Am Fam Physician. 2018;97(12):776-784
Author disclosure: No relevant financial affiliations.
Family physicians should be proficient in geriatric assessment because, as society ages, older adults will constitute an increasing proportion of patients. Geriatric assessment evaluates medical, social, and environmental factors that influence overall well-being, and addresses functional status, fall risk, medication review, nutrition, vision, hearing, cognition, mood, and toileting. The Medicare Annual Wellness Visit includes the key elements of geriatric assessment performed by family physicians. Comprehensive geriatric assessment can lead to early recognition of problems that impair quality of life by identifying areas for focused intervention, but a rolling geriatric assessment over several visits can also effectively identify subtle or hidden problems. Assessment should be tailored to patient goals of care and life expectancy. By asking patients and families to self-assess risks using precompleted forms, and by using trained office staff to complete validated assessment tools, family physicians can maximize efficiency by focusing on identified problems. Fall risk can be assessed with a single screening question: “Have you fallen in the past year?” The Beers, STOPP (screening tool of older persons' prescriptions), and START (screening tool to alert doctors to right treatment) criteria are helpful resources for reviewing the appropriateness of medications in older adults. Screening for depression is recommended when depression care supports are available; this can be performed with a brief two-item screen, the Patient Health Questionnaire-2. Older adults should be screened for unintentional weight loss and malnutrition. Although rates of hearing loss and vision loss increase with age, there is insufficient evidence to recommend screening in asymptomatic individuals. The U.S. Preventive Services Task Force advises clinicians to assess cognition when there is suspicion of impairment. Urinary incontinence can impair patients' quality of life, and it can be assessed with a two-question screening tool. Immunizations and advance care planning are also important components of the geriatric assessment.
Older adults with complex chronic conditions will be an increasing proportion of family physicians' patient population. In 2015, patients older than 65 years accounted for 31% of all U.S. office visits, and that proportion will grow. 1 Since 2013, every day 10,000 baby boomers turn 65 years of age and enter Medicare. 2 By 2030, the population older than 65 years will double to 72 million (20% of the total U.S. population). 2 Individuals are living longer, with multiple chronic illnesses, making them vulnerable to disability and diminished quality of life. Although 95% of older patients with complex needs have regular access to care, 58% struggle to navigate the system, and 62% are stressed about their ability to afford housing, utilities, or meals. 3 Geriatric assessment, which evaluates medical problems; cognitive, affective, and functional abilities; and social and environmental factors, can identify these unrecognized needs to improve the well-being of older adults.
Most of the literature supporting geriatric assessment models involves specialized geriatric team-based assessment. Comprehensive geriatric assessment is a systematic evaluation of frail older persons by a team of health professionals and consists of six core components: data gathering, team discussion, development of a treatment plan, and implementation of a treatment plan, with monitoring and revision as needed.
| Recommendations from the Choosing Wisely Campaign | |
|---|---|
| Recommendation | Sponsoring organization |
| Do not prescribe a medication without conducting a drug regimen review. | American Geriatrics Society |
| Do not assume a diagnosis of dementia in an older adult who presents with altered mental status and/or symptoms of confusion without assessing for delirium or delirium superimposed on dementia using a brief, sensitive, validated assessment tool. | American Academy of Nursing |
| Avoid using prescription appetite stimulants or high-calorie supplements for the treatment of anorexia or cachexia in older adults; instead, optimize social supports, discontinue medications that may interfere with eating, provide appealing food and feeding assistance, and clarify patient goals and expectations. | American Geriatrics Society |
The comprehensive geriatric assessment model has been studied in hospital, home care, and clinic settings. Virtually all trials of this model improved detection and documentation of problems in this population, but the impact on patient-oriented outcomes varied. 4 A meta-analysis of 29 trials showed that hospitalized older adults treated by a comprehensive geriatric assessment team were more likely to be alive and in their own homes 12 months after hospitalization. 5 In a survey of primary care physicians in a preferred provider organization who had referred patients for geriatric assessment, 69% of respondents agreed that outpatient comprehensive geriatric assessment more fully assessed the physical, mental, and social needs of patients than other consultative clinics. 6
Although formal comprehensive geriatric assessment includes a large team of clinicians, individual family physicians must use the interprofessional resources available. Geriatric assessment by an individual clinician expands the focus from a traditional disease-oriented visit to assess for common underreported conditions affecting quality of life and functional status.
