Medical Assessment

The medical assessment includes a review of the patient’s medical record, medication history (past and present), and a nutritional evaluation. On average, elderly patients have four to six diagnosable disorders, which may require the use of several medications. One disorder can affect another, and in turn a collective deterioration of both can lead to overall poor outcomes. Review of the patient’s medical record should focus on conditions that are more common in the elderly (geriatric syndromes) and in particular their risk factors.

Four shared risk factors—older age, baseline cognitive impairment, baseline functional impairment, and impaired mobility—have been identified within the five most common geriatric syndromes: pressure ulcers, incontinence, falls, functional decline, and delirium (Inouye et al., 2007). It is important that health care providers familiarize themselves with the common geriatric body area or system disorders that can directly influence these risk factors. Understanding the basic mechanisms involved in geriatric syndromes is essential to targeting therapeutic options.

During the medical assessment, the review of systems should be completed with special emphasis on sensory impairment, dentition, mood, memory, urinary symptoms, falls, nutrition, and pain. The U.S. Preventive Services Task Force (1996) recommends routine screening for visual and hearing impairment.

Hearing loss is the third most prevalent chronic condition in elderly people, after hypertension and arthritis, and its prevalence and severity increase with age. In persons age 65 to 75 years, the prevalence of hearing loss ranges from 20% to 40% (Cruikshanks et al., 1998; Rahko et al., 1985; Reuben et al., 1998), whereas in those over age 75, it ranges from 40% to 66% (Ciurlia-Guy et al., 1993; Parving et al., 1997).

Screening for hearing loss can be accomplished using two office-based methods: the audioscope (objective) and a validated short questionnaire (subjective). The audioscope is a handheld instrument that functions as an otoscope and audiometer and can be used to visualize the ear canal and eardrum and remove cerumen if necessary. The audioscope is easy to use, with 87% to 96% sensitivity and 70% to 90% specificity (Abyad, 1997; Mulrow, 1991). The Hearing Handicap Inventory for the Elderly–Short Version (HHIE-S) is a subjective, 10-item, 5-minute questionnaire with an overall accuracy of 75% in identifying hearing loss (Mulrow et al., 1990).

A formal audiologic evaluation should be offered to any patient who fails a hearing screening. The evaluation can assist in determining the need for further testing or management, including hearing aid, medical treatment, or surgical intervention.

Review of the patient’s current medication list, including over-the-counter (OTC) medications, as well as any drug allergies or previous adverse drug reactions, is a necessary component of the geriatric assessment. Adverse drug reactions (ADRs; also adverse drug events) are a significant public health issue, especially in the elderly population (Thomsen et al., 2007). Polypharmacy is defined as taking more than four medications and is an independent risk factor for both delirium and falls (Inouye et al., 2000; Molyan and Binder, 2007).

Patients or family members should be asked to bring in all the patient’s prescription medications and supplements at the initial visit and periodically thereafter. Clinicians can make sure patients have the prescribed drugs, but possession of these drugs does not guarantee adherence. Patients should be asked to demonstrate their ability to read labels (often printed in small type), open containers (especially the child-resistant type), and recognize their medications. Pillboxes may be helpful in organizing the patient’s medications by the week or month.

Nutritional evaluation is an integral part of the geriatric assessment. The type, quantity, and frequency of food eaten should be determined. Malnutrition and undernutrition can lead to health problems that include delayed healing and longer hospital stays. A reliable marker of nutritional problems is weight loss, specifically, more than 5% in the past month and 10% or greater weight loss in the last 6 months (Huffman, 2002). Clinicians should ask about any special diets (e.g., low carbohydrate, vegetarian, low salt) or self-prescribed “fad” diets. A nutritional screen can aid in further assessment of the patient’s nutritional health and help guide interventions (Figure 4-1). Additional questioning should include weight loss and change of fit in clothing; amount of money spent on food; and accessibility of grocers with a variety of fresh foods.

Figure 4-1 Nutrition questionnaires such as this (Determine Your Nutritional Health) can help in the assessment of the elderly patient’s nutritional health.

(Courtesy Nutrition Screening Initiative, Washington, DC, 2007.)

The ability to chew and swallow should also be evaluated. It may be impaired by xerostomia (dryness of mouth), which is common in elderly persons. Decreased taste or smell may reduce the pleasure of eating, so patients may eat less. Patients with decreased vision, arthritis, immobility, or tremors may have difficulty preparing meals and may injure or burn themselves when cooking. Patients worried about urinary incontinence may reduce their fluid intake and thus may eat less food.

