MOUNT SINAI JOURNAL OF MEDICINE 78:489497, 2011

489

Geriatric Assessment Tools

Sonja L. Rosen, MD and David B. Reuben, MD
David Geffen School of Medicine at UCLA, Los Angeles, CA

OUTLINE
MEDICAL ASSESSMENT TOOLS
Falls/Gait Disturbance
Hearing Impairment
Visual Impairment
Urinary Incontinence
Malnutrition/Weight Loss
Polypharmacy
FUNCTIONAL ASSESSMENT TOOLS
COGNITIVE ASSESSMENT TOOLS
PSYCHOLOGICAL ASSESSMENT TOOLS
SOCIAL ASSESSMENT
ECONOMIC ASSESSMENT
SPIRITUAL ASSESSMENT
CONCLUSION

ABSTRACT
In addition to medical diseases, psychological, social,
cognitive, and functional issues influence the health
of older persons. Therefore, the traditional medical
assessment alone is often not enough to evaluate
the older population with multiple comorbidities.
Out of this recognized need, the geriatric assessment has been developed, which emphasizes a
broader approach to evaluating contributors to health
in older persons. Geriatric assessment uses specific
tools to help determine patients status across several different dimensions, including assessment of
medical, cognitive, affective, social, economic, environmental, spiritual, and functional status. This article
reviews specific tools that practitioners can use in
their screening for the following geriatric syndromes:
hearing impairment, vision impairment, functional

Address Correspondence to:

Sonja L. Rosen,
Division of Geriatrics
David Geffen School of
Medicine at UCLA
Los Angeles, CA
Email: srosen@mednet.ucla.edu

Published online in Wiley Online Library (wileyonlinelibrary.com).

DOI:10.1002/msj.20277
2011 Mount Sinai School of Medicine

decline, falls, urinary incontinence, cognitive impairment, depression, and malnutrition. This article also
reviews spiritual, economic, and social assessment.
By identifying conditions that are common in the
elderly, geriatric assessment can provide substantial
insight into the comprehensive care of older persons,
from those who are healthy and high-functioning
to those with significant impairments and multiple comorbidities. Mt Sinai J Med 78:489497,
2011. 2011 Mount Sinai School of Medicine
Key Words: elderly, geriatric assessment.
In addition to medical diseases, psychological,
social, cognitive, and functional issues influence the
health of older persons. Therefore, the traditional
medical assessment (history of present illness,
past medical history, review of systems, physical
examination, and laboratory evaluation) alone is
often not enough to evaluate the older population
with multiple comorbidities. Out of this recognized
need, the geriatric assessment has been developed,
which emphasizes an approach different than the
standard medical evaluation.1 Geriatric assessment
uses specific tools to help determine patients
status across several different systems, including
assessment of medical, cognitive, affective, social,
economic, environmental, spiritual, and functional
status (Figure 1).

Traditional medical assessment

alone is often not enough to
evaluate the older population with
multiple comorbidities.
For the medical assessment, the standard physical examination and past medical history-taking is
augmented by an evaluation of possible geriatric
syndromes including hearing impairment, cognitive impairment, functional status, depression, falls,
gait disorder, and incontinence. The social assessment involves an in-depth history-taking, which may
involve obtaining information from collateral sources
such as family, neighbors, and friends. The psychological assessment includes screening for depression,

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S. L. ROSEN AND D. B. REUBEN: GERIATRIC ASSESSMENT TOOLS

Cognitive

Medical

Affective

Environmental

Functional
status

Social Support

Economic

Fig 1.

Spirituality

additional simple tests of balance and mobility can

also be performed quickly, including the ability
to maintain a side-by-side, semi-tandem, and fulltandem stance for 10 seconds each; resistance to a
nudge; and stability during a 360-degree turn. One

Underlying balance and gait

disorders can best be detected by
observing patients walking and
performing balance maneuvers.

