A Systematic-and Realistic-Approach to Functional Assessment of Elderly Persons

December 31, 2006

A 74-year-old man comes to your office because his wife and childrenhave noticed that his memory has become mildly impaired. He continuesto work part time in the family business. Recently, however, his daughter has found thathe is making significant errors with clients. For example, he has failed to show up for appointmentsthat he had scheduled, and has set up appointments with clients whom he has already served.Because of errors he has made in client billing, he has turned over the company’s bookkeepingresponsibilities to his daughter.

A 74-year-old man comes to your office because his wife and childrenhave noticed that his memory has become mildly impaired. He continuesto work part time in the family business. Recently, however, his daughter has found thathe is making significant errors with clients. For example, he has failed to show up for appointmentsthat he had scheduled, and has set up appointments with clients whom he has already served.Because of errors he has made in client billing, he has turned over the company's bookkeepingresponsibilities to his daughter.About 3 months ago, his wife noticed that she needed to prompt him to dress more professionally.More recently, she has had to remind him to shave. The family is quite distressed aboutthe decline they have seen in the patient, although he seems oblivious to their concerns.Is a comprehensive geriatric assessment warranted for this patient?A comprehensive geriatric assessmentis an evaluation of a patient'smedical, functional, psychosocial,nutritional, and environmentalstatus.1 It is a useful adjunct to thestandard clinical examination of elderlypersons, and differs from itby including nonmedical domains,by emphasizing functional ability,and by using interdisciplinary teams(Table 1).Because this patient's memoryimpairment has clearly affected hisjob performance, a comprehensivegeriatric assessment is likely to behelpful. WHAT DOES ACOMPREHENSIVE GERIATRICASSESSMENT INCLUDE?Although this type of assessmenthas been used for decades, itsrole was not clearly defined until1988, when the National Institutes ofHealth sponsored a consensus developmentconference on geriatric assessmentmethods for clinical decisionmaking.2 The consensus statementoutlined the following goals:

  • Improve diagnostic accuracy.
  • Guide the selection of interventionsto restore or preserve health.
  • Recommend an optimal environmentfor the patient.
  • Predict outcomes.
  • Monitor clinical change.


To these ends, structured assessmentmethods and tools havebeen developed. A variety of interdisciplinaryteams have been created tobest implement these methods. Differentsites have been studied to tryto determine where the assessmentshould be carried out. Risk profileshave been developed to identify patientswho would most benefit fromcomprehensive assessment.

Structured assessment tools.

In a general primary care practice,patient management involves optimaltreatment of each problem on theproblem list. In geriatrics, however,the essential factor is not the problemlist, but the patient's functional status.Therefore, all aspects of the assessmentfocus on what the patient cando, rather than on his or her disordersper se.The primary tools for assessinga patient's functional ability are theActivities of Daily Living (ADLs) andthe Instrumental Activities of DailyLiving (IADLs). ADLs are the selfcareskills a patient must have tomaintain the ability to live alone.IADLs suggest a higher functionallevel and include such tasks as managingfinances, shopping, and usingthe telephone. An inability to carryout these activities suggests that thepatient can remain independent ifthere is a caregiver willing to help.Determination of the patient's functionalability may help predict futuredisability and can guide rehabilitation.A geriatric review of systems(

Table 2

) that targets key syndromes-such as falls, urinary incontinence,and weight loss-is usefulto screen for potential difficulties.Structured assessments of cognitivefunction (such as the Mini-MentalState Examination) and mood (suchas the Geriatric Depression Scale)are usually performed in a comprehensivegeriatric assessment.

Interdisciplinary teams.

Geriatricshas evolved to become an interdisciplinaryspecialty. Because of thebroad scope of a comprehensive geriatricassessment, specialists from avariety of fields are called on to contributetheir expertise. Physicianswith specific training in geriatric medicineusually function as team leaders.Other team members typically includea nurse (often a clinical nursespecialist or nurse practitioner) and asocial worker. Some models also includepsychologists and physical therapists,because mood and gait disordersare seen frequently in olderadults.

Evaluation sites.

Comprehensivegeriatric assessment was initiallycarried out in hospital inpatient units.Assessments are now performed in extended-care facilities and outpatientreferral centers and as part of homecareprograms.

Targeting appropriate patient's.

Comprehensive geriatric assessmentis labor- and cost-intensive. Whenused randomly, the assessment isprohibitively expensive and loses itseffectiveness. For example, patientswith no functional impairments andvery frail patient's generally do notbenefit.Comprehensive geriatric assessmentis most helpful for 3 groups ofpatients:

  • Those who still live in the community,have multiple chronic disorders,and are beginning to experience functionaldecline.
  • Patients with certain geriatric syndromes-such as falls, urinary incontinence,weight loss, and memory impairment-that place them at increasedrisk for disability.
  • Those in transition-for example,those moving from home to an assistedliving facility.

In these types of patients, targetedassessment can help establish a diagnosisat an early stage of dysfunction,when treatment is most likely tobe effective.

DOES COMPREHENSIVEGERIATRIC ASSESSMENT"WORK"?

In the last decade, comprehensivegeriatric assessment has comeunder scrutiny as payors demand evidenceof the effectiveness of this approach.The outcomes of both inpatientand outpatient assessments havebeen studied in randomized controlledtrials as well as less structuredevaluations.A meta-analysis published in1993 concluded that survival andfunction were enhanced by assessmentprograms linked to strong longtermmanagement.

3

Other reportshave suggested that geriatric evaluationand management slow functionaldecline among high-risk communitydwellingolder persons, delay the developmentof disability, and improvemental health outcomes.

1,4-6

Although studies do not showchanges in Medicare expendituresfor patients who undergo comprehensivegeriatric assessment, and onlylimited data suggest increased survival,comprehensive assessment appearsto result in significant benefit toproperly selected patients and theirfamilies.

References:

REFERENCES:


1.

Boult C, Boult LB, Morishita L, et al. A randomizedclinical trial of outpatient geriatric evaluationand management.

J Am Geriatr Soc.

2001;49:351-359.

2.

National Institutes of Health Consensus DevelopmentConference Statement: geriatric assessmentmethods for clinical decision-making.

J Am GeriatrSoc.

1988;36:342-347.

3.

Stuck AE, Siu AL, Wieland GD, et al. Comprehensivegeriatric assessment: a meta-analysis of controlledtrials.

Lancet.

1993;342:1032-1036.

4.

Cohen HJ, Feussner JR, Weinberger M, et al. Acontrolled trial of inpatient and outpatient geriatricevaluation and management.

N Engl J Med.

2002;346:905-912.

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Stuck AE, Aronow HU, Steiner A, et al. A trial ofannual in-home comprehensive geriatric assessmentsfor elderly people living in the community.

N Engl J Med.

1995;333:1184-1189.

6.

Fried LP. Establishing benchmarks for qualitycare for an aging population: caring for vulnerableolder adults.

Ann Intern Med.

2003;139:784-786.

7.

Kane RL, Ouslander JG, Abrass IB, eds.

Essentialsof Clinical Geriatrics.

5th ed.

New York: McGrawHill; 2004.