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Functional AssessmentBarbara Cochrane, PhD, RN, FAAN, FGSA
Professor, School of Nursingbarbc@uw.edu
NW Geriatrics Workforce Enhancement Center, Geriatric Healthcare Series, Winter 2020
Disclosures
No commercial relationships to disclose
Fx Assessment (Cochrane), NW GWEC Winter 2020 1
Overview
Setting the stage
Risk factors for and potential outcomes of functional decline in older adults.
Differences between activities of daily living, instrumental activities of daily living, and physical performance
Assessment of ADLs, IADLs, and physical performance
Aging in America, 1900–2030
US Bureau of the Census. Adapted from: Himes (2002), Population Bulletin 56(4)
Fx Assessment (Cochrane), NW GWEC Winter 2020 2
Functional limitation among adults, 2010–2017
NCHS, National Health Interview Survey: https://www.cdc.gov/nchs/hus/contents2018.htm#Figure_012
Health and Functional Status of Medicare Enrollees, by Age and Gender, 2009
Kaiser Family Foundation Analysis of CMS Medicare Current Beneficiary Survey 2009 Cost & Use File
40%*
58%*
63%*
35%
49%51%
65 to 74 75 to 84 85+
9%*
17%*
29%
7%
13%
27%
65 to 74 75 to 84 85+
Women
Men
3+ Chronic Conditions 2+ ADL
Fx Assessment (Cochrane), NW GWEC Winter 2020 3
Disabilities by Age and Type
1Due to physical, mental or emotional condition; US Census Bureau 2016 American Community Survey
Medicare Beneficiaries Health Status, By Race/Ethnicity, 2011
Kaiser Family Foundation Analysis of CMS Medicare Current Beneficiary Survey 2011 Cost & Use File
Fx Assessment (Cochrane), NW GWEC Winter 2020 4
Models of Functioning
Nagi Model of Disablement (1965)
International Classification of Functioning, Disability, and Health (2001)
Nagi Model of Disablement
Active Pathology
Nagi (1965) In Sussman; Sociology and Rehabilitation. Wash, DC: Am Sociological Assoc; pp. 100–113
Fx Assessment (Cochrane), NW GWEC Winter 2020 5
Nagi Model of Disablement
Impairment: Loss or abnormality of mental, emotional, physiological, or anatomical structure or function
Functional limitation: Restriction or lack of ability to perform an action in the manner or within the range considered normal; results from impairment
Disability: Inability or limitation in performing socially‐defined activities and roles expected of individuals within a social and physical environment
Pope & Tarlov (Eds); IOM Committee on a National Agenda for the Prevention of Disabilities (1991). Disability in America: Toward a National Agenda for Prevention. Wash, DC: National Academies Press
International Classification of Functioning, Disability and Health
ICF 2001: http://www.who.int/classifications/icf/en/
Fx Assessment (Cochrane), NW GWEC Winter 2020 6
ICF Biopsychosocial Model
Functioning and disability: outcomes of interactions between health conditions and contextual factors.
Body functions/structures: physiological functions of body systems; anatomical parts of the body Impairments: problems in body function or structure
Activity: execution of a task or action by an individual Activity limitations: difficulties an individual may have in executing activities
Participation: involvement in a life situation. Participation restrictions: problems an individual may experience in involvement in life situations.
ICF 2001: http://www.who.int/classifications/icf/en/
ICF Contextual Factors
Person Environment
Gender
Age
Coping styles
Social background
Education
Profession
Past and current experience
Overall behavior pattern
Character
Social attitudes
Architectural characteristics
Legal and social structures
Climate
Terrain
ICF 2001: http://www.who.int/classifications/icf/en/
Fx Assessment (Cochrane), NW GWEC Winter 2020 7
Domains of Function
Physical
Sensory
Cognitive
Social
Emotional
Spiritual
Sexual
Communication
Vocational
Leisure
Self Care
Mobility
Functional Limitations
Source: Centers for Medicare and Medicaid Services, Medicare Current Beneficiary Survey
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Functional Status
Reflects strengths as well as the need for assistance
Influenced by: Physiological aging changes Acute and chronic illness – and treatment for same Adaptation to the physical environment
Contingent on: Motivation Cognition Sensory capacity (vision, hearing)
Risk Factors for Functional Decline Injuries
Acute illness
Medication side effects
Pain
Depression
Cognitive impairment
Malnutrition
Decreased mobility
Obesity
Prolonged bedrest
Changes in environment or routinesBurdick et al. (2005) J Gerontol 60A:258; Castilla‐Rilo et al. (2007) Intl J Geriatr Psychiatr 22:829; Boyd et al. (2008) JAGS 56:2171; Naglie & Gill (2009) Can J Geriatr 12:160; Covinsky et al. (2009) JAGS 57:1556
Fx Assessment (Cochrane), NW GWEC Winter 2020 9
Complications of Functional Decline
Loss of independence (e.g., cessation of driving)
Reduced quality of life
Falls and injury
Incontinence
Malnutrition
Decreased socialization
Depression
Illness and hospitalization
Nursing home admission
Death
Inouye et al. (1998) JAMA 279:1187; Ackerman et al. (2008) Gerontologist 48:802; Marengoni et al. (2008) J Intern Med 265:288
ADLs and Survival after Hospitalization
Boyd et al. (2008) JAGS 56:2171‐79
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Activities of Daily Living (ADLs)
Bathing
Dressing, undressing
Personal grooming
Eating
Toileting
Transferring
LTC services users needing assistance with activities of daily living, 2015‐2016
SOURCE: National Center for Health Statistics. Vital Health Stat 3(43). 2019
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Handling own finances, paying bills
Administering own medication
Housework
Laundry
Shopping
Cooking, meal preparation
Using the telephone
Driving, arranging transportation
Instrumental Activities of Daily Living (IADLs)
Instrumental Activities of Daily Living (IADLs)
More subtle disabilities
More influenced by
Gender
Cultural background
Fx Assessment (Cochrane), NW GWEC Winter 2020 12
Why is Functional Assessment Important?