Functional Assessment

A primary goal of the geriatric assessment is to identify interventions to help patients maintain function and stay at home in independent living situations. The functional assessment focuses on activities of daily living (ADLs) and risk screening for falls. The basic ADLs include eating, dressing, bathing, transferring, and toileting. The instrumental ADLs (IADLs) consist of shopping, managing money, driving, using the telephone, housekeeping, laundry, meal preparation, and managing medications (Katz, 1983). Home health and social services referral should be considered for patients who have difficulty with the ADLs. A simple method of screening patients for gait and mobility problems is to ask, “Have you fallen all the way to the ground in the past 12 months?” A positive screen should lead to a more thorough evaluation and consideration of a physical therapy referral (Ganz et al., 2007) (see Falls Assessment).

Psychological Assessment

The psychological assessment screens for cognitive impairment and depression, two conditions that significantly impact both the patient and the family. The most studied test to screen for cognition is the Mini-Mental State Examination, which is best for identifying patients with moderate or severe dementia. Depression can be readily screened with shorter versions of the original 30-item Yesavage Geriatric Depression Scale (GDS) (Yesavage et al., 1983). The five-item version of the GDS asks the following:

A score of greater than two positive answers is positive (97% sensitivity, 85% specificity) (Rinalde et al., 2003). The Yale Depression Screen (“Do you often feel sad or depressed?”) is a validated one-item GDS screening tool (Mahoney et al., 1994).

Social Assessment

It is important to assess the patient’s living situation and social support when performing a geriatric assessment. The living situation should be evaluated for potential hazards, especially if the patient is identified as being at risk of falling. The social assessment also includes questions about financial stressors and caregiver concerns. Advance planning is a key component of the assessment and includes clarifying the patient’s values and setting goals for care in case of future incapacity, including identifying the patient’s “power of attorney” for health care.

Summary

A geriatric assessment can identify frequent problems, thus leading to earlier interventions for the common medical and social concerns of the elderly population. It is important to remember, however, that patients may underreport medical problems because they worry about losing their independence. Patients may also be reluctant to repeat their health concerns to their primary care physician because they fear being perceived as having an emotional or psychiatric illness. Often, older patients will rationalize their symptoms as being a “normal” component of aging.

The key to a successful geriatric assessment is to establish trust and effective communication between the patient and the physician. Allotting for adequate time during appointments and, if needed, scheduling frequent office visits are essential to the gathering of information. Inquiring about recent socioeconomic changes, functional losses, or life transitions is also important. The physician should obtain the patient’s medical records before the first visit. A questionnaire targeted to the geriatric assessment domains should be completed by the patient, with family assistance if needed (Figure 4-2). Language, education, social support, economic status, and cultural/ethnic factors play a vital role in the patient’s health care outcome. A multidisciplinary approach is used to interventions and management. Preserving function and maintaining quality of life are the primary goals of the geriatric assessment (Miller et al., 2000).

Figure 4-2 Geriatric health questionnaires assist in gathering pertinent information regarding the functioning of the elderly patient.

Epidemiology

Falls result in significant morbidity and mortality as well as an increased rate of nursing home placement. Each year, approximately 30% of persons over age 65 fall at least once, and the incidence increases with age. Up to 10% of falls result in serious injury. Falls are the leading cause of injury-related deaths in people over 65 years (CDC, 2005). In the United States, hip fractures currently account for more than 300,000 hospitalizations, with a 1-year mortality rate of up to 33% (Sattin, 1992; Tinetti et al., 1998). By 2050, it is estimated that the worldwide number of hip fractures will rise to 6.26 million. Direct medical costs related to falls in adults age 65 or older exceeded $19 billion in 2000 (Stevens et al., 2006).

Falls also cause functional limitations by both direct injury and indirect psychological consequences. Postfall anxiety leads to loss of self-confidence in ambulation and self-imposed limitations in activity. Postfall anxiety syndrome can also result in depression, social isolation, and increased risk of falls from deconditioning. Because the cause of falls is often multifactorial, the assessment and interventions target several areas (Nevitt et al., 1989).

Risk Factors

The multiple risk factors for falling can be categorized as intrinsic or extrinsic. Intrinsic risk factors include age-related physiologic changes and diseases that affect the risk of falling (Table 4-3). Extrinsic risk factors include medications and environmental obstacles. The risk of falling increases significantly in people with multiple risk factors. A prospective study found that 19% of older patients with one risk factor have a fall in a given year, compared with 60% of older patients with three risk factors (Tinetti et al., 1998).

Table 4-3 Intrinsic Risk Factors for Falls

Taking four or more prescription drugs is itself a risk factor for falling. Also, several medication classes have a higher potential to cause falls, including tricyclic antidepressants, neuroleptic agents, serotonin reuptake inhibitors, benzodiazepines, and class 1A antiarrhythmic medications. Narcotic analgesics, antihistamines, and anticonvulsants are also associated with increased risk for falls (Ensrud et al., 2002; Rubenstein and Josephson, 2002).

