Here are the key steps in assessing cognition in older adults: 1. Use a standardized cognitive screening tool like the Mini-Mental State Examination (MMSE) or Mini-Cog to evaluate various cognitive domains including orientation, memory, attention and language. 2. Observe the patient's behavior and mood, looking for signs of depression, anxiety or other psychological issues that can impact cognition. 3. Get input from a family caregiver regarding any changes in the patient's cognitive or functional abilities. 4. Refer for neuropsychological testing if indicated based on screening results or concerns about specific impairments like memory problems. 5. Consider reversible causes of cognitive decline like medications, metabolic abnormalities, infections and discuss

2.  A multidisciplinary diagnostic process
intended to determine a frail older person’s
medical, functional, and psychosocial status
and limitations in order to develop a plan for
treatment and long-term follow-up.

3.  Physician
 Nurse Practitioner or Physician Assistant
 Nurse
 Social Worker
 Physical/Occupational/Speech /psychological
Therapist
 Pharmacist
 Dietician
 Dentist
Each member of team sees every
patient

5.  Highest priority:
 Prevention of decline in the independent
performance of ADLs
 Drives the diagnostic process and clinical decision
making
 Screen for preventable diseases
 Screen for functional impairments that may result in
physical disability and amenable to intervention

6.  Improve diagnostic accuracy
 Guide selection of interventions to restore or
preserve health
 Recommend optimal living environment
 Monitor clinical change over time
 Predict outcomes

8. 1. Screening or targeting of appropriate
patients.
2. Assessment and development of
recommendations.
3. Implementation of recommendations
(physician and patient adherence).

10. 1. Healthy elderly persons – living in the
community
2. Frail elderly persons – living in the
community
3. Institutionalized or severely impaired elderly
persons

11.  Frail because of age
 Decrease in functional status
 Change in mental status- cognition/affect
 Multiple medical problems
 Multiple psychosocial problems
 Take multiple medications
 New onset urinary or fecal incontinence
 Involuntary weight loss
 Frequent falls
 One or more sensory impairments
 Disruptive behavior or personality changes

13.  Common problems that have been identified
as warranting special attention in elderly
3. Cognitive Disorders:(Dementia/Delirium)
4. Polypharmacy
5. Falls/Gait Instability
6. Urinary Incontinence
7. Depression
8. Malnutrition

15.  Medical assessment
 Cognitive Function
 Affective Disorders
 Visual Impairment
 Hearing Impairment
 Dental Health
 Functional Status
 Nutritional Status
 Gait and Balance Impairment
 Social Support
 Environment
 Advance directives

16.  History. (H)
 Examination.(E)
 Assessment tool . (T)
 Referral. (R)

18.  Interview both( pt , care giver)
 Use old medical records
 More time consuming dt:
 Communication problem (hearing, vision,slow
processing and cognitive impairment)
 Underreporting
 Vague nonspecific symptoms
 Atypical presentation
 Multiple comorbidity,etiologies

19.  Previous surgical procedures
 Major illnesses and hospitalizations
 Previous transfusions
 Immunization status
 Preventive health measures
Mammography
Papanicolaou (Pap) smear
 Tuberculosis history and testing
 Medications
Previous allergies , adverse reactions
History of herbals, vitamins, laxatives
sleeping pills and cold preparations
 Topical, OTC drugs

20. SEXUAL HISTORY: Active or not
FAMILY HISTORY
 Irrelevant for dementia
 Psychiatric illness are relevant like depression and
dysthymia
PAIN HISTORY
 Characteristics of the pain
 Relation of pain to impairments in physical and social
function
 Analgesic history
 Patient's attitudes and beliefs about pain and its
management
 Effectiveness of treatments

21. Psychological history:
 Sleep pattern
 Behavioral history
 Cognitive function
 Affective disorder
 Psychiatric disorder

22.  Respiratory
 Cardiovascular
 Gastrointestinal
 Genitourinary
 Musculoskeletal
 Neurological
 Psychological

23.  Multiple complaints
 Select the bothering one
 The recently changing one
 The new one
 The backache for last 10 y with same ccc isn’t
worrisome but increasing severity is

