Introduction
As populations worldwide age, primary care practices are increasingly tasked with managing the complex health needs of older adults. Geriatric conditions, while profoundly impacting the well-being of seniors, are frequently overlooked in busy primary care settings. This oversight stems from various factors, including time limitations during consultations and a lack of specialized training in comprehensive geriatric assessment (CGA) among primary care physicians. To address this critical gap, the implementation of effective Screening Tools For Geriatrics Primary Care is essential. This article explores the epidemiological rationale for incorporating brief geriatric assessments into routine primary care. It advocates for the use of pragmatic screening tools for geriatrics primary care to identify older patients who would benefit from more in-depth evaluation and targeted interventions.
The Imperative of Systematic Geriatric Assessment in Primary Care
Primary care physicians are at the forefront of healthcare for an aging demographic, encountering a growing number of older patients often presenting with multiple, interacting health issues. Managing multimorbidity in older adults is further complicated by several factors. Firstly, the diagnosis of health problems can be obscured by atypical symptom presentation or communication barriers arising from conditions like hearing loss or cognitive impairment. Furthermore, the normalization of symptoms as simply “part of aging” by both patients and healthcare professionals often leads to underdiagnosis of significant geriatric conditions such as incontinence or cognitive decline [1]. Studies have shown that the quality of ambulatory care for older primary care patients with geriatric conditions is demonstrably lower compared to those with non-geriatric conditions [2]. Beyond medical complexities, psychosocial and environmental factors become increasingly critical in older adults, frequently coexisting with health problems and significantly affecting their management. Despite the clear need, primary care physicians often lack readily available guidance and efficient screening tools for geriatrics primary care to effectively assess these multifaceted impairments [3, 4].
Comprehensive Geriatric Assessment (CGA) was developed as a structured, multidimensional approach to systematically identify and manage these complex issues in older patients. CGA extends beyond simply listing medical and functional problems; it aims to holistically evaluate an older person’s overall health status, encompassing their resources, capabilities, and personal preferences [4]. The ultimate goal of CGA is to empower physicians to select and prioritize therapeutic interventions tailored to each individual patient’s unique needs. While this article focuses on the critical first step – utilizing brief screening tools for geriatrics primary care – it is important to understand that these tools are designed to identify individuals who may require a more complete CGA. Traditionally conducted by interdisciplinary teams in hospital or long-term care settings, CGA in primary care settings is typically undertaken by geriatricians or specially trained gerontological nurses [5, 6]. A full CGA, encompassing physical, mental health, and social circumstances, can be time-intensive, often requiring over 60 minutes, excluding the time needed for intervention planning [7].
The value of CGA in identifying geriatric conditions and improving patient care is well-documented across various settings, including community and primary care [2, 8, 9]. Notably, research in general practice emphasizes the particular benefit of CGA when the patient-physician relationship is relatively new (less than 2 years), revealing a doubling in the number of newly identified problems, regardless of the relationship quality [3]. However, the evidence supporting widespread CGA implementation in primary care remains somewhat limited due to fewer studies in this specific setting. This underscores the urgent need for practical and efficient screening tools for geriatrics primary care to bridge this evidence gap and enhance the care of older adults.
Targeting Brief Geriatric Assessment: Patient Groups and Objectives
The objectives of geriatric assessment in primary care are adaptable based on a patient’s overall health status, ranging from health promotion to early detection and informed decision-making for therapeutic interventions. The World Health Organization (WHO)’s framework for healthy aging categorizes target groups based on an older person’s intrinsic capacity (physical and mental) and functional ability. Intrinsic capacity and functional ability are defined as health-related attributes that enable individuals to pursue activities they value. “Fit” older adults, characterized by fewer chronic diseases and high intrinsic capacity and functional ability, are ideal candidates for health promotion and preventative strategies. However, universal CGA for this large group would be impractical due to time constraints. Conversely, older individuals already experiencing disability require integrated care pathways and may not derive significant benefit from CGA during routine preventative home visits [10]. Brief screening tools for geriatrics primary care are most effectively targeted at the intermediate group: older adults with two or more chronic conditions but with minimal or no existing disability. The aim here is to proactively identify early declines in capacity and implement timely interventions to slow further deterioration [11].
