JAMDA 18 (2017) 195e199

JAMDA
journal homepage: www.jamda.com

Editorial

Rapid Geriatric Assessment: A Tool for Primary Care Physicians

John E. Morley MB, BCh a, *, Milta O. Little DO, CMD b, Marla Berg-Weger PhD b
a
Divisions of Geriatric Medicine and Endocrinology, Saint Louis University School of Medicine, St. Louis, MO
b
Division of Geriatric Medicine, Saint Louis University School of Medicine, St. Louis, MO

In 2015 8.5% (7.2 million) of the world’s population was over
65 years of age (www.census.govþlibraryþdemo). By 2050, this per-
centage will double. At present, the world’s oldest country, Japan, has
26.6% of its population over 65 years of age and the United States 14.9%.
By 2050, older adults in Japan will comprise 39% of the population and
in the United States, 21% of the population will be 65 years or older.
Currently, worldwide the dependency ratio in the world for older
people to working age (20 to 64) younger people is 15 per 100, and it is
expected to rise to 33 by 2050. By 2050, the life expectancy in Japan and
Singapore will have risen from 84.7 to 91.6 years. Worldwide, the oldest
olddpeople 80 years and olderdwill triple by 2050. These statistics
need to be considered with the recognition that over the age of 70 years,
older persons undergo a rapid decline in physical and mental function.
Overall, this “aging tsunami” will place an increasing burden on the
health and social care systems throughout the world.
Steps to prevent deterioration in health are more effective and
cheaper than trying to cure functional deterioration after it occurs. The
profession recognizes that a focus on geriatric syndromes often pro-
duces better outcomes for the individual rather than trying to address
each of the components of the “multimorbidity of aging” separately.
Geriatricians are the “superspecialists” who, around the world, have
been tasked with focusing on geriatrics syndromes.1 In general, pri-
mary care clinicians have been trained to focus on each disease
separately and to ignore the development of geriatric syndromes,
often with disastrous consequences. Unfortunately, the number of
geriatricians around the world is very small, and their numbers are
either stagnating or growing very slowly. With the “aging tsunami”
upon us, this requires a rapid re-education of healthcare providers to
enable them to focus on the management of geriatric syndromes.
The core of geriatric care has been the geriatric assessment, an inter-
professional assessment of the older individual that can take 90 minutes or
more to complete. Key elements are the assessment of medical status,
functional capabilities, cognitive status, and psychosocial structure and
support. The geriatric assessment has been proven to reduce disability,
hospitalization, and institutionalization and improve quality of life.2,3 On
This project is supported by the Health Resources and Services Administration
(HRSA) of the US Department of Health and Human Services (HHS) under grant
number U1QHP28716 Geriatrics Workforce Enhancement Program for $843,079.
This information or content and conclusions are those of the author and should not
be construed as the official position or policy of, nor should any endorsements be
inferred by HRSA, HHS, or the US Government.
The authors declare no conflicts of interest.
* Address correspondence to John E. Morley, MB, BCh, Division of Geriatric
Medicine, Saint Louis University School of Medicine, 1402 S. Grand Blvd, M238, St.
Louis, MO 63104.
E-mail address: morley@slu.edu (J.E. Morley).
http://dx.doi.org/10.1016/j.jamda.2016.11.017
1525-8610/Ó 2016 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
the whole, it has tended to focus on persons with early signs of disability as
there have been insufficient geriatricians to focus on predisabilityd“frailty.”
Recent research has suggested that a focus on frailty and the common
syndromes causing it, and a similar focus on early cognitive impairment
(cognitive frailty) has the potential to markedly reduce future morbidity.4,5
Originally, the instruments used to screen for these geriatric syn-
dromes were cumbersome and took much longer to do than the time
available for an average primary care visit.6,7 To overcome this, a
number of shorter screening tests have been developed for health
professionals to use in older persons. These include the Kihon index in
Japan,8 the EasyCare screen in England and Holland,9 the Gerontopole
screen in Toulouse,10 and the Medicare Annual Wellness visit in the
United States.11 Recently, Saint Louis University has developed the
Rapid Geriatric Assessment (RGA) screen.12 The RGA is based on very
brief questionnaires that have each been validated in 3 or more con-
tinents. The RGA screens for frailty, sarcopenia, anorexia of aging, and
cognitive impairment. In addition, there is a single question concerning
completion of an advance directive. The RGA takes from 5 to 10 minutes
to administer, and we have shown that it can be done by a variety of
healthcare professionals. In Missouri, it has been successfully used in
over 3500 persons either as a case finding or screening tool. A
computerized algorithm used to guide the management of these syn-
dromes is under development and is being tested. This editorial will
examine the validity for each of the components of the RGA.
RGA
Frailty
Persons who are frail are at heightened risk of developing disability
when they are exposed to illness or psychological stressors.13 Three
types of frailty are recognized: The physical frailty phenotype of
Fried,14 multimorbidity,15 and psychosocial frailty.16 Frailty is most
useful when it is limited to persons who do not have any deficits in the
Katz basic activities of daily living (cannot walk or transfer, toilet,
wash, dress, or feed themselves).
The RGA uses the FRAIL scale to identify frailty:
F ¼ Are you fatigued?
R ¼ Resistance: Are you unable to climb a flight of stairs?
A ¼ Aerobic: Are you unable to walk a block?
I ¼ Do you have more than 5 illnesses?
L ¼ Have you lost more than 5% weight in 6 months?
1 or 2 positive answers ¼ prefrail; 3þ positive answers ¼ frail.
196 Editorial / JAMDA 18 (2017) 195e199

