Current Geriatric Diagnosis & Treatment, 1st Edition
Section I - Approach to the Geriatric Patient
4. Geriatric Assessment
Bree Johnston MD, MPH
The term geriatric assessment is generally used to describe a clinical approach to older patients that goes beyond a traditional medical history and physical. Although geriatric assessment may encompass many different settings, structures, and models of care, a unifying feature of all types of geriatric assessment is the clinical application of the biopsychosocial model to older patients.
The rationale of geriatric assessment is to better recognize common geriatric disorders in order to improve functional outcomes and quality of life for older adults. The elderly are heterogeneous in function; thus, the approach to geriatric assessment depends in part on the patient being assessed and the site of assessment.
Although this chapter is primarily geared toward the outpatient setting, many of the principles can be applied to patients in inpatient, home, and long-term care settings as well.
TEAMS IN GERIATRIC ASSESSMENT
Although geriatric assessment may be comprehensive and interdisciplinary and involve multiple team members (eg, social services, nursing, medical, physical therapy, occupational therapy, psychology, audiology, dentistry, pharmacy, nutrition, speech therapy), it may also involve just 2 or 3 informal team members and be much more simple in approach. An interdisciplinary team is one in which multiple disciplines meet together to develop a single treatment plan for a patient, whereas for a multidisciplinary team individual members perform separate assessments, notes, and treatment plans. In general, the extra work involved with an interdisciplinary team process is most justifiable in settings that serve primarily frail, complex patients. For patients in nursing homes or rehabilitation facilities, a treating team may consist of 5 or more disciplines with an interdisciplinary structure and use extensive assessment tools, whereas a geriatric outpatient practice may use an ad hoc team, brief screening tools, and follow-up with more extensive tests or team management only when indicated. Regardless, many of the principles of assessment are the same.
Functional impairment is common in the elderly and has many potential causes, including age-related changes, social factors, and disease. About 25% of patients older than 65 need the help of another person to perform activities of daily living (ADLs; bathing, dressing, eating, transferring, continence, toileting) or instrumental ADLs (IADLs; transportation, shopping, cooking, using the telephone, managing money, taking medications, cleaning, laundry). Fifty percent of individuals older than 85 need the help of another person to perform ADLs. Functional information should be included in the assessment of all older people.
Direct observation of function is the most accurate method of functional assessment but is impractical in most health care settings. Self-report of ADLs and IADLs is usually accurate but should be corroborated when possible, especially when the information is suspect.
Functional information can be used as a baseline to measure future declines in function and to determine the need for support services or placement, medical or surgical interventions (eg, need for knee replacement surgery), or rehabilitative therapies.
Subtle or new declines in IADL function may be an early sign of depression, dementia, fear of falling, worsening incontinence, loss of vision, or other disease, such as coronary artery disease. If no reversible cause of IADL decline is found after a reasonable medical search, the physician should focus on supportive services. Likewise, loss of ADL function often signals a worsening disease process or a combined impact of multiple comorbidities but at a more advanced stage. Although most persons with ADL impairments are able to stay home with appropriate services, a nursing home level of care may be necessary if persons with ADL impairments require placement.
For highly functional independent elders, standard functional screening measures will not be useful in capturing subtle functional impairments. One technique that may be useful for these elders is to identify and regularly query about a target activity, such as playing bridge, golf, fishing, or practicing law, that the patient enjoys and regularly participates in (advanced ADLs). If the patient begins to drop the activity, it may indicate an early impairment, such as dementia, incontinence, or worsening hearing loss.
Combined Screening Instrument
A number of simple geriatric screening instruments have been published for the purpose of increasing the detection of common geriatric conditions. The rationale of these instruments is to use a number of sensitive prescreening questions or instruments for common conditions and to follow up abnormal responses with further testing or interventions. At University of California, San Francisco, we adapted the screening instruments developed by Lachs et al and later modified by Moore et al (Figure 4-1). Our screening instrument is easy to use, well accepted by practitioners and patients, and relatively quick to administer. The tool could be even more efficient if parts of it were administered by nonphysician personnel. Although it has not been proved that the use of such instruments improves outcomes, it stands to reason that increased detection of common geriatric problems would result in improved outcomes if detection is linked to interventions that are proved to be effective in the literature.
