Health Articles

Most health care professionals quantify physical health by compiling a traditional problem list of defined diagnoses and symptom complexes. Also, most clinicians are aware of a few severity indicators, such as the New York Heart Association four-point functional disability scale (which can help clarify and communicate the degree of disability resulting from a cardiac condition) and the APACHE (Acute Physiology and Chronic Health Evaluation) scale for quantifying the severity of illness among acutely ill persons. Documenting the number of days of hospitalization and disability and the use of related health care services can help to define the severity of health problems, as well.
A number of detailed, disease-specific scales are also available for quantifying levels of function, dysfunction, disability, and handicap attributable to particular diseases; these instruments are similar to the New York Heart Association Scale. Some, such as measurements made in a pulmonary function or physiology laboratory, are purely quantitative; others, such as a quality-of-life scale, are purely qualitative. Still others, such as a dementia-disability scale, include both kinds of information. Well-established disease-related scales exist for dementia, depression, parkinsonism, and multiple sclerosis. One particularly useful scale for the comprehensive geriatric assessment is the Tinetti Balance and Gait Evaluation (see TABLE 17-5). This scale can be used to detect

A typical geriatric assessment begins with a review of the major domains of functional ability: activities of daily living (ADLs) and instrumental activities of daily living (lADLs). The ADLs include self-care activities that people must accomplish to survive without help, such as eating, dressing, bathing, transferring, and toileting. Patients unable to perform these activities usually require caregiver support for 12 to 24 h per day. The IADLs include performing heavy housework, going on errands, managing finances, and telephoning—activities required if the person is to remain independent in a house or apartment. Several reliable instruments have been developed for measuring patients’ abilities to perform ADLs and IADLs; perhaps the most widely used are the Katz ADL Scale and the Lawton IADL Scale (see TABLES 17-3 and 17-4). Clinicians use these instruments to detect problems in performing activities and to determine what kind of assistance may be needed. For instance, a top score of six out of six on the Katz ADL Scale indicates that a person has full basic function, usually implying that nursing home care is inappropriate. A score of two usually indicates adequate feeding and continence (since scoring is hierarchical) but impairment of the more advanced activities, implying that a caregiver or nursing home is needed for survival.
When patients have deficits in ADLs and IADLs, physicians usually need additional information about the patient’s environment and social situation. For example, the amount and type of caregiver support available, the strength of the patient’s social network, and the level of social activities in which the patient participates all influence the approach used to manage the deficits. Such information can readily be obtained by an experienced nurse or social worker.
Besides ADLs and IADLs, this domain includes higher level activities, sometimes called advanced ADLs (AADLs), which include exercise and the ability to travel independently on airplanes. However, these AADLs have not been as well quantified and usually are not included in comprehensive geriatric assessment for frail elderly persons.

Patients are referred for comprehensive geriatric assessment when both disease and functional status worsen. If disease alone worsens without affecting functional status, patients can usually be managed in primary care settings by primary care physicians. However, patients who have new, severe, or progressive deficits in functional status should be given a comprehensive geriatric assessment that encompasses the expertise of several disciplines. Also, when new disabilities are detected through periodic screening, comprehensive geriatric assessment may be recommended.
The four principal domains of comprehensive geriatric assessment are functional ability, physical health, psychologic health, and socio-environmental factors. Assessment of each can be achieved by using certain assessment instruments. Although these instruments are not essential for performing comprehensive geriatric assessment, they make the process more reliable and easier. They also aid communication of clinically relevant quantitative information among health care providers and permit tabulation of clinical data and measurement of change over time.
Several issues need to be considered in selecting an assessment instrument for a specific population: instrument reliability and validity, patient acceptance, time and personnel needed to administer the tests, and relevance and usefulness of the data to be collected. With most (but not all) instruments, these issues are addressed during development, testing, and publication. The instruments described in this chapter are some of the most useful, most widely used, and best validated. However, exclusion of a particular instrument does not imply a negative judgment.
Proper interpretation of the scores of these quantitative tests is based on the original references and clinical experience. TABLE 17-2 summarizes the general features of selected assessment instruments.

