Background
Primary care for older adults is becoming increasingly complex due to the aging global population and the rising prevalence of multiple health issues. Effectively managing the health of older patients requires recognizing and addressing not only typical medical conditions but also a spectrum of geriatric-specific issues that often go unnoticed. These overlooked conditions can range from functional and cognitive impairments to sensory deficits and nutritional deficiencies. The challenge is compounded by atypical symptom presentations, communication barriers, and a common misconception that these issues are simply ‘normal aging’ [1]. Consequently, the quality of care for older patients with geriatric conditions in primary care settings is often suboptimal [2]. Furthermore, psychosocial and environmental factors significantly impact older adults’ health, yet healthcare providers often lack structured approaches to assess these crucial aspects [3, 4].
Comprehensive Geriatric Assessment (CGA) emerged as a solution – a structured, multidimensional approach designed to identify and manage these complex issues in older patients. CGA extends beyond merely listing medical problems; it aims to understand a patient’s resources, capabilities, and personal preferences [4]. This holistic evaluation helps physicians tailor interventions to each patient’s unique needs. While this paper focuses on brief screening tools for selected geriatric conditions, it’s important to note that CGA also encompasses in-depth intervention planning, which is beyond the scope of this discussion. In typical primary care settings, unlike hospital environments where interdisciplinary teams conduct CGAs, geriatricians or specialized nurses usually perform these assessments [5, 6]. A complete CGA can be time-intensive, often exceeding 60 minutes, not including the time for intervention planning [7].
The effectiveness of CGA in identifying geriatric conditions and improving patient care has been well-documented across various settings, including community and primary care [2, 8, 9]. Notably, CGA is especially beneficial in new patient-physician relationships (less than 2 years), uncovering twice as many previously unidentified problems [3]. Despite these benefits, the evidence supporting routine CGA in primary care remains limited due to fewer studies in this specific setting.
Target Group and Objectives for Brief Geriatric Assessment
The goals of geriatric assessment in primary care are diverse, ranging from health promotion and early detection to guiding therapeutic decisions, depending on the patient’s overall health. The World Health Organization (WHO) defines target groups based on intrinsic capacity (physical and mental health) and functional ability within its healthy aging framework. Healthy, active older adults with high intrinsic capacity are ideal candidates for health promotion, but universal CGA for this large group would be impractical due to time constraints. Conversely, individuals with established disabilities require integrated care rather than initial CGA during preventive home visits [10]. The most suitable group for CGA are older adults with multiple chronic conditions but minimal disability, where the aim is to slow functional decline [11].
Patients scheduled for surgery or cancer treatments also benefit from brief CGA to identify those at higher risk for adverse outcomes. This proactive approach allows for peri-operative support, potentially reducing complications and hospital stays [12, 13].
Consensus suggests a two-step approach for brief CGA in primary care, targeting patients 75-80 years and older with multiple comorbidities, or those pre-surgical/oncological intervention [8]. Tools like EASY-Care and the PRISMA questionnaire combined with gait and mobility assessments are examples of this approach [14, 15].
This paper proposes a pragmatic strategy for primary care visits focusing on the early detection of geriatric conditions. It emphasizes screening, not comprehensive health promotion or resource/preference identification, which are essential for personalized intervention planning but outside this paper’s scope [16].
Patient Benefits of Preventative Geriatric Screening
Managing multiple chronic conditions in older adults is complex and often ill-suited to disease-specific interventions [17]. CGA offers a function-centered approach, addressing the disconnect between symptoms and underlying causes common in multimorbid older adults. It also aligns better with the diverse care expectations of aging individuals.
Studies have demonstrated that CGA, when applied in community and hospital settings, reduces disability, extends independent living, and decreases institutionalization by 20% within a year compared to standard care [18]. Among older adults receiving home care, CGA lowers hospital and nursing home admissions. Cost analyses indicate that increased home care services facilitated by CGA are offset by reduced institutional care costs [19].
Research in general practice indicates that approximately half of the problems identified through CGA are successfully managed by physicians within 12 months [3]. Many studies report improved care quality (e.g., fall-risk management [20]) and patient quality of life, with some showing reduced hospital readmission rates [21].
Cost-effectiveness of CGA is varied, depending on the population and interventions, as shown by meta-analyses [18]. More research is needed to fully understand the economic benefits of brief geriatric assessments in primary care [22].
