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48  American Family Physician www.aafp.org/afp Volume 83, Number 1 ◆ January 1, 2011

The Geriatric Assessment BASSEM ELSAWY, MD, and KIM E. HIGGINS, DO, Methodist Charlton Medical Center, Dallas, Texas

A pproximately one-half of the ambu- latory primary care for adults older than 65 years is provided by fam- ily physicians,1 and approximately

22 percent of visits to family physicians are from older adults.2,3 It is estimated that older adults will comprise at least 30 percent of patients in typical family medicine outpa- tient practices, 60 percent in hospital prac- tices, and 95 percent in nursing home and home care practices.4

A complete assessment is usually initiated when the physician detects a potential prob- lem such as confusion, falls, immobility, or incontinence. However, older persons often do not present in a typical manner, and atypi- cal responses to illness are common. A patient presenting with confusion may not have a neurologic problem, but rather an infec- tion. Social and psychological factors may also mask classic disease presentations. For example, although 30 percent of adults older than 85 years have dementia, many physicians miss the diagnosis.5,6 Thus, a more structured approach to assessment can be helpful.

The geriatric assessment is a multidimen- sional, multidisciplinary assessment designed to evaluate an older person’s functional ability, physical health, cognition and mental health, and socioenvironmental circumstances. It includes an extensive review of prescription

and over-the-counter drugs, vitamins, and herbal products, as well as a review of immu- nization status. This assessment aids in the diagnosis of medical conditions; development of treatment and follow-up plans; coordina- tion of management of care; and evaluation of long-term care needs and optimal placement.

The geriatric assessment differs from a typical medical evaluation by including nonmedical domains; by emphasizing func- tional capacity and quality of life; and, often, by incorporating a multidisciplinary team including a physician, nutritionist, social worker, and physical and occupational ther- apists. This type of assessment often yields a more complete and relevant list of medical problems, functional problems, and psycho- social issues.7

Because of the demands of a busy clinical practice, most geriatric assessments tend to be less comprehensive and more problem- directed. For older patients with many con- cerns, the use of a “rolling” assessment over several visits should be considered. The roll- ing assessment targets at least one domain for screening during each office visit. Patient- driven assessment instruments are also popular. Having patients complete question- naires and perform specific tasks not only saves time, but also provides useful insight into their motivation and cognitive ability.

The geriatric assessment is a multidimensional, multidisciplinary assessment designed to evaluate an older person’s functional ability, physical health, cognition and mental health, and socioenvironmental circumstances. It is usually initiated when the physician identifies a potential problem. Specific elements of physical health that are evaluated include nutrition, vision, hearing, fecal and urinary continence, and balance. The geriatric assessment aids in the diagnosis of medical conditions; development of treatment and follow-up plans; coordination of management of care; and evaluation of long-term care needs and optimal placement. The geriatric assessment differs from a stan- dard medical evaluation by including nonmedical domains; by emphasizing functional capacity and quality of life; and, often, by incorporating a multidisciplinary team. It usually yields a more complete and relevant list of medical problems, functional problems, and psychosocial issues. Well-validated tools and survey instruments for evaluating activities of daily living, hearing, fecal and urinary continence, balance, and cognition are an important part of the geriatric assessment. Because of the demands of a busy clinical practice, most geriatric assessments tend to be less comprehensive and more problem-directed. When multiple concerns are presented, the use of a “rolling” assess- ment over several visits should be considered. (Am Fam Physician. 2011;83(1):48-56. Copyright © 2011 American Academy of Family Physicians.)

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Functional Ability Functional status refers to a person’s ability to perform tasks that are required for living. The geriatric assessment begins with a review of the two key divisions of functional ability: activities of daily living (ADL) and instrumental activities of daily living (IADL). ADL are self-care activities that a person performs daily (e.g., eating, dressing, bath- ing, transferring between the bed and a chair, using the toilet, controlling bladder and bowel functions). IADL are activities that are needed to live independently (e.g., doing housework, preparing meals, taking medications properly,

managing finances, using a telephone). Physicians can acquire useful functional information by simply observ- ing older patients as they complete simple tasks, such as unbuttoning and buttoning a shirt, picking up a pen and writing a sentence, taking off and putting on shoes, and climbing up and down from an examination table. Two instruments for assessing ADL and IADL include the Katz ADL scale (Table 1)8 and the Lawton IADL scale (Table 2).9 Deficits in ADL and IADL can signal the need for more in-depth evaluation of the patient’s socioenvironmental circumstances and the need for additional assistance.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

The U.S. Preventive Services Task Force found insufficient evidence to recommend for or against screening with ophthalmoscopy in asymptomatic older patients.

