http://www.aafp.org/afp/2000/0215/p1089.html?

printable=afp

<< Return to Previous Page

February 15, 2000 Table of Contents

This is a corrected version of the article that appeared in print.

The Geriatric Patient: A Systematic Approach to Maintaining Health

KARL E. MILLER, M.D., ROBERT G. ZYLSTRA, ED.D., L.C.S.W., and JOHN B. STANDRIDGE, M.D., University of Tennessee College of Medicine, Chattanooga, Tennessee
Am Fam Physician. 2000 Feb 15;61(4):1089-1104. Related Editorial

The number of persons 65 years of age and older continues to increase dramatically in the United States. Comprehensive health maintenance screening of this population is becoming an important task for primary care physicians. As outlined by the U.S. Preventive Services Task Force, assessment categories unique to elderly patients include sensory perception and injury prevention. Geriatric patients are at higher risk of falling for a number of reasons, including postural hypotension, balance or gait impairment, polypharmacy (more than three prescription medications) and use of sedativehypnotic medications. Interventional areas that are common to other age groups but have special implications for older patients include immunizations, diet and exercise, and sexuality. Cognitive ability and mental health issues should also be evaluated within the context of the individual patient's social situationnot by screening all patients but by being alert to the occurrence of any change in mental function. Using an organized approach to the varied aspects of geriatric health, primary care physicians can improve the care that they provide for their older patients.

Current predictions suggest that the number of persons 65 years of age and older will more than double in the United States during the next 30 years. As a result, the number of elderly Americans could increase from 34 million in 1998 to approximately 69 million in 2030. This increase, combined with the disproportionate rate at which elderly patients use medical resources, will require that primary care physicians become increasingly knowledgeable about the needs of geriatric patients and increasingly efficient in the evaluation and management of concerns unique to these patients. The value of performing a comprehensive geriatric assessment appears to be equivocal. Simple screening instruments can be helpful in identifying patients at risk for common health problems and in improving the clinical assessment of a disease course.1 However, these screening tools may not be effective in reducing health care utilization or costs.2 The comprehensive geriatric assessment is often described in the literature as a multidisciplinary, time-intensive evaluation of a patient previously identified as being at significant risk for imminent morbidity or mortality. 2,3 An evaluation of this type is impractical in most primary care settings and is seldom used by practicing physicians.4 Yet the ongoing, long-term management component of primary care is a key ingredient in the success of outpatient geriatric evaluation.5 Effective primary care management of geriatric health issues, with its goal of caring for healthy and functional elderly patients, may perhaps be better described as comprehensive health screening. Using simple and easily administered assessment tools, physicians can improve the identification of specific problems that are common in the elderly and also shift their focus from disease-specific intervention to preventive care and proactive medical management.5 In 1996, the U.S. Preventive Services Task Force (USPSTF) published the second edition of its Guide to Clinical Prevention Services. 6 In this publication, the USPSTF updated earlier recommendations on preventive services for patients at various stages of life. The recommendations for patients 65 years of age and older include a number of items common to other age groups. The unique assessment categories for older patients are sensory perception (hearing and vision screening) and accident prevention. Assessment areas common to other age groups but with special implications for the elderly include diet and exercise, immunizations and sexuality. Although the USPSTF found little evidence in 1996 to support the value of screening for dementia, recent pharmaceutical advances have resulted in beneficial treatment options that were not available just a few years ago.7 Using the USPSTF recommendations as a guide, this article reviews available standardized assessment tools and techniques that can be used in outpatient settings. The goals are to encourage a systematic assessment of various areas of potential geriatric risk and to develop a database appropriate to the unique concerns of elderly patients. All of the information does not need to be gathered in one office visit. Multiple visits can be used to perform the entire assessment.

