G e r i a t r i c S y n d ro m e s a n d

Geriatric Assessment for

the G eneralist
Charlotte Carlson, MD, MPHa,*, Susan E. Merel, MD
b
,
Michi Yukawa, MD, MPHc

KEYWORDS
 Geriatric syndromes  Geriatric assessment  Frailty  Care delivery systems
 Primary care

KEY POINTS
 It is crucial to recognize geriatric syndromes, multifactorial conditions occurring primarily
in the elderly, in the primary care setting.
 The most important geriatric syndromes to recognize in primary care are falls, urinary
incontinence, frailty, and cognitive impairment.
 Elements of ideal geriatric primary care include assessment of functional status, frequent
medication review, careful evaluation of the benefits and burdens of any new test or treat-
ment, and frequent assessment of goals of care and prognosis.
 Innovative delivery systems, such as the GRACE, PACE, and Hospital-at-Home models,
can improve geriatric primary care. High-value features of geriatric care systems include
ensuring 24/7 access to care, providing a team-based approach to care, performing
medication reconciliation and comprehensive geriatric assessments, and integrating palli-
ative care into treatment planning.

INTRODUCTION

With an unprecedented growth of the aging population anticipated in the next century,
understanding the health needs and demands of older adults is of crucial importance
for the future of the US health care system. By 2050, 1 of every 5 people living in the
United States will be 65 or older.1 As more Americans are living longer, the practicing
generalist clinician will need to use geriatric principles, tools, and approaches in his or
her everyday work.

a
On Lok Senior Health by Institute of Aging, 3575 Geary Boulevard, San Francisco, CA 94118,
USA; b Division of General Internal Medicine, Department of Medicine, University of Washington,
1959 NE Pacific Street, Box 356429, Seattle, WA 98195, USA; c San Francisco VA Medical Center,
4150 Clement St, San Francisco, CA 93121, USA
* Corresponding author.
E-mail address: [email protected]

Med Clin N Am 99 (2015) 263–279

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264 Carlson et al

What is different about caring for an older adult? As a group, older adults have
increased rates of comorbidity, experience unique age-related physiologic changes,
and are more prone to iatrogenic illness than younger adults.2 Most older adults
have at least one chronic disease, if not multiple diseases, and substantial numbers
will have impairments in abilities to perform basic and instrumental activities of daily
living.3 The US elderly population is also heterogeneous, and many people in the older
than 65 age group are healthy, health conscious, and infrequent users of health care.
Geriatric assessment is a multifaceted approach that focuses on understanding the
physical, cognitive, psychological, and social domains of an individual older adult. A
crucial component of geriatric assessment includes the screening and evaluation for
geriatric syndromes. Geriatric syndromes acknowledge the complex interplay be-
tween age-related physiologic changes, chronic disease, and functional stressors in
older adults. The approach to managing key geriatric syndromes in the outpatient
setting (falls, cognitive impairment, incontinence, and frailty) is outlined in this article,
and tools for the practicing clinician to diagnose and treat geriatric syndromes in the
office visit also are provided.
Coordinating a comprehensive plan for a complex geriatric patient across multiple
health care settings is a challenging task, and often requires fundamental system
redesign to improve quality and coordination of care. As care of an older adult often
extends across a variety of care settings, including hospital, ambulatory clinic, reha-
bilitation center, and community-based long-term care settings, geriatric care delivery
is complex, and depends on coordination of multiple providers. As an introduction to
geriatric care system design, this article outlines high-value system features of geri-
atric care, and describes examples of current geriatric care models.

GERIATRIC SYNDROMES, FUNCTIONAL STATUS, AND THE FRAIL ELDERLY PATIENT IN

PRIMARY CARE

A geriatric syndrome is a multifactorial condition that involves the interaction between

