Vol 25 No. 2 / Apr - Jun 1999
of the Elderly Patient
Comprehensive assessment of the elderly patient is one of the most difficult areas in clinical geriatrics. This is compounded by time constraints and competing problems in the primary care setting. In this paper, we shall attempt to lay out the principles of geriatric assessment, the scope of such an assessment and a simple method of performing it in an outpatient setting.
Mindset Shift in when Managing Elderly Patients
Unlike the young, the elderly patient is more likely to have multiple illnesses, most of which would be of a degenerative or neoplastic nature. Common ones would be arthritis, hypertension, ischaemic heart disease and hearing impairment. Polypharmacy is a common phenomenon because of this, not forgetting the frequent use of proprietary medications for complaints such as constipation and lethargy. All too frequent patients mix occidental medications with other alternative therapies. Disease-disease, drug-disease and drug-drug interactions can then arise and increase the complexity of the medical problems.
Functional consequences of illnesses and complications vary from one patient to another. It may also determine the nature of further treatment, if any. For example, a patient who develops severe behavioural problems from Alzheimerís disease should be treated very differently from a patient who only has difficulty counting money but is otherwise still functioning well in the community. Function may take a longer time for recovery than the acute illness. A person who becomes bedbound from an acute illness may take many months before he regains his feet.
The elderly may not present in a "classical" manner. Altered response to illness is common. A patient presenting with confusion may not have a problem in the neurological system, but rather have an infection. Social and psychological factors may further obscure this "classical" presentation. Frequently the presentation is that of the "geriatric giants": confusion, falls, immobility and incontinence. Each of these "giants" is an indication for a more detailed assessment. Presentation may also be delayed because of various fears (such as that of hospitalisation), loss of faith in the health care system, denial or depression. Illness response to even appropriate treatment may not always show the same dramatic recovery as in the young, thereby also impacting on the functional status.
The socioeconomic environment impacts heavily on the management of patients. Aspects such as place of residence, financial independence and the presence of carers determine to a certain extent the optimal placement of the patient, and may even determine the need for institutionalisation.
Depression is more common in the elderly as compared to the young. It is frequently undiagnosed. Unlike the young, there is seldom reporting of mood changes. The elderly would more often have weight loss, agitation and even cognitive loss, a state known as pseudodementia.
Components of a Comprehensive Assessment
The geriatric assessment is aimed at these unique characteristics of the elderly. It is frequently multidimensional and multidisciplinary in nature. The assessment in the primary care setting frequently cannot achieve the same depth as that of an inpatient geriatric care team; nevertheless, it can be just as comprehensive in scope. Essentially, it comprises an assessment of the physical health, functional status, mental health and socioenvironmental status. Direct questioning is often required, as information may not be volunteered.
Evaluation of the Elderly Patient
A complete medical assessment in the elderly patient needs to be a forward-looking process, not only addressing the "chief complaint" as is done in traditional practice. A systems review is also frequently required as this may point towards the diagnosis; for example, an elderly person who apart from having frequent falls, also has chest pain, breathlessness, orthopnoea and lower limb oedema, would point towards a cardiovascular diagnosis instead of a neurological one. The sequence in which events develop is also important; for example, urinary incontinence that results from immobility because of undiagnosed Parkinsonís disease requires a very different treatment from one that was preceded by constipation because of poor fibre intake.
A thorough drug history is also required. All medications should be listed down, including over-the-counter medications. It is also important to capture who prescribed the various medications. Drug allergies and compliance must be noted.
A search for common chronic conditions in the elderly, in particular the presence of the "geriatric giants" is essential. Certain chronic conditions do occur more commonly in the elderly. These would be hypertension, diabetes mellitus, hypercholesterolemia, heart disease, hearing loss and arthritis. An often forgotten aspect is that of nutrition. The BMI (Body Mass Index) can be measured by Weight(kg)/Height2(m2). A value of less than 20 indicates that the patient is underweight.
