Health Screening Promotion Older Adult and Elderly
Minimum Data Set (MDS) 3.0 Overview
The Minimum Data Set (MDS) 3.0 is part of a federally mandated process for clinical assessment of all residents in facilities eligible for Medicare or Medicaid funding, including long-term care facilities (LTCFs), skilled nursing facilities (SNFs), and swing beds (hospital beds that can be used for either acute or SNF care).
The MDS is a standardized assessment tool that measures each resident’s functional capabilities and health needs, including physical, mental, psychosocial, and functional status.
It is one of the three components of the Resident Assessment Instrument (RAI). The other two components are the Care Area Assessment (CAA) process and the Utilization Guidelines.
The completed RAI yields information about the resident’s functional status, strengths, weaknesses, and preferences.
The MDS was developed in response to the Omnibus Budget Reconciliation Act of 1987 (OBRA-87).
The MDS manual defines a “physician” as a medical doctor (MD), doctor of osteopathy (DO), nurse practitioner (NP), physician assistant (PA), or clinical nurse specialist (CNS).
The MDS forms must be started within 48 hours after a new resident’s admission.
MDS assessments are required on admission, quarterly, annually, at the time of any significant change or correction, and at discharge.
The MDS results (as well as all Medicare and Medicaid bills) must be submitted electronically to Medicare or Medicaid through a secure broadband connection.
For resident transfers, the transferring facility must provide the new facility with necessary medical records, including appropriate MDS assessments, to support continuity of resident care.
Resident Assessment Instrument Items
OBRA rules require Medicare- and Medicaid-certified nursing homes to conduct initial admission and periodic assessments for all residents:
Diagnosis and health/medical history: RNs perform intake and comprehensive history.
Medications (including over-the-counter [OTC] drugs): Obtain record/history of current prescriptions. RN will obtain admitting orders and the necessary prescriptions from the attending physician.
“Brown bag” review for polypharmacy (including herbs, alternative therapies): Ask patient or family to bring all medications, vitamins, and other alternative medicines in a “brown bag.”
Cognition: Use Mini-Cog, Mini-Mental State Examination (MMSE), clock-drawing test. Look for signs of dementia, depression, bipolar disorder, and stroke.
Behaviors: Use behavioral assessment tool. Assess if combative, confused, demented, or experiencing sundown syndrome. Check for wandering history (aimless walking, leaving facility without permission).
Communication: Document whether patient is able to communicate, confused, aphasic, any history of stroke.
Hearing, speech, and vision: Check hearing, vision, use of prescription glasses, use of hearing aid. Perform neurologic exam.
Oral/nutritional evaluation (dietician and nurse): Check for missing teeth, dentures, oral ulcers from poor-fitting dentures, anorexia, dysphagia, weight loss, BMI. Document if patient can swallow solids, can feed self, or requires special equipment. See the “Nutritional Assessment” section.
Activities: Interview patient and/or family about routine and favorite activities.
Preferences for customary routine and activities: Obtain information regarding the resident’s preferences for daily routine.
Advance directives: If patient has an advance directive, obtain a copy (check for do-not-resuscitate [DNR] orders). If resident has dementia, ask family whether one is on file.
Elimination of bowel or bladder: Gather information about urinary and bowel continence, bowel patterns, use and response to bowel training/toileting programs.
Skin conditions: Document the risk, presence, appearance, and change of pressure injuries, wounds/lesions, treatment related to skin injury.
Special treatments, procedures, or programs: Identify any special treatments, procedures, and programs that the resident received during specified time periods.
Participation in goal setting: Record the participation of the resident, family, and/or significant others in the assessment to understand the resident’s overall goals.
Restraints: Record frequency that the resident is restrained by any type of device at any time during the day and night.
Assessment of Functional Status: Activities of Daily Living (ADL)
Self-care activities necessary for “independent” living depending on environment (e.g., home, retirement community, nursing home).
