HOLISTIC GERIATRIC ASSESSMENT TOOL

A. HISTORY
Ask about the following:
 Name
 Age
 Sex
 Weight
 Weight
 Birthday
 Birthplace
 Nationality
 Civil Status
 Educational Status
 Primary Care Provider

Medical History:
 History of previous allergies and diseases.
 Previous surgeries.
 Past treatment and regimens.
 Past use of alcohol, tobacco and drug use.
 History of major illnesses and hospitalization.
 Previous blood transfusion.
 Immunization status
 History of taking preventive health measure such as mammography and PAP
smear.
 History of tuberculosis infection.
 Ask if he/she is still sexually active.

Family History
 Family history of dementia, depression, and dysthemia.

History Of Present Illness

Onset:
 Location:
 Duration
 Associated symptoms:
 Aggravating and alleviating factors:
 Effects of any self- treatments for the problem

Pain History
 Characteristics of the pain.
 Relation of pain to physical and social function.
 Patient’s attitude and belief about pain and its management.

Fall History
 Previous history of falls causes and treatment.
  Locations and circumstances of fall
 Associated symptoms
 Other falls and near falls
 History of injury and inability to get up.

Review Of Medications:
 Are you currently taking any medications?
 If yes, for what particular condition are these medications for?
 Can you enumerate or identify the name of these medications?
 How often do you take each medication, at what prescribed dosage?

B. FUNCTIONAL ASSESSMENT
 INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADLS)
No assistance Minimal assistance Needs assistance
needed
If you had to take
your medications,
could you do it?

Can you prepare your

own meals?

Can you do
light/heavy
yardwork?

Can you use the

telephone?
Can you do your own
laundry?

Can you do
light/heavy
Housekeeping?
Can you drive your
car? (if you have)

Can you
handle/manage your
own money?
Can you get to places
that are out of
walking distance?

C. PHYSICAL ASSESSMENT
1) Circulatory Function
The following questions should be asked:
 Do you have any current problems with chest pain or discomfort especially
when associated with exertion?
 Are you taking any over-the-counter medications or herbal medicine?
 Do you feel stress? What could be your sources of stress?
 Do you adhere to any medical regimens?

Assess for the following:

 Blood pressure
 Chest sounds
 Pulse rate

2) Respiratory Function
The following questions should be asked:
 Do you ever have wheezing, chest pain, or a heavy feeling in your chest?
 How often do you get colds? Do you get colds that keep returning? How do
you treat them?
 How far can you walk? How many steps can you climb before getting short of
breath?
 Do you have any breathing problems when the weather gets cold or hot?
 How many pillows do you sleep on? Do breathing problems (e.g., coughing
and shortness of breath) ever awaken you from sleep?
 How much do you cough during the day? During each hour? Can you control
it?
 Do you bring up sputum, phlegm, or mucus when you cough? How much?
What color? Is it the consistency of water, egg white, or jelly?
 How do you manage respiratory problems? How often do you use cough
syrups, cold capsules, inhalers, vapors, rubs, or ointments?
 Did you ever smoke? If so, for how long and when and why did you stop?
How many cigarettes or cigars do you smoke daily? Do people you live with
or spend a lot of time with smoke?
 What kind of jobs have you had over your lifetime? Any in factories or
chemical plants?
 Do you live or have you lived near factories, fields, or high-traffic areas?

