ASSESSMENT OF THE HEALTH

STATUS OF OLDER PERSONS

MODULE 3

ERLINDA M. GUZMAN, RN, MAN

Instructor
OVERVIEW/INTRODUCTION:
◦ The geriatric assessment is a multidimensional, multidisciplinary assessment
designed to evaluate an older person's functional ability, physical health,
cognition and mental health, and socio-environmental circumstances.
◦ It is usually initiated when the physician identifies a potential problem.
◦ The geriatric assessment aids in the diagnosis of medical conditions;
development of treatment and follow-up plans; coordination of
management of care; and evaluation of long-term care needs and
optimal placement.
◦ The geriatric assessment differs from a standard medical evaluation by
including non-medical domains; by emphasizing functional capacity and
quality of life; and, often, by incorporating a multidisciplinary team.
◦ Well-validated tools and survey instruments for evaluation.
◦ Use of a “rolling” assessment over several visits should be considered.
LEARNING OUTCOMES:
At the end of the module, students should be able to:
1. Explain the basic concepts of elderly assessment, its
different principles and techniques.
2. Identify approaches that facilitate a successful assessment
of the older adult.
3. Demonstrate the assessment process in older persons.
4. Utilize different tools and techniques in performing
assessment to older persons.
5. Apply assessment principles and techniques in actual
elderly assessment.
FACTORS AFFECTING THE
HEALTH STATUS OF
OLDER PERSONS
FACTORS AFFECTING THE HEALTH
STATUS OF OLDER PERSONS
As people age, they become more susceptible to disease and
disability. However, much of the burden of ill health among
older people can be reduced or prevented by adequately
addressing specific risk factors, including:
1. injury
2. development of non-communicable diseases
3. poverty
4. social isolation and exclusion, mental health disorders
5. elder maltreatment
INJURY
◦ Falls and the injuries to which they often lead cause a large share of
the burden of disease and disability on older people. The risk of falls
increases steeply with age.
◦ Injuries from falls (such as femur fracture) usually require
hospitalization and costly interventions, including rehabilitation, and
cause much of the functional limitations that lead to the need for
long-term care, including admissions to nursing homes.
◦ Frailty in itself can considerably increase the risk of falls, which can
happen in all settings.
◦ Most falls are predictable and preventable. Some injury-prevention
measures (such as hip protectors) have been shown to be cost
effective or even cost saving.
RISK FACTORS OF NON-
COMMUNICABLE DISEASES
◦ Healthy ageing is a lifelong process.
◦ Patterns of harmful behavior, often established early in life,
can reduce the quality of life and even result in premature
death.
◦ Poor nutrition, physical inactivity, tobacco use and harmful
use of alcohol contribute to the development of chronic
conditions: 5 of these (diabetes, cardiovascular diseases,
cancer, chronic respiratory diseases and mental disorders).
POVERTY
◦ The risk of poverty grows with older age and is much higher
among women than men.
◦ Resources are limited to maintain health.
◦ Food, social/ leisure activities, assistive devices, etc.
◦ Many older people cannot afford to pay health costs,
including prescription drugs, from their own pockets.
SOCIAL ISOLATION AND EXCLUSION,
MENTAL HEALTH DISORDERS
◦ Loneliness, social isolation and social exclusion are important social
determinants and risk factors of ill health among older people. They
affect all aspects of health and well-being, including mental health,
the risk of maltreatment and the risk of emergency admission to
hospital for avoidable conditions, such as severe dehydration or
malnutrition.
◦ In all countries, older women have a higher risk of social isolation
than older men.
◦ Depression among older people is frequently undiagnosed. Mental
health support, including preventive action, is a vital, often
neglected, aspect of medical and social attention to older people.
ELDER MALTREATMENT