Key Dimensions for Preventative Geriatric Screening: Including HEENT Considerations
A systematic review of disability risk factors highlights functional, cognitive, affective, and social issues, alongside lifestyle and sensory impairments as modifiable elements affecting functional decline [23]. CGA typically includes risk factors meeting standard screening criteria: frequently overlooked impairments, sensitive and specific screening tests, acceptable risk-benefit ratio for diagnostics, and conditions amenable to intervention. Older adults prioritize hearing and vision, physical ability (ADLs, mobility, falls), continence, cognition, and emotional well-being as key areas of unmet needs [8]. Nutritional and social situations are often added [24]. Expert panels from WHO guidelines also recommend assessing declines in physical and mental capacities (mobility, nutrition, vision, hearing, cognition, depression), plus geriatric syndromes like incontinence and fall risk [4].
Integrating HEENT (Head, Eyes, Ears, Nose, and Throat) Considerations: While the original article does not explicitly focus on “HEENT,” sensory impairments, particularly vision and hearing, are critical components of geriatric assessment and directly relate to the “Eyes” and “Ears” aspects of HEENT. Preventative screening tools for geriatrics must incorporate HEENT-related assessments to comprehensively address common age-related sensory declines. Early detection and management of vision and hearing impairments are essential for maintaining quality of life and preventing further functional decline in older adults.
Integrating CGA into Primary Care Consultations
Time constraints are a major barrier to implementing full CGA in busy primary care practices. To address this, brief screening tools for geriatric conditions, taking about 15 minutes, have been developed [8, 24]. These tools identify patients who would benefit from more detailed assessments by their primary care physician or referral to a geriatrician.
The psychometric properties and clinical impact of these brief tools require further investigation. Currently, there is limited evidence favoring one tool or combination of tools over others. Tool selection should be based on practicality, target population profile, and healthcare system context.
Frailty identification tools, sharing similar domains with brief CGAs, have also been developed for primary care [7, 8, 14, 15, 24], reflecting the overlap between frailty and functional decline risk factors [25, 26].
This paper proposes a pragmatic approach for primary care physicians to screen for selected dimensions in older patients. While this selection isn’t strictly evidence-based, it targets prevalent, under-detected impairments with available screening tests and effective interventions. Recommendations from the US Preventive Services Task Force (USPSTF) [27] and the Canadian Task Force on Preventive Health Care [27, 28] inform these dimensions. Although these task forces sometimes find limited evidence for screening impact on clinical outcomes, WHO guidelines, based on expert consensus, include these dimensions due to their benefit-harm balance, alignment with patient values, and assessment feasibility [4]. This brief assessment can be completed in approximately 15 minutes, with annual repetition frequently suggested [29].
Screening for Functional Impairment
Functional ability, specifically how patients manage Activities of Daily Living (ADLs), is central to CGA. Assessing daily function is vital for identifying functional decline, reflecting the impact of health problems and predicting future functional trajectories [30]. Early detection of functional difficulties is the first step towards interventions to prevent further decline, restore function, and provide necessary support.
Functional status is evaluated by assessing difficulties in basic and instrumental ADLs (Table 1). Instrumental ADLs, requiring more complex neuropsychological skills, are usually affected before 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 closely linked to cognitive function. Impairment in instrumental ADLs like phone use, transportation, medication management, and finances significantly increases the odds of dementia diagnosis within a year [32]. A simple initial question about task performance difficulties can be useful [24]. However, discrepancies exist between self-reported and actual ADL performance, making caregiver input valuable.
Screening for Cognitive Impairment
Epidemiology
Dementia prevalence dramatically increases with age, from under 5% in 65-70 year olds to 30-40% in those over 90 [33]. Despite declining age-specific incidence, increased longevity means a growing number of dementia cases in coming years [34]. Cognitive impairment threatens independence and places a heavy burden on individuals, caregivers, and healthcare systems.
Under-diagnosis
Diagnosing dementia in primary care is challenging. Early dementia symptoms can be subtle and overlooked during brief consultations for other complaints. Consequently, many dementia cases remain undiagnosed until later stages [35, 36].
