Professional Documents
Culture Documents
DOI:10.1002/MSJ
MOUNT SINAI JOURNAL OF MEDICINE 491
Table 1. Simple Tests of Lower Extremities: Strength, Balance, Gait, and Fall Risk.
Question/Test Time to Administer Comments
Timed up & go <1 minute Sensitivity 88%, specificity 94% compared with geriatrician’s
evaluation using cutpoint >15 seconds
Gait speed >10 m <30 seconds >13 seconds predicts recurrent falls (likelihood ratio: 2.0, 95%
CI: 1.5–2.7)
Office-based maneuvers 2–3 minutes Some are part of Performance-Oriented Assessment of Mobility
Observed gait
Resistance to nudge
Tandem/semitandem stand
Rising from chair
360-degree turn
Functional reach 2 minutes Adjusted odds ratios for >2 falls within 6 months:
8.1 if unable to reach
4.0 if reach ≤6
2.0 if reach ≥6 but <10
Another alternative is the whisper voice test, they are unable to read all of the letters on the 20/40
administered by whispering 3 to 6 random words line with their eyeglasses on, and should then be
at a set distance from the patient’s ear and then referred for further evaluation by an ophthalmologist.
asking the patient to repeat the words. Patients fail Given the high prevalence of eye diseases in
the screening if they are unable to repeat half of the older population and the potential for adverse
the words correctly. This should be done out of the health consequences of impaired vision, a visit with
patient’s sight line to prevent lip reading, and the an optometrist or ophthalmologist is recommended
other ear should be covered. every 1 or 2 years by the American Academy
The most accurate office test is the AudioScope 3 of Ophthalmology11 and the American Optometric
(Welch Allyn, Inc., Skaneateles Falls, NY), a handheld Association.12
otoscope with a built-in audiometer. It should be set
at 40 dB to evaluate hearing loss in older persons. Given the high prevalence of eye
A pretone at 60 dB should be delivered, with 4 diseases in the older population
subsequent tones (500, 1000, 2000, and 4000 Hz), all
at 40 dB. If patients cannot hear the 1000 or 2000 Hz
and the potential for adverse
in both ears or both in one ear, they then need more health consequences of impaired
formal audiometric testing. vision, a visit with an optometrist
Finally, a screening tool that uses sociodemo-
graphic information coupled with 3 simple questions
or ophthalmologist is
(Table 2) has high accuracy in identifying older per- recommended every 1 or 2 years.
sons with hearing loss.9
Urinary Incontinence
Visual Impairment
Urinary incontinence is under-reported as well,
Visual impairment is a common sensory deficit in the often due to patients’ embarrassment or belief that
older population; all 4 major eye diseases (cataracts, incontinence is a normal part of aging. In fact,
macular degeneration, diabetic retinopathy, and it is a very common problem in both older men
glaucoma) increase in prevalence with age. Most and women, and can have deleterious effects on
older persons have presbyopia and require corrective their lives, including urinary tract infections, sleep
lenses. Visual deficiencies are also independently disruption with subsequent falls, and pressure ulcers.
associated with increased risk of falling, functional It is also a marker for higher mortality in older
decline, and depression.10 adults.13 There are many treatment options available,
The Snellen eye chart is standard method of including behavioral, pharmacologic, and surgical.
screening for visual impairment. This requires the A simple and efficient screen for urinary
patient to stand 20 feet from the chart and read letters, incontinence is a 2-item questionnaire that can be
using corrective lenses. Patients fail the screening if administered by the provider: (1) ‘‘In the last year,
DOI:10.1002/MSJ
492 S. L. ROSEN AND D. B. REUBEN: GERIATRIC ASSESSMENT TOOLS
Fig 2. UCLA Visit Form: Falls/Mobility Problems. Abbreviations: BP, blood pressure; Ca, calcium;
dc’d, discontinued; EKG, electrocardiogram; OA, osteoarthritis; P, pulse; PPI, proton pump inhibitor;
PT, physical therapy; w/o, without.