Interacting dimensions of geriatric assessment.

which complements a cognitive assessment including

screening for dementia. The purpose of this article
will be to review the specific tools that practitioners
can use in their screening for geriatric syndromes
when evaluating patients. For each of the dimension
of geriatric assessment, there is no gold-standard
screening instrument. Similarly, there are no minimum datasets of outpatient or inpatient geriatric
assessments. Rather, the choice of assessment tools
should depend upon the clinical situation, practice
resources, and comfort of the clinician with the
instruments.

MEDICAL ASSESSMENT TOOLS

Patients often think that some problems, such as
incontinence and falls, are a normal part of aging, and
therefore are unlikely to report them as a problem
to their physicians. Screening tools help to learn this
information from patients.

Falls/Gait Disturbance
More than one-third of community-dwelling older
persons fall each year, and falls are independently
associated with functional decline.2 Also, patients
who have fallen are at high risk for falling again
and having resulting injuries.3 Because older persons
frequently attribute falls to normal aging, it is very
important to ask older patients if they have fallen in
the last year, at their initial visit and at least annually.
The use of a previsit questionnaire can help elicit this
information efficiently.
Tests of gait, balance, and functional reach
(Table 1) help to assess patients risk of falling.
Underlying balance and gait disorders can best
be detected by observing patients walking and
performing balance maneuvers. To save time, this
evaluation can be performed while the patient is
entering or leaving the examining room. Several
DOI:10.1002/MSJ

can assess quadriceps strength by observing an older

person arising from a hard armless chair without the
use of his or her hands. Slow gait speed is also a
helpful marker for recurrent falls as well as reduced
survival. Patients whose gait speed exceeds 0.8 m
per second are likely to live beyond the median life
expectancy for age and sex, whereas those whose
gait speed is <0.8 m per second are likely to have
shorter survival.4 The timed up and go test is
a measure of the patients ability to rise from an
armchair, walk 3 m (10 feet), turn, walk back, and sit
down again; those who take longer than 20 seconds
to complete the test should receive further evaluation
as well.5
For patients who have tested positive for falls,
a structured visit note (Figure 2; can be downloaded
from
http://www.geronet.ucla.edu/professionals/
patient-care-resources) can be used at follow-up
visits. Physicians should then inquire about the circumstances of the fall. Patients with recurrent falls or
falls with any injury should receive a more detailed
evaluation, including assessment of all medications,
gait and balance, orthostatic blood pressure readings, and vision testing. These are also outlined in
Figure 2.

Hearing Impairment
Hearing impairment affects up to one-third of persons
aged >65 years. Independently, it is associated with
reduced cognitive and physical function, and reduced
social involvement.6 It is also often under-recognized
and therefore undertreated, and again often not selfreported by patients. There are several methods
to help screen for hearing loss (Table 2). One
simple method for a busy practitioner is simply
to rely on the patients own subjective report
of hearing loss.7,8 This involves asking patients
whether they feel they have hearing impairment.
An affirmative answer is considered a positive test for
hearing loss, and patients should be referred to an
audiologist.

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Table 1.

491

Simple Tests of Lower Extremities: Strength, Balance, Gait, and Fall Risk.
Question/Test

Time to Administer

Timed up & go

<1 minute

Gait speed >10 m

<30 seconds

Office-based maneuvers
Observed gait
Resistance to nudge
Tandem/semitandem stand
Rising from chair
360-degree turn
Functional reach

23 minutes

2 minutes

Comments
Sensitivity 88%, specificity 94% compared with geriatricians
evaluation using cutpoint >15 seconds
>13 seconds predicts recurrent falls (likelihood ratio: 2.0, 95%
CI: 1.52.7)
Some are part of Performance-Oriented Assessment of Mobility

Adjusted odds ratios for >2 falls within 6 months:

8.1 if unable to reach
4.0 if reach 6
2.0 if reach 6 but <10

Abbreviations: CI, confidence interval.

