Comprehensive evaluation of an older individual's health status is one of the most challenging aspects of clinical geriatrics. 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. Most importantly, it requires a perspective different from that used in the evaluation of younger individuals. Not only are the a priori probabilities of diagnoses different, but one must be attuned to more subtle findings. 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.
Comprehensive geriatric assessment 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 can prevent nursing home admissions and functional decline.
The purpose of the evaluation and the setting in which it takes place will determine its focus and extent. Considerations important in admitting a geriatric patient with a fractured hip and pneumonia to an acute care hospital during the middle of the night are obviously different from those in the evaluation of an older demented patient exhibiting disruptive behavior in a nursing home. Elements included in screening for treatable conditions in an ambulatory clinic are different from those in assessment of older individuals in their own homes or in long-term care facilities.
Despite the differences dictated by the purpose and setting of the evaluation, several essential aspects of evaluating older patients are common to all purposes and settings. Figure 3-1 depicts these aspects. Several comments on addressing them are in order:
Physical, psychological, and socioeconomic factors interact in complex ways to influence the health and functional status of the geriatric population.
Comprehensive evaluation of an older individual's health status requires an assessment of each of these domains. The coordinated efforts of several different health-care professionals functioning as an interdisciplinary team are needed.
Functional abilities should be a central focus of the comprehensive evaluation of geriatric patients. Other more traditional measures of health status (such as diagnoses and physical and laboratory findings) are useful in dealing with underlying etiologies and detecting treatable conditions, but in the geriatric population, measures of function are often essential in determining overall health, well-being, and the need for health and social services.
Components of assessment of older ...