Assessing the Older Adult

Older adults are encountered in various clinical settings, including primary care, acute care (hospitals), community care (e.g., hospital in the home), and residential aged care facilities. Some facilities may have Geriatric Evaluation and Management Units with specialists like nurse practitioners, geriatricians, and allied health staff for comprehensive geriatric assessments.

Iatrogenic Risks in Acute Care

Hospitals can pose iatrogenic risks (illnesses caused by medical treatment) to older adults. These risks include:

Adverse Drug Events: Due to altered physiology, pharmacokinetics, pharmacodynamics, drug compliance, or polypharmacy.
Polypharmacy: Can result in loss of function in activities of daily living.
Nutritional Deficits: Over 40% of patients in acute and sub-acute care are at high risk of malnutrition.
Deconditioning: Inactivity and bed rest can lead to a 5% decrease in muscle mass per day.

Malnutrition is associated with increased hospital stay length, delayed recovery, higher morbidity and mortality risks. It's an under-recognized issue, but awareness is growing, especially concerning frailty. Interventions include ensuring patients can reach their food, have appropriate utensils, and protecting meal times from conflicting activities.

Increased Risks in Acute Care for Older Adults

Older adults in acute care settings face increased risks such as:

Pressure injuries and skin tears.
Falls.
Deep vein thrombosis (DVT).
Chest infections and other hospital-acquired infections.
Delirium.
Urinary tract infections.

Royal Commission into Aged Care Quality and Safety (Australia, 2018)

Established in response to public outcry over deficiencies in aged care facilities. The Royal Commission's final report emphasizes the need for fundamental reform and redesign in aged care. Nurses are crucial in implementing these reforms. Aged care (both residential and home-based) is integral to the national support system and should deliver care responsive to older people's needs to achieve the best quality of life possible. Skilled gerontological nurses are well-positioned to lead person-centered, safe, and accountable care delivery.

Aged Care Standards:

Consumer dignity and choice.
Ongoing assessment and planning with consumers.
Personal care and clinical care.
Services and supports for daily living.
Organisational service environment.
Feedback and complaints.
Human resources.
Organisational governance.

These standards are important for ensuring safe and quality care for older adults.

Common Issues Experienced by Older Adults

Falls, incontinence, dementia, delirium, and depression are common issues. It's important to differentiate these conditions due to overlapping symptoms.

Delirium: A potentially reversible clinical condition with an acute decline in cognitive function. It is a serious disorder that can be fatal. Caused by interplay of biological factors disrupting neuron networks and is most commonly seen in older people aged 65 years or older. Estimates suggest that $10-18$ percent of Australians in this cohort have delirium on admission to hospital with another $2-8$ percent developing delirium whilst an inpatient.
- Predisposing factors: Existing cognitive impairment, depression, or sensory impairment.
- Precipitating factors: Infection, surgery, medication, or falls.
- Prevalence in hospital: In New Zealand, a study of patients aged $70$ years or older admitted to general medical wards reported that the prevalence of delirium was $23$ percent and the incidence during the hospital stay was $5.7$ percent.
- Post-op complication: Delirium is also the most common post op complication in older people who undergo surgery and there's an incidence of $50$ percent after high risk procedures such as hip fracture repair and cardiac surgery.
- Symptoms include confusion, agitation, restlessness, anxiety, and hallucinations.

Burden of Disease in Older Australians

Cardiovascular diseases and cancers account for 24% of the burden of disease, with cancers being more prevalent in males and neurological conditions more prevalent in females. Musculoskeletal issues are more common in females (possibly due to menopause-related hormonal changes increasing fracture risk). Other significant conditions include respiratory and endocrine diseases (including diabetes), as well as hearing and vision impairments.

Person-Centered Care

An approach that places the client/patient and their carer central to all aspects of care and decision-making. Key factors include:

Skilled, knowledgeable, and enthusiastic staff with good communication skills.
Opportunities for client, carer, and family involvement.
Staff reflection on values and beliefs.
Staff training and education.
Organisational support, mutual respect, and trust.

Person-centered care requires recognition of and connection with the person, a focus on their strengths and goals, an interdisciplinary approach, and recognition of the centrality of relationships. Nursing plays a key role in navigating integrated care, addressing the social, physical, and emotional aspects of the individual.