Injury Prevention
The USPSTF recommends that primary care physicians ask patients in most age groups about the routine use of safety belts and bike helmets, the availability of smoke detectors, the maintenance of hot water heater temperature at or below 48.8C (120F) and the danger of smoking near bedding or upholstery. 6 Fall prevention, however, is an assessment category unique to patients 65 years of age and older. The annual incidence of falls in patients over 65 years of age who live independently is approximately 25 percent but rises to 50 percent in patients over 80 years of age.8 Falls are responsible for a significant number of accidental deaths and traumatic injuries among the elderly. One third of patients with confirmed falls may not recall falling. 9
RISK FACTORS

Intrinsic factors that contribute to falls include age-related changes in postural control, gait and visual ability, and the presence of acute and chronic diseases that affect sensory input, the central nervous system and musculoskeletal strength and coordination. Certain medications can also increase the risk of falling (Table 1).10
TABLE 1.

Medications Associated with an Increased Risk of Falls in the Elderly

Antiarrhythmics Antihistamines Antihypertensives Antipsychotics

1 of 10

2/17/2013 5:53 AM

http://www.aafp.org/afp/2000/0215/p1089.html?printable=afp

Benzodiazepines and other sedative-hypnotics Digoxin (Lanoxin) Diuretics Laxatives Monoamine oxidase inhibitors Muscle relaxants Narcotics Tricyclic antidepressants and selective serotonin reuptake inhibitors Vasodilators
Adapted with permission from Reuben DB, Grossberg GT, Mion LC, Pacala JT, Potter JF, Semla TP. Geriatrics at your fingertips, 1998/99. Belle Mead, N.J.: Excerpta Medica, 1998.

Osteoporosis is one notable intrinsic factor that leads to falls. In patients with this condition, a pathologic fracture may precede a fall. In the absence of universally accepted criteria for the assessment of bone mineral density, screening should be directed at a risk assessment for osteoporosis (Table 2).
TABLE 2.

Risk Factors for Osteoporosis

Increasing age Female gender Early menopause Low body weight Small stature White or Asian race Family history Drug use (e.g., steroids, heparin) Low calcium intake Excessive alcohol intake Smoking Physical inactivity Conditions that impair calcium absorption High caffeine intake

Extrinsic factors that contribute to falls include poor lighting, obtrusive furniture, slippery floors, loose floor coverings and bathrooms without handrails or grab bars.
MOBILITY AND DEXTERITY

A comprehensive risk assessment for falls incorporates a review of all potential intrinsic and extrinsic factors, as well as a focused physical examination (Table 3).11 The physical examination can be a simple evaluation of one-leg balance (i.e., the ability to stand unassisted on one leg for five seconds)12 or a more structured evaluation such as the Get Up and Go test.13 In the Get Up and Go test, the patient is observed as he or she rises from a sitting position, walks 10 ft, turns and returns to the chair to sit. The effectiveness of the test for predicting falls can be enhanced by timing the process, with more than 16 seconds suggesting an increased risk of falling.14 Any observed or reported changes in gait, strength or balance may require further evaluation with a more detailed assessment.
TABLE 3.

Interventions to Reduce the Risk of Falling in the Elderly

Risk factors Postural hypotension: a drop in systolic blood pressure of 20 mm Hg or to < 90 mm Hg on standing Interventions Behavioral recommendations, such as ankle pumps or hand clenching, and elevating the head of the bed Decrease in the dosage of a medication that may contribute to hypotension; if necessary, discontinuation of the drug or substitution of another medication Pressure stockings Fludrocortisone (Florinef), 0.1 mg two or three times daily, if indicated Midodrine (ProAmatine), 2.5 to 5 mg three times daily Use of a benzodiazepine or other sedative-hypnotic drug Education about the appropriate use of sedative-hypnotic drugs Nonpharmacologic treatment of sleep problems, such as sleep restriction Tapering and discontinuation of medication Use of four or more prescription medications Environmental hazards for falling or tripping Review of medications Home safety assessment with appropriate changes, such as removal of hazards, selection of safer furniture (correct height, more stability) and installation of structures such as grab bars or handrails on stairs. Gait training Use of an appropriate assistive device Balance or strengthening exercises if indicated

Any impairment in gait

2 of 10

2/17/2013 5:53 AM

http://www.aafp.org/afp/2000/0215/p1089.html?printable=afp

Risk factors Any impairment in balance or transfer skills

Interventions Balance exercises and training in transfer skills if indicated Environmental alterations, such as installation of grab bars or raised toilet seats

