Key Areas of Functional Decline Related to Multiple Domains
Many patients demonstrate impairment in several of the domains described above. Problems with managing medications, nutrition and driving are a consequence of many medical and functional impairments, and often represent a great threat to patients' independence. Since these impairments often prompt older adults to require assistance from family, friends or hired caregivers, they may be embarrassed or threatened by decline in these areas and, therefore, may not bring them to the attention of their physicians. Therefore, it is important for clinicians to investigate and explicitly ask about these areas.
Medications
Older adults take more medicication than any other age group. In 2007–2008, over a third of Americans aged 60 years and over used five or more prescription drugs.[57] Despite their role in decreasing morbidity and increasing survival, medications are not without risks. Age-related physical changes, notably decline in renal function and increased permeability to the CNS, along with polypharmacy, make older adults at risk for adverse drug events.[58] Medication problems may subsequently lead to a hospital stay[59] and, thus, decline in patient independence.
Medication management is an instrumental ADL, key to patient function. Management of, and adherence to, medications is a cognitively demanding task requiring executive function, attention, planning and working memory.[60] Older adults tend to have multiple barriers to appropriate medication use, such as physical limitations (e.g., vision and dexterity), cognitive difficulties, health literacy or financial strain. Medication assessment, which includes both medication reconciliation and a comprehensive medication review, is therefore critical to geriatric functional assessment and patient safety.
Medication Screening. Screening for medication issues should begin with defining the medication list. The clinician needs to determine what medications patients are taking and how they take them. This process is called 'medication reconciliation', and we recommend a patient-centered method where information from the patient and caregiver is gathered. The medication list should incorporate medicines from all sources (i.e., all pharmacies, providers, and nonprescription herbals, vitamins and supplements) and include dosage, frequency, prescriber and any allergies or intolerances. Medication list templates are available online to help patients get started with this process.[104] Another screening mechanism is a 'brown bag' exercise; the patient brings all of his/her medications to an appointment and this supply is reviewed with a member of the healthcare team. As this can be time-intensive, pharmacists can be valuable team members in this area.
Medication Assessment. Once the provider establishes the medication list, the regimen itself can be assessed for safety and appropriateness. Medications can be compared with the Beers Criteria, which were updated in 2012, to identify potentially inappropriate medications in elderly patients. In addition, clinicians can refer to the screening tool of older individual's potentially inappropriate prescriptions (STOPP) and the screening tool to alert doctors to the right treatment (START) for an expanded list of medication regimen pitfalls. The STOPP tool is organized by physiological system (e.g., cardiovascular and endocrine) and lists drugs to 'lose' from a regimen since risks outweigh known benefits. Conversely, the START tool reminds clinicians to start indicated medications among patients without contraindications to such treatments. Table 2 provides medications that should be avoided in older adults based on both the 2012 Beers Criteria and the STOPP criteria.[61–64] The STOPP/START criteria are more sensitive than the 2003 Beers criteria for detecting potentially inappropriate medicines that cause adverse drug events;[61,65] however, to our knowledge, a direct comparison has not yet been made between STOPP/START and the 2012 updated Beers Criteria.
Drugs, particularly those with anticholinergic properties,[66] can worsen cognition and cause significant side effects in older adults.[64,66] Many anticholinergic side effects are common issues in older patients that have been discussed elsewhere in this article (e.g., constipation, incontinence and cognitive impairment). Medications, such as narcotics, benzodiazepines and antidepressants, may also contribute to falls. Thus, providers must be vigilant about medication assessments and consider any patient complaint or symptom associated with a possible drug-related problem, until proven otherwise. This will help prevent prescribing cascades, limit polypharmacy and work towards preserving patient function at home.
Nutrition
Maintaining adequate nutrition requires a robust network of physical, cognitive, psychological and social domains. As these domains become at risk with aging, the risk of malnutrition increases. Malnutrition can predispose patients to functional decline, falls, fractures, mobility impairments and so on. Thus, the screening and assessment of malnutrition are crucial.
Nutrition Screening. The first step in nutrition screening is to measure height and weight and calculate the BMI. BMI is equal to the weight (kg) divided by height (m) squared (kg/m2). As older patients naturally lose height, measurement of current height is important. The provider should then complete the mini nutritional assessment short form (MNA-SF), a brief (3–5 min) nutritional screening tool valid in many care settings (community, long-term and acute care).[67] International translations and training in administration of the MNA can be found online.[105] The MNA-SF consists of six questions related to food intake, weight loss in the last 3 months, mobility, psychological distress/acute disease, neuropsychological problems and BMI. Scoring 12 or more points on the MNA-SF rules out malnutrition with a negative predictive value of 100%. Patients with less than 12 points on the MNA-SF may be at risk and should undergo a more complete nutritional assessment.[67]
Nutrition Assessment. The full MNA includes the MNA-SF, as well as several additional questions about risk factors for malnutrition (such as living situation, pressure sores, protein and fluid intake, and cognitive impairment) and several measurements (calf and midarm circumference); it takes approximately 10–15 min to complete. The total score has a sensitivity of 96% and a specificity of 98% for the presence of malnutrition.[67] Depending on the total score, patients are classified into the following groups: normal nutritional status, at risk of malnutrition and malnourished.
Driving
In western societies, particularly rural and suburban areas without mass transit systems, there is an increased dependence on automobile travel to maintain independent functioning. For every mile driven in the USA, older drivers are more likely to be involved in a crash compared with younger drivers.[106] Additionally, older patients are more likely to sustain serious injuries because of their underlying comorbidities, including osteoporosis, coronary artery disease and system atrophy.[106] As with medication management and falls, driving ability represents an integration of major functional domains, particularly the physical and cognitive domains. Assessing and counseling older drivers is often challenging even for experienced physicians. Reporting laws for unsafe drivers vary by US state and physicians should be familiar with reporting laws in their state.
Driving Screening. It is important to begin with observing the patient carefully during the office visit. Be alert to poor hygiene, problems with vision, impaired mobility and abnormal attention/cognition.[106] Ask the patient if he/she drives; if they drive, ask questions to get a better sense of the patient as a driver.[106] Questions regarding history of crash/citation and family concern about driving may be useful in screening older drivers,[68] as well as getting lost. The patient's clinical and cognitive status also provides important information about driving safety. It is valuable to understand the driver's insights into driving limitations and whether they have self-imposed any driving restrictions (such as avoiding night-time driving, driving in rush hour or bad weather). Patients who self-restrict their own driving habits due to safety concerns, although they are demonstrating insight into their driving abilities, have been shown to be at higher risk of a crash in the next 2 years.[69] Patients who raise any concerns during driving screening should be further assessed.
Driving Assessment. The American Medical Association has published a comprehensive manual of how to evaluate the older driver, which is freely available online.[106] The assessment of the older driver focuses on the three key areas that are necessary for safe driving: vision, motor and cognition.[106] According to the American Medical Association manual, vision screening incorporates visual fields and acuity (using the Snellen chart); motor assessment incorporates range or motion, strength and gait assessment; and cognitive assessment involves tests of visuospatial and executive function, such as the trail-making test part B, and a clock-drawing test.[106] If healthcare providers have any concerns about a patient's driving safety, consideration should be given to referring patients to a driver rehabilitation specialist for further assessment. These are often occupational therapists, but can often be physical therapists, kinesiotherapists, psychologists or other specialists.
Aging Health. 2013;9(6):579-591. © 2013 Future Medicine Ltd.
