managing-geriatric-assessments

# Managing Geriatric Assessments

Conducts comprehensive geriatric assessment covering cognition, function, falls, polypharmacy, and goals.

## Why This Skill Exists

Adults aged 65 and older represent 17% of the U.S. population but account for 34% of hospitalizations and consume 36% of healthcare spending. The Comprehensive Geriatric Assessment (CGA) is a multidimensional, interdisciplinary diagnostic process that identifies medical, psychosocial, and functional capabilities and limitations to develop a coordinated plan for treatment and follow-up. Meta-analyses demonstrate that CGA reduces mortality, functional decline, and nursing home placement compared to usual care.

Primary care clinicians managing older adults face unique challenges: multimorbidity, polypharmacy (40% of adults ≥65 take ≥5 medications), cognitive impairment (undiagnosed in up to 50% of affected individuals), falls (one-third of adults ≥65 fall annually), and the need for advance care planning. This skill provides a structured CGA framework that addresses the geriatric syndromes and ensures that care is aligned with the patient's functional status, cognitive capacity, and goals of care.

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## Checkpoint A: Pre-Draft Intake (Mandatory)

1. What is the patient's age and primary reason for assessment (routine, post-hospitalization, functional decline, cognitive concern)? **Default: [REQUIRED]**
2. What is the patient's current living situation (independent, assisted living, with family, SNF)? **Default: assess**
3. What is the current medication count and has a Beers Criteria review been performed? **Default: count meds; Beers pending**
4. Has the patient had any falls in the past 12 months? **Default: [REQUIRED]**
5. Is there a concern for cognitive impairment (patient-reported, family-reported, or clinician-observed)? **Default: screen**
6. Has advance care planning been discussed or documented? **Default: review**
7. Does the patient have a caregiver? Is there caregiver burden? **Default: identify and assess**
8. What functional assistance does the patient currently receive (home health, PT/OT, meals on wheels, transportation)? **Default: assess**

### Documents to Request

- Current medication list including OTCs, herbals, and supplements
- Prior cognitive screening results (MMSE, MoCA, Mini-Cog)
- Functional assessment records (ADL/IADL scoring)
- Fall history and any prior fall workup results (orthostatic BPs, gait assessment, imaging)
- Advance directive, POLST/MOLST, healthcare proxy documentation
- Sensory assessments (audiometry, ophthalmology exam)
- Nutritional assessment (MNA-SF or weight trend)
- Caregiver assessment (Zarit Burden Interview if applicable)
- Home safety evaluation report if available
- Specialist consultation notes relevant to geriatric management

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## Step 1: Functional Status Assessment

**Activities of Daily Living (ADLs) — Katz Index:**

| ADL | Independent | Needs Assistance | Dependent |
|---|---|---|---|
| Bathing | Self-bathes completely | Needs help with one body part | Unable to bathe self |
| Dressing | Gets clothes and dresses without help | Needs help tying shoes or buttons | Unable to dress self |
| Toileting | Goes to toilet, manages clothes, cleans self | Needs some help | Unable to manage toileting |
| Transferring | Moves in/out of bed and chair unassisted | Needs some help | Unable to transfer |
| Continence | Full control of bladder and bowel | Occasional accidents | Frequent incontinence |
| Feeding | Feeds self without assistance | Needs help cutting food or preparing | Unable to feed self |

**Instrumental Activities of Daily Living (IADLs) — Lawton-Brody Scale:**

| IADL | Independent | Needs Assistance | Unable |
|---|---|---|---|
| Telephone use | Uses phone independently | Can answer but not dial | Cannot use phone |
| Shopping | Shops independently | Needs someone to go with | Cannot shop |
| Food preparation | Plans and prepares meals | Can heat prepared foods | Cannot prepare meals |
| Housekeeping | Maintains house independently | Needs help with heavy tasks | Cannot maintain house |
| Laundry | Does laundry completely | Can do light laundry | Cannot do laundry |
| Transportation | Drives or travels independently | Arranges own travel with help | Cannot travel without assistance |
| Medication management | Takes medications correctly | Needs reminders or preparation | Cannot manage medications |
| Finances | Manages finances independently | Needs help with banking | Cannot manage money |

**Scoring interpretation:** IADL loss typically precedes ADL loss and is an early marker of functional decline. Any new IADL dependency warrants investigation for cognitive impairment, depression, or new medical condition.

