REVIEW
A systematic review and comparison of functional assessments of community-dwelling elderly patients Katie J. Roedl, MS, FNP-C (Family Nurse Practitioner)1 , Lindsay S. Wilson, MS, FNP-C (Family Nurse Practitioner)2 , & Julie Fine, PhD, FNP-C (Associate Professor)3 1
Family Practice Clinic, Effingham, Illinois Dermatology Clinic, Mattoon, Illinois 3 Department of Advanced Practice Nursing, Indiana State University, Terre Haute, Indiana 2
Keywords Geriatric; assessment; activities of daily living (ADL); instrumental activities of daily living (IADL); physical function. Correspondence Julie Fine, PhD, FNP-C, Department of Advanced Practice Nursing, Landsbaum Center for Health Education, #2081433 N. 6 1/2 Street, Terre Haute, IN 47807. Tel: 812-237-2886; Fax: 812-237-8939; E-mail: julie.fi[email protected] Received: 4 December 2014; accepted: 25 March 2015 doi: 10.1002/2327-6924.12273
Abstract Purpose: To provide advanced practice nurses in primary care with information about self-reported functional assessments and physical performance-based functional assessments of geriatric patients living alone within the community at greatest risk of functional decline. Data sources: Databases searched include CINAHL, Healthsource: Nursing/Academic Edition, MEDLINE, PsycINFO, PsycARTICLES, Cochrane Library, and National Clearinghouse Guidelines. The review was limited to English, research, and the years 2000–2014. Key search words included geriatric, community-dwelling, functional assessment, activities and instrumental activities of daily living, Barthel Index, Katz Index, Lawton Scale, Vulnerable Elders Survey, Timed Up and Go Test, Gait Speed Test, Functional Reach Test, and primary care. Conclusions: Forty-three million individuals, age 65 and older, are currently living in the United States with numbers expected to double by 2050. Nurse practitioners will be at the forefront of assessing for functional decline and can use tools such as the Barthel Index and Gait Speed Test to improve elderly outcomes. Implications for practice: Self-reported functional questionnaires and physical functional performance tests can quickly be completed in the office to track the risk of functional decline over time. Interventions, such as physical therapy or other community resources, can be initiated when needed to reduce negative outcomes of functional decline.
Introduction When caring for the elderly population in primary care, providers must be able to assess functional, environmental, physical, psychological, social, and cultural variables efficiently. Because elderly patients do not always present with problems in a typical manner, geriatric assessment can often be time consuming. Functional capacity and quality of life are important factors in caring for elderly patients, particularly those living alone in the community (Elsawy & Higgins, 2011). Provider assessment for signs of self-neglect and functional decline in the geriatric population is imperative to prevent negative healthcare outcomes and increased costs (Hildebrand, Taylor, & Bradway, 2014). The United States census projects that by 2050 the population aged 65 and over will almost
160
double the estimated 43.1 million in 2012 (Ortman, Velkoff, & Hogan, 2014). With this increasing number of community-dwelling elderly individuals, primary providers will need to place high priority on assessing and intervening when signs of self-care neglect or reduced physical function are evident. Elder self-neglect puts individuals more at risk of negative outcomes, such as hospitalization, nursing home placement, and early mortality (Burnett et al., 2014). If providers assess functional abilities appropriately at office visits, interventions, such as physical therapy, exercise programs, community meal services, and volunteer programs, can be initiated to reduce negative outcomes of functional decline. The goal of this systematic review is to compare and establish the most efficient, reliable, and consistent functional assessment tool for primary care providers Journal of the American Association of Nurse Practitioners 28 (2016) 160–169 C 2015 American Association of Nurse Practitioners
K. Roedl et al.
to use with elderly adults during routine examinations. Cognitively impaired individuals require more extensive assessment, care, and followup beyond the scope of these research efforts. Our research focus is reviewing and evaluating self-reported and performance-based functional assessment tools that can be conducted in office settings. These tools assess the functional ability of elders to perform activities of daily living (ADLs) that are required to maintain independence within the community (Elsawy & Higgins, 2011). Functional ability can be divided into ADLs and instrumental ADLs (IADLs). ADLs include daily self-care activities such as getting out of bed, bathing, dressing, eating, and bathroom abilities. IADLs include other self-care activities needed to remain independent within the home, such as cleaning the house, making meals, being able to take medication correctly, properly managing money, and being able to use the telephone (Elsawy & Higgins, 2011).
