Geriatric Assessment Notes

Learning Outcomes

• Identify components of a comprehensive geriatric screening exam.

• Contrast history-taking & physical-exam techniques in older versus younger adults, recognizing how age impacts assessment.

• Adapt the approach to History & Physical (H&P) to accommodate aging-related changes, ensuring patient comfort and accurate data collection.

Concept of “Geriatric”

• Not defined solely by chronologic age—patients may remain vigorous well past traditional retirement age (e.g., centenarian runner Ida Keeling, 100 yrs, showcasing high functional capacity).

• Emphasizes functional status (ability to perform daily activities), physiologic reserve (body's capacity to cope with stress or illness), and individual priorities over a simple age number. This holistic view guides person-centered care.

Attitudes & Core Considerations

• Ask first: “What matters most to me?”—prioritizing patient-centered goals and values in treatment planning.

• Account for heterogeneity: geriatric patients span a wide range from robust and highly functional to frail and dependent, requiring individualized approaches.

• Ethical imperative to avoid ageism (discrimination based on age) and “running from old age” stereotypes, promoting respectful and unbiased care.

Common Geriatric Issues (“Geriatric Giants”)

These are highly prevalent, complex conditions often seen in older adults, significantly impacting their quality of life and healthcare utilization:

• Falls: A leading cause of injury and death in older adults.

• Confusion (delirium/dementia): Cognitive impairment significantly affects independence and safety.

• Incontinence: Often underreported but impacts dignity and social engagement.

• “Phalls” = polypharmacy/iatrogenic disorders: Complications arising from multiple medications or medical interventions.

• Impaired homeostasis: Reduced physiologic reserve leads to rapid decompensation (e.g., with minor infections or dehydration).

Ten-Minute Geriatric Screener (“DEEP IN”)

A quick, systematic approach to identify common geriatric syndromes during a brief encounter:

• Dementia / Depression / Drugs / “Doing it” (sexual history)

– Dementia: Screen for cognitive impairment.

– Depression: Screen for mood disorders.

– Drugs: Review medications for polypharmacy and adverse effects.

– “Doing it” (sexual history): Inquire about sexual activity, concerns, and safety.

• Eyes (functional vision): Assess visual acuity and difficulties.

• Ears (hearing): Assess auditory function. People that don’t hear will are at a higher risk for dementia and depression

• Physical performance & Phalls (falls): Evaluate mobility, balance, and fall risk.

• Incontinence: Screen for urinary or fecal incontinence.

• Nutrition: Assess for malnutrition or significant weight changes. Unintentional weight loss makes it more difficult for them to maintain strength and overall health, potentially leading to increased frailty and the risk of adverse health outcomes.

Cognitive & Mood Screening

Dementia

• Dementia ≠ memory loss only—it is a broader syndrome encompassing progressive declines in executive function, language, praxis (motor planning), visuospatial orientation, and other cognitive domains.

• Screening tools (ordered by depth and time commitment):

– Mini-Cog-decent: Combines a clock draw test and a 3-word recall task . A score of <3 typically suggests cognitive impairment, triggering further evaluation.

– Mini-Mental State Examination (MMSE)-decent: A 30-point questionnaire assessing orientation to time and place, registration (immediate recall), attention and calculation, recall (delayed), language, and drawing. While widely used, it has limitations, particularly for mild cognitive impairment, and is influenced by education level.

– Montreal Cognitive Assessment (MoCA)-better: Designed to be more sensitive for Mild Cognitive Impairment (MCI) and early dementia. It assesses a wider range of cognitive functions. Add 1 point if < 12 yrs education. A normal score is typically ext{26 or greater} /30.

– Neuropsychological evaluation-must screen first: The gold standard for comprehensive cognitive assessment, typically done after a positive screening result from the above tools, providing detailed insights into specific cognitive deficits.

Depression

• 5-item Geriatric Depression Scale (GDS-5): A brief, reliable self-report tool for depression screening in older adults, minimizing somatic complaints.

– Questions: Focus on core affective symptoms like life satisfaction, boredom, helplessness, preference to stay home, and worthlessness, using a yes/no format.

– Scoring: 0–1 = not depressed; 2–5 = probable depression (Sensitivity = 0.97, Specificity = 0.85), indicating a high likelihood of identifying true cases and ruling out false positives. Are you basically satisfied with your life?, Do you get bored easily? Do you often feel helpless in your daily activities? Do you prefer to stay home rather than go out? Do you feel worthless or like you have little to offer?