More than 25 controlled trials in different settings and a recent metaanalysis have shown that comprehensive geriatric assessment improves patient care and clinical outcomes. The benefits include greater diagnostic accuracy, improved mental and functional status, reduced mortality, decreased use of nursing homes and acute care hospitals, and greater satisfaction with care. Although the degree of benefit varies among the study settings and not all studies document each benefit, virtually all studies show at least some significant benefit. Unfortunately, the cost of these programs has limited their use. Although some cost-effectiveness evaluations indicate that these programs can save money by decreasing hospital readmissions and nursing home stays, few programs are in self-contained care systems that can achieve these subsequent savings. Thus, the growth of these programs has been slow. Targeting programs to the most appropriate patients is a key issue in demonstrating program impact. Although most elderly people could probably derive some benefit from comprehensive geriatric assessment, frail or ill people derive the most benefit. Programs that include not just consultation but also treatment, rehabilitation, long-term follow-up, and case management also tend to be most beneficial.

A number of factors must be considered when deciding on the setting for a patient’s assessment (see TABLE 17-1). A patient with mental or physical impairments may have difficulty complying with recommendations and keeping appointments in several locations. A functionally impaired elder who requires transportation may depend on family members and friends who worry about losing their jobs because of continual demands on their time and energy. Because increased periods of illness cause fatigue, a patient may need bed rest during the assessment process. Also, the interdisciplinary team must allow adequate uninterrupted time to complete the assessment.
Most comprehensive geriatric assessments do not require the full range of technology available nor the intense level of monitoring performed by physicians and nurses in acute care inpatient settings. However, hospitalization may be necessary if the assessment cannot be accomplished quickly in an outpatient setting. A specialized geriatric setting outside an acute care hospital (a day hospital or subacute inpatient geriatric evaluation unit) can provide an interdisciplinary team that has the time and expertise to perform services efficiently, an adequate level of monitoring, and beds for patients unable to sit or stand for long periods. Inpatient and day hospital assessment programs can offer intensiveness and speed, and they can care for particularly frail or acutely ill patients. Outpatient programs are usually less costly, and they eliminate the need for an inpatient stay.

A multidimensional, usually interdisciplinary, diagnostic process intended to determine a frail elderly person’s medical, psychosocial, and functional capabilities and problems. Comprehensive geriatric assessment has many immediate and long-term purposes, including achieving a multidimensional diagnostic evaluation, developing an overall plan for treatment and long-term follow-up, arranging for treatment and rehabilitation, facilitating primary care and case management, determining long-term care needs and optimal placement, and making the best use of health care resources.
A comprehensive geriatric assessment differs from a standard medical evaluation in its concentration on frail elderly people with complex problems, its emphasis on functional status and quality of life, and its frequent use of interdisciplinary teams. Although a comprehensive geriatric assessment may be carried out by a primary care physician in an office, generally it is best performed by personnel from several disciplines in a setting organized for their interaction.
The comprehensive geriatric assessment is usually initiated when primary care physicians or community health workers identify functional problems and disabilities. The assessment then continues with more in-depth evaluation of these problems by a physician or interdisciplinary team and the initiation of a therapeutic plan with a goal of maximizing health and functional status, and hence quality of life.
The basic concepts of comprehensive geriatric assessment, which have evolved over the last 60 years, incorporate elements of many disciplines, including the traditional medical history and physical examination, the social services assessment, functional evaluation and treatment methods derived from rehabilitation medicine, and psychometric methods derived from the social sciences. By incorporating all these perspectives into a compact assessment format, geriatricians have created a practical means of viewing the whole patient.
As geriatric care systems have emerged throughout the world, comprehensive geriatric assessment has become a central element. Geared to local needs and populations, geriatric assessment programs vary widely. Theydiffer in comprehensiveness, organization, and structural and functional components. The programs also are based in different settings, including hospital acute care units, hospital rehabilitation units, outpatient and office programs, and home visit outreach programs. Yet despite such diversity, the assessment programs share many common characteristics. Virtually all include multidimensional assessment, using one or more sets of assessment instruments to quantify functional, psychologic, and social parameters. Most use interdisciplinary teams to pool expertise and share enthusiasm in working toward common goals. Moreover, most programs attempt to couple assessment with an intervention, such as rehabilitation, counseling, or placement.