GeriKit: A Novel App for Comprehensive Geriatric Assessment

Abstract

Background:

Given the growth of the older adult population in the United States, there is a greater need for tools to enable students, trainees, and clinicians to master the comprehensive geriatric assessment. Our goal was to develop a mobile phone application (app) to assist in performing this assessment.

Methods:

We performed a market survey of 45 apps that related to geriatrics and health screening. We evaluated for usability, target audience, and instruments used. Deficiencies included: (1) focusing on a single domain; (2) being time-intensive; and (3) having components behind a paywall. We then designed an app that incorporates instruments that are well-validated, available at no cost, and brief in length.

Results:

GeriKit includes eight domains: cognition, depression, function, strength, medications, falls, and advance care planning. Each instrument requires fewer than 5 minutes, and once it is completed and scored, the user can access relevant educational materials. GeriKit was launched for Apple users in December 2020, and for Android in August 2021. There have been over 3,400 downloads to date.

Conclusions:

The GeriKit app makes the comprehensive geriatric assessment accessible to a wide audience, improving the ability to for learners to perform geriatric assessments.

INTRODUCTION

The comprehensive geriatric assessment is used to screen patients for physical, psychological, social, and functional deficits,¹ but is complex for students, trainees, and clinicians to perform.² Among the limitations are prohibitive licensing fees for some proprietary geriatric screening instruments and an inability to access the numerous independent validated tools in an efficient manner. At the same time, the wide availability of portable electronic devices has enabled uptake of mobile health (mHealth) apps, which can be easily accessed to support clinical decision making.³ Medical students in particular use healthcare apps for clinical care and personal learning.⁴ For a medical app to be successful in the learning environment, it must be engaging, offer user feedback, and assist with decision support.⁵

In response to the limitations of existing options, our team created GeriKit, the first free mHealth app for conducting comprehensive geriatric assessments. GeriKit is HIPAA-compliant and designed for use by both trainees and practicing clinicians. Through step-by-step instructions, the app coaches users on conducting assessments across multiple domains, serves as a clinical decision support tool, and includes explanations of each instrument with links to the original literature.

METHODS

Market survey of current apps

To begin our development process, we searched apps in both the Apple App Store and the Google Play Store using the keywords “aging,” “elderly,” “geriatric,” “older people,” “old people,” and “medical assessment,” and evaluated these existing geriatric assessment apps to understand the current landscape. We then searched for specific keywords related to eight areas of the geriatric assessment: hearing, vision, cognition, functional mobility, fall history, depressive symptoms, independence, urinary symptoms, and frailty (Table 1). We subsequently reviewed both stores’ pre-categorized “medical” app list to ensure our list was comprehensive.

Table 1.

Keywords for Geriatric education app market survey

Hearing	“hearing,” “hearing handicap screen,” “pure tone audiometry”
Vision	“visual function questionnaire,” “Snellen chart,” “Snellen,” “Snellen visual acuity”
Cognition	“cognition,” “cognition assessment,” “mini-cog,” “trail making test”
Functional mobility	“mobility,” “mobility assessment,” “gait speed,” “timed up and go,” “short physical performance battery”
Fall history	“fall,” “fall assessment,” “fall questionnaire”
Depressive symptoms	“depression screening,” “depression questionnaire,” “PHQ-2,” “PHQ-6”
Independence	“Independence screening,” “ADLs,” “IADLs”
Urinary Symptoms	“urinary screening,” “incontinence severity index,” “BPH Symptom index”
Frailty	“frailty,” “frailty assessment”

Abbreviations: PHQ = Patient Health Questionnaire; ADLs = Activities of Daily Living; IADLs = Instrumental Activities of Daily Living;

In total, we reviewed 45 apps by downloading and reviewing their relevant features. We assessed the purpose of the app, the strengths and weaknesses of that specific app, and whether it was related to geriatric education. We also evaluated ease of use, target audience, and if it required payment.