24. Weight changes
 Weight gain should prompt search for edema or
ascites
 Gradual loss of small amounts of weight is
common
 losses in excess of 5% of usual body weight over
12 months or less should prompt search of
underlying disease
Poor personal grooming and hygiene
 Can be signs of poor overall function, caregiver
neglect, and/or depression; often indicates a
need for intervention

25. COMMON PHYSICAL FINDINGS AND THEIR
POTENTIAL SIGNIFICANCE IN GERIATRICS
VITAL SIGNS
Blood Pressure
 Psuedo hypertension:( no end organ damage, osler’s
maneuver
 Assess Orthostatic Hypotension 3 min 20/10
Irregular pulse
 Arrhythmias are relatively common in otherwise
asymptomatic elderly
Temperature
 Hypothermia is more common
 Absent fever not exclude infection

26. Tachypnea
 Baseline rate should be accurately recorded to
help assess future complaints (such as
dyspnea) or conditions (such as pneumonia or
heart failure)
Pain
 is the 5th vital sign

27. Ulcerations
 Lower extremity vascular and neuropathic ulcers
common
 Pressure ulcers common and easily overlooked in
immobile patients
Diminished turgor
 Often results from atrophy of subcutaneous tissues
rather than volume depletion
 when dehydration suspected, skin turgor over chest
and abdomen most reliable
 Bruising :suspect abuse

28.  Nail:
 Longitudinal ridges
 Thin nail plate
 Lost lanula
 Ingrowing toe nail
 Face:
 Temporal a palpation ,tenderness
 xanthoma
Eye
 Enophtalmus:dt loss orbital fat
 Entropion
 Ectropion
 Arcus senilis
Mouth
Missing teeth
 Dentures often present; they should be removed to check for evidence of poor fit and
other pathology in oral cavity
 Xerostomia, fissured tongue, leukoplakia, bleeding gum
 edentulous

30. Gum health
Area under the tongue is a common site for early
malignancies
SKIN
Multiple lesions
 Actinic keratoses and basal cell carcinomas common;
most other lesions benign
 Ecchymosis may be a sign of abuse
CHEST
Abnormal lung sounds
 Crackles can be heard in the absence of pulmonary
disease and heart failure; often indicate atelectasis

31. CARDIOVASCULAR
Systolic murmurs
 S4 normally may be heard in elderly
 Ejection systolic murmur is Common and most often benign;
clinical history and bedside maneuvers can help to
differentiate those needing further evaluation.
Vascular bruits
 Carotid bruits may need further evaluation as it confers more
coronary and cerebrovascular events
 Femoral bruits often present in patients with symptomatic
peripheral vascular disease
Diminished distal pulses
 Presence or absence should be recorded as this information
may be diagnostically useful at a later time (e.g., if symptoms
of claudication or an embolism develop)

32. BREAST EXAMINATION
Retraction of Nipple and areola
 Exclude cancer
Masses or fixed breast
 Test for Consistency and mobility to Exclude cancer
ABDOMEN and RECTAL EXAMINATION
Prominent aortic pulsation
 Suspected abdominal aneurysms should be evaluated
by ultrasound
Fecal impaction
 Common
 Should be treated

33. GENITOURINARY
Atrophy
 Testicular atrophy normal
 Atrophic vaginal tissue may cause symptoms (such as
dyspareunia and dysuria) and treatment may be beneficial
Pelvic prolapse (cystocele, rectocele)
 Common and may be unrelated to symptoms; gynecologic
evaluation helpful if patient has bothersome, potentially
related symptoms
Adnexal mass
 Malignancy should be excluded
Urinary incontinence OR A chronically overfilled and
distended bladder
 Search for prostate

34. EXTREMITIES
Periarticular pain
 Can result from a variety of causes and is not always the result
of degenerative joint disease; each area of pain should be
carefully evaluated and treated
Limited range of motion
 Often caused by pain resulting from active inflammation,
scarring from old injury, or neurologic disease; if limitations
impair function, a rehabilitation therapist could be consulted
Edema
 Can result from venous insufficiency and/or heart failure; mild
edema often a cosmetic problem; treatment necessary if
impairing ambulation, contributing to nocturia, predisposing
to skin breakdown, or causing discomfort
 Unilateral edema should prompt search for a proximal
obstructive process

35. NEUROLOGIC
Abnormal mental status (i.e., confusion,
depressed affect)
 Delirium, dementia or depression should be
assessed.
Weakness
 Arm drift may be the only sign of residual
weakness from a stroke
 Proximal muscle weakness (e.g., inability to get
out of chair) should be further evaluated;
physical therapy may be appropriate

37.  Major eye diseases such as cataract,
macular degeneration, glaucoma, and
diabetic retinopathy increases with age.
 Require eye glasses due to presbyopia.
 Often unaware of their visual deficits.