Patients scheduled for surgical or oncological procedures represent another crucial target population for brief CGA. Utilizing screening tools for geriatrics primary care in this preoperative setting can effectively identify individuals at higher risk of adverse outcomes, enabling tailored peri-operative care plans that have been shown to reduce complication rates and length of hospital stays [12, 13].
A consensus is emerging to advocate a two-step approach for geriatric assessment in primary care, specifically targeting patients aged 75-80 and older with two or more comorbidities, or those undergoing surgical or oncological interventions [8]. Tools like EASY-Care are designed for primary care, helping practitioners identify frail older patients who then receive comprehensive assessment by a specialist nurse, often during a home visit [14]. Similarly, the British Geriatrics Society recommends using the PRISMA questionnaire, combined with gait and mobility assessments, as initial screening tools for geriatrics primary care [15].
This article proposes a pragmatic approach focused on integrating brief screening tools for geriatrics primary care into routine primary care consultations. The emphasis is on early detection of prevalent geriatric conditions rather than broad health promotion strategies in older adults. Furthermore, this discussion is deliberately limited to the initial screening phase and does not extend to the comprehensive identification of patient resources and preferences, which are integral components of full CGA and are essential for developing individualized intervention plans [16].
Patient-Centered Benefits of Geriatric Screening
The traditional focus on managing individual chronic diseases, while important, is often insufficient for older adults who typically present with multiple co-existing conditions [17]. CGA offers a more holistic approach, prioritizing function-related outcomes and addressing the well-documented disconnect between symptoms and underlying causes in older adults with multimorbidity. Moreover, CGA better accommodates the increasing diversity in individual expectations regarding healthcare as people age. By using screening tools for geriatrics primary care as the first step, we can pave the way for more personalized and effective care.
When implemented for community-dwelling and hospitalized older adults, CGA has demonstrated significant benefits, including reduced disability, extended independent living at home, and a 20% decrease in institutionalization rates over 12 months compared to standard care [18]. Among older adults receiving formal home care, CGA has been linked to a reduced risk of both hospital and nursing home admissions. Economic evaluations have shown that while CGA may increase the initial provision of home care interventions, these costs are offset by substantial reductions in institutional care costs in hospitals and nursing homes [19].
In the primary care setting, studies indicate that approximately half of the problems newly identified through CGA are successfully managed by the primary care physician within 12 months [3]. Numerous studies report improvements in the quality of care (e.g., enhanced fall-risk assessment and management [20]) and patients’ quality of life, with some demonstrating reductions in hospital admission rates [21].
Regarding cost-effectiveness, meta-analyses of CGA studies have yielded mixed results, varying depending on the target population and specific interventions [18]. Evidence on the economic benefits of brief screening tools for geriatrics primary care is still emerging and requires further investigation [22]. However, the potential for improved patient outcomes and more efficient resource allocation makes the adoption of these tools a compelling direction for primary care.
Essential Dimensions for Geriatric Screening
A systematic review of factors associated with disability identified functional, cognitive, affective, and social problems, along with sensory impairments and lifestyle habits to a lesser extent, as modifiable risk factors for functional decline [23]. The domains typically included in CGA and, by extension, brief screening tools for geriatrics primary care, align with established criteria for effective screening programs. These criteria include: the condition is prevalent and often under-recognized, reliable and valid screening tests are available, diagnostic procedures pose acceptable risk-benefit ratios, and effective interventions exist to improve the condition. A study specifically investigating unmet needs identified by older people themselves highlighted five priority domains: (a) hearing and vision; (b) physical ability, encompassing activities of daily living (ADL), mobility, and falls; (c) incontinence; (d) cognition; and (e) emotional well-being [8]. Nutritional status and social circumstances are frequently added to this essential list [24]. These dimensions are also endorsed by a panel of experts contributing to the WHO guidelines on integrated care for older people [4], which recommend assessing declines in physical and mental capacities (mobility, nutrition, vision, hearing, cognition, and depression) alongside geriatric syndromes (urinary incontinence and fall risk). Therefore, effective screening tools for geriatrics primary care should encompass these key dimensions to provide a comprehensive yet efficient initial assessment.