Table 1
SARC-F Screen for Sarcopenia

Component Question Scoring*

Strength How much difficulty do you have in lifting and carrying 10 pounds? None ¼ 0
Some ¼ 1
A lot or unable ¼ 2
Assistance in walking How much difficulty do you have walking across a room? None ¼ 0
Some ¼ 1
A lot, use aids, or unable ¼ 2
Rise from a chair How much difficulty do you have transferring from a chair or bed? None ¼ 0
Some ¼ 1
A lot or unable
Without help ¼ 2
Climb stairs How much difficulty do you have climbing a flight of ten stairs? None ¼ 0
Some ¼ 1
A lot or unable ¼ 2
Falls How many times have you fallen in the last year? None ¼ 0
1-3 falls ¼ 1
4 or more falls ¼ 2

*SARC-F scale scores range from 0e10 (ie, 0e2 points for each item; 0 ¼ best to 10 ¼ worst) and represent no sarcopenia (0e3) and sarcopenia (4e10).

The validity of this scale has been shown in Australia,17e19 the
United States,20e22 Hong Kong,23,24 Europe,25,26 Mexico,27,28 China,29
Turkey,30 and Korea.31 It is highly predictive of developing disability,
falls, hospitalization, institutionalization, and death.
Management of persons who are FRAIL positive can be determined
by the answer to the 5 questions. If the person is fatigued, then sleep
apnea, depression, hypothyroidism, B12 deficiency, anemia, and hy-
potension (both basal and orthostatic and postprandial) should be
considered. A thorough medication review to identify a pharmaco-
logic cause of fatigue should also be performed. Positive responses to
the resistance and aerobic questions suggest sarcopenia and can be
treated as outlined in the next section on sarcopenia. The disastrous
impact of polypharmacy is likely in persons with more than 5 ill-
nesses.32e34 In particular, anticholinergic burden, drug-drug in-
teractions, drugs altering muscle power, drug-induced hyponatremia,
overtreatment of blood pressure, and dehydration should be consid-
ered. In persons who have lost over 5% of their weight, the healthcare
provider should look for reversible causes of weight loss as outlined in
the third section. Consideration of using protein enriched foods or a
caloric supplement is also sensible.
A number of studies have successfully used multifactorial ap-
proaches (exercise, nutrition, and cognitive support) to successfully
reduce frailty burden.35e38 At present, there is sufficient data to sup-
port an aggressive approach to trying to reverse frailty and limit future
disability.
Sarcopenia
Sarcopenia is a low level of muscle function in the presence of loss
of muscle mass.39 Similarly to frailty, sarcopenia in the absence of
functional limitations is considered a predisabled state and is best
assessed and treated in those who are functionally independent.
Although there is certainly overlap between frailty and sarcopenia,
studies have determined that these are 2 separate clinical entities,
both which can lead to poor functional outcomes. Between 60% and
70% of frail persons are sarcopenic and, similarly, 30% of persons with
sarcopenia are not frail. For this reason, it is important to look for both
frailty and sarcopenia when assessing an older adult. Like frailty,
sarcopenia is a causative factor in disability, hospitalization, falls, and
death.40 The SARC-F Screen for Sarcopenia is presented in Table 1.
Management of sarcopenia consists of resistance and aerobic ex-
ercise which, ideally, should be continued for a year or more.41e45
Adjunctive therapy for sarcopenia should consist of a high protein
intake of 1.0 to 1.2 g/kg/day.46,47 This can be reached by giving a
protein supplement enriched in leucine or hydroxymethyl butyrate (a
metabolite of leucine).48,49 Both leucine and hydroxymethyl butyrate
increase protein synthesis by activating the mTOR (the mammalian