Purpose The purpose of our research is to provide an updated evidence-based practice review of valid and reliable functional assessments that improve patient care outcomes when used in the community-dwelling geriatric population living alone. Identifying early physical and functional decline in elderly adults improves the likelihood that health promotion recommendations by providers and lifestyle changes by patients can improve healthcare outcomes (Brach, VanSwearingen, Newman, & Kriska, 2002). Our clinical question is as follows: in community-dwelling elderly adults over the age of 65 who live at home without diagnosed cognitive impairment (P), is a standardized written self-rated functional assessment questionnaire completed at yearly follow-up examinations (I) compared to physical performance testing completed in the office by providers during physical examination (C) more accurate in diagnosing physical functional decline and need for intervention (O)?
Literature search methodology An EBSCOhost search scanned databases related to health care, such as Cumulative Index to Nursing and Allied Health Literature (CINAHL), Healthsource: Nursing/Academic Edition, MEDLINE, PsycINFO, and PsycARTICLES. The initial search of articles began in August 2014 with the following key terms: “geriatric,” “elderly,” “old,” “function,” “functional,” “functional assessment,” “functional questionnaire,” “functional assessment questionnaire,” “physical function,” “primary care,” “family practice,” “activities of daily living,” “community,” and “community dwelling.” The search was limited to research
Functional assessments in elderly
articles published between 2000 to 2014 in the English language and produced 37 articles that pertained to functional assessments in older adults. The articles were reviewed and a list was created of all the functional assessment tests used within the 37 articles to determine if there was a trend of more frequently used functional tests. After identifying over 20 assessment tools on the list, importance was placed on finding geriatric-friendly functional questionnaires and tests that were efficient (taking fewer than 15 min), reliable, and applicable to primary care. A Cochrane review of articles published from 2007 to 2014 was additionally conducted using the key terms of “elderly or old or senior or geriatric,” “decline,” and “community.” The Cochrane review produced 143 articles from 8653 total available with only one article relevant and applicable to our search topic regarding assessment tools for primary care. The following assessments were excluded. The Kohlman Evaluation of Living (KELS) assessment requires administration at home as well as taking 30 min to 45 min for completion (Hildebrand et al., 2014). The Functional Status Questionnaire (FSQ) assesses psychological and social functions in addition to ADLs (Brach et al., 2002). The Groningen Frailty Indicator focuses on cognitive, social, and psychological domains instead of strictly assessing ADLs (Simone & Haas, 2013), and the Short Form-36 (SF36) tool assesses emotional status, social status, and pain status in addition to physical functional status (Richardson et al., 2008). The Physical Performance Test includes assistive devices, such as a bowl, kidney beans, a book, a shelf, a jacket, and a penny, as well as 30 min for completion of the test (Brach et al., 2002). The Sherbrooke Postal Questionnaire and the Brief Risk Identification of Geriatric Health Tool (BRIGHT) Questionnaire are postal questionnaires that would likely take time and money to send out (Kerse, Boyd, McLean, Koziol-McLain, & Robb, 2008). Bissett, Cusick, and Lannin (2013) discussed the use of the Older American Resources and Services Assessment Questionnaire as a comprehensive functional assessment for older adults, but it is recommended for the emergency room. Other functional assessment tools were eliminated if they were used in environments other than in the primary care office setting such as physical therapy, a specialty office, within the home, at an assisted living facility, or within a nursing home. Studies that included patients having caretakers, either from outside or living within the home, such as a spouse or family member, were excluded from our research. None of the self-reported functional assessment or physical functional tests researched scored men or women differently and none of the articles found showed evidence of cultural insensitivity. The most commonly used assessment tools found within the initial 37-article search then became the focus of the 161
162
Self-reported patient interview or by observation of the patient’s performance in the care setting 10 questions
Self-reported patient interview or rated from observation by healthcare professional Six questions
Katz Index of Independence in Activities of Daily Living (Katz, Downs, Cash, & Grotz, 1970)b
Administration/ number of questions
Barthel Index of Activities of Daily Living (Barthel & Mahoney, 1965)a Adopted modification by Collin and Wade (1988) is more widely used because of scoring range of 0–20
Name/ author/ year
Table 1 Functional assessment questionnaires
− Bowels − Bladder − Grooming − Toilet use − Feeding − Transfer − Mobility − Dressing − Stairs − Bathing Assesses functional ability of elderly at that particular timeb − Bathing − Dressing − Toileting − Transferring − Fecal and urinary incontinence − Feeding
Activities assessed
No particular time found
2–3 min
Time
One point received for being independent, zero points for dependent Questionnaire defines independence versus dependence for each activitya
Each activity scored from completely independent to totally dependent or unable to complete the task
Scoring
Continued
Score of 6 means the patient is highly independent, score of 0 means the patient is very dependent
Adopted modification scores range from 0 (totally dependent) to 20 (completely independent)
Initial Barthel Index scores range from 0 to 100
Scoring interpretation
Functional assessments in elderly K. Roedl et al.