identifiable situation-specific stressors and underlying age-related risk factors, result-
ing in damage across multiple organ systems.4 Geriatric syndromes have a devastating
effect on the individual’s quality of life as they progress, may lead to significant
disability, and are part of the “cascade to dependency” that can often result in institu-
tionalization.5,6 An elderly patient whose chief complaint is a result of a geriatric syn-
drome will often present with symptoms that are difficult to attribute to the organ
system causing the initial pathology. The geriatric syndromes most relevant to those
caring for older adults in the outpatient setting are falls, cognitive impairment, inconti-
nence, and frailty.
Clinicians should attempt to treat or manage a geriatric syndrome even though a
single cause may not be able to be identified. Whereas in a younger person a workup
may look primarily for single diseases, the interaction of multiple physiologic changes
and comorbidities in an older adult warrant a broader perspective. Diagnostic testing
that would be relevant in a younger person may not be as beneficial in an older person,
and/or may lead to unnecessary treatment and/or harm for the patient. For example, in
the case of a fall, although an echocardiogram would be a likely part of the diagnostic
workup for a younger individual to rule out cardiac syncope, in an older adult, pursuing
an echocardiogram may be more likely to result in abnormalities that may lead to un-
necessary further diagnostic testing. Box 1 further illustrates the difference between a
traditional medical approach and the geriatric approach to a fall.
Geriatric syndromes overlap with common aging-related risk factors. In a
population-based cohort of community-dwelling elderly patients with falls,

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 Geriatric Assessment 265

Box 1
Comparison of traditional medical approach and geriatric approach to a syndrome, using falls
as an example

Traditional Medical Approach

Diagnosis and Treatment
1. Extensive search for cause of falls in most patients (eg, cardiac monitoring and
echocardiogram, neurologic workup with imaging if indicated, tilt-table testing)
2. Medical treatments directed at likely causes (eg, rate control for atrial fibrillation,
pacemaker for bradycardia, medical treatment for peripheral neuropathy)
Geriatric Approach
Risk Factor Assessment and Reduction
1. More limited search for medical cause of falls in some patients (eg, cardiac monitoring only
for clearly syncopal falls and only if treatment of cardiac condition would be within goals of
care)
2. More limited set of medical treatments if a clear medical cause of falls is found
3. Assess for risk factors for multifactorial mechanical falls and target interventions toward
eliminating risk factors (eg, strength training for leg weakness, training in use of assistive
device for transfers if falls occur during transfers, home safety evaluation by occupational
therapist, and installation of lights at home if falls triggered by inadequate lighting).

Adapted from Labella AM, Merel SE, Phelan EA. Ten ways to improve the care of elderly
patients in the hospital. J Hosp Med 2011;6:362; with permission.

incontinence, and functional dependence, Tinetti and colleagues7 found 4 indepen-

dent predisposing factors: upper and lower extremity weakness, decreased vision
and hearing, and anxiety or depression. Similarly, Inouye and colleagues8 performed
a systematic review of studies identifying risk factors for pressure ulcers, inconti-
nence, falls, functional decline, and delirium and found that older age, functional
impairment, cognitive impairment, and impaired mobility were shared risk factors.
Interventions may be effective in preventing some of these shared risk factors and
therefore managing more than one geriatric syndrome. For example, strategies for
management of delirium also may reduce falls, and Tai Chi may be helpful in prevent-
ing both falls and cognitive decline.9,10
Frailty is an important concept in geriatrics and has been described as “the over-
arching geriatric syndrome” due to its importance in predicting treatment benefit
and prognosis (Fig. 1).5 There are a number of subtly different definitions of frailty

Fig. 1. The relationship between risk factors, geriatric syndromes and poor outcomes. (Adapted
from Inouye SK, Studenski S, Tinetti ME, et al. Geriatric syndromes: clinical, research, and policy
implications of a core geriatric concept. J Am Geriatr Soc 2007;55:782; with permission.)

