Geriatric assessment is a broad term used to describe the health evaluation of the older patient, which emphasizes components and outcomes different from that of the standard medical evaluation. This approach recognizes that the health status of older persons is dependent upon influences beyond the manifestations of their medical conditions. Among these are social, psychological and mental health, and environmental factors. Geriatric assessment also places high value upon functional status, both as a dimension to be evaluated and as an outcome to be improved or maintained.
Although in the strictest sense geriatric assessment is a diagnostic process, many use the term to include both evaluation and management. Moreover, geriatric assessment is sometimes used to refer to evaluation by the individual clinician and at other times is used to refer to a more interdisciplinary process, comprehensive geriatric assessment (CGA). The terminology is further clouded because the latter process has evolved since its inception with respect to sites where the assessment is provided, the participating health professionals, the nature of the assessment, and the amount of follow-up and management that is included. Accordingly, any discussion of geriatric assessment must be precise in its description of the process of interest.
This chapter is divided into four components: (1) geriatric assessment by the individual clinician, with an emphasis on the outpatient setting; (2) a strategic approach to geriatric assessment for the practicing clinician; (3) CGA and evidence for its effectiveness; and (4) lessons learned from geriatric assessment that have been applied to health care delivery of older persons.
Geriatric assessment (Figure 11-1) by the individual clinician extends beyond the traditional disease-oriented medical evaluation of older persons' health to include assessment of cognitive, affective, functional, social, economic, environmental, and spiritual status, as well as a discussion of patient preferences regarding advance directives. Assessment instruments can be used to guide these evaluations but do not substitute for clinical skills and judgment, including the skill of eliciting important items from the patient's history and physical examination. Information obtained from assessment instruments can direct the clinician's attention to issues that are particularly relevant to an individual patient. Systematic assessment of the multiple domains noted above ensures that the evaluation is comprehensive. Some clinicians may prefer to rely on less formal questions to probe into potential problems. Examples of potential open-ended questions are provided later in this chapter.
Interacting dimensions of geriatric assessment.
Geriatric assessment differs according to the setting where the patient is being evaluated. In the hospital setting, the initial assessment is usually directed at the acute medical problem that precipitated the hospitalization. As the patient begins to recover and plans are initiated for discharge, other components (e.g., social support, environment) assume increasing importance in the assessment. The inpatient setting can be problematic for geriatric assessment because of the rapidly changing status of ...