GERIATRIC ASSESSMENT EFFICIENCY
Geriatric assessment can be time consuming. A number of strategies can help make the process more efficient, such as using sensitive, brief assessment instruments, and following up with more in-depth instruments when necessary, using nonphysician personnel to help perform standard geriatric assessments, and using observations to help make diagnoses (observing gait as part of physical examination).
Falls & Gait Impairment
Falls are the leading cause of nonfatal injuries and unintentional injury and death in older persons. Every older person should be asked about falls because many will not routinely volunteer such information. In addition, persons should be asked about perceived home hazards that might be remediable. Because gait impairments commonly coexist with falls, a gait assessment is important to perform in older people and is likely to be more sensitive for abnormalities (which are commonly multifactorial because of muscular weakness, arthritis, as well as specific neurological impairments) than other components of the neurological examination.
A number of techniques for gait assessment are available to the primary care practitioner. The first, the “Get Up and Go” test, involves asking a patient to get up from a chair without using arms, walk 10 ft, and turn around and sit down. The observer can look for problems with strength (inability to get up without using the hands), gait, balance, judgment, and use of adaptive devices. When the “Get Up and Go” test is timed (“Timed Up and Go”), performance in 15 s or longer is correlated with impairments in ADLs and falls. The Tinetti Gait and Balance Evaluation (see Appendix) provides a structured framework for assessing specific components of gait and balance. Poorer performance on this instrument is associated with an increased risk of falling. Many practitioners find this scale useful for refining diagnostic acumen for specific pattern recognition, monitoring changes over time, and providing more interrater reliability between exams than with more subjective examinations.
Recommendations regarding assessment of vision impairment by primary care physicians vary. Given the commonness of eye problems in older people and the inability of most primary care physician's offices to perform high-quality, comprehensive eye examinations, periodic examinations by an optometrist or ophthalmologist are reasonable for most older people. Periodic examinations by an optometrist or ophthalmologist are especially important for patients at high risk of glaucoma or with diabetes.
Vision screening in the primary care setting with a Snellen eye chart for far vision and a Jaeger card for near vision is relatively easy to perform and may provide valuable on-the-spot information for the practitioner. Although some authors have advocated using vision screening questions, it is not clear whether such questions are sensitive enough to be useful screening tools.
More than 33% of individuals older than 65 and 50% of those older than 85 have some hearing loss. Hearing loss is correlated with social and emotional isolation, clinical depression, and limited activity.
The optimal screening method for hearing loss in the elderly is undetermined. The whispered voice test is easy to perform; sensitivities and specificities range from 70-100%. Hand-held audiometry is also available, but performance probably depends on the skill of the operator and the environment in which it is performed. The U.S. Screening and Prevention Task Force recommends using screening questions about hearing loss in the elderly. Structured questionnaires such as the Hearing Handicap Inventory for Elderly-Screening (see Appendix) are most useful for assessing the degree to which hearing loss interferes with functioning.
Figure 4-1. Two-page simple geriatric screen (PT, physical therapy; DIAPPERS, Delirium, Infection, Atrophic urethritis and vaginitis; Pharmaceuticals, Psychological disorders, Excessive urinary output, Restricted mobility, Stool impaction; PVR, postvoid residual urine test; GDS, Geriatric Depression Scale; APS, Adult Protective Services; OT, occupational therapy; BMI, body mass index; MMSE, Mini-Mental State Exam.) Adapted from Lachs M et al: A simple procedure for general screening for functional disability in elderly patients. Ann Intern Med 1990;112:699; Moore A:Screening for common problems in ambulatory elderly: Clinical confirmation of a screening instrument. Am J Med 1996;100: 438; Podsiallo D et al: The timed up and go: A test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991;39:142; Whooley MA: Case-finding instruments for depression. J Geriatr Intern Med 1997;12:439.
Dementia is common in the elderly but is commonly missed by primary care practitioners. As treatments become more effective for Alzheimer's disease and related disorders, early diagnosis becomes more important. The Mini-Mental State Exam (see Appendix) is a useful screening test, but it often takes 10 min or longer to complete in persons with cognitive impairment. The 3-item recall, in combination with the clock draw, is briefer and has reasonable test characteristics. When the patient is able to remember all 3 items and can draw a completely normal clock, dementia is unlikely. If the patient is unable to perform either task correctly, further evaluation is indicated.
