Guide to a Comprehensive Geriatric

History

developed by

Maria H. van Zuilen, Ph.D.

Willa Xiong, B.S.
Marcos Milanez, M.D.
Michael J. Mintzer, M.D.

April 2013

Overview

This guide is designed for use by medical students in preparing for a series of home visits. The
narrative can be adapted for use by other medical trainees in almost any other clinical venue.
See companion users guide.
The purpose of this guide is to give you an overview of the different components to consider
when taking a history in an older adult. The history taking process with older adults is different
from that with younger adults because the geriatric population is more likely to have multiple
and often complex medical, social, economic, and psychological factors that impact functional
status and quality of life. There is no specific age at which to begin asking about the areas
addressed in this guide and no preset order in which to ask the questions. The setting in which
the person is seen and the purpose of the evaluation will help determine the focus and content
of the assessment. For example, in most medical settings, the reason for seeking care or the
chief complaint is addressed first. However, since your visit occurs in a non-clinical setting, the
home, you should begin by getting to know the person and learn about his or her background
and social history. This will help you establish rapport, which in turn will make it easier for you to
ask some of the more personal questions in other parts of the history. As William Osler said, It
is more important to know the person with the disease than the disease the person has. In a
clinical setting, it is often not feasible to gather all the information covered in this guide during
one encounter, but since you have ample time during your visit, we expect you to obtain a
comprehensive history.
Note: If at any time during your home visits you are concerned about a symptom, there are
several things you can do. First, if you think it is an emergency, let the person know that you are
calling 911. If you believe the symptom is urgent and needs to be addressed without delay, tell
the person to call their doctor immediately for an appointment. Finally, if you are unsure, you
can call the course directors to discuss your concerns.

Objectives
After reviewing this guide and completing your first home visit, you will be able to:
Discuss how a geriatric history differs from a history with a younger adult.
Describe the domains and purpose of a comprehensive geriatric assessment
Determine problems and stressors in the social and economic domains
Determine the formal and informal support systems in place that support function
Determine an older persons functional status by assessing his or her ability to
perform basic and instrumental activities of daily living
Screen for memory and mood problems in the psychological domain

Page 2 of 24

Take a medical history that is geared towards the recognition of common geriatric
syndromes and problems
Document the results of your geriatric assessment in standard history format

Using Effective Communication Skills

History taking involves the use of communication skills. During this visit, you will have an
opportunity to practice how to open and close a session and how to effectively communicate
during the session. You may encounter some barriers to communication, including vision and
hearing problems, language, low health literacy, and generational gaps. Here are some
strategies that promote effective communication.
At the beginning of the visit
Introduce and identify yourself State your name and medical school affiliation.
Ask how the person would like to be addressed (first name or surname) Use his or her name
during the interview.
Establish the agenda for the visit Explain the purpose of the visit and give an overview of what
you would like to accomplish during the interview. For example: We are here to take a
comprehensive history and learn about the support systems you have in place that help you live
successfully in the community.
Decrease background noises and distractions Turn off your cell phone during the visit. If a TV
or radio is on in the room, ask if this can be turned off.
During the visit
Face the person directly at eye level Sit close to the person you are interviewing. Maintain eye
contact when asking questions and make sure the person can clearly see your face.
Lower the pitch of your voice Older adults with hearing problems have difficulty with higher
pitch sounds. To compensate, lower your pitch when you speak. DO NOT SHOUT, as this raises
your pitch.
Ask one question at the time Avoid multipart questions; you may only get an answer to one
part.
Avoid medical jargon If a question is not understood, rephrase it in simpler terms.
Introduce each section Verbalizing that you are about to transition to a new topic helps the
person stay oriented. It also gives you a moment to mentally organize the topics you need to
address in the upcoming section. For example: Now I would like to ask you some questions
about your family history and some of the illnesses that run in your family.
Begin with open-ended questions Questions starting with phrases such as Tell me about,
What do you think, or How do you lead to more complete and meaningful answers.
However, closed-ended questions are appropriate for some parts of the history. They can also
be helpful when clarification is needed, or if there are time constraints and essential information
is needed (as in many clinical settings). Move from general to specific questions.
Use active listening skills Show that you are listening by using appropriate verbal and nonverbal cues, such as eye contact, head nods, uh huhs, smiles, and other content-congruent
expressions.
Restate or paraphrase information This shows that you are listening and understanding what
is being said. For example: Sounds like you are . So what you are saying is. Do I
understand correctly that?

Page 3 of 24

Summarize periodically This allows you to verify that you understand the main ideas or
concerns the person has expressed. It also aids the transition between interview sections.
Ask for clarification When needed, dont be afraid to ask questions to clarify certain points.
Show empathy and respond to feelings If the person gives a lot of abstract information without
emotion, you can ask how he or she is feeling. You can also use reflection putting words to
their underlying emotion to help you understand or clarify what the other person is
experiencing. For example: You seem to be feeling overwhelmed by ., It sounds like you
are really worried about . Allow moments of silence in the conversation, especially when a
difficult or emotional issue is discussed. This gives the person time to reflect and gather his or
her thoughts.
At the end of the visit
Thank the person for his or her time and participation in the program
Ask if the person has any questions Before ending the visit, always check if there are any
remaining questions or if there was anything else the person had wanted to share.
Make plans for the next visit (if applicable) Explain when the next visit will occur and when you
will contact them again.
Most importantly, allow the person to tell his or her story. Be prepared to share a little bit
about yourself as well have a conversation!

Using Effective Observation Skills

In addition to good communication, one of the most important skills you can develop as a
physician is observation. Using your senses (e.g., vision, hearing, smell) during all aspects of
your encounter will help you form a more well-rounded picture of the person you are
interviewing and their special needs in the different domains of a geriatric assessment.
Observation will help you identify patient behaviors, problems, and important safety
concerns, abuse, neglect, or self-neglect that may need urgent attention.
Observations starts from the moment you first make contact with the person you will be
interviewing. This often occurs during a first phone conversation to schedule an appointment.
Does the person seem confused? Do they understand why you are calling? Do you find
yourself repeating information? Are they able to hear you? These are just a few of the
questions to ask yourself that can provide clues to geriatric problems the person may be
experiencing such as memory loss or hearing impairment. If your visit is in the persons
home, observe how easy it is to get to their residence. Is it near public transportation? Does
the neighborhood appear safe? Does their home or apartment appear well-maintained and is
it easily accessible (e.g., stairs, elevator)?
Observation continues as you as you first meet the person. Do they remember why you are
there? Are they able to walk independently or do they use an assistive device for
ambulation? Do you notice any obvious physical abnormalities (e.g., stooped posture,
arthritic hands) or use of sensory aids (glasses or hearing aids)? Are they appropriately
dressed and well-groomed? Are there any noxious smells to suggest poor hygiene or inability
to keep up with the housework? Does the person appear sad or anxious? Is there someone

Page 4 of 24

else who is answering questions for the person? These observations will give you a first
impression of the person which you can confirm during the remainder of you interview.
Later in this guide, we have more specific recommendations for observation during your
interview, including areas to observe inside and around the home to determine safety
hazards.