3) GASTROINTESTINAL FUNCTION
The following questions should be asked:
 When was your last dental exam? How do you care for your teeth or dentures?
When did you get your dentures; how do they fit? Do you have any pain,
bleeding, or other symptoms?
 Does food taste differently to you than it did in the past? What do you do to
make food taste better? How is your appetite; how does it compare to earlier
years?
 Do you ever have a sore mouth, difficulty swallowing, choking, nausea,
vomiting, bleeding from your mouth, blood in your vomitus or stool, pain or
burning in your stomach or intestines, diarrhea, constipation, gas, bleeding
from your rectum?
 Have you noticed any recent changes in your weight? Have you been trying to
gain or lose weight?
 How often do you have indigestion? What seems to cause it and how is it
managed? Is there a sense of fullness or discomfort in the chest after meals?
Does regurgitation or belching ever occur?
 How often do you have a bowel movement? Do you have to take special
measures to move your bowels? If so, what are they? Do you strain to have a
bowel movement? Is there ever blood in your stools or on the toilet tissue?
What are the color and consistency of your bowel movements?
 Describe what and when you eat in a typical day. Do foods have a different
taste to you? Can you shop for and cook meals on your own? Has your eating
pattern changed?

4) GENITOURINARY FUNCTION
The following questions should be asked:
 Do you experience pain in your lower abdomen or anywhere else? Is there any
tenderness, discomfort, itching, or pain anywhere along your genital area? Do
you experience pain with intercourse?
 Do you have any abnormal bleeding or vaginal discharge recently?
 Do you have any difficulty urinating? Do you have any burning or pain with
urination? Has your urine changed color or developed an odor? Have you
noticed blood in your urine?
 When was your last pelvic or rectovaginal examination by a health care
provider? Was a Pap test performed? What was the result?
 Have you previously run some tests? Like blood test, ketones or urine
culture/analysis?

5) SEXUAL FUNCTION
The following questions should be asked:
 Are you sexually active? If the answer is no,why?
 How frequently do you have sex? Is this a satisfying frequency to you? If not,
how would you change the frequency of sex?
 Do you have sex with a single or multiple partners? Male or female partner?
 If you have sex with new partners, do you use a condom?
 Do you obtain pleasure from sex? If not, why not?
 Have you or your partner(s) ever been treated for a sexually transmitted
infection? If yes, for what disease and when?
 Do you or your partner(s) have risk factors for HIV/AIDS, such as a history of
blood transfusions, IV drug use, or sex with multiple partners or prostitutes?
 Male: Are you able to get an erection when you want to engage in sex? Do
you have orgasms and ejaculate when you have sex? If not, describe what
happens. Do you have any sores on your penis or any discharge?
 Female: Is sex comfortable for you? If not, describe. Do you have orgasms?
Do you have any vaginal discharge or bleeding?
 Is your partner satisfied with your sex life? If not, why not?
 Have you ever been or are you currently being sexually abused? Raped? If
yes, describe.
 If health conditions or disabilities are present: How has your condition
affected your ability to enjoy sex?
 What concerns do you have regarding your sex life?
 Do you have any questions about your sexual function that you would like me
to answer?

6) Neurological Function
 Do you experience any balance problem and sleep disturbances?
 Do you experience loss of memory or Alzheimer's disease?
 Are there any family history of stroke?
 Are there any occurrence of sleep disturbance, tremors, or seizures?
 Are there any history of loss of consciousness, fainting, convulsions, trauma,
tingling or numbness, tremors or tics, limping, paralysis, uncontrolled muscle
movements?
 Do you have any speech disorder?
  Do you have any presence of pain in the head, back, or extremities? If yes,
what are the onset and aggravating and alleviating factors?

Speech Assessment
 Ask the patient to pronounce the following syllables:
 me, me, me (to test the lips)
 la, la, la (to test the tongue)
 ga, ga, ga (to test the pharynx)
 To test for a receptive aphasia, ask the patient to follow a command such as
picking up a pencil; the patient’s inability to understand what these symbols
mean will prevent the command from being followed.
 Point to several objects and ask the patient to name them.
 Ask the patient to write a short sentence that you dictate and to read a sentence
from a newspaper. Ensure that the patient has the educational and visual
abilities to fulfill these demands.

Sensation
 Ask the patient to close his or her eyes and to describe the sensations felt.
 Touch various parts of the body such as forehead, cheeks, arms, hands, legs,
and feet lightly with your finger or a cotton wisp and note if the patient is able
to feel the sensations. Compare analogous areas on both sides of the body and
distal and proximal areas on the same extremity.
 If these primary sensations are intact, test the patient’s ability to identify two
simultaneous stimuli. To test cortical sensation, have the patient, again with
closed eyes, identify various objects placed in each hand.

