CHAPTER 2 COMPREHENSIVE GERIATRIC ASSESSMENT
Practice of Geriatrics
CHAPTER 2 COMPREHENSIVE GERIATRIC ASSESSMENT
T. Franklin Williams, M.D.
The Concept of Comprehensive Assessment
Situations in which Assessment may be Required
Domains of Assessment
Comprehensive Assessment Instruments
Translating Identified Needs into Appropriate Long-Term Care Services and Settings
The Need for Continuing Review of Assessment Findings
Comprehensive geriatric assessment has been well defined as a “multidimensional—usually interdisciplinary—diagnostic process designed to quantify an elderly individual’s medical, psychosocial, and functional capabilities and problems with the intention of arriving at a comprehensive plan for therapy and long-term follow-up.”1,2 This approach to decision making and developing plans for the care of older patients with complex problems at critical points in their lives has developed from the experience and observations of clinicians who have been deeply involved in the care of older persons during the past 60 years. This approach has been examined and refined in a number of studies in both inpatient and outpatient settings.
The Consensus Development Conference at the National Institutes of Health concluded that such an approach, when appropriately targeted, is effective in achieving the goals of improved diagnostic accuracy, guidance in selection of interventions to restore or preserve health, and aid both in choosing an optimal environment for care and in predicting outcomes and monitoring clinical change over time.3,4 Recent meta-analysis of controlled trials of comprehensive geriatric assessment has provided convincing evidence that these programs can decrease the use of institutional services, improve physical and mental functioning, and increase survival, particularly when the comprehensive assessment team continues to take primary responsibility for management and accomplishment of the goals determined.5,6 The value of such an assessment process is recognized in many countries.7,8 and 9
THE CONCEPT OF COMPREHENSIVE ASSESSMENT
As is well documented in other chapters in this text, many older people acquire chronic diseases that in turn result in varying degrees of disability. This is clearly not true for all elderly people. Some in their eighties and nineties continue to be vigorous in all aspects of life. However, the number of older people who have some degree of impairment in carrying out their usual functions does increase in the later years, with over 70% of those aged 80 and older reporting some limitation in activity.10 Such older people may be referred to as frail elderly and they are the ones who are likely to need some form of long-term assistance or care to continue to maintain as much independence in living as possible.
To determine the types of assistance needed by frail elderly people and to help make arrangements for their care, the physician and other health professionals must conduct a comprehensive diagnostic evaluation or assessment that is fully analogous to the careful diagnosis that must precede any type of treatment decision. The medical conditions that underlie and contribute to the functional losses must be identified and appropriately treated, but this is only a part of the necessary effort. The types and degrees of functional losses themselves must be carefully addressed as well as the extent of family and other social supports available to help meet the older person’s needs.
Unfortunately, careful functional and social assessments as steps in decision making for long-term care are often neglected, resulting in the provision of inappropriate types of long-term care. Without a careful diagnostic evaluation, frail elderly people may end up in nursing homes when they might be able to live in less confining settings or at home with support services. Conversely, the patient with unassessed needs may not be provided with the type or degree of long-term care that he or she requires, resulting in increased disability or accelerated burnout on the part of family caregivers.
In contrast, careful use of comprehensive assessment and recommendations for long-term care result both in care that is more appropriate for the needs of the person and in less use of institutional care such as nursing homes. Functional assessment is also essential as a basis for the choice of rehabilitative therapies and for following the progress of patients with chronic disabilities.
In this chapter the following aspects of assessment are addressed:
Situations in which assessments may be or should be carried out.
Special features of the diagnostic assessment that are relevant to long-term decisions (i.e., the multiple domains that must be assessed, the need for comprehensive multidisciplinary efforts, and the need for consistency).
Comprehensive assessment instruments.
Translation of the identified needs into appropriate services and appropriate settings for care.
The need for continuing review of assessment findings.
SITUATIONS IN WHICH ASSESSMENT MAY BE REQUIRED
Assessment of frail elderly people may be needed for a variety of purposes: (1) screening for early detection of potential disabilities, (2) case finding to offer relevant care to those who need it, (3) comprehensive diagnostic work-up as part of developing a plan of therapy, (4) monitoring progress, (5) determining the level or setting of long-term care required, and (6) determining the appropriateness of use of long-term care services and facilities.
