Comprehensive health assessment
Comprehensive health assessment is the cornerstone of quality care of older people. It leads to improved identification and management of health care needs. Clinical studies have shown that older people with multiple health and functional problems benefit from comprehensive health assessment, through:23
- reduced medication useimproved functioning or reduction in functional decline
- improved quality of life and mental health
- improved client/carer satisfaction and a reduction in carer burden
- reduced use of hospital services
- reduced need for residential care
- decreased annual health care costs
- prolonged survival.
The multidimensional assessment incorporates physical, psychological and social function as well as medical health, and so a multidisciplinary approach is often helpful. Assessment is generally undertaken using standardised tools, structured or semistructured proformas, and checklists24 (see Tools).
Residential aged care facilities are required to assess needs and produce care plans for all residents. These plans have a strong focus on personal and nursing care. Medicare rebates have been introduced to support GPs' participation in multidisciplinary assessment and care through doing comprehensive medical assessments and contributing to residents' care plans (see Organisational aspects of medical care).
General practitioners have reported that comprehensive medical assessment of residents is useful for giving structure to the admission process, helps to formally introduce advance care planning and to clarify who can give consent for care. However, its use needs to be flexible and appropriate to the resident's personal situation, so that it can focus on each individual's needs and contribute to multidisciplinary health assessment and care planning.25
Comprehensive medical assessment at the time of admission would include review of background information and recent investigations. Additional information can be collected from direct questioning of residents or other informants (eg. relative/carer, RACF staff), direct observation by trained health professionals, and medical records. Each information source has inherent limitations, so it is valuable to combine information from residents, RACF staff, relatives/carers and medical documents (eg. ACAS report, resident care plan, advance care plan, hospital discharge, or medical correspondence). The accuracy of information from direct questioning of older people can be limited by acute illness, impaired cognition, impaired hearing, impaired communication (dysarthria, dysphasia), depression, limited proficiency in English, fear of significant change to lifestyle, and denial of problems. Most people admitted to residential care have some cognitive impairment, therefore it is advisable to seek collateral information as a matter of course from relatives/carers and RACF staff. Use direct observation and assessment from other health professionals and geriatric assessment services for patients with very complex problems or unstable conditions. For example, physiotherapists assess gait and balance, occupational therapists assess activities of daily living, speech pathologists assess swallowing, pharmacists perform medication reviews, and nurses assess continence.
When conducting a comprehensive medical assessment, it is desirable to see residents earlier in the day when less tired, sitting out of bed facing you at a similar level in a quiet well lit environment. Endeavour to ensure that any needed spectacles are readily available (and clean) and that hearing aids, if needed, are functioning. Complete the assessment over several visits if necessary. Ask what they consider the main problem is and their goals for care. Seek permission to gain further information from relatives/carers and other sources, and to share health information with other relevant service providers.26 It is important to respect patient autonomy by fostering understanding, avoiding coercion, and recognising the right of residents to reject advice or refuse the communication of personal information to others.27
Ethnic groups differ widely in their approach to decision making (ie. involvement of family and carers), disclosure of medical information (eg. cancer diagnosis), and end of life care (eg. advance care planning and resuscitation preferences).28 Also, wide differences appear among individuals within ethnic groups, therefore, in caring for patients of any ethnicity:29
- use the patient's preferred terminology for their cultural identity in conversation and health records
- determine whether interpreter services are needed; if possible use a professional interpreter rather than a family member
- recognise that patients may not conceive of illness in western terms
- determine whether the patient is a refugee or survivor of violence or genocide
- explore early on patient preferences for disclosure of serious clinical findings and confirm at intervals
- ask if the patient prefers to involve or defer to others in the decision making process
- follow patient preferences regarding gender roles.
Particular attention should be paid to assessing residents with impaired communication skills, eg. due to dementia, stroke, visual or hearing difficulties.30 Consider cognitive impairment or depression in residents appearing 'flat', not making good eye contact or responding to questions. For residents with hearing impairment (who can not hear normal spoken conversation from 1 m away in a quiet room), check ears for wax and that any hearing aid is working, then speak slowly and loudly so they can see your mouth. 31 Establish whether the resident has a written advance care plan, and if they have appointed a representative to make health care decisions for them in the event that they are incapable of doing so themselves.