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266 Carlson et al

used in geriatric research, but the definition most relevant to the practicing clinician is
a clinical syndrome including 3 or more of the following: unintentional weight loss, self-
reported exhaustion, weakness, slow walking speed, and/or low physical activity
(Box 2).11 Fried and colleagues11 showed that the frailty phenotype in elders followed
over a 3-year period is independently predictive of incident falls, disability, hospitaliza-
tion, and death. Furthermore, frail elders are at an increased risk for developing other
geriatric syndromes.5 Identifying frailty in a patient often can change the trajectory of
care, because it implies a more limited life expectancy and increased disease burden.
Evaluation of functional status is an important component of geriatric assessment
and should be part of routine geriatric care. Functional impairment, defined as a lim-
itation on a person’s ability to perform basic tasks, such as bathing or dressing, may
be the first harbinger of a geriatric syndrome. For example, a study of preclinical
disability in community-dwelling older adults with normal cognition and mild cognitive
impairment (MCI) suggested that inability to perform 2 specific instrumental activities
of daily living (IADLs), shopping and balancing one’s checkbook, correctly classified
80% of the cohort as having MCI; difficulty with these 2 IADLs was more accurate
in discriminating those with normal cognition from those with MCI than Mini-Mental
State Examination (MMSE) scores or depressive symptoms.12 Conversely, specific
conditions that are commonly discovered as part of evaluation for geriatric syn-
dromes, such as extremity weakness, depression, and vision and hearing loss, are
predictors of future functional decline both on their own and as part of a geriatric syn-
drome (eg, a patient with hearing loss may be at increased risk for falls and also may
develop functional disability related specifically to the hearing loss, such as the
inability to use a telephone to complete his or her IADLs).13
Evaluating functional status, frailty, and other geriatric syndromes while simulta-
neously addressing individual disease processes is at the heart of geriatric approach
to primary care (Fig. 1). Switching from a single disease framework to a broader ho-
listic approach, as outlined in Boxes 3 and 4, helps tailor care planning to the individ-
ual patient and maximizes the overall treatment benefit. Studies have found that using
a geriatric approach that focuses on functional assessment improves ability of a pa-
tient to comply with the treatment plan and helps prevent adverse drug events.14
Furthermore, developing a comprehensive assessment of the geriatric patient helps
to guide decision-making and incorporate patient preferences into decisions, helping
patients and families evaluate whether evidence-based treatments will truly benefit a
specific older adult.15

Box 2
Definition of frailty
A clinical syndrome including 3 or more of the following:
1. Unintentional weight loss of more than 10 lb in the previous year
2. Self-reported exhaustion
3. Weakness (as measured by grip strength in the lowest 20% by gender and body mass index)
4. Slow walking speed (in the lowest 20% by gender and height)
5. Low physical activity (as measured by kcal/wk in the lowest 20%)

Note: this is a definition for research purposes and cannot be measured precisely in the clinic
setting, but provides a helpful framework.
Adapted from Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a
phenotype. J Gerontol A Biol Sci Med Sci 2001;56:M148; with permission.

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 Geriatric Assessment 267

Box 3
Ten ways to optimize primary care for the frail elderly in the traditional primary care setting

1. Learn to quickly identify frail elderly patients; they are most vulnerable to adverse
outcomes and most benefit from a holistic geriatric approach
2. Be aware of common geriatric syndromes, including falls, delirium/cognitive impairment,
functional dependence, and urinary incontinence and consider them in every patient
3. Familiarize yourself with efficient assessment tools for geriatric syndromes; teach
nonphysician staff to administer them when possible
4. Be familiar with community resources, such as fall prevention programs, PACE programs,
and senior centers
5. Consider a patient’s goals, life expectancy, and functional status before considering any
test or procedure
6. Review advanced directives and goals of care periodically
7. Familiarize yourself with the Beers Criteria, use it to identify potentially inappropriate
medications in the elderly and perform comprehensive medication review periodically
8. Adopt an evidence-based approach to health screening in the frail elderly
9. Have a high suspicion for mood disorders in the frail elderly and consider using geriatric-
specific screening tools, such as the 5-item Geriatric Depression Scale
10. Provide caregiver support when possible.

Adapted from American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American
Geriatrics Society updated Beers criteria for potentially inappropriate medication use in older
adults. J Am Geriatr Soc 2012;60:616–31; and Hoyl MT, Alessi CA, Harker JO, et al. Development
and testing of a five-item version of the geriatric depression scale. J Am Geriatr Soc
1999;47:873–8.

A PRACTICAL APPROACH TO THE ASSESSMENT OF SPECIFIC GERIATRIC SYNDROMES

A complete assessment of geriatric syndromes often requires an interprofessional

team approach, which may not be readily available in the typical outpatient practice.
However, there are evaluation tools that can be performed relatively quickly that are
just as effective in diagnosing geriatric syndromes. A brief approach to screening of
the 4 most common geriatric syndromes, falls, cognitive impairment, urinary inconti-
nence, and frailty, are addressed in the following sections.
Falls
Approximately one-third of community-dwelling adults older than 65 have 1 fall per
year.16 Some risk factors for falls can be modified, whereas others cannot be
improved.17 The American Geriatrics Society and the British Geriatrics Society devel-
oped a fall prevention algorithm that can be easily used for fall assessment (Fig. 2).18 A
comprehensive fall evaluation requires an interprofessional team approach, but the
initial assessment can be performed in primary care clinics. Simple tests, such as
the Get Up and Go and Functional Reach Tests, can be done in less than a minute
and can provide accurate risk for falls (Table 1).19–23 A thorough physical examination
should include a vision test and a thorough examination of the patient’s feet and
shoes. Laboratory tests may include a complete blood count to rule out significant
anemia, a chemistry panel to rule out electrolyte abnormalities, and Vitamin B12
and 25-OH Vitamin D levels. After the clinician has completed the falls assessment,
he or she should consider simple evidence-based interventions, including referral to
a physical therapist for balance and strengthening exercises and occupational

