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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 be effective in reducing health care utilization or costs. 1 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 4 management component of primary care is a key ingredient in the success of outpatient geriatric evaluation. 5 Effective primary care management of geriatric health issues, with its goal of caring for healthy and functional elderly patients, may perhaps be better Antiarrhythmics Antihistamines Antihypertensives Antipsychotics Benzodiazepines and other sedativehypnotics Digoxin (Lanoxin) Diuretics 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 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, physicians can improve the identification of specific 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 sedative hypnotic 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 8 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 11 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 12 13 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 14 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 Use of a benzodiazepine or other sedative-hypnot ic drug Education about the appropriate use of sedative-hypnotic drugs Nonpharmacologic treatment of sleep problems, such as sleep restriction Tapering and discontinuation of medication Use of four or more prescription medications Review of 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 transfer skills Balance exercises and training in transfer skills if indicated Environmental alterations, such as installation of grab bars or raised toilet seats Impairment in leg or arm muscle strength or impaired range of motion (hip, ankle, knee, shoulder, hand or elbow) Exercises with resistive bands and putty; resistance training two or three times a week, with resistance increased when the patient is able to complete 10 repetitions through the full 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. tested with a Snellen eye chart. Other studies have 15 For the missing item, see the original print version of this publication. 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 agerelate d 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. Hearing The prevalence of hearing loss in the geriatric population ranges from 14 to 46 percent, 17,18 6 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 Elderly Screening 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 17 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 23 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 num bers 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. 3 I eat few fruits, vegetables or milk products. 2 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. 2 2 I do not always have enough money to buy the food I need. I eat alone most of the time. 4 1 I take three or more different prescribed or over-the-counter drugs a day. 1 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. 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 sexuality, ask open and direct questions, and treat them as normal sexual persons. 27 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 effec ts 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? _____ _____ 1 1 Date? _____ 1 Day? _____ 1 Month? _____ 1 State? Country? _____ _____ 1 1 Town or city? _____ 1 Hospital? _____ 1 Floor? _____ 1 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. _____ 3 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. _____ 5 Recall 5. Ask for the names of the three objects learned in question 3. (Give one point for _____ 3 each correct answer.) Language 6. Point to a pencil and a watch. Have the patient name them as you point. _____ 2 7. Have the patient repeat "No ifs, ands or buts." _____ 1 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." _____ 3 9. Have the patient read and obey the following: "CLOSE YOUR EYES." (Write the words in large letters.) _____ 1 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.) _____ 1 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.) _____ 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. De pression 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 is at a premium. 41 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. 42 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? Yes / NO 2. Have you dropped many of your activities and interests? YES / No 3. Do you feel that your life is empty? 4. Do you often get bored? YES / No YES / No 5. Are you in good spirits most of the time? 6. Are you afraid that something bad is going to happen to you? Yes / NO YES / No 7. Do you feel happy most of the time? Yes / NO 8. Do you often feel helpless? YES / No 9. Do you prefer to stay at home, rather than going out and doing new things? YES / No 10. Do you feel you have more problems with memory than most? YES / No 11. Do you think it is wonderful to be alive now? Yes / NO 12. Do you feel pretty worthless the way you are now? YES / No 13. Do you feel full of energy? 14. Do you feel that your situation is hopeless? Yes / NO YES / No 15. Do you think that most people are better off than you are? 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 3 2 Completely unable to use the telephone 1 2. Can you get to places that are out of walking distance? Without help 3 With some help 2 Completely unable to travel unless special arrangements are made 1 3. Can you go shopping for groceries? Without help With some help 3 2 Completely unable to do any shopping 1 4. Can you prepare your own meals? Without help 3 With some help Completely unable to prepare any meals 2 1 5. Can you do your own housework? Without help 3 With some help 2 Completely unable to do any housework 6. Can you do your own handyman work? 1 Without help 3 With some help 2 Completely unable to do any handyman work 1 7. Can you do your own laundry? Without help 3 With some help 2 Completely unable to do any laundry at all 8a. Do you take any medicines or use any medications? 1 Yes (If "yes," answer question 8b.) No (If "no," answer question 8c.) 1 2 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) 3 2 Completely unable to take own medicine 8c. If you had to take medicine, could you do it? 1 Without help (in the right doses at the right time) 3 With some help (take medicine if someone prepares it for you and/or reminds you to take it) Completely unable to take own medicine 2 1 9. Can you manage your own money? Without help 3 With some help 2 Completely unable to handle money 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 Sexuality _____ Review of chronic conditions and medications _____ Smoke detectors (in place and working) Hot water temperature at <=48.8°C _____ (120°F) _____ Initiation of discussion about sexuality _____ Smoking near bed or upholstery Review of chronic conditions and _____ medications _____ Poor lighting _____ Obtrusive furniture _____ Slippery floors and loose rugs _____ Handrails and grab bars _____ One-leg balance (5 seconds) Continence Initiation of discussion about _____ incontinence _____ Focused physical examination (pelvis, prostate, rec tum) _____ "Get Up and Go" test* Mental status (consider one of the following) Sensorium _____ Mini-Mental State _____ Snellen eye chart _____ Clock Test _____ Ophthalmology examination _____ Informant Questionnaire on Cognitive Decline in the Elderly Hearing Handicapped Inventory for the _____ ElderlyScreening version _____ Geriatric Depression Scale _____ Pure tone audiometry Nutrition _____ Yale Depression Screen _____ Questioning about suicide _____ Nutritional Health Screen _____ Tooth brushing, flossing and dental visits Social issues Changes in living arrangements, _____ finances or activities _____ Caregiver support or burnout Immunizations _____ Tetanus and diphtheria toxoid _____ Influenza vaccine _____ Advance directives Family training in cardiopulmonary _____ resuscitation _____ Pneumococcal vaccine _____ Activities of Daily Living _____ Instrumental Acti vities 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 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). the Snellen eye chart Hearing Use an audioscope set at 40 dB. Test the patient's hearing using 1,000 and 2,000 Hz. Inability to hear 1,000 or 2,000 Hz in both ears or inability to hear frequencies in either ear Leg mobility 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." Unable to complete task in 15 seconds Urinary incontinence 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?" "Yes" to both questions Nutrition and weight loss Ask this question: "Have you lost 10 pounds "Yes" to the question or a weight over the past 6 months without trying to do so?" of less than 45.5 kg (100 lb) If the patient answers "yes," weigh the patient. Memory Three-item recall Unable to remember all three items after 1 minute Depression Ask this question: "Do you often feel sad or depressed?" "Yes" to the question Physical disability Ask the patient these six questions: "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. REFERENCES 1. Maly RC, Hirsch SH, Reuben DB. 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