38.  Should ask questions regarding reading,
watching television, or driving. (H)
 Snellen Chart is used to screen for visual
deficits. (T)
 Patient stands 20 ft. from the chart and read
letters using corrective lens.
 Inability to read >20/40 implies impairment in
vision.
 Referral to Ophthalmologist if needed. (R)

41.  Associated with decreased cognition,
depression, dissatisfaction with life, and
withdrawal from social activities.
 Usually bilateral.
 Occurs in the high frequency range.

42.  Questions about hearing difficulties. (H)
 Inspect ear for impacted cerumen. (E)
 Whisper voice ,finger rub test . (E)
 Audioscope (T)
 Hearing Handicap Inventory. (T)
 Referral . (R)

43.  Inability to hear 40 decibles tone at 1000 or
2000 Hz in one or both ears implies failed
hearing test.

44.  An alternative to hand-held audio scope.
 Done by whispering 3 – 6 words at a distance
of 8, 12, or 24 inches from the patient’s ear.
 Examiner should stand behind the patient
and have one ear covered during the
examination.
 Inability to repeat >50% of the whispered
words is considered a failed screening.

45.  Whisper Test
3 words
12 to 24 inches
Macphee GJA Age Aging, 1988

46. 3. D o e s a h e a r in g p r o b le m c a u s e y o u t o f e e l
e m b a r r a s s e d w h e n y o u m e e t n e w p e o p le ?
Ye s S o m e t im e s N o
4. D o e s a h e a r in g p r o b le m c a u s e y o u t o f e e l
f r u s t r a t e d w h e n t a lk in g t o m e m b e r s o f
y o u r f a m ily ? Ye s S o m e t im e s N o
5. Do yo u ha ve d if f ic u lt y w h e n s ome one
s p e a k s in a w h is p e r ? Ye s S o m e t im e s
No
6. D o y o u f e e l h a n d ic a p p e d b y a h e a r in g
p r o b le m ? Ye s S o m e t im e s N o
7. Does a h e a r in g p r o b le m c aus e yo u
d if f ic u lt y w h e n v is it in g f r ie n d s , r e la t iv e s , o r
n e ig h b o r s ? Ye s S o m e t im e s N o
8. Does a h e a r in g p r o b le m c a u s e y o u t o
a t t e n d r e lig io u s s e r v ic e s le s s o f t e n t h a n
y o u w o u ld lik e ? Ye s S o m e t im e s N o

47.  INSTRUCTIONS: The purpose of this scale is to identify the
problems your hearing loss may be causing you. Please select
YES, SOMETIMES, or NO for each question. Do not skip a
question if you avoid a situation because of your hearing
problem. If you use a hearing aid, please answer the way you hear
without a hearing aid.
 Total ‘No’ _____ X 0 = _______
 Total ‘Yes’ _____ X 4 = _______
 Total ‘Sometimes’ _____ X 2 = _______
 TOTAL SCORE _______
 If your score is greater than 10, a hearing test is
recommended

49. MMSE
Mini-cog test
Clock drawing test
Animal naming test

50. ‫‪‬مقياس الحالة العقليةالتوجه ) الهتداء(‬
‫‪ ‬تقدر تقول لي إحنا في سنة كام ؟‬
‫‪‬تقدر تقول لي إحنا في فصل إيه؟‬
‫‪ ‬تقدر تقول لي إحنا في شهر إيه؟‬
‫/5‬ ‫تقدر تقول لي النهاردة إيه؟‬
‫‪ ‬تاريخ النهاردة ايه ؟‬
‫‪‬‬
‫إحنا فين دلوقت؟‬
‫إحنا في الدور الكام؟‬ ‫`‬
‫أنت تتبع حي إيه؟‬ ‫‚‬
‫أنت تتبع محافظة إيه؟‬ ‫°‬
‫/5‬ ‫‚ إحنا في جمهورية إيه؟‬

