How to use these 6 risk indicators in every day consults

Traditionally, risk has been assessed by looking at factors such as age, gender, and medical history. However, there are other indicators that can provide valuable insight into a patient’s risk of developing disease and adverse events- particularly in older adults. Here are six indicators of risk that can help provide a snapshot of overall health and wellbeing, and can be easily implemented, even in a short consultation.

1. Gait Speed

Gait speed is an important predictor of health outcomes in older adults. Research has shown that slower gait speed is associated with an increased risk of falls, disability, and mortality, even after controlling for age, gender, and comorbidities (1). In fact, gait speed has been proposed as the “sixth vital sign” in older adults (2).

GPs can assess gait speed during routine visits by having the patient walk a short distance, such as 4 meters, at their usual pace. If a patient’s gait speed is found to be slow (more than 5 seconds) it warrants further investigation and exploration of ways to improve their physical function, such as exercise programs, physiotherapy, or mobility aids.

2. Grip strength

Grip strength is a useful indicator of overall physical function, muscle mass, and the ability to perform activities of daily living all of which are all important indicators of health and functional status. It has been found to be strongly associated with both health and longevity, with research showing that low grip strength is associated with a higher risk of developing various health conditions, including cardiovascular disease, diabetes, and disability. In addition, low grip strength has been found to be a predictor of mortality, with several studies showing that individuals with weaker grip strength have a higher risk of death from all causes. (3,4).

GPs can use grip strength as a simple and non-invasive measure of physical function to help identify who may benefit from interventions aimed at improving overall health and mobility. Grip strength can be measured using a hand-held dynamometer. The patient holds the dynamometer at their side with their elbow at a right angle and squeezes as hard as they can for about 3 seconds. The average is taken from 3 attempts and can be compared to normal ranges for age and gender (5).

3. Post-operative delirium

Post-operative delirium is a common and serious complication of surgery, particularly in older adults. It is characterized by confusion, disorientation, and changes in behaviour and can lead to longer hospital stays, increased healthcare costs, and a higher risk of mortality (6). There is also a growing body of research linking post-operative delirium with an increased risk of developing dementia later in life (7).

GPs can play a critical role in identifying patients at risk for post-operative delirium by reviewing their medical history and medication use. They can also work with patients, their surgeons, and anaesthetists to optimise pre-operative care and watch for signs of delirium during hospitalisation and after discharge. GPs should monitor patients who have experienced post-operative delirium for signs of cognitive decline and refer them to specialists as needed.

4. Living alone

One in four Australian households is a lone-person household and by the age of 80, 40% of women live alone. (8) Living alone and the social isolation and loneliness that can stem from it have been linked to a range of adverse health effects, such as cardiovascular disease, depression, cognitive decline and higher rates of hospitalisation, disability, and mortality (9,10) Even a perceived feeling of “being lonely” is associated with adverse outcomes (11).

As part of routine visits, GPs can ask patients about any changes in living arrangements or social networks (such as the deaths of friends and family) to assess for risk of loneliness and social isolation. If they ask the patient directly if they “feel lonely”, it can also help reduce stigma and give clinicians a better understanding of the social factors that might be impacting a patient’s health and well-being. If a patient lives alone or reports feeling lonely the GP can refer patients to community resources such as seniors’ groups or volunteer organizations like Men’s/ Women’s Sheds to help them stay connected and engaged.

5. Health of teeth and gums

Oral health is an often-neglected aspect of overall health that can have significant implications for morbidity and mortality risk. Poor oral health has been linked to a higher risk of cardiovascular disease, diabetes, and respiratory infections (12,13,14). In addition, dental problems can lead to pain, difficulty eating, and poor nutrition.

There are financial and geographical barriers to accessing dental care for some populations and GPs can (and do) provide basic oral health services to their patients. (15) To get a more complete picture of a patient’s risk, GPs can collect dental history and conduct basic oral exams, such as checking for cavities, gum disease, and oral cancer. They can also encourage patients to maintain good oral hygiene, such as brushing and flossing regularly, and to seek dental care when necessary.

6. The “Surprise Question”

“Would you be surprised if this patient were to die in the next six/ twelve months?”

It may seem like an odd question to ask yourself, and it is not a definitive predictor of mortality, but a metanalysis of 22 studies which analysed the outcomes of more than 25,000 estimates found that clinicians’ intuitions were correct about 75% of the time. (16). While there are many factors, algorithms and tools that can be used to calculate a patient’s prognosis; the “Surprise Question” (or SQ) can be a helpful starting point.

GPs are trained to observe and evaluate a patient’s symptoms and may pick up on subtle signs that indicate that a patient is nearing the end of their life. By asking themselves the surprise question, GPs can tap into their intuition to identify patients who may benefit from palliative care, start important conversations about end-of-life planning and improve the quality of care for their patients.

References:

1. Studenski S, Perera S, Patel K, et al. Gait speed and survival in older adults. JAMA. 2011;305(1):50-8
2. Middleton A, Fritz SL, Lusardi M. Walking speed: the functional vital sign. J Aging Phys Act. 2015 Apr;23(2):314-22.
3. Dodds, Richard M., et al. “Grip strength across the life course: normative data from twelve British studies.” PloS one 9.12 (2014): e113637.
4. Celis-Morales, Carlos A., et al. “Associations of grip strength with cardiovascular, respiratory, and cancer outcomes and all cause mortality: prospective cohort study of half a million UK Biobank participants.” bmj 361 (2018).
5. Massy-Westropp, Nicola M., et al. “Hand Grip Strength: age and gender stratified normative data in a population-based study.” BMC research notes 4.1 (2011): 1-5.
6. Vacas S, Cole DJ, Cannesson M. Cognitive Decline Associated With Anesthesia and Surgery in Older Patients. JAMA. 2021;326(9):863-864.
7. Goldberg TE, Chen C, Wang Y, et al. Association of Delirium With Long-term Cognitive Decline: A Meta-analysis. JAMA Neurol. 2020;77(11):1373-1381.
8. De Vaus, D., & Qu, L. (2015). Demographics of living alone (Australian Family Trends No. 6). Melbourne: Australian Institute of Family Studies.
9. Pimouguet C, Rizzuto D, Lagergren M, Fratiglioni L, Xu W, (2107) Living alone and unplanned hospitalizations among older adults: a population-based longitudinal study, European Journal of Public Health, Volume 27, Issue 2, April 2017, 251-256,
10. Holt-Lunstad, Julianne, et al. “Loneliness and social isolation as risk factors for mortality: a meta-analytic review.” Perspectives on psychological science 10.2 (2015): 227-237
11. Teguo, Maturin Tabue, et al. “Feelings of loneliness and living alone as predictors of mortality in the elderly: the PAQUID study.” Psychosomatic medicine 78.8 (2016): 904-909.
12. Dietrich, T., Webb, I., Stenhouse, L. et al. Evidence summary: the relationship between oral and cardiovascular disease. Br Dent J 222, 381–385 (2017).
13. D’Aiuto, F., Gable, D., Syed, Z. et al. Evidence summary: The relationship between oral diseases and diabetes. Br Dent J 222, 944–948 (2017).
14. Manger, Deborah, et al. “Evidence summary: the relationship between oral health and pulmonary disease.” British dental journal 222.7 (2017): 527-533.
15. heng, An-Lun, et al. “Encounters and management of oral conditions at general medical practices in Australia.” BMC health services research 22.1 (2022): 1013.
16. White, Nicola, et al. “How accurate is the ‘Surprise Question’at identifying patients at the end of life? A systematic review and meta-analysis.” BMC medicine 15 (2017): 1-14.