Search tips
Search criteria 


Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
JAMA. Author manuscript; available in PMC 2010 June 23.
Published in final edited form as:
PMCID: PMC2822435

Medical Care for the Final Years of Life: “When you're 83, it's not going to be 20 years”


The case of an 83-year old man who has had a falls-related injury and continues to be the sole caregiver for his wife with dementia exemplifies a common situation that clinicians face—planning for the final years of an elderly person's life. To appropriately focus on the patient's most pressing issues, the approach should begin with an assessment of life expectancy and incorporate evidence-based care whenever possible. Short-term issues are aimed at efforts to restore the patient to his previous state of health. Mid-range issues focus on providing preventive care and identifying geriatric syndromes, as well as helping him cope with the psychosocial needs of being a caregiver. Long-term issues relate to planning for his eventual decline and meeting his goals for the end of life.

However, the workload and inefficiencies of primary care practice present barriers to providing optimal care for older persons. Systematic approaches, including team care, are needed to adequately manage chronic diseases and coordinate care.

The Patient's Story

Mr Z is an 83-year-old man with gout, osteoarthritis, and worsening gait who has fallen several times in the past year. He is the primary caregiver for his wife of 62 years, who was diagnosed with dementia 4 years ago. A retired businessman, Mr Z continues to serve on several corporate and charitable boards of directors. Over the past few years he has been slowing down and notes that his “gait is off.” He has fallen twice outside his home. Ten months ago, he tripped outside and broke 2 ribs. A month ago, he fell again when he “missed a step” in a restaurant and “tore ligaments” in his left knee. After the second injury, Mr Z used a wheelchair for a few weeks but now walks with a quad cane. He works with a physical therapist to improve his gait and endurance.

Current medications are allopurinol (for gout), potassium (for long-standing hypokalemia), and occasional acetaminophen with codeine (for knee pain). He has declined calcium or vitamin D supplements because he fears a recurrence of calcium oxalate kidney stones.

Mr Z reports that he drinks 1 glass of wine with dinner but did not drink alcohol immediately before he fell. He lives in a ground floor condominium with a 15-step interior staircase (with railing) from the garage 1 floor below. He continues to drive.

Mr Z cares for his wife who has moderate Alzheimer disease but remains independent in her activities of daily living (ADLs) and has no psychological or behavioral complications; Mr Z performs all of her instrumental activities of daily living (IADLs), including cooking, transportation, and finances. He says he is managing fine and declines additional help because his wife does not like people in their home. Mrs Z fired several of the home health aides whom Mr Z had hired and refuses to move into a setting with more assistance, a wish Mr Z has acceded to.

Mr Z denies depression or memory problems and says he has a great deal of support from his friends and 2 children, who live nearby. He also attends an Alzheimer disease support group. He knows that his wife's condition will worsen but he has not yet brought himself to formulate specific future plans. He is currently considering respite options.

Mr Z receives his care in several medical settings from both primary care and specialty physicians. He received a screening colonoscopy 2 years ago and has received influenza vaccine (this season), pneumococcal vaccination (10 years ago), and zoster vaccine (3 months ago). Mr Z had an eye examination 6 months ago; no visual risk factors for falling were identified.

Mr Z's sitting blood pressure was 125/60 with a pulse of 78; standing, the blood pressure was 133/60, with a pulse of 80. Lung and cardiac examinations were normal. There was full range of motion in both hips (flexion, adduction, and abduction). His right knee was swollen but not painful and there was no erythema. He was able to get out of a chair without using his arms. Sensation in both lower extremities was intact to light touch. There was no cogwheel rigidity, tremor, or shuffling gait. Mental status was alert; he was oriented to time, place, and person and was quite articulate.

Urinalysis, complete blood count, and serum chemistries (including uric acid, thyrotropin, and lipid panel) were normal.

Recent physical therapy evaluation showed a normal standing balance for his age as assessed by computerized posturography. The leg lengths differed with right leg length = 32.25 inches and left leg length = 33.25 inches. This was corrected by modifying his right shoe with a heel lift. The physical therapy evaluation also included assessments of falls risk, muscle strength, flexibility, and functional mobility. On the Performance-oriented Mobility Assessment (Tinetti Scale)1, he scored 24/25 for balance—the only deficit was an inability to perform 1-legged stance; he scored 7/12 for gait, with deficits on step length (right foot not passing left foot), truncal stability (marked sway noted), and walk stance (widened base of support). His total score was 31/37, in the range of “moderate” fall risk (26–31). On lower extremity muscle testing, his strength was only 4/5 of right and 3+/5 of left hip abductors; 4+/5 of right and 3+/5 of left hip adductors; 4+/5 of both knee flexors; 4/5 of both knee extensors; all other muscles were 5/5. In tests of mobility, Mr Z was fully independent with gait, transfers, and bed mobility.

Mr Z and his geriatrician, Dr B, were interviewed by a Care of the Aging editor in December 2008.

Putting Mr Z's health issues into perspective

Mr Z: I guess over the last few years, I never gave much thought to what would happen to me. …But I see that when you're 83, it's not going to be 20 years…I don't think. There's going to be a time, sometime down the road, when I can't make the decisions.

