The elderly of our society have been called our fastest growing minority.1 Although now comprising approximately 1 1% of our nation's population, those over the age of 65 may be over 21% of the total population by the year 2030. 2 Furthermore, the over-85 age group, commonly referred to as the "old-old", the most rapidly growing segment, are increasing at six times the rate of the general population.2 One impact of increased numbers of elderly is that greater demands are being placed on health-care services due largely to the progressive incidence of chronic disease with age. On average, the number of chronic illnesses for those 64 to 69 years old is four and the mean increases to five for those over age 75. 3 These frequently cited statistics present significant implications to nurses both as members of society and as health professionals.
With advanced age, the cumulative effects of age and disease have a significant impact on the functionai reserve of all organ systems.4 A greater percentage of a person's reserve is required to maintain functional status as capabilities and resources diminish. Cornprehensive functional assessment therefore is a cornerstone of gerontological nursing.
Although dedication to the achievement of an optimal functional status for patients/clients is a basic premise of professional nursing, regardless of practice setting or population, geriatric functional assessment requires a specific perspective.
There are basically two components of a comprehensive geriatric functional assessment. First, it must consist of an integration of the biological, psychological, and social functioning domains. Functioning in one area directly influences functioning in other areas and this interrelationship is especially important to the well-being of the elderly. Secondly, because of the multiplicity, complexity, and chronicity of health problems of the aged, functional assessment of the elderly must also be be interdisciplinary.5 To paint a portrait of functional status of the elderly requires the interactive resources of several health-care disciplines so that the final product is the result of interdisciplinary collaboration.
Functional Assessment Protocol
This article describes the functional assessment protocol utilized in one geriatric clinical setting. Over a period of 10 years, the interdisciplinary team of the Geriatrics Section of the William S. Middleton Veterans Administration Hospital has developed a comprehensive geriatric functional assessment protocol. We employ this in our Hospital Based Home Care (HBHC) and Geriatric Evaluation Unit (GEU) programs.
Our assessment protocol encompasses the following components:
Personal (includes financial status/perceptions of health problems)
Social Physical (includes health mainte - nance: allergies, skin tests, vaccinations and nutritional status)
Mental (cognitive and psycho/ emotional status)
Functional (mobility, ADL, IADL)
Environmental Caregiver Stress
The overall goals we seek to achieve in employing this assessment protocol are:
1. Restoring and maintaining function at the maximum level possible. Since ours is a population of elderly residing in the community, fostering optimal independence is critical.
2. Identifying elderly at risk. We are particularly concerned about our ability to identify the potential for falls, dementia, caregiver strain, lack of support services and moderate to severe impairment of the ability to perform ADL's. This focus is derived from community-based geriatric assessment studies which have shown these factors to be the most potent predictors of institutionalization.6
3. Monitoring outcomes. This is necessary to evaluate effectiveness of care. We review our management plans on a periodic basis to ensure recurrent evaluation of treatment strategies.
We employ a number of assessment instruments to aid in data quantification. Although no scoring form alone replace clinical judgment, standardized tools in particular do provide a common intra-and interdisciplinary language. They are also invaluable adjuncts to guide clinicians in screening for needs, determining diagnosis, identifying therapy and resource utilization, and documenting change over time . Some of these tools and our experience in utilizing them are described to emphasize the merits of a comprehensive approach to geriatric functional assessment. In selecting assessment instruments, we looked for these features: Ease of administration - relatively simple to use - manageable in length
Ease of interpretation
Documented reliability and validity
Applicability to elderly living in the community
Sensitivity to change over time
Mobility and Basic Activities of Daily Living (ADL)
Among the array of functional abilities, mobility is possibly the most important in determining independence of the elderly and their needs for health care. Limitations in the ability to move impinge on the performance of all other tasks. We use the Barthel Self-Care Index to assess and monitor basic mobility and ADL's.7
The Barthel Index is summative with a total maximum score of 100. A patient scoring 100 is continent, feeds himself, dresses himself, gets up out of bed and chairs unassisted, bathes himself, walks at least a block, and can ascend and descend stairs. This does not mean that he is able to live alone; he may not be able to cook, keep house, or use a telephone, but he is able get along without personal attendant care.
We have found the separate scoring of bowel and bladder control allowed by the tool to be of particular value as the two types of incontinence have major but different impacts on an older person's ability to remain in the community.
