Assessment of the frail elderly patient
Comprehensive geriatric assessment is an evidence-based process that improves outcomes. It involves taking the history from the patient and, with the patient’s consent, from a carer or relative, followed by a systematic assessment of:
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cognitive function and mood
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nutrition and hydration
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skin
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pain
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continence
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hearing and vision
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functional status.
The extent and focus of the assessment depend on the clinical presentation. In non-acute settings such as the general practice or outpatient clinic or day hospital, focus on establishing what diseases are present, and also which functional impairments and problems most affect the patient’s life.
In acute settings such as following acute hospital referral, focus on what has changed or is new. Seek any new symptoms or signs of illness and any changes from baseline physical or cognitive function.
The complexity of the problems presented, and the need for comprehensive and systematic analysis, mean that assessment is divided into components undertaken at different times, by different members of the multiprofessional team ( Box 17.1 ).
| Professional | Key roles in assessment of |
|---|---|
| Physician | Physical state, including diagnosis and therapeutic intervention |
| Psychiatrist | Cognition, mood and capacity |
| Physiotherapist | Mobility, balance, gait and falls risk |
| Occupational therapist | Practical functional activities (self-care and domestic) |
| Nurse | Skin health, nutrition and continence |
| Dietician | Nutrition |
| Speech and language therapist | Speech and swallowing |
| Social worker | Social care needs |
There is no specific age at which a patient becomes ‘elderly’; although age over 65 years is commonly used as the definition, this has no biological basis, and many patients who are chronologically ‘elderly’ appear biologically and functionally younger, and vice versa.
Frailty becomes more common with advancing age and is likely to be a response to chronic disease and ageing itself. A frail elderly person typically suffers multimorbidity (multiple illnesses) and has associated polypharmacy (multiple medications). They often have cognitive impairment, visual and hearing loss, low bodyweight and poor mobility due to muscular weakness, unstable balance and poor exercise tolerance. Their general functional reserve and the capacity of individual organs and physiological systems are impaired, making the individual vulnerable to the effects of minor illness.
Factors influencing presentation and history
Classical patterns of symptoms and signs still occur in the frail elderly, but modified or non-specific presentations are common due to comorbidity, drug treatment and ageing itself. As the combination of these factors is unique for each individual, their presentations will be different. The first sign of new illness may be a change in functional status: typically, reduced mobility, altered cognition or impairment of balance leading to falls. Common precipitants are infections, changes in medication and metabolic derangements but almost any acute medical insult can produce these non-specific presentations ( Fig. 17.1 ). Each of these presentations should be explored through careful history taking, physical examination and functional assessment.
Disorders of cognition, communication and mood are so common that they should always be considered at the start of the assessment of a frail older adult.
Communication difficulties, cognition and mood
Communication can be challenging ( Box 17.2 ). The history can be incomplete, difficult to interpret or misleading, and the whole assessment, including physical examination, may be time-consuming.
| Problem | Comment/causes |
|---|---|
| Deafness | Nerve or conductive |
| Dysphasia | Most commonly due to stroke disease but sometimes a feature of dementia |
| Dysarthria | Cerebrovascular disease, motor neurone disease, Parkinson’s disease |
| Dysphonia | Parkinson’s disease |
| Dementia | Global impairment of cognitive function |
| Delirium | Impaired attention, disturbance of arousal and perceptual disturbances |
| Depression | May mimic dementia or delirium |
Whenever possible, assess the patient somewhere quiet with few distractions. Make your patient comfortable and ensure they understand the purpose of your contact. Provide any glasses, hearing aids or dentures that they need and help them to switch on and adjust their hearing aid if necessary. If they still cannot hear you clearly, use an electronic communicator, or if they can read easily, write down simple questions and instructions.
Cognitive function includes the processes of perception, attention, memory, reasoning, decision making and problem solving ( p. 323 ). Cognitive impairment increases with age and has implications for assessment, treatment, consent and prognosis. Consider cognitive impairment if a patient has limited ability to cooperate with you, cannot recall their medical history or seems to deny all symptoms, even when they are clearly unwell. Other problems, including impaired hearing, low mood or dysphasia, can mimic cognitive impairment. Some patients present with apparently good social skills or ‘façade’ and cover their impaired memory by diverting the conversation to another topic. Do not ascribe changes in cognition to age alone without excluding dementia or delirium ( p. 323 ).
Depression is common in frail elderly people and may be difficult to diagnose. Consider this if your patient struggles to concentrate, or is withdrawn or reluctant to interact. A formal psychiatric assessment and corroborating history from a carer or friend may be valuable. Standardised rating scales are available such as the Geriatric Depression Scale.
Patients are often fearful that they will be admitted to hospital or not return home after admission, and may play down their symptoms or functional limitations. Always try to corroborate the history from a carer, relative or friend, with the patient’s consent.
The history
The presenting symptoms
Frail elderly patients often have multiple symptoms. Take time to detail each symptom, and separate those arising from new acute illness from those due to background disabilities.
Ask:
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How long have you had a particular symptom?
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Has it changed recently?
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When were you last totally free of the symptom?
Try to establish what the patient’s symptoms, functional abilities and mental status were before the new presenting problem. This helps set realistic goals for treatment and rehabilitation.
The patient’s perspective may vary from yours, particularly in acute settings. For example, a patient referred following sudden loss of consciousness may be unconcerned by this but anxious about longstanding back pain. These symptoms are not coincidental; if it is important to your patient, it should be important to you.
Common presenting symptoms
Decreased mobility
Ask about:
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the patient’s usual mobility, when it changed and if the change was abrupt
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any falls
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use of walking aids
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history of recent head injury, fevers or rigors, dizziness or poor balance
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lower limb weakness, numbness or paraesthesia
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joint pain, especially in the back, neck or lower limbs
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any bladder or bowel symptoms
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current drug treatment and whether this has changed recently
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how the change in mobility is affecting their daily life.