C 15

Patients with chronic otitis media or sudden hearing loss, or who fail any hearing screening tests should be referred to an otolaryngologist.

C 21, 23

Hearing aids are the treatment of choice for older patients with hearing impairment, because they minimize hearing loss and improve daily functioning.

A 23

The U.S. Preventive Services Task Force has advised routinely screening women 65 years and older for osteoporosis with dual-energy x-ray absorptiometry of the femoral neck.

A 37

The Centers for Medicare and Medicaid Services encourages the use of the Beers criteria as part of an older patient’s medication assessment to reduce adverse effects.

C 39, 40

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

Table 1. Katz Index of Independence in Activities of Daily Living

Activities (1 or 0 points) Independence (1 point)* Dependence (0 points)†

Bathing

Points:

Bathes self completely or needs help in bathing only a single part of the body, such as the back, genital area, or disabled extremity

Needs help with bathing more than one part of the body, getting in or out of the bathtub or shower; requires total bathing

Dressing

Points:

Gets clothes from closets and drawers, and puts on clothes and outer garments complete with fasteners; may need help tying shoes

Needs help with dressing self or needs to be completely dressed

Toileting

Points:

Goes to toilet, gets on and off, arranges clothes, cleans genital area without help

Needs help transferring to the toilet and cleaning self, or uses bedpan or commode

Transferring

Points:

Moves in and out of bed or chair unassisted; mechanical transfer aids are acceptable

Needs help in moving from bed to chair or requires a complete transfer

Fecal and urinary continence

Points:

Exercises complete self-control over urination and defecation

Is partially or totally incontinent of bowel or bladder

Feeding

Points:

Gets food from plate into mouth without help; preparation of food may be done by another person

Needs partial or total help with feeding or requires parenteral feeding

Total points‡:

*—No supervision, direction, or personal assistance. †—With supervision, direction, personal assistance, or total care. ‡—Score of 6 = high (patient is independent); score of 0 = low (patient is very dependent).

Adapted with permission from Katz S, Downs TD, Cash HR, Grotz RC. Progress in development of the index of ADL. Gerontologist. 1970;10(1):23.

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Physical Health The geriatric assessment incorporates all fac- ets of a conventional medical history, includ- ing main problem, current illness, past and current medical problems, family and social history, demographic data, and a review of systems. The approach to the history and physical examination, however, should be specific to older persons. In particular, top- ics such as nutrition, vision, hearing, fecal and urinary continence, balance and fall prevention, osteoporosis, and polypharmacy should be included in the evaluation. Table 3 is an example of a focused geriatric physical examination.

SCREENING FOR DISEASE

In the normal aging process, there is often a decline in physiologic function that is usu- ally not disease-related. However, treatment of diabetes mellitus, hypertension, and glau- coma can prevent significant future morbid- ity. Screening for malignancies may allow for early detection, and some are curable if treated early. It is important that physicians weigh the potential harms of screening before screening older patients. It is essential to consider family preferences regarding treat- ment if a disease is detected, and the patient’s functional status, comorbid conditions, and predicted life expectancy. If an asymptom- atic patient has an expected survival of more than five years, screening is generally medi- cally warranted, assuming that the patient is at risk of the disease and would accept treat- ment if early disease was detected.10,11

The Agency for Healthcare Research and Quality has developed an online tool called the Electronic Preventive Services Selec- tor (http://epss.ahrq.gov/ePSS/search.jsp) that can be downloaded to smartphones. It can assist physicians in identifying age- appropriate screening measures.

NUTRITION

A nutritional assessment is important because inadequate micronutrient intake is common in older persons. Several age- related medical conditions may predispose patients to vitamin and mineral deficiencies. Studies have shown that vitamins A, C, D,

Table 2. Lawton Instrumental Activities of Daily Living  Scale (Self-Rated Version)

For each question, circle the points for the answer that best applies  to your situation.

1. Can you use the telephone?

Without help

With some help

Completely unable to use the telephone

3

2

1 2. Can you get to places that are out of walking distance?