Integrating Brief CGA Screening into Primary Care Consultations
Time constraints are a major barrier to implementing full CGA in busy primary care practices. To overcome this, various combinations of brief instruments have been developed to efficiently identify geriatric conditions within the time limitations of typical primary care consultations [8, 24]. These screening tools for geriatrics primary care enable basic multidimensional screening in approximately 15 minutes, effectively identifying patients who may benefit from more detailed assessment by their primary care physician or referral to a geriatrician for specialized evaluation and management.
The psychometric properties and clinical impact of these brief screening instruments are still under investigation, and robust evidence favoring one tool or combination over another is limited. Therefore, the selection of screening tools for geriatrics primary care should be guided by practicality, suitability to the specific patient population, and the context of the particular healthcare system.
Concurrently, numerous instruments have been developed to identify frailty in primary care settings [7, 8, 14, 15, 24]. These frailty screening tools often include domains similar to those in brief CGA, reflecting the overlapping nature of frailty and functional decline, which share common risk factors [25, 26]. This convergence further supports the integrated use of screening tools for geriatrics primary care to address both frailty and broader geriatric concerns.
This article proposes a pragmatic approach for primary care physicians to utilize a selected set of dimensions when caring for older patients. While this selection is not strictly evidence-based in its specific combination, each proposed dimension shares key characteristics: significant prevalence of impairment, frequent under-detection, availability of valid brief screening tests, and corresponding effective therapeutic or supportive interventions. For several of these dimensions, we refer to evidence summaries from the US Preventive Services Task Force (USPSTF) [27] and the Canadian Task Force on Preventive Health Care [27, 28]. In some cases, these task forces deemed the evidence on the impact of screening and subsequent management on clinical outcomes insufficient for formal recommendations. However, the WHO guidelines, based on expert consensus, incorporate these same dimensions, considering the balance of benefits and harms, alignment with older persons’ values, and the cost and feasibility of assessment [4]. Such a brief evaluation using screening tools for geriatrics primary care can realistically be completed within approximately 15 minutes. While the optimal frequency of repeat screening is not definitively established, annual assessments are commonly suggested [29].
Screening for Functional Impairment
A cornerstone of CGA is evaluating a patient’s functional ability, specifically their capacity to perform usual Activities of Daily Living (ADLs). Assessing daily function is crucial for identifying functional decline as it reflects the real-world consequences of underlying health problems. Furthermore, functional status is a powerful predictor of prognosis and future functional trajectory [30]. Early detection of functional difficulties, coupled with investigation into their underlying causes, is the essential first step towards implementing interventions to prevent further functional loss, restore function where possible, and address the resulting needs for support and personal care. Screening tools for geriatrics primary care must include functional assessment to capture this vital aspect of geriatric health.
Functional status is typically assessed by evaluating difficulties or impairments in both basic and instrumental ADLs, as detailed in Table 1. Instrumental ADLs (IADLs) are more complex activities requiring higher-level neuropsychological function than basic self-care ADLs. Consequently, impairments in IADLs often manifest before difficulties with basic ADLs [31].
Table 1. Description of basic and instrumental activities of daily living
| Basic activities of daily living include the following [73]: | Instrumental activities of daily living include the following [31]: |
|---|---|
| Bathing | Use the telephone |
| Dressing | Use public transportation |
| Toileting | Do grocery shopping |
| Transferring (in-out of bed/chair) | Prepare meals |
| Continence (bladder, bowel) | Handle own medication |
| Eating | Handle finances |
| Do housekeeping | |
| Do laundry |
Difficulties with instrumental ADLs are strongly correlated with cognitive function. For instance, the emergence of impairment in four IADLs (telephone use, public transportation, medication management, and financial handling) has been shown to increase the odds of a dementia diagnosis in the subsequent 12 months by 4-fold (with one IADL impaired) to 10-fold (with 3 or 4 IADLs impaired) [32]. Given the time constraints of clinical encounters, initiating functional assessment with a general question about the onset of difficulties in performing ADLs and IADLs can be a practical approach for primary care [24]. However, discrepancies often exist between self-reported ADL performance and actual capabilities. Therefore, inquiring with family members or caregivers about observed difficulties in ADLs can provide valuable supplementary information when using screening tools for geriatrics primary care.
