Instructor: Mary McDonald, MD
Reviewed by: Anne Walling, MB, ChB
Functional Assessment is a formalized, comprehensive review of the older person's daily activities, cognition, continence, special senses, mobility, and specific psychosocial issues.
Specific Learning Objectives:
A. Introduction
Before reviewing the learning objectives and content, please take the following Pre-Test.
Please review the Objectives, Content material, and Cases before our class session. We will apply the tasks in the Skills Objectives to these cases, and you should think about them ahead of time.
B. Attitudes - Third year medical students will be able to:
C. Knowledge - Third year medical students will be able to:
D. Skills - Third year medical students will be able to:
As you proceed through "AGING GAMES", become familiar with the methods of assessment for the various functional categories. Some of you will be asked during the discussion section to demonstrate your ability to perform a functional assessment.
G. Readings
Required Readings
- Arseven, A, Chang, CH, Arseven, OK, Emanuel, LL. Assessment Instruments. Clin Geriatr Med. 2005 Feb; 21(1): 121-46, ix.
- Kuo, HK, Scandrett, KG, Dave, J, Mitchell, SL. The influence of outpatient comprehensive geriatric assessment on survival: a meta-analysis. Arch Gerontol Geriatr, 2004 Nov-Dec; 39(3):254-54
H. Cases
When caring for older adults, physicians need to be aware of the common age and disease related disorders that can negatively affect "functional ability" (e.g., sensory, motor, and cognitive skills).
How and when a physician becomes familiar with the functional abilities of the older adult varies depending on the current health status and needs of an individual. In some situations, full interdisciplinary evaluation termed Comprehensive Geriatric Assessment is appropriate. In other situations, a brief screen of abilities by the physician, or "Review of Function" is adequate.
Comprehensive Geriatric Assessment
CGA is an interdisciplinary approach to the evaluation of an older person's physical, psychosocial and functional abilities.Indications for CGA:
- multiple medical problems
- change in mental status
- decrease in functional status
- community-dwelling, frail elderly
Examples:
- a 78 y/o woman with cataracts and 6 medications
- an 82 y/o woman with history of arthritis, COPD, hypertension, CHF and recurrent urinary tract infections
- a 72yo man who is brought in by his daughter after losing his way home several times
- an 82yo woman who presents with functional decline and weight loss
- Much research has gone into evaluation of CGA. Documented benefits of geriatric assessment include:
- increased use of community services
- more appropriate medication regimen
- improved function
- reduced mortality
In some patients or care settings a full assessment as described above may not be appropriate or feasible. It is still useful, however, for primary care physicians to have a method for screening older adults for common age and disease related disorders that can negatively impact function.
Outlined below are the categories that should be included in such a review of function, including what to ask and look for in your patient along with appropriate screening test to use as needed. To help you remember the categories, we have developed the mnemonic.
Assessment:
Questions to ask patient:
- Do you have difficulty hearing?
- Can you read the fine print of a newspaper?
- Do you have difficulty hearing in a crowd of people?
Performance tests to observe:
- Observation- Your own assessment of the patient's ability to hear and comprehend during your H & P is important.
- Otoscope- First check the external auditory canal. Very often cerumen is responsible for a conductive hearing loss.
- Finger rub- Rub two fingers together at each ear. Without hearing loss, this should be easily heard. A less sensitive test, but acceptable.
- Audiometry can be used if there is loss noted by your observation or on the finger rub test.
- set audiometer at 40dB
- test 500, 1,000, 2,000, 4,000 Hz F/U: Formal audiology should be recommended for patients with failure to hear 1,000 or 2,000 Hz
Top 4 diagnoses in elderly after presbyopia:
- cataracts
- macular degeneration
- glaucoma
- diabetic retinopathy
Assessment:
Questions to ask patient:
- Do you have trouble with your vision?
- When was your last eye exam?
Performance tests to observe:
- Eye chart at 20 feet with corrective lenses.
- Alternate- Ask the patient to read a sign on the wall and a magazine headline and sentence.
F/U: Ophthalmology for all patients unable to read all letters at 20/40 or unable to read either item.