The initial ADL assessment and scoring of the Barthel are done at the time of a patient's acceptance into our HBHC or GEU programs and repeated according to need, but at a minimum of sixmonth or one-year intervals, to allow monitoring of change over time. Scoring is based on performance either by report or observation; the latter is by far more accurate. Specific scoring criteria are provided. Data compiled on our patient population relative to scores on the Barthel Index have been described elsewhere.8
We have found this instrument to be of value in helping us monitor our patients' performance in activities of daily living as well as an aid in identifying the need for health-care supports for both elderly patients and their caregivers. This tool can be useful to nurses in both the hospital and nursing home settings in assisting their discharge planning. It can be helpful in predicting patient readiness for discharge as well as in pointing out gaps in support systems. It is equally applicable to nurses practicing in the community in determining needed support services, as well as helping lo predict potential caregiver stress.
Instrumental Activities of Daily Living (IADL)
These tasks, as conceptualized by pioneers such as Lawton, who attempted during the 1950s to organize various activities of human behavior, are somewhat more complex than the basic ADL's and are particularly necessary for satisfactory community self-maintenance. These skills focus on the individuals' ability to interact with their environment and include the following tasks of daily living:
use of transportation,
use of telephone,
home maintenance, and
use of non-working or leisure time.
In our clinical practice, we have not found one tool satisfactory to us in assessing and monitoring our high-risk, community elderly population in their ability to engage in instrumental or selfmaintenance tasks of daily living. At the present time, we are testing an instrument developed by members of our team which we call ALSAR (Assessment of Living Skills and Resources).
This tool attempts to match selfmaintenance tasks with available resources both to determine performance as well as need. We can then more effectively define and target interventions ranging from home modifications to referrals to community agencies.
Mental Status (Cognitive and Psycho/Emotional Domains)
In addition to the physical ability to perform tasks such as dressing, satisfactory functional status requires cognitive abilities such as sequencing, sorting, selection, and judgment. Cognitive performance may be seen as a marker for overall functional vulnerability. Therefore, screening cognitive status has been a component of our functional assessment from the beginning.
We used the Cognitive Capacity Screening Exam, described by Jacobs,9 as a basic indicator of mental status for a number of years. We found it to be an adequate indicator and to predictably correlate with self-care ability. However, because Folstein's Mini Mental State10 has been selected as our hospital's cognitive screen, we have recently begun using it as our cognitive assessment instrument. The advantage of the Folstein tool is that it is already used quite extensively in clinical assessments. A disadvantage is that it is somewhat biased against persons with serious visual or motor dysfunction.
All cognitive screens are constrained by patient anxiety or fatigue, and can have scoring inconsistencies caused by rater subjectivity. In and of themselves, cognitive screens are not diagnostic. However, periodic assessment of cognitive performance can be helpful in uncovering deficits and remain a valuable indicator of the need for a comprehensive mental status evaluation.
Depression has come to be considered the most common emotional disorder of advanced age and a major health problem among the elderly." Since mood significantly influences function, we include a depression screen in our functional assessment protocol, but we have encountered a lack of screening tools that have been validated on the elderly. This paucity of tools was recently described by Weiss.12
We selected the Geriatric Depression Screen described by Brink and Yesavage13 because it is easy to answer, self-rating and has been standardized in a geriatric population. It eliminates questions relating to somatic symptoms based on the premise that the high prevalence of physical illness in the elderly biases toward the diagnosis of depression. We found it necessary to modify the original tool because it did not include questions regarding suicidal ideation. We used the GDS for two years, but subsequently made the decision to switch to the Carroll Depression Screen14 which is designed to correlate closely with the Hamilton and Beck tools.
In our experience, the presence of somatic symptoms, as is addressed in the Carrofl Depression Screen, is an important element in diagnosing depression in the elderly. As has been pointed out by Gurland, depression may present as a somatic illness more commonly with the elderly than with younger persons.15 The Carroll Depression Screen is also self-rating, and has been shown to discriminate well between degrees of depression. In using a depression screen, along with a cognitive screen, we are seeking to identify trends. We are noi attempting to diagnose clinical depression with the use of this screening tool but are looking for indications of the need for further assessment.
Spouses - most of whom are elderly themselves - and children are identified as the primary caregivers of the majority of patients in our program. This is true as well in our society as a whole where it has been estimated that 80% of the home health care of the elderly in the US is conducted by family members. 16 It is our experience that on average, spouses and families provide a broad spectrum of care, but the strain of 24-hour-a-day care can be great and primary caregivers can readily succumb to what is commonly referred to as "caregiver stress."
We strongly believe in the need to assess for this phenomenon on a periodic basis to help anticipate the need for necessary supports for the caregivers and offset the possibility of them exceeding their limitations. We have been using the Carroll Depression Screen and the Caregiver Strain Index described by Robinson17 to help guide in our interviews of caregivers and identify areas of stress.
Tool Selection and Maintenance
The assessment tools selected by our geriatric health-care programs are used to assist us in gathering data, planning care, and monitoring response. Tlirough a process of on-going effort to optimize our assessment skills, a protocol of functional assessment for our elderly clients has evolved. The model we follow certainly may not be applicable to every geriatric health-care program. It is shared as an example of one interdisciplinary team's attempt to define a protocol which is inclusive of the components of a comprehensive functional assessment for an older population.
