Older individuals generally place high value on 'aging in place' – maintaining independence and remaining in their own home. If maintaining this function is the focus of care for the older patient, the provider should spend time assessing function longitudinally. This becomes key when stressors such as acute illness, delirium or surgery make the patient vulnerable to precipitous functional decline.
Independent Functioning Screening
An informed historian, such as a family member or caregiver, is critical in assessing the level of independent functioning, particularly among individuals with cognitive difficulties. The activities of daily living (ADLs) and instrumental ADLs are considered the 'gold standard' of functional assessment (Figure 1). The ADLs and instrumental ADLs are self-reported measures of performance on basic and more complex tasks of self-care, respectively.[2,3] Dependence in these functional measures have been linked to patient outcomes, including depression, nursing home admission and even mortality.
Documenting functional status. Healthcare providers may assess whether patients perform each activity of daily living/instrumental activity of daily living independently, with assistance, or whether they are completely dependent on others.
A: Needs assistance; D: Dependent on others; I: Independent.
Data taken from [2,3].
Independent Functioning Assessment
Criteria for frailty have been validated and are useful to fully assess patients with functional dependence on screening. While patients were previously considered to be 'frail' because they were old and declining, specific diagnostic criteria for frailty have provided an important prognostication component to the assessment of function. Frailty criteria include three of the following five characteristics: weight loss, exhaustion, low physical activity, slow walking speed and weakness. It is crucial for providers to identify frail patients since frailty increases the risk of ADL and mobility decline, falling, disability, institutionalization and 3- and 7-year mortality.
Since functional abilities represent the integration of the effects of multiple, complex disease states, it is important to perform a comprehensive assessment of various key domains. Aging is often associated with significant changes in physical and cognitive abilities, as well as emotional and social support structures. This review will detail components of the physical, cognitive, psychological and social domains. Functional status represents the final outcome of these four key domains (Figure 2), which are critical to assess in older patients, particularly those who suffer from frailty and struggle with maintaining functional independence.
Function, as manifested by activities/instrumental activities of daily living, represents the integration of physical, cognitive, psychological and social domains.
A deterioration in function leads to a frail phenotype.
This review focuses on the available first-generation assessment instruments that target specific disease states or problems, making them quite practical for a busy primary care practice. However, second-generation instruments (which cross numerous clinical domains) and third-generation assessment instruments (which extend to multiple care settings) also exist, and may be considered when comprehensively assessing older adults. InterRAI is a not-for-profit research consortium of clinicians, researchers and health administrators that developed a suite of third-generation assessment instruments. Initially these were designed for long-term residential care, but have been expanded to other groups including home care. Further details can be found at.
Aging Health. 2013;9(6):579-591. © 2013 Future Medicine Ltd.