Delirium vs Dementia vs Depression

Distinguishing these is crucial due to different prognoses and management strategies:

• Delirium: Characterized by an acute onset, fluctuating level of consciousness (LOC), and prominent inattention. Symptoms often worsen in the evenings (sundowning) and can include hallucinations or motor disturbances. It is a medical emergency.

• Dementia: Involves a chronic, typically progressive, decline in cognitive function with a stable diurnal pattern. Memory loss is often initial, followed by other cognitive deficits. It develops slowly over months to years.

• Depression: An episodic mood disorder, where cognitive symptoms (e.g., poor concentration, forgetfulness) are common but often resolve with treatment of the underlying mood disorder. Mornings are often worse due to circadian rhythm disturbances; prominent anhedonia (loss of pleasure), guilt, and vegetative symptoms (e.g., sleep disturbance, appetite changes) are key features.

Medication Review ("Drugz")

• Obtain brown-bag list—ask the patient to bring all prescription (Rx) and over-the-counter (OTC) items, herbals, and supplements they take. This provides the most accurate and complete medication list.

• High-risk flags: Identifying patients at greater risk for adverse drug events or drug interactions based on several criteria:

– Taking >4 prescribed drugs (polypharmacy).

– Benzodiazepine use: Associated with increased fall risk and cognitive impairment in older adults.

– BEERS-criteria medications: Drugs identified by the American Geriatrics Society as potentially inappropriate for older adults due to high risk of adverse effects.

• Consider de-prescribing whenever the risk of a medication outweighs its benefit, aiming to reduce pill burden, adverse effects, and optimize therapeutic outcomes.

Sexual History

• Frequently omitted but essential: Discussion of sexual health and activity is important for overall well-being, quality of life, and safety. Address sexually transmitted infections (STIs), intimacy concerns, erectile/vaginal issues, consent capacity, and safety from abuse or coercion.

Sensory Assessment

Hearing

• Simple query: “Do you need the TV louder than others?” or “Do you have trouble hearing in crowded places?”; observe for lip-reading or use of Live-Listen devices, indicating potential hearing impairment.

• Formal tools: Can include a whispered voice test (screening at a fixed distance), handheld audioscope (for basic pure-tone screening), or referral to audiology for a comprehensive audiogram to determine type and degree of hearing loss.

Vision

• Ask about common age-related eye conditions: Cataract (clouding of the lens), glaucoma (optic nerve damage, often from high intraocular pressure), retinopathy (e.g., diabetic retinopathy), and Age-related Macular Degeneration (AMD).

• Functional question: Inquire about specific difficulties with daily tasks such as driving, reading, watching TV, or performing Activities of Daily Living (ADLs) due to vision.

• If positive ⇒ Administer Snellen chart (for distance acuity) or Jaeger card (for near vision); refer to ophthalmology for definitive diagnosis and management.

Physical Performance & Falls

Functional Assessment

Evaluating functional capacity is paramount in geriatrics:

• Two tiers of functional assessment:

– ADLs (Activities of Daily Living): Basic self-care tasks crucial for independent living. Examples include self-hygiene, dressing, toileting, ambulating (basic mobility), bathing, and feeding oneself.

– IADLs (Instrumental Activities of Daily Living): More complex activities necessary for independent living in the community. Examples include using the phone, managing transportation, shopping for groceries or essentials, preparing meals, light housekeeping, doing laundry, managing medications, and handling finances.

• Timed Up & Go (TUG): A widely used test assessing mobility, balance, and fall risk. The patient stands from a chair, walks 3 meters (10 feet), turns, walks back to the chair, and sits down. A time of <10 is considered normal, while >14 indicative of an increased fall risk.

• 30-Second Chair Stand Test: Measures lower body strength and endurance by counting how many times a person can stand from a chair and sit down without using their arms in 30 seconds. Used as an adjunct.

• 4-Stage Balance Test: Assesses static balance through a series of increasing difficulty stances (feet together, semi-tandem, tandem, single leg stand). Used as an adjunct to identify balance deficits.

Falls Epidemiology

• A significant public health concern: Approximately 1:4 adults > 65 fall each year. Falls are highly multifactorial, stemming from a complex interplay of sensory decline (e.g., vision, proprioception), orthostatic hypotension, polypharmacy (medications affecting balance or consciousness), and various underlying diseases (e.g., Parkinson's, arthritis, neuropathy).

