This is the first article in a six-part series discussing the key domains of health to investigate when assessing older people. It comes with a self-assessment enabling you to test your knowledge after reading it, as well as a handout for a journal club discussion
Older people often have multiple and complex care needs, so assessing them is a highly skilled activity. Their health issues and care needs are sometimes summed up in ‘catchy’ phrases, but it is important to adopt a comprehensive, multidisciplinary and patient-centred approach to their assessment. In today’s healthcare system, pressures on time and resources can mean that certain aspects of assessments are prioritised over others, which can be detrimental to comprehensiveness. This first article in a six-part series outlines the fundamental principles of the assessment of older people. Subsequent articles will explore the five domains that should be explored when assessing older people: the physical, psychological, functional, social and spiritual domains.
Citation: Wiltjer H, Kendall N (2019) Assessment of older people 1: definition, principles and tools. Nursing Times [online]; 115: 5, 37-40.
Authors: Hanneke Wiltjer is lecturer in nursing at HZ University of Applied Sciences, Vlissingen, The Netherlands; Nyree Kendall is senior lecturer and lead for district nursing, University of Bolton.
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People are living for longer (Office for National Statistics, 2018) and older people increasingly need to use health services (Humphries et al, 2016), so it is important that all members of the multidisciplinary team have the right knowledge and skills to meet the needs of this patient group.
Older people use a range of healthcare services, from acute hospitals to community care. Members of the nursing team – including nurses, nursing assistants, nursing associates and healthcare assistants (HCAs) – play an important role in caring for them, while a range of other health professionals are involved in assessing their individual needs. For example, a physiotherapist may undertake a stair assessment; a nurse or HCA may undertake a skin assessment; an occupational therapist may review the need for equipment that will support their independence; and a doctor or a non-medical prescriber such as a nurse or pharmacist may review their medication.
Previous series in Nursing Times have explored what happens to the human body when it ages (’effects of ageing’ series) and when it is confined to bed (‘effects of bedrest’ series) for longer periods. This series discusses the comprehensive assessment of older people’s care needs, which should cover at least five domains: physical, psychological, functional, social and spiritual. This first article introduces the topic and the remaining five articles will discuss each assessment domain.
Categorising complex needs
Although many older people are vital, healthy and enjoying a good quality of life, this group often presents with a multitude of care needs. The earlier series on the anatomy and physiology of ageing showed how the body changes as people age (’effects of ageing series’). Normal ageing processes may, by themselves, result in certain care needs; an older person may, for example, need support to manage incontinence due to loss of bladder elasticity or poor balance due to loss of muscle mass (Blundell and Gordon, 2015). In addition to these normal ageing processes, older people may have illnesses that require professional care; for example, an older person who has diabetes and Parkinson’s disease may need home visits from district nurses to give them insulin injections if they can no longer self-administer because they have lost dexterity.
Different ways of summarising or clarifying the complex and varied health issues and care needs of older people have been suggested:
- Fried et al (2001) suggested frailty, multimorbidity and disability as the main problems in older age;
- The ‘three Ds’ are dementia, delirium and depression; in some cases, a fourth D – cognitive decline – is added (Harris, 2017);
- The five ‘geriatric Ms’ are mind, mobility, medications, multi-complexity and ‘matters most to me’ (Tinetti et al, 2017);
- The ‘geriatric giants’ identified by Bernard Isaacs in 1965 were impaired vision and hearing, incontinence, instability, and intellectual impairment; they have recently been expanded to include frailty and sarcopenia (Morley, 2016).
These different ways of listing older people’s health issues and care needs aim to provide clarity and structure by cataloguing key aspects in a ‘catchy’ way, making them easier to remember, for the benefit of those who care for older people (Tinetti et al, 2017). However, while they may be helpful in practice, they never encompass all aspects of older people’s care, so health professionals need to adopt a comprehensive and multidisciplinary approach when assessing and meeting patients’ needs (Ellis et al, 2017; Wieland and Hirth, 2003).
Definition and purpose
The term assessment is commonly used in healthcare and has a number of definitions. One way to define it is as an evaluation during which “information is collected to identify the patient’s needs and formulate a treatment plan” (Segen’s Medical Dictionary, 2011). In this definition, assessment ranges from gaining information about the patient to interpreting that information and acting on it (Wiltjer, 2017). It is the definition that we have adopted for this series.
The Nursing and Midwifery Council (2018) stipulates that assessments are an important part of nursing practice, as they require nurses to “demonstrate and apply knowledge of body systems and homoeostasis, human anatomy and physiology, biology, genomics, pharmacology and social and behavioural sciences when undertaking full and accurate person-centred nursing assessments and developing appropriate care plans”. Annexe B of the proficiency standard for nurses (NMC, 2018a) focuses on “Procedures for assessing needs for person-centred care”. It includes numerous aspects of assessment practice, such as physical aspects, mental health and wellbeing, hygiene needs and promoting independence. The NMC (2018a) also urges nurses to work together with patients and others (notably other members from the multidisciplinary team) when conducting needs assessments.
