Geriatric Assessment

Dolores Buscemi, MD
Dept. of Internal Medicine
 Objectives

 Understand that geriatric patients have

multiple problems that often require a
multidisciplinary approach
 Understand the benefits of geriatric
assessment
 Be able to identify which persons benefit
the most from geriatric assessment
 Know how to identify functional
impairments in an elderly person
Geriatric Medicine

 What is geriatric medicine?

Geriatric Medicine
 Definition:
 Comprehensive assessment and management
of the older patient with chronic disability,
multiple medical and social problems

 Goal:
 Optimize function
 Multiple disciplines involved – physician,

nursing, rehabilitation medicine, social work

Geriatric Medicine

 Why are we concerned?

Geriatric Medicine
 Elderly people are subject to
deteriorating function, diverse
diseases and environmental
challenges that can lead to the
development of frailty and the
inability to live independently
Demography
 1900 people > 65: 4% population
 2000 : 12%
 2030 : 20%

 Total number of elderly was 3.1 million in

1900/ by 2000 it was 35 million

 Life expectancy:
 75 years at birth
 82 years at 65
Demography
 Aging of the population has
heightened demand for
comprehensive health services
 Persons > 65 account for 1/3 health
expenditures
 More frequent and more prolonged
hospitalization
 85% at least one chronic illness/30% 3
or more
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 Disease and disability are common at
advanced age but it is unclear whether
the continued growth of the older
population will lead to increased numbers
of debilitated elderly requiring extensive
medical/social support

 Disease prevention and health promotion

might be developed to delay the onset of
chronic illness and disability
Aging
 Processes occurring during the
postmaturational life span that
progressively decreases the ability
of an organism to adapt to
environmental change and
increases likelihood of dying
 Includes alterations in biochemistry,
decrease in physiologic capacity and
increased disease susceptibility
 Theories of Aging

 Two representative categories of aging

theory

 Oxidative stress
 Genetically regulated aging
Oxidative Stress
 Normal metabolism generates
oxygen – free radicals that lead to
cumulative damage of DNA,
proteins and lipids over time
 Supported by observation that low
levels of oxygen free radicals or
overexpression of protective
antioxidant enzymes leads to longer
lifespan in some species
Oxidative Stress
 Aging may occur as result of
cumulative mutations in DNA or
errors in transcription or translation
 May occur as result of oxidative
damage or spontaneoulsy
 Insufficient to explain all age related
physiologic changes
Genetically Regulated
 Programmed control aging process
 Telomere attrition
 Telomeres are redundant DNA
sequences at ends of chromosomes
essential for mitosis
 Certain cell lines have less activity of
telomerase over time
 Further cell division no longer possible
Normal Aging
 Physiologic functioning is highly
variable among older individuals
 Aging populations without disease on
average are characterized by
physiologic decline
 Often difficult to distinguish “normal
aging” from disease associated with the
aging process
Normal Aging
 Normal aging (absence of disease)
often classified into two categories:
 Usual
 Aging accompanied by typical
nonpathologic losses of physiologic
function
 Successful
 Physiologic decline during aging is

minimal/absent
Normal Aging
 Physiologic losses have been attributed to
modifying effects of extrinsic variables
 Diet
 Exercise
 Psychosocial factors
 Need for further research into strategies
by which life-style modifications might
reduce morbidity
An 85 year old man is admitted to the hospital
with dehydration, fever and marked
disorientation. He is presumed to have fallen,
because he was found lying on the floor in his
bedroom. He had been discharged from a
rehabilitation hospital 2 months ago, after
recovering from an acute CVA. At that time he
was able to ambulate with a walker, and do
basic self-care.
He is febrile and tachypneic and has dry
mucous membranes. Chest x-ray is consistent
with a left lower lobe pneumonia.
Atypical Presentation of Illness

