ASSESSING OLDER ADULTS

LEARNING OBJECTIVES
1. Describe common structural and functional
changes among older adults.
2. Differentiate common variations and geriatric
syndromes.
3. Utilize correct assessment techniques and
tools in performing physical assessment among
older adults.
Special Characteristics in Geriatrics

RAMPS
Reduced body reserve
Atypical presentation
Multiple pathology
Polypharmacy
Social adversity
Geriatric Giants -atypical presentation

Instability (Fall)
Immobility
Intellectual impairment
Incontinence
Inappetite
Iatrogenesis
 MYTHS
• Elderly people are incompetent and incapable of
making decisions or handling their own affairs.

• Most elderly live in nursing homes

• All elderly people live in poverty

• Older people are lonely and unhappy

• Elderly do not want to work

• “Old Age” begins a 65

• Retirement ends your active life

 Physical Changes of Aging

• Most physical changes that occur with aging are

gradual and take place over a long period of
time. In addition, the rate and degree of change
varies among individuals.
• Factors such as disease can increase the speed
and degree of the changes. Lifestyle,
nutrition, economic status, and social
environment can also have effects.
• If an individual can recognize the changes as a
normal part of aging, the individual can
usually learn to adapt to & cope with change
 The Comprehensive Assessment of an Older Person
What are the clues for increasing urgency?
• Age – extreme
• Lives alone
• Source of referral
• Urgency annotation
• New features of illness
• Polypharmacy
• Recent functional decline
• Worsening confusion (i.e. delirium)
There is clearly a potential conflict between urgency of response,
maintenance of a multi-disciplinary approach and occupational safety and
health issues.
 The Comprehensive Assessment of an Older Person
Medically-orientated Assessment
• The Geriatric Assessment is performed in addition to standard medical
history and physical examination.
• The assessment seeks to uncover common conditions of frailty that affect
functional status, e.g.
- Impaired vision
- Impaired hearing
- Reduced mobility and falls
- Geriatric syndromes - Cognition
- Depression
- Malnutrition
- Urinary incontinence
- Falls
- Iatrogenic illness
 The Comprehensive Assessment of an Older Person

INTERDISCIPLINARY
• The comprehensive assessment can be done by a generic elderly health care
worker, a General Practitioner, medical specialist or through a multi-disciplinary
approach.
• It can be extended over time and place.
• The tools of assessment are the structured interview utilising screening
instruments for:
Cognitive
Affective
Functional
Social (context and consequences)
Economic status
• Assessment especially useful for :
» People in transition
» Recent onset of physical or cognitive impairment
Fragmented (medical) care
Care-giver strain.
Nursing Health History
 Basic Components of a Nursing Health History

 Client Profile/ Biographic Data

 Family Profile
 Occupational profile
 Living Environment Profile
 Recreation/ Leisure Profile
 Resources/ support systems used
 Description of typical day
 Present health status
 Past health status
 Family history
 Review of systems
 Approach to an elderly patient
• Physical assessment

• Mental assessment

• Function assessment

• Social assessment
 CGA/ Functional
KATZ INDEX OF ACTIVITIES OF DAILY LIVING

•Bathing
•Dressing
Independent
•Toileting
Assistance
•Transfer
Dependent
•Continence
•Feeding
Katz S et al. Studies of Illness in the Aged: The Index of ADL; 1963.
Comprehensive Geriatric Assessment
INSTRUMENTAL ACTIVITIES OF DAILY LIVING

•Telephone
•Traveling
•Shopping Independent
•Preparing meals Assistance
•Housework Dependent
•Medication
•Money
The Oars Methodology: Multidimensional Functional Assessment Questionnaire; 1978.
 Barthel Index
• Tool used for measuring functional status,
rates self care abilities in areas of feeding,
moving, toileting, bathing, walking, propelling
a wheelchair, using stairs, dressing and
controlling bowel and bladder.
 Functional Performance tests:
MOBILITY
• 1. STANDING BALANCE
• 2.WALKING SPEED
• 3. CHAIR STANDS
 “Get up & Go Test”
QUALITATIVE CHAIR STAND

abnormal normal

High Risk RAPID GAIT

12/31 (39%)

abnormal normal

High Risk Low Risk

13/38 (34%) 6/128 (4.7%)
 “Get up and Go”
• ONLY VALID FOR PATIENTS NOT USING AN ASSISTIVE
DEVICE
• Get up and walk 10ft, and return to chair

• Seconds Rating
• <10 freely mobile
• <20 mostly independent
• 20-29 variable mobility
• >30 assisted mobility
• Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the “Get-up and Go” test. Arch
phys Med Rehabil. 1986; 67(6): 387-389.
 Get up and Go
• Sensitivity 88%
• Specificity 94%
• Time to complete <1min.
• Requires no special equipment

• Cassel, C. Geriatric Medicine: An Evidence-Based Approach, 4th edition,

Instruments to Assess Functional Status, p. 186.
 Visual Impairment
• Visual Impairment
– Prevalence of functional blindness (worse than
20/200)
• 71-74 years 1%
• >90 years 17%
• NH patients 17%
– Prevalence of functional visual impairment
• 71-74 years 7%
• >90 years 39%
• NH patients 19%
 Hearing Impairment

• Hearing Impairment
– Prevalence:
• 65-74 years = 24%
• >75 years = 40%
– National Health Interview Survey
• 30% of community-dwelling older adults
• 30% of >85 years are deaf in at least one ear
 Hearing Impairment
• Audioscope
– A handheld otoscope with a built-in audiometer
• Whisper Test

