4 - Developing Clinical Expectations | Understanding Thin Client/Server Computing (Strategic Technology Series)

Editors: Kane, Robert L.; Ouslander, Joseph G.; Abrass, Itamar B.

Title: Essentials of Clinical Geriatrics, 5th Edition

> Table of Contents > Part I - The Aging Patient and Geriatric Assessment > Chapter 3 - Evaluating the Geriatric Patient

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Chapter 3

Evaluating the Geriatric Patient

Comprehensive evaluation of an older individual's health status is one of the most challenging aspects of clinical geriatrics. It requires a sensitivity to the concerns of people, an awareness of the many unique aspects of their medical problems, an ability to interact effectively with a variety of health professionals, and often a great deal of patience. Most importantly, it requires a perspective different from that used in the evaluation of younger individuals. Not only are the a priori probabilities of diagnoses different, but one must be attuned to more subtle findings. Progress may be measured on a finer scale. Special tools are needed to ascertain relatively small improvements in chronic conditions and overall function compared with the more dramatic cures of acute illnesses often possible in younger patients. Creativity is essential in order to incorporate these tools efficiently in a busy clinical practice.

The purposes of the evaluation and the setting in which it takes place will determine its focus and extent. Considerations important in admitting a geriatric patient with a fractured hip and pneumonia to an acute care hospital during the middle of the night are obviously different from those in the evaluation of an older demented patient exhibiting disruptive behavior in a nursing home. Elements included in screening for treatable conditions in an ambulatory clinic are different from those in assessment of older individuals in their own homes or in long-term-care facilities.

Despite the differences dictated by the purpose and setting of the evaluation, several essential aspects of evaluating older patients are common to all purposes and settings. Figure 3-1 depicts these aspects. Several comments on addressing them are in order:

FIGURE 3-1 Components of assessment of older patients.

Physical, psychological, and socioeconomic factors interact in complex ways to influence the health and functional status of the geriatric population.
Comprehensive evaluation of an older individual's health status requires an assessment of each of these domains. The coordinated efforts of several
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different health care professionals functioning as an interdisciplinary team are needed.
Functional abilities should be a central focus of the comprehensive evaluation of geriatric patients. Other more traditional measures of health status (such as diagnoses and physical and laboratory findings) are useful in dealing with underlying etiologies and detecting treatable conditions, but in the geriatric population, measures of function are often essential in determining overall health, well being, and the need for health and social services.

Just as function is the common language of geriatrics, assessment lies at the heart of its practice. Special techniques that address multiple problems and their functional consequences offer a way to structure the approach to complicated geriatric patients. Geriatric assessment has been tested in a variety of forms. Table 3-1 summarizes the findings from a number of randomized, controlled trials of different approaches to geriatric assessment (Rubenstein, 1991). A randomized trial of annual in-home comprehensive geriatric assessment demonstrated the potential to delay the development of disability and reduce permanent nursing home stays (Stuck et al., 1995; Bula et al., 1999). More recent controlled trials of approaches to hospitalized geriatric patients suggest comprehensive geriatric assessment by a consultation team with limited follow-up does not improve health or survival of selected geriatric patients (Reuben et al., 1995), but that a special acute geriatric unit can improve function and reduce discharges to institutional care (Landefeld et al., 1995). A controlled multisite VA trial of inpatient geriatric evaluation and management demonstrated significant reductions in functional

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decline without increased costs (Cohen et al., 2002). Results of outpatient geriatric assessment have been mixed and less compelling (Cohen et al., 2002). However, a randomized trial of outpatient geriatric assessment with an intervention to improve adherence to the recommendations prevented functional decline (Reuben et al., 1999).

TABLE 3-1 EXAMPLES OF RANDOMIZED CONTROLLED TRIALS OF GERIATRIC ASSESSMENT

SETTING	EXAMPLES OF ASSESSMENT STRATEGIES	SELECTED OUTCOMES*
Community/outpatients	Social worker assessment and referral Nursing assessment and referral Annual in-home assessment by nurse practitioner Multidisciplinary clinic assessment	Reduced mortality Reduced hospital use Reduced permanent nursing home use Delayed development of disability
Hospital inpatient (specialized units)	Interdisciplinary teams with focus on function, geriatric syndromes, rehabilitation	Reduced mortality Improved function Reduced acute hospital and nursing home use
Hospital inpatient consultation	Geriatric consultation teams	Mixed results Some studies improved function and lower short-term mortality Other studies show no effects
* Not all studies show improvements in all outcomes. See text and Rubenstein et al., 1991.

There is considerable variation in approaches to the comprehensive assessment of geriatric patients. Various screening and targeting strategies have been used to identify appropriate patients for more comprehensive assessment. These strategies range from selection based on age to targeting patients with a certain number of impairments or specific conditions. Sites of assessment vary as well,

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and include the clinic, the home, the hospital, and different levels of long-term care. Geriatric assessment also varies in terms of which discipline carries out the different components of the assessment as well as in the specific assessment tools used. Despite the dramatic variation in approach to targeting, personnel used, and measures employed, a clear pattern of effectiveness has emerged. Taken together, these results are both heartening and cautioning. Systematic approaches to patient care are obviously desirable. The issue is more how formalized these assessments should be. Research data suggest that the specifics of the assessment process seem to be less important than the very act of systematically approaching older people with the belief that improvement is possible.

Because of the multidimensional nature of geriatric patients' problems and the frequent presence of multiple interacting medical conditions, comprehensive evaluation of the geriatric patient can be time-consuming and thus costly. Strategies that can make the evaluation process more efficient include the following:

The development of a closely-knit interdisciplinary team with minimal redundancy in the assessments performed.
Use of carefully designed questionnaires that reliable patients and/or caregivers can complete before an appointment.
Incorporation of screening tools that target the need for further, more in-depth assessment.
Use of assessment forms that can be readily incorporated into a computerized relational data base.
Integration of the evaluation process with case management activities that target services based on the results of the assessment.

