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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.
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Teams and Clinical Sites of Care
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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.”)
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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.
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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.
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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.
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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 ...