Impairment in leg or arm muscle strength or impaired range of motion (hip, ankle, knee, shoulder, hand or elbow)

Exercises with resistive bands and putty; resistance training two or three times a week, with resistance increased when the patient is able to complete 10 repetitions through the full range of motion

Adapted with permission from Tinetti ME, Baker DI, McAvay G, Claus EB, Garrett P, Gottschalk M, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 1994;331:8217

Sensory Perception
Changes in vision and hearing occur as patients age. Because these changes can have a great impact on well-being, the USPSTF recommends regular vision and hearing screening for patients 65 years of age and older. 6
VISION

One study found that 72 percent of community-based patients more than 64 years of age had impaired vision as tested with a Snellen eye chart. 15 Other studies have detected lower percentages of geriatric patients with vision problems, but the prevalence of visual impairment is still quite high. The most common causes of visual impairment in the elderly include presbyopia, cataracts, glaucoma, diabetic retinopathy and age-related macular degeneration. Changes in vision can cause a significant number of problems for elderly patients, including an increased risk for falls.16 The Snellen eye chart is an appropriate tool for visual acuity screening in the elderly. Referral to an ophthalmologist should be considered when visual acuity is worse than 20/40 (with normal corrective lenses, if applicable) and visual impairment is interfering with daily activities. The USPSTF found insufficient evidence to recommend for or against screening with ophthalmoscopy performed by primary care physicians in asymptomatic elderly patients. However, patients at high risk for glaucoma (i.e., black patients over 40 years of age, white patients over 65 years of age and patients with diabetes mellitus, myopia, ocular hypertension or a family history of glaucoma) should be referred to an eye care specialist for tonometry, funduscopy and visual field examination. The optimal frequency for glaucoma screening in these patients is uncertain.6
HEARING

The prevalence of hearing loss in the geriatric population ranges from 14 to 46 percent,17,18 but only 20 percent of primary care physicians routinely screen elderly patients for hearing loss.18 As a result of psychologic, financial and mechanical impediments, only 32 percent of persons with moderate to marked hearing loss use a hearing aid. 17 Presbycusis, a progressive high-frequency hearing loss, is the most common cause of hearing impairment in geriatric patients. 19 This type of hearing loss decreases the ability to interpret speech, which can lead to a decreased ability to communicate20 and a subsequent increased risk for social isolation and depression. 17 Hearing loss in the elderly can also adversely affect physical, emotional and cognitive well-being.21 Questionnaires such as the Hearing Handicap Inventory for the ElderlyScreening version (HHIES) have been shown to accurately identify persons with hearing impairment18 (Figure 1).22 The reference standard for establishing hearing impairment, however, remains pure tone audiometry, which can be performed in the physician's office. Combining the HHIES questionnaire with pure tone audiometry has been shown to improve screening effectiveness.20

Hearing Handicap Inventory for the ElderlyScreening Version

The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication.
FIGURE 1.

Appropriate interventions include periodic screening to provide early detection of hearing impairment, cautious use or avoidance of ototoxic drugs, and support for the obtainment and continued use of hearing aids.17 Interventions to be considered, depending on the degree of hearing loss, are provided in Table 4.10
TABLE 4.

Interventions Based on the Degree of Hearing Loss in the Elderly

The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication.

Nutrition
Malnutrition and undernutrition are common yet frequently overlooked problems in the geriatric population. Elderly patients with a compromised nutritional state require longer hospital stays and develop more complications. 23 One simple screening device for geriatric nutrition is the Nutritional Health Screen (Figure 2).23 This assessment tool is simple to administer, can be graded by a health care professional or family member, and may help to prevent nutritional problems in at-risk patients.