51. ‫تسجيل المعلومات‬
‫ا قولك 3 كلمات, قولهم ورايه, ها سالك عليهم تاني كمان شويه )كورة- شجرة- قلم(‬
‫/3‬
‫) أكثر من 5 سنوات دراسة( اطرح 7 من 001 و الباقي شيل منه 7 و أنت نازل, و توقف بعد 5‬
‫مرات:) 39-68-97-27-56(‬
‫ذا كان غير قادر علي الطرح: يتهجا كلمة أسيوط‬
‫) اقل من 5 سنوات دراسة ( اطرح 3 من 02 و الباقي شيل منه 3 وأنت نازل و توقف بعد 5 مرات‬
‫/5‬
‫استرجاع الذاكرة:‬
‫/3‬ ‫قول ال 3 كلمات اللي قولناهم قبل كده )كورة –شجرة- قلم(‬
‫اللغة:‬

52. ‫اكتب جملة مفيدة أو قول جملة مفيدة‬ ‫•‬
‫/1‬
‫ارسم هذا الشكل‬ ‫‪‬‬
‫____________‪Date‬‬ ‫‪_____ Total Score ‬‬

53.  Subjects told to 1 point for the clock circle
▪ Draw a large circle 1 point for all the numbers being in
▪ Fill in the numbers on a clock the correct order
face 1 point for the numbers being in the
▪ Set the hands at 8:20 proper special order
1 point for the two hands of the
 No time limit given clock
 Scoring (subjective): 1 point for the correct time.
▪ 0 (normal)
▪ 1 (mildly abnormal)
▪ 2 (moderately abnormal)
▪ 3 (severely abnormal)
A normal score is four or five points.

55.  Components
 3 item recall: give 3 items, ask to repeat, divert and recall
 Clock Drawing Test (CDT)
▪ Normal (0): all numbers present in correct sequence and
position and hands readably displayed the represented time
 Give 1 point for each recalled word after the CDT
distractor. Score 1–3.
 A score of O indicates positive screen for dementia.
 A score of 1 or 2 with an abnormal CDT indicates positive screen for
dementia.
 A score of 1 or 2 with a normal CDT indicates negative screen for
dementia.
 A score of 3 indicates negative screen for dementia

56.  Category fluency
 Highly sensitive to Alzheimer’s disease
 Scoring equals number named in 1 minute
 Average performance = 18 per minute
 < 12 / minute = abnormal
 Requires patient to use temporal lobe semantic stores
 60 seconds
 Using a cutoff of 15 in one minute:
 Sens 87% - 88%
 Spec 96%

58.  Highest prevalence of depression and suicide in elderly
 Geriatric Depression Screen (GDS)- Yesavage
 30 y/n questions
 15 y/n questions
 Single question just as sensitive
▪ Do you feel sad or depressed?
▪ Are you worried something bad will happen to you?

