Assessment of Physical Function   7  

Denise M. Kresevic

OVERVIEW

Physical functioning is a dynamic process of interaction between individuals and their environments. The process is influenced by motivation, physical capacity, illness, cognitive ability, pain, and the external environment, including social supports. Management of these day-to-day activities (e.g., 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. These assessements also serve as important parameters for goal setting and interprofessional collaboration.

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. Likewise, improvements in function signal recovery and a return to health. 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 risk of complications (e.g., malnutrition, falls); hospital readmissions, likelihood of being discharged to a nursing home setting (Fortinsky, Covinsky, Palmer, & Landefeld, 1999); and mortality (Boyd, Xue, Guralnik, & Fried, 2005; Rozzini, Sabatini, & Trabucchi, 2005), as well as decreased functional recovery (Boyd et al., 2005; Boyd, Ritchie, Tipton, Studenski, & Wieland, 2008; Gill, Allore, & Guo, 2004; Volpato et al., 2007) and quality of life.

BACKGROUND AND STATEMENT OF PROBLEM

Physical functioning, the ability to manage day-to-day functioning (e.g., bathing, dressing, ambulating, managing medications), rather than the absence of disease, is the cornerstone of health for older adults. Maintaining a safe level of independent functioning may pose a challenge for older adults dealing with acute illness or exacerbations of chronic illnesses. Hospitalization can also contribute to functional decline, with decline experienced by an estimated 20% to 40% of hospitalized older adults (Landefeld, Palmer, Kresevic, Fortinsky, & Kowal, 1995). Functional decline is a common complication in hospitalized older adults, even in those with good baseline function (Gill, Allore, Gahbauer, & Murphy, 2010). The cause of this decline appears multifactorial and includes individual as well as environmental factors. Evidence that targeted interventions are effective in preventing and reversing functional decline continues to mount (Barnes et al., 2012). Hospitalization provides a unique opportunity to assess function, provide evidenced-based interventions, plan for services, and promote “successful aging.”

Educational intervention has demonstrated improvements in caregiver knowledge and patient outcome (Resnick, Galik, Boltz, & Pretzer-Aboff, 2011).

Patient risk factors for functional decline include prehospitalization functional loss; the presence of two or more comorbidities; taking five or more prescription medications; having had a hospitalization or emergency room visit in the previous 12 months (McCusker, Kakuma, & Abrahamowicz, 2002); depression (Covinsky et al., 1998); impaired cognition, including delirium (Inouye, Schlesinger, & Lydon, 1999; Narain et al., 1988); pain (Reid, Williams, & Gill, 2005); nutritional problems; adverse medication effects (Graf, 2006); fear of falling (Boltz, Capezuti, & Shabbat, 2011); low self-efficacy and outcome expectations (McAuley et al., 2006; Resnick, 2002); and attitudes toward functional independence and views on hospitalization (Boltz, Capezuti, & Shabbat, 2011; Boltz, Capezuti, Shabbat, & Hall, 2010; Boyd et al., 2008; Brown, Williams, Woodby, Davis, & Allman, 2007).

These risk factors for functional decline are also associated with common risk factors for functional decline, including 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., 1995).

Studies over the past 20 years have found that the use of multidisciplinary assessements and nursing protocols can reduce hospital length of stay and costs while maintaining patient outcomes and not increasing hospital readmission rates (Barnes et al., 2012).

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 7.1).

ASSESSMENT OF THE PROBLEM

Assessment of function includes an ongoing systematic process of identifying the older person’s physical abilities and need for help or assistance. Functional assessment also provides the opportunity to identify individual strengths and measures of “successful aging” and also promotes maintenance of health. This information is especially important for nurses in planning for transitions of care, including discharge to other facilities or home 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 (e.g., following a new stroke or hip replacement surgery); (c) information regarding care needs and eligibility for services, including safety, physical therapy, and post hospitalization needs; and (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 (Table 7.1; 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 on 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.

TABLE 7.1

Functional Assessment of Older Adults

Assessment Instruments

Collecting systematic information regarding tasks of daily living (e.g., bathing, dressing, ambulating, 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.

The Katz Index of Independence in Activities of Daily Living (commonly referred to as the Katz ADL index) assesses activities of daily living (ADL), including bathing, dressing, transferring, toileting, continence, and eating (Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963). This scale is used widely 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 a 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 ADL, including the Barthel index for physical functioning and the Older Americans Resources and Services ADL scale (OARS-ADL; 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 (IADL) 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 ADL provides useful information for nursing care needs both during and after hospitalization, IADL information helps target critical post hospital care needs. Although direct observation of the patient’s IADL 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 IADL include the Lawton IADL scale, the Older Americans Resources and Services Instrumental Activities of Daily Living (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 (dependence) to 8 (independent self-care). Reliability coefficients have been reported to be 0.96 for men and 0.93 for women (Kane & Kane, 2000).

More recent, scales that address frailty have been developed to assist in the assessment of at-risk individuals. Frailty is characterized by five components: weight loss, fatigue, handgrip, physical activity, and walking speed (Fried et al., 2009). The most widely used is the Fried Frailty scale (see Chapter 27). This scale uses objective and self-report data.

Assessment of function in individuals with dementia presents a unique challenge. The Direct Assessment of Functional Abilities (DAFA), a 10-item observational measure of IADL, has been found to be useful in assessing function in the presence of dementia (Karagiozis, Gray, Sacco, Shapiro, & Kawas, 1998; see 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 (see Chapter 20, “Reducing Adverse Drug Events”). 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 Patients

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 ADL 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 examination 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 (e.g., hair, teeth, fingernails) and condition of clothing (e.g., 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 ADL and IADL 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 (see Chapter 19, “Preventing Falls in Acute Care”). 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 after hospital 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 fall 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 as walking paths free of clutter, handrails, 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 perform, 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 ADL 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 persons 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 inches away from the individual. Inability to repeat five 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 bedside assessment should be referred for additional assessment and treatment. Amplifier devices may be useful and are an inexpensive item to stock on hospital nursing units.

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 confusional states and not reflect baseline cognitive function (Kruianski & Gurland, 1976; see Chapter 6, “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 17, “Delirium: Prevention, Early Recognition, and Treatment”).

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 (e.g., urinary tract infection [UTI], pneumonia, postoperative recovery), impaired ADL 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. In some cases, functional decline may accompany a predictable downward spiral associated with end-stage chronic diseases such as Alzheimer’s disease or terminal illnesses. However, even in individuals with these conditions, all potentially reversible causes should be fully explored.

INTERVENTIONS AND CARE STRATEGIES

Functional ability is a sensitive indicator of health in older adults. The need for assistance with ADL is an important nursing assessment to provide safe individualized care during hospitalization and also 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, refer 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 and communicating these assessments to the care team across transitions. 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 (see Chapter 14, “Preventing Functional Decline in the Acute Care Setting”).

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 information essential to plan for continued care across settings.

Stay updated, free articles. Join our Telegram channel

Join