Download The Geriatric Patient: A Systematic Approach to Maintaining Health

The Geriatric Patient: A Systematic Approach to
Maintaining Health
KARL E. MILLER, M.D.,
ROBERT G. ZYLSTRA, ED.D., L.C.S.W., and
JOHN B. STANDRIDGE, M.D.
University of Tennessee College of Medicine, Chattanooga, Tennessee
The number of persons 65 years of age and older continues to increase dramatically in the United
States. Comprehensive health maintenance screening of this population is becoming an important
task for primary care physicians. As outlined by the U.S. Preventive Services Task Force,
assessment categories unique to elderly patients include sensory perception and injury prevention.
Geriatric patients are at higher risk of falling for a number of reasons, including postural
hypotension, balance or gait impairment, polypharmacy (more than three prescription medications)
and use of sedative-hypnotic medications. Interventional areas that are common to other age
groups but have special implications for older patients include immunizations, diet and exercise,
and sexuality. Cognitive ability and mental health issues should also be evaluated within the context
of the individual patient's social situation--not by screening all patients but by being alert to the
occurrence of any change in mental function. Using an organized approach to the varied aspects of
geriatric health, primary care physicians can improve the care that they provide for their older
patients. (Am Fam Physician 2000;61:1089-104.)
See editorial
on page 949.
Current predictions suggest that the number of persons 65 years of age and older will
more than double in the United States during the next 30 years. As a result, the number
of elderly Americans could increase from 34 million in 1998 to approximately 69 million in 2030.
This increase, combined with the disproportionate rate at which elderly patients use medical
resources, will require that primary care physicians become increasingly knowledgeable about the
needs of geriatric patients and increasingly efficient in the evaluation and management of concerns
unique to these patients.
The value of performing a comprehensive geriatric assessment appears to be equivocal. Simple
screening instruments can be helpful in identifying patients at risk for common health problems and
in improving the clinical assessment of a disease course. However, these screening tools may not
1
be effective in reducing health care utilization or costs.
2
The comprehensive geriatric assessment is often
described in the literature as a multidisciplinary, time-
TABLE 1
Medications Associated with an
as being at significant risk for imminent morbidity or Increased Risk of Falls in the
mortality. An evaluation of this type is impractical in Elderly
intensive evaluation of a patient previously identified
2,3
most primary care settings and is seldom used by
practicing physicians. Yet the ongoing, long-term
Antiarrhythmics
Antihistamines
management component of primary care is a key
Antihypertensives
ingredient in the success of outpatient geriatric
Antipsychotics
Benzodiazepines
evaluation.
and other sedativehypnotics
Effective primary care management of geriatric health Digoxin (Lanoxin)
Diuretics
issues, with its goal of caring for healthy and
4
5
functional elderly patients, may perhaps be better
Laxatives
Monoamine oxidase
inhibitors
Muscle relaxants
Narcotics
Tricyclic
antidepressants and
selective serotonin
reuptake inhibitors
Vasodilators
described as comprehensive health screening. Using
Adapted with permission from Reuben DB,
Grossberg GT, Mion LC, Pacala JT, Potter
physicians can improve the identification of specific JF, Semla TP. Geriatrics at your fingertips,
1998/99. Belle Mead, N.J.: Excerpta
problems that are common in the elderly and also shift Medica, 1998.
simple and easily administered assessment tools,
their focus from disease-specific intervention to
preventive care and proactive medical management.
5
In 1996, the U.S. Preventive Services Task Force (USPSTF) published the second edition of its
Guide to Clinical Prevention Services. In this publication, the USPSTF updated earlier
6
recommendations on preventive services for patients at various stages of life. The recommendations
for patients 65 years of age and older include a number of items common to other age groups. The
unique assessment categories for older patients are sensory perception (hearing and vision
screening) and accident prevention. Assessment areas common to other age groups but with special
implications for the elderly include diet and exercise, immunizations and sexuality. Although the
USPSTF found little evidence in 1996 to support the value of screening for dementia, recent
pharmaceutical advances have resulted in beneficial treatment options that were not available just a
few years ago.
7
Using the USPSTF recommendations as a guide, this article reviews available standardized
assessment tools and techniques that can be used in outpatient settings. The goals are to encourage a
systematic assessment of various areas of potential geriatric risk and to develop a database
appropriate to the unique concerns of elderly patients. All of the information does not need to be
gathered in one office visit. Multiple visits can be used to perform the entire assessment.
