except End of Life. Outpatient screening of unintentional weight loss of 10% or greater in one year is indicative of significant malnutrition.
Using validated screening tools such as the Simplified Nutritional Appetite Questionnaire (SNAQ) or Mini‐Nutritional Assessment (MNA) can identify patients who are malnourished or at risk for malnutrition.8
Height
Since measuring height is a low‐cost screening intervention – and as bone loss occurs, height may decrease – it may be an effective and economical method to identify early osteoporosis of the spine for Robust and Frail elderly. One study showed a significant association with historical height loss of 1.5 cm and vertebral fractures.9
Pain
Pain should now be considered the fifth vital sign and should be assessed at every visit for patients in all categories. Use of Likert scales (e.g. 1–10) or a pictorial scale (e.g. facial expressions) can be useful to quantify pain. Even patients with dementia can be evaluated for pain, using such tools as the CNA Pain Assessment Tool (CPAT) and the Pain Assessment in Advanced Dementia Scale (PAINAD‐G).10,11
Medication review including over‐the‐counter (OTC) and herbal medicines
The risk of adverse drug events, poor compliance, and drug–drug interactions, and even the risk of hospitalization, are most associated with the number of drugs taken, while underlying comorbidities and, to some extent, age contribute to this risk.12,13 Patients should maintain an up‐to‐date medication list, including OTC and herbal preparations, to bring in at each office visit or hospitalization. Medication reviews should be performed for patients in all four categories at each office visit to assess for duplication, drug–drug or drug–disease interactions, adherence, affordability, and side effects.
Lifestyle education
Recommendations about areas of lifestyle education in general apply mainly to the Robust and Frail elderly, with a lower level of recommendation for the Moderately Demented elderly. Activity level should be queried because a low level of activity is a significant predictor of mortality among older adults.14 In Robust elderly, physical activity plays an important role in preventing and reducing mortality and treatment of various chronic and disabling conditions (e.g. obesity, cardiovascular disease, stroke, diabetes mellitus type 2, hypertension, depression, osteoporosis, osteoarthritis, cognitive decline). Frail elderly undergoing randomized trials of exercise experienced fewer falls and injuries and less healthcare utilization. Although the USPSTF does not recommend behavioural counselling of elderly patients by primary care physicians to promote increased physical activity, other professional organizations, such as the American College of Physicians (ACP), American Heart Association (AHA), and American College of Sports Medicine (ACSM) support exercise promotion in the elderly. Specific recommended exercises fall into four categories: aerobic, muscle strengthening, flexibility activities, and balance training.
Physicians should ask patients about smoking and should clearly and directly advise all smokers to quit. Patients who want to quit should be assisted with self‐help materials, encouraged to set a quit date, referred for behavioural therapy, or advised to try OTC or prescription medications.
Alcohol abuse can initially be screened for by asking what quantity a patient consumes regularly. Men who consume more than four drinks per day and women who consume more than two drinks per day are at risk of alcohol‐related problems.15 A more thorough assessment should include screening tools such as the CAGE questionnaire, MAST, or AUDIT. Of these three, the CAGE questionnaire has the best sensitivity and specificity for diagnosing alcohol dependence.16 Both the USPSTF and the American Geriatrics Society (AGS) recommend that primary care providers screen their older patients for alcohol misuse.
Areas of education for injury prevention include the use of car seat belts, alcohol‐related risks in relation to driving, home environmental hazards to reduce falls, and the restriction of access to firearms and driving with depressed and cognitively impaired patients.16
Maintain awareness of elder abuse
Physicians and other healthcare professionals should maintain awareness at all times for patients in all categories. A review of elder abuse screening and assessment instruments has shown that older adults were unlikely to report episodes of elder mistreatment, and identification of 70% or more of elder mistreatment comes from third‐party observers.17 Healthcare providers should consider referral to a social service agency for evaluation of mistreatment if elderly patients present with unexplained contusions, burns, bite marks, genital or rectal trauma, pressure ulcers, or a BMI of less than 17.5%.
The term awareness is used because no particular standardized evaluation tool for elder abuse has been shown to be better than others.18
Assess ADLs and IADLs
Prevention of functional decline is one of the hallmarks of geriatric care. Loss of function among older people is associated with long‐term care placement, morbidity, and mortality. Thus, although there is no direct evidence for how often to screen older patients in each of the four categories for functional change, given the importance of this health parameter, it is recommended for patients in all categories at the intervals as noted in Table 9.1.
Two commonly used measurements of function are activities of daily living (ADLs) (bathing, dressing, toileting, transferring, continence, feeding) and instrumental activities of daily living (IADLs) (telephone, shopping, food preparation, housekeeping, transportation in the community, taking medications, handling finances).
Visual acuity and auditory testing
Although both of these are an accepted part of the comprehensive geriatric assessment (CGA), the level of recommendation for testing these areas is ‘Consider’ for patients in all categories. Based on a review of vision screening studies, direct evidence of vision screening in asymptomatic older adults in primary care settings found no effect in improving visual acuity or other clinical outcomes.19 The USPSTF concluded that evidence is insufficient to determine whether screening older adults for visual impairment improves functional outcomes. However, due to improved treatment of various chronic eye diseases, the National Eye Institute, the American Optometric Association, and the American Academy of Ophthalmology recommend routine comprehensive eye examinations in asymptomatic patients performed by optometrists or ophthalmologists every one to two years.
Likewise, although there is evidence that decreased hearing is common and associated with negative outcomes, there is a lack of EBM that screening will improve outcomes.20 However, the use of hearing aids or surgical intervention has a positive effect on quality of life. The ACOVE authors suggest an annual hearing screening by either questionnaire or hand‐held audiometry.
Ask about urinary incontinence
The level of recommendation here is the highest for all categories because urinary incontinence is common among women and may occur in men and is easy to screen for (usually one to two questions), and multiple effective treatments are available.
Males: screen for erectile dysfunction (ED) and hypogonadism
It is recommended that this be done for males in the Robust and Frail categories but should only be considered in males with moderate (not severe) dementia. ED is common, with multiple treatments available.
Male hypogonadism is also common and is associated with muscle weakness and osteoporosis. The ADAM (Androgen Deficiency in Aging Males) screen for hypogonadism has high sensitivity and adequate specificity (Chapter 95 for details).