Coordination and Cerebellar Function

 Hold up your finger and ask the patient to touch it and then touch his or her
nose; have the patient continue this action as you move your fingers to
different areas. Do this point-to-point testing with both arms of the patient, and
note uneven, jerking movements and the inability to touch your finger or his or
her nose.
 To test coordination in the lower extremity, have the patient lie down and run
the heel of one foot against the shin of the other leg.
 Test the ability to make rapid alternating movements by having the patient
rapidly tap his or her index finger on the thigh or a table surface.
 Tandem walking, in which the patient walks heal to toe as though walking a
tightrope, also tests coordination; patients with arthritic deformities may not
be able to perform this test. Have weak or poorly coordinated patients hold
your hand during the tandem walking test.

Reflexes
 To test the corneal reflex, gently touch the cornea with a wisp of clean cotton.
Tissue and gauze are too rough and can cause corneal abrasions. Normally, the
eye should blink.
 Test the Babinski reflex by stroking the sole of the patient’s foot. Normally,
the toes should flex; an abnormal response is extension and fanning of the
toes.
7) Musculoskeletal Function
The following questions should be asked:
 Do you have any history of sore joints? Which joints are affected? What is the
duration and type of pain? How do you manage pain?
 Do you have history of bone and muscle injury?
 Does your jaw ever get stiff or hurt when you chew?
 Do you get a stiff neck?
 Does your shoulder ever tighten?
 Do your ribs ache or feel tender?
 Do your hips hurt after you have walked for a while?
 Are your joints stiff in the morning?
 Do you have back pain or stiffness?
 Do you have muscle cramps?
 How far are you able to walk?
 Are you able to take care of your home, get in and out of a bathtub, and climb
stairs?
 Do you participate in any exercise and physical activity?

Muscles
 Inspect the muscles for size. Compare the muscles on one side of the body
(e.g., of the arm, thigh, and calf) to the same muscle on the other side. For any
discrepancies, measure the muscles with a tape.
 Inspect the muscles and tendons for contractures (shortening).
 Inspect the muscles for tremors, for example by having the client hold the
arms out in front of the body
 Test muscle strength. Compare the right side with the left side.
Sternocleidomastoid: Client turns the head to one side against the resistance of your
hand. Repeat with the other side.
Trapezius: Client shrugs the shoulders against the resistance of your hands. Deltoid:
Client holds arm up and resists while you try to push it down.
Biceps: Client fully extends each arm and tries to flex it while you attempt to hold
arm in extension.
Triceps: Client flexes each arm and then tries to extend it against your attempt to
keep arm in flexion.
Wrist and finger muscles: Client spreads the fingers and resists as you attempt to
push the fingers together.
Grip strength: Client grasps your index and middle fingers while you try to pull the
fingers out.
Hip muscles: Client is supine, both legs extended; client raises one leg at a time while
you attempt to hold it down.
Hip abduction: Client is supine, both legs extended. Place your hands on the lateral
surface of each knee; client spreads the legs apart against your resistance.
Hip adduction: Client is in same position as for hip abduction. Place your hands
between the knees; client brings the legs together against your resistance.
Hamstrings: Client is supine, both knees bent. Client resists while you attempt to
straighten the legs.
Quadriceps: Client is supine, knee partially extended; client resists while you attempt
to flex the knee.
Muscles of the ankles and feet: Client resists while you attempt to dorsiflex the foot
and again resists while you attempt to flex the foot.

Bones
 Inspect the skeleton for structure.
 Palpate the bones to locate any areas of edema or tenderness

Joints
 Inspect the joint for swelling. Palpate each joint for tenderness, smoothness of
movement, swelling, crepitation, and presence of nodules
 Assess joint range of motion. Ask the client to move selected body parts. The
amount of joint movement can be measured by a goniometer, a device that
measures the angle of the joint in degrees.

