Geriatric
Directions: Assess an older adult using the Geriatric Assessment Tool (link located in Files link). Complete all Tables (6 in total) and submit by deadline. Regarding Table 3: perform a head to toe physical assessment on the client, document positive findings and current medications (if any indicated for the body system). For example, vital signs: high blood pressure (Amlodipine 5 mg PO daily, eyes: glaucoma (Xalatan 0.005% one drop both eyes daily).
48 American Family Physician www.aafp.org/afp Volume 83, Number 1 ◆ January 1, 2011
The Geriatric Assessment BASSEM ELSAWY, MD, and KIM E. HIGGINS, DO, Methodist Charlton Medical Center, Dallas, Texas
A pproximately one-half of the ambu- latory primary care for adults older than 65 years is provided by fam- ily physicians,1 and approximately
22 percent of visits to family physicians are from older adults.2,3 It is estimated that older adults will comprise at least 30 percent of patients in typical family medicine outpa- tient practices, 60 percent in hospital prac- tices, and 95 percent in nursing home and home care practices.4
A complete assessment is usually initiated when the physician detects a potential prob- lem such as confusion, falls, immobility, or incontinence. However, older persons often do not present in a typical manner, and atypi- cal responses to illness are common. A patient presenting with confusion may not have a neurologic problem, but rather an infec- tion. Social and psychological factors may also mask classic disease presentations. For example, although 30 percent of adults older than 85 years have dementia, many physicians miss the diagnosis.5,6 Thus, a more structured approach to assessment can be helpful.
The geriatric assessment is a multidimen- sional, multidisciplinary assessment designed to evaluate an older person’s functional ability, physical health, cognition and mental health, and socioenvironmental circumstances. It includes an extensive review of prescription
and over-the-counter drugs, vitamins, and herbal products, as well as a review of immu- nization status. This assessment aids in the diagnosis of medical conditions; development of treatment and follow-up plans; coordina- tion of management of care; and evaluation of long-term care needs and optimal placement.
The geriatric assessment differs from a typical medical evaluation by including nonmedical domains; by emphasizing func- tional capacity and quality of life; and, often, by incorporating a multidisciplinary team including a physician, nutritionist, social worker, and physical and occupational ther- apists. This type of assessment often yields a more complete and relevant list of medical problems, functional problems, and psycho- social issues.7
Because of the demands of a busy clinical practice, most geriatric assessments tend to be less comprehensive and more problem- directed. For older patients with many con- cerns, the use of a “rolling” assessment over several visits should be considered. The roll- ing assessment targets at least one domain for screening during each office visit. Patient- driven assessment instruments are also popular. Having patients complete question- naires and perform specific tasks not only saves time, but also provides useful insight into their motivation and cognitive ability.
The geriatric assessment is a multidimensional, multidisciplinary assessment designed to evaluate an older person’s functional ability, physical health, cognition and mental health, and socioenvironmental circumstances. It is usually initiated when the physician identifies a potential problem. Specific elements of physical health that are evaluated include nutrition, vision, hearing, fecal and urinary continence, and balance. The geriatric assessment aids in the diagnosis of medical conditions; development of treatment and follow-up plans; coordination of management of care; and evaluation of long-term care needs and optimal placement. The geriatric assessment differs from a stan- dard medical evaluation by including nonmedical domains; by emphasizing functional capacity and quality of life; and, often, by incorporating a multidisciplinary team. It usually yields a more complete and relevant list of medical problems, functional problems, and psychosocial issues. Well-validated tools and survey instruments for evaluating activities of daily living, hearing, fecal and urinary continence, balance, and cognition are an important part of the geriatric assessment. Because of the demands of a busy clinical practice, most geriatric assessments tend to be less comprehensive and more problem-directed. When multiple concerns are presented, the use of a “rolling” assess- ment over several visits should be considered. (Am Fam Physician. 2011;83(1):48-56. Copyright © 2011 American Academy of Family Physicians.)
