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Office-based assessment of the older adult

Office-based assessment of the older adult
Literature review current through: Jan 2024.
This topic last updated: Dec 15, 2021.

INTRODUCTION — Today's individuals are living longer compared with prior generations. According to the United States Census Bureau, pre-COVID-19 pandemic statistics project that approximately 20 percent of the population will be 65 years or older by 2050. These older persons will be increasingly diverse with respect to sociodemographic and health status. Therefore, it is necessary to approach geriatrics comprehensively, understanding all domains of health and looking beyond one's numerical age to predict prognosis, morbidity, and mortality. Assessment of older persons’ medical, mental health, and social dimensions facilitates informed decision-making and care planning.

This topic will discuss an approach to assessment of the older adult being seen in the generalist's office, including the domains of assessment and a practical approach to performing the assessment. The more formal interdisciplinary comprehensive geriatric assessment, appropriate for selected patients with specific geriatric concerns; an approach to health maintenance in the geriatric population; and management of multiple morbidity in older adults are discussed separately. (See "Comprehensive geriatric assessment" and "Geriatric health maintenance" and "Multiple chronic conditions".)

The use of telemedicine for office visits is discussed elsewhere (see "Telemedicine for adults"). Due to the COVID-19 pandemic, the use of telemedicine has increased significantly and many clinical settings have adapted more innovative methods of telecommunication with secure virtual platforms for patient encounters, including the assessment of older persons. Although the preference is for in-person encounters, particularly to assess components such as gait and balance, telehealth will likely remain a valuable modality in providing ongoing health care to all individuals.

PRINCIPLES OF ASSESSMENT OF THE OLDER PATIENT — Geriatric assessment recognizes the multidimensionality of contributors to health and function and can provide key diagnostic insights into the health of the older patient. An important concept to understand is the term homeostenosis, which refers to the phenomenon where one's reserve capacity diminishes over with aging. With stress, insult, and illness, it becomes harder to recover to a prior baseline or restore homeostasis.

Assessments of particular importance in older persons include:

Hearing (see "Evaluation of hearing loss in adults")

Vision (see "Geriatric health maintenance", section on 'Vision screening')

Polypharmacy (see "Drug prescribing for older adults" and "Deprescribing")

Mobility (see 'Mobility assessment' below)

Cognition (see "The mental status examination in adults")

Depression (see "Diagnosis and management of late-life unipolar depression")

However, assessment of the older patient looks beyond medical conditions at a spectrum of domains including [1]:

Social

Functional

Frailty (see "Frailty")

Advance directives and goals of care (see "Advance care planning and advance directives")

Economic

Psychosocial (see "Diagnosis and management of late-life unipolar depression")

Environmental

Ranging from brief screens to more extensive evaluations, the geriatric assessment addresses how the interaction of these domains affects health and functional status. The geriatric assessment typically is performed by the geriatrician, or primary care provider, often with help from office staff.

A related concept is comprehensive geriatric assessment, which also covers multiple dimensions but focuses on frail older adults who are seen in referral and relies on an interdisciplinary team of health professionals. (See "Comprehensive geriatric assessment".)

Although geriatric assessment is often regarded as a series of evaluations of specific dimensions, it must be considered in the context of the overall direction of the patient's health course and the patient's goals and preferences for care going forward. For example, life expectancy and comorbidities can influence a patient's medical evaluation, management approach, and goals of care (eg, to optimize function, prolong survival, or maximize comfort).

FUNCTIONAL ASSESSMENT — Functional status can be seen as a measure of the overall impact of an individual's health in the context of his or her environment and social support network. It reflects the ability of an individual to perform the physical and social tasks necessary for usual activities and roles. In addition to the management of symptoms and diseases, good medical management must consider functional status and goals for future functional status.

Rationale for assessing functional status — Changes or losses in function should be understood in a context that extends beyond the patient's medical conditions and addresses the environmental and social supports that affect an older person's needs and goals. There are multiple reasons to determine a patient's functional status and goals for functional status. These include:

Impaired functional status can often be the first sign of disease onset, deconditioning, or inadequate social support. For example, the initial sign of a medical problem (eg, hypothyroidism, Alzheimer disease, or heart failure) may be a decline or change in functional status rather than a clinical abnormality.

Understanding baseline function provides insight needed for setting appropriate expectations and goals of medical therapy. The functional assessment can provide valuable prognostic information to direct appropriate diagnostic evaluation, treatment plans, and goal discussions.