Injury Prevention
The USPSTF recommends that primary care physicians ask
patients in most age groups about the routine use of safety
belts and bike helmets, the availability of smoke detectors,
the maintenance of hot water heater temperature at or
Risk factors for falls include
environmental hazards, gait and
balance disturbances, use of sedativehypnotic drugs and polypharmacy.
below 48.8°C (120°F) and the danger of smoking near
bedding or upholstery. Fall prevention, however, is an assessment category unique to patients 65
6
years of age and older.
The annual incidence of falls in patients over 65 years of age who live independently is
approximately 25 percent but rises to 50 percent in patients over 80 years of age. Falls are
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responsible for a significant number of accidental deaths and traumatic injuries among the elderly.
One third of patients with confirmed falls may not recall falling.
TABLE 2
Risk Factors for Osteoporosis
9
Risk Factors
Intrinsic factors that contribute to falls include agerelated changes in postural control, gait and visual
ability, and the presence of acute and chronic diseases
Increasing age
Female gender
Early menopause
Low body weight
Small stature
White or Asian race
Family history
Drug use (e.g.,
steroids, heparin)
Low calcium intake
Excessive alcohol
intake
Smoking
Physical inactivity
Conditions that impair
calcium absorption
High caffeine intake
that affect sensory input, the central nervous system
and musculoskeletal strength and coordination.
Certain medications can also increase the risk of
falling (Table 1).
10
Osteoporosis is one notable intrinsic factor that leads
to falls. In patients with this condition, a pathologic
fracture may precede a fall. In the absence of
universally accepted criteria for the assessment of bone mineral density, screening should be
directed at a risk assessment for osteoporosis (Table 2).
Extrinsic factors that contribute to falls include poor lighting, obtrusive furniture, slippery floors,
loose floor coverings and bathrooms without handrails or grab bars.
Mobility and Dexterity
A comprehensive risk assessment for falls incorporates a review of all potential intrinsic and
extrinsic factors, as well as a focused physical examination (Table 3). The physical examination
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can be a simple evaluation of one-leg balance (i.e., the ability to stand unassisted on one leg for five
seconds) or a more structured evaluation such as the "Get Up and Go" test. In the "Get Up and
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Go" test, the patient is observed as he or she rises from a sitting position, walks 10 ft, turns and
returns to the chair to sit. The effectiveness of the test for predicting falls can be enhanced by timing
the process, with more than 16 seconds suggesting an increased risk of falling. Any observed or
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reported changes in gait, strength or balance may require further evaluation with a more detailed
assessment.
TABLE 3
Interventions to Reduce the Risk of Falling in the Elderly
Risk factors
Interventions
Postural hypotension: a drop in
systolic blood pressure of >=20 mm
Hg or to <90 mm Hg on standing
Behavioral recommendations, such as ankle pumps or hand
clenching, and elevating the head of the bed
Decrease in the dosage of a medication that may contribute
to hypotension; if necessary, discontinuation of the drug or
substitution of another medication
Pressure stockings
Fludrocortisone (Florinef), 0.1 mg two or three times daily, if
indicated
Midodrine (ProAmatine), 2.5 to 5 mg three times daily
Education about the appropriate use of sedative-hypnotic
drugs
Nonpharmacologic treatment of sleep problems, such as
sleep
restriction
Tapering and discontinuation of medication
Review of medications
Use of a benzodiazepine or other
sedative-hypnotic drug
Use of four or more prescription
medications
Environmental hazards for falling or
tripping
Home safety assessment with appropriate changes, such as
removal of hazards, selection of safer furniture (correct
height, more stability) and installation of structures such as
grab bars or handrails on stairs.
Any impairment in gait
Gait training
Use of an appropriate assistive device
Balance or strengthening exercises if indicated
Any impairment in balance or
Balance exercises and training in transfer skills if indicated
transfer skills
Environmental alterations, such as installation of grab bars
or raised toilet seats
Impairment in leg or arm muscle
Exercises with resistive bands and putty; resistance training
strength or impaired range of motion two or three times a week, with resistance increased when
(hip, ankle, knee, shoulder, hand or the patient is able to complete 10 repetitions through the full
elbow)
range of motion
Adapted with permission from Tinetti ME, Baker DI, McAvay G, Claus EB, Garrett P, Gottschalk M,
et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the
community. N Engl J Med 1994;331:821-7
Sensory Perception
Changes in vision and hearing occur as patients age. Because these changes can have a great impact
on well-being, the USPSTF recommends regular vision and hearing screening for patients 65 years
of age and older.