Screening for Cognitive Impairment
Epidemiology: The prevalence of dementia rises sharply with age, ranging from under 5% in adults aged 65-70 to 30-40% in those aged 90 and older [33]. Despite a trend towards decreasing age-specific dementia incidence rates, increased longevity means the absolute number of individuals living with dementia is projected to grow significantly in the coming decades [34]. Cognitive impairment profoundly threatens functional independence and places a substantial burden on older individuals, their caregivers, and healthcare systems. Therefore, including cognitive screening tools for geriatrics primary care is crucial.
Under-diagnosis: Diagnosing dementia in the primary care setting can be challenging. Beyond the general diagnostic complexities in older adults, early dementia symptoms may be subtle, easily missed, or even deliberately concealed during brief office visits focused on other presenting complaints. Consequently, a significant proportion of individuals with dementia remain undiagnosed until later stages of the disease [35, 36].
Rationale for Screening: While effective pharmacological treatments for Alzheimer’s disease are still lacking, and concerns exist about the potential stigma associated with a dementia diagnosis, proactive detection of cognitive impairment offers numerous benefits. It allows for the identification of reversible causes of memory problems (such as depression), facilitates optimal management of co-existing comorbidities, and empowers patients and families to proactively plan for future care and make informed decisions [36]. The use of cognitive screening tools for geriatrics primary care is therefore ethically and clinically justified despite the absence of a cure for Alzheimer’s.
Brief Screening Instrument: Among available cognitive screening tests, the Mini-Cog stands out as particularly well-suited for primary care use. It can be administered in approximately 2-4 minutes, demonstrates good sensitivity (73-99%) and specificity (75-93%), and is relatively independent of linguistic and educational background [35, 37]. The Mini-Cog combines a three-item word recall test with the Clock Drawing Test. Suspect cognitive impairment when a patient cannot recall any words or recalls only one or two words with an abnormal clock drawing. Patients with positive Mini-Cog screening results should be referred for more comprehensive neuropsychological evaluation.
Screening for Depression
Epidemiology: Clinically significant depressive disorders affect approximately 10-15% of older adults [38]. Older populations are particularly vulnerable to depression risk factors such as health problems, sensory and cognitive impairments, adverse life events, bereavement, and social isolation. Including depression screening tools for geriatrics primary care is therefore essential.
Under-diagnosis: Detection and appropriate treatment rates for depression in older adults remain low, with primary care physicians recognizing only about half of depressed patients [38]. Compared to younger adults, older individuals are less likely to present with classic depressive symptoms and more often report physical complaints like pain or insomnia when depressed [39]. Impairments in decision-making and memory are also common, highlighting the complex bidirectional relationship between cognition and mood in older adults with depression.
Rationale for Screening: The use of brief questionnaires to screen for anxiety and depression symptoms has been extensively validated in primary care. Patients generally find these questionnaires acceptable, with most agreeing that primary care physicians should inquire about mood and anxiety [40]. From a clinical perspective, primary care approaches that integrate screening and intervention have been shown to improve patients’ depressive symptoms, quality of life, and functional impairment [38, 41]. Therefore, the benefits of incorporating depression screening tools for geriatrics primary care are well-established.
Brief Screening Instrument: Very brief, two-question screening tools are available that possess excellent psychometric properties and are particularly convenient for primary care use [42, 43]. Patients are asked if, over the past two weeks, they have often felt little interest or pleasure in doing things, and if they have often been bothered by feeling down, depressed, or hopeless. Negative responses to both questions effectively rule out depressive problems, while any positive response should raise suspicion for depression (sensitivity 95%, specificity 65% compared to clinical diagnostic interviews [42]) and prompt further assessment. Using a more nuanced scoring system for each answer (0=not at all, 1=several days, 2=more than half the days, 3=nearly every day) can improve specificity without significantly compromising sensitivity (sensitivity 83% and specificity 90% for a score of 3 or more) [44].
