Geriatric Assessment Principles

• Principles of Geriatric Assessment One was presented by Renee Levy, DHS(c), MMS, PA-C in Spring 2025.

Objectives

• Identify common physical examination requirements for the geriatric population
• Understand techniques for approaching geriatric patients and caregivers
• Know key physical examination findings specific to this age group
• Apply knowledge of geriatric findings and abnormalities during examination
• Recognize social determinants of health impacting patient outcomes
• Develop cultural awareness
• Collaborate with the patient's healthcare team for comprehensive care

Topics Covered

• Overview of Assessment
• Interprofessional Team
• Goals of Care
• Functional Assessment/Decline
• Falls
• Vision and Hearing
• Addressing Multimorbidity
• Atypical Presentations of Illness
• Prevention & Health Promotion
• Defining Adequate Nutrition

Overview of Assessment

• Clinical approach to older patients
• Goes beyond traditional medical history and physical exam

Assessment

• It is for patients typically 65 years of age and older
• Three main outcomes of geriatric assessment: prognosis, goals of care, and functional status
• Assessment tools are determined by the setting and the patient's functional level
• Outpatient teams concentrate on higher functioning levels, mobility, and meal preparation
• Long-term care settings focus on ADLs, medical support, rehab potential, and discharge planning

Activities of Daily Living (ADL)

• Ambulating: Ability to move and walk independently
• Feeding: Ability to feed oneself
• Dressing: Ability to select and put on clothes
• Personal Hygiene: Ability to bathe, groom, and maintain dental, nail, and hair care
• Continence: Ability to control bladder and bowel function
• Toileting: Ability to use the toilet appropriately and clean oneself

Independent Activities (Instruments) of Daily Living (IADL)

• Transportation and shopping: Ability to procure groceries, attend events, and manage transportation
• Managing finances: Ability to pay bills and manage financial assets
• Shopping and meal preparation: Ability to get a meal on the table and shop for clothing
• Housecleaning and home maintenance: Ability to maintain a clean and tidy living area
• Managing communication: Ability to manage telephone and mail
• Managing medications: Ability to obtain and take medications as directed

ADLs vs IADLs

• IADLs differ from ADLs because assistance is usually required when tasks become difficult to manage independently

Interprofessional Team

• Multiple professions collaborate to develop a single, comprehensive treatment plan for a patient

Multidisciplinary Teams

• Most commonly seen in inpatient and rehabilitation units; also PACE sites and long-term facilities
• In outpatient settings, teams are less formal and often virtual

Goals of Care

• Critical tools for all clinicians caring for older adults

Patient Goals

• Understanding patient values and their preferences is critical
• Involves compromise and trade-offs
• Maintaining independence or relieving pain may be more important than prolonging life
• Surrogate decision maker is advised
• Advance directives for healthcare and finances are of utmost importance

Functional Assessment/Decline

• Measures the overall impact of health conditions

Functional Status

• Includes physical and psychosocial environment, and the ability to perform ADLs
• Important for planning care, monitoring therapy responses, and determining prognosis
• Should be assessed initially and periodically
• Elements include patient's health, medical, cognitive, psychological, and social barriers, and communication
• Geriatric assessment is influenced by the clinical site of care

Falls

• Evaluating fall risk is vital
• Leading cause of nonfatal injuries and death in geriatrics
• Risk factors: visual impairment, medications, home safety
• Timed Up and Go: Measures ability to get up from a chair, walk 3 meters, return, and sit down
  • Normal completion is under 10 seconds; abnormal is over 20 seconds

Vision and Hearing

• Vision and hearing screening are of utmost importance

Vision

• Cataracts and age-related macular degeneration are common vision problems
• Glaucoma and the need for corrective lenses is also common
• Presbyopia, or impaired vision as a result of aging, is common
• Annual ophthalmology visits are recommended
• Questions to ask: trouble driving, watching TV, reading, or performing ADLs?
• Presbyopia involves trouble reading fine print and is a universal eye change beginning in the 40s

Hearing

• Loss of acuity for high-range sounds is possible
• 33% of adults over 65 and 50% of those over 85 have deficits
• Associated with social/emotional isolation, depression, cognitive decline, and limited activity
• Hearing Handicap Inventory for Elderly-Screening is recommended

Addressing Multimorbidity

• It involves the presence of two or more chronic co-occurring conditions
• Associated with negative health outcomes and accelerated functional decline
• It Increases symptom burden, Reduces quality of life, and causes mortality and increases cost of care
• Often excluded from randomized clinical trials
• Treatment may not consider co-occurring conditions causing special management challenges with complicated treatment regimens
• Time constraints leave one feeling inadequate to care for complexities and reimbursements do not reflect the complexity