Health Assessment Domains

Comprehensive assessment aims to identify unreported and unmet healthcare needs. Specific domains include:

Medical Health: Medical history (cardiovascular, musculoskeletal, neurological, hearing, vision), pain, falls, dizziness, appetite, weight changes, fatigue, exercise tolerance, communication, swallowing, bladder/bowel function, sleeping habits, sexual function, foot problems, medications, allergies, smoking/alcohol history, diet, immunisation, dental history, and advanced care planning.
Physical Function: Activities of daily living (ADLs) such as eating, dressing, bathing, grooming, toileting, mobility, and balance; instrumental activities of daily living (IADLs) such as using the telephone, cooking, housework, medication management, finances, shopping, and transportation.
Psychological Function: Cognition (acute and chronic confusion), social and recreational activities, behavior patterns, and life preferences.
Social Function: Living arrangements, residence type, co-habitants, social support, carer issues/burden, carer health, economic well-being, living environment safety, access to aids, modifications, and suspicion of elder abuse or neglect.

Sources of Assessment Information

Patient self-report.
Carer or family member reports (if cognitive impairment is present).
Informant reports from others who know the patient well.
Direct observation of the patient performing ADLs.
Secondary written sources such as hospital records, medical reports, and investigation results.

Conducting Assessments of Older Adults

Ensure a well-lit, comfortable, and quiet environment.
Establish rapport, addressing the person respectfully and with patience and cultural sensitivity.
Balance assessment complexity with the individual's endurance, pacing the assessment and allowing for breaks.
Use validated screening tools and input from family members or medical records.

Older people may overestimate their health or attribute new symptoms to normal aging. Cognitive impairment may necessitate data collection from other reliable sources and direct observation.

Health Interview Considerations for Older Adults

Address any vision impairments and provide assistance as needed.
Assess for hearing deficits and their impact on understanding and consent.
Consider mobility issues and provide necessary assistance.
Be aware of fatigue and factor in breaks.
Address pain or other health conditions that may impair focus. Maintain comfort, dignity, and privacy.

Health History

Begin by obtaining a history of the presenting complaint. The health history should be comprehensive, including medical, social, and family history, as well as a review of body systems. Document subjective data in the patient's own words. Comprehensive assessments by nurses with specialist gerontological skills can reduce length of stay and the incidence of geriatric syndromes. Geriatric nurse consultants can administer comprehensive geriatric assessments and uncover clinically actionable findings.

Specialist Assessments

Developmental Assessments: How to maintain and develop new activities to retain functional capacities of the older person. Might be accepting and adjusting to changes in mental and physical strength and agility and health status for the older person or maintain and develop activities that contribute to a continuing sense of usefulness, self worth and enhanced self image.
- Includes tools like the Functional Assessment Screening in the Elderly (FASE), quality of life assessments, and depression tools.
- Aged care facilities use the Minimum Data Set for Nursing Facility Resident Assessment and Care Screening.
Cultural and Spiritual Assessments: Cultural origins affect healthcare practices and beliefs. Faith and religious practices are coping mechanisms.
Nutritional Assessment: Tools assess deficits and weight loss. Challenges include declining caloric needs, decreased taste, less efficient absorption, chewing/swallowing issues, disability affecting food preparation, financial constraints, social isolation, and medication effects.
Pain Assessment: Understand that older adults may use different language to describe pain. Inquire about the pain's duration, location, severity, quality, and impact on ADLs. Identify factors that worsen or relieve the pain. Chronic pain affects physical function; longer consultation times and simple pain assessment tools can enhance communication and assessment.

Physical Examination

Functional Ability: Functional status assessment is important. Acute illness or worsening of chronic illness and hospitalizations can contribute to a decline in the ability to perform tasks necessary to live independently. Data from functional assessment provides objective information to assist with individualised needs or to plan for specific in home services. A functional assessment can also assist to focus on the person's baseline capabilities, facilitating early recognition of changes requiring further assessment.
ADLs: Self-care activities like feeding, bathing, dressing, transferring, toileting.
IADLs: Housework, meal preparation, managing finances.
Lawton Instrumental Activities of Daily Living Scale: Assesses independent living skills, scoring ranges from zero (low function/dependent) to eight (high function/independent).
Cognition: Mental status assessments (MMSE; Depression Scale)
Mobility: Balance, aids used
Vision: Ability to read

Vital Signs in Older Adults

Normal aging changes affect respiratory and cardiovascular systems, impacting vital signs. Normal ranges include:

Respiratory Rate: 12-24 breaths per minute.
Temperature: Lower body temperature (down to 35.5°C may be normal).
Blood Pressure: Both diastolic and systolic may rise due to decreased vascular elasticity. Postural hypotension is common.