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268 Carlson et al

Box 4
Suggested approach to the evaluation and management of the older adult with
multimorbidity
Based on recommendations of the American Geriatrics Society Expert Panel on the Care of
Older Adults with Multimorbidity
1. Inquire about the patient’s and/or caregiver’s primary concern and/or objectives for visit.
2. Conduct a complete review of the care plan for the person with multimorbidity OR focus
on a specific aspect of care.
3. What are the current medical conditions and interventions? Is there adherence/comfort
with the treatment plan?
4. Consider patient preferences.
5. Is relevant evidence available regarding important outcomes?
6. Consider the patient’s prognosis.
7. Consider interactions within and among treatments and conditions.
8. Weigh benefits and harms of components of the treatment plan.
9. Communicate and decide for or against implementation or continuation of intervention/
treatment.
10. Reassess at selected intervals for benefit, feasibility, adherence, and alignment with
preferences.

Adapted from American Geriatrics Society Expert Panel on the Care of Older Adults with Multimor-
bidity. Patient-centered care for older adults with multiple chronic conditions: a stepwise approach
from the American Geriatrics Society. J Am Geriatr Soc 2012;60:1958; with permission.

Fig. 2. Falls assessment algorithm. (Adapted from Panel on Prevention of Falls in Older Per-
sons, American Geriatrics Society and British Geriatrics Society. Summary of the updated
American Geriatrics Society/British Geriatrics Society clinical practice guideline for preven-
tion of falls in older persons. J Am Geriatr Soc 2011;59:150.)

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 Geriatric Assessment 269

Table 1
Assessment tools for falls/gait abnormality

Assessment
Tools for Falls Brief Description
Performance-Oriented Patient is asked to perform a series of maneuvers that test the quality
Mobility Assessment of transfer, balance, and gait (ie, sitting balance, rising from a chair,
standing balance, 1-leg balance, balance with eyes closed). Each
movement is rated as normal, adaptive, or abnormal.19
Short Physical Tests of standing balance (tandem, semitandem and side-by-side
Performance Battery stands).
Test of walking speed (8-foot walking speed).
Test of ability to get up from a chair with arms across the chest.20
Berg Balance Test 14-item test including sitting to standing, standing unsupported,
sitting unsupported, transfers, standing with eyes closed, reaching
forward with an outstretched arm, and so forth. Each task is scored
from 0–4. Maximum score is 56 and score <45 imply increased risk
for falls.21
Get Up and Go Patient is asked to get up from an armchair without using his or her
hands. Then patient walks across the room (3 m) and turns and
walks back to the chair and sits down. If this test takes >13.5 s to
complete then he or she is at risk for future falls.22
Functional Patient is asked to stand perpendicular and close to a wall with arms
Reach Test forward. Then ask the patient to extend the arm forward as far as
possible without losing balance to taking a step. Measure the
difference in arm stretch from standing to the reached position. If
the functional reach is <10 inches then he or she has increased risk
for falling.23

therapists for home safety evaluation; collaboration with a pharmacist to review and
adjust medications; and ophthalmology evaluation.

Cognitive Impairment
Cognitive impairment and dementia are conditions feared by older adults and their
families because of chronic, debilitating decline, resulting in loss of personality and in-
dependence. Dementia is common, with a prevalence of dementia of 5% for adults
aged 71 to 79 and 24% for a person between the ages of 80 and 89. For adults older
than 90 years, dementia prevalence rate is 37%.24
The most commonly used screening tests for cognitive impairment are listed in
Table 2. Whereas the MMSE is the most commonly used test for research purposes,

Table 2
Screening tests for cognitive impairment

Tests Description
MMSE 30-item test that is copyright protected. Need to adjust for age
and level of education. Score 24 is considered abnormal.
Montreal Cognitive 30-item test that has been validated in multiple languages. It is
Assessment (MoCA) not copyright protected. It can be downloaded free at www.
mocatest.org. Score of 26 is considered abnormal.26
Mini-cog Clock-drawing test and 3-item recall. If both are normal, then rule
out cognitive impairment. If either one is abnormal, then screen
in as cognitive impairment.27