Domains of a Geriatric Assessment

Comprehensive evaluation of an older
persons health status involves a different
perspective from that used to evaluate
younger adults. It requires an appreciation
for how issues in multiple domains of
function (physical, psychological,
socioeconomic) can interact in complex ways
to affect a persons functional status and
well-being. For example, a person who
cannot afford their medications may end up
with uncontrolled hypertension. This in turn
may lead to a fall and a fracture requiring
hospitalization and eventual nursing home
placement due to the decline in functional
status especially if the person does not have
the social support system in place to return
back home. Functional status or self-care
ability is central, as this dictates the need for
medical and social services.

Medical/ Physical

Self-Care
Function
Socio-Economic

Psycho-logical

Older people want to remain independent as long as possible. A comprehensive assessment of

all domains using special tools to screen for the presence of major illness and problems that
occur more frequently in the elderly (e.g., memory and mood disorders, mobility problems, and
medication issues) will help you identify early interventions aimed at reducing the impact of
these problems on function and quality of life. In practice, geriatric assessment and
implementation of interventions is done by an interdisciplinary team of providers.

Social Domain
Demographic Data and Background Information
This information is important because it not only helps the healthcare provider determine the
patients risks, but may also provide information about services the patient is eligible for. Certain
health problems are more prevalent in particular age groups, racial or ethnic groups, and
occupations. Low health literacy and health risk behaviors are also more common in some
groups. You will inquire about the persons:

Page 5 of 24

Age Although you will record the persons chronological age, it should be noted that
this data tells you very little about the person. You may see a 90-year old who is very
active and completely independent or a 65-year old who needs partial assistance with
daily activities.
Race or ethnic background Hispanic or Latino origin; White, African American,
American Indian and Alaska Native, Asian, Native Hawaiian and Other Pacific Islander
Marital/relationship status Married/cohabitating, single, widowed, or divorced
Level of education Note the highest degree obtained
Birthplace and residences If foreign-born, assess citizenship status as this determines
services the patient is eligible for
Family constellation Parents, siblings, children, grandchildren
Primary language spoken at home Also assess English proficiency
Work history Type of work, industrial exposures, duration of employment (If retired,
note the primary occupation the person)
Military service record Is the person a veteran and thus eligible for extra services?
Significant life experiences Major positive or negative life events such as the death of
child, loss of a home, a job promotion, or celebration of a 50th wedding anniversary can
impact a persons sense of self and well-being.
Health literacy As you are obtaining this background information, begin to form an
impression of how well the person will be able to understand the health information a
medical provider might communicate (e.g., instructions on how to take medications, the
meaning of test results, or information on how to access available services).

Current Living Situation and Environment

Evaluating the persons living situation and physical environment can provide information on the
existing support systems, social stressors and burdens, ease of access to services (i.e.,
transportation, shopping, doctors office, pharmacy), and the safety of the living conditions.
Information to gather includes:
With whom the person lives (i.e., spouse, children, grandchildren, alone)
Type of residence (i.e. house, apartment, senior living community, assisted living facility,
1 vs. 2 story residence)
Location of residence (i.e., proximity to family, public transportation if needed, stores)
Environmental safety (i.e., neighborhood safety, safety in and around the house)

Formal and Informal Supports

There is a common misconception that many older people live in a nursing home, or live alone
and isolated from their family without support. In fact, according to the 2010 Profile of Older
Americans1, only 4.1% of the 65+ population live in an institutional setting such as a nursing
home. In addition, among non-institutionalized older adults, only 30.1% live alone. Many of
those who live alone live close to their children and see them often. One of the main reasons
older adults are able to continue living in the community, despite developing dependencies, is
the presence of informal and formal support systems. When these systems are not available,
the risk for hospitalization and institutionalization increases drastically.
Informal supports consist of unpaid help and services received from family, friends, neighbors,
or community and church groups. Formal supports refer to paid services received, such as
those from public and private social service agencies or health services providers (e.g. doctors
and nurses). As part of a geriatric history, you should routinely assess the formal and informal

Page 6 of 24

support systems in place to support the persons functional independence. Almost all older
adults use several formal and informal support services. If the person is relatively independent,
one quick way to assess the availability of supports is to ask: Do you have any relatives,
friends, or neighbors who would take care of you for a few days if needed?
The table below lists some examples of formal and informal supports in several domains.
FORMAL

INF ORMAL

Telephone alert system or medical alert

system for emergencies
Taxi, special discounted transportation
services for elderly, buses and trains, paid
shuttle service to shopping/supermarket
Grocery delivery service; Meals on Wheels or
other prepared meals delivery service
Housekeeper, house cleaning service, laundry
or dry cleaning service, yard service, hired
handyman
Visiting nurse or home health aide who
provides medical or personal care (bathing,
dressing) and medication management;
prescription delivery service
Financial management/planner, accountant,
money manager or advisor
Social and recreational services such as day
care programs, senior centers, and clubs that
require a fee or membership
Medical and mental health services (e.g.
physician, psychologist, grief counselor);
Veterans Affairs
Physical therapy, exercise classes, fitness
center or SilverSneakers membership

Telephone buddy system with family, friends,

or group; someone who regularly checks in
Transportation to necessary appointments
and/or shopping provided by family, friends,
community volunteer, or free community
shuttle service
Meals prepared by family or friends, including
meals prepared in advance for reheating
Family or friends who help with cleaning,
laundry, and other chores in and around the
house
A family member or friend who helps with
medical or personal care, or who helps sort
medications, fill insulin syringes in advance, or
refill medications before they run out
A family member or friend who helps with the
bills, balancing the checkbook, or taxes
Community centers
Community support groups, spiritual or
religious counselor (can be formal or informal)
Mall walking program, walking with neighbors;
free water aerobics or other exercise classes

