Comprehensive Geriatric Assessment Nursing CE Course for APRNs

through continued maintenance of function, dignity, and self-determination. A CGA is critical to identifying and managing conditions to prevent complications (Ghimire & Dahal, 2023; Ward & Reuben, 2022).

Comprehensive Geriatric Assessment

Older adults represent the most complex patients in health care. The underlying cause for a patient's presenting symptoms is frequently overlooked or misidentified, leading to extensive consumption of health care resources through urgent care or emergency department (ED) visits and hospitalizations. These missed diagnoses cause increased morbidity, mortality, and ultimately disability. These miscues also lead to frustration and distrust among patients, not to mention the frustration these situations can prompt for caregivers and HCPs. A CGA is a multidimensional, multidisciplinary diagnostic and treatment process that identifies psychosocial, medical, and functional limitations to implement a coordinated care plan. It can help identify conditions and syndromes earlier and more accurately. A full assessment should also obtain information regarding the patient's current functional ADLs and instrumental activities of daily living (iADLs); gait, balance, and fall risks; visual and auditory acuity; mood, memory, executive functioning, and problem-solving; and risk for or presence of skin breakdown (Ghimire & Dahal, 2023; Stefanacci, 2022; Ward & Reuben, 2022).

A series of assessment tools may be utilized during a CGA. For example, the Mini-Mental State Exam (MMSE) is a validated measure of cognition. The Fulmer SPICES tool assesses older adults for sleep disturbances, problems with eating or feeding, incontinence, confusion, evidence of falls, and skin breakdown. The Community College of Philadelphia created the Advancing Care Excellence for Seniors (ACE.S) framework in partnership with the National League for Nursing (NLN) as an educational guide to instruct nursing students on how to assess an older patient's function, identify their expectations, and work through shared decision-making to coordinate care and manage any identified deficits or conditions to improve QOL and reduce caregiver stress. The established care plan should be well-coordinated across disciplines, culturally inclusive and sensitive, and tailored to the individual's unique wishes, resources, and strengths. Assessing a patient's relative risk will help identify early prevention strategies to avoid complications. For example, the ACE.S framework highlights the heightened risk associated with transitions, many of which occur later in life. These transitions happen when an individual is adjusting to life with adult children, learning to function after a spouse's death, moving to a different environment, or moving between care settings. The Hartford Institute for Geriatric Nursing (HIGN) developed a series of assessment tools entitled Try This. These two-page guides provide information and assessments for particular conditions that the HCP can complete in less than 20 minutes. These tools can be accessed free of charge on Hartford's website, hign.org. The SPICES tool mentioned above is the first item in the Try This series (HIGN, n.d.; NLN, n.d.; Ward & Reuben, 2023).

Given that a CGA requires various disciplines to work collaboratively to create a care plan, these services can be costly, making appropriate referrals essential. Patients who should be considered for referral to a CGA program include those who are over 65 with one or more chronic or complicated health conditions. CGA programs are most beneficial for moderately ill patients but not those at either end of the wellness spectrum (very healthy or gravely ill). For this reason, CGA programs are most appropriate for patients with medical comorbidities (heart failure, cancer); psychosocial disorders (depression, isolation, dementia); certain high-risk conditions (falls, functional disabilities); and a history of or a risk for a high rate of health care utilization, as well as those experiencing a change in their living situation (beginning services with in-home caregivers, moving from their home to an assisted living facility). Most programs rely on a core team consisting of a nurse, a clinician, and a licensed social worker (LSW) to complete the assessment. Ancillary professionals are used on a case-by-case basis, such as physical therapists, occupational therapists (OTs), speech and language pathologists (SLPs), dietitians, pharmacists, psychiatrists, psychologists, dentists, audiologists, podiatrists, and opticians (Ghimire & Dahal, 2023; Stefanacci, 2022; Ward & Reuben, 2022).

Assessment programs may be limited by local access and reimbursement for certain services and are often broken into separate components. Team communication is completed virtually through the electronic health/medical record (EHR/EMR). A CGA typically consists of six steps: (a) data gathering, (b) discussion among the team, (c) development of a treatment plan, (d) implementation of the treatment plan, (e) monitoring the patient's response to the plan, and (f) revision of the treatment plan if needed. Both the second and third steps should involve participation by and input from the patient and their caregivers if possible. Many programs have shifted the focus away from tertiary prevention to incorporate primary and secondary prevention strategies. Written (or electronic) questionnaires can save valuable time by gathering a large amount of information prior to the assessment, allowing the team to focus on areas of concern. The preliminary questionnaire will typically review the patient's history (past medical history, current medications, social history, review of systems, surgical history), as well as information regarding the current level of function, assistance required for ADLs and iADLs, fall history, urinary or fecal incontinence, pain, mood symptoms, and vision or hearing difficulties. It should also inquire about the patient's social support network and the existence of any advance directives, such as a durable power of attorney or proxy decision-maker for health care (Ghimire & Dahal, 2023; Heflin, 2023; Stefanacci, 2022; Ward & Reuben, 2022). The core components of most CGAs include the following.

• Functional capacity (the ability to drive and perform other basic, instrumental, and advanced ADLs)
• Fall risk
• Cognition
• Mood
• Social support
• Financial concerns
• Goals of care
• Advance care preferences
• Polypharmacy (Ghimire & Dahal, 2023; Stefanacci, 2022; Ward & Reuben, 2022)

Optionally, some CGAs may also include an assessment of the patient's:

• Nutrition or recent weight changes
• Urinary incontinence
• Sexual function
• Vision/hearing
• Dentition
• Living situation
• Spirituality (Ghimire & Dahal, 2023; Stefanacci, 2022; Ward & Reuben, 2022)

 

Table 2 provides an example of a geriatric assessment instrument, addressing the domains and the components that coincide with each domain.

Table 2

Geriatric Assessment Instrument

Domain	Components
Functional ability	Degree of difficulty bathing, dressing, toileting, eating, and transferring from bed and chair Control of bowel and bladder Degree of difficulty doing housework, prepping meals, taking medications, running errands, using the telephone, and managing finances
Assistive devices	Use of personal devices (oxygen, walker, cane, wheelchair) Use of environmental devices (hospital bed, shower bench, grab bar)
Caregivers	Use of paid (nurses, aides) and unpaid (friends, family) caregivers
Medications	List of prescription and non-prescription medications used
Nutrition	Height, weight, body mass index (BMI) Weight fluctuations
Preventive measures	Frequency of routine blood pressure measurements, immunizations, guaiac testing, thyroid-stimulating hormone (TSH), and dental care Use of smoke detectors Regularity of exercise
Cognition	Mini-Cog screening (ability to remember three objects after 1 minute and draw a clock face)
Affect	Feelings of depression, sadness, or hopelessness Lack of pleasure or interest in doing things
Advanced directives	Establishment of a durable power of attorney and living will
Substance misuse	Misuse of tobacco, alcohol, caffeine, prescribed medications, or recreational drugs
Gait and balance	Number of falls in the previous 6 months Extent of maximal forward reach while standing Time required to get up from a chair, walk 10 feet, turn around, walk back, and sit
Sensory function	Snellen exam (ability to read at 20/40 or better, with corrective lenses if needed) Whisper test (ability to report three numbers whispered 2 feet behind the head)
Upper extremity mobility	Ability to clasp hands behind the back and head

(Stefanacci, 2022)

 

Functional Capacity

Functional capacity refers to a patient's ability to perform basic, instrumental, and advanced ADLs. This can include toileting, grooming, eating, cooking, driving, and managing finances. If a patient loses the ability to perform these tasks, they are often described as experiencing a functional decline. By contrast, physical frailty in older adults is typically defined as weight loss, malnutrition, slow gait, fatigue, weakness, and inactivity. Failure to thrive (FTT) in older patients is a syndrome of global decline consisting of weight loss, decreased appetite, poor nutrition, and inactivity that is often accompanied by dehydration, symptoms of depression, impaired immunity, and reduced cholesterol. As opposed to the FTT syndrome that affects pediatric patients who cannot achieve an expected functional level, older adults with the same complex symptoms are unable to maintain their previously acquired functional status. These terms may be used interchangeably or describe distinct points along a continuum between the virility and independence associated with middle age and complete dependence and death at the end of life. For example, a patient may decline in their ability to function independently, beginning with a classification of robust and declining to pre-frail, then frail, and finally qualifying as FTT near the end of their life. Other experts consider physical frailty to be a component of FTT, along with physical disability and neuropsychiatric impairment, although these latter components are not required to diagnose FTT. FTT and frailty are often related to adverse effects of medication(s) and medical comorbidities and are compounded by psychosocial factors. An accurate assessment of the patient's prior level of functioning or baseline is crucial to recognizing a significant change or downward trend (Agarwal, 2023; Ward & Reuben, 2022).

