Screening Tools for Geriatric Assessment by Specialists

© Springer International Publishing Switzerland 2017
John R. Burton, Andrew G. Lee and Jane F. Potter (eds.)Geriatrics for Specialists10.1007/978-3-319-31831-8_8

8. Screening Tools for Geriatric Assessment by Specialists

John R. Burton  and Jane F. Potter2

The Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, 5505 Hopkins Bayview Circle, Baltimore, MD 21224, USA

Division of Geriatrics and Gerontology, Home Instead Center for Successful Aging, Department of Internal Medicine, University of Nebraska Medical Center, 986155 Nebraska Medical Center, Omaha, NE 68198-6155, USA



John R. BurtonProfessor of Medicine

Geriatric assessmentDiagnostic toolsEvaluation of seniors

A specialist clinician can and should use easily performed assessment tools to help in the evaluation of older patients. Such assessment instruments help any clinician screen for underlying problems that could put a patient at high risk for an adverse outcome from a new medication or procedure a specialist is considering. Such underlying clinical problems often are subtle and may not be listed on the patient list of chronic problems or in the referral letter.

The senior population roughly over the age of 80 years is characterized by increasing vulnerability . This vulnerability has many causes but to simplify it relates to three cardinal differences in this population compared to those that are younger:

  1. 1.

    The presence of multiple chronic health problems in an individual. Typically an octo- or nona-genarian has 10–15 chronic health problems. One health problem may mask the symptoms of another and treating one problem may have an adverse impact on another. Such a situation typically leads to polypharmacy and the high risk of an adverse drug effect including a drug–drug interaction.


  2. 2.

    The continuous loss of physiological reserve. Such losses demonstrated consistently by several longitudinal studies begin around the age of 30 years. The physiological losses are subtle and deterioration occurs slowly. Most typically these progressing changes are appreciated earliest among athletes who notice they have lost their competitive edge. Competition times in running and swimming, for example, gradually get slower over the years even with continued vigorous training and without injury. These physiological changes are quite variable among organs and individuals. However, by age 80 or so an individual has lost so much physiological reserve that they are at increased risk of a significant clinical problem developing after a perturbation such as an operation, a diagnostic procedure, a fall, or a new medication.


  3. 3.

    Heterogeneity among individuals, therefore, is remarkable. This heterogeneity makes the care of an older person unique and often precludes the clinician from applying published clinical trials (which rarely include very old individuals) and, especially, clinical guidelines to a patient over age 80 or so. This heterogeneity requires the clinician to apply considerable judgment when advising a diagnostic test, surgical intervention, or medical treatment for such a patient. Always a careful clinical risk–benefit judgment must be made and the patient needs to be a part of such discussions if complications and unexpected outcomes are to be minimized and patient understanding and satisfaction are to be maximized. While this heterogeneity is frustrating to many clinicians, it is remarkably rewarding to others as it demands maximum clinical knowledge, ideal communication skills, and knowing each patient and their goals extremely well.


Therefore, for a specialist trying to guide a senior, screening for subtle associated problems is important. Simple tools may be of value in this regard. Many of these tools are discussed in detail in other chapters, but here are discussed practical and common assessment tools that have been well studied and disseminated. They are discussed in a single chapter to make access easier when a clinician is seeing a patient and time is limited. These assessment tools are most often done by various members of an interdisciplinary team (a group of clinicians of different professions and/or training working regularly and collaboratively to achieve a unified approach). In the office setting these assessment tools are often performed by a nurse working in close partnership with a physician, nurse practitioner, or physician assistant.

8.1 Fall Risk

Falls by older patients are common after the initiation of certain new medications, procedures, or hospitalization. Estimation of the risk may help the clinician avoid a fall by alerting all to the increased fall risk and can lead to developing preemptive preventive strategies. The Timed Up and Go Test is the most popular for a quick assessment of fall risk. This evaluation can be done in a few seconds. It is easy and provides some sense of a patient’s mobility and risk of falling [1, 2]. Some experienced clinicians simply observe the patient coming into the office or getting on to the examination table. While valuable, this simple observation strategy seems to be less accurate than The Timed Up and Go Test.

To perform the Timed Up and Go Test , the clinician gives the following instructions to the patient and informs the patient he or she is being timed. The patient is instructed to:

  1. 1.

    Rise quickly from the arm chair;


  2. 2.

    Walk 10 feet using a cane or walker if they normally do so;


  3. 3.

    Turn around;


  4. 4.

    Walk back to the chair and sit down.


