Headings
Functional status · Cognition · Mood · Falls and mobility · Medications · Nutrition · Social support · Goals of care · Plan
When to use it
Use this for a comprehensive review of an older adult who is becoming frail, forgetful or unsteady, or whose family is worried about living at home. It covers function, cognition, mood, falls, nutrition and social support in one pass, then anchors the plan to the patient’s own goals. It goes much deeper than an annual wellness visit and usually needs a longer appointment.
Example
Fictional example
Functional status
B.T., 84. Independent in bathing and dressing. Needs help with shopping and bills since spring.
Cognition
MoCA 21 of 30, lost points on recall and clock drawing. Daughter reports missed appointments.
Mood
GDS-15 score 3. Enjoys church group.
Falls and mobility
Two falls in 6 months, both at night. Timed Up and Go 16 seconds. Uses no walking aid.
Medications
Eight medications. Takes zolpidem 5 mg nightly.
Nutrition
Weight down 6 lb in 6 months. Skips lunch.
Social support
Widowed, lives alone. Daughter visits twice weekly.
Goals of care
Wants to stay in her own home.
Plan
Taper zolpidem. Physical therapy for gait. B12, TSH, metabolic panel. Meal delivery referral. Revisit living arrangements in 3 months.