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2

The Comprehensive Geriatric Assessment

Rainier P. Soriano

Learning Objectives

Upon completion of the chapter, the student will be able to:

1. Explain the rationale behind the comprehensive geriatric assessment (CGA).

2. Enumerate the components of the CGA and the process of care.

3. Identify the members of the CGA team and understand their corre- sponding roles in the team.

4. Identify the various assessment instruments used to evaluate the differ- ent components or dimensions of the CGA.

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Material in this chapter is based on the following chapters in Cassel CK, Leipzig RM, Cohen HJ, Larson EB, Meier DE, eds. Geriatric Medicine: An Evidence- Based Approach, 4th ed. New York: Springer, 2003: Koretz B, Reuben DB. Instru- ments to Assess Functional Status, pp. 185–194. Reuben DB. Comprehensive Geriatric Assessment and Systems Approaches to Geriatric Care, pp. 195–204.

Selections edited by Rainier P. Soriano.

Case (Part 1)

An 84-year-old African-American woman comes to your offi ce accom- panied by her niece. You begin your history by asking the patient why she came to see you. She replied: “I don’t know why I’m here!” Her niece then interjects: “She has problems with memory.”

General Considerations

Geriatric assessment refers to an overall evaluation of the health status of the elderly patient. The well-being of any person is the result of the interac- tions among a number of factors, only some of which are medical. Thus, an overall functional assessment is more holistic than the traditional medical

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evaluation. The ultimate goal of these evaluations is to improve or maintain function.

Conceptually, comprehensive geriatric assessment is a three-step process:

(1) screening or targeting of appropriate patients; (2) assessment and devel- opment of recommendations; and (3) implementation of recommenda- tions, including physician and patient adherence with recommendations.

Each of these steps is essential if the process is to be successful at achieving health and functional benefi ts.

Frequently, assessment instruments are used in geriatric assessments to evaluate the various components of patients’ lives that contribute to their overall well-being. These components, or domains, include cognitive func- tion, affective disorders, sensory impairment, functional status, nutrition, mobility, social support, physical environment, caregiver burden, health- related quality of life, and spirituality. The results from an individual geriatric assessment can be used to establish a baseline for future compari- sons, form diagnoses, monitor the course of treatment, provide prognostic information, and screen for occult conditions. A list of some suggested instruments appears in Table 2.1.

Screening and Selection of Appropriate Patients

Most CGA programs have used some type of identifi cation of high risk (targeting) as a criterion for inclusion in the program. The purpose of such selection is to match health care resources to patient need. For example, it would be wasteful to have multiple health care professionals conduct assess- ments on older persons who are in good health and have only needs for pre- ventive services. Rather the intensive (and expensive) resources needed to conduct CGA should be reserved for those who are at high risk of incurring adverse outcomes. Such targeting criteria have included chronological age, functional impairment, geriatric syndromes (e.g., falls, depressive sympto ms, urinary incontinence, functional impairment), specifi c medical conditions (e.g., congestive heart failure), and expected high health care utilization.

Each of these criteria has been shown to be effective in identifying patients who may benefi t from some type of geriatric assessment and man- agement. However, none of these criteria are effective in identifying patients who would benefi t from all geriatric assessment and management programs. Accordingly, the specifi c targeting criteria should be matched to the type of assessment and intervention that is being implemented.

Assessment and Development of Recommendations

Once patients have been identifi ed as being appropriate for CGA, the tra- ditional model of CGA invokes a team approach to assessment. Such teams are intended to improve quality and effi ciency of care of needy older

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Table 2.1. Suggested brief geriatric assessment instruments Domain Instrument Sensitivity (%) Specicity (%) Time (min) Cut point Comments Cognition DementiaMMSE (3)79100a 461009<24bWidely studied and accepted Timed Time941003746<2<3 sec for time and Sensitive and quick and Change<10 sec for change Test (8) DeliriumCAM (12) 9410090–95<5 Sensitive and easy to apply Affective GDS 5 Question978512Rapid screen disorders form (17) Visual Snellen chart (62) Gold standard Gold standard 2 Inability to read at Universally used impairment 20/40 line 50% Hearing Whispered 8090 7089 0.5 correct No special impairment voice (23,62) equipment needed Pure tone 94–1007094 <5Inability to hear2 of Can be performed audiometry4 40-dB tones by trained offi ce (23,25) (0.5, 1, 2, and 3 kHz) staff Dental healthDENTAL (28)8290<2 Score of 2 (estimated) Nutritional Weight loss of 6570 8788 Yes to either status >10 lb in 6 months or weight <100 lb (63) Gait and Timed up-and-go 8894<1>20 seconds Requires no special balance test (46,63) equipment a While some studies gave found lower sensitivities, most studies of dementia subjects fall in this range (3). b Cutoff is dependent on a number of variables including age, education, and racial or ethnic background (3). Source: Koretz B, Reuben DB. Instruments to assess functional status. In: Cassel CK, Leipzig RM, Cohen HJ, et al, eds. Geriatric Medicine, 4th ed. New York: Springer, 2003.