The clinician or an assistant starts the patient by indicating that they will be timed and then giving a precise start command. Accomplishing this is recorded in seconds and the fall risk is related to the elapsed time from the Go command until the patient sits back down: 10 or less—low risk for fall; 11–19—moderate; 20–29—high risk; and 30 or greater is impaired mobility and a very high risk of falling. A clinician knowing the risk for a fall will want to talk with the patient and ideally with the primary care provider to weigh the risk and benefit of any considered intervention. If the potential for a fall is significant and the benefit of a new therapeutic or diagnostic perturbation is consider to outweigh the risk, preventive strategies such as precautionary guidance to the patient or physical therapy consultation may be appropriate. The Timed Up and Go test is not completely predictive of the fall risk in community dwelling elders but it is simple and the most popular and it when markedly abnormal gives the clinician some sense of the likelihood of a fall.

Other gait assessment tools have been validated and are of considerable value. The simplest of these is Gait Speed. Gait speed in one study was assessed by timing a patient’s walk (at their normal or usual pace) over a measured 5 m. If six or more seconds is required (0.833 m/s or slower), there is an incremental higher risk of mortality and major morbidity in a study of older patients undergoing cardiac surgery [3]. The same cut off appears in numerous studies supporting that gait speed 0.8 m/s or better is necessary for independent community ambulation [4]. A simple approach is to measure a 5 or 4 (see frailty below) m or longer distance in an office hallway, time the patient, and calculate his or her speed.

8.2 Dementia

Cognitive impairment of any level is a significant risk factor for complications from any clinical perturbation such as hospitalization, a diagnostic or therapeutic procedure, or medication. Such impairment may effect up to 20 % of seniors over the age of 80. Further cognitive impairment is not always obvious to even a trained clinician and for specialists it may not be in the referral note of a patient especially when this problem is only mild or modest. Accordingly, if cognitive impairment has not earlier been evaluated, it is in the best interest of the patient if the specialist or his or her staff screens an older patient for cognitive impairment. The Mini Cog™ [5] is the simplest and most popular such assessment tool :

  1. 1.

    Instruct the patient to listen carefully and remember three unrelated but simple words and then repeat the words. Pen, watch, and tie are examples.


  2. 2.

    Instruct the patient to draw the numbers of the face of a clock after handing the individual a paper with only a blank circle representing the outline of the clock.


  3. 3.

    Instruct the patient to draw the hands of a clock to represent a specific time such as 9:15 or 1:25. The patient may take as much time as needed to complete this task.


  4. 4.

    Then instruct the patient to repeat the three words given before the clock drawing distraction.


Scoring is simple: one point is given for each correctly recalled word after completing the clock drawing.

Zero is a positive screen for dementia; one-two with an abnormal clock drawing is a positive screen; one-two with a normal clock drawing is a negative screen; a score of three is a negative screen.

A clock drawing is normal only if the numbers are placed in appropriate sequence and the hands are displayed properly. A positive screen for dementia should alert the specialist to the risk of potentially underlying cognitive impairment.

The Mini-Cog test is copyrighted and cannot be modified, reproduced or disseminated without the permission of its primary developer, Soo Borson, MD, of the University of Washington. Other cognitive assessment tools are available [6] but the Mini-Cog [7] seems to be the simplest and most popular.

There are several other more elaborate assessment tools to evaluate and monitor over time cognitive impairment. Perhaps one of the most popular is the Mini-Mental State Examination (MMSE) . The MMSE was developed decades ago [8] and has been well validated and widely disseminated. It is a 30-point evaluation that takes about 7–10 min to complete. It is influenced by age and education but remains popular. Currently its copyright is held by Psychology Assessment Services (PAS ) who offer copies of it and a training manual for sale on line. One can enter MMSE in web search engine to find examples. Another is the Montreal Cognitive Assessment (MoCA ). This test is especially valuable in early dementia and in those with vascular dementia. Information on performing and interpreting this test is readily available on the following web site: www.​mocatest.​org. On this site one can access detailed information, in many languages, about the instrument. There are no copyrights or restrictions on its use.

8.3 Delirium

Delirium is in older people often of the hypoactive type (as opposed to the hyperactive, typical more common in younger individuals). Because of this, the diagnosis of delirium is easily missed by even experienced clinicians. Recognizing delirium is of critical importance as its presence in a patient portends a serious situation that often will markedly worsened with a new insult such as a procedure or new medication. Delirium in all forms is a serious risk factor for rapid mental deterioration, prolonged hospitalization, complications, and death. Risk factors for delirium are advanced age, multiple co-morbidities, and underlying brain disease, even if mild. Many medications including those not requiring a prescription are associated with the development of delirium.

The well-validated Confusion Assessment Method ( CAM) is the most widely used screening tool [9]. Delirium is diagnosed classically by evaluating nine features: acute onset, inattention, disorganized thinking, altered level of consciousness, disorientation, memory impairment, perceptual disturbances, psychomotor agitation or retardation, and altered sleep–wake cycle.