Nutritional Health Screen

3 of 10

2/17/2013 5:53 AM

http://www.aafp.org/afp/2000/0215/p1089.html?printable=afp

FIGURE 2. Nutritional health screen. Adapted with permission from The clinical and cost-effectiveness of medical nutrition therapies: evidence and estimates of potential medical savings from the use of selected nutritional intervention. June 1966. Summary report prepared for the Nutritional Screening Initiative, a project of the American Academy of Family Physicians, the American Dietetic Association and the National Council on the Aging, Inc., and funded in part by a grant from Ross Products Division, Abbott Laboratories Inc.

The USPSTF recommendation for encouraging regular tooth brushing, flossing and dental visits gains importance in the elderly.6

Immunizations
A 1990 report24 indicated that fewer than 30 percent of adults had received updated tetanus-diphtheria, influenza and pneumococcal immunizations. The poor compliance rate was determined to be secondary to patients' concerns about adverse reactions to immunizations and physicians' overlooking the need for such immunizations. In recent years, however, immunization rates in adults have improved. Data from the Centers for Disease Control and Prevention indicated that the 1997 rates for influenza and pneumococcal vaccinations were 65.5 percent and 45.5 percent, respectively. 25 Primary care physicians must be diligent in assessing the immunization status of geriatric patients and providing the recommended vaccines. As suggested by the USPSTF,6 an annual influenza vaccination in the fall is recommended for all elderly patients. Patients over 65 years of age should also receive at least one pneumococcal vaccination in their lifetime, with high-risk patients receiving a second immunization in six years. The tetanus-diphtheria (Td) toxoid should be given every 10 years. The Td toxoid is given again after five (or more) years if the patient suffers a wound that would be classified as dirty.

Sexuality
Although the tempo and intensity of sexual activity may change over time, problems that relate to a person's ability to have and enjoy sexual relations should not be considered part of the normal aging process. Studies show that 74 percent of married men and 56 percent of married women over 60 years of age remain sexually active.26 Common problems affecting sexual functioning include arthritis, diabetes, fatigue, fear of precipitating a heart attack and side effects from alcohol, prescription drugs and over-the-counter medications.27 Older patients state that they would like their physician to initiate discussions about sexuality, ask open and direct questions, and treat them as normal sexual persons. 28

Continence
Incontinence is estimated to occur in 11 to 34 percent of elderly men and 17 to 55 percent of elderly women. 29 Although incontinence is common, is frequently reversible30 and has significant social and emotional consequences,31 relatively few patients volunteer that they are having problems or request treatment. 32 The first step in screening for urinary incontinence is to ask the patient if he or she is experiencing any problems in this area. Two straightforward questions are Do you ever lose urine when you don't want to? and Have you lost urine on at least six separate days? Affirmative answers to both questions constitute a positive screen. In this situation, further evaluation is necessary. Evidence of stress incontinence is elicited by questions such as Do you ever lose urine when you cough, exercise, lift, sneeze or laugh? The assessment for urinary incontinence should include an evaluation of cognitive function, fluid intake, mobility, medication side effects and previous urologic surgeries.30 The physical examination should focus on the lower genitourinary tract in women and the prostate gland in men. A rectal examination can determine the presence of fecal impaction, and a simple urinalysis can be used to screen for infection or glycosuria.

Mental Status
Changes in mental status can have a profound impact on elderly patients and their families. Two of the more common changes are cognitive decline and depression.
COGNITION

Dementia is chronic and progressive, and it is characterized by the gradual onset of impaired memory and deficits in two or more areas of cognition, such as anomia, agnosia or apraxia. For the diagnosis of dementia to be established, these deficits must be present with no alteration of consciousness and no underlying medical cause that would better explain the deficits.

4 of 10

2/17/2013 5:53 AM

http://www.aafp.org/afp/2000/0215/p1089.html?printable=afp

Two of the more commonly used screening tools for dementia are the Mini-Mental State (Figure 3)33 and the Clock Test. 34 An alternative to patient testing is a structured family report using the Informant Questionnaire on Cognitive Decline in the Elderly (IQCDE). 35 Although less discriminating than the Mini-Mental State, the IQCDE is not affected by a patient's educational level or premorbid intelligence. 36 Combining these tools can increase the sensitivity of the screening process and identify additional patients in the early stages of dementia. 37

