Functional Assessment of the Older Adult

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.

Functional AssessmentFunctional Assessmentof the Older Adultof the Older Adult

Chapter 30Chapter 30


Chapter 30: Functional Assessment of the Older AdultChapter 30: Functional Assessment of the Older Adult

Functional Assessment of the Functional Assessment of the Older AdultOlder Adult

Comprehensive assessment of an older adult Comprehensive assessment of an older adult Requires knowledge of normal aging changes and Requires knowledge of normal aging changes and

effects of chronic diseases, heredity, and lifestyleeffects of chronic diseases, heredity, and lifestyle Comprehensive geriatric assessment is Comprehensive geriatric assessment is

multidimensional and incorporates not only multidimensional and incorporates not only physical examination, but also assessments of:physical examination, but also assessments of:• Mental status Mental status

• Functional statusFunctional status

• Social and economic statusSocial and economic status

• PainPain

• Examination of physical environment for safety concernsExamination of physical environment for safety concerns

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Functional Assessment of the Functional Assessment of the Older AdultOlder Adult (cont.)(cont.)

Comprehensive assessment of an older adult Comprehensive assessment of an older adult (cont.)(cont.) Multiple disciplines may participate in assessmentMultiple disciplines may participate in assessment

• Physicians, nurses, physical, occupational and speech Physicians, nurses, physical, occupational and speech therapists, social workers, case managers, nutritionists, therapists, social workers, case managers, nutritionists, and pharmacistsand pharmacists

• Early recognition of disabilities and treatable conditions Early recognition of disabilities and treatable conditions is instrumental in preserving function and quality of life is instrumental in preserving function and quality of life for older adultsfor older adults

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U.S. has large and expanding population of U.S. has large and expanding population of older adultsolder adults In 2004 persons 65 years of age and older totaled In 2004 persons 65 years of age and older totaled

12% of U.S. population and 38% of acute hospital 12% of U.S. population and 38% of acute hospital discharges and consumed 44% of total inpatient discharges and consumed 44% of total inpatient days of care days of care

Older adults also comprise 80% of home care Older adults also comprise 80% of home care visits and 90% of those in nursing homesvisits and 90% of those in nursing homes

Number of adults aged 65 years and older in U.S. Number of adults aged 65 years and older in U.S. with disabilities is approximately 7 millionwith disabilities is approximately 7 million

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Normal changes of aging do not necessarily Normal changes of aging do not necessarily represent pathologyrepresent pathology With imposition of acute and chronic illnesses, With imposition of acute and chronic illnesses,

including hospitalization, older adults may be including hospitalization, older adults may be predisposed to disabilitypredisposed to disability• Older adults may arrive not only with an acute illness Older adults may arrive not only with an acute illness

such as pneumonia, but also with ongoing chronic such as pneumonia, but also with ongoing chronic “geriatric syndromes,” such as urinary incontinence, “geriatric syndromes,” such as urinary incontinence, fragile skin, confusion, problems with eating or feeding, fragile skin, confusion, problems with eating or feeding, falls, and sleep disordersfalls, and sleep disorders

• If these syndromes are not identified early, an older adult If these syndromes are not identified early, an older adult may have functional declinemay have functional decline

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Functional AbilityFunctional Ability

Functional ability refers to one’s ability to Functional ability refers to one’s ability to perform activities necessary to live in modern perform activities necessary to live in modern societysociety Includes driving, using telephone, and performing Includes driving, using telephone, and performing

personal tasks such as bathing and toiletingpersonal tasks such as bathing and toileting• Also incorporates older adult’s physiologic and Also incorporates older adult’s physiologic and

psychological status and physical and social environmentpsychological status and physical and social environment

• Functional status: individual’s actual performance of Functional status: individual’s actual performance of activities and tasks associated with his or her current life activities and tasks associated with his or her current life roles and dependent on motivation, vision and hearing, roles and dependent on motivation, vision and hearing, degree of assistance needed to accomplish tasks, and degree of assistance needed to accomplish tasks, and cognitioncognition

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Functional AbilityFunctional Ability (cont.)(cont.)

