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Geriatrics is the branch of medicine concerned with the health and care of older adults, defined by the American Geriatrics Society (AGS) as adults aged 65 years or older. Normal (e.g., stiffening of arteries, osteoporosis, decline in cognitive function) predispose older adults to multiple chronic conditions, disability, adverse pharmacological reactions, and decreased quality of life. A comprehensive geriatric assessment, usually performed by a primary care physician, can help identify older adults' health care needs and develop management plans that improve their well-being. This assessment involves evaluating functional status, screening for geriatric syndromes (e.g., frailty, cognitive impairment, and malnutrition), providing appropriate preventive care, assessing medications, and establishing treatment goals and advance directives. Older adults with significant impairment or complex care needs may require referral to a geriatrician. Depending on their current functional status and care needs, the appropriate care setting for an older adult may be a private home, a short-term post-acute care facility (an acute inpatient rehabilitation facility or a skilled nursing facility), or a long-term care facility (an assisted living facility, nursing home, or long-term acute care hospital).
General principles 
- Usually a multidisciplinary assessment led by a primary care physician or geriatrician
- Includes typical elements of a clinical examination with additional emphasis on assessing functional and cognitive abilities
- Explores social and environmental factors impacting a patient's functional status
The geriatric assessment can be performed over multiple scheduled visits as necessary. 
- At the start of any hospital admission for older adults 
- Consider outpatient geriatric assessment if patients present with any of the following: 
Geriatric assessments allow for the early identification and management of conditions that can impact functional status and quality of life. Therefore, they are usually inappropriate for patients with end-stage disease (e.g., advanced dementia, terminal cancer) or complete functional dependence. 
- Perform a functional status assessment.
- Screen for geriatric syndromes.
- Assess social factors.
- Provide appropriate preventive care.
- Establish a care plan according to the patient's needs and preferences.
- Discuss the importance of establishing timely
- Preferences for future medical care and interventions
- A surrogate decision-maker
- Multiple referrals, e.g., to a nutritionist, physical therapist, and social worker, are often required.
- Consider referral to a geriatrician if the patient is: 
Functional status assessment
Functional status assessment 
Functional status assessments are used to evaluate an individual's ability to perform tasks of daily living in order to determine their care needs.
Over 50% of adults require help with activities of daily living by the age of 90 years. 
Basic activities of daily living (ADLs)
Definition: six basic self-care tasks performed daily 
- Transferring (getting in or out of bed or standing up from a chair)
- Example screening tools
Standard physical examination: Look for features suggesting difficulties with ADLs.
- Grooming and hygiene 
- Signs of injuries suggestive of unsteadiness/falls
- Ability to dress/undress (e.g., button shirt, take off shoes)
- Ability to move from a chair to the examination table
Always look at the feet! Uncut toenails may provide the first clue to impaired functional status in older adults. 
Instrumental activities of daily living (IADLs)
Definition: eight standard activities required to live independently
- Grocery shopping
- Doing laundry
- Using the telephone
- Preparing meals
- Example screening tool: Lawton IADL scale
Advanced activities of daily living (a-ADLs)
A decline in a-ADLs may indicate early cognitive impairment.
Definition: nonessential activities that require a high level of cognitive functioning, e.g. : 
- Use of electronic devices (e.g., cell phone, computer)
- Example screening tool: Late-life function and disability instrument (LLFDI) 
Confirm that a change in a-ADLs is not due to physical or other limitations (e.g., limited mobility, lack of opportunity) before attributing it to possible cognitive impairment. 
- A group of complex health conditions that may result from multiple risk factors and organ system impairments
- Makes individuals vulnerable to additional physical stressors or insults
- Risk factors increase with age and may include:
|Screening for geriatric syndromes |
|Syndrome||Indications for screening||Example screening methods|
|Frailty|| || |
|Cognitive impairment and dementia|| |
|Malnutrition in older adults|| |
|Hearing loss|| |
|Vision loss|| |
|Urinary incontinence|| |
|Decubitus ulcers|| || |
Up to 80% of cognitive impairment diagnoses are missed by primary care physicians. 
Frailty assessment 
- Consider for all older adults.
- Outpatient screening is particularly important for patients at increased risk, e.g.: 
- Current or former smokers
- Individuals negatively impacted by
- Patients with specific comorbidities
- Screen older adults on admission to hospital to help establish prognosis and care goals. 
- Example screening tools
Management of frailty 
- Refer for a multicomponent physical activity program that includes resistance and balance training.
- Address contributors, e.g., polypharmacy, weight loss, fatigue.
- Consider the need for social support.
Falls in older adults 
The following guidance is based on the current CDC STEADI algorithm for falls. 
Ask all older adults annually: Have you fallen in the past year?
- If yes: What were the circumstances of the fall(s)?
- If no, ask:
- Do you feel unsteady when standing or walking?
- Are you worried about falling?
- If yes to any question: at risk for falls; perform a fall risk assessment.
- If no to all questions: Recommend general fall prevention strategies (see “Fall prevention in older adults”).
Older adults should be screened for fall risk annually, beginning with the question, “Have you fallen in the past year?” 