Dr B: Mr Z is by far one of my healthiest patients in that he doesn't have any cognitive impairment. His biggest issues are his gait and his mobility. Over the year and a half that I've seen him, he's had a couple of big falls. [I]t took him a while to rebound and his gait never fully recovered. There have been incremental steps of decline.

Although Mr Z's problems seem minor and self-limited, he has embarked on the journey that will represent the final chapter of his life. His physician's role is to ascertain Mr Z's personal trajectory on that pathway, clarify his goals, and together develop a plan to monitor and achieve those goals, periodically reassessing as he ages.

To help Mr Z remain independent for as long as possible, recommended care should be based on evidence whenever possible. For persons of Mr Z's age and older, however, a conventional evidence-based approach is modified by 3 important caveats:Prognosis. For some patients, co-morbidities can worsen prognosis such that screening tests and treatments of demonstrated effectiveness for healthier older persons of the same age would not be beneficial within the expected survival period. Insufficient evidence. The evidence base guiding the management of many conditions affecting older persons is insufficient, especially for those age 80 years or older. Older persons and those with co-morbidities are often excluded from clinical trials, and some conditions are difficult to study or have not received priority for research. Consequently, treatment recommendations often must extrapolate beyond the evidence-base. Patient goals and preferences. Patients' goals may relate to a functional or health state (eg, being able to walk independently), symptom control (eg, control of pain or dyspnea), living situation (eg, remaining in one's home), or survival (eg, living long enough to reach a personal milestone such as a family member's wedding). Sometimes patient and physician goals may differ. For example, a patient may seek a cure when the physician believes that only symptom management is possible. In other cases, the physician believes that a better outcome is possible but the patient declines to pursue the recommended path (eg, physical therapy to regain mobility). In addition, patient preferences for specific treatments may lead to care that is not the best evidence-based option (eg, using pads to manage urinary incontinence even though effective behavioral and pharmacologic therapy is available)

Eventually, however, Mr Z's physician will need to manage his inevitable decline and his care will be guided by Mr Z's personalized goals. In this phase, the evidence for many decisions may not fit the individual patient's specific clinical situation or unique cluster of medical and social issues. Hence, the physician must rely on experience, general knowledge, and clinical judgment. This combination of the science, wisdom, and skill of medicine is the key to providing the best care for older patients in their final years.

This article presents the way in which clinicians can use prognosis to tailor their approach to caring for elderly patients. By addressing the types of issues Mr Z will face over time, beginning with his current problem, a fall-related injury, an approach to his goals and treatment for the next 5 years and for the longer term will be presented. The final section focuses on practice changes that clinicians can make to manage these issues efficiently and comprehensively for aging patients.


For specific disease management issues (eg, falls prevention) and clinical questions (eg, the value of vitamin and mineral supplements) relevant key terms with limits of “human,” “English language,” “aged” and “80 years and older,” and when appropriate, “clinical trials” were used to search Medline for evidence. For consideration for inclusion in Box 1 “Questions and Simple Tests for General Screening Assessment of Frail Older Patients” Medline search terms geriatric screening instruments and geriatric assessment instruments with the same limits were used; disease-specific instruments (eg, for patients with cancer or stroke) and those in specific settings (eg, hospital, nursing home, emergency department) other than the office were excluded. For most dimensions of geriatric assessment, many instruments are available and candidates were selected based on brevity, psychometric characteristics, and ease of use. Priority for final inclusion was given to those that could be administered via questionnaire or by office staff rather than requiring a clinician. For each domain, 1 or 2 instruments were selected as examples of currently used screening instruments. Finally, the Centers for Disease Control, the US Preventive Services Task Force, and the National Center for Health Statistics Web sites were searched to provide evidence-based recommendations and other data.

Assessing prognosis and life expectancy

Dr B: I always start by asking, “How are you doing?” I'll also ask if there is anything that he wants to talk about. I let the patient set the agenda. Then I'll review the big issues about his gait, how many falls, what happened. I'll assess his gait. Then I'll focus on his caregiver strain, his mood, ask about depression, how are things going with his wife…

Medical visits should begin with an assessment of the patient's agenda and issues, including immediate concerns and threats to quality of life. However, to appropriately focus the limited time available, the clinician must establish priorities, determined in part by prognosis..

To understand Mr Z's health trajectory, the clinician can draw upon both clinical experience and epidemiologic data on life expectancy and prognosis (Table 1). Life tables enable one to estimate remaining life by age, sex, and race. The median survival for 83-year-old white men in the US is 6.22 to 6.93 years, which provides an initial estimate of Mr. Z's life expectancy. However, life tables do not consider clinical characteristics or functional status, which can lead to wide variations in survival. For example, an 85-year-old man has a 75% chance of surviving 2 years and a 25% chance of living 9 years,2 with the variability being largely dependent on comorbid conditions and functional status. Although the actual survival of individual patients may deviate substantially from predicted survival, estimates of prognosis may guide thinking about disease prevention and other long-term strategies, and frame treatment discussions.

