The Geriatric Patient: A Systematic Approach to Maintaining Health

Author: Karl E. Miller, John B. Standridge
Date: Feb 15, 2000

The number of persons 65 years of age and older continues to increase dramatically in the United States. Comprehensive health maintenance screening of this population is becoming an important task for primary care physicians. As outlined by the U.S. Preventive Services Task Force, assessment categories unique to elderly patients include sensory perception and injury prevention. Geriatric patients are at higher risk of falling for a number of reasons, including postural hypotension, balance or gait impairment, polypharmacy (more than three prescription medications) and use of sedative-hypnotic medications. Interventional areas that are common to other age groups but have special implications for older patients include immunizations, diet and exercise, and sexuality. Cognitive ability and mental health issues should also be evaluated within the context of the individual patient's social situation-not by screening all patients but by being alert to the occurrence of any change in mental function. Using an organized approach to the varied aspects of geriatric health, primary care physicians can improve the care that they provide for their older patients. (Am Fam Physician 2000;61:1089-104.)

Current predictions suggest that the number of persons 65 years of age and older will more than double in the United States during the next 30 years. As a result, the number of elderly Americans could increase from 34 million in 1998 to approximately 69 million in 2030. This increase, combined with the disproportionate rate at which elderly patients use medical resources, will require that primary care physicians become increasingly knowledgeable about the needs of geriatric patients and increasingly efficient in the evaluation and management of concerns unique to these patients.

The value of performing a comprehensive geriatric assessment appears to be equivocal. Simple screening instruments can be helpful in identifying patients at risk for common health problems and in improving the clinical assessment of a disease course.1 However, these screening tools may not be effective in reducing health care utilization or costs.2

The comprehensive geriatric assessment is often described in the literature as a multidisciplinary, time-intensive evaluation of a patient previously identified as being at significant risk for imminent morbidity or mortality.2,3 An evaluation of this type is impractical in most primary care settings and is seldom used by practicing physicians.4 Yet the ongoing, long-term management component of primary care is a key ingredient in the success of outpatient geriatric evaluation.5

Effective primary care management of geriatric health issues, with its goal of caring for healthy and functional elderly patients, may perhaps be better described as comprehensive health screening. Using simple and easily administered assessment tools, physicians can improve the identification of specific problems that are common in the elderly and also shift their focus from disease-specific intervention to preventive care and proactive medical management.5

In 1996, the U.S. Preventive Services Task Force (USPSTF) published the second edition of its Guide to Clinical Prevention Services.6 In this publication, the USPSTF updated earlier recommendations on preventive services for patients at various stages of life. The recommendations for patients 65 years of age and older include a number of items common to other age groups. The unique assessment categories for older patients are sensory perception (hearing and vision screening) and accident prevention. Assessment areas common to other age groups but with special implications for the elderly include diet and exercise, immunizations and sexuality. Although the USPSTF found little evidence in 1996 to support the value of screening for dementia, recent pharmaceutical advances have resulted in beneficial treatment options that were not available just a few years ago.7

Using the USPSTF recommendations as a guide, this article reviews available standardized assessment tools and techniques that can be used in outpatient settings. The goals are to encourage a systematic assessment of various areas of potential geriatric risk and to develop a database appropriate to the unique concerns of elderly patients. All of the information does not need to be gathered in one office visit. Multiple visits can be used to perform the entire assessment.

Injury Prevention

The USPSTF recommends that primary care physicians ask patients in most age groups about the routine use of safety belts and bike helmets, the availability of smoke detectors, the maintenance of hot water heater temperature at or below 48.8[degree sign]C (120[degree sign]F) and the danger of smoking near bedding or upholstery.6 Fall prevention, however, is an assessment category unique to patients 65 years of age and older.