Basic activities of daily living (ADL): Eating (self-feeding), personal hygiene (brushing teeth, bathing), ambulation (walking, wheelchairs), bowel and bladder management.
Intermediate ADL (IADL): Shopping and preparing meals, housework, using electronics (stoves, telephones, television), managing finances, driving a car.
Advanced ADL (AADL): Fulfilling multiple roles (spouse, parent, caretaker) while also participating in recreational or occupational tasks.
Assessment of Functional Status: Katz Index of Independence in Activities of Daily Living
Measure used to assess an older adult’s independence.
Contains six items. Each item scored 1 for independence (no supervision/direction/personal assistance) or 0 for dependence.
Highest possible score: 6 (independent); lowest: 0 (very dependent).
Katz ADL items (examples): Bathing, Dressing, Toileting, Transferring, Continence, Feeding.
Assessment of Functional Status: Lawton Instrumental Activities of Daily Living (IADL) Scale
Measure used to assess independence; identifies current functioning and potential changes over time.
Contains eight categories, more complex than Katz.
Scoring: based on highest level of functioning in each category; summary score ranges from 0 (low function, dependent) to 8 (high function, independent).
Categories:
Ability to use telephone
Shopping
Food preparation
Housekeeping
Laundry
Mode of transportation
Responsibility for own medications
Ability to handle finances
Assessment of Functional Status: Fried Physical Frailty Phenotype
Five criteria:
Weight loss: >10 ext{ lb} \ ([4.53 ext{ kg}])
Weakness: measured by grip strength (digital hand dynamometer)
Exhaustion: self-report
Slow walking speed: = 15 \text{ ft} \ (4.57 \text{ m})
Low physical activity: in kcal/week
Classification:
1-2 criteria: “intermediate” frailty
3+ criteria: “frail”
Falls and Fall Risk
Falls and fall injuries include soft-tissue injuries, head injuries, fractures, and lacerations.
Majority of hip fractures are due to falls.
Higher risk in white women; elderly have higher mortality from falls/related complications; deaths occur mainly in those ≥65 years.
Risk factors:
Past fall history
Difficulty walking or balancing
Lower-extremity weakness or arthritis
Frailty and age >75
Female sex
History of stroke
Orthostatic hypotension
Adverse medication effects; polypharmacy (≥4 drugs); psychotropic drugs
Dementia/cognitive impairment; chronic illness
Poor eyesight/hearing; poor night vision
Home hazards: area rugs, poorly fitting shoes/slippers, poor lighting; living alone
Fall assessment components:
Medications: polypharmacy; sedating meds; anticholinergic burden; beta-blockers; antidepressants
Gait, balance, mobility: Get Up and Go test; functional reach test; PT referral for in-depth assessment
Muscle strength: handgrip strength; ability to bear weight; chair-to-bed transfer
Visual acuity: use of glasses; cataracts; glaucoma history
Hearing: whisper test or audiometer; CN VIII involvement
Heart rate and rhythm: arrhythmias; ECG; CAD/MI history
Postural hypotension: medications causing hypotension (antihypertensives)
Feet and footwear: foot problems; diabetes; footwear fit; wide shoes; slip-resistant soles
Factors that decrease fall risks:
Proper lighting; nightlights; accessible bedside lamp
Regular weight-bearing and leg-strengthening exercises; gait training as needed
Tai chi for balance and strength
Adequate nutrition and hydration; calcium and vitamin D; annual eye exams
Brown bag medication and vitamin review with provider
Proper-fitting, non-slip shoes; removal of home hazards; secure rugs
Adaptive equipment:
Bathing/toilet safety: elevated toilet seats; grab bars; shower chairs
Walking/other equipment: PT evaluation; cane/walker recommendations; durable medical equipment coverage (often up to 80% by Medicare/Medicaid/other plans)
Cane types: regular, foldable, quad-foot; cane length measured by arm drop; ensure rubber feet are intact; replace as needed
Walker types: foldable/nonfoldable; with/without casters
Wheelchairs and scooters: various styles; scooters up to ~300 lb; higher cost
Safety note for cane technique: hold cane in the opposite side of the weaker leg; "up with the good, down with the bad"
Vision: Legal blindness defined as best corrected visual field of 20/200 or less in the better eye; common elderly eye conditions include age-related macular degeneration (AMD), primary open-angle glaucoma, cataract, diabetic retinopathy, temporal arteritis; signs of vision loss include eye dominance, bumping into objects, hesitant steps, head tilting, reading difficulties; oculotoxic medications listed below; visual aids listed later.