CDC STEADI Algorithm (simplified)

A structured approach for fall prevention, guiding assessment and intervention based on risk level:

• Screen (Stay Independent 4-item questionnaire): Asks about fall history and balance concerns. Any Yes response, or if the patient reports dizziness, vision problems, or difficulty with walking, should trigger gait/strength tests.

• Categorize based on screening and tests:

– No problems → Low Risk: Provide fall prevention education, recommend ext{Vitamin D and Calcium supplementation} (for bone health), and encourage regular exercise (e.g., balance and strength training).

– Gait problem + 0–1 falls → Moderate Risk: In addition to low-risk interventions, conduct a medication review for fall-inducing drugs, and provide a prompt referral for physical therapy (PT) for balance and gait training.

– >2 injury / abnormal gait → High Risk: Requires a comprehensive multifactorial work-up to identify reversible causes (e.g., syncope, arrhythmias). Implement interventions including a PT referral, vision assessment, home safety evaluation (e.g., removal of rugs, grab bars), and close follow-up within 30 days to monitor progress.

Incontinence

• Screening question: “In the last year, have you lost urine on >6 days This simple question can identify many individuals with incontinence, prompting further assessment. Many patients are reluctant to spontaneously report incontinence due to embarrassment or belief it is a normal part of aging.

• SOUP mnemonic: Helps categorize and guide the assessment of urinary incontinence:

– Stress: Leakage with cough, sneeze, laugh (increased intra-abdominal pressure).

– Overflow: Bladder overdistention due to outlet obstruction or detrusor underactivity.

– Urge: Sudden, strong urge to urinate, often with involuntary leakage (overactive bladder).

– Physical/Psychological causes: Other factors like limited mobility, cognitive impairment, or psychological conditions impacting access to toilets or recognition of need.

Nutrition

Assessing nutritional status is vital, as malnutrition can significantly affect health outcomes and recovery from illness in older adults.

• Indicators of nutritional risk:

– BMI (Body Mass Index): Calculate using the formula BMI = rac{weight hinspace (kg)}{height^2 hinspace (m^2)} . Lower BMIs (e.g., < 20-22) can indicate risk.

– Weight < 100 hinspace ext{lb} : A rough but strong predictor, with a Positive Predictive Value (PPV) ≈ 1 for severe malnutrition in certain populations.

– Unintended weight loss: Losing ext{10 lb or more} or ext{5% of body weight} within ext{6 months} without trying can double mortality risk, indicating significant underlying health issues or inadequate intake.

• Geriatric weight-loss mnemonic “DEAD”: Guides the search for causes of unintentional weight loss:

– Drugs: Medications causing anorexia, nausea, altered taste.

– Eating ability: Difficulty chewing, swallowing (dysphagia), dental problems.

– Access to food: Financial constraints, limited mobility, inability to shop or prepare meals.

– Disease: Chronic illnesses (e.g., cancer, heart failure, depression), malabsorption, hyperthyroidism.

Frailty

Concepts

Frailty is a distinct clinical syndrome characterized by increased vulnerability to stressors and adverse outcomes.

• Homeostenosis: An age-related narrowing of physiologic reserve. It describes the reduced capacity of various organ systems to maintain homeostasis under stress, meaning even minor stressors can lead to rapid decompensation and adverse health events (the “precipice”).

• Definitions stress “variable vulnerability” and “reduced reserves to endogenous/exogenous stressors.” Frail individuals have diminished strength, endurance, and physiological function, increasing their risk of disability, dependency, and death.

Adverse Outcomes

Frailty is a strong predictor of poor health outcomes across various settings:

• ext{Increased} hinspace ext{post-operative} hinspace ext{mortality} and complications.

• ext{Higher} hinspace ext{risk} hinspace ext{of} hinspace ext{cardiovascular} hinspace ext{disease} death.

• ext{Increased} hinspace ext{Emergency} hinspace ext{Room} hinspace ext{recidivism} (frequent visits).

• ext{Higher} hinspace ext{risk} hinspace ext{of} hinspace ext{falls} within the community and healthcare settings.

• ext{Increased} hinspace ext{disability} and loss of independence.

• ext{Accelerated} hinspace ext{cognitive} hinspace ext{decline} .

• ext{Higher} hinspace ext{healthcare} hinspace ext{costs} due to increased resource utilization.

Frailty Phenotype (Fried)

This is a widely used research definition of frailty based on five measurable physical characteristics. At least ext{3 of 5 criteria} categorize an individual as frail, while ext{1-2 criteria} indicate pre-frailty (a state of increased risk).

