Human Development

Geriatric assessment: comprehensive functional and cognitive review

Clinical Overview and When to Suspect Functional/Cognitive Decline

— Target population: adults ≥65 years, especially those with multimorbidity, polypharmacy, frailty, recent hospitalization, falls, or caregiver concern.

— Goals: maintain independence, reduce hospitalizations and institutionalization, identify reversible contributors to decline, align care with patient goals.

— Medicare Annual Wellness Visit (AWV) — required to include a Health Risk Assessment, functional/ADL review, cognitive impairment detection, fall risk, depression screen, and advance care planning.

— Trigger events: unintentional weight loss, new incontinence, falls, delirium episode, hospital discharge, "failure to thrive," caregiver burnout, transition to assisted living.

— Polypharmacy (≥5 medications) or use of any Beers Criteria drug.

— Medical (chronic disease control, nutrition, vision/hearing, continence, pain)

— Functional (ADLs, IADLs, gait/balance)

— Cognitive (memory, executive function, mood)

— Social (caregiver, finances, elder abuse, advance directives)

— Environmental (home safety, driving, access to care)

Board pearl: A "vague" presentation in an older adult — "just not himself," declining appetite, new falls, missed appointments — is the classic Step 3 cue to perform a full CGA rather than chase a single complaint. The exam rewards stepping back to assess function and cognition before ordering more tests or starting more drugs.

Step 3 management: Schedule a dedicated CGA visit (often 45–60 minutes, billable under AWV + chronic care management codes) when triggers are present.

Comprehensive Geriatric Assessment (CGA) is a multidimensional, interdisciplinary evaluation of an older adult's medical, functional, cognitive, psychosocial, and environmental status used to generate a coordinated care plan.

When to initiate CGA in ambulatory practice:

Five core domains assessed:

Evidence base: CGA in hospitalized elders reduces death/dependency at follow-up (NNT ~13 to remain alive and home) and reduces nursing home admission.

Presentation Patterns and Key History

— Pneumonia → confusion, falls, anorexia (not fever/cough)

— MI → dyspnea, delirium, fatigue (not chest pain)

— UTI → functional decline, new incontinence (not dysuria)

— Hyperthyroidism → apathy, weight loss, atrial fibrillation

— Depression → somatic complaints, cognitive slowing ("pseudodementia")

— Mind: cognition, mood, delirium history

— Mobility: falls, gait, balance, ADL/IADL function

— Medications: polypharmacy, adherence, Beers/STOPP drugs

— Multicomplexity: multimorbidity, biopsychosocial issues

— Matters most: patient goals, values, advance directives

— ADLs (Katz): Bathing, Dressing, Toileting, Transfers, Continence, Feeding

— IADLs (Lawton): Shopping, Housekeeping, Accounting/finances, Food prep, Transportation, Telephone, Medications, Laundry ("SHAFT-TML")

— Loss of IADLs typically precedes ADL loss by years; early IADL decline (especially finances and medications) is a sensitive marker for mild cognitive impairment.

— Vision (last exam, cataracts), hearing (use of aids), dentition, swallowing

— Sleep, nocturia, constipation, urinary/fecal incontinence

— Sexual function (often unasked)

— Falls in past year, fear of falling

— Alcohol use, social isolation, food insecurity

Key distinction: Delirium = acute, fluctuating, inattention, often reversible. Dementia = chronic, progressive, memory ± executive dysfunction. Depression = mood-driven, "I don't know" answers, intact attention. Step 3 stems frequently force you to differentiate these three on history alone before ordering any test.

Board pearl: New-onset urinary incontinence in a previously continent elder = functional decline marker, not just a "bladder problem."

Atypical disease presentation is the rule in geriatrics. Always ask: "What is different from baseline?"

Geriatric "5 Ms" framework (American Geriatrics Society) to structure history:

Functional history (must-ask):

Targeted review of systems with high geriatric yield:

Collateral history is essential — interview caregiver separately when feasible to capture insight loss, behavioral change, and unsafe behaviors (e.g., stove left on, getting lost driving).

Physical Exam Findings and Functional/Performance Testing

— Orthostatic BP (supine, then 1 and 3 min standing): drop of ≥20 systolic or ≥10 diastolic, or symptoms — common cause of falls, often iatrogenic.

— Resting tachycardia may be masked by beta-blockers; afebrile sepsis is common.

— Weight at every visit; >5% loss in 6 months triggers workup for malignancy, depression, dysphagia, dementia, medication effect.

— Vision: handheld Snellen or Rosenbaum card; whisper test or finger rub for hearing; refer to audiology for formal testing if abnormal.

— Untreated hearing loss is an independent modifiable risk factor for dementia (Lancet Commission).

— Timed Up and Go (TUG): rise from chair, walk 3 m, turn, return, sit. ≥12 seconds = increased fall risk.

— Gait speed over 4 m: <0.8 m/s predicts adverse outcomes; <0.6 m/s = frailty.

— 30-second chair stand for lower-extremity strength.

— Romberg, tandem stance for balance; observe footwear, assistive device use.