Without help

With some help

Completely unable to travel unless special arrangements are made

3

2

1 3. Can you go shopping for groceries?

Without help

With some help

Completely unable to do any shopping

3

2

1 4. Can you prepare your own meals?

Without help

With some help

Completely unable to prepare any meals

3

2

1 5. Can you do your own housework?

Without help

With some help

Completely unable to do any housework

3

2

1 6. Can you do your own handyman work?

Without help

With some help

Completely unable to do any handyman work

3

2

1 7. Can you do your own laundry?

Without help

With some help

Completely unable to do any laundry

3

2

1

8a. Do you use any medications?

Yes (If “yes,” answer question 8b)

No (If “no,” answer question 8c)

1

2 8b. Do you take your own medication?

Without help (in the right doses at the right time)

W ith some help (take medication if someone prepares it for you or reminds you to take it)

Completely unable to take own medication

3

2

1 8c. If you had to take medication, could you do it?

Without help (in the right doses at the right time)

W ith some help (take medication if someone prepares it for you or reminds you to take it)

Completely unable to take own medication

3

2

1 9. Can you manage your own money?

Without help

With some help

Completely unable to handle money

3

2

1

NOTE: Scores have meaning only for a particular patient (e.g., declining scores over time reveal deterioration). Some questions may be sex-specific and can be modified by the interviewer.

Adapted with permission from Lawton MP, Brody EM. Assessment of older people: self- maintaining and instrumental activities of daily living. Gerontologist. 1969;9(3):181.

Geriatric Assessment Table 3. Sample Focused Geriatric Physical Examination

Signs Physical sign or symptom Differential diagnoses

Vital signs

Blood pressure Hypertension Adverse effects from medication, autonomic dysfunction

Orthostatic hypotension Adverse effects from medication, atherosclerosis, coronary artery disease

Heart rate Bradycardia Adverse effects from medication, heart block

Irregularly irregular heart rate Atrial fibrillation

Respiratory rate Increased respiratory rate greater than 24 breaths per minute

Chronic obstructive pulmonary disease, congestive heart failure, pneumonia

Temperature Hyperthermia, hypothermia Hyper- and hypothyroidism, infection

General Unintentional weight loss Cancer, depression

Weight gain Adverse effects from congestive heart failure medication

Head Asymmetric facial or extraocular muscle weakness or paralysis

Bell palsy, stroke, transient ischemic attack

Frontal bossing Paget disease

Temporal artery tenderness Temporal arteritis

Eyes Eye pain Glaucoma, temporal arteritis

Impaired visual acuity Presbyopia

Loss of central vision Age-related macular degeneration

Loss of peripheral vision Glaucoma, stroke

Ocular lens opacification Cataracts

Ears Hearing loss Acoustic neuroma, adverse effects from medication, cerumen impaction, faulty or ill-fitting hearing aids, Paget disease

Mouth, throat Gum or mouth sores Dental or periodontal disease, ill-fitting dentures

Leukoplakia Cancerous and precancerous lesions

Xerostomia Age-related, Sjögren syndrome

Neck Carotid bruits Aortic stenosis, cerebrovascular disease

Thyroid enlargement and nodularity Hyper- and hypothyroidism

Cardiac Fourth heart sound (S4) Left ventricular thickening

Systolic ejection, regurgitant murmurs

Valvular arteriosclerosis

Pulmonary Barrel chest Emphysema

Shortness of breath Asthma, cardiomyopathy, chronic obstructive pulmonary disease, congestive heart failure

Breasts Masses Cancer, fibroadenoma

Abdomen Pulsatile mass Aortic aneurysm

Gastrointestinal, genital/rectal

Atrophy of the vaginal mucosa Estrogen deficiency

Constipation Adverse effects from medication, colorectal cancer, dehydration, hypothyroidism, inactivity, inadequate fiber intake

Fecal incontinence Fecal impaction, rectal cancer, rectal prolapse

Prostate enlargement Benign prostatic hypertrophy

Prostate nodules Prostate cancer

Rectal mass, occult blood Colorectal cancer

Urinary incontinence Bladder or uterine prolapse, detrusor instability, estrogen deficiency

