Medical Assessment

The medical assessment includes a review of the patient's medical record, medication history (past and present), and a nutritional evaluation. On average, elderly patients have four to six diagnosable disorders, which may require the use of several medications. One disorder can affect another, and in turn a collective deterioration of both can lead to overall poor outcomes. Review of the patient's medical record should focus on conditions that are more common in the elderly (geriatric syndromes) and in particular their risk factors.

Four shared risk factors—older age, baseline cognitive impairment, baseline functional impairment, and impaired mobility—have been identified within the five most common geriatric syndromes: pressure ulcers, incontinence, falls, functional decline, and delirium (Inouye et al., 2007). It is important that health care providers familiarize themselves with the common geriatric body area or system disorders that can directly influence these risk factors. Understanding the basic mechanisms involved in geriatric syndromes is essential to targeting therapeutic options.

During the medical assessment, the review of systems should be completed with special emphasis on sensory impairment, dentition, mood, memory, urinary symptoms, falls, nutrition, and pain. The U.S. Preventive Services Task Force (1996) recommends routine screening for visual and hearing impairment.

Hearing loss is the third most prevalent chronic condition in elderly people, after hypertension and arthritis, and its prevalence and severity increase with age. In persons age 65 to 75 years, the prevalence of hearing loss ranges from 20% to 40% (Cruikshanks et al., 1998; Rahko et al., 1985; Reuben et al., 1998), whereas in those over age 75, it ranges from 40% to 66% (Ciurlia-Guy et al., 1993; Parving et al., 1997).

Screening for hearing loss can be accomplished using two office-based methods: the audioscope (objective) and a validated short questionnaire (subjective). The audioscope is a handheld instrument that functions as an otoscope and audiometer and can be used to visualize the ear canal and eardrum and remove cerumen if necessary. The audioscope is easy to use, with 87% to 96% sensitivity and 70% to 90% specificity (Abyad, 1997; Mulrow, 1991). The Hearing Handicap Inventory for the Elderly-Short Version (HHIE-S) is a subjective, 10-item, 5-minute questionnaire with an overall accuracy of 75% in identifying hearing loss (Mulrow et al., 1990).

A formal audiologic evaluation should be offered to any patient who fails a hearing screening. The evaluation can assist in determining the need for further testing or management, including hearing aid, medical treatment, or surgical intervention.

Review of the patient's current medication list, including over-the-counter (OTC) medications, as well as any drug allergies or previous adverse drug reactions, is a necessary component of the geriatric assessment. Adverse drug reactions (ADRs; also adverse drug events) are a significant public health issue, especially in the elderly population (Thomsen et al., 2007). Polypharmacy is defined as taking more than four medications and is an independent risk factor for both delirium and falls (Inouye et al., 2000; Molyan and Binder, 2007).

Patients or family members should be asked to bring in all the patient's prescription medications and supplements at the initial visit and periodically thereafter. Clinicians can make sure patients have the prescribed drugs, but possession of these drugs does not guarantee adherence. Patients should be asked to demonstrate their ability to read labels (often printed in small type), open containers (especially the child-resistant type), and recognize their medications. Pillboxes may be helpful in organizing the patient's medications by the week or month.

Nutritional evaluation is an integral part of the geriatric assessment. The type, quantity, and frequency of food eaten should be determined. Malnutrition and undernutrition can lead to health problems that include delayed healing and longer hospital stays. A reliable marker of nutritional problems is weight loss, specifically, more than 5% in the past month and 10% or greater weight loss in the last 6 months

(Huffman, 2002). Clinicians should ask about any special diets (e.g., low carbohydrate, vegetarian, low salt) or self-prescribed "fad" diets. A nutritional screen can aid in further assessment of the patient's nutritional health and help guide interventions (Figure 4-1). Additional questioning should include weight loss and change of fit in clothing; amount of money spent on food; and accessibility of grocers with a variety of fresh foods.

The ability to chew and swallow should also be evaluated. It may be impaired by xerostomia (dryness of mouth), which is common in elderly persons. Decreased taste or smell may reduce the pleasure of eating, so patients may eat less. Patients with decreased vision, arthritis, immobility, or tremors may have difficulty preparing meals and may injure or burn themselves when cooking. Patients worried about urinary incontinence may reduce their fluid intake and thus may eat less food.

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