Assessment tools cannot substitute for good clinical skills and judgements. As clinicians we need to be aware that assessment tools can tell us more than just a score.
Assessment involves collecting information that gets to know the patient in detail, evaluates their risks and the nature of problems to be identified.
Assessment should integrate all the relevant issues. It should explore the medical, physiological, social and psychological function of the older person.
The assessment process encourages us to be curious and to consider the best possible interventions that we can employ to minimise risks and maximise our patient’s quality of life. This can ultimately involve balancing some risks with some gains and working with our team and the older person and their family to make an informed choice about this.
Assessment supports us to:
- treat the condition that caused the admission (such as shortness of breath)
- detect and quantify additional conditions or psychosocial issues that contribute to or complicate the admission and respond to them as able both during the admission and when planning for discharge. For example
- depression - consider if the person needs a medical review
- poor nutrition - consider what can be done to optimise the person’s intake
- social isolation, or risk of loneliness - consider how you can encourage the person to participate in their care by harnessing their personal and social connections, and consider linking them to supports that are meaningful to them on discharge
- use strategies to prevent conditions that often emerge during hospital stays but can be avoided (such as delirium and falls).
We can gather information as part of the assessment process from multiple sources, and these may vary at the stages of a hospital admission.
The four main sources of information are:
- Older people themselves - self report.
- Others who know the older person well - informant report.
- Observation of the person undertaking various activities - direct observation.
- Various secondary written or verbal sources - including hospital records, medical reports, investigation results, communication from community care providers.
Unless there are reasons to suspect otherwise the older person is considered the best source of information about their own health1. Direct observation is the best source of information about physical function; however, we should consider how the environment or setting where observations take place may impact on the older person’s performance.
Assessment tools can be focussed on exploring one particular condition such as pain, pressure injury or nutrition. They can also be more comprehensive and encompass a broader focus beyond one particular issue. Examples of these types of tools include:
- InterRAI Comprehensive Assessment Tool: Acute
- Systematic Evaluation and Intervention for Seniors At Risk (SEISAR) - a short, standardised, comprehensive tool for the evaluation of active geriatric problems in seniors in the emergency department.
The assessment tool or scale should enable collection of useful patient data that supports interpretation of the holistic health status, identifies patient needs, and informs care planning and interventions to restore health and wellbeing.
Selecting an assessment tool
Consider the following factors when selecting an assessment tool include:
- A standardised tool can reduce variation in practices and interpretation of findings and allow comparison across assessments.
- A validated assessment tool ensures the right data is captured to evaluate the patient and their progress.
- Is a specific tools mandated for specific circumstances or settings? See the individual topics for examples.
- Does the tool cater for cultural or language differences?
- Is the tool appropriate for the physiology of ageing?
The format used will also depend on the discipline, skill and expertise of the clinician, the context and setting of the assessment, the time available and the number of assessors involved. The assessment can be:
- unstructured – if the professional expertise of the assessor is high
- semi-structured – incorporates specific tools and checklists
- structured and standardised – using global assessment instruments.
Comprehensive Geriatric Assessment
There is no gold standard for assessment of older people; however, a Comprehensive Geriatric Assessment is highly recommended to understand the multidimensional complex care needs of frail older people and to determine both short and long term care needs.
A Comprehensive Geriatric Assessment can be undertaken by any member of the interdisciplinary healthcare team who has the required knowledge and skills. Multiple team members with specific skills may need to be involved depending on the patient’s needs.
Ideally, the assessment should be completed within the patient’s first 24 hours in hospital and communicated to all team members, the patient and informal carers.
We also need to be aware of the following when conducting assessments of older people:
- At all times, it is vital that we maintain an understanding the older person’s perspective.
- In acute hospital settings, circumstances may mean older people are not able or willing to be actively involved when health professionals assess them.
- Older people may take more time to complete tools than younger people, so allow for rests during formal assessments.
- Ensure that any needs for communication assistances are met. These may include use of interpreters, ensuring the older person is wearing their glasses and/or hearing aids if they are used routinely.
- Do not assume older people know why they are being assessed. Explain why certain questions or tests are being undertaken.
- Establish cognitive status as early as possible in an assessment. Do not assume older people are able to hear, comprehend what is said or are capable of accurate, intelligible responses (for example if they are acutely unwell).
- Note that appearing ‘flat’, minimal eye contact and being non-committal responses may indicate depressive symptoms are present. Depressed older people can give the appearance of being cognitively impaired.
- Consider the need for an interpreter for those with limited English proficiency. The interpreter can also assist with cultural care delivery.
- Consider specific cultural issues and seek assistance necessary from cultural liaison officers or Indigenous health workers.
Applying clinical skills to assessment
Good clinical skills, observation, listening, interpreting and clinical judgement are all vital in decision-making.
When we assess older patients, we use tools and draw on our clinical reasoning skills. The reasoning cycle2 sets out the elements of effective clinical decision-making:
- Consider the patient situation
- Collect cues and information – through observation, questions
- Process the information – what does it mean?
- Identify problems and issues – what does the information indicate?
- Establish goals – what actions need to be taken?
- Take actions
- Evaluate outcomes
- Reflect on process and new learning.
1. Levett-Jones, T. (2013). Clinical Reasoning: Learning to think like a nurse. Frenchs Forest: Pearson Australia
2. Dorevitch 2004 p 229 in Nay, R., Garratt, S., & Fetherstonhaugh, D. (2013). Older People: Issues and Innovations in Care (4th ed.). Australia: Churchill Livingstone Australia