---

## Step 2: Cognitive Assessment

Administer a validated screening tool:

| Tool | Time | Score Range | Positive Screen | Strengths |
|---|---|---|---|---|
| Mini-Cog | 3 minutes | 0-5 | ≤2 | Quick; minimal education bias |
| MoCA (Montreal Cognitive Assessment) | 10-15 minutes | 0-30 | <26 (adjust +1 if education ≤12 years) | Sensitive for MCI; tests executive function |
| MMSE (Mini-Mental State Exam) | 10 minutes | 0-30 | <24 | Historical standard; less sensitive for MCI |
| SLUMS (Saint Louis University Mental Status) | 7 minutes | 0-30 | <27 (HS education); <25 (less than HS) | Free; good sensitivity |

**If screen is positive:**
1. Assess for reversible causes: TSH, B12, folate, BMP, CBC, RPR/VDRL, urinalysis, depression (PHQ-9)
2. Obtain brain MRI (or CT if MRI contraindicated) to evaluate for structural pathology
3. Assess for delirium (CAM — Confusion Assessment Method) if acute change
4. Consider neuropsychological testing for diagnostic confirmation
5. Classify: Mild Cognitive Impairment (MCI) vs. dementia (Alzheimer's, vascular, Lewy body, frontotemporal)
6. Document functional impact: MCI = preserved IADLs; dementia = impaired IADLs/ADLs

**Driving safety:** If cognitive impairment identified, assess driving safety; refer to OT driving evaluation if uncertain. Document discussion and recommendation in chart.

---

## Step 3: Fall Risk Assessment and Prevention

**Screening:** Ask all patients ≥65 at every visit:
- "Have you fallen in the past 12 months?"
- "Do you feel unsteady when standing or walking?"
- "Are you worried about falling?"

**If ANY positive response, perform multifactorial fall risk assessment:**

| Risk Factor | Assessment Tool | Intervention |
|---|---|---|
| Gait and balance | Timed Up and Go (TUG) ≥12 seconds = elevated risk; 30-second chair stand | Physical therapy referral; balance training (tai chi) |
| Orthostatic hypotension | Supine → standing BP at 1 and 3 minutes; positive if SBP drop ≥20 or DBP drop ≥10 | Medication review; compression stockings; adequate hydration |
| Medications | Review for fall-risk medications: benzodiazepines, opioids, anticholinergics, antihypertensives, SSRIs | Deprescribe per Beers Criteria; reduce sedatives |
| Vision | Snellen chart; last ophthalmology exam | Refer ophthalmology; update prescription; cataract evaluation |
| Footwear | Assess shoes for fit, stability, non-slip soles | Recommend supportive, low-heeled footwear |
| Home hazards | Home safety checklist (loose rugs, poor lighting, grab bars, stairs) | OT home evaluation; modifications |
| Vitamin D | 25-OH vitamin D level | Supplement to ≥30 ng/mL; 800-1000 IU daily minimum |
| Osteoporosis | DXA if indicated; FRAX calculation | Treat per osteoporosis protocol |

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## Step 4: Polypharmacy and Deprescribing

**Polypharmacy definition:** ≥5 concurrent medications (hyperpolypharmacy: ≥10)

**Beers Criteria (AGS, updated 2023) — Medications to AVOID in adults ≥65:**

| Category | Medications to Avoid | Rationale |
|---|---|---|
| Anticholinergics | Diphenhydramine, hydroxyzine, chlorpheniramine, oxybutynin, paroxetine | Cognitive impairment, delirium, falls, constipation, urinary retention |
| Benzodiazepines | Diazepam, lorazepam, alprazolam, clonazepam | Falls, fractures, cognitive impairment, delirium |
| Non-benzodiazepine hypnotics | Zolpidem, zaleplon, eszopiclone | Falls, delirium; limited efficacy in elderly |
| First-generation antipsychotics | Haloperidol (long-term), chlorpromazine | Falls, EPS, cognitive decline; black box for dementia |
| NSAIDs (chronic) | Ibuprofen, naproxen, diclofenac | GI bleeding, renal impairment, CVD risk, HTN |
| Sulfonylureas (long-acting) | Glyburide | Prolonged hypoglycemia |
| Muscle relaxants | Cyclobenzaprine, methocarbamol, metaxalone | Sedation, falls, anticholinergic effects |
| PPIs (chronic, >8 weeks without indication) | Omeprazole, pantoprazole | C. diff risk, osteoporosis, hypomagnesemia |