There are multiple reasons for carrying out an assessment – the first and foremost being to gain information about the patient so that the health professional can provide appropriate care (Wieland and Hirth, 2003). Beyond this, comprehensive assessment can also aim to enhance patients’ independence; reduce the length of their stay in a care setting; prevent hospital admissions (and readmissions); reduce costs; increase patient and professional satisfaction; and improve practice (Elsawy and Higgins, 2011; Wieland and Hirth, 2003).
Formal and informal assessment
Assessment is a combination of formal and informal practice (Wiltjer, 2017; Benner, 2001). A nurse filling in admission paperwork is carrying out an assessment in a formal manner using documentation as a guide. A nurse walking past a patient and noticing dark urine in the catheter bag, an uneaten dinner and a person who seems much drowsier than the day before is also making an assessment, albeit an informal one. This sudden, unprompted type of assessment is not necessarily steered by documentation but nevertheless provides the nurse with information about the patient that may lead to further attention and action.
Both kinds of assessment are important, as both help health professionals determine their patients’ needs (Wiltjer, 2017). Although guidelines advocate the use of formal assessments (NHS England, 2014; Department of Health, 2001), health professionals from various disciplines have described informal assessment as crucial to their practice (Wiltjer, 2017).
Benner argued that more experienced nurses are more skilled in conducting informal assessments than less experienced nurses. Informal assessment practice is enhanced by experience and those who undertake informal assessments cannot always fully explain them to others. “It is not possible to recapture from the experts in explicit, formal steps, the mental processes or all the elements that go into their expert recognitional capacity to make rapid patient assessments” (Benner, 2001). Informal assessment can remain invisible to other members of the multidisciplinary team, as well as to the patients who are being assessed (Wiltjer, 2017).
This series acknowledges the value of both formal and informal assessment practice in the care of older people. However, even if an assessment is done in an informal manner, ideally it should still be documented or recorded in some way to provide a clear and comprehensive record of the patient’s care (NMC, 2018b).
Three generations of tools
In 1935, Marjory Warren started to lay the foundations of the approach we currently use in the care of older people in the UK, significantly changing it from previous practice. Warren, who was a hospital-based physician and is considered the mother of modern geriatric medicine, advocated the rehabilitation of older people using a multidimensional and multidisciplinary approach (Warren, 1946). Hospital environments were adapted to meet the needs of older people and stimulate their independence and recovery, which at the time was revolutionary.
Her ideas have been taken further, resulting in three generations of assessment tools. First-generation tools focus on one domain or topic (Bernabei et al, 2008); an example is the Malnutrition Universal Screening Tool (MUST), which is used in most NHS trusts to assess patients’ nutritional status.
Second-generation assessment tools are multidimensional (Bernabei et al, 2008) and their reliability and validity have been tested for use in a single care setting – for example, acute or long-term. Examples are the tools proposed by the international collaborative InterRAI, aimed at improving the quality of life of vulnerable people through a seamless and comprehensive assessment system (Wellens et al, 2012).
Third-generation assessment tools are multidimensional and designed to be used across multiple settings (Bernabei et al, 2008). The ‘single assessment process’, introduced in the UK in 2001, incorporated multiple dimensions and was meant to be used in a variety of settings, where all professionals would gain access to the same information, thereby avoiding duplication and improving communication (Challis et al, 2010). Unfortunately, the project failed, partly due to logistic differences between care settings (Challis et al, 2010).
In current practice, a variety of first- and second-generation assessment tools are used to assess the needs of older people.
Comprehensive geriatric assessment
The gold standard for assessing older people is a comprehensive geriatric assessment (CGA) (Ellis et al, 2017). This is “a multidimensional interdisciplinary diagnostic process focused on determining a frail older person’s medical, psychological and functional capability to develop a coordinated and integrated plan for treatment and long-term follow-up” (Wieland and Hirth, 2003). Based on that definition, the assessment of an older person should:
- Be multidimensional (addressing at least medical, psychological and functional domains);
- Involve interdisciplinary teamwork and an integrated and coordinated team approach;
- Include a treatment plan and long-term follow-up.
Some people contend that CGAs are used on most frailty wards in the UK (NHS Benchmarking Network, 2017). However, most CGAs carried out on frailty wards do not meet all the criteria mentioned above, which leads others to conclude that CGAs are not commonly used (Gladman et al, 2016). This does not mean no assessments are taking place: formal and informal assessments of a number of domains take place continuously, as different professionals undertake different assessment processes for each patient in their care (Wiltjer, 2017).