This chapter focuses on the general aspects of assessing geriatric patients. Sections on geriatric consultation, preoperative evaluation, and environmental assessments are included at the end of the chapter.

Chapter 15 includes information on case management and other health services, and Chap. 16 is devoted to the assessment and management of geriatric patients in the nursing home setting.

THE HISTORY

Sir William Osler's aphorism, Listen to the patient, he'll give you the diagnosis, is as true in older patients as it is in younger patients. In the geriatric population, however, several factors make taking histories more challenging, difficult, and time-consuming.

Table 3-2 lists difficulties commonly encountered in taking histories from geriatric patients, the factors involved, and some suggestions for overcoming these difficulties. Impaired hearing and vision (despite corrective devices) are common and can interfere with effective communication.

TABLE 3-2 POTENTIAL DIFFICULTIES IN TAKING GERIATRIC HISTORIES

DIFFICULTY	FACTORS INVOLVED	SUGGESTIONS
Communication	Diminished vision Diminshed hearing	Use well-lit room Eliminate extraneous noise Speak slowly in a deep tone Face patient, allowing patient to see your lips Use simple amplification device for severely hearing impaired If necessary, write questions in large print
Communication	Slowed psychomotor performance	Leave enough time for the patient to answer
Underreporting of symptoms	Health beliefs Fear Depression Altered physical and physiological responses to disease process Cognitive impairment	Ask specific questions about potentially important symptoms (see Table 3-3) Use other sources of information (relatives, friends, other caregivers) to complete the history
Vague or non-specific symptoms	Altered physical and physiological responses to disease process Altered presentation of specifc diseases Cognitive impairment	Evaluate for treatable diseases, even if the symptoms(or signs) are not typical or specific when there has been a rapid change in function Use other sources of information to complete history
Multiple complaints	Prevalence of multiple coexisting diseases Somatization of emotions masked depression (see Chap. 5)	Attend to all somatic symptoms, ruling out treatable conditions Get to know the patient's complaints; pay special attention to new or changing symptoms Interview the patient on several occasions to complete the history

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Techniques such as eliminating extraneous noises, speaking slowly and in deep tones while facing the patient, and providing adequate lighting can be helpful. The use of simple, inexpensive amplification devices with Walkman -style earphones can be especially effective, even among the severely hearing impaired. Patience is truly a virtue in obtaining a history; because thought and verbal processes are often slower in older than in younger individuals, patients should be allowed adequate time to answer in order not to miss potentially important information.

Many older individuals underreport potentially important symptoms because of their cultural and educational backgrounds as well as their expectations of illness as a normal concomitant of aging. Fear of illness and disability or depression accompanied by a lack of self-concern may also render the reporting of symptoms less frequent. Altered physical and physiologic responses to disease processes (see Chap. 1) can result in the absence of symptoms (such as painless myocardial infarction or ulcer and pneumonia without cough). Symptoms of many diseases can be vague and nonspecific because of these age-related changes. Impairments of memory and other cognitive functions can result in an imprecise or inadequate history and compound these difficulties. Asking specifically about potentially important symptoms (such as those listed in Table 3-3) and using other sources of information (such as relatives, friends, and other caregivers) can be very helpful in collecting more precise and useful information in these situations.

TABLE 3-3 IMPORTANT ASPECTS OF THE GERIATRIC HISTORY

SOCIAL HISTORY
Living arrangements Relationships with family and friends Expectations of family or other caregivers Economic status Abilities to perform activities of daily living (see Table 3-8) Social activities and hobbies Mode of transportation Advance directives (see Chap. 17)
PAST MEDICAL HISTORY
Previous surgical procedures Major illnesses and hospitalizations Previous transfusions Immunization status Influenza, pneumococcal, tetanus Preventive health measures Mammography Papanicolaou (Pap) smear Flexible sigmoidoscopy Antimicrobial prophylaxis Estrogen replacement Tuberculosis history and testing Medications (use the brown bag technique; see text) Previous allergies Knowledge of current medication regimen Compliance Perceived beneficial or adverse drug effects
SYSTEMS REVIEW
Ask questions about general symptoms that may indicate treatable underlying disease such as fatigue, anorexia, weight loss, insomnia, recent change in functional status Attempt to elicit key symptoms in each organ system, including the following:
SYSTEM	KEY SYMPTOMS
Respiratory	Increasing dyspnea Persistent cough
Cardiovascular	Orthopnea Edema Angina Claudication Palpitations Dizziness Syncope
Gastrointestinal	Difficulty chewing Dysphagia Abdomnal pain Change in bowel habit
Genitourinary	Frequency Urgency Nocturia Hesitancy, intermittent stream, straining to void Incontinence Hematuria Vaginal bleeding
Musculoskeletal	Focal or diffuse pain Focal or diffuse weakness
Neurological	Visual disturbances (transient or progressive) Progressive hearing loss Unsteadiness and/or falls Transient focal symptoms
Psychological	Depression Anxiety and/or agitation Paranoia Forgetfulness and/or confusion

At the other end of the spectrum, geriatric patients with multiple complaints can frustrate the health care professional who is trying to sort them all out. The

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multiplicity of complaints can relate to the prevalence of coexisting chronic and acute conditions in many geriatric patients. These complaints may, however, be deceiving. Somatic symptoms may be manifestations of underlying emotional distress rather than symptoms of a physical illness, and symptoms of physical conditions may be exaggerated by emotional distress (see Chap. 7). Getting to know patients and their complaints and paying particular attention to new or changing symptoms are helpful in detecting potentially treatable conditions.

Table 3-3 lists aspects of the history that are especially important in geriatric patients. It is often not feasible to gather all information in one session; shorter interviews in a few separate sessions may prove more effective in gathering these data from some geriatric patients.

