Comprehensive Geriatric Assessment
Adults 65 years of age and older currently make up about 15% of the US population. However, this age group accounts for 33% of all prescription drug purchases! While many of these drugs are useful and appropriate, a fair number of them come with risks that far outweigh their benefits in an older adult population. “Polypharmacy” is a term we use to describe using more medications than is clinically indicated. “Overprescribing” refers to using medications that have been inappropriately selected or dosed for an older adult. More than 30% of US older adults have received at least one potentially inappropriate medication (PIM). Potential consequences of overprescribing include adverse drug events, drug-drug interactions, decreased quality of life, and unnecessary costs.
Hearing & Vision
Hearing loss is associated with higher incidences of social isolation, family discord, lack of self-esteem, anger, and depression in older adults. Studies also suggest strong associations between hearing loss and cognitive impairment.
Loss of vision is ranked third (after arthritis and heart disease) in the list of chronic conditions that cause older adults to need help with activities of daily living. Vision loss is associated with depression, falls, and there is some suggestion that it may contribute to impaired cognitive function as well.
Major depressive disorders are rare among physically healthy older adults, but depressive symptoms are common among people with physically debilitating illnesses. Depression in elders may not manifest as “sustained sadness” but rather sustained loss of pleasure and interest in activities that had previously been enjoyable. Depression can also manifest as impaired concentration, sleep disturbance, and loss of appetite. Loneliness and social isolation are risk factors for late life depression.
Sleep problems are common among older adults, particularly those with other chronic medical conditions. Indeed, two-thirds of older adults with multiple comorbidities have sleep problems. Most commonly, these problems involve difficulty falling asleep, nighttime awakening, early morning awakening, and daytime sleepiness. Poor sleep is associated with cognitive decline and a decreased quality of life in older adults.
Frailty is a physiological state of heightened vulnerability. It is characterized by weakness, slowed walking speed, low physical activity, low energy, or easy exhaustion, and/or weight loss. Frail older adults are less able to tolerate stressors (infection, injury, hospitalization, surgery) and are more likely to have adverse outcomes from such events. Evaluation for early signs of frailty allows for the opportunity to implement strategies aimed at slowing (or perhaps reversing) the progression of frailty.
Dementia is typically a disease of later life, generally beginning after 65 years of age. Alzheimer’s Disease is the most common type of dementia, accounting for about two-thirds of all cases and affecting 6-8% of those 65 or older. By the time adults have reached the age of 85, 45% of them will have developed Alzheimer’s. There are tremendous social and financial implications associated with dementia not only for patients but for their families as well. Early diagnosis, supportive treatment plans, and advanced care planning can greatly improve quality of life for patients and their families.
Falls & Prevention
Every second of every day, an older adult in the US will fall! One in three older adults will experience a fall each year. Most falls result in minor soft-tissue injuries, but 10-20% of falls result in fractures, more serious soft tissue injuries, or head traumas. Of those who do not experience physical injury, falls are associated with subsequent declines in functional status, greater likelihood of nursing home placement, increased use of medical services, and development of a fear of falling.
Often glossed over in primary care, Nutrition is a huge component of health maintenance and disease prevention in all stages of life - including older adulthood! Dietary modification is first line treatment in many chronic diseases including diabetes, obesity, arthritis, obstructive sleep apnea, incontinence, etc. Likewise, maximizing nutrition can help maintain muscle mass, strength, and energy in later life.
Exercise is arguably the most important component of healthy aging! The health benefits include reduction in risk of coronary artery disease, stroke, hypertension, high cholesterol, diabetes, osteoporosis, depression, falls, constipation, and even some types of cancer. Additionally, there is strong evidence that physical activity has a beneficial effect on functional capacity in older adults. The phrase “use it or lose it” often rings true!
Functional Status refers to a person’s ability to perform activities of daily living such as bathing, dressing, toileting, etc. It is not a disease state per se, but rather the ramifications or outcomes of having disease. Assessing for functional status allows us to identify weaknesses, implement treatment plans, and make modifications to help ensure the safety of older adults.
Evaluating whether an older adult is “safe” to drive can be a daunting and emotionally difficult task for family members. For most Americans, driving represents autonomy and independence. Therefore, “handing over the keys” is something that few people are ready or willing to do. By optimizing health as we age, we can hope to prolong our ability to operate a car safely. The American Geriatrics Society has published guidelines for assessing and counseling older drivers. When older drivers meet these guidelines, their families can feel confident that he/she can continue to drive safely.
The prevalence of urinary incontinence increases with age, affecting 15-30% of all adults aged 65 years and older. The cause of urinary incontinence is usually multifactorial and may include medical conditions, functional and cognitive impairment, and medication side effects. Fecal incontinence is less common but may still affect up to 15% of people >70 years old. There are many therapeutic options for incontinence. Contrary to public opinion, it is not something we just have to live with!
Advance Care Planning
Advance Care Planning is the process in which patients and their doctors engage in evolving discussions about patient’s goals of care and care preferences at the end of life (or in the case of a medical emergency). This process empowers patients to have autonomy and control over their final years by anticipating possible future needs and events, and planning for them ahead of time.
Caregiving is the experience of providing physical and emotional care to another person. Informally, this occurs commonly within families and amongst friends. While caregiving is a gratifying and rewarding “job”, it can also be exhausting. Experience shows us that supporting the caregiver is often the best way to support the patient.
All of topics listed here are key components of the Comprehensive Geriatric Assessments performed at Evergreen Geriatrics, LLC. By conducting these assessments, Dr Alhumaid is able to develop a thorough understanding of her patients’ health status and goals. She then works with her patients to incorporate evidence-based medical practices into individualized patient plans.
*Data pulled from Geriatric Review Syllabus, 11th Edition, American Geriatric Society, 2022