The Geriatric Patient

Functional Capacity Assessment

The concept of functional status is very important in geriatric medicine. It is a measure of how the patient performs activities important in daily life, or activities of daily living (ADL). These activities are divided into three groups:

• Self-care ADLs include dressing, bathing, transferring from bed to chair, toileting, grooming, and feeding oneself.

• Instrumental ADLs include meal preparation, managing finances, using the phone, taking medications, doing housework, shopping, and managing transportation.

• Mobility ADLs specifically look at walking from room to room, climbing stairs, and walking outdoors.

Assessing functional capacity from these categories essentially focuses on exploring whether or not the patient can perform these activities independently, or if there have been any recent changes or adjustments in how these activities are performed. Decline in ADL function in an older adult can signal the need for a change in living situation. This change may mean obtaining in-home help, pursuing rehabilitation efforts, or even moving to a facility that can provide the care needed. Bathing is usually the ADL most associated with disability, and often is the main reason older adults are referred for home care services.

See Video 25.1 .

There is a physical testing component to examining functional status for the geriatric patient as well. It is always important to assess the use of any assistive devices such as canes and walkers. Watching the patient walk and use these devices is very informative. For example, there are patients who decide to use a walker that once belonged to their spouse because they needed physical support, and the device was already on hand in their home. When equipment is not used as prescribed, it may be that the patient is using the wrong device for their particular problem, and very often the device is not set to the right height requirements. These concerns can be addressed and corrected during the patient encounter rather quickly. To assess proper cane height, have the patient stand with his/her arms relaxed at his/her side. The top of the cane should be at the crease of the patient's wrist. Physical therapists are extremely helpful in advising as to the right appliance and fit as well. For example, a patient who has issues with balance and may need more support with standing probably should not use a rollator. ⁶

6 A rollator is an ambulatory device that consists of a frame with three or four large wheels, handlebars, and a built-in seat, which allows the user to stop and rest when needed.

This patient would likely benefit more from a standard walker.

An important performance-based test is the “ Timed Get Up and Go Test. ” To perform this test, your patient rises from a chair, walks 10 feet, turns, walks back to the chair, turns again, and sits down. Completing this sequence in less than 10 seconds would translate to normal function. Patients who take longer than 20 seconds to complete this sequence require further evaluation, and may be at risk for decline in their overall ADLs. Performing this test in the office is easy, and it allows a physician to watch their patient walk. This activity alone is very powerful. Very often, in a busy outpatient practice, patients are seated in an exam room waiting for their physician to arrive for their appointment, making it possible for a provider to never see how their patient ambulates. This would be a critical miss in geriatrics. Assessing gait leads to an important database of information ranging from falls risk to disease diagnosis. For example, Parkinson disease patients have a very typical gait. They walk with small shuffling steps, and there may be a generalized slowness. Many ambulate with short steps that eventually become faster. This is called a “ festinating gait. ”

Other easy-to-incorporate office-based assessments include simply asking your patient to rise from a seated position with their arms folded across their chest, thus not allowing the patient to use their arms for support in the process. This allows the physician evaluator to assess weakness at the hip flexor and knee flexor joints, as well as quadriceps strength. This is also highly predictive of future disability, and offers a clear place to intervene with physical therapy for improvement in function. The single strongest predictor of future disability and death, however, is gait speed. It has even been proposed as a possible geriatric vital sign. A patient who can walk 50 feet in a hallway in less than 20 seconds would have no impairment. ⁷

7 Studenski S, Perera S, Patel K, et al. Gait speed and survival in older adults. JAMA 2011;305(1):50.

Finally, asking the patient if they have had any falls within the last year and describe the details of these events are very important. Nearly a third of community-dwelling older adults will fall each year. Future falls can be prevented by exploring the reasons why they occurred and then intervening to change the surrounding circumstances. Exercise, physical therapy, and vitamin D supplementation have all been associated with a reduced fall risk in patients over the age of 65.

Nutritional Assessment

Patient weight should be measured at all visits. Unintentional weight loss of more than 5% of body weight in 6 months or a BMI less than 20 should prompt further workup. Underlying malignancy is a common reason for weight loss in the elderly. However, there are many other (and multifactorial) reasons for unintentional weight loss in an older adult patient that can be treated. Using the mnemonic “ Meals on Wheels ” is an easy way to remember them: ⁸

8 Morley JE, Silver AJ. Nutritional issues in nursing home care. Ann Intern Med . 1995;123:850.

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9 Huffman, GB. Evaluating and treating unintentional weight loss in the elderly. Am Fam Physician 2002;65(4):640.

• M: Medications effects

• E: Emotional problems, especially depression

• A: Anorexia nervosa, alcoholism

• L: Late-life paranoia

• S: Swallowing disorders

• O: Oral factors (e.g., poor fitting dentures and caries)

• N: No money

• W: Wandering and other dementia-related behaviors

• H: Hyper- or hypothyroidism, hyperparathyroidism, and hypoadrenalism

• E: Enteric problems

• E: Eating problems (inability to feed oneself)

• L: Low salt/cholesterol diet restriction effect

• S: Social problems (isolation, unable to access preferred foods) and stones

Cognitive Assessment

Among Americans, 5.7 million are living with Alzheimer disease. In fact, every 65 seconds, someone in the United States develops the disease. The vast majority of these patients are over the age of 65 years. Essentially, one in every 10 people over the age of 65 years in the United States has Alzheimer dementia. The prevalence increases with increasing age, affecting a third of the patients over the age of 85. ¹⁰

10 Hebert LE, Weuve J, Scherr PA, et al. Alzheimer's disease in the United States (2010–2050) estimated using the 2010 Census. Neurology. 2013;80(19):1778.

