Geriatric Nursing and Physical Function in Older Adults
Whats are Physical Functions
Physical functioning is a dynamic process of interaction between
individuals and their environments. The process is influenced by motivation,
physical capacity, illness, cognitive ability, and the external environment
including social supports.
Management of these day-to-day activities (eg,
eating, bathing, ambulating, managing money) serves as the foundation for safe,
independent functioning of all adults.
Functional assessment instruments
provide a common language of health for patients, family members, and health
care providers across settings, especially for care of older adults.
The consequences of not assessing for change in status are
significant. Acute changes in functional ability often signal an acute illness
and an increased need for assistance to maintain safety.
These changes have
important implications for nursing care across settings, but especially during
hospitalization. The ability to assess functional status is critical in
accurately identifying normal aging changes, illness, and disability, and in
developing an individualized plan for continuity of care across settings.
The
failure to assess function can lead to increased decline (eg, malnutrition,
falls), decreased quality of life, and the need for institutional care.
Problems Related to Physical Functions
The ability to manage day-to-day functioning (eg, bathing,
dressing, managing medications), rather than the absence of disease, is the
cornerstone of health for older adults. As individuals age or become ill, they
may require assistance to accomplish these activities independently.
Hospitalization can also contribute to functional decline, with decline
experienced by an estimated 20%-40% of hospitalized older adults (Landefeld,
Palmer, Kresevic, Fortinsky, & Kowal, 1995).
Although the exact cause of
the decline is often a combination of factors including acute illness, it can
in part be caused by environmental factors of hospitalization that could be
prevented or ameliorated by skilled nursing care (McCusker, Kakuma, &
Abrahamowicz, 2002). In fact, hospitalization provides a unique opportunity to
assess function, plan for services, and promote “successful aging.”
Common risk factors for functional decline include falls, injuries,
acute illness, medication side effects, depression, malnutrition, baseline
functional impairment, and decreased mobility associated with iatrogenic
complications such as incontinence, falls, and pressure sores (Creditor, 1993).
In one randomized clinical trial of hospitalized older adults, the daily
nursing assessment of ability to perform bathing, dressing, grooming,
toileting, transferring, and ambulation during routine nursing care yielded
information necessary for maintenance of function in self-care activities
(Landefeld et al. ., nineteen ninety five).
This chapter addresses the need for and goals of functional
assessment of older adults in acute care, and it provides a clinical practice
protocol to guide nurses in this assessment (Protocol 6.1).
Assessment of Physical Functions
Assessment of function includes an ongoing systematic process of
identifying the older person’s physical abilities and need for help. Functional
assessment also provides the opportunity to identify individual strengths and
measures of “successful aging.”
This information is especially important for
nurses in planning for discharge and evaluating continuity of care. Nurses are
in a pivotal position in all care settings, but particularly during
hospitalization, to assess the functional status of older adults by direct
observation during routine care and through information gathered from the
individual patient. the patient’s family, and any other long-term caregivers.
Including critical components of functional assessments into
routine assessments in the acute care setting can provide:
(a) baseline functional
capacity and recent changes in level of independence indicative of possible
illness, especially infections
(b) baseline information to benchmark patients’
response to treatment as they move along the continuum from acute care to
rehabilitation or from acute to subacute care (eg, following a new stroke or
hip replacement surgery)
(c) information regarding care needs and eligibility
for services, including safety, physical therapy, and posthospitalization
needs
(d) information on quality of care. The ongoing use of a
standardized functional assessment instrument promotes systematic communication
of the patient’s health status between care settings.
It also allows units to
compare their level of care with other units in the facility, measure outcomes,
and plan for continuity of care.
Campbell, Seymour, Primrose, & ACMEPLUS Project, 2004).
Although gathering information about functional status is a critical indicator
of quality care in geriatrics, it requires significant time, skill, and
knowledge.
Older persons often present to the care setting with multiple
medical conditions resulting in fatigue and pain. Acute illnesses may be
superimposed upon multiple interrelated medical comorbidities.