Another alternative is the whisper voice test,

administered by whispering 3 to 6 random words
at a set distance from the patients ear and then
asking the patient to repeat the words. Patients fail
the screening if they are unable to repeat half of
the words correctly. This should be done out of the
patients sight line to prevent lip reading, and the
other ear should be covered.
The most accurate office test is the AudioScope 3
(Welch Allyn, Inc., Skaneateles Falls, NY), a handheld
otoscope with a built-in audiometer. It should be set
at 40 dB to evaluate hearing loss in older persons.
A pretone at 60 dB should be delivered, with 4
subsequent tones (500, 1000, 2000, and 4000 Hz), all
at 40 dB. If patients cannot hear the 1000 or 2000 Hz
in both ears or both in one ear, they then need more
formal audiometric testing.
Finally, a screening tool that uses sociodemographic information coupled with 3 simple questions
(Table 2) has high accuracy in identifying older persons with hearing loss.9

they are unable to read all of the letters on the 20/40

line with their eyeglasses on, and should then be
referred for further evaluation by an ophthalmologist.
Given the high prevalence of eye diseases in
the older population and the potential for adverse
health consequences of impaired vision, a visit with
an optometrist or ophthalmologist is recommended
every 1 or 2 years by the American Academy
of Ophthalmology11 and the American Optometric
Association.12

Given the high prevalence of eye

diseases in the older population
and the potential for adverse
health consequences of impaired
vision, a visit with an optometrist
or ophthalmologist is
recommended every 1 or 2 years.
Urinary Incontinence

Visual Impairment
Visual impairment is a common sensory deficit in the
older population; all 4 major eye diseases (cataracts,
macular degeneration, diabetic retinopathy, and
glaucoma) increase in prevalence with age. Most
older persons have presbyopia and require corrective
lenses. Visual deficiencies are also independently
associated with increased risk of falling, functional
decline, and depression.10
The Snellen eye chart is standard method of
screening for visual impairment. This requires the
patient to stand 20 feet from the chart and read letters,
using corrective lenses. Patients fail the screening if

Urinary incontinence is under-reported as well,

often due to patients embarrassment or belief that
incontinence is a normal part of aging. In fact,
it is a very common problem in both older men
and women, and can have deleterious effects on
their lives, including urinary tract infections, sleep
disruption with subsequent falls, and pressure ulcers.
It is also a marker for higher mortality in older
adults.13 There are many treatment options available,
including behavioral, pharmacologic, and surgical.
A simple and efficient screen for urinary
incontinence is a 2-item questionnaire that can be
administered by the provider: (1) In the last year,
DOI:10.1002/MSJ

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Fig 2. UCLA Visit Form: Falls/Mobility Problems. Abbreviations: BP, blood pressure; Ca, calcium;
dcd, discontinued; EKG, electrocardiogram; OA, osteoarthritis; P, pulse; PPI, proton pump inhibitor;
PT, physical therapy; w/o, without.

have you ever lost urine and gotten wet? If so,

(2) Have you lost urine on 6 separate days? Another
single question, Have you had urinary incontinence
that is bothersome enough that you would like
to know how it could be treated? may convey
additional value in helping to determine which
patients would want further evaluation and therapy.
The 3IQ questionnaire helps the clinician differentiate
between urinary stress and urge incontinence using
self-report questions.14
DOI:10.1002/MSJ

Malnutrition/Weight Loss
The term malnutrition has been used to refer
to a wide spectrum of deficiencies (eg, proteinenergy, vitamins) and excesses (eg, obesity,
hypervitaminosis)15 that place older persons at risk
for other health conditions, functional decline, and
death. Nutritional disorders are very common in older
persons, the most common one being obesity (body
mass index > 30 kg/m2 ) in community-dwelling

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Table 2.

493

Simple Tests of Hearing Loss.