The approach to assessment and the methods used must be modified according to which purpose is relevant. Unfortunately, there is a tendency to attempt to apply a method or protocol developed for one purpose to another use or in different circumstances, and this leads to unsatisfactory results. This chapter deals primarily with comprehensive assessment as a necessary part of the diagnostic work-up of individual frail elderly people; reference to the other purposes served by assessments is made simply to remind the reader that caution must be exercised in considering the use of guides or protocols developed for other purposes.
The most important use of comprehensive assessment as part of the diagnostic work-up of a frail elderly person is to evaluate a patient whose physical, mental, or social condition is changing, most likely in the direction of an increased need for long-term services. Such a person may be seen in one of the following ways: He or she may (1) present to a physician in his or her office; (2) be referred to a health or social agency, which in turn recommends a comprehensive diagnostic assessment; (3) be seen on geriatric consultation in a hospital; or (4) be referred to a geriatric evaluation clinic or inpatient unit. These people are reaching or have reached a critical point because of changes in their functional status or changes in the family support system available, and they are often facing a decision about whether to continue to live at home with increased support services or to enter a long-term care institution.
In the presence of such complex and relatively urgent problems it is difficult for a physician to conduct an adequate assessment in his or her office. Both the constraints of time and the limited immediate availability of a range of professionals from other disciplines usually require the physician to conduct or arrange for a comprehensive multidisciplinary assessment in a clinic or hospital or nursing care unit established to serve this need.
The essential components of such specialized geriatric units and clinics include (1) regular participation in the diagnostic evaluation by physicians, nurses, and social workers with special competence in this area; (2) accessibility of consultants in other specialties such as psychiatry, neurology, and rehabilitation medicine, and occasionally in other fields such as arthritis, endocrinology, physical therapy, occupational therapy, and speech therapy; (3) ready availability and appropriate use of diagnostic radiologic and laboratory procedures; (4) development of consistent data bases; and (5) establishment of regular team conferences to review all information and an effective system for transmission of findings and recommendations to other professionals for follow-up.
DOMAINS OF ASSESSMENT
Comprehensive geriatric assessment should begin with a careful thorough general medical evaluation (see Chapter 1 and also the detailed summary by Applegate11). The most important domains or areas that must be considered when making decisions about long-term care include (1) the need for chronic medical treatment, (2) the level of physical functioning, (3) the level of mental functioning, (4) the availability of family and social supports, and (5) environmental features. These areas of assessment are discussed next in relation to the approaches and methods that may be used in clinical practice; more detailed analyses, including critical comparisons of different methods and discussion of other uses of assessment, are available elsewhere.7,12,13
Need for Chronic Medical Treatment
A patient’s need for certain modalities of chronic treatment may call for very specific equipment and specialized personnel, which in turn have a major impact on the care plan, including who will provide the care and where the care can be given. For example, a patient may need help in managing a tracheostomy or other type of ostomy; he may need oxygen, intravenous fluids or medications, traction, or frequent treatments by a respiratory therapist, physical therapist, occupational therapist, or speech therapist; or he may need specialized nursing care, for example, for care of a major pressure ulcer. In some instances it may be possible to train family caregivers to provide such care. In other instances it is important to recognize when family members are not capable of carrying out these services, which then must be provided by professional home support services or in an institution. In any event, these treatment needs must be fully identified in the assessment process.
Assessment of Physical Function
Limitations in a person’s ability to carry out ordinary daily physical activities are the most common cause of a need for long-term care assistance. It may appear to be tautologic to say that a person who cannot carry out an ordinary daily activity that is necessary for independent living must have some assistance or service; however, diagnostic assessment of such functional characteristics has been neglected so often that the need for it must be emphasized. The therapeutic goal is to provide assistance to compensate for the identified functional disability or disabilities, thus ensuring continued independent living to the maximum extent possible.
Assessment of physical and mental function is part of the diagnostic work-up of a frail older patient and is distinct from and only secondarily related to the diagnosis of specific disease entities that may cause the loss of such function. That is, it is necessary to determine the functional characteristics of a patient and address them specifically in the therapeutic plan no matter what the underlying causes are. Proper treatment of the latter may contribute to improved function, but some degree of functional loss may continue even with optimal treatment of disease.
The development of consistent useful approaches to the assessment of physical function owes much to the original work of Katz and his colleagues14 in defining activities of daily living (ADL) and to Lawton and Brody15,16 in defining the so-called instrumental activities of daily living (IADL). Table 2-1 and Table 2-2 list the key elements in these assessments.