6
Vision
Hearing Handicap Inventory for the
ElderlyScreening Version
One study found that 72 percent of community-based
patients more than 64 years of age had impaired vision as The rightsholder did not grant rights to
reproduce this item in electronic media.
For the missing item, see the original
print version of this publication.
tested with a Snellen eye chart. Other studies have
15
detected lower percentages of geriatric patients with
vision problems, but the prevalence of visual impairment
is still quite high. The most common causes of visual
FIGURE 1.
impairment in the elderly include presbyopia, cataracts, glaucoma, diabetic retinopathy and agerelated macular degeneration. Changes in vision can cause a significant number of problems for
elderly patients, including an increased risk for falls.
16
The Snellen eye chart is an appropriate tool for visual acuity screening in the elderly. Referral to an
ophthalmologist should be considered when visual acuity is worse than 20/40 (with normal
corrective lenses, if applicable) and visual impairment is interfering with daily activities.
The USPSTF found insufficient evidence to recommend for or against screening with
ophthalmoscopy performed by primary care physicians in asymptomatic elderly patients. However,
patients at high risk for glaucoma (i.e., black patients over 40 years of age, white patients over 65
years of age and patients with diabetes mellitus, myopia, ocular hypertension or a family history of
glaucoma) should be referred to an eye care specialist for tonometry, funduscopy and visual field
examination. The optimal frequency for glaucoma screening in these patients is uncertain.
6
Hearing
The prevalence of hearing loss in the geriatric population ranges from 14 to 46 percent,
17,18
but only
20 percent of primary care physicians routinely screen elderly patients for hearing loss. As a result
18
of psychologic, financial and mechanical impediments, only 32 percent of persons with moderate to
marked hearing loss use a hearing aid.
17
TABLE 4
Interventions Based on the
Degree of Hearing Loss in the
Elderly
The rightsholder did not grant rights to
Presbycusis, a progressive high-frequency hearing
reproduce this item in electronic media.
loss, is the most common cause of hearing impairment For the missing item, see the original print
version of this publication.
in geriatric patients. This type of hearing loss
19
decreases the ability to interpret speech, which can
lead to a decreased ability to communicate and a
20
subsequent increased risk for social isolation and depression. Hearing loss in the elderly can also
17
adversely affect physical, emotional and cognitive well-being.
21
Questionnaires such as the Hearing Handicap Inventory for the ElderlyScreening version (HHIES)
have been shown to accurately identify persons with hearing impairment (Figure 1). The reference
18
22
standard for establishing hearing impairment, however, remains pure tone audiometry, which can be
performed in the physician's office. Combining the HHIES questionnaire with pure tone audiometry
has been shown to improve screening effectiveness.
20
Appropriate interventions include periodic screening to provide early detection of hearing
impairment, cautious use or avoidance of ototoxic drugs, and support for the obtainment and
continued use of hearing aids. Interventions to be considered, depending on the degree of hearing
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loss, are provided in Table 4.
10
Nutrition
Malnutrition and undernutrition are common yet frequently overlooked problems in the geriatric
population. Elderly patients with a compromised nutritional state require longer hospital stays and
develop more complications.
23
One simple screening device for geriatric nutrition is the Nutritional Health Screen (Figure 2). This
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assessment tool is simple to administer, can be graded by a health care professional or family
member, and may help to prevent nutritional problems in at-risk patients.
The USPSTF recommendation for encouraging regular tooth brushing, flossing and dental visits
gains importance in the elderly.
6
Nutritional Health Screen
Read the statements below. Circle the number in the "yes" column for each statement that applies
to you. Add up the circled numbers to get your nutritional score.
Yes
I have an illness or condition that has made me change the kind and/or amount of food I eat.
2
I eat fewer than two meals a day.
I eat few fruits, vegetables or milk products.
I have three or more drinks of beer, liquor or wine almost every day.
I have tooth or mouth problems that make it hard for me to eat.
I do not always have enough money to buy the food I need.
I eat alone most of the time.
I take three or more different prescribed or over-the-counter drugs a day.
Without wanting to, I have lost or gained 10 pounds in the past six months.
I am not always physically able to shop, cook and/or feed myself.
3
2
2
2
4
1
1
2
2
The scale is scored as follows:
0 to 2 = You have good nutrition. Recheck your nutritional score in 6 months.