Question/Test

Time to Administer

Audioscope
Whisper test
Hearing handicap

12 minutes
1 minute
2 minutes

Inventory for the elderly NHANES battery

Age > 70 = 1
Male sex = 1
12th-grade education = 1
Previously saw doctor about trouble
hearing = 1
Without hearing aid, cannot hear whisper
across the room = 1
Without hearing aid, cannot hear normal
voice across the room = 2

<2 minutes

Comments
Sensitivity 87%90%, specificity 70%90%
Sensitivity 80%100%, specificity 82%89%
Sensitivity 48%63%, specificity 75%86% at
cutpoint >8
Sensitivity 80%, specificity 80% at cutpoint of >3

Abbreviations: NHANES, National Health and Nutrition Examination Survey.

older persons. Obesity is associated with functional

decline and more comorbidities, such as type 2 diabetes mellitus and osteoarthritis. Weight loss has
commonly been used to define undernutrition and
also predicts increased mortality. Although weight
loss may be voluntary, any weight loss in an older
person raises concern for underlying illnesses (eg,
malignancy, depression) or social/functional barriers
(poverty, inability to shop or prepare meals).

Although weight loss may be

voluntary, any weight loss in an
older person raises concern for
underlying illnesses (eg,
malignancy, depression) or
social/functional barriers (poverty,
inability to shop or prepare meals).
At the initial visit, patients should be weighed
and asked about previous weight loss in the last
6 months. Height should also be obtained in order
to calculate body mass index, which should be
calculated at the initial visit and when there is a
significant change in weight.
There are also several self-administered screening instruments available. The Mini-Nutritional
Assessment16,17 predicts adverse outcomes that may
or may not be related to the nutritional components
of the instrument. The 4-item Simplified Nutrition
Assessment Questionnaire asks about appetite and
how food tastes, and has been associated with weight
loss in a cross-sectional study.18
Malnutrition in the hospitalized older patient
is common and has been associated with higher
mortality, delayed functional recovery, and higher

rates of nursing-home use.19 Persistent decreased

intake and weight loss in the hospital should prompt
investigation. Malnutrition in the hospitalized older
patient can also be a marker for another occult process. For example, evaluation of poor oral intake
may reveal an underlying delirium or untreated pain
causing decreased oral intake. Measuring albumin
and prealbumin, though not a specific indicator of
malnutrition, can also be helpful in assessing prognosis. Albumin is also affected by inflammatory states
related to concomitant illness, stress, and traumatic
or surgical conditions. Its half-life is 18 days, and so
measurement at admission may provide a nutritional
baseline. Prealbumin, with a half-life of 2 days, may
be more helpful to monitor response to nutritional
treatment, although it is also affected by inflammatory
states.

Polypharmacy
Polypharmacy is very common in the older population, associated with adverse drug reactions, and
can result in hospitalizations and increased morbidity. Patients often visit >1 healthcare provider and
fill prescriptions at multiple pharmacies. Therefore,
monitoring the many medications patients are on for
drug-disease and drug-drug interactions is imperative
at the initial and every follow-up visit. There are several ways to perform this task. Providers can ask their
patients to bring all of their medications in to their
visits with them, including over-the-counter medications. Previsit questionnaires can be completed prior
to the initial visit with a complete list of patients
prescription and nonprescription medications. Office
staff can then review these medication lists with
patients and bring any discrepancies to the physicians attention at the time of the patients visit.
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Clinicians can easily review drug-drug interactions with readily available drug software programs,
and should do so when prescribing a new medication. Some programs can be used on smartphones
and personal digital assistants.