Alzheimer dementia is the most common type of dementia. When one considers the additive effects of other common dementias (e.g., vascular dementia, Parkinson disease related dementia, and Lewy body dementia), along with some of the less common etiologies, the prevalence approaches 40% to 50% of the population at age 90. Screening for cognitive compromise is essential. Patients with cognitive impairment are at increased risk for adverse outcomes, including delirium, accidents, medication nonadherence, and worsening disability. Early detection of dementia and mild cognitive impairment (MCI) is important because early treatment initiation is beneficial to patients. Additionally, there are many ways that health care providers can intervene to improve quality of life, safety, and supports for these patients.

There are quite a few validated tools available to make a quick office-based assessment:

Psychological Assessment

Depression is not a normal part of aging. However, it is estimated that 1 in 10 older adults seen in the primary care setting would meet the criteria for major depressive disorder. A significant amount of others would present with more subclinical findings: low energy, insomnia, or somatic complaints. The presence of even subclinical depression increases the risk of disability and declining function. Concurrent depression makes it harder for seniors to recover from acute illness over time. Untreated depression is also associated with leads to social, cognitive, and quality of life decline, as well as increased health care utilization and suicide. ¹⁴

14 https://consultgeri.org/try-this/general-assessment/issue-4 . Accessed February 25, 2019.

Screening for depression should be part of any office-based geriatrics assessment. In a busy office setting, taking the time to ask only one screening question—“Do you often feel sad or depressed?”—can, at the very least, identify patients who would need further evaluation. The two most common office-based screening tools are the Geriatric Depression Scale (GDS) and the Patient Health Questionnaire (PHQ). The GDS exists in long (30 question) and short (15 question) forms. Both versions are assessment tools only and not meant to substitute for a diagnostic interview and further evaluation. The GDS does not screen for suicidality. Both forms are available, and translated into many languages, at https://web.stanford.edu/~yesavage/GDS.html . The PHQ-2 ¹⁵

15 Kroenke K, Spitzer RL, Williams JB. The patient health questionnaire-2: validity of a two-item depression screener. Med Care 2003;41:1284.

is a two-question version of the PHQ. It asks about feelings of depression and hopelessness as well as the ability to gain pleasure from or be interested in doing things over this time period. It is scored on a 0- to 6-point scale. A score of 3 or higher should prompt further evaluation with the PHQ-9 scale. The PHQ-9 is a valid and reliable tool to measure the severity of depression, and it has the advantage of being able to be self-administered. ¹⁶

16 Kroenke K, Spitzer RL, Williams JBW. The PHQ-9 validity of a brief depression severity measure. J Gen Intern Med . 2001;16(9):606.

See Video 25.2 .

Medication Reconciliation

Older adults in America use one-third of all of the drugs prescribed in the country. The average older adult takes at least five prescription medications. ¹⁷

17 https://www.mdmag.com/conference-coverage/aafp_2010/how-many-pills-do-your-elderly-patients-take-each-day . Accessed February 25, 2019.

Seniors are also high utilizers of supplements, complimentary alternative medicine, and other over-the-counter preparations. Medication reconciliation should be performed at every visit with an older adult patient and at every transition point in care. It is not uncommon to uncover errors of duplication or omission as well as significant adverse medication interactions. The easiest way to do this is through a “brown bag” review: simply asking your patient to bring everything they are taking to the office in a brown bag. Patient- or family-prepared medication lists are also helpful, but you may need to ask specifically about supplements and over-the-counter preparations, as many patients will leave these off a “traditional” medication list.

See Video 25.3 .

Social Assessment

There are several elements to a social assessment that are important to consider in an initial or follow-up encounter with an older adult. Here are some of those elements, and some sample questions that prompt a deeper exploration:

• Cultural background: Are there cultural issues involved in the understanding or meaning of illness? Are there important cultural issues to understand about your own interactions with a particular patient and their family? What is the patient's preferred language?

• Spiritual background: How does religion and spirituality play into medical decision making for this patient? How does it affect the way in which they view their own illness?

• Home safety: What is the setup in the home? Is the patient bedroom on the ground floor? How many stairs are involved in gaining entry to the home? Are there railings or grab bars? What kinds of equipment does the bathroom have? Have there been any accidents? Are there throw rugs that are not secured?

• Finances: How does the patient pay for your medications? How do they pay for food? Are they responsible for paying their own bills? Are there gaps in what they can afford that are concerning to them?

• Screening for elder abuse. Does the patient feel safe in the home? Is it difficult to explain physical findings or accidents? What is the interaction like between the family members or caregivers and the patient? Is the patient dressed appropriately for the weather? Do they have all of the food, medication, and services they need? Are there any signs of neglect? It's important to think not just about physical abuse but also emotional and financial abuse. Ask about internet usage. Older adults are often the target of online financial fraud or mail fraud.

• Examining the structure of the patients’ personal support system. Do they need or have a caregiver? What is the level of caregiver burden/stress? Are there resources this patient may be eligible for to extend the reach of their caregiver?