◦ Elder maltreatment is defined as physical, sexual,

mental and/or financial abuse and/or neglect of
people aged 60 years and older.
◦ Maltreatment affects both the mental and physical
well-being of older people and, if unchecked, reduces
the quality of life and survival.
 PRINCIPLES AND TECHNIQUES
IN ASSESSMENT OF THE HEALTH
STATUS OF OLDER PERSONS
PRINCIPLES AND TECHNIQUES IN ASSESSMENT
OF THE HEALTH STATUS OF OLDER PERSONS
◦ Assessment involves collecting information that gets to know the
patient in detail, evaluates their risks and the nature of problems to
be identified.
◦ Assessment should integrate all the relevant issues. It should explore
the medical, physiological, social and psychological function of the
older person.
◦ The assessment process encourages us to be curious and to consider
the best possible interventions that we can employ to minimize risks
and maximize our patient’s quality of life. This can ultimately involve
balancing some risks with some gains and working with our team and
the older person and their family to make an informed choice.
PRINCIPLES AND TECHNIQUES IN ASSESSMENT
OF THE HEALTH STATUS OF OLDER PERSONS
Assessment supports us to:
◦ treat the condition that caused the admission (such as shortness of breath)
◦ detect and quantify additional conditions or psychosocial issues that
contribute to or complicate the admission and respond to them as able
both during the admission and when planning for discharge. For example:
❖depression - consider if the person needs a medical review
❖poor nutrition - consider what can be done to optimize the person’s
intake
❖social isolation, or risk of loneliness - consider how you can encourage
the person to participate in their care by harnessing their personal and
social connections, and consider linking them to supports that are
meaningful to them on discharge
PRINCIPLES AND TECHNIQUES IN ASSESSMENT
OF THE HEALTH STATUS OF OLDER PERSONS
◦ Use strategies to prevent conditions that often emerge during hospital stays
but can be avoided (such as delirium and falls).
◦ We can gather information as part of the assessment process from multiple
sources, and these may vary at the stages of a hospital admission.
◦ The four main sources of information are:
1. Older people themselves - self report.
2. Others who know the older person well - informant report.
3. Observation of the person undertaking various activities - direct
observation.
4. Various secondary written or verbal sources - including hospital records,
medical reports, investigation results, communication from community
care providers.
PRINCIPLES AND TECHNIQUES IN ASSESSMENT
OF THE HEALTH STATUS OF OLDER PERSONS
◦ Unless there are reasons to suspect otherwise the older person is
considered the best source of information about their own health.
◦ Direct observation is the best source of information about physical
function; however, we should consider how the environment or
setting where observations take place may impact on the older
person’s performance.
ASSESSMENT TOOLS
◦ Assessment tools can be focused on exploring one particular
condition such as pain, pressure injury or nutrition. They can also be
more comprehensive and encompass a broader focus beyond one
particular issue. Examples of these types of tools include:
◦ Comprehensive Geriatric Assessment Tool
◦ Systematic Evaluation and Intervention for Seniors At Risk (SEISAR)
- a short, standardized, comprehensive tool for the evaluation of
active geriatric problems in seniors in the emergency department.
◦ The assessment tool or scale should enable collection of useful
patient data that supports interpretation of the holistic health status,
identifies patient needs, and informs care planning and
interventions to restore health and wellbeing.
 Nutritional Screening Risk Factors:
 Non-compliance or knowledge deficit of modified diet  History of poor appetite/oral intake  NPO or clear liquids >3 days,
 Unplanned significant weight loss in past 1-3 months  GI Disease or Surgery not on TPN / IV support
 Difficulties in chewing/ swallowing/ feeding self  DM; Chronic Renal Dse. *  Tube feeding; TPN *
 Routine use of herbal/dietary supplements  abnormal laboratory values  Surgical pts. 70 y.o. & above
 Special nutritional requirements: lactating; w/ Stage 3 or 4 wounds; w/ an ostomy; vegetarian;  Other: _________________
cultural and spiritual considerations
* Automatic trigger for referral to Registered Nutritionist (RND)
Identify Nutritional Risk Score  2 = High nutritional risk (3 or 4 nutritional risk factors identified or any single starred (*) item )
 1 = Moderate nutritional risk (2 nutritional risk factors identified)
(Score of 1 or 2 refer to RND)  0 = Very little or no nutritional risk (0 or 1 nutritional risk factor identified)

Remarks: ____________________________________________________________________________________________
Braden score on admission (circle appropriate number)
Sensory
Moisture Activity Mobility Nutrition Friction
Perception
4 No impairment 4 Rarely moist 4 Walks frequently 4 No limitations 4 Excellent
3 Occasionally 3 Walks 3 No apparent
3 Slightly limited moist occasionally 3 Slightly limited 3 Adequate problem
2 Wheelchair- 2
2 Very limited 2 Very moist bound 2 Very limited Inadequate 2 Potential problem
1 Completely 1 Completely
limited 1 Constantly moist 1 Bed-bound immobile 1 Very poor 1 Problem

