WebQuest

Functional Assessment in the Older Adult

Different Functional Status Assessment Tools

The assessment of functional status is critical when caring for the older adult patient. Normal aging, changes, acute illness, worsening chronic illness, and hospitalization can contribue to a decline in the ability to perform tasks necessary to live independently in the community. The information from a functional assessment can provide objective data to assist with targeting individualized rehabilitation needs or to plan for specific in home services such as capabilities, facilitating early recognition of changes that many signify a need either for additional resources or for a medical work up for the patient. There are many functional status assessment tools available to monitor a patients ability to perform daily task and the ability to self manager. Some tools used today are listed below:

The Northwestern Geriatric Functional Status Review Instrument: A screening tool used to identify areas needing more in-depth assessment and /or intervention (card included).

Instructions for use and scoring

Physical status
Score each task 0 or 1 except for vision and hearing (Vision - 2 points for 20/20, allow 2 errors, and 1 point for 20/60, allow 1 error; Hearing, 1 point each ear, if hears correctly). If a task cannot be complete in less than 30 seconds, go on to the next one.
Follow-up recommendations: The complete physical exam and formal motor/mobility evaluation will dictate interventions such as OT, PT, hearing and vision aids, etc.
Cognitive status
Attentional: If all correct = 4. Subtract #'s of each miss down to 4 which = 0.
Memory: 1 point for each object recalled.
Visual-Spatial: Clock face, 1 point for valid attempt, 2 if clearly recognizable.
Depression: Translate 0-10 to a 0-4 scale as follows: 9-10 = 4, 6-8 = 3, 4-5 = 2, 2-3 = 1, 0-1 = 0.
ADL's/IADL's
Note: proper answer to "Do you..." questions is "No." If possible, verify with family. Also observe patient. If this subtotal score is low, patient will need extensive post-hospital care services, and may need to change their living arrangements.
Environmental/Social
These are crucial risk factors. For post-hospital care and preventing readmission, contact Social Work/Case Management for follow-up.

Scoring:

Total score of all four domains with especially poor performance noted. Interventions should be designed and initiated specifically for the individual patient after thorough evaluation. A score of 30-36 suggests significant functional impairment with need for further assessment and measures to prevent further decline. For this group it is especially important to identify home and social support systems. A score of 25 or below indicates that the patient will likely have a prolonged hospital stay, will use increased inpatient resources and is at high risk for iatrogenesis. The lower the score, the more likely it is that nursing home placement will be the outcome of hospitalization unless early interventions are mobilized to address deficits (Salzman, 2012)

The Lawton Instrumental Activity of Daily Living Tool - This tool is an appropriate instrument to assess independent living skills.

The Lawson IADL is an easy to administer instrument that provides self-reported information about functional skills necessary to live in the community. Administration time is 10-15 minutes. Specific Deficits identified can assist nurses and other disciplines in planning for safe discharge of the patient. Limitations of the instruments can include the self-report or surrogate method of administration rather than a demonstration of the functional task. This may lead to over-estimation or under-estimation of ability. In addition, the instrument may not be sensitive to small, incremental changes in function. The tool includes:

Ability to Use Telephone - Operates telephone on own initiative; looks up phone numbers;
Shopping : Takes care of all shopping needs independently; Shops independently for small purchases; Needs to be accompanied on any shopping trip; Completely unable to shop
Food Preparation: Plans, prepares, and serves adequate; Meals independently; Prepares adequate meals if supplied with ingredients; Heats and serves prepared meals or prepares mealsbut does not maintain adequate diet; Needs to have meals prepared and served
Housekeeping: Maintains house alone with occasion assistance(heavy work); Performs light daily tasks such as dishwashing; Bed making; Performs light daily tasks, but cannot maintainacceptable level of cleanliness; Needs help with all home maintenance tasks; Does not participate in any housekeeping tasks
Laundry: Does personal laundry completely; Launders small items, rinses socks, stockings, etc; All laundry must be done by others
Mode of Transportation: Travels independently on public transportation ; or drives own car; Arranges own travel via taxi, but does not; Use public transportation; Travels on public transportation when assisted; Travel limited to taxi or automobile with assistance of another; Does not travel at all
Responsibility for Own Medication: Is responsible for taking medication in correctdosages at correct time; Takes responsibility if medication is prepared; in advance in separate dosages; Is not capable of dispensing own medication
Ability to Handle Finances: Manages financial matters independently (budgets,writes checks, pays rent and bills, goes to bank);collects and keeps track of income; Manages day-to-day purchases, but needs help with banking, major purchases, etc; Incapable of handling money

