Journal of Gerontological Nursing

Guidelines for developing instruments to ENHANCE CASE-FINDING AMONG OLDER ADULTS

Gregory A Bechtel, RN, MPH, PhD; Cathy Shriver, RN, MHS, MSN


Abstract: This article discusses the necessity of developing reliable and valid instruments to enhance case finding efforts among older adults who may be at risk for alterations in their optimal level of functioning and health. Case studies are provided to demonstrate to nurses how misconceptions can occur when assessment tools are neither reliable nor valid in extracting critical information. While the use of reliable and valid case-finding instruments can detect high-risk circumstances and reduce the likelihood of premature death and disability, erroneous information can have adverse economic and health consequences for the individual, family, and community.


Abstract: This article discusses the necessity of developing reliable and valid instruments to enhance case finding efforts among older adults who may be at risk for alterations in their optimal level of functioning and health. Case studies are provided to demonstrate to nurses how misconceptions can occur when assessment tools are neither reliable nor valid in extracting critical information. While the use of reliable and valid case-finding instruments can detect high-risk circumstances and reduce the likelihood of premature death and disability, erroneous information can have adverse economic and health consequences for the individual, family, and community.

Older adults comprise the most rapidly growing segment of the American population. Based on current health care expenditures, older adults will assume a greater percentage of costs in the future (Arcangelo, 1994). Inappropriate allocation of resources to meet anticipated tertiary care needs of this group will have adverse affects by severely diminishing the limited resources available. Through early detection, variations from optimal individual and family health patterns can be identified and corrected. Working to eliminate high-risk behaviors and environmental circumstances, nurses have the opportunity to optimize the health of elderly clients and their caregivers by appropriately identifying variables which diminish health functioning (Sayles- Cross, 1993). The purpose of this article is to assist nurses in the development of case-finding instruments which effectively and accurately identify situations which may adversely affect older individuals and their families.

While screening and case-finding tools may be similar in nature, the former is most beneficial when targeting the needs of those who are not actively managed by a health care professional. Thus, case-finding instruments are more deliberate and intense. Should a health, environmental, or socioeconomic problem not be identified during case-finding efforts, the subsequent lack of follow-up can lead to adverse consequences as follow-up tends to be rare. This is especially true among poor elderly and those residing in rural areas.

Objectives of an effective casefinding program for the elderly should include: 1) an identification of potential areas deficient in personal and family self-care patterns, 2) an increase in the effectiveness and use of home health and community services, and 3) a decrease in morbidity and mortality by providing clients with health-enhancing knowledge and vehicles to maintain positive health habits. Decisions to act which are derived from incorrect interpretation of data from these objectives can result in inappropriate interventions, misallocation of resources, and conflicts between health providers and family members.

The development of reliable and valid instruments to identify or predict patterns of unhealthy lifestyles or unsafe environmental conditions is an essential step in optimizing a community's health. If case-finding instruments are used incorrectly, measure extraneous variables, or are not consistent over time, morbidity and mortality rates could increase. For example, clients who are provided information on consuming a nutritional diet, cautioned against hazardous environmental activities, and counseled on appropriate times to take medication, may be less likely to present at the emergency room.

Much like a diagnosis of coronary heart disease is made in conjunction with findings from multiple diagnostic tests, case-finding instrument results should be integrated into a holistic assessment of the individual situation. To assist in the working management of developing a screening instrument, Bechtel & Wood (1996) developed guidelines which are adaptable to case-finding among the elderly. While adhering to these principles will not guarantee success, negating them will almost certainly produce results which are neither reliable nor valid.

GUIDELINE 1. Case-finding tools must never be used as either the sole diagnostic criteria or the standard in the decision-making process, regardless of reliability and validity.

Case study: An environmental and social assessment of Stuart and Ruth revealed sub-standard living conditions and multiple environmental hazards in their home. This elderly couple was living with minimal support from either their family or community although they stated they were personally satisfied with their surroundings. Using a casefinding instrument which allegedly discerned sanitation, safety, and health functioning concepts, it was determined that the couple was living below minimal public health standards. Action was subsequently taken to improve the home environment and, potentially, the couple's quality of life.

Unfortunately, the interventions were based on the screening tool which did not address the couple's coping or adaptive ability. In other words, while the assessment tool may have correctly revealed significant risk factors (e.g., unable to use toilet, old food in the refrigerator, unlocked doors, and broken floors) it did not measure patterns of the couple's adaptation to their environment (e.g., able to use bedpan, old food was not consumed, protected neighborhood, and devices to sense breaks in the floor). Had such adaptations been recognized, the couple may not have been removed from their home and efforts to enhance their adaptability may have been obtained. While the instrument had some validity in identifying actual and potential health problems, it was not able to identify the intrinsic adaptability which rendered the instrument suspect to the couple's ability to function appropriately.

Although clients may appear to be at risk, they may also have adapted appropriately to the situation. The ability to function independently should be the most useful overall indicator of the need for interventions. Conditions may be hazardous for some individuals but not for others. The capacity to determine selfcompliance is not necessarily reduced by either age or physical health patterns. Acting upon the interconnectedness of biological, social, psychological, and spiritual needs will enhance the optimal functioning of the older adult (CutilloSchmitter, 1996).

GUIDELINE 2. The situation must be addressed in its entirety.

