Clinical Forum

Geriatric best practices in nursing: Optimizingfunctional independenceKaren L. Rice, MSN, APRN, BC

Currently, older adults comprise approximately 13% of thepopulation, with projections expected to exceed 20% by the year2040. This graying of America has serious implications regard-ing the economic and social costs associated with both age-related functional limitations and those associated with thesequelae of chronic disease. The ability to perform activities ofdaily living (ADL) has been identified as an important predictorof age-related disability. In addition, the limitations in the abilityto perform ADLs are considered predictors of nursing homeplacement, increased utilization of physician and hospital ser-vices, less use of primary and preventative care, compromisedquality of life, and increased mortality.1

The process of aging is generally associated with a decline infunctional independence. Furthermore, the limited functionalreserves of the immune, pulmonary, cardiac, and vascular sys-tems frequently predispose older adults to the greatest risk fordecline in functional independence, especially when hospital-ized. Although this functional decline may be attributed toage-related changes in the ability to adapt to acute illness, thishigh-risk population is prone to both iatrogenic complicationsand nosocomial infections. In addition, several other factors thatcontribute to functional decline are listed in Table 1.2

The effects of declining physical and cognitive levels offunction may be further complicated by the impact of chronicdisease. Older patients are at particularly high risk of poorfunctional outcomes when placed in situations in which there isa loss of function compared with their baseline. Although thisfrequently occurs in the hospitalized patient, acute illness in anysetting poses the same risk of functional decline. Similarly,progressive deteriorating chronic diseases, such as Parkinson’s

disease and peripheral arterial disease, are frequently associatedwith limitations in physical function.

Oftentimes the oldest of old are frequently unable to recoverADLs, which may be lost during treatment (ie, inability toambulate, deconditioning, and medication-induced mental statuschange). In a prospective observational study of 2293 patientswho were older than 70 years and admitted to an acute carefacility, Covinsky et al3 reported that 35% of patients declined inADL function between baseline and discharge. Although mostinvestigations suggest that a decline in cognitive and physicalfunction is associated with frailty, Black and Rush4 suggest thatthe inverse relationship also exists.

Loss of independence is the greatest fear frequently reportedby older adults. However, nurses often fail to address this fearbecause most individuals are uncomfortable with the dialoguerequired to circumvent the problem. Whether clinical practice isin the ambulatory or acute care setting, nurses are uniquelypositioned to anticipate and minimize the risks associated withfunctional decline in the older adult population. The initial stepin targeting the problem is assessment. Several useful instru-ments to assess potential problems and risks are described inTable 2.

In order to optimize the level of independence in high-riskpatients, more discussion regarding realistic outcomes mustoccur. In my experience, patients are simply read detailed lists ofthe complications associated with interventional procedures;

Karen L. Rice, MSN, APRN, BC, is an Adult Nurse Practitioner/Geriatric Resource Nurse at the Ochsner Clinic Foundation,Department of Nursing, New Orleans, Louisiana.

Address reprint requests to Karen L. Rice, MSN, APRN, BC,Ochsner Clinic Foundation, Department of Nursing, 1514 Jef-ferson Highway, New Orleans, LA 70121.

J Vasc Nurs 2003;21:151-2.

Copyright © 2003 by the Society for Vascular Nursing, Inc.

1062-0303/2003/$30.00 � 0

doi:10.1016/S1062-0303(03)00052-9

TABLE I

FACTORS COMMONLY ASSOCIATED WITHFUNCTIONAL DECLINE IN OLDER ADULTS

Causative factors● Stereotypical negative expectations by health care

providers

● Unnecessary restrictions on physical activity

● Insufficient time allocated for self-care

● Immobility

● Lack of understanding regarding treatment options

● Lack of knowledge regarding alternative livingarrangement options

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however, less time is spent on assuring that a realistic under-standing of the outcome exists. Frequently, patients hear adescription of potential complications but do not process theuntoward impact on their lifestyle. For instance, does the patientwith a thoracoabdominal aortic aneurysm and chronic obstruc-tive pulmonary disease understand the possibility of being ven-tilator dependent in a long-term care setting as a risk of surgicalmanagement? Similarly, does the 86-year-old with cerebrovas-cular disease who is forgetful and living alone understand that analternative living arrangement such as assisted living is morelikely to facilitate a higher level of independence over timeversus living alone?

Chronic disease in the older adult potentially creates asignificant impact on functional independence. Thus, nursingstrategies (Table 3) associated with improved clinical outcomes

in chronic diseases should also be useful in vascular patients.2

With appropriate patient assessment, family involvement, andinterdisciplinary collaboration, there is hope for optimizing func-tional independence for the older adult vascular patient.

REFERENCES

1. Dunlop DD, Manheim LM, Sohn M, Liu X, Chang RW.Incidence of functional limitation in older adults: the impactof gender, race, and chronic conditions. Arch Phys MedRehabil 2002;83:964-71.

2. Eliopoulos C. Gerontological nursing. Acute conditions ingerontological nursing. 5th ed. Philadelphia: Lippincott;2001. p. 378–95.

3. Covinsky KE, Palmer RM, Fortinsky RH, Counsell SR,Stewart AL, Kresevic D, et al. Loss of independence inactivities of daily living in older adults hospitalized in med-ical illnesses: increased vulnerability with age. J Am GeriatrSoc 2003;51:451-8.

4. Black SA, Rush RD. Cognitive and functional decline inadults aged 75 and older. J Am Geriatr Soc 2002;50:1978-86.

WRITING AWARD

The Journal of Vascular Nursing Article Award honors nurse authors for their efforts to createa publishable manuscript. Manuscripts will be judged for accuracy of content, relevance to vascularnursing practice, and excellence of writing style. All feature articles published in the Journal ofVascular Nursing during the calendar year will be considered for the JVN Article Award. The awardrecipient will be given a plaque commemorating the award and a cash prize donated by Mosby. Theaward and cash prize will be presented at the annual symposium. Announcement of the awardrecipient will appear in the Journal of Vascular Nursing and in SVN...prn.

TABLE II

INSTRUMENTS TO ASSESS AND MEASUREOLDER ADULT PROBLEMS AND RISKS

Focus of assessment Measurement instrument*

Cognitive assessment ● Folstein Mini-mental StateExam

● Confusion Assessment Method(CAM)

Level of function ● Katz Index of Independence inactivities of daily living

● Instrumental activities of dailyliving (IADL)

Fall risk ● Fall Risk Assessment

Nutritional assessment ● Nutrition & HydrationAssessment

Risk for pressure ulcerdevelopment

● Braden Scale

Caregiver strain ● Caregiver Strain Index

Depression ● Geriatric Depression Scale

*Instruments available at www.hartfordign.org.

TABLE III

STRATEGIES ASSOCIATED WITH IMPROVEDCLINICAL OUTCOMES IN OLDER ADULTS

Nursing strategies● Monitor medications

a. Evaluate for appropriateness

b. Assure age-adjusted dosages

● Encourage independence

● Assist patient/family with decision making

a. Advance directives

b. Treatment options

● Provide patient/family education regarding thetreatment plan

● Avoid hospitalization or limiting length of stay

● Engage in interdisciplinary collaboration

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