Geriatric assessment is labor- and time-intensive, and, therefore, should target patients who can most benefit. Possible triggers for an assessment include multimorbidity, cognitive changes, functional status changes, frailty, risk of falling, medication nonadherence, polypharmacy, transitions in care setting, unexplained weight loss, and family concerns for safety. Geriatric assessment is generally not as useful in patients with terminal illness, advanced dementia, or complete functional dependence. To overcome the time-intensity barriers, which are a challenge for patients and clinicians, family physicians can adapt the comprehensive geriatric assessment into their clinics in a variety of ways. Portions of the geriatric assessment can be performed over several regularly scheduled visits. Targeting at least one domain for screening during each office visit can be integrated into staff workflow with the use of structured templates to guide evaluation of problems such as falls, dementia, or urinary incontinence.
Medicare's Annual Wellness Visit is an opportunity to incorporate geriatric assessment into a single office visit. The elements of the Annual Wellness Visit are listed in Table 1, with suggested tools for assessment in addition to several new billing codes. 7 Screening and counseling should be adjusted based on prognosis and life expectancy (Table 2). 8
| ≥ 10 years remaining life expectancy | 5 to < 10 years remaining life expectancy | Moderate dementia | Near end of life | |
|---|---|---|---|---|
| Healthy lifestyle counseling | ||||
| Smoking cessation | Every visit | Every visit | Discuss with caregiver | Not recommended |
| Alcohol misuse | Annually | Annually | Annually | Initially, then if symptomatic |
| Exercise | Annually | Annually | Consider annually | Consider |
| Sexual function | Annually | Annually | Consider annually | Not recommended |
| Driving assessment | Consider | Consider | Routinely | Consider |
| Geriatric health issues | ||||
| Depression screening | Annually | |||
| Falls risk assessment | Annually | |||
| Gait and balance screening | Annually | |||
| Urinary incontinence screening | Annually | |||
| Hearing impairment screening | Consider annually | Not recommended | ||
| Visual acuity testing | Consider annually | Not recommended | ||
| Cognitive impairment screening | If symptomatic | |||
| Advance directives completion | Complete and update as needed | |||
To maximize efficiency, physicians may delegate data-gathering to leave more time for addressing problems. Validated screening instruments completed by trained office staff, as well as patient- and caregiver-completed tools, can be used to collect information on history, prevention measures, and functional status (eTable A).
Precompleted basic and instrumental activities of daily living scales may identify declines in functional status. For highly functional patients, a simple open-ended question asking how a typical day is spent provides a good review of daily function.
Falls are common and often unreported. One-third of community-dwelling individuals older than 65 years fall every year. 9 A single screening question, “Have you fallen in the past year?” is highly effective. A positive response is associated with a 2.8-times higher likelihood of falling in the next year. 10 The American Academy of Family Physicians (AAFP) does not recommend an automatic comprehensive fall assessment, but it should be considered in the context of individual patient needs. 11
Physician assessment of gait can begin with direct observation as the patient enters the examination room. Reduced gait speed has been associated with reduced survival in pooled analysis of nine cohort studies, and patients with slow gait are more likely to fall. 12 The Get Up and Go Test measures a patient's ability to rise from a chair, walk 3 m (10 ft), turn, walk back, and sit down again. Evaluation by the family physician may be a simple qualitative assessment of normal or impaired, but if staff are assessing, then a timed score with the Timed Up and Go Test may be preferable (Table 3). 13 , 14 A patient who takes longer than 12 seconds on the Timed Up and Go Test or a physician assessment that gait is mildly abnormal or worse should be evaluated further. Patients at high risk of falling need a multifactorial assessment including orthostatic vital signs, visual acuity testing and cataract screening, gait and balance testing, medication review, and investigation of environmental hazards in the home. 15
Early identification of functional decline and fall risk can lead to interventions that maximize independence and safety. Effective multifactorial interventions such as regular exercise and balance training, minimizing polypharmacy, treating visual impairment, managing hypotension, and using proper footwear can reduce the frequency of falling and may help maintain functional status. 10 The U.S. Preventive Services Task Force (USPSTF) recommends exercise to prevent falls (grade B) and that clinicians selectively offer multifactorial interventions to prevent falls to community-dwelling adults 65 years or older who are at increased risk of falls. The USPSTF also cautions that patients and clinicians should consider the balance of benefits and harms based on the circumstances of prior falls, presence of comorbid medical conditions, and the patient's values and preferences. 16
Increased use of prescription and over-the-counter medications puts older adults at risk of adverse drug reactions, impaired cognition, falls, and functional decline. 17 A thorough medication review can identify medications that are underprescribed and necessary, those that are not being used correctly, and those that are inappropriate and should be discontinued. The Beers, STOPP (screening tool of older persons' prescriptions), and START (screening tool to alert doctors to right treatment) criteria are helpful resources for reviewing the appropriateness of medications in older adults. 18 , 19 The Beers criteria list potentially inappropriate medications for most older adults, medications to avoid with specific conditions, combinations that may lead to harmful interactions, and medications that should be dosed differently for persons with poor kidney function. 18 STOPP and START comprise clinically significant criteria for potentially inappropriate prescribing in older persons and potential prescribing omissions. 19 When reviewing medications for older adults, it is important to take into account the patient's ability to adhere to the medication regimen, the patient's goals of treatment, and the time to achieve benefit from the medication in relation to the patient's life expectancy. Strategies to improve adherence include using pillboxes, easy-open lids on bottles, daily organized medications in blister packs, once-daily medications instead of more frequent administration, and direct patient education with a pharmacist.