Mini-Mental State

FIGURE 3. Mini-Mental State. Adapted with permission from Folstein MF, Folstein SE, McHugh PR. Mini-mental state. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:18998. DEPRESSION

Depression significantly increases morbidity and mortality.38 As opposed to dementia, depression is usually characterized by a relatively rapid onset, intact but possibly retarded cognitive abilities and a generally time-limited duration. The Geriatric Depression Scale, shown in Figure 4,39 is a good screening tool to use in older patients. 40 It avoids issues related to physical symptoms and asks questions requiring only a yes or no answer. The one-question Yale Depression Screen (Do you often feel sad or depressed?) has also been found to be an effective screening tool41 and may be worth considering when clinical time is at a premium.

Geriatric Depression Scale (Short Form)

5 of 10

2/17/2013 5:53 AM

http://www.aafp.org/afp/2000/0215/p1089.html?printable=afp

FIGURE 4. Geriatric Depression Scale (short form). Adapted with permission from Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol 1986;5:16572.

An assessment for suicide risk is important in geriatric patients who appear depressed. The best way to accomplish this task is to ask direct, yet nonthreatening questions. An effective interview progression might be to begin by asking patients if they are concerned that they are becoming a burden to their family and if they have ever felt that their family might be better off without them. This is followed by questions about active suicidal ideation. 42

Social Issues
Because multiple aspects of the social situation can influence functional ability, efficient use of time can be made by asking patients and family members if any recent changes have occurred in living arrangements, finances or activities. Actual or potential care-givers can provide information about a patient's social network and support system, as well as the availability of care. 6 Evaluating a caregiver's potential for feeling overwhelmed is important in determining the risk of burning out. Referral to agencies such as the Alzheimer's Association or a local senior center can provide functional and emotional support for patients and caregivers. 6 Other issues that need to be addressed with patients and caregivers include advance directives, the living will and the durable power of attorney. Finally, the USPSTF recommends that all family members of geriatric patients receive training in cardiopulmonary resuscitation.6 Remaining as independent as possible for a long as possible is a primary concern for most elderly patients. The level of supportive assistance that is needed can quickly be determined by asking the patient and/or caregiver about the patient's ability to perform the Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). An ADL evaluation form is provided in Figure 5,43 and an IADL evaluation form is presented in Figure 6.44 Having the patient complete a structured series of activities, such as the Performance Test of Activities of Daily Living (PADL), provides similar information without reporting bias.45

Activities of Daily Living Scale

The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication.
FIGURE 5.

Instrumental Activities of Daily Living (Self-Rated Version)

6 of 10

2/17/2013 5:53 AM

http://www.aafp.org/afp/2000/0215/p1089.html?printable=afp

FIGURE 6. Instrumental Activities of Daily Living Scale (self-rated version). Adapted with permission from Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist 1969;9:27985.

One recent study indicated that short-term memory and orientation are the domains most closely associated with ADL dependence. The study findings suggested that a shortened version of the Mini-Mental State that included only the recall of three words and the orientation to month, year and address could be a valid and time-efficient assessment tool. 46

Final Comment
Geriatric patients present multiple challenges to primary care physicians. Using a standard assessment plan, which might include a chart-based checklist of counseling topics (Figure 7),6 as well as a brief screening list (Table 5),47 physicians can prevent or delay some of the major causes of morbidity and mortality in their older patients. The assessment can be performed over time and during multiple visits. By performing comprehensive health screening, physicians can provide appropriate interventions and improve quality of life for their geriatric patients.

Checklist of Assessment Areas for Maintaining Healthy Geriatric Patients

7 of 10

2/17/2013 5:53 AM

http://www.aafp.org/afp/2000/0215/p1089.html?printable=afp

FIGURE 7. Areas of assessment in a systematic approach to maintaining healthy geriatric patients. Information from U.S. Preventive Services Task Force. Guide to clinical preventive services: report of the U.S. Preventive Services Task Force. 2d ed. Baltimore: Williams & Wilkins, 1996.

8 of 10

2/17/2013 5:53 AM

http://www.aafp.org/afp/2000/0215/p1089.html?printable=afp

TABLE 5.