59. ‫:‬ ‫‪ ‬ﺈختر الجواب اﻷنسب لحالتك النفسية خلل اﻷسبوع الماضي‬
‫1- هل ﺃنت بشك ٍ عام را ٍ عن حياتك ؟ نعم ‪ ‬كل ‪‬‬
‫ض‬ ‫ل‬ ‫‪‬‬
‫2- هل تخّيت عن العديد من نشاطاتك و ﺇهتماماتك ؟ نعم ‪ ‬كل ‪‬‬ ‫ل‬ ‫‪‬‬
‫3- هل تشعرۥ ﺃ ّ حياتك فارغة ؟ نعم ‪ ‬كل ‪‬‬
‫ن‬ ‫‪‬‬
‫4- هل تصاب بالملل عادة" ؟ نعم ‪ ‬كل ‪‬‬ ‫‪‬‬
‫5- هل ﺃنت في مزا ٍ حسن في ﺃغلبية الوقت ؟ نعم ‪ ‬كل ‪‬‬
‫ج‬ ‫‪‬‬
‫6- هل تخاف ﺃن يصيبك مكروه ؟ نعم ‪ ‬كل ‪‬‬ ‫‪‬‬
‫7- هل تشعرۥ بالسعادة ﺃغلبية الوقت ؟ نعم ‪ ‬كل ‪‬‬ ‫‪‬‬
‫8- هل تشعرۥ عادة" ﺃّك بحاجة ﺇلى مساعدة ؟ نعم ‪ ‬كل ‪‬‬
‫ن‬ ‫‪‬‬
‫9- هل تف ّل البقاء في غرفتك على الخروج و القيام بنشاطا ٍ جديدة ؟ نعم ‪ ‬كل ‪‬‬
‫ت‬ ‫ض‬ ‫‪‬‬
‫01- هل تشعرۥ ﺃ ّ مشاكل الذاكرة تصيبك ﺃكثر من غيرك ؟ نعم ‪ ‬كل ‪‬‬
‫ن‬ ‫‪‬‬
‫11- هل تعتقد ﺃّه ﻷم ٌ رائع بقاؤك حيا" الن ؟ نعم ‪ ‬كل ‪‬‬
‫ر‬ ‫ن‬ ‫‪‬‬
‫21- هل تشعرۥ ﺃّك ل تجدي نفعا" في الوقت الحالي ؟ نعم ‪ ‬كل ‪‬‬
‫ن‬ ‫‪‬‬
‫31- هل تشعرۥ ﺃّك شديد النشاط ؟ نعم ‪ ‬كل ‪‬‬
‫ن‬ ‫‪‬‬
‫41- هل تعتقد ﺃ ّ وضعك ميؤوس منه ؟ نعم ‪ ‬كل ‪‬‬
‫ن‬ ‫‪‬‬
‫51- هل تعتقد ﺃ ّ ﺃغلبية الّاس بوض ٍ ﺃفضل من اّذي ﺃنت عليه ؟ نعم ‪ ‬كل ‪‬‬
‫ل‬ ‫ع‬ ‫ن‬ ‫ن‬ ‫‪‬‬
‫‪‬‬

60. Choose the best answer for how you have felt over the past week:
 1. Are you basically satisfied with your life? YES / NO
 2. Have you dropped many of your activities and interests? YES / NO
 3. Do you feel that your life is empty? YES / NO
 4. Do you often get bored? YES / NO
 5. Are you in good spirits most of the time? YES / NO
 6. Are you afraid that something bad is going to happen to you? YES / NO
 7. Do you feel happy most of the time? YES / NO
 8. Do you often feel helpless? YES / NO
 9. Do you prefer to stay at home, rather than going out and doing new things? YES / NO

61.  10. Do you feel you have more problems with memory than most? YES /
NO
 11. Do you think it is wonderful to be alive now? YES / NO
 12. Do you feel pretty worthless the way you are now? YES / NO
 13. Do you feel full of energy? YES / NO
 14. Do you feel that your situation is hopeless? YES / NO
 15. Do you think that most people are better off than you are? YES / NO
 Answers in bold indicate depression. Although differing sensitivities and
specificities have been obtained across studies, for clinical purposes a
score > 5 points is suggestive of depression and should warrent a follow-
up interview. Scores > 10 are almost always depression.

63.  Basic Activities of Daily Living (ADLs)
 Tasks essential to be independent in your own
home or room
 Instrumental Activities of Daily Living (IADLs)
 Tasks essential to be independent in the
community
 Advanced Activity of Daily Living (AADLs)

64. Bathing (sponge, shower, or tub)
Independent: needs no assistance
Assisted: needs assistance only in bathing a single part (as back or
disabled extremity)
Dependent: needs assistance in bathing more than one part of the body
and in getting in or out of tub or does not bathe self
Dressing
Independent: gets clothes from closets and drawers; puts on clothes,
outer garments, braces; manages fasteners; act of tying shoes excluded
Assisted: need partial assistant
Dependent: does not dress self or remains partly undressed
Toileting
Independent: gets to toilet; gets on and off toilet; arranges clothes; cleans
organs of excretion (may manage own bedpan used at night only and may
not be using mechanical supports)
Assisted: receives assistance in getting to and using toilet
Dependent: uses bedpan or commode

