6: Geriatric Assessment

Geriatric assessment is a broad term that describes a clinical approach to older patients that goes beyond a traditional medical history and physical exam to include functional, social, and psychological domains that affect well-being and quality of life. Although geriatric assessment has been adapted to different settings, structures, and models of care, 4 key concepts inform the approach: the clinical site of care, prognosis, patient goals, and functional status.

Although geriatric assessment may be comprehensive and involve multiple team members (eg, social workers, nurses, physicians, rehabilitation therapists, pharmacists), it may also involve just a single clinician and be much more simple in approach. In general, teams that use an interdisciplinary or interprofessional approach (teams in which multiple disciplines meet together to develop a single comprehensive treatment plan for a patient) are most common in settings that serve primarily frail, complex patients, such as inpatient units, rehabilitation units, PACE (Program for All-Inclusive Care of the Elderly), and long-term care facilities. In outpatient settings, teams are less likely to be formalized, and if present, are more likely to be virtual, asynchronous and multidisciplinary (teams in which each discipline develops its own assessment and treatment plan) than interdisciplinary. (For more information, see Chapter 5, “The Interprofessional Team.”)

Regardless of team composition, the setting and functional level of the patient population being served will determine what assessment tools are most appropriate. For example, long-term care settings are likely to focus on basic activities of daily living (eg, bathing), whereas outpatient teams are more likely to focus on higher levels of functioning, such as mobility and ability to prepare meals. In inpatient settings, the focus is on preventing deconditioning, providing medical support (eg, nutrition), and discharge planning, including assessing rehabilitation potential and best setting for discharge. Regardless of the team structure, site, and tools being used, many of the principles of assessment are the same.

An older adult’s prognosis can be critically important in determining which interventions are likely to beneficial or burdensome for that individual. In community-dwelling older persons, prognosis can be estimated initially by using life tables that consider the patient’s age, gender, and general health. For example, <25% of men age 95 years will live 5 years, whereas nearly 75% of women age 70 years will live 10 years. However, persons with chronic diseases may have substantially shorter survival. When an older patient’s clinical situation is dominated by a single disease process (eg, lung cancer metastatic to brain), prognosis can sometimes be estimated well with a disease-specific instrument. Even when disease-specific prognostic information is available, frequently the range of survival is wide. Moreover, prognosis generally worsens with age (especially age >90 years) and with the presence of serious age-related conditions, such as dementia, malnutrition, or impaired ability to walk. See Chapter 3, “Goals of Care & Consideration of Prognosis,” for a more comprehensive approach to prognostication in the older patient.

When an older person’s life expectancy is >10 years (ie, 50% of similar persons live longer than 10 years), the appropriateness of tests and treatments is generally the same as for younger persons. When life expectancy is <10 years (and especially when it is much less), choices of tests and treatments should be made on the basis of their ability to improve that particular patient’s prognosis and quality of life in the context of that patient’s life expectancy. The relative benefits and harms of tests and treatments often change as prognosis worsens.

Palliative care services should be considered for any patient with a life-limiting illness, particularly when the prognosis is less than 18 months. If the prognosis is 6 months or less, hospice should be considered, if consistent with the patient’s goals of care.

Although patients vary in their values and preferences, many frail older adults prioritize maintaining their independence or relieving pain or other symptoms over prolonging survival. Values and preferences are determined by speaking directly with a patient or, when the patient cannot express preferences reliably, with the patient’s surrogate. Even patients who cannot make complicated decisions can often express preferences, and should be involved in decision making as much as they are able. See Chapter 12, “Ethics & Informed Decision Making,” for a more thorough discussion of patient decision making.

Values and preferences are often easiest to assess in the context of a specific medical decision. For example, the clinician might ask a patient considering chemotherapy for a new cancer, “Tell me about the risk and discomfort you are willing to go through to achieve an increased chance of living an extra 6 months.” In assessing values and preferences, it is important to keep in mind that patients should be definitive sources of information about their preferences for outcomes and experiences; however, they usually do not have adequate information to express informed preferences for specific tests or treatments, and require guidance from a clinician who can explain how the tests or treatments might help achieve the patient’s goals. Therefore, it is often more useful to ask about values (“What is the least acceptable quality of life for you?” or “If you were critically ill, would you like us to focus more on comfort and quality of life or prolonging life?”) rather than interventions lacking a context (“Would you want pressors?”). Patients’ preferences often change over time. For example, some patients find living with a disability more acceptable than they would have before experiencing it. Some patients change their values based on important events, such as their desire to live to see the graduation or birth of a grandchild.

Every older person should be encouraged to complete advance directives for both health care and finances, to designate a surrogate decision maker, and to discuss their values and preferences with their surrogate and with their health care clinicians. Many states honor a specific advance directive form that is signed by both patient and physician and serves as both an advance directive and order sheet that is portable across different sites of care. Examples of this form would include the POLST or MOLST (physician or medical orders for life-sustaining treatment).