Indicate Score and Identify Risk, please check (✓) one Total Risk Score __________
 Very High Risk  High Risk  Medium risk  Low Risk
Score < 10 Score 10 – 12 Score 13 - 14 Score ≥ 15
Remarks: ___________________________________________________________________________________________________
SELECTING AN ASSESSMENT TOOL
Consider the following factors when selecting an assessment tool
include:
1. A standardized tool can reduce variation in practices and
interpretation of findings and allow comparison across
assessments.
2. A validated assessment tool ensures the right data is captured to
evaluate the patient and their progress.
3. Is a specific tools mandated for specific circumstances or settings
4. Does the tool cater for cultural or language differences?
5. Is the tool appropriate for the physiology of ageing?
SELECTING AN ASSESSMENT TOOL
The format used will also depend on the discipline, skill and
expertise of the clinician, the context and setting of the
assessment, the time available and the number of assessors
involved. The assessment can be:
1. unstructured – if the professional expertise of the assessor is
high
2. semi-structured – incorporates specific tools and checklists
3. structured and standardized – using global assessment
instruments
COMPREHENSIVE GERIATRIC ASSESSMENT
◦ There is no gold standard for assessment of older people; however, a
Comprehensive Geriatric Assessment is highly recommended to
understand the multidimensional complex care needs of frail older
people and to determine both short and long term care needs.
◦ A Comprehensive Geriatric Assessment can be undertaken by any
member of the interdisciplinary healthcare team who has the required
knowledge and skills.
◦ Multiple team members with specific skills may need to be involved
depending on the patient’s needs.
◦ Ideally, the assessment should be completed within the patient’s first 24
hours in hospital and communicated to all team members, the patient
and informal carers.
CONDUCTING ASSESSMENTS
Be aware of the following when conducting assessments of older people:
◦ At all times, it is vital that we maintain an understanding the older person’s
perspective.
◦ In acute hospital settings, circumstances may mean older people are not able
or willing to be actively involved when health professionals assess them.
◦ Older people may take more time to complete tools than younger people, so
allow for rests during formal assessments.
◦ Ensure that any needs for communication assistances are met. These may
include use of interpreters, ensuring the older person is wearing their glasses
and/or hearing aids if they are used routinely.
◦ Do not assume older people know why they are being assessed. Explain why
certain questions or tests are being undertaken.
CONDUCTING ASSESSMENTS
◦ Establish cognitive status as early as possible in an assessment. Do not
assume older people are able to hear, comprehend what is said or are
capable of accurate, intelligible responses (for example if they are
acutely unwell).
◦ Note that appearing ‘flat’, minimal eye contact and being non-
committal responses may indicate depressive symptoms are present.
Depressed older people can give the appearance of being cognitively
impaired.
◦ Consider the need for an interpreter. The interpreter can also assist with
cultural care delivery.
◦ Consider specific cultural issues and seek assistance necessary from
cultural liaison officers or Indigenous health workers.
APPLYING CLINICAL SKILLS TO ASSESSMENT
◦ Good clinical skills, observation, listening, interpreting and clinical judgement
are all vital in decision-making.
◦ When we assess older patients, we use tools and draw on our clinical reasoning
skills. The reasoning cycle sets out the elements of effective clinical decision-
making:
◦ Consider the patient situation
◦ Collect cues and information – through observation, questions
◦ Process the information – what does it mean?
◦ Identify problems and issues – what does the information indicate?
◦ Establish goals – what actions need to be taken?
◦ Take actions
◦ Evaluate outcomes
◦ Reflect on process and new learning.
 FUNCTIONAL
ASSESSMENT OF
OLDER PERSONS
FUNCTIONAL ASSESSMENT OF
OLDER PERSONS
◦ The quality of life is determined by its activities. – Aristotle

◦ Functional Screening is important because…

1. Chronological age is poor indicator of ability.
2. Hospitalized older adults are at high risk for loss of function
skills.
3. Environmental constraints (IV’s, catheters, side rails)
decreased expectations for performance (ageism)
4. New disabilities or illness
5. Loss of functional abilities is a major cause of
institutionalization.
The goal of a functional assessment
screening is to…
1. restore or improve health
2. monitor changes
3. enhance independence
4. identify disabilities
5. screen for issues needing further assessment and referral
6. evaluate the need for community resources and equipment

Functional assessment includes all of these components:

