PATIENT-CLINICIAN COMMUNICATION
COMPREHENSIVE GERIATRIC ASSESSMENT
Geriatric assessment is a multifaceted approach to the care of the older adult with the goal of promoting wellness and independent function. Function is defined broadly to encompass the physical, cognitive, psychologic, and social domains. The scope of the assessment of any individual domain depends on the site of care, the patient’s level of frailty, time constraints, the goals of care, and the availability of a multidisciplinary team. The essential aspects of geriatric assessment should be performed routinely in all sites of care, whether the ambulatory setting, the emergency department, the hospital, the nursing home, or the home. Whenever possible, assessments should be performance based. An informant, ideally a caregiver or family member who lives with the patient, is often required to provide or to verify pertinent historical information about the older patient’s day-to-day functioning.
Efficient strategies are required to incorporate geriatric assessment into routine office practice. One such strategy entails rapid screening of targeted areas (Table 6.1), followed by comprehensive assessment in areas of concern. Many of the initial screens can be completed by trained office staff; some can be completed by the patients themselves while seated in the waiting area or at home prior to the visit. The use of a “rolling” assessment, which targets at least one area for screening during each office visit, should be considered. Finally, in the absence of specific target symptoms, parts of the routine examination, such as auscultation of the chest and palpation of the abdomen, can be replaced by aspects of geriatric assessment, such as observation of gait, balance, and transfers.
Because of the demands of a busy clinical practice, the time available for office visits is often constrained. Time tends to be less important, however, than the skills of the clinician in facilitating communication with older patients. Table 6.2 lists several simple strategies that may be used to enhance communication. (See also the table on communication in Hearing Impairment.) To accommodate the high prevalence of sensory deficits among older persons, particular attention should be given to the environment of the examination room. The use of simple, inexpensive amplification devices with lightweight earphones can be especially effective, even for the severely hearing-impaired person. During the course of the interview, the clinician should go beyond the customary clinical inquiries by asking open-ended questions such as, “What would you like me to do for you?” Finding out what the patient wants can be a prime mechanism for solving potential problems, generating trust, and improving mutual satisfaction in the patient-clinician relationship.
The importance of a full, appropriately detailed physical examination cannot be overstated. Many older adults cannot see well enough to report signs of disease or have cognitive impairment that prevents them from being able to accurately report symptoms. The clinician cannot assume that “no news is good news” in the care of older adults.
Functional status refers to the person’s ability to perform tasks that are required for living. These tasks, usually referred to as activities of daily living (ADLs), are listed in Table 6.3. When assessing function, ask whether the patient is independent or requires the help of another person to complete the tasks. Bathing is typically the basic ADL with the highest prevalence of disability, and disability in bathing is often the reason why older persons receive home aide services. To identify patients with “preclinical” disability, that is, those who do not yet require personal assistance but who are at risk for becoming disabled, ask about perceived difficulty with the tasks and whether the patient has changed the way he or she completes the task because of a health-related problem or condition. Assess the use of any assistive devices, such as a cane or walker, as well as duration and circumstances of use.
Outside of a rehabilitation setting, performance-based testing of most of the self-care and instrumental ADLs is not practical. Hence, performance-based testing of functional status focuses primarily on mobility, including transfers, gait, and balance. Ask the patient to stand from the seated position in a hard-backed chair while keeping his or her arms folded. Inability to complete this task suggests lower extremity, or quadriceps, weakness and is highly predictive of future disability. Once he or she is standing, observe the patient walk back and forth over a short distance, ideally with the usual walking aid. Abnormalities of gait include path deviation; diminished step height or length or both; trips, slips, or near falls; and difficulty with turning. The tasks 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 make up the “Timed Get Up and Go” test. Persons who can complete this sequence of maneuvers in less than 10 seconds have intact mobility; those who take 20 seconds or longer require further evaluation.
An alternative assessment strategy is to measure gait speed as a predictor of future disability. A gait speed of 0.80 m per second allows for independent community ambulation; a speed of 0.60 m per second allows for community activity without the use of a wheelchair. These norms indicate that patients who can walk 50 feet in your office corridor in 20 seconds or less should be able to walk independently in normal activities.