Extremities Abnormalities of the feet Bunions, onychomycosis

Diminished or absent lower extremity pulses

Peripheral vascular disease, venous insufficiency

Heberden nodes Osteoarthritis

Pedal edema Adverse effects from medication, congestive heart failure continued

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and B 12

; calcium; iron; zinc; and other trace minerals are often deficient in the older pop- ulation, even in the absence of conditions such as pernicious anemia or malabsorp- tion.12 There are four components specific to the geriatric nutritional assessment: (1) nutritional history performed with a nutri- tional health checklist; (2) a record of a patient’s usual food intake based on 24-hour dietary recall; (3) physical examination with particular attention to signs associated with inadequate nutrition or overconsumption; and (4) select laboratory tests, if applicable. One simple screening tool for nutrition in older persons is the Nutritional Health Checklist (Table 4).13

VISION

The most common causes of vision impair- ment in older persons include presbyopia, glaucoma, diabetic retinopathy, cataracts, and age-related macular degeneration.14 The U.S. Preventive Services Task Force (USPSTF) found insufficient evidence to recommend for or against screening with ophthalmoscopy in asymptomatic older patients.15 In 1995, the Canadian Task Force on the Periodic Health Examination advised primary care physicians to use a Snellen chart to screen for visual acuity, and recom- mended that older patients who have had diabetes for at least five years have an assess- ment by an ophthalmologist. Additionally,

Table 3. Sample Focused Geriatric Physical Examination (continued)

Signs Physical sign or symptom Differential diagnoses

Muscular/skeletal Diminished range of motion, pain Arthritis, fracture

Dorsal kyphosis, vertebral tenderness, back pain

Cancer, compression fracture, osteoporosis

Gait disturbances Adverse effects from medication, arthritis, deconditioning, foot abnormalities, Parkinson disease, stroke

Leg pain Intermittent claudication, neuropathy, osteoarthritis, radiculopathy, venous insufficiency

Muscle wasting Atrophy, malnutrition

Proximal muscle pain and weakness Polymyalgia rheumatica

Skin Erythema, ulceration over pressure points, unexplained bruises

Anticoagulant use, elder abuse, idiopathic thrombocytopenic purpura

Premalignant or malignant lesions Actinic keratoses, basal cell carcinoma, malignant melanoma, pressure ulcer, squamous cell carcinoma

Neurologic Tremor with rigidity Parkinson disease

NOTE: When performing a geriatric physical examination, physicians should be alert for some of these signs and symptoms.

Table 4. Nutritional Health Checklist

Statement Yes

I have an illness or condition that made me change the kind or amount of food I eat.

2

I eat fewer than two meals per day. 3

I eat few fruits, vegetables, or milk products. 2

I have three or more drinks of beer, liquor, or wine almost every day. 2

I have tooth or mouth problems that make it hard for me to eat. 2

I don’t always have enough money to buy the food I need. 4

I eat alone most of the time. 1

I take three or more different prescription or over-the-counter drugs per day.

1

Without wanting to, I have lost or gained 10 lb in the past six months.

2

I am not always physically able to shop, cook, or feed myself. 2

NOTE: The Nutritional Health Checklist was developed for the Nutrition Screening Initiative. Read the statements above, and circle the number in the “yes” column for each statement that applies to you. Add up the circled numbers to get your nutritional score.

SCORING

0 to 2 = You have good nutrition. Recheck your nutritional score in six months. 3 to 5 = You are at moderate nutritional risk, and you should see what you can do to improve your eating habits and lifestyle. Recheck your nutritional score in three months. 6 or more = You are at high nutritional risk, and you should bring this checklist with you the next time you see your physician, dietitian, or other qualified health care pro- fessional. Talk with any of these professionals about the problems you may have. Ask for help to improve your nutritional status.

Adapted with permission from The clinical and cost-effectiveness of medical nutri- tion therapies: evidence and estimates of potential medical savings from the use of selected nutritional intervention. June 1996. Summary report prepared for the Nutri- tion Screening Initiative, a project of the American Academy of Family Physicians, the American Dietetic Association, and the National Council on the Aging, Inc.