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270 Carlson et al

it is copyright protected. However, the MoCA and Mini-cog tests may be used freely in
the clinic, and are just as sensitive and specific in screening for cognitive deficit as the
MMSE.25–28
Laboratory tests should be ordered to rule out potentially reversible causes such as
metabolic abnormalities (hypothyroidism, hypercalcemia, or hyperglycemia), rapid
plasma reagin (RPR) to rule out syphilis, and Vitamin B12 levels.28 The yield of a
head computed tomography (CT) scan or MRI for evaluation of cognitive impairment
remains controversial, especially in a patient without neurological abnormalities. How-
ever, if no neuroimaging has been conducted recently, a noncontrast head CT scan or
MRI can be obtained to evaluate for normal-pressure hydrocephalus, subdural hema-
toma, or tumor.28
Diagnosing patients with cognitive impairment or dementia is paramount in guiding
clinical care and arranging for adequate social support. Advanced care planning be-
comes crucial, as dementia often progresses to limit the capacity of patients to under-
stand risks and benefits of important medical and social decisions. Ideally, clinicians
should discuss a patient’s preference for end-of-life care and establish a health care
proxy or durable power of attorney at diagnosis of MCI or mild dementia. Home safety
and driving issues should be also addressed. In some states, clinicians are mandated
to report moderate and severe dementia patients to the Department of Motor Vehicles,
and older adults with MCI or mild dementia may need to take a special test annually to
keep their driver’s license. For patients with moderate dementia, focus should remain
on safety, particularly risk for wandering and getting lost, behavior disturbance, and,
importantly, assess for caregiver burden or stress. For patients with severe dementia,
providers should shift the care to maximizing comfort and quality of life.

URINARY INCONTINENCE

Urinary incontinence (UI) occurs in approximately 15% to 30% of healthy community-

dwelling older adults. UI is frequently underreported because of the patient’s embar-
rassment to discuss this with the physician and some misconception that it is part of
normal aging. UI can be divided broadly into 2 categories: acute or reversible UI and
chronic UI. Potential causes of acute UI include infection, atrophic vaginitis, delirium,
psychological disorder, reduced mobility, excess urine output, stool impaction, and
medications.29 Common causes of chronic UI are listed in Table 3.28 Although chronic
UI is more commonly encountered in older adults, some may develop acute UI, and
thus evaluation for reversible causes of UI is warranted.
As with all geriatric syndromes, a thorough history of UI is the foremost step in
assessment. A voiding diary to document timing, circumstances and severity of UI,
amount of urine leaked, potential triggers, and frequency of UI is very helpful for

Table 3
Categories of chronic urinary incontinence

Types Symptoms
Stress Loss of urine with increased abdominal pressure, after cough, laughing, or
straining.
Urge Detrusor overactivity and feeling of frequent urge to urinate.
Mixed Usually a combination of stress and urge incontinence.
Overflow Overdistended bladder, which leads to frequent leakage of urine.
Functional Urinary incontinence in a setting of normal function of urinary tract. Inability to
access the toilet, commode, or urinal in time.

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 Geriatric Assessment 271

clinicians and patients.28 Table 4 outlines screening tools that can be used to quickly
identify UI in the clinic.30–33 A thorough review of all medications, including over-the-
counter medications, is essential in excluding pharmaceutical causes of UI. Physical
examination should include a cardiac examination to rule out congestive heart failure,
abdominal examination to evaluate for distended bladder or abnormal mass, and
rectal examination to assess prostate size or abnormal mass and rectal tone to rule
out spinal cord or neuropathic dysfunction. Gynecologic examination in women
should be performed if physically possible to assess for organ prolapse, vaginal atro-
phy, or uterine/pelvic mass. Simple laboratory tests, such as urinalysis and urine cul-
ture to rule out infection, and electrolytes to evaluate renal function and rule out
metabolic causes are sufficient.