Balance can be tested progressively by asking the patient to stand first with his or her feet side by side, then in semi-tandem position, and finally in tandem position. Difficulty with balance in these positions predicts an increased risk of falling. Although standardized instruments, such as the Tinetti Performance-Oriented Mobility Assessment, may be used to quantify impairments in gait and balance, a qualitative assessment is usually sufficient to make recommendations about the need for an assistive device, such as a cane or walker. When assessing gait and balance, particularly in older women, clinicians should observe for the use of proper footwear, that is, flat, hard-soled shoes. (Also see the Appendix, for falls-assessment guidelines.)
Finally, clinicians can often glean useful functional information by observing their older patients as they complete simple tasks, such as unbuttoning and buttoning a shirt or blouse, picking up a pen and writing a sentence, taking off and putting on shoes, touching the back of the head with both hands, and climbing up and down from an examination table.
Poor nutrition in the older person may reflect concurrent medical illness, depression, dementia, inability to shop or cook, inability to feed oneself, or financial hardship. Aside from visual inspection for signs of malnutrition, older persons should have their weight and height measured routinely. A low body mass index (ie, kg/m2 < 20) or an unintentional weight loss of more than 10 pounds in 6 months suggests poor nutrition and requires further evaluation. (See Malnutrition.)
Although visual impairment from cataracts, glaucoma, macular degeneration, and abnormalities of accommodation usually worsens with age, older persons are often unaware of their visual deficits. Asking about difficulty with driving, watching television, or reading may uncover a problem with vision. As a brief performance-based screen, an older patient can be asked to read (using corrective lenses, if applicable) a short passage from a newspaper or magazine, with the caveat that low literacy is not an uncommon problem among older persons. Significant impairment in vision can be confirmed through the use of a Snellen chart or Jaeger card; the inability to read greater than 20/40 is the standard criterion. (See Visual Impairment.)
The high prevalence of hearing loss among older persons and its association with depression, dissatisfaction with life, and withdrawal from social activities make it an important target for assessment. Hearing loss is usually bilateral and in the high-frequency range. Hearing should be assessed routinely during the history-taking session and can be assessed more formally using a hand-held AudioScope. Inability to hear a 40-dB tone at 1000 or 2000 Hz in both ears or at either of these frequencies in one ear is considered abnormal and, in the absence of cerumen impaction, warrants a discussion about referral for formal audiometric testing. (See Hearing Impairment.)
The prevalence of cognitive decline doubles every 5 years after the age of 65 and approaches 40% to 50% at age 90. Most patients with dementia do not complain of memory loss or even volunteer symptoms of cognitive impairment unless specifically questioned. Older persons with cognitive impairment, even in the absence of dementia, are at increased risk for accidents, delirium, medical nonadherence, and disability. Therefore, an important feature of every assessment of an older adult, especially those aged 75 years and older, is a brief cognitive screen.
Because short-term memory loss is typically the first sign of dementia, the best single screening question is recall of three words after 1 minute. Anything other than perfect recall should lead to further testing. An alternative strategy adds orientation to day of the week, month, and year to the three memory items. A cut-off of three or more errors has a sensitivity and specificity of nearly 90% for a diagnosis of dementia. The most commonly used instrument for formal testing of cognition is the Folstein Mini–Mental State Examination (MMSE), which assesses orientation, registration and recall, attention and calculation, language, and visual-spatial skills. Although scores on the MMSE need to be interpreted in the context of educational attainment, race and age, scores lower than 24 generally warrant further evaluation for possible dementia.
An often overlooked area of cognition, which is essential for proper goal-directed behaviors, is executive function. The clock-drawing test is valuable because it assesses executive control and visual-spatial skills, two domains of cognition that are otherwise not tested or incompletely tested by the MMSE. In the clock-drawing test, the patient is asked to draw the face of a clock and to place the hands correctly to indicate 2:50 or 11:10. The clock-drawing test is combined with the three-item recall in the Mini-Cog Assessment Instrument for Dementia, a brief screening test that has been recently developed and validated. The Mini-Cog also has the advantage over the MMSE of being both very sensitive and specific when used with those patients whose native language is not English and those with less than a high school education.