have you ever lost urine and gotten wet?’’ If so, Malnutrition/Weight Loss
(2) ‘‘Have you lost urine on 6 separate days?’’ Another
single question, ‘‘Have you had urinary incontinence The term ‘‘malnutrition’’ has been used to refer
that is bothersome enough that you would like to a wide spectrum of deficiencies (eg, protein-
to know how it could be treated?’’ may convey energy, vitamins) and excesses (eg, obesity,
additional value in helping to determine which hypervitaminosis)15 that place older persons at risk
patients would want further evaluation and therapy. for other health conditions, functional decline, and
The 3IQ questionnaire helps the clinician differentiate death. Nutritional disorders are very common in older
between urinary stress and urge incontinence using persons, the most common one being obesity (body
self-report questions.14 mass index > 30 kg/m2 ) in community-dwelling
DOI:10.1002/MSJ
MOUNT SINAI JOURNAL OF MEDICINE 493
older persons. Obesity is associated with functional rates of nursing-home use.19 Persistent decreased
decline and more comorbidities, such as type 2 dia- intake and weight loss in the hospital should prompt
betes mellitus and osteoarthritis. Weight loss has investigation. Malnutrition in the hospitalized older
commonly been used to define undernutrition and patient can also be a marker for another occult pro-
also predicts increased mortality. Although weight cess. For example, evaluation of poor oral intake
loss may be voluntary, any weight loss in an older may reveal an underlying delirium or untreated pain
person raises concern for underlying illnesses (eg, causing decreased oral intake. Measuring albumin
malignancy, depression) or social/functional barriers and prealbumin, though not a specific indicator of
(poverty, inability to shop or prepare meals). malnutrition, can also be helpful in assessing prog-
nosis. Albumin is also affected by inflammatory states
Although weight loss may be related to concomitant illness, stress, and traumatic
voluntary, any weight loss in an or surgical conditions. Its half-life is 18 days, and so
measurement at admission may provide a nutritional
older person raises concern for baseline. Prealbumin, with a half-life of 2 days, may
underlying illnesses (eg, be more helpful to monitor response to nutritional
malignancy, depression) or treatment, although it is also affected by inflammatory
states.
social/functional barriers (poverty,
inability to shop or prepare meals). Polypharmacy
At the initial visit, patients should be weighed Polypharmacy is very common in the older popu-
and asked about previous weight loss in the last lation, associated with adverse drug reactions, and
6 months. Height should also be obtained in order can result in hospitalizations and increased morbid-
to calculate body mass index, which should be ity. Patients often visit >1 healthcare provider and
calculated at the initial visit and when there is a fill prescriptions at multiple pharmacies. Therefore,
significant change in weight. monitoring the many medications patients are on for
There are also several self-administered screen- drug-disease and drug-drug interactions is imperative
ing instruments available. The Mini-Nutritional at the initial and every follow-up visit. There are sev-
Assessment16,17 predicts adverse outcomes that may eral ways to perform this task. Providers can ask their
or may not be related to the nutritional components patients to bring all of their medications in to their
of the instrument. The 4-item Simplified Nutrition visits with them, including over-the-counter medica-
Assessment Questionnaire asks about appetite and tions. Previsit questionnaires can be completed prior
how food tastes, and has been associated with weight to the initial visit with a complete list of patients’
loss in a cross-sectional study.18 prescription and nonprescription medications. Office
Malnutrition in the hospitalized older patient staff can then review these medication lists with
is common and has been associated with higher patients and bring any discrepancies to the physi-
mortality, delayed functional recovery, and higher cian’s attention at the time of the patient’s visit.
DOI:10.1002/MSJ
494 S. L. ROSEN AND D. B. REUBEN: GERIATRIC ASSESSMENT TOOLS
Clinicians can easily review drug-drug interac- these functions into quality-of-life questions (eg,
tions with readily available drug software programs, Study Short-Form 3620 and Short-Form1221 ). Asking
and should do so when prescribing a new medica- older persons about how they spend their day also
tion. Some programs can be used on smartphones gives insight into higher level of functioning of health-
and personal digital assistants. ier older persons, when they are still independent in
their ADLs and IADLs.
