Screening for common problems in ambulatory elderly: clinical confirmation of a screening instrument

To develop a test that will be administered by nonphysician office staff to screen elderly persons seen in ambulatory settings for problems commonly contributing to functional disability.

We reviewed the literature to identify problems that reduce function and screening measures appropriate for use in office settings. Using this information, we developed an instrument including screening items for malnutrition/weight loss, visual impairment, hearing loss, cognitive impairment, urinary incontinence, depression, physical disability, and reduced leg mobility. This instrument was tested on 109 new patients at a university-based ambulatory geriatrics medicine clinic and validated using two standards: blinded and unblinded geriatricians' assessments. For each of the individual items on the screening instrument, we calculated sensitivity and specificity using both the blinded and unblinded geriatricians' evaluations as the reference standards, prevalence of the disorders, positive and negative predictive values, inter-rater reliability, and the direct annual costs of administering the test for an individual physician's office.

The screen was administered in 8 to 12 minutes. Inter-rater agreement varied by item from 77% to 100%. The sensitivities of the items varied between 0.65 to 0.93 (blinded) and 0.70 to 0.95 (unblinded). Specificities ranged between 0.50 to 0.95 (blinded) and 0.64 to 0.95 (unblinded). Problem prevalences varied from 21% to 72%. Positive and negative predictive values were 0.60 to 0.91 and 0.77 to 0.96, respectively. Direct annual costs for a clinical practice include a one-time $530 fee for equipment and, depending on the screening administrator's salary, between $1 to $7 per patient screened.

The screening instrument is relatively inexpensive and brief and easy to use in the ambulatory setting. It is good validity and reliability when compared to the assessment of a geriatrician. We are currently conducting a randomized trial to assess the effectiveness of the screen among older persons seen in community physicians' offices.