Comprehensive Geriatric Assessment

Thank you for referring this patient for assessment and consideration for our home-based primary care team. Intake visit was conducted on 1 November 2024, from 09:00 to 10:00. Reason for Assessment: - Cognitive decline and functional impairment. - Collateral history was obtained from the patient's daughter. History: Patient is an 82-year-old female with a history of hypertension and mild cognitive impairment. She reports increasing difficulty with memory and managing her medications. She has been experiencing falls in the last 6 months. Cognition: - Cognitive domains affected: Short term memory, executive function. - Short term memory issues: Patient struggles to recall recent events and appointments. - Executive function: Difficulty with planning and problem-solving. - Mood: Patient reports feeling sad and withdrawn, but denies suicidal ideation. - Depression and anxiety screening results: GDS-15 score of 8, indicating mild depression. - Sleep concerns: Patient reports difficulty falling asleep and staying asleep. Falls/mobility: - Dizziness with postural change: Yes, patient reports feeling lightheaded when standing up quickly. - Falls: Yes, patient has fallen twice in the last 6 months, both resulting in minor injuries. - Change in gait: Yes, patient's gait is slow and unsteady. Medical History: - Past medical history: Hypertension, mild cognitive impairment, osteoarthritis. - Previous surgeries: Right hip replacement 5 years ago. Functional Assessment: - Activities of daily living (ADLs): Patient requires assistance with bathing and dressing. - Instrumental activities of daily living (IADLs): Patient struggles with managing finances and medications. - Mobility and gait: Slow and unsteady gait, uses a cane for ambulation. - Use of assistive devices: Cane. - Vision: Reports blurry vision. - Hearing: Reports some hearing loss. - Ability to leave the home: Limited due to mobility issues. - Screening test results (e.g., MMSE, MoCA): MoCA score of 18. Social History: - Living situation: Lives alone in a single-family home. - Support system: Daughter provides daily support. - Occupation and retirement status: Retired teacher. - Alcohol, tobacco, and substance use: Denies alcohol or tobacco use. No illicit substance use. Other Geriatric Syndromes: - Falls: Recurrent falls. - Sleep issues: Insomnia. ESAS: - Pain, if mentioned: Mild pain in the right hip. - Tiredness, if mentioned: Reports feeling tired most of the time. - Depression, if mentioned: Reports feeling depressed. Current Medications: - Lisinopril 10mg daily - Donepezil 5mg daily Immunizations: - Pneumococcal vaccine - Influenza vaccine Physical Examination: - General appearance: Appears frail and elderly. - Cardiovascular system: Regular rate and rhythm. - Musculoskeletal system: Decreased range of motion in the right hip. - Neurological examination: Mild cognitive impairment. Investigations: - Pertinent lab work: CBC, CMP, TSH, Vitamin D. Impression: Mild cognitive impairment with functional decline and recurrent falls. Plan and Recommendations: - Management plan: Referral to physical therapy for gait training and fall prevention. Medication review. Home safety assessment. - Referrals to specialists or services: Physical therapy, occupational therapy. - Donepezil: Continue. - Goals of care: Maintain independence and prevent falls. Follow-up: Follow-up in 2 weeks.