Functional capacity, or frailty, can be utilized to determine an older adult's prognosis regarding functional decline and death in an upcoming period and to help differentiate patients who may not derive significant benefit from treating asymptomatic chronic conditions (hypertension, DM). Impairment in ADLs is associated with an increased risk of depression, falls, institutionalization, and death. As a component of the CGA, functional capacity should be assessed using a validated tool such as the Vulnerable Elders Scale-13 (VES-13), a screening tool with 13 items related to age, self-rated health, and the ability to perform certain functional and physical activities. It is designed to predict the potential for functional decline or death within the next 5 years for community-dwelling patients over 65. It can be self-administered during an office visit or by nonmedical personnel via telephone in less than 5 minutes. Scores range from 1 to 10, with higher scores indicating a worse prognosis. Research suggests that patients whose VES-13 score is 3 or higher have 4.2 times the odds of functional decline or death within the next 2 years compared to patients with a score of 2 or below (Min et al., 2009; Heflin, 2023; Rand Corporation, n.d.; Ward & Reuben, 2022). Table 3 outlines the scoring for the VES-13.

Table 3

VES-13 Scale

Domain

Age 75 to 85 (1 point) older than 85 (3 points)

Self-rated health good, very good, and excellent (0 points) fair and poor (1 point)

ADLs/iADLs Needs assistance with: bathing or showering (1 point) money management (1 point) light housework (1 point) shopping (1 point) transfer (1 point)

Difficulty in special activities performance of housework (1 point) lifting and carrying 10 pounds (4.5 kg; 1 point) writing or handling and grasping small objects (1 point) kneeling, bending, and stooping (1 point) reaching out and lifting upper extremities above the shoulder (1 point) walking 0.25 miles (1 point)

(Rand Corporation, n.d.; Ward & Reuben, 2022)

 

The Karnofsky Performance Status Scale was developed in the early 1990s to compare the effectiveness of different therapies and establish a prognosis for patients. The scale assigns a score of 0 to 100 based on the patient's description of their functional abilities, with a lower Karnofsky score indicating serious illness and less likelihood of survival (Christensen, 2023).

Similarly, the Clinical Frailty Scale (CFS) is commonly used to assess functional capacity in clinical practice due to its brevity. This Canadian tool purports to "summarize information based on a clinical encounter" and "roughly quantify an individual's overall health status" by assigning a score (Dalhousie University, n.d.). The scores ranged from 1 ("very fit, indicating a patient who is robust, active, energetic, motivated, and fit") to 7 ("severely frail, completely dependent on others for ADLs or terminally ill") in the original scale (Dalhousie University, n.d.; Rockwood et al., 2005). The CFS was expanded in 2007, adding scores of 8 and 9 to characterize more severe cases of frailty and differentiate between severely frail, very severely frail, and terminally ill patients. Finally, in 2020, version 2.0 was released with minor edits to the categorical descriptions. The authors note that using the scale requires clinical judgment after observing a patient's mobility, balance, use of a walking aid, and reports of their ability to dress, feed themselves, cook, shop, and manage their finances. The user must ask the patient (or an accompanying caregiver) how they have been moving, functioning, thinking, and feeling about their health over the previous 2 weeks. The authors also recommend reviewing the patient's current medications (to ascertain pre-existing medical conditions) and their activity level. How the patient moves, functions, thinks, and engages in activity helps differentiate between the first three categories. In categories 4 through 7, cognition plays a more prominent role, and their activity/exercise habits are less conspicuous. Patients in categories 8 and 9 are considered to be near the end of life, with 9 representing those with fewer than 6 months of estimated life left. If a patient fits equally well in two categories, the authors recommend assigning a higher (more dependent) score. Scores should be based on knowledge of the patient's baseline health state. The CFS has not been validated for use in younger patients (Dalhousie University, n.d.; Rockwood & Theou, 2020).

The Katz Index of Independence in ADLs scale assesses a patient's essential life skills and is included in the second issue of the Try This series by the HIGN. Patients are scored on their independence or dependence related to ADLs (bathing, dressing, toileting, transferring, continence, and feeding). A score of 6 indicates that the patient is independent, and a score of 0 indicates complete dependence.

The Lawton iADL scale is designed for use in community-dwelling populations and is included in the 23rd issue of the Try This series by the HIGN. A simple observation of the patient's dressing or undressing may give valuable information regarding their functional status, range of motion, apraxia (difficulty executing skilled movements or activities), and balance. Some health-related QOL instruments also include ADL components, such as the Medical Outcomes Study Short Form 36 (SF-36), the Short Form Health Survey (SF-12), and the patient-reported outcomes measurement information system instruments. Aside from ADLs, gait speed can accurately predict functional decline and early mortality. Gait speed can be assessed by timing the patient while they walk 6 meters or 20 feet. Research indicates persistent untreated hypertension only increases mortality in patients over 65 if their gait speed is at least 0.8 m (2.6 feet)/second. The timed Get Up and Go test is another option for assessing gait speed and is discussed in greater detail in the forthcoming section on Falls Risk (Agarwal, 2023; Randhawa & Varghese, 2023; Ward & Reuben, 2022). Table 4 outlines the scoring for the Katz Index for ADLs.

Table 4

Katz Index of Independence in ADLs

ADL	Independence (1 Point for Each)	Dependence (0 Points for Each)
Bathing	The patient bathes themselves completely or needs help with one area of the body (genital area, back, disabled extremity).	The patient needs help bathing two or more parts of the body or total care; needs help getting in or out of the shower or tub.
Dressing	The patient is able to get clothes from closets or drawers and put them on independently, including fasteners; they may have help tying shoes.	The patient needs help dressing themselves or needs to be dressed.
Toileting	The patient is able to go to the toilet, get on and off, arrange clothes, and clean the genital area themselves.	The patient needs help to transfer to the toilet and to clean themselves or use a bedpan or commode.
Transferring	The patient is able to get in and out of the bed or chair unassisted. Mechanical transfer aides are acceptable.	The patient needs help to transfer in and out of the bed or chair or requires a complete transfer.
Continence	The patient is able to maintain complete control over urination and defecation.	The patient is partially or totally incontinent of bowel and bladder.
Feeding	The patient is able to get food from the plate to their mouth independently. Another person may prepare the food.	The patient needs partial or total help with feeding or requires parenteral feeding.