8) Sensory Function
The following questions should be asked:
 When and where was the examination done?
 Was an ophthalmologist or optometrist seen?
 Did the eye examination include tonometry?
 Was a full audiometric evaluation or basic hearing screening done?
 Has there been any change in your vision? Please describe.
 Are your glasses as useful to you as they were when you first obtained them?
 Do you experience pain, burning, or itching in the eyes?
 Do you ever see spots floating across your eyes? How often does this happen
and how large and numerous are the spots?
 Do you ever see flashes of light or halos?
 Are your eyes ever unusually dry or watery?
 Do you have difficulty with vision at night, in dimly lit areas, or in bright
areas?
 Does anyone in your family have glaucoma or other eye problems?
 Have you noticed any change in your ability to hear? Please describe.
 Are certain sounds more difficult for you to hear than others?
 Do you ever experience pain, itching, ringing, or a sense of fullness in your
ears?
 Do your ears accumulate a lot of wax? How do you manage this?
 Is there ever drainage from your ears?

Eyes
 Inspect the eyes for unusual structure, drooping eyelids, discoloration, and
abnormal movement. Note any lesions on the eyelids.
  Palpation of the eyeballs with the eyelids closed can reveal hard-feeling eyes
with extremely elevated intraocular pressure (IOP) and spongy-feeling eyes
with fluid volume deficits.
 Perform a gross evaluation of visual acuity by having the patient read a
Snellen chart or various sized lettering on a newspaper. If the patient is unable
to see letters on the chart or newspaper, estimate the extent of the visual
limitation by determining if the patient is able to see fingers held up before
him or can merely make out figures.
 To perform a gross test of the visual field, have the patient focus straight
ahead. While facing the patient, bring your finger into the field of view. Note
when the patient indicates seeing your finger compared with when you are
able to see it. If the patient has restrictions in seeing all portions of the visual
field, review the exact nature of this problem.
 Test extraocular movements by having the patient follow your finger as you
move it to various points, horizontally and vertically.

Ears
 Inspection of the ears commonly shows cerumen accumulation, increased hair
growth, and atrophy of the tympanic membrane, which causes it to appear
white or gray.
 Cerumen impactions should be noted and removed.
 A small, crusted, ulcerated lesion on the pinna can be a sign of basal or
squamous cell carcinoma.
 Perform a gross evaluation of hearing by determining the patient’s ability to
hear a watch ticking. Check both ears.
 Weber and Rinne tests can be performed to assess sounds at different
frequencies. These tests involve placing a vibrating tuning fork next to the ear
or against the skull; this will stimulate the inner ear to vibrate. The Rinne
tuning fork test helps evaluate a patient’s hearing ability by air conduction
compared with that of bone conduction. The Weber tuning fork test helps
determine a patient’s hearing ability by bone conduction only, and this test is
useful when hearing loss is asymmetrical.

9) INTEGUMENTARY FUNCTION
 Do you have any problems or concerns in your skin?
 Have you had any rashes, itching, dryness, frequent brushing or any open lesions
in your skin recently?
 Do you sometimes feel numb in your extremities?
 Have you noticed any changes in your skin?
 What is your current skin care?
 Do you experience any problems with healing in relation to your skin?

Skin
 Inspect skin color (best assessed under natural light and on areas not exposed to
the sun).
 Inspect uniformity of skin color.
 Assess edema, if present (i.e., location, color, temperature, shape, and the degree
to which the skin remains indented or pitted when pressed by a finger). Measuring
 the circumference of the extremity with a millimeter tape may be useful for future
comparison.
 Inspect, palpate, and describe skin lesions. Apply gloves if lesions are open or
draining. Palpate lesions to determine shape and texture. Describe lesions
according to location, distribution, color, configuration, size, shape, type, or
structure. Use the millimeter ruler to measure lesions. If gloves were applied,
remove and discard gloves. Perform hand hygiene.
 Observe and palpate skin moisture.
 Palpate skin temperature. Compare the two feet and the two hands, using the
backs of your fingers.
 Note skin turgor (fullness or elasticity) by lifting and pinching the skin on an
extremity or on the sternum.
 Inspect signs of elder abuse.
 Inspect skin breakdown from urinary incontinence.
 Inspect for pressure ulcers.

