GERIATRIC ASSESSMENT

The geriatric assessment differs from a standard medical evaluation in three general ways: (1) it focuses on elderly individuals with complex problems, (2) it emphasizes functional status and quality of life, and (3) it frequently takes advantage of an interdisciplinary team of providers. Components of the Geriatric Assessment The geriatric assessment incorporates all aspects of a conventional history including demographic data, chief complaint, present illness, past and current medical problems, family and social history, and review of systems. History and Physical Assessment The History Demographic Data Full name ; Age, sex and birth date ; Marital status ; Source of history and reliability of historian Chief Complaint Primary reason for visit, ideally in patient's own words ;Duration of presenting symptoms Present Illness Chronological narrative of reasons for patient visit.; Persistence, change, severity, character, resolution and disabling effects of initial symptoms.; Presence of new symptoms and/or associated symptoms ;History of similar symptoms in the past; Aggravating and mitigating factors Past History Previous history. General state of health Childhood diseases; Immunizations (Tetanus-diphtheria, pertussis, measles, mumps, rubella, hepatitis A&B, influenza, varicella, h. flu., polio) ; Chronological list of adult medical diseases, injuries and operations (not already mentioned in "Present Illness" Hospitalizations (not already mentioned); Allergies, including clinical description of exposure; Medications, including dosage, duration and indication ;Diet Social History Birthplace and residences ; Level of education ;Ethnicity and race; Marital status ; Quality of significant relationships and health of partner; Vocation, including type of industry, past and present industrial exposures, duration of employment and retirement vacations, including hobbies and other interests; Habits, including quality of sleep, exercise, recreation, consumption of alcohol and other drugs (including route of administration, if applicable), tobacco use (in packyears), alcohol use, and travel abroad ; Significant life experiences Family History Presence of disease with recognized familial importance in first degree relatives - type II diabetes, tuberculosis, cancer, hypertension, allergy, heart disease, neurological or psychiatric disease, arthritis, osteoporosis, bleeding tendency ;Similar presenting symptoms in family members. Review of Systems General Gastrointestinal Lymphatic Urinary Skin Female reproductive Head Male reproductive Eyes Sexual and physical abuse Ears Musculoskeletal Nose and sinuses Peripheral vessels Mouth and throat Neurologic Neck Psychiatric Breasts Endocrine Respiratory Hematologic Cardiac The Physical Examination Demographic Data decision on accurate information. Geriatric practitioners often find it challenging to obtain objective historical information especially when it is subject to the incomplete memory of patients with impaired cognition, or the biased interpretation of family members and others caregivers. You should, therefore, always note the identity of the historian and your assessment of their reliability and objectivity. Chief Complaint and Present Illness Elderly patients are famous for presenting with any combination of non-specific, apparently unrelated and seemingly trivial complaints. Sometimes they have no complaint at all. Unlike many younger patients, it is the rare elder who walks in and hands her physician a discrete and easily recognizable diagnosis. This is for several reasons. First, many older patients interpret their pain or

dysfunction as "normal" signs of aging. It would not occur to them to seek medical attention for say, joint pain or insomnia. They may visit their physicians simply to mollify a spouse or child. Fear and denial may also play a role when patients present with no, or irrelevant, complaints. Elderly patients suffer disproportionally from a number of chronically painful conditions, with arthritis leading the list. Second, in geriatrics, multiple problems are the rule. Complex pathophysiology presents in clinically complex ways, and it is not unusual for one organ system to signal pathology in another. Third, insurmountable communication barriers may prevent elderly patients from receiving effective attention. Cultural incompatibilities, memory loss, depression, and hearing impairment may all contribute to the collection of an inadequate, or even unintelligible, description of the chief complaint and present illness.

