Interdisciplinary geriatric assessment
Christi Stewart, Michael L. Moran and Timothy L. Kauffman
Introduction
Many approaches to the care of the geriatric patient have been lumped under the rubric of ‘geriatric assessment’. Indeed, in terms of process and outcome, geriatric assessment is one of the most widely studied aspects of geriatric healthcare. By 2013, there were thousands of published reports on geriatric assessment and numerous meta-analyses had been performed.
The American Geriatrics Society (AGS) Core Writing Group of the Task Force on the Future of Geriatric Medicine has outlined a series of core attributes and competencies for geriatric medicine (Besdine et al., 2005). These include ‘coordinated care that includes communication among providers’ and ‘interdisciplinary team care with shared responsibility for patient care processes and outcomes’. The goal of this chapter is to examine the philosophical underpinnings of the interdisciplinary approach to geriatric medicine and to examine some of the models of how geriatric assessment has been operationalized and to point out some of the weaknesses and future directions of research for this model of healthcare.
Philosophical underpinnings of geriatric assessment
Secondary Aging Must be Distinguished from Primary Aging
Physiologists often divide aging into two categories – primary or physiological aging and secondary or pathological aging. Primary aging includes those physiological changes that can be ascribed solely to the passage of time. Several theories have been set forth to explain the changes caused by primary aging. These include denaturation of proteins through cross-linking, cumulative damage from free radicals, a programmed decline in immune function and an internal biological clock that is genetically determined. This last theory gained credibility from cross-species studies that related longevity to the number of cell doublings that could occur in cell culture. The number of cell doublings proved to be species-specific and varied directly with the longevity of the species. (See Chapter 1 for additional information about theories of aging.)
Secondary aging involves those decrements in function that can be ascribed to disease processes. Primary and secondary aging are sometimes difficult to distinguish from each other. For example, it was once thought that there was a substantive decline in cardiac output that was age related and due to primary aging. However, it has been discovered that the aging heart has no significant alteration of heart rate, stroke volume, or cardiac output (Sebastian & Pfeifer, 2007).
Likewise, in the era before autopsy studies had been done upon people with dementia, it was believed that dementia was simply a primary process of the senium rather than secondary aging. Autopsy series later disclosed that cognitive losses could be explained by specific pathologies such as multiple strokes or the senile plaques and neurofibrillary tangles of Alzheimer’s disease. It is now known that, even though the speed of effortful mental processing slows with aging due to cortical atrophy, in the absence of disease, cognition remains well preserved (Weaver et al., 2006).
How do these principles relate to geriatric assessment? It is the role of geriatric assessment to tease out the effects of secondary aging and to reverse them through specific treatments, to ameliorate them through interventions that may improve, although not cure, the underlying condition or to assist the patient to function better by enlisting support services or altering the patient’s environment to make that environment more conducive to the patient’s needs.
Coexistence of multiple diseases and the cascade of illness
When clinicians are first trained in medicine, they are commonly taught to think in terms of the ‘chief complaint’. This approach proves to be much too restrictive in the practice of geriatric medicine. Here, the most common scenario is one of multiple, coexisting pathologies that are all conspiring to harm the patient’s functional ability and that the patients themselves may find difficult to describe from a symptomatic perspective.
An example of the cascade effect of multiple problems might be the patient who presents with delirium. Such a change in mental status is a final common pathway for many medical and psychiatric conditions. In this example, the pathology might be traced back as follows: the patient has some moderate renal insufficiency and prostatic hypertrophy. The prostatic hypertrophy leads to urinary retention, which further worsens renal function, which leads to azotemia and anorexia, which leads to reduced fluid and nutritional intake, which leads to even further worsening of renal function and a relentless downward spiral. This example of the interrelationship of organ system function demonstrates a cascade of illness that affects many organs.
A challenge of geriatric assessment is to trace the cascade of events back to find key points in each patient’s unique pathophysiology where treatment or addition of medical or support services may halt or reverse the downward spiral. Because of the complexity of this process, an interdisciplinary approach is often most successful. The National Institute of Aging defines a comprehensive geriatric assessment as a multidisciplinary evaluation in which the multiple problems of older persons are uncovered, described and explained, if possible, and where the resources and strengths of the person are catalogued, needs for services assessed and coordinated care plan developed to focus interventions on the person’s problems.
As any cohort ages, variability increases
Given the overlap of physiological and pathological aging, and the intrinsic difficulty of teasing one process apart from others for any given organ system, it is impossible to predict the physiological function of any individual based on age alone. One may speak of chronological age vs. physiological age. To speak of a young 80-year-old or an old 65-year-old does not sound like an oxymoron to the geriatric practitioner.