TABLE 2-1 ASSESSMENT OF ACTIVITIES OF DAILY LIVING
TABLE 2-2 ASSESSMENT OF INSTRUMENTAL ACTIVITIES OF DAILY LIVING
The ordinary activities of daily living can be categorized as personal self-care activities (e.g., feeding oneself, bathing, dressing, toileting), activities involving moving around independently (e.g., moving from bed to a walking position or wheelchair, and achieving locomotion), and maintaining control of bladder and bowel function. A person who can carry out all these functions independently does not need the assistance of anyone else. Conversely, the lack of ability to perform any of these activities does mean that some external assistance must be provided. Some help with bathing and dressing, if this is all that is required, can usually be provided by a family member or staff of a minimum-care domiciliary facility once or twice a day. On the other hand, a person who needs regular help with ambulation or feeding or who is incontinent obviously requires almost constant attendance.
The IADL involve the ability of a person to manage his or her living environment—that is, to procure and prepare food, manage the laundry and clean the house, and travel to necessary or desirable activities outside the home. Any lack of ability to carry out these functions for oneself means that some type of assistance or service is needed; such services may be more varied and may not have to be as personal as those required to address ADL needs.
In assessing all of these characteristics of daily functioning it is essential to determine not only what the person can do but also what she or he does do based on direct observations or reports by a reliable observer (family member or professional). Also, in persons with a cognitive impairment (who often have normal physical function), it is essential to assess and record how much supervision, cueing, and reminding is required by caregivers. Such needs can be at least as burdensome as actually providing care to compensate for a physical impairment.
To document the ADL and IADL status of patients, a number of protocols and scales have been developed to provide consistency in the information obtained so that it can be communicated more easily between health care providers and may also be useful in documenting changes that take place over time. Such protocols are also useful as decision-making tools by those who provide and pay for services. The most widely used assessment forms and guides have recently been reviewed.12,17
In regular medical practice it is highly desirable to select a format in which to record the functional assessment information routinely and consistently as part of the medical record. A good example is the procedure outlined by Lachs and colleagues.18 The precise details of any functional limitation should be noted because such details serve as a basis for planning recommendations for specific supportive services. A total score or scale, made in an attempt to summarize an overall impression of degree of disability, serves no useful purpose in guiding specific therapeutic plans.
Assessment of Mental, Emotional, and Psychobehavioral Function
Limitations in mental function can result in losses of autonomy that are just as severe as losses due to problems in physical function, and they can, of course, also contribute to limitations in ADL and IADL. Losses of mental function often require types of assistance that differ from the assistance needed to compensate for physical needs.
Methods of assessing the mental, emotional, and psychobehavioral status of frail elderly people in ways that are useful in determining the need for long-term care services are not as adequately developed as is desirable. Several relatively short tests of mental or cognitive function have been developed and are widely used. Each of them includes questions that test the individual’s orientation, short-term and longer-term memory, ability to do arithmetic, and ability to reproduce a geometric design. The most commonly used tests are described by Applegate and colleagues12 and Gurland and associates.19,20 These tests can identify the presence of a significant degree of decline in mental or cognitive function. However, they do not correlate well with how well a person can actually perform his or her daily living activities. For example, a patient with considerable loss of memory (typically the first sign of dementia) may perform very poorly on such tests (e.g., the patient may be oriented only to people and have no ability to answer the other questions correctly) and yet may still function satisfactorily and independently in his or her familiar home environment. Conversely, a person may score well on a number of items, such as the arithmetic and geometry questions, and may show some features of retained memory, yet he may be quite confused when carrying out ordinary daily activities and need almost constant supervision. Furthermore, we do not yet know enough to relate specific segments of such cognitive tests to specific anatomic or physiologic abnormalities in the central nervous system.
Despite such limitations, it is probably still helpful to employ one of the commonly used tests as a regular part of the work-up of an elderly frail patient to identify any gross evidence of dementia and to provide a baseline for future comparisons to detect evidence of change. The identification of any evidence of dementia by such tests should call for a thorough work-up to determine the extent and nature of the dementia and to identify potentially modifiable functional disorders of whatever cause. More refined and useful techniques for measuring and following mental status are under development.