Another useful question to assess executive function is asking the patient to name as many four-legged animals as possible in 1 minute. Fewer than 8 to 10 animals or repetition of the same animals is abnormal and suggests the need for further evaluation.
Although the prevalence of major depression among community-dwelling older persons is only about 1% to 2%, a large number of older persons suffer from significant symptoms of depression below the severity threshold of major depression as defined by the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. These subthreshold depressive symptoms, which often include somatic complaints such as poor sleep and fatigue, increase the risk of physical disability and slower recovery after an acute disabling event. They are also associated with a significant increase in the cost of medical services, even after accounting for the severity of chronic medical illness. Hence, clinicians should have a high index of suspicion for depressive symptoms and a low threshold for treatment. The best single question to ask is, “Do you often feel sad or depressed?” An affirmative response warrants further evaluation of other depressive symptoms, perhaps through the use of a standardized instrument such as the 15-item Geriatric Depression Scale (see the Appendix).
Anxiety and worries are also important symptoms in older patients and are often a manifestation of an underlying depressive disorder. Finally, because older persons are particularly likely to experience the loss of a loved one, special efforts should be made to recognize and manage the consequences of bereavement. (See Depression and Other Mood Disorders.)
The social assessment consists of several elements, including ethnic, spiritual, and cultural background, the availability of a personal support system, the need for a caregiver and his or her role, presence of caregiver burden, the safety of the home environment, the patient’s economic well-being, the possibility of elder mistreatment, and the patient’s advance directives. Although a comprehensive social assessment may not be feasible in a busy office practice, clinicians caring for older patients should be mindful of these aspects of an older patient’s life. Some older persons, for example, may be illiterate, uneducated, or have a poor command of English, making it difficult for them to navigate through the complexities of the current health care system. Clinicians can uncover important clues to unmet needs by inquiring about the availability of help in case of an emergency. For frail older persons, particularly those who lack social support, referral to a visiting nurse may be helpful in assessing home safety and level of personal risk. (See Psychosocial Issues, “Cultural Aspects of Care; Elder Mistreatment.)
During the past decade, quality of life has been embraced as a convenient catchphrase to denote important patient outcomes other than death and traditional physiologic measures of morbidity. Although a gold standard does not exist, most instruments designed to measure quality of life include various aspects of physical, cognitive, psychologic, and social function. Perhaps the most commonly used instrument is the Short Form-36 Health Survey (SF-36), which includes 36 items organized into eight domains—physical function, role limitations due to physical health, role limitations due to emotional health, bodily pain, social functioning, mental health, vitality, and general health perceptions. The SF-36 has been tested extensively among community-living persons and hospitalized patients, but it may not be suitable for use among the oldest-old persons, especially those who are frail, because of floor effects and insensitivity to clinically important changes in health status.
When assessing quality of life, ask about patient preferences regarding medical care and goals of care. Goals can be multiple, diverse, and sometimes conflicting. There is striking heterogeneity among older patients with respect to physiologic function, health status, belief systems, cultural and ethnic backgrounds, values, and personal preferences. The successful management of chronic conditions, such as diabetes mellitus, arthritis, and heart failure, requires that patients, families, and clinicians work collaboratively to define the specific problems, to elicit personal preferences, and to establish the goals of care. A patient’s cultural and ethnic heritage will have an important role in her understanding of her illness, its meaning in her life, and her response to it. It is crucial, therefore, for the physician to have an appreciation of that heritage and the role it plays in the patient’s understanding of health and illness. (See Cultural Aspects of Care.) Treatment plans that include patient preferences have been shown to enhance adherence and increase satisfaction, and they have the potential to improve patient outcomes.
Evaluating the older driver presents a difficult challenge to the physician. The automobile is the most important, and often the only, source of transportation for older persons. Yet a variety of age-related changes, chronic conditions, and medications place the older person at risk for automobile accidents. Although the absolute number of crashes involving older drivers is low, the number of crashes per mile driven and the likelihood of serious injury or death are higher than for any age group other than those aged 16 to 24 years.