Assessment of gait involves two important areas: mobility and fall history. Keep in mind the important relationship between immobility and poor outcome.
Assessment:
Questions to ask patient:
- Do you feel unsteady when you walk?
- Do you use anything to help you walk?
- Have you had any falls? Near falls?
Performance tests to observe:
- Range of motion
- Upper extremity:
- shoulder range of motion:
Left: Subject is asked to put both hands together behind neck (External rotation)
Right: Subject is asked to place both hands together in back at waist level (Internal rotation)
Lower extremity: included in the Up and Go Test (see below)
Gait and balance
The "Get Up and Go" Test for Gait Assessment in Elderly Patients (To begin, have the patient sit in a straight-backed high-seat chair).
Instruction for the patient:
- Get up (without use of armrests, if possible)
- Stand still momentarily
- Walk forward 10ft (3 m)
- Turn around and walk back to chair
- Turn and be seated
Factors to note:
- Sitting balance
- Transfers from sitting to standing
- Pace and stability of walking
- Ability to turn without staggering
F/U: Physical and occupational Therapists
Assessment:
Questions to ask patient:
- Do you have trouble with sleep?
- How many hours of sleep do you get each night?
- Do you nap during the day?
F/U: Full MD evaluation and referral
Weight
- 15% of outpatients and 50% of inpatients are underweight
- Weight and nutrition do not always go hand in hand!
- You can be thin and well-nourished or heavy and malnourished.
- Overweight can cause problems for specific health conditions, such as HTN, Diabetes and Arthritis.
- Undernutrition - not weight alone - is linked to increased morbidity, frequent readmissions, and increased mortality.
- Data do not support efficacy of nutritional supplementation, such as Ensure™, etc.
- Serial weights are the most sensitive screening tool.
Assessment:
Questions to ask patient:
- "Without trying to, have you lost or gained 10 pounds in the last six months?"
- Do you experience any difficulty swallowing?
Observations to make:
- Determine Body Mass Index (BMI)
weight in kg
height in meters2underweight < 22 - 24
overweight > 28 - 30
- Determine serial weights
F/U: Significant BMIs or changes require full MD evaluation
Dental
Patient questions:
- "Do you have trouble with your teeth or dentures?"
- "When was your last visit to the dentist?"
F/U: MD eval with dental evaluation as needed
Assessment:
Questions to ask patient:
- Do you have problems with your bowels?
- Do you ever lose control of your bowels?
F/U: MD evaluation and referral as indicated
Assessment:
Questions to ask patient:
- In the last year, have you ever lost your urine and gotten wet?
- For men - Do you have any difficulty starting your urine stream?
F/U: MD evaluation for positive response or symptoms of significant bother to patient.
Assistance
- Finding out what kind of help an older person has in the home can help you understand their limitations and resources.
- Many patients are unaware of the services they may be eligible for such as home health aides, transportation, or meals on wheels, etc.
Assessment:
Questions to ask patient:
- What help do you have at home?
- Who would you call on to help if you became ill?
F/U: MD, RN, MSW refer for community based services.
BADL/IADL's
- Impairments = risk factors for falls and institutionalization.
- Number or severity of medical diagnoses does not always predict functional impairment.
- Identification of problems allows for modification before a negative outcome occurs.
- Less than 10% of community-dwelling older adults have BADL deficits.
Assessment:
Basic Activities of Daily Living and Instrumental Activities of Daily Living:
Do you need help with any of the following:
Basic Activities of Daily Living (commonly called ADLs)
Dressing
Yes
No
Eating
Yes
No
Walking
Yes
No
Going to the Bathroom
Yes
No
Bathing
Yes
No
Instrumental Activities of Daily Living (IADLs)
Shopping
Yes
No
Housekeeping
Yes
No
Accounting/Bill paying
Yes
No
Food/Meal preparation
Yes
No
Travel/Driving
Yes
No
F/U: MD, RN, MSW refer for appropriate assistance.