3 words

12 to 24 inches
Macphee GJA Age Aging, 1988
 Cognitive Dysfunction
• Dementia
– Prevalence: 30% in community-dwelling patients
>85 years
– Alzheimer’s disease and vascular dementias
comprise >80% of cases
• Risk for functional decline,
delirium, falls and
• caregiver Stress
 MMSE
• 30 item instrument that has been used to
screen cognitive difficulties

• Determination of dementia or delirium

• Test orientation, STM, attention, calculation

ability, language ad construction.
• 30 – impairment
• Below 24- dementia

• * educational level scoring

 The Mini-Cog
• Components
– 3 item recall: give 3 items, ask to repeat, divert and recall
– Clock Drawing Test (CDT)
• Normal (0): all numbers present in correct sequence
and position and hands readably displayed the
represented time

• Abnormal Mini-Cog scoring with best performance

– Recall =0, or
– Recall ≤2 AND CDT abnormal
 Clock Drawing Test Instructions
– Subjects told to
• Draw a large circle
• Fill in the numbers on a
clock face 12
11 1
• Set the hands at 8:20 2
10
– No time limit given
– Scoring (subjective): 9 3
• 0 (normal) 8 4
• 1 (mildly abnormal) 7 5
6
• 2 (moderately abnormal)
• 3 (severely abnormal)

Borson S. et al Int J Geriatr Psychiatry 2000;15:1021-1027

 Clock Drawing Test
• Clock Drawing Test:
– “Draw a clock”
• Sensitivity=75.2%
• Specificity=94.2%
 Animal Naming Test
• Category fluency
• Highly sensitive to Alzheimer’s disease
• Scoring equals number named in 1 minute
– Average performance = 18 per minute
– < 12 / minute = abnormal
• Requires patient to use temporal lobe semantic stores
• 60 seconds
• Using a cutoff of 15 in one minute:
– Sens 87% - 88%
– Spec 96%

Canninng, SJ Duff, et al.; Diagnostic utility of abbreviated fluency measures in

Alzheimer disease and vascular dementia; Neurology Feb. 2004, 62(4)
 Depression
• 10% of >65 y/o with depressive symptoms
• 1% with major depressive disorder
• Associated with physical decline of
community-dwelling adults and hospitalized
patients
 Comprehensive Geriatric Assessment
GERIATRIC DEPRESSION SCALE (Short Form)

1. Are you basically satisfied with your life?

2. Have you dropped any of your activities?
3. Do you feel that your life is empty?
4. Do you often get bored?
5. Are you in good spirits most of the time?
6. Are you afraid that something bad is going to happen to
you?
7. Do you feel happy most of the time?
8. Do you often feel helpless?
 Comprehensive Geriatric Assessment
GERIATRIC DEPRESSION SCALE (Short Form)

9. Do you prefer to stay home at night, rather than go

out and do new things?
10. Do you feel that you have more problems with
memory than most.
11. Do you think it is wonderful to be alive now?
12. Do you feel pretty worthless the way you are
now?
13. Do you feel full of energy?
14. Do you feel that your situation is hopeless?
15. Do you think that most persons are better off than
you are?
• Are you single, married,divorced,….
• Does your spouse live here also?
• Who lives with you?...
 Comprehensive PA of Frail and
medically complex elder
FANCAPES
• F- luids
• A- eration
• N-utrition
• C- ommunication
• A- ctivity
• P-ain
• E- Elimination
• S- ocialization &
Social skills
 Comprehensive Geriatric Assessment
• Other domains to be assessed:
– Current health status: nutritional risk, health
behaviors, tobacco, and ETOH use and exercise
– Social assessments: especially elder abuse if
applicable
– Health promotion and disease prevention
– Values history: advanced directives, end of life
care
 Comprehensive Geriatric Assessment
• Report Outline
– Reason for evaluation
– Medical history, current health status
– Functional status
– Social assessment, current psychiatric status
– Preference for care in event of severe illness
– Summary statement
– Care plan
 Comprehensive Geriatric Assessment
• Care Plan
– Recommended services: either agency or family
members
– How often will it be provided
– How long it will be provided
– What financing arrangements will pay for it
– DYNAMIC PLAN, CONTINUAL ASSESSMENT
 Comprehensive Geriatric Assessment

What am I going to do with the information

obtained?
•The most critical step for clinicians is the
integration of the data that have been obtained
form the instruments.
• A common pitfall is to establish a diagnosis that is
based solely on poor performance on an
assessment instrument.
• Information obtained is sometimes underutilized
or ignored by clinicians.
 Mini Nutritional
Assessment (MNA)
- validated nutrition screening and assessment tool
that can identify geriatric patients age 65 and above
who are malnourished or at risk of malnutrition
 Geriatric Depression Scale
(GDS)
- suitable as a screening test for depression symptoms in
the elderly; ideal for evaluating the clinical severity of
depression and therefore for monitoring treatment
 Examples of atypical presentation
diseases present as mechanism
 hyperthyroidism apathy not agitated ↓ ß-receptor sense
 hypothyroidism depression, weak sedentary life
 infections no fever,leucocytosis ↓ interleukin I
 peritonitis no guarding weak rectus M.
 hypoglycemia no adrenergic ↓ ß-receptor sense
 congestive heart no dyspnea, sedentary life
failure confusion, ↓ function of liver & brain
mild jaundice
RUQ pain
Thank you for your excellent attention