Table 3.

Case-finding for Complex Chronic Conditions in Seniors 75+ (C5-75): Level 2 Screening.

Level 2 Screening Process
Nutrition	Fracture Risk	Urinary Incontinence	Depression, Anxiety, Social Isolation
Measure height Measure weight Ask: (i) Have you lost weight in the past 6 months without trying to lose weight? (ii) Have you been eating less than usual for more than a week? If “YES” to both, send to dietitian.	If on medications for osteoporosis *: MD is reminded to review appropriateness of therapy and monitoring If not on medications for osteoporosis: (i) Order X-ray T-L spine if: rib–pelvis distance ≤ 2 fingerbreadths, or Wall-Occiput distance > 5 cm, or measured height decrease of ≥ 2 cm over 3 years, or decrease of > 6 cm from patient’s tallest recalled height (ii) If ≥ 3 years since last BMD, order a BMD Ensure ≥ 800 IU Vitamin D	Ask: Do you leak urine or wet yourself? If “yes,” ask: Does it bother you enough that you’d like to have this looked into further? If “Yes”: (i)Send urine for urinalysis and culture (ii)Provide handout on avoidance of caffeine, alcohol, and excessive drinking of fluids (iii)Order post-void residual pelvic ultrasound (iv)Refer to incontinence program.	Administer PHQ-2; If score ≥ 3, request completion of PHQ-9. If PHQ-9 score ≥ 10, MD is notified 2.Administer GAD-2; If score ≥ 3, request completion of GAD-7. If GAD-7 score ≥ 10, MD is notified 3. Administer LSNS-6; If score < 12, refer for social work assessment
Caregiver Burden (if applicable)	Cognitive Impairment	Falls Risk	Assessment Urgency Algorithm (AUA)
If caregiver is present, administer 4-item Zarit scale (if caregiver is not present, obtain verbal consent to contact by phone). If score ≥ 8, request caregiver to complete 22-item Zarit scale If score ≥ 17, MD is notified and social work referral recommended.	If not seen in Memory Clinic within 1 year, administer Mini-Cog If positive score, MD is notified and referral to the Memory Clinic suggested	Obtain orthostatic vitals Ensure optometrist or ophthalmologist assessment within past one year Check cane/walker height Gait quality assessment Ask: (i) Do you ever feel unsteady on your feet or that you might lose your balance? (ii) Are you worried about falling? If “yes” to either question, refer to Mobility Clinic.	Administer and record score. If 6, MD is notified and recommendation made for referral to geriatric medicine.

* Medications for osteoporosis: risedronate; alendronate; denosumab; zolendronic acid; raloxifene; teriparatide. PHQ-2/PHQ-9 = Patient Health Questionnaire (2 and 9 question versions), GAD-3/GAD-7 = General Anxiety Disorder (3 and 7 item versions), BMD = Bone mineral density, LSNS = Lubben Social Network Scale.