Knowing the patient's prehospitalization functional status allows comparison with the level of function at the time of discharge and informs discharge plans.

Measuring functional status is an excellent way to follow the progress of a patient with chronic disabilities and acute illness.

Components of functional status — The most commonly used measures of function evaluate three levels of activities of daily living:

Activities of daily living (ADLs)

Instrumental activities of daily living (IADLs)

Advanced activities of daily living (AADLs)

Basic activities of daily living — Basic ADLs are self-care activities that an individual must accomplish in order to remain self-sufficient. These include: bathing, dressing, toileting, transferring, maintaining continence, and feeding. Patients tend to lose these abilities in this order and regain them in the opposite order during rehabilitation.

Inability to perform these tasks indicates the need for caregiver assistance in the home or placement into a higher level of care. Nursing homes provide ADL assistance, and some assisted living facilities (ALFs) can provide assistance with ADLs, but usually at additional cost. Dependency in ADLs is uncommon among community-dwelling older persons, with approximately 10 percent affected [2]. Approximately 20 percent of community-dwelling older adults have difficulty with ADLs, however, which may be a harbinger of further functional decline and high health care utilization [3]. Many older patients lose ADL function or independence after being hospitalized [4].

Instrumental activities of daily living — IADLs are higher-level activities that individuals must perform or have help with to remain independent in their homes. These include: using the telephone, shopping, doing housework, doing laundry, preparing meals, driving, taking medications, and managing money. As technology has become increasingly important in daily life, some have proposed adding the ability to use technology (eg, cell phones, e-mail, the internet) to the list of IADLs. Some of these new technologies (eg, electronic banking) may help overcome physical limitations (eg, inability to drive) but may be associated with risks (eg, scamming and fraud). Dependency in IADLs is more common than ADL dependency among community-dwelling older adults (approximately 17 percent have dependency in at least one IADL [5]). The progressive loss of more IADL functions translates into more difficulty maintaining a household. Some social services (eg, Meals on Wheels, Homemaker Services, Paratransit and ride-hailing services) are available to provide assistance with these needs. ALFs also provide help with IADLs.

Advanced activities of daily living — AADLs are tasks requiring a higher level of understanding and integration into societal and community roles [6]. Some examples include occupational, recreational, and travel activities. AADLs are both personal and optional, in effect a "functional signature" that can change with time for health reasons or simply because of personal preferences.

Assessing functional status — Tools are available for use as an aid in assessing ADLs. Two commonly used indices are the Katz index for ADLs (table 1) and the Lawton scale for IADLs (table 2). A practical approach to collecting ADL and IADL information is by administering a previsit questionnaire that the patient or caregiver can complete (table 3). These self-administered questions also allow the identification of who helps when assistance is needed.

AADLS are best determined by asking open-ended questions (eg, “How do you spend your days?” “What do you like to do?”). Asking these questions periodically provides a measure of higher level functioning that can be monitored. Although decline or cessation of AADLs may simply be the result of a personal choice, it is worthwhile to explore whether health reasons precipitated or contributed to the change.

The source of information about functional status is also important. Many individuals tend to over-report their abilities, whereas family members may under-report abilities. Evaluation from physical and occupation therapists can provide a more objective perspective on an individual's capabilities and can help guide rehabilitation goals and care needs. For example, a driving evaluation by an occupational therapist may help determine whether it is safe for an older person to continue driving.

FRAILTY — Frailty is a clinical syndrome of physiologic decline resulting in heightened vulnerability to adverse outcomes including falls, fractures, hospitalizations, surgical complications, disability and dependency, and mortality. Frailty has been conceptualized as physical (phenotypic or syndromic), deficit accumulation (due to cumulative comorbidities), functional status, or a combination of functional and biologic indicators.

More than 60 frailty instruments have been developed and used for a variety of purposes, most commonly for risk assessment for adverse clinical outcomes. These instruments variably assess the following domains: physical function/disability, physical activity, cognition, comorbidity, weight loss, and other domains (eg, social, sensory, demographic). The Clinical Frailty Scale (CFS) (figure 1) is an effective and rapid way to assess frailty in older adults. There are nine levels of functionality described, ranging from "very fit," or level one, to “terminally ill," or level nine. The CFS utilizes criteria such as activity levels, dependence for activities of daily living (ADLs)/instrumental ADLs (IADLs), and life expectancy. Other commonly used instruments include the Physical Frailty Phenotype and the Vulnerable Elders Survey-13 (table 4).

