As part of physical health assessment, we have identified the importance of vision, hearing and multimorbidity review, and polypharmacy harm. The other essential sub-domains include nutritional status and balance.
Nutritional status
Maintaining adequate nutrition
requires the contribution of physical, cognitive, psychological and social
domains. These domains become impaired with advancing age and increase the risk
of malnutrition. Inadequate micronutrient intake is common in older persons, as
several age-related medical conditions predispose them to vitamin and mineral
deficiencies. Malnutrition further predisposes them to functional decline,
mobility impairment, falls, fractures etc. Nutritional deficiency is also associated
with poor outcome after hospitalization for acute illness, frailty, sarcopenia (low
muscle mass), poor memory (due to vitamin deficiencies) etc. Hence screening
and assessment of malnutrition are a crucial part of CGA.
There are four components
specific to geriatric nutritional assessment:
1. Nutritional
history performed with a nutritional health checklist.
2. A
record of a patient’s usual food intake based on 24-hour diet recall.
3. Physical
examination with particular attention to signs of inadequate nutrition
4. Select
laboratory tests.
Many nutrition screening tools
are available for malnutrition identification. The American Society for
Parenteral and Enteral Nutrition (ASPEN) recommends the subjective global
assessment (SGA) tool. It requires the patient to record weight changes,
functional capacity, dietary intake, metabolic stress, loss of subcutaneous
fat, and ankle swelling. It has the advantage of simple operation,
repetitiveness, and no need for any laboratory tests. Its subjective reporting
makes it inaccurate.
The mini-nutritional assessment
(MNA) is an elderly-specific tool and is well-validated in nutritional risk
screening and nutritional status assessment. It includes nutritional
assessment, subjective assessment, anthropometry and general assessment. A
score of 24-30 indicates good nourishment, 17-24 indicates a risk of
malnutrition and a score <17 indicates malnutrition. An even simpler version
called mini-nutritional assessment short-form (MNA-SF) was developed in 2001.
It has a high correlation with MNA and a useful screening tool.
After assessing the nutritional
status, it is essential to identify factors which contribute to it. These may include
low vision, poor dentition (teeth), tremors in hand, painful wound in the oral
cavity, difficulty in swallowing, poor dietary practices, constipation, altered
taste perception due to medications, joint pain, neurological disease such as
stroke, Parkinson’s disease, socioeconomic causes etc. The management should
include an expert dietitian and aim to tackle the factor/factors which lead to
undernutrition.
Balance
Impaired balance in older persons
often manifests as falls and fall-related injuries. Around one-third of
community-living older persons fall at least once per year, with many falling multiple
times. Falls are among the leading causes of chronic disability in older adults,
leading to fractures, soft tissue damage, brain damage, hospitalization and
death. The risk of falling should be assessed by explicitly asking the patient
about falls and testing balance, gait and lower extremity strength. A simple
screening question to screen for falls is to ask:
· Have you ever had a fall in the past year
Individuals who say yes should be
further asked regarding the number of falls (single episode or recurrent falls),
the circumstances leading to falling (accidental slip/trip, blackout, dizziness
etc.), details of the fall (usually from the patient as well as a witness of
fall), complications following the fall (loss of consciousness, hip or low back
pain, headache, change in sensorium) etc. We can divide the factors which lead
to falls into intrinsic and extrinsic factors. Extrinsic factors include wet
floor, high steps, low lighting, clutter on the floor (toys, wires), ill-fitting
footwear etc. Intrinsic factors include poor vision, medications that cause low
BP on standing, increased frequency of micturition (making a person prone to
falls during the night), joint disease, neurological and cardiac disease,
making the person prone for falls. A detailed history and physical examination
help identify the cause/causes of fall in an older adult.
There are many methods and scales
for balance and fall risk assessment. Balance can be assessed by asking the
patient to maintain a side-by-side, semi-tandem, and full-tandem position for
10 seconds. The times up-and-go (TUG) test evaluates the capability to rise from
a chair, walk three meters, turn, walk back, and sit down again on the chair.
Patients who take longer time are at increased risk of fall. Also, during the
test observation of how the patient walks (the stride length, step height, arm
swing, turning around, stooped posture etc.) gives a clue to the cause of imbalance.
A detailed evaluation, including a physiotherapist, also helps to plan management
and rehabilitation.
By screening older adults, we
identify common, yet often missed conditions. And the corrective steps taken can
improve the quality of life, adding life to years.