(Katz et al., 1970; Ward & Reuben, 2022)

 

Frailty

Frailty in older adults is defined by weight loss, malnutrition, and inactivity. Older adults with frailty experience physiological decline that places them at an increased risk of adverse outcomes, an increased symptoms burden such as fatigue and weakness, medical complexity, and reduced tolerance to medical and surgical interventions. Frailty prevalence estimates vary between 4% and 16% of community-dwelling adults over 65 and up to 43% for older adults with cancer. Pre-frailty is estimated at 28% to 44% in adults over 65. Although older age is a risk factor for frailty, it does not define frailty. Risk factors for frailty in the U.S. patient population include lower educational level, smoking, hormone replacement therapy, African American or Hispanic American ethnicity, unmarried status, depression or the administration of antidepressants, and intellectual disability. Female patients and those with lower incomes, more comorbidities, and poorer overall health also have an increased risk. Frailty is a significant predictor of hip fractures, disability, and hospitalization and is also a precursor to many other geriatric syndromes, including falls, delirium, and incontinence (Agarwal, 2023a; Poursalehi et al., 2023; Voelker, 2018; Walston, 2023; Ward & Reuben, 2022).

The pathophysiology of frailty may be related to the dysregulation of the patient's stress response system, which typically involves endocrine, immune, and metabolic dysfunction. Some age-related changes that are associated with frailty include decreased hormone production (growth hormone, insulin-like growth factor, dehydroepiandrosterone sulfate, reproductive hormones, and vitamin D), increased cortisol levels, increased inflammatory markers (interleukin 6 and C-reactive protein [CRP]), altered glucose metabolism, dysregulation of the autonomic nervous system, and changes in the renin-angiotensin system and cellular mitochondria. Frailty may be diagnosed or assessed using either of two methods: A physical or phenotypic approach is designed to capture signs and symptoms indicative of vulnerability to poor outcomes, while a deficit accumulation or index method identifies cumulative comorbidities and illnesses. Although a patient's age, comorbidities, and disability are typically associated with frailty, these components should not be used to diagnose the syndrome (Voelker, 2018; Walston, 2020). Dozens of frailty measurement tools have been developed for use, but there is no gold standard. The Cardiovascular Health Study provided some diagnostic criteria for frailty, entitled the Fried Frailty Tool or Frailty Phenotype. This tool is validated to assess physical frailty and is the most frequently cited, although it is somewhat difficult to utilize in a clinical setting. This phenotype is identified in patients meeting at least three of the following five characteristics.

• weight loss (at least 5% of body weight within a year)
• exhaustion (based on the patient's report regarding effort required for activity)
• weakness (may be based on decreased grip strength)
• slow gait speed (more than 6 seconds to ambulate 15 feet or 4.6 m)
• reduced physical activity (under 270 kcal expended/week for females, 383 for males; Agarwal, 2023; Walston, 2023)

A deficit accumulation or index approach to diagnosing frailty involves the patient's account of their current medical and functional status or history to identify their illnesses, functional and cognitive decline, and social factors. These elements are combined to establish the patient's frailty score. The most common rationale for utilizing this method over the physical frailty approach is that the patient's cognitive decline is considered a factor. This is vital, as frailty is associated with an increased risk of cognitive decline, and cognitive decline increases a patient's risk of adverse outcomes. This tool requires answering 20 or more medical and functional questions, and the information can be obtained from the medical record (Walston, 2023).

Several rapid screening tools for frailty are often used to identify older adult patients at increased risk and qualification for a formal CGA. These tools allow HCPs to quickly identify vulnerable older adults so that care plans can be adjusted based on the identified needs. The CFS is an example, as previously described. The FRAIL scale can be completed quickly (in a few minutes) during a patient's history. It includes asking the patient about the following.

• Fatigue: Have you felt fatigued most or all the time in the last month?
• Resistance: Do you have difficulty climbing a flight of stairs?
• Ambulation: Do you have difficulty walking a block?
• Illnesses: Do you have any chronic medical conditions, such as DM, cancer, hypertension, chronic lung disease, heart disease or heart failure, angina, asthma, kidney disease, or a history of stroke or heart attack?
• Loss of weight: Have you lost more than 5% of your body weight in the last year without trying? (Walston, 2023)

Each question is answered with yes or no, with 1 point assigned for each affirmative answer. A score of 0 represents a robust patient, 3 to 5 represents a frail patient, and some categorize a score of 1 or 2 as pre-frail. The Study of Osteoporotic Fractures frailty tool assesses for unintentional weight loss (5% of body weight in the last year), the ability to stand from a seated position in a chair five times without using the arms, and whether the patient feels "full of energy." A positive screening indicating the need for further evaluation is defined as meeting two of the three components. The Edmonson scale uses a series of 14 questions to assess a patient's general health, function, cognition, social support, and nutrition (Walston, 2020).

If frailty is suspected, the patient history should include a detailed account of their energy level, including their reports of fatigue. Caregiver observations regarding their ability to function should also be included, with specific accounts of their ability to maintain activity such as climbing a flight of stairs or walking a block without needing to stop and rest. The patient's exam should include asking them to stand up five times from a seated position without using the arms for support. The provider should note how the patient walks down the hall and within the exam room to assess ambulation (Walston, 2023).

Any physical assessment of an older adult should include height, weight, BMI, and notation of any recent changes (in the last year) and whether these changes were intentional. Malnutrition in an older adult patient may initiate a cycle of frailty, leading to a decrease in lean muscle mass, which reduces strength, aerobic capacity, gait speed, and activity level, resulting in functional decline and progressive frailty. Although weight loss is central to the frailty phenotype, patients with poor nutrition who satisfy at least three of the remaining four characteristics may still be diagnosed as frail. This is especially important for frail older adults with obesity who may not exhibit the weight loss expected. As mentioned earlier, the assessment of recent weight changes is a common (although not required) component of a CGA. Causes of weight loss should be explored, including inadequate intake (adverse medication effects, socioeconomic factors, poor oral health, xerostomia [dry mouth]) or increased energy expenditure (increased activity, medical conditions) (Agarwal, 2023). The mnemonic MEALS ON WHEELS summarizes some of the common causes of malnutrition and unintentional weight loss in adults.

• Medications (antiepileptic drugs [AEDs], digoxin [Lanoxin], anticholinergics, angiotensin-converting enzyme inhibitors, antibiotics, chemotherapeutic agents)
• Emotional problems (mood disorders such as depression or anxiety)
• Anorexia (loss of appetite, anorexia nervosa or tardive)
• Late-life paranoia or alcoholism
• Swallowing disorders (odynophagia [painful swallowing], dysphagia [difficulty swallowing])
• Oral factors (dental carries/abscess, ill-fitting dentures, xerostomia)
• No money (economic hardship, food deserts, lack of transportation to obtain food)
• Wandering (such as in dementia patients)
• Hyperthyroidism or hyperparathyroidism
• Entry problems/malabsorption
• Eating problems (upper extremity or jaw weakness due to stroke, tremor)
• Low-salt or low-cholesterol diet
• Shopping and food preparation problems (food deserts, lack of transportation to obtain food) (Agarwal, 2023a; Ritchie & Yukawa, 2023)

Multiple medical conditions can also contribute to weight loss, such as malignancy (the most common); GI conditions (peptic ulcer disease, chronic pancreatitis, inflammatory bowel disease); cardiac conditions (heart failure, coronary artery disease); pulmonary conditions (chronic obstructive pulmonary disease, interstitial lung disease); infectious conditions (tuberculosis [TB], bacterial endocarditis); neurologic conditions (stroke, dementia, Parkinson's disease); endocrine disorders (DM, thyroid dysfunction); renal conditions (uremia, nephrotic syndrome); psychiatric conditions (depression, alcohol use disorder); or rheumatic conditions (polymyalgia rheumatica). Malnutrition and weight loss can indicate a deficiency in thiamine, vitamin B₁₂, vitamin C, or zinc (Agarwal, 2023; Ritchie & Yukawa, 2023). In addition, differential diagnoses to consider when evaluating a patient at risk for frailty should include other conditions that may lead to unintentional weight loss; functional decline; fatigue; and weakness, such as vasculitis; hypertension; peripheral vascular disease; chronic kidney disease, anemia; and vascular dementia (Walston, 2023).