Interventions for prevention or mitigation of frailty include exercise, particularly group exercises [7], and nutritional supplementation. When frailty is identified, it is important to review advance care planning to ensure patient's goals and values will be considered moving forward. Frailty is discussed in more detail elsewhere. (See "Frailty".)

MOBILITY ASSESSMENT — Mobility includes a wide range of activities, from walking across a room to airline travel. Assessment therefore may be directed at the ability to move within a near distance or the ability to move outside of the immediate environment. At the low end of the mobility spectrum is the assessment of gait, balance, and risk of falling. Mobility over a wider geographic range is at the high end of the spectrum.

Assessment should begin with a simple history. Two recommended screening questions are [8,9]:

Do you have difficulty climbing up 10 steps or walking 0.25 miles?

Because of health or physical reasons, have you modified the way you climb 10 steps or walk 0.25 miles (either by changing the method or frequency of these activities)?

Qualitative gait assessment — Direct qualitative and quantitative observation of gait to determine stability is a quick and important assessment component. Qualitative aspects include evaluation of include:

Step length (eg, heels do not clear toes of other foot)

Step height (eg, heels do not clear floor)

Hesitancy

Sway

Symmetry

Continuity

Path deviation

Gait speed — Gait speed is also a helpful marker and correlates with risk for recurrent falls and major osteoporotic fractures as well as frailty and survival [10-13].

The recommended protocol is to time an individual while walking a four-meter route with two administrations, one as quickly as possible and one at a usual pace [14]. The test can be done relatively simply by clinical support staff and requires a four-meter walkway and a stop watch. Patients who take more than 13 seconds to walk 10 meters (0.8 meters per second) are more likely to have recurrent falls [10]. Patients whose gait speed exceeds 0.8 meters per second are likely to live beyond the median life expectancy for age and sex, whereas those below 0.8 meters per second are likely to have shorter survival [11]. However, for screening purposes, a speed of one meter per second may be an easier threshold to remember and be more practical to follow in the clinical setting [15].

Slow gait speed presents an opportunity for initiating preventive strategies, as improvements in even 0.1 meters per second in speed have been associated with reduced eight-year mortality rates [11,16]. Preventive strategies may include community-based exercise programs for higher-functioning patients or physical therapy for those who are more impaired. As examples in specific patient populations, low-level treadmill exercise has been shown to improve gait speed among patients with Parkinson disease [17] and resistance training improved gait speed in stroke survivors [18]. However, the clinical utility of testing gait speed in practice settings has yet to be proven and recommendations about whether to measure this routinely cannot be made. Nonetheless, it is a safe, simple, and inexpensive measure that may provide value in monitoring patients and providing some prognostic information [14].

Balance — Tests of balance include:

The ability to maintain a side-by-side, semi-tandem, and full-tandem stance for 10 seconds (figure 2)

Resistance to a nudge

Stability during a 360-degree turn

Functional reach (ie, how far a patient can reach without taking a step or losing balance)

In each of the balance tests, the examiner should be positioned to stabilize the patient if the maneuver precipitates a loss of balance. This can be accomplished by standing close, face-to-face, and holding the patients hands until the side-by-side, semi-tandem, or full-tandem stance are observed (ie, letting go of the patient's hands) and remaining vigilant in observing loss of balance. Similarly, resistance to a nudge should be tested with the examiner's arm and hand positioned behind the patient's back so that if the nudge precipitates loss of balance, the examiner can stabilize the patient.

Muscle strength — Quadriceps strength can be assessed briefly by observing an older person rising from a hard armless chair without the use of his or her hands. Although other muscle groups may be important to test, particularly when there is neuropathy or neurologic disorders, quadriceps weakness is most closely associated with falls and hip fractures [13].

The timed "up and go" test combines some features of strength and gait (table 5). It is a timed test of the patient's ability to rise from a standard armchair, walk 3 meters (10 feet), turn, walk back, and sit down again. Patients who take longer than 20 seconds to complete the test should receive further evaluation [19]. However, this test does not provide insight into the qualitative aspects of gait that also help the clinician with diagnosis and treatment. Additionally, a systematic review and meta-analysis found that the test's sensitivity was only 31 percent and the test had limited ability to predict falls [20]. (See 'Qualitative gait assessment' above.)