The annual incidence of falls in patients over 65 years of age who live independently is approximately 25 percent but rises to 50 percent in patients over 80 years of age.8 Falls are responsible for a significant number of accidental deaths and traumatic injuries among the elderly. One third of patients with confirmed falls may not recall falling.9

Risk Factors

Intrinsic factors that contribute to falls include age-related changes in postural control, gait and visual ability, and the presence of acute and chronic diseases that affect sensory input, the central nervous system and musculoskeletal strength and coordination. Certain medications can also increase the risk of falling (Table 1).10

Osteoporosis is one notable intrinsic factor that leads to falls. In patients with this condition, a pathologic fracture may precede a fall. In the absence of universally accepted criteria for the assessment of bone mineral density, screening should be directed at a risk assessment for osteoporosis (Table 2).

Extrinsic factors that contribute to falls include poor lighting, obtrusive furniture, slippery floors, loose floor coverings and bathrooms without handrails or grab bars.

Mobility And Dexterity

A comprehensive risk assessment for falls incorporates a review of all potential intrinsic and extrinsic factors, as well as a focused physical examination (Table 3).11 The physical examination can be a simple evaluation of one-leg balance (i.e., the ability to stand unassisted on one leg for five seconds)12 or a more structured evaluation such as the "Get Up and Go" test.13 In the "Get Up and Go" test, the patient is observed as he or she rises from a sitting position, walks 10 ft, turns and returns to the chair to sit. The effectiveness of the test for predicting falls can be enhanced by timing the process, with more than 16 seconds suggesting an increased risk of falling.14 Any observed or reported changes in gait, strength or balance may require further evaluation with a more detailed assessment.

Sensory Perception

Changes in vision and hearing occur as patients age. Because these changes can have a great impact on well-being, the USPSTF recommends regular vision and hearing screening for patients 65 years of age and older.6

Vision

One study found that 72 percent of community-based patients more than 64 years of age had impaired vision as tested with a Snellen eye chart.15 Other studies have detected lower percentages of geriatric patients with vision problems, but the prevalence of visual impairment is still quite high. The most common causes of visual impairment in the elderly include presbyopia, cataracts, glaucoma, diabetic retinopathy and age-related macular degeneration. Changes in vision can cause a significant number of problems for elderly patients, including an increased risk for falls.16

The Snellen eye chart is an appropriate tool for visual acuity screening in the elderly. Referral to an ophthalmologist should be considered when visual acuity is worse than 20/40 (with normal corrective lenses, if applicable) and visual impairment is interfering with daily activities.

The USPSTF found insufficient evidence to recommend for or against screening with ophthalmoscopy performed by primary care physicians in asymptomatic elderly patients. However, patients at high risk for glaucoma (i.e., black patients over 40 years of age, white patients over 65 years of age and patients with diabetes mellitus, myopia, ocular hypertension or a family history of glaucoma) should be referred to an eye care specialist for tonometry, funduscopy and visual field examination. The optimal frequency for glaucoma screening in these patients is uncertain.6

Hearing

The prevalence of hearing loss in the geriatric population ranges from 14 to 46 percent,17,18 but only 20 percent of primary care physicians routinely screen elderly patients for hearing loss.18 As a result of psychologic, financial and mechanical impediments, only 32 percent of persons with moderate to marked hearing loss use a hearing aid.17

