Screening and assessment

Older people have a higher risk of functional decline and preventable harm during a hospital stay than younger people. This is due to changing physiology and the presence of multiple, complex and often chronic problems.

Clinicians often focus on an older person’s acute health problems that led to the hospital admission. We may neglect to prioritise issues such as nutrition and hydration, maintaining mobility, providing good pressure care and the psychosocial and emotional needs of the person - all of which can impact negatively on an older person’s outcomes.

The issues of social isolation and loneliness, which are distinct but related concepts, are gaining increasing attention in Australia and overseas as they can have a significant impact on an individual’s health. Identifying those at risk of these issues and developing a person-centred plan to actively engage the older person, encouraging them to participate in their care in hospital and after their discharge, is integral to good care.

Providing the best care for older people rarely requires a single intervention. However, the complexity of integrating multiple assessments, managing best practice interventions for different risks and integrating patient preferences is not a straightforward task.

Screening and assessment on admission and throughout an older person’s hospital stay can help us to quickly identify and respond to actual or potential risks to patient safety and wellbeing.

This topic provides an overview of some components of screening and assessment. It is to be read in conjunction with the accompanying clinical topics and with health service policy and procedures.

Assessment and ageing

Screening is the process of identifying risks that indicate a patient would benefit from further or more detailed assessment.

Assessment is the process of collecting information to identify the exact nature of a patient’s problems and protective factors (medical, physical, social and psychological). The information collected during an assessment should be analysed, interpreted, verified and communicated. It is used to inform the development of a prioritised, individualised person-centred care plan that includes evidence-based responses to treat a problem and prevent harm.

Screening and assessment are more than completing forms. As clinicians, we draw on our clinical reasoning skills, work with our team, and with the older person and their family, to establish their needs, wants and status.

Screening and assessment of our older patients, on admission and throughout their hospital stay, can identify concerns and changes, monitor progress and inform safe, effective and appropriate care.

Screening and assessment of older patients

Screening and assessment for older people is different to screening and assessment of younger people because older people often present to hospital with non-specific symptoms, and those symptoms may indicate different concerns and mask other issues that occur with ageing. For example, the symptoms of a urinary tract infection in a younger person may be frequent urination, pain from bladder spasms, blood in the urine, and fever. In an older person, the first sign of a urinary tract infection may be confusion or a fall as the other symptoms can be masked by changes that occur with ageing.¹

Normal age-related changes

Older age provides a challenge for patients and clinicians to identify ‘normal’ from ‘abnormal’. While everyone is different and therefore ages in a different way and at a different rate, ‘normal’ ageing is generally accompanied by a decline in many homeostatic and metabolic processes.

Normal ageing can cause changes that require interventions to prevent further deterioration and to assist the person maintain their wellness. If illness does occur, the older person often has less reserve and less capacity to recover than younger people.

Changes in physical, cognitive and mental function are ‘normal’ ageing. Things to consider for older people in hospital include:

• Decreased muscle strength and aerobic capacity
• Decreased bone density and joint flexibility
• Vasomotor instability
• Skin thins and loses elasticity
• Changes in nutritional requirements and loss of appetite
• Changes in bladder and bowel function
• Decreased glucose tolerance
• Reduction in sensory perception
• Memory loss and reduced cognitive awareness
• Changes in mental health and wellbeing
• Altered sexual functioning.

Losses, such as bereavement and changes in function, are common experiences for older people and can be risk factors for loneliness and social isolation. These can in turn increase risk of various health problems.² Older patients are also more likely to have multiple comorbidities which may increase their risk of social isolation.³

It is up to us to be curious, determine what matters to our patients, think about the information we collect and consider the best possible interventions that we can employ to minimise risks and maximise our patient’s quality of life. This can involve balancing some risks with some gains and working with our team and the older person and their family to make an informed choice about this.

Screening

Screening identifies people or conditions that would benefit from further assessment. The aim is to identify concerns early and avoid further problems in hospital.

Screening usually involves using a prompt to identify various ‘red flags’ or risks associated with the patient. These can include medical, functional and psychosocial risk factors such as:

• being older than 70 and living alone. This includes an increased risk of isolation or loneliness that negatively affects a person's physical and mental health, and increases the risk of mortality⁴
• a diagnosis of dementia or displaying signs of cognitive impairment
• a recent stay in hospital
• polypharmacy, a history of falls, mobility problems and incontinence
• a recent unexplained weight loss
• a functional limitation with personal care, domestic and community participation
• relying on a significant amount of community service support.

Once we have identified any of the above red flags, we can use targeted screening tools as outlined in the individual topics in this section. Trained staff can conduct screening at any time during a person’s time in hospital. Ideally screening is conducted on admission and regularly throughout the episode of care. Early screening is important in establishing a baseline for monitoring an older person’s level of function and identifying changes in health.

Screening can identify increased risk for functional decline and in many cases trigger an immediate response to mitigate risk until further assessment is possible.

Examples of screening tools

Identification of Seniors at Risk Screening Tool (ISAR)⁶ - a six item screening tool for seniors in the emergency department.

Fulmer SPICES: An Overall Assessment Tool for Older Adults - SPICES is an alert system that obtains information to help prevent health deterioration in the older adult patient.

UCLA Loneliness Scale - a set of three questions currently recommended in the International Consortium for Health Outcome Measures (ICHOM) to measure if an older person is feeling lonely

Assessment process

Assessment tools cannot substitute for good clinical skills and judgements. As clinicians we need to be aware that assessment tools can tell us more than just a score.

Assessment involves collecting information that gets to know the patient in detail, evaluates their risks and the nature of problems to be identified.

Assessment should integrate all the relevant issues. It should explore the medical, physiological, social and psychological function of the older person.