— Skin: pressure injuries, bruising patterns suggesting abuse

— Oral: xerostomia, dentition, ill-fitting dentures (nutrition)

— Cardiac: aortic stenosis murmur (syncope/falls)

— Neuro: parkinsonism (bradykinesia, rigidity), peripheral neuropathy, focal deficits

— MSK: kyphosis, joint deformity, sarcopenia (loss of temporalis, thenar bulk)

— Feet: calluses, ulcers, nail pathology — direct fall risk

Step 3 management: A patient with TUG ≥12 sec or any fall in past year needs a STEADI fall workup: medication review, vision check, orthostatics, vitamin D 800 IU, and referral to PT for strength/balance training. Avoid the trap of ordering brain MRI before doing the bedside gait assessment.

Board pearl: Gait speed is the "sixth vital sign" in geriatrics.

Vitals with geriatric nuance:

Sensory exam:

Mobility and balance — perform in clinic:

Targeted exam findings:

Frailty assessment (Fried phenotype): ≥3 of — unintentional weight loss, exhaustion, weakness (grip), slow gait, low activity.

Diagnostic Workup — Cognitive, Functional, and Mood Screening Tools

— Mini-Cog (3-item recall + clock draw): 3-minute screen; abnormal = 0–2/5 → proceed to formal testing. Best initial Step 3 tool when time-limited.

— MoCA (Montreal Cognitive Assessment): score /30, <26 = abnormal; sensitive for mild cognitive impairment and executive dysfunction (frontal/vascular).

— MMSE: /30, <24 = abnormal; less sensitive to MCI and executive function; copyrighted.

— SLUMS: alternative, free, sensitive to MCI.

— Katz ADL index and Lawton IADL scale — administer formally at AWV.

— Document baseline so future decline is measurable.

— PHQ-2 → PHQ-9 for depression (validated in elderly).

— Geriatric Depression Scale (GDS-15): ≥5 suggests depression; avoids somatic items confounded by aging.

— CBC, CMP, TSH, B12, ± folate, ± RPR, ± HIV if risk

— Vitamin D, calcium if bone/fall concern

— Urinalysis only if symptomatic — do not treat asymptomatic bacteriuria even if "confused" baseline

— Medication review for anticholinergics, benzodiazepines, opioids, sedating antihistamines

— CAM (Confusion Assessment Method): (1) acute onset + fluctuating course, AND (2) inattention, PLUS (3) disorganized thinking OR (4) altered consciousness.

Key distinction: MoCA detects MCI; MMSE often misses it. When the stem says "scored 28/30 on MMSE but family says she gets lost driving and can't manage finances," the right next test is MoCA, which probes executive function.

Board pearl: A "confused elder" presenting acutely needs CAM + medication review + infection workup + electrolytes + glucose — not a memory clinic referral until delirium is excluded.

Cognitive screening (USPSTF: insufficient evidence to screen universally, but screen any patient with symptoms or AWV trigger):

Functional screening:

Mood:

Initial laboratory evaluation for cognitive impairment (rule out reversible causes):

Delirium screen in hospitalized/acute settings:

Diagnostic Workup — Advanced and Confirmatory Studies

— Indications for non-contrast MRI brain (preferred) or CT if MRI contraindicated:

— Age <65 at onset, rapid progression (<1–2 years), focal neuro signs, gait disorder preceding cognition (think NPH), seizures, anticoagulation/head trauma, atypical features.

— Look for: hippocampal atrophy (AD), strategic infarcts/white matter disease (vascular), ventriculomegaly out of proportion to atrophy (NPH), frontotemporal atrophy (FTD), microbleeds (CAA).

— Neuropsychological testing: when screen is borderline, when distinguishing depression vs. dementia vs. MCI, or for forensic/capacity questions.

— CSF biomarkers (Aβ42, total tau, phospho-tau) or amyloid PET / plasma p-tau217: emerging; consider with neurology if anti-amyloid therapy (lecanemab) is being considered.

— FDG-PET: distinguishes AD (temporoparietal hypometabolism) from FTD (frontal/temporal).

— DaTscan (Ioflupane SPECT): reduced striatal uptake in DLB/Parkinson dementia.

— Grip strength (dynamometer), DEXA for body composition, prealbumin not recommended for routine nutrition assessment (acute phase reactant).

— ECG for arrhythmia/conduction disease; echo if murmur or syncope.

— Tilt table or Holter only with recurrent unexplained syncope.

— Vitamin D level; treat if deficient.

Step 3 management: Do not routinely order MRI for typical, slowly progressive amnestic dementia in an 80-year-old — the diagnosis is clinical, and imaging adds little. Reserve MRI for red flags.

Board pearl: Gait disturbance that precedes cognitive decline is NPH until proven otherwise; gait that follows memory loss is Alzheimer disease.

When to image the brain in cognitive decline:

Specialized testing:

Frailty/sarcopenia workup if suspected:

Falls workup additions:

NPH triad (Hakim): wet, wobbly, wacky — urinary incontinence, gait apraxia (magnetic), cognitive slowing. Confirm with large-volume LP tap test showing gait improvement → shunt candidacy.

Risk Stratification and the CGA-Driven Care Plan

— Reversible drivers (med side effects, depression, hearing loss, B12 deficiency, hypothyroidism, OSA, alcohol)

— Modifiable risks (falls, polypharmacy, malnutrition, isolation)

— Irreversible diagnoses requiring planning (advanced dementia, severe frailty, end-stage organ disease)

— Robust: standard preventive care, screen per USPSTF.

— Pre-frail: exercise (resistance + aerobic), protein 1.0–1.2 g/kg/day, vitamin D if deficient.

— Frail: comprehensive interdisciplinary plan; deintensify glycemic/BP targets; reassess cancer screening utility; advance care planning is mandatory.