Accurate diagnosis of disease and geriatric conditions is essential to formulate a list of medical problems and goals of care. Diagnostic evaluation involves obtaining a detailed history, examining the resident and ordering appropriate investigations. A detailed history includes: identifying the current main medical problems, past medical history, systems review, medication review, smoking and alcohol, nutritional status, oral health, immunisation status (influenza, tetanus, pneumococcus), and advance care planning.
The systems review helps to identify conditions commonly associated with ageing that may otherwise be unrecognised. Ask about:32
- loss of appetite
- weight loss or gain (amount, time period)
- oral health (mouth, teeth, gums, presence of dentures)
- poor exercise tolerance
- pain (location, character, intensity)
- dizziness (postural, vertigo, dysequilibrium)
- falls (number in past 6 months, location, time of day, mechanism: slip/trip, overbalancing, legs giving way, dizziness or syncope)
- cardio-respiratory symptoms (including chest pain, palpitations, shortness of breath)
- musculoskeletal symptoms (including arthritis, stiffness, weakness)
- neurological symptoms (including loss of sensation or power)
- hearing (including availability and use of aids)
- vision (including availability, use and type of spectacles, when vision last tested)
- feet and usual footwear
- swallowing (solids and liquids)
- communication (speech, handwriting)
- sleep habits (including pattern, duration, use of hypnotic medication)
- elimination (including usual pattern of bladder and bowel function, continence, use of aids)
- sexual function (including libido, symptoms of dysfunction).
Consider referral for a residential medication management review on admission and annually (see Medication management, and Organisational aspects)
Any illness in older residents may be associated with loss of independence in self care and mobility, which may in turn increase dependence on family and community services. People are admitted to a RACF because they have lost their independence in self care and mobility, and their needs can no longer be adequately met by their families, friends or community services.
The World Health Organisation has described functional consequences of disease in terms of 'abnormality of body structure and function', 'activity limitation' and 'participation restriction'. 33 Abnormalities of body structure and function can be thought of entirely within the skin. They can result from any cause (eg. hemiplegia from cerebral infarction, or hip fracture from trauma). Activity limitations reflect the consequences of abnormalities of body structure and function in terms of functional performance and activity by the individual (eg. inability to walk following hemiplegia from stroke). Activity limitations can be conceptualised as reflecting problems at the level of the person. Participation restrictions are concerned with the disadvantages experienced by the individual as a result of impairments and disabilities (eg. inability to use public transport due to inability to walk following hemiplegia from stroke or hip fracture from trauma). Participation restrictions reflect interaction with the person's surroundings. Participation restrictions can be thought of as the inability to fulfil roles that are normal for people given their age, gender and position in society. Using this classification framework, all residents will have diseases, abnormalities of body structure and function, activity limitations and personal care participation restrictions at the time of their admission to a RACF.
Accommodation in the facility and the admission assessment ensure that the personal care needs have been met and that there are no participation restrictions. Further functional assessments provide the means to consider whether there are activity limitations, and abnormalities of body structure and function that need to be addressed to prevent and/or reverse decline in a resident's physical, psychological and social function.
The Barthel Index (see Tools) is widely used to assess changes in self care and mobility activities of daily living. However, for older people in RACFs, the Barthel Index may give only a broad brush picture, as its ability to reflect change in function is limited by a floor effect and by lack of sensitivity to change. The floor effect occurs because many residents score in the lowest categories in most items in the Barthel Index, and in the event of deterioration there is no possibility to score their function any lower. The sensitivity to change is limited, as important improvements do not necessarily result in a change in score.34
When asking an older person about their physical function, it is important to recognise the distinction between their 'capacity' (which can be established by asking 'Can you..?') and their 'performance' (which can be established by asking 'Do you..?'). Older people in RACFs may perform below their capacity due to lack of support, feeling unwell or afraid (especially of falling), or the lack of suitable aids or environmental modifications.35 Relatives/carers and RACF staff are well placed to provide information concerning the physical function of residents. However, sometimes they may underestimate capacity or may not have had sufficient contact to be able to provide up-to-date information. Direct observation by trained health professionals is likely to provide more accurate measurement of functional capacity than either self or informant reports which tend to reflect actual performance.