Table 1
Life Expectancy (in years) for older persons by age, race, and sex3

To identify high priority issues, the clinician might first draw upon clinical experience to categorize Mr Z's current and future issues into 3 time periods: short-term (within the next year), mid-range (within the next 5 years), and long-term (beyond 5 years). The longer the range of projections, the less can be said with certainty about his future health and social needs. Figure 1 demonstrates how events and diseases could alter Mr Z's trajectory of function and survival from gradual decline (trajectory A) to more rapid or precipitous decline and death. For example, Mr Z could fall and fracture his hip (trajectory C) or develop Alzheimer Disease (trajectory B). Although meeting Mr Z's health care needs will require continual reevaluation of goals, this framework allows the clinician to focus on the more immediate issues while keeping the long-term issues in mind. Table 2 presents the anticipated treatment and monitoring tasks over the next 5+ years based on Mr Z's current health status.

Figure 1
Possible future functional and health status trajectories for Mr Z. Trajectory A assumes good health and gradual functional decline with Mr Z living twice the median survival for 85-year old US men. Trajectory B assumes that he develops a chronic degenerative ...
Table 2
Treatment and monitoring of Mr Z.

Short term issues (next year)

Dr B: After I call for a patient from the waiting room, as we walk down the hall, I'm really looking at how the patient is walking and if they look unsteady. … I'm pretty direct. I told Mr Z that he wasn't walking as well as the previous time that I'd seen him. He agreed right away … We talked about the risk of falling and some of the bad things that could happen. He agreed that he definitely wanted physical therapy.

The most pressing issues for Mr Z are rehabilitation from his recent injury and reduction of the risks of falling in the future and of harm if he does fall. Most of the recommended evidence-based falls evaluation4,5 has already been performed. Specifically, the circumstances surrounding Mr Z's falls have been assessed and Dr B has evaluated potentially contributing medications, postural hypotension, vision, gait, and balance. He has been referred to physical therapy and was given an assistive device and an exercise prescription, which he is following. The physical therapist should communicate with the clinician about progress and need for continued therapy versus transition to a community-based falls prevention or exercise program.

Many patients who have multiple falls are home bound and are, therefore, eligible for a more comprehensive home safety evaluation by a rehabilitation therapist or nurse who goes to the house under the auspices of Home Health. This evaluation often leads to modifications (eg, installation of grab bars, railings, lighting) that may help prevent future falls. A randomized clinical trial of older persons with mobility limitations who had recently been hospitalized; participants in the intervention group had 31% fewer falls at 1 year compared to the control group.6 A recent Cochrane review found that home assessment and modifications can reduce falls by 41% among those with visual impairment and by 44% among those at high risk (prior falls or 1 or more risk factors) for falling; but there was no effect for those at low risk.7

Based on 2 meta-analyses, Vitamin D supplementation can reduce falls (by 22%)8 and hip (by 20%) and nonvertebral fractures (by 18%).9 Thus, Mr Z's physician should prescribe 800 IU of vitamin D.10 A bone-mineral density study11 should be obtained and the results used to reopen the discussion about calcium supplementation and, if he has osteopenia or osteoporosis, bisphosphonate therapy. Both observational and clinical trial data suggest that calcium supplementation does not increase the risk of nephrolithiasis12 and a low calcium diet may increase the risk of recurrent stones.13

During this period of rehabilitation, Mr Z should be seen every 1-2 months, to monitor progress, revise his treatment plan if necessary, and to provide encouragement. In addition, Mr Z's functional status should be explored (Box 1). (AU: Table 2 does not mention assessing functional status. Should it be added to short term? Should the Box 2 questions be completed by all patients except the terminally ill?) Although he is independent in completing basic ADLs and IADLs, inquiring about difficulty with ADLs may provide additional prognostic information.14 In addition, performance-based testing of gait speed: side-by-side, semi-tandem, and tandem stance; and standing from a chair may provide prognostic information beyond the patient's self-reported functioning.15

Other geriatric aspects of health should also be assessed. Box 1 provides a list of domains and screening questions that are appropriate for all elderly patients who are not terminally ill and can be self- or medical assistant-administered. Positive screens need further evaluation by either the primary care or another clinician.16 The frequency of these assessments and the age when they should begin has not been determined. One approach would be to assess these annually beginning at age 75 years, when impairments become more common, and in older persons less than 75 years who have multiple co-morbidities. Major illnesses (eg, those requiring hospitalization) should prompt reevaluation earlier and more frequently than annually, particularly of ADLs and IADLs; gait, balance, and falls; depression; and cognitive problems.

Mid-range issues (next 5 years)

Mr Z: About 4 years ago, my wife started having her first episodes of Alzheimer disease. It's changed some things in our house considerably. [O]ne of the worst things that happened was that they had to take the car away from her. She was upset about losing her independence. Now, I have become a caretaker… I have gone to see the Family Caretakers Alliance.

Dr B: I asked him what was involved in his caregiving for his wife …was he doing her activities of daily living? … I'm trying to understand how much of a problem it is and where we can help.

The next set of issues to address with Mr Z are the mid-range issues that will require planning and in some cases preventive steps. Such issues would be pertinent for adults with at least a 3–5 year life expectancy. With the short-term interventions, Mr z should be expected to return to his baseline mobility status.If he does not develop new symptoms or signs, the frequency of Mr Z's primary care visits could be extended to intervals of 3–6 months. At each of his follow-up visits, Mr Z should be asked whether he has fallen or has fear of falling; an affirmative response would warrant reassessment of what has changed and whether new treatment is indicated. For example, worsened balance after may require additional physical therapy.