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MOUNT SINAI JOURNAL OF MEDICINE 495
Test Positive Screen (Cutpoint) Positive Likelihood Ratio Negative Likelihood Ratio
MMSE 24 3.4–11.8 0.10–0.37
Abbreviated mental status test 6 or 7 6–12 0.35–0.063
Clock drawing Various 4–7.8 0.17–0.3
Mini-cog 2 13 0.25
7-minute screen Logistic regression 47 0.09
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496 S. L. ROSEN AND D. B. REUBEN: GERIATRIC ASSESSMENT TOOLS
not volunteer that they are depressed, but instead and medical expenses.27 Older Americans are also
present with vague complaints as self-reported helping their children more, given the recession’s
fatigue, or more specific symptoms of anorexia effect on younger Americans as well. Older persons
with subsequent weight loss and sleep disturbance. who are dependent in their ADLs and/or IADLs, and
Therefore, it is important for physicians to screen do not have family readily available to fulfill these
for depression in patients for whom there is any needs, may be able to tap into their savings or equity
concern. The Patient Health Questionnaire-923 is a (eg, through reverse home mortgages) to pay for
validated self-administered tool. A score of >10 has caregivers, though often as a last resort.28 If personal
a sensitivity of 88% and a specificity of 88% for major resources are not available, they can apply for
depression. A 2-item version (PHQ-2) has been used caregiver support through state or federal agencies.
for screening.24 This screener asks the patient, ‘‘Over Economics plays a large role in undernutrition,
the past 2 weeks, how often have you been bothered as discussed earlier, as well as ability to buy
by any of the following problems? Little interest or medications. Therefore, the physician should probe
pleasure in doing things. Feeling down, depressed, or as to whether the patient has sufficient social and
hopeless.’’ Responses are scored as follows: 0 = not economic support. Patients sometimes are reluctant
at all, 1 = several days, 2 = more than half the days, to admit that they are having difficult financial times.
3 = nearly every day. Persons who score ≥3 have a Physicians can review insurance coverage. Patients
75% probability of having a depressive disorder. with Medicaid may qualify for additional medical or
In patients who may not be able to complete social benefits. Physicians can consult social workers
a self-administered tool (secondary to cognitive to help explore if patients qualify for Medicaid or
or visual impairment), the Geriatric Depression other state or federal assistance programs. Physicians
Scale may be more helpful. This tool is physician can also help connect patients to financial assistance
administered with yes-or-no answers, and available programs offered by drug manufacturers to help
in 5-item,25 15-item,26 and 30-item versions. lower the cost of specific medications.
DOI:10.1002/MSJ
MOUNT SINAI JOURNAL OF MEDICINE 497
example). Physicians can then review areas of 12. American Optometric Association Consensus Panel on
concern with patients at their first visit, and schedule Comprehensive Adult Eye and Vision Examination.
Practice Guideline: comprehensive adult eye and
follow-up visits to address issues further as needed.
vision examination. Reference Guide for Clinicians.
In the future, implementation of the above screening http://www.aoa.org/documents/CPG-1.pdf. Published
strategies and validated tools should become easier April 28, 2005. Accessed May 2008.
with advances in technology and electronic medical 13. Johnson TM II, Bernard SL, Kincade JE, et al. Urinary
records. In addition, with the advent of innovations in incontinence and risk of death among community-
living elderly people: results from the National Survey
practice, such as the Patient-Centered Medical Home,
on Self-Care and Aging. J Aging Health 2000; 12: 25–46.
many of the performance-based initial screens will be 14. Brown JS, Bradley CS, Subak LL, et al. The sensitivity
performed by office staff. These approaches should, and specificity of a simple test to distinguish between
in turn, help these assessments become more effi- urge and stress urinary incontinence. Ann Intern Med
cient and less time-consuming to incorporate into 2006; 144: 715–723.
15. Reuben DB, Greendale GA, Harrison GG. Nutrition
daily practice.
screening in older persons. J Am Geriatr Soc 1995; 43:
415–425.
16. Guigoz Y, Lauque S, Vellas BJ. Identifying the elderly at
DISCLOSURES risk for malnutrition: the Mini Nutritional Assessment.
Clin Geriatr Med 2002; 18: 737–757.
Potential conflict of interest: Nothing to report. 17. Guigoz Y. The Mini Nutritional Assessment (MNA)
review of the literature–What does it tell us? J Nutr
Health Aging 2006; 10: 466–487.
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DOI:10.1002/MSJ