Lifestyle (Hobbies and Habits)

You can begin by asking the person to describe a typical day: Tell me about your activities
on a typical day. Then follow up with specific questions to assess each of the areas below.
Hobbies and social activities
Ask: What do you like to do for fun? What social activities do you engage in? Have
you cut down on your hobbies or social activities? If yes, determine why.
Exercise
Assess overall activity level, and formal and informal exercise regimens. What type of
exercises or sports do you engage in? What types of physical activities do you do in
and around the house? Have you cut down on your exercise and physical activities for
medical or other reasons? If yes, ascertain why.
Nutrition
Determine the persons typical diet and any barriers to healthy eating. What is your diet like
tell me what you eat on a typical day and how often you eat? Here are some warning signs

Page 7 of 24

for nutritional risk you can ask about that are included in a survey developed as part of the
Nutrition Screening Initiative2:
The presence of a medical condition that has caused a change in eating pattern or
difficulty swallowing
Eating fewer than 2 meals a day
Eating few fruits, vegetables, or milk products
Tooth loss or mouth pain causing difficulty chewing Possibly due to ill-fitting dentures
Economic hardship Not having enough money to buy food
Social isolation that results in the person eating alone most of the time
Multiple medicines Taking 3 or more prescribed or over-the counter medications
Involuntary weight loss/gain of more than 10 pounds in the last 6 months
Needing assistance in self care Not being able to shop or cook independently
Excessive alcohol use (having 3 or more drinks every day)
Another useful strategy to determine nutritional status is to do a refrigerator biopsy. Ask
permission to look in the refrigerator. This will help you determine if the person has enough
food. Note the diversity and freshness of the food. You can do this as part of your home safety
assessment.
Caffeine use
Ask: On a typical day, how many cups of coffee or other caffeine-containing beverages
(tea, soda, energy drinks, etc) do you have? Ascertain type, amount, and frequency. Three
8oz cups of coffee (about 250mg of caffeine) is considered average or moderate. Although
moderate caffeine intake has been linked to some positive outcomes such as increased
alertness, habitual caffeine consumption greater than 400 mg per day has been linked to
medical problems, including high blood pressure, heart disease, gastrointestinal problems,
insomnia, anxiety, and detrussor instability (unstable bladder) 3.
Tobacco use
Assess current and prior use. Do you smoke cigarettes or use other tobacco products
(cigars, pipes, chewing tobacco, snuff)? If no, Have you ever smoked cigarettes or
used other tobacco products? If yes, find out how much. Report amount in pack years
(number of packs per day X years smoked) or, if they chew, cans per day. It is also helpful to
ascertain the type and brand of cigarettes smoked, and any previous attempts to quit. If
previous attempts have been made, ask why they were not successful.
Alcohol use
Assess current and prior use. Do you drink alcohol? If no, Did you ever drink in the
past? If yes, elicit the frequency, amount, and type of use. The National Institute of Alcohol
Abuse and Alcoholism recommends that adults over age 65 who are healthy and do not take
medications have no more than 3 drinks on a given day and no more than 7 drinks in a week.
Those with health problems or on certain medications may need to drink less or not at all.4
Physiologic changes result in increased sensitivity to alcohol with age. The same amount of
alcohol causes a greater degree of intoxication in an older person, compared to a younger one.5
Alcohol by itself can be harmful, but presents an added danger when mixed with prescription or
over-the-counter medications. Alcohol can reduce or alter the effectiveness of these
medications.
If you are concerned about current abuse, ask the CAGE questions.6
Have you ever felt you should Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?

Page 8 of 24

Have you ever felt bad or Guilty about your drinking?

Have you ever had a drink first thing in the morning (Eye opener) to steady your nerves
or get rid of a hangover?
In the general population, a score of 2 or higher should raise a high suspicion for problem
drinking or alcohol abuse. However, alcohol use disorders can be missed in older adults
because they often have reduced social and occupational involvement. Hence, a cutoff of 1 may
be used in the older population.
Substance use
Ask: Do you use street drugs like marijuana, cocaine, or ecstasy? If yes, determine type,
amount and frequency.
Although older adults are less likely to use illegal substances than younger adults, it is still an
important area to inquire about. Alcohol and other substance use problems are underrecognized and under-reported in the elderly. The effects of these problems (e.g. falls,
confusion, insomnia, depression, nutritional deficiencies, cardiovascular disease) are commonly
mistaken for signs of normal aging, or assumed to be related to medical or psychiatric problems.
Incorporating questions about alcohol and substance use as a routine part of the history will
facilitate early identification and treatment of these problems.
Personal Safety
The percentage of older adults who are victims of abuse, neglect, or exploitation is estimated to
be between 2-10%, but the large majority of cases never come to the attention of authorities.
The perpetrator is most likely to be a family member or caregiver.7 Therefore, questions such as
Do you feel safe at home? and Have you ever been hurt by (felt threatened, controlled
by, or afraid of) someone at home? are best asked without family members or caregivers
present. Although the U.S. Preventive Services Task Force (USPSTF) has made no specific
recommendations for or against the routine screening for elder abuse8, it is important to ask
about personal safety, especially in frail, dependent elders who are at highest risk. In the
absence of a caregiver, sometimes self-neglect is seen. Poor personal hygiene, an inadequate
living environment, not filling prescriptions, and missing medical appointments may be signs of
neglect. Note that reporting of elder abuse is mandatory in most states.
Note: If you suspect elder abuse or neglect, please immediately contact the course
director who will help you report the case to Adult Protective Services if warranted.
Caregiver Burden
About one in six older persons serve as an unpaid caregiver for a family member (e.g. spouse,
parent, sibling, disabled child, grandchild) or non-relative, and this number is expected to grow
in the next few decades.9 On average, caregivers spend about 20 hours a week providing care.8
As one might expect, care giving responsibilities can take a toll on a persons emotional,
physical, and financial wellbeing. Ask if the person has a caregiver role: Do you serve as a
caregiver for a family member or other person? If so, determine the extent of this role,
adequacy of support received, and how the person is coping. Follow up questions you can ask
are: How are you coping with these responsibilities?, Do you have assistance from
family members or community agencies to give you respite or help you when need it?
Some signs to watch for in caregivers include depression, drug or alcohol abuse, lack of support
from family or friends, and an inability to cope with stress. These factors all increase the risk of
the care recipient being mistreated.
Home Safety To be completed during your third and final home visit
Driving Safety
Recent crash statistics from the National Highway Traffic Safety Administration show that drivers