Ten-Minute Screen for Geriatric Conditions

Problem Vision Screening measure Ask this question: Because of your eyesight, do you have trouble driving a car, watching television, reading or doing any of your daily activities? If the patient answers yes, test each eye with the Snellen eye chart while the patient wears corrective lenses (if applicable). Hearing Leg mobility Urinary incontinence Use an audioscope set at 40 dB. Test the patient's hearing using 1,000 and 2,000 Hz. Inability to hear 1,000 or 2,000 Hz in both ears or inability to hear frequencies in either ear Time the patient after giving these directions: Rise from the chair. Then walk 20 feet briskly, turn, walk back to the chair and sit down. Ask this question: In the past year, have you ever lost your urine and gotten wet? If the patient answers yes, ask this question: Have you lost urine on at least 6 separate days? Ask this question: Have you lost 10 pounds over the past 6 months without trying to do so? If the patient answers yes, weigh the patient. Memory Depression Physical disability Three-item recall Ask this question: Do you often feel sad or depressed? Ask the patient these six questions: Are you able to do strenuous activities, like fast walking or bicycling? Are you able to do heavy work around the house, like washing windows, walls or floors? Are you able to go shopping for groceries or clothes? Are you able to get to places that are out of walking distance? Are you able to bathesponge bath, tub bath or shower? Are you able to dress, like put on a shirt, button and zip your clothes, or put on your shoes?
Adapted with permission from Moore A, Siu AL. Screening for common problems in ambulatory elderly: clinical confirmation of a screen instrument. Am J Med 1996;100:43843. Copyright 1996, with permission from Excerpta Medica Inc.

Positive screen Yes to question and inability to read at greater than 20/40 on the Snellen eye chart

Unable to complete task in 15 seconds . Yes to both questions

Nutrition and weight loss

Yes to the question or a weight of less than 45.5 kg (100 lb)

Unable to remember all three items after 1 minute Yes to the question [corrected] No to any of the questions

The Authors
KARL E. MILLER, M.D., is associate professor of family medicine and director of predoctoral education and research at the University of Tennessee College of Medicine, Chattanooga. Dr. Miller earned his medical degree from the Medical College of Ohio, Toledo, and completed a residency in family practice at Flower Memorial Hospital, Sylvania, Ohio. ROBERT G. ZYLSTRA, ED.D., L.C.S.W. is director of behavioral science and instructor in the Department of Family Medicine at the University of Tennessee College of Medicine, Chattanooga. Dr. Zylstra earned a master of social work degree at the University of Michigan, Ann Arbor, and a doctor of education degree at the University of Memphis. JOHN B. STANDRIDGE, M.D., is assistant professor of family medicine at the University of Tennessee College of Medicine, Chattanooga, and medical director of Alexian Health Care Center, Signal Mountain, Tenn. He earned his medical degree at the University of Tennessee College of Medicine, Memphis, and completed a family practice residency at Roanoke (Va.) Memorial Hospital. Dr. Standridge also earned a Certificate of Added Qualification in Geriatric Medicine. Address correspondence to Karl E. Miller, M.D., Department of Family Medicine, University of Tennessee, Chattanooga Unit, 1100 East Third St., Chattanooga, TN 37403. Reprints are not available from the authors.

REFERENCES 1. Maly RC, Hirsch SH, Reuben DB. The performance of simple instruments in detecting geriatric conditions and selecting community-dwelling older people for geriatric assessment.
Age Ageing. 1997;26:22331.

2. Toseland RW, O'Donnell JC, Engelhardt JB, Hendler SA, Richie JT, Jue D. Outpatient geriatric evaluation and management. Results of a randomized trial. Med Care.
1996;34:62440.

3. Reuben DB, Frank JC, Hirsch SH, McGuigan KA, Maly RC. A randomized clinical trial of outpatient comprehensive geriatric assessment coupled with an intervention to increase
adherence to recommendations. J Am Geriatr Soc. 1999;47:26976.