Screening for Sensory Impairments
Epidemiology: Sensory impairments are highly prevalent in older adults, topping the list of geriatric impairments. Approximately 30-45% of individuals aged 75 and older experience hearing impairment that affects their communication abilities [17, 45]. Visual impairment also affects nearly 50% of adults over 75, with up to 10% reporting inability to read newspapers even with corrective lenses (USPSTF data). The impact of sensory impairments on functional trajectories is likely underestimated, often manifesting indirectly through reduced social engagement, diminished psychological well-being, cognitive decline, and, in the case of visual impairment, increased fall risk [17, 46–48]. Thus, sensory impairment screening tools for geriatrics primary care are crucial.
Under-diagnosis: Visual and hearing impairments frequently go undiagnosed because they typically develop and progress gradually in older adults and are still sometimes mistakenly considered normal consequences of aging. Even when diagnosed, proper management of sensory conditions remains insufficient despite the availability of effective interventions. Notably, most older adults with significant hearing impairment do not receive appropriate management or hearing aids [49], and almost 4 out of 10 older adults have uncorrected refractive errors [50].
Rationale for Screening: While definitive data on improved clinical outcomes solely from systematic screening of asymptomatic individuals is still limited [27], evidence indicates that screening and diagnostic procedures for sensory impairment are generally safe. Furthermore, sensory function can often be improved through surgical, corrective, or adaptive interventions, with minimal complication risks and positive impacts on quality of life and overall well-being. Collectively, these factors suggest a net benefit from sensory impairment screening, especially among adults over 75. Similarly, studies on hearing impairment management indicate that clinical benefits are most pronounced in patients with moderate-to-severe hearing loss (>40 dB). Therefore, targeting screening efforts toward adults aged 75 and older can enhance the efficiency of sensory impairment screening tools for geriatrics primary care [27, 51].
Brief Screening Instrument:
Hearing Impairment: The clinical relevance of detecting mild (25-40 dB) hearing loss remains uncertain regarding evidence-based interventions. Thus, an initial step in identifying significant hearing impairment can be a simple question about perceived hearing loss. This approach demonstrates approximately 70% sensitivity and specificity compared to audiometry [17]. Among other tests, the whispered voice test is well-suited for primary care, showing good overall sensitivity (>90%) and specificity (>75%) according to USPSTF syntheses [27].
Visual Impairment: Screening for visual impairment using the Snellen eye chart performs better than screening questionnaires [52]. However, it is important to note that visual acuity testing primarily identifies refractive errors and is less effective at detecting early macular degeneration or cataracts. Therefore, while the Snellen chart is a useful screening tool for geriatrics primary care, it should be complemented by awareness of other common age-related eye conditions.
Screening for Nutritional Problems
Epidemiology: Undernutrition is not highly prevalent among community-dwelling adults aged 65-75, who are often overweight [53]. However, its prevalence rises sharply after age 75-80, likely triggered by factors such as chronic illnesses, medications, and socio-economic and psychological challenges. Nutritional screening tools for geriatrics primary care become increasingly important in this older age group.
Under-diagnosis: Involuntary weight loss, especially in overweight individuals, is frequently overlooked. However, such weight loss is a significant predictor of poor functional trajectory and other adverse outcomes, either directly or as a consequence of underlying dental problems, physical or mental illness.
Rationale for Screening: The fundamental premise of nutritional screening is that early identification of nutritional concerns allows for timely intervention. However, the benefits of nutritional supplementation have been demonstrated primarily in individuals with overt malnutrition, rather than those merely considered “at risk” [54]. Therefore, the focus of nutritional screening tools for geriatrics primary care should be on identifying established malnutrition or significant risk factors.
Brief Screening Instrument: Body Mass Index (BMI) is commonly used as a single screening measure, but it has limitations in specificity. A BMI under 22 kg/m2, however, should raise suspicion for potential malnutrition in older adults, as it is associated with increased mortality [55]. A question about involuntary weight loss over recent months is a frequently used alternative, with a loss of 5% or more in one month or 10% or more over six months often used as a cutoff for defining malnutrition [56]. Brief instruments like the Mini-Nutritional Assessment Short-Form (MNA-SF), specifically designed for older adults, incorporate appetite, weight loss, and BMI, sometimes combined with questions about acute illness. While their added value over simply monitoring weight and BMI is still being studied, the MNA-SF is a frequently used and validated screening tool for geriatrics primary care [57].