Functional status can be viewed as a summary measure of the overall impact of health conditions in the context of a patient’s physical and psychosocial environmental. Functional status information is important for planning, monitoring responses to therapy, and for determining prognosis. Functional impairment is common in older adults and has many potential causes, including age-related physiological and cognitive changes, disuse, disease, social factors, and the interplay between any of these. According to the 2007 Centers for Medicare and Medicaid Services, Medicare Current Beneficiary Survey, 29% of patients age 65 years and older had limitations in basic activities of daily living (ADLs: bathing, dressing, eating, transferring, continence, toileting) and 14% had limitations in instrumental ADLs (IADLs; transportation, shopping, cooking, using the telephone, managing money, taking medications, cleaning, laundry). IADLs are activities that are essential for independent living. Subtle or new declines in IADL function may be an early sign of dementia, or other disease, such as Parkinson disease. Loss of ADL or IADL function often signals a worsening disease process or the combined impact of multiple comorbidities. Level of ADL and IADL impairment can usually be determined by self- or proxy report, but should be corroborated when possible. When accurate functional information is essential for planning, direct observation by a physical or occupational therapist can be invaluable.

For highly functional independent elders, standard functional screening measures will not capture 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, or fishing that the patient enjoys and regularly participates in (advanced ADLs). Although many of these activities reflect patient preferences that may change over time, if the patient begins to drop the activity, it may indicate an early impairment, such as dementia, incontinence, or worsening vision or hearing loss.

Functional status should be assessed initially and periodically thereafter, particularly after hospitalization, severe illness, or after the loss of a spouse or caregiver. Unexpected changes in functional status should prompt a comprehensive evaluation. If no reversible cause of functional decline is found after a reasonable medical search, the clinician should focus on supportive services, and when necessary, placement in a different living setting. For more information about functional ability and assessment in older persons, refer to Chapter 2, “Consideration of Function & Functional Decline.”

Preventive services include counseling on healthy behaviors, screening to detect asymptomatic disease, and vaccinations. Specific preventive interventions for an individual patient should be based upon evidence-based guidelines, the patient’s estimated life expectancy, and the patient’s values and goals. The U.S. Preventive Services Task force has an interactive website with specific recommendations based on the patient’s age, gender, tobacco use, and sexual activity (http://epss.ahrq.gov/PDA/about.jsp) (see Chapter 8, “Prevention & Health Promotion”).

Falls are the leading cause of nonfatal injuries and unintentional injury and death in older persons. Every older person should be asked about falls at least annually. Because gait and balance 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 and arthritis, as well as specific neurologic impairments) than other components of the neurologic examination.

Components of the gait exam include observing if the patient can get up from a chair without using the hands (to test quadriceps strength), observing symmetry, stride length, step height, and width of stance. Balance can be tested by observing stability with eyes closed, with a sternal nudge, with a 360-degree turn, and ability to maintain side by side, tandem, and semitandem stance for 10 seconds. The “Timed Up and Go” tests a person’s ability to get up from a chair, walk 3 meters, return, and sit down. Although a variety of cut-off scores are used for this test, inability to complete the task in fewer than 15 seconds is generally considered abnormal, and longer times are associated with a greater risk of functional impairments. Patients with an abnormal gait evaluation should be evaluated further for potentially reversible causes (see Chapter 25, “Falls & Mobility Disorders,” and Chapter 59, “Assessing Older Adults for Syncope Following a Fall”).

The prevalence of cataract, age-related macular degeneration, glaucoma, and need for corrective lenses increases with advancing age. 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 older people, particularly those who have diabetes or are at high risk of glaucoma, such as African Americans.

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. A vision screening question such as, “Do you have difficulty driving, watching television, reading or doing any of your daily activities because of your eyesight, even while wearing glasses?,” is helpful but may not be sensitive enough to replace a formal vision assessment (see Chapter 61, “Managing Vision Impairment in Older Adults”).

More than 33% of individuals older than age 65 years and 50% of those older than age 85 years 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 older adults is undetermined. The whispered voice test is easy to perform but many patients will still require formal follow up testing; sensitivities and specificities range from 70% to 100%. Handheld audiometry with the Welch-Allyn AudioScope can increase the accuracy of screening if performed in a quiet environment. The U.S. Screening and Prevention Task Force recommends using screening questions about hearing loss in older adults. Structured questionnaires such as the Hearing Handicap Inventory for Elderly–Screening are most useful for assessing the degree to which hearing loss interferes with functioning (see Chapter 62, “Managing Hearing Impairment in Older Adults”).

Dementia is common in older adults but is commonly missed by primary care practitioners. Early diagnosis of Alzheimer disease and related disorders is important in order to identify potentially treatable contributors (which are uncommon), and to involve the patient in advance care planning for health care and finances. As medications and treatments for Alzheimer disease become more effective, early screening will become more important. The 3-item recall, in combination with the clock draw (the mini-cog) is a brief screen that is sensitive for detecting dementia. Patients who fail the mini-cog should be followed up with a more in-depth mental status examination.