Oculotoxic Medications (vision):
Sildenafil (Viagra): bluish vision; ischemic optic neuropathy
Anticholinergics: may precipitate acute-angle glaucoma
Diuretics and calcium channel blockers: may affect glaucoma progression
Alpha-blockers: may affect risk during cataract surgery
Bisphosphonates: orbital inflammation, uveitis, scleritis
Visual Aids: Magnifiers (handheld/binoculars), electronic magnifiers, computer magnifiers, talking watches, large-print devices, and devices with large buttons
Hearing: Involves brain, CN VIII, inner/middle/external ear
Sensorineural hearing loss: inner ear/vestibulocochlear nerve; presbycusis is age-related sensorineural hearing loss; typically symmetric and high-frequency loss
Signs of hearing loss: volume keeps increasing; difficulty understanding speech in noise; asking for repetition; trouble on the phone; tinnitus; dizziness
Risk factors for hearing loss: chronic tinnitus, older age, ototoxic meds, loud noise exposure, comorbidities (diabetes, neurologic disorders)
Ototoxic Medications (hearing):
Aminoglycosides (e.g., gentamicin), vancomycin; macrolides (e.g., erythromycin); higher risk with kidney disease
NSAIDs/aspirin/salicylates; phosphodiesterase-5 inhibitors (sildenafil, tadalafil, vardenafil)
Loop diuretics (furosemide); many chemotherapeutics (cisplatin has highest incidence)
Hearing Evaluation and Tests:
External ear and tympanic membrane exam; remove cerumen if TM view obstructed; perform hearing tests; look for cone of light, retraction, bulging TM, erythema
Gold standard: Diagnostic audiometry in a soundproof booth by a professional audiologist
Weber Test: determine lateralization; normal hear both ears equally; lateralization to the good ear suggests sensorineural loss, to the bad ear suggests conductive loss; cerumen occlusion may lateralize to the bad ear
Rinne Test: AC > BC in normal; if BC > AC, suggests conductive loss; Weber test consistency also used
Whispered Voice Test: stand ~2 ft behind patient; occlude one ear; whisper alphabet/ numbers; testing alternatives include rubbing hair near ear; accuracy varies
Tympanogram: flat line or reduced peak indicates poor TM mobility (otitis media or cerumen)
New technology: handheld otoscope with built-in screening audiometer (AudioScope) or tablet-based audiometry apps
Nutritional Assessment: MyPlate and Dietary Guidelines
MyPlate recommendations (USDA): educate patients via MyPlate materials (handouts and apps)
Daily guidelines:
Water: 8 glasses/day unless contraindicated (e.g., heart failure)
Exercise: at least 150 minutes/week (30 minutes, 5 days/week) if not contraindicated
Protein: seafood twice a week; cold-water fish preferred (omega-3 fatty acids); vegan alternative: flaxseed oil
Reduce: solid fats and added sugars; avoid high-sugar alcohols; be mindful of GI effects of sugar alcohols
Eat a variety of colorful fruits and vegetables
Sodium: limit to less than 3 g/day
See Lesson: Table 5.1 Dietary Guidelines for Americans (Adapted for Age 50+) for age-50+ guidelines
Caloric requirements per day for adults >50 years
Women: not less than 1200 calories/day; not physically active 1{,}600; moderately active 1{,}800; active 2{,}000-2{,}200
Men: not less than 1500 calories/day; not physically active 2{,}000-2{,}200; moderately active 2{,}200-2{,}400; active 2{,}400-2{,}800
Dietary Guidelines for Americans (Adapted for Age 50+)
Vegetables: 2–3 cups/day; include a variety of colors
Fruits: 1½–2 cups/day; ½ cup 100% fruit juice counts as 1 serving
Grains: 5–8 ounces/day; whole grains preferred; gluten considerations if needed
Proteins: 5–6½ ounces/day; includes vegetarian options (egg, beans/tofu, peanut butter, nuts/seeds)
