Geriatric Assessment: An Office-Based Approach.

Family physicians should be proficient in geriatric assessment because, as society ages, older adults will constitute an increasing proportion of patients. Geriatric assessment evaluates medical, social, and environmental factors that influence overall well-being, and addresses functional status, fall risk, medication review, nutrition, vision, hearing, cognition, mood, and toileting. The Medicare Annual Wellness Visit includes the key elements of geriatric assessment performed by family physicians. Comprehensive geriatric assessment can lead to early recognition of problems that impair quality of life by identifying areas for focused intervention, but a rolling geriatric assessment over several visits can also effectively identify subtle or hidden problems. Assessment should be tailored to patient goals of care and life expectancy. By asking patients and families to self-assess risks using precompleted forms, and by using trained office staff to complete validated assessment tools, family physicians can maximize efficiency by focusing on identified problems. Fall risk can be assessed with a single screening question: "Have you fallen in the past year?" The Beers, STOPP (screening tool of older persons' prescriptions), and START (screening tool to alert doctors to right treatment) criteria are helpful resources for reviewing the appropriateness of medications in older adults. Screening for depression is recommended when depression care supports are available; this can be performed with a brief two-item screen, the Patient Health Questionnaire-2. Older adults should be screened for unintentional weight loss and malnutrition. Although rates of hearing loss and vision loss increase with age, there is insufficient evidence to recommend screening in asymptomatic individuals. The U.S. Preventive Services Task Force advises clinicians to assess cognition when there is suspicion of impairment. Urinary incontinence can impair patients' quality of life, and it can be assessed with a two-question screening tool. Immunizations and advance care planning are also important components of the geriatric assessment.

Recognizing and Managing Polypharmacy in Advanced Illness.

Older adults, particularly those late in life, are at higher risk for medication misadventure, yet bear the burden of increasing polypharmacy. It is incumbent on practitioners who care for this vulnerable population to use one or more approaches to deprescribe medications that impose a greater burden than benefit, including medically futile medications. It is essential that health care providers use compassionate communication skills when explaining these interventions with patients and families, pointing out that this is a positive, patient-centric intervention.

Electronic end-of-life care registry: the Utah ePOLST initiative.

As a patient's end-of-life approaches, it is typical for the disease to be the focus of treatment instead of the dying patient. There is limited congruence between the care preferred by patients and the treatment actually delivered to patients during their end-of-life. The Physician Orders for Life-Sustaining Treatment Paradigm has been endorsed or is in development in all but three states and the District of Columbia in an effort to ensure that patients are provided with adequate opportunities to specify their end-of-life care preferences. However, most states are using paper forms to document these preferences which may be inaccessible when needed. We have developed an electronic end-of-life care registry that allows authorized users to store and retrieve information pertaining to patients' end-of-life care preferences. In this paper, we describe (a) the requirements identified for the registry from the users' perspective and (b) the design and development of the electronic registry.