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persons by delegating responsibility to the health professionals who are most appropriate to provide each aspect of care. Appropriateness in this case indicates both special expertise (e.g., social workers have unique knowledge about community resources) and costs of providing care (e.g., a nurse may be able to conduct some medical assessments as well as a physician). Such team care requires a set of operating principles and gov- ernance. Otherwise, it can result in uncoordinated, redundant, or dysfunc- tional care.

Implementing Recommendations from the Comprehensive Geriatric Assessment

In inpatient settings where the assessment team has primary care of the patient, generally implementation of recommendations is not a problem, provided that there are adequate resources. However, patients may refuse to participate in diagnostic or therapeutic plans. When the CGA team is providing consultative services, the link between recommendations and implementation is less certain. In outpatient settings, the implementation of CGA recommendations is particularly tenuous because the process can fail at several points including lack of implementation of CGA recom- mendations by primary care physicians and poor adherence to CGA rec- ommendations by patients. Successful strategies to increase adherence to CGA recommendations have included telephone calls from the primary care provider to the referring physician with follow-up patient-specifi c recommendations by mail, and patient and family education including empowerment techniques. Newer technologies, including fax and e-mail, are increasingly being used to communicate recommendations. Even when primary care physicians and patients are in agreement with CGA recom- mendations, access barriers to receiving indicated services may limit the effectiveness of outpatient CGA. These access barriers include lack of transportation, fragmented services, and gaps in insurance coverage. A potential solution to some of these obstacles is use of home health agen- cies, which can provide a wide range of services to those who are homebound.

The Comprehensive Geriatric Assessment Team

The composition of the CGA team has traditionally included core and extended team members. Core members evaluate all patients, whereas extended team members are enlisted to evaluate patients on an as-needed basis. Most frequently, the core team consists of a physician (usually a geriatrician), a nurse (nurse practitioner or nurse clinical specialist), and a social worker.

The extended members of the team include a variety of rehabilitation therapists (e.g., physical, occupational, speech therapy), psychologists or

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psychiatrists, dietitians, pharmacists, and other health professionals (e.g., dentists, podiatrists).

Regardless of the composition of the team, a key element is the training of the team (1) to ensure that team members have an adequate understand- ing of the CGA process; (2) to raise the level of expertise of team members in their specifi c contribution to the team; (3) to develop standard approaches to problems that are commonly identifi ed through CGA; (4) to defi ne areas of responsibility of individual team members; and (5) to learn to work effectively as a team.

Components of the Process of Care in the CGA

If CGA is to be effective, the following six components of the process of care must be addressed: (1) data gathering, (2) discussion among team members, (3) development of a treatment plan, (4) implementation of the treatment plan, (5) monitoring response to the treatment plan, (6) revising the treatment plan as necessary.

With increased fl exibility in team structure and scheduling, team dis- cussions in outpatient and home settings are increasingly changing from face-to-face meetings to conference calls or via Internet confer encing. In this manner, discussions can occur at convenient times, even though team members may be in geographically disparate locations. However, in inpa- tient settings, where discharge planning is an excep tionally important role for the team, most meetings still occur face-to-face.

Case (Part 2)

The patient’s niece starts telling you her aunt’s history. She says, “She lives alone. She shops and prepares food herself. However, last week she started to boil some water and completely forgot it was on the stove.

The plastic cover was completely melted. When I asked her about this she said she just forgot. She often forgets where she has placed things.

This has been going on for many years but has gotten worse just recently.

Also, at one time she has fallen at home at night after tripping on a rug.