Rationale for Screening
Due to the lack of effective Alzheimer’s treatments and concerns about stigma, systematic dementia screening is not universally recommended [27, 28]. However, proactive detection offers benefits, including diagnosing reversible causes of memory issues (e.g., depression), managing comorbidities, and enabling patients and families to plan for the future [36].
Brief Screening Instrument
The Mini-Cog is a practical tool for primary care, taking 2-4 minutes with good sensitivity (73-99%) and specificity (75-93%), independent of language and education [35, 37]. It combines a three-word recall test with the Clock Drawing Test. Suspect cognitive impairment if a patient recalls no words or recalls one or two with an abnormal clock drawing. Positive Mini-Cog results warrant referral for comprehensive neuropsychological testing.
Screening for Depression
Epidemiology
Significant depression affects 10-15% of older adults [38]. Older populations are more vulnerable to depression risk factors like health issues, sensory and cognitive impairments, life events, bereavement, and social isolation.
Under-diagnosis
Detection and treatment rates remain low, with primary care physicians recognizing only about half of depressed patients [38]. Older adults may present depression with physical symptoms like pain or insomnia, rather than typical emotional symptoms [39]. Cognitive and memory impairments can also be associated with depression, highlighting the complex interplay between mood and cognition.
Rationale for Screening
Short anxiety and depression questionnaires are well-accepted in primary care, with patients agreeing physicians should inquire about mood [40]. Screening and intervention programs improve depressive symptoms, quality of life, and functional impairment [38, 41].
Brief Screening Instrument
Two-question tools are highly effective and convenient for primary care [42, 43]. Patients are asked about their interest/pleasure in activities and feelings of depression/hopelessness over the past two weeks. Negative answers to both questions effectively rule out depression, while any positive answer (sensitivity 95%, specificity 65% [42]) necessitates further evaluation. More detailed scoring improves specificity (sensitivity 83%, specificity 90% for a score of 3 or more [44]).
Screening for Sensory Impairments: Vision and Hearing (HEENT Relevant)
Epidemiology
Sensory impairments are highly prevalent in geriatrics. Hearing impairment affecting communication impacts 30-45% of adults over 75 [17, 45]. Visual impairment affects nearly 50% of this age group, with up to 10% unable to read newspapers even with correction (USPTSF). Sensory impairments significantly impact functional trajectory through reduced social engagement, psychological well-being, cognitive function, and increased fall risk, especially with visual impairment [17, 46–48].
Under-diagnosis
Vision and hearing impairments often remain undiagnosed due to their gradual onset and misattribution to ‘normal aging.’ Management is also inadequate, with most older adults with significant hearing loss not receiving appropriate aids or interventions [49]. Nearly 40% have under-corrected refractive errors [50].
Rationale for Screening
While outcome data for systematic sensory screening in asymptomatic individuals is limited [27], screening and diagnostics are safe, and interventions (surgical, corrective, adaptive) can improve sensory function with minimal risk and positive impacts on quality of life. Screening, especially for adults over 75, is thus beneficial. Management of hearing impairment shows most benefit in moderate-to-severe cases (> 40 dB), suggesting adults over 75 are a key target population for efficient screening [27, 51].
Brief Screening Instrument
Hearing Impairment
Given uncertain benefits of detecting mild hearing loss (25-40 dB), initial screening can start with a single question about perceived hearing loss. This has approximately 70% sensitivity and specificity compared to audiometry [17]. The whispered voice test is well-suited for primary care, with high sensitivity (> 90%) and specificity (> 75%) [27].
Visual Impairment
The Snellen eye chart is more effective for visual impairment screening than questionnaires [52]. However, it primarily detects refractive errors and is less effective for early macular degeneration or cataracts. Comprehensive HEENT screening should include both hearing and basic vision tests to address these prevalent sensory impairments effectively.
Caption: Example of a Snellen chart used for visual acuity testing, a key component of preventative HEENT screening for geriatric patients.
Screening for Nutritional Problems
Epidemiology
Undernutrition is less common in community-dwelling adults aged 65-75, who are often overweight [53]. However, prevalence sharply rises after 75-80, linked to chronic illness, medications, and socioeconomic/psychological issues.
Under-diagnosis
Involuntary weight loss, especially in overweight patients, is often missed. Yet, it predicts poor functional outcomes and other adverse health events, potentially due to dental problems or underlying physical/mental illness.
