functional assessment · functional assessment barbara cochrane, phd, rn, faan, fgsa professor,...

Functional AssessmentBarbara Cochrane, PhD, RN, FAAN, FGSA

Professor, School of [email protected]

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)


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


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


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


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/


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 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



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


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


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


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


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


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


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


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)


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


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


https://consultgeri.org/try‐this/general‐assessment/issue‐23

Ideal Outcome Measures

Objective

Reliable, valid and responsive

Simple to administer

Inexpensive


“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


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


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


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)


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



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


The 4‐Step Balance Test


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


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



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


Assessment of Function

ADLs

IADLs

Participation (Advanced ADLs)

Performance measures

Cognitive function

Depression

Sensory


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


functional assessment · functional assessment barbara cochrane, phd, rn, faan, fgsa professor,...

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