Page 9 of 24

65 years and older have fewer accidents per 100,000 licensed drivers than those younger than
55.11 Because older adults drive fewer miles than any other age group, it has been argued that
crash statistics should be reported per mile driven. When statistics are examined on a per-mile
basis, older drivers have higher rates of traffic violations, collisions, and fatalities than drivers
from any other age group, with the exception of younger drivers ages 15 through 24. Older
drivers are at a much higher risk of getting into an accident while making a left turn. Although
most older adults self-restrict their driving at night, on highways, in heavy traffic, and in bad
weather, and are less likely to drive under the influence of alcohol, they are significantly more
likely to have the following risk factors for unsafe driving: confusion, poor vision and hearing,
severe arthritis and limited mobility, uncontrolled medical conditions (e.g. diabetes, heart
disease), and side effects of certain medications.
Here are a few statements and questions to help you begin the discussion about driving safety.
Ask follow-up questions if needed.
Tell me about any changes you have made to your driving behavior.
Tell me about any accidents you have been in during the past 6 months.
Have you gotten any new dents, dings, or scratches on your car lately?
How often do you forget to wear your seatbelt?
Do you ever drink alcohol before driving?
Have you ever gotten lost while driving?
Has anyone complained about your driving?
As healthcare providers, you should recognize signs of, and risk factors for, unsafe driving.
Intervene appropriately and, if needed, help the person find alternative means of transportation
before he or she becomes a danger to self and others.
Advance Directives
The term advance directives is most commonly used to refer to treatment preferences and the
designation of a surrogate decision-maker in the event that a person becomes unable to make
medical decisions on his or her own. The prevalence of advance directives in older adults has
increased over the past few decades mostly as a result of changes in legislation. However,
many older adults who have advance directives have not discussed them with their health care
provider. There are three main types of advance directives.
1. Living will A written document that allows individuals to specify what types of medical
treatment they desire and how they wish to be treated in case they become
incapacitated.
2. Health care proxy or durable power of attorney for health care (DPAHC). A legal
document in which individuals designate another person to make health care decisions,
in case they are rendered incapable of making their wishes known. (State laws vary.
Often a health care proxy form can be completed by the patient alone but, in order to
establish a DPAHC, a notary or preparation by a lawyer may be required.)
3. Do not resuscitate (DNR) order A form that allows individuals to request not to be
resuscitated if their heart or breathing stops.

Page 10 of 24

In the broadest sense, advance directives can pertain to any kind of advance end-of-life
planning completed, including organ donation, durable power of attorney (for financial affairs),
estate planning, and funeral arrangements.

To introduce this topic you might ask Who is the person that should make decisions for
you if had a medical emergency and could not speak for yourself? Then determine what
advance directives the person has in place and if they have followed the appropriate steps to
ensure these directives will be implemented when needed (e.g., provided a copy to all their
doctors, store the documents in an easily accessible location, inform family members of the
content and the location, keep a wallet size copy with them, and update them periodically).
Spirituality
Assessing a persons spirituality or religious beliefs and practices can give you a better
understanding of how he or she might cope with life stressors, such as chronic medical illness
or terminal illness. Affiliation with a religious or spiritual group can also be a source of informal
support. Begin with an introductory question, such as Do you consider yourself a spiritual
or religious person? Then you can follow up if needed and determine what religion the
person practices, how often he or she attends services or participates in activities, what
supports might be available through these affiliations, and how the persons beliefs help him or
her cope with medical problems and life stressors.
Sexual Health History
The sexual health history is frequently not addressed in older adults, in part because physicians
and patients are uncomfortable raising the topic. Data from a recent national study of sexuality
and health among older adults shows that many men and women remain sexually active well
into their 70s and 80s, but that almost half of those who were sexually active reported at least
one sexual problem (lack of desire, vaginal dryness, erectile dysfunction).12 Older adults are
more likely to have physical diseases or to be on medications that can cause sexual
dysfunction. Certain higher-risk sexual behaviors also increase with age. When a spouse or
partner dies, new sexual partners come on the scene. Sometimes, older adults date multiple
partners and, perhaps due to a lack of concern about pregnancy, are less likely than younger
adults to use condoms. Age offers no protection against sexually transmitted diseases (STDs).
Over the past few decades, the number of STDs in the older age group has increased for both
men and women, with men who use erectile dysfunction drugs at the highest risk for STDs.13
Before delving into the sexual history, you should ascertain if the person is comfortable talking
about this topic. You can begin by asking, Are you comfortable discussing your sexual
history right now? Reassure the person that he or she can decline to answer any question.
Here are a few suggested questions:
Are you currently sexually active?
Are you involved in an intimate relationship?
Do you have any problems or concerns about your sexual desire or performance?
Are you concerned that a medication you are taking might be affecting your sexual
abilities?
Do you use any medications to help you with your sexual desire or performance?
Do you use a condom or other form of protection when having sex?