Depression in older adults often presents in an atypical manner, such as apathy, weight loss, or cognitive impairment (e.g., responding to questions with “I don't know”), especially when there is comorbid cognitive impairment. Depression can lead to significant weight loss, decline in functional status, increased risk of suicide, and overall increased mortality and increased use of health care services. 20
The USPSTF and the AAFP recommend screening adults for depression only when staff-assisted depression care supports are available for accurate diagnosis, effective treatment, and follow-up. 21 , 22 Screening for depression can be performed with a brief two-item screen, the Patient Health Questionnaire-2 (PHQ-2). 23 A positive result (score of 3 or greater) on the simple screen should be followed by the Patient Health Questionnaire-9, which has been validated as a reliable measure of depression severity in older adults. 24
Undernutrition is associated with increased need for health care services and mortality. Among older adults receiving home health care, 12% were malnourished and 51% were at risk of malnourishment. 25 Medicare defines normal body mass index (BMI) in older adults as 23 to 30 kg per m 2 ; BMI less than 23 kg per m 2 is associated with increased mortality. 26 Screening for nutritional impairment in older adults can be accomplished by asking a single question (e.g., “Have you lost weight in the past six months?”), monitoring weight, or asking patients or caregivers to complete the Mini Nutritional Assessment (eTable A). Older adults who unintentionally lose 5% or more of their body weight in six months or have a low BMI require further evaluation for poor nutrition. Through the Choosing Wisely Campaign, the American Geriatrics Society recommends against the use of appetite stimulants or high-calorie supplements because of the lack of proven effectiveness in long-term survival or improvement in quality of life. Instead, it recommends discontinuing medications that contribute to weight loss and diminish appetite, providing appealing foods, ensuring social support, and offering feeding assistance. 27
Hearing loss is often unrecognized by patients, and affects more than 80% of adults older than 80 years. Only 10% to 20% of older adults with hearing loss have used hearing aids. 28 Moderate to severe hearing loss is associated with a three- to fourfold higher incidence of dementia. 29 The USPSTF and the AAFP concluded that there was insufficient evidence to recommend screening for hearing loss in asymptomatic adults older than 50 years. 28 , 30 Physicians should assess for objective hearing impairment when the patient or a family member raises a concern, or if there are cognitive or mood symptoms that could be influenced by hearing loss, and refer for hearing aids when appropriate. Although audiometry is the screening standard, a whispered voice test at 2 ft or a single question (e.g., “Do you feel you have hearing loss?”) is an effective alternative. 30
Vision loss is common among older adults in the United States, affecting 12% of those 65 to 74 years of age and 15% of those 75 years and older. 31 Common causes of visual impairment include macular degeneration, cataracts, glaucoma, refractive errors, and diabetic retinopathy. Decreased visual acuity increases the risk of falls, fractures, social isolation, and depression. In 2016, the USPSTF and AAFP concluded that the current evidence was insufficient to assess the balance of benefits and harms of screening for impaired visual acuity in older adults. 32 , 33 Despite lack of evidence of benefit, vision testing offers little harm and can be accomplished by office staff using a Snellen chart.
Cognitive impairment rates increase with age. In primary care, impaired cognition may go unrecognized in up to 81% of affected patients. 34 The USPSTF and AAFP concluded that there is insufficient evidence for screening for cognitive impairment, but the USPSTF advises clinicians to assess cognition when there is suspicion of impairment. 35 , 36 The Medicare Annual Wellness Visit requires assessment of cognitive function by direct observation, self-report, and concerns raised by family members, care-givers, or others. 7 A brief, structured cognitive assessment using the Mini-Cog tool improves primary care physicians' spontaneous detection of mild cognitive impairment or dementia from 59% to 83%. 37 The Mini-Cog test combines three-item recall and clock drawing, and has been validated against the Mini-Mental State Examination. 38 Medical staff can administer the Mini-Cog in five minutes or less. 34 The Mini-Mental State Examination, although well known and well studied, has fallen out of favor because of copyright fees.