Past Medical History similar to the information obtained from other patient populations. The only difference is that the data are more extensive, generated by more providers, and the source is potentially more distant. Patients and caregivers alike may not know or recall important details from medical or surgical events taking place thirty, forty or fifty years ago. In their effort to be comprehensive and accurate, therefore, geriatric practitioners need to frequently locate and obtain medical records from multiple sources existing long ago and far away. Elderly patients are so frequently on multiple medications, prescribed by different physicians, over extended periods of time, they are at considerable risk for adverse drug interaction and overmedication. Central to the assessment objectives is careful documentation of all medication (prescription an over-thecounter) their doses, indications and effects. Nutrition Compared to the general population, the elderly are more vulnerable to inadequate nutrition for a number of reasons. These predominantly include (1) limited dentition or ill-fitting dentures, (2) diminished appetite due to loneliness, depression or appetite- uppressing drugs, (3) prevalent medical conditions including constipation, congestive heart failure, cancer and dementia, (4) lack of financial resources, and (5) noncompensated disabilities resulting in limited access to food and/or inability to prepare meals. an elder is at increased risk of obesity by inactivity, low socioeconomic status, and limitations in food variety. Geriatric practitioners should consider performing a complete nutritional evaluation with any change in presenting symptoms, medical condition or functional status. Many times such changes are associated with dietary intake and nutritional requirements. A nutritional assessment involves the evaluation of : current weight in comparison to ideal body weight, with determination of BMI to evaluate for underweight or obesity. recent changes in body weight. current medications and their potential to affect the patient's nutritional status. functional status to determine if the patient can purchase and prepare food for himself, plus mental status with regard to their interest in food. food intake by food groups for a quick estimation of adequacy of diet. vitamin/mineral supplementation. Information from the medical and social histories that has direct bearing on nutritional status in the elderly includes: Medical virtually any significant chronic disease any recent acute illness or surgery presence of allergies family history of diet-related disease usual weight and recent involuntary weight changes presence of dentures and satisfaction with them cognitive impairment depression and other psychiatric diagnoses a wide array of medications and their adverse interactions with food exercise and sleep patterns Social occupation, retirement and income level participation in economic assistance programs living arrangements availability of transportation and shopping educational and reading level motivation and adherence to medical recommendations Dietary Assessment. A dietary assessment includes information about the patients intake of food and liquids during a "usual day", preferably the previous 24 hours.

Physical Examination. Numerous findings on physical exam may be indicators of nutritional status. The examiner must pay particular attention to the patient's general appearance, anthropometrics (height and weight), oral cavity, vision and hearing, and upper extremity mobility. Selected Laboratory Tests. There is not a routine panel of blood tests that is appropriate to all geriatric patients, or any patients for that matter. Clinicians must carefully select each laboratory test based on the totality of the patient's clinical presentation. However, the following tests may enhance the overall nutritional assessment of elderly patients:. Serum albumin to help determine protein and immune status. Serum cholesterol and homocysteine to determine risk level for CVD. (Total cholesterol levels above 240 mg/dl indicate considerable risk for CVD; levels below 160 may indicate gastrointestinal problems.) Blood glucose in diabetics and periodically in non-diabetic elders since glucose intolerance increases with aging. Hemoglobin/hematocrit to evaluate for anemia, a prevalent condition in the elderly. Vitamin B12 (especially in vegans, with indications of achlorhydria and gastrointestinal problems). Social History Covers a vast area of information ranging from a patient's level of education to their views on terminal care. Vocation and Education It is important to remember that raising a family, looking for a job, going to school and enjoying retirement are all legitimate "vocations". Many older adults who have retired from their "careers" continue to work part time or volunteer. Habits, including quality of sleep, exercise, recreation, consumption of alcohol and other drugs (including route of administration, if applicable), tobacco use (in packyears), alcohol use, and travel abroad Exercise. The numerous and beneficial health effects of regular exercise in the elderly operate in both the short and long-term. Exercise decreases blood pressure, weight, cardiovascular and cerebrovascular risk, osteoarthritic joint pain and stiffness, osteoporosis and overall mortality. It improves glucose tolerance, strength, cardiopulmonary fitness, agility and flexibility, balance, sleep, mood and cognition. > Information obtained in the assessment ought to include the frequency and duration of aerobic and nonaerobic exercise, the type of activity (walking, swimming, gardening, heavy housework), method of monitoring intensity (heart rate, fatigue, pain), presence of orthopedic and or cardiovascular diagnoses or symptoms, and the occurrence and nature of injuries. Sleep. Practitioners need to carefully assess the sleep quantity (nighttime duration frequency and duration of daytime naps), sleep quality (sleep latency and ability to stay asleep, vigilance on waking, and presence of nightmares), sleep environment, bedtime habits, and medical conditions affecting sleep (depression, congestive heart failure, carpal tunnel syndrome). Sexual Activity. Elders have sex. Even though impotence, diminished libido and dyspareunia (pain with intercourse, usually related to vaginal dryness) are extremely common in older adults, they are uncommonly the topic of conversation in their doctors' offices. Since all three conditions are potentially treatable (more so recently with the introduction of Viagra), it is crucial that practitioners obtain such information, despite their own misgivings about broaching the subject, especially when a generation or two separates them from their patients. Asking straightforward, close-ended questions in a non-judgmental fashion ("Are you currently sexually active?" as opposed to "Are you still sexually active after all these years?), usually works well. Substance Use. Although the prevalence of illicit drug use in the geriatric population is relatively low, older adults do not lose interest in most other substances. It is extremely rare for anyone to take up smoking late in life, so the vast majority of elders who smoke have been doing so for decades. Similarly, elders who have no prior history of alcoholism, or other addictive behavior, do not suddenly develop a pattern of addictive behavior in their seventies and eighties. Many older smokers reasonably assume that the damage from years of smoking has been done; the common refrain being "If it hasn't killed them yet, why quit?" Useful assessment questions include: Is the patient a current or former smoker? What does he smoke (or chew) and how much (recorded in pack-years)? Have there been attempts to quit and were they successful? Is there any exposure to environmental (second-hand) tobacco smoke? Security. As elders become more dependent, their vulnerability to intentional injury