 Age and other factors affect signs

and symptoms of illness in older
people
 Factors That Influence
Response

 Age-associated changes in physiologic

function (Host factors)
 Alterations of perception to pain
 Absence of signs or symptoms seen in younger
patients
 Burden of Co-morbid disease
 Acute illness in one system may stress reduced
reserve capacity of another
 Produces unrelated signs and symptoms that can
distract from correct etiology
 Urosepsis presenting as delirium in a person with
cognitive impairment
Factors That Influence Response
 Treatment of Disease
 Treatment of one illness may unmask
previously undiagnosed pathologic
condition
 Urinary outlet obstruction may become
apparent when pharmacologic agent with
anticholinergic properties is given and
provokes urinary retention
 Treatment of Disease
 Signs and symptoms may appear
straightforward, further evaluation to
uncover an occult contributing disease is
appropriate
 Certain nonspecific syndromes require more
thorough investigation
 Failure to thrive
 Acute change in appetite
 Decline in self-care capacity
 Onset of falls
 Change in intellectual function
 New onset of incontinence
Hazards of Bed Rest
 Imposition of bed rest has been
shown to have physiologic and
psychologic hazards
 Elderly persons have less physiologic
reserve
 More prone to the adverse effects of
bed rest
 Hazards of Bed Rest
 Physiologic Consequences
 Cardiac output declines/Pulmonary
volumes decline
 Urinary concentrating ability decreases
 Calcium and nitrogen loss can exceed intake
 Decrease in muscle strength/ Decrease in
endurance
 Skin breakdown/Pressure sores

 Increased risk for DVT

 Central nervous system function altered

 Emotional lability; poor short-term memory
Hazards of Bed Rest
 Prevention
 Passive range of motion exercises
 Assumption of upright posture several
minutes/day
 Frequent changes of position

 Routine orders for hospitalized patients

to be out of bed for meals and daily
ambulation
 Comprehensive Geriatric
Assessment

 NIH Consensus Conference:

“The multiple problems of older persons are

uncovered, described and explained, if
possible, and the resources and strengths
of the person are catalogued, the need for
services assessed, and a coordinated care
plan developed to focus interventions on
the person’s problems.”
Benefits of Comprehensive Geriatric
Assessment

 May reveal previously undetected medical or

psychiatric diagnoses that need evaluation or
treatment

 Identification of functional deficits predicts

need for social and environmental
interventions
 Improve use of community services/more
appropriate placement
Benefits of Comprehensive Geriatric
Assessment

 Improves function
 Repetition of functional assessment may
be used to gauge impact of therapy
 More appropriate medication use
 May decrease number of acute care days
Functional Status
 The capacity of an individual to
function in multiple domains
(physical, mental, social, emotional)
and at multiple levels (organ
function, function of person as
whole, function of person in society)
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Who should be evaluated?
Three patient categories

1. Healthy elderly persons – living in

the community
2. Frail elderly persons – living in the
community
3. Institutionalized or severely
impaired elderly persons
 Patients who benefit most
 Frail because of age
 Decrease in functional status
 Change in mental status- cognition/affect
 Multiple medical problems
 Multiple psychosocial problems
 Take multiple medications
 New onset urinary or fecal incontinence
 Involuntary weight loss
 Frequent falls
 One or more sensory impairments
 Disruptive behavior or personality changes
Multi-Disciplinary Team Approach
 Interdisciplinary team to make
assessments and develop a diagnosis and
treatment plan
 Each member of team sees every patient
 Team Members: physician, nurse, social
worker, physical and occupational
therapy, psychology, rehabilitation
medicine, audiology, clinical pharmacy
and nutrition
Multi-Disciplinary Team Approach
 Model has been limited
 Shortage of health care professionals
trained in geriatric medicine
 Poor reimbursement

 Methods have been developed to

administer functional status
assessments in physician offices
Components of CGA
 Complete History and Physical
 Laboratory as indicated
 Prevention Screening
Geriatric Syndromes
 Common problems that have been identified as
warranting special attention in elderly

3. Cognitive Disorders
Dementia/Delirium
 Polypharmacy
 Falls/Gait Instability
 Urinary Incontinence
 Depression
 Malnutrition
Components of CGA

 Set of assessment protocols that

focus on screening for physical and
psychosocial impairments and
disabilities
Components of CGA
 Measures to evaluate disability and
functional status
 Activities
of Daily Living
 Instrumental Activities of Daily Living

