Clinical Geriatrics

For older patients with complex health problems, comprehensive geriatric assessment, care coordination, and adherence to the principles of geriatric pharmacology are among the key elements of high-quality healthcare embodied within the principles of geriatric medicine. Geriatric assessment is the logical starting point for such care since it guides and informs all that follows.

Unfortunately, the lack of geriatricians and other geriatrics healthcare providers is an issue for many older patients and for their primary care physicians (PCPs). As the number of older adults rises, this shortfall will become increasingly acute. That’s why it is becoming more important for PCPs and other clinicians who care for older people to familiarize themselves with the goals of geriatric assessment.

Geriatric assessment goes beyond the standard adult comprehensive history and physical examination. It includes a much more extensive evaluation. In addition to the standard elements of a physical examination, there is evaluation of those elements of special significance in older adults—orthostatic vital signs, vision, hearing, gait and balance, cognition, and affect. It should also include an in-depth medication review (covering prescribed and over-the-counter drugs, and vitamins and herbs); a review of immunization status and of difficulties with or dependency in instrumental and basic activities of daily living (ADLs); and an evaluation of living arrangements, social supports and activities, and advance directives.

This kind of assessment usually yields a more complete and relevant list of medical problems (eg, diabetes, hypertension, past strokes, cataracts), functional problems (eg, difficulty walking, a history of falls, the need for assistance with ADLs), and psychosocial issues (eg, the presence of depression, social isolation). These require individualized yet coordinated, integrated plans of care for further evaluation, treatment, referral, and patient and/or caregiver education.

Geriatric assessment and care coordination can be highly effective and also cost effective. Research suggests that geriatric assessment can lead to optimized prescribing; reduce the incidence of adverse drug events, the need for specialty services, diagnostic studies, ER visits, and hospitalizations; and improve outcomes. A 2006 study of nearly 1400 older adults who were hospitalized at 11 VA medical centers found that those randomly assigned to an inpatient geriatric unit where they underwent a comprehensive geriatric assessment fared better than those assigned to usual inpatient care. The former were roughly one-third less likely to need nursing home placement. Though not statistically significant, the mean savings was $1027 for each patient in the geriatric assessment group. Linking geriatric assessment with coordinated care is likely to boost savings further. In Harris County, Texas, the Evercare STAR + PLUS pilot program, which emphasizes care coordination and now serves approximately 65,000 older adults countywide, saved the state government roughly $123 million over two years.

American Geriatrics Society (AGS) publications, such as the Geriatrics Review Syllabus, and educational programs offered by medical schools, Geriatric Education Centers, community and teaching hospitals, regional medical societies, and AGS state affiliates can help PCPs refine their skills in geriatric assessment. (A listing of AGS state affiliates and contacts is at www.americangeriatrics.org/affiliates/current_ags_affiliates.shtml.)
I also recommend “Assessing Care of Vulnerable Elders™ Physician
Education Program,” a CD-ROM guide to geriatric assessment created by David B. Reuben, MD, Chief of the Division of Geriatrics, and Director of the Multicampus Program in Geriatric Medicine and Gerontology at UCLA.