• Criteria:

– Slow gait: Walking time > 6 hinspace ext{seconds} for ext{15 feet} , adjusted for gender and height. Reflects reduced strength and poor balance.

– Weak grip: Low grip strength, measured with a dynamometer, adjusted for gender and BMI. Indicative of overall muscle weakness.

– Low activity: Low weekly caloric expenditure, reflecting reduced physical activity level.

– Self-reported exhaustion: Feeling that everything is an effort or unable to get going (based on specific questions from the CES-D scale).

– Weight loss ext{10 lb} or more / year: Unintended weight loss, indicative of catabolism or inadequate intake.

FRAIL Scale

A simpler, quick screening tool for frailty, often used in clinical settings:

• 1 hinspace ext{point} is given for each positive response to: Fatigue, Resistance (inability to climb one flight of stairs), Ambulation (inability to walk one block), Illness ( > 5 chronic diseases), Loss of weight ( ext{5 lb or more} in the past year).

• Scoring: 0 = robust (not frail); 1–2 = pre-frail; ext{3 or more} = frail. Its simplicity makes it easy to incorporate into routine clinical practice.

Driving

• Evaluate driving ability when there are concerns about cognitive, visual, or motor decline. Driving is a complex IADL that requires intact executive function, rapid reaction time, and good vision. Consider referral for an Occupational Therapy (OT) driving evaluation, which provides objective assessment of driving fitness and recommendations for adaptations or cessation.

General Principles for Geriatric H&P

Adapting the clinical encounter for older adults optimizes information gathering, patient comfort, and accuracy.

Environment

• Optimize the clinical setting: Ensure well-lit conditions (to compensate for age-related vision changes), a warm room (older adults are more sensitive to cold), a quiet environment (to minimize distractions and aid hearing), and non-glare surfaces. Provide safe, height-adjustable exam tables and chairs to facilitate transfers and reduce fall risk.

Communication

• Tailor communication: Face the patient directly (for lip-reading and attention), use a lower-pitched voice (due to common presbycusis affecting high frequencies), speak at a moderate pace, and allow extra processing time for responses. Always include family members or caregivers in discussions with the patient's permission, as they can provide valuable collateral information and support.

Comprehensive Content (“5 Domains”)

Geriatric assessment goes beyond traditional medical history to encompass holistic aspects:

• Medical: Comprehensive Past Medical History (PMH), detailed medication reconciliation, nutritional status, dentition (oral health impact on eating), sensory impairments (vision, hearing), pain assessment, and incontinence evaluation.

• Mental: Assessment of cognition (memory, executive function), mood (depression, anxiety), and spirituality (important for coping and quality of life).

• Physical: Evaluation of functional status (ADLs/IADLs), gait, and balance, identifying limitations and fall risk.

• Environmental: Detailed social history (living situation, support network), financial stability, home hazards assessment, and screening for elder abuse risk.

• Care Preferences: Discussion of patient goals, values, and wishes regarding life-sustaining treatments (e.g., advance directives, DNR orders).

Wheelchair-Bound Exams

• Adherence to ADA (Americans with Disabilities Act) guidelines: Clinicians cannot refuse care to wheelchair-bound patients. Aspects of the exam not requiring a supine position (e.g., head, neck, cardiac auscultation, respiratory exam) may be performed while the patient is seated in their wheelchair. For a full physical examination, including abdominal or lower extremity assessment, practices must provide lift-equipped exam tables to safely transfer and position the patient.

Elder Abuse

• All clinicians are mandated reporters: Healthcare professionals have a legal and ethical obligation to report suspected elder abuse to appropriate authorities (e.g., Adult Protective Services).

Risk Factors

• Factors increasing vulnerability to abuse:

– Cognitive impairment: Reduces ability to report or understand abuse.

– Dependency: Physical or financial reliance on others increases vulnerability.

– Isolation: Lack of social contact makes abuse less likely to be detected.

– Family conflict: High stress or unresolved issues can escalate to abuse.

– Substance abuse: Can impair judgment in both victim and abuser; abuser's substance abuse is a major risk factor.

– Financial stress: Can motivate financial exploitation by caregivers.

Types, Screening Questions & Signs

• Abandonment: Intentional desertion of an elder. Screening question: “Is there anyone you can call if you need help?” Signs: Patient left alone, caregiver absent for extended periods of time, elder lacking necessities.