Functional ability refers to one’s ability to Functional ability refers to one’s ability to perform activities necessary to live in modern perform activities necessary to live in modern society (cont.)society (cont.) Functional status is not static; older adults may Functional status is not static; older adults may

move continuously through varying stages of move continuously through varying stages of independence and disabilityindependence and disability• Lack of social support or safe physical setting are Lack of social support or safe physical setting are

environmental issues affecting functional status and environmental issues affecting functional status and ability to live independentlyability to live independently

• Interaction of these components provides a snapshot of Interaction of these components provides a snapshot of an older adult’s functional status at a given point in timean older adult’s functional status at a given point in time

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Refers to one’s ability to perform activities Refers to one’s ability to perform activities necessary to live in modern society (cont.)necessary to live in modern society (cont.) Assessment of function is important geriatric tenet Assessment of function is important geriatric tenet

to provide a baselineto provide a baseline• For continuing comparisonFor continuing comparison

• Predict prognosisPredict prognosis

• Assists practitioner with objective measures to determine Assists practitioner with objective measures to determine efficacy of treatmentsefficacy of treatments

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Functional ability refers to one’s ability to Functional ability refers to one’s ability to perform activities necessary to live in modern perform activities necessary to live in modern society (cont.)society (cont.) Functional assessmentFunctional assessment

• Basis for care planning, goal setting, and discharge Basis for care planning, goal setting, and discharge planningplanning

• Needed for eligibility to obtain services such as durable Needed for eligibility to obtain services such as durable medical equipment, home modifications, and inpatient or medical equipment, home modifications, and inpatient or outpatient rehabilitation servicesoutpatient rehabilitation services

• For older adult and family, a functional assessment can For older adult and family, a functional assessment can identify areas for current and future planningidentify areas for current and future planning

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Functional assessment includes three Functional assessment includes three overarching domainsoverarching domains Activities of daily living (ADL), Activities of daily living (ADL), Instrumental activities of daily living (IADL) Instrumental activities of daily living (IADL) MobilityMobility

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Two approaches to functional assessmentTwo approaches to functional assessment Individual’s self-report about his or her ability to Individual’s self-report about his or her ability to

perform tasksperform tasks Observing his or her ability to perform tasksObserving his or her ability to perform tasks

• For persons with memory problems, use of surrogate For persons with memory problems, use of surrogate reporters (proxy reports), such as family members or reporters (proxy reports), such as family members or caregivers may be necessary, keeping in mind that they caregivers may be necessary, keeping in mind that they may either overestimate or underestimate actual abilitiesmay either overestimate or underestimate actual abilities

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Activities of daily livingActivities of daily living ADLs measure tasks necessary for self-careADLs measure tasks necessary for self-care

• EatingEating

• Bathing Bathing

• Grooming (washing, combing hair, shaving, cleaning Grooming (washing, combing hair, shaving, cleaning teeth, dressing)teeth, dressing)

• ToiletingToileting

• Walking, including propelling a wheelchair, using stairsWalking, including propelling a wheelchair, using stairs

• Transferring, such as bed to chairTransferring, such as bed to chair ADL instruments are designed as either self-report, ADL instruments are designed as either self-report,

observation of tasks, or proxy/surrogate reportobservation of tasks, or proxy/surrogate report

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ADL instrumentsADL instruments Katz Index of Independence in ADLKatz Index of Independence in ADL Barthel IndexBarthel Index Functional Independence Measure (FIM)Functional Independence Measure (FIM) Rapid Disability Rating Scale-2 (RDS-2)Rapid Disability Rating Scale-2 (RDS-2)

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Instrumental activities of daily livingInstrumental activities of daily living Goal of measuring functional abilities necessary Goal of measuring functional abilities necessary

for independent community livingfor independent community living• IADLs include shopping, meal preparation, IADLs include shopping, meal preparation,

housekeeping, laundry, managing finances, taking housekeeping, laundry, managing finances, taking medications, and using transportationmedications, and using transportation

• These instruments may have cultural and gender biases, These instruments may have cultural and gender biases, especially in older cohortsespecially in older cohorts

• IADL instruments measure tasks historically done by IADL instruments measure tasks historically done by women, and most do not address activities done women, and most do not address activities done primarily by men, such as home repairs and working in primarily by men, such as home repairs and working in yardyard