She did not break anything, but bruised her shoulder and forehead. She also used to go to church almost every day but rarely goes now. She hardly socializes and prefers to stay at home and watch TV. She does not have any kids and we’re her closest relatives. You also have to shout, she’s very hard of hearing. She has the hearing aids but she doesn’t like wearing them.”

What dimensions of the comprehensive geriatric assessment need to be addressed in the patient?

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Dimensions of Geriatric Assessment

Cognitive Function

Assessment of the cognition of elderly patients generally focuses on detec- tion of dementia and delirium. Although these two conditions can be dis- tinguished by time course, pathophysiology, and clinical features, they may coexist. In fact, the presence of dementia is a risk factor for the develop- ment of delirium in elderly hospitalized patients (1).

Cognitive Impairment

The prevalence of dementia, an acquired, progressive impairment of mul- tiple cognitive domains, is age dependent. Therefore, the yield of screening for cognitive impairment increases as the population ages. Because the initial phases of impairment can be quite subtle, it can be diffi cult for a cli- nician to make the incidental discovery of cognitive impairment. Struc- tured examination techniques may be helpful in detecting early dementia.

The most widely used assessment tool for cognitive status is the Mini–

Mental State Examination (MMSE) (2). Originally developed to detect delirium, dementia, and affective disorders in inpatient settings, it has since been validated in a number of other settings (3). In a 5- to 10-minute period of time, the MMSE tests a number of cognitive domains: orientation, reg- istration, attention and calculation, language, recall, and visual-spatial ori- entation. It is easy to apply and interpret. In fact, the instrument can be given by offi ce staff after minimal training. The Short Portable Mental Status Questionnaire (4) is similar in design but has a more narrow focus.

It requires that the patient answer many of the same orientation questions as the MMSE, but also asks for the name of the current and past president, the patient’s mother’s maiden name, and his or her birthday, address, and phone number. As the questionnaire is shorter, it takes less time to admin- ister. A disadvantage to both of these performance tests is that they measure functions that are not particularly relevant in everyday life, such as drawing intersecting pentagons and performing serial subtraction.

Other useful and rapidly administered performance-based tests are the clock drawing task and the Time and Change Test. Several clock drawing tests and clock completions tests have currently been validated and they assess executive functioning and visuospatial skills. There are standard- ized scoring methods for the drawing (5), and one of these tests has been shown to have a high negative predictive value for Alzheimer’s disease (6).

The Time and Change Test is a brief performance-based test in which a patient must read a clock face set at 11 : 10 and separate one dollar in change from a collection of coins totaling $1.80 (7,8). It has been shown to be accurate for both inpatient and outpatient populations (7,8). To improve sensitivity, time thresholds may be applied; taking longer than 3

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seconds to correctly tell the time and longer than 10 seconds to correctly make change indicates the need for further evaluation.

A very different type of cognitive assessment is the Set Test (9). As origi- nally described, the patients are given four categories (colors, fruit, towns, and animals) and an unlimited amount of time to list as many members of that category as possible. The maximum score in each category is 10. A score under 5 is considered abnormal (10). This test examines a number of cognitive domains including language, executive function, and memory.

Unimpaired older persons should be able to generate a list of 10 items within 1 minute. (See Chapter 13: Depression, Dementia, Delirium, page 216.) Delirium

Delirium is an acute, fl uctuating alteration in level of consciousness and attention. It is a common occurrence, particularly in hospitalized elderly patients. Because its manifestations can be variable, it is often overlooked.

Delirium is associated with increased morbidity and cost of care.

Several assessment instruments can facilitate the detection of delirium (11). The most commonly used is the confusion assessment method (CAM) (12). When using it, the examiner diagnoses delirium based on the demon- stration of (1) an altered mental status with an acute onset and fl uctuating course, (2) impaired attention, and (3) either disorganized thinking or a change in level of consciousness. Its high sensitivity and brevity make the confusion assessment method a clinically useful instrument. Clinical tests of attention, such as digit span or stating the months of the year backward, may also help detect delirium at an early stage. Because of the temporal variability that is the hallmark of delirium, a patient may seem entirely lucid at the time of evaluation. (See Chapter 13: Depression, Dementia, Delirium, page 236.)

