Rosemary Browne, MD, College of Medicine, University of Arizona
|TIPS FOR PERFORMING GERIATRIC EVALUATION
The practice of medicine traditionally approaches illness from a disease-based, organ system framework. This method works well for most patients seeking medical care. Older adults can challenge this construct, however, as they accumulate multiple complex chronic conditions, geriatric syndromes, and psychosocial stressors. Optimizing the health of these complicated patients requires a broad and systematic evaluation, termed "comprehensive geriatric assessment." This process works best when undertaken by a trained interprofessional team using multidimensional diagnostic methods and management plans. Financial constraints and lack of personnel, however, often preclude such a comprehensive approach. This issue of Elder Care offers an approach to geriatric evaluation that individual clinicians can use during routine outpatient practice.
When taking a medical history from older adults, clinicians should ask about a variety of issues, not just the standard questions used with younger individuals. Table 1 lists some key issues that should be included in a geriatric history.
|Table 1. Components of a Geriatric Medical History
In addition to performing a standard physical exam to evaluate and monitor medical disorders, the examination of older adults should consider several additional factors. These are noted in Table 2.
Table 2. Important Components of a Geriatric Physical
Many older adults experience daily challenges that affect their well-being and quality of life, but which do not fit neatly into organ-based diagnostic categories. These "geriatric syndromes" are multi-factorial in etiology and cross conventional organ system boundaries. As these symptoms are often not volunteered by patients, and are not addressed during a standard history and review of systems, they may go unrecognized and untreated.
The most common and important geriatric syndromes include pressure ulcers, incontinence, gait disorders and falls, functional decline, and cognitive impairment. Other problems that are common in the geriatric population include poor nutrition, poor oral/dental hygiene, and chronic pain. Resources to help assess and address these conditions are listed in Table 3.
|Table 3. Geriatric Syndromes Resources/Tools|
|Pain Communication Tools|
In addition to asking about the issues listed in Tables 1 and 2, clinicians should evaluate patients for hearing and vision impairments, overall functional status, ability to perform activities of daily living, and frailty. Resources to assist with these evaluations, along with an approach recommended by the American Geriatrics Society for dealing with patients who have multiple chronic medical conditions, are shown in Table 4.
|Table 4. Resources to Aid in Geriatric Evaluation|
|Multiple Chronic Conditions|
Lack of awareness of psychosocial issues can also be a barrier to optimal care. Depression, mental illness, and substance abuse can affect treatment compliance and quality of life. Poor social support, financial stress, and even elder abuse can go unnoticed if not asked about during a thorough review. Resources for addressing a variety of psychosocial issues are shown in Table 5.
|Table 5. Psychosocial Resources/Tools|
|End of Life Issues|
Finally, for well-functioning older adults, clinicians should consider performing age-appropriate, guideline-directed screening tests. Note, however, that the US Preventive Services Task Force concludes that the current evidence is insufficient to assess the balance of benefits and harms of routinely screening all older adults for impaired visual acuity, hearing loss, elder abuse, and cognitive impairment.
References and Resources
- Carlson, C, Merel, S, Yukawa, M. Geriatric Syndromes and Geriatric Assessment for the Generalist. Med Clin N Am. 2015; 99:263--279.
- Tatum, P, Talabreza, S, Ross, J. Geriatric Assessment: An Office-Based Approach. Am Fam Physician. 2018; 97(12): 776-784.