Fall risk assessment
This should be performed for patients who screen positive for fall risk or who present after an acute fall.
- Identify risk factors, including:
Perform a physical examination, including:
- Postural vital signs (to identify orthostatic hypotension)
Musculoskeletal tests to evaluate gait, strength, and balance, e.g.: 
Get up and go test
- Ask the patient to get up from a straight-backed chair, walk 3 m (10 ft), turn around, walk back, and sit down again.
- The result is abnormal if patients have qualitative impairments or the test takes > 12 seconds. 
- Performance-oriented mobility assessment ( ) 
- Get up and go test
- Visual acuity testing
- Feet and footwear assessment 
Fall prevention in older adults 
The aim of preventive measures is to maximize the patient's independence and safety in line with their values and preferences.
- Provide general education, e.g., on medication interaction risks, appropriate footwear, home hazards.
- Recommend regular exercise (including aerobic, balance, and strength training). 
- Ask about vitamin D intake (from diet, supplements, sunlight) and risk factors for vitamin D deficiency; consider recommending a supplement. 
As indicated according to risk assessment
- Optimize the management of comorbidities, including medication adjustments.
- Minimize the number of medications that may contribute to falls; (see “” below for details).
- Refer to occupational therapy for a .
- Evidence of poor gait, strength, or balance: Refer for physical therapy.
- Consult additional specialists as required (e.g., ophthalmologist, podiatrist).
- For hospitalized patients, consider additional measures. 
Falls are the leading cause of injury-related death in adults aged ≥ 65 years. 
Neuropsychological assessment in older adults 
Example screening tests: see also “Cognitive testing.”
- Patient: MMSE  , , or
- Carer: Informant questionnaire on cognitive decline in the elderly 
Management considerations: see also “Management of major neurocognitive disorder.”
- Consider a diagnosis of dementia), especially in patients with acute or fluctuating symptoms. (instead of or in addition to
- Early diagnosis of MCI is important, as interventions such as aerobic exercise may help prevent progression to dementia (see “Prevention of dementia”). 
- For patients who drive and have a diagnosis of MCI or dementia, check state laws to determine if: 
- Patients are required to take an annual test to maintain their driver's license.
- Physicians are mandated to report MCI diagnoses to the Department of Motor Vehicles.
Continuity of care is important for the early detection of signs of cognitive decline. 
- Indication: Screen all patients annually.
Example screening tests
- ≥ 3) or (followed by if score is
- GDS-15 
- Management considerations: See “Depression in older adults.”
Nutritional assessment in older adults 
- Indication: Consider screening all older adults annually.
- Screening options
- Monitor weight and .
- Ask the patient if they have lost weight in the past six months.
- Ask the patient or caregiver to complete the .
- Any of the following are considered a positive screen and should prompt further evaluation:
- Screening options
A BMI < 23 kg/m2 is associated with increased mortality in older adults. 
Unintentional weight loss in older adults 
Etiology: no identifiable cause in ∼ 25% of patients. Causes may include:
- Malignancy or other acute or chronic disease
- Psychiatric or neurological conditions
- Oropharyngeal problems
- Functional disability
- Social factors
- Adverse effects of medications
- Treat the underlying cause; if the cause is unknown, consider close observation for 3–6 months, then reevaluate. 
- Optimize eating. 
- Refer to a dietitian for counseling.
- Recommend smaller, more frequent meals and snacks.
- Ensure foods are appealing, varied, and adapted for any swallowing difficulties.
- Encourage eating with others. 
- Ensure patients with difficulties feeding themselves receive adequate assistance at mealtimes.
- Refer to nutritional support programs in the community, if available.
- Avoid appetite stimulants (e.g., megestrol) and oral nutritional supplements in most patients. 
- Consider supplements for patients who are either : 
- Unable to increase caloric intake with foods
- Currently hospitalized or post-discharge
- For patients with comorbid depression, mirtazapine may be appropriate. 
- Encourage regular exercise. 
Do not routinely prescribe appetite stimulants or high-calorie supplements to improve appetite or increase weight in older adults. 
For information on living arrangements, see “Care settings for older adults.”
- Evaluate for:
- Social support, e.g., by asking about: 
- Who the patient lives with
- The frequency of visits from friends and/or family
- The number of close friends available for emotional support
- Availability of help in case of sickness or disability
- Financial difficulties, e.g., ability to pay for food, medication, and rent
Risk factors for , e.g. : 
- Isolation and lack of social support
- Functional impairment
- Decreased physical health
- Lower income
- Living in a shared space with many household members
- Social support, e.g., by asking about: 
- If concerns are identified:
- Refer to social work or contact Social Services.
- For patients experiencing loneliness or social isolation, consider: 
Social isolation, both objective and perceived, increases the risk of mortality in older adults. 
Contact if is suspected.
Opportunities for preventive care
- Chronic conditions
- Immunizations: Determine if vaccinations are up-to-date according to the , including
- Lifestyle factors: If remaining life expectancy is ≥ 5 years, ask about these factors regularly and provide necessary counseling. 