A comprehensive history of weight loss should include access to food; the number, size, and content of daily meals; assistance required for grocery shopping, meal preparation, or eating; difficulty with chewing; and any associated symptoms of anorexia, early satiety, or dysphagia. A validated tool can help identify anorexia, malnutrition, or risk for malnutrition, such as the Simplified Nutritional Assessment Questionnaire or the Mini-Nutritional Assessment. The physical examination should include an assessment of the oral cavity. Laboratory testing should be done to evaluate for treatable conditions, including a complete blood count (CBC), basic metabolic profile (BMP), liver function tests (including albumin), vitamin B₁₂, vitamin D, and TSH. Additionally, a consultation with an SLP or dietitian can further ascertain the underlying etiology of unintentional weight loss and inform an appropriate treatment plan to address the identified issues (Agarwal, 2023).

 

FTT

Frailty exists on a spectrum, with the end stage of frailty on the continuum often considered to be FTT. FTT may result from three components: physical frailty, disability (difficulty or dependency in completing ADLs), and impaired neuropsychiatric function (delirium, depression, and dementia). The prevalence of FTT in community-dwelling adults is 5% to 35% and 25% to 40% in adults living in a skilled nursing facility (SNF). Many factors increase the risk of FTT. The mnemonic 11 D's of "The Dwindles" outlines many of the precipitators of FTT: disease (medical illness); dementia; delirium; drinking alcohol or other substance misuse; drugs; dysphagia; deafness, blindness, or other sensory deficits; depression; desertion by family, friends (social isolation); destitution (poverty); and despair (giving up). A comprehensive history should be used to identify potential medical or psychiatric comorbidities or prescription medications contributing to FTT. A review of systems should be completed to elucidate when and how symptoms initially emerged and changed with time. Systemic immune symptoms (fever, chills, pain, sweating) may indicate a chronic infectious process, such as TB, bronchiectasis, or endocarditis. A patient's decline in vision or hearing may contribute to inactivity and functional decline, so essential vision and hearing screens should be completed to rule out either of these conditions as a contributing factor. A brief physical exam should be used to identify any orthopedic or rheumatologic concerns leading to inactivity, such as arthritis, polymyalgia rheumatica, or podiatric conditions. Feeding difficulties and other causes of malnutrition, as outlined above, should be reviewed and eliminated or addressed as appropriate (Agarwal, 2023; Ali, 2020; Walston, 2023). Laboratory testing for patients with FTT should include the following.

• CBC with differential
• BMP
• Liver function studies, including albumin
• Urinalysis
• Serum calcium and phosphate
• TSH
• Vitamin B₁₂ and folate level
• Total cholesterol
• 25-hydroxyvitamin D (Agarwal, 2023; Walston, 2023)

Additional laboratory studies or diagnostic imaging may also be indicated, such as erythrocyte sedimentation rate, CRP, blood cultures, and a chest radiograph to rule out infection or other imaging studies if malignancy is suspected (Agarwal, 2023).

As previously mentioned, the components of FTT typically include neuropsychiatric impairment and are often accompanied by symptoms of depression. This impairment facilitates the worsening of malnutrition, disability, and frailty. Delirium, dementia, and depression are the most likely etiologies for cognitive decline in older adults, which can also be due to underlying medical conditions or adverse effects of medication (anticholinergics). Delirium can be defined as an acute deterioration in cognitive function and attention. Risk factors for delirium include dementia, sensory impairment, severe illness, depression, hypovolemia (volume depletion), and medical comorbidities. Delirium makes the CGA process more challenging, especially when assessing mood (for depression and other mood disorders) and cognition (for dementia). During mental status or cognitive screening, insufficient attention from the patient should prompt the health care team to consider possible delirium. Mood disorders, such as depression, may cause disability, malnutrition, weight loss, frailty, and FTT. Depression increases mortality risk in older adults, with an incidence rate of 5% (in community-dwelling older adults) to 25% (in the LTC population). Before establishing a treatment plan for a patient with frailty or FTT, the patient and their caregiver(s) should engage in an extensive conversation to clarify their goals of care. The treatment plan should be based on the patient's priorities. In this context, a thorough CGA can efficiently and effectively guide an older adult's care via shared decision-making and clear goals. For example, pain management may be a key focus in the care plan for many patients diagnosed with frailty or FTT (Agarwal, 2023; The American Geriatric Society [AGS] Beers Criteria Update Expert Panel, 2023). The screening process for dementia is discussed in greater detail in the forthcoming Cognition section of this activity, while depression screening is discussed in the upcoming Mood section.

All patients with FTT should undergo a thorough medication review to assess for and address polypharmacy. If a medication with the potential for adverse effects is identified, the situation should be discussed with the patient, including the risks and benefits of continuing the medication, alternatives for replacing the medication, or the process of deprescribing the medication. If a medication is replaced or deprescribed, the patient should be monitored closely for signs or symptoms of withdrawal in the short term, as well as improvement in FTT symptoms after the medication has been stopped. Medications commonly associated with FTT include AEDs, benzodiazepines, beta-blockers, central alpha agonists, diuretics, glucocorticoids, opioids, and SSRIs, as well as taking more than four prescription medications. Please see the NursingCE course Polypharmacy and Prescribing for additional details regarding prescribing and deprescribing medications safely for older adult patients (Agarwal, 2023; Ali, 2020).

 

Fall Risk

A fall is an event when an individual inadvertently drops to the ground, typically caused by acute disorders (seizure, stroke) or environmental hazards (tripping or being struck by a moving object). Falls are the leading cause of injury-related deaths in adults over 65. Each year, over 14 million (1 in 4) older adults (over 65) report falling, with 37% of those falls resulting in an injury that requires medical treatment. The CDC reports that approximately 3 million older adults are seen in EDs each year, resulting in 800,000 hospitalizations, most related to head injuries and hip fractures. Falls can cost approximately $50 billion annually in medical costs. In addition, falls can threaten the independence of older adults, and many will not report a fall for fear of being placed in an LTC facility. HCPs must be diligent about screening for falls because the history of a fall doubles the risk of a future fall (CDC, 2023a; Ward & Reuben, 2022).

The first step in assessing risk is a simple history of falls in the last year. Patients with inadequate balance/gait disturbance or a history of falls have an increased risk for future falls, thereby risking their independence. Most falls are multifactorial in etiology, with a complex interaction of intrinsic (age-related, functional decline, adverse medication reactions), extrinsic (environmental hazards), and situational factors (hurrying to the bathroom or being distracted) contributing to the risk. Intrinsic factors include instability, unsteady gait, visual disturbances (acuity, depth perception), sensory loss, and muscle weakness. Other risk factors include cognitive impairment, arthritis, stroke history, orthostatic hypotension, dizziness, and anemia. Of these, gait or balance disturbance was the most consistent risk factor across numerous studies, followed by medications. Falls associated with syncope or that occur in patients with a prior history of a fall with injury or who present with decreased executive functioning indicate an increased risk of significant harm. Cognitive impairment and depression affect the brain's executive functioning, including high-level balance and gait coordination. Since many people wrongly assume that falls are an inevitable component of aging, falls frequently go unreported if the patient is not asked directly and if there is no significant associated injury. Often, HCPs who care for a patient following a fall focus solely on addressing the related injuries rather than the underlying causes of the fall (Frith et al., 2019; Kiel, 2023a, 2023b).