Fall risk and assessment — Over one-third of community-dwelling older persons fall each year, and falls are independently associated with functional decline [21]. All older patients should be asked at least yearly if they have fallen, and frail older persons should be asked about falls at every visit (algorithm 1). In addition, asking about fear of falling can identify patients at risk of future falls. The US Center for Disease Control and Prevention (CDC)'s 12-item Stay Independent Questionnaire is also a useful screening tool.

A falls assessment extends beyond evaluating gait mobility and includes measuring orthostatic blood pressure readings, assessing vision, reviewing medications, a foot inspection, and testing balance and lower-extremity strength [22]. Patients can also be given a home safety checklist developed by the CDC to complete, with further in-home assessment by a physical or occupational therapist if appropriate. Their risk of osteoporotic fracture should also be assessed using the FRAX, the Fracture Risk Assessment Tool, which can be completed with or without bone mineral density data. (See "Falls in older persons: Risk factors and patient evaluation" and "Falls: Prevention in community-dwelling older persons".)

Life-space assessment — Life-space assessments have been validated that measure extended mobility ranging from within one's dwelling to beyond one's town (form 1). Assessing life-space mobility, including the frequency and destination of trips, aids determination of an individual's degree of independence [23] and has predictive validity for mortality [24,25].

SOCIAL AND ENVIRONMENTAL ASSESSMENT — The wellbeing of older adults is greatly influenced by social and environmental factors, particularly as medical morbidity and functional impairments increase. These factors include the physical environment where the person lives, access to needed services, and social support for both physical and emotional needs. Individually and in combination, these factors affect a patient's clinical conditions and influence the treatment options available. For example, discharge planning from the hospital or post-acute care (eg, skilled nursing facility [SNF]) to home in a medically stable patient is dependent upon whether the patient is able to function independently in the home environment or has adequate help. From a physical perspective, environmental changes such as home safety modifications (eg, grab bars) may be needed. From a social perspective, the patient may be independent in activities of daily living (ADLs) but dependent in instrumental ADLs (IADLs), and family or friends may be needed to cook, shop, or provide transportation on a temporary or ongoing basis.

Taking a social history — The social history should include questions about the following components:

Living environment

Meal preparation and content (meals provided or individual prepares; adequacy of diet)

Support structure (who provides emotional support; who to call for help; need for medical alert service, such as Lifeline)

Family relationships

Education

Habits (alcohol, tobacco, gambling)

Caregiving needs (who shops, who cleans, who drives or provides transportation, who cuts nails)

Participation in exercise and recreational activities (frequency and duration of exercise; hours of television or video per day)

Community involvement

Advanced care planning

A previsit questionnaire can be helpful in obtaining this information (table 6).

For patients with functional impairment or diseases that require caregiving, the clinician should determine the main source of support at home for caregiving, which may include family, friends, or paid caregivers. The stability of the patient's support system and signs of caregiver burnout should be sought. Although social network scales have been developed and used for research purposes, they are less useful in clinical settings compared with the information that can be obtained by a clinical interview. Other important dimensions include financial security and safety, which are often better assessed by other members of the health care team (eg, social workers, physical or occupational therapists) who can assess the patient through home health agencies if the patient is homebound.

Available support services — Most older persons prefer to remain in their homes, and a variety of services are available to help make this possible, including adult day care centers, home delivery meal services, transportation services, community centers for social activities, and religious programs. Other more specific services may include financial or legal aid services and housekeeping.

Caregivers provide assistance with ADL and IADL tasks depending on the need. Caregivers do not need to be certified, can be hired through an agency or independently, or may be a family member or friend who chooses to take on the responsibility of care. In the United States, the costs of caregivers are not covered by Medicare and typically are paid privately or through long-term care insurance.

In some states, Medicaid will pay for a limited number of caregiver hours for those meeting eligibility criteria, such as In-Home Supportive Services (IHSS). IHSS provides in-home services and care for older or low-income adults, as well as those with certain disabilities, to allow them to maximize stay in their home. Services can include assistance with household chores, personal care, transportation, and paramedical services ordered by the clinician. IHSS is financed by state, county, and federal funds.

Many communities have a network of aging services, volunteer companions, agencies that provide nursing or homemaking services, and transportation for older adults or persons with disabilities. The National Association of Area Agencies has established an Eldercare Locator website to help connect older Americans and their caregivers with information on senior services in their area. The National Council on Aging has created a website that facilitates access to community services, including those that are free or low-cost.

Adult daycare centers provide a combination of health, social, and support services and group activities for older adults. These centers provide meals, recreational activities, and some health services to those who need supervision out of their home environments. Most operate during the daytime hours, so those enrolled can attend during the day and return home in the afternoon/evening. Adult day services also can provide a good transition period and short-term rehabilitation after hospital discharge. Social activities can help the individual maintain physical, psychosocial, and cognitive health. These centers can also provide respite to caregivers, which allow them to perform their own daily tasks and provides intermittent relief from the strain of caregiving.

Home delivery meal services, usually sponsored by Administration on Aging (Older Americans Act Title IIIc), can provide both hot and cold meals several times a day to homebound older adults, those residing in senior living facilities, or those attending adult/senior centers.

Senior transportation programs are available in most communities. Types of service can include door-to-door transportation from one location to another requiring advanced notice, while others may have a fixed route and schedule with predetermined stops without prior reservations required. Some ridesharing programs provide transportation for groups to destinations such as medical appointments, adult daycare centers, and senior centers. Commercial transport companies may offer special services for older adults and persons with disabilities. The Eldercare Locator provides local information and resources. In addition, some ride-hailing services (eg, Uber) can provide assistance helping riders into and out of vehicles and can load and unload assistive devices into the trunk of the vehicle. In addition, some companies (eg, Go Go Grandparent) provide access to services without the need for the older person to use a smartphone.

Senior centers offer a wide array of activities for older adults. Recreational centers and sport clubs offer exercise and group activities. Senior centers also offer other activities including arts and crafts, adult education, cultural activities, trips to special events, and health screenings.

Residential options for independent living — A major question that frequently arises is whether the older person is in the right living environment. The answer to this question must balance respect for a person's autonomy and independence with concerns about safety. Expanded options for housing depend upon needs, financial resources, and local availability and range from living at home (with additional support as needed) to assisted living to custodial care at nursing homes. Regardless of what is best for an older person at the current time, the "fit" of living situation should be monitored as the person's health and functional status change.

Increasingly popular options for those who have resources are independent living facilities (ILFs) for seniors who desire the conveniences of community living while still having their own housing unit. ILFs can range from apartment complexes to separate houses and can vary widely in cost. Residents need to be independent with ADLs and personal care but can get help with light housekeeping and meals. Opportunities are available for social activities, outings, exercise programs, and transportation. ILFs may be part of Continuing Care Retirement Communities (CCRCs), also called life-care communities, which include multiple levels of care on one campus (eg, independent living, assisted living, memory care, and nursing homes). This allows for a more streamlined transition when residents move from one level of care to another based on changes in functional status or care needs.

Options for residential facilities — Older people who do not have adequate support or the ability to live in their own home may need to consider residential long-term settings, and a range of options are available depending upon needs and resources.

Assisted living facilities (ALFs) are options for individuals who need additional assistance with ADLs and certain care needs while still remaining in a home-like environment. Some locations may have a separate unit for those with cognitive impairment. Residents live in their own units, which may include a living quarter, private bathroom, and sometimes small cooking or food storage area. Services provided may include administration or supervision of medications and help with personal care, usually for an additional fee. Dining service and group activities are available, although the individual can choose to follow their own routines. Residents should be able to get out of bed, transfer, and go to the bathroom independently unless they hire a caregiver. ALFs are paid for privately, although there may be limited coverage from Medicaid and waiver programs. These facilities usually do not have nursing or clinical staff on site, so medical related issues are directed back to the primary care providers. Additional services may be provided by home health services such as physical and occupational therapy, speech therapy, intermittent nursing care, and blood work or portable imaging.

An alternative to ALFs in some locations are board and care facilities that offer a house-style living environment that typically accommodates four to six residents. Individuals have their own rooms, and sometimes bathroom, but share the dining, living, and outdoor areas with other residents. Care is provided by aides trained in basic nursing and personal care. Board and cares are sometimes more affordable than other higher-level care settings but are paid for privately; some allow assistance from Medicaid or the Supplemental Security Income (SSI) program.

Nursing homes can provide both post-acute and long-term care. Short-term, post-hospitalization stays for skilled services (eg, rehabilitation, wound care, intravenous [IV] antibiotics, gastronomy tube [g-tube] management) are covered by Medicare following a three-day hospital stay. However, Centers for Medicare and Medicaid Services (CMS) authorized a temporary waiver in response to the COVID-19 pandemic under the Social Security Act (SSA) Section 1812 (f), allowing individuals to qualify for skilled nursing facility benefits without meeting the three-day inpatient stay criteria. Medicare Advantage (Medicare-managed care) and alternative payment model (eg, Accountable Care Organizations) patients do not require a three-day stay and the SNF three-day waiver rule allows for beneficiary admission to be approved [26]. The first 20 days of skilled care are covered 100 percent by Medicare and the subsequent 21 to 100 days are covered 80 percent per incident as long as there is a skilled need. Therapy can be up to maximum of two hours a day, six days a week.

Custodial services are provided for residents who remain in the facility long-term and need continued ADL assistance. These are covered by private pay, long-term care insurance, or Medicaid. Increasingly, alternative nursing home structures and staffing approaches have provided personal choice and more home-like options for institutional long-term care [27].

It is important to differentiate nursing home and SNFs from acute rehabilitation hospitals (table 7). Acute rehabilitation units are sometimes part of an acute care hospital and provide more intensive rehabilitative services with the expectation that the individual will return to his/her prior level of function. Participation in rehabilitation usually requires a minimum of three hours per day, up to seven days per week. Patients are often evaluated for their ability to participate in this level of rehabilitation therapy as well as the need for multiple types of therapy prior to acceptance by the facility. Finally, long-term acute care hospitals (LTACHs) are different than nursing homes as they provide care for hospital-level medical conditions through more comprehensive diagnostics including respiratory care for ventilated patients. The average length of stay must be 25 days or greater and there must be a need for intensive medical care.

As of October 2019, the CMS has made changes to home health and SNF payment systems. The change switched from the prior Resource Utilization Group (RUG) to the new Patient Driven Payment Model (PDPM), which focuses on the medical complexity of patients rather than reimbursement for rehabilitation time. These changes were made in efforts to align payment rates with patient conditions, characteristics, and costs of providing care and to hold providers more accountable for patient outcomes [28].

ASSESSMENT OF PROGNOSIS AND PATIENT GOALS

Prognosis — In contrast to caring for younger persons who usually have decades of life ahead, clinicians must recognize that older patients have fewer years remaining. Prognosis can be used to guide clinical decision-making, including whether to offer preventive services or treatment for long-term consequences of diseases (table 8) [29].

Prognosis is generally assessed by two approaches. The first uses patient characteristics, including clinical conditions, to estimate the probability that a patient will survive for a specified time (eg, five years) from the time of assessment or to a specified age (eg, age 100). Several prognostic instruments have been validated for use in community-dwelling, hospitalized, and nursing home patients [29], and online calculators are available. (See "Communication of prognosis in palliative care", section on 'The science of estimating prognosis'.)

The other approach is life expectancy, which is generally provided in years and can be found in life tables that estimate remaining life by age, sex, and race. Life tables generally do not consider clinical information (table 9) [30]. However, an example of a life table that provides estimates of life expectancy among persons with various levels of functional status and mobility for persons up to age 85 years is provided (table 10) [31]. Although actual survival of individual patients may deviate substantially from predicted survival, estimates of prognosis can frame treatment discussions and guide thinking about disease prevention and other long-term strategies.

Patient goals — For healthier older persons and those with few chronic conditions, traditional disease-oriented outcomes are appropriate. For frail older persons with short life expectancy and those with multiple comorbid conditions, however, a goal-oriented approach has been advocated [32]. In this approach [22], clinicians and patients identify and focus on a patient's individual health goals within or across a variety of dimensions (eg, symptoms; physical functional status, including mobility; social and role functions). The discussion about treatment is framed in terms of individually desired rather than population-desired health states. For example, one patient may want to walk independently and is willing to undergo prolonged rehabilitation following a hip fracture. Another may be satisfied with using a walker if they are able to achieve mobility sufficient for activities of daily living (ADLs) and getting around the house.

Focusing on goals allows the patients to identify outcomes that span multiple conditions. As a result, decision-making for overarching goals may be easier for patients with multiple conditions. Clinicians and patients can select treatments to achieve specified goals, including making choices to reduce treatment for one condition to permit optimizing treatment for another, depending upon which therapy is most likely to achieve the patient's goals. Clinicians can then monitor how well these goals are being met and adjust treatment accordingly as goals are achieved, not achieved, or change with disease progression or improvement. An approach to setting and monitoring goals is provided in the figure (figure 3) [33]. (See "Multiple chronic conditions", section on 'Elicit patient goals and priorities'.)

Advance care planning — Advance care planning involves communicating values and preferences with other decision-makers and health providers to ensure management accurately reflects one's goals and personal wishes. Advance care planning can be divided into several categories and documents: advanced directive forms, durable power of attorney for health care (DPOAHC), living wills, and Physician Orders for Life-Sustaining Treatment (POLST) or Medical Orders for Life-Sustaining Treatment (MOLST). (See "Advance care planning and advance directives".)

Advance directives are set of instructions that allow one to express values toward the end of life and designate a health care proxy. These are not medical orders. A living will is a type of advance directive with written instructions outlining one's health care wishes and detailing more specific preferences and procedures that one may or may not want toward the end of life. The POLST or MOLST is a medical order that provides instructions on specific treatments during an emergency, specifically addressing cardiopulmonary resuscitation, medical interventions, and artificially administered nutrition. (See "Advance care planning and advance directives".)

It is important for goals of care discussions and advance care planning to occur proactively before a crisis event occurs. Furthermore, when one's health is declining, ongoing communication is crucial to ensure care remains aligned with wishes and within the realistic context of their clinical condition and prognosis.

A comfort-oriented approach with palliative care and eventually hospice may be considered when there is a terminal illness where goals are focused on comfort over cure. (See "Hospice: Philosophy of care and appropriate utilization in the United States".)

MULTIDIMENSIONAL ASSESSMENT INSTRUMENTS — Multidimensional assessment includes evaluation of various dimensions of clinical importance in the care of older persons (table 11). Several groups have demonstrated the feasibility and yield of using office staff to administer case-finding and screening instruments that assess many of the dimensions described above. This approach can improve the practitioner's efficiency and increase the number of new and treatable problems detected in their older patients. Office staff must be properly trained to administer these instruments, which can be time-consuming. One published screener takes approximately 22 minutes to administer [34] and another takes an estimated 10 minutes to administer [35]. This time must be taken from other office tasks and the cost of screening may be considerable. As a result, the trend has been to use more efficient approaches described below. (See 'A practical approach to geriatric assessment in office settings' below.)

Another approach to multidimensional assessment focuses on the health-related quality of life of older persons. Although health-related quality of life instruments are not commonly used clinically, it is possible that their role they may emerge in determining clinical outcomes for performance-based payment structures.

Numerous instruments have been developed that evaluate aspects of general health, physical and mental morbidity, and social health. Frequently, this approach has been termed patient-reported outcome measures (PROMs), which have good statistical reliability supporting their use in individuals and groups as well as evidence of validity and responsiveness. These instruments have been used in research settings and to survey populations, including within health care systems. For example, the Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. One component of HEDIS is the Medicare Health Outcomes Survey, which includes the Veterans Rand 12-item survey (table 12) [36].

The most commonly used multidimensional quality of life instruments in the United States include the Medical Outcomes Study Short-form 36 (SF-36) [37], its briefer eight-item version (SF-8), and the Patient-Reported Outcomes Measurement Information System 29-item Health Profile (PROMIS-29) [38].

A PRACTICAL APPROACH TO GERIATRIC ASSESSMENT IN OFFICE SETTINGS — In the effort to be comprehensive yet efficient, new efforts to promote teamwork in office-based practice are emerging. In the past, teams often meant interdisciplinary teams that included some combination of clinicians, nurses, social workers, rehabilitation therapists, dietitians, and pharmacists. However, assembling an interdisciplinary assessment team is impractical for most practitioners and probably unnecessary for most office practices. New approaches to teamwork focus on redesigning the work of assessing patients using existing office personnel, which may be enhanced by additional personnel that are part of patient-centered medical homes.

For example, previsit questionnaires can be used to gather information about past medical and surgical history, medication/allergies, social history including available social support resources, preventive services, ability to perform functional tasks and need for assistance, home safety, and advanced directives. In addition, the previsit questionnaire can include specific questions assessing vision, hearing, falls, urinary incontinence, and depressive symptoms. One example of a previsit questionnaire from the Division of Geriatric Medicine at UCLA Health is available. These questionnaires can be administered electronically either through tablets in waiting rooms or via internet sites. Responses can be fed directly into the electronic health record.

With training, staff can also take larger roles in assessing and monitoring older persons with specific conditions or problems. Staff can administer self-report questionnaires, ask specific questions about conditions, and perform standard tests to identify and monitor the following conditions:

Visual impairment – Snellen eye chart

Hearing loss – Whisper test or screening audiometry

Malnutrition – Weight and height [body mass index]

Polypharmacy – Review medications to ensure that patient is taking medications as prescribed

Falls risk/immobility – Timed up-and-go test, postural blood pressures

Osteoporosis – Calculate FRAX, the Fracture Risk Assessment Tool

Urinary incontinence – Post-void residual, urine dipstick

Cognitive impairment – Mini-Cog or Mini-Mental State Examination

Depression – Patient Health Questionnaire Nine Item [PHQ-9]

Diabetic neuropathy – Monofilament testing, finger-stick glucose measurement/point-of-care A1C

"Huddles" are brief discussions among the clinician and the clinical staff before a patient care session, during which each patient on the schedule is discussed briefly, with each member contributing what they know about the patient since the last visit. The clinician can then identify information that should be collected prior to the start the visit. Huddles can facilitate patient flow and information-gathering, while maximizing team collaboration and investment in patient care.

There is no evidence base to determine appropriate time intervals for geriatric assessment. However, a reasonable approach is to assess some of these issues beginning at age 65 years with the Medicare Annual Wellness visit, which requires assessment of functional and cognitive status. Persons who are age 75 years and older and those less than age 75 years who have multiple comorbidities might also be screened and reassessed annually for the remaining components. In addition, some elements of geriatrics assessment (ie, assessing activities of daily living [ADLs] and instrumental ADLs [IADLs]; gait, balance, and falls; mood/affect; and cognition) should be performed after major illnesses, especially those requiring hospitalization.

SUMMARY AND RECOMMENDATIONS

With advancing age and increased burden of chronic medical conditions, assessment of non-medical dimensions affecting health becomes increasingly important. Domains of geriatric assessment include social, functional, economic, psychosocial, cognitive, and environmental. Geriatric assessment must be considered in the context of the overall direction of the patient's health course and the patient's goals and preferences for care are going forward. (See 'Principles of assessment of the older patient' above.)

Functional status is a measure of overall health impact in the context of an individual's environment and social support network and reflects the ability of an individual to carry on the physical and social tasks necessary for usual activities and roles. Components of functional status are activities of daily living (ADLs), instrumental activities of daily living (IADLs), and advanced activities of daily living (AADLs). Two commonly used indices are the Katz index for ADLs (table 1) and the Lawton scale for IADLs (table 2). AADLS are best determined by asking open-ended questions (eg, “How do you spend your days?” “What do you like to do?”). (See 'Functional assessment' above.)

Assessment of mobility should include the spectrum from gait and balance to travel outside the home. Gait speed is also a helpful marker and correlates with risk for recurrent falls as well as frailty and survival. (See 'Mobility assessment' above.)

An older person's best living environment is determined by assessment of health and functional needs coupled with assessment of preferences and resources. Many options are available and the optimal location balances autonomy and safety. The appropriateness of an older person's living situation should be monitored as the person's health and functional status change. (See 'Social and environmental assessment' above.)

Life expectancy and prognosis should be considered in medical decision making in frail or very old persons. The limitations of instruments to assess prognosis should be recognized. For frail older persons with short life expectancy and those with multiple conditions, medical decision-making that focuses on individual goals is more appropriate than aiming to achieve population-desired goals. (See 'Assessment of prognosis and patient goals' above.)

Multidimensional screening and health-related quality-of-life instruments have not been routinely integrated into clinical practice but may be valuable in some circumstances to capture and monitor patients’ perceptions of their health. (See 'Multidimensional assessment instruments' above.)

Increasingly, geriatric assessment is incorporating input from non-clinician office staff, patients and their families/loved ones and may involve standing orders, forms, and questionnaires. There is no evidence base to determine appropriate time intervals for geriatric assessment. A reasonable approach is to assess functional status annually beginning at age 65 years through the Medicare Annual Wellness Visit and supplement these with additional components for persons who are less than age 75 years who have multiple comorbidities or who are 75 years or older. In addition, some elements of geriatrics assessment (ie, assessing ADLs and IADLs; gait, balance, and falls; mood/affect; and cognition) should be performed after major illnesses, especially those requiring hospitalization. (See 'A practical approach to geriatric assessment in office settings' above.)

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Topic 17040 Version 28.0

References

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