Physical restraints have been used in an attempt to reduce falling. Although the focus here is on community-dwelling elderly persons, it is worth noting that use of physical restraint in the nursing home and hospital setting does not reduce the risk of falling and is instead associated with an increased risk of injury (Neufeld et al., 1999). Since the 1980s, the use of physical restraints has been appropriately and dramatically reduced.

Screening

At present, no one screening test can be recommended to identify potential fallers (Gates et al., 2008). The two best predictors of falls are a history of falls and a reported abnormality in gait or balance (Ganz et al., 2007). “Have you had any falls in the past year?” is a simple screening question that can be answered by the patient or caregiver in a previsit questionnaire. For patients who have not fallen, the pretest probability of a fall in the upcoming year ranges from 19% to 36%. Also, asking the patient, “Have you noticed any problems with gait, balance, or mobility?” is another simple screening question. Answering “yes” to either screening question warrants further assessment (Tinetti, 2003).

Falls Assessment

Falls assessment should include a multifactorial evaluation beginning with the circumstances surrounding the fall(s), associated symptoms, risk factor assessment, and medication history (Table 4-4). The physician should ask about the environment (e.g., indoors or outdoors, dark or well lighted, time of day), environmental obstacles (e.g., throw rugs, door thresholds, stairs), and footwear worn at the time. The history should also include questions about prodromal symptoms (e.g., lightheadedness, dizziness), if there was a loss of consciousness or other symptoms of arrhythmias (i.e., palpitations). If available, obtain information from a witness. The evaluation should also include questions about risk factors, functional abilities and medication history (AGS et al., 2001).

Table 4-4 Initial Evaluation of Falls

Postural blood pressure and pulse are important assessments in the examination. Up to 30% of older persons have orthostatic hypotension, and although some may be asymptomatic, others become lightheaded and dizzy (Luukinen et al., 1999). The musculoskeletal examination should focus on range of motion in the legs, inflammatory or degenerative conditions of the leg joints, kyphosis, and abnormalities of the feet. The neurologic examination should include proprioception, coordination, muscle strength, and cognition. The cardiovascular examination should focus on detecting potential causes of falls (e.g., arrhythmias, aortic stenosis). Visual acuity and hearing should be assessed. Disturbances in gait and balance can be identified through the patient or caregiver’s direct report or a simple office-based assessment, such as the “get up and go” test (Podsiadlo and Richardson, 1991). This test may be scored, timed, or used as an overall assessment of the patient’s gait, stability, balance, and strength. The patient is asked to stand from a seated position, walk about 10 feet (3 meters), turn around, walk back, and sit down again. If the patient needs to push off the chair or rock back-and-forth several times to arise, leg strength is diminished. The task should be completed within 10 seconds. Gait abnormalities, such as poor step height, decreased stride length, and shuffling, may be observed. A wide-based stance and slow, multiple-point turning may reveal poor balance.

Laboratory evaluation and imaging are based on the history and clinical findings. If an underlying metabolic abnormality is suspected (e.g., diabetes, anemia, dehydration), appropriate blood tests may assist in the diagnosis. If a patient is suspected of having syncope, cardiac rhythm monitoring (e.g., Holter or event monitor) is appropriate. An echocardiogram may be necessary for evaluation of a murmur. Neuroimaging with magnetic resonance imaging (MRI) or computed tomography (CT) is indicated for the evaluation of focal findings on neurologic examination.

Management

Evidence has demonstrated that a multifactorial approach and intervention strategy is needed to reduce the rate of falling in older patients (Figure 4-3). Because one of the most modifiable risk factors is medication use, medication review is a key component of management (Hanlon et al., 1997). The review should focus on decreasing the dose or discontinuing sedating medications. If orthostasis is present, adjustment of diuretics and antihypertensive medications should be considered. The role of vitamin D in fall prevention is questionable. Although, it probably does not decrease the risk of falls, except in patients with low levels of vitamin D, supplementation should be started in patients with osteopenia or osteoporosis (Gillespie et al., 2009).

Figure 4-3 Practice guideline for the prevention of falls in older persons.

(From American Geriatrics Society (AGS), British Geriatrics Society, and American Academy of Orthopedic Surgeons Panel on Falls Prevention: Guideline for the prevention of falls in older persons. J Am Geriatr Soc 2001;49:664-672.)