Atypical Presentations of Illness

• Prevalence increases with age
• Risks include increasing age (over 85), multimorbidity, polypharmacy, cognitive impairment, and residing in a care institution
• Examples include dehydration, acute abdomen, infection, cardiovascular disease, depression, UTI, pneumonia, hyperthyroidism, and gout

Atypical Presentation: Dehydration

• May present as delirium or mobility disorders

Atypical Presentation: Acute Abdomen

• Consisting of silent, constipation, and tachypnea

Atypical Presentation: Infection

• Symptoms may be a change in functional status or menta status

Atypical Presentation: Cardiovascular disease

• New onset fatigue, dizziness, confusion

Atypical Presentation: Depression

• Symptoms may be anxiety, diminished self-care, loss of appetite, and altered loss of cognition

Atypical Presentation: UTI

• Sepsis with bandemia or leukopenia, abdominal pain

Atypical Presentation: Pneumonia

• Sepsis with bandemia or leukopenia, abdominal pain

Atypical Presentation: Hyperthyroidism

• Symptoms may be fatigue, confusion, and agitation

Atypical Presentation: Gout

• Symptoms include polyarticular, fever

Prevention & Health Promotion

• Preventive interventions can limit disease and disability
• Tailor prevention interventions to each individual
• Balance benefits and harms with patient’s life expectancy and values
• Avoid one-size-fits-all approaches
• Lead to improved health outcomes by reduced morbidity and mortality
• The Framework for prevention is anchored by weighing potential harms with expected time for potential benefits
• It can be controversial and practice specific
• The American Geriatric Society provides several guidelines

Prevention and Screening

• Falls
• Depression
• Vision and Hearing
• Cognitive Impairment
• Elder Abuse
• Exercise/Nutrition
• Substance Abuse
• Sexual Health
• Sleep
• Immunizations
• Diabetes
• Osteoporosis
• Hyperlipidemia
• Hypertension
• Abdominal Aortic Aneurysm
• Aspiring use
• Breast Cancer
  • Breast
  • Colorectal
  • Cervical
  • Prostate
  • Lung

Health Promotion

• Screening for common geriatric conditions plays a key role
• Screenings include Falls, Depression, Nutrition, Vision/Hearing, Cognitive Impairment and Elder Abuse
• Healthy living encouraged with Immunizations, Exercise, Sexual health, and Sleep
• Minimizing substance abuse is important

Defining Adequate Nutrition

• Nutritional needs change with aging, obesity, and malnutrition

Nutrition

• A BMI below 19 is associated with increased mortality rates
• 35-65% of hospitalized geriatric patients suffer from malnutrition
• 60% of geriatric residents in institutions suffer from malnutrition
• Daily energy requirements decline with age, resulting in decreased muscle mass and physical activity
• Recommended dietary allowances of vitamins and minerals are similar to middle age; increase calcium and vitamin D.
• Fat intake should not exceed 30% of total calories; fat provides the most calories per gram
• Recommended diets for geriatric patients include Mediterranean, DASH (Dietary Approaches to Stop Hypertension), and high fiber diets

Malnutrition

• It has adverse effects of unintentional weight loss like Functional decline and an Increase in mortality rate
• Increased risk for Hospitalizations, Pressure ulcers, Postural hypotension, Poor wound healing, Cognitive decline and Infection
• Potential causes include Medical, Psychosocial and Pharmacologic factors
• Undiagnosed cancer makes up to to 16%-36% of unintentional weight loss

Obesity

• BMI > 35; BMI of 30-35 may apply
• 27.6% of women and 28.4% of men over 65 are considered Obese
• 36.5% of the black population is considered Obese, compared to 35.3% of the American Indian population, and 32.8% of the Hispanic population
• Factors associated with increased risk are: HTN, Dyslipidemia, Diabetes mellitus, Coronary artery disease, Stroke, Osteoarthritis, Sleep apnea, Cancer etc

Obesity - Weight Loss

• Requires a combination of diet and exercise
• Weight loss medication is also an option
• A BMI over 40 is associated with higher mortality rates

Social Determinants of Health - Questions for Patient or Caregiver

• How are you going to pay for this?
• How will you be able to take care of yourself?
• How will you get the prescription?
• Will you be able to go to bathe, cook, perform self-care tomorrow?
• Is it difficult for you to come back in 2 weeks?
• Are you going to be able to carry out our plan????