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The performance of simple instruments in detecting geriatric conditions and selecting community dwelling older people for geriatric assessment

Age and Ageing, May, 1997 by Rose C. Maly, Susan H. Hirsch, David B. Reuben

Keywords: geriatric assessment, screening, fails, depression, functional impairment

Introduction

Comprehensive geriatric assessment (CGA) is an interdisciplinary approach to identifying and addressing the multiple medical and psychosocial problems of elderly people. Overall, controlled studies of CGA have demonstrated significant benefits from the process, including reduced mortality and hospital admissions, improved physical and cognitive functioning and increased likelihood of living at home [1]. Most of these benefits have been demonstrated in hospital settings generally in formal inpatient geriatric evaluation and management units. Studies of home assessment programmes, primarily conducted in Europe, have shown some overall benefit in the odds of living at home [1, 2] and, in some studies, lower mortality [3-6]. Randomized controlled studies of CGA on an outpatient or ambulatory basis have been much less convincing. although some small benefits have been realised [7-11].

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Geriatric assessment is a three-stage process: (i) identifying or targeting appropriate patients, (ii) assessing the patient and developing recommendations and (iii) implementation of the recommendations by physician and patient [12-15]. One reason why outpatient CGA has been less successful may be the failure to exclude older people too healthy to benefit from the process [16]. In a recent meta-analysis of all known randomized controlled trials of CGA, targeting of frailer patients for CGA was associated with improved outcomes [1], albeit only in the case of hospital-based studies. However, no randomized controlled trial of outpatient CGA to date has specifically excluded subjects `too healthy' to benefit. Targeting of older people for CGA may be even more important in the outpatient setting than in hospitals and rehabilitation or skilled nursing facilities, where elderly patients have been already identified as having a major health problem or functional deficit.

A possible approach to identifying older people appropriate for outpatient CGA would be to use formal screening instruments. Validated screening measures have been shown to significantly improve detection of previously unrecognized geriatric syndromes in older medical outpatients [17, 18]. Abnormal results on formal screening measures may serve as a proxy for frailty in elderly people and normal results may be used to exclude older people likely to be too healthy to benefit from CGA.

The purpose of this study was to evaluate the clinical performance of simple screening instruments in selecting older people for outpatient CGA; these instruments could be rapidly completed by large numbers of elderly people in community settings. Screening measures for four geriatric syndromes--depression, urinary incontinence, falls and functional impairment--were used in targeting this population for outpatient CGA. These four conditions were chosen because they are relatively common in the elderly population, ranging from 15 to 30% in prevalence in community-based samples [19-22], are potentially treatable [23-27] and are often overlooked by the medical profession. Thus, these conditions may be particularly appropriate for identification and recommendations through CGA. A subgroups analysis in one trial of inpatient CGA has revealed that patients with depression, falls or low functional status scores (three out of four of our target conditions) had improved 1 year survival from the CGA process [28].

We evaluated the diagnostic performance of the screening battery by determining the test characteristics of each of the four screening measures (sensitivity. specificity, positive predictive value and accuracy) within the sample population. We next evaluated the clinical performance of these screening questions in identifying those community-dwelling older people needing major medical intervention for each of these conditions, as determined by CGA. Finally, we examined the four-component screening strategy as a whole, by assessing how often CGA resulted in major medical recommendations in the entire sample and by determining the relationship between the number of screening conditions failed and having received major medical recommendations.

Methods

This study was undertaken as part of a larger study to improve the effectiveness of consultative outpatient CGA [15]. Community-dwelling older people were screened at senior centre meal sites (where federally funded meals are served for lower income elders), churches, retirement hotels, senior education sites and low-income senior housing units. A self-report screening questionnaire that included 16 screening questions for the four target conditions and 19 questions about socio-demographic and other information was completed by each participant. (See Appendix for details of screening measures.) The entire questionnaire took an average of 11 min to complete; the 15 screening questions alone took less than 5 min.

To screen for functional impairment, subscales from the Functional Status Questionnaire [29, 30] were used, including the physical function scale, which consisted of basic activities of daily living (BADL) and intermediate activities of daily living (IADL) and the social activities subscale of the social/role function scale (see Appendix for subscale items). Scoring of these subscales for this study was as described by Jette et al. [29], with each subscale score ranging from 0 to 100, with 100 indicating no deficits. Warning levels to indicate significant functional limitations for these subscales have been developed using an expert panel of clinicians [29]. Subjects in the present study failed for functional impairment if they scored at or below these warning levels for any one of the three subscales (89 for BADL, 72 for IADL and 78 for social activities).

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The performance of simple instruments in detecting geriatric conditions and selecting community dwelling older people for geriatric assessment

Age and Ageing, May, 1997 by Rose C. Maly, Susan H. Hirsch, David B. Reuben

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