Often shortchanged in medical evaluations, the social history is a critical component. Understanding the patient's socioeconomic environment and ability to function within it is crucial in determining the potential impact of an illness on an individual's overall health and need for health services. Especially important is the assessment of the family's feelings and expectations. Many family caregivers of frail geriatric patients have feelings of both anger (at having to care for a dependent family member) and guilt (over not being able or willing to do enough), and have unrealistic expectations. Such unrealistic expectations are often based on a lack of information and can interfere with care if not discussed. Unlike younger patients, older patients often have had multiple prior illnesses. The past medical history is, therefore, important in putting the patient's current problems in perspective; this can also be diagnostically important. For example, vomiting in an elderly patient who has had previous intraabdominal surgery should raise the suspicion of intestinal obstruction from adhesions; nonspecific constitutional symptoms (such as fatigue, anorexia, and weight loss) in a patient with a history of depression should prompt consideration of a relapse. Because older individuals are often treated with multiple medications, they are at increased risk of noncompliance and adverse effects (see Chap. 14). A detailed medication history (including both prescribed and over-the-counter drugs) is essential.

The brown bag technique is very helpful in this regard; have the patient or caregiver empty the patient's medicine cabinet into a brown paper bag and bring it at each visit. More often than not, one or more of these medications can, at least in theory, contribute to geriatric patient's symptoms.

A complete systems review, focusing on potentially important and prevalent symptoms in the elderly, can help overcome many of the difficulties described above. Although not intended to be all-inclusive, Table 3-3 lists several of these symptoms.

General symptoms can be especially difficult to interpret. Fatigue can result from a number of common conditions such as depression, congestive heart failure, anemia, and hypothyroidism. Anorexia and weight loss can be symptoms of an underlying malignancy, depression, or poorly fitting dentures and diminished

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taste sensation. Age-related changes in sleep patterns, anxiety, gastroesophageal reflux, congestive heart failure with orthopnea, or nocturia can underlie complaints of insomnia. Because many frail geriatric patients limit their activity, some important symptoms may be missed. For example, such patients may deny angina and dyspnea but restrict their activity to avoid the symptoms. Questions such as How far do you walk in a typical day? and What is the most activity you carry out in a typical day? can be helpful in patients suspected of limiting their activities to avoid certain symptoms.

THE PHYSICAL EXAMINATION

The common occurrence of multiple pathologic physical findings superimposed on age-related physical changes complicates interpretation of the physical examination. Table 3-4 lists common physical findings and their potential significance in the geriatric population.

TABLE 3-4 COMMON PHYSICAL FINDINGS AND THEIR POTENTIAL SIGNIFICANCE IN GERIATRICS

PHYSICAL FINDINGS	POTENTIAL SIGNIFICANCE
VITAL SIGNS
Elevated blood pressure	Increased risk for cardiovascular morbidity; therapy should be considered if repeated measurements are high (see Chap. 11)
Postural changes in blood pressure	May be asymptomatic and occur in the absence of volume depletion Aging changes, deconditioning, and drugs may play a role Can be exaggerated after meals Can be worsened and become symptomatic with antihypertensive, vasodilator, and tricyclic antidepressant therapy
Irregular pulse	Arrhythmias are relatively common in otherwise asymptomatic elderly; seldom need specific evaluation or treatment (see Chap. 11)
Tachypnea	Baseline rate should be accurately recorded to help assess future complaints (such as dyspnea) or conditions (such as pneumonia or heart failure)
Weight changes	Weight gain should prompt search for edema or ascites Gradual loss of small amounts of weight common; losses in excess of 5% of usual body weight over 12 months or less should prompt search of underlying disease
GENERAL APPEARANCE AND BEHAVIOR
Poor personal grooming and hygiene (e.g., poorly shaven, unkempt hair, soiled clothing)	Can be signs of poor overall function, caregiver neglect, and/or depression; often indicates a need for intervention
Slow thought processes and speech	Usually represents an aging change; Parkinson's disease and depression can also cause these signs
Ulcerations	Lower extremity vascular and neuropathic ulcers common Pressure ulcers common and easily overlooked in immobile patients
Diminished turgor	Often results from atrophy of subcutaneous tissues rather than volume depletion; when dehydration suspected, skin turgor over chest and abdomen most reliable
EARS (SEE CHAP. 13)
Diminished hearing	High-frequency hearing loss common; patients with difficulty hearing normal conversation or a whispered phrase next to the ear shouldbe evaluated further Portable audioscopes can be helpful in screening for impairment
EYES (SEE CHAP. 13)
Decreased visual acuity (often despite corrective lenses)	May have multiple causes, all patients should have thorough optometric or ophthalmologic examination Hemianopsia is easily overlooked and can usually be ruled out by simple confrontation testing
Cataracts and other abnormalities	Fundoscopic examination often difficult and limited; if retinal pathology suspected, thorough ophthalmologic examination necessary
MOUTH
Missing teeth	Dentures often present; they should be removed to check for evidence of poor fit and other pathology in oral cavity Area under the tongue is a common site for early malignancies
SKIN
Multiple lesions	Actinic keratoses and basal cell carcinomas common; most other lesions benign
CHEST
Abnormal lung sounds	Crackles can be heard in the absence of pulmonary disease and heart failure; often indicate atelectasis
CARDIOVASCULAR (SEE CHAP. 11)
Irregular rhythms	See vital signs, above
Systolic murmurs	Common and most often benign; clinical history and bedside maneuvers can help to differentiate those needing further evaluation Carotid bruits may need further evaluation
Vascular bruits	Femoral bruits often present in patients with symptomatic peripheral vascular disease
Diminished distal pulses	Presence or absence should be recorded as this information may be diagnostically useful at a later time (e.g., if symptoms of claudication or an embolism develop)
ABDOMEN
Prominent aortic pulsation	Suspected abdominal aneurysms should be evaluated by ultrasound
GENITOURINARY (SEE CHAP. 8)
Atrophy	Testicular atrophy normal; atrophic vaginal tissue may cause symptoms (such as dyspareunia and dysuria) and treatment may be beneficial
Pelvic prolapse (cystocele, rectocele)	Common and may be unrelated to symptoms; gynecologic evaluation helpful if patient has bothersome, potentially related symptoms
EXTREMITIES
Periarticular pain	Can result from a variety of causes and is not always the result of degenerative joint disease; each area of pain should be carefully evaluated and treated (see Chap. 10)
Limited range of motion	Often caused by pain resulting from active inflammation, scarring from old injury, or neurologic disease; if limitations impair function, a rehabilitation therapist could be consulted
Edema	Can result from venous insufficiency and/or heart failure; mild edema often a cosmetic problem; treatment necessary if impairing ambulation, contributing to nocturia, predisposing to skin breakdown, or causing discomfort Unilateral edema should prompt search for a proximal obstructive process
NEUROLOGIC
Abnormal mental status (i.e., confusion, depressed affect)	See Chaps. 6 and 7
Weakness	Arm drift may be the only sign of residual weakness from a stroke Proximal muscle weakness (e.g., inability to get out of chair) should be further evaluated; physical therapy may be appropriate