Fall-Risk Assessment
Epidemiology: Approximately one in three individuals aged 65 and older experiences a fall each year, and one in ten of these falls results in significant injury, making falls a leading threat to functional independence in older adults. A history of previous falls and activity restriction due to fear of falling synergistically increase the risk of future falls threefold [58, 59]. Fall-risk assessment is therefore a critical component of screening tools for geriatrics primary care.
Under-diagnosis: In the absence of injury, falls are often underreported to primary care physicians. However, this seemingly simple information is a powerful indicator of future fall risk [60].
Rationale for Screening: Detecting fall risk is a crucial component of geriatric assessment because effective interventions are available to prevent future falls and mitigate their consequences. Patients with a history of falls but without gait or balance problems should receive counseling on secondary fall prevention strategies (e.g., promoting physical activity, considering calcium and vitamin D supplementation). Those at higher risk require comprehensive assessment of contributing risk factors and individualized intervention plans. Cochrane reviews have identified exercise programs, including Tai Chi, and home safety interventions as effective in reducing fall rates and fall risk by approximately 25-30% [61]. Community-based, multi-modal fall prevention programs are often available to address multiple risk factors concurrently. Therefore, incorporating fall-risk screening tools for geriatrics primary care is essential for preventative care.
Brief Screening Instrument: Given the multifaceted nature of fall risk, encompassing diseases, medications, cognition, sensory and gait impairments, and environmental hazards, a comprehensive evaluation is impractical as an initial screening step. However, assessing a patient’s overall fall risk should be a core component of brief geriatric assessment.
Based on guidelines from the American and British Geriatrics Societies and input from healthcare providers, a fall prevention toolkit has been developed to assist healthcare professionals in fall-risk assessment and management [62]. Initial screening questions identify patients at risk by inquiring about previous falls, fear of falling, and perceived unsteadiness while standing or walking. Gait and balance assessment can be efficiently incorporated using the “Up and Go” test (patient rises from a chair, walks 3 meters, turns, and sits back down) or by observing if the patient stops walking while talking, a strong predictor of fall probability [63]. Simple gait speed measurement is also a robust prognostic indicator [64]. A gait speed below 0.8 m/s (i.e., 5 seconds or more to walk 4 meters at usual pace) should trigger further evaluation for fall risk, frailty, and mobility impairment. These simple assessments are valuable additions to screening tools for geriatrics primary care.
Social Isolation
Epidemiology: Aging often coincides with shrinking social networks due to the loss of peers, and reduced mobility can limit social participation. Societal trends, such as the shift from intergenerational to single-person households, further increase the risk of social isolation in older adults [65]. Nearly half of older adults in Europe live alone, and 10-20% report recurrent feelings of loneliness, particularly those living alone and with low social participation [66, 67]. Social isolation screening tools for geriatrics primary care are important for identifying vulnerable individuals.
Rationale for Screening: Social support is a crucial domain to evaluate during CGA. Social support acts as a buffer against stressful life events and improves the management of chronic diseases [65, 68, 69]. For example, identifying potential social support in case of health problems has been linked to lower rates of hospital utilization [70, 71]. However, older patients are often reluctant to spontaneously discuss social isolation. One study of primary care patients aged 65 and older found that only 15% of those reporting loneliness had mentioned it to their general practitioner [66]. Therefore, proactive screening is needed to identify social isolation using screening tools for geriatrics primary care.
Brief Screening Instrument: A simple and direct approach is to ask the patient whether they have someone available to help them in case of emergency or illness [72]. This single question can serve as an initial screen for social support networks within screening tools for geriatrics primary care.
Conclusion
Employing a selection of brief screening tools for geriatrics primary care can significantly improve the identification of frequently overlooked health problems in older adults. Positive screening results should trigger further, more in-depth assessments and management strategies tailored to the individual patient’s beliefs, preferences, and expectations. While definitive data on the optimal frequency of repeat screening is lacking, annual assessments have demonstrated good diagnostic yield. Although formal evaluation of this two-step approach is still warranted, we strongly believe that integrating brief screening tools for geriatrics primary care into routine practice has the potential to deliver many of the benefits associated with comprehensive community-based CGA programs, provided that identified problems are effectively addressed following the initial assessment. By adopting these pragmatic screening strategies, primary care physicians can proactively enhance the health and well-being of their aging patient population.
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References
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