 Consideration of living situation –

adequacy and safety
 Discussion with patient/family
regarding preferences for future
medical care
Screening Assessments Used in
Comprehensive Geriatric
Assessment
A 72 year old man is brought to your office by
his son because he is unable to handle his
financial affairs. The patient is a retired
accountant and has enjoyed good health.
He has some insight into his mental
problems. He is taking no medication.
Since his wife died 6 months ago, he has
lived alone

Physical examination reveals blood pressure of

180/100 and a left carotid artery bruit. The
rest of the exam and lab work is
unremarkable. MRI of the head is
unremarkable.
Cognitive Impairment
 Dementia is common but often goes
unrecognized
 Some cases are potentially treatable
or reversible
 Important to identify patients with
impairment, even if not treatable, in
order to plan for future care
Cognitive Impairment
 Prevalence of cognitive impairment
varies greatly by age and clinical
setting
 Community dwelling patients
 > 65 y/o have 10% Alzheimer’s rate
 > 85 y/o have 47% rate

 Prevalence much greater in

institutionalized settings
Cognitive Impairment
 Extensive screening batteries for
cognitive impairment have been
developed
 Most widely used is the Mini-Mental
State Examination (MMSE)
 Takes about 5-10 minutes to
administer
Folstein Mini-Mental Status
Exam
 ORIENTATION
 Ask for year, season,
date, day, month
 Ask for state, county,
town, place,street
 REGISTRATION
 Name three unrelated
objects. Ask patient to
repeat
 ATTENTION/
CALCULATION
- Subtract 7 from
100,repeat 5 times
TOTAL SCORE 30; SCORE < 20 PROBABLE DEFICIENCY
 RECALL
 Recall three previous
objects
 LANGUAGE
 Show wrist watch and
ask what it is
 Ask to repeat “no, ifs
ands or buts”
 On blank piece of paper
print “Close your eyes”
and ask patient to do it
 Give patient a blank
piece of paper and ask
him to write a sentence
Cognitive Impairment
 Positive result indicated need for
further evaluation
 Can use for monitoring by repeating
screen at later date and see if
improvement or deterioration takes
place
Depression
 Common disorder in the elderly
 Under diagnosed
 Impairments range from depressive
symptoms to major depression
Depression-Screening
 Geriatric Depression Scale
 Designed specifically for frail older
patients
 Series of 30 YES/NO questions covering
symptoms and manifestations of
depression
 Takes 10-15 minutes to administer
 Score > 14 greatly increases
probability of depression
 Score < 9 greatly decreases probability
Geriatric Depression Scale

Are you basically satisfied with your life? Yes/NO

Have you dropped many of your interests?
YES/No
Do you feel your life is empty? YES/No
Do you often feel bored? YES/No
Are you in good spirits most of the time? Yes/NO
Afraid something bad is going to happen? YES/No
Do you feel happy most of the time? Yes/NO
Do you often feel helpless? YES/No
Do you prefer to stay at home? YES/No
Do you feel you have memory problems? YES/No
Do you think it is wonderful to be alive? Yes/NO
Do you feel worthless? YES/No
Do you feel full of energy?
Yes/NO
Do you feel your situation is hopeless? YES/No
Do you think most people are better off than you?YES/No
Depression- Screening
 Demented patients frequently suffer
from depression
 Measures have been developed to
screen for depression without
reliance on patient self-report
 Caregiver asked questions about
presence of a number of
symptoms/manifestations of depression
Depression
 Should be aware of other problems
causing cognitive impairment
 Delirium

 Anxiety

 Hostility

 Psychosis

 Behavioral Problems
An 85 year old woman comes to your office
for the first time because she ahs lost 9.1 kg
in the last 6 months. She has no appetite
and foods taste different to her. A careful
history fails to identify a likely cause for
weight loss. She has HTN and OA.

Physical exam shows a markedly

underweight and frail woman. Her gait is
slow and she has difficulty getting out of a
chair without assistance.
Musculoskeletal Impairment and
Immobility
 Unsteadiness
 Abnormality sitting or getting up from a
chair
 Turning or walking with difficulty
 Step height

Impairments in these areas increase the

risk of falling in older persons
Often undetected in a standard history and
physical
Screening Tests
 Upper extremity mobility
 Manual dexterity
 Lower extremity mobility
Evaluations of Balance and Gait
 Balance Measures
 Sitting balance (leaning vs steady)
 Ability to rise from chair

 Immediate standing balance

 Standing balance (wide based, narrow

based or assisted)
 Sternal nudge

 Standing balance w/ eyes closed

BALANCE SCORE ___/16 < 10 = HIGH FALL RISK

 Evaluations of Balance and Gait
 Gait Observations
 Initiation
of gait
 Step length

 Step height

 Step continuity

 Step symmetry

 Walking stance

 Amount of trunk sway

 Path deviation

GAIT SCORE ___/12 < 9 = HIGH FALL RISK

Malnutrition
 Increased risk for poor nutritional
status because of chronic disease,
poverty, social isolation, cognitive
impairment and functional disability
 Associated with impaired wound
healing, increased surgical
complications and increased
mortality
Indicators
 Body weight < 100 pounds highly
sensitive
 Can also occur patients > 100 pounds
 Historical clues
 Involuntary weight loss of 10% body fat
 Physical Exam
 Glossitis,
loss of subcutaneous fat, muscle
wasting, edema
 Lab
 Serum albumin
DETERMINE Checklist
 Tool developed by Nutrition Screening
Initiative
 Based on warning signs described by the
word
 Disease, Eating poorly, Tooth loss/mouth pain,
Economic hardship, Reduced social contact,
Multiple Medicines, Involuntary weight
loss/gain, Needs assistance in self-care,
Elderly years >80
 Score
 0-2 Good
 3-5 Moderate risk
 >6 High risk
Visual and Hearing Impairment
 Visual impairment
 13%

 Hearing impairment
 65-74y/o 25%
 >85y/o 50%
Visual Impairment
 Methods available for office
screening have limitations
 Sensitivity/Specificityhave not been
established in older adults
 Limitations in diagnostic accuracy of
glaucoma screening by primary care
physician
Visual Impairment
 Screening should be performed
using Snellen test
 Specific questions about functional
disability that might be due to poor
vision
 Referral to Ophthalmologist if
needed
Hearing Impairment
 Hand held audioscope
 Performed in 90 seconds
 94% sensitive, 72% specific
 Physical exam techniques such as
whispered voice or finger rub can be used
 Accuracy of tests may be enhanced if
combined with short questionnaire on
functional disability associated with
hearing impairment
Functional Assessment
 Complement to screening for
specific impairments
 Helpwith determining overall health
and well being
 Guide to treatment plan
 Help to plan long-term care services
 Monitor effectiveness of
interventions
Functional Assessment
 Choice between methods and
instruments to measure function
depends on frailty of patient
population, time available for
assessment and intended use of
information
Activities of Daily Living
 One of the original methods and in
wide use today
 Focuses on basic activities
Bathing Transferring
Dressing Continence
Toileting Feeding
Instrumental Activities of Daily
Living

 Focus on more complex activities important for

independent living in the community

Shopping
Using the telephone
Handling finances
Housekeeping
Using transportation
Food preparation
Taking medication
Assessment of Home Safety
 Throughout the interior several
common features
 Scatterrugs, adequate lighting, enough
room for easy mobility, emergency
telephone numbers posted
 Kitchen
 Bathroom
 Outside the home
Assessment of Social Support
 Assess the patient’s emotional
support
 Identify actual/potential caregivers
 Ask who would be available in an
emergency
 Social information and background
may help assess coping ability
Long Term Options/Placement
 Support for remaining in the home
 Home health
 Provider service

 Day care

 If unable to remain in the home

 Assisted living facility
 Subsidized senior apartments

 Nursing home
Conclusions
 Value of CGA has been evaluated in the
inpatient and outpatient settings
 Demonstrated to improve medical care
provided to frail elderly
 Controlled studies have shown improved
patient outcomes
 No study has shown worse outcomes
 Inpatient units may improve survival
Conclusions
 CGA should be targeted to patients
with potentially improvable function
 Optimal targeting criteria have not
been established
 May be that a patient without
potential for improved function
might benefit from depression
screening, medication review
Conclusions

Comprehensive Geriatric
Assessment has been advanced as a
means to more effectively diagnose
and manage complex medical
problems of frail elderly