◦ Environmental o Community
◦ Physical o Extended family
◦ Socio- Psychological o Living environment
◦ economical
FUNCTIONAL ASSESSMENT SCREENING
◦ Vision / Hearing
◦ Mobility (arms, legs)
◦ Oral / Nutrition
◦ Elimination
◦ Cognitive
◦ Home Environment
◦ Social Support
◦ Chronic Pain
◦ Medications
◦ Includes systematic review of these areas:
◦ ADL: Activities of Daily Living; or Basic ADL (BADL)
◦ IADL: Instrumental Activities of Daily Living (IADL)
◦ AADL: Advanced ADL (AADL)
When doing an assessment…
◦ Assess, don’t assume.
◦ Watch, don’t just ask.
◦ Obtain baseline information: it is important to know
what is normal for this individual.
◦ Identify what helpers, equipment, and supports make
doing activities of daily life possible.
 VISION AND HEARING
VISION
Screening Condition of Glasses
Snellen Chart
◦ When was the last eye exam?
◦ Minimum is every two years. If diagnosed with diabetes or an eye condition such as glaucoma,
eye exams could be as frequent as every 6-12 months.
HEARING
◦ Hearing Whisper Test (Stand behind the person and whisper a word in each ear.)
◦ Finger rub (Stand behind the person and rub two fingers together by each ear.)
Cerumen
◦ Build up interferes with the conduction of sound.
Hearing Aids
◦ Check batteries frequently; they last anywhere from less than a week to less than a month.
◦ Can cause an increase of cerumen impaction.
EXTREMITIES AND MOBILITY
UPPER EXTREMITIES
Can the individual…
◦ Touch the palms of the hands to back of the head? Reach up over the head? Touch the hands
together behind the waist?
Upper Mobility is needed for…
◦ Combing and washing hair
◦ Getting items off a shelf
◦ Putting on a shirt
◦ What other activities require upper mobility?
LOWER EXTREMITIES
“Get Up and Go” Test Get up from a chair
◦ Walk 10 feet
◦ Turn around and walk back
◦ Sit down again
◦ Problems with the above correlate with abnormal gait and increased risk of falling.
ORAL AND NUTRITION
ORAL SCREENING
Inspect the oral cavity and check … Ask…
◦ the condition of teeth
◦ the condition and fit of dentures
◦ for oral lesions or infections such as candidiasis
◦ Ask…Do you have any problems eating or swallowing?
◦ When was your last dental appointment?

Quadruple A’s of Nutrition

◦ Appearance - Does the person look well nourished?
◦ Appetite - How is the person’s appetite?
◦ Access - Does the person have access to funds to buy food? Get to the store?
◦ Ability - Can the person prepare own meals? Open cans? Cook safely?
◦ DETERMINE nutrition screen for older adults in Optimal Aging Competency
ELIMINATION
Elimination: “DRIP”
◦ D - Delirium, Depression, Dementia
◦ R - Retention, Restricted mobility and/or environment
◦ I - Infection, Inflammation, Impaction
◦ P - Pharmaceuticals, Polyuria
◦ If incontinence is a new problem, it must be evaluated
further.
 COGNITION
COGNITIVE FUNCTION
Delirium, Depression, Dementia Remember!
◦ Delirium - onset hours to days
◦ Depression - onset weeks to months
◦ Dementia - onset months to years
◦ Remember! If an older adult was not confused a few hours or days ago, his or her
confusion usually indicates an acute problem that requires prompt evaluation.
◦ The Three Ds of Confusion
Cognitive Function Screening Tools
◦ Short Blessed Test (SBT)
◦ Geriatric Depression Scale (GDS)
◦ Cornell Depression Scale
◦ These tools do not diagnose a condition. They merely indicate that further follow-up
is necessary.
ACTIVITY Instrumental Activities of Daily Living
Ask if need help with activities which are
Basic Activities of Daily Living more complex, such as…
Ask if need help with activities done ◦ Writing
every day, such as …
◦ Reading
◦ Bathing and grooming/ Dressing
◦ Cooking
◦ Ambulation/Walking
◦ Cleaning
◦ Transfers
◦ Shopping
◦ Toileting
◦ Doing laundry
◦ Eating
◦ Going up stairs
Advanced Activities of Daily Living
◦ Using the telephone
◦ Related to work (professional or
◦ Outside activities
community) and hobbies
◦ Speaking engagements ◦ Managing medications
◦ Social gathering: prayer meetings ◦ Managing money
◦ Attend a painting class, etc. ◦ Transportation
Home Environment
◦ Ask if have trouble going up and down stairs.
Ask if have had any falls inside or outside of the home.
◦ What kinds of safety hazards should you assess that might be present in the
home?
Social Support
◦ Who would be able to help in case of illness or emergency?
◦ What community and family resources are available?
Chronic Pain
◦ Do you experience pain that prevents you from doing certain activities?
Medications
◦ What medications do you take?
◦ What are the medications for?
◦ Do you have any trouble taking them?
CAREGIVERS
Being a caregiver is hard work. It is not unusual for a
◦ Caregiver to neglect his or her own health while taking care of a
loved one.
◦ Be sure to ask the caregiver how he or she is doing and what
ways he or she is using to take care of self.

