Recognition of the complex interaction of age-related physiologic changes, multiple comorbid illnesses, and functional stressors helps determine the health-care needs of older adults. Many older persons with multiple chronic conditions have daily symptoms, use multiple medications, visit several health-care providers, and require assistance with their activities of daily living (ADLs). Such individuals are likely to utilize various health-care settings such as the emergency department (ED), acute care hospital, rehabilitation, and nursing home. They are at risk of poor health outcomes and functional decline.

The ambulatory clinic is an ideal setting for comprehensive assessment that addresses domains beyond the usual medical conditions [9]. This comprehensive assessment fosters understanding of the complex interplay between medical, social, psychological, and value factors and elucidates opportunities for interventions to bolster independent function and support patient and family goals for care [10] (see also Chap. 10).

The comprehensive assessment is often performed with participation of multidisciplinary health professionals, depending on the size of the clinic team. In some health systems, geriatric clinic is a referral clinic for episodic consultation, while in others geriatric clinic providers become the primary care providers for older patients with complex medical and psychosocial issues. In many geriatric clinics, a nurse practitioner, social worker, and nurse case manager are part of the core team. Nonclinical office staff may assist in information gathering and screening. Other health professionals (pharmacist, physical therapist, psychiatrist, or psychologist) may be a part of the team. An interdisciplinary approach facilitates comprehensive care management, coordination of services, optimal medication management, and individualized care plans for patients and their caregivers. Information about the patient’s goals, values, and preferences for care is a major component of person-centered care and guides providers to tailor plans of care.

Rapid screening tools are available to screen various domains of geriatric assessment [11] (see Chap. 10). These tools identify concerns and help target assessments. Strategies to optimize efficiency include using pre-visit questionnaires, initial screening by ancillary staff, and spreading out screening of various domains over multiple visits.

Medication reconciliation is a critical task. Patients or caregivers should bring to each visit either the medications themselves or a comprehensive list of all (e.g., prescription and over-the-counter) medications, including supplements, with doses. The most common classes of medications implicated in ED visits for older persons are oral antiplatelet medications, oral hypoglycemics, insulin, and warfarin [13]. One commonly used guideline for medications to avoid is the Beers Criteria [14].

Increasing evidence is available to guide screening prevention in older persons. In the USA, older persons receive only about 50% of recommended care [15]. Screening for hypertension, diabetes mellitus, breast cancer, glaucoma, osteoporosis, and colorectal cancer is generally recommended. Prostate cancer screening is more controversial but is generally recommended for men over 50 whose life expectancy exceeds 10 years. Limitations in life expectancy, health status, and preferences for care all influence decisions about screening and preventive care. A coordinated effort to prevent falls in older adults has been recommended by the World Health Organization and many other agencies recognizing the personal and societal cost of fall-related injuries [16]. This report describes the importance of building awareness of falls prevention and treatment, improving the assessment of each individual, and facilitating culturally appropriate intervention to reduce falls among older adults [17–19].

While the US Preventive Services Task Force (USPSTF) does not recommend screening older adults for cognitive impairment, it is important to recognize signs of cognitive decline and to conduct further assessments [20].

The immunization status should be checked and acted upon as needed (Table 11.2).