14.1 Comprehensive Geriatric Assessment & Frailty

ABIM Internal Medicine Exam

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2 Chapter 1: Cardiovascular Disease (14% of Exam)

1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection

3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)

2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia

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13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications

15 Chapter 14: Geriatric Syndromes (3% of Exam)

14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings

16 Chapter 15: Allergy & Immunology (2% of Exam)

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17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology

16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design

18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)

17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity

19 Chapter 18: Perioperative Medicine & Medical Consultation

18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications

20 Chapter 19: Ophthalmology (1% of Exam)

19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease

21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)

20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders

14.1 Comprehensive Geriatric Assessment & Frailty

Key Takeaways Explain This Topic AI

Principles of the geriatric assessment is a separately enumerated blueprint subsection.

Functional status is measured with activities of daily living and instrumental activities of daily living, which are more predictive of outcomes than diagnosis counts.

Frailty is a distinct syndrome of reduced physiologic reserve that predicts falls, disability, hospitalization and mortality independent of comorbidity.

Resistance exercise and adequate protein intake are the interventions with the best evidence for frailty and sarcopenia.

Screening for geriatric syndromes should be periodic and structured, because patients rarely volunteer falls, incontinence or cognitive change.

Last updated: August 2026

Geriatric medicine requires a paradigm shift from single-disease pathophysiology to holistic, multidimensional assessment. The physiological decline of aging is characterized by homeostenosis—the progressive constriction of physiological reserve across organ systems—rendering older adults exceptionally susceptible to functional disability, iatrogenic injury, and multi-organ decompensation from minor physiological stressors.

1. Comprehensive Geriatric Assessment (CGA) & Functional Domains

The Comprehensive Geriatric Assessment (CGA) is an evidence-based, multidimensional, interprofessional diagnostic and therapeutic process designed to determine an older adult's medical, psychosocial, and functional capabilities, culminating in an integrated, coordinated plan for treatment and long-term follow-up.

The Core Domains of CGA

Medical / Physical Health: Chronic multimorbidity, polypharmacy, nutritional status, sensory deficits (vision, hearing), dentition, pain, and fall history.

Functional Status: Quantitative performance of basic and instrumental daily living skills.

Cognitive & Mental Health: Screening for cognitive impairment, delirium risk, depression (Geriatric Depression Scale [GDS-15]), and anxiety.

Socio-Environmental Circumstances: Caregiver network, social support, physical living environment safety, financial resources, and transportation access.

Advance Care Planning: Values, healthcare proxy designation, and goal-concordant medical preferences.

Functional Stratification: ADLs vs. IADLs

Functional status is the single most powerful predictor of hospitalization, nursing home placement, and 1-year mortality in older adults—often far outweighing chronological age or specific disease diagnoses.

Functional Domain Classification Instrument Specific Component Activities Clinical Significance & Failure Sequence

Activities of Daily Living (ADLs) Katz Index of ADLs 1. Bathing (washing body in tub/shower); 2. Dressing (selecting and putting on clothes/fasteners); 3. Toileting (getting to commode, cleaning self); 4. Transferring (moving between bed and chair); 5. Continence (complete bowel and bladder control); 6. Feeding (getting food from plate into mouth) Fundamental self-care tasks essential for basic survival.; Failure Sequence: Bathing and dressing typically fail first; feeding is the most resilient and fails last in advanced dementia/frailty.; Loss of >=1 ADL requires direct human caregiving assistance.

Instrumental Activities of Daily Living (IADLs) Lawton-Brody IADL Scale 1. Managing Medications (taking correct pills/dosages on time); 2. Managing Finances (paying bills, balancing checkbook); 3. Using the Telephone (dialing, answering calls); 4. Shopping for Groceries / Essentials ; 5. Preparing Food / Meal Planning ; 6. Housekeeping (cleaning, routine maintenance); 7. Doing Laundry ; 8. Transportation (driving, navigating public transit) Complex organizational tasks required for independent community living.; Failure Sequence: IADLs depend heavily on executive function and short-term memory; IADL deficits precede ADL deficits and represent the clinical hallmark distinguishing Mild Cognitive Impairment from early Dementia.

2. Frailty: Phenotypic Model & Clinical Implications

Frailty is a clinical biological syndrome characterized by decreased physiological reserve and diminished resistance to stressors, resulting from cumulative, multi-system physiological dysregulation (endocrine, immune, neuromuscular, cardiovascular). Frail older adults experience disproportionate functional collapse following minor insults (e.g., uncomplicated urinary tract infection, mild dehydration, elective surgery).

Fried Phenotypic Criteria for Frailty

The Fried criteria (Cardiovascular Health Study) define frailty using 5 standardized phenotypic domains:

Unintentional Weight Loss: Loss of >10 lbs (>4.5 kg) or >5% of baseline body weight in the preceding 12 months.

Self-Reported Exhaustion: Positive response on the Center for Epidemiological Studies Depression (CES-D) scale to "I felt that everything I did was an effort" or "I could not get going" for >=3 days in the past week.

Weakness (Low Grip Strength): Dominant hand grip strength measured by isometric dynamometer in the lowest 20% of the population (stratified by gender and body mass index [BMI]; typically <29-32 kg for men, <17-20 kg for women).

Slow Walking Speed (Sluggish Gait): Time required to walk 4 meters (15 feet) in the lowest 20% of the population (gait speed < 0.8 meters/second ).

Low Physical Activity: Caloric expenditure on the Minnesota Leisure Time Activities questionnaire in the lowest 20% (<383 kcal/week for men, <270 kcal/week for women).

Diagnostic Scoring & Triage

Robust / Non-Frail: 0 criteria met.

Pre-Frail: 1 or 2 criteria met (high risk of progressing to full frailty; target for preventive multicomponent exercise and nutritional therapy).

Frail: >= 3 criteria met .

ABIM Board Pearl: Frailty is NOT synonymous with multimorbidity or advanced chronological age. A frail patient undergoing elective major surgery (e.g., total hip arthroplasty, CABG) has a 4-fold higher risk of 30-day postoperative complications, prolonged institutionalization, delirium, and mortality compared to a non-frail patient of identical age and comorbidities. Preoperative frailty assessment is mandatory for risk stratification.

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