Predict outcomes Function and comfort are outcomes people care about (may view their health in terms of how well they can function rather than in terms of disease alone)
Maintaining or maximizing health and functional independence is a main objective in care of older adults
Function predicts hospital survival better than medical diagnosis
Monitor clinical change over time
Ikegami (1995) NEJM 332:598; Incalzi (1992), JAGS 40:34; Narain (1988), JAGS 36:775
Why is Functional Assessment Important?
Understand personal care needs
Identify needed support services
Revise medication regimen
Plan ahead for the need for formal resources: Home care
Environmental or other accommodations
Family availability
Other accommodations
Recommend optimal living environment
Fx Assessment (Cochrane), NW GWEC Winter 2020 13
Percentage of Medicare enrollees 65+ w/ functional limitations, by residential setting (2013)
U.S. Census Bureau (adapted from Federal Interagency Forum on Aging‐Related Statistics: Older Americans 2016: Key Indicators of Well‐Being)
Functional Assessment
Measure performance of skills needed to handle everyday life
Function safely and independently in one’s home or room Activities of Daily Living (ADLs)
Tasks essential to function and be independent in the community Instrumental Activities of Daily Living (IADLs)
Participation in work, recreation, social networks Advanced Activities of Daily Living
Fx Assessment (Cochrane), NW GWEC Winter 2020 14
Functional Assessment
Advanced ADLs if person comes to office unaccompanied (i.e., based on social history)
IADLs if comes to office with family member or other person (particularly if they made the appointment) or if grooming raises a question about functional status
Begin with Basic ADLs if person lives in nursing home or other long‐term care facility
Asking about ADLs from a Third Party
In some cases, confirm or augment the functional history from family member or friend:
If additional insights are needed
If older adult is cognitively impaired
If history seems inconsistent with appearance Unkempt (bathing) Urine odor on clothes (continence) In wheelchair (ambulation)
Fx Assessment (Cochrane), NW GWEC Winter 2020 15
Katz Index of Independence in ADLs
Bathing
Dressing
Toileting
Transferring
Continence
Feeding
Each rated as 1 (independence) or 0 (dependence)
https://consultgeri.org/try‐this/general‐assessment/issue‐2
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How to Ask about ADLs
Ask direct, specific questions in reference to recent activities
Ask what help if any was needed: How do you usually bathe? Do you need any help to do that?
Did you dress yourself this morning? vs. Can you dress yourself?
Did you drive your car recently? vs. Can you drive?
Lawton IADL Scale
Ability to use telephone
Shopping
Food preparation
Housekeeping
Laundry
Mode of transportation
Responsibility for own medications
Ability to handle finances
Each domain rated according to highest level of function
Fx Assessment (Cochrane), NW GWEC Winter 2020 17
https://consultgeri.org/try‐this/general‐assessment/issue‐23
Ideal Outcome Measures
Objective
Reliable, valid and responsive
Simple to administer
Inexpensive
Fx Assessment (Cochrane), NW GWEC Winter 2020 18
“Measures in which an individual is asked to
perform a specific task in a standardized
manner and the performance is evaluated in
an objective, uniform manner using
predetermined criteria.”