Rationale for Screening
Early identification of nutritional concerns is the aim of screening. However, nutritional supplementation benefits are primarily seen in overt malnutrition, not just ‘at-risk’ individuals [54].
Brief Screening Instrument
BMI is a common initial measure but lacks specificity. A BMI under 22 kg/m2 in older adults suggests potential malnutrition and is associated with increased mortality [55]. Inquiring about involuntary weight loss (e.g., ≥5% in a month or ≥10% in 6 months [56]) is a frequent alternative. Brief tools like the Mini-Nutritional Assessment Short-Form (MNA-SF) [57], including appetite, weight loss, and BMI, are also used to identify patients needing detailed nutritional assessments, though their added value over simple weight and BMI monitoring is still under study.
Fall-Risk Assessment
Epidemiology
Annually, one in three adults over 65 falls, and one in ten sustains a significant injury, making falls a major threat to independence. Prior falls and fear of falling triples future fall likelihood [58, 59].
Under-diagnosis
Falls without injury are often unreported to primary care physicians, yet this information is crucial for identifying at-risk patients [60].
Rationale for Screening
Fall-risk detection is vital in geriatric assessment as effective fall prevention interventions exist. Patients with prior falls but no gait/balance issues should receive secondary prevention counseling (physical activity, calcium/vitamin D). Higher-risk individuals need comprehensive risk factor assessment and tailored interventions. Cochrane reviews show exercise programs (including Tai Chi) and home interventions reduce fall rates and risk by 25-30% [61]. Community-based, multi-modal fall prevention programs addressing multiple risk factors are often available.
Brief Screening Instrument
Given diverse fall risk factors (diseases, drugs, cognition, sensory/gait impairment, environment), comprehensive review is impractical as a first step. However, overall fall risk assessment should be part of brief geriatric screening.
Fall prevention toolkits, based on American and British Geriatrics Societies guidelines, aid healthcare professionals in assessing and addressing fall risk [62]. Initial questions assess fall history, fear of falling, and perceived instability. Gait and balance are assessed using the Get-Up-and-Go test or observing if the patient stops walking while talking, a strong fall predictor [63]. Gait speed measurement is also prognostic [64]. Speed below 0.8 m/s (≥5 seconds to walk 4m) indicates higher fall risk, frailty, and mobility impairment, warranting further assessment.
Caption: Assessing gait and balance is crucial in preventative geriatric screenings to identify fall risks.
Social Isolation
Epidemiology
Aging often involves shrinking social networks due to peer loss and reduced mobility. Societal shifts like decreased intergenerational living increase social isolation risk [65]. In Europe, nearly half of older adults live alone, with 10-20% reporting loneliness, especially when living alone with low social participation [66, 67].
Rationale for Screening
Social support is a key CGA component. It buffers stress and improves chronic disease management [65, 68, 69]. Social support availability in health crises correlates with lower hospital use [70, 71]. However, older patients rarely discuss social isolation spontaneously; only 15% of lonely older primary care patients mentioned it to their GPs in one study [66].
Brief Screening Instrument
A simple question about emergency/sickness support availability is useful [72].
Conclusions
Brief screening tools can effectively identify frequently overlooked problems in older patients, including HEENT-related sensory impairments. Positive screening results should prompt further assessments and management, aligned with patient preferences and expectations. While optimal reassessment intervals are undefined, annual evaluations show good diagnostic yield. Formal evaluation of this two-step approach is needed, but it is likely to provide many benefits of comprehensive community-based CGA programs, provided identified issues are properly addressed after initial screening. Integrating HEENT-focused questions and tests into these screenings will enhance their effectiveness in preventative geriatric care.
Acknowledgements
Not applicable
Funding
No funding was received for this work.
Availability of data and materials
Not applicable (no original data used)
Authors’ contributions
Both authors contributed to the design of the work, literature search, and manuscript drafting as well as revisions. Both authors read and approved the final manuscript.
Ethics approval and consent to participate
Not applicable
Consent for publication
Not applicable
Competing interests
The authors declare that they have no competing interests.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Laurence Seematter-Bagnoud, Phone: +41-21-314-3803, Email: [email protected].
Christophe Büla, Email: [email protected].
References
[References from original article, maintain numbering]
Associated Data
Data Availability Statement
Not applicable (no original data used)