It is important to be realistic about time pressures in the current healthcare system, which have been highlighted by the King’s Fund (Ward and Chijoko, 2018). There are high workloads in all healthcare settings, from acute to community, and hence, at times, a need to prioritise tasks due to limited resources. This may influence how assessments are undertaken, as certain domains may take priority over others at certain times (Jones, 2016). Prioritising certain aspects over others allows professionals to manage a high workload, but it may also, at times, compromise the comprehensive aspect of assessments (Ball et al, 2014).
Boxes 1 and 2 describe two patients (one in hospital and one in the community) who need a CGA, giving you an opportunity to reflect on what questions you need to ask yourself when conducting CGAs.
Box 1. Reflection exercise: an assessment in hospital
Edith Robinson* is admitted to hospital after falling and breaking her hip. She is 86 years old and lives alone in the house where she and her husband raised their four children (an old cottage with several steps in the living area and kitchen). Her husband died three weeks ago. Her daughter, who found Mrs Robinson lying on the floor, was not sure how long she had been there.
On admission, Mrs Robinson appears acutely confused. Blood tests revealed dehydration and anaemia. Her daughter explained that Mrs Robinson has type 2 diabetes (for which she takes daily metformin), heart failure (for which she takes blood pressure medication) and osteoporosis (for which she takes calcium tablets). She also takes laxatives for chronic constipation and pain medication for arthritic knee pain. Her daughter expresses concern about her mother’s lack of appetite, recent weight loss and a foot ulcer that is not healing.
Mrs Robinson is awaiting surgical review and the immediate focus of care is her hip fracture. Beyond her urgent care, she needs a comprehensive geriatric assessment (CGA). You are responsible for conducting a CGA for Mrs Robinson. You ask yourself the following questions:
- What are her care needs? How might they be interlinked?
- How can her care needs be addressed?
- Which members of the multidisciplinary team need to be involved?
- What should her care plan include? What are the short- and long-term goals?
* Not her real name
Box 2. Reflection exercise: an assessment CGA in the community
Martin Fisher* is 85 years old and lives with his wife, aged 83, in a large three-story house. A year ago, Mr Fisher was diagnosed with Parkinson’s disease, and he has been on the same dose of medication for the condition since then. Carers visit daily to help him with activities of daily living.
Lately Mr Fisher’s cognition has deteriorated. At times he is verbally aggressive to the carers as well as to his wife. His mobility is deteriorating: he has not been able to have a shower for the past seven days and has been sleeping in a chair, as he is unable to get to his bedroom, even though it is on the ground floor. Mr Fisher’s wife is struggling to cope, as she is unwell herself. She has severe arthritis and had a heart attack three months ago.
The carers have asked a district nurse to review the situation. You are on the district nursing team and conduct a comprehensive geriatric assessment of Mr Fisher’s and his wife’s needs. You ask yourself the following questions:
- What are their care needs and how may they be interlinked?
- How can their care needs be addressed?
- Which members of the multidisciplinary team will need to be involved?
- What should the care plan for Mr Fisher and his wife include? What are the short- and long-term goals?
* Not his real name
Different setting, different focus
The aim of this series is to explore the assessment of older people in different care settings. A comprehensive and multidisciplinary approach is advocated for all settings and all professionals to support older people’s dignity and independence (Ellis et al, 2017; NHS, 2014). However, according to the setting, assessment may have a slightly different focus.
In acute care settings, the focus is on what is most urgent (World Health Organization, 2013) and assessment therefore addresses, as a priority, the acute reason for admission; for example, when a patient is admitted with acute heart failure, cardiac treatment will be the care team’s priority. Discharge and rehabilitation, which will eventually become the main aim, initially take second place (Wiltjer, 2017). This is in line with the way healthcare is currently organised – that is, with a focus on a single issue (Baumbusch et al, 2016).
In community care settings, the focus is on enhancing and supporting independence in everyday life; for example, for patients with chronic heart failure, the focus will be on managing the long-term condition so they can continue to live in their preferred way – for example, in their own home. The focus is on managing the patient’s condition in the long term according to their preferred lifestyle.
Assessment allows health professionals to gain insight into individual needs and thus provide person-centred care. Older people often have complex health needs requiring a multidimensional and multidisciplinary approach, so conducting assessments is a highly skilled activity. Future articles in this series will explore assessment in the physical, functional, psychological, social and spiritual domains – the idea being to use them as ‘building blocks’ towards a comprehensive assessment, leading to person-centred and holistic care.
- Assessment of older people should cover psychological, physical, functional, social and spiritual domains as a minimum
- Pressures on time and resources mean that certain domains are sometimes given priority
- A comprehensive and multidisciplinary approach is needed when assessing older people
- The gold standard tool for assessing older people is the comprehensive geriatric assessment
Also in this series
- Test your knowledge with Nursing Times Self-assessment after reading this article. If you score 80% or more, you will receive a personalised certificate that you can download and store in your NT Portfolio as CPD or revalidation evidence.
- Take the Nursing Times Self-assessment for this article
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