**Deprescribing protocol:**
1. List all medications and indication for each
2. Flag Beers Criteria medications, duplications, and drugs without clear indication
3. Prioritize: deprescribe highest-risk medications first (anticholinergics, benzodiazepines)
4. Taper (do not abruptly stop benzodiazepines, SSRIs, opioids, beta-blockers, corticosteroids)
5. Monitor after each medication change (2-4 week follow-up)
6. Document deprescribing rationale and patient agreement

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## Step 5: Advance Care Planning and Goals of Care

| Component | Action | Documentation |
|---|---|---|
| Healthcare proxy | Identify designated decision-maker | Name, relationship, contact information in chart |
| Advance directive | Review or facilitate completion | Copy in chart; distribute to hospital, family |
| POLST/MOLST | Complete if serious illness, life-limiting condition, or patient preference | Signed by patient and provider; actionable in emergency |
| Goals of care discussion | What matters most to the patient (independence, comfort, longevity) | Narrative note with patient's own words |
| Code status | Full code, DNR, DNI, comfort care only | Documented and communicated to all care teams |
| Palliative care referral | If serious illness with symptom burden or prognostic uncertainty | Place referral; does not require hospice eligibility |
| Hospice evaluation | If prognosis ≤6 months and patient/family preferences align | Hospice agency referral; continued PCP involvement |

Document: who participated, what was discussed, decisions made, and follow-up plan. Bill ACP time under 99497/99498 if ≥16 minutes spent.

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## Checkpoint B: Post-Draft Alignment (Mandatory)

1. Are ADLs and IADLs quantified with validated instruments (Katz Index, Lawton-Brody)?
2. Has cognitive screening been performed with a validated tool and result documented?
3. Has fall risk been assessed with multifactorial interventions planned?
4. Has a Beers Criteria review been completed with deprescribing plan documented?
5. Has advance care planning been addressed with specific documents identified or completed?

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## Quality Audit

- [ ] Functional status assessed with Katz ADL Index and Lawton-Brody IADL Scale
- [ ] Cognitive screening performed with validated tool (Mini-Cog, MoCA, or MMSE) and score documented
- [ ] Reversible causes of cognitive impairment screened (TSH, B12, depression, medication effects)
- [ ] Fall screening performed at every visit (3-question screen)
- [ ] Fall risk assessment multifactorial if positive screen (gait, orthostatic BP, medications, vision, home safety)
- [ ] Timed Up and Go performed with result documented
- [ ] Medication list reviewed against Beers Criteria with findings documented
- [ ] Polypharmacy addressed with deprescribing plan (specific medications targeted, taper schedule)
- [ ] Advance care planning discussed or offered with specific documents identified
- [ ] Healthcare proxy identified and documented in chart
- [ ] Nutritional status assessed (MNA-SF score or weight trend)
- [ ] Sensory assessment (vision and hearing) performed or referred
- [ ] Social support and caregiver burden evaluated
- [ ] Driving safety assessed if cognitive impairment identified
- [ ] Immunizations current (influenza, pneumococcal PCV20, Shingrix, COVID-19, Tdap)

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## Guidelines

- Never apply standard adult disease targets (A1c <7%, BP <130/80, LDL <70) to frail elderly without considering life expectancy, functional status, and treatment burden; over-treatment causes more harm than under-treatment in this population
- The Beers Criteria is a screening tool, not an absolute prohibition list; some Beers medications may be appropriate for individual patients with documented rationale
- Anticholinergic burden is cumulative and dose-dependent; assess total anticholinergic load, not just individual medications
- Benzodiazepine taper must be gradual (reduce by 10-25% every 2-4 weeks); abrupt discontinuation can cause seizures, especially in long-term users
- Fall prevention requires multimodal intervention; single interventions (e.g., vitamin D alone) are less effective than combined approaches (exercise + medication review + home modification)
- Cognitive screening is not the same as diagnosis; a positive screen requires diagnostic evaluation including reversible cause workup and functional assessment
- Goals of care conversations should be revisited at least annually and after any significant health event (hospitalization, new diagnosis, functional decline)
- Caregiver burden is a geriatric syndrome in itself; screen caregivers for depression and burnout using the Zarit Burden Interview or similar tool