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the task force advised that patients at high risk of glau- coma, including black persons and those with a positive family history, diabetes, or severe myopia, undergo peri- odic assessment by an ophthalmologist.16

HEARING 

Presbycusis is the third most common chronic con- dition in older Americans, after hypertension and arthritis.17 The USPSTF is updating its 1996 recom- mendations, but currently recommends screening older patients for hearing impairment by periodically questioning them about their hearing.18 Audioscope examination, otoscopic examination, and the whis- pered voice test are also recommended. The whispered voice test is performed by standing approximately 3 ft behind the patient and whispering a series of letters and numbers after exhaling to assure a quiet whisper. Fail- ure to repeat most of the letters and numbers indicates hearing impairment.19 As part of the Medicare-funded initial preventive physical examination, physicians are encouraged to use hearing screening questionnaires to evaluate an older patient’s functional ability and level of safety.20 Questionnaires such as the screening ver- sion of the Hearing Handicap Inventory for the Elderly

accurately identify persons with hearing impairment21 (Table 5 22). Additionally, patients’ medications should be examined for potentially ototoxic drugs. Patients with chronic otitis media or sudden hearing loss, or who fail any screening tests should be referred to an otolaryngologist.21,23 Hearing aids are the treatment of choice for older persons with hearing impairment, because they minimize hearing loss and improve daily functioning.23

URINARY CONTINENCE 

Urinary incontinence, the unintentional leakage of urine, affects approximately 15 million persons in the United States, most of whom are older.24 Urinary incon- tinence has important medical repercussions and is asso- ciated with decubitus ulcers, sepsis, renal failure, urinary tract infections, and increased mortality. Psychosocial implications of incontinence include loss of self-esteem, restriction of social and sexual activities, and depres- sion. Additionally, incontinence is often a key deciding factor for nursing home placement.25 An assessment for urinary incontinence should include the evaluation of fluid intake, medications, cognitive function, mobil- ity, and previous urologic surgeries.14 The single best

Table 5. Screening Version of the Hearing Handicap Inventory for the Elderly

Question Yes (4 points)

Sometimes (2 points)

No (0 points)

Does a hearing problem cause you to feel embarrassed when you meet new people?

Does a hearing problem cause you to feel frustrated when talking to members of your family?

Do you have difficulty hearing when someone speaks in a whisper?

Do you feel impaired by a hearing problem?

Does a hearing problem cause you difficulty when visiting friends, relatives, or neighbors?

Does a hearing problem cause you to attend religious services less often than you would like?

Does a hearing problem cause you to have arguments with family members?

Does a hearing problem cause you difficulty when listening to the television or radio?

Do you feel that any difficulty with your hearing limits or hampers your personal or social life?

Does a hearing problem cause you difficulty when in a restaurant with relatives or friends?

Raw score (sum of the points assigned to each of the items)

NOTE: A raw score of 0 to 8 = 13 percent probability of hearing impairment (no handicap/no referral); 10 to 24 = 50 percent probability of hearing impairment (mild to moderate handicap/referral); 26 to 40 = 84 percent probability of hearing impairment (severe handicap/referral).

Adapted with permission from Ventry IM, Weinstein BE. Identification of elderly people with hearing problems. ASHA. 1983;25(7):42.

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question to ask when diagnosing urge incontinence is, “Do you have a strong and sudden urge to void that makes you leak before reaching the toilet?” (positive likelihood ratio = 4.2; negative likelihood ratio = 0.48). A good question to ask when diagnosing stress incon- tinence is, “Is your incontinence caused by coughing, sneezing, lifting, walking, or running?” (positive likeli- hood ratio = 2.2; negative likelihood ratio = 0.39).26

BALANCE AND FALL PREVENTION

Impaired balance in older persons often manifests as falls and fall-related injuries. Approximately one-third of community-living older persons fall at least once per year, with many falling multiple times.27,28 Falls are the leading cause of hospitalization and injury-related death in persons 75 years and older.29

The Tinetti Balance and Gait Evaluation is a useful tool to assess a patient’s fall risk.28,30 This test involves observ- ing as a patient gets up from a chair without using his or her arms, walks 10 ft, turns around, walks back, and returns to a seated position. This entire process should take less than 16 seconds. Those patients who have dif- ficulty performing this test have an increased risk of fall- ing and need further evaluation.31

Older persons can decrease their fall risk with exercise, physical therapy, a home hazard assessment, and with- drawal of psychotropic medications. Guidelines address- ing fall prevention in older persons living in nursing homes have been published by the American Medi- cal Directors Association and the American Geriatrics Society.32,33