At these visits, Dr B should inquire about Mr Z's functional status, his wife's health, and his ability to cope with her illness. Because Mr Z will be the primary decision-maker about where he and his wife live, this will be a topic for ongoing discussion. Currently he is able to accommodate her desire to remain in their home but changes in her condition, or his, may prompt reevaluation. It is likely that her needs eventually will exceed his capacity and additional help in the home or relocation will be necessary. Sometimes patients with dementia become less resistant to having help in the home as the dementia progresses.

Based on Mr Z's evolving situation, the clinician may need to further assess for depression, recommend additional supportive services, or refer to psychiatry or social work. Referrals to community-based organizations (eg, the Alzheimer's Association) can augment the quality of dementia care that the general internist or family physician can provide, particularly by providing caregiver counseling.17 Discussions might also explore the amount and types of support that their children can provide and the role of other community-based resources such as day care centers that can provide some respite time for Mr Z. These are typically private pay but some have sliding scale fees based on income. At some point, Mr Z may also benefit from seeing a social worker, a financial planner, or an attorney who is experienced with eldercare issues. Legal issues, such as power of attorney and signatory authority, may need to be addressed. Although social work and case management services are available in the community, these services are generally not covered by fee-for-service Medicare and must be paid for out-of-pocket except for those who have Medicaid or are in managed care programs.

It is likely that Mr Z will outlive his wife and he will need to prepare for life as a widower. The clinician can be exceptionally valuable in helping patients like Mr Z go through the grieving process and adjust to the next phase of their lives by inquiring about personal interests, goals, values, and physical, environmental, social, and financial resources. In contrast to the structured assessment that a social worker might do, these can be done more informally over time.

Preventive care to maintain health

As Dr B continues to follow Mr Z, it will be important to build the relationship, establishing trust, rapport, and mutual understanding as they consider the longer-term issues that he will face. Keeping him as healthy as possible should include appropriate preventive services and assessment of social and lifestyle issues. Among the preventive services are vaccinations and screening tests to detect asymptomatic disease. Although the effectiveness of vaccines in the elderly population is not as convincing as in younger age groups, several are indicated on the Centers for Disease Control's recommended adult immunization schedules18 including annual influenza vaccination, 1-time pneumonia vaccination, 1-time herpes zoster vaccination, 2 doses of varicella vaccination (if no evidence of immunity), and tetanus toxoid vaccination every 10 years. Currently, the Advisory Committee on Immunization Practices does not recommend routine pneumococcal revaccination of immunocompetent adults.19 The financing of zoster vaccination through Medicare Part D has made prescribing and administration cumbersome for both patients and physician practices. In most cases, physicians need to provide a prescription that the patient must fill and bring to the physician's office to be injected.

Although the value of screening for cancers has not been demonstrated for persons of Mr Z's age, there is good evidence that screening and appropriate treatment of other asymptomatic diseases confers beneficial health outcomes. For example, performing bone mineral density testing in a man of Mr Z's age, even in the absence of prior falls, is cost-effective.11 A strategy of screening and treating with bisphosphonates if the femoral neck T score is ≤ 2.5 costs less than $50,000 per quality-adjusted life-year and considerably less if nonproprietary formulations costing less than $500 per year are used.11 Blood pressure screening can be justified as treatment of hypertension leads to a 21% reduction in rate of death form any cause in patients of Mr Z's age.20 The US Preventive Services Task Force (USPSTF) provides evidence-based recommendations for screening tests21 and has created an interactive Web site with recommendations based on the patient's age, sex, tobacco use, and current sexual activity. Because little evidence supports most screening interventions in someone of Mr Z's age and his life expectancy, there are relatively few preventive services recommendations for him (Table 3). For example, no cancer screening tests are recommended. Currently, the Task Force offers little guidance about the frequency of screening for older persons and when to cease screening.

Table 3
US Preventive Services Task Force (USPSTF) recommendations for an 83-year old, nonsmoking, sexually inactive man (

Calcium supplements, multivitamins, and aspirin are commonly prescribed as preventive measures but their value is less well established. A meta-analysis demonstrated no benefit from calcium supplements alone in preventing hip fractures.22 The Women's Health Initiative cohorts failed to show that multivitamins reduce cancer, cardiovascular disease, or mortality23 and a randomized clinical trial showed no benefit on the prevention of infections24. The USPSTF concludes that there is insufficient evidence to recommend aspirin to prevent cardiovascular outcomes in persons ≥ 80 years of age, such as Mr Z.25

Once recovered from his current injury, Mr Z should begin to engage in balance exercise programs to reduce his risk of falling (eg, Tai Chi)26 and aerobic exercise (eg, walking) to reduce the risk of functional decline.27 Similarly, maintaining social contacts and particularly cognitive training may help prevent functional decline,28 although this evidence is more preliminary.

Long-range issues (beyond 5 years)

The clinician should also keep in mind longer term issues that patient will face if his health does not deteriorate in the near future (Figure 1, trajectory A). Over the next 5–10 years, Mr Z will likely need to reconsider his living situation regardless of his wife's condition. Unless he has a catastrophic or rapid decline, he and his physician will also need to plan for his functional decline and frailty. Will he be able to remain in his condominium or will he require more support such as assisted living? These decisions will be guided by his personal preference, his financial resources, and safety concerns. Balancing a patient's desire for independent living with the ability to do so safely is a common conundrum that physicians must face with their elderly patients.