Driving assessment: Assess older adults with risk factors, e.g. : 
- Conditions, medications, or symptoms that could impact driving
- New functional impairment
- Concerns from caregiver(s)
General principles 
- The impact of aging on pharmacokinetics increases the likelihood of adverse effects and interactions in older adults (see “Fundamentals of pharmacology”). 
- Polypharmacy in older adults is common (especially in those living in long-term care facilities) because of multiple comorbidities. 
- Older age, polypharmacy, and limited health literacy all contribute to an increased risk of medication errors. 
- Lower starting doses, slow titration, and frequent reviews are recommended. 
Principles of prescribing for older adults 
- Consider if nonpharmacological alternatives, e.g., diet or exercise, are more appropriate. 
- Check if existing medications may be causing the current symptoms (i.e., avoid the prescribing cascade).
- Consult the Beers criteria to determine if the medication is suitable in older adults.
- Review existing medications for potential interactions (see “Polypharmacy”).
- Use with the patient and/or their carer, considering the following patient factors:
- Select the correct dosage. 
- Select the correct formulation: Consider difficulties with swallowing. 
Provide clear instructions. 
- Explain what the medication is for and how it works.
- Support dosage information with written instructions.
- Advise patients on common adverse effects and what to do if they occur.
Consult the Beers Criteria and perform a medication review before prescribing new medication for older adults. 
- Monitor patients regularly. 
- Consider adjusting the dose of long-term medications as patients age. 
- Regularly review medications to see if they are still appropriate. 
- Definition: the regular and concurrent use of multiple medications (usually defined as ≥ 5 medications) 
- Age > 62 years
- Cognitive impairment, frailty, mental health conditions, or developmental disability
- Complex care needs, e.g., multiple chronic conditions or care involving multiple subspecialists
- No primary care physician
- Living in a long-term care facility
- Consequences include increased risk of:
- Conduct a (e.g., brown bag medication review).
- When considering adding a new medication, follow principles of prescribing for older adults.
- For patients requiring multiple medications, consider strategies to help patients take them correctly (e.g., use of pillboxes, written instructions).
Patients who see multiple subspecialists are at increased risk of polypharmacy; primary care physicians should regularly undertake medication reviews for patients with multiple comorbidities. 
Polypharmacy in older adults is associated with an increased risk of , cognitive and functional decline, and falls. 
Beers criteria 
- The AGS Beers criteria are recommendations for pharmacological care in older adults to improve medication selection and reduce adverse events.
- Recommendations are divided into the following categories:
- Many commonly prescribed drugs (e.g., NSAIDs, proton pump inhibitors, opioids, benzodiazepines) may be harmful in older adults.
|2019 AGS Beers criteria: selected medication recommendations |
|Drug class||Potentially problematic medications||Effects||Recommendations|
|CNS-active drugs|| |
|Antidiabetics|| || |
|Antihypertensives|| || |
| || |
General principles 
- There are three basic types of care settings for older adults:
- Community-based care
- Short-term post-acute care facilities
- Long-term care facilities
- When deciding on an appropriate care setting, consider:
- The patient's functional status assessment
- Social factors (see “Assessment of social situation”)
- The needs and preferences of the patient, family, and/or caregiver
- Use the change in care plan as an opportunity to discuss . 
- Periodically reassess the need for relocation to another care setting.
In the US, the Eldercare Locator Hotline (1-800-677-1116) and website (https://eldercare.acl.gov) can be used to find appropriate services.
- Consider the need for a
; for patients with significant physical impairments: 
- Renovation work, e.g., adding a bathroom on the first floor, may be necessary.
- A move to preadapted or more suitable housing (e.g., a single-storey house) may allow independent living for longer.
- Ensure that the individual is able contact emergency services if required.
- Evaluate the need for additional services, such as:
- A part-time or full-time caregiver (e.g., a home health aide) depending on the individual's functional status
- Therapy services (e.g., physical therapy, occupational therapy) provided at home or at an outpatient facility
- Referral to community services, e.g.: 
Talk separately to the primary caregiver to assess for and prevent . Informal caregiving (i.e., volunteering to take care of a friend or family member) can impact mental and physical health. 
Short-term post-acute care facilities 
These facilities provide specific services for all adults on a short-term basis following discharge from the hospital.
Acute inpatient rehabilitation facility
- Provides multidisciplinary intensive rehabilitation therapies and nursing services
- To qualify for Medicare reimbursement, patients must both: 
- Require multiple forms of therapy, at least one of which must be physical or occupational
- Be able to participate in therapy for 3 hours per day for 5 days per week 
- Skilled nursing facility (SNF)
Long-term care facilities 
Residential long-term care is often required if an older adult requires ongoing assistance.
Assisted living facility
- Provides personal care services and some health-related care with 24-hour supervision
- Residents have fewer assistance requirements than nursing home residents. 
- A physician is not routinely present.
- Typically provides two levels of long-term care:
- Skilled nursing care 
- Custodial (nonmedical) care 
- A physician is available 24 hours a day. 
- Typically provides two levels of long-term care:
Long-term acute care hospital (LTACH) 
- Provides care for patients with complex medical needs (e.g., ventilator-dependent), typically following a critical illness
- Stays are prolonged (≥ 25 days).
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