Other mental disorders in older persons that may have major effects on mental function include depression, delirium, and paranoid psychotic states. Depression occurs so commonly and is so often either not recognized or passed off as dementia that special attention should be paid to detecting its presence. In the regular work-up of the patient, the observations of the physician, nurse, or social worker should provide clues to this problem. In addition, one of the standardized short depression tests may be used as a screening test to identify the need for a more intensive work-up and possible treatment (see Chapter 28). However, as with the mental status tests, the results of these depression tests cannot be used as a quantitative reflection of the degree of loss of daily functional ability due to depression.21
In a patient with any features that suggest delirium, including hallucinations and paranoid tendencies, one should always look for possible causes, such as the side effects of medications, the use of drugs or alcohol, or the presence of metabolic disorders (see Chapter 27).
Symptoms of unusual or difficult behavior in confused or depressed patients can impose severe burdens on those who are providing care, whether at home or in an institution, and the presence or absence of such symptoms should be ascertained from the caregivers. Questions should be asked about wandering, agitation, abusive or assaultive behavior, fluctuating emotional state, bizarre actions (e.g., hoarding, undressing), hallucinations, impaired judgment, or depressive and suicidal tendencies. It is very important to learn what may be worrying the patient or triggering her or his symptoms. Knowledge of the lifetime patterns of daily practices and preferences can help caregivers understand and respond usefully to these symptoms. Approaches to addressing these challenges are further discussed in Chapter 29.
Assessment of Social Function and Social Supports
The characteristics of the environment in which the frail elderly person is currently living, including both the social and physical environments, often contribute, positively or negatively, to the clinical condition for which the patient is being seen and are always important in making plans for long-term care. The degree of social function and the degree of support that the patient receives and can expect to receive from family and friends are often deciding factors in determining whether institutional care is necessary. The capabilities and desires of family members must be assessed as well as the presence or extent of burnout from their current care burdens. Information is also needed about the present and potential availability of services from supportive agencies. The social worker on the assessment team should be involved with the family, social agencies, and patient and should play a role from the earliest stage of the assessment consultation in obtaining essential information.22,23
As discussed by Kane22 and others, other social dimensions that should be assessed include the presence of social networks and resources, the patient’s subjective well-being, values, and preferences, the burden on the caregiver and any evidence of elder abuse.
Assessment of Environmental Characteristics
The physical environment of the patient’s home and surroundings should be assessed by a visiting or community health nurse or by a member of the assessment team. This is an essential step in determining whether the patient can continue to function safely and effectively in that setting, given his or her functional limitations. This assessment can also identify measures that might be taken to modify the home to make it more suitable to the patient’s limitations, such as the installation of handrails, raised toilet seats, or widened doors for wheelchair use. To make precise recommendations, it is often necessary for an occupational therapist or a specially trained community health or visiting nurse to visit the home. Guidelines for assessing the home environment have recently been presented in practical detail.24
COMPREHENSIVE ASSESSMENT INSTRUMENTS
Because most of the elements of assessment described in the preceding section are essential parts of the diagnostic work-up and the decision-making process for determining what types of long-term supportive services are needed, a number of comprehensive multidisciplinary assessment guides or protocols have been developed. These have been used primarily by community-based agencies in their role as decision makers—that is, in determining the types of services needed. However, the information collected in this way can also be very helpful to the physician and other members of the assessment team during their diagnostic work-up of a patient and in following the course of the patient. Examples are the Philadelphia Geriatric Center multi-level assessment instrument of Lawton and associates,25 the Older American Resources and Services (OARS) instrument used at Duke University,26 and the comprehensive assessment and referral evaluation (CARE) instrument.27
One major development is the use of a national resident assessment instrument for nursing homes, the Minimum Data Set (MDS), which is now required for admission of all persons to nursing homes as part of the Omnibus Budget Reconciliation Act of 1987. This portion of the Act in turn was a response by Congress to the Institute of Medicine report on the quality of care in nursing homes.28 The development of the MDS has been described29 and commented upon.30 Its contents have been carefully developed to assist the staffs of nursing homes in developing comprehensive individual approaches to the care of each new resident. It is likely (and desirable) that the newly revised MDS 2 will become a routine part of guiding the care of older people in organized home care services as well as nursing homes and will be found useful in all comprehensive geriatric assessment settings as well.
Although the information that may be made available to the assessment team from the use of such instruments can be helpful, it does not take the place of careful review and, when indicated, further exploration of each of the areas of assessment described previously.