FRAILTY

As discussed previously, frailty is often thought of as the overarching geriatric syn-

drome, given its impact across disease states and great impairments in function.
Approximately 5% of Americans older than 60 have been diagnosed with frailty.34
Frailty can change a treatment trajectory, most commonly by increasing the impact
of physical stress during acute medical illness or surgery. Several studies have shown
that preoperative frailty is associated with higher postoperative complications after

Table 4
Screening tools for urinary incontinence

Tool Description
The 3 Incontinence 1. During the past 3 mo, have you leaked urine? If the answer is yes,
Questions (Brown then complete the rest of the questionnaire.
et al,31 2006) 2. During the past 3 mo, did you leak urine: when you were per-
forming some physical activity? Without physical activity? When
you had the urge to urinate, could you get to the toilet fast
enough?
3. During the past 3 mo, did you leak urine most often: when you
were performing some physical activity? Without physical activity?
When you had the urge to urinate, could you get to the toilet fast
enough?
American Urologic During the past month:
Association BPH How often did you feel you did not empty your bladder fully?
Symptom Score How often did you have to urinate within 2 h?
Index (Barry How often did you have to stop and restart urination?
et al,32 1995) How often did you find it difficult to delay urination?
How often did you notice a weak urinary stream?
How often did you have to push and strain to start urination?
How often did you have to urinate at night?
Likert scale of 0–5: 0 5 not at all and 5 5 almost always
Overactive Bladder How much have you been bothered by the following:
Validated 8 Question Frequent daytime urination?
Awareness Tool Uncomfortable urge to urinate?
(Coyne et al,33 2005) Sudden urge to urinate?
Loss of small amount of urine?
Uncontrollable urge to urinate?
Urine loss due to strong desire to urinate?
Nighttime urination?
Waking up at night to urinate?
Likert scale of 0–5: 0 5 not at all and 5 5 bothered a very great deal

Data from Refs.31–33

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272 Carlson et al

colorectal and cardiac surgery than nonfrail or prefrail patients.35,36 Similarly, frail pa-
tients had longer hospital stays and higher 30-day readmission rates postoperatively
than nonfrail or prefrail individuals.35,36 Patients with chronic renal failure and frailty
had increased risk of mortality than those without frailty.37 Frail patients experiencing
an acute coronary syndrome had longer hospital stay, decreased procedure use, and
increased mortality compared with nonfrail patients.38 Given the close relationship be-
tween frailty and treatment outcome, early recognition of frailty is paramount in guiding
clinical care and discussing future procedures with patients and their families.
In 2001, several predictive scales were introduced to define and characterize frailty.
Frailty index (FI) was defined using the data from the Canadian Study of Health and
Aging. The original 92 items included physical symptoms and signs, functional impair-
ments, and laboratory abnormalities, and since then various versions of the FI have
been developed and tested to predict morbidity and mortality.39,40 The formula for
determining the FI is included in Table 5. High FI scores have been shown to be highly
correlated with mortality, but obtaining all the information on FI is not very practical in a
busy outpatient clinic practice.41 The Frail phenotype was developed and operation-
alized in the Cardiovascular Health Study.11 It is based on 5 items, but some charac-
teristics are not easily ascertained from patients, such as grip strength and estimation
of their activity levels (see Table 5). The FRAIL and Study of Osteoporotic Fractures
Frailty Scale are easier to administer (see Table 5).42–45
Several studies have compared and contrasted these frailty scales and they found
all of them to be effective in predicting mortality among community-dwelling older
adults.41,44,45 Therefore, the FRAIL and Study of Osteoporotic Fracture Frailty scales,
which are easier to perform than the other frailty scales, are the recommended instru-
ments for use in a clinic setting.

GERIATRIC CARE SYSTEMS: INNOVATIVE CARE DELIVERY FOR THE COMPLEX PATIENT
Contrasting Complex Geriatric Care Needs with Usual Primary Care Needs
Complex geriatric patients have different care needs than most primary care patients.
Unlike patients with intermittent, acute problems, complex geriatric patients have mul-
tiple chronic diseases and daily symptoms, and frequently require services from
different practitioners in the hospital, home, community, and outpatient settings.
Because of frequent care needs, geriatric patients have high utilization of health
care services and are among the most costly patients in the health care system.46,47
The most influential determinant of cost and complexity in geriatric medicine is func-
tional disability. Patients with chronic conditions in combination with limitations on
their ability to perform basic daily functions due to physical, mental or psychosocial
challenges account for twice the average of Medicare spending.48 Functional limita-
tions are accompanied by a need for assistance by others to perform routine activities
of life, and thus require ongoing long-term services and supports.48
Because of a need for ongoing long-term supports, episode-based care delivery
systems often do not provide enough opportunity for complex geriatric patients to ac-
cess care. As complex patients require frequent coordination and comprehensive as-
sessments, planned visits become important approaches to care. Instead of focusing
only on acute complaints, these assessments place an emphasis on identifying early
complications and prevention of functional decline. Complex geriatric patients are het-
erogeneous in disease severity and presentation and require integration of functional
status and prognosis into care planning. Because of this heterogeneity, available
treatment options differ. Personal values and priorities become an essential part of
determining care plans for complex geriatric patients.