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An awareness of age-related physical changes is important to the interpretation of many physical findings and therefore subsequent decision making. For example, age-related changes in the skin and postural reflexes can influence the evaluation of hydration and volume status; age-related changes in the lung and lower-extremity edema secondary to venous insufficiency can complicate the evaluation of symptoms of heart failure.

Certain aspects of the physical examination are of particular importance in the geriatric population. Detection and further evaluation of impairments of vision and hearing can lead to improvements in quality of life. Evaluation of gait may uncover correctable causes of unsteadiness and thereby prevent potentially devastating falls (see Chap. 9). Careful palpation of the abdomen may reveal an aortic aneurysm, which, if large enough, might warrant consideration of surgical removal. The mental status examination is especially important; this aspect of the physical examination is discussed further below and in Chap. 6.

LABORATORY ASSESSMENT

Abnormal laboratory findings are often attributed to old age. While it is true that abnormal findings are common in geriatric patients, few are true aging changes. Misinterpretation of an abnormal laboratory value as an aging change may result in underdiagnosis and undertreatment of conditions such as anemia.

Table 3-5 lists those laboratory parameters unchanged in the elderly and those commonly abnormal. Abnormalities in the former group should prompt further evaluation; abnormalities in the latter group should be interpreted carefully. Table 3-5 also notes important considerations in interpreting commonly abnormal laboratory values.

TABLE 3-5 LABORATORY ASSESSMENT OF GERIATRIC PATIENTS

LABORATORY PARAMETERS UNCHANGED*
Hemoglobin and hematocrit White blood cell count Platelet count Electrolytes (sodium, potassium, chloride, bicarbonate) Blood urea nitrogen Liver function tests (transaminases, bilirubin, prothrombin time) Free thyroxine index Thyroid-stimulating hormone Calcium Phosphorus
COMMON ABNORMAL LABORATORY PARAMETERS
PARAMETER	CLINICAL SIGNIFICANCE
Sedimentation rate	Mild elevations (10 20 mm) may be an age-related change.
Glucose	Glucose tolerance decreases (see Chap. 12); elevations during acute illness are common.
Creatinine	Because lean body mass and daily endogenous creatinine production decline, high-normal and minimally elevated values may indicate substantially reduced renal function.
Albumin	Average values decline (<0.5 g/mL) with age, especially in acutely ill, but generally indicate undernutrition.
Alkaline phosphatase	Mild asymptomatic elevations common; liver and Paget's disease should be considered if moderately elevated.
Serum iron, iron- binding capacity, ferritin	Decreased values are not an aging change and usually indicate undernutrition and/or gastrointestinal blood loss.
Prostate-specific antigen	May be elevated in patients with benign prostatic hyerplasia. Marked elevation or increasing values when followed over time should prompt consideration of further evaluation in patients for whom specific therapy for prostate cancer would be undertaken if cancer were diagnosed.
Urinalysis	Asymptomatic pyuria and bacteriuria are common and rarely warrant treatment; hematuria is abnormal and needs further evaluation (see Chap. 8).
Chest radiographs	Interstitial changes are a common age-related finding; diffusely diminished bone density generally indicates advanced osteoporosis (see Chap. 12).
Electrocardiogram	ST-segment and T-wave changes, atrial and ventricular arrhythmias, and various blocks are common in asymptomatic elderly and may not need specific evaluation or treatment (see Chap. 11).
* Aging changes do not occur in these parameters; abnormal values should prompt further evaluation.
Includes normal aging and other age-related changes.

FUNCTIONAL ASSESSMENT

General Concepts

Ability to function should be a central focus of the evaluation of geriatric patients (see Fig. 3-1). Medical history, physical examination, and laboratory findings are all of obvious importance in diagnosing and managing acute and chronic medical conditions in older people, as they are in all age groups. But once the dust settles, functional abilities are just as, if not more, important to the overall health, well being, and potential need for services of older individuals. For example, in a patient with hemiparesis, the nature, location, and extent of the lesion may be important in the management, but whether the patient is continent and can climb the steps to an apartment makes the difference between going home to live or going to a nursing home.

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The concern about function as a core component of geriatrics deserves special comment. Functioning is the end result of the various efforts of the geriatric approach to care. Optimizing function necessitates integrating efforts on several fronts. It is helpful to think of functioning as an equation:

This admitted oversimplification is meant as a reminder that function can be influenced on at least three levels. The clinician's first task is to remediate the

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remediable. Careful medical diagnosis and appropriate treatment are essential in good geriatric care. Adequate medical management, however, is necessary but not sufficient. Once those conditions amenable to treatment have been addressed, the next step is to develop the environment that will best support the patient's autonomous function.

Environmental barriers can be both physical and psychological. It is easier to recognize the physical barriers: stairs for the person with dyspnea, inaccessible cabinets for the wheelchair-bound, and so on. Psychological barriers refer especially to the dangers of risk aversion. Those most concerned about the patient may restrict activity in the name of protecting the patient or the institution. For example, hospitals are notoriously averse to risk; older patients will be restricted to a wheelchair rather than risk them falling when walking.