3 to 5 = You are at moderate nutritional risk. See what you can do to improve your eating habits
and lifestyle. Recheck your nutritional score in 3 months.
6 or more = You are at high nutritional risk. Bring this checklist the next time you see your doctor,
dietitian or other qualified health or social service professional. Talk with any of these professionals
about the problems you may have. Ask for help to improve your nutritional status.
FIGURE 2. Nutritional health screen.
Adapted with permission from The clinical and cost-effectiveness of medical nutrition therapies:
evidence and estimates of potential medical savings from the use of selected nutritional
intervention. June 1966. Summary report prepared for the Nutritional Screening Initiative, a project
of the American Academy of Family Physicians, the American Dietetic Association and the National
Council on the Aging, Inc., and funded in part by a grant from Ross Products Division, Abbott
Laboratories Inc.
Immunizations
A 1990 report indicated that fewer than 30 percent of adults had received updated tetanus24
diphtheria, influenza and pneumococcal immunizations. The poor compliance rate was determined
to be secondary to patients' concerns about adverse reactions to immunizations and physicians'
overlooking the need for such immunizations. In recent years, however, immunization rates in
adults have improved. Data from the Centers for Disease Control and Prevention indicated that the
1997 rates for influenza and pneumococcal vaccinations were 65.5 percent and 45.5 percent,
respectively.
25
Primary care physicians must be diligent in assessing the
The U.S. Preventive Services Task
immunization status of geriatric patients and providing the Force recommends annual influenza
recommended vaccines. As suggested by the USPSTF, an vaccination and at least one
6
pneumococcal vaccination for all
annual influenza vaccination in the fall is recommended for patients over 65 years of age.
all elderly patients. Patients over 65 years of age should
also receive at least one pneumococcal vaccination in their lifetime, with high-risk patients
receiving a second immunization in six years. The tetanus-diphtheria (Td) toxoid should be given
every 10 years. The Td toxoid is given again after five (or more) years if the patient suffers a wound
that would be classified as "dirty."
Sexuality
Although the tempo and intensity of sexual activity may change over time, problems that relate to a
person's ability to have and enjoy sexual relations should not be considered part of the normal aging
process. Studies show that 74 percent of married men and 56 percent of married women over 60
years of age remain sexually active.
26
Common problems affecting sexual functioning include arthritis, diabetes, fatigue, fear of
precipitating a heart attack and side effects from alcohol, prescription drugs and over-the-counter
medications. Older patients state that they would like their physician to initiate discussions about
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sexuality, ask open and direct questions, and treat them as normal sexual persons.
28
Continence
Incontinence is estimated to occur in 11 to 34 percent of elderly men and 17 to 55 percent of elderly
women. Although incontinence is common, is frequently reversible and has significant social and
29
30
emotional consequences, relatively few patients volunteer that they are having problems or request
31
treatment.
32
The first step in screening for urinary incontinence is to ask
Assessment for urinary incontinence
the patient if he or she is experiencing any problems in this should include evaluation of cognitive
area. Two straightforward questions are "Do you ever lose function, fluid intake, mobility,
urine when you don't want to?" and "Have you lost urine
medication side effects and previous
urologic surgeries.
on at least six separate days?" Affirmative answers to both
questions constitute a positive screen. In this situation, further evaluation is necessary. Evidence of
stress incontinence is elicited by questions such as "Do you ever lose urine when you cough,
exercise, lift, sneeze or laugh?"
The assessment for urinary incontinence should include an evaluation of cognitive function, fluid
intake, mobility, medication side effects and previous urologic surgeries. The physical examination
30
should focus on the lower genitourinary tract in women and the prostate gland in men. A rectal
examination can determine the presence of fecal impaction, and a simple urinalysis can be used to
screen for infection or glycosuria.
Mental Status
Changes in mental status can have a profound impact on elderly patients and their families. Two of
the more common changes are cognitive decline and depression.
Cognition
Dementia is chronic and progressive, and it is characterized by the gradual onset of impaired
memory and deficits in two or more areas of cognition, such as anomia, agnosia or apraxia. For the
diagnosis of dementia to be established, these deficits must be present with no alteration of
consciousness and no underlying medical cause that would better explain the deficits.