table 1Medications Associated with an Increased Riskof Falls in the ElderlyAntiarrhythmicsAntihistaminesAntihypertensivesAntipsychoticsBenzodiazepines and other sedative-hypnoticsDigoxin (Lanoxin)DiureticsLaxativesMonoamine oxidase inhibitorsMuscle relaxantsNarcoticsTricyclic antidepressants andselective serotonin reuptake inhibitorsVasodilatorsAdapted with permission from Reuben DB, Grossberg GT, Mion LC, PacalaJT, Potter JF, Semla TP. Geriatrics at your fingertips, 1998/99. BelleMead, N.J.: Excerpta Medica, 1998.table 2Risk Factors for OsteoporosisIncreasing ageFemale genderEarly menopauseLow body weightSmall statureWhite or Asian raceFamily historyDrug use (e.g., steroids, heparin)Low calcium intakeExcessive alcohol intakeSmokingPhysical inactivityConditions that impair calcium absorptionHigh caffeine intaketable 3Interventions to Reduce the Risk of Falling in the ElderlyRisk factors InterventionsPostural hypotension: a drop in Behavioral recommendations, such asankle pumps or hand clenching,systolic blood pressure of and elevating the head of the bed20 mm Hg or to [LESS THAN]90 mm Hg Decrease in the dosage of amedication that may contribute toon standing hypotension; if necessary, discontinuation of the drugor substitution of another medication Pressure stockings Fludrocortisone (Florinef), 0.1 mg two or three times daily,if indicated Midodrine (ProAmatine), 2.5 to 5 mg three times dailyUse of a benzodiazepine or other Education about the appropriate useof sedative-hypnotic drugssedative-hypnotic drug Nonpharmacologic treatment of sleep problems,such as sleep restriction Tapering and discontinuation of medicationUse of four or more prescription Review of medicationsmedicationsEnvironmental hazards for falling Home safety assessment withappropriate changes, such as removal ofor tripping hazards, selection of safer furniture (correct height,more stability) and installation of structures such as grab bars orhandrails on stairs.Any impairment in gait Gait training Use of an appropriate assistive device Balance or strengthening exercises if indicatedAny impairment in balance or Balance exercises and training in transferskills if indicatedtransfer skills Environmental alterations, such as installation ofgrab bars or raised toilet seatsImpairment in leg or arm muscle Exercises with resistive bands andputty; resistance training two orstrength or impaired range of three times a week, withresistance increased when the patientmotion (hip, ankle, knee, is able to complete 10 repetitionsthrough the full range of motionshoulder, hand or elbow)Adapted with permission from Tinetti ME, Baker DI, McAvay G, Claus EB,Garrett P, Gottschalk M, et al. A multifactorial intervention to reducethe risk of falling among elderly people living in the community. N EnglJ Med 1994;331:821-7Hearing Handicap Inventory for the Elderly-Screening Version Yes Sometimes No (4 points) (2 points) (0 points)Does a hearing problem cause you to feel _________ _________ _________embarrassed when you meet new people?Does a hearing problem cause you to feel _________ _________ _________frustrated when you are talking to membersof your family?Do you have difficulty hearing when someone _________ _________ _________speaks in a whisper?Do you feel handicapped by a hearing problem? _________ _________ _________Does a hearing problem cause you difficulty when _________ _________ _________you are visiting friends, relatives or neighbors?Does a hearing problem cause you to attend _________ _________ _________religious services less often than you would like?Does a hearing problem cause you to have _________ _________ _________arguments with family members?Does a hearing problem cause you difficulty when _________ _________ _________you listen to a television or radio?Do you feel that any difficulty with your hearing _________ _________ _________limits or hampers your personal or social life?Does a hearing problem cause you difficulty when _________ _________ _________you are in a restaurant with relatives or friends?The scale is scored as follows: 0 to 8 = No self-perceived handicap10 to 22 = Mild to moderate handicap24 to 40 = Significant handicapFIGURE 1. Clinical scale to detect hearing loss: Hearing HandicapInventory for the Elderly-Screening version.Adapted with permission from Ventry IM, Weinstein BE. Identification ofelderly people with hearing problems. ASHA 1983;25:37-42. Copyright1983.table 4Interventions Based on the Degree of Hearing Lossin the ElderlyHearing