Nursing Management of Physical Function in Old Adults

Nursing Management of Physical Function in Old Introduction

Physical functioning is a dynamic process involving the interaction between individuals and their environment. This process is influenced by various factors, including motivation, physical capacity, illness, cognitive ability, and external elements such as social support. In geriatric nursing, the management of day-to-day activities (e.g., eating, bathing, ambulating, managing money) forms the foundation for safe, independent functioning in older adults. This article provides a detailed exploration of physical functions in older adults, associated problems, assessment methods, and effective care strategies.

Understanding Physical Functions

What are Physical Functions?

Physical functions refer to the capabilities required to carry out daily activities essential for independent living. These activities, known as Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs), are fundamental to maintaining quality of life. ADLs typically include tasks like bathing, dressing, feeding, and toileting, while IADLs encompass more complex activities, such as managing finances, shopping, and preparing meals.

The process of physical functioning is highly dynamic and is shaped by the interplay between an individual’s intrinsic factors (e.g., strength, endurance, cognitive capacity) and extrinsic factors (e.g., environmental support, social networks). Functional assessment instruments provide a common language for healthcare providers, patients, and families, facilitating effective communication and care planning across various settings.

The Importance of Assessing Physical Functions

Failure to assess changes in physical function can have significant consequences for older adults. Acute changes in functional ability often indicate underlying acute illness or increased need for assistance to maintain safety. These changes can have important implications for nursing care, particularly during hospitalization, where the ability to assess functional status is critical in distinguishing between normal aging, illness, and disability.

Accurate functional assessment helps in developing an individualized care plan and ensuring continuity of care across different settings. Failure to assess function can lead to increased decline (e.g., malnutrition, falls), decreased quality of life, and a greater need for institutional care.

Problems Related to Physical Functions

Factors Contributing to Functional Decline

Functional decline in older adults is often multifactorial, involving both intrinsic and extrinsic factors. Key factors contributing to functional decline include:

1. Physical and Cognitive Impairments: Aging is often accompanied by declines in physical strength, mobility, and cognitive abilities, which can affect the capacity to perform ADLs and IADLs.
2. Acute Illness and Hospitalization: Hospitalization, particularly for acute illness, is a major risk factor for functional decline in older adults. Studies suggest that 20%-40% of hospitalized older adults experience a decline in functional ability during their hospital stay (Landefeld et al., 1995). Hospitalization-related factors such as bed rest, medical procedures, and lack of mobility contribute to this decline (McCusker et al., 2002).
3. Environmental Factors: Hospital environments can be disorienting and lack the familiar cues that support older adults’ independence. Factors such as poor lighting, lack of mobility aids, and restrictive care routines can further contribute to functional decline.
4. Medication Side Effects: Polypharmacy and adverse drug reactions are common in older adults and can result in dizziness, confusion, and falls, all of which negatively impact functional abilities.
5. Depression and Social Isolation: Depression is a common issue in older adults and can reduce motivation to engage in activities or adhere to rehabilitation programs, contributing to functional decline. Similarly, social isolation can reduce physical activity levels and lead to deconditioning.
6. Malnutrition: Poor nutritional status, which is prevalent in older adults, especially those with chronic illnesses, can lead to muscle wasting, weakness, and increased susceptibility to infections, all of which contribute to functional decline.

Specific Functional Decline Concerns

1. Mobility and Ambulation: Reduced ability to walk and move independently is a significant concern. Impaired ambulation can result in falls and further injury, leading to a cycle of declining mobility and increased dependence (Creditor, 1993).
2. Sensory Deficits: Impaired vision and hearing can hinder the ability to perform everyday tasks and can contribute to isolation, reduced social interaction, and cognitive decline (Tinetti & Ginter, 1998).
3. Cognitive Impairments: Cognitive decline, including conditions like dementia, significantly affects an individual’s ability to manage daily tasks, adhere to medication regimens, and maintain personal safety (Kruianski & Gurland, 1976).

Assessment of Physical Functions

Comprehensive Functional Assessment

Functional assessment is a systematic process that identifies an older person’s physical abilities and need for help. It also highlights individual strengths and potential areas for promoting “successful aging.” This information is crucial for planning discharge and ensuring continuity of care. In all care settings, but particularly during hospitalization, nurses play a pivotal role in assessing functional status through direct observation and gathering information from patients, family members, and long-term caregivers.

Functional assessment in acute care settings should provide:

1. Baseline Functional Capacity: To benchmark changes in a patient’s level of independence, indicative of possible illness.
2. Response to Treatment: Baseline information to track patients’ responses to treatments as they transition from acute to subacute care or rehabilitation.
3. Care Needs and Safety Planning: Information regarding care needs and eligibility for services, including safety, physical therapy, and post-hospitalization requirements.
4. Quality of Care Indicators: Ongoing use of standardized functional assessment instruments promotes systematic communication about patient status and facilitates care planning across settings.

Instruments for Assessing Physical Functions

Standardized assessment instruments provide a structured way to collect information about physical function. They ensure comprehensive assessments, enable communication in a common language, and allow benchmarking of information over time.

