What are the recommendations for geriatric patient care at home to promote overall well-being, independence, and Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs)?

Recommendations for Geriatric Patient Care at Home

Home-based geriatric care must prioritize a multidisciplinary approach combining nutritional optimization, functional assessment with standardized ADL/IADL tools, occupational and physical therapy referrals, adaptive equipment provision, and caregiver education to maintain independence and quality of life. 1

Core Framework: The Geriatric 5Ms Approach

Apply the Geriatric 5Ms framework systematically to structure home care: Mind (cognitive/mood), Mobility (physical function), Medications (polypharmacy review), What Matters Most (patient goals), and Multicomplexity (social determinants). 1

Mind and Emotional Well-being

• Screen for depression using the Geriatric Depression Scale (GDS) or Patient Health Questionnaire-9 (PHQ-9), as depressive symptoms are strongly associated with both ADL and IADL impairment. 2, 3
• Assess cognitive function using the Montreal Cognitive Assessment (MoCA) rather than MMSE when mild impairment is suspected, as MoCA is more sensitive for detecting early decline. 2
• Obtain informant input using standardized tools like the Everyday Cognition scale (ECog) or Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), as patient self-report alone is unreliable. 2

Functional Assessment and ADL/IADL Support

Conduct periodic assessment of both basic ADLs (bathing, dressing, toileting, transferring, continence, feeding) and IADLs (shopping, meal preparation, housekeeping, medication management, finance management, communication via technology, transportation). 1

Specific Intervention Algorithm:

1. For IADL difficulties or ADL requiring "some help": Refer to occupational therapy as the primary intervention. 4

2. For mobility impairments or gait speed ≥4 seconds: Prioritize physical therapy referral for deconditioning and balance training. 4

3. For basic ADL assistance needs: Arrange home health aide services, but note that Medicare requires concurrent skilled nursing or rehabilitation services for coverage. 5, 4

Adaptive Equipment and Environmental Modifications

Provide adaptive equipment immediately rather than waiting for functional recovery, as early provision prevents complications and maintains independence. 4

• For eating difficulties: Built-up handle utensils, rocker knives, plate guards. 4
• For mobility: Walkers, wheelchairs, assistive devices based on individual assessment. 6
• For vision impairment: Enhanced lighting, as near visual acuity and contrast sensitivity are significantly associated with specific ADL/IADL performance. 7

Modify home environment to address: 5, 4

• Kitchen safety and fire prevention
• Adequate lighting throughout
• Handrails on stairs
• Removal of loose rugs
• Bathroom safety equipment

Nutritional Interventions

Implement individualized nutritional care as part of comprehensive treatment, as nutritional interventions improve ADL independence and quality of life. 1

• Conduct periodic nutritional assessments using the Mini Nutritional Assessment (MNA). 1
• Provide protein-enriched meals and additional protein drinks when indicated. 1
• Ensure adequate hydration, as all older persons should be considered at risk of low-intake dehydration. 1
• Avoid dietary restrictions generally; weight-reducing diets should only be considered in obese older persons with weight-related health problems and must be combined with physical exercise. 1

Medication Management

Review medications for appropriateness and address polypharmacy, as potential prescribing omissions (PPOs) are associated with lower IADL scores at 3-month follow-up. 3

• Designate a family member to fill pillboxes weekly and store medications (except as-needed medications) in the family member's home rather than with the patient when cognitive impairment exists. 1
• Provide written instructions detailing the medication regimen, indications, and monitoring directions to encourage family participation. 1
• Address medication affordability, as up to 20% of medication nonadherence in older adults results from cost concerns. 1

Promoting Happiness and Quality of Life

Prioritize patient preferences and goals through advance care planning discussions using tools like PREPARE (Prepare for Your Care) or Five Wishes. 1

Focus on maintaining functional status (staying at home) rather than aggressive disease management when life expectancy is reduced, as goals shift in advanced age. 1

Provide assistance with food provision and intake during meals, as this intervention improves energy intake and reduces mortality risk without perceived harm. 1

Continue nutritional interventions after hospitalization, as effects on ADL independence persist only as long as nutritional care is provided. 1

Caregiver Support and Education

Train family caregivers in range of motion exercises, positioning techniques, and proper use of assistive devices before assuming care responsibilities. 4

Assess caregiver capacity and document limitations, anxiety, confusion, or poor coping skills that may affect care quality. 5

Coordinate care through a trusted primary clinician, as multimorbidity (present in 260 out of 1000 adults over 80) requires integrated management. 1

Fall Prevention

Implement mandatory interventions for patients with fall history: 4

• Orthostatic blood pressure checks
• Balance training programs
• Gait and assistive device evaluation
• Berg Balance Scale or Postural Assessment Scale assessment

Social Determinants and Multicomplexity

Address financial concerns, as one-third of older patients are defined as net worth poor, leading to adverse health outcomes. 1

Evaluate social support systems and living situation, as patients who are older, living alone, or lack adequate support require more intensive home services. 5

Assess health literacy using tools like the Rapid Estimate of Adult Literacy in Medicine (REALM) to tailor education appropriately. 1

Critical Pitfalls to Avoid

• Do not delay equipment provision while waiting for functional recovery; early adaptive equipment prevents complications. 4
• Do not assume home health aide services alone are sufficient; Medicare requires concurrent skilled nursing or therapy for reimbursement. 5, 4
• Do not overlook caregiver education; family members require training before discharge. 4
• Do not provide generic recommendations; tailor assistance to the specific home environment with consideration of structural barriers. 4
• Do not rely solely on patient self-report without informant input, as variable insight leads to inaccurate assessment. 2
• Do not use vague language like "needs assistance"; specify exact ADL impairments and level of assistance required (standby, minimal, moderate, maximal, total). 5

Monitoring and Follow-up

Use the same assessment tools at regular intervals (typically every 6-12 months) to track changes over time reliably. 2

Monitor ADL scores from baseline through follow-up for early detection of functional decline. 2

Continue multidisciplinary team interventions as long as needed, as comprehensive care approaches show sustained benefits on ADL independence, reduced nursing home admissions, and reduced mortality. 1