level (dB) Degree of loss Interventions25 to 40 Mild Control background noise and use louder speech.41 to 55 Moderate Speak slowly and recommend hearing aid.56 to 70 Moderately severe All of the above71 to 89 Severe All of the above90 Profound All of the above; a behind-the-ear hearing aid is necessary.Adapted with permission from Reuben DB, Grossberg GT, Mion LC, PacalaJT, Potter JF, Semla TP. Geriatrics at your fingertips, 1998/99. BelleMead, N.J.: Excerpta Medica, 1998.Nutritional Health ScreenRead the statements below. Circle the number in the "yes" column foreach statement that applies to you. Add up the circled numbers to getyour nutritional score. YesI have an illness or condition that has made me change the kind and/oramountof food I eat. 2I eat fewer than two meals a day. 3I eat few fruits, vegetables or milk products. 2I have three or more drinks of beer, liquor or wine almost every day. 2I have tooth or mouth problems that make it hard for me to eat. 2I do not always have enough money to buy the food I need. 4I eat alone most of the time. 1I take three or more different prescribed or over-the-counter drugs aday. 1Without wanting to, I have lost or gained 10 pounds in the past sixmonths. 2I am not always physically able to shop, cook and/or feed myself. 2The scale is scored as follows: 0 to 2 = You have good nutrition. Recheck your nutritionalscore in 6 months. 3 to 5 = You are at moderate nutritional risk. See what you cando to improve your eating habits and lifestyle. Recheck your nutritionalscore in 3 months. 6 or more = You are at high nutritional risk. Bring thischecklist the next time you see your doctor, dietitian or otherqualified health or social service professional. Talk with any of theseprofessionals about the problems you may have. Ask for help to improveyournutritional status.FIGURE 2. Nutritional health screen.Adapted with permission from The clinical and cost-effectiveness ofmedical nutrition therapies: evidence and estimates of potential medicalsavings from the use of selected nutritional intervention. June 1966.Summary report prepared for the Nutritional Screening Initiative, aproject of the American Academy of Family Physicians, the AmericanDietetic Association and the National Council on the Aging, Inc., andfunded in part by a grant from Ross Products Division, AbbottLaboratories Inc.Mini-Mental StateWrite in the points for each correct response. A total of 30 points ispossible. Score PointsOrientation 1. What is the: Year? _____ 1 Season? _____ 1 Date? _____ 1 Day? _____ 1 Month? _____ 1 2. Where are we? State? _____ 1 Country? _____ 1 Town or city? _____ 1 Hospital? _____ 1 Floor? _____ 1Registration 3. Name three objects, taking 1 second to say each. Then ask thepatient to _____ 3repeat all three names after you have said them. (Give one point foreachcorrect answer.) Repeat the answers until the patient learns all three.Attention and calculation 4. Serial sevens. Have the patient count backward from 100 by 7's.(Stop _____ 5after five answers: 93, 86, 79, 72, 65. Give one point for each correctanswer.) Alternatively, have the patient spell WORLD backwards.Recall 5. Ask for the names of the three objects learned in question 3. (Giveone _____ 3point for each correct answer.)Language 6. Point to a pencil and a watch. Have the patient name them as youpoint. _____ 2 7. Have the patient repeat "No ifs, ands or buts." _____ 1 8. Have the patient follow a three-stage command: "Take a paper inyour _____ 3hand. Fold the paper in half. Put the paper on the floor." 9. Have the patient read and obey the following: "CLOSE YOUR EYES."_____ 1(Write the words in large letters.)10. Have the patient write a sentence of his or her choice. (Thesentence _____ 1should contain a subject and an object, and it should make sense. Ignorespelling errors when scoring.)11. Have the patient copy the following design. (Give one point if allsides _____ 1and angles are preserved and if the intersecting sides form aquadrangle.) Total _____Geriatric Depression Scale (Short Form)For each question, choose the best answer for how you felt over the pastweek. 