Stanford University Geriatric Education Resource Center  

HBV19: Geriatric Assessment and the Twenty-Minute Visit

Instructional Manual For Resident and Attending Physicians

Table of Contents.

1. The Older Patient - A Typical Scenario  4
2. What is Geriatric Assessment?  4
3. The Epidemiological Imperative  5
4. A Review of the More Common Instruments  5
5. Getting Started: Communication Barriers and Strategies for Overcoming Them 10
6. Integration Of Assessment Tools Into Everyday Practice 12
7. References 13
8. Appendix of Instruments 17

This manual is meant to be used in conjunction with an accompanying videotape, but can serve as stand-alone text providing background material useful to teacher and learner.

Imagine you are a medical resident on your third day of an ambulatory 2 month block in a private practitioner's office. You have seen a number of patients with sore throats, cough, hypertension, and diabetes when the nurse tells you that you have a new patient, Mr. Caldwell, an 83 year old gentleman who moved to this area 3 months earlier. His daughter has given the office some brief background information. He recently moved from North Carolina to be closer to his daughter here in upstate, NY. He is living in an apartment just a few houses down from where she resides. She reports that he has led a generally active life though he had given up driving before the move North. He brought with him some medical records which, after briefly scanning, indicate mild CHF with one related hospitalization for that in 1996. He has non-insulin dependent diabetes which he controls with diet alone and hypertension which seems to have been well controlled with Vasotec. He is on no other medications. He has had a yearly flu shot, but hasn't had more than 2 visits to a physician in the past 3 years. His daughter dropped him off and will return to pick him up, but wants to speak with you later in the day. How do you want to proceed?

The traditional approach would be to conduct a complete history and physical. There are important reasons to consider proceeding in a somewhat different manner. While all pertinent clinical information could in fact be gathered by asking the appropriate questions and performing the essential physical evaluations, the traditional medical model of the clinical encounter may limit these efforts, leaving important geriatric conditions undetected. Formal assessment instruments, which include standardized questionnaires and physical maneuvers have been employed to ensure comprehensiveness and accurately reproducible measures over time. Such instruments constitute much of what forms the basis of geriatric assessment. While these tools can be employed by physicians, nurses and other trained medical staff, providing a framework for a thorough evaluation of an area of specific concern, the efficiency of a busy office or medical clinic is at considerable risk. Becoming familiar with the most common of these instruments and comfortable in their use will however, enable you to begin incorporating aspects of these tools in your everyday work with older patients.

Geriatric assessment is the multidimensional evaluation of older persons designed specifically for those individuals who are frail or at significant risk for functional decline. It includes an evaluation of physical and mental health, as well as a determination of functional status. Social assessment, an exploration of economic status, potential caregiver burden, personal values, which entails a discussion about advanced care directives, and screening for elder abuse are also included.

Geriatric assessment for the primary care practitioner might best be viewed as a means of screening for common geriatric conditions that are often missed with the traditional history and physical. It provides not only a means to detecting existing conditions, but also a method for understanding the specific nature of that individual's problem, so that further diagnostic workup, (if necessary), and treatment can be pursued.

Research has shown that experienced clinicians can miss significant dementia, depression and gait disorders, for example. Physicians do not routinely perform mental status testing on their patients and few patients with dementia in outpatient practice are detected without specific screening. Cognitive impairment results in poor correlation between self reported and objective measures of physical functioning. In addition, cognitively impaired hospitalized patients fare poorly in comparison to their unimpaired counterparts with respect to morbidity, mortality, and loss of independence. Functional assessment assists a physician in determining a patient's ability to remain independent and directs specific interventions to increase that likelihood. In addition, understanding the functional impact of medical illness on patients and families is essential if rehabilitation is to occur in a timely and appropriate manner.

We will focus upon specific instruments for the purpose of illustrating how important aspects of such instruments can be integrated into a busy office practice. In addition, by "sensitizing" you to issues specific to aging, we anticipate your patient evaluations will increase in relevance beyond the scope of the typical history and physical, even without the specific application of any formal assessment tool.

User Comments

I liked the comprehensiveness and the discussion of open vs. closed questions. This is exportable.

Generally quite well done and very appropriate for viewing by house staff and medical students.

Including comments by house staff in the video is effective.

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