Vol. 23 Issue 15
A role for occupational therapy in comprehensive assessment of health, function and quality of life
As the geriatric population expands, occupational therapists will be called upon to assist in ensuring quality of life for older adults. As the health care industry changes and becomes more consumer-driven due both to cost and demand, family caregivers and older adults themselves will be proactive in seeking assistance to age in place and preserve quality of life.
Based on current statistics, most older adults will experience multiple chronic diseases; over half of older adults will be affected by arthritis and hypertension. (Federal Interagency on Aging Related Statistics, 2006) With this prevalence, older adults will not only need health care but will also need to learn appropriate health maintenance.
Occupational therapists can assist in this process by providing geriatric assessments for older adults and their families. According to the Merck Manual of Geriatrics, a geriatric assessment "differs from a standard medical evaluation by including nonmedical domains, by emphasizing functional ability and quality of life." (2006)
In 2005, the American Geriatrics Society (AGS) published a position paper stating that comprehensive geriatric assessments have "demonstrated usefulness in improving the health status of frail, older patients." The AGS position paper supports the inclusion of geriatric assessments in health care education and calls upon insurers, including Medicare, to recognize and support geriatric assessments. (2005)
The purpose of a comprehensive geriatric assessment is to paint a "health picture" of an older adult in multiple areas of health and wellness. This comprehensive picture provides the basis for creating a plan to deal with current health issues, to prevent future ones and to prepare for changes in health status.
A variety of health care professionals, including occupational therapists, can perform geriatric assessments. In many cases, geriatric assessments include an interdisciplinary team of experts. Typically, following the assessment, the provider or team develops a comprehensive plan of care to help both the older adult and his caregivers address any areas of concern and prepare for the future. Geriatric assessments can be performed within the home, in a hospital or at an outpatient clinic.
What to Assess
Generally, a geriatric assessment is meant to be comprehensive and explore the life of an older adult very holistically. Geriatric assessments not only focus on current problems or difficulties but also on future challenges that may develop. This is especially important if the older adult has any kind of chronic disease that will progressively impact activities of daily living and quality of life.
A basic geriatric assessment will cover the following: the individual's current health status, functional status, cognitive status, living situation, social supports, medications and current services used by the individual (e.g., Meals on Wheels). (Hunter, et. al., 2007)
The Merck Manual of Geriatrics suggests assessing the following elements: daily function, assistive device use, caregiver support, medications, nutritional status, general health status (i.e. blood pressure, cholesterol, etc), cognition, affect, advance directives, substance use, gait, balance, sensory abilities and active range of motion. (2006)
Geriatric assessments can be tailored specifically to the needs of the client. The comprehensive nature of the assessment process allows all areas of the individual's health to be addressed and to target specific areas. Of course, there is debate over which assessment tools are appropriate to include in the comprehensive assessment. For example, one study presents that the Kohlman Evaluation of Living Skills (KELS) is a good match for community dwelling elders. (Pickens, et. al., 2007) the box below shows a variety of recommended assessments, based on the discretion of the health care practitioner.
Although guidelines and suggestions have been made regarding appropriate assessment tools, there is no rule or strict standard detailing which tools to use when performing a geriatric assessment. Since the assessment is meant to be holistic, it is important to use tools that screen areas quickly to ensure the entire assessment is not too time-consuming, which impacts not only billing and cost but the client himself. The assessment's length can affect performance and ultimately the individual's plan of care. Further, in an effort to utilize evidence-based medicine, use tools that have been shown to be valid and reliable.
Evidence for Assessments
Geriatric assessments are recommended both for the well elderly as well as for individuals with a variety of health issues. Rao, Seo and Cohen (2004) recommend a comprehensive geriatric assessment for older adults diagnosed with cancer, claiming these assessments affect comorbidity.
Geriatric assessments have also been used to establish intervention for individuals experiencing elder abuse. (Heath, et. al., 2005) This research demonstrates that geriatric assessments can be used for individuals with a variety of chronic diseases or disabilities.
Geriatric assessments have been shown to have multiple benefits to older adults. First, these comprehensive assessments provide a holistic look into the life of the individual and how both the individual and his caregiver(s) can address current issues and prepare for future ones. Presumably, geriatric assessments will reduce health care costs by helping prepare for future issues and educate individuals and caregivers.
Quality of life is another factor that geriatric assessments potentially impact. Both health care savings and quality of life are difficult to measure, but geriatric assessments have been shown to impact fall prevention, appropriate medication management and screening for cognition problems. (Scanlan, 2005)
Role of OT
Occupational therapists can play a role in performing geriatric assessments by providing such services as an individual or as a member of the team. Geriatric assessments are a good fit for occupational therapists due to their holistic nature and exploration into one's entire occupational being.
Many of the assessments recommended as part of a comprehensive geriatric assessment are already familiar to OTs. Occupational therapists also tend to think about health in a holistic manner, and are trained to involve both the client and family in the treatment process. All of these elements of a geriatric assessment align with the philosophy and practice standards for occupational therapists. Lastly, there is a need to address the health concerns facing older adults, and geriatric assessments are an efficient way to ensure that older adults are able to age in place.
One area not mentioned in literature on geriatric assessments is assessment of the environment. The environment, whether home or hospital, is an important factor in function and well-being. Occupational therapists deeply understand the impact of the environment on an individual's function. Exploring the home environment, including the potential risks, is important to fall prevention, quality of life and home safety, making it a relevant part of the geriatric assessment process.
Currently there are no standards or licensure laws dictating who can and cannot perform a geriatric assessment in the health care industry. Therefore, occupational therapists can step up to the plate and play a valuable role in this area of practice, which will become increasingly relevant as our population ages.
OTs are excellent candidates to assist or perform a geriatric assessment. Resources and guidelines for performing geriatric assessments are available both in the literature and through the American Geriatrics Society.
References available at www.advanceweb.com/OT and upon request.
Joy D. Voltz, OTD, OTR/L, is an assistant professor of clinical education in the department of occupational therapy at Creighton University Medical Center. You are encouraged to reach her at: firstname.lastname@example.org.
Recommended standardized assessments to be used as part of ageriatric assessment
Activities of daily living
Katz ADL Scale
Lawton IADL Scale
Mini-Mental State Examination
Geriatric Depression Scale
Balance and Gait
Tinetti Balance and Gait Evaluation