Issues of Concern
Issues of concern in geriatric assessment can be broadly divided into the following 4 classes:
- Functional Status
- Physical Health
- Vision impairment
- Hearing loss
- Nutrition status
- Fall prevention
- Urinary Incontinence
- Osteoporosis and arthritis
- Polypharmacy and Medication Reconciliation
- Cognitive Assessment
- Sleep and insomnia
- Mood disorder
1. Functional Status
Evaluation of one's ability to perform activities required to live independently comprises functional status assessment. It can be broadly divided into 2 levels - basic activities of daily living (BADL), which includes activities of self-care such as feeding, dressing, bathing, toileting, grooming, controlling bladder and bowel movements, etc. and instrumental activities of daily living (IADL) which includes activities to live independently such as taking medications, shopping, preparing meals, driving/using public transport, handling finances, doing household works, using telephone, etc. Commonly used indices to assess such activities are the Katz index for BADL and the Lawton scale for IADL. Information about functional status can also be achieved by asking open-ended questions about their daily activities. Functional status is directly affected by physical health, so any change in functional status should prompt further evaluation. There are various validated tools to measure functional ability, such as the Vulnerable Elders Scale-13 or Clinical Frailty Scale. Recently, gait speed has also been proposed as a screening tool for functional status. One pooled analysis showed gait speed is associated with better survival for every 0.1 m/s increments.
2. Physical Health
Geriatric assessment should include detailed medical history and physical examination, with particular focus on problems specific to the elderly such as vision, hearing, nutrition, fall prevention, urinary incontinence, osteoporosis, and preventative health.
Preventative health includes screening for diseases such as diabetes mellitus, hypertension, cancer, etc. Early identification and treatment may be beneficial in diabetes, hypertension as well as in certain malignancies. However, the American Geriatric Society recommended that such screenings be based on patient's preferences, life expectancy, and co-morbid conditions rather than solely on age-based criteria. Older patients may have many co-morbid conditions that can shorten their life, hence the potential benefits of such screening tests and patient's preference for further evaluation and invasive procedure if screened positive should be taken into account before the screening. For the same reason, screening should be focused on treatable conditions which can provide immediate benefit to their quality of life rather than on asymptomatic diseases. Similarly, vaccine-preventable infections such as influenza, pneumonia, herpes zoster, etc., represent major causes of morbidity and mortality in older patients. Hence, most societies recommend following vaccines routinely for older patients: influenza vaccine, pneumococcal vaccine, herpes zoster vaccine and tetanus, Diptheria, and acellular pertussis vaccine. Depending on specific co-morbidities, an older patient may qualify for other vaccines as well.
Visual impairment affects older patients' functional status, especially functions such as driving, preparing meals, managing money, etc. are significantly affected. It is also associated with falls, cognitive decline, and depression in the elderly. Older patients are at increased risk of visual impairment due to age-related decline as well as co-morbid conditions. Common causes of visual impairment in the elderly are cataracts, glaucoma, presbyopia, macular degeneration, diabetic retinopathy, and hypertensive retinopathy. Although studies show an increased association of visual impairment with functional decline, one meta-analysis of 5 randomized controlled trials failed to show any evidence of decreased visual impairment with visual screening in the elderly. The U.S. Preventive Services Task Force (USPSTF) did not find sufficient evidence to recommend routine visual screening in older patients. However, any decline in functional capacity, cognition, or falls should prompt a visual assessment. This can be done with a Snellen chart, questionnaires, or direct fundoscopic examination. In contrast to USPSTF, the American Academy of Ophthalmology recommends comprehensive eye examinations every 1 to 2 years for adults 65 years and older.
Hearing loss is, in fact, the third most common condition in older patients. Like visual impairment, hearing loss is associated with functional decline, poor cognition, and dementia, social isolation, and depression. USPSTF does not recommend routine screening for hearing loss in older patients due to insufficient evidence. However, the decline in cognition, functional capacity, or mood should lead to hearing loss screening. Rapid test such as whispered voice test has shown to be highly sensitive and specific for screening. Providers should be aware of difficulties in communication due to hearing loss and avoid misdiagnosing it as cognitive decline or stroke. Patients who fail the screening test should be referred to an otolaryngologist for possible need of a hearing aid.
Up to 15% of the community-dwelling elderly population is affected by malnutrition, which is associated with a decline in physical health, such as poor wound healing, anemia, immune dysfunction, etc. Poor cognition, functional decline, and an overall increase in mortality. Besides organic causes (chronic medical conditions, malignancy, poor dentition, etc.), various psychosocial causes (depression, alcoholism, isolation, bereavement, etc.) also lead to malnutrition in the elderly. Although there is no single laboratory screening test for this condition, clinical assessment, serial weights on clinic visits, and various validated tools such as Mini Nutritional Assessment (MNA) or Geriatric Nutrition Risk Index (GNRI) can be used for nutritional assessment in older patients. The elderly population at-risk as determined by one of these screening strategies should undergo further evaluation to determine the cause and initiate treatment such as optimizing chronic medical conditions, proper dentition, adequate assistance for physically or mentally disabled patients, and oral supplementation or enteral feeding as needed.