Two of the more commonly used screening tools for dementia are the Mini-Mental State (Figure
3) and the Clock Test. An alternative to patient testing is a structured family report using the
33
34
Informant Questionnaire on Cognitive Decline in the Elderly (IQCDE). Although less
35
discriminating than the Mini-Mental State, the IQCDE is not affected by a patient's educational
level or premorbid intelligence. Combining these tools can increase the sensitivity of the screening
36
process and identify additional patients in the early stages of dementia.
37
Mini-Mental State
Write in the points for each correct response. A total of 30 points is possible.
Score Points
Orientation
1. What is the:
2. Where are we?
Year?
Season?
Date?
Day?
Month?
State?
Country?
Town or city?
Hospital?
Floor?
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Registration
3. Name three objects, taking 1 second to say each. Then ask the patient to repeat
all three names after you have said them. (Give one point for each correct answer.)
Repeat the answers until the patient learns all three.
_____
Attention and calculation
Serial sevens. Have the patient count backward from 100 by 7's. (Stop after five
answers: 93, 86, 79, 72, 65. Give one point for each correct answer.) Alternatively,
have the patient spell WORLD backwards.
_____
Recall
5. Ask for the names of the three objects learned in question 3. (Give one point for _____
1
1
1
1
1
1
1
1
1
1
3
5
3
each correct answer.)
Language
6. Point to a pencil and a watch. Have the patient name them as you point.
7. Have the patient repeat "No ifs, ands or buts."
8. Have the patient follow a three-stage command: "Take a paper in your hand. Fold
the paper in half. Put the paper on the floor."
9. Have the patient read and obey the following: "CLOSE YOUR EYES." (Write the
words in large letters.)
10. Have the patient write a sentence of his or her choice. (The sentence should
contain a subject and an object, and it should make sense. Ignore spelling errors
when scoring.)
11. Have the patient copy the following design. (Give one point if all sides and
angles are preserved and if the intersecting sides form a quadrangle.)
_____
_____
2
1
_____
3
_____
1
_____
1
_____
1
Total _____
FIGURE 3. Mini-Mental State.
Adapted with permission from Folstein MF, Folstein SE, McHugh PR. "Mini-mental state." A
practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res
1975;12:189-98.
Depression
Depression significantly increases morbidity and mortality. As opposed to dementia, depression is
38
usually characterized by a relatively rapid onset, intact but possibly retarded cognitive abilities and
a generally time-limited duration.
The Geriatric Depression Scale, shown in Figure 4, is a good screening tool to use in older
39
patients. It avoids issues related to physical symptoms and asks questions requiring only a "yes" or
40
"no" answer. The one-question Yale Depression Screen ("Do you often feel sad or depressed?") has
also been found to be an effective screening tool and may be worth considering when clinical time
41
is at a premium.
An assessment for suicide risk is important in geriatric patients who appear depressed. The best way
to accomplish this task is to ask direct, yet nonthreatening questions. An effective interview
progression might be to begin by asking patients if they are concerned that they are becoming a
burden to their family and if they have ever felt that their family might be better off without them.
This is followed by questions about active suicidal ideation.
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Geriatric Depression Scale (Short Form)
For each question, choose the best answer for how you felt over the past week.
1. Are you basically satisfied with your life?
2. Have you dropped many of your activities and interests?
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?
9. Do you prefer to stay at home, rather than going out and doing new things?
10. Do you feel 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 people are better off than you are?
Yes / NO
YES / No
YES / No
YES / No
Yes / NO
YES / No
Yes / NO
YES / No
YES / No
YES / No
Yes / NO
YES / No
Yes / NO
YES / No
YES / No
The scale is scored as follows: 1 point for each response in capital letters. A score of 0 to 5 is
normal; a score above 5 suggests depression.
FIGURE 4. Mini-Mental State.
dapted with permission from Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent
evidence and development of a shorter version. Clin Gerontol 1986;5:165-72.
Social Issues
Because multiple aspects of the social situation can influence functional ability, efficient use of time
can be made by asking patients and family members if any recent changes have occurred in living
arrangements, finances or activities. Actual or potential caregivers can provide information about a
patient's social network and support system, as well as the availability of care.
6
Evaluating a caregiver's potential for feeling overwhelmed is important in determining the risk of
"burning out." Referral to agencies such as the Alzheimer's Association or a local senior center can
provide functional and emotional support for patients and caregivers.
6
Other issues that need to be addressed with patients and caregivers include advance directives, the
living will and the durable power of attorney. Finally, the USPSTF recommends that all family
members of geriatric patients receive training in cardiopulmonary resuscitation.