65. Transfer
Independent: moves in and out of bed independently and moves in and out of
chair independently
Assisted: using mechanical supports
Dependent: assistance in moving in or out of bed and/or chair; does not perform
one or more transfers
Continence
Independent: urination and defecation entirely self-controlled
Assisted: : partial or incontinence in urination or defecation; or partial control by
enemas, catheters, or regulated use of urinals and/or bedpans
Dependent total incontinence in urination or defecation; partial or total control by
enemas, catheters, or regulated use of urinals and/or bedpans
Feeding:
Independent: gets food from plate or its equivalent into mouth (precutting of
meat and preparation of food, as buttering bread, are excluded from evaluation)
Assisted: assistance in act of feeding
Dependent: does not eat all or parenteral feeding

66.  The Index of Independence in Activities of Daily Living is based on an
evaluation of the functional independence or dependence of patients in
bathing, dressing, toileting,transferring, continence, and feeding.
Specific definitions of functional independence and dependence appear
below the index.
 A – Independent in feeding, continence, transferring, toileting, dressing,
and bathing
 B – Independent in all but one of these functions
 C – Independent in all but bathing and one additional function
 D – Independent in all but bathing, dressing, and one additional function
 E – Independent in all but bathing, dressing, toileting, and one additional
function
 F – Independent in all but bathing, dressing, toileting, transferring, and
one additional function
 G – Dependent in all six functions
 Other – Dependent in at least two functions, but not classifiable as C, D,
E, or F.

67. bility to Use Telephone
Operates telephone on own initiation, looks up and dials numbers, etc. 1
Dials a few well-known numbers 1
Answers telephone but does not dial 1
Does not use telephone at all 0
hopping
Takes care of all shopping needs independently 1
Shops independently for small purchases 0
Needs to be accompanied on any shopping trip 0

68. ousekeeping
Maintains house alone or with occasional assistance (e.g., on heavy work-domestic help‌) 1
Performs light daily tasks such as dishwashing, bed making 1
Performs light daily tasks but cannot maintain acceptable level of cleanliness 1
Needs help with all home maintenance tasks 1
Does not participate in any housekeeping tasks 0
aundry
Does personal laundry completely 1
Launders small items ”rinses socks, stockings, etc. 1

69. esponsibility for Own Medications
Is responsible for taking medication in correct dosages at correct times 1
Takes responsibility if medication is prepared in advance in separate dosages 0
Is not capable of dispensing own medication 0
bility to Handle Finances
Manages financial matters independently (budgets, write checks, pays rent, bills, goes to
bank), collects and keeps track of income 1

70.  Evaluates the persons ability to participate in
societal, community, and family roles.
 It also assesses for recreational and
occupational activities. These activities
varies among individuals and may be a
valuable tools in monitoring functional status
prior to the development of disability.

71.  Patient specific activities that can be used to
detect subtle functional losses in high
functioning patients
 Can be job or recreation oriented
 Socializing, playing bridge , working, playing
golf, playing music, dancing, practicing law,
flying a plane, gardening.

73.  Food taken (type, quantity, frequency)
 No of hot meal / week
 Characteristic diet (low salt , low protein)
 Alcohol intake
 Fluid intake
 Dietary fiber
 OTC vitamin , herbal medicine
 pt’s ability to feed himself
 Change in taste ,smell, teeth

74.  MNA® Short Form
 Nutrition Screening Initiative
 DETERMINE checklist
 MUST (Malnutrition Universal
Screening Tool)
 Nutrition Risk Screening (NRS)
(ESPEN)

75. 1. Body mass index (BMI)
(kg/m2)
2. Weight loss in past 3 months?
3. Acute illness or major stress in
past 3 months?
4. Mobility
5. Dementia or depression
6. Has appetite & food intake
declined in past 3 months?

