Comprehensive Geriatric Assessment

INTRODUCTION

Presentation of illnesses in the elderly patient may be different from the young.  Because multiple problems are the norm, and underlying chronic diseases are prevalent, the age-old teaching of ‘poverty of diagnosis’ may not be applicable.  While on one hand, there is a need to search for explanations for a sign or symptom, on the other hand, there is a limit to this exercise.  Therefore, we should be searching for  conditions that can make a difference to the elderly person when appropriately treated.  What are these conditions, and how best should we go about doing it ?  These are the questions that we attempt to answer.

GOALS OF A COMPREHENSIVE GERIATRIC ASSESSMENT:

1. Improve diagnostic accuracy
2. Avoid iatrogenesis
3. Clarify functional status and its implication for care decisions
4. Determine risk factors for functional decline
5. Identify interventions to preserve or restore functional capabilities
6. Recommend the optimal care environment
7. Provide an accurate prognosis for social and medical planning
8. Help monitor clinical change over time.

IS THERE A GROUP THAT IS PARTICULARLY IMPORTANT TO PRACTISE COMPREHENSIVE GERIATRIC ASSESSMENT ?

It has benefits for older as well as older women, but is especially crucial for women for several reasons:

Women constitute a larger proportion of older population than men.

Women live longer and experience a longer period of need and dependence on others at the end of life.

Women are prone to earlier and more severe involvement in many of the geriatric syndromes to which older individuals are susceptible.

The assessment can be divided into 2 aspects:

1. assessment of main complaint/s  and
2. assessment of hidden problems

1. Assessment of Main Complaint/s

History taking is often the weakest part of the assessment.  Poor history may be contributed by failing memory, denial, confusion or dementia, deafness or even aphasia.  Main carers may not be attentive to their complaints, and may wrongfully attribute their problems to ageing (ageism).  History input from all sources should be carefully assessed.  Sound amplification may be used for hearing-impaired patients.

Examination of the patient is plagued with pitfalls because many ‘abnormal’ signs may actually be within ‘normal’ limits for the elderly.  Table 1 summarizes these signs.

To complete the clinical assessment, appropriate laboratory investigations should be done.  In order to interpret the results accurately, we should remember that in the elderly the normal range of many values changes with age; therefore, an abnormal value may not indicate disease.  Table 2 summarizes the effects of ageing on various laboratory values. 

There are some results which are abnormal if detected in the young, but might be present in old age.  They are rheumatoid factors, VDRL and bacteriuria.

Rheumatoid Factors:

These are autoantibodies that are found in more than two-thirds of adults with rheumatoid arthritis (RA).  These autoantibodies include IgG, IgM and IgA, but the most commonly used method detects IgM rheumatoid factors.  The tendency for a positive test increases with age, such that 10 to 20% of individuals over 65 will test positive.  RF may be elevated transiently after vaccination or transfusion and in relatives of patients with RA¹.

A positive test will only be significant if the titre is high (>1:128) with suggestive clinical presentation.

VDRL:

A false positive VDRL is often found in the elderly male or female patient.  The titre is usually low and Treponema Pallidium Haem-Agglutination test (TPHA) is negative.

Bacteriuria:

The prevalence of asymptomatic bacteriuria increases in the elderly, especially among females.  It has been estimated that as much as 10 to 50% of females will have them.  It does not require treatment².

2. Assessment of Hidden Problems

Most people over the age of 65 have at least one chronic condition.  Most prevalent are arthritis (53%), hypertension (42%), hearing impairments (40%), and heart disease (40%).  In addition, the major killers of the elderly, that is, circulatory disease, neoplasms, and injuries, can be prevented and their effect delayed by timely and appropriate measures.  The goal of this assessment is to identify risk factors for these categories of illness and to alert patients and family members.  Through health maintenance, the practitioner can help the elderly to maintain current levels of functioning and prevent further disability.  

a. How effective is this ?