This risk-averse behavior may be compounded by concerns about efficiency. Personal care is personnel intensive. It takes much more time and patience to work with patients to encourage them to do things for themselves than to step in and do the task. But that pseudoefficiency breeds dependence.

The third factor relates to the concept of motivation. If the care providers believe that the patient cannot improve, they will likely induce despair and discouragement in their charges. The tendency toward functional decline may become a self-fulfilling prophecy. Indeed, the opposite belief that improvement is quite likely with appropriate intervention may be the critical element in the success of geriatric evaluation units. Belief in the possibility of improvement can play another critical role in geriatric care. Psychologists have developed a useful paradigm referred to as the innocent victim. The basic concept is that caregivers respond in a hostile manner to those they feel impotent to help. If given a sense of empowerment, perhaps by using assessment tools and intervention strategies such as the ones provided in this book, for approaching the complex problems of older persons, care providers are likely to feel more positive toward those individuals and be more willing to work with them rather than avoiding them. The more an information system can provide feedback on accomplishments and progress toward improved function, the more the provider will feel positively about the older patient.

Table 3-6 summarizes several other important concepts about comprehensive functional assessment in the geriatric population, which were identified in a Consensus Development Conference at the National Institutes of Health (NIH, 1988). To a large extent the purpose, setting, and timing of the assessment dictate the nature of the assessment process. Table 3-7 lists the different purposes and objectives of functional status measures. Generally, functional assessment begins with a case-finding or screening approach in order to identify individuals for whom more in-depth and interdisciplinary assessment might be of benefit. Assessment is often carried out at points of transition, such as a threatened or actual decline in health status or impending change in living situation. Without this type of targeting, the assessment of older people may be time-consuming and

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not cost-effective. Numerous standardized instruments are available to assist in the assessment process.

TABLE 3-6 IMPORTANT CONCEPTS FOR GERIATRIC FUNCTIONAL ASSESSMENT

The nature of the assessment should be dictated by its purpose, setting, and timing (see Table 3-7).
Input from multiple disciplines is often helpful, but routine multidisciplinary assessment is not cost-effective.
Assessments should be targeted:
1. Initial screening to identify disciplines needed.
2. Times of threatened or actual decline in status, impending change in living situation, and other stressful situations.
Standard instruments are useful, but there are numerous potential pitfalls:
1. Instruments should be reliable, sensitive, and valid for the purposes and setting of the assessment.
2. How questions are asked can be critically important (e.g., performance vs. capability).
3. Discrepancies can arise between different informants (e.g., self-report vs. caregiver's report).
4. Self- or caregiver report of performance, or direct observation of performance may not reflect what the individual does in everyday life.
5. Many standard instruments have not been adequately tested for reliability and sensitivity to changes over time.
Open-ended questions are helpful in complementing information from standardized instruments.
The family's expectations, capabilities, and willingness to provide care must be explored.
The patient's preferences and expectations should be elicited and considered paramount in planning services.
A strong link must exist between the assessment process and follow-up in the provision of services.

TABLE 3-7 PURPOSES AND OBJECTIVES OF FUNCTIONAL STATUS MEASURES

PURPOSE	OBJECTIVES
Description	Develop normative data
	Depict geriatric population along selected parameters
	Assess needs
	Describe outcomes associated with various interventions
Screening	Identify from among population at risk those individuals who should receive further assessment and by whom
Assessment	Make diagnosis
Assessment	Assign treatment
Monitoring	Observe changes in untreated conditions
Monitoring	Review progress of those receiving treatment
Prediction	Permit scientifically based clinical interventions
Prediction	Make prognostic statements of expected outcomes on the basis of given conditions

There are numerous potential pitfalls in the use of standardized assessment instruments (Kane and Kane, 2000; see Table 3-6). The critical concept in using standardized instruments is that they should fit the purposes and setting for which they are intended, and there must be a solid link between the assessment process and the follow-up provision of services. In addition, the assessment process

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should include a clear discussion of the patient's preferences and expectations, as well as the family's expectations and willingness to provide care. The importance of functional status assessment has been highlighted by data documenting the ability of functional status measures to predict mortality in older hospitalized patients (Inouye et al., 1998).

Assessment Tools for Functional Status

This chapter focuses on the assessment of physical and mental function. Mental function is also discussed in Chap. 6. Table 3-8 lists examples of measures of physical functioning. Physical functioning is measured along a spectrum. For disabled persons, one may focus on the ability to perform basic self-care tasks, often referred to as activities of daily living (ADL). The patient is assessed on ability to conduct each of a series of basic activities. Data usually come from the patient or from a caregiver (e.g., a nurse or family member) who has had a sufficient opportunity to observe the patient. In some cases, it may be more useful to have the patient actually demonstrate the ability to perform key tasks. Grading of performance is usually divided into three levels of dependency: (1) ability to perform the task without human assistance (one may wish to distinguish

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those persons who need mechanical aids like a walker but are still independent); (2) ability to perform the task with some human assistance; and (3) inability to perform, even with assistance. Distinguishing independent without difficulty from independent with difficulty may provide complementing prognostic information (Gill et al., 1998).

TABLE 3-8 EXAMPLES OF MEASURES OF PHYSICAL FUNCTIONING

Basic activities of daily living (ADL)
   Feeding
   Dressing
   Ambulation
   Toileting
   Bathing
   Transfer (from bed and toilet)
   Continence
   Grooming
   Communication
Instrumental activities of daily living (IADL)
   Writing
   Reading
   Cooking
   Cleaning
   Shopping
   Doing laundry
   Climbing stairs
   Using telephone
   Managing medication
   Managing money
   Ability to perform paid employment duties or outside work (e.g., gardening)
   Ability to travel (use public transportation, go out of town)

Commonly used tools for assessing physical function are included in the Appendix. There may be discrepancies between patient or caregiver reports and what the individuals actually do in their everyday life. Moreover, there may be differences between reported physical functional status and actual measures of physical performance. Reuben's Physical Performance Test is one example of a practical assessment that provides insights into actual performance and prognostic information (Reuben et al., 1992). (The Physical Performance Test is included in the Appendix.) Other performance-based assessments of gait and balance are discussed in Chap. 9.