— Cancer screening (mammography, colonoscopy, PSA) generally stopped when life expectancy <10 years — benefits accrue over a decade while harms are immediate.

— DM A1c target: <7.5% healthy elder, <8.0% moderate comorbidity, <8.5% frail/limited life expectancy (ADA).

— BP: SPRINT supports <130 systolic in fit elders; in frail, target <140/90 and avoid orthostasis.

— Statins for primary prevention: shared decision-making >75; continue secondary prevention if tolerated.

— Referrals: PT/OT, audiology, ophthalmology, dietitian, social work, pharmacy, geriatric psychiatry, palliative care.

— Home safety evaluation; consider PACE program for dual-eligible frail elders.

— Caregiver support and respite resources.

Step 3 management: When the stem presents a frail 84-year-old on 11 medications with A1c 6.2% on insulin + glipizide and recent falls, the answer is deintensify diabetes therapy (stop sulfonylurea, loosen A1c target to <8%) — not add another agent.

Board pearl: "Time-to-benefit" trumps "lifetime risk" in geriatric prevention decisions.

After data gathering, synthesize across domains into a problem list that prioritizes the patient's goals ("Matters most"):

Frailty stratification guides intensity of intervention:

Life expectancy–based decision making (ePrognosis tool):

Care coordination outputs:

Pharmacotherapy — Deprescribing and Beers Criteria

— Benzodiazepines and Z-drugs (zolpidem, eszopiclone): falls, fractures, delirium, cognitive impairment. Taper, don't stop abruptly.

— First-gen antihistamines (diphenhydramine, hydroxyzine): strongly anticholinergic.

— Tricyclic antidepressants (amitriptyline, doxepin >6 mg): anticholinergic, orthostasis.

— Skeletal muscle relaxants (cyclobenzaprine, methocarbamol).

— Anticholinergic bladder agents (oxybutynin IR) — prefer mirabegron or trospium.

— Sliding-scale insulin as sole regimen.

— Glyburide / chlorpropamide — long-acting sulfonylureas, prolonged hypoglycemia.

— NSAIDs chronic — GI bleed, AKI, HTN, heart failure exacerbation.

— Antipsychotics for behavioral symptoms of dementia — boxed warning, ↑ mortality; reserve for danger to self/others after non-pharm fails.

— PPIs >8 weeks without indication — C. difficile, fractures, B12 deficiency.

— Meperidine — neurotoxic metabolite.

— Cholinesterase inhibitors (donepezil, rivastigmine, galantamine) for mild–moderate AD; modest symptomatic benefit; SEs: bradycardia, syncope, GI upset, weight loss, nightmares.

— Memantine (NMDA antagonist) for moderate–severe AD; can combine with donepezil.

— Anti-amyloid mAbs (lecanemab, donanemab): early AD with confirmed amyloid; risk of ARIA (edema/hemorrhage); requires MRI monitoring and APOE genotyping.

— Avoid cholinesterase inhibitors in patients with syncope, severe bradycardia, or active PUD.

Step 3 management: At every CGA visit, perform a brown-bag medication review; apply the STOPP/START criteria; deprescribe one medication per visit when feasible.

Board pearl: Donepezil + non-DHP calcium channel blocker or beta-blocker can cause symptomatic bradycardia and falls — always check the med list.

Polypharmacy (≥5 medications) independently predicts falls, hospitalization, and mortality. The CGA's most impactful intervention is often deprescribing.

AGS Beers Criteria — high-yield drugs to avoid/limit in adults ≥65:

Pharmacotherapy for cognitive disease:

Depression in elderly: start sertraline or escitalopram (SSRIs); avoid paroxetine (anticholinergic) and TCAs. Start low, go slow; reassess at 4–6 weeks.

Procedures and Non-Pharmacologic Interventions

— Exercise interventions — strongest evidence; tai chi, Otago program, supervised PT for strength/balance.

— Multifactorial intervention for high-risk patients (recurrent falls, gait impairment).

— Vitamin D supplementation: routine for fall prevention is not recommended (USPSTF Grade D in community-dwelling, non-deficient); treat documented deficiency.

— Home safety modifications: grab bars, lighting, remove throw rugs, raised toilet seats, shower chairs (OT home eval).

— Footwear; podiatry care.

— Cataract surgery reduces falls; first-eye surgery has strongest effect.

— Structured routine, orientation cues, sensory aids

— Music therapy, reminiscence, cognitive stimulation

— Caregiver education (most evidence-based intervention to delay institutionalization)

— Treat underlying pain (often missed cause of agitation)

— DICE approach for BPSD: Describe, Investigate, Create plan, Evaluate

— Behavioral therapy first: timed voiding, bladder training, pelvic floor exercises

— Pessary for prolapse-related stress incontinence

— Surgery (sling) for refractory stress incontinence in appropriate candidates

— Oral nutritional supplements between meals (not with) in undernourished elders

— Dental referral, swallow evaluation if dysphagia

— Avoid PEG tubes in advanced dementia — no mortality benefit, increased aspiration and pressure injury

— Annual high-dose or adjuvanted influenza ≥65

— PCV20 (or PCV15 + PPSV23) pneumococcal

— RSV vaccine ≥75 (and 60–74 at increased risk), shared decision-making

— Shingrix ≥50, 2 doses

— Tdap once then Td/Tdap q10y

— COVID-19 per current guidance

CCS pearl: On a CCS case of an elder admitted post-fall, advance the clock: order PT/OT consult, social work, home safety eval, medication reconciliation, orthostatic vitals, vitamin D level, and schedule outpatient PCP follow-up within 7 days.