In addition, sensory aging changes, particularly vision and
hearing, can threaten the accuracy of responses. Ideally, information regarding
functional status should be elicited as part of the routine history of older
adults and incorporated into daily care routines of all caregivers.
In
addition, comprehensive assessment of function provides an opportunity to teach
patients and families about normal aging as well as indicators of pathology.
Instruments to Assess Physical Functions
Collecting systematic information regarding tasks of daily living
(eg, bathing, dressing, walking, using a phone, taking medications, managing
finances) can be accomplished by the use of standardized instruments.
The use
of standardized instruments serves to ensure inclusive assessments, the ability
to communicate in a common language, and the ability to benchmark information
over time. Several instruments have been developed over the years to measure
function.
Although all measure components of function, the decision of which
instrument to use depends on the primary purpose of the assessment and the
institutional preferences and resources (Kane & Kane, 2000). No single
instrument will meet the needs of all care settings.
Many performance-based measures and observational instruments can
be incorporated into routine care practices without significantly burdening
caregivers.
Incorporating electronic medical record templates into routine
documentation can function as a prompt for providers, decreasing the time and
increasing the communication of the results of these assessments.
(commonly referred to as Katz ADL index) assesses activities of daily living
(ADL) including bathing, dressing, transferring, toileting, continence, and
feeding (Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963).
This scale is
widely used to assess function of older adults in all settings including during
hospitalization (Mezey, Rauckhorst, & Stokes, 1993). Originally, the Katz
ADL index was proposed as an observation tool with scores ranging from 1 to 3,
indicating independent ability, limited assistance, and extensive assistance
for each activity .
Over time, the instrument has evolved into a dichotomized
tool with independent versus dependent ability of each task (Kane & Kane,
2000). With established reliability (0.94-0.97), it is easy to use either as an
observational or self-reported measure of level of independence (Kane &
Kane, 2000).
The Katz ADL index is easily incorporated into history and
physical assessment flowsheets and takes little time to complete.
Many other
tools exist to assess ADLs, including the Barthel index for physical
functioning and the Older Americans Resources and Services ADL scale (Burton,
Damon, Dillinger, Erickson, & Peterson, 1978; Mahoney & Barthel, 1965:
Mezey et al., 1993 ).
In addition to ADL tools, instruments to measure more complex
physical function called instrumental activities of daily living (ADLs) have
been proposed to be included in a comprehensive assessment of function in older
adults.
The majority of these instruments assess the individual’s function in
relation to the environment. Common IADL skills identified include using a
phone, shopping, meal preparation, housekeeping, laundry, medication
administration, transportation, and money management (Kane & Kane, 2000).
Although assessment of ADLs provides useful information for nursing care needs
both during and after hospitalization, IADL information helps target critical
posthospital care needs. Although direct observation of the patient’s IADLs may
not occur during an acute hospitalization, it is important for the nurse to
assess this information to plan for the patient’s discharge.
Common instruments
used to measure IADLs include the Lawton IADL scale, the Older Americans
Resource and Services IADL (OARS-IADL) scale, and the Direct Assessment of
Functional Abilities (DAFA) scale.
Perhaps the most widely used IADL instrument for hospitalized older
adults is the Lawton IADL scale. This scale assesses eight items with each
scored from 0 (dependency) to 8 (independent self-care). Reliability
coefficients have been reported to be 0.96 for men and 0.93 for women (Kane
& Kanc, 2000).
Assessment of function in individuals with dementia presents a
unique challenge.
A recently developed instrument, the DAFA, is a 10-item
observational measure of IADLs useful in assessing function in the presence of
dementia (Karagiozis, Gray, Sacco, Shapiro, & Kawas, 1998; see
http://www.consultgerirn.org /resources and the Resources section of this
chapter for assessment instruments).
Regardless of the instrument used, basic ADL, and IADL function
should be assessed for each patient, including capacity for dressing, eating,
transferring, toileting, hygiene, ambulation, and medication adherence.
Appropriate assessment instruments
should be readily available on the acute care unit for reference and/or
incorporated into routine documentation instruments for history, daily
assessment, and discharge planning.