1. Are you basically satisfied with your life? Yes / NO 2. Have you dropped many of your activities and interests? YES /No 3. Do you feel that your life is empty? YES / No 4. Do you often get bored? YES / No 5. Are you in good spirits most of the time? Yes / NO 6. Are you afraid that something bad is going to happen to you? YES /No 7. Do you feel happy most of the time? Yes / NO 8. Do you often feel helpless? YES / No 9. Do you prefer to stay at home, rather than going out and doing newthings? YES / No10. Do you feel you have more problems with memory than most? YES /No11. Do you think it is wonderful to be alive now? Yes / NO12. Do you feel pretty worthless the way you are now? YES / No13. Do you feel full of energy? Yes / NO14. Do you feel that your situation is hopeless? YES / No15. Do you think that most people are better off than you are? YES /NoThe scale is scored as follows: 1 point for each response in capitalletters. A score of 0 to 5 is normal;a score above 5 suggests depression.Activities of Daily Living ScaleName:__________________________________________________________________________ Date of evaluation: _______________For each area of functioning listed below, check the description thatapplies. (The word "assistance" applies to supervision, direction orpersonal assistance.)Bathing (sponge bath, tub bath, or shower) ___ ___ ___Receives no assistance (gets in and out of Receives assistance inbathing only one Receives assistance in bathing more thanbathtub by self if tub is usual means of part of the body (such as backor legs) one part of the body (or is not bathed)bathing)Dressing (gets clothes from closets and drawers, including underclothesand outer garments, and uses fasteners, including braces, if worn) ___ ___ ___Gets clothes and gets completely dressed Gets clothes and gets dressedwithout Receives assistance in getting clothes or inwithout assistance assistance, except for assistance in tying getting dressed, or stays partly or shoes completely undressedToileting (going to "toilet room" for bowel and urine elimination,cleaning self after elimination and arranging clothes) ___ ___ ___Goes to "toilet room," cleans self and Receives assistance in goingto "toilet Does not go to "toilet room" for thearranges clothes without assistance (may room," in cleaning self or inarranging elimination processuse an object for support, such as cane, clothes after elimination, orin usingwalker or wheelchair, and may manage night bedpan or commodenight bedpan or commode, emptying inmorning)Transfer ___ ___ ___Moves in and out of a bed and chair Moves in and out of a bed andchair Does not get out of bedwithout assistance (may use object for with assistancesupport, such as cane or walker)Continence ___ ___ ___Controls urination and bowel movement Has occasional "accidents" Supervision helps keep urine or bowelcompletely by self control; catheter is used; or person is incontinentFeeding ___ ___ ___Feeds self without assistance Feeds self, except for needing Receives assistance in feeding or is fed assistance in cutting meat or buttering partly or completelyusing tubes or bread intravenous fluidsInstrumental Activities of Daily Living (Self-Rated Version)For each question, circle the points for the answer that best applies toyour situation. 1. Can you use the telephone? Without help 3 With some help 2 Completely unable to use the telephone 1 2. Can you get to places that are out of walking distance? Without help 3 With some help 2 Completely unable to travel unless special arrangements aremade 1 3. Can you go shopping for groceries? Without help 3 With some help 2 Completely unable to do any shopping 1 4. Can you prepare your own meals? Without help 3 With some help 2 Completely unable to prepare any meals 1 5. Can you do your own housework? Without help 3 With some help 2 Completely unable to do any housework 1 6. Can you do your own handyman work? Without help 3 With some help 2 Completely unable to do any handyman work 1 7. Can you do your own laundry? Without help 3 With some help 2 Completely unable to do any laundry at all 1 8a. Do you take any medicines or use any medications? Yes (If "yes," answer question 8b.) 1 No (If "no," answer question 8c.) 2 8b. Do you take your own medicine? Without help (in the right doses at the right time) 3 With some help (take medicine if someone prepares it for youand/or reminds you to take it) 2 Completely unable to take own medicine 1 8c. If you had to take medicine, could you do it? Without help (in the right doses at the right time) 3 With some help (take medicine if someone prepares it for youand/or reminds you to take it) 2 Completely unable to take own medicine 1 9. Can you manage your own money? Without help 3 With some help 2 Completely unable to handle money 1FIGURE 6. Instrumental Activities of Daily Living Scale (self-ratedversion).Adapted