Two Page Simple Geriatric Screen Page 2
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2SIMPLE GERIATRIC SCREEN (continued)
Abnormal
Action
Comments
Review medications that patient brought in
Confusion about meds Consider simplification
> 5 meds
Medi-set or other aid
Doesn’t bring in
Consider
______________________________
PHYSICAL EXAM ITEMS
(the next few items will be performed by nursing staff in some settings)
Weight/BMI
BMI <21
Alert provider
______________________________
And ask “have you lost weight?”
Loss of 5%
Or Nutrition eval
If so, how much?
Consider medical, dental,
social
Jaeger Card or Snellen eye chart
Can't read 20/40
Alert provider or refer
______________________________
Test each eye (with glasses)
Whisper short sentence @ 6-12 inches
Unable to hear
Cerumen check
______________________________
(Out of visual view) OR audioscopy
Retest/refer/
Hearing handicap inventory
Name three objects/re-ask in 5 minutes
Unable
MMSE or other
______________________________
Draw 8 inch circle and ask patient to draw clock
Clock abnormal
MMSE or other
______________________________
"Rise from your chair (do not use arms
Observed problem
Tinetti and / or
to get up), walk 10 feet, turn, walk back
or unable in <15
further exam
to the chair and sit down
Home eval & PT
______________________________
"Touch the back of your head with your hands"
Unable to do
Further exam
"Pick up the pencil"
either
Consider OT
______________________________
(Remember to ask about the 3 items!)
Other areas of concern: caregiver stress, alcohol, social isolation, exercise, sexuality, advance directives and health care wishes.
Additional Comments:
Adapted from Lachs et al., 1990 & Moore et. al., 1996.
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Parent category: Life