Examination, Evaluation, Diagnosis, and Prognosis in Older Adults
What the candidate must understand
Examination is layered: history (including collateral report and medication review), systems review, and then targeted tests. Know the performance-based measures and their properties: gait speed (usual and fast), Short Physical Performance Battery, Timed Up and Go and its cognitive dual-task variant, 30-second chair stand, 6-minute walk, Berg Balance Scale, Dynamic Gait Index, and the 4-stage balance test. Know cognitive screens (Mini-Cog, MoCA), depression (PHQ-9, Geriatric Depression Scale), and function (Katz ADL, Lawton IADL). Know that grip strength and gait speed are single-item frailty markers.
Prognosis is anchored in reserve. Gait speed under 0.8 m/s signals elevated risk; under 0.6 m/s signals high risk in hospitalized or frail populations. Slow chair stand and low grip strength predict functional decline and mortality independent of comorbidity.
Traps
- Using a screening tool as a diagnosis (Mini-Cog flags, it does not diagnose dementia).
- Confusing ceiling effects: Berg is weak for high-level community ambulators; the Dynamic Gait Index and Functional Gait Assessment are better there.
- Forgetting to test dual-task performance, which reveals fall risk that single-task gait misses.
- Treating a screening cutoff as absolute rather than a trigger for further evaluation.
- Missing the difference between capacity (what the patient can do in clinic) and performance (what they do at home).
Worked example
An 82-year-old walks 0.55 m/s, needs 22 seconds for five chair stands, and scores 18/30 on the MoCA. Interpretation: high fall and functional-decline risk, likely multifactorial (sarcopenia, cognition, possible deconditioning). Prognosis is guarded without intervention, so the plan should prioritize strength and balance training, medication review, and home safety, with reassessment at 6 to 8 weeks using the same measures.