Fall prevention (USPSTF Grade B for adults ≥65 at increased risk):

Cognitive and behavioral interventions for dementia:

Incontinence:

Nutrition:

Vaccinations (critical CGA component):

Special Populations — Renal, Hepatic, and Very Old

— GFR declines ~1 mL/min/yr after age 40; creatinine often normal-appearing despite reduced clearance due to low muscle mass.

— Use CKD-EPI 2021 (race-free) eGFR; Cockcroft-Gault still preferred for drug dosing of narrow-therapeutic-index agents (DOACs, digoxin, vancomycin).

— Dose-adjust: gabapentin, pregabalin, levetiracetam, allopurinol, metformin (avoid if eGFR <30), DOACs.

— Avoid: NSAIDs, nitrofurantoin if CrCl <30, Mg-containing laxatives, phosphate bowel preps.

— Phase I (CYP) metabolism declines; phase II (conjugation) preserved.

— Prefer lorazepam, oxazepam, temazepam (LOT) if benzodiazepine truly required — no active metabolites.

— Acetaminophen max 3 g/day in chronic liver disease or heavy users; otherwise 4 g remains FDA limit but practical cap is 3 g in frail elders.

— ↓ Total body water → ↑ concentration of hydrophilic drugs (lithium, digoxin)

— ↑ Body fat → ↑ Vd and prolonged half-life of lipophilic drugs (benzos, amiodarone)

— ↓ Serum albumin → ↑ free fraction of highly bound drugs (phenytoin, warfarin)

— Cancer screening generally not recommended.

— Statins for primary prevention: stop or do not initiate.

— Anticoagulation for AFib: still indicated unless high bleeding risk; DOACs preferred over warfarin (apixaban best studied in frail elderly with CKD).

— BP targets liberalized; avoid orthostatic hypotension.

Key distinction: "Start low, go slow, but go" — undertreatment is as harmful as overtreatment. Don't withhold guideline-directed therapy (anticoagulation for AFib, statin for secondary prevention) solely on the basis of age.

Board pearl: A normal creatinine of 1.0 in an 85-year-old woman often equals a CrCl ~35 — dose-reduce accordingly.

Aging kidneys:

Hepatic considerations:

Body composition changes:

The "oldest old" (≥85):

Frailty + CKD: dialysis decisions should integrate prognosis and goals; conservative kidney management is a valid path.

Special Populations — Caregivers, LGBTQ+ Elders, and Cultural Considerations

— Up to 40% of caregivers of patients with dementia screen positive for depression; assess with PHQ-9.

— Zarit Burden Interview quantifies caregiver strain.

— Caregiver health predicts patient outcomes; caregiver death/illness is a leading driver of nursing home placement.

— Connect to Area Agency on Aging, respite care, adult day programs, Alzheimer's Association resources.

— Document caregiver as part of care team; obtain HIPAA release.

— Higher rates of social isolation, depression, and reluctance to disclose; many fear discrimination in long-term care.

— Ask about chosen family and partner; ensure advance directives explicitly name partners (especially if not married).

— Screen for HIV regardless of age if risk factors; HIV-associated neurocognitive disorder is a differential for cognitive complaints.

— Use professional interpreters, not family — particularly for cognitive testing (family may "help").

— Cognitive screens (MMSE, MoCA) have education and language biases; consider RUDAS or culturally validated tools for low-literacy or non-English-speaking patients.

— Cultural views on disclosure of dementia diagnosis and end-of-life care vary; explore family decision-making norms.

— Screen for combat exposure, PTSD, Agent Orange exposure (Parkinson, certain cancers), traumatic brain injury history.

— VA offers Home Based Primary Care and geriatric programs.

— Telemedicine for cognitive follow-up; in-clinic CGA may be only annual.

— Driving cessation has outsized impact on independence — plan transportation alternatives before discussing license surrender.

Step 3 management: When caregiver burden is high, respite care + caregiver support group + treat caregiver's own depression are interventions that improve patient outcomes. The exam rewards naming the caregiver as a target of intervention.

Board pearl: Always have two interviews when cognition is in question — patient alone (to detect insight loss and uncover abuse) and informant alone (to get accurate history).

Caregiver assessment is part of CGA:

LGBTQ+ older adults:

Cultural and language considerations:

Veterans:

Pregnancy and pediatrics — not applicable, but adult children of aging parents are often the "patients in the room": educate on disease trajectory, safety planning, and self-care.

Rural elders:

Complications and Adverse Outcomes

— Falls / fractures: 1/3 of community elders fall annually; hip fracture 1-year mortality ~20–30%.

— Delirium: occurs in 30% of hospitalized elders; doubles mortality; persistent cognitive decline in many survivors.

— Pressure injuries: preventable; risk = immobility, malnutrition, incontinence, sensory loss.

— Incontinence: social isolation, skin breakdown, UTIs, falls (rushing to bathroom).

— Malnutrition / sarcopenia: poor wound healing, infection, frailty progression.

— Polypharmacy adverse drug events: ~30% of hospital admissions in elders.

— Functional decline during hospitalization: "post-hospital syndrome" — up to 1/3 lose an ADL during admission.

