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.

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

Step 1: Functional Status Assessment

Activities of Daily Living (ADLs) — Katz Index:

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

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:

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:

Step 4: Polypharmacy and Deprescribing

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

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

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

Step 5: Advance Care Planning and Goals of Care

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

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?

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)

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