10) ENDOCRINE AND METABOLIC FUNCTION

The following questions should be asked:
 Do you have a family history of diabetes?
 Have you experienced weight loss or any changes in appetite?
 How has your energy level changed in the last few days or weeks? How does
it affect your daily activities such as cooking, household chores, or activities
outside the home? When is your energy at its lowest level? When does it seem
to be at its best?
 Are you experiencing any vision problems?
 Have you observed slow wound healing?
 Do you experience headache? How often?
 Have you experienced any gastrointestinal problems? (constipation, ulcers)
 Did you experience specific symptoms such as polyphagia, polydipsia, and
polyuria?

Assess the following:

Nursing observation and assessment questions should address the occurence of:
- nervousness
- heat intolerance
- weight loss
- tremor
- tremor
- palpitations
 Skin changes (dry, flaky)
 Fluid retention (edema and weight gain)
 Fatigue
 Forgetfulness
 Constipation
 Unusual sensitivity to the cold
 11) HEMATOLOGIC AND IMMUNE FUNCTION
Hematologic Function
 Do you experience fatigue or chest pain?
 Have you noticed/experienced cold hands and feet?
 Is there blood in your stools?
 What is your usual food for meal? It is rich in iron?
 Is there a time wherein you became febrile due to infections? How many days
did it take?
 Have you ever been vaccinated for infections such as pneumococcal vaccine,
typhoid vaccine etc?
 Have you previously run some tests? Like CBC, (RBC count, Hgb, Hct)

Immunologic Function
Ask about the following:
 Current or recent infection
 Access and use of vaccines to prevent infections
 OB history of the client, any past sexually transmitted disease
 Sexual practices, the frequency, the number of their sexual partners, and the
contraceptive used
 Prophylaxis used

D. COGNITIVE ASSESSMENT
 Orientation: Ask the patient his or her name, where he or she is, the date,
time, and season.
 Memory and retention: Ask the patient to remember three objects. First, ask
the patient to recall the items immediately after being told; then, after asking
several other questions, ask for recall of the three items again; near the end of
the assessment, ask what the three items were one last time.
 Three-stage command: Ask the patient to perform three simple tasks.
 Judgment: Present a situation that requires basic problem solving and
reasoning.
 Calculation: Ask the patient to count backward from 100 by increments of 5;
if this is difficult, ask the patient to count backward from 20 by increments of
2. Simple arithmetic problems may also be asked, if they are within the realm
of the patient’s educational experience.

MINI-MENTAL STATE EXAMINATION (MMSE)

Maximum Patient’s Questions
Score Score
5 “What is the year? Season? Date? Day of the week? Month?”
5 “Where are we now: State? County? Town/city? Hospital? Floor?”
3 The examiner names three unrelated objects clearly and slowly,
then asks the patient to name all three of them. The patient’s
response is used for scoring. The examiner repeats them until
patient learns all of them, if possible (up to six trials). Number of
trials: ___________
After completing this task, tell the patient, "Try to remember the
words, as I will ask for them in a little while."
5 “I would like you to count backward from 100 by sevens.” (93, 86,
 79, 72, 65, …) Stop after five answers. Alternative: “Spell
WORLD backwards.” (D-L-R-O-W)
3 “Earlier I told you the names of three things. Can you tell me what
those were?”
2 Show the patient two simple objects, such as a wristwatch and a
pencil, and ask the patient to name them.
1 “Repeat the phrase: ‘No ifs, ands, or buts.”
3 “Take the paper in your right hand, fold it in half, and put it on the
floor.” (The examiner gives the patient a piece of blank paper.)
1 “Please read this and do what it says.” (Written instruction is
“Close your eyes.”)
1 “Make up and write a sentence about anything.” (This sentence
must contain a noun and a verb.)
1 “Please copy this picture.” (The examiner gives the patient a blank
piece of paper and asks him/her to draw the symbol below. All 10
angles must be present and two must intersect.)

