In addition to conventional assessment of symptoms, diseases, and medications, comprehensive assessment addresses three topics: prognosis, values and preferences, and ability to function independently. Each topic merits at least brief consideration in each clinical decision. For many clinical interventions, harms occur with the interventions or shortly thereafter, and benefits may not occur until years later; such interventions are generally contraindicated when life expectancy is less than the time until benefit. Comprehensive assessment is warranted before major clinical decisions are made (eg, whether major surgery should be performed, or whether a patient should be admitted to the hospital). In hospitalized patients, comprehensive assessment improves survival and increases the number of people who return home.
When an older person’s life expectancy is longer than 10 years (ie, 50% of similar persons live longer than 10 years), it is reasonable to consider effective tests and treatments much as they are considered in younger persons. When life expectancy is less than 10 years (and especially when it is much less), choices of tests and treatments should be made based on their ability to affect a clinical outcome that is valued by the patient in the context of their estimated life expectancy. The relative benefits and harms of tests and treatments often change as prognosis worsens, and net benefit (benefits minus harms) often worsens.
When an older patient’s clinical situation is dominated by a single disease process (eg, lung cancer metastatic to brain), prognosis can be estimated well with a disease-specific instrument. Even in this situation, however, prognosis generally worsens with age (especially over age 90 years) and with the presence of serious age-related conditions, such as dementia, malnutrition, or functional impairment.
When an older patient’s clinical situation is not dominated by a single disease process, prognosis can be estimated initially by considering basic demographic and health elements (Figure 4–1). For example, less than 25% of men aged 95 will live 5 years, whereas nearly 75% of women aged 70 will live 10 years. The prognosis for older persons living at home can be estimated by considering age, sex, comorbid conditions, and function. The prognosis is worse for older persons discharged from the hospital than for those living at home and can be estimated by considering sex, comorbid conditions, and function at discharge. A compilation of indices with online calculators that allow for estimating prognosis in multiple clinical settings can be found at ePrognosis (https://eprognosis.ucsf.edu).
Median life expectancy of older men and women. (Data derived from Arias E. United States Life Tables, 2011. Natl Vital Stat Rep. 2015;64(11):1–63.)
ASSESSMENT OF VALUES & PREFERENCES
Although patients vary in their values and preferences, many frail older patients prioritize maintaining their independence over prolonging survival. Values and preferences are determined ...