBUTIONS

Conceptualization, JG, PL, LKL, ET, YYD; Data curation, JG, PL; Investigation, JG, PL; Methodology, YYD; Project administration, ET, YYD; Supervision, WSL, RAM, LT, YYD; Writing–original draft, JG, PL, WST; Writing–review & editing, JG, PL, LKL, WST, ET, WSL, RAM, LT, YYD.

SUPPLEMENTARY MATERIALS

Supplementary materials can be found via https://doi.org/10.4235/agmr.24.0198.

Table S1.

List of consensus statements

agmr-24-0198-Supplementary-Table-S1.pdf

Table S2.

Non-consensus statements after Round 2

agmr-24-0198-Supplementary-Table-S2.pdf

Table S3.

Domains and sub-domains to assess

agmr-24-0198-Supplementary-Table-S3.pdf

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