Scoring: For each category, circle the item description that most closely resembles the client�shighest functional level (either 0 or 1). (Graf, 2007)

Click the Lawton IADL tool Link : (More information below)

Lawton IADL

Katz Index of Independence in Activities of Daily Living (ADL) - Appropriate instrument to assess functional status as a measurement of the client�s ability to perform activities of daily living independently.

The Katz Index of IADL is used to detect problems in performing activities of daily living and to plan care accordingly. This index is used to detect adequacy of performance in the six functions of bathing, dressing, toileting, transferring, continence, and feeding. The targeted population for this test is for the older adult patient. . It does not assess more advanced activities of daily living. Although the Katz ADL Index is sensitive to changes in declining health status, it is limited in its ability to measure small increments of change seen in the rehabilitation of older adults. A full assessment should follow when appropriate. Clients are scored yes/no for independence in each of the six functions. A score of 6 indicates full function, 4 indicates moderate impairment, and 2 or less indicates severe functional impairment (Shelkey & Wallace, 2012)

For full access to index follow the link below: Katz Index of Independence in ADL's

Comprehensive Geriatric Assessment (CGA) - a multidisciplinary diagnostic and treatment process that identifies medical, psychosocial, and functional limitations of a frail older person in order to develop a coordinated plan to maximize overall health with aging.

The CGA is used to evaluate frail, older adults by a team of healthcare professionals to identify a treatments for health problems and lead to better health and functional status outcomes. CGA programs are initiated through a referral by the primary care clinician or by a clinician caring for a patient in the hospital setting. The CGA assessment varies depending on different settings of care (eg, home, clinic, hospital, nursing home). CGA is not available in all settings, due to issues related to the time required for evaluation, need for coordination of multidisciplinary specialties, and lack of reimbursement for some components of the assessment (eg, outpatient social work, pharmacy, and nutrition). Preliminarily, the questionnaires are given out to those being assessed to gather information about general history (eg, past medical history, medications, social history, review of systems), as well as gather information specific to CGA, such as the ability to perform functional tasks and need for assistance, fall history, social support (family and friends), depression symptoms, vision and hearing difficulties, and if the patient has a durable power of attorney. Changes in functional status (eg, not being able to bathe independently) should prompt further diagnostic evaluation and intervention. Measurement of functional status can be valuable in monitoring response to treatment and can provide prognostic information that assists in long-term care planning. The CGA evaluates and assesses:

Functional capacity
Fall risk
Cognition
Mood
Polypharmacy
Social support
Financial concerns
Advanced care preferences

Nutrition/weight change
Urinary continence
Sexual function
Vision/hearing
Dentition
Living situation
Spirituality
Functional status: change in functional status should prompt for more evaluation and interventions.
ADLs : Bathing, dressing, toileting, maintaining continence, grooming, feeding, transferring
IADLs: Shopping for groceries, driving or using public transportation, using the telephone, performing housework, doing home repair, preparing meals, doing laundry, taking medication, handling finances
Gait Speed: Gait speed alone predicts functional decline and early mortality in older adults. Assessing gait speed helps the diagnoses increase risk of fall and physical illness such as hypertension.
Home assessment (Ward & Reuben, 2012)