Nutritional Screening Tools

Early identification of nutrition risk is important. Commonly used tools include:

Mini Nutritional Assessment (MNA) and MNA-Short Form.
Malnutrition Universal Screening Tool (MUST).
Simplified Nutritional Assessment Questionnaire.
Malnutrition Screening Tool (MST).

The MNA-Short Form (MNA-SF) is a validated tool for identifying malnutrition risk in those aged $65+$ . A score of $0-7$ indicates malnourishment, $8-11$ indicates at risk, and $12-14$ indicates well-nourished.

Pain Assessment Tools (Examples)

In 2018, just over one million people in aged care and 65 and over were living with chronic pain, which represented rates almost double that of the working population. In New Zealand in twenty eighteen-twenty nineteen, an estimated $28$ percent of people aged $65$ to $74$ , and $33$ percent of those aged $75$ years or older experienced chronic pain.

Brief Pain Inventory (Short Form): Assesses pain severity and its impact on daily functioning. Rated on a $10$ point scale.

Falls Risk Assessment

Falls Risk Assessment Tool: A common tool assessing fall risk status (recent falls, medications, psychological function, cognitive status), risk factor checklist, and action plan.
Low risk: $5-11$ , medium risk: $12-15$ , high risk: $16-20$
Repeat assessment after any change in function or fall. Be alert to signs of acute health conditions, like a urinary tract infection, which can suddenly impact a person's balance and increase fall risk.

Pressure Injuries

Use tools such as the Waterloo or Braden scale to identify risk. Assessment should include: skin integrity, mobility, activity, nutrition, sensory perception, blood supply and overall status of health. Pressure injuries are localized injuries to the skin and/or underlying tissue, usually over a bony prominence, due to pressure or pressure combined with shear. Prevention is key.

Skin Tears

Use the STAR Skin Tear Classification System. Skin tears are trauma-induced partial or full-thickness wounds, primarily on extremities of older adults. Ageing and photo ageing is high risk and standardised evaluation is important.

Dementia-Specific Pain Assessment

Abbey Pain Scale: An Australian assessment tool, also known as the ABI. Useful for patients with advanced dementia. Quick to administer; assesses nonverbal pain cues (behavioral and physiological changes). Re-administer one hour after analgesia to assess effectiveness. Pain indicators include change in:
- vocalisation.
- facial expression.
- body language.

It assess whether those patients are:

rocking.
guarding part of the body.
Withdrawn
behavioral changes such as increased confusion.
refusing to eat.
alteration in usual patterns.

Or it evaluate the existence of any physiological changes, so might be something like they're perspiring or flushing, and any physical changes such as skin tears or pressure areas.

It's important to assess for pain in persons with dementia, as pain relief may reduce agitated behaviors.

Cognitive Status Assessment

Mini-Mental State Examination (MMSE): Assesses orientation, registration, attention and calculation, recall, and language: Valid and commonly used. Total scores of; $24-30$ indicate no impairment, $18-23$ indicate mild impairment, and $0-17$ indicate severe impairment.

Delirium Assessment

Replacement of the term dementia to major and mild neurocognitive disorders in an effort to reduce dementia related stigma to recognise the continuum of cognitive decline and to facilitate early diagnosis. Timely identification of delirium can facilitate early implementation of non pharmacological strategies for prevention and management, which may improve outcomes for the older person.

Validated assessment tools improve the recognition of delirium.

Confusion Assessment Method (CAM): Most widely used. Captures acute onset and fluctuating course, inattention, disorganized thinking, and altered consciousness.
4AT: Assesses alertness, orientation, attention, and acute changes. A score of $4+$ suggests delirium and cognitive impairment, score of $1-3$ indicates cognitive impairment. A score of zero does not exclude delirium or cognitive impairment.

Delirium is a medical emergency. The underlying causes need to be identified and treatment aims to alleviate symptoms and reduce risk of complications. Delirium usually lasts for only a few days but may continue for weeks or months.

Disability

An umbrella term for impairments, activity limitations, and participation restrictions. Can be associated with genetics, illness, accidents, or aging. In 2015, 50% of men and 52% of women aged $65+$ had some form of disability; this proportion was higher (78% of men and 80% of women) for those aged $85+$ . In 2015, $15$ % of men and $22$ % of women aged $65$ and over experienced disability as a severe or profound core activity limitation.

Mechanisms of Disability

Physiological: Congenital defects, genetic abnormalities, trauma.
Psychological: Nervous or emotional conditions, mental illness, brain injury.
Social: Language, body language, social interaction, values and beliefs.
Biopsychosocial: Combination of psychological, physiological, and social mechanisms.

Person-centered approach is important for any patient, regardless of age or disability status.