FUNCTIONAL ASSESSMENT TOOLS

Functional performance can be viewed as a measure
of overall impact of health conditions in the context of
a patients environment and social support system.1
Therefore it is essential to assess the patients
functional status at the initial visit, and any change in
functional status should prompt further investigation.
This can be assessed at 3 levels: basic activities of
daily living (BADLs), instrumental activities of daily

Functional performance can be

viewed as a measure of overall
impact of health conditions in the
context of a patients environment
and social support system.
living (IADLs), and advanced activities of daily living
(AADLs). The BADLs are the tasks that patients
need to be able to complete on their own, or have
assistance to complete, in order to be able to live in
their own residences: transferring, toileting, bathing,
dressing, continence, and feeding. The IADLS are
the abilities one needs to maintain an independent
household: shopping for groceries, driving or being
able to use public transportation, telephone skills,
meal preparation, housework, home repair, laundry,
taking medications, and handling finances. Patients
may be dependent in 1 IADLs but still able to live
at home alone given they are independent in their
ADLS and have family support to help pay bills, for
example. Understanding the areas of impairment is
essential to being able to meet the patients needs
with appropriate resources and also often helps with
diagnosis. For example, in a patient with dementia,
the inability to feed oneself usually is indicative of an
advanced dementia. Measurement of AADLs (societal,
family, recreational, and occupational tasks) can also
be helpful in detecting changes in functional status
prior to onset of disability.
These questions can be completed prior to
the initial visit with a use of a previsit questionnaire (Figure 3; can be downloaded from http://
www.geronet.ucla.edu/professionals/patient-care-re
sources) or can be formally asked at the initial visit.
There are also several instruments that incorporate
DOI:10.1002/MSJ

these functions into quality-of-life questions (eg,

Study Short-Form 3620 and Short-Form1221 ). Asking
older persons about how they spend their day also
gives insight into higher level of functioning of healthier older persons, when they are still independent in
their ADLs and IADLs.

COGNITIVE ASSESSMENT TOOLS

Detection of cognitive impairments early can identify
treatable conditions, such as ischemic brain disease,
when risk factors can be then better controlled,
helping to prevent progression of disease. Detection
of Alzheimers disease can lead to appropriate
pharmacologic treatment and improvements in
patient safety by garnering appropriate resources to
assist with ADLs and IADLs. Early detection may
also help facilitate long-term planning, including
identifying preferences for care and sources of
financial and caregiver support that will be important
as the disease progresses.
The Mini-Mental State Examination, a 30-item
interviewed administered assessment, is a validated
and commonly used screening tool. Expected scores
are based on age and educational level. There are
also several shorter validated screens for cognitive
impairment listed in Table 3.22 These include the
Mini-Cog test, which combines 3-team registration
and recall with clock drawing. The clock-drawing
component of these tests helps evaluate higher
executive functioning and is less influenced by
educational level and culture.
It is important to note that scoring perfectly on
any cognitive screening test does not preclude the
diagnosis of dementia. Functional-status performance
is interpreted along with cognitive testing in order
to diagnose level of dementia. Highly educated
persons may score perfectly but have deficiencies
in insight and judgment. Conversely, patients may
score less than optimally on a screening test because
of language barriers or education, but have good
performance when tested in greater depth.

Scoring perfectly on any cognitive

screen does not preclude the
diagnosis of dementia.
PSYCHOLOGICAL ASSESSMENT TOOLS
Depression and other affective disorders are common
in the older population. Moreover, older adults may

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Fig 3.
Table 3.

495

UCLA Previsit Questionnaire.

Examples of Brief Screening Questions for Cognitive Impairment.22

Test
MMSE
Abbreviated mental status test
Clock drawing
Mini-cog
7-minute screen

Positive Screen (Cutpoint)

Positive Likelihood Ratio

Negative Likelihood Ratio

24
6 or 7
Various
2
Logistic regression

3.411.8
612
47.8
13
47

0.100.37
0.350.063
0.170.3
0.25
0.09

Abbreviations: MMSE, Mini-Mental State Examination.

