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Health care for older adults focuses on function, which covers the physical, cognitive/mental (eg, thinking and remembering), psychological, and social aspects of a person’s life. "Quality of life" is a term that is often used as a single, general measurement of the combination of all these functional aspects of life. Each aspect of function should be evaluated routinely in all sites of care, such as the doctor’s office, the hospital, an assisted-living facility, or the home.

The goal of health assessment for older adults is to encourage and promote wellness and independent function. One approach that works well is for health care providers to rapidly screen several areas by asking screening questions related to various areas of health and function. Whenever a potential problem is found, it is then evaluated more completely. Answers to screening questions should be based on the older person’s day-to-day activities. Another person who is familiar with the older person being assessed (ideally a caregiver or family member) is often needed to provide (or verify) additional information about the older person’s daily functioning.

• Assessment of Physical Functions
• Functional status
• Transfer
• Walking
• Balance
• Nutrition
• Vision
• Hearing
• Assessment of Thinking, Understanding, and Remembering
• Memory
• Executive function
• Assessment of Psychological Functions
• Social Assessment
• Quality of Life
• Comprehensive Geriatric Assessment
• The Older Driver

The physical aspects of function include overall functional status, nutrition, vision, and hearing.

Functional status refers to the tasks a person can perform in daily life. These tasks are usually referred to as "activities of daily living" or ADLs. The self-care tasks (eg, bathing, eating, etc) are especially important, because these are the basic ADLs considered essential for independent living. Healthcare providers usually ask whether the person requires the help from someone else to complete these basic tasks. They will also ask about the person’s ability to manage household affairs, such as using the telephone, stove, or washer. These are called instrumental ADLs.

Although it is not practical to test someone’s ability to perform ADLs for self care and to manage household affairs in the doctor’s office, other functions can be assessed during an office visit: walking ability, balance, and ability to transfer from one position or surface to another (eg, from sitting to standing or bed to chair, etc). It is important to wear proper footwear during an assessment, so that your healthcare provider can see whether the problem is actually physical or is possibly related to your shoes. Proper footwear means comfortable, flat, hard-soled shoes.

Healthcare professionals may use formal, standardized tests to assess balance and mobility. However, simpler tests (like those described above) are often enough for routine assessments and follow-up recommendations, such as the need for a cane or walker.

A common way to evaluate the ability of a person to transfer is to ask him or her to stand from a seated position in a hard-backed chair, while keeping the arms folded. Inability to complete this task suggests lower leg weakness and the possibility of future disability.

From a standing position, the older person will be asked to walk back and forth over a short distance, usually using any walking aid (eg, a cane) that he or she uses routinely. The person may also be asked to get up from the chair, walk about 10 feet, turn around, walk back to the chair, turn around again, and then sit back down. Normally, a person should complete this "Timed Get Up and Go" test in <10 seconds. People who take longer than 10 seconds may be at increased risk of falls. Those who take 20 seconds or longer require further evaluation.

Walking speed can also be used to predict possible future disability. People who can walk 50 feet in 20 seconds or less can usually walk independently in normal activities.

Balance is often tested several times, doing balance exercises that become more and more difficult. The person being assessed is first asked to stand with his or her feet side by side, and then with one foot in front of the other at varying distances apart. Difficulty with balance in these positions is associated with an increased risk of falling.

Older adults may not eat well for a variety of reasons, including the following:

Older adults should be examined for signs of malnutrition and have their weight and height measured routinely. Your healthcare provider may use a term called "body mass index" or BMI. Your BMI is your weight in kilograms divided by the square of your height in meters (ie, kg/m²). A BMI <20 kg/m²) or an unintentional weight loss of more than 10 pounds suggests poor nutrition, which should be investigated promptly (see Nutrition).

Vision can be affected by cataracts, glaucoma, macular degeneration, and changing eye shape that usually worsens with age. These changes in the eye can make it more difficult to see things up close or to see things to the side (peripheral vision). They can also make us more sensitive to glare, such a light off a shiny surface.

Because many problems with vision develop slowly, older adults often don’t realize how much vision they have lost. If you are having difficulty with driving, watching television, or reading, you likely have a visual problem. Your healthcare provider may ask you to read a short passage from a newspaper or magazine (wearing your glasses if necessary) as a simple test of vision. Standardized eye tests (eg, reading a chart with lines of letters of progressively small size) may be used to confirm that a vision problem exists. Older adults should have 20/40 vision or better on these tests. All older adults should have a complete eye examination by an ophthalmologist at least once a year. (See also Vision.)

Hearing loss is common among older adults and, unfortunately, can often lead to depression, dissatisfaction with life, and withdrawal from social activities. Typically, hearing loss occurs in both ears, and people have a harder time hearing high-frequency sounds. Consonants (eg, "p," "s," or "t") in words are high-frequency sounds that make it possible for you to understand what is being said. Vowels (eg, "a," "e," "i," "o," and "u") are low-frequency sounds that make it possible for you to hear something that is being said. With a high-frequency hearing loss, you may feel that you can hear but not understand what is being said. Often, people with some hearing loss think that other people are mumbling. Trying to hear in a noisy room is especially difficult, and someone shouting only makes the noise worse.