Page 11 of 24

 Have you ever had, or been tested for, any sexually transmitted infections?
(Advise the person to discuss any concerns he or she has with his or her doctor.)
References:
1
Administration on Aging. A Profile of Older Americans: 2010. U.S. Department of Health and Human Services,
Washington DC (online). Available at: http://www.aoa.gov/AoAroot/Aging_Statistics/Profile/2010/index.aspx.
Accessed March 21, 2013.
2
Nutrition Screening Initiative. Report of Nutrition Screening 1: Toward a Common View. Washington, DC: Nutrition
Screening Initiative, 1991.
3
Nawrot P, et al. Effects of caffeine of human health. Food Additives and Contaminants, 2003;20(1):1-30
4
http://www.niaaa.nih.gov/alcohol-health/special-populations-co-occurring-disorders/older-adults. Accessed July 10,
2013
5
Dufour M, Fuller RK. Alcohol in the elderly. Annu Rev Med 1995;46:123132.
6
Ewing JA. Detecting alcoholism: the CAGE questionnaire. JAMA 1984;252(14):1905-1907
7
National Center on Elder Abuse. Elder Abuse Prevalence and Incidence. Washington DC: National Center on Elder
Abuse, 2005.
8
Screening for Family and Intimate Partner Violence, Topic Page. March 2004. U.S. Preventive Services Task Force
(online). Available at: http://www.uspreventiveservicestaskforce.org/uspstf/uspsfamv.htm. Accessed March 21, 2013.
9
The National Alliance for Caregiving and AARP. Caregiving in the U.S. 2009. Washington DC. National Alliance for
Caregiving. 2009,
10
Gillespie LD, et al. Interventions for preventing fall in older people living in the community. Cochrane Database of
Systematic Reviews 2012, Issue 9. Art. No.: CD007146.
11
National Highway Traffic Safety Administration. Traffic safety facts 2009 data, Washington DC. NHTSA (online).
Available at: http://www-nrd.nhtsa.dot.gov/Pubs/811402EE.pdf. Accessed on March 21, 2013.
12
Lindau ST, et al. A national study of sexuality and health among older adults in the U.S. NEJM, 2007;357(8):762774.
13
Jena AB, et al. Sexually transmitted diseases among users of erectile dysfunction drugs: Analysis of claims data.
Annals of Internal Medicine, 2010;153:1-7.

Economic Domain
In the economic domain you will assess financial security and health care coverage. The
economic well-being of older adults impacts their health and functional status. In 2011, about
3.6 million elders (8.7%) lived below the official poverty cutoff ($10,890 for a single person and
$14, 710 for a couple). This rate is lower than that for the nation at large (15.0%). However, an
additional 2.4 million older adults (5.8%) were considered near-poor (i.e., income between the
poverty level and 125% of this level).14 Moreover, the poverty threshold does not take into
account the added out-of-pocket medical costs many older adults face, which can cut severely
into their disposable income. If such costs are taken into consideration, as is done in the
Supplemental Poverty Measure, the poverty rate for elders rises to 15%.15 Because lower
income is associated with poorer health outcomes, a persons financial health is an essential
component of the geriatric assessment. To determine if there are any economic stressors, it is
helpful to learn about a persons sources of income, medical coverage, need for financial
assistance, and need for assistance with managing their finances. Here are a few questions you
can ask:

Page 12 of 24

What are your main sources of income (i.e., job earnings, social security, pensions,
savings, or income from assets)?
Do you find it difficult at times to cover all your expenses such as housing, bills, and
food?
Who manages your finances? Do you have any concerns with how your finances are
being managed?
What kind of health insurance or health care coverage do you have (i.e., Medicare,
Medicaid, private health insurance plan such as a health maintenance organization or
preferred provider organization, military health plan, private pay)?
Are there times when it is difficult for you to pay for your health care or medications?
Do you ever delay seeking care because of the cost?

References:
14
DeNavas-Walt C, Proctor BD, Smith JC, U.S. Census Bureau, Current Population Reports, P60-243, Income,
Poverty, and Health Insurance Coverage in the United States: 2011, U.S. Government Printing Office, Washington,
DC, 2012.
15
Short K. U.S. Census Bureau, Current Population Reports, P60-244, The research SUPPLEMENTAL POVERTY
MEASURE: 2011, U.S. Government Printing Office, Washington, DC, 2012.

Psychological Domain
The two key areas you should assess in the psychological domain are memory and mood.

Memory
A 2011 report by the Alzheimers Association concludes that 1 in 8 older Americans (13%) have
a dementia, with Alzheimers disease being the most common type.16 Although the USPSTF
guidelines state there is insufficient evidence to recommend for or against the routine screening
for dementia17, physicians should watch out for signs of cognitive and functional decline that
might signify the early stages of dementia. We recommend that you obtain both a subjective
and objective assessment of the persons memory. Begin with a screening question, such a
Do you have any problems with your memory? You can then ask some specific questions
to determine if the person has trouble remembering appointments, recent events, familiar
people and places, paying bills, or taking medicines.
There are many screening tools for cognitive impairment, but here are two brief tools that can
be administered under 3 minutes: the Mini-Cog 18(see Appendix A) and verbal fluency, the
number of animals named in 1 minute. For verbal fluency, there are detailed norms adjusted for
age and education.19 However, the average for 60-79 year olds is about 17 and for 80-95 yearsolds it is about 14 for someone with 9-12 years of education. A score of less than 12 should
raise some concerns. We recommend that you administer one or both of these tests.

Mood
Depression commonly occurs with medical illnesses, but it is frequently unrecognized. Nearly
two-third of visits to primary care physicians may involve a psychological component. Having

Page 13 of 24

depression increases ones risk for certain conditions, including cardiovascular disease and
stroke.20 The USPSTF recommends screening for depression when appropriate supports are in
place to assure accurate diagnosis, treatment, and follow-up.21 However, the research evidence
for screening in older adults is limited.
Asking two simple screening questions may be as effective as longer instruments in detecting
depression. 22
Over the past two weeks
Have you often been bothered by feeling down, depressed, or hopeless?
Have you often been bothered by little interest or pleasure in doing things?
If a person responds yes to either of these questions, consider asking some follow up
questions to more fully assess the persons mood. Symptoms of depression to ask about can be
remembered with the acronym SIGECAPS, which stands for: Sleep disturbance (insomnia or
hypersomnia)*, reduced Interest in activities, excessive Guilt or self blame, loss of Energy*,
Concentration difficulties, Appetite (increased or decreased)*, Psychomotor agitation or
retardation*, and Suicidal ideation. The starred items are vegetative symptoms that can occur in
other medical illnesses. The other items are psychological symptoms and some elderly are less
willing to talk about psychological problems. Keep this in mind when using and interpreting the
SIGECAPS.