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Geriatric Assessment
January 1, 2011 ◆ Volume 83, Number 1 www.aafp.org/afp American Family Physician 49
Functional Ability Functional status refers to a person’s ability to perform tasks that are required for living. The geriatric assessment begins with a review of the two key divisions of functional ability: activities of daily living (ADL) and instrumental activities of daily living (IADL). ADL are self-care activities that a person performs daily (e.g., eating, dressing, bath- ing, transferring between the bed and a chair, using the toilet, controlling bladder and bowel functions). IADL are activities that are needed to live independently (e.g., doing housework, preparing meals, taking medications properly,
managing finances, using a telephone). Physicians can acquire useful functional information by simply observ- ing older patients as they complete simple tasks, such as unbuttoning and buttoning a shirt, picking up a pen and writing a sentence, taking off and putting on shoes, and climbing up and down from an examination table. Two instruments for assessing ADL and IADL include the Katz ADL scale (Table 1)8 and the Lawton IADL scale (Table 2).9 Deficits in ADL and IADL can signal the need for more in-depth evaluation of the patient’s socioenvironmental circumstances and the need for additional assistance.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Clinical recommendation Evidence rating References
The U.S. Preventive Services Task Force found insufficient evidence to recommend for or against screening with ophthalmoscopy in asymptomatic older patients.
C 15
Patients with chronic otitis media or sudden hearing loss, or who fail any hearing screening tests should be referred to an otolaryngologist.
C 21, 23
Hearing aids are the treatment of choice for older patients with hearing impairment, because they minimize hearing loss and improve daily functioning.
A 23
The U.S. Preventive Services Task Force has advised routinely screening women 65 years and older for osteoporosis with dual-energy x-ray absorptiometry of the femoral neck.
A 37
The Centers for Medicare and Medicaid Services encourages the use of the Beers criteria as part of an older patient’s medication assessment to reduce adverse effects.
C 39, 40
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.
Table 1. Katz Index of Independence in Activities of Daily Living
Activities (1 or 0 points) Independence (1 point)* Dependence (0 points)†
Bathing
Points:
Bathes self completely or needs help in bathing only a single part of the body, such as the back, genital area, or disabled extremity
Needs help with bathing more than one part of the body, getting in or out of the bathtub or shower; requires total bathing
Dressing
Points:
Gets clothes from closets and drawers, and puts on clothes and outer garments complete with fasteners; may need help tying shoes
Needs help with dressing self or needs to be completely dressed
Toileting
Points:
Goes to toilet, gets on and off, arranges clothes, cleans genital area without help
Needs help transferring to the toilet and cleaning self, or uses bedpan or commode
Transferring
Points:
Moves in and out of bed or chair unassisted; mechanical transfer aids are acceptable
Needs help in moving from bed to chair or requires a complete transfer
Fecal and urinary continence
Points:
Exercises complete self-control over urination and defecation
Is partially or totally incontinent of bowel or bladder
Feeding
Points:
Gets food from plate into mouth without help; preparation of food may be done by another person
Needs partial or total help with feeding or requires parenteral feeding
Total points‡:
*—No supervision, direction, or personal assistance. †—With supervision, direction, personal assistance, or total care. ‡—Score of 6 = high (patient is independent); score of 0 = low (patient is very dependent).
Adapted with permission from Katz S, Downs TD, Cash HR, Grotz RC. Progress in development of the index of ADL. Gerontologist. 1970;10(1):23.
Geriatric Assessment
50 American Family Physician www.aafp.org/afp Volume 83, Number 1 ◆ January 1, 2011
Physical Health The geriatric assessment incorporates all fac- ets of a conventional medical history, includ- ing main problem, current illness, past and current medical problems, family and social history, demographic data, and a review of systems. The approach to the history and physical examination, however, should be specific to older persons. In particular, top- ics such as nutrition, vision, hearing, fecal and urinary continence, balance and fall prevention,…