OSTEOPOROSIS

Osteoporosis may result in low-impact or spontaneous fragility fractures, which can lead to a fall.14 Osteoporo- sis can be diagnosed clinically or radiographically.34 It is most commonly diagnosed by dual-energy x-ray absorp- tiometry of the total hip, femoral neck, or lumbar spine, with a T-score of –2.5 or below.35,36 The USPSTF has advised routinely screening women 65 years and older for osteoporosis with dual-energy x-ray absorptiometry of the femoral neck.37

POLYPHARMACY

Polypharmacy, which is the use of multiple medica- tions or the administration of more medications than clinically indicated, is common in older persons. Among older adults, 30 percent of hospital admissions and many preventable problems, such as falls and confusion, are believed to be related to adverse drug effects.38 The Cen- ters for Medicare and Medicaid Services encourages the

use of the Beers criteria, which list medication and medi- cation classes that should be avoided in older persons, as part of an older patient’s medication assessment to reduce adverse effects.39,40 In 2003, a consensus panel of experts revised the criteria.41 The Beers criteria can be found at http://www.dcri.duke.edu/ccge/curtis/beers.html.

Cognition and Mental Health DEPRESSION

The USPSTF recommends screening adults for depres- sion if systems of care are in place.42 Of the several validated screening instruments for depression, the Geriatric Depression Scale and the Hamilton Depression Scale are the easiest to use and most widely accepted.43 However, a simple two-question screening tool (“Dur- ing the past month, have you been bothered by feelings of sadness, depression, or hopelessness?” and “Have you often been bothered by a lack of interest or pleasure in doing things?”) is as effective as these longer scales.43,44 Responding in the affirmative to one or both of these questions is a positive screening test for depression that requires further evaluation.

DEMENTIA

Early diagnosis of dementia allows patients timely access to medications and helps families to make preparations for the future. It can also help in the management of other symptoms that often accompany the early stages of dementia, such as depression and irritability. As few as 50 percent of dementia cases are diagnosed by phy- sicians.45 There are several screening tests available to assess cognitive dysfunction; however, the Mini- Cognitive Assessment Instrument is the preferred test for the family physician because of its speed, convenience, and accuracy, as well as the fact that it does not require fluency in English (Table 646,47).

Socioenvironmental Circumstances According to the U.S. Census Bureau, approximately 70 percent of noninstitutionalized adults 65 years and older live with their spouses or extended family, and 30 percent live alone.48 Determining the most suitable living arrangements for older patients is an important function of the geriatric assessment. Although options for housing for older persons vary widely, there are three basic types: private homes in the community, assisted living residences, and skilled nursing facilities (e.g., rehabilitation hospitals, nursing homes). Factors affect- ing the patient’s socioenvironmental circumstances include their social interaction network, available sup- port resources, special needs, and environmental safety.

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Problem List As assessment data are obtained, they need to be recorded to allow all members of the health care team to easily access the information. The family physician can generate a problem list that includes any condition or event requiring new or ongoing care; the medical, nutritional, functional, and social implications; and proposed interventions. This type of assessment allows older patients to benefit from an interdisciplinary team that is effectively assessing and actively managing their health care.

The Authors BASSEM ELSAWY, MD, is a geriatrics faculty member in the Methodist Charl- ton Medical Center Family Practice Residency Program, Dallas, Tex. He is also medical director at several long-term care and hospice facilities in Dallas.

KIM E. HIGGINS, DO, is a third-year family medicine resident at Methodist Charlton Medical Center.

Address correspondence to Bassem Elsawy, MD, Methodist Health Sys- tem, 3500 W. Wheatland Rd., Dallas, TX 75237 (e-mail: bassemelsawy@ mhd.com). Reprints are not available from the authors.

Author disclosure: Nothing to disclose.

REFERENCES

1. Xakellis GC. Who provides care to Medicare beneficiaries and what set- tings do they use? J Am Board Fam Pract. 2004;17(5):384-387.

2. American Academy of Family Physicians. Facts about family medicine. http://www.aafp.org/facts.xml. Accessed May 3, 2010.

3. National Hospital Ambulatory Medical Care Survey. Washington, DC: National Center for Health Statistics, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2005.

4. Mold JW, Mehr DR, Kvale JN, Reed RL. The importance of geriatrics to family medicine: a position paper by the Group on Geriatric Educa- tion of the Society of Teachers of Family Medicine. Fam Med. 1995; 27(4):234-241.