Commonly Used Assessment Instruments

1. Katz Index of Independence in Activities of Daily Living (ADL Index): This widely used tool assesses basic activities such as bathing, dressing, transferring, toileting, continence, and feeding (Katz et al., 1963). It has established reliability and can be easily incorporated into routine assessment flowsheets. The tool has been adapted to measure either independent versus dependent ability or levels of assistance needed.
2. Barthel Index for Physical Functioning: This tool measures the ability to perform ten basic ADLs and provides a score that helps identify areas where patients need support (Mahoney & Barthel, 1965).
3. Older Americans Resources and Services (OARS) ADL and IADL Scales: These scales provide a comprehensive assessment of both basic and instrumental activities of daily living, which are critical for planning post-hospital care (Burton et al., 1978).
4. Lawton Instrumental Activities of Daily Living (IADL) Scale: This scale is often used in acute care settings to assess the ability to perform more complex tasks, such as managing finances, medication adherence, and housekeeping. It is a valuable tool for discharge planning and post-hospital care needs (Lawton & Brody, 1969).
5. Direct Assessment of Functional Abilities (DAFA) Scale: Particularly useful for individuals with dementia, this 10-item observational measure evaluates the ability to perform IADLs in the presence of cognitive impairment (Karagiozis et al., 1998).

Specific Functional Assessments

Ambulation

Ambulation is a key aspect of functional assessment. The ability to walk safely is crucial for self-care both in the hospital and after discharge. Early nursing assessment of the patient’s ability to walk is essential to ensure safety and prevent falls.

The “Get Up and Go” test is a simple, performance-based measure of ambulation, balance, and gait. It involves observing the patient sitting in a chair, standing, walking, and pivoting. Observations focus on speed, hesitancy, stumbling, swaying, or unsafe maneuvers, and performance is scored from 1 (normal balance and steady gait) to 5 (severely abnormal balance and gait) (Tinetti & Ginter, 1998).

Interventions for those with impaired ambulation may include creating safe walking paths, using handrails, and providing rest areas to encourage daily ambulation rather than bed rest.

Sensory Capacity

Sensory changes, particularly in vision and hearing, significantly impact the ability to perform ADLs. Assessing functional vision can be done by having the patient read from a newspaper or prescription bottle. Similarly, hearing acuity can be assessed using the “whisper test” or by identifying the sound of a ticking watch.

Proper use of glasses and hearing aids should be ensured, and environmental adaptations, such as magnifying glasses or hearing amplifiers, should be readily available to nursing staff.

Cognitive Capacity

Cognitive function is a critical component of functional capacity. Assessments should gather baseline cognitive data and differentiate between acute confusional states and baseline cognitive function. Changes in cognition may indicate delirium or other reversible conditions and should be evaluated immediately (Kruianski & Gurland, 1976).

Causes of Functional Decline

Functional decline can be caused by a variety of factors, including acute illness, environmental changes, medication side effects, and sensory or cognitive impairments. It is important to assess for underlying reversible causes, such as infections, metabolic imbalances, or medication interactions.

With appropriate care and rehabilitation, recovery from acute illnesses should lead to the restoration of baseline function. Nurses should advocate for comprehensive assessments, including musculoskeletal or neurological examinations and referral to therapies as needed.

Interventions and Care Strategies

Promoting Functional Ability

Functional ability is a sensitive indicator of health in older adults. Nurses play a crucial role in identifying and addressing functional decline. Early interventions should focus on promoting mobility, preventing bed rest, encouraging physical activity, ensuring adequate nutrition, and facilitating communication among all care team members.

Key Interventions Include:

1. Encouraging Mobility and Exercise: Preventing bed rest and promoting ambulation and exercise are essential strategies. Providing safe walking paths, adaptive equipment, and opportunities for physical therapy can enhance mobility and prevent further decline.
2. Ensuring Adequate Nutrition: Nutritional assessments should be conducted regularly, and interventions should be implemented to address any deficiencies. Providing adequate hydration and high-protein diets can help maintain muscle mass and strength.
3. Providing a Safe Environment: Modifying the environment to reduce fall risks, such as installing handrails, removing clutter, and ensuring proper lighting, is crucial. Nurses should also educate patients and families on safety measures at home.
4. Facilitating Interdisciplinary Care: Collaboration with physical therapists, occupational therapists, dietitians, social workers, and other healthcare providers is essential for developing comprehensive care plans that address all aspects of physical function.
5. Implementing Restorative Nursing Care: Restorative nursing care focuses on helping patients regain and maintain their highest level of function. This includes exercises, mobility training, self-care education, and support for independence.

Use of Assessment Information

Knowledge of ADL and IADL abilities is critical for developing individualized nursing care plans and for discharge planning. Comprehensive assessments provide essential information to ensure continuity of care across settings, identify rehabilitation needs, and facilitate transitions to home or other care environments.

Conclusion

Assessment and management of physical function are integral to geriatric nursing care. Nurses must be skilled in using standardized assessment tools, implementing interventions to promote functional ability, and collaborating with interdisciplinary teams to ensure the best outcomes for older adults. By focusing on comprehensive assessments, early interventions, and patient-centered care strategies, nurses can help prevent functional decline, enhance quality of life, and support successful aging in the older population.