When assessing an older adult, which assessments should be completed first?

With roughly 1 in 3 older adults falling each year, prioritizing initial assessments is vital for proactive senior care. When assessing an older adult, which assessments should be completed first? A systematic approach focusing on foundational health metrics ensures no critical red flags are missed.

Quick Summary

Prioritizing initial assessments for older adults involves first addressing urgent risks like falls, evaluating functional status (ADLs/IADLs), and screening for cognitive and mood impairments. This foundational data guides a more comprehensive geriatric assessment and personalized care planning, ensuring the most immediate health and safety needs are met.

Key Points

• Prioritize Safety: Screen for fall risk and immediate dangers first, as falls are a major threat to senior health and independence.

• Evaluate Function: Assess activities of daily living (ADLs) and instrumental activities of daily living (IADLs) to gauge current capacity for self-care.

• Screen for Cognitive Changes: Conduct a brief screen for cognitive impairment and mood disorders to identify subtle changes affecting safety and well-being.

• Review Medications Early: Perform a quick reconciliation of all medications, including OTCs and supplements, to identify polypharmacy and reduce risk of adverse effects.

• Consider Social Context: Look into the patient's living situation and social support network to identify potential environmental hazards or risks of isolation.

• Use Brief Screening Tools: Utilize validated, rapid screening tools like the Timed Up and Go test and the Mini-Cog to efficiently cover key domains.

Prioritizing the Initial Assessment in Older Adults

A comprehensive geriatric assessment (CGA) is a cornerstone of modern senior care, but the process must begin with a focused approach. The initial assessments serve as a critical triage, quickly identifying the most urgent issues related to safety, independence, and immediate health risks. These early findings guide the subsequent, more detailed evaluation, ensuring that care is both holistic and efficient. Instead of a single answer to the question "When assessing an older adult, which assessments should be completed first?", the best practice involves a prioritized sequence focusing on function, cognition, and safety.

Prioritizing Immediate Safety: Falls and Mobility

Falls are a leading cause of injury and disability in older adults, making fall risk assessment a top priority during any initial evaluation. Observing a patient's gait as they enter the room can offer immediate insight into their mobility and balance.

Key Fall Risk Assessments

• History of Falls: A simple, direct question about any falls within the last year is one of the most predictive risk factors.
• Timed Up and Go (TUG) Test: This quick, performance-based test measures a patient's ability to rise from a chair, walk a short distance (10 feet), turn, and sit back down. Completing the task in over 12 seconds indicates an increased risk of falls.
• Postural Hypotension: Measuring blood pressure while the patient is lying and then standing can reveal dizziness or orthostatic hypotension, another significant fall risk factor.

Evaluating Functional Status: ADLs and IADLs

After ensuring immediate safety, the next step is to evaluate functional status, which measures an individual's ability to perform tasks necessary for daily living. This provides a crucial baseline of their independence.

Activities of Daily Living (ADLs)

ADLs are basic self-care tasks essential for independent living. Assessing them first helps determine the level of immediate support a person may need.

• Bathing: The ability to get in and out of a tub or shower safely.
• Dressing: Managing clothing, including buttons and zippers.
• Toileting: Using the toilet without assistance.
• Transferring: Moving from bed to chair and back.
• Continence: Controlling bladder and bowel movements.
• Feeding: The ability to feed oneself.

Instrumental Activities of Daily Living (IADLs)

IADLs are more complex tasks related to living independently within the community. Impairment often appears in IADLs before ADLs.

• Managing Finances: Paying bills and handling cash.
• Preparing Meals: Cooking and managing groceries.
• Managing Medications: Taking the correct dosage at the right time.
• Using Transportation: Driving or using public transit.
• Housekeeping: Performing light and heavy household chores.

Screening for Cognitive and Psychological Changes

Changes in cognitive function or mood are often missed but profoundly impact an older adult's health and safety. Early screening is critical.

Brief Cognitive Screening

• Mini-Cog: A quick, 3-minute test involving a 3-item word recall and a clock-drawing test. It is simple and does not depend heavily on language or education.
• Montreal Cognitive Assessment (MoCA): While slightly longer (10 minutes), the MoCA provides a more comprehensive overview of cognitive domains and can be a good next step if the Mini-Cog suggests impairment.