Observation
During your interview, also observe the person and his or her environment, as this can provide
additional clues to an existing memory or mood disorder. Is the person appropriately dressed
and groomed? Is the persons environment clean and well-maintained? Is there a family
member present who answers most of the questions? Also pay attention to how questions are
answered. Difficulty findings words, repeating information, frequent delays in responding, and
giving brief, non-specific answers may be signs of dementia. Persons with depression may
appear sad and have a flat affect (i.e., lack of an emotional response). If available, use a
secondary informant to verify information when concerns about memory problems arise.
Note: If an elderly person is experiencing new periods of acute confusion (witnessed by you,
family, friends, or hospital staff), you must consider this a medical emergency (delirium), end the
interview, and send the patient for immediate medical evaluation.
References:
16
Alzheimers Association, 2011 Alzheimers Disease Facts and Figures, Alzheimers & Dementia, Volume 7, Issue 2
17
Screening for Dementia, Topic Page. June 2003. U.S. Preventive Services Task Force [online]. Available at:
http://www.uspreventiveservicestaskforce.org/uspstf/uspsdeme.htm. Accessed on March 21, 2013.
18
Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The mini-cog: a cognitive vital signs measure for dementia
screening in multi-lingual elderly. Int J Geriatr Psychiatry 2000;15(11):10211027.
19
Tombaugh TN, Kozak J, Rees L. Normative data stratified by age and education for two measures of verbal fluency:
FAS and Animal Naming. Arch Clin Neuropsych 1999;14(2):167-177.
20
O'Connor EA, Whitlock EP, Beil TL, Gaynes BN. Screening for depression in adult patients in primary care settings:
a systematic evidence review. Ann Intern Med 2009;151:793-803.
21
Screening for Depression in Adults, Topic Page. December 2009. U.S. Preventive Services Task Force [online].
Available at: http://www.uspreventiveservicestaskforce.org/uspstf/uspsaddepr.htm. Accessed March 22, 2013 from
22
Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression. Two questions are as
good as many. J Gen Intern Med 1997;12:43945

Functional Domain
Page 14 of 24

A persons functional status is central to all domains. Functional status refers to the persons
ability to carry out basic activities of daily living (ADLs) and instrumental activities of daily
living (IADLs). ADLs include bathing, dressing, toileting, transferring, continence, and feeding
(see Appendix C). A good way to remember the ADLs is that they make up the morning routine
for most of us. The ADL scale is hierarchical in order and represents not only the progressive
loss of physical function with age and disease progression, but also the return of these abilities
upon recovery or rehabilitation. So if a person is able to bathe independently, he or she is likely
able to perform all other ADLs. The only exception may be incontinence, which can be the
results of medical issues. When interviewing an older person who arrives at a medical
appointment unaccompanied, it may not be necessary to ask about all the ADLs. Use your
judgment.
IADLs require a higher level of cognitive functioning and include shopping, cooking, using the
telephone, managing finances, housekeeping, doing the laundry, handyman work, and
managing medications (see Appendix D). Think of the IADLs as the things you need to be able
to do independently when you first move out of your parents home into a place of your own.
Data from the 2009 National Health Interview Survey shows that limitations in ADLs and IADLs
increase significantly with age (see table below).23
Age group
65-74 years
75 and older

At least one
ADL limitation
3.1%
10.3%

At least one
IADL limitation
6.4%
20.3%

Note: Data do not include incontinence

One factor to consider when assessing IADLs is that some people have never performed certain
tasks. For example, some men may have never cooked, cleaned, or done laundry. In this case,
needing assistance with these IADLs should NOT be interpreted as representing functional
decline. It does, however, indicate the need for support services.
A persons ability to perform his or her ADLs and IADLs is helpful for care planning during a
hospital stay, and is vital information to obtain prior to discharge planning. If a person has selfcare deficits, you may not be able to discharge him or her to the home environment unless
adequate support systems are in place to assist with these deficits.
Reference:
23
Adams PF, Martinez ME, Vickerie JL. Summary health statistics for the U.S. population: National Health Interview
Survey, 2009. National Center for Health Statistics. Vital Health Stat, 2010;10(248).

Physical/Medical Domain

Page 15 of 24

There are several important factors to consider when assessing the medical domain in an older
person. First, many medical concerns are under-reported and/or under-recognized, and the
interviewer must ask specific questions about these issues. For example, urinary incontinence is
often an embarrassing problem and patients will not mention it unless they are asked
specifically about it. Second, symptoms are often expressed as a loss of function rather than as
a typical medical symptom. For example, a patient may say, I cannot lift my grandchild
anymore, when the symptom is pain in the shoulder from arthritis. When interviewing an older
person, it becomes important to ask targeted questions about the presence of geriatric
syndromes and medical problems more prevalent in the elderly, and to address the underlying
reasons for functional impairments. You can introduce this section by saying, Now, I would like
to ask you some questions about your health.

Self-Perceived Health Status

Self-perceived health status is a subjective measure of personal health that correlates with
having a chronic disease or risk factors for poor health, and with morbidity and early mortality
risk.24 It can be assessed with a single question: How would you rate your health in general
- excellent, very good, good, fair, or poor? After introductions, this is often a good way to
begin the interview of an older person you are meeting for the first time. Self-perceived health
decreases with age, as can be seen in the table below based on date from the 2009 National
Health Interview Survey. 23
Age Group
65-74 years
75 and older

Excellent
17.0
10.6

Self Perceived Health Status

Very Good
Good
Fair
29.8
33.4
14.9
24.7
35.8
20.6

Poor
4.9
8.4

As a follow up question, you can ask the person How much do your health problems interfere
with performing your daily activities and your ability to do the things you like to do?

Physical Appearance and Initial Observations

The first few minutes of an interview with an older person often reveals a trove of information.
Does the person appear his or her stated age? Is the person appropriately dressed, groomed,
and nourished? A more focused observation will rapidly reveal important information you may
need during the interview: Do you notice any glasses or hearing aids? Are assistive devices for
ambulation close by, or does the person require assistance with minimal movement? Is there an
overtly obvious physical abnormality, such as eye problems, a missing limb, or body
dissymmetry? Is there a caregiver present? You can rapidly recognize important clues that are
relevant when the interview becomes more detailed.
Do not overlook your other senses. What do you hear from the beginning of the interview? Are
the answers brief or nonspecific enough (see psychological domain) to suggest a thinking
disorder? What do you smell? Are there any odors to suggest poor hygiene, incontinence, or an
underlying medical disorder? Use all of your senses to observe the person for important clues
of disease or underlying medical issues.

