Geriatric Assessment: Principles and Objectives

Objectives of Geriatric Assessment

• Identify common physical examination requirements associated with the geriatric population
• Understand techniques to approach geriatric patients and caregivers
• Know key physical examination findings in the geriatric age group
• Recognize and apply knowledge of specific geriatric findings/abnormalities during physical examinations
• Recognize social determinants of health and how they can impact patient health outcomes
• Develop cultural awareness when treating geriatric patients
• Collaborate within the patient’s healthcare team for psychological testing, physical/occupational/speech therapy, etc.

Principles of Geriatric Assessment

• 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

• Geriatric assessment is a clinical approach to older patients that goes beyond a traditional medical history and physical exam

Assessment Outcomes

• Three main outcomes of geriatric assessment: prognosis, goals of care, and functional status
• The assessment tools used are determined by the setting and functional level of the patient population
• Outpatient teams focus on higher levels of functioning, mobility, and meal preparation
• Long-term care settings focus on ADLs, providing medical support, assessing rehab potential, and discharge planning

Activities of Daily Living (ADL)

• Ambulating: Ability to move from one position to another and walk independently
• Feeding: Ability to feed oneself
• Dressing: Ability to select appropriate clothes and put them on
• Personal hygiene: Ability to bathe and groom oneself, maintain dental, nail, and hair care
• Continence: Ability to control bladder and bowel function
• Toileting: Ability to get to and from the toilet, use it appropriately, and clean oneself

Independent Activities (Instruments) of Daily Living (IADL)

• Transportation and shopping: Procuring groceries, attending events, and managing transportation
• Managing finances: Paying bills and managing financial assets
• Shopping and meal preparation: Everything required to get a meal, including shopping for clothing
• Housecleaning and home maintenance: Cleaning kitchens, maintaining living areas, and home maintenance.
• Managing communication with others: Managing telephone and mail
• Managing medications: Obtaining and taking medications as directed

ADLs vs IADLs

• IADLs differ from ADLs, as people often seek outside assistance when IADL tasks become difficult to manage

Interprofessional Team

• Involves multiple professions working together to develop a single, comprehensive treatment plan for a patient

Multidisciplinary Teams

• Most commonly seen in inpatient units, rehabilitation units, Programs for All-Inclusive Care for the Elderly (PACE) sites, and long-term facilities
• In outpatient settings, they are likely less formal and virtual

Patient Goals

• Goals of care are critical tools for clinicians caring for older adults
• Understanding patients’ values and preferences is essential
• Consider compromise and trade-offs in treatment plans
• Maintaining independence or relieving pain may be more important than prolonging life
• Surrogate decision-makers may be advised and advance healthcare and financial directives are of utmost importance

Functional Assessment/Decline

• This is a summary to measure the overall impact of health conditions
• Includes physical and psychosocial environments and the ability to perform ADLs

Functional Status

• Important for planning care, monitoring responses to therapy, and determining prognosis
• Includes elements of the patient's health, medical/cognitive/psychological/social barriers, and communication barriers
• Geriatric assessment is often influenced by the clinical site of care

Falls

• Falls risk should be evaluated
• Falls are a leading cause of nonfatal injuries and death in geriatrics
• Risk factors include visual impairment, medications, and home safety
• The Timed Up and Go test measures the ability to get up from a chair, walk 3 meters, return, and sit down
• Normal score: Completing the task in less than 10 seconds; Abnormal score: Greater than 20 seconds

Vision and Hearing

• Vision and hearing screenings are of utmost importance

Vision

• Common issues include cataracts, age-related macular degeneration, and glaucoma
• Patients may need corrective lenses for presbyopia
• Annual ophthalmology visits are recommended
• Important interview questions: Do you have trouble driving, watching TV, reading, or performing ADLs?
• Presbyopia involves trouble reading fine print and is a universal eye change that begins in the 40s

Hearing

• Often a loss of acuity for high-range sounds
• 33% of those over 65 and 50% of those over 85 have deficits
• Associated with social/emotional isolation, clinical depression, cognitive decline, and limited activity
• Use the Hearing Handicap Inventory for Elderly-Screening recommended

Addressing Multimorbidity

• Multimorbidity is the presence of two or more chronic co-occurring conditions
• Associated with negative health outcomes, accelerated declines in functional status, increased symptom burden, reduced quality of life, mortality, and increased cost of care
• Often excluded from randomized clinical trials and treatments may not always consider co-occurring conditions
• Can have special management challenges with complicated treatment regimens and leave one feeling inadequate in caring for complexities
• Reimbursements do not reflect the complexity

Atypical Presentations of Illness

• Prevalence of atypical illness presentation increases with age

Atypical Presentation - Risks

• Increasing age (over 85), multimorbidity, polypharmacy, cognitive impairment, and residing in a care institution are common risks