76.  MNA > 23: dietary
informations
 MNA < 17: refer to a
specialist, do more
comprehensive
assessment, using
biological markers:
albumin, CRP..
 MNA between 17 and 23:
Were the patient have
difficulties, how can we
help, useful for
intervention studies

78. YES
1. Do you have an illness or condition that made you change the kind and amount of 2
food you eat.
2. Do you eat fewer than two meals per day. 3
3. Do you eat few fruits, vegetables, or milk products. 2
4. Do you have 3 or more drinks of beer, liquor or wine almost every day. 2
5. Do you have tooth or mouth problems that make it hard for you to eat. 2
6. Do you always have enough money to buy food. 4
7. Do you eat alone most of the time. 1
8. Do you take 3 or more different prescribed or over the counter drugs per day. 1
9. Without wanting to, have you lost or gained 10lbs. in the last 6 months. 2
10. Are you physically unable to shop, cook, or feed yourself. 2
A score of 0-2 is good, 3-5 moderate nutritional risk and greater than 6
equal high nutritional risk.

82.  Diet
 A more precise questionnaire is needed to have the correct amount of
consumed intake.
▪ The 7-day dietary record routine seems to have a good
reproducibility in assessing the intake of energy and fluids in
geriatric patients, but may be to long and to complex for non
expert professionals.
▪ 3-day food records could be sufficient for a correct estimation of
current food intake.
 Some new validated method is proposed as the photography method
of nutritional assessment

83.  Physical Exam
▪ Loss of SQ fat
▪ Muscle wasting
▪ Edema in ankles
▪ Edema in sacral area
▪ Ascites
▪ Anthropometric parameters
Weight, body mass index are the most important anthropometrics parameters,

84.  Weight
Individuals removed shoes and heavy cloths prior to weighing.
 Height
Subjects stood with their scapula, buttocks and heels resting against a wall, the neck was held in a
natural non-stretched position, the heels were touching each other, the toe tips formed a 45°
angle and the head was held straight with the inferior orbital border in the same horizontal
plane as the external auditive conduct (Frankfort's plane).
 Body circumferences
Mid-brachial, calf, waist and hip circumferences were measured using a flexible non-elastic
measuring tape. Individuals stood with feet together and arms resting by their sides. The hip
circumference was measured from the maximum perimeter of the buttocks. The waist
circumference was taken as the plane between the umbilical scar and the inferior rib border.
The waist circumference was used to identify individuals with possible health risks based upon
threshold values of ≥ 88 cm for women and ≥ 102 cm for men
 Knee-heel length
 Body-mass index (BMI)
BMI was estimated by dividing weight (kg) by height2 (m2) . Individuals were considered
malnourished if their BMI was less than 18.5, normal from 18.5 to 24.9 and overweight if ≥ 25
 Waist to hip ratio (WHR)
This was estimated by dividing waist circumference by hip circumference . The threshold WHR was
≥ 0.85 for women and ≥ 1.00 for men

85.  Biochemical parameters
 Plasma albumin, Cholesterol, Hemoglobin and Transferrin are the
most used laboratory parameters in long term care.
 CRP, total lymphocytes may also be used linked to higher mortality)

86.  At entry: Weight, BMI, MNA,
 Every 3 months: Weight, if weight loss more than 2
kg,
▪ MNA
▪ Weight each months

88.  >6 concurrent diagnosis.
 >12 doses of medications per day.
 A prior ADE.
 A low body weight or BMI.
 Age >85 years.
 Creatinine clearance <50ml/minute.

90.  Previous history of falls causes and
treatments.
 Did you fall last year ?
 Location & circumstances of Fall
 Associated symptoms
 Other falls or near falls
 Medications (including nonprescription) and
alcohol
 Injury & ability to get up

91.  Lower extremity or quadriceps
weakness can evaluated by asking
the patient to stand from a seated
position in a hard back chair while
keeping their hands folded.
 Inability to complete this task
suggest lower extremity weakness
and is highly predictive for future
disability.