30 TOTAL
 E. PSYCHOLOGICAL ASSESSMENT
The following questions should be asked:
 How would you describe your quality of life?
 What would add to your quality of life?
 Would you describe yourself as someone who is aging successfully?
 What would help you age successfully?

GERIATRIC DEPRESSION SCALE

YES NO
1. Are you basically satisfied with your life?
2. Have you dropped many of your activities and interests?
3. Do you feel that your life is empty?
4. Do you often get bored?
5. Are you hopeful about the future?
6. Are you bothered by thoughts you can’t get out of your head?
7. Are you in good spirits most of the time?
8. Are you afraid that something bad is going to happen to you?
9. Do you feel happy most of the time?
10. Do you often feel helpless?
11. Do you often get restless and fidgety?
12. Do you prefer to stay at home, rather than going out and doing new
things?
13. Do you frequently worry about the future?
14. Do you feel you have more problems with memory than most?
15. Do you think it is wonderful to be alive now?
16. Do you often feel downhearted and blue?
17. Do you feel pretty worthless the way you are now?
18. Do you worry a lot about the past?
19. Do you find life very exciting?
20. Is it hard for you to get started on new projects?
21. Do you feel full of energy?
22. Do you feel that your situation is hopeless?
23. Do you think that most people are better off than you are?
24. Do you frequently get upset over little things?
25. Do you frequently feel like crying?
26. Do you have trouble concentrating?
27. Do you enjoy getting up in the morning?
28. Do you prefer to avoid social gatherings?
29. Is it easy for you to make decisions?
30. Is your mind as clear as it used to be?
F. SOCIAL ASSESSMENT
The following questions should be asked:
 Is there any one special person you could call or contact if you needed help?
 In general, other than your children, how many relatives do you feel close to
and have contact with at least once?
 In general, how many friends do you feel close to and have contact with at
least once a month?
 When you need help, can you count on anyone for house cleaning, groceries
or ride?
 Could you use more help with daily task?
 Can you count on anyone for emotional support?

G. SPIRITUAL ASSESSMENT
The following questions should be asked:
 What is your faith or religion?
 Are you involved with a church, temple, or faith community? What is it?
Would you like to have them involved with your care?
 Are there religious practices that are important to you? Are you able to
practice them now? If not, is there a way I can assist you in practicing them?
 Do you believe in God or a higher power? Could you please describe what that
belief means to you?
 Do you read the Bible or other religious text? Are you able to do this reading
now?
 What do you think God’s role is in your illness and healing?
 Is there anything about your faith or spiritual beliefs that is causing you
distress, discomfort, or conflict?
 What is most meaningful to you?
 What gives your life purpose?
 What is your source of strength or support?
 From whom do you receive love?
 Who are the most significant recipients of your love?
 Do you feel like you have unfinished business? Things you need to say to
someone? Forgiveness you wish to seek or offer?
 What are your fears?
 How can I (we) best support your spiritual beliefs and practices at this time?

HOPE QUESTIONS for SPIRITUAL ASSESSMENT:

H
 What are your sources of hope, strength, comfort and peace?
 What do you hold on to during difficult times?

O
 Are you part of the religious or spiritual community?
 Does it help you now? How?

P
  Do you have personal spiritual beliefs?
 What aspects of your personality or spiritual practices do you find
most helpful?

E
 Does your current situation affect your ability to do the things that
usually help you spirituality?
 Are there any specific practices or restrictions I should know about in
providing your medical care?
 If the patient is dying, how your beliefs affect the kid of medical care
you would like me to provide over the next few days?