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IADL instrumentsIADL instruments Lawton Instrumental Activities of Daily LivingLawton Instrumental Activities of Daily Living OARS-IADL , Older Americans Resources and OARS-IADL , Older Americans Resources and

Services Multidimensional Functional Assessment Services Multidimensional Functional Assessment Questionnaire-IADLQuestionnaire-IADL

Direct Assessment of Functional Abilities (DAFA) Direct Assessment of Functional Abilities (DAFA)

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Advanced activities of daily living (AADLs)Advanced activities of daily living (AADLs) Activities older adults perform as family member, Activities older adults perform as family member,

member of society and community, including member of society and community, including occupational and recreational activitiesoccupational and recreational activities• Various AADL instruments commonly include self-care, Various AADL instruments commonly include self-care,

mobility, work (either paid or volunteer), recreational mobility, work (either paid or volunteer), recreational activities/hobbies, and socializationactivities/hobbies, and socialization

• Occupational therapists often perform assessment of Occupational therapists often perform assessment of AADLsAADLs

• Older adult sets priorities for these activities so that Older adult sets priorities for these activities so that interventions can be individualizedinterventions can be individualized

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AADL instrumentsAADL instruments Physical Performance Test (PPT)Physical Performance Test (PPT) Performance Activities of Daily Living (PADL)Performance Activities of Daily Living (PADL) Up and Go TestUp and Go Test

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Assessment of cognitionAssessment of cognition Assessment of cognitive status in older adults is Assessment of cognitive status in older adults is

an important part of the functional assessmentan important part of the functional assessment Domains of cognition included in most mental Domains of cognition included in most mental

status assessments status assessments • AttentionAttention

• MemoryMemory

• OrientationOrientation

• LanguageLanguage

• Visuospatial skillsVisuospatial skills

• Higher cognitive functionsHigher cognitive functions

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Altered cognition in older adults is commonly Altered cognition in older adults is commonly attributed to three disordersattributed to three disorders Dementia Dementia DeliriumDelirium DepressionDepression

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Social domainSocial domain Focuses on relationships within family, social Focuses on relationships within family, social

groups, and communitygroups, and community• Comprises multiple dimensions including sources of Comprises multiple dimensions including sources of

formal and informal assistance available from those formal and informal assistance available from those relationshipsrelationships

• Comprehensive social assessment is typically spread Comprehensive social assessment is typically spread over several evaluation periodsover several evaluation periods

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Social domain (cont.)Social domain (cont.) Informal supportInformal support

• Includes family and close long-time friends, and is Includes family and close long-time friends, and is usually provided free of chargeusually provided free of charge

Total economic value of informal caregiving in U.S. Total economic value of informal caregiving in U.S. estimated to be more than twice amount paid for nursing estimated to be more than twice amount paid for nursing home carehome care

• Services provided include tasks such as shopping, Services provided include tasks such as shopping, bathing, feeding, and paying billsbathing, feeding, and paying bills

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Social domain (cont.)Social domain (cont.) Formal supportsFormal supports

• Include programs such as social welfare and other social Include programs such as social welfare and other social service and health care delivery agencies such as home service and health care delivery agencies such as home health carehealth care

• Several studies conclude that presence of a caregiver is Several studies conclude that presence of a caregiver is most important factor in discharge plan of older adults most important factor in discharge plan of older adults from an acute care hospitalfrom an acute care hospital

• Knowing who would be available to help person if he or Knowing who would be available to help person if he or she becomes ill is important to document even for she becomes ill is important to document even for healthy eldershealthy elders

• Several standardized assessment instruments are Several standardized assessment instruments are available to provide structured assessmentavailable to provide structured assessment

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Caregiver AssessmentCaregiver Assessment

Primary caregiversPrimary caregivers Increased stress, burden, and impaired physical Increased stress, burden, and impaired physical

health for caregiverhealth for caregiver Especially spouse and adult children often face Especially spouse and adult children often face

• High levels of demandHigh levels of demand

• Limitations on personal freedom Limitations on personal freedom

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Caregiver AssessmentCaregiver Assessment (cont.)(cont.)

