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An aging population brings new opportunities and challenges for primary-care providers (PCPs). Increasing numbers of older adults are presenting for office visits, almost twice as often as younger adults. This creates need and emphasizes the important role of the PCP in older-adult office visits.1
The growing number of older adults relates in part to aging baby boomers and more elders living to advanced years; this includes the oldest old and sometimes the frail elder. Since older adults are a unique population, honing elder assessment skills for efficient screening and effective care is vital. Focusing on function should be central to all evaluations of older adults and is considered a minimum competency in the care of these individuals.2,3
Since older adults often present with long histories and multiple chronic medical problems, a functional approach to assessment provides an effective and efficient method of determining individual needs.2
Functional screenings remind providers to keep the big picture in mind when assessing and diagnosing. This article provides an overview of the interplay of multiple factors associated with the aging process, key screening points in functional assessment as a basis for screening older adults to determine their health-care needs, and further resources to enhance care for elders. Functional assessment screening has particular relevance for those older adults with advanced age and multiple comorbidities.
Purposes of functional screening
Think of functional status as a snapshot of how patients are currently negotiating everyday life. Changes in patient function may be the first indicator of a decline in physical or mental health.2 Considering how common a complex presentation is in the older adult, starting with a functional screen serves multiple purposes. It can be an efficient starting point when dealing with an array of nonspecific symptoms, exploring possible etiologies, and separating normal aging changes from symptoms.
Identifying the big picture of function allows PCPs to work backward in identifying causative factors for the functional deficits, eventually leading to the capture of conventional diagnoses. Starting with functional screening provides the opportunity to gain further confirmatory data specific to patient concerns. Standardized approaches to completing and recording functional status provide the added benefit of easy comparisons over time.
The importance of functional screening
The elderly population is a heterogeneous group. In addition to having diverse cultural backgrounds, older adults differ greatly from one another in terms of functional abilities. Problems faced by this patient population are often multifactorial. Health issues or syndromes may emerge from a number of concurrent problems in the frail older adult patient. The following points summarize some complexities of assessing the older adult.
Physical aging. Multiple physiologic changes accompany the aging process, affecting each body system to some degree. These changes affect different individuals at different rates and are influenced by current and previous lifestyles.4 The ability to distinguish normal aging changes from disease states is a key competency.3
Comorbidities and chronic disease. An estimated 80% of individuals aged 65 years and older have at least one chronic disease, and as many as 50% have two or more. Assessment is complicated by the coexistence of physical changes associated with aging and symptoms from chronic disease.1
Nonspecific response to illness or masked symptoms. Unfortunately, frail elders do not always present with obvious symptoms that can be easily linked to a specific diagnosis. Such atypical responses as acute confusion or falls can indicate further systemic problems.
Syndromes. Elders often present with syndromes or functional deficits that differ from traditional medical diagnoses. Syndromes—defined as a common collection of symptoms (e.g., incontinence or dementia)—are frequently identified in elders.4 There are benefits to the advice, “Think syndromes,” as typical diagnoses do not always match presenting symptoms.
Acute problems on top of chronic illness. Acute problems on top of chronic illness also need to be considered. For example, acute physical illnesses can exist concomitantly with dementia. Recognizing and treating such acute problems as urinary tract infections (UTIs) is critical because of the potential physical and functional consequences of these conditions.
Medication regimens. Medications can benefit or confound treatment of elders. Extensive lists of medications — sometimes from multiple providers and pharmacies — present a plethora of challenges. OTC medications are frequently incorporated into this mix. Polypharmacy often leads to otherwise preventable problems for elders.
Primary-care office visits and functional screening
Functional screening components can be completed separately or integrated into a more traditional systems review. Complementary to the more typical disease-focused history and physical, the functional screen promotes mindfulness of potential common problems in individuals of advanced age. Completing at least simple screens of frequently seen problem areas helps the clinician identify important factors that can affect treatment plans. Approaches to the primary-care screening can be organized into three areas: (1) initiating the visit; (2) key functional screening areas; and (3) visit closure.
Initiating the visit
Ask the patient to bring in his or her medical passport/health summary and medications. Since longevity means more information to share, coaching patients to bring even a simple passport with approximate dates of acute illnesses or surgeries and ongoing chronic problems can make the visit more efficient. Additionally, asking patients to keep and share symptom journals can improve time management and quality of care. Bags of clearly labeled medication containers allows the PCP to compare the patient’s understanding with the written expectations.
For complex patient presentations, the PCP may find it useful to develop a worksheet that summarizes functional issues along with traditional diagnoses and ongoing treatments. Organizing major points may help synthesize and identify health-related patterns. Concerns can emerge that are not otherwise evident and can help name the patient problem or identify areas requiring further workup.
Key functional screening areas
A systematic functional screen helps sort out the often complex presentations as well as differentiate normal aging changes from physical diagnoses. Key components to address in this systematic screen include: sensory status, cognitive and behavioral disorders, mobility and function, eating and nutrition, incontinence/elimination issues, and social support/environmental resources. Table 1 lists commonly recommend screenings from the literature. Successful responses to the task or question indicate a negative screen. Positive findings call for more detailed workup.
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
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