Polypharmacy increases the risk of falls and should be carefully considered before prescribing a new medication or during the assessment to prevent or complete a workup after a fall (Saljoughian, 2019). Medications that are consistently correlated with patient falls include central nervous system (CNS) active drugs such as neuroleptics, benzodiazepines, and antidepressants, as well as vasodilators for hypertension or heart rate control (Kiel, 2020). The AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults—generally known as The BC—was last updated in 2023. This list includes the following medications that should be avoided for older patients at risk of falls: serotonin-norepinephrine reuptake inhibitors (which were newly added since the 2015 list was released); SSRIs, tricyclic antidepressants (TCAs); AEDs; antipsychotics; benzodiazepines; nonbenzodiazepine receptor agonist hypnotics (Z drugs, such as zolpidem [Ambien], zaleplon [Sonata], and eszopiclone [Lunesta]); and opioids, specifically mu-opioid receptor agonists (AGS BC Update Expert Panel, 2023). Alcohol use increases the risk of falls among patients over age 65, as does going barefoot or wearing shoes with an elevated heel; the use of footwear with a thin, hard sole or minimal heel height appears to reduce the risk of falls, although the research on footwear is minimal and can be conflicting. Patients should be instructed to remove any obvious home hazards, such as loose throw rugs, to reduce the risk of falls. However, research regarding the effectiveness of this type of intervention is lacking (Kiel, 2023a, 2023b).

The recommendations regarding assessments for fall risk are based on those endorsed by the AGS, the American Academy of Orthopedic Surgeons, and the British Geriatrics Society. Patients over 65 should be asked at least once a year about falls or difficulties with balance or gait. Those who report a single fall should undergo a gait and balance evaluation during the physical exam using a validated test, such as the Tinetti Performance Oriented Mobility Assessment (POMA) tool or the Get Up and Go test. The POMA tool takes 10 to 15 minutes to administer and produces a score ranging from 0 to 28 based on nine balance tests and seven gait tests. A score of 25 or higher indicates a low fall risk, while a score under 19 indicates a high fall risk. The Get Up and Go test added a timed component and was then referred to as the Timed Up and Go test or TUG. The scale ranges from 1 (regular, well-coordinated movements and no walking aid) to 5 (severely abnormal, as evidenced by the need for standby physical support). The patient should be seated in an armchair of standard height to begin the test. They are instructed to stand (without using the chair arms if possible), walk forward 10 feet (3 meters), turn around, return to the chair, turn around again, and be seated. The examiner is instructed to note the patient's sitting balance, ability to transfer and turn or pivot, and pace and stability of walking. The timed test should begin upon standing, end with re-seating, and be compared to results from an age-adjusted cohort, as listed in Table 5 (Kiel, 2023a, 2023b).

Table 5

TUG Reference Values

Age (years)	Mean Time (95% CI)
60 to 69	8.1 (7.1 to 9.0) seconds
70 to 79	9.2 (8.2 to 10.2) seconds
80 to 99	11.3 (10 to 12.7) seconds

(Bohannon, 2006; Kiel, 2023a)

A patient with a TUG test time of greater than 20 seconds may not be physically safe to transfer or leave the house independently. Additional options available to assess musculoskeletal function quickly in an older patient include the functional reach test, the Short Physical Performance Battery (SPPB), or the Berg Balance Test. The functional reach test involves a patient standing with both feet planted and their shoulders perpendicular to a mounted yardstick at the level of the acromion. The patient is instructed to reach with a closed fist as far forward as possible without taking a step or losing their balance, measuring their total reach with the yardstick. Patients who have a reach below 6 inches (15 cm) indicate an increased risk of falls. The SPPB captures a wide range of functional abilities, asking the patient to perform tandem, semi-tandem, and side-by-side stands; a 13-foot (4-meter) timed walking test; and raises from a chair five times. Components are predictive of falls, and scores below 9 indicate disability in ADLs and mobility within 1 to 6 years. The Berg Balance test is easy to administer and common in rehabilitation, inpatient, and outpatient settings and predicted the risk of multiple falls in patients over 65 in a study (Agarwal, 2023; Kiel, 2023a, 2023b).

Those who report multiple falls, describe gait or balance difficulties (either by report or as evidenced by the brief evaluation described above) or seek care due to injuries suffered during a fall should undergo a multifactorial fall risk assessment. This evaluation should include reviewing the patient's medical history, including their current medications, history of falls, footwear use, and environmental hazards. The patient's activity at the time of their fall, any prodromal symptoms, and when and where the fall occurred are essential aspects of a fall history. Dizziness or loss of consciousness may indicate orthostatic hypotension, cardiac disease, or neurological disease. The physical exam should include a cognitive and functional assessment, including gait, balance, and mobility screenings; vision and hearing screening; assessment for cognitive, sensory, or neurological impairment; muscle strength and foot assessment; and cardiac screening to determine rate/rhythm and postural hypotension. A validated tool, such as the Downtown Fall Risk Index, can establish fall risk for patients within various health facility settings but has not been standardized for non-health facility settings (Kiel, 2023a, 2023b).

Basic laboratory testing (hemoglobin, serum urea nitrogen, creatinine, glucose, and vitamin D) may help identify patients with dehydration, anemia, or autonomic neuropathy related to DM. Additional physical exam components should include the following.

• Postural vital signs (to assess for postural hypotension)
• A visual acuity screening using a snellen chart
• An auditory acuity test, such as the whisper test or a hand-held audiometer (vii cranial nerve deficits can lead to vestibular dysfunction)
• An inspection of the extremities for foot or joint deformities (bunions, callouses, or arthritic joint deformities)
• A neurological examination to assess lower extremity strength, sensation, gait, and postural stability (sensory neuropathies and lower extremity weakness increase the risk of falls; Kiel, 2023a, 2023b)

Imaging studies (brain or spine imaging, echocardiography) or cardiovascular diagnostics (rate/rhythm monitoring via a Holter or similar wearable monitor) should be recommended on a case-by-case basis concerning findings obtained during the history and physical exam. They are not performed routinely for all patients with a fall history. An echocardiogram may be reasonable for a patient with an audible murmur. At the same time, a spine or brain magnetic resonance image (MRI) may be appropriate for a patient with gait and neurological abnormalities, lower extremity spasticity, or reflex abnormalities (Kiel, 2023a, 2023b).

 

Cognition

The incidence of dementia increases with age, especially after the age of 85. Early diagnosis is critical, allowing treatable conditions to be addressed and initiating advance care planning while the patient can participate. However, many patients with cognitive impairment remain undiagnosed. A thorough history with a brief cognitive screening serves as an adequate cognitive evaluation for an older patient. A 2020 systematic review by Hemmy and colleagues aimed to establish the sensitivity and specificity of several common cognitive screens, as listed in Table 6. While the evidence was limited, they confirmed that the available screens were highly sensitive and specific for distinguishing dementia from normal cognition. However, the screens' accuracy was diminished when distinguishing mild dementia from normal cognition and dementia from mild cognitive impairment. The group found that existing studies were small in scale, and direct comparisons were lacking (Hemmy et al., 2020; Ward & Reuben, 2022).

Table 6

Sensitivity and Specificity of Common Brief Cognitive Screens

Test Evaluated	Sensitivity	Specificity	Based On  (# of studies)
Standalone Tests
Montreal Cognitive Assessment	0.94	0.94	2
Brief Alzheimer Screen	0.92	0.97	1
MMSE	0.88	0.94	7
Clock-Drawing Test	0.79	0.88	8
Language Tests
Category Fluency	0.92	0.89	9
Memory Tests
List Delayed Recall	0.89	0.94	5

(Hemmy et al., 2020)

Positive screening should prompt additional evaluation. Medical conditions that may be treatable should be ruled out, including vitamin B₁₂ deficiency, thyroid dysfunction, depression, and numerous brain or neurological disorders. If indicated, detailed neuropsychological testing should be completed by a licensed neuropsychologist or clinical psychologist. Imaging studies (MRI or computed tomography scan) and referral to a neurologist or gerontologist should also be considered (Ward & Reuben, 2022). For additional information regarding the assessment, diagnosis, and treatment of dementia, please refer to the NursingCE course on Alzheimer's Disease: Diagnosis, Treatment, and Research.