Positive results on a cognitive screening test do not diagnose dementia, but should lead to more comprehensive evaluation of memory, language, visual-spatial, and executive function, as well as how identified deficits interfere with daily activities. The Montreal Cognitive Assessment is one tool that assesses these domains in depth. AAFP's Cognitive Care Kit includes several other validated, evidence-based instruments for cognitive evaluation (eTable A).
Although no pharmacologic agents are indicated for patients identified with mild cognitive impairment but not dementia, an exercise prescription is an appropriate intervention. A meta-analysis of 11 studies showed that exercise improved global cognition, and an aerobic component to the exercise appears to be important. 39
Urinary incontinence is a common condition impacting 70% of long-term nursing home residents, and 24% of community-dwelling older adults experience incontinence that is rated as moderate to very severe. 40 Although the incidence increases with age, urinary incontinence is abnormal at any age and significantly affects quality of life.
Incontinence is often unidentified because of embarrassment. A two-question screening tool is effective in identifying urinary incontinence: (1) In the past year, have you ever lost your urine and gotten wet? and (2) If so, have you lost your urine on at least six separate days? 41 Positive responses to both questions should lead to a more in-depth assessment of transient and established factors that are contributing to the incontinence.
Geriatric assessment is an opportunity to identify older adults who have not received recommended vaccinations. Patients older than 60 years account for 60% of tetanus cases and more than 90% of influenza deaths, and the morbidity of pneumonia and zoster greatly increases after 65 years of age. The Advisory Committee on Immunization Practices (ACIP) recommends annual influenza vaccination. 42 It also recommends that clinicians not miss the opportunity to vaccinate persons older than 65 years with the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine and the tetanus and diphtheria toxoids (Td) booster vaccine every 10 years thereafter. 43 For pneumonia vaccination, the ACIP recommends the 13-valent pneumococcal conjugate vaccine (Prevnar 13) at 65 years of age and the 23-valent pneumococcal polysaccharide vaccine (Pneumovax 23) one year later. 44 The ACIP recommends two doses of recombinant herpes zoster vaccine (Shingrix) administered two to six months apart for immunocompetent adults 50 years or older. 45
Geriatric assessment provides opportunity to review preferences for medical care, such as prolonging life, maintaining independence, preventing illness, relieving suffering, and maximizing time with family and friends. Understanding these goals should inform specific treatment plans, including preferences for preventive care and decisions regarding life-sustaining treatments. Completion of advance directives should document patient goals and preferences for future medical care, and identify the patient's chosen surrogate decision maker. This is a particular priority when dementia is diagnosed and some partial decision making is preserved.
There are several evidence-based tools to engage older adults in shared decision making. 46 , 47 Resources such as the Prepare for Your Care 48 (https://www.prepareforyourcare.org/) and the Stanford Letter Project (https://med.stanford.edu/letter.html) websites can help persons prioritize goals and facilitate advance care planning before the office visit.
Once assessment is complete, the problem list should be updated with newly identified geriatric syndromes, and care plans should be modified based on patient goals. eTable B provides a compendium of practice recommendations from American Family Physician for subsequent management of geriatric conditions.
This article updates a previous article on this topic by Elsawy and Higgins. 49
Data Sources: A Medline search was completed in OVID. The following grouped concepts were searched as subject headings and/or textwords with truncation: (geriatric assessment or geriatric or elderly or gerontolo$) and (depress$ or cognition disorders or cognitive dysfunction or hearing loss or vision or vision disorders or accidental falls or fall or falling or falls or cancer or neoplasm$) and screen$. The search results included meta-analyses, systematic reviews, and general review articles. Additional sources searched include the Cochrane database, DynaMed, MEDLINE In-Process, and U.S. Preventive Services Task Force website. Search dates: February 7, 2017, and February 27, 2018.
The authors thank Susan Meadows and Susan Elliott for assistance in the literature review and reference formatting, and Diane Herigon for assistance with manuscript review and table preparation.
This material is the result of work supported with resources and the use of facilities at South Texas Veterans Health Care System, San Antonio, Tex., and the George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah.