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ASSESSMENT
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OBJECTIVES
Know and understand:
• How to assess the functional ability of the
older adult
• The key elements of a rapid screen
• Strategies to enhance communication with
older patients
• How to perform a comprehensive geriatric
assessment
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TOPICS COVERED
• Principles of Geriatric Assessment
• Patient-Clinician Communication
• Physical Assessment
• Medication Assessment
• Cognitive Assessment
• Psychologic Assessment
• Social Assessment
• Functional Status
• Acute Functional Decline
• Quality of Life
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PRINCIPLES OF GERIATRIC ASSESSMENT
• Perform routinely in all sites of care
• Assessments should be performance-based.
• Ideally, have informant present to provide or
verify pertinent historical information
• Incorporating geriatric assessment into routine
office practice requires use of efficient
strategies
 One such stepped approach entails rapid
screening of targeted areas, followed by
comprehensive assessment in areas of concern
STRATEGIES FOR RAPID SCREENING
(1 of 4)
Domain
Functional
status
Rapid screen
Answers “Yes” to one or more of the
following: Because of a health or physical
problem, do you need help to:
a) Take a bath or shower?
b) Walk across a room?
c) Prepare meals?
d) Manage medications?
e) Manage the household finances?
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STRATEGIES FOR RAPID SCREENING
(2 of 4)
Domain
Mobility
Nutrition
Vision
Rapid screen
“Timed Get Up and Go” test: unable to
complete in <15 sec
Usual gait speed: unable to walk 50
feet in <20 sec
Unintentional weight loss of ≥5% in
prior 6 months (or BMI < 20kg/m2)
If unable to read a newspaper headline
and sentence while reading corrective
lenses, test each eye with Snellen
chart: unable to read greater than 20/40
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STRATEGIES FOR RAPID SCREENING
(3 of 4)
Domain
Rapid screen
Hearing
Acknowledges hearing loss when
questioned or unable to perceive a
letter/number combination whispered at
a distance of 2 feet
Cognitive
function
3-item recall: unable to remember all 3
items after 1 minute
Mini-Cog: recall = 0 or recall <3 and
abnormal clock
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STRATEGIES FOR RAPID SCREENING
(4 of 4)
Domain
Depression
Rapid screen
Answers “Yes” to either of the following:
In the past month have you often been
bothered by:
a) Feeling down, depressed, or
hopeless?
b) Having little interest or pleasure in
doing things?
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PATIENT-CLINICIAN COMMUNICATION:
EFFECTIVE STRATEGIES (1 OF 2)
• Use a well-lit room and avoid backlighting
• Minimize extraneous noise and
interruptions
• Face the patient directly, sitting at eye level
• Speak slowly
• Inquire about hearing deficits; raise the
volume and lower the tone of your voice
accordingly
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PATIENT-CLINICIAN COMMUNICATION:
EFFECTIVE STRATEGIES (2 OF 2)
• If necessary, write questions in large print
• Allow sufficient time for the patient to
answer
• Provide patient education materials that
are appropriate for individuals with low
health literacy
• Ask open-ended question: “What would
you like me to do for you?”
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PHYSICAL ASSESSMENT
Physical assessment includes:
• Vision
• Hearing
• Nutrition
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VISION
• Cataracts, glaucoma, macular degeneration,
and abnormalities of accommodation worsen
with age
• Ask about everyday tasks
 Driving, watching TV, reading
• Use performance-based screening
 Ask patient to read from newspaper, magazine
 Use Snellen chart or Jaeger card
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HEARING
•
Hearing loss is common among older adults
•
Impaired hearing  depression, social withdrawal
•
Assess first for cerumen impaction
•
Hearing loss usually bilateral and in high-frequency
range
•
Refer for formal audiometry testing if:
 Acknowledges hearing loss when questioned
 Unable to perceive letter/number combination whispered at a
distance of 2 feet
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ASSESS NUTRITIONAL STATUS
• Screen for malnutrition
 Visual inspection
 Measure height, weight, BMI
•
•
BMI = weight (kg) / height (m2)
•
Watch for low BMI (<20 kg/m2)
•
Watch for unintended weight loss ≥ 5% in 6 months
Poor nutrition may reflect medical illness,
depression, dementia, inability to shop or cook,
inability to feed oneself, or financial hardship
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MEDICATION ASSESSMENT
• Review prescribed and OTC medications
• Look for:
 Polypharmacy
 Treatment failure
 Medication nonadherence
• May be a sign of financial issues, fear of being overmedicated, or lack of understanding of the need for a
medication
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COGNITIVE ASSESSMENT
• Prevalence of cognitive decline
 Doubles every 5 yr after age 65
 Nearly 50% of those aged 90+
• Most people with dementia do not complain of
memory loss
• Cognitively-impaired older persons are at  risk
for accidents, delirium, medical nonadherence,
and disability
COGNITIVE ASSESSMENT:
PERFORMANCE MEASURES
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• Mini-Cog
 Combines 3-word recall and clock draw test
• Folstein’s Mini-Mental State Examination (MMSE)
 Widely used but now proprietary, and with limitations
• Montreal Cognitive Assessment (MoCA) and St. Louis
University Mental Status Examination (SLUMS)
 More commonly used validated tools to assess
cognition
 Both assess memory, executive function, abstract
thinking, attention, calculation, visual-spatial skills
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PSYCHOLOGICAL ASSESSMENT
Although prevalence of major depression among
older adults is low (1%2%), the rate is higher in
primary care, and many older adults suffer from
depression below the severity threshold of major
depression
• Ask, “Do you often feel sad or depressed?”
• If patient responds affirmatively do further
evaluation, eg, Geriatric Depression Scale or
PHQ-9
• Watch for signs of anxiety, bereavement
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SOCIAL ASSESSMENT
• Ethnic, spiritual, and cultural background
• Availability of a personal support system
• Caregiver burden
• Economic well-being
• Safety of the home environment
• Elder mistreatment
• Advance directives
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FUNCTIONAL STATUS (1 of 2)
• Activities of daily living (ADLs)
Bathing, dressing, transferring, toileting, grooming,
feeding oneself
• Instrumental activities of daily living (IADLs)
Using telephone, preparing meals, managing
finances, taking medications, doing laundry, doing
housework, shopping, managing transportation
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FUNCTIONAL STATUS (2 of 2)
• “Timed Up and Go” test
Consists of rising from the chair, walking 10 feet (3
meters), turning around and returning to the chair,
turning, and then sitting back down in the chair
• Gait speed
Strongest predictor of future disability and death
• Life space
Assessment offers complementary strategy for
distinguishing among levels of mobility
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ASSESSING THE OLDER DRIVER
• Although the absolute number of crashes
among older drivers is low . . .
• The number of crashes per mile driven and
the likelihood of serious injury and death are
higher than for any other age group except
young adults 16 to 24 years old
RISK FACTORS FOR
OLDER DRIVERS
•
Poor visual acuity and contrast sensitivity
•
Dementia (particularly deficits in visual-spatial skills and
visual attention)
•
Impaired neck and truck rotation
•
Limitations of shoulders, hips, ankles
•
Foot abnormalities
•
Poor motor coordination and speed of movement
•
Alcohol and medications that affect alertness
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WHEN AN ACCIDENT OR DRIVING
VIOLATION OCCURS
• Discuss safety concerns with the older driver and
with spouse or family member, if possible
• Urge consideration of other modes of
transportation
• Refer for formal driving evaluation
• Remember that driving cessation may result in:
 Reduced activity level
 Depressive symptoms
•
Learn and follow individual state laws on
reporting impaired drivers
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ACUTE FUNCTIONAL DECLINE
• Usually precipitated by an illness or injury (hip
fracture, stroke, heart failure, pneumonia)
• Among frail persons, 1/3 of new disability
episodes occur in absence of discernible illness
or injury
• Most recover independent function within 6
months, but are at high risk of subsequent
disability
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QUALITY OF LIFE
•
Includes various aspects of physical, cognitive,
psychological, and social function
•
Short Form‒36 Health Survey (SF‒36): assesses
physical function, limitations due to physical and
emotional health, bodily pain, social functioning,
mental health, vitality, general health perceptions
•
Ask about patient preferences regarding medical
care and goal of care
•
Acknowledge the role of culture and ethnicity on
understanding of health and illness
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SUMMARY
• The focus of geriatric assessment is on function
• Successful assessment promotes wellness and
independence
• Strategies that enhance communication with older
patients should be used
• Comprehensive assessment includes physical,
cognitive, psychological, and social aspects of
health
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CASE 1 (1 of 4)
• An 84-year-old woman, lives independently, concerned
about driving. On 2 occasions, she had minor collisions
when she was backing up her car (she dislodged
rearview mirror and struck a fire hydrant, each time on
the passenger side).
