Geriatric Assessment and Functional Status
The comprehensive geriatric assessment
The comprehensive geriatric assessment (CGA) is a multidimensional, team-based process covering medical, functional, cognitive, psychological, social, and environmental domains, followed by an individualized care plan. Evidence supports CGA in improving survival and living circumstances for hospitalized older adults. Questions test whether you screen for function rather than simply cataloging diagnoses.
Function: ADLs and IADLs
Basic activities of daily living (ADLs) - bathing, dressing, toileting, transferring, continence, feeding - reflect physical self-care. Instrumental activities of daily living (IADLs) - managing money, medications, shopping, transportation, cooking, telephone use, housekeeping - reflect the ability to live independently in the community. IADLs are typically lost first in progressive cognitive decline, and among ADLs, bathing is usually lost earliest while feeding is lost last. A key exam trap is documenting only ADLs and missing executive dysfunction revealed by IADL loss (e.g., a patient who pays bills twice or drives unsafely with an intact Katz score).
Screening instruments
Common tools include the Katz ADL index and Lawton IADL scale; the Mini-Cog (three-item recall plus clock drawing) and MoCA for cognition; the 15-item Gerontology Depression Scale; gait speed and the Timed Up and Go for mobility; and the Braden scale for pressure injury risk. Gait speed under 0.8 m/s or a Timed Up and Go over 12 seconds signals elevated fall and functional decline risk.
Traps
Assuming a patient living alone is functionally intact without asking about IADLs; using the MMSE without adjusting for education and language; forgetting sensory screening (hearing and vision) and advance care planning as part of assessment.
Rule of thumb
For any older patient, ask "Who does the cooking, banking, and medications?" A change in the answer is a functional red flag even when examination is reassuring.