Although routine health screening is still controversial, studies have indicated that the preventive approach can be effective for a variety of disorders in the elderly.  The following are examples:

i. Hypertension

Hypertension is a major risk factor of cardiovascular disease.  The European Working Party (EWP) has demonstrated that therapy is worthwhile in double-blind placebo-controlled study using triamterene/hydrochlorothiazide as the first drug of choice³.   The results were gratifying.  Both cardiovascular mortality and morbidity were reduced by 30% in the group treated.  

ii. Neoplasm

Neoplasms occur much more commonly in elderly people and are more likely to cause death.  50% of all breast cancers occur after age 65, and the peak incidence of colorectal cancer is 80 years old.  Both these cancers have shown treatment response as good in those over 70 as in younger patients⁴. 

iii. Injuries and Accidents

These are often caused by multiple factors, like peripheral neuropathy, over-medication, and depression.  Recognition and treatment of hearing  and visual impairment may prevent falls.  A careful review of drug regimens might avoid adverse reactions leading to falls, like postural hypotension from vasodilator or diuretics, and sedation from benzodiazepines.  

b. How should this be done ?

i. History

When taking the history in the elderly, the doctor must remain neutral since family members and the patients may present their own interpretation of events which may be inaccurate.  It may at times be essential to hear the history separately to arrive at some clarity.  This is particular important when it comes to the mental state, since mental changes occurring over several years is prognostically very different from one of recent onset.  In addition to history relating to chief complaint and the relevant past medical history, the functional status and drug history should be obtained. 

Functional status must be recorded carefully as an important baseline that will dictate therapeutic measures.  Hence, a stroke victim who has been in a wheelchair for 3 years is unlikely to benefit from any well-meaning regimen of intensive rehabilitation.  However, attention should be paid to prevention of complications that may arise   like development of pressure sores, constipation, urinary abnormalities, and even a second stroke that may cause a further deterioration in function.  One way in which we can keep tab on functional status is to record systematically on an Activity of Daily Living (ADL) scale, such as the Barthel Index. The focus of ADL assessment is the ability to perform self care.  In the basic and intermediate functional categories, if the patient cannot perform these activities, someone else will have to provide these services.  If the patient’s self care deficiencies cannot be corrected, this can cause considerable burden on both informal and formal systems of  care.  Although all ADLs are important, the ability to self transfer is particularly crucial.  Patients who can move from bed to chair to toilet on their own have an excellent chance to stay in their own home, those without this capability usually require institutionalization in a long-term care facility.

ACTIVITIES OF DAILY LIVING: CATEGORIES

Basic: bathing, dressing, toileting, transfer, continence, self feeding

Intermediate: Shopping, transportation, use telephone, prepare meals, take medications, manage money, keeping the house clean and tidy, and do laundry.

Advance: strenuous physical activities like hiking, bicycling etc.  Heavy work around house like washing windows etc, walk more than 1 mile with rest, more than 0.25 mile without rest.

Drug history should be complete, and this include all over-the-counter medications, vitamins and eye drops.  This may shed light on diseases that patients are not fully aware of, as well as on treatments that have been tried in the past. 

Social history should also be assessed as it has implications on how best the patient can be managed.  An elderly person with poor social support may not do well at home even though he may only have mild functional disability.  However, someone with a greater functional disability could still be successfully managed at home if social support is adequate.  This is often linked with the financial status of the patient, especially in this era where foreign maids play a greater role in looking after the frail elderly at home.  The existence of reliable support, whether family members, friends, or community centers, will improve longevity and quality of life.

Healthy or unhealthy habits should be assessed as they usually have an influence on the disease state of the patient.  These include smoking, alcohol consumption and exercise.

2. Physical Examination

When examining a geriatric patient, the clinician should strive to avoid patient discomfort, maintain patient dignity, and distinguish signs of disease from changes that occur with normal ageing⁵.

The general examination should include the following⁶:

1. What is the general appearance of the patient – sick, weak, depressed or healthy ?
2. What is the ambulation status – is the patient independent, or does he require assistance to come into the office ?  What is his gait like ? 
3. Is the patient well groomed or disheveled ?

Height and weight should be recorded not only as a baseline, but also as an indication of nutritional status.  They can give indications of malnutrition or obesity (through the Body Mass Index [BMI]), depression or underlying malignancy (through progressive weight loss), and renal or cardiac disease (through progressive weight gain from fluid retention).  