Synthesis of evidence

There were several important gaps in the geriatric education app space. First, most apps focused only on a single domain, such as frailty or hearing. Second, many were time-intensive to use. Third, many failed to be interactive, acting functionally as textbooks. Fourth, many had only select components that were free, with other instruments that were restricted behind a paywall. Based on this review, it was apparent that a free, evidence-based geriatric assessment app could benefit patient care and clinical training.

Initial prototype design

We incorporated tools to assess cognition, depression, function, strength, fall screening, nutrition, polypharmacy, and advance care planning, and envisioned this app being used in a variety of settings including outpatient visits (e.g. the Medicare annual wellness visit), skilled nursing facility visits, and inpatient screenings. For each of the eight domains, we selected tools that are routinely used in geriatric care, in the public domain (available without a licensing fee), and could be easily translated to a mobile app format. Where appropriate, we contacted instrument creators to approve their use in GeriKit.

The aim was for the app to be simple, streamlined, HIPAA-compliant, and aesthetically pleasing so that a user could conduct an assessment efficiently and effectively, and would want to use the tool repeatedly. The results page of each assessment features a “next steps” tab that briefly explains the follow up needed based on the patient’s result as well as a “resources” tab. Since the application is intended for learners, we included links for users to read more about the tools in the app. We then solicited feedback from colleagues at our institutions.

Successive iterations

Based on the feedback we received, we adjusted both the language and presentation of the tools in the app as necessary to make it self-explanatory for learners.

Launch and Usability

We launched the app in the Apple app store in December 2020 (https://apps.apple.com/us/app/gerikit/id1544200999), and in the Google Play Store in August 2021 (https://play.google.com/store/apps/details?id=com.gerikit.app), and promoted GeriKit on social media and through the American Geriatrics Society virtual forum.

To study the app’s usability, we embedded within the app a validated anonymous survey.⁸ Using a Likert scale (strongly agree to strongly disagree), users can respond to questions about the app and its ease of use, and they have the opportunity to offer open-ended qualitative feedback.

RESULTS

CONTENT

We determined which tools to use in GeriKit by evaluating for ease of use, validity, and effectiveness.

Cognition

There are several well-validated tools that the United States Preventive Services Taskforce (USPSTF) and Centers for Medicare & Medicaid Services (CMS) recommend to help assess cognitive decline in older adults, including the Mini-Mental Status Exam (MMSE), the Montreal Cognitive Assessment (MoCA), the Mini-Cog, and the AD8.⁹ We included two options: one tool to administer to a caregiver and another to administer to a patient.

The AD8 is a brief dementia screening questionnaire that is validated to be administered to both patients and caregivers, though it has been shown to be more accurate when given to caregivers.¹⁰ The Mini-Cog, in contrast, is most useful when a caregiver is not present.¹¹ The Mini-Cog requires the patient to repeat three words, draw the face of a clock with the hands illustrating a pre-specified time, and then recall the original three words. Our version of the Mini-Cog was modified for GeriKit with the expertise of Dr. Soo Borson, who co-created the Mini-Cog.

Depression

Depression screening is a routine part of all geriatric clinical exams. The PHQ2 and PHQ9 are frequently considered the standard of care for evaluating older adults for depression.¹² They are brief, easy to complete, and based on the DSM-5 diagnosis of Major Depressive Disorder.

Function

Screening the patient and caregiver for activities of daily living (ADLs) and independent activities of daily living (IADLs) using validated scales helps learners identify patients’ deficits and allow them to communicate those needs to the interdisciplinary care team.¹³

Strength

Many of the tests involved in assessing strength in older adults require equipment. For example, the handgrip strength test requires a dynamometer, and the Timed Up and Go test requires a stopwatch and a space at least three meters long. Since many clinics lack these resources, we used the 30-Second Chair Stand as our metric for strength, which requires only the presence of a chair.¹⁴ The 30-Second Chair Stand has been shown to be a reliable indicator of lower body strength in older adults when compared to the Timed Up and Go test.^15,16

Nutrition

Evaluation of nutritional status is important in older adults, for whom malnutrition often goes undetected.¹⁷ The Mini Nutrition Assessment (MNA) is considered the gold standard.¹⁸ Because it is a simple questionnaire, it was easily converted with permission from Nestlé Health Science to its form in GeriKit.