with permission from Lawton MP, Brody EM. Assessment of olderpeople: self-maintaining and instrumental activities of daily living.Gerontologist 1969;9:279-85.Checklist of Assessment Areas for Maintaining Healthy Geriatric PatientsInjury prevention_____ Use of safety belts or helmets_____ Smoke detectors (in place and working)_____ Hot water temperature at c48.8[degree sign]C (120[degree sign]F)_____ Smoking near bed or upholstery_____ Poor lighting_____ Obtrusive furniture_____ Slippery floors and loose rugs_____ Handrails and grab bars_____ One-leg balance (5 seconds)_____ "Get Up and Go" test*Sensorium_____ Snellen eye chart_____ Ophthalmology examination_____ Hearing Handicapped Inventory for the Elderly-Screening version_____ Pure tone audiometryNutrition_____ Nutritional Health Screen_____ Tooth brushing, flossing and dental visitsImmunizations_____ Tetanus and diphtheria toxoid_____ Influenza vaccine_____ Pneumococcal vaccineSexuality_____ Review of chronic conditions and medications_____ Initiation of discussion about sexualityContinence_____ Review of chronic conditions and medications_____ Initiation of discussion about incontinence_____ Focused physical examination (pelvis, prostate, rectum)Mental status (consider one of the following)_____ Mini-Mental State_____ Clock Test_____ Informant Questionnaire on Cognitive Decline in the Elderly_____ Geriatric Depression Scale_____ Yale Depression Screen_____ Questioning about suicideSocial issues_____ Changes in living arrangements, finances or activities_____ Caregiver support or burnout_____ Advance directives_____ Family training in cardiopulmonaryresuscitation_____ Activities of Daily Living_____ Instrumental Activities of Daily Living_____ Performance Test of Activities of Daily Living*-The patient rises from a sitting position, walks 10 feet, turns andreturns to the chair to sit. The test is positive if these activitiestake more than 16 seconds.FIGURE 7. Areas of assessment in a systematic approach to maintaininghealthy geriatric patients.Information from U.S. Preventive Services Task Force. Guide to clinicalpreventive services: report of the U.S. Preventive Services Task Force.2d ed. Baltimore: Williams & Wilkins, 1996.table 5Ten-Minute Screen for Geriatric ConditionsProblem Screening measure Positive screenVision Ask this question: "Because of your eyesight, do "Yes"to question and inability to read you have trouble driving a car, watching atgreater than 20/40 on the Snellen television, reading or doing any of your daily eye chart activities?" If the patient answers "yes," test each eye with the Snellen eye chart while the patient wears corrective lenses (if applicable).Hearing Use an audioscope set at 40 dB. Test the Inability to hear1,000 or 2,000 Hz in patient's hearing using 1,000 and 2,000 Hz. both ears or inability to hear frequencies in either earLeg mobility Time the patient after giving these directions: Unable to complete task in 15 "Rise from the chair. Then walk 20 feet briskly, seconds turn, walk back to the chair and sit down." .Urinary Ask this question: "In the past year, have you "Yes" toboth questions incontinence ever lost your urine and gotten wet?" If the patient answers "yes," ask this question: "Have you lost urine on at least 6 separate days?"Nutrition and Ask this question: "Have you lost 10 pounds over "Yes" to the question or a weight of weight loss the past 6 months without trying to do so?" less than 45.5 kg (100 lb) If the patient answers "yes," weigh the patient.Memory Three-item recall Unable to remember all three items after 1 minuteDepression Ask this question: "Do you often feel sad or "Yes" to thequestion depressed?"Physical Ask the patient these six questions: "Yes" to any ofthe questions disability "Are you able to do strenuous activities, like fast walking or bicycling?" "Are you able to do heavy work around the house, like washing windows, walls or floors?" "Are you able to go shopping for groceries or clothes?" "Are you able to get to places that are out of walking distance?" "Are you able to bathe-sponge bath, tub bath or shower?" "Are you able to dress, like put on a shirt, button and zip your clothes, or put on your shoes?"Adapted with permission from Moore A, Siu AL. Screening for commonproblems in ambulatory elderly: clinical confirmation of a screeninstrument. Am J Med 1996;100:438-43. Copyright 1996, with permissionfrom Excerpta Medica Inc.

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