Case (Part 3)

The patient says, “I don’t know why I’m here. Oh, I remember that time when I left the pot on the stove. Well I just forgot. Do you know how old I am? I’m 84 years old and my memory is not what it used to be. I go to the shop myself when my knees don’t hurt. Usually I just eat whatever is left over in my refrigerator when I don’t get to the store. I also fell one time, I think. I had to go to the bathroom and I fell. I hit my head but it wasn’t bad. I didn’t break any bones or anything. I don’t go out much. I’m alone most of the time. I love going to church but I couldn’t hear what my minister is saying. I also couldn’t read the program. Well I’m 84 years old and it comes with age. I have a hearing aid but they don’t work. I take my medicines but I don’t remember what they are but I do take them!”

What additional dimensions of the geriatric assessment need to be addressed based on the patient’s story?

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Affective Disorders

Depression is one of the most common psychiatric disorders affecting older persons. It is associated with signifi cant morbidity and mortality (13). The earliest depression scales relied heavily on the presence of somatic symp- toms (14,15). Hence, the scales may be less useful for geriatric populations with a high prevalence of such symptoms due to other comorbid medical illness (16). The Geriatric Depression Scale (GDS) was specifi cally designed for elderly patients (17). Initially validated in a 30-question format, a 15-question version also has been validated, and a fi ve-item version has been described (18,19). The threshold scores for a positive depression screen are 15, 5, and 2, respectively (17–19). An even more concise approach, a single-question screen, “Do you ever feel sad or depressed?” has been validated (20). The single question may be as accurate in identifying depression as the 30-item GDS (21), although this technique identifi es too many false positives to be useful as a screening instrument (22). (See Chapter 13: Depression, Dementia, Delirium, page 227.)

Visual Impairment

The leading causes of visual loss in older adults—cataract, glaucoma, age-related macular degeneration, and diabetic retinopathy—are preva- lent and treatable. One accepted method of screening is having patients read the letters from the handheld Jaeger card at a distance of 14 inches from their eyes. Decreased visual acuity is defi ned as the patient being unable to read the 20/40 line. The wall-mounted Snellen chart, generally considered to be the gold standard, can be similarly used. Visual acuity tests do not assess the functional impact of visual impairment. Self-report instruments such as the Activities of Daily Vision Scale (23), the Visual Function (VF-14) (24), and the National Eye Institute Visual Function Questionnaire (25) assess patients’ perceptions of impairments of their visual function. (See Chapter 9: Vision and Hearing Impairment, page 143.)

Case (Part 4)

On your examination, the patient is in no distress. Her blood pressure (BP) = 170/80 mmHg, heart rate (HR) = 72/min, respiration rate (RR)

= 18/min afebrile. She has cataracts on both eyes with the left lens more opaque than the right. On otoscopy, she has impacted cerumen in both ears, thus the tympanic membranes were not visualized. The rest of her exam are unremarkable.

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Hearing Impairment

Hearing impairment can result in social isolation, depression, and decreased functional status. Treatment by amplifi cation with a hearing aid has been demonstrated to improve quality of life. Analogous to the visual impair- ments screens, both performance-based and self-reported measuring tools are used to determine hearing loss.

Performance tests include the whispered voice, fi nger rub, and tuning forks. Of these, the whispered voice test has been shown to have acceptable sensitivity and specifi city to be useful as a screen (26).

The examiner performs it by initially asking the patient to repeat a series of words. Then the examiner stands out of sight of the patient, occludes one of the patient’s ears, and whispers one of the previously spoken words at a minimum of 6 cm from the patient’s ear. A passing score is the ability to correctly repeat at least 50% of the whispered words. Screening can also be accomplished with the audioscope, a hand- held otoscope with a built-in audiometer capable of delivering a 40-dB tone at 500, 1000, 2000, and 4000 Hz frequencies. Patients fail the screen if they are unable to hear at least two of the four tones. Compared to pure tone audiometry, the audioscope has a sensitivity of 94% and a specifi city of 72% for detecting hearing impairment. Its positive predictive value is 60% (27). (See Chapter 9: Vision and Hearing Impairment, page 152.)