Most elders with functional impairment live Most elders with functional impairment live with help of informal supportwith help of informal support Spouse, daughter, or other family memberSpouse, daughter, or other family member High levels of functional dependency place a High levels of functional dependency place a

burden on caregiver and may result in caregiver: burden on caregiver and may result in caregiver: • BurnoutBurnout

• Sleep disturbancesSleep disturbances

• Depression Depression

• MorbidityMorbidity

• Increased mortalityIncreased mortality

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Older person’s need for institutionalization Older person’s need for institutionalization often better predicted from assessment of often better predicted from assessment of caregiver than from severity of patient’s caregiver than from severity of patient’s illnessillness Health and well-being of patient and caregiver are Health and well-being of patient and caregiver are

closely linkedclosely linked• Part of caring for a frail elder involves paying attention to Part of caring for a frail elder involves paying attention to

the well-being of caregiverthe well-being of caregiver

• Social worker may help identify programs such as Social worker may help identify programs such as caregiver support groups, respite programs, adult day caregiver support groups, respite programs, adult day care, or hired home health aidescare, or hired home health aides

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Assessment of caregiver burdenAssessment of caregiver burden All caregivers should be screened for caregiver All caregivers should be screened for caregiver

burdenburden• Caregiver burden is perceived strain by person who Caregiver burden is perceived strain by person who

cares for an elderly, chronically ill, or disabled personcares for an elderly, chronically ill, or disabled person

• Caregiver burden is linked to caregiver’s ability to cope Caregiver burden is linked to caregiver’s ability to cope and handle stressand handle stress

• Level of care older adult requires may exceed caregiver Level of care older adult requires may exceed caregiver abilityability

• Signs of possible caregiver burnout include multiple Signs of possible caregiver burnout include multiple somatic complaints, increased stress and anxiety, social somatic complaints, increased stress and anxiety, social isolation, depression, and weight lossisolation, depression, and weight loss

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Assessment of caregiver burden (cont.)Assessment of caregiver burden (cont.) Caregiver Strain IndexCaregiver Strain Index

• Screening tool that identifies caregivers needing a more Screening tool that identifies caregivers needing a more comprehensive assessment comprehensive assessment

Brief tool with 13 questions addressing potential strain in Brief tool with 13 questions addressing potential strain in employment, financial, physical, social, and time domainsemployment, financial, physical, social, and time domains

Caregiver stress can lead to elder mistreatmentCaregiver stress can lead to elder mistreatment Thorough assessment may identify opportunities to prevent Thorough assessment may identify opportunities to prevent

and stop elder mistreatmentand stop elder mistreatment

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Elder mistreatmentElder mistreatment Elder abuse and neglect refer to acts of omission Elder abuse and neglect refer to acts of omission

or commission that result in harm or threatened or commission that result in harm or threatened harm to the health or welfare of an older adultharm to the health or welfare of an older adult• Elder abuse is umbrella term used to describe one or Elder abuse is umbrella term used to describe one or

more of following situations: physical abuse, sexual more of following situations: physical abuse, sexual abuse, emotional or psychologic abuse, financial or abuse, emotional or psychologic abuse, financial or material exploitation, abandonment, neglect, or a material exploitation, abandonment, neglect, or a combination of thesecombination of these

• One study estimates that more than 551,000 people who One study estimates that more than 551,000 people who are 60 years of age and over and who are living in are 60 years of age and over and who are living in community experience abuse, neglect, or self-neglectcommunity experience abuse, neglect, or self-neglect

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Elder mistreatment (cont.)Elder mistreatment (cont.) Among known perpetrators of abuse and neglect, Among known perpetrators of abuse and neglect,

a family member was identified in 90% of casesa family member was identified in 90% of cases• Two thirds of perpetrators were spouses and adult Two thirds of perpetrators were spouses and adult

children children

• Health care providers may assume behavior exhibited Health care providers may assume behavior exhibited during assessment is due to a dementia, confusion, or during assessment is due to a dementia, confusion, or paranoia, therefore minimizing elder’s report of paranoia, therefore minimizing elder’s report of mistreatmentmistreatment

• Health professionals and general public lack awareness Health professionals and general public lack awareness on how pervasive elder mistreatment ison how pervasive elder mistreatment is