Can be administered by nonmedical personnel in person or over the phone of self-reported activities 13 questions
Vulnerable Elders Survey-13 (Saliba et al., 2001) d
− Telephone − Travel − Shopping − Meal preparation − Housework − Handyman work − Laundry − Medication − Administration (three questions) − Managing finance − Age − Self-rated health − Limitations in physical capability (stooping, lifting, reaching, grasping, walking, heavy housework) − Limitations in functional capability (shopping, managing money, walking, light housework, bathing)
Activities assessed
b
Barthel information from Hartigan (2007) and Sainsbury et al. (2005). Katz information from Suijker et al. (2014), Yang et al. (2014), and Dong et al. (2009). c Lawton information from Iwarsson (2005), Graf (2008), and Fairhall et al. (2013). d Vulnerable Elders Survey from Min et al. (2009), McGee et al. (2008), and Saliba et al. (2001)
a
Administered by written questionnaire or by interview through self-reported activities 11 questions
Administration/ number of questions
Lawton Instrumental Activities of Daily Living Scale (Lawton & Brody, 1969)c
Name/ author/ year
Table 1 (Continued)
4 min
10–15 min
Time
Patients automatically receive one point if aged 75–84, receive three points if 85 years old or more − If the patient answers yes to a question with an asterisk, the patient is given points according to the scale directions
Three points for independent without help of others, two points received for needing some help of others, one point received for completely unable to do the activity on own
Scoring
High scores predictive of poor health Score of 0–1 mean the patient is more likely to be in excellent health
Scores are interpreted based on individual patient with declining scores over time meaning deterioration of function -0 (lower function) to 8 (high function)
Scoring interpretation
K. Roedl et al. Functional assessments in elderly
163
Functional assessments in elderly
K. Roedl et al.
Table 2 Physical functional assessments
Name/author/year Functional Reach Test (Duncan et al., 1990)a
Gait Speed Test (Wells and Wade, 2013)b
Timed Up and Go Test (Podsiadlo & Richardson, 1991)c
Administration Measures maximal distance reached past length of arm. Subject stands with feet comfortable distance apart, forward flex dominant arm to 90°, reach forward as far as possible. Measured by yardstick affixed to wall. Location of the third metacarpal recorded. Three trials were performed with the average of last two noted. 2 m course is measured and marked. Patient instructed to walk at usual pace. When first line reached, clock starts. Clock stopped at second line. Subjects stands up from sitting position in a chair (seat height 44–47 cm), walks 3 m at comfortable pace, turns, walks back to chair and sits down.
Time
Scoring
Scoring interpretation
5 min
Inches reached
A systematic review and comparison of functional assessments of community-dwelling elderly patients Katie J. Roedl, MS, FNP-C (Family Nurse Practitioner)1 , Lindsay S. Wilson, MS, FNP-C (Family Nurse Practitioner)2 , & Julie Fine, PhD, FNP-C (Associate Professor)3 1
Family Practice Clinic, Effingham, Illinois Dermatology Clinic, Mattoon, Illinois 3 Department of Advanced Practice Nursing, Indiana State University, Terre Haute, Indiana 2
Keywords Geriatric; assessment; activities of daily living (ADL); instrumental activities of daily living (IADL); physical function. Correspondence Julie Fine, PhD, FNP-C, Department of Advanced Practice Nursing, Landsbaum Center for Health Education, #2081433 N. 6 1/2 Street, Terre Haute, IN 47807. Tel: 812-237-2886; Fax: 812-237-8939; E-mail: julie.fi[email protected] Received: 4 December 2014; accepted: 25 March 2015 doi: 10.1002/2327-6924.12273
Abstract Purpose: To provide advanced practice nurses in primary care with information about self-reported functional assessments and physical performance-based functional assessments of geriatric patients living alone within the community at greatest risk of functional decline. Data sources: Databases searched include CINAHL, Healthsource: Nursing/Academic Edition, MEDLINE, PsycINFO, PsycARTICLES, Cochrane Library, and National Clearinghouse Guidelines. The review was limited to English, research, and the years 2000–2014. Key search words included geriatric, community-dwelling, functional assessment, activities and instrumental activities of daily living, Barthel Index, Katz Index, Lawton Scale, Vulnerable Elders Survey, Timed Up and Go Test, Gait Speed Test, Functional Reach Test, and primary care. Conclusions: Forty-three million individuals, age 65 and older, are currently living in the United States with numbers expected to double by 2050. Nurse practitioners will be at the forefront of assessing for functional decline and can use tools such as the Barthel Index and Gait Speed Test to improve elderly outcomes. Implications for practice: Self-reported functional questionnaires and physical functional performance tests can quickly be completed in the office to track the risk of functional decline over time. Interventions, such as physical therapy or other community resources, can be initiated when needed to reduce negative outcomes of functional decline.