Confusion
Check that the patient can hear you clearly and ask if they would like a friend or relative to be with them. Although a confused patient may struggle to give an accurate history or clear description of symptoms, never ignore what they tell you, as their perspective remains important to your care. Take a collateral history.
Establish:
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the person’s normal cognitive state and whether the change has been abrupt or gradual
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any symptoms of common infections, such as urinary frequency, productive cough, fever or rigors
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whether the person has any pain, and if so, where
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current drug treatment and adherence, with any recent changes.
Falls
A collateral history is helpful if a fall has been witnessed.
Establish:
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the patient’s usual mobility
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how many falls they have had, over what timescale and whether injuries, including head injury, have been sustained
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the presence of dizziness or lightheadedness, and whether the problem is true vertigo or worse on standing ( p. 123 )
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the presence of palpitations, limb weakness, paraesthesia or any joint pain, especially in the back, neck or lower limbs
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quality of vision
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any problems with the feet
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any recent symptoms of infection (see earlier)
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current drug treatment and any recent changes.
Past medical history
Detail the past history and known comorbidities from all available sources, including any previous records. Comorbidities may not be directly relevant to the current problem but may influence prognosis and the feasibility and appropriateness of potential investigations and treatments ( Box 17.3 ).
Drug history
Polypharmacy is associated with drug interactions, adverse events and difficulties with adherence. Take a detailed drug history, supplemented by the following:
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Identify all medications, including over-the-counter preparations.
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Ask whether any drugs have been started or stopped recently, or doses of regular medications altered.
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Explore the patient’s ability to self-administer drugs; ask if they use a dosette box or if a carer helps with administration.
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Explore the ability to read labels, open bottles or use inhalers correctly.
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If patients have their drugs with them, go through them together. Ask patients what they believe each one is for, how it affects them and how often they take it.
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Ask if there are any drugs that they sometimes omit, such as diuretics on days when they are going out.
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Ask carers if there are partially used supplies of drugs in the house.
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Clarify any ‘allergies’ or previous adverse events. Explore what symptoms the patient believes to be caused by their drugs, as some may be unrelated. If in doubt, regard the allergy as significant.
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Contact the prescriber, if necessary, to confirm details of the drug history.
Family history
A first presentation of disease with a strong genetic basis is unlikely, but family history is still important to patients who have lost siblings or children to specific conditions and who may believe that their own symptoms are related.
Social and functional history
Complement a comprehensive social history with information about the patient’s functional ability, as this affects their capacity to cope at home, and what assistance they need to support their function there.
Ask about:
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Their normal mobility and whether they transfer from chair to bed or toilet, and walk alone.
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Use of a walking aid and whether they can manage stairs
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Their current level of function, what it was before, and the time course of any functional deterioration.
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How they manage day-to-day activities:
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Can they wash and dress?
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Do they do their own shopping and prepare their own meals?
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Abrupt functional decline suggests a more acute underlying precipitant or disease. Insidious decline suggests alternate pathologies or progression of underlying chronic disease. Seek corroboration from a friend, relative or carer, but interpret all information obtained in association with objective functional assessment by yourself and other members of the multiprofessional team (see Box 17.1 ).
The elderly patient’s home environment is important:
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Does anyone else live with the patient? Patients who live alone often require more support.
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Have they lived in their current home for long?
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What is access like to the house/bedroom/toilets? Do they use stairs, inside or outside?
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What carer support does the patient have (home help, family or friends)? How often does any carer visit and what does each person do for the patient?
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If in sheltered accommodation:
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Are meals provided?
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Is there an on-site warden or personal safety alarms?
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How does the patient feel about living there and do they wish to return?
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Do they still have a job, and if so, what is it?
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If they are retired, find out what they did, as it may be relevant to their condition and gives insight into their past life. Retirement can lead to social isolation, which contributes to mood disorders.
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Can the patient still get out by themselves or accompanied, or are they house-bound? How many visitors do they have?
Consider that patients may still be driving and there will be safety issues in the presence of visual or cognitive defects. Establish lifestyle information. Alcohol overuse is not infrequent and there may be many pack-years of cigarette use.
Systematic enquiry
Many diseases in frailer people present with non-specific functional deterioration such as immobility. The systematic enquiry is important, as it may provide clues to specific underlying precipitants. Supplement the standard systematic enquiry with questions in the following areas:
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Cognition and mood: has the patient noticed any memory problems or has anyone else commented on their memory? Does anyone help them with letters and bills? Ask about how they sleep at night. How would they describe their mood and appetite? Are they still interested in previous pursuits, such as reading or following favourite television programmes?
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Nutrition: has their weight been steady over the past few months? Have they noticed their clothes getting loose? How many meals do they have in the day and do they eat meat, fish, vegetables and fruit? Who prepares their meals? Do they have any problems with their teeth or gums? If they wear dentures, do they fit well? Is their mouth dry?
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Pain: always ask specifically about pain, as this may affect mobility and sleep.
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Continence: ask whether they ever notice incontinence or leakage from their bladder or bowels. Are they aware when they are about to pass urine or a stool? Do they ever find it hard to get to the toilet in time? Ask men about prostatic symptoms ( p. 235 ) in particular. Do these problems stop them doing activities?
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Sensory impairment: ask about any problems with vision and whether they wear glasses. Can they can see the television and read a newspaper? If they wear a hearing aid, find out if it is working and whether they are wearing it.
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Balance and falls: do they ever feel unsteady on their feet? Ask specifically about any falls in the past year and obtain a careful description of these (p. 331). Find out how they would call for help if they fell and could not get up.
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