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Assessing for elder mistreatmentAssessing for elder mistreatment General guideline: ask direct and simple questions General guideline: ask direct and simple questions

• Structure your assessment questions in nonjudgmental Structure your assessment questions in nonjudgmental and nonthreatening mannerand nonthreatening manner

• Start with general questions and become progressively Start with general questions and become progressively more specific if person’s responses indicate elder more specific if person’s responses indicate elder mistreatmentmistreatment

• Interview elder and caregiver together and separatelyInterview elder and caregiver together and separately Not only to detect abusive behavior but assess for Not only to detect abusive behavior but assess for

caregiver stresscaregiver stress Caregivers may be reluctant to discuss personal problems Caregivers may be reluctant to discuss personal problems

in front of person who depends on their carein front of person who depends on their care

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Assessing for elder mistreatment (cont.)Assessing for elder mistreatment (cont.) Clues to elder abuse include:Clues to elder abuse include:

• Observations that caregiver reluctant to leave elder Observations that caregiver reluctant to leave elder alone with health providersalone with health providers

• Person defers excessively to caregiver to answer Person defers excessively to caregiver to answer questionsquestions

• Delays between injuries and when treatment is soughtDelays between injuries and when treatment is sought

• Inconsistencies noted between observed injury and Inconsistencies noted between observed injury and explanationexplanation

• Lack of appropriate clothing or hygiene Lack of appropriate clothing or hygiene

• History of “doctor shopping” or not having a primary History of “doctor shopping” or not having a primary health care providerhealth care provider

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Assessing for elder mistreatmentAssessing for elder mistreatment (cont.)(cont.) Clues to elder abuse include: (cont.)Clues to elder abuse include: (cont.)

• Positive finding of these clinical situations does not Positive finding of these clinical situations does not necessarily mean that abuse has occurred, but rather necessarily mean that abuse has occurred, but rather that further assessment is neededthat further assessment is needed

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Risk factors for abuseRisk factors for abuse Typical profile of elder abuse victimTypical profile of elder abuse victim

• FemaleFemale

• 75 years or older75 years or older

• Limited resourcesLimited resources

• Residing with familyResiding with family

• Disruptive behaviorDisruptive behavior

• Social isolationSocial isolation

• Caregiver financially dependent on elderCaregiver financially dependent on elder

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Theories and frameworks of elder Theories and frameworks of elder mistreatmentmistreatment Causes of elder mistreatment are multifacetedCauses of elder mistreatment are multifaceted

• No single theory fully provides an answerNo single theory fully provides an answer

• One theory is that elder abuse is caused when caregiver One theory is that elder abuse is caused when caregiver has too many demands on his or her time and acts out has too many demands on his or her time and acts out by mistreating older adultby mistreating older adult

• Stress should be seen as a trigger for abuse rather than Stress should be seen as a trigger for abuse rather than a direct causea direct cause

• Another theory is cycle of family violence or Another theory is cycle of family violence or intergenerational violenceintergenerational violence

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Theories and frameworks of elder Theories and frameworks of elder mistreatmentmistreatment (cont.)(cont.) Causes of elder mistreatment are multifaceted Causes of elder mistreatment are multifaceted

(cont.)(cont.)• Caregivers who are abused as children grow up to abuse Caregivers who are abused as children grow up to abuse

the abusive parentthe abusive parent

• Family members with impairments are more likely to be Family members with impairments are more likely to be the primary caretakers because they are the ones at the primary caretakers because they are the ones at home and available because of a lack of employmenthome and available because of a lack of employment

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DocumentationDocumentation Proper documentation is important in recording Proper documentation is important in recording

suspected cases of elder mistreatmentsuspected cases of elder mistreatment Precise recording of findings is crucial because Precise recording of findings is crucial because

medical records may become part of legal recordmedical records may become part of legal record If possible, document verbatim descriptions of If possible, document verbatim descriptions of

events and draw or photograph physical findingsevents and draw or photograph physical findings

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Environmental AssessmentEnvironmental Assessment

Environmental modifications can promote Environmental modifications can promote mobility and reduce risksmobility and reduce risks Common environmental risks include:Common environmental risks include:

• LightingLighting

• RugsRugs

• HallwaysHallways

• CordsCords

• Toilet seatsToilet seats

• Neighborhood safetyNeighborhood safety

• Transportation accessTransportation access

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Spiritual AssessmentSpiritual Assessment

Spiritual assessment is highly individualSpiritual assessment is highly individual May be delayed until provider-client relationship May be delayed until provider-client relationship

has been developedhas been developed• Open-ended questions provide a foundation for future Open-ended questions provide a foundation for future

dialogdialog

• Sample question posed during initial assessment may be Sample question posed during initial assessment may be “Do you consider yourself to be a spiritual person?” “Do you consider yourself to be a spiritual person?”