Most patients with dementia exhibit a slow and steady cognitive decline over months with intact attention and remote memory despite impaired short-term memory, judgment, confusion, and disorientation. Patients with dementia may experience paranoia and hallucinations, although these events are rare. In contrast, cognitive impairment associated with attention deficit that develops over hours or days may indicate delirium, which can be difficult to distinguish from dementia. Delirium is an acute confusional state characterized by an altered level of consciousness with a reduced ability to focus, sustain, or shift attention, resulting in cognitive and perceptual disturbances not associated with pre-existing dementia. A key feature that defines delirium is the high likelihood that the acute cognitive change is related to a medical condition, medication, substance use, or withdrawal. It typically persists for days but may last for months if the underlying cause is not correctly identified and treated quickly. Symptoms often worsen throughout the day, peaking in the evening. In older patients who are acutely ill, cognitive and behavioral changes may be the only noticeable symptom of their underlying illness. Psychomotor disturbances (hypoactivity or hyperactivity), sleep disturbances, emotional disturbances, hallucinations, and delusions often accompany delirium. Individuals with underlying brain disorders (dementia, Parkinson's disease, or stroke) are at increased risk for delirium. Other risk factors include age and sensory impairment. Patients initially may appear easily distracted and, in more advanced cases, present as lethargic, drowsy, or nearly comatose. They often exhibit memory loss, disorientation, and speech or language abnormalities (Francis, 2019; Francis & Young, 2022).

Delirium can occur at any age but is most common after 70. An estimated 10% of older adults are admitted to the hospital with delirium, and an additional 15% to 50% will experience delirium at some point during hospitalization. Delirium is a common postoperative complication among older adults. Research estimates that 10% to 20% of older adults undergoing major elective surgery and 50% undergoing high-risk procedures will experience delirium postoperatively due to various factors, including anesthesia and pain medications. Postoperative delirium can increase a patient's hospital length of stay by 2 to 3 days and is associated with a 7% to 10% increase in 30-day mortality. Since delirium can occur during any illness or surgery, it can be challenging for HCPs to recognize and manage it effectively, leading to complications and poor outcomes. Health care costs attributable to delirium are estimated to be $164 billion annually. The clinical presentation of delirium can vary significantly, with three identified subclasses: hyperactive, hypoactive, and mixed motor. Patients with hyperactive delirium will have more spontaneous movements that are purposeless, uncontrollable, and inefficient. These patients may appear agitated, restless, and anxious and are more likely to exhibit psychotic features (hallucinations) that interfere with the delivery of care, including attempting to remove external devices (drains, IV lines, face masks). In contrast, patients with hypoactive delirium will have slowed mentation, withdrawn attitude, lethargy, and decreased movements. The mixed motor subtype of delirium is characterized by fluctuations between hypoactive and hyperactive states (Ali & Cascella, 2022; Huang, 2023).

Delirium is a clinical manifestation of stress that impacts the CNS function in a vulnerable patient. There are numerous potential pathophysiological causes of delirium, with each patient likely experiencing one or more interconnected and complex processes. Medications can be a significant precipitating factor, and older adults are particularly vulnerable to the effects of these medications and the risk of delirium (Ali & Cascella, 2022; Francis, 2019; Francis & Young, 2022; Huang, 2023). Medications that are more likely to cause delirium include:

• new medications or three or more medications
• recent or prolonged exposure to anesthesia
• anticholinergics (diphenhydramine [Benadryl], benztropine [Cogentin], scopolamine [Maldemar], atropine)
• opioids
• NSAIDs
• benzodiazepines (midazolam [Versed], lorazepam [Ativan])
• non-BZRA or Z-drugs (zolpidem [Ambien], zaleplon [Sonata], and eszopiclone [Lunesta])
• neuromuscular blockades
• dopamine agonists (amantadine [Symmetrel], levodopa, pramipexole [Mirapex])
• hypoglycemics
• skeletal muscle relaxants (cyclobenzaprine [Flexeril], baclofen [Lioresal])
• GI agents (antiemetics, antispasmodics, histamine 2 receptor blockers, loperamide [Imodium])
• antihistamines (promethazine [Phenergan])
• antibiotics (aminoglycosides, cephalosporins, fluoroquinolones, Linezolid [Zyvox], macrolides, penicillins, sulfonamides, cycloserine [Seromycin], isoniazid [Nydrazid], metronidazole [Flagyl], rifampin [Rifadin])
• antivirals (acyclovir [Zovirax])
• AEDs (carbamazepine [Tegretol], levetiracetam [Keppra], phenytoin [Dilantin], valproate [Depakote], vigabatrin [Vigadrone])
• antidepressants (mirtazapine [Remeron], SSRIs, TCAs)
• antipsychotics
• cardiovascular and hypertensive drugs (antiarrhythmics, beta-blockers, clonidine [Catapres], digoxin [Lanoxin], diuretics, methyldopa [Aldomet])
• corticosteroids (Ali & Cascella, 2022; AGS BC Update Expert Panel, 2023; Francis, 2019; Francis & Young, 2022; Huang, 2023)

For additional information on the diagnosis and management of delirium, please refer to the NursingCE course on Management of Common Geriatric Syndromes.

 

Mood Disorders

Depression often affects older adults (with a prevalence of 2% to 10% in community-dwelling older adults) but is not a normal part of aging. Sadness, stress, and grief are expected reactions to some of the common life events that occur after the age of 65, such as experiencing the departure of grown children; selling a home to downsize; retiring; losing family members and loved ones; declining social, cognitive, or physical functioning due to age or illness; and decreasing independence due to disability. The prevalence of depression increases with comorbid medical conditions and within health care settings, climbing as high as 50% in SNF residents. Risk factors for late-life depression include female sex, social isolation, previously married status (separated, divorced, or widowed), lower socioeconomic status, comorbid medical conditions, chronic pain, insomnia, functional impairment, and cognitive impairment (Espinoza & Unutzer, 2023; Halverson, 2023a).

Depression in older adults increases suffering, impairs functional status, increases mortality risk, and increases the consumption of health care resources. Depression in older adults may involve atypical symptoms, leading to underdiagnosis and undertreatment. Cognitive impairment can complicate the assessment of a mood disorder. A simple screening (see Table 7) improves the diagnostic process and should be easy to administer. The Two-Question Screener asks the patient if they have been bothered by feeling down, depressed, or hopeless or noticed a lack of interest or pleasure in doing things they previously enjoyed in the last month (anhedonia; Ward & Reuben, 2022). Older adults with depression may present with a lack of response to standard medical treatment for an unrelated condition, poor motivation to participate in their medical care, somatic symptoms that are more severe than expected, or decreased engagement with the health care team. For those older than 85, a dysphoric mood is a less reliable indicator of depression (Espinoza & Unutzer, 2023).