6
The rightsholder did not grant rights to reproduce this item in electronic media. For the missing
item, see the original print version of this publication.
FIGURE 5.
Remaining as independent as possible for a long as possible is a primary concern for most elderly
patients. The level of supportive assistance that is needed can quickly be determined by asking the
patient and/or caregiver about the patient's ability to perform the Activities of Daily Living (ADLs)
and Instrumental Activities of Daily Living (IADLs). An ADL evaluation form is provided in
Figure 5, and an IADL evaluation form is presented in Figure 6. Having the patient complete a
43
44
structured series of activities, such as the Performance Test of Activities of Daily Living (PADL),
provides similar information without reporting bias.
45
Instrumental Activities of Daily Living (Self-Rated Version)
For each question, circle the points for the answer that best applies to your situation.
1. Can you use the telephone?
Without help
With some help
Completely unable to use the telephone
2. Can you get to places that are out of walking distance?
Without help
With some help
Completely unable to travel unless special arrangements are made
3. Can you go shopping for groceries?
Without help
With some help
Completely unable to do any shopping
4. Can you prepare your own meals?
Without help
With some help
Completely unable to prepare any meals
5. Can you do your own housework?
Without help
With some help
Completely unable to do any housework
6. Can you do your own handyman work?
Without help
With some help
Completely unable to do any handyman work
7. Can you do your own laundry?
3
2
1
3
2
1
3
2
1
3
2
1
3
2
1
3
2
1
Without help
With some help
Completely unable to do any laundry at all
8a. Do you take any medicines or use any medications?
Yes (If "yes," answer question 8b.)
No (If "no," answer question 8c.)
8b. Do you take your own medicine?
Without help (in the right doses at the right time)
With some help (take medicine if someone prepares it for you and/or reminds you to take it)
Completely unable to take own medicine
8c. If you had to take medicine, could you do it?
Without help (in the right doses at the right time)
With some help (take medicine if someone prepares it for you and/or reminds you to take it)
Completely unable to take own medicine
9. Can you manage your own money?
Without help
With some help
Completely unable to handle money
3
2
1
1
2
3
2
1
3
2
1
3
2
1
FIGURE 6. Instrumental Activities of Daily Living Scale (self-rated version).
Adapted with permission from Lawton MP, Brody EM. Assessment of older people: self-maintaining
and instrumental activities of daily living. Gerontologist 1969;9:279-85.
One recent study indicated that short-term memory and orientation are the domains most closely
associated with ADL dependence. The study findings suggested that a shortened version of the
Mini-Mental State that included only the recall of three words and the orientation to month, year
and address could be a valid and time-efficient assessment tool.
46
Checklist of Assessment Areas for Maintaining Healthy Geriatric Patients
Injury prevention
_____ Use of safety belts or helmets
_____ Smoke detectors (in place and working)
Hot water temperature at <=48.8°C
_____
(120°F)
_____ Smoking near bed or upholstery
_____ Poor lighting
_____ Obtrusive furniture
_____ Slippery floors and loose rugs
_____ Handrails and grab bars
_____ One-leg balance (5 seconds)
_____ "Get Up and Go" test*
Sensorium
Sexuality
Review of chronic conditions and
_____
medications
_____ Initiation of discussion about sexuality
Continence
Review of chronic conditions and
_____
medications
Initiation of discussion about
_____
incontinence
Focused physical examination (pelvis,
_____
prostate, rectum)
Mental status (consider one of the
following)
_____ Mini-Mental State
_____ Snellen eye chart
_____ Ophthalmology examination
Hearing Handicapped Inventory for the
_____
ElderlyScreening version
_____ Pure tone audiometry
Nutrition
_____ Nutritional Health Screen
_____ Tooth brushing, flossing and dental visits
Immunizations
_____ Tetanus and diphtheria toxoid
_____ Influenza vaccine
_____ Pneumococcal vaccine
_____ Clock Test
Informant Questionnaire on Cognitive
_____
Decline in the Elderly
_____ Geriatric Depression Scale
_____ Yale Depression Screen
_____ Questioning about suicide
Social issues
Changes in living arrangements,
_____
finances or activities
_____ Caregiver support or burnout
_____ Advance directives
Family training in cardiopulmonary
_____
resuscitation
_____ Activities of Daily Living
_____ Instrumental Activities of Daily Living
Performance Test of Activities of Daily
_____
Living
*--The patient rises from a sitting position, walks 10 feet, turns and returns to the chair to sit. The
test is positive if these activities take more than 16 seconds.