Case study: Mr. & Ms. Williams had multiple vials of medications located throughout their home. A home health nurse attempted to persuade the family to discard the medications which were no longer used based on a polypharmacy screening tool. This instrument ascertained the number/type of medications, expiration date, compatibility with other medications, and status with current medical diagnosis. The couple resisted because of the expense in purchasing new medications. The couple knew the actions of each medication, its side-effect, and the appropriate time to take each pill. When a need for pharmacological intervention arose, they took the appropriate medication following consultation with their health care provider. Adhering to the guidelines of an unreliable case-finding instrument, select medications would have been discarded which could have adversely affected the Williams financially in addition to infringing on their ability to provide self-directed care.

What are the factors that precipitate high-risk situations for the elderly? Underlying cause(s) of the circumstance or risk-factor, not the symptom itself, should always be addressed. Misunderstanding of cultural Health practices can lead to inappropriate use of resources and further isolation (Evans & Cunningham, 1996). Allocating resources based solely on the client's inability to function according to standardized norms may not be in the best interest of the client, family, or society. Unfortunately, case-finding instruments have historically been culturally insensitive and inappropriate to ethnic values.

GUIDELINE 3. Cultural and ethnic values must always be addressed in the context of family and environment.

Case study: Mr. Gonzalez, an 88year-old man diagnosed with "a nervous condition," lived alone in an old trailer outside the city limits. He had been admitted to the community hospital three times in the past year due to falls outside his home late at night. Social services used a case-finding instrument to determine the environmental conditions of the home. Results from the instrument suggested Mr. Gonzalez was at a high risk for falls due to mental lapses in judgment, and a decision was made to place him in a longterm care facility. Mr. Gonzalez vehemently opposed this forced relocation, creating emotional and financial chaos with the family. Had someone considered that Mr. Gonzalez was the senior member of his extended family and insisted on "watching over his homeland," the conflict may have been avoided and other alternatives explored.

Has the client adapted to the situation in ways that may not be obvious to the provider? Do other risk factors exist which are not accounted for in the screening instrument? Perceived stress of the client, rather than identification of concepts found on a case-finding instrument, may be far more useful in determining the client's level of functioning (Backer, 1995). By discussing the intent of the screening instrument with the client, the health care provider will be more likely to gain consent for interventions through mutual decision-making. Care must be undertaken to insure that variables reflected in the instrument represent the true intent of the nursing staff.

GUIDELINE 4. Discuss the findings of the tool with the client.

Case study: Mae Guerrero was very upset when she was informed that because of her inability to walk, her oldest daughter was going to force her to move and live with other family members. Maria, her oldest daughter, had completed a survey from the local senior citizens center which attempted to measure independent functioning, economic resources, and social support. The results of this instrument suggested that Mae was incapable of living independently and the nurse, siding with Maria, insisted that Mae move in with her daughter. Had Maria or the nurse discussed the results of the instrument with Mae, they could have identified common concerns and acted appropriately. But because Maria and the nurse viewed the survey as an "absolute truth," conflict erupted between mother, daughter, and health provider.

A summative evaluation may suggest that a particular concept is a health concern to either the client or nurse, but making a diagnosis from summative scores is analogous to averaging scores from a repon card. Each specific factor or problem area in the instrument must be addressed separately and in the context of the client's adaptability to uniquely adapt to a given circumstance. Concurrently, summative qualities of a screening instrument may suggest no singular problem area, although many minor alterations may represent a significant health issue. The linkage of each component to the whole is synonymous with "circles of care," the necessity to integrate multiple strategies in providing and evaluating nursing care (Magilvy, Congdon, & Martinez, 1994).

GUIDELINE 5. Each item within the case-finding instrument must be addressed.

Case study: Mr. Peterson lived with his elderly mother in a rural community, 10 miles from the nearest health care facility. The local College of Nursing was providing home visits to assess their environmental and social conditions. Using a screening instrument found in their community health nursing textbook, the students were unable to identify any adverse health conditions based on the summative score evaluations. However, when the nursing instructor made a home visit, the first thing noticed was an electrical cord transposed over Mr. Peterson's oxygen tubing, both of which were atop a fan resting on a wooden floor. The students claimed knowledge of this hazard in the screening tool, but because only one block was marked and three were needed to establish a priority concept, no environmental diagnosis, and subsequently no interventions, were made in this area.


Screening instruments are not intended to be diagnostic but a preliminary tool for identifying presumptive cases of unrecognized conditions or risk-factors. These tools are simply a guide that lead the health provider to investigate specific problems, both real and potential, within defined parameters. If the condition examined is perceived or actualized, further evaluation or diagnostic studies should be undertaken prior to any intervention.

Data collected by these instruments must be culturally appropriate, relevant, unbiased, and understandable to all those involved in the fact-finding process, ideally, the instrument should be used as part of a multidisciplinary approach to problem identification, intervention, and evaluation and must include the client's ability to cope and adapt to the situation.

Among older adults, social isolation, neglect, and environmental hazards are primary concerns which can adversely affect individual health functioning and financial resources. This group is most likely to benefit from case-finding tools as they are less likely to interact with health care professionals (Haworth, 1993). Determining appropriate strategies for facilitating independence in elderly clients can be initiated by using reliable and valid case-finding instruments. Appropriately identifying barriers to positive health practices and recognizing unique individual and family adaptive coping mechanisms can lead to an enhanced quality of life. Thus, optimal levels of functioning occur with minimal use of resources when solutions are developed to resolve potential "disasters waiting to happen." The ability of a nurse to use case-finding tools in a holistic assessment can be the first step in maintaining independence for clients.

Note: Names in this article have been changed for anonymity purposes.


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