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In addition to these general geriatric measures of functional status, other functional assessment tools are commonly used in different settings. Examples include the following:

The Short Form 36 a global measure of function and well-being that is increasingly being used in outpatient settings. This measure has a disadvantage in the frail geriatric population because of a ceiling effect that is, it does not distinguish well between sick and very sick older people.
The Minimum Data Set (MDS) a comprehensive assessment mandated on admission with quarterly updates in Medicare/Medicaid certified nursing facilities.
The Functional Independence Measure (FIM) a detailed assessment tool commonly used to monitor functional status progress in rehabilitation settings.

A structured assessment of cognitive function should be part of every complete geriatric functional assessment. Because of the high prevalence of cognitive impairment, the potential impact of such impairment on overall function and safety and the ability of patients with early impairments to mask their deficits, clinicians must specifically attend to this aspect of functional assessment. At a minimum, assessment should include a test for orientation and memory. A standardized geriatric mental status test is included in the Appendix (the Folstein Mini-Mental State Examination). Although these tests do not probe the variety of intellectual functions appropriate for a more detailed assessment, they are quick, easy, scorable, and reliable. More detailed assessment of cognitive function is discussed in Chap. 6.

ENVIRONMENTAL ASSESSMENT

We emphasized earlier that patient function is the result of innate ability and environment. The clinician must, therefore, be particularly concerned with the older patient's environment. For many patients, an assessment should include an evaluation of the available and potential resources to maintain functioning. Just as physicians comfortably prescribe drugs, they should also be prepared to prescribe environmental interventions when necessary.

Rehabilitation therapists (i.e., physical, occupational, speech) are especially skilled at functional assessment, developing and implementing rehabilitative plans of care targeted at potentially remediable functional impairments, and making specific recommendations about environmental modifications that can enhance safety and functional ability. An environmental prescription may include alterations in the physical environment (e.g., ramps, grab bars, and elevated toilet seats), special services (e.g., meals on wheels, homemaking, home nursing), increased social contact (e.g., friendly visiting, telephone reassurance, participation in recreational activities), or provision of critical elements (e.g., food or money).

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The ability to identify the environmental interventions and function supports needed to maintain in the community may be the essential difference between enabling an older person to remain at home versus transferring that person to an institution. Although identifying the need is not tantamount to providing the resource, it is an important first step.

ASSESSMENT FOR PAIN

Recent guidelines published by the American Geriatrics Society recommend that on initial presentation or admission of an older person to any healthcare service, the patient should be assessed for evidence of persistent pain (AGS Panel on Persistent Pain in Older Persons, 2002). Patients with persistent pain that may affect physical function, psychosocial function, or other aspect of quality of life should undergo a comprehensive pain assessment. Tables 3-9 and 3-10 list important aspects of the history and physical examination in assessment of pain, respectively. For patients who are cognitively intact assessment of pain should be by direct questioning of the patient. Quantitative assessment of pain should be recorded by use of a standard pain scale. A verbal scale of zero to ten, with zero meaning no pain and ten meaning the worst pain possible, is frequently used. Other scales, pain thermometer and faces, studied in older populations, are illustrated in Figure 3-2. In cognitively impaired and nonverbal patients pain assessment should be by direct observation or history from caregivers. Patients should be observed for pain-related behaviors during movement. Unusual behavior in a patient with severe dementia should trigger assessment for pain as a potential cause.

TABLE 3-9 IMPORTANT ASPECTS OF THE HISTORY IN ASSESSMENT OF PAIN

Characteristics of the pain
Relation of pain to impairments in physical and social function
Analgesic history (present, previous, prescribed, over-the-counter,
alternative remedies, alcohol use, side effects)
Patient's attitudes and beliefs about pain and its management
Effectiveness of treatments
Satisfaction with current pain management
Social support and health care accessibility

TABLE 3-10 IMPORTANT ASPECTS OF THE PHYSICAL EXAMINATION IN ASSESSMENT OF PAIN

Careful examination of the site of pain, and common sites for pain referral
Focus on the musculoskeletal system
Focus on the neurological system including weakness and dysesthesia
Observation of physical function
Psychological function
Cognitive function

FIGURE 3-2 Samples of two pain intensity scales that have been studied in older persons. Directions: Patients should view the figure without numbers. After the patient indicates the best representation of their pain, the appropriate numerical value can be assigned to facilitate clinical documentation and follow-up. (From AGS Panel, 2002)

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NUTRITIONAL ASSESSMENT

Several parameters are used in assessing nutritional status in older adults. Some anthropometric variables are probably effective estimators of major aspects of body composition (Table 3-11). They cannot provide a complete description of the nutritional status of an individual and are not highly correlated with biochemical or hematologic indicators of nutritional status.

TABLE 3-11 ASSESSMENT OF BODY COMPOSITION

ASSESSMENT	COMPONENT
Weight	Global
Body mass index	Total fat
Skin fold	Percent fat
Waist:hip ratio	Central adiposity
Upper arm circumference	Lean body mass

Although weight is a global measure, it can be obtained easily from adults and is useful in the absence of edema. Body mass index (BMI = kg/m²) is best correlated with total body fat. Triceps and subscapular skin folds are highly correlated with the percentage of body fat in older adults. Waist:hip ratio is a parameter of central adiposity. Upper arm circumference is correlated with lean body mass and may be particularly helpful in edematous patients in whom weight is misleading. The effect of the aging process on lean body mass is so great that it remains a poor reflection of nutritional status in older adults.

Serum albumin is a practical indicator of malnutrition in older adults. However, liver disease, proteinuria, and protein-losing enteropathies must be excluded. A low serum albumin may be indicative of malnutrition, but a normal or increased serum albumin concentration does not necessarily indicate normality. Thyroxine-binding prealbumin and/or retinol-binding protein are more sensitive indices than are albumin and transferrin.