Both Mr and Mrs Z have in place durable powers of attorney for health care, and Mr Z has discussed his preferences with his son. A durable power of attorney is helpful in overcoming some of the limitations of living wills and other documents that only specify wishes in specific situations. The person designated with power of attorney can speak for an incapacitated patient to make decisions about the situation at hand. If a patient has specific wishes about life-sustaining therapies, the clinician and patient (or surrogate) should also complete a standard Physician Order for Life-Sustaining Treatment (POLST) form, which can help ensure that his preferences for end-of-life care are followed in all settings where care is provided, including by emergency medical services (EMS) personnel. Although POLST forms are not recognized by all states, this approach is expanding.29

How to provide this care in primary care settings

Managing the short-term, mid-range, and long-term issues that Mr Z is likely to face will take a substantial amount of time. Without better systems of care primary care physicians cannot accomplish all the work that needs to be done.30 Accordingly, clinicians should consider restructuring their practices to accommodate the diverse ongoing needs of elderly patients using currently available approaches.31 A population-based approach provides a useful framework to guide practice redesign to meet the full range of patients' needs. This framework divides patients into 3 populations: those who are functioning well, with or without chronic diseases and have life expectancies of ≥ 10 years; those who are functioning poorly and often have multiple chronic diseases and have life expectancies of >2 and < t0 years; and those who are at the end of life and have life expectancies of < 2 years., Patients in each population may receive care for their specific diseases and coordination among clinicians in the community, hospital, or nursing home. For patients who are at the end of life, the focus is on only short-term issues, whereas for those with multiple chronic diseases who may be frail (such as Mr Z's wife), the focus is on both the short- and mid-term. For those like Mr Z, who are healthy or have few chronic diseases, issues that fit within all 3 time frames are relevant. Table 4 indicates how priorities change based on life expectancy. Tools and approaches to each type of patient can be tailored to help the primary care physician save time and focus on the issues of greatest importance to the patient.

Table 4
Priorities in the care of elderly patients by life expectancy

Communication across health care systems and across providers is essential. The majority of practices in the United States32 do not have a fully electronic medical record that communicates across sites of care. E-mail communication about progress of patients in hospital (eg, a daily update on patients) and nursing home settings (an e-mail and dictated summary when discharged home) can help maintain continuity whether other physicians are involved in patients' care.

In the office setting, prevention and screening tasks should be routinely incorporated, as much as possible, into the practice through standing orders and pre-visit questionnaires. Examples are available at

Management of specific geriatric conditions (eg, falls, urinary incontinence) can also be structured to provide high quality, efficient, and comprehensive office-based care.33,34 This care includes identification through screening or case-finding as described above, follow-up on positive screens, and monitoring response to treatment with revision of the treatment plan as needed. Tools such as structured visit notes that lead providers through recommended care processes and patient information sheets that identify nearby community-based resources can facilitate high quality, comprehensive care. Several disease management strategies that add dedicated personnel (eg, a depression clinical specialist or a “guided care” nurse who coordinates care and provides suggestions for management of specific disorders) or have linked the health care system with community-based organizations have improved quality of care and have led to some better clinical outcomes.35,36,37,38 These programs fit well within the Chronic Care Model,39 a theoretical construct that espouses better health care linked to community-based services through 4 components: delivery system design, self-management support, decision support, and clinical information systems. Patients become more informed and activated and practice teams are more prepared to be proactive with the intended result of improved clinical and functional outcomes. A meta-analysis examining the Model's effect on asthma, congestive heart failure, depression, and diabetes demonstrated that interventions with at least 1 Chronic Care Model element had beneficial effects on clinical outcomes and processes of care across all conditions.40 However, implementing this type of care requires staff, support systems, and a payment mechanism.

Currently the workload of primary care practice, the lack of preparation of physicians to initiate and complete practice redesign, and the economics of medical practice are substantial barriers to adopting these approaches. The Patient-Centered Medical Home (PCHM) advocated by internists, family physicians, pediatricians, and osteopaths41 might provide a mechanism to develop systematic approaches to managing chronic diseases along the principles of the Chronic Care Model, including providing team care when appropriate. For Mr Z, the PCMH might mean that some tasks (eg, monitoring his falls risk, coordinating care between Mr Z's many physicians, and communicating with Mrs Z's physician) may not be done by Dr. B. Most of the increased payment proposed as part of the PCMH will need to be devoted to providing new services by additional personnel who have clearly defined, complementary roles and to enhancing the information systems available to the office team. Based on early experience, the transition to medical homes is unlikely to be easy or quick.42

Mr Z's future care

As Mr Z ages, he will need to receive evidence-based care, when evidence is available, and care based on good clinical reasoning when it is not. A summary of the anticipated monitoring and treatment for Mr Z based on his current health status is provided in Table 2. However, this plan will certainly change as new diseases and conditions appear. For Mr Z and his physician, this is the great unknown, which will be discovered through screening and presentation of new symptoms. Regardless of what emerges, optimal care for Mr Z will require a prepared physician who has maintained clinical skills and knowledge through processes such as maintenance of board certification.43 Mr Z's physician will also need to provide care in an efficiently redesigned health care system, using teams (even in solo and small group practices), and incorporating the Chronic Care Model. Finally, Mr Z will need a physician who will serve as his advocate and guide as he confronts the medical and social issues of the last years of his life. Anything less is unlikely to meet his current and future needs.