Dairy: 3 cups/day of low-fat milk; 1 cup milk ≈ 2 oz cheese or 1 cup yogurt
Seafood: 8–10 ounces/week; prefer sardines/small fish, salmon
Oils: 5–8 teaspoons/day (olive, canola, flaxseed, nuts, avocado)
Solid fats: limit; avoid lard and animal fats
Nutritional Issues in Older Adults
Conduct comprehensive dietary/history and anthropometric measurements
Clinically significant weight loss (MDS criteria):
Weight loss of 5 ext{%} of usual body weight in 30 days OR weight loss of ext{≥}10 ext{ extperthousand} of usual body weight in 180 days (6 months). Edema/fluid retention can mask malnutrition.
History: past medical health history; preferred foods, appetite patterns, snacking, fluid intake; unintentional weight loss
Malnutrition risk factors: decreased taste/appetite/swallowing; poor dentition; food insecurity; adverse meds; depression; dementia; social isolation
Screening tools: Serial body weight; bioelectrical impedance for fat/lean mass; arm circumference; food diary; refer to dietitian when indicated
Questionnaires: Mini Nutritional Assessment–Short Form (MNA-SF): 6 questions; Simplified Nutrition Assessment Questionnaire: 4 items; sensitivity ~88 ext{%}, specificity ~84 ext{%} for LTC residents
Unintentional Weight Loss and Failure to Thrive in Elders
Defined as >5 ext{%} weight loss in the past 30 days or >10 ext{%} in the past 180 days
Assess dental health, gum disease, missing teeth, dentures, oral ulcers
Rule out underlying medical diagnoses such as major depression, anemia, hypothyroidism
Laboratory Testing for Nutritional Assessment
Prealbumin: hepatic protein; sensitive for malnutrition; high-risk patients may be tested 1–2× per week
Albumin: decreased levels associated with higher mortality
CBC: check for iron-deficiency anemia
Folate and vitamin B12: assess deficiency and macrocytic anemia
Vitamin D: many elderly are deficient; may need supplementation
TSH: rule out thyroid disease; hypothyroidism more common in elderly (esp. females)
Anthropometric Measurements
Waist-to-hip ratio (WHR): women > 0.8 and men > 1.0 indicate abdominal obesity and higher cardiometabolic risk
BMI: overweight 25.0-29.9; obesity ext{≥}30; BMI 25–27 associated with lower mortality in elderly than BMI <25
Handgrip Strength
Indicator of functional status; weak grip associated with malnutrition; severe malnutrition linked to very weak grip
Nutritional Interventions for Community-Dwelling Older Adults
Assess need for assistance with grocery shopping, cooking, and feeding
Companionship can improve nutrition; assess for depression; leverage community resources (e.g., YMCA)
SNAP (Supplemental Nutrition Assistance Program) and Medicaid eligibility as available
Meals on Wheels programs deliver meals 2–3 times daily
Nutritional Interventions for Long-Term Care Residents
Correct factors adversely affecting oral intake if possible; refer to dietitian for evaluation
Dietitian calculates basal energy and caloric needs; consider high-calorie supplements
Consider multivitamin and calcium with vitamin D (e.g., 1,200 mg/day)
Review prescriptions and OTC meds for anorexia-causing effects
Encourage meals in dining room to reduce isolation; assess for depression and consider appetite-stimulating antidepressants (e.g., mirtazapine) if appropriate
Check for dentures during meals; offer food variety and snacks; monitor fluid intake; water preferred; daytime hydration recommended to minimize nocturia
Specialized Diets
Clear Liquid/Full Liquid (short-term, 2–3 days, without supplementation)
Mechanical Soft (Pureed) Diet for chewing/swallowing problems
Soft Diet: suitable for chewing/swallowing issues or GI irritation; examples include milk/dairy, soft lean meats; avoid seeds/nuts/dried fruits/hard/crunchy foods