DOI:10.1002/MSJ

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not volunteer that they are depressed, but instead

present with vague complaints as self-reported
fatigue, or more specific symptoms of anorexia
with subsequent weight loss and sleep disturbance.
Therefore, it is important for physicians to screen
for depression in patients for whom there is any
concern. The Patient Health Questionnaire-923 is a
validated self-administered tool. A score of >10 has
a sensitivity of 88% and a specificity of 88% for major
depression. A 2-item version (PHQ-2) has been used
for screening.24 This screener asks the patient, Over
the past 2 weeks, how often have you been bothered
by any of the following problems? Little interest or
pleasure in doing things. Feeling down, depressed, or
hopeless. Responses are scored as follows: 0 = not
at all, 1 = several days, 2 = more than half the days,
3 = nearly every day. Persons who score 3 have a
75% probability of having a depressive disorder.
In patients who may not be able to complete
a self-administered tool (secondary to cognitive
or visual impairment), the Geriatric Depression
Scale may be more helpful. This tool is physician
administered with yes-or-no answers, and available
in 5-item,25 15-item,26 and 30-item versions.

SOCIAL ASSESSMENT
There is a great deal of interdependency between
patients social situations and their functional status. For example, persons dependent in ADLs or
IADLs must have sufficient social or financial support to meet their needs. If patients are healthy but
have no social support (family or friends), physicians should inquire who would help them should
they have an increased level of need. For patients
who are dependent in functional activities, it is
important to ask who helps them perform each
specific task (Figure 3; can be downloaded from
http://www.geronet.ucla.edu/professionals/patientcare-resources). A variety of private and public
resources can provide further assessment if the initial
screening indicates a problem. Home assessments
provided by home health social worker can also help
further reveal levels of support at home.

ECONOMIC ASSESSMENT
The current economic crisis has affected many older
Americans, who are often on fixed incomes. More
older Americans are filing for bankruptcy, having
lived on credit and emptied their retirement funds
in the face of lost assets and increasing living
DOI:10.1002/MSJ

and medical expenses.27 Older Americans are also

helping their children more, given the recessions
effect on younger Americans as well. Older persons
who are dependent in their ADLs and/or IADLs, and
do not have family readily available to fulfill these
needs, may be able to tap into their savings or equity
(eg, through reverse home mortgages) to pay for
caregivers, though often as a last resort.28 If personal
resources are not available, they can apply for
caregiver support through state or federal agencies.
Economics plays a large role in undernutrition,
as discussed earlier, as well as ability to buy
medications. Therefore, the physician should probe
as to whether the patient has sufficient social and
economic support. Patients sometimes are reluctant
to admit that they are having difficult financial times.
Physicians can review insurance coverage. Patients
with Medicaid may qualify for additional medical or
social benefits. Physicians can consult social workers
to help explore if patients qualify for Medicaid or
other state or federal assistance programs. Physicians
can also help connect patients to financial assistance
programs offered by drug manufacturers to help
lower the cost of specific medications.

Patients with Medicaid may

qualify for additional medical or
social benefits.
SPIRITUAL ASSESSMENT
Spirituality can have a significant influence on overall
health. Though there are no formal assessment
instruments that are common in clinical use,
physicians should inquire whether spiritual or
religious beliefs play an important role for patients.
This can help give insights into their care plan and
goals of care. In the hospitalized setting, chaplaincy
support can be very helpful in helping to align
patients medical decisions with their belief system.

CONCLUSION
Geriatric assessment is an essential part of the comprehensive care of older persons, from the healthy
and high-functioning to those with significant impairments and multiple comorbidities. Many of the above
assessments can be completed prior to the initial
visit with the use of a previsit questionnaire (see
http://www.geronet.ucla.edu/images/stories/docs/
professionals/Geri Pre-visit Questionnaire.pdf for an

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example). Physicians can then review areas of

concern with patients at their first visit, and schedule
follow-up visits to address issues further as needed.
In the future, implementation of the above screening
strategies and validated tools should become easier
with advances in technology and electronic medical
records. In addition, with the advent of innovations in
practice, such as the Patient-Centered Medical Home,
many of the performance-based initial screens will be
performed by office staff. These approaches should,
in turn, help these assessments become more efficient and less time-consuming to incorporate into
daily practice.

DISCLOSURES
Potential conflict of interest: Nothing to report.

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DOI:10.1002/MSJ