— Foley catheters → CAUTI, delirium, immobility — remove ASAP

— Tethers (IVs, telemetry, restraints) → deconditioning, delirium

— NPO orders → malnutrition, dehydration

— Sleep disruption → delirium

— Anticholinergic burden — additive across multiple drugs

— Dementia is not an absolute contraindication early on, but moderate–severe dementia, recent crashes, getting lost, slowed reaction time → recommend cessation.

— Many states have mandatory physician reporting for dementia-related driving impairment (varies — know your state for the AWV).

— On-road driving evaluation by OT is gold standard.

— Types: physical, sexual, emotional, financial, neglect (most common), self-neglect.

— Red flags: bruises in unusual locations, unexplained weight loss, missed appointments, caregiver answering all questions, withdrawn affect, financial irregularities.

— Mandatory reporting in all 50 states to Adult Protective Services for suspected abuse/neglect (does not require proof).

Step 3 management: A delirious post-op elder needs non-pharmacologic delirium bundle first — reorientation, mobilization, sleep hygiene, hydration, glasses/hearing aids, removal of tethers. Use low-dose haloperidol or quetiapine only for severe agitation threatening safety.

Board pearl: Restraints (physical or chemical) worsen delirium and increase injury risk.

Geriatric syndromes — multifactorial conditions producing disproportionate morbidity:

Iatrogenesis hotspots:

Driving safety:

Elder mistreatment (5–10% prevalence):

When to Escalate Care — Consult and Transition Decisions

— Diagnostic uncertainty in cognitive decline (especially young-onset, rapid, atypical)

— Complex polypharmacy not responding to PCP-led deprescribing

— Recurrent falls despite intervention

— Behavioral and psychological symptoms of dementia (BPSD) requiring medication

— Capacity determination in complex cases

— Failure to thrive

— Acute delirium without clear reversible outpatient cause

— Falls with injury or unable to return safely home

— Inability to perform basic ADLs acutely (caregiver collapse)

— Suspected elder abuse requiring safe placement

— Acute medication toxicity (digoxin, warfarin, lithium)

— Advanced dementia (FAST stage 7), recurrent aspiration, weight loss despite supplementation

— Symptom burden in any advanced illness

— Goals-of-care clarification

— Hospice eligibility: prognosis ≤6 months if disease runs its usual course; for dementia, requires FAST 7c + comorbidity (pneumonia, sepsis, decubitus, weight loss).

— Neurology / memory clinic: atypical dementia, candidate for anti-amyloid therapy

— Geriatric psychiatry: treatment-resistant depression, severe BPSD, late-life psychosis

— Orthogeriatrics / co-management: hip fracture (reduces mortality and LOS)

— Pharmacy: complex polypharmacy review

— Ethics consult: capacity disputes, surrogate disagreements

CCS pearl: For an elderly hip fracture patient, on the CCS case: order ortho consult, geriatrics co-management, DVT prophylaxis, pain control with scheduled acetaminophen + low-dose opioid (avoid meperidine), early mobilization, delirium precautions, vitamin D/calcium, bone density on follow-up, and PT/OT. Pre-op echo only if active cardiac symptoms — not routinely.

Board pearl: Functional status before fracture is the strongest predictor of post-fracture recovery — document it on admission.

Geriatrics consultation indications (outpatient or inpatient):

Hospital admission triggers for elders presenting from clinic:

ACE (Acute Care for Elders) units / NICHE programs reduce functional decline and length of stay — refer when available.

Palliative care consultation:

Other key consultants:

Key Differentials — The Three Ds (Dementia vs. Delirium vs. Depression)

— Acute (hours–days), fluctuating course, inattention is hallmark, altered consciousness, disorganized thinking

— Often hyperactive (agitated) or hypoactive (lethargic, missed) or mixed

— Causes: infection (UTI, pneumonia), medications (anticholinergics, opioids, benzos), metabolic (Na, glucose, Ca, uremia), hypoxia, MI, stroke, urinary retention, fecal impaction, alcohol/benzo withdrawal, post-op

— Tool: CAM; reversible in most when underlying cause treated; cognition may not return fully to baseline

— Chronic, progressive (months–years), preserved consciousness, attention intact early

— Subtypes:

— Alzheimer: amnestic + visuospatial; insidious onset

— Vascular: stepwise, focal signs, executive dysfunction, vascular risk factors

— Lewy body: fluctuating cognition, visual hallucinations, parkinsonism, REM sleep behavior disorder, neuroleptic sensitivity

— Frontotemporal: behavioral/personality change or primary progressive aphasia; younger onset

— Mixed: common — AD + vascular

— Subacute onset, mood-congruent, "I don't know" answers, intact attention on testing, complains of memory loss (real dementia often hides it)

— Sleep/appetite/anhedonia; responds to SSRI trial

— Subjective + objective cognitive complaint, preserved function — key distinction from dementia

— 10–15%/yr conversion to dementia

— No FDA-approved pharmacotherapy; exercise + cognitive engagement + vascular risk control

Key distinction: A patient with new confusion who cannot count backward from 20 to 1 has delirium until proven otherwise — inattention is the defining feature. A patient who can attend but cannot remember three words at 5 minutes has a memory problem (MCI/dementia).

Board pearl: Delirium can be the only presenting sign of MI, sepsis, or stroke in an elder. Workup before sedating.