The number of people who have problems related to thinking or remembering doubles every 5 years after age 65. By age 90, about half of us have problems with some mental functions. Even in the absence of diagnosed dementia, older adults with some mental difficulties are at increased risk of accidents, delirium, missed medication and doctor appointments, and disability. It is important to be aware that most people with these problems do not complain of memory loss or symptoms of lessened mental abilities, even when specifically questioned. Healthcare providers often ask simple questions to screen for mental problems during office visits with older adults, especially those 75 years old and older (see Problems with Thinking, Understanding, and Remembering).

Memory loss is typically the first sign of dementia. The best single screening test for memory is to try and remember three words after one minute. Anything other than perfect recall means that further testing should be done. The most commonly used formal test is the Folstein Mini-Mental State Examination (MMSE), which assesses word recall, attention, and calculation, language, and visual-spatial skills.

An often overlooked area of thinking is "executive function." This refers to the ability to be flexible (ie, change behavior in a changing situation), understand new intentions, or plan/schedule actions. A useful question to evaluate executive function is asking a person to name as many four-legged animals as possible in one minute. Listing fewer than eight to ten animals or repeating the names of the same animals is abnormal and suggests the need for further evaluation. The "clock-drawing test" also evaluates executive function, as well as visual-spatial skills. In the clock-drawing test, the person is asked to draw the face of a clock and to place the hands correctly to indicate 2:50 or 11:10.

A large number of older adults suffer from some symptoms of depression. Anxiety and worries are important symptoms in older people that often suggest an underlying depression. In addition, older adults are particularly likely to experience the loss of a loved one, resulting in grief that can lead to depression.

People showing symptoms of depression are at increased risk of physical disability. They also recover more slowly after an event that causes disability, such as a broken bone. Symptoms of depression should be treated as soon as possible. The best single question a healthcare provider and ask is, "Do you often feel sad or depressed?" A "yes" response means that the possibility of depression should be further evaluated.

A social assessment should address numerous areas, including the following:

• the availability of family and friends to provide personal support
• the need for a caregiver (and what type of help the caregiver routinely provides)
• the general financial situation of the older person
• the possibility of elder mistreatment
• advance directives of the older person

Although it isn’t practical to conduct a comprehensive social assessment in a doctor’s office, older adults should discuss these issues with their healthcare providers. Similarly, healthcare providers should be mindful of these social needs. For example, healthcare providers might inquire about the availability of help in case of an emergency, as a way to prompt discussion about potential problems. For frail older persons, particularly those who lack social support, referral to a visiting nurse may be helpful in assessing home safety and level of personal risk.

During the past decade, the term "quality of life" has been used as sort of a catch-all phrase to describe overall health and well-being beyond traditional measures of disease. Quality of life includes various aspects of physical, mental, psychological, and social function. Your health care provider may ask you to fill out a short questionnaire that asks several questions about each major area of your health.

Quality of life can mean different things to different people. For example, pain management may be most important to some people, while mobility is the main goal for others. Older adults should discuss their expectations and wishes with their healthcare providers, family, and caregivers.

Comprehensive geriatric assessment (CGA) involves extensive testing done to more specifically determine an older adult’s medical, psychological, social, and functional capabilities and limitations. The goal of a CGA is to develop an overall plan for treatment and long-term follow-up.

A CGA is expensive and time consuming, because it requires a highly trained team of doctors, nurse clinicians, physical and occupational therapists, geriatric psychiatrists, and social workers. For this reason, CGA is typically used in inpatient eldercare units that are staffed by highly trained professionals. In these settings, CGA can help improve function and can reduce placement in a nursing home and readmissions to hospitals. This success generally requires that a team of health care providers who are highly trained in geriatric medicine take over the direct care of the patient for an extended period. The CGA is unlikely to be successful if this team is simply consulted without being involved in ongoing clinical care and following through on recommendations.

Evaluating the older driver is difficult for both healthcare providers and families of older adults. Cars are the most important, and often the only, source of transportation for older people. Yet, a variety of age-related changes, chronic conditions, and medications may place older adults at risk of car accidents. The absolute number of crashes involving older drivers is low, because older drivers spend less time behind the wheel than younger drivers. However, the number of crashes per mile driven and the chance of serious injury or death during a crash is higher for drivers over 65 years old than for any age group except drivers 16-24 years old.

To their credit, most older people adjust their driving behaviors and habits. Risk can be reduced by avoiding rush-hour traffic, busy or congested streets, night driving, and driving during bad weather. Regardless, impaired drivers who stay on the road are a safety hazard to themselves and to other drivers, passengers, and pedestrians. Unfortunately, many older drivers are not aware of their driving limitations. Common sources of driving impairment include the following:

• decreased vision
• dementia
• limited range of motion of the neck, shoulders, hips, ankles or trunk
• foot abnormalities
• poor coordination
• alcohol (all ages)
• medications that affect alertness (eg, narcotics, tranquilizers, antihistamines, antidepressants, antipsychotics, sedatives, muscle relaxants, etc; also all ages)

Any report of an accident or moving violation should trigger an evaluation of the driving ability of an older adult. In fact, physicians in many states are encouraged, if not required, to report their concerns to the department of motor vehicles. Healthcare providers and family members need to discuss safety concerns honestly with each other and with the older driver. Alternative methods of transportation should be considered (eg, taking the bus). However, recommendations to stop driving should not be made lightly, because a sudden loss of driving privileges can lead to decreased activity and increased symptoms of depression symptoms in older adults. Referral for a formal driving evaluation by a skilled occupational therapist may be helpful in confirming unsafe driving behaviors and possibly in suggesting specialized equipment to correct for certain physical disabilities.