Early nutritional intervention has been shown to improve functional outcome of at-risk older adults.  In the elderly, undernutrition is more dangerous than overweight.  In patients who are edematous, 

Arm muscle circumference [midarm circumference – 0.314 x tricep skin fold]  can be used to gauge nutritional status.  However, weight adjusted for height, gender and age remains a cornerstone of nutritional evaluation.  This can be done by use of either weight-for-height tables by age and gender.  Other gauges of nutritional status include:

SCALES: Sadness, Cholesterol, Albumin, Loss of weight, Eating problems, Shopping and food preparation.  A cholesterol of about 160 mg/dl or less indicates serious undernutrition in older patients.  The most useful concentration of albumin that indicates risk of malnutrition associated adverse events appears to be closer to 4 g/dl than the traditional 3.5 g/dl.

DETERMINE: Disease, Eating poorly, Tooth loss or mouth pain, Economic hardship, Reduced social contact, Medications, Involuntary weight loss or gain, Need assistance with self care, Elder years > 80.

Examination of head and neck

Visual Examination

The impact of failing sight on an elderly person with coexisting disabilities may be profound, and may predispose to falls and threaten precious independence.  The damaged self-image makes many old people deny their blindness.  

Studies have proven the value of examining elderly eyes, and in particular, for cataracts and glaucoma.  This could be done by simple ophthalmoscopic examination and a visual acuity test using the Snellen Chart  (See Table 3)⁷. 

Auditory Examination

Auditory acuity can be evaluated roughly with a wristwatch.  Hearing impairment can seriously impair the patient functionally and mentally, and lead to social isolation and paranoia⁸.

Impacted ear wax can lead to severe deafness and discomfort of the patient.  Auroscope examination will clinch the diagnosis.  Air and bone conduction studies can be performed in the usual manner to localize the loss.  

If the auditory canal is clear, the patients could be referred to an audiologist for a hearing test.  The commonest cause of nerve deafness in the elderly is age related degeneration of the cochlear (presbycusis).  Prescription of a hearing aid may help the patient to hear and improve his quality of life.  

Dental Examination

This is often missed in the physical examination of the elderly because we assume that it is under the realm of the dental surgeon.  It has several medical indications.  Poor dental hygiene would affect appetite (due to bad taste in the mouth) and therefore nutrition.  It is a source of sepsis (dental abscesses, gingivitis) as well as a source of aspiration pneumonia.  Such patients should be referred to a dental surgeon for treatment.  Edentulous subjects could be assessed for fitting of dentures as this will improve their self image and allow them to eat and chew better.

In those fitted with dentures, the doctor should check for generalized fit and examined for bacterial plaque and food debris.  Areas of reversible local irritation caused by excessive dental pressure should be noted.

The area under the tongue, a common site for early malignancies, should be inspected.  Suspicious lesions need to be biopsied, usually by an oral surgeon.

Examination of the Chest

Breast examination

The breasts must be palpated because there is clear evidence that incidence of breast cancer increases with age⁹. Physician’s examinations are 87% sensitive for picking up lesions > 1.0 cm in diameter in silicone models¹⁰.  Retraction  of the nipple secondary to age-related changes can be everted with gentle pressure around the nipple, whereas retraction due to an underlying growth cannot.

Cardio-Respiratory system

Blood pressure  should be measured in both supine and standing positions because of the increased prevalence of postural hypotension in the elderly.  A systolic drop of more than 20 mmHg is considered as significant for postural hypotension, and especially so when symptomatic.  This is a common cause of dizziness and falls, and may be exaggerated by drugs (like diuretics and vasodilator).  The risk of falls is increased if the standing systolic blood pressure is less than 110 mmHg.  A blood pressure of more than 160/90 mmHg is considered elevated.  In patients with elevated blood pressure but no end-organ damage from hypertension, one must consider the phenomenon of ‘pseudo hypertension’ due to non-elastic, atherosclerotic arteries.  Osler’s maneuver is performed by inflating the blood pressure cuff above systolic pressure and then palpating the radial or brachial artery.  If the pulseless artery is palpable, the true intraarterial blood pressure reading may be lower than the blood pressure obtained by auscultation¹¹.