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 Geriatric Assessment 273

Table 5
Frailty index scales

Name of Scale Descriptions Scale

FI39 92 items6 Score range from
Number of health deficits present Frail score >0.25, prefrail
FI5
Number of health deficits measured score 0.25–0.2
Frail phenotype–based Weight loss 10 pounds unintentionally Score range from 0–5
Cardiovascular in 12 mo Frail score 3–5, prefrail
Health Study42 Grip strength: lowest 20% score 1–2
Exhaustion: self-report
Slow walking time/15 feet (by gender and
height)
Low activity:
Men <383 kcal/wk
Women <270 kcal/wk
FRAIL (Fatigue, Fatigue: How much time during the Score range from 0–5
Resistance, past 4 wk they felt tired. 1 point if Frail score 3–5, prefrail
Ambulation, Illness, they answered most of the time or score 1–2
Loss of Weight)43 all the time.
Resistance: They had any difficulty
walking up 10 steps alone without
rest or assistance. One point if they
answered yes.
Ambulation: Whether they had any
difficulty walking several hundred
yards alone and without aids. One
point if they answered yes.
Illness: scored 1 point if they reported
5 illness
Loss of weight: scored 1 point if 5%
weight
loss within past 12 mo.
Study of Osteoporotic Weight loss >5% in the past 12 mo Score range from 0–3
Fractures Frailty Inability to get up from a chair 5 times Frail score 2–3, prefrail
Scale44 without using the arms score 1
Negative answer to “do you feel full of
energy?”

Data from Refs.39,42–44

Features of Complex Care Delivery Models That Provide Value to Geriatric Patients
Complex geriatric patients are at the center of reform efforts to improve care and con-
trol cost, and a number of programs to improve care for complex geriatric patients
have been developed in recent years. The high-performing models of complex care
delivery share 5 core features (Table 6). First, systems that provide complex geriatric
patients 24/7 access to their medical team have found higher patient satisfaction with
care and lower emergency department use.49,50 Having 24/7 access allows for discov-
ery of symptoms early in a chronic disease course, thus preventing unnecessary hos-
pitalization. Continuity with a primary care provider has been found to be associated
with reductions in mortality, and evidence suggests that night and weekend access is
crucial to improving quality of care for complex geriatric patients.
Second, an interdisciplinary team-based approach to care that includes more than
one discipline is important for ensuring coordination of care for complex geriatric pa-
tients. Although there is no standard composition of team structure, most models

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274 Carlson et al

Table 6
High-value features of geriatric care delivery models

Feature Description/Rationale
24/7 Access to care Allows for discovery of symptoms early in chronic disease course
Team-based approach Multidisciplinary team improves coordination and increases
patient engagement
Medication reconciliation Prevents adverse events during care transitions
Comprehensive Self-management tools and caregiving support can improve
assessment engagement in plan and smooth transitions in care
Integration of Helps improve quality of life and align care with patient and
palliative care family goals

include a registered nurse (RN) and social worker.51,52 The most effective models use
intensive case management and rely on smaller caseloads to ensure quality coordina-
tion of care.50,53
Third, performing medication reconciliation after transitions in care, particularly after
a hospitalization, can improve quality of care and aid in coordination for complex geri-
atric patients.54 Medication-related discrepancies are common when patients transi-
tion from hospital to home health care. For example, in one large cohort study, 14% of
65-year-old or older community-dwelling adults experienced 1 or more medication
discrepancy after discharge.55 Randomized trials have found that care transition inter-
ventions involving RN-pharmacist or pharmacist visits help to resolve issues with tran-
sition and reduce adverse events and rehospitalization.56–58
Fourth, performing comprehensive geriatric assessments, which combine medical,
social, and behavioral aspects of care into treatment planning, can improve quality
and efficiency of care.59 Comprehensive geriatric assessment commonly includes
medication management, vision, mobility, fall assessment, and home safety. Assess-
ments are then used to develop individualized care plans to tailor the care services to
the patient.
Finally, delivery systems that integrate palliative care into planning for complex
patients increase patient satisfaction and decrease utilization of care.60,61 The most
relevant aspects of palliative care medicine for complex geriatric patients are
quality-of-life assessment, symptom management, advance care planning, and atten-
tion to family experiences in care.62 Providing support for caregivers in the form of
respite care also is an important feature of high-performing geriatric models of care.