Box 1 Questions and Simple Tests for General Screening Assessment of Frail Older Patients*

Functional status

Activities of Daily Living (ADLs)
  • bathing
  • dressing
  • toileting
  • transferring
  • maintaining continence
  • feeding

Responses are: able to complete without assistance, able but with difficulty, unable to complete without assistance.

Instrumental Activities of Daily Living (IADLs)
  • using the telephone
  • shopping
  • preparing meals
  • housekeeping
  • doing laundry
  • using public transportation or driving
  • taking medication, and handling finances

Responses are: able to complete without assistance, unable to complete without assistance)

Visual impairment

  • Do you have difficulty driving or watching television or reading or doing any of your daily activities because of your eyesight, even while wearing glasses?44

Yes=positive screen

Alternative is screening using Snellen eye chart.

Hearing impairment

National Health and Nutrition Examination Survey (NHANES) battery45
  • Is your age > 70 years? (1 point)
  • Are you male gender >(1 point)
  • Do you have 12 or fewer years of education? (1 point)
  • Did you ever see a doctor about trouble hearing (2 points)
  • Without a hearing aid, can you usually hear and understand what a person says without seeing his face if that person whispers to you from across the room? (if no, 1 point)
  • Without a hearing aid, can you usually hear and understand what a person says without seeing his face if that person talks in a normal voice to you from across the room? (if no, 2 points)

≥ 3 points= positive screen

Alternative is Audioscope.46

Urinary incontinence

ACOVE-2 Screener34
  • Have you had urinary incontinence (lose your urine) that is bothersome enough that you would like to know how it could be treated?

Yes=positive screen.


  • Have you lost any weight in the last year?47

Loss of ≥ 5 percent of usual body weight in last year= positive screen.

Gait, balance, falls

ACOVE-2 Screener34
  • Have you fallen 2 or more times in the past 12 months?
  • Have you fallen and hurt yourself since your last doctor's visit?
  • Have you been afraid of falling because of balance or walking problems?

Any yes=positive screen.



Over the past 2 weeks, how often have you been bothered by:

  • Little interest or pleasure in doing things?
  • Feeling down, depressed, or hopeless?

Responses are scored: 0 = Not at all, 1 = Several days, 2 = More than half the days, 3 = Nearly every day.

≥ 3=positive screen.

Cognitive problems

Three-item recall49

< 2 items recalled=positive screen

Clock drawing test50

Any of the following errors=positive screen

  • Wrong time
  • No hands
  • Missing numbers
  • Number substitutions
  • Repetition
  • Refusal

Environmental problems

Home safety checklists51


*All except Snellen eye chart, audioscope, and evaluation for cognitive problems can be assessed by self-report using questionnaires