Atypical Presentation - Examples

• Dehydration can lead to delirium and mobility disorders
• Acute abdomen can present as silent, constipation, or tachypnea
• Infection can cause a change in functional status and mental status
• Cardiovascular disease can manifest as new-onset fatigue, dizziness, or confusion
• Depression can involve anxiety, diminished self-care, irritability, weight loss, or loss of cognition
• UTI presents with sepsis with bandemia or leukopenia, accompanied by abdominal pain
• Pneumonia symptoms can be sepsis with bandemia or leukopenia, with abdominal pain
• Hyperthyroidism can cause fatigue, confusion, and agitation
• Gout can result in polyarticular pain and fever

Prevention & Health Promotion

• Preventive interventions can limit disease and disability

Prevention

• Tailor prevention interventions to each individual, balance benefits and harms with respect to their life expectancy and values, and avoid one-size-fits-all
• Interventions should improve morbidity and mortality
• Weigh potential harms with expected benefits
• Prevention and screening may be controversial, so be practice-specific
• The American Geriatric Society (AGS) provides guidelines

Areas for Prevention and Screening

• Falls, depression, vision/hearing, cognitive impairment, elder abuse, exercise/nutrition, substance abuse, sexual health, sleep, and immunizations
• Also diabetes, osteoporosis, hyperlipidemia, hypertension, abdominal aortic aneurysm, aspiring use, and breast cancer
• Screen for breast/colorectal/cervical/prostate/lung cancer

Health Promotion

• Screening for common geriatric conditions, like falls, depression, nutrition, vision/hearing, cognitive impairment, and elder abuse, plays a key role
• Implement healthy living behaviors; immunizations, exercise, sexual health, sleep, and minimizing substance abuse

Nutrition

• Nutritional needs change with aging, obesity, and malnutrition
• BMI less than 19 associates with increased mortality rates.
• 35-65% of hospitalized geriatric patients suffer from malnutrition; 60% of geriatric residents in institutions are affected
• Daily energy requirements decline with age, resulting in decreased muscle mass and physical activity
• Recommended dietary allowances of vitamins and minerals should be similar to middle age, focusing on calcium and Vitamin D
• Fat intake should be less than 30 percent of the total calories
• Recommended diets are Mediterranean, DASH (dietary approaches to stop hypertension), and high-fiber

Malnutrition - Adverse Effects

• Unintentional weight loss, functional decline, increased mortality rate
• Increased risk for hospitalizations, pressure ulcers, postural hypotension, poor wound healing, cognitive decline, and infection
• Potential causes: medical, psychosocial, and pharmacologic
• Undiagnosed cancer occurs in 16-36% of unintentional weight loss

Obesity

• BMI greater than 35 or BMI between 30-35 may apply a diagnosis of obesity
• Prevalence: 27.6% of women over 65, 28.4% of men over 65, 36.5% of Black adults, 35.3% of American Indian adults, and 32.8% of Hispanic adults
• Implement weight loss strategies by combining diet and exercise, while avoiding weight loss medication
• BMI greater than 40 is associated with higher mortality rates
• Obesity may increase the risk for hypertension, dyslipidemia, diabetes mellitus, coronary artery disease, stroke, osteoarthritis, sleep apnea, and certain cancers (breast, prostate, and colon)

Social Context of Older Adults

• Social factors influence the health and quality of life of the geriatric population
• Affects health and care of the geriatric population
• Components:
  • Loneliness and social isolation
  • Food insecurity
  • Housing and long-term services and support
  • Finances
  • Legal issues

Caregiving and Caregiving Support

• Vital to maintaining independence
• Components:
  • Importance of caregivers
  • Invisibility of caregivers
  • Demographics of caregiving
  • Caregiver roles
  • Assessment of caregivers
  • Examples of institutional support for caregivers
  • Public mandates to support caregivers
  • Caregivers and patient privacy
  • Caregiver resources
• Medication management, health system coordination, complex medical tasks, assistance with ADLs and IADLs are often provided
• Caregivers are sometimes considered a "shadow workforce"
• 34 million caregivers nationwide are caring for someone over 50 years old
  • 60% are women and 40% are men
  • 50% have an additional job
  • Average 24 hours per week; 23% report 41 hours per week
  • Provide 59%-99% assistance with ADLs and IADLs
  • Average age of a caregiver for an older adult is 63 years old
• Becoming a caregiver may be a gradual process or a sudden role
• Most have a network of support and share responsibilities with more than one person
• Caregiver assessments can be conducted by social workers, case managers, nurses, physicians, or others
• The Family Caregiver Alliance National Consensus Report (2006) assigns seven domains for a family caregiver assessment
  • Domains include caregiver values, preferences, well-being, skills, and abilities