To adequately assess function, sensory and
cognitive capacity should be established and environmental adaptations, such as
magnifying glasses or hearing amplifiers, may be necessary and should be
accessible to nursing staff.
Direct Assessment of Patient
Although nurses often rely on reports of physical functioning and
capacity for ADL and IADL from patients and family members, direct observation
provides strong evidence for current capacity versus past ability.
Functional assessments are constantly conducted by nurses every
time they notice that a patient can no longer pick up a fork or has difficulty
walking. A comprehensive functional assessment leads to more than simply
noticing a change in activity or ability. however.
In a systematic manner,
nurses need to assess the ability of a patient to perform ADLs in the context
of the patient’s baseline functional and hospitalization status.
While assessing functional status, the patient should be made as
comfortable as possible, with frequent rest periods allowed. Adaptive aids,
such as glasses and hearing aids, should be applied.
Often, family members
accompany the older person and can assist in answering questions regarding
function. It is important for patients and family members to understand that
baseline functional levels as well as any recent changes in function need to be
reported.
Many older adults may be reluctant to report decline in function,
fearing that such reports will threaten their autonomy and independent living.
Occasionally, the history and physical exam may reveal clues to
further identify functional status. Muscle weakness and atrophy of legs may
indicate lack of ability to safely ambulate independently.
Temporal muscle
wasting may indicate moderate-to-severe malnutrition resulting from inability
to shop, prepare meals, or adequately consume sufficient calories.
Hand
contractures present with arthritis or cerebral vascular accidents alert the
nurse to pay particular attention to performance versus self-report of ability
to open pill bottles, dial a phone, or write checks.
General appearance (eg,
hair, teeth, fingers) and condition of clothing (eg, clean and dry versus
urine-soaked undergarments) may give rise to information on bathing, dressing,
continence, and ability to do laundry.
Specific Functional Assessments Ambulation
Inherent in both ADLs and IADLS is ambulation, a critical parameter
for functional assessment. Early nursing assessment of the hospitalized
patient’s ability to walk is very important in order to ensure safety and
prevent falls and injuries.
The ability to safely ambulate is
contingent on the ability to transfer, propel forward, and pivot with
sufficient strength and balance. Ambulation is necessary for self-care both in
the hospital and posthospital discharge. It is also a very sensitive indicator
of acute health changes.
Therefore, the ability to ambulate should be assessed
by both self- or proxy report and by direct observation. Some instruments used
to assess ambulation, balance, and gait are sensitive measures of mobility
(Applegate, Blass, & Franklin, 1990); however, they are also complex and
time consuming to use.
Therefore, direct observation of an individual’s ability
to get out of bed, sit in a chair, assume a standing position, and steadily
walk a short distance with or without assistive devices-is much simpler to do
yet important to ensure safety (Applegate et al. ., 1990; Cress et al., 1995).
An efficient performance-based measure of ambulation, balance, and
gait that can be observed during routine care of the hospitalized patient is
the “Get Up and Go” test (Cress et al., 1995). To do a Get Up and Go test,
patients are observed sitting in a chair. standing, walking, and pivoting.
Direct observation of the patient should include an assessment of speed of
performance, hesitancy, stumbling, swaying, grabbing for support , or unsafe
maneuvers such as sitting too close to the edge of a chair or dizziness while
pivoting (Tinetti & Ginter, 1998) .
Performance is scored from 1 (normal
balance and steady gait) to 5 (severely abnormal balance and gait) which is
clear evidence of falls risk (Kane & Kane, 2000). Assessment of unsafe
transfers or ambulation indicates the need to begin immediate restorative
therapies to prevent falls and injuries.
These can include attention to
environmental designs such walking paths free of clutter, hand rails, and rest
areas to encourage daily ambulation as opposed to bed rest and immobility
(Creditor, 1993).
Although the Get Up and Go test is easy to do, it is
relatively subjective. Objectivity may be enhanced by timing the tasks (Kane
& Kane, 2000).
