Resident Editor: Kendra Moore, MD, MBE

Faculty Editor: Don Ng, MD

​Background

• By 2050, Americans over age 65 is projected to comprise 22.5% of the population, up from just 15% in 2015.
• 23% of patients over age 65 have 5 or more chronic medical conditions – these patients account for 68% of Medicare spending

Geriatric Assessment

• Multidimensional, multidisciplinary assessment involving MD, pharmacy, SW, nursing
• Best carried out over multiple visits, or a Medicare Annual Wellness Visit is a good opportunity to assess all dimensions (but allow at least an hour to perform all the components of the Wellness Visit as required by Medicare)
• Goal is maintaining functional status and achieving the best possible quality of life

Sensory Evaluation: Vision

• Common causes of visual impairment: presbyopia, cataracts, glaucoma, diabetic retinopathy, and age related macular degeneration
• Screening: For patients >65, American Academy of Ophthalmology recommends annual dilated exams to screen for glaucoma, macular degeneration and cataracts. At a minimum, a Snellen eye exam should be done yearly
• Referral to Ophthalmology: Definitely if visual acuity <20/40, diabetic, high risk for glaucoma (African American, +FHx, diabetes, severe myopia); recommend yearly exam by ophtho/optometry for all geriatric patients, as dx of age-related macular degeneration requires a dilated exam and glaucoma assessment requires tonometry and formal visual field testing.

Sensory Evaluation: Hearing

• Most common cause of hearing loss: presbycusis (high frequency loss)
• Screening: Ask patients about hearing yearly, whisper test or audiometry every 3 yrs
  • Hearing Handicap Inventory for the Elderly Screening (HHIE-S)
  • Whisper Test: stand behind patient 3 feet and whisper letters/numbers for them to repeat
  • Otoscopic Exam: rule out cerumen impaction

Cognition/Depression

• Should assess cognitive function with Mini-Cog or Mini-Mental Status Exam, followed by a MOCA if brief screening is abnormal.
• Screening with PHQ-9 or Geriatric Depression Scale and GAD-7 is recommended.

Social Environment

• Living situation: Ask about social interaction, support resources, special needs, environmental safety. Consider home safety evaluation if concerned.
• Caregiver support/burnout: Ask if s/he has enough support at home, screen for abuse/neglect.
  • Resources for caregiver support in San Francisco: Family Caregiver Alliance, Alzheimer’s Association, On Lok, Adult Day Health, IHSS, Institute on Aging
• Nutrition: Ask about weight loss or barriers to food/eating (i.e., poor dentition, inability to get to grocery store, inability to cook, etc.)
  • Resources: nutritionist referral, meals on wheels, lunch programs for seniors (IOA)

Functional Status

• Assess patient’s ability to perform his/her own I/ADLs
• Assess physical fitness and stability, can use the Short Physical Performance Battery (SBBP), refer to physical therapy if concerns

Gait/Falls/Home Safety

• Ask patients if they’ve had any falls in the last 6 months
• Durable Medical Equipment: Hospital bed, shower chair, bedside commode, walker/cane, grab bars
• Lifeline button: Ask if patient has or needs, especially if they live alone or spend a lot of day alone. Cost for subscription ranges from $20-$40 per month

Incontinence

• All patients should be asked about incontinence- consider using the Incontinence Impact Questionnaire (IIQ-7).

Medication Review

• Problem: Up to 30% of hospital admissions and many preventable problems can be attributed to adverse drug effects; 50-60% of elderly people are taking a medication without an indication
• Screening: Carefully review all prescription, OTC, vitamins, and supplements
  • Should have patient periodically bring all pill bottles to clinic (for provider or RN visit) to ensure s/he is taking everything correctly
• Beers Criteria: list of medications and medication classes that should be avoided in older persons (http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf)

Advance Care Planning

• Can use a variety of resources to explore preferences and values including Go Wish cards, Prepare for Your Care, Five Wishes, etc. 
• Most important priority should be to define a health care proxy and record this information in the chart.

Reference

Administration on Aging. Statistics on the Aging Population. www.aoa.gov/AoARoot/Aging_Statistics/index.aspx. Accessed 11/22/2009.

Anderson, GF. Medicare and chronic conditions. The New England Journal of Medicine. 2005; 353(3):305-9.

Elsawy B, Higgins KE. The Geriatric Assessment. Am Fam Physician. 2011; 83(1):48-56.

Johnston CB, Harper GM, Landefeld CS. “Geriatric Disorders.” Common Medical Diagnoses and Treatment. 2011. USA. McGraw Hill Publishing Company.