1. Tinetti ME. Performance-oriented assessment of mobility problems in elderly patients. J Am Geriatr Soc. 1986;34:119. [PubMed]
2. Social Security Online, the official website of the US Social Security Administration. Content last reviewed or modified April 22, 2009, accessed 6/07/09.
3. Arias E, United States life tables . National vital statistics reports. no 9. vol 56. National Center for Health Statistics; Hyattsville, MD: 2004. 2007.
4. Guideline for the prevention of falls in older persons American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. J Am Geriatr Soc. 2001 May;49(5):664–72. [PubMed]
5. Chang JT, Ganz DA. Quality indicators for falls and mobility problems in vulnerable elders. J Am Geriatr Soc. 2007;55(Suppl 2):S327–34. [PubMed]
6. Nikolaus T, Bach M. Preventing falls in community-dwelling frail older people using a home intervention team (HIT): results from the randomized Falls-HIT trial. J Am Geriatr Soc. 2003 Mar;51(3):300–5. [PubMed]
7. Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG, Rowe BH. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2009 Apr;15(2):CD007146. Review. PubMed PMID: 19370674. [PubMed]
8. Bischoff-Ferrari HA, Dawson-Hughes B, Willett WC, Staehelin HB, Bazemore MG, Zee RY, Wong JB. Effect of Vitamin D on falls: a meta-analysis. JAMA. 2004 Apr 28;291(16):1999–2006. [PubMed]
9. Bischoff-Ferrari HA, Willett WC, Wong JB, Stuck AE, Staehelin HB, Orav EJ, Thoma A, Kiel DP, Henschkowski J. Prevention of nonvertebral fractures with oral vitamin D and dose dependency: a meta-analysis of randomized controlled trials. Arch Intern Med. 2009 Mar 23;169(6):551–61. [PubMed]
10. Lips P, Bouillon R, van Schoor NM, Vanderschueren D, Verschueren S, Kuchuk N, Milisen K, Boonen S. Reducing fracture risk with calcium and vitamin D. Clin Endocrinol (Oxf) 2009 Sep 10; Epub ahead of print. [PubMed]
11. Schousboe JT, Taylor BC, Fink HA, Kane RL, et al. Cost-effectiveness of bone densitometry followed by treatment of osteoporosis in older men. JAMA. 2007;298(6):629–637. [PubMed]
12. Heaney RP. Calcium supplementation and incident kidney stone risk: a systematic review. J Am Coll Nutr. 2008 Oct;27(5):519–27. [PubMed]
13. Borghi L, Schianchi T, Meschi T, Guerra A, Allegri F, Maggiore U, Novarini A. Comparison of two diets for the prevention of recurrent stones in idiopathic hypercalciuria. N Engl J Med. 2002 Jan 10;346(2):77–84. [PubMed]
14. Gill TM, Robison JT, Tinetti ME. Difficulty and dependence: two components of the disability continuum among community-living older persons. Ann Intern Med. 1998 Jan 15;128(2):96–101. [PubMed]
15. Reuben DB, Seeman TE, Keeler E, Hayes RP, Bowman L, Sewall A, Hirsch SH, Wallace RB, Guralnik JM. Refining the categorization of physical functional status: the added value of combining self-reported and performance-based measures. J Gerontol A Biol Sci Med Sci. 2004 Oct;59(10):1056–61. [PubMed]
16. Reuben DB, Rosen S. Principles of Geriatric Assessment. In: Halter JB, Ouslander JG, Tinetti ME, Studenski S, High KP, Asthana S, editors. Hazzard's Principles of Geriatric Medicine and Gerontology. 6th Edition McGraw Hill; 2009. pp. 141–153.
17. Reuben DB, Frank JC, Katz D, McCreath H, Roth C, Hirsch SH, Wenger NH. A Practice Redesign Intervention to Improve the Quality of Dementia Care: Results of a Pilot Study. AGS Annual Meeting; Chicago, III. April 30.2009. [PMC free article] [PubMed]
18. Centers for Disease Control and Prevention Recommended adult immunization schedule–United States, 2009. MMWR. 2008;57(53) accessed 6/05/09.
19. Department Of Health And Human Services. Centers for Disease Control and Prevention . Pneumococcal Polysaccharide Vaccine (10/6/09) Vaccine Information Statement. accessed 6/05/09.
20. Beckett NS, Peters R, Fletcher AE, Staessen JA, Liu L, Dumitrascu D, Stoyanovsky V, Antikainen RL, Nikitin Y, Anderson C, Belhani A, Forette F, Rajkumar C, Thijs L, Banya W, Bulpitt CJ. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008 May 1;358(18):1887–98. Epub 2008 Mar 31. [PubMed]
21. AHRQ Publication No. 08-05118-EF. Agency for Healthcare Research and Quality; Rockville, MD: Jul, 2008. U.S. Preventive Services Task Force Procedure Manual.
22. Bischoff-Ferrari HA, Dawson-Hughes B, Baron JA, Burckhardt P, Li R, Spiegelman D, Specker B, Orav JE, Wong JB, Staehelin HB, O'Reilly E, Kiel DP, Willett WC. Calcium intake and hip fracture risk in men and women: a meta-analysis of prospective cohort studies and randomized controlled trials. Am J Clin Nutr. 2007 Dec;86(6):1780–90. [PubMed]
23. Neuhouser ML, Wassertheil-Smoller S, Thomson C, Aragaki A, Anderson GL, Manson JE, Patterson RE, Rohan TE, van Horn L, Shikany JM, Thomas A, LaCroix A, Prentice RL. Multivitamin use and risk of cancer and cardiovascular disease in the Women's Health Initiative cohorts. Arch Intern Med. 2009 Feb 9;169(3):294–304. [PMC free article] [PubMed]
24. Avenell A, Campbell MK, Cook JA, Hannaford PC, Kilonzo MM, McNeill G, Milne AC, Ramsay CR, Seymour DG, Stephen AI, Vale LD. Effect of multivitamin and multimineral supplements on morbidity from infections in older people (MAVIS trial): pragmatic, randomised, double blind, placebo controlled trial. BMJ. 2005 Aug 6;331(7512):324–9. [PMC free article] [PubMed]
25. Department Of Health And Human Services Agency for Healthcare Research and Policy. US Preventive Services Task Force Electronic Preventive Services Selector accessed 6/06/09.
