Assessment
Core content
Assessment items test whether you can build a complete, purposeful database before naming a problem. Know the components: chief complaint in the patient's own words; history of present illness using OLDCARTS (onset, location, duration, character, aggravating and associated factors, relieving factors, timing, severity); past medical and surgical history; a full medication list including OTC products, herbals, and supplements; allergies with the type of reaction; family and social history (tobacco, alcohol, substance use, occupation, home safety, caregiver availability); and a targeted review of systems.
Adult-gerontology assessment adds domains that exams for younger adults underweight: functional status (ADLs/IADLs), cognition (Mini-Cog, MoCA), mood (PHQ-2, then PHQ-9), fall risk (Timed Up and Go, orthostatic vital signs), nutrition and weight trend, continence, vision and hearing, and advance care preferences.
Traps
The classic trap is attributing a new symptom to "normal aging." Delirium is never normal; new confusion in an older adult is a medical problem until proven otherwise, and the Confusion Assessment Method (CAM) is the screening tool. Another trap is failing to recognize atypical presentations: myocardial infarction may present as dyspnea, fatigue, or epigastric discomfort; infection may occur without fever; hypothyroidism may look like depression. Questions that give a single blood pressure reading and expect a hypertension diagnosis, or that ignore a medication as the cause of a new symptom, are also common distractors.
Rule of thumb
For any new symptom in an older adult, ask first: could this be a drug? Then: could this be delirium, depression, or functional decline rather than a new chronic disease?
Worked example
A 79-year-old is brought in for confusion that began two days after starting oxybutynin. The correct first step is a delirium workup - CAM, medication review, vital signs, hydration status, urinalysis, glucose - not a dementia screen and not a psychiatry referral.