Low Residue (Low Fiber) Diet: for GI issues or post-surgery; avoid high-fiber foods
Renal Diet: fluid restriction; possible low-protein; limit potassium, phosphorus, and sodium; consult renal dietitian
Hepatic Diet: restrict protein to reduce ammonia; high in carbohydrates; moderate fat; B-complex vitamins; avoid excess meats and salt
Enteral Feeding
For terminal illness or failure to thrive with intact GI tract; consider tube feeding if feasible
Initial routes: orogastric or nasogastric
Placement confirmed by chest radiograph; check tube position before every feed by aspirating stomach contents
NG tube placement complications: pneumothorax, perforations, empyema, bronchopleural fistula, aspiration pneumonia
New technology: AudioScope and tablet-based enteral screening tools can assist
Nutrition Terms
Anorexia: loss of appetite with many causes (dementia, meds, taste/smell changes, depression)
Cachexia: multifactorial metabolic disorder with illness; associated with higher fall risk; check serum albumin (low)
Sarcopenia: loss of muscle mass, strength, performance; causes include low hormones, immobility, poor activity, low protein; higher risk of falls and functional decline
Satiety: feeling of fullness after meals; early satiety or dysphagia with weight loss warrants GI evaluation
Disease Prevention and Health Maintenance
Regular, balanced, moderate exercise reduces major disability risk in the elderly and is tied to health maintenance; annual health maintenance visits emphasize preventive care
Medicare spending tends to be higher for individuals with four or more chronic conditions
Healthy People 2030 focuses on reducing health problems and improving quality of life for older adults; key indicators include:
Access to health services and preventive services: routine vision and hearing screenings; better blood pressure and HbA1c control; cholesterol checks; influenza and pneumonia vaccines; cancer screenings (mammography, colorectal cancer)
Injury and violence prevention: fall prevention programs (e.g., A Matter of Balance, Stepping On, Tai Ji Quan: Moving for Better Balance); hip fracture prevention; disability prevention
Mental health: identify mental health disorders impacting physical health; dementia prevention/treatment options; nutrition and physical activity emphasis
Nutrition and physical activity goals include increasing fresh foods, increasing aerobic activity (150 minutes/week with allowance for abilities), increasing resistance training, and reducing obesity
Substance/tobacco use: reduce binge drinking; reduce tobacco use
USPSTF Clinical Preventive Services for Older Adults (Immunizations and Screenings)
Immunizations (examples):
COVID-19: Moderna, Pfizer, BioNTech; primary series 2 doses at 0 and 3–8 weeks, plus booster; administer as per current guidance
Influenza: inactivated quadrivalent and trivalent vaccines (e.g., Fluzone High-Dose, FLUAD); annual fall/winter IM administration; approved for those 65+ years
Tetanus, Diphtheria, and Acellular Pertussis (Tdap) or Td: booster every 10 years; Tdap or Td; administer after wound if last booster ≥5 years ago
Herpes Zoster (Shingrix): indicated for adults ≥50 years; two doses separated by 2–6 months; highly effective in preventing shingles and PHN; contraindicated with severe vaccine component allergy or active shingles; not for pregnancy
Pneumococcal Vaccines: one dose PCV15 or one dose PCV20; if PCV15 used, follow with PPSV23 at least 1 year later; if PPSV23 given first, wait at least 1 year before PCV13 (Prevnar) when applicable; if PPSV23 given before age 65, booster after 5 years