About 28% of older adults report falling at least once in the last year, as per a recent cross-sectional study in the United States. Besides obvious health hazards such as hip fractures and trauma, falls also cause limitations in physical and social activities directly and due to fear of falling indirectly, further leading to functional decline. In the US, the toll on health care cost due to falls is around $50 billion. Therefore, the American Geriatric Society recommends all adults above 65 be screened for falls and instability annually. One meta-analysis of 33 studies evaluating 26 tools for fall risk assessment did not find a single tool to have both high sensitivity and specificity to assess fall risk.
A systematic review of 18 studies reported fall to be multifactorial with the following risk factors - history of falls, gait or balance impairment, orthostatic hypotension, visual impairment, cognitive impairment, impairment in activities of daily living, and medications such as benzodiazepines, antidepressants, diuretics, etc. Of these, the two most predictive risk factors were history of falls and gait or balance impairment. When adjusted for other variables, age was not as important as the aforementioned two risk factors in predicting falls. Hence, a simple approach could be to ask for a history of falls and any abnormality in gait and balance. The patient will be at high risk if he/she answers "yes" to any one of these questions. Due to multifactorial causes, high-risk patients benefit more from a multidisciplinary approach formulating individualized fall prevention strategies, some of which can include exercise programs, optimizing medical conditions, discontinuing medications such as benzodiazepine, environmental safety, and use of assistive devices.
Most studies show the prevalence of urinary incontinence (UI) in the range of 25-45% and rise further with aging. However, UI is not a normal or inevitable consequence of aging. Older patients suffering from UI cannot participate in social activities leading to isolation, increased risk of depression, and functional disability. It can also increase the risk of falls, fractures, affects sexual health, and causes an overall reduction in quality of life. UI can be classified into 5 types - stress, urge, overflow, mixed and functional. Stress incontinence is leakage of urine due to activities that increase abdominal pressure. Urge incontinence is characterized by leakage of urine after a sudden urge to void. Overflow incontinence manifests as frequent small volume leaks, usually due to bladder outlet obstruction or neurological disorders. Functional incontinence refers to incontinence resulting from an inability to use the toilet independently due to functional disability such as cognitive impairment or limited mobility. Mixed incontinence is the combination of 2 or more types of incontinence.
Initial evaluation of incontinence should comprise a non-invasive approach, including detailed medical history, fluid intake assessment, self-voiding diary, etc.; however, complicated cases may necessitate urodynamic studies. A simple and reproducible validated tool to differentiate stress and urge incontinence is 3 Incontinence Questions which comprises questions about urinary leaks. Conservative treatments such as behavioral modification, dietary modification, pelvic floor muscle training, timed voiding, and weight loss should be tried first. Various pharmacological therapies are available for urge incontinence. A systematic review of 13 trials showed anticholinergics as the only pharmacological therapy that decreased urinary leakage in urge incontinence. Devices such as pessaries can be used for incontinence associated with pelvic organ prolapse. Similarly, surgical options such as sling procedures and neuromodulation can be offered to carefully selected patients with incontinence.
Osteoporosis and Arthritis
Osteoporosis and osteopenia are common in the elderly and can lead to fractures even with mild trauma. Increased bone loss due to aging and menopause in women puts older patients and post-menopausal women at high risk of osteoporosis. Screening and diagnosis should be with dual-energy X-ray absorptiometry of the hip and/or spine. Due to their increased risk, USPSTF recommends routine screening of women older than 65 for osteoporosis. Preventive measures in the elderly should include early diagnosis, nutritional supplements with calcium and vitamin D, and fall prevention.
Osteoarthritis (OA) is a major cause of disability and pain in older patients. About 50% of people will have OA changes in knees by age 65, and almost everyone will have at least 1 joint affected with OA by age 75. Evaluation should include ruling out infectious process, rheumatoid arthritis, polymyalgia rheumatic, gout, and pseudogout. A careful history, physical examination, arthrocentesis, laboratory tests, and radiographic imaging may be necessary to come to a diagnosis. Medication such as NSAIDs and acetaminophen are used primarily to manage symptoms as no pharmacological cure is available for OA. Despite early enthusiasm, glucosamine and chondroitin sulfate have not shown to decrease pain in a recent clinical trial. Joint replacement surgery for carefully selected older patients may provide maximum benefit in improving the quality of life.
Patients older than 65 use more than 30% of all prescribed medication in the U.S. Polypharmacy in the elderly is multifactorial - multiple comorbidities, multiple specialties on board, multiple hospitalization and transition of care, self-medication, prescription cascade, and cognitive decline in the elderly contribute to polypharmacy.