Evaluation of the senses would comprise the evaluation of sight, hearing and the oral cavity. The elderly frequently under-report hearing loss. They also frequently do not report defective hearing aids and furthermore, underuse hearing aids when prescribed. The oral cavity and dentures, if any, should be looked at. Ill-fitting dentures are not an uncommon cause of poor nutrition.
One often missed clinical sign is that of postural hypotension, which may be due to diseases like diabetes mellitus, ischaemic heart disease, hyponatremia or any hypovolemic state; it may also be iatrogenic from drugs like antihypertensive medications and levodopa.
Function can be divided into Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL.) The ADL can be remembered as a simple mnemonic DEATH: Dressing, Eating, Ambulating, Toileting and Hygiene. The mnemonic for IADL is SHAFT: Shopping, Housekeeping, Accounting, Food preparation and Transportation. Simple questions regarding each of these abilities would be sufficient. When impairments are detected, ascertaining the timing and the reason for them can help determine the underlying cause and the potential for reversibility. Acute and subacute losses are frequently signs of diseases and treatment may restore function.
As a part of the testing for ambulation, the joints of the lower limbs need to be assessed for their range of pain-free motion; balance and gait should also be tested. Balance can be tested by the use of the "Functional Reach Test". Mount a ruler at the patientís shoulder height. The patient then raises his arm parallel to the ground. He then leans forward as far as possible without losing his balance. If he cannot reach beyond 6 inches without losing his balance or taking a step forward, the patient is at high risk for falls within 6 months. Gait can be tested with the "Get-up-and-go Test". Observe the patient getting up from a chair, walking a distance of 3 metres, turning around and sitting back on the chair.
Upper limb function can be tested by asking him to go through some simple maneuvers.
Mental state examination would revolve around cognition and depression. Although there are other aspects of cognition like abstract thinking and judgement, it is only practical to test memory and orientation in the clinic. One simple method would be the use of the Abbreviated Mental Test (AMT). This is a 10-point assessment scale:
Depression is usually not reported. A direct question like, "Do you often feel sad or depressed?" may be useful. If the patient has symptoms that suggest depression like weight loss or deteriorating function, a more detailed interview may be required. Drugs like digoxin, benzodiazepines, antihistamines can also cause depressive symptoms.
A social assessment would include a history of the carers, the patientís financial status and his home environment. Though not commonly done, home visits are immensely helpful. A simpler assessment would involve asking the carer, "Do you feel overwhelmed?" A question for the patient would be, "Who is available to help you in event of an emergency?"
In the well elderly, frequently only a clinical assessment is required. Some simple laboratory investigations that may be helpful are a Full Blood Count, a Renal Function Panel, a Chest X-Ray, an Electrocardiogram and a Lipid Panel. In a frail patient, a Thyroid Function Test, a Vitamin B12 level, a Folate level and a serum Calcium may be helpful.
Putting it Together
Table 1 shows a clinical assessment model that can be completed within 10 minutes. This may not have to be done in one sitting. A checklist can be used to see if any of the aspects of an assessment have been missed.
Through such an assessment, it is hoped that asymptomatic illnesses may be detected and a health maintenance programme planned for. An accurate diagnosis and problem list can be formulated. Rational therapy can then be initiated. Referral to institutions, physiotherapists, medical social workers and the home nursing foundation may be required.
A comprehensive geriatric assessment is not out of the realms of a primary care practice. With widespread practice of assessments among the primary practice population, the hope of a healthy elderly population would not be an impossibility.
1. Gudmundsson A, Carnes M. Geriatric assessment: Making it work in primary care practice. Geriatrics 1996; 51 (Mar) 55-65.
2. Fleming KC, Evans JM et al. Practical Functional Assessment of Elderly Persons: A Primary-Care Approach. Mayo Clin Proc 1995; 70:890-910.
Table 1 Clinical Assessment model