Sensory Capacity
Evaluation of the potential impact of sensory changes on the
performance of ADLs is often underestimated. Impaired vision is especially
important in medication adherence and safety.
A simple test for functional
vision is to have older adults read from a newspaper. A moderate impairment can
be noted if only the headline can be read (Tinetti & Ginter, 1998). Another
way to assess vision is to have older people read prescription bottles.
Functional assessment of safe medication administration includes the ability to
read pill bottles and repeat directions for use, potential side effects, and
instructions of when to contact a health care provider.
Glasses should be
available with clean lenses. Inability to read raises questions of literacy,
undiagnosed vision difficulties, and safety for medication administration.
Often overlooked is the number of older people who may not be able to read but
are too embarrassed to reveal that information.
As part of routine care, older
adults should be encouraged to actively participate each day in learning about
medications. In addition, at the time of discharge, nurses need to verify
patient and family knowledge and skills regarding medications.
This may include
discussing medications as well as directly observing older adults opening pill
bottles and identifying the correct pills.
Hearing ability is also essential for functioning and cognition.
Individuals with decreased hearing may be inaccurately labeled as cognitively
impaired. Hearing aids may not have been sent to the hospital with the older
patient and should be obtained by the family.
Hearing acuity may be validated
by asking patients to identify the sound of a ticking watch. The “whisper
test” may also be used. This is performed by whispering 10 words while
standing 6 in. away from the individual. Inability to repeat 5 of the 10 words
indicates a need for further assessment of hearing acuity.
Occlusion of the
external ear canal by cerumen, an easily treatable cause of decreased hearing
acuity, may be evident with visualization (Mathias, Nayak. & Isaacs, 1986).
Individuals with hearing deficits detected as part of Cognitive Capacity
Cognitive function is a major factor in a person’s functional
capacity, and baseline data regarding cognitive function should be gathered.
However, such assessments most often initially rely on information provided by
family members because acute illness may manifest as acute confessional states
and not reflect baseline cognitive function (Kruianski & Gurland, 1976.
Assessing Cognitive Function). Fluctuating attention may indicate an
acute, reversible impairment (delirium) or temporary reactions to
hospitalization.
An acute change in cognition should be evaluated immediately
for the presence of a potentially life-threatening, reversible medical
condition (see Chapter 11. Delirium).
Cause of Functional Decline
All instances of functional decline should be assessed for an
underlying reversible cause such as acute illness. With the resolution of acute
illness (eg, urinary tract infection [UTI), pneumonia, postoperative recovery),
impaired ADLs are expected to return to baseline with appropriate care and
rehabilitation.
Comprehensive musculoskeletal or neurological examination,
laboratory tests, or referral for a therapeutic trial of physical or
occupational therapy may be needed to boost recovery.
Interventions And Care Strategies
Functional ability is a sensitive indicator of health in older
adults. The need for assistance with ADLs is an important nursing assessment
that aids in care planning during and after a hospital stay.
Sudden loss of
function, including the ability to ambulate, is the hallmark of acute illness
in older adults.
Although recovery from illness may be associated with
improvements in function, early nursing interventions to address care needs,
referral to therapy, and modify environments of care help to ensure safety and
decrease further loss of function.
Therefore, all nurses must be skilled at
incorporating a comprehensive functional assessment into all patient care
assessments.
Nurses need to be knowledgeable and skilled in assessment of
function, implementing supportive environments, and providing
geriatric-sensitive care to prevent functional decline.
Geriatric-sensitive
care incorporates strategies to prevent bed rest, encourage exercise and
ambulation, ensure adequate nutrition, and encourage ongoing communication
among all team members. Such care is essential in maximizing safe, independent
functioning of hospitalized older adults.
Use of Assessment Information
Knowledge of ADL, and IADL abilities, including shopping,
housework, finances, food preparation, medication administration, and
transportation, is an important part of providing individual nursing care for
comprehensive discharge planning (Woolf, 1990).
In summary, for older people,
the evaluation of function represents the cornerstone of good nursing care and
affords a sound baseline by which to provide essential information to plan for
continued care across settings.