Evaluation can occur at different levels of intensity and at different stages of a disease. It can be comprehensive or more focused. Comprehensive evaluation of an older individual’s health status is one of the most challenging aspects of clinical geriatrics. Geriatrics addresses multimorbidity. It involves sorting out the manifestations of multiple simultaneous problems. It requires sensitivity to the concerns of people, awareness of the many unique aspects of their medical problems, ability to interact effectively with a variety of health professionals, and often a great deal of patience. It requires a perspective different from that used to evaluate younger individuals. Not only are the a priori probabilities of diagnoses different, but one must be attuned to subtler findings. Because functioning is a key element in geriatric management, assessment must address a wider range of domains that include social function and mental health. Progress may be measured on a finer scale. Special tools are needed to ascertain relatively small improvements in chronic conditions and overall function compared with the more dramatic cures of acute illnesses often possible in younger patients. Creativity is essential to incorporate these tools efficiently in a busy clinical practice.
We have come to appreciate the implications of the range of clinical status. We typically think of the spectrum of geriatric patients in a pyramid, where those with the most disabilities are least frequent but use the most services. Figure 3-1, shows what is referred to as the Kaiser Pyramid. The topmost group, representing about 3% to 5% of the older population, accounts for a disproportionate amount of care. Another 15% to 20% need good management for a single chronic disease. By contrast, the remaining 70% to 80% need relatively little care, and much of that is directed toward health promotion. Sorting patients in this way allows for better targeting of resources. Assessment offers a means to achieve this sorting.
The Kaiser Pyramid. (Data from National Health Services (NHS) and the University of Birmingham.)
Assessment alone will not improve health; some action has to be taken based on the information. Assessments can be made to develop a care plan of interventions, or they can form the basis for predicting future health status. Knowing an older patient’s status can help decide if he or she is a good candidate for aggressive treatment.
Comprehensive geriatric assessment, when its findings are acted on, has been shown to improve both mortality and the chances of remaining in the community (Barer, 2011; Ellis et al, 2011). The challenge is to use it efficiently. Complex patients and those facing major long-term care decisions are strong candidates, but studies have also shown benefit for persons presumably at low risk. As described in Chapter 4, home visits to basically well older persons seem to prevent nursing ...