Delirium:

Dementia (major neurocognitive disorder):

Depression ("pseudodementia"):

Mild Cognitive Impairment (MCI):

Key Differentials — Reversible Mimics of Cognitive Decline

— Hypothyroidism — slowed cognition, weight gain, constipation; check TSH

— B12 deficiency — cognitive impairment, peripheral neuropathy, gait ataxia (subacute combined degeneration); metformin and PPI use are risk factors

— Hyponatremia (SIADH, thiazides, SSRIs) — confusion, falls

— Hypercalcemia — "stones, bones, groans, psychiatric overtones"

— Hypoglycemia — especially on sulfonylureas/insulin

— UTI (only if symptomatic — don't treat asymptomatic bacteriuria), pneumonia, occult abscess

— Neurosyphilis — RPR/FTA-ABS in atypical dementia

— HIV-associated neurocognitive disorder — screen ≥65 if risk factors

— Normal pressure hydrocephalus (wet, wobbly, wacky) — surgically treatable

— Chronic subdural hematoma — especially on anticoagulants, after minor trauma; CT head

— Brain tumor, especially frontal meningioma

— Anticholinergics (top offender), benzos, opioids, sedating antihistamines, muscle relaxants, antiepileptics, digoxin, lithium, steroids, bladder anticholinergics

— Calculate Anticholinergic Cognitive Burden (ACB) score — ≥3 associated with cognitive decline

— Alcohol use disorder — Wernicke-Korsakoff; chronic use → cortical atrophy

— Carbon monoxide (faulty heaters in winter)

— Heavy metals (rare, but on the board)

— Obstructive sleep apnea — cognitive impairment reversible with CPAP

— Late-life depression, anxiety, PTSD reactivation

— Bereavement

— Autoimmune encephalitis (anti-NMDA, LGI1), Hashimoto encephalopathy, paraneoplastic limbic encephalitis — rapidly progressive dementia warrants CSF and antibody panel.

Step 3 management: Cognitive workup must include TSH, B12, CMP, CBC at minimum; add RPR, HIV, vitamin D, urinalysis (if symptomatic) based on history. Treating B12 deficiency or hypothyroidism may produce dramatic improvement.

Board pearl: Rapidly progressive dementia (<1 year) requires urgent neurology referral — think Creutzfeldt-Jakob, autoimmune encephalitis, paraneoplastic, NPH.

Endocrine/metabolic:

Infectious:

Structural:

Medication-induced cognitive impairment:

Toxic/substance:

Psychiatric/sleep:

Autoimmune/paraneoplastic (rapid onset):

Secondary Prevention and Long-Term Plan

— Multifactorial assessment within 1 month (STEADI algorithm)

— Refer to PT for individualized exercise; tai chi for community programs

— Medication review (taper psychotropics, sedatives)

— Treat vitamin D deficiency

— Vision optimization; cataract surgery

— Home safety eval by OT

— Footwear; consider hip protectors in high-risk LTC residents

— Bone health: DEXA, calcium 1200 mg/day, vitamin D 800 IU, anti-resorptive therapy if osteoporosis (T-score ≤−2.5) or prior fragility fracture

— Establish healthcare proxy / durable power of attorney for healthcare while capacity remains

— POLST/MOLST for portable medical orders on resuscitation, intubation, artificial nutrition, hospitalization

— Discuss disease trajectory; plan for in-home support, day programs, eventual residential care

— Driving plan; firearm safety review (often overlooked)

— Wandering: medical ID bracelet, door alarms

— Annual brown-bag review; targeted deprescribing

— Single pharmacy, pill organizer, blister pack

— Medication reconciliation at every transition

— DEXA at 65 (women) and 70 (men) per USPSTF; earlier with risk factors

— Pharmacotherapy: oral bisphosphonate first-line; consider denosumab (renal-friendly) or anabolic (teriparatide, romosozumab) for severe osteoporosis

— Drug holiday after 5 years oral / 3 years IV bisphosphonate if low risk

Step 3 management: After a hip fracture, start anti-osteoporosis therapy (IV zoledronic acid often preferred — once-yearly, adherence-proof) typically 2 weeks post-op once vitamin D replete. Failure to treat after fragility fracture is a national quality gap.

Board pearl: "Treatment gap" after fragility fracture — <25% of patients receive bone therapy. Exam loves this teaching point.

Falls — secondary prevention after a fall:

Dementia — long-term care planning:

Polypharmacy maintenance:

Vaccinations and screenings updated annually at AWV.

Bone health:

Cardiovascular secondary prevention: continue statin, antiplatelet, ACEi/ARB, beta-blocker as indicated post-MI/stroke regardless of advanced age unless side effects or limited life expectancy.