Table 7

Depression Screens for Older Adults

	Number of Items	Sensitivity	Specificity
Two-Question Screener	2	0.97	0.67
Patient Health Questionnaire-2 (PHQ-2)	2	1.0	0.77
Geriatric Depression Scale (GDS)	5	0.97	0.85
Patient Health Questionnaire-9 (PHQ-9)	9	0.88	0.88
Cornell Scale for Depression in Dementia	19	0.90	0.75
Center for Epidemiologic Studies Depression Scale	20	0.93	0.73

(Espinoza & Unutzer, 2023; Ward & Reuben, 2022)

The Two-Question Screener and PHQ-2 are nearly identical, except that the Screener refers to a duration of 1 month, while the PHQ-2 refers to the last 2 weeks. If both of the questions in the PHQ-2 are answered affirmatively by the patient, the remaining seven questions that make up the PHQ-9 can be completed to improve the screen's specificity. See Table 8 for the PHQ-9 screening components. Ranges of depression scores include 5 to 9 (mild), 10 to 14 (moderate), 15 to 19 (moderately severe), and 20 or greater (severe) (Espinoza & Unutzer, 2023; Ward & Reuben, 2022).

Table 8

PHQ-9 Depression Questionnaire

Over the last 2 weeks, how often have you been bothered by any of the following problems?	Not at all	Several days	More than half the days	Nearly every day
Little interest or pleasure in doing things	0	1	2	3
Feeling down, depressed, or hopeless	0	1	2	3
Trouble falling asleep, staying asleep, or sleeping too much	0	1	2	3
Feeling tired or having little energy	0	1	2	3
Poor appetite or overeating	0	1	2	3
Feeling bad about yourself, or that you are a failure, or have let your family down	0	1	2	3
Trouble concentrating on things (reading the newspaper or watching television)	0	1	2	3
Moving or speaking so slowly that other people could have noticed, or being so fidgety or restless that you have been moving around a lot more than usual	0	1	2	3
Thoughts that you would be better off dead or hurting yourself in some way	0	1	2	3

(Espinoza & Unutzer, 2023, Table 5)

The GDS is specifically designed for use in older adults. This five-item self-report instrument has been studied in several different settings. Two out of five depressive responses ("no" to question 1 or "yes" to questions 2 to 5) suggest a depression diagnosis. The questions include (Espinoza & Unutzer, 2023; Ward & Reuben, 2022):

• Are you basically satisfied with life?
• Do you often get bored?
• Do you often feel helpless?
• Do you prefer staying at home rather than going out and doing new things?
• Do you feel pretty worthless the way you are now?

The Cornell Scale is the only instrument validated for cognitively impaired patients. It includes direct responses from the patient as well as observer data. The Center for Epidemiologic Studies Depression Scale is commonly utilized in primary care and community studies (Espinoza & Unutzer, 2023; Ward & Reuben, 2022).

Major depressive disorder (MDD) is defined by the presence of at least one major depressive episode (MDE) in an individual with no history of mania or hypomania. Based on high-quality evidence, the American Psychiatric Association (APA, 2022) strongly recommends that clinicians use the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) criteria to determine a diagnosis of MDD, MDE, and other specified or unspecified depressive disorders. The DSM-5-TR outlines the required diagnostic criteria for a diagnosis of MDD, as summarized in Table 9. Of note, criteria A through C represent an MDE. These symptoms must be new for the individual or worsening of an existing symptom and must be present over 2 weeks. A diagnosis requires a thorough interview, as individuals often circumvent direct questioning when discussing their mood. For other patients, symptoms of MDD can present as a physical manifestation (such as pain). Other patients may report feelings of agitation or anger instead of sadness. A diagnosis can be complicated if the individual has a concurrent disease that can produce similar symptoms (cancer, diabetes, or pregnancy) (APA, 2022).

 

Table 9

DSM-5-TR Diagnostic Criteria for Major Depressive Disorder*

Criterion A  (at least five signs are required over at least 14 days)	The presence of either (a) lack of interest/enjoyment or (b) depressed mood, in addition to the following. significantly reduced interest or enjoyment in most activities for the majority of the day, practically every day, self-reported or observed poor or sad mood for the majority of the day most days; may be based on tearfulness observed by others or self-reports of unhappiness, unfulfillment, or despondency psychomotor excitement or delay most days; must be obvious to others, not solely a self-report of symptoms reduced mental clarity, focus, or decision-making almost every day feelings of insignificance or extreme, unwarranted guilt most days; may be unrealistic substantial (at least 5% of total body weight) unintentional decrease or increase in weight in a month inability to sleep at night or stay awake during the day despite getting an adequate amount of sleep the night before most days feeling lethargic, weary, or exhausted most days preoccupation with death, consistent suicidal ideations with or without a specific plan, or an attempted suicide
Criterion B	The symptoms create substantial anguish or dysfunction in essential settings, such as work, school, or around friends/family.
Criterion C	The symptoms are unrelated to the effects of a physical illness or substance use.
Criterion D	The symptoms are not more accurately attributed to another mental health diagnosis.
Criterion E	There is no history of a period of manic or hypomanic symptoms (unrelated to substance use or another physical illness).

(APA, 2022)

*This is an interpretive representation of the diagnostic criteria detailed in the DSM-5-TR; the provider should reference the diagnostic guidelines listed in the DSM-5-TR to make an actual diagnosis.

Grief, which is also common among older adults, can be difficult to distinguish from MDD or MDE. Feelings of emptiness and loss characterize grief, and dysphoria occurs in varying intensity (associated with reminders of the departed) but typically decreases over time. These "waves" or "pangs" of grief are interspersed by periods of humor or positive emotions. Thoughts tend to focus on the deceased and joining them, but suicidal ideations are uncommon. While guilt is common regarding actions or lack of actions regarding the deceased, self-esteem is preserved. By contrast, dysphoria in MDE is consistent, and thoughts are largely self-critical and pessimistic. Feelings of worthlessness and thoughts of suicide are common (APA, 2022). For additional information regarding the diagnosis and management of depression in older adults, please refer to the NursingCE courses on Depression and Management of Common Geriatric Syndromes. For additional information regarding suicide, please refer to the NursingCE course on Suicide Prevention.

 

Social and Financial Resources

A brief social history can establish available resources for older adults if they become ill or injured and require additional assistance in the future. A lack of social support often becomes a determining factor in living arrangements and the necessary level of care for older individuals as they develop numerous medical comorbidities and require an increasing level of assistance. Preemptive screening can allow additional time for planning and resource referral. An essential physical examination to identify suspicious injuries (contusions, burns, bite marks, pressure injuries, or malnutrition) can flag potential cases of physical abuse or neglect. Other than unexplained injuries, red flags indicating abuse include substance use disorder (SUD) in a caregiver, limited social support, observed changes in patient behavior when in the presence of the caregiver, or poor adherence with filling and administering prescribed medications. As with all cases of potential abuse or neglect, the patient should be asked objective, open-ended, and nonjudgmental questions in a private setting, not in front of the caregiver in question. In some states/jurisdictions, HCPs are mandated to report any suspicion of abuse in older adults, but specific regulations vary (Agarwal, 2023; Ward & Reuben, 2022).

Self-neglect among older adults is defined as the "refusal or failure to provide oneself with care and protection in areas of food, water, clothing, hygiene, medication, living environments, and safety precautions" (Dong, 2017). Self-neglect can compromise an older adult's well-being, and in the U.S., self-neglect is determined to be the underlying cause for roughly 40% of neglect cases reported to Adult Protective Services. Prevalence is difficult to estimate due to a paucity of research on the topic and variable operational definitions and measurement methods. The Chicago Health and Aging Project found a self-neglect prevalence of 21% among Black participants and only 5.3% among White participants across 5,519 total study participants. While the 2010 Elder Justice Act defines self-neglect as "the inability, due to physical or mental impairment or diminished capacity, to perform essential self-care," numerous conceptual definitions have been developed since that time, and no universal operational definition exists. Risk factors are equally difficult to define but generally include cognitive impairment (diminished executive or global functioning), physical disability (the presence of multiple chronic conditions, SUD), and psychological distress (depressed mood). Self-neglect also appears to occur more commonly among older adults with limited family or social support and engagement. Self-neglect not only impacts well-being but also increases health care resource utilization and mortality risk. It typically leads to poor adherence to the medical care plan and nutritional deficiencies (Dong, 2017; Kaplan, 2023). For additional information regarding self-neglect in older adults, please refer to the NursingCE course on Management of Common Geriatric Syndromes, Part 2.