The assessment process encourages us to be curious and to consider the best possible interventions that we can employ to minimise risks and maximise our patient’s quality of life. This can ultimately involve balancing some risks with some gains and working with our team and the older person and their family to make an informed choice about this.

Assessment supports us to:

• treat the condition that caused the admission (such as shortness of breath)
• detect and quantify additional conditions or psychosocial issues that contribute to or complicate the admission and respond to them as able both during the admission and when planning for discharge. For example
  • depression - consider if the person needs a medical review
  • poor nutrition - consider what can be done to optimise the person’s intake
  • social isolation, or risk of loneliness - consider how you can encourage the person to participate in their care by harnessing their personal and social connections, and consider linking them to supports that are meaningful to them on discharge
• use strategies to prevent conditions that often emerge during hospital stays but can be avoided (such as delirium and falls).

We can gather information as part of the assessment process from multiple sources, and these may vary at the stages of a hospital admission.

The four main sources of information are:

1. Older people themselves - self report.
2. Others who know the older person well - informant report.
3. Observation of the person undertaking various activities - direct observation.
4. Various secondary written or verbal sources - including hospital records, medical reports, investigation results, communication from community care providers.

Unless there are reasons to suspect otherwise the older person is considered the best source of information about their own health¹. Direct observation is the best source of information about physical function; however, we should consider how the environment or setting where observations take place may impact on the older person’s performance.

Assessment tools

Assessment tools can be focussed on exploring one particular condition such as pain, pressure injury or nutrition. They can also be more comprehensive and encompass a broader focus beyond one particular issue. Examples of these types of tools include:

• InterRAI Comprehensive Assessment Tool: Acute
• Systematic Evaluation and Intervention for Seniors At Risk (SEISAR) - a short, standardised, comprehensive tool for the evaluation of active geriatric problems in seniors in the emergency department.

The assessment tool or scale should enable collection of useful patient data that supports interpretation of the holistic health status, identifies patient needs, and informs care planning and interventions to restore health and wellbeing.

Selecting an assessment tool

Consider the following factors when selecting an assessment tool include:

• A standardised tool can reduce variation in practices and interpretation of findings and allow comparison across assessments.
• A validated assessment tool ensures the right data is captured to evaluate the patient and their progress.
• Is a specific tools mandated for specific circumstances or settings? See the individual topics for examples.
• Does the tool cater for cultural or language differences?
• Is the tool appropriate for the physiology of ageing?

The format used will also depend on the discipline, skill and expertise of the clinician, the context and setting of the assessment, the time available and the number of assessors involved. The assessment can be:

• unstructured – if the professional expertise of the assessor is high
• semi-structured – incorporates specific tools and checklists
• structured and standardised – using global assessment instruments.

Comprehensive Geriatric Assessment

There is no gold standard for assessment of older people; however, a Comprehensive Geriatric Assessment is highly recommended to understand the multidimensional complex care needs of frail older people and to determine both short and long term care needs.

A Comprehensive Geriatric Assessment can be undertaken by any member of the interdisciplinary healthcare team who has the required knowledge and skills. Multiple team members with specific skills may need to be involved depending on the patient’s needs.

Ideally, the assessment should be completed within the patient’s first 24 hours in hospital and communicated to all team members, the patient and informal carers.

Conducting assessments

We also need to be aware of the following when conducting assessments of older people:

• At all times, it is vital that we maintain an understanding the older person’s perspective.
• In acute hospital settings, circumstances may mean older people are not able or willing to be actively involved when health professionals assess them.
• Older people may take more time to complete tools than younger people, so allow for rests during formal assessments.
• Ensure that any needs for communication assistances are met. These may include use of interpreters, ensuring the older person is wearing their glasses and/or hearing aids if they are used routinely.
• Do not assume older people know why they are being assessed. Explain why certain questions or tests are being undertaken.
• Establish cognitive status as early as possible in an assessment. Do not assume older people are able to hear, comprehend what is said or are capable of accurate, intelligible responses (for example if they are acutely unwell).
• Note that appearing ‘flat’, minimal eye contact and being non-committal responses may indicate depressive symptoms are present. Depressed older people can give the appearance of being cognitively impaired.
• Consider the need for an interpreter for those with limited English proficiency. The interpreter can also assist with cultural care delivery.
• Consider specific cultural issues and seek assistance necessary from cultural liaison officers or Indigenous health workers.

Applying clinical skills to assessment

Good clinical skills, observation, listening, interpreting and clinical judgement are all vital in decision-making.

When we assess older patients, we use tools and draw on our clinical reasoning skills. The reasoning cycle⁷ sets out the elements of effective clinical decision-making:

• Consider the patient situation
• Collect cues and information – through observation, questions
• Process the information – what does it mean?
• Identify problems and issues – what does the information indicate?
• Establish goals – what actions need to be taken?
• Take actions
• Evaluate outcomes
• Reflect on process and new learning.

Responding to assessment

The result of the screening and assessment process is the development and implementation of a care plan in conjunction with the patient and their family.

The aim of a care plan is to meet the individual patient’s needs and goals. When compiling a care plan, take the time to get to know what matters to your patient and what they would like to achieve. Maximise their opportunities to participate in their care, tailor simple evidence based strategies to their needs and encourage them to play an active role in maintaining their health. Revisit and update the care plan following reviews of progress or changes in the patient’s status.

Interventions identified in a care plan can involve:

• curative care - to improve specific conditions
• comfort care - to improve quality of life when an older person is receiving palliative care
• preventive strategies to minimise risk of functional decline such as pressure care, nutrition and hydration, regular mobilisation, maintaining continence, pain management, orientation and cognitive functioning, and maintaining social connections both during and after a stay in hospital.

Once we have introduced the interventions, we need to regularly assess the older person’s ability to participate in the implementation of the plan and adjust the interventions as required.