Resident Editor: Lena Makaroun, M.D.; Jocelyn Ko, M.D.

Faculty Editor: Carla Perissinotto, M.D., M.H.S.

Background

• Functional status is more informative than age alone.
• Functional status and decline are often predictors of death, falls, hospitalizations, postoperative complications, and nursing home admissions.
• 28% of older adults have an ADL disability in the last 2 years of their life.
• Recognizing functional decline early and preventing progression is more effective than recovering function already lost.
• Functional status can provide prognostic information to assist in clinical decision making and long-term care planning.

Evaluation

• Activities of daily living (ADLs) and Instrumental activities of daily living (IADLs) should be assessed at least on a yearly basis. In addition, assess ADLs and IADLs on admission to the hospital, and following any hospitalization as ~30% of patients >70 years old hospitalized for a medical illness are discharged with a new ADL disability.
• Document whether the patient is dependent, partially dependent, or independent. The usual question is: “Because of a mental or physical health condition, do you need help with any of the following: 

• Measure gait speed: Eg, From a standing start, ask your patient to walk for 4 meters while timed. Instruct them to walk at their usual pace, as if they were walking down the street.
  • Gait speed slower than 0.6 m/s predicts functional decline and early mortality in older adults.
• Identify health conditions or impairments that may be contributing to the patient’s disability (eg, cardiopulmonary disease, musculoskeletal conditions, mood disorders, cognitive disorders, neurologic conditions, endocrine conditions, vision problems, hearing problems, pain, anemia, medication adverse effects)
• When conducting a functional assessment make sure to ask about how the patient is functioning in the home, and who is helping them maintain independence. This includes the following questions:

1. Does the patient have a caregiver?
   • Are they paid? Family members?
   • Agency or Private?
   • Hours worked, back-up plan?
   • Caregiver stress, burnout risk?
   • Caregiver skill level?
2. What kind of environment do they live in (apartment, home, assisted living, safe neighborhood)? Is it accessible or are there stairs?
3. Do they have durable medical equipment?
   • Mobility: cane, walkers, wheelchair, Hoyer lift
   • Home Safety: hospital bed, mattress, bathroom equipment, grab bars, shower chair, raised toilet seat
4. Do they have emergency services in place? (i.e., workable phone, emergency call system (i.e. Vitalink), POLST form, emergency contact list)

Key Tip: Consider using the “Risk and Functional Assessment” ICD-10 as a place to document the results of your evaluation. There is also a Frailty Navigator in Epic where you can document gait speed, grip strength, ADL and IADLs.  

Management

• Focus on addressing underlying medical conditions and impairments that are potentially modifiable
  • Examples of interventions: hip replacement, cataract surgery, antidepressants, medications to improve congestive heart failure symptoms, balance/strength/gait training, hearing aids, pain management, discontinuing sedating medications
• Address any needs for assistive devices and environmental modifications
  • Referral to PT for assessment for assistive device and home safety evaluation
  • Order any necessary DME
• If screens positive for IADL impairment: May benefit from support services such as meals on wheels, in home support services, paratransit
• If screens positive for ADL impairment: May benefit from additional caregiver support at home or higher level of care
• Provide information on implementing emergency call system
• Involve your social worker in helping with providing information and referrals for the services above 
• Consider involving Geriatrics as patients develop more functional impairments

References

Elsawy, B, & Higgins, KE. The geriatric assessment. Am Fam Physician 2011;83(1);48-56.

Katz S.  Assessing self-maintenance: activities of daily living, mobility, and instrumental activities of daily living.  J Am Geriatr Soc 1983;31(12):721-727.

Covinsky KE, Pierluissi E, Johnston C. Hospitalization-Associated Disability: “She Was Probably Able to Ambulate, but I’m Not Sure”. JAMA 2011;306(16):1782-1793.

Lawton MP, Brody EM.  Assessment of older people: self-maintaining and instrumental activities of daily living.  Gerontologist 1969;9:179-186.

Studenski S, et al. Gait speed and survival in older adults. JAMA 2011;305(1):50.

Smith AK, et al. Disability during the Last Two Years of Life. JAMA 2013;173(16):1506-1513.

Colon-Emeric CS, et al. Functional Decline in Older Adults. Am Fam Physician. 2013;88(6):388-394.