Follow-Up, Monitoring, and Rehabilitation

— Routine stable elder: every 3–6 months

— Recently discharged: follow-up within 7–14 days (Medicare Transitional Care Management — billable codes 99495/99496); reduces readmissions

— Initiated new psychotropic: 2–4 weeks

— Started cholinesterase inhibitor: 4–6 weeks for tolerance, 3–6 months for response

— Falls/fracture: PT progress at 4–6 weeks, then 3 months

— Annual Wellness Visit yearly

— Weight every visit — early sign of disease progression or depression

— BP including orthostatics in patients on antihypertensives or with falls

— Cognitive screen yearly at AWV and any concern

— Functional status (ADLs/IADLs) yearly and after any illness

— Caregiver well-being check

— Mood screen (PHQ-2/9) yearly

— Cholinesterase inhibitors: pulse for bradycardia, weight

— Memantine: renal function

— Anti-amyloid mAb: scheduled MRIs for ARIA-E/H at infusions 5, 7, 14

— DOACs: annual CBC, CMP; more often if CKD

— Diuretics: electrolytes 1–2 weeks after initiation/change

— Acute inpatient rehab (3-hour rule, ≥2 disciplines) for motivated patients post-stroke/fracture

— Subacute SNF rehab for those needing less intensive therapy

— Home health PT/OT under Medicare requires homebound status and skilled need

— Cardiac and pulmonary rehab improve outcomes in elders — refer post-MI, post-CABG, COPD GOLD B+

— Exercise: 150 min/week moderate aerobic + 2 days resistance + balance training

— Nutrition: protein 1.0–1.2 g/kg, Mediterranean pattern

— Sleep hygiene; avoid hypnotics

— Social engagement; treat hearing loss

— Advance care planning revisited annually

CCS pearl: After hospital discharge of an elder, the single highest-yield order is PCP follow-up in 7 days + medication reconciliation + home health PT — readmission prevention 101.

Board pearl: Hearing aid use is associated with reduced dementia incidence in high-risk older adults (ACHIEVE trial) — treat hearing loss aggressively.

Visit cadence after CGA:

Monitoring parameters:

Lab monitoring with common drugs:

Rehabilitation:

Counseling at every visit:

Ethical, Legal, and Patient Safety Considerations

— Capacity is a clinical, decision-specific determination made by any physician.

— Competence is a legal determination by a court.

— Four pillars of capacity: (1) understand information, (2) appreciate it applies to self, (3) reason through options, (4) communicate a stable choice.

— Capacity can fluctuate (delirium) and is task-specific — a patient may have capacity to choose a meal but not consent to chemotherapy.

— Document the assessment; use a tool (Aid to Capacity Evaluation) for complex cases.

— Advance directive (living will + healthcare proxy)

— POLST/MOLST — actionable medical orders signed by clinician; honored across settings

— Revisit at major transitions (new dementia diagnosis, hospitalization, decline)

— Medicare reimburses ACP discussions (CPT 99497/99498)

— Patient with mild dementia still has capacity for many decisions — assess, do not assume

— Adult child cannot override a capacitated patient's refusal

— If patient lacks capacity AND no surrogate, two-physician decision or court-appointed guardian for major decisions

— Suspected elder abuse/neglect/exploitation → Adult Protective Services in all 50 states; reporters are immune from civil liability when reporting in good faith

— Some states mandate reporting of dementia-related driving impairment to DMV — know your state

— Self-neglect is reportable in most states

— Hospital → SNF → home is the highest-risk corridor for medication errors and readmissions

— Use medication reconciliation at every transition (Joint Commission core measure)

— Provide a written, simplified discharge summary; teach-back method with caregiver

— Pending labs/imaging at discharge — ensure follow-up loop closure

— "Hospital-acquired" geriatric harms are preventable: falls, pressure injuries, CAUTI, C. difficile, delirium

Step 3 management: A mildly demented patient who refuses recommended surgery but understands risks and alternatives — respect the refusal. Refusing care ≠ lacking capacity.

Board pearl: Goals-of-care conversations are a billable, evidence-based intervention — not optional.

Capacity vs. competence:

Surrogate decision-making hierarchy (varies by state, typical order): healthcare proxy → spouse → adult children → parents → siblings. Use substituted judgment (what would the patient want?) before best interest.

Advance care planning:

Informed consent edge cases — Step 3 favorites:

Mandatory reporting:

Patient safety in transitions of care:

Driving cessation: approach as a process, not an event; involve family; offer transportation alternatives; document discussion.

High-Yield Associations and Rapid-Fire Clinical Facts

Board pearl: When in doubt on a Step 3 geriatric stem, the answer involves stopping a medication, addressing function, or having a goals-of-care conversation — not adding another test.

5 Ms of geriatrics: Mind, Mobility, Medications, Multicomplexity, Matters most.

TUG ≥12 seconds = increased fall risk → STEADI protocol.

Gait speed <0.8 m/s = adverse outcome marker; "sixth vital sign."

MoCA <26 = abnormal; better than MMSE for MCI and executive function.

Mini-Cog = fastest screen (3-min); abnormal if 0–2/5.

CAM = delirium = acute + fluctuating + inattention + (disorganized thinking OR altered consciousness).

NPH triad: wet, wobbly, wacky — gait first, treat with shunt.

Lewy body dementia: visual hallucinations + parkinsonism + fluctuations + REM sleep behavior disorder; avoid typical antipsychotics — neuroleptic sensitivity.

B12 deficiency: macrocytic anemia + peripheral neuropathy + cognitive change; risk factors metformin, PPI, vegan diet.

Asymptomatic bacteriuria: do NOT treat in elders (except pregnancy or pre-urologic procedure).

PEG tubes in advanced dementia: no mortality benefit; don't order.

Beers Criteria worst offenders: benzodiazepines, diphenhydramine, glyburide, oxybutynin, sliding-scale insulin, chronic NSAIDs, meperidine, antipsychotics for BPSD.

Stop cancer screening when life expectancy <10 years.

A1c target in frail elders: <8.0–8.5%; deintensify, don't push lower.

SPRINT showed BP <120 reduced events in fit ≥75 — but be cautious in frail.