• Involving chaplains or clergy members, when possible Involving chaplains or clergy members, when possible and appropriate, can provide older adult with support and and appropriate, can provide older adult with support and can serve as resource to cliniciancan serve as resource to clinician

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Special ConsiderationsSpecial Considerations

Cultural considerationsCultural considerations Culture influences all parts of person’s life Culture influences all parts of person’s life

• He or she may want to try traditional/alternative practices He or she may want to try traditional/alternative practices to prevent or treat certain conditionsto prevent or treat certain conditions

• Learn how person’s culture fits together with suggested Learn how person’s culture fits together with suggested interventionsinterventions

• Culture also influences whether older adult relies on: Culture also influences whether older adult relies on: Family or friends for care and decision makingFamily or friends for care and decision making Disclosure of medical information and diagnosisDisclosure of medical information and diagnosis Nutrition preferencesNutrition preferences End-of-life care, i.e., advance directives and resuscitation End-of-life care, i.e., advance directives and resuscitation

preferencespreferences

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Special ConsiderationsSpecial Considerations (cont.)(cont.)

Assessing those in painAssessing those in pain Alleviating pain should be priority over other Alleviating pain should be priority over other

aspects assessmentaspects assessment• Providing comfort can help maximize information Providing comfort can help maximize information

gatheredgathered

• It may be necessary to administer premedicationIt may be necessary to administer premedication

• Paramount to remember older adults with cognitive Paramount to remember older adults with cognitive impairment do not experience less pain impairment do not experience less pain

• This population suffers from conditions typically This population suffers from conditions typically associated with pain, such as arthritis, osteoporosis, associated with pain, such as arthritis, osteoporosis, cancer, and shinglescancer, and shingles

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Assessing those in painAssessing those in pain (cont.)(cont.) Alleviating pain should be priority over other Alleviating pain should be priority over other

aspects assessment (cont.)aspects assessment (cont.)• A variety of pain assessment scales are available to use A variety of pain assessment scales are available to use

in cognitively impaired older adult population in cognitively impaired older adult population

• The “gold standard” continues to be person’s self-reportThe “gold standard” continues to be person’s self-report

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Assessing elders with altered cognitionAssessing elders with altered cognition Cognitive impairment may severely restrict ability Cognitive impairment may severely restrict ability

expressionexpression• Gathering information from elder firsthand always best Gathering information from elder firsthand always best

but not always feasiblebut not always feasible

• To ensure collection of reliable information one strategy To ensure collection of reliable information one strategy is to interview caregiver or familyis to interview caregiver or family

• Never assume that he or she cannot respond to Never assume that he or she cannot respond to questions even with cognitive impairmentquestions even with cognitive impairment

• Using yes or no questions may prevent frustrationUsing yes or no questions may prevent frustration

• If a family member or caregiver does need to provide If a family member or caregiver does need to provide collateral information, avoid doing this in front of clientcollateral information, avoid doing this in front of client

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Assessment at end of lifeAssessment at end of life Ideally, all aspects of social assessment would be Ideally, all aspects of social assessment would be

completed before approach to end of lifecompleted before approach to end of life• Maximize interventions to make person comfortableMaximize interventions to make person comfortable

• If interviewing is not possible, pull all available data If interviewing is not possible, pull all available data together to formulate enhancing interventionstogether to formulate enhancing interventions

• Use information from caregivers and other existing Use information from caregivers and other existing sourcessources

• Be conscious that caregiver stress may be enhanced Be conscious that caregiver stress may be enhanced during this time of added strainduring this time of added strain

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Documents

Functional Assessment of the Older Adult