◦ Remember: Preserving, nurturing, measuring, recording, and

communicating function are the core of good geriatric care.
LIVING CONDITIONS
OF OLDER PERSONS
LIVING CONDITIONS OF OLDER
PERSONS
◦ Although some of the variations in older people’s health are genetic, much is
due to people’s physical and social environments – including their homes,
neighborhoods, and communities, as well as their personal characteristics –
such as their sex, ethnicity, or socioeconomic status.
◦ These factors start to influence the ageing process at an early stage. The
environments that people live in as children – or even as developing fetuses –
combined with their personal characteristics, have long-term effects on how
they age.
◦ Environments also have an important influence on the development and
maintenance of healthy behaviors. Maintaining healthy behaviors throughout
life, particularly eating a balanced diet, engaging in regular physical activity,
and refraining from tobacco use all contribute to reducing the risk of non-
communicable diseases and improving physical and mental capacity.
LIVING CONDITIONS OF OLDER
PERSONS
◦ Behaviors also remain important in older age.
◦ Strength training to maintain muscle mass and good nutrition can
both help to preserve cognitive function, delay care
dependency, and reverse frailty.
◦ Supportive environments enable people to do what is important
to them, despite losses in capacity. The availability of safe and
accessible public buildings and transport, and environments that
are easy to walk around are examples of supportive
environments.
World Health Organization’s Response:
Global Strategy and Action Plan on Aging and Health
1. Commitment to Healthy Ageing. Requires awareness of the value of Healthy
Ageing and sustained commitment and action to formulate evidence-based
policies that strengthen the abilities of older persons.
2. Aligning health systems with the needs of older populations. Health systems need
to be better organized around older people’s needs and preferences, designed to
enhance older people’s intrinsic capacity, and integrated across settings and care
providers. Actions in this area are closely aligned with other work across the
Organization to strengthen universal health care and people-centred and
integrated health services.
3. Developing systems for providing long-term care. Systems of long-term care are
needed in all countries to meet the needs of older people. This requires
developing, governance systems, infrastructure and workforce capacity. WHO’s
work on long-term care (including palliative care) aligns closely with efforts to
enhance universal health coverage, address non-communicable diseases, and
develop people-centred and integrated health services.
World Health Organization’s Response:
Global Strategy and Action Plan on Aging and Health

4. Creating age-friendly environments. This will require actions to combat

ageism, enable autonomy and support Healthy Ageing in all policies and at
all levels of government. These activities build on and complement WHO’s
work during the past decade to develop age-friendly cities and communities
including the development of the Global Network of Age Friendly Cities and
Communities and an interactive information sharing platform Age-friendly
World.
5. Improving measurement, monitoring and understanding. Focused research,
new metrics and analytical methods are needed for a wide range of ageing
issues. This work builds on the extensive work WHO has done in improving
health statistics and information, for example through the WHO Study on
global AGEing and adult health (SAGE)
RESOURCES:
Textbooks:
Kane, Robert L., Resnick, Barbara, Essentials of Clinical Geriatrics 6th Edition (2009),
Mc-Graw-Hill Companies, Inc.
Mauk, Kristen L., Gerontological Nursing: Competencies for Care 2nd edition (2010),
Jones and Barlett Publishers
Natividad, J. N., Kuan, L. G., S. R. Bonito, A. O. Balabagno, et. al., Caring for the
Older Person (2005), University of the Philippines, Office of Academic Support and
Instructional Services
Tabloski, Patricia A., Essentials Of Gerontological Nursing 1st Edition (2006), Pearson
education Inc.
Walker, Lynne, Patterson, Elizabeth, et. al., General PRACTICE Nursing (2010), Mc-
Graw-Hill Companies, Inc.
Internet Sources:
http://www.info@jbpub.com/
http://www.doh.gov.ph/