Examples of Geriatric Care Systems

Programs to improve delivery of care for complex geriatric patients vary widely in
design, target population, and goals. Successful care models can be generally classi-
fied into 3 categories: comprehensive programs that provide all medical and social
care, consultant-based programs that work in partnership with primary care teams,
and short-term interventions that target transitions in care (Table 7).
Comprehensive, community-based geriatric systems are designed to provide
nursing home–level care in a home or community (ie, adult day center) setting. These
programs integrate inpatient, outpatient, and long-term care services, and coordinate
all medical and social aspects of care. The Program of All-Inclusive Care of the Elderly
(PACE) is an example of a Medicare-funded system that provides comprehensive care
services to community-dwelling frail adults.63 To qualify for a PACE program, a person
must be at least 55 years of age and eligible for care in a nursing home. PACE

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 Geriatric Assessment 275

Table 7
Examples of geriatric care models

Model Type Description Example

Comprehensive Provides comprehensive care, including Program for All-Inclusive Care for
models hospital, home care, respite care, and the Elderly (PACE)64,65
personal care
Consult models Provides added geriatric team (often Geriatric Resources for Assessment
nurse practitioner and/or social and Care for Elders (GRACE)52
worker) as consultants to primary care
practice
Short-term Targets transitions in care (ie, from Hospital-at-Home Model68
models hospital to skilled nursing facility or Care Transitions Model55
from hospital to home) or provides
short-term hospital-level care at home

programs revolve around the provision of medical and social services by an interdis-
ciplinary team. Much of the care is delivered at an adult day center.64 Compared with
the general Medicare population, PACE participants spend fewer days in the hospital,
and sustain greater function and independence at home.63
Another model type involves adding geriatric consultants to primary care teams. A
consultant-type approach allows primary care teams to tailor services to a patient’s
specific medical and social needs. In these models, nurse practitioners and/or social
workers often are used to coordinate care, and provide comprehensive geriatric
assessment and symptom monitoring in-home settings. An example of a home-
based coordinated model is Geriatric Resources for Assessment and Care of Elders
(GRACE), which integrates home visits by nurse practitioners alongside primary
care teams.65 GRACE was shown to improve social and mental health measures,
and reduce emergency room visits, in a population of low-income older patients.66
Finally, instead of comprehensive care or consulting assessment, geriatric care inter-
ventions can involve short-term interventions, such as providing hospital-level care for
acute conditions at home, or providing intensive short-term transitional care at
hospitals. One example of a short-term in-home model is Hospital-at-Home, which pro-
vides hospital-level care for older home-limited adults for conditions such as cellulitis,
chronic heart failure exacerbation, or pneumonia. The Hospital-at-Home model has
been shown to reduce per-patient costs with increase in patient satisfaction and similar
quality standards to hospital care.67,68 Among the transition models targeting complex
patients at discharge from hospitals, models described by Naylor and colleagues69 and
Coleman and colleagues55 have both reduced costs by avoiding unnecessary readmis-
sions or prolonged skilled nursing home stays. Successful features of these interven-
tions include frequent in-home assessment and coordination with primary care
teams to identify gaps in care and improve response to added support if needed.

FUTURE CONSIDERATIONS

As the population ages, the complexity of older patients will increase the demands on
the US health care system. Because of national shortages of geriatricians, there is an
increasing need for generalists to have knowledge of geriatric principles, approaches,
and models of care. Essential elements of good geriatric primary care include the
recognition of geriatric syndromes, evaluation of functional status, and the use of
prognosis and patient goals in determining a realistic diagnostic and treatment plan.
Innovative models of geriatric care delivery, including the GRACE, PACE, and

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276 Carlson et al

Hospital-at-Home programs, can improve geriatric care. Important elements of these

care delivery models include improved access to a multidisciplinary team, periodic
comprehensive geriatric assessment, medication reconciliation, and integration of
palliative care into primary care. More widespread dissemination of these models
would improve geriatric care nationwide. Clinicians providing care to the elderly
without access to these models can improve care by using efficient screening tools
for geriatric syndromes, recognizing frailty and its effect on prognosis, incorporating
prognosis and patient preferences into medical decision-making, and using a multi-
disciplinary approach to care whenever possible.

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