Present Health and History of Present Illness

The health history in an older adult generally includes the same information as that for younger
adults, but there is some additional information you will gather. The probability of certain
conditions is higher in the elderly and, with this in mind, you will ask some targeted questions to
assess if these conditions are present. Older adults may have multiple chronic conditions and

Page 16 of 24

complaints and can have a long history of experience with illness and the healthcare system. It
can be a challenge to sort it all out. A systematic approach helps assure completeness.
Current medical problems
Ask the person to describe the health problems he or she currently has, and what treatments he
or she is receiving for these problems. The medication history is described in more detail below.
To obtain more detail about acute symptoms, you can use the OLD CARTS mnemonic tool
(Onset, Location, Duration, Character, Aggravating/Alleviating factors, Radiation, Timing,
Severity).
Below is a list of geriatric syndromes and chronic conditions more common in the elderly.
Because of their prevalence, you should assess whether the person currently has, or has had,
any of these health problems. Some sample questions are provided. Many of these questions
can be incorporated in your Geriatric-focused review of systems.
Hearing impairment
Do you have difficulty hearing conversations even if you are in a quiet environment?
Do you have difficulty talking on the phone?
Do others comment that the TV is too loud?
Do you wear a hearing aid?
Visual impairment (cataracts, glaucoma, macular degeneration)
Do you have trouble seeing when performing daily tasks, such as reading, driving, or
watching TV?
Can you read the labels on your pill bottles?
Do you wear glasses or contact lenses?
Diabetes
Do you have diabetes or problems controlling your blood sugar?
Hypertension
Do you have high blood pressure?
Cardiovascular disease
Do you have any heart disease? Chest pain? Palpitations? Shortness of breath? Dizziness?
Do you have any problems with circulation in your legs, pain in your legs when you walk, or
varicose veins?
Lung disease or upper/lower respiratory tract problems
Do you have chronic breathing problems or asthma?
Do you have problems with your sinuses?
Do you have a chronic cough; do you cough up mucus or phlegm?
Stroke or Transient Ischemic Attack (TIA)
Have you ever had a stroke or a mini stroke (sudden weakness on one side of your body,
sudden speech problems, or brief moments of confusion)?
Nutritional compromise (included in the social domain)
Memory problems/dementia (included in the psychological domain)
Mood problems/depression (included in the psychological domain)
Falls/Mobility
Have you had a fall in the past 6 months? (If yes, explore the surrounding circumstances)
Are you concerned about falling? Do you use an aid for walking?
Do you have any illnesses that impair your mobility or bone health (arthritis, stroke,
Parkinsons disease, osteoporosis, vitamin D deficiency, etc)?
Kidney, Bladder, and Urinary Incontinence
Do you have any problems with your kidneys?

Page 17 of 24

Do you have trouble with your bladder (and prostate in men)?

Do you ever lose urine when you cough, sneeze, laugh, or exercise?
Do you ever lose urine when you dont want to?
Do you ever wear a pad to protect you from urinary accidents?
Pain
Are you experiencing pain or discomfort?
If yes, administer a pain rating scale: On a scale from 0-10 with 0 being no pain and 10
the worst pain you can imagine, how would you rate your pain right now?
Does your pain interfere with normal daily activities or sleep?
Past Illnesses
Determine what major illnesses the person has had. With advancing age and a lifetime of
exposure to common viral illnesses, a past history of childhood illnesses becomes less relevant.
It may be more relevant to inquire about active childhood diseases (chicken pox, measles,
mumps, varicella) in younger family members that present an immediate risk for acute illness,
especially in the setting of pre-existing cardiopulmonary disease. See immunizations section for
the recommendations to prevent infectious diseases in the elderly.
Operations, procedures, or hospitalizations
Determine the reason for care. Ask about what medications, treatments, or procedures were
provided during hospitalizations. Also ask about prior admissions to rehabilitation or skilled
nursing facilities. Record these in chronological order.
Immunizations and preventive health measures To be completed during your second
home visit
Health care providers
Determine all health care providers (physician and non-physician) the person is using, and how
often he or she sees each one. It is sometimes a surprise to learn how often elderly adults see
health care providers and how many different providers they see. Many of these providers do
not know the therapies being offered and delivered by the others. Central coordination of care
and good communication between providers can improve health outcomes and reduce potential
adverse events. Ask about:
Primary care physicians and specialists
Complementary/alternative practitioners (chiropractor, acupuncturist, massage therapist)
Non-pharmacological providers (physical therapist, social worker, psychologist)
Culturally-sanctioned providers (herbalist, Voodoo priest, shaman)
Personal trainer or exercise coach
Medication review
A review of medication use is essential during the interview. Almost 30% of older adults use
more than five prescription medications, and more than half of older adults use five or more
prescription medications, over-the-counter medications, and/or dietary supplements.26 Many
older patients have burdens in the medical, psychological, and socioeconomic domains that
place them at increased risk for nonadherence and adverse medication events. It is critical that
a thorough list of patient medications is obtained to assure a complete understanding of the
illnesses and issues being treated, and to assess the potential barriers to adherence.
Prescription medications Ask about current prescription medications from all health
care providers. This includes lotions, creams, eye-drops, ear drops, inhalers, injectables,
transdermal patches, and oxygen.

Page 18 of 24

Over-the-counter medications (OTCs) Ask if the person is taking any medications

obtained at the drug store.
Complementary and herbal medications Assess the use of herbals, vitamins, and
potions.
Borrowed or shared medications Ask if the person is taking any medications given by
friends or family members, and if he or she shares medications with others. (Caution:
This is an unsafe practice and should be strongly discouraged.)
Research medications: Patients may volunteer to be in a research study. They may not
know the names of drugs used in the study, but will have the name of the study principle
investigator to contact if needed.
For each medication, record the name, indication (what are you taking this medication
for?) dose, and schedule (how often do you take it each day?). You will be able to
form a good impression of the persons understanding of his or her medications and how
to use them appropriately.
Adherence Most people do not take their medications as prescribed 100% of the time.
In recognition of this, start with a statement such as Many people have problems
remembering to take their medications on a regular basis. How often do you
forget to take a medication? If indicated, ask follow-up questions: What do you do
when you realize you skipped a dose? or Are there other reasons you sometimes
skip a dose or do not take a medication as prescribed?
Allergies/side effects/adverse reactions Although providers make distinctions among
these types of reactions, patients do not. Therefore, it is important to record what type of
reaction occurs. For example, breathing problems and skin rashes are allergic reactions,
whereas nausea and constipation are side effects. Severe allergic reactions or side
effects may be adverse when they cause significant harm to patients, or require a
hospital admission.
Ask about dependence or addiction to specific medications
Ask if discontinuing any medication led to withdrawal symptoms
Other medication problems (seeing the labels, opening the bottles, getting refills, etc)
If you are interviewing the person in their home, ask the person if you may take a look at
the location the medications are stored. This may help you identify potential safety
issues (e.g., medications from different family members stored in the same location).

