Rotation Prep

Published July 10, 2019

Geriatric Assessment & Transition of Care

A comprehensive geriatric assessment of older adults is important for evaluating physical health, functional ability, social and family support, and mental health. A multidisciplinary approach is required in order to optimize health and functional independence.

Guiding Questions

  • What are the components of the geriatric assessment?

  • What is the impact of hospitalization on functional independence?

  • What interventions are useful to maximize functional independence?

When an older adult is hospitalized, the hospitalization itself signifies a marker of insult that can precipitate disability. This insult can have lasting impact on the individual’s functional independence to perform activities of daily living. The care during hospitalization often occurs in multiple settings. The fragmented care and transitions of care can leave the elderly individual vulnerable to poorly executed transitions. A number of interventions, such as Project RED (Re-Engineered Discharge) and Project BOOST (Better Outcomes by Optimizing Safe Transitions), are used to reduce harms associated with care transition.

The key features of a safe transition of care for older adult patients are:

  • a timely and thorough discharge summary, including follow-up testing and appointments

  • safe discharge-medication reconciliation, with de-prescribing to reduce polypharmacy (see the Medication Management section)

  • appropriate education of patient and family regarding the treatment plan and what to do if a problem arises

  • assessment of the patient and family’s understanding of this plan

Learn more about the components of geriatric assessment here.