Cholinesterase inhibitor + beta-blocker = bradycardia/syncope.

First-line BPSD therapy: non-pharmacologic (DICE); reserve antipsychotics — black box ↑ mortality.

Vitamin D for fall prevention in community-dwelling, non-deficient elders: USPSTF Grade D (don't routinely give).

Hip fracture 1-year mortality: 20–30%.

AGS frailty tool: Fried phenotype (3+ of weight loss, exhaustion, weakness, slowness, low activity).

Hospice for dementia: FAST stage 7c + comorbid event.

Sertraline/escitalopram = first-line depression in elders; avoid paroxetine, TCAs.

Elder abuse: mandatory APS report in all 50 states; neglect most common.

PCV20 preferred single-dose pneumococcal regimen ≥65 (or PCV15 → PPSV23).

Shingrix 2-dose ≥50.

Anti-amyloid mAbs: monitor for ARIA; APOE4 homozygotes highest risk.

Board Question Stem Patterns

Board pearl: Step 3 geriatric stems reward doing less and integrating more — synthesize function, cognition, social context, and goals.

Pattern 1 — "Vague decline": 82F brought by daughter for "not herself," weight loss, missed appointments, takes 9 meds. Right answer: comprehensive geriatric assessment with cognitive screen, functional assessment, depression screen, medication review — not MRI brain first.

Pattern 2 — Acute confusion in hospital: 78M post-op day 2 hip surgery, agitated at night, pulling at lines. Right answer: CAM-positive delirium → non-pharm bundle (reorient, mobilize, hydrate, glasses, hearing aids, remove Foley), search for cause (urinary retention, pain, med, infection); avoid benzos and physical restraints; low-dose haloperidol only if dangerous agitation.

Pattern 3 — Recurrent falls: 79F two falls in 6 months, on lorazepam, amitriptyline, glyburide, oxybutynin. Right answer: deprescribe the Beers drugs; PT referral; orthostatic BP; vision check; vitamin D if deficient; home safety eval.

Pattern 4 — Dementia subtype identification: Fluctuating cognition + visual hallucinations + parkinsonism + acted out dreams → DLB; avoid antipsychotics, especially typicals.

Pattern 5 — Reversible dementia mimic: New cognitive complaints + macrocytic anemia + paresthesias → B12 deficiency.

Pattern 6 — NPH: Magnetic gait + urinary incontinence + cognitive slowing → MRI shows ventriculomegaly → LP tap test → VP shunt.

Pattern 7 — Pseudodementia: Recent widow, "I don't know" answers, sleep/appetite changes, intact attention → depression; start sertraline.

Pattern 8 — Inappropriate cancer screening: 83-year-old frail nursing home resident, asked about screening colonoscopy. Right answer: stop screening; life expectancy <10 years.

Pattern 9 — Asymptomatic bacteriuria: Demented nursing home patient at baseline, urine cx +E. coli, no fever/dysuria. Right answer: do not treat.

Pattern 10 — Capacity question: Mildly demented man refuses CABG, can articulate risks/alternatives. Right answer: respect his decision; he has capacity.

Pattern 11 — Elder abuse: Frail elder with bruises in various stages, caregiver answers all questions, withdrawn affect. Right answer: report to APS (mandatory); ensure safety; do not require proof.

Pattern 12 — Driving in dementia: Mild AD, got lost, minor crash. Right answer: on-road OT evaluation; if state mandates, report to DMV; counsel cessation with transportation plan.

Pattern 13 — Advance care planning trigger: New dementia diagnosis. Right answer: discuss goals, identify healthcare proxy, complete advance directive while capacity present.

One-Line Recap

The comprehensive geriatric assessment is a structured, multidimensional, function-and-goal-centered evaluation across the 5 Ms — Mind, Mobility, Medications, Multicomplexity, and Matters most — that uncovers reversible contributors to decline, drives deprescribing, prevents iatrogenic harm, and aligns care with what the older adult actually values.

Board pearl: Function and goals — not age — drive geriatric decision-making.

Screen smart: Mini-Cog or MoCA for cognition, Katz/Lawton for function, PHQ-9 or GDS for mood, TUG and gait speed for mobility, CAM for delirium, brown-bag for medications — done at every Annual Wellness Visit and any trigger event (fall, hospitalization, weight loss, new incontinence, caregiver concern).

Intervene wisely: Deprescribe Beers/STOPP medications, optimize sensory function (hearing aids, cataract surgery), prescribe exercise + protein + vitamin D when deficient, refer to PT/OT, treat depression with SSRI, treat reversible cognitive contributors (B12, TSH, OSA, NPH), reserve antipsychotics in BPSD for genuine danger, and remember that caregiver support is a patient-level intervention.

De-intensify when appropriate: Loosen A1c to <8–8.5% in frail elders, individualize BP avoiding orthostasis, stop cancer screening when life expectancy <10 years, discontinue primary-prevention statins in advanced frailty, and never treat asymptomatic bacteriuria — but never withhold guideline-directed therapy (AFib anticoagulation, secondary CV prevention) on the basis of age alone.

Plan ahead: Capacity assessment is decision-specific and clinical; complete advance directives and POLST/MOLST early; mandatory APS reporting for suspected elder mistreatment; ensure 7–14 day post-discharge follow-up with medication reconciliation; revisit goals of care at every major transition; and remember that on Step 3, the right geriatric answer is usually stop a drug, address function, or have the conversation — not order one more test.