Patients who screen positive for possible dementia should also have further assessment of whether or not they have advance directives, have decision making capacity, and whether they have processes in place for protecting their finances (see Chapter 22, “Cognitive Impairment & Dementia” and Chapter 52, “Evaluating Confusion in Older Adults”).

Incontinence in older adults is common but often goes unmentioned. Women are twice as likely as older men to be incontinent; overall, approximately 6% to 14% of older women experience incontinence daily. Ask a simple question, such as, “Is inability to control your urine a problem for you?” or “Do you have to wear pads, diapers, or briefs because of urine leakage?” Positive answers should be followed up with a more complete assessment, as determined by the patient’s goals (see Chapter 39, “Urinary Incontinence”).

Depression is commonly missed in primary care. Although major depression is no more common in older adults than in younger populations, depressive symptoms are more common in older adults. In ill and hospitalized older patients, the prevalence of depression is ≥25%. The PHQ-2 is a sensitive screening tool for depression. Positive responses should be followed up with more extensive screen (eg, the PHQ-9), and, if positive, a comprehensive interview conducted (see Chapter 45, “Depression & Other Mental Health Issues”).

Nutritional problems among the elderly include obesity, undernutrition, and specific vitamin and nutrient deficiencies. Unintentional loss of >5% of body weight should trigger further evaluation, which should include consideration of oral health issues (eg, loss of dentures), medical issues (eg, dementia or malignancy), and social issues (eg, loss of transportation). Loss of 5% of body weight in 1 month or 10% of body weight over 6 months is associated with increased morbidity and mortality.

Increasingly, obesity is becoming a problem in the elderly and is associated with multiple morbid conditions, including diabetes, osteoarthritis, poor mobility, and obstructive sleep apnea. Obesity in the older adult is defined as a body mass index (BMI) of ≥30 kg/m² (see Chapter 68, “Defining Adequate Nutrition for Older Adults”).

The average older person takes 4–5 medications, and many older adults receive medications from more than 1 physician, which increases the risk for medication discrepancies and adverse drug events. Medications should be reviewed with the primary care practitioner, pharmacist, or nurse at every visit. Patients should be encouraged to bring all of their medications, including nonprescription drugs, (the “brown bag assessment”) to every visit. Regular pharmacy reviews and commercially available medication management programs can help primary care providers monitor for potential inaccuracies and potential drug–drug interactions (see Chapter 9, “Principles of Prescribing for Older Adults,” and Chapter 53, “Addressing Polypharmacy & Improving Medication Adherence in Older Adults”).

Providing primary care for a frail older adult requires that attention be paid to family caregivers as well as to the patient, because the health and well-being of the patient and caregivers are intricately linked. High levels of functional dependence place an enormous burden on a caregiver. Burnout, depression, and poor self-care 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 aides.

Old age can be a time of reduced resources, both social and financial. The 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. Every older person should be encouraged to engage in advance financial planning when they are being encouraged to complete medical advance directives.

Assessment of the patient’s environment should include asking about their ability to access needed community resources (eg, banking, grocery, pharmacy) either themselves or via proxy, the safety of their home, and the appropriateness of their environment for their level of functional impairment. When the safety of the home is in question, a home safety assessment by a home health care agency is appropriate.

Because of the possibility of abuse, vulnerable elders should have the opportunity to be interviewed alone. Direct questioning about abuse and neglect is may be useful, 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 seeking 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 (see Chapter 72, “Detecting, Assessing, & Responding to Elder Mistreatment”).

A number of strategies can help make the process of geriatric assessment more efficient for busy primary care practices, such as using previsit screening questionnaires, using nonphysician personnel to help perform standard geriatric assessments, and having standardized protocols for following up on positive results. Screening instruments such as the ones by Lachs et al and Moore et al (Figure 6–1) are useful in the primary care setting. A number of well-designed previsit questionnaires for elders are available (eg, www.geronet.ucla.edu/images/stories/docs/professionals/Geri_Pre-visit_Questionnaire.pdf). The Medicare Annual Wellness Visit also can facilitate the performance of many of these assessment in a separate visit that does not need to address the patient’s ongoing medical problems. New reimbursement models for team based medical homes may make performing geriatric assessment in primary care more practical for many practices than it is currently.

Agency for Healthcare Research and Quality. Search for Recommendations. http://epss.ahrq.gov/ePSS/search.jsp

Centers for Disease Control and Prevention. http://www.cdc.gov/mmwr/PDF/wk/mm753-Immunization.pdf

Social Security Administration. Life Expectancy Tables. http://www.ssa.gov/OACT/STATS/table4c6.html

UCLA GeroNet. Healthcare office forms. http://geronet.ucla.edu/centers/acove/office_forms.htm

U.S. Preventive Services Task Force. Home page. http://www.uspreventiveservicestaskforce.org/