To their credit, the vast majority of older persons make prudent adjustments in their driving behaviors by avoiding rush hour or congested thoroughfares or by not driving at night or during adverse weather conditions. Nonetheless, impaired older persons who continue to drive represent an important safety hazard not only to themselves but also to other drivers, passengers, and pedestrians. Pertinent risk factors for automobile accidents include poor visual acuity (less than 20/40) and contrast sensitivity; dementia, particularly deficits in visual-spatial skills and visual attention; impaired neck and trunk rotation; and poor motor coordination and speed of movement. Alcohol and medications that adversely affect alertness, such as narcotics, benzodiazepines, antihistamines, antidepressants, antipsychotics, sedatives, and muscle relaxants, may impair driving skills and increase crash risk. Hence, caution is warranted when initiating or adjusting the dose of these medications, and patients should be warned about potential adverse effects on driving safety.
Any report of an accident or moving violation should trigger an assessment of the patient’s driving capacity. Discuss safety concerns honestly with the older driver, and ideally with a spouse or other family member as well, particularly when the patient lacks insight into his or her driving limitations. Alternative modes of transportation should be considered. Recommendations to stop driving, however, should not be proffered lightly, since driving cessation can lead to a decrease in activity level and an increase in depressive symptoms. Referral for a formal driving evaluation by a skilled occupational therapist may be helpful in confirming unsafe driving behaviors or, perhaps, in suggesting interventions such as adaptive equipment to correct for specific physical disabilities. In the interest of public safety, physicians should know their state’s law on reporting impaired drivers. In most states, physicians are encouraged, and in some states mandated, to report their concerns to the licensing agency. (See also the section on driving in Legal and Ethical Issues.) An excellent reference for physicians caring for older drivers is The Physician’s Guide to Assessing and Counseling Older Drivers. Developed by the American Medical Association in cooperation with the National Highway Traffic Safety Administration, it was recently made available free of charge. Visit the Web site: http://www.ama-assn.org/ama/pub/category/10791.html to view the publication, download it, or order a printed copy.
Comprehensive geriatric assessment (CGA) is a process intended to determine a patient’s medical, psychosocial, and functional capabilities and limitations, with the goal of developing an overall plan for treatment and long-term follow-up. Because CGA typically requires a highly trained team of geriatricians, geriatric nurse clinicians, physical and occupational therapists, geriatric psychiatrists, and social workers, it is expensive and time consuming. Success generally requires the geriatric team to take over the direct care of the patient. An extended period of intensive team involvement with ongoing care is essential to assure the efficacy of the intervention. When the geriatric team assumes a purely consultative role (ie, without a role in implementing the recommendations), CGA is unlikely to be successful in improving patient outcomes.
CGA has had its greatest success in terms of improving function and reducing nursing-home placement and hospital readmissions, in inpatient geriatric units that are staffed by highly trained professionals. Accumulating evidence, however, suggests that preventive home visitation programs may also be beneficial. A meta-analysis of randomized trials demonstrated that these programs decrease nursing-home admissions and reduce functional decline if the interventions are based on comprehensive geriatric assessment with extended follow-up, include multiple follow-up home visits, and target persons at lower risk for death.
■ Cohen HJ, Feussner JR, Weinberger M, et al. A controlled trial of inpatient and outpatient geriatric evaluation and management. N Engl J Med. 2002;346(12) 905–912.
This landmark clinical trial evaluated the effectiveness of geriatric evaluation and management in outpatient clinics and inpatient units among nearly 1400 predominantly male patients, aged 65 years or older, who were seen at 11 Veterans Affairs medical centers and had at least two potential markers of frailty. The results revealed modest but significant benefits of the geriatric evaluation and management inpatient units on basic activities of daily living, physical performance, and four domains of quality of life. In contrast, the outpatient geriatric clinics offered relatively little benefit. There was no improvement in survival related to either inpatient or outpatient geriatric evaluation and management. Over the course of a year, the two programs were cost-neutral relative to usual care. The investigators speculate that improvements in usual care over the past two decades could account for the absence of a survival benefit, which had been documented in two prior single-site trials.
■ Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146−M156.