Medical devices, implants and transplants

With increasing medical technology, your older patients are more likely to be using medical
therapies beyond medications. A few simple questions such as Do you have any medical
devices inside of you? or Do you use any devices that provide treatment for an illness?
may elicit additional information about the devices used to manage medical conditions. A few
examples include assistive devices for ambulation, rehabilitation devices, prosthetic limbs,
implanted devices such as a pacemaker or AICD (automatic implantable cardioverter
defibrillator), devices that improve blood flow (stent or ventricular-peritoneal shunt), and medical
machines (home oxygen, CPAP). Since transplantation is becoming a common and accepted
medical technology, it is important to ask about a history of organ or tissue transplantation.
Family medical history
Family history should include the common illnesses and problems considered for all patients,
with special attention to illnesses that impair function. With advancing age, some aspects of the
family history become less contributory. For example, by the time a person reaches the age of
90, a family of heart disease will not put that person at a higher risk than other people their age.

Page 19 of 24

Ask about dementia (e.g., Alzheimer Disease, vascular dementia)

Ask about diseases that impair special senses especially vision or hearing (e.g.,
glaucoma, cataracts, profound hearing loss)
Ask about illnesses that affect mobility (e.g., arthritis, strokes, neuromuscular diseases
like multiple sclerosis)
Ask about any cancers that might run in the family.
Ask about any illnesses in the family that may have required nursing home placement or
other caregiver assistance.

References:
23
Rabin D, Petterson S, Bazemore A et al. Decreasing self-perceived health status despite rising health expenditures.
Am Fam Physician. 2009;80(5):427
24
Advisory Committee on Immunization Practices. Recommended Adult Immunization Schedule: United States, 2013.
Ann Intern Med 2013 Feb;158(3):191-199
25
Qato DM, Alexander C, Conti RM et al. Use of prescription and over-the-counter medications and dietary
supplements among older adults in the Unites States. JAMA 2008;300:28672878.

Page 20 of 24

Appendix A
MINI-COG
1) GET THE PATIENTS ATTENTION, THEN SAY: I am going to say three words
that I want you to remember now and later. The words are

Banana

Sunrise

Chair.

Please say them for me now. (Give the patient 3 tries to repeat the words. If unable after
3 tries, go to next item.)
(Fold this page back at the TWO dotted lines BELOW to make a blank space and cover the
memory words. Hand the patient a pencil/pen).
2) SAY ALL THE FOLLOWING PHRASES IN THE ORDER INDICATED: Please draw a
clock in the space below. Start by drawing a large circle. (When this is done,
say) Put all the numbers in the circle. (When done, say) Now set the hands to
show 11:10 (10 past 11). If subject has not finished clock drawing in 3 minutes,
discontinue and ask for recall items.
-----------------------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------------------------------------------------------------------3) SAY: What were the three words I asked you to remember?
_________________ _________________ _________________ (Score 1 point for each)
3-Item Recall Score
Score the clock (see instructions below):
Normal clock 2 points
Abnormal clock 0 points

Clock Score

Total Score = 3-item recall plus clock score

0, 1, or 2 impairment more likely; 3, 4, or 5 impairment less likely

Page 21 of 24

CLOCK SCORING
NORMAL CLOCK

A NORMAL CLOCK HAS ALL OF THE FOLLOWING ELEMENTS:

All numbers 1-12, each only once, are present in the
correct order and direction (clockwise).
Two hands are present, one pointing to 11 and one
pointing to 2.
ANY CLOCK MISSING ANY OF THESE ELEMENTS
IS SCORED ABNORMAL. REFUSAL TO DRAW A
CLOCK IS SCORED ABNORMAL

SOME EXAMPLES OF ABNORMAL CLOCKS (THERE ARE MANY OTHER KINDS)

Abnormal Hands

Missing Numbers

______________________________________________________________________
Mini-CogTM copyright S Borson, all rights reserved. Reproduced with permission. For
further information contact the author soob@uw.edu.

Page 22 of 24

Appendix C
Activities of Daily Living Scale
Independent
Yes

No

1. Bathing - Can give self a sponge bath, tub bath, or shower (with
either no assistance or assistance in bathing only one part of the body)
2. Dressing - Gets clothes and dresses without any assistance except
for tying shoes
3. Toileting - Goes to toilet room, uses toilet, arranges clothes, and
returns without any assistance (may use cane or walker for support and
may use bedpan or urinal at night)
4. Transferring - Moves in and out of bed and chair without assistance
(may use cane or walker)
5. Continence - Controls bowel and bladder completely by self (without
occasional accidents)
6. Feeding - Feeds self without assistance (except for help with cutting
meat or buttering bread)
Total ADL Score (Number of yes answers, out of possible 6)
A score of 6 indicates full function; a score of 4, moderate impairment; and a score of 2,
severe impairment.
Adapted with permission from: Katz S, Downs TD, Cash HR, et al. (1970). Progress in the development of the index
of ADL, Gerontologist, 10, 20-30

Page 23 of 24

Appendix D
Instrumental Activities of Daily Living Scale
1. Can you use the without help,
telephone
with some help, or
are you completely unable to use the telephone?

3
2
1

without help,
4. Can you get to
places beyond
with some help, or
walking distance

are you completely unable to travel unless special arrangements are made?

7. Can you go
shopping for
groceries

without help,

with some help, or

are you completely unable to do any shopping?

10. Can you prepare without help,

your own meals with some help, or
are you completely unable to prepare any meals?

13. Can you do your without help,

own housework with some help, or
are you completely unable to do any housework

3
2
1
3
2
1

16. Can you do your without help,

own handyman with some help, or
work

19. Can you do your without help,

own laundry
with some help, or

are you completely unable to do any handyman work?

22. Do you or could

you take
medicine

2
1
2

are you completely unable to do any laundry at all?

without help,

with some help, or

are you completely unable to take your own medication?

25. Can you manage without help,

your own money with some help, or
are you completely unable to manage money?
Adapted with permission from: http://www.abramsoncenter.org/pri/documents/MAI.pdf.

Page 24 of 24

3
2
1