92.  Gait Observations
 Initiation of gait Step length Step height
 Step continuity Step symmetry Walking stance
 Amount of trunk sway Path deviation
 Gait speed
▪ 0.8 meters/sec indicates that the patient is capable of independent
ambulation within the community.
▪ of 0.6 meters/sec indicates participation in community activities
without the use of a wheelchair
▪ Patients who can ambulate 50 feet in the office corridor in 20
seconds or less should be able to walk independently in normal
activities

93.  Sitting balance (leaning vs steady)
 Ability to rise from chair
 Immediate standing balance
 Standing balance (wide based, narrow based or
assisted)
 Sternal nudge
 Standing balance w/ eyes closed

94. BALANCE SCORE = _____/16
Gait score=- _____/12
TOTAL SCORE (Gait + Balance ) = _____/28
{< 19 high fall risk, 19-24 medium fall risk,
25-28 low fall risk}

97.  ONLY VALID FOR PATIENTS NOT USING AN
ASSISTIVE DEVICE
 The task of rising from an armless chair, walking
10ft, turn, walk back and sit down is termed the
“Get-up and Go Test.” Those taking long than 10
seconds to complete this tasks are at increased risk
for falls
 Seconds Rating
 <10 freely mobile
 <20 mostly independent
 20-29 variable mobility
 >30 assisted mobility
 Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the “Get-up and Go” test. Arch
phys Med Rehabil. 1986; 67(6): 387-389.

98. Pain Assessment

99.  Location
 Quality
 Severity
 Duration
 Exacerbating/relieving factors
 Efficacy of current treatmen
 Impact on mobility
 Impact on sleep
 Impact on appetite
 Imact on mood
 Impact on social life

100.  Numerical scales
 Visual analog scales
 Verbal Descriptor scales
 Behavioral cues

103.  Grimacing
 Agitation
 Restlessness
 Moaning/crying
 Guarding
 Appetite and activity changes
 Irritability/swearing

105.  Duration, severity, symptoms, previous
treatment, medications, GU surgery
 3 P’s
 Position of leakage (supine, sitting, standing)
 Protection (pads per day, wetness of pads)
 Problem (quality of life)
 Reversible causes (Diappers)
 Categorize incontinence
 Bladder record or diary

106.  Mental status
 Mobility
 Fluid overload
 Abdominal exam
 Neurologic exam
 Pelvic
 Rectal

107.  Stress test (diagnostic for stress incontinence; specificity >90%)
 Post-void residual
 Blood Tests (calcium, glucose, BUN, Cr)
 Urine Culture
 Simple (bedside) Cystometrics

108. Social Assessment

109.  Should include availability of help in case of
emergency.
 Availability of a personal support system.
 Living arrangement.
 Relationship with (family, friends, neighbours)
 Social activities, hobbies, spiritual participation
 Need for a caregiver.
 Caregiver burdens.
 Economic status.
 Elder mistreatment.
 Advanced directives.

110.  For the frail elderly availability of help from
family or friends can determine whether a
functionally dependent person remains at
home or is institutionalized.
 For those frail elders that lack support, a
visiting nurse may be helpful in the
assessment of home safety and level of
personal risk, i.e., stairs, location of
bathrooms, bathroom grab bars, and smoke
alarms.

111.  S - Do you feel Safe at home? What Stress do
you feel in your relationship?
 A - Do you feel Afraid or have you been
Abused by any of your caregivers?
 F - Are there any Family or Friends that you
could ask for help or support?
 E – Do you have a safe place to go in case of
an Emergency? Is it an Emergency now?

112.  Caregiver does not come to appointments
 Is concerned about medical costs
 History of substance abuse, mental health
problems, conflicts with patient
 Dominates interview, won’t leave, won’t let
patient talk
 Defensive, hostile, or indifferent
 Dependence on patient for income/housing

114. D - Dementia, Depression, Drugs
E - Eyes
E - Ears
P - Physical Performance, Phalls, Psychosocial
I - Incontinence
N -Nutrition

115.  Start low , go slow
 Try to limit number of medications and avoid prescribing “a
pill for every ill”
 Try not to start two drugs at the same time
 Make sure it is the right dose
 Avoid “inappropriate medications”- Beers criteria
 Watch out for potential drug-drug, drug-disease interactions
 Make sure patient and caregiver understand what the
medication is for , how and when to take it, possible side
effects

116. At least annually:
 Ask patient to bring in all medications (including
OTC, herbal prep)
 Ask patient how each medication is being taken
 Look for medications with duplicate therapeutic
or pharmacologic profiles
 Eliminate unnecessary medications
 Simply the medication regimen – fewest
possible number of medications and doses per
day
 Always review any changes in writing with the
patient and caregiver, provide the changes in
writing