26. Voukelatos A, Cumming RG, Lord SR, Rissel C. A Randomized, Controlled Trial of tai chi for the Prevention of Falls: The Central Sydney tai chi Trial. J Am Geriatr Soc. 2007;55:1185. [PubMed]
27. Penninx BW, Messier SP, Rejeski WJ, Williamson JD, DiBari M, Cavazzini C, Applegate WB, Pahor M. Physical exercise and the prevention of disability in activities of daily living in older persons with osteoarthritis. Arch Intern Med. 2001 Oct 22;161(19):2309–16. [PubMed]
28. Willis SL, Tennstedt SL, Marsiske M, Ball K, Elias J, Koepke KM, Morris JN, Rebok GW, Unverzagt FW, Stoddard AM, Wright E, ACTIVE Study Group Long-term effects of cognitive training on everyday functional outcomes in older adults. JAMA. 2006 Dec 20;296(23):2805–14. [PMC free article] [PubMed]
29. Hickman SE, Sabatino CP, Moss AH, Nester JW. The POLST (Physician Orders for Life-Sustaining Treatment) paradigm to improve end-of-life care: potential state legal barriers to implementation. J Law Med Ethics. 2008;36(1):119–40. 4. Spring. [PubMed]
30. Baron RJ. The chasm between intention and achievement in primary care. JAMA. 2009 May 13;301(18):1922–4. [PubMed]
31. Ganz DA, Fung CH, Sinsky CA, Wu S, Reuben DB. Key elements of high-quality primary care for vulnerable elders. J Gen Intern Med. 2008 Dec;23(12):2018–23. Epub 2008 Oct 7. [PMC free article] [PubMed]
32. DesRoches CM, Campbell EG, Rao SR, Donelan K, Ferris TG, Jha A, Kaushal R, Levy DE, Rosenbaum S, Shields AE, Blumenthal D. Electronic health records in ambulatory care--a national survey of physicians. N Engl J Med. 2008 Jul 3;359(1):50. [PubMed]
33. Reuben DB, Roth C, Kamberg C, Wenger NS. Restructuring primary care practices to manage geriatric syndromes: the ACOVE-2 intervention. J Am Geriatr Soc. 2003;51:1787–93. [PubMed]
34. Wenger NS, Roth CP, Shekelle PG, Young RT, Solomon DH, Kamberg CJ, Chang JT, Louie R, Higashi T, MacLean CH, Adams J, Min LC, Ransohoff K, Hoffing M, Reuben DB. A Practice-based Intervention to Improve Primary Care for Falls, Urinary Incontinence and Dementia. J Am Ger Soc. 2009 Mar;57(3):547–55. Epub 2009 Jan 16. [PubMed]
35. Vickrey BJ, Mittman BS, Connor KI, et al. The Effect of a Disease Management Intervention on Quality and Outcomes of Dementia Care. Annals of Internal Medicine. 2006;145:713–726. [PubMed]
36. Callahan CM, Boustani MA, Unverzagt FW, Austrom MG, Damush TM, Perkins AJ, Fultz BA, Hui SL, Counsell SR, Hendrie HC. Effectiveness of collaborative care for older adults with Alzheimer disease in primary care: a randomized controlled trial. JAMA. 2006;295(18):2148–57. [PubMed]
37. Unützer J, Katon W, Callahan CM, Williams JW, Jr, Hunkeler E, Harpole L, Hoffing M, Della Penna RD, Noël PH, Lin EH, Areán PA, Hegel MT, Tang L, Belin TR, Oishi S, Langston C. IMPACT Investigators. Improving Mood-Promoting Access to Collaborative Treatment. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA. 2002 Dec 11;288(22):2836–45. [PubMed]
38. Boult C, Reider L, Frey K, Leff B, Boyd CM, Wolff JL, Wegener S, Marsteller J, Karm L, Scharfstein D. Early effects of “Guided Care” on the quality of health care for multimorbid older persons: a cluster-randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2008 Mar;63(3):321–7. [PubMed]
39. Wagner EH. Chronic Disease Management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1:2–4. [PubMed]
40. Tsai AC, Morton SC, Mangione CM, Keeler EB. A meta-analysis of interventions to improve care for chronic illnesses. Am J Manag Care. 2005 Aug;11(8):478–88. [PMC free article] [PubMed]
41. American Academy of Family Physicians (AAFP) American Academy of Pediatrics (AAP) American College of Physicians (ACP) American Osteopathic Association (AOA) Joint Principles of the Patient-Centered Medical Home. 2007. Accessed November 10, 2007.
42. Nutting PA, Miller WL, Crabtree BF, Jaen CR, Stewart EE, Stange KC. Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Ann Fam Med. 2009 May-Jun;7(3):254–60. [PubMed]
43. Holmboe ES, Wang Y, Meehan TP, Tate JP, Ho SY, Starkey KS, Lipner RS. Association between maintenance of certification examination scores and quality of care for Medicare beneficiaries. Arch Intern Med. 2008 Jul 14;168(13):1396–403. [PubMed]
44. Moore AA, Siu AL. Screening for common problems in ambulatory elderly: Clinical confirmation of a screening instrument. Am J Med. 1996;100:438. [PubMed]
45. Reuben DB, Walsh K, Moore AA, Damesyn M, Greendale GA. Hearing loss in community-dwelling older persons: national prevalence data and identification using simple questions. J Am Geriatr Soc. 1998 Aug;46(8):1008–11. [PubMed]
46. Yueh B, Shapiro N, MacLean CH, Shekelle PG. Screening and management of adult hearing loss in primary care: scientific review. JAMA. 2003 Apr 16;289(15):1976–85. [PubMed]
47. Wallace JI, Schwartz RS, LaCroix AZ, Uhlmann RF, Pearlman RA. Involuntary weight loss in older outpatients: incidence and clinical significance. J Am Geriatr Soc. 1995 Apr;43(4):329–37. [PubMed]
48. Kroenke K, et al. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care. 2003;41:1284–92. [PubMed]
49. Siu AL. Screening for dementia and investigating its causes. Ann Intern Med. 1991;115(2):122. [PubMed]
50. Lessig MC, Scanlan JM, Nazemi H, Borson S. Time that tells: critical clock-drawing errors for dementia screening. Int Psychogeriatr. 2008 Jun;20(3):459–70. Epub 2007 Oct 1. [PMC free article] [PubMed]
51. Department Of Health And Human Services. Centers for Disease Control and Prevention accessed 6/9/09.