Advance Directives
It is vital to discuss these issues with patients before a crisis occurs and the patient cannot participate in the necessary discussions about the extent of care desired
Assessment:
Questions to ask the patient:
- Who would help make medical decisions for you if you became very ill?
F/U: Patients with inadequate end of life plans need ND and MSW evaluation.
Depression
- Depression is one of the most common psychiatric diagnoses in the elderly.
- It can be difficult to separate depression from dementia. Patients may present with similar cognitive deficits such as memory loss or an inability to concentrate.
- Highest suicide risk? -- older white men
- Clinician must maintain a high index of suspicion for depression when encountering a patient with cognitive or functional decline with unclear etiology.
Assessment
Questions to ask patient:
- Have you been feeling sad and blue recently?
- Do you struggle with your nerves or feel anxious?
- IF YES, complete the Geriatric Depression Scale
F/U: Combine GDS with full MD evaluation
Cognitive Decline
- The prevalence of dementia increases with age, affecting up to 20 - 50% of those > 85 years of age
- Dementia can be associated with:
- increased use of health care services and mortality
- high caregiver burden
Assessment:
The clinician can often uncover cognitive decline by careful observation of patients' responses curing history taking.
Questions to ask patient:
Performance tests to observe:
- Have you had trouble with your memory lately?
- Cognitive Screening tests
- Look beyond "Alert & Oriented x 3"!
- Initial screening test
- Three item recall at one minute: e.g... dog, table, apple
- Folstein Mini Mental State Exam (MMSE) if patient does not get 3/3 correct at one minute
- View the actual MMSE paper exam
- View a practitioner performing an MMSE exam
- View the practitioner performing the exam when the patient is unable
to do "serial 7's".F/U: Patients with abnormal responses need MD evaluation
Home Environment
- Most common home hazards:
- stairs
- bathroom
- flooring
- lighting
- kitchen
Assessment:
Questions to ask patient:
- Who do you live with?
- Are there stairs you must use?
- Where are the bathrooms located?
F/U: MD, RN, MSW to use in planning home based or community service needs.
Daily Activities
- Knowing the types of activities your patient enjoys can help you design a care plan to maximize their ability to participate in those activities
Assessment:
Questions to ask patient:
- What keeps you busy during the day?
F/U: MD, RN, MSW may use to refer for community based or home resources as needed.
Sexual Function
- Sexual activity does not have to stop as we age!
- Change/decrease in libido is common, but overall sexual functioning is highly dependent on an individual patient's medical history.
Assessment:
Questions to ask patient:
- Are you dissatisfied with your sexual relations?
F/U: MD evaluation with referral as needed.
Mr. C
Identifying Information:
Mr. C is an 82 year old white male. He is a retired grocery store owner, is widowed and lives alone. His daughter lives in the area and speaks with her father daily. Mr. C's daughter is concerned because he has been losing weight for the past six months. She arranges for a doctor's appointment and accompanies her father.Chief Complaint:
Mr. C has no specific medical complaints. His daughter reports 20 pound weight loss in 6 months.
What information would you seek in your interview with Mr. C and/or his daughter?
Choose as many answers as you feel apply.
- Status of his arthritis
- He reports that his arthritis is well controlled. No NSAIDS.
- Social Support:
- Mr. C feels he is doing well in his own home, his daughter disagrees. She does all his shopping, cleaning, cooking, etc.
- Finances:
- Mr. C has a good retirement income as well as support from his daughter.
- Constitutional complaints
- He denies fever, chills, night sweats.
- Gastrointestinal complaints
- His weight loss has been about 20 pounds over the past 6 months. He denies abdomen pain, indigestion, n, v, changes in bowel movements, BRBPR, melena, anorexia.
- Cardiac
- He has no CP, DOE, change in exercise tolerance. His HTN has been easy to control. Many years on Atenolol.
- Psychiatric complaints
- Mr. C vehemently denies depression.
- Neurologic & Cognitive Abilities
- Mr. C denies problems. No complaints compatible with TIAs. His daughter states she is concerned because he has begun forgetting appointments such as his standing brunch date after church and has called her in the middle of the night on two occasions sounding confused.