Guralnik et al. J Gerontol;1989:M141‐146
Functional Mobility: Performance Measures
Functional Mobility: Performance Measures
Physical performance measures –usually reflect components of ADLs
More objective
Less influenced by language, culture, and education
Giuliani et al. (2008) Gerontologist 48:203; Guralnik et al. (1989) J Gerontol 44:M141
Fx Assessment (Cochrane), NW GWEC Winter 2020 19
Performance Measures Predict Adverse Outcomes
Dependency in ADL and IADL
Mobility impairment
Falls
Hospitalization
Institutionalization
Death
Performance Measures
Wide variety of performance measures –mobility, balance, exercise capacity –used in the older adults
Get Up and Go/Timed Up and Go (TUG)
Functional Reach
Walk Tests
Other performance batteries
Fx Assessment (Cochrane), NW GWEC Winter 2020 20
Gait
Normal gait requires Joint mobility
Appropriate timing and intensity of muscle action
Proprioceptive, vestibular, and visual sensory input
Observe person walking, look for clues Imbalance, instability, falls
Increased energy expenditure
Muscle weakness
Pain
Lack of fluid motion (arm swing, step height, turning)
Assessment: Chair Stand
Centers for Disease Control and Prevention: https://www.cdc.gov/steadi/materials.html
Fx Assessment (Cochrane), NW GWEC Winter 2020 21
Get Up and Go
Get Up and Go Test
Seated in chair with arms
Rise without using the arms
Walk 10 feet (mark this off)
Turn around
Return to chair
Turn and sit
Evaluate mobility, balance, gait, transfer ability, walking
Podsiadlo & Richardson (1991) JAGS, 39:142‐148
Get Up and Go Scoring
1 = Normal (no evidence of being at risk of fall)
3 = Mildly abnormal (undue slowness, hesitancy, abnormal movements of trunk or upper limbs, staggering, stumbling)
5 = Severely abnormal (appeared at risk of falling during the test)
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Timed Up & Go (TUG) Test
Adaptation of Get Up & Go Test
Encourage person to use customary walking assistive devices and complete task as fast as safely possible
Scoring based on time it takes to go from sit to stand to walk 3 meters and back to sit Score of <20 – independent with transfers and gait
Score of 20‐29 – “a gray zone”
Score of ≥30 – assist with balance and functional activities
Podsiadlo & Richardson (1991) JAGS 39:142; VanSwearingen & Brach (2001) Phys Ther 81:1233
The Timed Up and Go (TUG) Test
Centers for Disease Control and Prevention: https://www.cdc.gov/steadi/materials.html
Fx Assessment (Cochrane), NW GWEC Winter 2020 23
TUG: Fall Risk
Using arms to rise from the chair
Instability on first standing
Stumbling
Hesitancy
Grabbing for support
Short, discontinuous steps
Excessive trunk sway
Undue slowness Staggering on turns
Unsafe maneuvers
Balance
Normal balance requires multiple inputs Proprioception from joints (peripheral nerves)
Vision
Vestibular function (inner ear, 8th nerve)
Data integrated in brainstem, cerebellum
Usually need 2 of 3 system inputs to maintain balance
Also required: basic bone/muscle integrity
Fx Assessment (Cochrane), NW GWEC Winter 2020 24
The 4‐Step Balance Test
Centers for Disease Control and Prevention: https://www.cdc.gov/steadi/materials.html
Functional Reach
Test of balance
Measures furthest distance person can reach forward while standing and not taking a step
Leveled measuring device mounted on wall at shoulder height
Ask person to hold arm straight out (shoulder height) and reach as far forward as possible without taking a step
Score of < 6 inches – limited balance, increased fall risk (?based on meta‐analysis*)
*Rosa et al. (2019), Archives of Gerontology & Geriatrics 81:149‐170
Fx Assessment (Cochrane), NW GWEC Winter 2020 25
Performance measures provide ~ different information than functional status
Base your choice of measures on population and goals
Frailty — literature is evolving / somewhat conflicting Some studies report poor feasibility/reliability of some performance measures (e.g., TUG, functional reach)
Tager et al. (1997), J Gerontol 52:M52‐M55
Performance Measures Considerations
Cognitively impaired individuals—avoid multi‐task performance measures, such as the TUG
Standing from a sitting position often requires cueing or physical assistance, so are probably best avoided
The functional reach is also not feasible in cognitively impaired individuals
Single‐task walking maneuvers may be more reliable
Performance Measures Considerations
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Inpatient populations: Both performance measures and functional status measures should be included as outcome measures
Single‐task walking maneuvers may not be feasible (depending on course length or walking time)
TUG provides clinically relevant information for assessing assess safety for discharge (i.e., ability to transfer from a chair and walk a short distance)
Functional reach may be appropriate in those who have predominantly balance problems affecting their mobility
Performance Measures Considerations
Assessment of Function
ADLs
IADLs
Participation (Advanced ADLs)
Performance measures
Cognitive function
Depression
Sensory
Fx Assessment (Cochrane), NW GWEC Winter 2020 27
Maintain Function/Minimize Decline
Maintain a daily routine
Encourage activity and exercise
Healthy eating
Socialization/engagement
Educate family, friends, caregivers
Adapt environment to maximize safety, minimize falls, stay independent
Home visits with comprehensive geriatric assessment
Beswick (2008) Lancet 371:725; Gu & Conn (2008) RINAH 31:594; Chin A Paw (2008) Sports Med 38:781; Gitlin (2009) JAGS 57:476; Liu & Lapane (2009) Gerontologist 49:344; Naglie & Gill (2009) Can J Geriatr 12:160
Maintain Function/Minimize Decline
Judicious use of medications
Assess and treat for pain
Diagnosis and treatment of depression and cognitive impairment
Management of medical comorbidities
Early rehabilitation for hospitalized older adults
Minimize bed rest
Explore alternatives to physical restraints
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