- Functional status
- Nutrition
- Vision
- Hearing
- History and context of a fall event
- Timed Get Up And Go Test
- Chair Stand Test
- Gait and Balance Testing
- Tinetti Gait and Balance Scale
- Observational
- Orthostatic vital signs
- Medication review
- Vision check
- History
- Interview patient and caregiver separately
- Begin with broad based questions
- Be nonjudgmental with caregivers
- Physical
- Poor hygiene
- Dirty/torn/inappropriate clothing
- Neglected hair/nails
- Injuries
- Bruises to upper torso
- Scratches/skin findings where patient cannot reach
- Scalp injuries
- Behavior
- Expressions of fear, avoidance of caregiver
- Lack of eye contact with caregiver
- Caregiver insisting on being present for all interactions
- Serial switching of healthcare providers
- Inconsistent history
- 3 item recall
- The Geriatric Depression Scale
- Patient Health Questionnaire-9 (PHQ-9)
- Patient Health Questionnaire-2 (PHQ-2)
- Have you been troubled by feeling down, depressed, or hopeless?
- Have you expressed little interest or pleasure in doing things?
- Cornell Scale for Depression in Dementia