What can be predicted is that, as people age, they become less and less like each other. No two persons age identically. Some encounter diseases, others suffer traumatic injuries and others cope with both. Genetics and lifestyle choices add to the variability of aging individuals. With this complicated picture of aging in mind, the ACOVE (Assessing Care of the Vulnerable Elderly) guidelines developed in 2007 define the vulnerable elderly as anyone over 75 years old, and anyone aged 65–74 years old who is at greater risk of death or functional decline over a 2-year period. These guidelines also recommend that any vulnerable elderly person should receive the elements of a comprehensive geriatric assessment within 3 months (Wenger et al., 2007).
The increasing diversity that comes with age has a direct effect on geriatric assessment. For geriatric assessment to work well, it is crucial that both diagnostic and therapeutic approaches be individualized for each patient. Attempting a ‘cookbook’ approach to the solution of clinical problems in such a diverse group could easily lead to iatrogenic harm. The recent trend toward the creation and application of clinical pathways or protocols in the treatment of specific conditions must proceed carefully and contain greater flexibility when dealing with issues in geriatric medicine.
Again, the interdisciplinary approach, because of its greater clinical diversity, can better account for the pluralism of this unique population.
Diminished homeostatic reserve blocks recovery
Perhaps the best definition of aging is ‘increasing susceptibility to the forces of mortality due to decreased homeostatic reserve’. Homeostasis concerns the body’s ability to maintain itself in a steady state and to get itself back on track whenever there is perturbation from that steady state. Ability to maintain a constant temperature, constant blood pressure and constant blood glucose level are all examples of homeostasis.
When homeostatic reserves are constrained, there is diminished likelihood of survival with any extreme stress. A key principle in geriatric assessment is to recognize that homeostatic reserves are diminished and that patients are more sensitive to both the disease processes and the iatrogenic effects of intervention. This should lead to a more conservative and individualized approach in the application of therapeutic maneuvers and drug therapies.
These issues are especially important in geriatric rehabilitation. A common scenario is the elderly patient who has suffered a hip fracture and requires surgical repair. With postoperative pain and analgesia, the patient often suffers such setbacks as postoperative delirium, fever, anemia from blood loss, atelectasis and hypoxemia. Thus, the rehabilitation measures may be delayed for several days by intercurrent illness. While at bedrest, the older patient may be losing in the order of 11–12% of their muscle strength per week (English & Paddon-Jones, 2010) and 1–2% of aerobic capacity daily. Given that up to 70% of geriatric patients have poor muscle mass (sarcopenia) at baseline (Fiatarone, 2009), these losses become highly significant and make rehabilitation and recovery all the more difficult.
In this setting, the patient might not cope well physically or psychologically with the arduous exercise demands of rehabilitation. The twice-daily treatments of up to 4 hours imposed by government regulations for Medicare reimbursed rehabilitation may be too rigorous for some of these more frail individuals. Sometimes, rehabilitation must occur at a more gradual pace and in the long-term care setting.
Diseases present in an atypical fashion
Among geriatric patients, the common presentations of illness are often replaced by the less specific and more global findings of increased confusion, weakness, anorexia and tendency to fall. One sees such phenomena as ‘silent myocardial infarction’, ‘afebrile pneumonia’ and ‘depression without sadness’. The first manifestation of urosepsis might be falling, or the presenting symptom of a myocardial infarction might be increased agitation. In geriatric assessment, the clinician must cast a wider net in attempting to make diagnoses.
Other diseases typically present only in the elderly or much more frequently in the elderly, and the index of suspicion for these problems must remain higher. These disorders include such entities as polymyalgia rheumatica, temporal arteritis and Parkinson’s disease.
Diseases are underreported
Geriatric patients commonly underreport their problems. Sometimes, cognitive impairment gets in the way of an accurate relating of historical information. Occasionally patients assume that their concerns, such as pain or incontinence, are a normal part of the aging process. They may also be fearful that their symptoms indicate a more ominous diagnosis, such as cancer, with unpleasant and costly treatment options. Older persons can also be concerned that their medical problems will lead to a loss of independence, and their reports may under-represent the impact these problems have on their overall functioning. At other times, depression may lead to a sense of hopelessness about the possibility of getting help.
Self-report questionnaires and structured assessment tools to measure cognition, affect and function can yield quite useful information if they are administered carefully by a trained individual and in a nonthreatening manner. These tools add additional important information to the historical database and are often included in a comprehensive geriatric assessment.
The process of geriatric assessment
To maximize benefit, the process of geriatric assessment involves an interdisciplinary approach. The most consistent team members that form the traditional core of this assessment process are the geriatrician or geriatric nurse practitioner, nurse and social worker. Ancillary team members have included the occupational therapist, physical therapist, psychiatrist or psychologist, nutritionist, speech therapist, exercise physiologist, recreational therapist and respiratory therapist. One of the very first outpatient assessment programs even employed an architect because of the frequency with which changes in the patient’s home environment were being recommended.
The process of a comprehensive geriatric assessment involves making a diagnosis, weighing diagnostic and therapeutic options, monitoring health outcomes, prognostication, long-term care planning, maximizing function and wellbeing, and reduction of poor outcomes. It is a multidisciplinary, multidimensional assessment designed to evaluate functional ability, physical health, cognition and mental health, and socioenvironmental circumstances (Elsawy & Higgins, 2011). It can also include assessment of nutrition, hearing and vision, urinary and fecal continence, gait and falls risk, osteoporosis and polypharmacy.