When trying to decide on appropriate instruments for clinical use, it may be tempting to select one multidimensional assessment instrument which samples information in several domains (physical, social, mental, functional) rather than using a collection of smaller instruments targeted for specific purposes. The applicability of multidimensional instruments, originally developed to screen very large populations for research purposes, to the clinical setting is currently under debate.18 We have not found one multipurpose instrument that satisfactorily meets all our needs.
To ensure that each assessment instrument is adequately gathering and screening data, tools must be periodically monitored as to their usefulness and applicability. As a result of ongoing evaluation of tools used in our Geriatrics Section over the years, we have chosen to modify the structure of some tools or abandon others in favor of ones most applicable to our needs. To enhance inter-rater reliability, we provide staff training through our orientation and on-going, in-service programs.
Boundaries between the various health-care settings are blurring. As the result of prospective payment and DRG's, hospital patients with higher levels of acuity are being discharged earlier to the community or nursing home. Increasingly, nursing homes will act as intermediaries between hospital and home and will serve a growing number of temporary as well as permanent residents. With more rapid shifts in populations among health-care settings, there is an increased demand on nurses as well as other members of the health-care team, to quickly anticipate needs at the point of entry into a healthcare program, for periodic monitoring, and at the time of exit to facilitate discharge planning.
No matter where our practice setting - acute or chronic, institutional or community - I would urge consideration of using screening tools in all practice settings to aid data gathering and facilitate communication between nurses as well as with other members of the health-care team.
Tools such as the Barthel Self-Care Index are particularly helpful, not only in anticipating performance ability and potential for caregiver stress, but also the allocation of equipment and support services. However, keep in mind that tools are just that - tools - to aid and facilitate, not substitute for clinical judgment. Used appropriately, they enhance our knowledge base and clinical expertise and assist us in achieving our ultimate goal which is quality patient care.
- 1. Mackintosh DR: Systems of Health Care. Boulder. CO. Westview Press. 1978.
- 2. Fowles DG: A Profile of older Americans1985. Program Resources Dept, American Association of Retired Persons and the Adminstration of Aging, US Depi of Health and Human Services.
- 3. Collins JG: Prevalence of Selected Chronic Conditions. Vital and Health Statistics Series 10, No 155, National Center for Health Statistics. Hyattsville, Maryland, 1986.
- 4. Shock N: The physiology of aging. Scientific American 1962; 206(!):IOO-110.
- 5. Campbell LJ, Cole KD: Geriatric Assessment Teams, in Rubenslein LZ, Campbell LJ. Kane RL (eds): Clinics in Geriatric Medicine. Philadelphia, WB Saunders, 1987. vol 33. pp 99-110.
- 6. Martin DC, Morycz RK, McDowell BJ: Community-based geriatric assessment. J Am GerialrSoc 1985; 33(9):602-606.
- 7. Mahoney F, Barthel D: Functional evaluation: The Barthel Index. MS Med J 1965; ?4(2):61-65.
- 8. Hasselkus BR: Barthel Self-Care Index and geriatric care patient. Physical and Occupational Therapy in Geriatrics 1982; 1(4): 11-22.
- 9. Jacbos JW. Bernhard MR, Delgado A, et al: Screening for organic mental syndromes in the medically ill. Ann cf Intern Med 1977; 86(l):40-46.
- 10. Folstein MF, Folstein SE, McHugh PR. et al: Mini-mental state: A practical method of grading the cognitive state of patients for the clinician. J Psvchiatr Research 1975; 12:189-198.
- 11. Finlayson RE, Martin LM: Recognition and management of depression in the elderly. Mayo Clin Proc 1982; 115-120.
- 12. Weiss IK. Nagel CL. Aronson MK: Applicability of depression scales to the old old person. J Am Geriair Soc I986; 34(3):215-2I8.
- 13. Brink TL, Yesavage JA, Lum O, et al: Screening tesis for geriatric depression. Clinical Gerontologisy 1982; (1):37-43.
- 14. Carral! BJ, Feinberg M, Smonse PE, et al: The Carroll Rating Scale for depression: Development, reliability, and validation. Brit J Psychiatry 1981; 138:194-300.
- 15. Gurland BJ: The comparative frequency of depression in various adult age groups. J Geronlol 1976; 31:283-292.
- 16. Cantor MH: Strain among caregivers. Geronlologisl 1983; 23(6):597-604.
- 17. Robinson B: Validation of a caregiver strain index. J Am Geriair Soc 1983; 38(3):344348.
- 18. Applegate WB: Use of assessment instruments in clinical settings. J Am Geriatr Soc 1987; 35(l):45-50.