Functional Status Assessment

Susan Saltzman, N.D., R.N., F.N.P.

Functional status assessment is fundamental to geriatric care. Function, the ability to manage daily routines, can not be well-correlated with medical diagnoses or length of the problem list. A change in functional status is often the only or the first sign of illness or exacerbation of a chronic condition. A recent study has indicated four risk factors for functional decline in hospitalized elderly patients: pressure sore, pre-existing functional impairment, cognitive impairment, and low social activity. Clinical outcomes of patients who exhibit functional decline were nursing home placement and death.

• Purposes of functional assessment - 1) to indicate presence and severity of disease, 2) to measure a person's need for care, 3) to monitor change over time, and 4) to maintain an optimally cost effective clinical operation.
  
• Components of functional assessment - Vision and hearing, mobility, continence, nutrition, mental status (cognition and affect), affect, home environment, social support, ADL-IADL.
  
  • ADL's (activities of daily living) are basic activities such as transferring, ambulating, bathing, etc.
  • IADL's (instrumental ADL's) are more complex tasks requiring a combination of physical and mental function such as using the telephone, preparing meals, arranging transportation, managing finances.

Other members of the "team" in the ambulatory or in-patient setting can formally or informally collect data on functionality. For example; questions about activities done that day, "how did you get here?", "did you do your own hair?". Simple observations: who is accompanying the patient? What is their role? How the patient responds to the usual request "take off your clothing, put on the gown and get up on the table (or bed)" can tell a lot about how the patient functions.

The Northwestern Geriatric Functional Status Review Instrument:
A screening tool used to identify areas needing more in-depth assessment and /or intervention (card included).

Instructions for use and scoring

• Physical status
  Score each task 0 or 1 except for vision and hearing (Vision - 2 points for 20/20, allow 2 errors, and 1 point for 20/60, allow 1 error; Hearing, 1 point each ear, if hears correctly). If a task cannot be complete in less than 30 seconds, go on to the next one.
  Follow-up recommendations: The complete physical exam and formal motor/mobility evaluation will dictate interventions such as OT, PT, hearing and vision aids, etc.
• Cognitive status
  Attentional: If all correct = 4. Subtract #'s of each miss down to 4 which = 0.
  Memory: 1 point for each object recalled.
  Visual-Spatial: Clock face, 1 point for valid attempt, 2 if clearly recognizable.
  Depression: Translate 0-10 to a 0-4 scale as follows: 9-10 = 4, 6-8 = 3, 4-5 = 2, 2-3 = 1, 0-1 = 0.
  Follow-up recommendations: Formal Folstein testing and/ or use of the Geriatric Depression Scale (G.D.S. short form). If the patient fails the attentional question, evaluate for delirium and correlate with neurological exam, level of consciousness, etc. Memory impairment raises the question of dementia. Impairment in spatial relations suggests possible parietal lobe dysfunction.
• ADL's/IADL's
  Note: proper answer to "Do you..." questions is "No." If possible, verify with family. Also observe patient. If this subtotal score is low, patient will need extensive post-hospital care services, and may need to change their living arrangements.
  Follow-up recommendations: Further evaluation via Social Work, Discharge Planning, Case Management.
• Environmental/Social
  These are crucial risk factors. For post-hospital care and preventing readmission, contact Social Work/Case Management for follow-up.

Conclusions

Total score should be recorded, and any of the four domains with especially poor performance noted. Consultations or interventions need to be designed and initiated specifically for the individual patient after thorough evaluation. A score of 30-36 suggests significant functional impairment with need for further assessment and measures to prevent further decline. For this group it is especially important to identify home and social support systems. A score of 25 or below indicates that the patient will likely have a prolonged hospital stay, will use increased inpatient resources and is at high risk for iatrogenesis. The lower the score, the more likely it is
that nursing home placement will be the outcome of hospitalization unless early interventions are mobilized to address deficits.

• Other data collection can be obtained by office staff and physicians, for example:
  
  Nutrition - Height and weight and direct observation of teeth, gums, and dentures.
  
  Mobility - Observation of patient transfer from waiting room to exam room, to undressing, to exam table.
  
  Cognition - Vision- Hearing - Waiting room observation of patient and care giver and ask, for example, "how did you get here today?"
  
  Drug Inventory - Including all over-the-counter medications. All these should be made regular components of the patient record via check-lists for ease of updates.

*Revised for the 3rd edition by James R. Webster, Jr., MD