TRANSLATING IDENTIFIED NEEDS INTO APPROPRIATE LONG-TERM CARE SERVICES AND SETTINGS
Once the information described previously has been gathered, the physician and other health professionals must work with the patient, family members, and any relevant agency personnel to develop a plan of care that is appropriate for the identified needs of the patient. This plan should identify the specific types of services required and the options for settings in which these services may be appropriately provided.
Development of such a plan of care usually requires the expert knowledge and participation of others on the health care team—that is, a community health or visiting nurse, a social worker, and often others as well, such as an occupational or physical therapist. In other words, a true team effort, involving the patient and family as well as professionals, is usually necessary to establish a sound care plan. Although members of such a team may be dispersed in various community agencies, the goals of formulating a care plan can be accomplished through consulting relationships.
It should be kept in mind that the entire process of assessment and decision making about long-term care is in itself a stressful experience for the frail older person. A trusted personal advocate who is a source of personal support should always accompany and help sustain the older person through this process. This person can be a family member, a close friend, or a representative of a social agency.31
It is useful to organize one’s thinking about this translation of identified needs into service plans around some form of decision sequence.32 The following series of questions may serve the same purpose. These questions, which are based on assessment data, should be considered in developing long-term care plans:
Does this person need further specialized diagnostic work-up or intensive rehabilitation treatment before a long-term care plan can be developed?
If so, such steps should be taken first on an outpatient or inpatient basis.
Is this person physically and mentally capable of managing independently all activities of daily living and instrumental activities of daily living?
If so, no special long-term care plans or living arrangements are needed. However, the person should undergo appropriate periodic checkups for chronic conditions, and arrangements should be made to ensure that he or she is in regular contact with a supportive network.
Can this person manage all personal and instrumental activities of daily living within his or her home? That is, does he or she simply need assistance in traveling to and from necessary or desirable activities outside the home, such as shopping, visits to physicians, or social and religious activities?
If so, assistance with transportation or provision of shopping services should suffice. However, such a person is at high risk for social isolation, and positive attention should be paid to maintaining or adding social activities, including day programs.
Can this person prepare regular and adequate meals and perform other household chores (e.g., cleaning, laundry) by himself or herself, or are these functions performed by a spouse or other housemate?
If not, these housekeeping functions must be provided by nearby family members, meals-on-wheels or housekeeper services, or staff members of a domiciliary facility in which the person may live.
Can this person maintain adequate personal hygiene (e.g., bathe himself or herself) and dress and undress adequately?
If not, some help or supervision is needed, probably twice daily, from a family member, home health aide, or similar staff member of a congregate living institution, such as those in an assisted living or intermediate care facility.
Can this person ambulate independently, with or without mechanical assistive devices such as canes or walkers, and manage any necessary stairs in his or her dwelling?
If not, can the person transfer to and operate a wheelchair without assistance? Any limitation in locomotion or transfer may require a different living environment (e.g., a one-floor dwelling or a congregate living facility) or personal assistance several times daily by a family member or health aide for toileting, coming to meals, and so forth.
Is this person sufficiently oriented and mentally and emotionally competent to manage being alone all day or for hours at a time?
If not, constant or almost constant supervision by a family member, companion, or health aide is necessary in the home; alternatively, residence in a facility that has a restricted environment or a constantly supervising staff may be needed. Regular attendance in a highly supportive day center may help meet this need as well as adding variety and social involvement to the person’s life.
Is this person usually continent of urine and feces?
If not, thorough evaluation and an effort to treat any identifiable causes are indicated. If these are not successful, frequent daily personal care by family members or personal care aides in the home or an institution is necessary.
Can this person feed himself?
If not, assistance with eating at every meal by family or personal care aides at home or in an institution is necessary.
Does this person have some disability that requires regular nursing or rehabilitative therapy, such as care of pressure ulcers, ostomy care, respiratory treatment, or physical or occupational therapy?
If so, this care must be provided by visiting home health care services or in an institution staffed to provide these services.
THE NEED FOR CONTINUING REVIEW OF ASSESSMENT FINDINGS
This chapter has focused on the importance of developing an approach to functional assessment as an essential part of making an initial decision about long-term care. The findings must be incorporated into the ongoing care activities of the primary physician, the other professionals involved in the care of the patient, and family members, and must be reviewed regularly because further changes in the functional status of the patient are likely.
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