Dental Health

Dental disease, like visual or hearing impairment, requires a specialist for management. Nevertheless, primary care providers should recognize dental problems and the resulting functional impact so that they can make appropriate referrals. Two of the assessment instruments available are the Geriatric Oral Health Assessment Index (GOHAI) and the DENTAL instrument. The GOHAI (28) is a 12-item self- report measure that assesses the impact of oral disease in three domains:

physical function, psychosocial function, and discomfort. It is sensitive to the change of function and symptoms that occur after the subject receives dental care (29). The DENTAL instrument, on the other hand, is used for screening purposes and to provide dental referrals from primary care practices (30). It is composed of a list of six conditions:

dry mouth, oral pain, oral lesions, diffi culty eating, altered food selection, and no recent dental care. The presence of one of the fi rst three or two of the latter three conditions should trigger a dental referral.

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Functional Status

Functional status has been defi ned as “a person’s ability to perform tasks and fulfi ll social roles associated with daily living across a broad range of complexity” (31). Measures of functional status are used for a wide variety of purposes. Clinicians apply them to establish baselines, to monitor the course of treatment, or for prognostic purposes.

Examinations of function may be divided into three levels: basic activi- ties of daily living (BADL) (32), instrumental activities of daily living (IADL) (33), and advanced activities of daily living (AADL) (34). Basic activities of daily living refer to those functions that are necessary, but not suffi cient, for maintaining an independent living status. Katz et al. (32) describe basic functional tasks: feeding, maintaining continence, transfer- ring, toileting, dressing, and bathing. Individuals with multiple dysfunc- tions at this level require signifi cant in-home support, such as 24-hour care, or nursing home admission.

Instrumental activities of daily living are more complicated levels of activity that are necessary to maintain an independent household. These include tasks such as paying bills, taking medications, shopping, and pre- paring food. People with several defi ciencies in these areas usually require an assisted living, extensive community services, or some in-home support.

At this level, opportunity and motivation are important contributors to maintaining function (35).

The highest level of activity is represented by the AADL. These are tasks such as working, attending religious services, volunteering, and main- taining hobbies. These are the most complex and require the highest level of multiple abilities to complete and thus the most sensitive to changes in health status.

Performance-based measures of functional status provide useful prog- nostic information. Several instruments have been developed including those that focus on lower extremity function (e.g., standing balance, gait speed, and rising from a chair) (36) and those that include upper extremity function (37). These instruments predict functional decline, institutional- ization, and mortality.

Case (Part 5)

On your assessment, the patient has a MMSE of 24/30, a 15-item GDS score of 7, and a timed Up and Go Test of >20 seconds. She says that she rarely socializes due to fear of embarrassment. The patient says that she is independent on all activities of daily living (ADLs) and most instrumental activities of daily living (IADLs). She needs assistance with her housework, medication management, and money matters.

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Nutritional Status

Malnutrition occurs frequently among elderly patients, particularly those residing in nursing facilities. It has been associated with increased mortal- ity, morbidity, and admission to nursing homes (38).

Nutritional status can be evaluated by self-report screens, biochemical markers, and anthropometric measures. The most widely used self-report screen is the 10-question, self-administered checklist portion of the Nutri- tion Screening Initiative (39,40). A score of six or more indicates that a patient is at risk for malnutrition. If patients score at this level, they are prompted to see health care providers for more in-depth evaluations.

Checklist scores can predict future disability and identify persons at high risk for hospitalization (41).

Biochemical markers, though not specifi c for malnutrition, can be used as prognostic indicators. The most studied serum marker is the serum albumin. It predicts morbidity and mortality in community-dwelling, hos- pitalized, and institutionalized patients (42). Hypocholesterolemia is also associated with increased mortality (43). The combination of hypoalbu- minemia and hypocholesterolemia can be used to predict long-term mor- tality and functional decline (44).

Anthropometric tools have been used to assess nutrition. The easiest one for the primary practitioner to employ is the body mass index (BMI).

It is calculated by dividing the body weight in kilograms by the square of the height in meters. A BMI of less than 22 indicates undernutrition and predicts future mortality (45). Measurements of skin folds assess nutri- tional status. However, these measurements require specialized equipment and training and may not be reliable in elderly patients. (See Chapter 11:

Nutrition, page 177.)

Gait and Balance Impairment

Falls are a major cause of morbidity and mortality in geriatric patients.