Early recognition of cognitive impairment is a particularly important aspect of assessment, as it may have a significant impact upon how assessment information is obtained and from whom. It is important to distinguish between delirium (acute) and dementia (chronic) (see Table 5 and Dementia). The incidence of delirium is greater in those with pre-existing cognitive impairment (see Delirium). Depression is a common problem that can have a negative impact if not recognised and treated (see Depression). Loss and grief for older residents and their families are key features of both entering and living in residential aged care. Changes in physical and mental functioning may lead to changes in role, status, and relationships with relatives and others. There may be a loss of valued skills and attributes, companionship and intimacy, identity and autonomy, possessions and surroundings, and expectations for the future.36,37 The sense of loss may be difficult to acknowledge because the older person is still alive and the journey may be protracted, with no definite starting or end point.38 Grief may be accompanied by guilt, anxiety and confusion.
Assessment includes type of residential living arrangements (single or shared room), living environment and services, social support, financial circumstances, elder abuse or neglect and family issues. Social support includes the availability and adequacy of social input and emotional support from relatives/carers, RACF residents/staff/volunteers, and others. Elder abuse may be physical, psychological, financial or social, and may include neglect as well as actual harm. Carer issues also need to be considered. These may include the burden that the care role places on them; the provision of adequate support; and their own health status, needs and expectations.
Assessment of capacity
General practitioners are increasingly required to assess residents' capacity to make decisions such as granting a power of attorney, making an advance care plan, or choosing a health care investigation or treatment.
Capacity and the lack of capacity are legal concepts. Capacity is determined by whether a person can understand and appreciate information about the context and decision, not the actual outcomes of choices made, and not whether they can perform tasks. For instance, illness can temporarily impair capacity, and chronic conditions such as schizophrenia or Alzheimer disease do not automatically mean incapacity. A declaration of incapacity is serious as it implies a need to assume responsibility for the incapable person's wellbeing. Valid assessments of capacity are necessary to honour the ethical principles of respect for individuals, beneficence and justice.
Capacity can be divided into a number of broad domains which include capacity to make a will or grant a power of attorney, make an advance care plan, manage finances or property, choose medical treatment, and manage personal care. Decision making in various domains involves a mixture of cognitive and functional abilities, and a person can be incapable in one domain and capable in another. A capable person:
- knows the context of the decision at hand
- knows the choices available
- appreciates the consequences of specific choices
- does not base choices on delusional constructs.
It is easy to judge the capacity of someone who is clearly capable or incapable. When a person has partial understanding and their capacity is borderline, the GP may undertake a more systematic assessment or refer to a psychologist or geriatrician. Table 1 shows a six step assessment process developed to help judge capacity. Decisional aids are available to assess capacity in specific domains (step 5).40
Table 1. The six step capacity assessment process 41
- Ensure that assessment of decision making capacity is done only when a valid trigger is present (situations that place the allegedly incapable person or others at risk, and on the face of it appear to be due to lack of capacity)
- Engage the person being assessed in the process
- Gather information to describe the context, choices and their consequences
- Educate the person about the context, choices and their consequences
- Assess capacity
- Take action based on results of the assessment
Medical management and review
Problems identified from the comprehensive medical assessment and the resident's situation and wishes at the time will determine the goals for current management and what emphasis is placed on;
- treatment of disease
- rehabilitation and restoration of function
- symptom control and palliative care.
Goals should also be discussed for future care (see Advance care planning). The comprehensive medical assessment, active problem list and goals of care can be incorporated into the resident's care plan and reviewed regularly. Chronic conditions such as diabetes, and cardiovascular and respiratory diseases may be assessed and managed according to existing disease specific guidelines. However, goals of care will vary depending on the stage of illness, comorbidities and wishes of the resident. The GP can then monitor the resident's management and health status and adjust management as necessary at scheduled visits.
Scheduled RACF visit checklist:42
- Evaluate patient for interval functional change
- Check vital signs, weight, laboratory tests, consultant reports since last visit
- Review medications (correlate to active diagnoses)
- Sign orders
- Address RACF staff concerns
- Write SOAP notes in resident record (SOAP: subjective data, objective data, assessment, plan)
- Revise problem list as needed
- Update advance care plan at least yearly
- Update resident: update family member(s) as needed.
Education and involvement of relatives/carers in a resident's care can improve clinical outcomes, reduce feelings of loss and captivity, and increase satisfaction with care.43 General practitioners play a significant role in supporting residents and relatives/carers with plain language information about the condition, management and likely course. This includes sensitivity to the different cultural needs of families and how they care for their older relatives, responding to any feelings or concerns, and referring for counselling and support if required (see Contacts).44,45