managing-geriatric-assessments

name	managing-geriatric-assessments
description	Conducts comprehensive geriatric assessment covering cognition, function, falls, polypharmacy, and goals. Use when evaluating elderly patients, performing geriatric assessments, or managing complex older adults.
tags	["management","primary-care","patient-care"]
metadata	{"author":"casemark","practice_areas":["Family Medicine","Internal Medicine","Primary Care"],"document_types":["Management Report"],"skill_modes":["Management","Coordination"]}

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.

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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.

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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