• History: osteoarthritis of the cervical and lumbar spine
and mild hearing impairment
• Medications: acetaminophen and calcium plus vitamin D
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CASE 1 (2 of 4)
• Functional assessment: intact cognition and vision, with
near-visual acuity 20/30 in each eye. She fails the
whisper test.
• Physical examination
 Decreased range of motion in neck and back in all planes
(unchanged from previous findings)
 Diffuse osteoarthritic deformities in the knees and hands
 Decreased range of motion at the hips
 Mild kyphosis
 Motor strength and deep tendon reflexes are symmetric and intact
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CASE 1 (3 of 4)
Which one of the following is the most appropriate next
step?
A. Obtain radiography of the cervical spine in 3 views.
B. Recommend that she no longer drive.
C. Refer to physical therapy.
D. Refer to audiology.
E. Refer to occupational therapy.
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CASE 1 (4 of 4)
Which one of the following is the most appropriate next
step?
A. Obtain radiography of the cervical spine in 3 views.
B. Recommend that she no longer drive.
C. Refer to physical therapy.
D. Refer to audiology.
E. Refer to occupational therapy.
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CASE 2 (1 of 3)
• An 80-year-old woman hospitalized after fall and hip
fracture
• History: stable osteoarthritis of the knees, peripheral
neuropathy
• Prior to fall, she lived alone and managed all instrumental
activities of daily living; occasionally used cane or walker
for mild problems with balance
• Current status, 4 days after surgery:
 Needs assistance of 2 persons for transfer
 Frequently incontinent of urine
 Eating very little
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CASE 2 (2 of 3)
Which one of the following is the most likely
outcome for this patient 6 months after the fracture?
A. Continued slow functional decline
B. Recovery to her pre-fracture level of function
C. Partial recovery of function
D. Stability at the level of function on hospital
discharge
E. Death
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CASE 2 (3 of 3)
Which one of the following is the most likely
outcome for this patient 6 months after the fracture?
A. Continued slow functional decline
B. Recovery to her pre-fracture level of function
C. Partial recovery of function
D. Stability at the level of function on hospital
discharge
E. Death
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CASE 3 (1 of 3)
• An 85-year-old man with 2 episodes of low-volume
urinary incontinence in the last year, when he “waited
too long”
• Functional assessment:
 Near-visual acuity of 20/50 on the right and 20/60 on the left
with correction
 Fails whisper test in right ear
 Gait speed at usual pace is 0.9 m/sec
• Mini-Cog screen: 2 of 3 items on recall, completes an
accurate clock
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CASE 3 (2 of 3)
Which one of the following is the most
appropriate next step for evaluation of
functional disability?
A. Refer to audiology.
B. Refer to ophthalmology.
C. Refer to physical therapy.
D. Complete additional cognitive testing.
E. Complete an incontinence evaluation.
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CASE 3 (3 of 3)
Which one of the following is the most
appropriate next step for evaluation of
functional disability?
A. Refer to audiology.
B. Refer to ophthalmology.
C. Refer to physical therapy.
D. Complete additional cognitive testing.
E. Complete an incontinence evaluation.
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GRS9 Slide Editor:
Tia Kostas, MD
GRS9 Chapter Author:
Thomas M. Gill, MD
GRS9 Question Writer:
Chandrika Kumar, MD, FACP
Managing Editor:
Andrea N. Sherman, MS
Copyright © 2016 American Geriatrics Society