5. Small GW, Rabins PV, Barry PP, et al. Diagnosis and treatment of Alzheimer disease and related disorders. Consensus statement of the American Association for Geriatric Psychiatry, the Alzheimer’s Association, and the American Geriatrics Society. JAMA. 1997;278(16):1363-1371.

6. Knopman DS. The initial recognition and diagnosis of dementia. Am J Med. 1998;104(4A):2S-12S, discussion 39S-42S.

7. Landefeld CS. Improving health care for older persons. Ann Intern Med. 2003;139(5 pt 2):421-424.

8. Katz S, Downs TD, Cash HR, Grotz RC. Progress in development of the index of ADL. Gerontologist. 1970;10 (1):20-30.

9. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9(3):179-186.

10. American Geriatrics Society Ethics Committee. Health screening deci- sions for older adults: AGS position paper. J Am Geriatr Soc. 2003; 51(2):270-271.

11. Walter LC, Covinsky KE. Cancer screening in elderly patients: a framework for individualized decision making. JAMA. 2001;285(21):2750-2756.

12. Kiseljak-Vassiliades K, Aoun P, Gambert SR. Basic nutrition for successful aging: part II. Clin Geriatr. 2006;14(5):29-35.

13. The clinical and cost-effectiveness of medical nutrition therapies: evidence and estimates of potential medical savings from the use of selected nutritional intervention. June 1996. Summary report prepared for the Nutrition Screening Initiative, a project of the American Acad- emy of Family Physicians, the American Dietetic Association and the National Council on the Aging, Inc.

14. Miller KE, Zylstra RG, Standridge JB. The geriatric patient: a system- atic approach to maintaining health [published correction appears in Am Fam Physician. 2000;62(7):1519-1520]. Am Fam Physician. 2000; 61(4):1089-1104.

15. Guide to Clinical Preventive Services: Report of the U.S. Preventive Ser- vices Task Force. 2nd ed. Baltimore, Md.: Williams & Wilkins; 1996.

16. Canadian Task Force on the Periodic Health Examination. Periodic health examination, 1995 update: 3. Screening for visual problems among elderly patients. CMAJ. 1995;152(8):1211-1222.

17. Cruickshanks KJ, Wiley TL, Tweed TS, et al. Prevalence of hearing loss in older adults in Beaver Dam, Wisconsin. The Epidemiology of Hearing Loss Study. Am J Epidemiol. 1998;148(9):879-886.

18. U.S. Preventive Services Task Force. Screening for hearing impairment in older adults. In: Guide to Clinical Preventive Services. 2nd ed. Washing- ton, DC: U.S. Department of Health and Human Services; 1996.

19. Pirozzo S, Papinczak T, Glasziou P. Whispered voice test for screening for hearing impairment in adults and children: systematic review. BMJ. 2003;327(7421):967.

20. Milstein D, Weinstein BE. Hearing screening for older adults using hear- ing questionnaires. Clin Geriatr. 2007;15(5):21-27.

21. Reuben DB, Walsh K, Moore AA, Damesyn M, Greendale GA. Hear- ing loss in community-dwelling older persons: national prevalence data and identification using simple questions. J Am Geriatr Soc. 1998; 46(8):1008-1011.

Table 6. Mini-Cognitive Assessment Instrument

Step 1. Ask the patient to repeat three unrelated words, such as “ball,” “dog,” and “window.”

Step 2. Ask the patient to draw a simple clock set to 10 minutes after eleven o’clock (11:10). A correct response is drawing of a circle with the numbers placed in approximately the correct positions, with the hands pointing to the 11 and 2.

Step 3. Ask the patient to recall the three words from Step 1. One point is given for each item that is recalled correctly.

Interpretation

Number of items correctly recalled

Clock drawing test result

Interpretation of screen for dementia

0 Normal Positive

0 Abnormal Positive

1 Normal Negative

1 Abnormal Positive

2 Normal Negative

2 Abnormal Positive

3 Normal Negative

3 Abnormal Negative

Adapted with permission from Ebell MH. Brief screening instruments for dementia in primary care. Am Fam Physician. 2009;79(6):500, with additional information from reference 47.

Geriatric Assessment

56  American Family Physician www.aafp.org/afp Volume 83, Number 1 ◆ January 1, 2011

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