mechanistic target of rapamycin) pathway within cells.50
Individuals with sarcopenia who are falling should be referred to a
physical therapist for a full gait and balance assessment. This can be
done with the Tinetti gait and balance assessment,51 the Short Phys-
ical Performance Battery,52 the Berg balance test53 or the Toulouse-St.
Louis Falls assessment.54 In persons who are falling, the focus should
be on balance as well as resistance exercises. Approximately one-third
of persons who fall have unrecognized syncope; thus, special atten-
tion should be paid to the possibility that they have postural hypo-
tension55 or postprandial hypotension.56 In recurrent fallers, it may be
prudent to insert a loop recorder to detect arrhythmias.57
Motoric cognitive risk syndrome occurs in persons with Mild
Cognitive Impairment who have a slow walking speed and memory
Table 2
Simplified Nutritional Appetite Questionnaire
1. My appetite is
A. very poor
B. poor
C. average
D. good
E. very good
2. When I eat
A. I feel full after eating only a few mouthfuls
B. I feel full after eating about a third of a meal
C. I feel full after eating over half a meal
D. I feel full after eating most of the meal
E. I hardly ever feel full
3. Food tastes
A. very bad
B. bad
C. average
D. good
E. very good
4. Normally I eat
A. less than 1 meal a day
B. 1 meal a day
C. 2 meals a day
D. 3 meals a day
E. more than 3 meals a day
Instructions: Complete the questionnaire by circling the correct answers and then
tally the results based on the following numerical scale: A ¼ 1, B ¼ 2, C ¼ 3, D ¼ 4,
E ¼ 5.
Scoring: If the mini-Simplified Nutrition Assessment Questionnaire is less than 15,
there is a significant risk of weight loss.
 Editorial / JAMDA 18 (2017) 195e199
Table 3
The Rapid Cognitive ScreeneInternational Version
1. Please remember these 5 objects. I will ask you what they are later. [Read each object to patient using approximately 1-second intervals.]
Apple Pen Tie House Car
2. [Give patient pencil and the blank sheet with clock face.] This is a clock face. Please put in the hour markers and the time at 10 minutes to 11 o’clock. [2 points/hour markers
ok; 2 points/time correct]
3. What were the 5 objects I asked you to remember? [1 point/each]
4. I’m going to tell you a story. Please listen carefully because afterwards, I’m going to ask you about it.
Jill was a very successful stockbroker. She made a lot of money on the stock market. She then met Jack, a devastatingly handsome man. She married him and had 3 children.
They lived in Rome. She then stopped work and stayed at home to bring up her children. When they were teenagers, she went back to work. She and Jack lived happily ever
after.
What country did they live in? [1 point]
0e5 points ¼ dementia; 6e7 points ¼ mild cognitive impairment; 8e10 points ¼ normal.
problems.58 It is particularly common in persons who have had a ce-
rebrovascular accident, depression, or Parkinson disease. These per-
sons and those with more fully developed dementia often have a dual
tasking deficit (cannot walk and talk at the same time) as the cause of
their falls. Specific physical therapy, focusing on the ability to walk
while being distracted is essential to improve function in these
individuals.
Simplified Nutrition Assessment Questionnaire
Anorexia of aging, both physiological and pathologic, is very
common in older persons and is a major cause of weight loss.59
Weight loss in older persons leads to loss of muscle and bone,
increasing the risk for hip fracture. In addition, weight loss in older
persons is associated with increased mortality. The Simplified Nutri-
tion Assessment Questionnaire has been shown to be highly predic-