FIGURE 7. Areas of assessment in a systematic approach to maintaining healthy geriatric patients.
Information from U.S. Preventive Services Task Force. Guide to clinical preventive services: report
of the U.S. Preventive Services Task Force. 2d ed. Baltimore: Williams & Wilkins, 1996.
Final Comment
Geriatric patients present multiple challenges to primary care physicians. Using a standard
assessment plan, which might include a chart-based checklist of counseling topics (Figure 7), as
6
well as a brief screening list (Table 5), physicians can prevent or delay some of the major causes of
47
morbidity and mortality in their older patients. The assessment can be performed over time and
during multiple visits. By performing comprehensive health screening, physicians can provide
appropriate interventions and improve quality of life for their geriatric patients.
TABLE 5
Ten-Minute Screen for Geriatric Conditions
Problem
Screening measure
Positive screen
Vision
Ask this question: "Because of your eyesight, do "Yes" to question and inability to
you have trouble driving a car, watching
read at greater than 20/40 on
Hearing
Leg mobility
Urinary
incontinence
Nutrition and
weight loss
Memory
Depression
Physical
disability
television, reading or doing any of your daily
activities?"
If the patient answers "yes," test each eye with
the Snellen eye chart while the patient wears
corrective lenses (if applicable).
Use an audioscope set at 40 dB. Test the
patient's hearing using 1,000 and 2,000 Hz.
Time the patient after giving these directions:
"Rise from the chair. Then walk 20 feet briskly,
turn, walk back to the chair and sit down."
Ask this question: "In the past year, have you
ever lost your urine and gotten wet?"
If the patient answers "yes," ask this question:
"Have you lost urine on at least 6 separate
days?"
Ask this question: "Have you lost 10 pounds
over the past 6 months without trying to do so?"
If the patient answers "yes," weigh the patient.
Three-item recall
Ask this question: "Do you often feel sad or
depressed?"
Ask the patient these six questions:
the Snellen eye chart
Inability to hear 1,000 or 2,000
Hz in both ears or inability to
hear frequencies in either ear
Unable to complete task in 15
seconds
"Yes" to both questions
"Yes" to the question or a weight
of less than 45.5 kg (100 lb)
Unable to remember all three
items after 1 minute
"Yes" to the question
"No" to any of the questions
"Are you able to do strenuous activities, like fast
walking or bicycling?"
"Are you able to do heavy work around the
house, like washing windows, walls or floors?"
"Are you able to go shopping for groceries or
clothes?"
"Are you able to get to places that are out of
walking distance?"
"Are you able to bathe--sponge bath, tub bath or
shower?"
"Are you able to dress, like put on a shirt, button
and zip your clothes, or put on your shoes?"
Adapted with permission from Moore A, Siu AL. Screening for common problems in ambulatory
elderly: clinical confirmation of a screen instrument. Am J Med 1996;100:438-43. Copyright 1996,
with permission from Excerpta Medica Inc.
The Authors
KARL E. MILLER, M.D.,
is associate professor of family medicine and director of predoctoral education and research at the
University of Tennessee College of Medicine, Chattanooga. Dr. Miller earned his medical degree
from the Medical College of Ohio, Toledo, and completed a residency in family practice at Flower
Memorial Hospital, Sylvania, Ohio.
ROBERT G. ZYLSTRA, ED.D., L.C.S.W.
is director of behavioral science and instructor in the Department of Family Medicine at the
University of Tennessee College of Medicine, Chattanooga. Dr. Zylstra earned a master of social
work degree at the University of Michigan, Ann Arbor, and a doctor of education degree at the
University of Memphis.
JOHN B. STANDRIDGE, M.D.,
is assistant professor of family medicine at the University of Tennessee College of Medicine,
Chattanooga, and medical director of Alexian Health Care Center, Signal Mountain, Tenn. He
earned his medical degree at the University of Tennessee College of Medicine, Memphis, and
completed a family practice residency at Roanoke (Va.) Memorial Hospital. Dr. Standridge also
earned a Certificate of Added Qualification in Geriatric Medicine.
Address correspondence to Karl E. Miller, M.D., Department of Family Medicine, University of
Tennessee, Chattanooga Unit, 1100 East Third St., Chattanooga, TN 37403. Reprints are not
available from the authors.
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