Increasingly, frailty is recognized as a geriatric syndrome, distinct from disability and comorbidity, which results from a multisystem reduction in reserve capacity and confers high risk for adverse outcomes. The investigators of this report developed an operational definition (or “phenotype”) of frailty that is based on the presence of three or more of the following criteria: unintentional weight loss, self-reported exhaustion, weakness, low physical activity, and slow gait speed. Using data from the Cardiovascular Health Study, the investigators provide preliminary evidence to support the predictive validity of the proposed phenotype. If further validated in subsequent studies, the standardized phenotype could be a valuable tool for clinicians to identify and manage affected individuals and for researchers to evaluate the consequences and causes of frailty.
■ Gill TM, Kurland B. The burden and patterns of disability in activities of daily living among community-living older persons. J Gerontol A Biol Sci Med Sci. 2003; 58:70−75.
In this longitudinal study, the investigators interviewed 754 nondisabled community-living persons aged 70 years or older monthly for 2 years to determine the presence and severity of disability in four key activities of daily living: bathing, dressing, walking, and transferring. The investigators found that disability is a dynamic process with considerable diversity, particularly among persons who are physically frail by virtue of slow gait speed. For example, 42% of nondecedents who were physically frail had multiple months or episodes of disability over 2 years, with no single pattern representing the disability experience of more than half the participants. These findings provide strong evidence to support an emerging paradigm of disability as a reversible, and often recurrent, event.
■ Mouton CP, Esparza YB. Ethnicity and geriatric assessment. In: Gallo JJ, Fulmer T, Paveza GJ, et al., eds. Handbook of Geriatric Assessment. 3rd ed. Gaithersburg, MD: Aspen Publishers, Inc., 2000:13−27.
As the U.S. population of older persons becomes increasingly diverse in terms of ethnicity and race, clinicians must become better attuned to cultural factors that may influence assessment, such as educational attainment, language, and attitudes about illness and treatment. This informative chapter discusses ways that geriatric assessment can be modified for patients from diverse ethnic groups. The authors discuss several general issues, including the heterogeneity of ethnic groups; the reliability, validity, and use of assessment instruments; strategies to enhance communication; and the elicitation of beliefs and attitudes about illness. They focus on culturally competent assessment in relation to physical function, cognitive impairment, depression, social and economic issues, and ethics in medical decision making.
■ Smeeth L, Fletcher AE, Stirling S, et al. Randomised comparison of three methods of administering a screening questionnaire to elderly people: findings from the MRC trial of the assessment and management of older people in the community. BMJ. 2001;323(7326):1403−1407.
In this remarkable study set in the United Kingdom, the investigators compared three different methods of administering a screening questionnaire to a sample of nearly 33,000 persons aged 75 years or older, using a randomized design. The response rate was significantly higher for the postal questionnaire (83.5%) than for face-to-face interviews by a lay interviewer (73.9%) or nurse (75.9%). The proportion of missing or invalid responses was low overall (2.1%), but was greater for the postal questionnaire than for the other two methods. Counterintuitively, the specificity of the screening questions was higher than the sensitivity for vision, hearing, depression, and cognition, although the values differed little by mode of administration. Although the ongoing randomized trial will ultimately determine whether health outcomes differ by screening method, the results of this report provide strong evidence to support the use of a postal questionnaire as a feasible, efficient strategy to identify potentially modifiable impairments, problems, and conditions in a defined population of older persons.
■ Studenski S, Perera S, Wallace D, et al. Physical performance measures in the clinical setting. J Am Geriatr Soc. 2003;51(3):314−322.
Several epidemiologic studies have demonstrated that simple tests of physical performance are effective at stratifying risk for functional decline, health care utilization, and death among large, population-based samples of community-living older persons. In this prospective cohort study, evidence is provided to support the utility of physical performance tests in the primary care setting. Gait speed alone and a composite measure of physical performance, which included gait speed, chair stands, and progressive balance, predicted hospitalization and decline in function and health status over 12 months among persons aged 65 year or older in two outpatient settings. These results, coupled with those of prior studies, provide strong support for the use of performance-based tests as geriatric “vital signs” in everyday clinical practice.
Thomas M. Gill, MD