and loss of property increases. For this reason, the social assessment must include an evaluation of security risks experienced by patients living in the community. Has the apartment building hired a doorman? Is the home equipped with security alarms and fire detectors? Is there a working telephone? Are trustworthy neighbors easily accessible? Injury Risk. At this point in the assessment, the focus is on the patient's physical surroundings at home and his or her history of falling. How adequate is the ambient lighting? How many levels must occupants traverse over stairs? Is the house or apartment fully accessible by wheelchair? Where are the bathroom, kitchen and bedroom in relation to one another? Are there throw rugs and other trip hazards? Are there grab bars and mats in the tubs? How many times has the patient fallen in the past year? What were the circumstances and consequences of the falls? Has the patient develop a fear of falling out of proportion to the physical risks? Community Services. Although family members and other non-professionals provide upwards of 80% of the care received by non-institutionalized elders, there is a long list of community-based services. Largely due to interest in cost-containment and recent advancements in technology, the home healthcare industry has boomed in recent years. In addition to selected hospital-based services (like dialysis and intravenous antibiotic treatment), in-home support includes hospice care, physician house calls, visiting nurses, home health aides, Meals on Wheels, and hired homemakers to name of few. Group counseling, adult day centers, congregate meals and respite-care are examples of out-of-home support. Community-based health care services include a designated primary care physician, ambulatory care center, acute and rehabilitative facilities, mental health providers and provision of pharmaceuticals. Caregivers. family members meet the great majority of disabled elders' needs, the patient of interest is frequently also a caregiver. If this is the case, assessment questions turn to the beneficiary of such care and its affect on the patient. Who is she caring for and how ill or disabled is this person? How often and for how long does she provide care, and what exactly is involved? Are her responsibilities causes stress and exhaustion, ill health, or an unacceptable loss of independence? Transportation An important objective of the geriatric assessment is to make decisions that maximizes an elder's independence and minimizes risk to his safety and the safety of others. This part of the assessment focuses on the patient's transportation requirements, driving habits, and accident history. How does the patient get around (own car, public transportation, private livery service)? Is this acceptable? What are the typical destinations and what is the frequency of travel? If the patient drives, what type of vehicle? Does she possess a valid driver's license? Is a seatbelt routinely used (of course, this applies to all patient populations)? How many traffic violations have there been in the past year? How many accidents, including related injuries and hospitalizations? Review of Systems Any thorough clinical evaluation includes a complete review of systems . The geriatric assessment's ROS emphasizes questions specifically pertaining to the functional capabilities of elders.