Sensory status. A majority of older adults have visual and hearing impairments that can often be improved with corrective devices.2 Given the vital roles of vision and hearing in communication and social activity, the importance of screening for opportunities to improve these senses cannot be overstated.
Presbyopia (age-related diminished vision) and presbycusis (age-related gradual high-frequency hearing loss) are common physical changes. Elders can be screened quickly for these problems. For example, check visual acuity by asking the patient to read large print or complete a Snellen chart screen with corrective lenses in place. Either audiometry or the whispered-voice test (in which the examiner, out of the patient’s view, asks the patient to repeat a whispered phrase) serves as a simple screen of functional hearing.2
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Check for hearing deficits related to cerumen impaction. Any vision or hearing deficits indicate the need for patient follow-up to determine opportunities for corrective devices that can promote safe and meaningful interaction.
Cognitive and behavioral disorders. Sometimes referred to as “the three Ds,” depression, dementia, and delirium can be common in the oldest-old population and a challenge to differentiate. Any of these deficits impact overall function.
Depression has been called the common cold of late life. Late-onset disorders may relate to late-life stressors. Multiple physical and emotional losses in aging are painful and can compound the potential for depression.
Screening for depression is important since symptoms can be more nonspecific in elders. A basic screening question asks, “Have you been bothered by feeling sad or hopeless in the past month?” Follow-up to a positive response should include a standardized test, such as the Geriatric Depression Scale.5 Weight loss can indicate a need for further depression screening. Elderly white men have the highest rate of completed suicide, making screening for and follow-up treatment of depression in older adults imperative.6 Include questions about alcohol intake or substance abuse; these are common sources of relief from emotional pain.7
Dementia typically has a slow, insidious progression of symptoms. An estimated 50% of persons aged 85 years and older will be affected by or develop Alzheimer disease (AD).8 A simple screen includes asking an older patient to repeat three unrelated words provided by the examiner and then to recall these words three minutes later. Forgetting the words indicates the need for follow-up with the either the Mini-Cognitive Assessment Instrument (Mini-Cog) (Table 2) or the Mini-Mental State Examination to gain more detailed information.7
Delirium — an acute but treatable syndrome — must be differentiated from dementia, which has a slow and chronic progression. A history of rapid functional change or change in patient behavior (e.g., increased lethargy, confusion, or agitation) is often the first sign of an acute problem. Such infections as UTI or pneumonia are common causes of delirium. Fluid and electrolyte imbalances, constipation/impaction and adverse drug reactions are other common differentials. Approaches to evaluating rapid functional change should focus on identifying acute causative factors.