If caregivers accompany a patient, they should be screened regularly for burnout and referred to local resources such as respite care, support groups, and counseling. A financial assessment can be crucial in identifying unknown or previously untapped resources for an older patient in need, such as state or local benefits, long-term care insurance, or veteran benefits. The multidisciplinary CGA team should include an LSW who is familiar with available resources and access methods. The LSW should evaluate the patient's current financial situation and assess for additional resources if needed. An LSW can also address social isolation, patient and family education, advanced care planning, and referrals to community or mental health resources (Agarwal, 2020; Ward & Reuben, 2022). For additional information regarding the assessment, diagnosis, and care of victims of abuse, please refer to the NursingCE course on Domestic and Community Violence.

 

Goals of Care

Patients and their families should be central throughout the CGA process; most importantly, they should be allowed to prioritize their outcomes along the way. This health wish list of future achievements or goals often includes regaining a vital skill (such as walking without the aid of a device). A patient's goals are often social (attending a grandchild's graduation or wedding, living at home) or functional (independence with ADLs) and less often directly health-related (to lose 10 pounds, to decrease systolic blood pressure below 140). Goals should be both short- and long-term, as well as personalized. Progress should be monitored regularly to track whether goals have been met or to modify goals if needed. A formal method for establishing and monitoring goals may be used; the Goal Attainment Scale is a free tool that utilizes patient-reported outcomes (Ward & Reuben, 2022). Each patient determines their outcome measures, and their definition of success is agreed upon at the outset. The score is calculated using a 5-point scale for each goal, ranging from +2 (patient achieved much more than expected) to -2 (patient achieved much less than anticipated) (Shirley Ryan Abilitylab, 2020).

 

Advance Care Preferences

To differentiate from discussions regarding goals of care, documenting a patient's advance care preferences involves determining which interventions they find acceptable and who should make future health care decisions for the patient if their health deteriorates and precludes them from making such decisions themselves. These discussions should occur while the patient has the mental faculties needed to participate fully and articulate their wishes. Patients should be asked about specific interventions designed to extend life (feeding tubes, intubation, ventilator support), how their preferences may change if their medical team advises against further aggressive or curative treatments, and how decisions should be made if current caregivers become overwhelmed and cannot care for the patient in their current environment. Formal tools have been developed to assist providers in facilitating discussions about end-of-life care and promote shared decision-making. Due to their extensive skills in this area, an LSW should be recruited to assess and then address advanced-care planning concerns with each patient during the CGA process (Agarwal, 2023; Ward & Reuben, 2022).

 

Polypharmacy

The performance of thorough medication reconciliation and medication review is an essential component of the CGA. Roughly one-half (44% of men and 57% of women) of those over the age of 65 take at least five medications (prescription or over-the-counter) every week. In this same age group, 12% of patients take at least 10 medications. Polypharmacy becomes an issue if it contributes to negative outcomes, such as adverse events, nonadherence, and increased costs. Polypharmacy has been established as an independent risk factor for hip fractures in older adults. Being prescribed various medications by multiple HCPs increases the risk of adverse events and drug-drug interactions for older adult patients. Polypharmacy also leads to therapeutic duplication, unnecessary medications, and poor adherence. Risk factors for polypharmacy include age, education, ethnicity, health status, and access to a pharmacy. The risk of a drug-drug interaction rises as the number of medications increases. A patient taking five to nine different medications has a 50% chance of an interaction, but this probability increases to 100% in a patient taking 20 or more medications. While polypharmacy increases the risk of poor adherence, older adults may also have difficulty with forgetting to take their medications, poor vision, limited financial resources, and limited access to a pharmacy or transportation to a pharmacy, all of which have been shown to reduce medication regimen adherence. Patients may also elect to reduce the dose or stop a medication if they perceive an unpleasant symptom caused by the medication (Nguyen et al., 2020; Rochon, 2023; Saljoughian, 2019; Ward & Reuben, 2022).

For a complete discussion regarding polypharmacy in older adults, including how to address this issue and age-specific prescribing considerations for older adults, please see the Nursing CE course Care Considerations for Older Adults: The Assessment and Management of Polypharmacy.

 

Outcomes

Research has confirmed that the CGA process leads to enhanced detection and documentation of geriatric problems and syndromes. Outcomes such as decreased hospitalization rate, SNF admission, and mortality vary based on the setting and specific CGA model used. Settings that have been studied include home assessments, acute geriatric units, post-hospital discharge, outpatient consultations, and inpatient consultations. A nurse typically leads home geriatric assessment teams that also consist of a physical therapist, LSW, and psychologist who focus on preventative as opposed to rehabilitative services. Patients are generally followed for a year, and telephone follow-ups are standard. Many homebound or home-limited older adults have not received an in-home assessment. Home CGAs reduce functional decline and mortality but not admissions to LTC facilities (Ward & Reuben, 2022).

Acute geriatric care units are referred to as Geriatric Evaluation and Management Units in U.S. Department of Veterans Affairs Hospitals or Acute Care of the Elderly units in private hospitals. These units are typically staffed by clinicians who assume primary care for the patient, implementing recommendations seamlessly, and a skilled team of professionals (nurses, physical therapists, OTs, SLPs, LSWs) who tailor care to the older adult population and enhance consistency. This model of care is designed to prevent the prolonged functional decline that is typically seen after acute hospitalizations among frail older adults. Compared to standard inpatient care, patients who received a CGA as a component of an Acute Care of the Elderly unit were less likely to be living in LTC facilities and more likely to be living at home a year after hospital admission. Studies have not shown a reduction in dependence, cognitive status, or mortality (Walston, 2023; Ward & Reuben, 2020).

Post-hospital discharge CGA programs are designed to identify vulnerable patients using a multidimensional assessment. Comprehensive discharge planning and home visits with nurses to follow up in the weeks after discharge are supplemented by telephone calls and specialty home visits from physical therapists, OTs, or LSWs, or additional nursing visits if indicated. These CGAs should be initiated a day or two before discharge. The research on the effectiveness of post-discharge CGAs is mixed, although it may reduce hospital readmission rates, cost, and ED visits. Programs designed for patients discharged from the ED can reduce future ED visits and hospital admissions (Ward & Reuben, 2022).

Outpatient CGA programs may be beneficial, but only when they address adherence to program recommendations and focus on patients at increased risk of hospitalization. These programs may reduce functional decline, fatigue, depression, and the use of health services. The Geriatric Resources for Assessment and Care of Elders program incorporates an APRN into the interdisciplinary care team. This measure has reduced ED visits and hospitalizations and improved QOL for low-income seniors. The Guided Care program, which incorporates a specially trained RN into the primary care team for chronically ill high-risk patients, showed a reduction in home health care episodes, LTC admissions, and days of hospitalization for some patients. Practice redesign approaches that focus on specific conditions may improve the quality of care for falls, incontinence, and dementia. Inpatient CGA programs have shown little to no long-term benefit in patient outcomes. However, comanagement surgical programs with a geriatrician may reduce complications, delirium, mortality, and rehospitalization for patients after a hip fracture. Similar programs have resulted in reduced length of stay and inpatient postoperative mortality. Patients who participate in a CGA program after a hip fracture are less likely to be discharged to an LTC or assisted living facility (Ward & Reuben, 2022).

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