The key components of a comprehensive geriatric assessment involve an initial determination of goals of the assessment by patients and family members, which can often help to elucidate concerns regarding functional or cognitive incapacities and socioeconomic weaknesses. Then data are collected through collateral interviews with caregivers and family members and with patients to help with objective evidence to support and explain those concerns and help with diagnosis. Various cognitive and psychological testing is also done with patients at this time. In order to coordinate and implement the various recommendations of the separate professionals involved in the interdisciplinary approach, a team conference is typically held after the initial assessment. The care plan is crafted with input from the various team members. Often, a family conference is then held with the patient and all involved family members and caregivers. The purpose of this conference is to communicate with and educate the patient and caregivers, to make official recommendations, and to answer questions. It also provides yet another opportunity to assess for caregiver burden and to move to alleviate it if it is clinically significant.
Follow up remains essential to ensuring the success of the recommendations made at the initial visit. The follow up plan for patients will depend on the initial presentation, complexity of medical conditions and setting in which the initial assessment was performed. However, it is critical to assure there is a follow up plan so that patients and families can review test results with the provider, monitor response to therapy and revise the treatment plan if necessary. It is also important to ensure follow-up and accurate relay of information with appropriate specialists, such as neurologists, psychiatrists, physical and occupational therapists and community resources.
The interdisciplinary model of geriatric assessment has been applied to a variety of settings (Gill, 2010). The most common have been adult medical–surgical hospital wards, outpatient clinics, inpatient geropsychiatry units, nursing homes, rehabilitation hospitals and patient homes. There are also more complex models that involve many team members and are found in the inpatient and consultation models. In terms of traditionally measured outcomes (such as mortality, functional status, frequencies of hospitalization and nursing home placement), research study results are mixed. Because of the mixed models of geriatric assessment and differing sites of practice, meta-analyses and generalizations about the value of geriatric assessment are difficult. Nevertheless, some reviewers (Jouanny, 2005) have felt that the data are convincing in terms of reduction in mortality, lowered rates of nursing home placement and lowered levels of caregiver burden.
The Case Study of Mrs A (see Case Study), an example of the geriatric team in action, may help to illustrate many of the principles of geriatric assessment. This 85-year-old patient was suffering primarily from an illness (polymyalgia rheumatica) that is found exclusively in the elderly population. In the absence of any symptoms suggesting cranial arteritis, many clinicians would institute an empiric trial of corticosteroid therapy without doing a temporal artery biopsy and gauge the response to therapy. A dramatic response, as was seen in this case, helps to confirm the diagnosis.
The next most important problems, those of the cognitive impairment and dysphoria, reveal how multiple coexisting pathologies can conspire to create dysfunction. The suddenness of the onset of the patient’s delusions and cognitive decline suggested either a vascular process or a reaction to the anticholinergic effects of amitriptyline. The low cobalamin level is also a common finding and could also be contributing to the cognitive loss. In many instances of geriatric assessment the caregiver becomes as much a client as the patient. Predictable respite is one effective means of reducing caregiver stress, and referral of the patient to an adult daycare program is an ideal way to provide predictable respite. In this case, when alleviated of some of the caregiving burden, the daughter could once again enjoy her relationship with her mother.
The perception on the part of family members that the patient was functioning much better cognitively even though objective improvement could not be measured represents another phenomenon deserving of mention. Significant disparity between ‘perceived’ and ‘measured’ improvement often exists.
The benefits of the comprehensive geriatric assessment can also be demonstrated through this case report. These include an opportunity to gather family/caregiver input and allowing those persons to feel heard in the difficult times as well as in the success of the treatment plan. It also allows the chance for interdisciplinary interaction and discussion regarding a patient, and provides an overall assessment, education and treatment plan to be identified in a short period of time, and provides support to a patient’s primary care provider to allow comprehensive follow-up and continuation of the treatment plan through that provider.
Directions for future research
The technology of geriatric assessment has been under attack because it is viewed as labor-intensive and inadequately reimbursed. Were the data of research studies more conclusive with regard to outcomes, it would be easier to advocate the widespread application of interdisciplinary geriatric assessment. The main challenge in the light of what has been learned seems to be selective application of this interdisciplinary approach, targeting those subjects and contexts in which geriatric assessment is determined to be cost-effective.
Other areas of active research in this field include investigation into the optimal place to perform geriatric assessment. Some intriguing studies suggest that the optimal site may be in the patient’s own home (Nikolaus & Bach, 2003). Other important questions also have to be answered. Do data that have been collected largely through interview reflect what the patient is actually able to perform? Do data on functional status, which are often garnered by physical therapy and occupational therapy in a laboratory setting, correlate well with what the patient can do in his or her own home?
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