Geriatric Assessment

GERIATRIC ASSESSMENT NOTES
OBJECTIVES

  • Identify the normal physiologic process of aging, differentiating it from disease states.

  • Identify classic geriatric syndromes (e.g., falls, delirium, incontinence, frailty) and nonspecific symptoms (e.g., confusion, fatigue, weight loss) that may represent specific illnesses in older adults.

  • Identify “hidden” illnesses that occur in the elderly due to atypical presentations, such as infections without fever or myocardial infarction without chest pain.

  • Identify how the presentation of acute illness is modified in older patients, including the importance of eliciting the Chief Complaint (CC), History of Present Illness (HPI - 7 parameters), and Review of Systems (ROS) from older patients, acknowledging potential communication barriers and atypical symptom presentation.

  • Analyze the medical complexity and comorbidities that affect geriatric patients, such as polypharmacy and multiple chronic conditions, and how they contribute to the challenges of eliciting medical history.

  • Identify components of patient-centered care in geriatric care and adapt health history to include areas of specific concern for older adults, emphasizing goals of care and advanced directives.

  • Identify strategies to minimize potential barriers in communication (e.g., sensory deficits, cognitive impairment), history, and physical examination (PE), and utilize adaptive strategies to mitigate such problems.

  • Elicit baseline information in five domains of geriatric care, which are crucial for a holistic assessment and care planning:

    • Mental health, including cognitive function and mood disorders,

    • Physical health, encompassing chronic diseases and functional status,

    • Functional abilities, including Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs),

    • Social support, evaluating networks and living environment,

    • Economic resources, assessing affordability of care and necessities.

  • Identify effective interviewing skills and an organized approach to meet the goals of each visit, recognizing that multiple visits may be necessary for comprehensive assessment.

  • Emphasize the importance of developing relationships with geriatric patients, their caregivers, and family, fostering trust and facilitating shared decision-making.

  • Describe expected age-related physical changes encountered during physical examination, distinguishing them from pathological findings.

INTRODUCTION

  • Older adults increasingly represent a large part of the patient population, particularly in the U.S., with projections indicating that by 2030, nearly one in five U.S. residents will be 65 years or older.

  • The fastest growing age group is individuals over 85 years old, presenting unique challenges and healthcare needs.

  • Older adults may present differently than younger patients with common conditions due to altered physiology, multiple comorbidities, and blunted symptom responses.

  • There is a distinct approach to assessing older adults compared to younger adults.

    • Younger Adults: implement a disease-oriented approach, focusing on diagnosing and treating single conditions.

    • Older Adults: adopt a “successful aging” approach focusing on maximizing health span rather than just lifespan, emphasizing functional independence, quality of life, and prevention of age-related decline.

UNDERSTANDING GERIATRICS

  • Terminology:

    • Geriatrics, elderly, older adult: these terms carry specific connotations; it is important to consider person-first language and to understand that chronological age alone is not synonymous with health status. Specific considerations in assessments of these populations should be made to avoid ageism and ensure appropriate care delivery.

EVALUATING THE GERIATRIC PATIENT

  • Potential Challenges:

    • Provider perspective: communication differences may arise due to sensory deficits (hearing, vision) or slower processing speeds in older patients; assessing the depth of patient histories can be complex due to multiple comorbidities and fragmented records.

    • Patient perspective: may have cognitive barriers (e.g., memory impairment, early dementia) or emotional barriers (e.g., fear of losing independence, embarrassment, cultural norms) affecting willingness to disclose symptoms or concerns.

    • Complexity and comorbidities significantly affect the comprehensiveness of medical history, often leading to polypharmacy and atypical disease presentations.

    • Issues of surrogacy, capacity, and Power of Attorney (POA) are paramount in decision-making for older adults, especially when cognitive impairment affects their ability to make informed choices.

  • Potential Difficulties of Physical Exam: Physical limitations such as joint stiffness, pain, decreased mobility, or fatigue can affect the thoroughness and comfort of the exams. Sensory impairments can also make cooperation challenging.

GERIATRIC 5 Ms APPROACH

  • This framework provides a comprehensive and patient-centered way to organize geriatric assessment and care:

  • 1. Mind: Encompasses cognitive states, including assessment for mood disorders (e.g., depression, anxiety) and various forms of dementia. Cognitive screening tools are often utilized.

  • 2. Mobility: Involves assessing functional mobility, gait, and balance to prevent falls, maintain independence, and manage conditions that affect movement. This also ties into physical activity recommendations.

  • 3. Medications: A critical review of optimal dosing, identification of underprescribing, concurrent prescribing, and overprescribing (polypharmacy). It considers medications as common risk factors for falls, adverse drug reactions, and emphasizes deprescribing when appropriate.

  • 4. What Matters Most: Focused on gathering patient-centric goals, treatment preferences, and meaningful health goals. This includes discussions about advanced directives, end-of-life care preferences, and aligning medical interventions with individual values.

  • 5. Multicomplexity: Recognizes the prevalence of multiple complex diagnoses (e.g., diabetes, heart failure, arthritis, neurological conditions) and how they interact to impact patient care, requiring an integrated and coordinated approach.

PATIENT APPROACH AND COMMUNICATION

  • Characteristics of Effective Communication:

    • Show respect, patience, and cultural awareness, using appropriate language and addressing the patient directly.

    • Adjust physical settings: ensure good lighting to accommodate visual impairments, adaptive seating for comfort and ease of movement, and minimize background noise to aid hearing.

    • Avoid technological barriers; ensure that electronic health records or devices do not detract from direct patient interaction.

    • Consider pacing the conversation effectively, allowing adequate time for the patient to process questions and respond, permitting time for reminisce but noting endurance limits and potential fatigue.

    • Utilize multiple visits if needed to gather comprehensive information on health goals and treatment preferences, especially for complex cases, rather than rushing a single encounter.

ELICITING SYMPTOMS AND CHIEF COMPLAINTS

  • Begin with open-ended questions to encourage patients to share their concerns freely, as some patients may be reluctant to volunteer information due to various reasons (e.g., fear, modesty, belief that symptoms are