Pulse rate should be assessed as many hidden problems might just present as an unexplained tachycardia (like an infection), or atrial fibrillation (like thyrotoxicosis or a silent myocardial infarct).  Heart rate response to postural change can provide important information about the cause of orthostatic hypotension.  for example, a rise of less than 10 beats per minute with a drop in blood pressure suggests baroreceptor reflex impairment¹².

There is also an increased incidence of valvular calcification and ischemic heart disease in the elderly.  Systolic ejection murmurs occur more often after age 70 and generally are due to hemodynamically insignificant aortic valve sclerosis.  These short, early peaking murmurs are usually no louder than grade 2/6 and rarely radiate to the carotids.

An S₄ is common in the elderly and is of little import, whereas an S₃ gallop points toward an overloaded ventricle.  diastolic murmurs in the elderly are always abnormal.

They should also be assessed for evidence of peripheral vascular disease, aneurysms and carotid bruits.  Between 40 and 75% of arteries with asymptomatic bruits do not have major significant compromise in blood flow.  Similar sounds can also be produced by anatomic variations and tortuosity, venous hum, goiter, and transmitted cardiac murmurs.  The presence of carotid bruits correlates more strongly with generalized atherosclerosis and coronary insufficiency than with cerebrovascular symptoms¹³.

Abdominal Examination

The physician will search for organomegaly, masses or abdominal aortic aneurysm.  Rectal examination is mandatory.  

It will give an idea of prostatic size (in males) and to detect any rectal masses.  It may bring out the problem of constipation or silent faecal impaction.  Palpation and percussion of the urinary bladder is important to seek for asymptomatic retention of urine.

A gynecologic examination will also rule out genital rash, utero-vaginal prolapse or the presence of masses in the pelvis.

Musculo-skeletal Examination

Examination of the extremities for joint deformities (osteoarthritis, rheumatoid arthritis), muscular atrophy and asymmetry is useful for baseline documentation even if this is not a current active problem.

Examination of the feet is also critically important in the elderly patient.  Diabetic-related ulceration, fungal infection of the skin or toenails, calluses, bunions, and plantar warts are common podiatric conditions in the elderly.  These may bring to light improper footwear.  Hence, patients must be asked to take off their shoes and socks to have a good examination of the feet.

Neurologic Examination

Falls

Risk of falls should be assessed esp. in females.  It is related to the number and type of medication, standing hypotension of < 110 mmHg systolic pressure, muscle weakness, lack of outdoor activity and those living alone.  It is also increased in those with history of falls.

Mental state examination

This is again a neglected part of the neurologic examination.  Information on the mental state of the patient will give invaluable information in the future care of the patient.  Though many scales are available, one that is familiar to the doctor and that is easy to administer should be used. This is merely a tool to screen out those patients that will benefit from further work up.  One scale that can be used is the 10 questions Modified Mini-Mental Test in table 4.  

Other screening test includes the use of clock drawing and or cube drawing.  All these formal cognitive evaluation tests require adjustment for educational level.  For example, using the Folstein Mini Mental State Test, for those with less than 8 years of formal education, a score of 17 or less is required to distinguish normal from pathological, whereas one with > 9 years of education requires a score of less than 23.

Motor function, gait disturbance and coordination can be tested when the patient comes into the consultation room or transfers from chair to the examination couch.  Reflexes remain present with advancing age except for the ankle reflexes, which disappear in nearly half of patients by age of 70 years.  Abnormal hyperreflexia or Babinski response may indicate previous silent cerebral infarctions.

Psychological assessment for depression is also useful as it is a common problem in the elderly.

Laboratory Tests

As part of a comprehensive assessment of the elderly patient,  certain laboratory tests become ‘routine’. 

Beyond these, test recommendations are based on symptoms and risk factors.

CONCLUSIONS:

A full assessment of the ‘geriatric’ patient can be very time consuming and difficult.  But unless this basic step is made, there is just no way an accurate diagnosis can be made.  An accurate diagnosis and appreciation of the problems, together with a careful management plan may lead to a reduction in the need for advanced and complex medical regimens, including prolonged hospitalizations.  Early detection of disease may also delay functional disabilities, resulting in a better quality of life for patient and family.