Gerontological Assessment: Physical, Functional, Cognitive, Psychosocial, and Environmental
Comprehensive geriatric assessment
Screen the geriatric giants - immobility, instability, incontinence, iatrogenic harm, and intellectual impairment - across physical, functional, cognitive, psychosocial, and environmental domains. Assessment is longitudinal: compare with the person's baseline.
Functional status predicts outcomes better than diagnosis. Katz ADLs (bathing, dressing, toileting, transferring, continence, feeding) decline after Lawton IADLs (shopping, finances, medications, transportation, housekeeping); losing IADLs is an early warning. Mobility: Timed Up and Go (roughly over 12 seconds flags risk), chair stand, orthostatic vitals. Falls are multifactorial - never stop at 'she fell.'
Cognition: the Mini-Cog (three-item recall plus clock draw) is a quick screen; MMSE and MoCA are more detailed but biased by education, language, and sensory loss, and MoCA is more sensitive to mild cognitive impairment. None diagnoses dementia - that requires a history of decline plus functional impact. Delirium uses the CAM: acute onset and fluctuation, inattention, disorganized thinking, altered consciousness. Depression: GDS-15 (yes/no format avoids somatic items) and PHQ-9 screen; they do not diagnose. Rule out hearing loss, cerumen, and vision loss before calling someone confused.
Also assess nutrition (appetite, weight, dentition, swallowing), medications (brown-bag review, Beers criteria, anticholinergic burden), home safety and driving, caregiver strain, mistreatment risk, social isolation, and advance care planning.
Atypical presentation is the classic trap: infection may show as confusion, falls, or poor intake rather than fever; pain may be under-reported - use a behavioral tool such as PAINAD in advanced dementia. Never accept 'it's just aging' as an answer. Worked example: a hospitalized 82-year-old becomes acutely confused. A positive CAM means delirium until proven otherwise; search for medication effects, pain, urinary retention, constipation, dehydration, hypoxia, and infection.