Medication

Polypharmacy is defined as the use of five or more medications. If the patient uses more than five medications, the learner is referred to the Beers Criteria, Deprescribing Aid, or the STOPP/START criteria. These validated instruments help the learner better determine which types of medications are less safe for the patient.^19–21

Fall Screening

We modified our fall screening based on the Centers for Disease Control (CDC) STEADI fall prevention initiative screener that is brief and clinically useful.²² If the patient screens positive for falls, there are several next steps that the CDC suggests, including checking orthostatic blood pressure measurements and visual acuity. STEADI also refers the learner to the Beers Criteria and the 30-Second Chair Stand, both of which are incorporated into other parts of our app.

Advance Care Planning

Though advance care planning is important to discuss with all patients, advance care planning documentation requirements vary widely from state to state. Since GeriKit is intended to be used anywhere, we included a link to an advance care planning website, Prepare for Your Care, which gives information specific to all 50 states in the United States.²³

DESIGN

We sought to make the app as user-friendly as possible. The workflow of each tool in GeriKit is the same: the user selects a domain, follows the directions given, clicks the results, and then can view a section with resources about the tool along with suggestions for next steps. We designed the app to be aesthetically pleasing, using large icons and clear instructions. In order to maintain HIPAA compliance, patient information is not stored in the app. The result for each respective assessment is available for the user to view until they return to the app’s home screen.

DISCUSSION

While the population of older adults is increasing, there is a shortage of geriatrics specialists to care for this medically and psychosocially complex group.⁶ We created GeriKit because of the pressing need for all trainees and practicing clinicians to become adept at conducting assessments of complex older patients.

Our guiding principle in creating GeriKit was prioritizing the incorporation of tools that are brief, user friendly, and easily conducted without intensive supervision. Through an iterative development process, our multi-disciplinary team targeted assessment tools that would fulfill this mandate. Our needs assessment of the current mobile health app landscape demonstrated that there is a scarcity of apps that perform this function in assessing older adults, and GeriKit has the potential to train all levels of learners as well as clinicians on conducting these comprehensive assessments.

Although validated tools can be found on various websites and in the medical literature, a mobile app has the potential not only to serve as a repository for this information, but also to offer coaching to the user. This app has the ability to train medical students, residents, and fellows in an efficient and interactive manner. Practicing clinicians and mid-level providers who may not be familiar with geriatrics would benefit from using this app in the outpatient, inpatient, and skilled nursing setting. This app also has the potential to be useful to those practicing outside of geriatrics, internal medicine, and family medicine, such as for those performing preoperative assessments. We promoted the app through the American Geriatrics Society member forum and social media, and have over 3,400 downloads to date. Many of those who downloaded the app work in fields including physical therapy, occupational therapy, and nursing.

Limitations

The app relies on the existence of wireless internet access to use the embedded links, does not save information in a file, and does not integrate with the electronic medical record. In some domains such as medications, we relied on the user to understand how to apply information provided from various sources. Certain domains (delirium assessment and frailty) were not included in the initial version, although our intent is to add them at a later date. Additionally, we used screening tools available in English only.

CONCLUSION

To our knowledge, GeriKit is the first English language geriatric assessment mobile app which is comprehensive, easy to use, and cost-free. Future research on GeriKit will focus on the usability of the app and on its value in training students, residents, and fellows. Our vision is for the app to be useful not only to those training to become internists, family physicians, and geriatricians, but also for those practicing in the allied health professions.

Figure 1:

Screenshot of strength testing using 30-second chair stand