- Medication Use:
- Other than his prescribed medications. Mr. C occasionally uses Tylenol PM™ for sleep-turns out to be every other night or so.
- Dietary History:
- Mr. C states that he eats 2 meals per day, including the food his daughter brings to him each night. He eats mostly prepared foods in cans or TV dinners. He drinks water, coffee, or soda. He eats fresh fruit when his daughter brings it, rare fresh vegetables. He states he can cook but does not like to make a mess.... so he does not.
- Pulmonary
- Review of this system does not significantly contribute at this point.
- Status of his hypertension
- No MI, CVA, renal or retinal disease known.
- Functional Abilities:
- Mr. C states that he gets along just fine doing his own cleaning, cooking, bathing, shopping, etc. His daughter disagrees with him stating she is doing just about everything with the exception of bathing him because he will not allow her to help him.
The remainder of the history reveals the following:
Past Medical History:
- HTN, well controlled, no MI, no CVAs
- Arthritis, knees
- s/p appendectomy
Medications:
- Tylenol™ ES prn pain
- Atenolol™ 50mg po q day
- Tylenol™ PM prn sleep
Allergies:
- NKDA
Family History:
- one brother died of MI at 42
- one sister well at 84
Social History:
- widowed, 3 children, one in area
- retired owner of grocery stores
- tobacco in past, heavy, none for 20 years
- alcohol in past, none recently
ROS:
- negative except as above
Physical Exam:
What areas of the physical exam should you focus on?
Choose as many answers as you feel apply.
- General condition
- Well-developed, well nourished, white male, slightly disheveled with poor hygiene but in no acute distress.
- Vital signs
- BP= 130/80
- P= 60
- Temp= 37
- RR= 16
- Weight= 147
- Height= 5ft. 9in
- Extremities
- No acute joints
- Lungs
- CTA, non-labored.
- GU
- Rectal tone normal, prostate mildly enlarged without focal nodularity.
- HEENT
- NC/AT, PERRLA, EOMI, sclerae anicteric, conjunctivae pink, mucous membranes moist, pharynx non-injected, TM clear, Nares clear.
- Cardiovascular
- RRR, soft systolic murmur, no gallup, no peripheral edema, pulses 2+ and equal.
- Orthostatic measurements
- SUPINE..... BP=130/80, P= 60
- UPRIGHT..... BP= 120/86, P= 60
- Skin
- Warm, no acute rashes, lesions.
- Neck
- Supple, no lymphadenopathy, ? mild thyromegaly.
- Abdomen
- Soft, good BS, non-tender, non-distended, no masses, no hepatosplenomegaly.
- Lymphadenopathy
- Negative axillary, supraclavicular, femoral.
- Neuro
- Alert, o/3, short-term recall, cranial nerves wnl, motor 5/5 all groups, no drift or tremor, sensory intact, light touch, pin prick, vibratory. DTRs wnl. Gait slightly wide-based but balanced.
- Back
- Mild kyphosis No TTP
What further screening tests could be useful in you evaluation at this point?
Choose as many answers as you feel apply.
- Hearing screening
- Certainly important when doing a dementia evaluation. In this case, the patients hearing was adequate during your visit. It is unlikely that hearing deficit contributed significantly to his cognitive difficulties.
- MMSE 24/30
- Get up and Go
- he patient was able to rise from the chair without using his arms. His gait was slightly wide based, but otherwise he had good balance and speed.
- ADL/IADL
- Mr. C is DEPENDENT for ALL IADLs
- Mr. C is INDEPENDENT for ALL ADLs
- GDS
- The patient scored +3 on the GDS (scores of >5 are suggestive for depression). While he may have some element of mood disorder, it is unlikely to be the cause of his cognitive loss.
- Vision screening
- Presbyopia and early cataracts, no intervention needed.
- Dental screening
- Several teeth in need of removal, poor gum health.
- Laboratory screening
- For weight loss of uncertain origin: CBC, Chem panel, TSH, B12, ESR, UA. Further labs to evaluate the possibility of dementia will be further discussed in the dementia module.
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