Core components of a functional assessment
Functional assessment is a cornerstone of geriatric care, focusing on a patient's overall capacity rather than medical diagnoses alone. A functional assessment is most effective when conducted by a multidisciplinary team, which may include doctors, nurses, physical therapists, occupational therapists, and social workers. The assessment can be performed in various settings, such as a doctor's office, hospital, or the patient's home, and involves several key domains.
Activities of daily living (ADLs)
ADLs are fundamental self-care tasks typically learned in early childhood that are essential for independent living. The ability to perform these tasks is a key indicator of a person's functional status. Common ADLs assessed include:
- Bathing: The ability to wash oneself completely or with minimal assistance.
- Dressing: The capacity to get clothes from drawers and closets and put them on without help.
- Toileting: The ability to get to and from the toilet, use it, and manage personal hygiene.
- Transferring: The process of moving in and out of a bed or chair.
- Continence: The capacity to control bladder and bowel movements.
- Feeding: The ability to bring food from a plate to the mouth and eat independently.
Instrumental activities of daily living (IADLs)
IADLs involve more complex activities that are necessary for functioning independently within the community. Because they require higher cognitive and physical function, a decline in IADLs often occurs before a decline in basic ADLs. Examples of IADLs include:
- Using the telephone: The ability to look up and dial numbers and answer the phone.
- Shopping: Independently managing all aspects of grocery and clothes shopping.
- Food preparation: Planning, cooking, and serving adequate meals.
- Housekeeping: Performing basic chores such as cleaning and laundry.
- Medication management: Taking medications accurately and on schedule.
- Managing finances: Handling money, paying bills, and keeping track of income.
Mobility and balance
Beyond ADLs and IADLs, functional assessment includes evaluating physical capabilities that affect mobility and balance. Simple physical tests can provide a clear picture of a patient's risk of falls or need for support.
- Timed Up and Go (TUG) Test: This measures the time it takes for a patient to rise from a chair, walk 10 feet, turn around, walk back, and sit down. A time exceeding 12 seconds may indicate an increased risk of falls.
- Gait Speed: An assessment of walking speed, which has been associated with survival and functional status.
Cognitive and psychosocial factors
A person's ability to function is heavily influenced by cognitive and mental health. Assessments in this area address potential issues that could impair independence.
- Cognitive screening: Simple tools like the Mini-Cog test assess memory and cognitive function. A cognitive assessment can help detect conditions like dementia or mild cognitive impairment.
- Mood assessment: The Geriatric Depression Scale or other tools can be used to screen for depression, which commonly affects functional ability.
- Social and environmental evaluation: Reviewing the patient's living situation, support network, and any environmental hazards is critical for creating a holistic care plan.
Tools and techniques for assessment
Healthcare providers use standardized instruments and observation to conduct functional assessments. The choice of tool depends on the setting and the patient's needs. Patient and caregiver reports are also essential components of the evaluation.
Comparison of functional assessment tools
| Assessment Tool | Area of Focus | Description | Ideal Population |
|---|---|---|---|
| Katz Index of ADLs | Basic Activities of Daily Living (ADLs) | Evaluates independence in six basic functions: bathing, dressing, toileting, transferring, continence, and feeding. | Patients with significant functional impairment where basic self-care is a concern. |
| Lawton IADL Scale | Instrumental Activities of Daily Living (IADLs) | Measures more complex activities such as shopping, cooking, and managing finances. | Community-dwelling older adults who are otherwise capable and healthy. |
| Timed Up and Go (TUG) Test | Mobility and Balance | Measures the time to stand up, walk 10 feet, turn, and sit down again. | Screening for fall risk in community-dwelling older adults. |
| Mini-Cog | Cognitive Function | Combines a 3-item recall test and a clock-drawing test to screen for cognitive impairment. | Rapid, routine screening for potential cognitive decline. |
Observation and patient-reported information
In addition to formal scales, a healthcare provider can gain valuable insights simply by observing the patient's movements during a routine visit. Questions about a patient's ability to manage daily tasks can be directed to the patient, but a caregiver's input is often critical for accurate assessment, especially for those with cognitive challenges. The Medicare Annual Wellness Visit also provides an opportunity to incorporate key elements of a geriatric assessment.
Benefits of a geriatric functional assessment
The benefits of a comprehensive functional assessment extend beyond a simple diagnosis, focusing on enhancing quality of life and independence.
- Tailored care plans: The assessment results provide a foundation for creating individualized care plans that address specific needs and goals.
- Increased independence: By identifying functional limitations, interventions can be implemented to maintain or improve a person's ability to live independently.
- Better health outcomes: Studies show that comprehensive geriatric assessments can lead to improved functional and mental status, reduced mortality, and fewer hospital admissions.
- Optimal placement: For individuals with higher care needs, assessment aids in evaluating long-term care options.
- Effective discharge planning: For hospitalized older adults, a functional assessment helps ensure effective and safe discharge planning.
Challenges and considerations
Functional assessments can present several challenges that healthcare providers must navigate to ensure accurate and effective care.
- Multiple comorbidities: Many older adults have multiple chronic conditions, which can complicate both diagnosis and treatment plans.
- Cognitive impairment: Patients with cognitive decline may over-report their abilities, while those with depression may under-report, impacting the validity of self-reported questionnaires.
- Resource constraints: For busy clinical practices, conducting a full geriatric assessment can be time-consuming, leading to less comprehensive evaluations.
- Variability in tools: There is a lack of consensus on a single best set of tools for every situation, and tools may not be sensitive enough to detect small changes in function.
- Adherence to interventions: Ensuring that older adults follow through with recommended lifestyle changes and interventions can be complex due to bio-psycho-social factors.
Conclusion
The functional assessment for geriatric patients is an indispensable and multifaceted process for evaluating an older adult's physical, cognitive, and psychosocial abilities to maintain independence. By moving beyond a traditional medical model to include assessments of ADLs, IADLs, mobility, and cognition, healthcare providers can gain a holistic understanding of a patient's well-being. While challenges exist, including the complexity of multimorbidity and resource limitations, the benefits are clear: improved functional and mental outcomes, reduced hospitalizations, and a better overall quality of life. Ultimately, a functional assessment helps clinicians and a multidisciplinary team develop and implement targeted, patient-centered care plans that support independence and meet the evolving needs of older adults.
Additional resources
- American Geriatrics Society: Provides educational resources, guidelines, and toolkits for healthcare professionals focused on the care of older adults.
