4 Evaluation of the Outpatient Geriatric Patient

David Eibling

Introduction

Older adults differ from younger adults in many ways that can affect evaluation strategies and, ultimately, treatment decision making. This chapter reviews the most salient of these characteristics and offers guidance to otolaryngologists with geriatric patients.

Population demographics mean that ever-increasing numbers of older adults will seek otolaryngology care in the coming decades.¹ The impact of these changes will be ubiquitous, affecting the entire discipline with the exception of pediatric specialties and practices. Otolaryngologists readily understand that outpatient evaluation of a child differs from that of an adult, but many physicians do not recognize that the evaluation of an elderly adult also requires modification. Some of the differences between older adults and younger or middle-aged adults may not be readily apparent. Moreover, older adults vary dramatically within specific age ranges, with far more heterogeneity than children or even young adults. It is not uncommon to encounter patients in their 90s who appear to have lower disease burden than many in their 50s and 60s. The potential reasons for these disparities are numerous and collectively drive the need to comprehensively evaluate older patients who present for otolaryngological care.

The unique characteristics of older adults that impact outpatient evaluation in the typical otolaryngology practice include, but are not limited to, the following:

• Reduced functional reserve (frailty)

• Multiple comorbidities

• Polypharmacy

• Multiple physicians

• Sensory impairment (vision, hearing loss, olfaction)

• Reduced mobility

• Impaired balance with increased risk of falls

• Dysphagia, eating disorders

• Cognitive decline

• Inadequate social support

• Goals and expectations differ from those of younger adults

Comprehensive Geriatric Assessment (CGA)

The standard benchmark for geriatric evaluation is the comprehensive geriatric assessment (CGA), which is a standard assessment performed by geriatricians.² The CGA is intended to serve as a baseline for the geriatrician in directing a patient’s medical care. As its name implies, it is comprehensive, requires hours to complete, and is usually unnecessary for the purposes of decision making in an otolaryngological office. Performance of a CGA should therefore be delegated to geriatricians. However, there are multiple evaluation components that should be performed by otolaryngologists, particularly those regarding surgical candidacy for older adults. These are discussed in this chapter in roughly descending order of importance. A useful tool is the Vulnerable Elderly Survey 13 (VES-13), which assesses physical well-being and strength as well as the subject’s ability to perform common activities of daily living (ADLs) without assistance.³

Reduced Functional Reserve

Increased risk of frailty is the most critical defining characteristic of the elderly of which otolaryngologists must be aware. Frailty, a measure of reduced functional reserve, places the older adult at risk for a plethora of adverse and unanticipated consequences from seemingly minor interventions, including increased likelihood of surgical complications as well as ultimate hospital discharge to a setting other than home.^4,5 Younger adults have substantial functional reserves in all organ systems in that they routinely use only a percentage of the total capacity of the organ system. Older adults may appear to be just as resilient as younger adults at first glance, but when stressed they may quickly exhaust their resources and suffer multiple-system organ failure. Therefore, assessment of frailty must be considered a fundamental part of any evaluation of older adults when surgical intervention is a consideration. Like Justice Potter’s famous statement regarding pornography, most people would state they are unable to define frailty, although they “recognize it when (they) see it.” However, as practitioners of the science as well as the art of medicine physicians are obligated to be more rigorous in their assessments than merely relying on subjective impression. Evaluation of frailty falls into this paradigm because objective measures of frailty exist and are used by some practitioners. These measures have been validated by several longitudinal studies, including studies that demonstrate a strong correlation with surgical outcomes.4–6 Measures may be demonstrated either on examination or via biochemical assessment. Several biochemical measures, such as circulating levels of D dimer (D-dimer assay) and interleukin-6 (IL-6) have been reported to correlate with other measures of frailty.⁶ For the purposes of outpatient evaluation there are several easily performed tests that all otolaryngologists can incorporate into their clinical practice. The reader will note that these can be divided roughly into subjective (exhaustion; reduced anxiety level) and objective (unintentional weight loss > 10 lb; getup-and-go test; grip strength) criteria.⁴

The get-up-and-go test is performed by arising from a sitting position, walking 8 feet, and returning and sitting. Scoring is 1 through 3, with loss of a point for (1) using arms to get up, (2) uncertain gait, and (3) taking longer than 10 seconds.⁷ Another test often used is measurement of walking speed (15 feet in 6 seconds or less).⁸

Grip strength is measured with a dynamometer, a low-cost device in common use. Normal men should produce more than 29 kg (median 39 kg), women somewhat less.⁹ Both of these measures correlate with both short-term and long-term survival and are considered valid measures of frailty.

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