Measles, Mumps, and Rubella (MMR): adults born before 1957 are generally considered immune
Other USPSTF recommendations for older adults (selected)
Abdominal Aortic Aneurysm (AAA) screening: one-time ultrasound for men 65–75 who have ever smoked
Abnormal Blood Glucose: screen overweight/obese adults 40–70
Alcohol and Drug Misuse: screen and provide brief counseling or referral as needed
Aspirin for primary prevention of CVD and colorectal cancer: low-dose aspirin for adults 50–59 with 10-year CVD risk ≥10% and no bleeding risk, with life expectancy >10 years; individualize for 60–69
Blood Pressure: confirm diagnosis with measurements inside and outside clinical settings before treatment
Breast Cancer: biennial mammography 50–74
BRCA risk assessment: assess family history; refer for counseling/testing as indicated
Colorectal Cancer: screen ages 45–75 with colonoscopy, sigmoidoscopy, or high-sensitivity FOBT
Depression: screen with appropriate systems for accurate diagnosis, treatment, and follow-up
Falls Prevention: exercise/physical therapy and falls-prevention programs for at-risk community-dwelling adults 65+
Hepatitis C: screen adults 18–79 years without known liver disease
Lung Cancer: annual low-dose CT for current or former smokers 55–80 with ≥30 pack-year history who quit within 15 years
Osteoporosis: bone density testing for women ≥65 or younger with fracture risk equal to or greater than 65
Statins: consider low-to-moderate-dose statin for adults 40–75 with ≥1 risk factor and 10-year ASCVD risk ≥10%
Immunizations and Vaccination Details for Older Adults
Abbreviated immunization schedule notes:
Abbreviated vaccine lists include: HPV, hepatitis B, and others as per guidelines; the document focuses on older adult priority vaccines
Measles, Mumps, and Rubella (MMR) immune status noted for those born before 1957
Pneumococcal vaccines sequencing recap:
If PCV15 or PCV20 used: follow with PPSV23 after at least 1 year
If PPSV23 given first, wait at least 1 year before PCV13 if indicated; prior PPSV23 booster timing may apply if administered before age 65
Flu, shingles, tetanus, and COVID vaccines special notes:
Shingrix (Shingles) requires two doses; protection against shingles and postherpetic neuralgia is high
Flu vaccines should be given annually; high-dose formulations may be preferred for those ≥65
Td/Tdap boosters every 10 years and after certain wound exposures
COVID-19 vaccines: updated recommendations may adjust intervals and boosters; the document notes 2-dose primary series with a booster
Additional Immunization Details and Special Considerations
Special vaccine highlights:
Pneumococcal vaccines: PCV15/PCV20; PPSV23 timing; sequence with PPSV23 if PCV is given first; boosters considered based on age and risk
Influenza vaccine considerations for egg allergy: if only hives, vaccine acceptable; severe egg allergy may require special handling
Shingrix efficacy: 97% in 50–69, 91% in 70+; protects against PHN ~90%
Abbreviated age-based recommendations emphasize high-risk groups and comorbidity considerations
Key Definitions and Quick References
Legal blindness: best corrected visual field ≤ 20/200 in the better eye
Obra-87: key regulatory framework that shaped the MDS
MDS thresholds for weight loss and frailty anchored to percent changes or specific metric cutoffs as noted above
Common acronyms:
MDS: Minimum Data Set
RAI: Resident Assessment Instrument
CAA: Care Area Assessment
FDA/USPSTF: U.S. Preventive Services Task Force
If you would like, I can reorganize these notes into a printable one-page crib sheet or tailor a version focused on sections most likely to appear on your exam. Also, I can add a concise glossary of terms or flashcard-style Q&A at the end.