tive of weight loss 6 months later both in nursing home and
community-dwelling elders.60 Besides its validation in the United
States, it has been validated in Japan,61 the United Kingdom,62 and
France.63 Table 2 provides the Simplified Nutrition Assessment
Questionnaire.
Treatment of anorexia in older persons requires a focus on
reversible causes.64 These include medications, depression, alco-
holism, elder abuse, late life paranoia, swallowing, and oral problems,
nosocomial infections such as Helicobacter pylori, Addison disease,
tremors and other eating problems, therapeutic diets, and gallstones.
There is evidence that a fluid oral caloric supplement can improve
outcomes.65,66
Cognitive Dysfunction
Problems with memory are very common among older persons.
However, these deficits are rarely recognized by physicians.5 The
recognition of cognitive dysfunction is important as it changes the
methods by which the physician should communicate with the pa-
tient.5,67 In addition, there are numerous treatable causes of mild
cognitive impairment and dementia.68 Both the Saint Louis University
Mental Status test and the Montreal Cognitive Assessment can detect
mild cognitive impairment as well as dementia.69,70 Recently, we
developed the Rapid Cognitive Screen, which is based on the Saint
Louis University Mental Status test.71 The Rapid Cognitive Screen has
high sensitivity and specificity for identifying mild cognitive impair-
ment (Table 3).
Persons with cognitive impairment and their care partners need
help with medication administration, should be accompanied to
physician visits, should not have guns at home, and should be assessed
for driving impairment. Treatable causes of cognitive impairment
include anticholinergic drugs, depression, hypothyroidism, vitamin
B12 deficiency, visual and hearing impairment, normal pressure hy-
drocephalus, tumors and other space occupying lesions, inflammatory
cytokine excess and central nervous system infections, alcoholism,
197
atrial fibrillation, and sleep apnea.72 The FINGER study (the Finnish
Geriatric Intervention Study to Prevent Cognitive Impairment and
Disability) has shown that a Mediterranean diet, exercise, treatment of
vascular disease, socialization, and computer games slows the rate of
cognitive impairment in older persons.73 Extra virgin olive oil has
been shown to be highly effective at improving memory in persons
with dementia.74,75 Cognitive stimulation therapy increases mental
status in persons with moderate dementia.76e78
Advance Directives
The health professional needs to know if patients have an advance
directive.79 Persons of all ages should be helped to understand the
utility of the advance directive and be helped with understanding the
choices they have. A useful web resource for completing and discus-
sing advance directives is the Advance Care Planning - National
Institute of Health site at https://www.nia.nih.gov/health/publication/
advance-care-planning.
Conclusions
The RGA is proving to be a useful tool for health professionals to
recognize major geriatric syndromes in older persons. It also reminds
health professionals to recognize if the person does not have an
advance directive. The components of the RGA should be viewed as
routine tests given to all older adults, just like checking blood pres-
sure. At Saint Louis University, we are developing a computerized
assisted management plan to guide healthcare professionals in the
management of these geriatric syndromes. We have also developed a
series of informational handouts for patients and caregivers, high-
lighting the appropriate referrals and lifestyle measures they can take,
depending on which syndrome they have.
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