Assessments of gait and balance impairment should begin with the clini- cian asking patients about their histories of falls, including frequency, resulting injury, and circumstances surrounding each incident. However, because many patients do not recall previous falls (46), self-report mea- sures alone may not be suffi cient. Performance-based assessment instru- ments can be more useful. For example, the Performance-Oriented Assessment of Mobility (47) employs a series of simple tasks: sitting and standing balance, turning, standing without the use of upper extremities for a push-off, and gait. Five other common maneuvers—head turning, reaching, bending over, back extension, and standing on one leg—can be

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added for a further assessment of balance. All of these simulate real-life situations in which the patient may be at increased risk for falls. While impairment in these activities is not diagnostic of a particular pathologic process, clinicians can use this information to identify those in need of further diagnostic evaluation.

Other screening instruments include the Timed Up-and-Go Test (48) and functional reach (49). In the Timed Up-and-Go Test, patients arise from a seated position, walk 3 meters, turn around, return to the chair, and sit down. A healthy, elderly individual should be able to complete this task in less than 10 seconds; any result greater than 20 seconds should prompt a more in-depth evaluation. This test may also be useful to follow patients over time for functional decline.

Although falls themselves create disability, even the fear of falling can produce functional limitation. The Survey of Activities and Fear of Falling in the Elderly is an instrument designed to evaluate how this fear contrib- utes to the restriction of physical activity (50). (See Chapter 20: Instability and Falls, page 356.)

Social Support

There is a strong association between patients’ social functioning and health status. Clinicians should be familiar with their patients’ levels of social interaction. During times of physical or emotional stress, these social networks may mean the difference between remaining independent in the community or requiring nursing home care. As part of the social history, the health care provider should ask about who lives with the patient, who provides meals and transportation if the patient is unable to do so, and if the patient provides care for anyone else. These questions are particularly important because any subsequent absence of a caregiver, if present, would have major implications for the patient’s well-being. (See Chapter 6:

Psychosocial Infl uences in Health in Late Life, page 80.)

Environment

Although physicians rarely perform home safety evaluations themselves, many home health providers are trained to do so. These evaluations are covered by Medicare for those who are eligible for home health services.

Environmental hazards that may lead to falls are common in community- based housing and in retirement communities (51). The most common hazards are poor lighting, pathways that are not clear, and loose rugs or other slip and trip threats. (See Chapter 20: Instability and Falls, page 366.)

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Caregiver Burden

Because dementia and other chronic illnesses affecting the elderly are prevalent, older persons are frequently caregivers for their spouses or other relatives. The psychological, physical, and economic burden associated with caregiving can be substantial. Moreover, such stress also has effects on patients who are recipients of care. Increased caregiver burden inde- pendently predicts use of medical services and nursing home placement (52). Interventions to decrease the stress of caregivers may delay nursing home placement (53).

Scales to assess caregiver burden are primarily used for research (54), but some may have clinical applications. The Screen for Caregiver Burden (55) evaluates spouse caregivers of patients with Alzheimer’s disease. It is a 25-item self-administered questionnaire that is sensitive to changes over time. The Caregiving Hassles Scale also evaluates the stress experienced by the caregivers of family members with Alzheimer’s disease (56). This 42-item self-administered instrument focuses on the minor irritations asso- ciated with providing care on a daily basis.

Quality of Life

Many elderly patients have chronic diseases that result in discomfort and disability. As it is impossible to cure these problems, the goal is to amelio- rate suffering and improve patients’ perceptions of their lives. Measure- ments of health-related quality of life provide feedback to researchers and clinicians so they can better target their efforts. Unfortunately, there is not yet any brief, widely accepted quality-of-life scale specifi cally targeting the geriatric population.

Case (Part 6)

The patient’s niece adds, “She has been followed-up at the medical clinic for more than 10 years but she has had sporadic visits. She was hospitalized before for blood clots in the legs that actually went to her lungs. She had a colonoscopy 2 years ago and they found this growth.

They did a biopsy and they said it wasn’t cancer. I have all of her medi- cines with me. She has glaucoma and she takes these eye drops on both eyes. She also has this ‘water pill’ that she takes for her high blood pres- sure. She also has a cane to help her but she doesn’t use it outside the house. She says it’s ‘too obvious.’” The patient’s niece was almost tearful when she was telling you all of this. She says that she feels frustrated.

She is a mother of four children herself.

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Spirituality

For many older patients, spiritual beliefs are very important components of quality of life. Furthermore, attendance at religious services has been associated with decreased mortality (57). The SPIRIT mnemonic provides a structure for taking a patient’s spiritual history (58). The interview covers Spiritual belief system, Personal spirituality, Integration within a spiritual community, Ritualized practices and restrictions, Implications for medical care, and Terminal events planning. These issues may be particularly important for patients who are approaching death. As with problems in other domains, clinicians should not hesitate to involve specialists. Clergy members can be helpful, especially during times of health crisis.