Taking multiple medications can cause serious adverse effects due to the drug itself, drug-drug interaction, and drug-disease interaction. Besides, there are also increased chances of iatrogenic illness due to overprescribing, poor compliance due to multiple medications, increased falls, overall poor quality of life, increased hospitalization, and even death. Commonly prescribed drugs such as aspirin, warfarin, oral hypoglycemic agents, insulin, and digoxin are responsible for most hospitalizations due to adverse drug effects. The medication list should be scrutinized to see if any new signs and symptoms in the elderly are due to the prescribed medication. It is, thus, important to do a comprehensive medication reconciliation at least annually and after each transition of care to check if the medication in use is really necessary. Physicians can refer to the American Geriatric Society's Beers criteria which lists the potentially inappropriate medication that should be avoided in the elderly.
4. Cognitive Assessment
Prevalence of mild cognitive impairment (MCI) and dementia increases with age. The prevalence of dementia is around 5% to 7%, and that of MCI is about 4 times that of dementia. Due to their age, multiple comorbidities, and above-described factors, older patients are at increased risk of MCI and dementia. Many of these older patients present to primary care providers with complaints of memory problems. Early detection of such conditions can help determine the reversible causes, initiate appropriate pharmacological interventions early and help patients and caregivers plan for the future. Hence, providers should have a low threshold to screen for cognitive decline in elderly patients. There are various validated tools to screen for cognitive declines, such as Mini-Mental State Exam (MMSE), Montreal Cognitive Assessment (MoCA) test, and Mini-Cog. Mini-Cog, due to its simplicity and minimal language interpretation, can be used in multi-lingual patients.
Insomnia is one of the common presenting problems of older patients. Poor sleep is associated with increased fatigue, falls, nursing home placement, poor quality of life, and overall mortality. Quality of sleep decreases with aging. Sleep disorders could be primary such as insomnia, restless leg syndrome, obstructive sleep apnea, or secondary to comorbid medical, psychiatric, behavioral, environmental, or medication side effects. Assessment of sleep disorder should include evaluation for secondary causes if any. Due to increased side-effects of hypnotics used in the treatment of insomnia, non-pharmacological interventions such as cognitive behavioral therapy, education about sleep hygiene and expected changes with aging, stimulus control, decreased daytime sleep and dietary modifications are the first line of treatment for insomnia.
Almost half of the cases of depression have their onset at 60 or older. Depression is associated with decreased cognition, physical and social functioning, self-care, and independence. Older patients with depression die at a higher rate; a portion of that death rate results from the highest suicide rate among older adults. Options for treatment, when diagnosed early, include psychotherapy and antidepressant medications. USPSTF recommends screening for depression in all adults. Patient Health Questionnaire (PHQ) 2 is a validated screening tool for depression screening, which, if positive, should be followed by PHQ 9 to diagnose depression in the elderly.
Some of the Other Issues of Concern Include
- Home safety
- Driving safety
- Elder mistreatment
Goals of care and advanced directives
Home safety: About 57,000 adults above age 65 died of unintentional injuries in 2018 as per the Centers for Disease Control and Prevention (CDC), more than half of which is estimated to be due to falls. Decline in overall health at old age along with isolation leads to a higher risk of accidents at home. Clinicians should discuss common ways to prevent falls at home, such as lights, handrails, and walking assistance devices. CDC has published a checklist for home fall prevention for older adults, which can be found at https://www.cdc.gov/steadi/pdf/check_for_safety_brochure-a.pdf
Driving: Driving is a complex task and is affected by the decline in visual, motor, and cognitive ability in old age. However, it is also one of the important IADLs that help older patients maintain mobility and engage socially. Therefore, the prospect of "retiring from driving" is highly stressful for the elderly, and such recommendations should be made based on individualized assessment. Besides testing for visual acuity, neck mobility, and reaction time, a multidisciplinary approach including an ophthalmologist, a psychiatrist, a pharmacist, a physical therapist, and an occupational therapist can help assess and improve driving function. If the risk of driving is high, options for alternative forms of transportation and mobility should be discussed with patients and caregivers.
Mistreatment: Elder mistreatment includes abuse and neglect. Various studies show the prevalence of elder mistreatment ranging from 2 to 36%. In the U.S., the prevalence is around 9.5%. Still, the reported prevalence is low as elder abuse tends to be underreported. Some of the signs of mistreatment could be bruising in unusual places, burns, bite marks, genital trauma, pressure ulcers, BMI<17.5 kg/m2, frequent emergency room visits, etc. Such patients should be screened for mistreatment and may need further evaluation by a social worker.
Goals of Care and Advanced Directives
Clinicians should discuss goals of care and advance directives primarily in ambulatory settings, well in advance of facing health crises. Effective communication allows the patient to cope with the serious illness and empowers them to direct their treatment. Goals of care discussion should be individualized as different patients would have different short or long-term goals. Similarly, advanced directives discussion allows the providers to know about the patient's wishes, prevents confusion at the end of life, and minimizes healthcare costs by deferring unwanted medical procedures. Such discussions do not increase depression, anxiety, or hopelessness in patients rather improve their quality of life and even survival by up to 25%. It also decreases stress, anxiety, and depression among family members and improves family satisfaction.