These nine criteria are well described in the Diagnostic and Statistical Manual for Mental Disorders. Classically studies on delirium used an expert psychiatrist’s evaluation as the gold standard for the diagnosis of delirium. To make the evaluation of delirium more accessible to all clinicians a simplified assessment tool was created and validated [10, 11]. The Confusion Assessment Method (CAM ) is based on evaluating the patient for a change in cognition and has four cardinal features:

  1. 1.

    A rapid onset with a fluctuating course with changes over minutes to hours;


  2. 2.



  3. 3.

    Disorganized thinking; and/or


  4. 4.

    Altered level of consciousness.


The diagnosis of delirium requires the presence 1, 2 and either 3 or 4.

The timing of the onset and the nature of the course of the symptoms are self-evident. However, hypoactive delirium is often mistaken for dementia in a clinical setting and it is imperative to establish the onset of symptoms especially by asking other observers such as family members. Delirium is different from dementia. Dementia is only properly evaluated in a patient with a clear consciousness and is manifest by a slowly progressive course and without fluctuation from 1 min, hour, or day to the next as occurs in delirium. Delirium frequently occurs in cognitively impaired individuals making the evaluation of the level of dementia difficult to assess.

Inattention can be assessed by observing that the patient is not tuned into the conversation or is not fully aware of the surroundings. A patient with delirium will often drift off in midsentence or just stare at something other than the clinician. A quick test is to have patients say the months of the year backward.

Disorganized thinking is detected by illogical or disconnected responses to questions. Responses are often irrelevant, rambling, or incoherent or the patient may have hallucinations or delusions.

Consciousness can be assessed by evaluating the mental status for hypo or hyperactivity (agitation). A common clinical trap is to assume that the patient is sleepy or just waking up when, in fact, this is hypoactive delirium.

The optimal use of the CAM is based on observations during cognitive testing such as performing the mini-mental state examination (see above). Some experience and training is suggested for the best results. A CAM training manual is available from the scholars who first introduced it by entering into a web search engine Hospital Elder Life Program or www.​elderlifeprogram​.​med.​yale.​edu. The menu bar can direct one to the Assessment Instruments.

A valuable guideline for post-operative delirium is available. It was published in late 2014 by an expert panel sponsored by the American College of Surgeons and the American Geriatrics Society with support from the John A. Hartford Foundation. This guideline may be found on the following AGS website: www. The guideline can be downloaded for no charge to AGS members and for a small fee for non-members. A more detailed discussion of delirium can be found in the Delirium chapter.

8.4 Frailty

Frailty is a clinical phenotype that is a marker for increased vulnerability to adverse health outcomes and increased mortality after surgical or medical interventions or other perturbation. The diagnosis of ‘frailty’ to date has mostly been utilized in research settings to identify those at increased risk of adverse outcomes and for biological studies. For example, in a study of over 1000 older adults receiving general surgery, those who were frail were up to 20 times more likely to need care in a post-acute facility as compared to those who were robust or not frail [12]. Subspecialists are increasingly interested in the identification of the frail subset of older adults in order to help predict and potentially prevent adverse outcomes related to procedures and treatments. Dozens of frailty assessment methods have evolved over the past several years that may be useful to clinicians as they attempt to determine which older adults may be at most risk for adverse outcomes. Most of the tools perform well at identifying vulnerable older adults. A recent consensus conference on frailty suggested that those over age 70 should be screened for physical frailty, in part because physical frailty can be potentially treated or prevented with specific modalities, and the adverse outcomes associated with frailty ameliorated [13]. Use of any of these tools by clinicians has been delayed because of confusion about which tool to choose, and because of lack of research on how to manage a patient differently once frailty status is determined.

In general, there have been two approaches to the identification of frailty, which in turn has driven the development of multiple frailty assessment tools. The physical frailty or phenotype approach suggests that frailty emerges from an age-related biological process that results in weakness, fatigue, low levels of activity. The frailty index approach suggests that frailty is driven by an accumulation of illnesses as well as cognitive and social decline that can be ultimately additive. Few guidelines exist on how to best choose a tool for the purpose at hand. Most tools have not been extensively validated or utilized across populations, and few comparison studies have been done that show clear benefit of using one tool over the other. In addition, different tools may or may not be good matches for the intended use. For example, a brief screening tool may be appropriate for risk stratification while a more formal frailty assessment could be required to define preoperative interventions meant to modify surgical outcomes.

8.4.1 Frailty Measures

Given the wide array of tools and the wide variety of populations in which the tools may need to be implemented, the choice of which to use must be tailored to a clinical situation and clinical need. In addition, choosing tools that have been previously used in a variety of populations and have demonstrated predictive validity in several settings should also influence the choice of tools. Time to complete a frailty assessment also matters in a clinical setting. The development of discipline specific clinical guidelines of how best to manage frail older adults in a variety of clinical settings is needed to more fully utilize assessment tools.

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Aug 25, 2017 | Posted by in GERIATRICS | Comments Off on Screening Tools for Geriatric Assessment by Specialists

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