• Physical: Non-accidental use of force resulting in bodily injury. Screening question: “Has anyone ever hit, slapped, kicked, or otherwise hurt you?” Signs: Unexplained bruises, fractures, burns, bilateral injuries, patient anxiety or fear around a specific caregiver.

• Exploitation: Illegal or improper use of an elder’s funds, property, or assets. Screening question: “Has anyone taken your money or possessions without your permission, or forced you to give them money or sign papers?” Signs: Unpaid bills despite adequate income, missing checks or property, unexplained withdrawals from bank accounts, sudden changes in legal documents (e.g., will).

• Neglect: Failure by a caregiver to provide necessary care. Screening question: “Are you getting enough care, food, water, and medicines?” Signs: Dehydration, malnutrition, pressure ulcers (bedsores), poor personal hygiene (unwashed, soiled clothes), untreated medical conditions, unsafe living conditions.

• Psychological: Infliction of mental or emotional anguish. Screening question: “Has anyone ever yelled at you, threatened you, or made you feel bad about yourself?” Signs: Observed irritability or agitation in the patient, patient fear or social withdrawal in the presence of a specific individual, depression, anxiety, changes in personality or behavior.

Physical-Exam Variants in Healthy Aging

Differentiating normal age-related changes from pathology is essential to avoid over-diagnosis or under-diagnosis.

General

• Heart rate variability decreases; isolated systolic hypertension (elevated systolic with normal diastolic pressure) is common due to stiffening of arteries; decreased lean muscle mass; increased body fat (re-distribution of fat to central areas).

Dermatologic

• Skin becomes thin, dry, and wrinkled with reduced elasticity; common benign lesions include cherry angiomas, seborrheic keratoses, solar lentigines (age spots), and skin tags; nails may become thick and yellow (onychauxis); increased facial hair in women and ear/nose hair in men is common.

HEENOT (Head, Eyes, Ears, Nose, Oral, Throat)

• Thyroid may feel fibrotic or nodular but typically remains euthyroid; decreased tear production (dry eyes); arcus senilis (white/gray ring around the iris) is a common benign finding; increased risk of cataracts (lens opacity), glaucoma (optic nerve damage), and age-related macular degeneration (AMD); presbycusis (age-related high-frequency hearing loss) is universal; decreased smell (hyposmia) and taste (hypogeusia); prominent auricles (ears) and nose due to cartilage growth; dental attrition (worn teeth) and risk of periodontal disease.

Respiratory

• Barrel chest appearance due to changes in thoracic cage; decreased chest expansion; reduced Pulmonary Function Test (PFT) values (e.g., FEV1, vital capacity) due to decreased lung elasticity and strength.

Cardiovascular

• A S4 hinspace ext{heart} hinspace ext{sound} (atrial gallop) is common due to stiffening of the left ventricle; benign flow murmurs (e.g., systolic ejection murmur at the base) are frequent, but there is also an increased prevalence of pathologic murmurs (e.g., aortic stenosis); varicosities (enlarged, twisted veins) are common; dorsalis pedis (DP) and posterior tibial (PT) pulses may be harder to palpate due to arterial changes or edema.

Abdominal

• Abdomen may feel softer from decreased abdominal wall tone and loss of muscle mass.

Musculoskeletal

• Broad-based gait (feet wider apart for stability) is common with age; kyphosis (exaggerated thoracic curvature) and loss of height; osteoarthritis (degenerative joint disease) is nearly universal; increased risk of compression fractures from osteoporosis; always ask about falls and assess gait/balance.

Neurologic

• Processing speed for cognitive tasks is slower; decreased vibration and position sense in the lower extremities; hyporeflexia (reduced deep tendon reflexes) can be a normal finding; a benign essential tremor (bilateral, symmetrical, action tremor) is common; cognition, including memory and executive function, remains largely unchanged in healthy aging, though retrieval speed may slow.

Normal vs Pathologic

• It is crucial to differentiate benign age-related variants (e.g., arcus senilis, scattered solar lentigines, S4 heart sound) from true disease processes (e.g., corneal lipid disorder, melanoma, congestive heart failure). The key is to consider the functional impact of the finding and whether it is progressive or static in nature to determine if intervention is needed.

Inspirational / Social Context

• Images of active elders participating in events like the Senior Games or stories of “trouble-making” grandmas (e.g., advocating for social change) serve to emphasize the potential for high function, continued engagement, and diverse roles that older adults can maintain and