4. Tryon AF, Mayfield GK, Bross MH. Use of comprehensive geriatric assessment techniques by community physicians. Fam Med. 1992;42:4536. 5. Reuben DB, Maly RC, Hirsch SH, Frank JC, Oakes AM, Siu AL, et al. Physician implementation of and patient adherence to recommendations from comprehensive geriatric
assessment. Am J Med. 1996;100:44451.

6. U.S. Preventive Services Task Force. Guide to clinical preventive services: report of the U.S. Preventive Services Task Force. 2d ed. Baltimore: Williams & Wilkins, 1996. 7. Shadlen MF, Larson EB. What's new in Alzheimer's disease treatment?Reasons for optimism about future pharmacologic options. Postgrad Med. 1999;105:10918. 8. Tinetti MD. Falls. In: Cassel CK, et al., eds. Geriatric medicine. 2d ed. New York: Springer-Verlag, 1990: 52834. 9. Cummings SR, Nevitt MC, Kidd S. Forgetting falls. The limited accuracy of recall of falls in the elderly. J Am Geriatr Soc. 1988;36:6136. 10. Reuben DB, Grossberg GT, Mion LC, Pacala JT, Potter JF, Semla TP. Geriatrics at your fingertips, 1998/99. Belle Mead, N.J.: Excerpta Medica, 1998. 11. Tinetti ME, Baker DI, McAvay G, Claus EB, Garrett P, Gottschalk M, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community.
N Engl J Med. 1994;331:8217.

12. Vellas BJ, Wayne SJ, Romero L, Baumgartner RN, Rubenstein LZ, Garry PJ. One-leg balance is an important predictor of injurious falls in older persons. J Am Geriatr Soc.
1997;45:7358.

13. Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the get up and go test. Arch Phys Med Rehabil . 1986;67:3879. 14. Okumiya K, Matsubayashi K, Nakamura T, Fujisawa M, Osaki Y, Doi Y, et al. The timed up and go test is a useful predictor of falls in community-dwelling older people
[Letter]. J Am Geriatr Soc. 1998;46:9289.

9 of 10

2/17/2013 5:53 AM

http://www.aafp.org/afp/2000/0215/p1089.html?printable=afp

15. Wun YT, Lam CC, Shum WK. Impaired vision in the elderly: a preventable condition. Fam Pract. 1997;14:28992. 16. Carter TL. Age-related vision changes: a primary care guide. Geriatrics. 1994;49:374245. 17. Popelka MM, Cruickshanks KJ, Wiley TL, Tweed TS, Klein BE, Klein R. Low prevalence of hearing aid use among older adults with hearing loss: the Epidemiology of Hearing
Loss Study. J Am Geriatr Soc. 1998;46:10758.

18. Reuben DB, Walsh K, Moore AA, Damesyn M, Greendale GA. Hearing loss in community-dwelling older persons: national prevalence data and identification using simple
questions. J Am Geriatr Soc. 1998;46:100811.

19. Maggi S, Minicuci N, Martini A, Langlois J, Siviero P, Pavan M, et al. Prevalence rates of hearing impairment and comorbid conditions in older people: the Veneto Study. J Am
Geriatr Soc. 1998;46:106974.

20. Lichtenstein MJ, Bess FH, Logan SA. Validation of screening tools for identifying hearing-impaired elderly in primary care. JAMA. 1988;259:28758[Published erratum in JAMA
1990;264:38]

21. Jerger J, Chmiel R, Wilson N, Luchi R. Hearing impairment in older adults: new concepts. J Am Geriatr Soc. 1995;43:92835. 22. Ventry IM, Weinstein BE. Identification of elderly people with hearing problems. ASHA. 1983;25:3742. 23. The clinical and cost-effectiveness of medical nutrition therapies: evidence and estimates of potential medical savings from the use of selected nutritional intervention. June 1966.
Summary report prepared for the Nutritional Screening Initiative. A project of the American Academy of Family Physicians, the American Dietetic Association and the National Council on the Aging, Inc., and funded in part by a grant from Ross Products Division, Abbott Laboratories Inc.