In animals, dietary deprivation of protein results in anemia. Because anemia is one of the earliest manifestations of protein-calorie malnutrition, its presence should alert the physician to the possibility of malnutrition. Total lymphocyte count may be a very good marker for nutritional problems.

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Some important factors need to be considered in evaluating a given patient. Table 3-12 presents some factors that put older patients at risk for malnutrition. Individuals with such problems should have an evaluation of nutritional status. Some patients may have several concurrent diseases that impair nutritional status (Table 3-13). Protein-energy malnutrition may ensue and is associated with poor prognosis. The Mini Nutritional Assessment (MNA) and Subjective Global Assessment (SGA) predict mortality in geriatric patients (Persson et al., 2002), and are valuable tools for the assessment of nutritional status in older adults. The Short-Form Mini Nutritional Assessment (MNA-SF) can be used in a two step screening process in which persons identified as at risk on the MNA-SF would receive additional assessment (Rubenstein et al., 2001; Table 3-14). The MNA

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(Guigoz et al., 1996) may be advantageous for the latter since it classified fewer patients than the SGA as well-nourished and those identified as well-nourished on the MNA had a better 3 year survival than those well-nourished by the SGA (Persson et al., 2002).

TABLE 3-12 CRITICAL QUESTIONS IN ASSESSING A PATIENT FOR MALNUTRITION

Is there any reason to suspect malnutrition?
If so, of which nutrient(s) and to what extent?
What are the pathophysiological mechanisms (e.g., alteration in nutrient
intake, digestion and absorption, metabolism, excretion, or requirements)?
What etiology underlies the pathophysiological mechanism(s)?

TABLE 3-13 FACTORS THAT PLACE OLDER ADULTS AT RISK FOR MALNUTRITION

Drugs (e.g., reserpine, digoxin, antitumor agents)
Chronic disease (e.g., congestive heart failure, renal insufficiency, chronic gastrointestinal disease)
Depression
Dental and periodontal disease
Decreased taste and smell
Low socioeconomic level
Physical weakness
Isolation
Food fads

TABLE 3-14 MINI NUTRITION ASSESSMENT

GERIATRIC CONSULTATION

Geriatric consultation may be requested to address specific clinical issues (e.g., confusion, incontinence, recurrent falling), to perform a comprehensive geriatric assessment (often in the context of determining the need for placement in a difficult living setting), or to perform a preoperative evaluation of a high-risk geriatric patient. In this chapter, we discuss the latter two types of consultation.

Comprehensive Geriatric Consultation

A comprehensive geriatric consultation includes the following:

A geriatric-oriented history and physical examination attending to the issues reviewed earlier in this chapter.
Medication review; in addition, geriatric patients should be questioned about alcohol abuse.
Functional assessment.
Environmental and social assessment, focusing especially on caregiver support and other resources available to meet the patient's needs.
Discussion of advance directives.
A complete list of the patient's medical, functional, and psychosocial problems.
Specific recommendations in each domain.

A systematic screening process to identify potentially remediable geriatric problems may be a useful tool for the comprehensive consultation.

One such screening strategy is illustrated in Table 3-15 (Moore and Siu, 1996). It may also be useful, especially in capitated systems, to use a tool that identifies risk for crises and expensive health care utilization. The Pra instrument is one such tool (Table 3-16; Pacala et al., 1997). Among frail, dependent, geriatric patients, screening for risk factors and elder abuse is important. Elder abuse is more common among older people who are in poor health and who are physically and cognitively impaired. Additional risk factors include shared living arrangements with a relative or friend suspected of alcohol or substance abuse, mental illness, or a history of violence.

TABLE 3-15 EXAMPLE OF A SCREENING TOOL TO IDENTIFY POTENTIALLY REMEDIABLE GERIATRIC PROBLEMS

PROBLEM	SCREENING MEASURE	POSITIVE RESULT
Poor vision	Ask, Do you have difficulty driving, watching television, reading, or doing any of your daily activities because of your eyesight? If yes, then test acuity with Snellen chart, with corrective lenses	Inability to read better than 20/40 on Snellen chart
Poor hearing	With audioscope set at 40 dB, test hearing at 1000 and 2000 Hz	Inability to hear 1000 or 2000 Hz in both ears or either frequency in one ear
Poor leg mobility	Time the patient after asking, Rise from the chair. Walk 20 feet briskly, turn, walk back to the chair, and sit down.	Unable to complete task in 15 s
Urinary incontinence	Ask, In the past year, have you ever lost your urine and gotten wet? If yes, then ask, Have you lost urine on at least 6 separate days?	Yes to both questions
Malnutrition and weight loss	Ask, Have you lost 10 pounds over the past 6 months without trying to do so? and then weigh the patient	Yes to the question or weight <100 lb
Memory loss	Three-item recall	Unable to remember all three items after 1 min
Depression	Ask, Do you often feel sad or depressed?	Yes to the question
Physical disability	Ask six questions: Are you able to: Do strenuous activities such as fast walking or bicycling? Do heavy work around the house like washing windows, walls, or floors? Go shopping for groceries or clothes? Get to places that are out of walking distance? Bathe: either a sponge bath, tub bath, or shower? Dress, including putting on a shirt, buttoning and zipping, and putting on shoes?	No to any question
Source: From Moore and Siu, 1996, with permission.

TABLE 3-16 QUESTIONS ON THE PRA INSTRUMENT FOR IDENTIFYING GERIATRIC PATIENTS AT RISK FOR HEALTH SERVICE USE

In general, would you say your health is:
(excellent; very good; good; fair; poor)
In the previous 12 months, have you stayed overnight as a patient in a hospital?
(not at all; one time; two or three times; more than three times)
In the previous 12 months, how many times did you visit a physician or clinic?
(not at all; one time; two or three times; four to six times; more than six times)
In the previous 12 months, did you have diabetes?
(yes; no)
Have you ever had: Coronary heart disease? (yes; no)
                             Angina pectoris? (yes; no)
                             A myocardial infarction? (yes; no)
                             Any other heart attack? (yes; no)
Your sex?
(male; female)
Is there a friend, relative, or neighbor who would take care of you for a few days if necessary?
(yes; no)
Your date of birth?
(month ;day ;year )

Frequent emergency room visits for injury or exacerbations of chronic illness should also raise suspicion for abuse. Table 3-17 illustrates an example of an

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effective format for documenting the results of the consultation, listing the problems and recommendations first.