Detecting and Assessing Elder Mistreatment

• Elder mistreatment is defined as an act, or failure to act, by a person in a relationship of trust with a geriatric patient that results in harm to the older adult
• Expanded to include actions or inactions that put older adults at serious risk for harm
• Types of elder abuse:
  • Physical
  • Sexual
  • Psychological/Emotional
  • Financial
  • Neglect
• Prevention:
  • Caregiver support interventions
  • Money management programs
  • Helplines for caregivers/older adults to receive resources
  • Emergency shelters
  • Multidisciplinary teams to facilitate coordination of resources
• Risk Factors:
  • Functional dependence
  • Physical disability
  • Cognitive impairment
  • Poor mental health
  • Low income
  • Female gender
  • Caregiver substance abuse, mental illness, financial dependence on the victim
• Hispanics have the lowest risk of emotional and financial abuse or neglect of elderly
• Screening Questions:
  • Does anyone hurt you?
  • Do you feel safe where you live?
  • Has someone not helped you when you needed their help?
  • Who takes care of your finances or pays your bills?
• Try to interview the patient alone and with the caregiver
• Get a clear mechanism of injury for any visible injuries
• Thorough skin evaluation
• Intervention:
  • Abuse Intervention Model (AIM) provides framework
  • Characteristics of a vulnerable adult
  • Characteristics of trusted other or perpetrator
  • The living and care environments
  • Thorough H&P
  • Thorough documentation
• Treatment:
  • Reporting
  • Ongoing care planning
  • Social services
  • Interprofessional intervention
  • Legal interventions

Ethics and Informed Decision

• There is a duty to protect those who cannot care for themselves
• To assess decision-making capacity as an essential first step:
  • Functional dependence
  • Physical disability
  • Cognitive impairment
• The patient must demonstrate understanding of the situation including the risks, benefits, and alternatives
• The decision must be consistent with the patient's values and preferences over time
• Ethical Principles:
  • Respect for autonomy
    • Goals and values discussions
    • Priority setting
    • Prognostic disclosure
  • Nonmaleficence and beneficence
    • Best interests
    • Balancing harms, risks, and benefits
    • Concern about the living environment
  • Justice
    • Consider the needs and associated costs of the individual
    • Clinicians may need to take a leadership role in financial stewardship; refer the patient to appropriate help
• Advance Care Planning
  • Includes process to understand the patient's understanding with family and surrogates
    • Inquire: Goals, values, and preferences for future care
  • Use a written form
    • Can be recorded in: Advance Directives and Living Wills
  • Allows a form of extended autonomy
    • Patient might not be able to speak for themselves
  • Example:
    • DNR, DNI, Feeding Tube, Trach, Vegatative State, Quadriplegia

Palliative Care

• Integrates the core competencies of specialized fields of medicine to improve care and enhance the quality of life of older adults living with serious illnesses
• Utilizes an interdisciplinary team
• The model of care is patient and family-centered
• Provided for any serious illness stage
• Can be given concurrently with life-prolonging treatments to improve outcomes
• Hospice Care:
  • Palliative care is provided for patients with limited life expectancy
  • Must meet conditions mandated by Hospice Medicare Benefit
  • Provides medical, psychological, and spiritual support
• Challenges to Palliative Care:
  • Prognostic ambiguity
  • Poor communication between providers among families
  • Occurs in Long-term care settings
    • Hospice care increased from 28% to 40% from 2004 to 2009
  • Educating caregivers; there is usually a network of family and friends
• Symptom Management:
  • Pain
  • Dyspnea
  • Nausea and vomiting
  • Delirium
  • Grief and depression
  • Fatigue and somnolence
  • Advanced dementia

Evidence-Based Care to Older Persons

• Understand the limitations of applying clinical research literature to the geriatric population
• Good studies often exclude older persons
• Enrollment of older patients tends to be limited to robust patients
• Examine available evidence and critically assess the extent to how it may apply to the patient in from of you
• Explicit age exclusions
• Implicit age exclusions
• Co-morbidity
• Polypharmacy
• Functional impairment
• Cognitive impairment
• Inability to consent
• Nursing home patients
• Unintentional exclusions
• Inquiries:
  • Were older patients included in the study?
    • Now mandated by NIH supported research
  • How do the patients in the study differ from the patient?
  • What outcomes matter to the patient?
  • How does the patient life expectancy impact the risk and benefits of treatment?

Social Determinants of Health - Questions

• Directed to 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 bathe, cook, and 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????

Ethics Informed Decision - Vignette One

• An 87 year-old female that has a long-standing history of DM Type 2, CHF, HTN, and has mild cognitive impairments is now at the office with her daughter
• Pt ambulates with a cane and has not seen mom lately, so things have possibly deteriorated at the home
• Home has excessive clutter, trip hazards, and smelly, visible garbage in the kitchen
• Pt thinks her vision has now worsened since last visit, but she stated that she is fine
• Important Talking Points: What's changed since her daughter's last visit several months ago
• Can be asked questions to see if there has been an impact of: Food nutrition, blood sugar monitoring, falls, money, visitors, incontinence, and any loss of mini memories

Objective Examination

• On PE find normal vitals, but BP is elevated 180/82.
• Pt has disheveled, unkempt, and odorous appearance
• Cognitive assessment gives her 23/30
• All other exam values are normal

Intervention

• Home health care will go out for a home visit the next day
• Social worker finds that her living conditions are less desirable, so physical
• Therapy includes an unsafe environment from many trip hazards
• pt’ Med bottles have not been found, plus she takes her pills mixed together on the kitchen counter.
• pt’ daughter brings her to see you later that week but is adamant doesn't want to leave her home to allow her mom to stay with her
  • they will need major help in listing some ways that you can make a differences