Assessment Domains

Comprehensive geriatric assessment is most successful when conducted by a geriatric interdisciplinary team, which typically includes a geriatrician, a nurse, a social worker, and a pharmacist. For most elderly patients, the outpatient clinic is a sufficient and relatively inexpensive setting for evaluation; comprehensive geriatric assessment usually does not require the technology or intense monitoring available in an acute care inpatient setting. However, patients with physical or mental impairments may have difficulty keeping appointments, and chronically ill patients who need to rest during the assessment process may require inpatient assessment.

The principal domains assessed in all forms of geriatric assessment are functional ability, physical health, cognitive and mental health, and the socioenvironmental situation. Standardized instruments make evaluation of these domains more reliable and efficient (see Table 4-2). They also facilitate the communication of clinical information among health care practitioners and the monitoring of changes in the patient's condition over time.

Functional ability: Comprehensive geriatric assessment begins with a review of the major categories of functional ability: activities of daily living (ADLs) and instrumental activities of daily living (IADLs). ADLs are self-care activities that a person must perform every day (eg, eating, dressing, bathing, transferring between the bed and a chair, using the toilet, controlling bladder and bowel). Patients unable to perform these activities and obtain adequate nutrition usually require caregiver support 12 to 24 hours/day. IADLs are activities that enable a person to live independently in a house or apartment (eg, preparing meals, performing housework, taking drugs, going on errands, managing finances, using a telephone). Reliable instruments for measuring patients' abilities to perform ADLs and IADLs and for determining what kind of assistance may be needed include the Katz ADL Scale (see Table 4-3) and the Lawton IADL Scale (see Table 4-4). Deficits in ADLs and IADLs indicate a need for additional information about the patient's socioenvironmental situation. When elderly persons begin to need help performing these activities, their risk of becoming more dependent increases.

Physical health: The approach to the history and physical examination must be geriatric-specific. In particular, vision, hearing, continence, gait, and balance must be considered. The Tinetti Balance and Gait Evaluation (see Table 21-2) is a useful assessment instrument.

Cognitive and mental health: Several screening tests for cognitive dysfunction have been validated; the Mini-Mental State Examination is popular because it efficiently tests most of the major aspects of cognitive function. Of the several validated screening instruments for depression, the Geriatric Depression Scale and the Hamilton Depression Scale (see Table 33-4 and Table 33-5) are the easiest to use and most widely accepted. However, a two-question screening instrument ("During the past month, have you been bothered by feelings of sadness, depression, or hopelessness? Have you often been bothered by a lack of interest or pleasure in doing things?") is as effective as these longer scales. Specific psychiatric symptoms (eg, paranoia, delusions, behavior abnormalities) are evaluated in the psychologic assessment, but they are less easily quantified and are rarely included in rating scales.

Socioenvironmental situation: Factors that affect the patient's socioenvironmental situation are complex and difficult to quantify. They include the social interaction network, available social support resources, special needs, and environmental safety and convenience, which influence the treatment approach used. Such information can readily be obtained by an experienced nurse or social worker. Several assessment instruments are available, but none is quantitative or clinically useful. A checklist can be used to assess home safety. (see Table 20-3)