Strengths and Weaknesses of Instruments

Assessment instruments are simply tools to begin an evaluation process.

It is easy to overestimate their value and make their application an end unto itself. The crucial step in the use of assessment instruments is the interpretation of their fi ndings. Knowing how to proceed based on positive or negative results is one of the most important duties of the clinician.

The choice of which assessment instrument to use is based on a careful consideration of its relative strengths and weaknesses as they apply to a given clinical situation. For instance, comprehensive but lengthy interview- based questionnaires may be appropriate for research settings but not in clinical practice. Patients are usually unwilling to submit to prolonged interviews, and practitioners are unlikely to have enough time to conduct them. Thus, clinically useful assessment instruments must be concise.

An element to consider is the contrast between measures of capacity and those of performance. There are advantages and disadvantages to each approach. Capacity refers to what patients report they are able to do. As the task or skill at issue is not actually performed in an observed setting, the rating process can be completed quickly. Similarly, there is no need for any special equipment. The chief disadvantage of capacity assessment is the reliance on patients’ subjective estimates of their abilities. Thus, clini- cians frequently ask what patients actually do instead of what they can do.

Because some patients function substantially below their capacity, this approach may underestimate their functional ability.

Performance-based measures are direct observations of particular actions. Advantages include an increase in objectivity as patients’ biases and those of their proxies are minimized. Disadvantages include the need to train the observer and the costs for specialized equipment to create the task being observed—an audiometer to create a tone, stairs to climb, etc.

Some tasks (e.g., role functions), however, cannot be measured in clinical settings. Patient factors may also affect the performance of the instrument

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in clinical settings. These include educational level, social background, gender, and ethnicity (59–61). An additional element—patient fatigue—

can affect scores on cognitive or performance-based measures.

Finally, each test has a limited range in which it is sensitive. These are commonly referred to as ceiling and fl oor effects. A ceiling effect describes limited usefulness of an instrument because virtually everyone scores at the top. Conversely, a fl oor effect is when everyone scores at the bottom of the scales. For example, in a population of healthy community-dwelling older persons, the ceiling effect would apply if one measured BADL.

Almost all of the patients are able to complete all of the relevant tasks.

Similarly, in a nursing-home population, almost all patients will be depen- dent in all items of the IADL scale; thus the instrument does not capture a range of function—a fl oor effect.

Incorporating Assessment Instruments

The biggest challenge for clinicians with regard to assessment instruments is incorporating them into a busy practice. The particular combination of self-reported and performance instruments that results in the best yield, highest accuracy, and most effi cient use of time varies from practice to practice. Similarly, how to best utilize trained ancillary staff to maximize the amount of useful information obtained during each offi ce visit depends on the patient populations and resources of each practitioner. Finally, assessment instruments are valuable only if the practitioner can respond to abnormal fi ndings. Hence, clinicians should be knowledgeable and skilled in the management of the conditions detected, including having referral resources available.

General Principles

• Geriatric assessment refers to an overall evaluation of the health status of the elderly patient. It is a three-step process: (1) screening or targeting of appropriate patients; (2) assessment and development of recommendations; and (3) implementation of recommendations, including physician and patient adherence with recommendations.

• Assessment instruments are used in geriatric assessments to evaluate the various components of patients’ lives that contribute to their overall well-being. These components, or dimensions, include cogni- tive function, affective disorders, sensory impairment, functional status, nutrition, mobility, social support, physical environment, care- giver burden, health-related quality of life, and spirituality.

• Assessment instruments are simply tools to begin an evaluation process. It is easy to overestimate their value and make their applica- tion an end unto itself.

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Suggested Readings

Koretz B, Reuben DB. Instruments to assess functional status. In: Cassel CK, Leipzig RM, Cohen HJ, et al., eds. Geriatric Medicine, 4th ed. New York:

Springer, 2003:185–194.

Reuben DB. Comprehensive geriatric assessment and systems approaches to geri- atric care. In: Cassel CK, Leipzig RM, Cohen HJ, et al., eds. Geriatric Medicine, 4th ed. New York: Springer, 2003:195–204.

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