Scanlan J, Borson S: The Mini-Cog: Receiver operating characteristics with expert and nave raters. Int J Geriatr Psychiatry 2001;16:216. (The combination of the 3-item recall and the clock draw test was highly sensitive and specific for dementia. Validation in other populations is needed before this test is widely implemented as a screening test.)
Incontinence in the elderly is common but often goes unmentioned. Women are twice as likely as older men to be incontinent; overall, ~6–14% of older women experience incontinence daily. A simple question about involuntary leakage of urine is a reasonable screen. Some authors advocate following up a single screening question with “Have you lost your urine on at least 5 different occasions?,” but it is equally reasonable to ask patients whether they perceive incontinence to be a problem or have to wear pads, diapers, or briefs because of urine leakage.
Depression is commonly missed in primary care. Although major depression is no more common in the elderly than in younger populations, depressive symptoms are. In ill and hospitalized elders, the prevalence of depression is≥25%.A positive response to either of 2 questions is sensitive for depression:
Over the past month, have you often been bothered by feeling sad, depressed, or hopeless?
During the past month, have you often been bothered by little interest or pleasure in doing things?
Positive responses should be followed up with more comprehensive interviews because the specificity of a positive response is not high.
Weight loss or poor nutritional status may be an indicator of functional decline, dementia, or medical illness. Although there is no agreement how or who to screen, checking for weight loss, body mass index, and physical signs of malnutrition (eg, temporal wasting, loss of muscle mass) and weight loss is easy and reasonable in a primary care setting. Unintentional loss of>5% of body weight should trigger further evaluation. Loss of 5% of body weight in 1 mo or 10% of body weight over 6 mo is associated with increased morbidity and mortality.
Providing primary care for a frail elder requires that attention be paid to the caregiver as well as the patient because the health and well-being of the patient and caregiver are intricately linked. High levels of functional dependence place an enormous burden on a caregiver.
Burnout, neglect, and abuse are possible consequences of high caregiver loads. Asking the caregiver about stress, burnout, anger, and guilt is often instructive. For the stressed caregiver, a social worker can often identify helpful programs such as caregiver support groups, respite programs, adult day care, and hired home health aids.
Because of the possibility of abuse, vulnerable elders should have the opportunity to be interviewed alone. Direct questioning about abuse and neglect is wise, particularly under circumstances of high caregiver load. Clues to the possibility of elder abuse include observation of behavioral changes in the presence of the caregiver, delays between injuries and treatment, inconsistencies between an observed injury and an associated explanation, lack of appropriate clothing or hygiene, and unfilled prescriptions. A simple question—“Do you ever feel unsafe or threatened?”—is a reasonable initial screen.
Financial & Emotional Resources
Old age can be a time of reduced resources, both emotional and financial. The old–old are at particular risk of social isolation and poverty. Screening questions about social contacts and financial resources are often helpful in guiding providers in designing realistic treatment and social service planning.
- Many (but not all) articles examining the impact of geriatric assessment have shown an improvement in functional outcomes and reduced nursing home placement.
- Those interventions showing the greatest impact tend to be associated with provision of care over time, and primary, rather than consultative, care.
- How geriatric assessment can best be incorporated into primary care has not yet been determined, particularly within the constraints of current reimbursement schedules and productivity standards.
Cohen HJ et al: A controlled trial of inpatient and outpatient geriatric evaluation and management. N Engl J Med 2002; 346:905. (Assessment conducted at 11 Veteran's Affairs Medical Centers showed significant reductions in functional decline with inpatient geriatric evaluation and management and significant improvements in mental health with outpatient geriatric evaluation and management with no increase in costs.)
Campion E: Specialized care for elderly patients. N Engl J Med 2002;346:874. (Review of the history of geriatric assessment.)
Stuck AE et al: Home visits to prevent nursing home admission and functional decline in elderly people. Systematic review and meta-regression analysis. JAMA 2002;287:1022. (Preventive home visit programs had no overall impact on mortality or other outcomes. However, programs that had more than 9follow-up visits showed a 34% reduction in nursing home visits, and those that had multidimensional geriatric assessment and follow-up were associated with a 24% reduction in functional decline.)