TABLE 3-17 SUGGESTED FORMAT FOR SUMMARIZING THE RESULTS OF A COMPREHENSIVE GERIATRIC CONSULTATION

Identifying data, including referring physician
Reason(s) for consultation
Problems
1. Medical Problem List
2. Functional Problem List
3. Psychosocial Problem List
Recommendations
Standard documentation
1. History, including medications, significant past medical and surgical history, system review
2. Social and environmental information
3. Functional assessment
4. Advance directive status
5. Physical exam
6. Laboratory and other test data

PREOPERATIVE EVALUATION

Geriatricians are often called upon by surgeons and anesthesiologists to assess elderly patients before surgical procedures. Table 3-18 lists several of the key factors involved in the preoperative evaluation of geriatric patients. Although older patients (age >70 years) have higher rates of major perioperative complications and mortality after nonemergent major noncardiac surgical procedures than do younger patients, mortality is low, even in patients 80 years of age or older (Polanczyk et al., 2001). Morbidity and mortality, however, are influenced to a greater extent by the presence and severity of systemic illnesses and whether the procedure is elective versus emergent. Thus, evaluating a geriatric

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patient's preoperative status and risk for surgery necessitates a thorough assessment of cardiopulmonary and renal function as well as nutritional and hydration status. Factors that increase the risk of perioperative cardiac complications in patients undergoing noncardiac surgery include ischemic heart disease, congestive heart failure, diabetes mellitus, and renal insufficiency (Lee et al., 1999). Patients with a recent history of myocardial infarction, active angina, pulmonary edema, and severe aortic stenosis are at especially high risk (Mangano and Goldman, 1995). Preoperative pulmonary function tests and arterial blood gases are rarely of prognostic value. Assessment of exercise tolerance may be helpful, for example, the ability to climb one flight of stairs. In patients with low

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risk for cardiac complications, no beta-blockade is necessary. In patients at increased risk for cardiac complications, modified exercise testing, dipyridamole thallium scanning, or dobutamine echocardiography may be indicated (Palda and Detsky, 1997). Coronary artery bypass grafting or percutaneous coronary revascularization should be limited to patients who have a clearly defined need for the procedure that is independent of the need for noncardiac surgery (Fleisher and Eagle, 2001).

TABLE 3-18 KEY FACTORS IN THE PREOPERATIVE EVALUATION OF THE GERIATRIC PATIENT

Age >70 is associated with an increased risk of complications and death
1. Risk varies with the type of procedure and local complication rates
2. Emergency procedures are associated with much higher risk
3. Comorbid conditions, especially cardiovascular, are more important risk factors than age per se
The appropriateness and risk-benefit ratio of the proposed surgery must be carefully considered
Underlying conditions must be evaluated and optimally managed before nonemergency surgery, e.g.:
1. Cardiovascular disease, especially heart failure
2. Pulmonary status
3. Renal function
4. Diabetes mellitus
5. Thyroid disease (which is often occult)
6. Anemia
7. Nutrition
8. Hydration and volume status, especially in patients on diuretics
Medication regimens should be carefully planned; some drugs should be continued, others should be withheld, and some necessitate dosage adjustments
Several cardiovascular conditions substantially increase risk, including:
1. Myocardial infarction within 6 months
2. Pulmonary edema
3. Angina (especially if unstable)
4. Severe aortic stenosis
Specific laboratory evaluations may be helpful in some situations, e.g.:
1. Pulmonary function tests and arterial blood gas with respiratory symptoms, obesity, chest deformity (e.g., kyphoscoliosis), abnormal chest radiographs, planned thoracic or upper abdominal procedure
2. Noninvasive cardiac testing in high and intermediate risk for cardiac event patients
3. Creatinine clearance with unstable or borderline renal function, or the use of nephrotoxic or renally excreted drugs
The documented effectiveness, risks, and benefits of perioperative prophylactic measures should be considered:
1. Beta-blocker administration*
2. Antithrombotic prophylaxis
3. Antimicrobial prophylaxis

* See Fleisher and Eagle, 2001.

See Geerts et al., 2001.

See Medical Letter, 1999.

Underlying conditions that are prevalent in the geriatric population, such as hypertension, congestive heart failure, chronic obstructive lung disease, diabetes mellitus, anemia, and undernutrition, need particularly careful management in the preoperative period (Thomas and Ritchie, 1995; Schiff and Emanuele, 1995). Medication regimens should be scrutinized in order to determine whether specific drugs should be continued or withheld. Results from several well-designed clinical trials suggest that use of beta-blockers perioperatively is associated with significant reductions in cardiac morbidity and mortality (Auerbach and Goldman, 2002). High and intermediate cardiac event risk patients with negative noninvasive test results should begin beta-blockade therapy. Those with positive noninvasive test results should have consideration of additional therapies to reduce risk, for example, coronary revascularization. Careful consideration should also be given to perioperative prophylactic measures for the prevention of thromboembolism and infection, many of which have documented efficacy in specific situations (Medical Letter, 1999; Geerts et al., 2001).

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Many surgeons and anesthesiologists tend to favor regional over general anesthesia for geriatric patients. Regional anesthesia (e.g., epidural), however, may have several potential disadvantages. Patients may require added intravenous sedation and/or analgesia, thus increasing the risks of perioperative cardiovascular and mental status changes. Significant cardiovascular changes can, in fact, occur during regional anesthesia; thus invasive monitoring may be required in some patients. Neither the incidence of deep vein thrombosis nor the amount of blood loss seems to be substantially decreased compared to general anesthesia. Thus, decisions about the type of anesthesia should be carefully individualized on the basis of patient factors, the nature of the procedure, and the preferences of the surgical team.

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