Supervised exercise programs should be considered for patients at high risk for falls; exercise can reduce the physical risk factors (Rose, 2008). Specifically, programs that focus on two of three exercise components (strengthening, balance training, and aerobic/endurance training) for a minimum of 12 weeks have shown the most benefit (Costello and Edelstein, 2008). Finally, home hazard evaluation and intervention is an essential component in the assessment of falls in elderly

Definition

The National Center on Elder Abuse (2009) defines elder abuse as “a term referring to any knowing, intentional, or negligent act by a caregiver or any other person that causes harm or a serious risk of harm to a vulnerable adult.” Although terms vary across states, elder abuse can be generally categorized into several types: physical abuse, emotional abuse, sexual abuse, exploitation, neglect, self-neglect, and abandonment (Table 4-5). Elder abuse is also classified by its setting. Domestic abuse occurs in the home of the victim. Institutional abuse occurs in a nursing home, hospital, assisted-living center, or group home.

Table 4-5 Elder Abuse: Definitions

Modified from National Center on Elder Abuse. http://www.ncea.aoa.gov/NCEAroot/Main_Site/Index.aspx. October 2009.

Risk Factors

Awareness of risk factors for abuse can increase the chance of identification and early intervention. Although research is ongoing, several characteristics of both the victim and the abuser should trigger further screening questions. Risk factors associated with the victim include shared living situations, history of dementia, and social isolation. Perpetrator risk factors include a history of mental illness (specifically depression), alcohol abuse, and financial dependency (Lachs and Pillemer, 2004).

Screening

There is no consensus that asymptomatic patients should be screened for elder abuse. The American Medical Association (AMA, 1992) suggests that all outpatients be screened for family violence, but the U.S. Preventive Services Task Force (2009) concluded that there was insufficient evidence for or against screening for older adults or their caregivers for elder abuse. Patients should be screened if there is a suspicion of elder abuse. The questions should be open-ended, nonthreatening, and asked in a variety of ways to assess for the different forms of elder abuse (Table 4-6). A positive response should be followed by more direct questions as to the nature of the abuse. Direct questioning by physicians has been shown to increase reporting (Oswald et al., 2004).

Table 4-6 Screening Questions for Elder Abuse

Clinical Manifestations

Certain behavioral and physical signs should raise suspicion for elder abuse. Behavioral signs in the caregiver include answering for the patient, insisting on being present for the entire visit, failing to offer assistance, and displaying indifference or anger. Behavioral signs in the elderly patient include poor eye contact, hesitation to talk openly, or fearfulness toward the caregiver. Other indicators of possible abuse include confusion, paranoia, anxiety, anger, and low self-esteem. Physical signs that may signal neglect include poor hygiene, malnutrition, dehydration, pressure ulcers, and injuries (Table 4-7). Medication nonadherence may also be a warning sign for abuse.

Table 4-7 Physical Signs of Elder Abuse

Assessment

In suspected cases of abuse, the assessment includes a thorough history, physical examination, and functional, cognitive, and mental health assessments. The patient and the caregiver should be interviewed alone and separately (Abbey, 2009). Documentation begins with the description of the abusive or neglectful event, using the patient’s words whenever possible. The duration, frequency, and severity of the abuse should be recorded. If injuries are present, a detailed description of the injuries and photographs, if available, should be documented. Assessment of functional dependence can be helpful in recommending resources, whereas evaluation of cognitive impairment is important in assessing both risk and capacity. The assessment should also include a mental health screening, with particular attention to depression, anxiety, insomnia, and alcohol abuse.

The elderly patient’s caregiver should be assessed for caregiver stress and for risk factors for elder abuse, including alcohol abuse, depression, and financial dependency.

Management

Because the cause of elder abuse is often multifactorial, management involves a multidisciplinary approach with social workers and legal, financial, and APS representatives. The immediate management is determined by the safety and capacity assessments. Is the patient in any immediate danger? If so, acute hospitalization, safe home placement, and a protective court order may be indicated. If the patient lacks capacity, the physician should work with APS on options, including guardianship, financial management resources, and order of protection if indicated. In other cases, management should focus on utilizing community resources to maintain the patient in the least restrictive environment. The emphasis is to decrease social isolation and caregiver stress. Interventions can include respite care, home health or custodial services, counseling, and drug or alcohol rehabilitation.

Reporting Requirement

All 50 states have laws authorizing APS departments to intervene in cases of elder abuse. It is important for primary care physicians to know their state’s requirements on mandatory reporting for elder abuse and which type of abuse (e.g., physical, emotional, sexual, financial) requires reporting. Higher rates of abuse have been documented in states that require public education regarding elder abuse and states that require mandatory reporting (Jogerst et al., 2003). Mandatory reporting laws in 42 states are controversial because they conflict with a competent elder’s autonomy and with the physician-patient relationship. In such cases, physicians should explain their legal obligation to report and emphasize that the goal of reporting is to develop a care plan to assist the patient.