24. Douglas KC, Rush DR, O'Dell M, Monroe A, Ausmus M. Adult immunization in a network of family practice residency programs. J Fam Pract. 1990;31:51320. 25. Influenza and pneumococcal vaccination levels among adults aged > or = 65 yearsUnited States, 1997. MMWR Morb Mortal Wkly Rep. 1998;47:797802. 26. Diokno AC, Brown MB, Herzog AR. Sexual function in the elderly. Arch Intern Med. 1990;150:197200. 27. Kaiser FE. Sexuality in the elderly. Urol Clin North Am. 1996;23:99109. 28. Johnson B. Older adults' suggestions for health care providers regarding discussions of sex. Geriatr Nurs. 1997;18:656. 29. Thom D. Variation in estimates of urinary incontinence prevalence in the community: effects of differences in definition, population characteristics, and study type. J Am Geriatr
Soc. 1998;46:47380.

30. Brandeis GH, Baumann MM, Hossain M, Morris JN, Resnick NM. The prevalence of potentially remedial urinary incontinence in frail older people: a study using the Minimum
Data Set. J Am Geriatr Soc. 1997;45:17984.

31. DuBeau CE, Levy B, Mangione CM, Resnick NM. The impact of urge urinary incontinence on quality of life: importance of patients' perspective and explanatory style. J Am
Geriatr Soc. 1998;46:68392.

32. Roberts RO, Jacobsen SJ, Rhodes T, Reilly WT, Girman CJ, Talley NJ, et al. Urinary incontinence in a community-based cohort: prevalence and health-care-seeking. J Am
Geriatr Soc. 1998;46:46772.

33. Folstein MF, Folstein SE, McHugh PR. Mini-mental state. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:18998. 34. Tuokko H, Hadjistavropoulos T, Miller JA, Beattie BL. The Clock Test: a sensitive measure to differentiate normal elderly from those with Alzheimer's disease. J Am Geriatr Soc.
1992;40:57984.

35. Jorm AF, Jacomb PA. The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): socio-demographic correlates, reliability, validity and some norms. Psychol
Med. 1989;19:101520.

36. Mulligan R, Mackinnon A, Jorm AF, Giannakopoulos P, Michel JP. A comparison of alternative methods of screening for dementia in clinical settings. Arch Neurol .
1996;53:5326.

37. Mackinnon A, Mulligan R. Combining cognitive testing and informant report to increase accuracy of screening for dementia. Am J Psychiatry. 1998;155:152935. 38. Gallo JJ, Rabins PV, Lyketsos CG, Tien AY, Anthony JC. Depression without sadness: functional outcomes of nondysphoric depression in later life. J Am Geriatr Soc.
1997;45:5708.

39. Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol . 1986;5:16572. 40. Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey M, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res.
198283173749.

41. Mahoney J, Drinka TJ, Abler R, Gunter-Hunt G, Matthews C, Gravenstein S, et al. Screening for depression: single question versus GDS. J Am Geriatr Soc.
1994;42:10068.

42. Devons CA. Suicide in the elderly: how to identify and treat patients at risk. Geriatrics. 1996;51:6772. 43. Katz S. Assessing self-maintenance: activities of daily living, mobility, and instrumental activities of daily living. J Am Geriatr Soc. 1983;31:7217. 44. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9:17985. 45. Kruiansky J, Gurland B. The performance test of activities of daily living. Int J Aging Hum Dev. 1976;7:34352. 46. Gill TM, Williams CS, Richardson ED, Berkman LF, Tinetti ME. A predictive model for ADL dependence in community-living older adults based on a reduced set of cognitive
status items. J Am Geriatr Soc. 1997;45:4415.

47. Moore A, Siu AL. Screening for common problems in ambulatory elderly: clinical confirmation of a screen instrument. Am J Med. 1996;100:43843.

COMMENTS

You must be logged in to view the comments. Login

Copyright 2000 by the American Academy of Family Physicians. This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests. AFP Home | About Us | Contact Us | Subscribe/Renew | AFP by E-Mail | Permissions About Online Access | Employment Opportunities Information for: Authors | Advertisers

10 of 10

2/17/2013 5:53 AM