Screening for Depression

Depression is common but often under-diagnosed in older adults, where symptoms may present as physical complaints. The Patient Health Questionnaire-2 (PHQ-2) is a simple, two-question screen for depression that can be used initially.

Prioritizing a Medication Review (Polypharmacy)

Polypharmacy, the use of multiple medications, is a major health risk for older adults, contributing to falls, cognitive changes, and adverse drug events. A systematic medication review should be completed early.

• Review all medications: This includes prescription drugs, over-the-counter medications, and supplements.
• Address potentially inappropriate medications: The American Geriatrics Society's updated Beers Criteria is a resource for identifying drugs to avoid in older adults.

Table: Comparison of Initial Assessment Domains and Tools

Assessment Domain	Key Screening Questions or Tools	Importance	Next Step if Positive
Safety & Mobility (Falls)	- Have you fallen in the past year?
- Timed Up and Go (TUG) Test	Immediate identification of fall risk, a leading cause of injury.	Multifactorial falls risk assessment and physical therapy referral.
Functional Status (ADLs/IADLs)	- Do you need help with bathing, dressing, or managing medications?	Determines current level of independence and need for support.	Detailed functional assessment and targeted support services.
Cognitive Screening	- Mini-Cog (3-word recall, clock draw)	Identifies potential cognitive impairment that affects safety and decision-making.	Further neuropsychological testing and diagnostic workup.
Medication Review	- What medications and supplements are you taking?	Prevents adverse drug events and dangerous interactions from polypharmacy.	Collaboration with a pharmacist for reconciliation and deprescribing.
Psychological State (Mood)	- PHQ-2 (feelings of sadness or lack of interest)	Screens for depression, which can mimic or exacerbate physical symptoms.	More in-depth depression screening (PHQ-9) and mental health referral.

The Role of Social and Environmental Factors

These factors are less about immediate clinical risk but are critical to understanding a patient's overall well-being and ability to remain independent. A brief assessment should include:

• Social Support: Asking about living situation and who can help in an emergency.
• Environmental Hazards: Addressing potential home hazards like poor lighting or clutter.

Conclusion: A Phased Approach to Holistic Care

There is no single "first" assessment, but rather a prioritized, multi-domain screening process. In a non-emergency context, the initial evaluation should begin with immediate safety concerns (like fall risk) and functional capacity, as these directly impact a person's immediate independence and well-being. This is quickly followed by cognitive and mood screening and a comprehensive medication review. These early assessments provide a powerful snapshot that enables healthcare professionals to identify hidden problems and create a targeted, person-centered plan for a more comprehensive geriatric evaluation. This systematic, yet efficient, approach is vital for promoting healthy aging and improving outcomes in older adults. For more in-depth information on geriatric care, consult resources from authoritative bodies like the American Academy of Family Physicians.

Frequently Asked Questions

What is the very first thing to assess in an older adult in a non-emergency setting?

The very first assessment should focus on immediate safety concerns, particularly mobility and fall risk. This can start with simple observation and a quick screening question about recent falls.

Why is functional assessment completed so early?

Functional status is assessed early because it provides a foundational understanding of an older adult's level of independence. Changes in ADLs or IADLs are often early indicators of declining health and can signal the need for immediate support or a deeper evaluation.

How is a quick cognitive assessment performed?

Healthcare providers can use brief screening tools like the Mini-Cog, which takes only a few minutes. It involves asking the patient to remember a few words and draw a clock face, providing a fast screen for cognitive impairment.

Is polypharmacy a priority assessment?

Yes, reviewing a patient's medication list for polypharmacy (the use of multiple medications) is a priority due to the high risk of adverse drug events, interactions, and complications in older adults.

What does assessing environmental factors involve?

Assessing environmental factors involves asking about the patient's home environment, looking for potential hazards like loose rugs or poor lighting, and inquiring about their social support system to ensure a safe living situation.

When assessing an older adult who recently fell, which assessments should be completed first?

Following a fall, the first assessments should include a full physical examination for injuries, a detailed fall risk assessment (e.g., TUG test), and a review of medications and potential contributing health conditions.

Do these initial assessments replace a full geriatric assessment?

No, these initial screenings are meant to be a rapid triage to identify high-priority issues. The findings from these screenings then guide a more comprehensive geriatric assessment (CGA) and individualized care plan, which may be conducted over multiple visits or by a multi-disciplinary team.