Introduction When caring for the elderly population in primary care, providers must be able to assess functional, environmental, physical, psychological, social, and cultural variables efficiently. Because elderly patients do not always present with problems in a typical manner, geriatric assessment can often be time consuming. Functional capacity and quality of life are important factors in caring for elderly patients, particularly those living alone in the community (Elsawy & Higgins, 2011). Provider assessment for signs of self-neglect and functional decline in the geriatric population is imperative to prevent negative healthcare outcomes and increased costs (Hildebrand, Taylor, & Bradway, 2014). The United States census projects that by 2050 the population aged 65 and over will almost
160
double the estimated 43.1 million in 2012 (Ortman, Velkoff, & Hogan, 2014). With this increasing number of community-dwelling elderly individuals, primary providers will need to place high priority on assessing and intervening when signs of self-care neglect or reduced physical function are evident. Elder self-neglect puts individuals more at risk of negative outcomes, such as hospitalization, nursing home placement, and early mortality (Burnett et al., 2014). If providers assess functional abilities appropriately at office visits, interventions, such as physical therapy, exercise programs, community meal services, and volunteer programs, can be initiated to reduce negative outcomes of functional decline. The goal of this systematic review is to compare and establish the most efficient, reliable, and consistent functional assessment tool for primary care providers Journal of the American Association of Nurse Practitioners 28 (2016) 160–169 C 2015 American Association of Nurse Practitioners
K. Roedl et al.
to use with elderly adults during routine examinations. Cognitively impaired individuals require more extensive assessment, care, and followup beyond the scope of these research efforts. Our research focus is reviewing and evaluating self-reported and performance-based functional assessment tools that can be conducted in office settings. These tools assess the functional ability of elders to perform activities of daily living (ADLs) that are required to maintain independence within the community (Elsawy & Higgins, 2011). Functional ability can be divided into ADLs and instrumental ADLs (IADLs). ADLs include daily self-care activities such as getting out of bed, bathing, dressing, eating, and bathroom abilities. IADLs include other self-care activities needed to remain independent within the home, such as cleaning the house, making meals, being able to take medication correctly, properly managing money, and being able to use the telephone (Elsawy & Higgins, 2011).
Purpose The purpose of our research is to provide an updated evidence-based practice review of valid and reliable functional assessments that improve patient care outcomes when used in the community-dwelling geriatric population living alone. Identifying early physical and functional decline in elderly adults improves the likelihood that health promotion recommendations by providers and lifestyle changes by patients can improve healthcare outcomes (Brach, VanSwearingen, Newman, & Kriska, 2002). Our clinical question is as follows: in community-dwelling elderly adults over the age of 65 who live at home without diagnosed cognitive impairment (P), is a standardized written self-rated functional assessment questionnaire completed at yearly follow-up examinations (I) compared to physical performance testing completed in the office by providers during physical examination (C) more accurate in diagnosing physical functional decline and need for intervention (O)?
Literature search methodology An EBSCOhost search scanned databases related to health care, such as Cumulative Index to Nursing and Allied Health Literature (CINAHL), Healthsource: Nursing/Academic Edition, MEDLINE, PsycINFO, and PsycARTICLES. The initial search of articles began in August 2014 with the following key terms: “geriatric,” “elderly,” “old,” “function,” “functional,” “functional assessment,” “functional questionnaire,” “functional assessment questionnaire,” “physical function,” “primary care,” “family practice,” “activities of daily living,” “community,” and “community dwelling.” The search was limited to research
Functional assessments in elderly
articles published between 2000 to 2014 in the English language and produced 37 articles that pertained to functional assessments in older adults. The articles were reviewed and a list was created of all the functional assessment tests used within the 37 articles to determine if there was a trend of more frequently used functional tests. After identifying over 20 assessment tools on the list, importance was placed on finding geriatric-friendly functional questionnaires and tests that were efficient (taking fewer than 15 min), reliable, and applicable to primary care. A Cochrane review of articles published from 2007 to 2014 was additionally conducted using the key terms of “elderly or old or senior or geriatric,” “decline,” and “community.” The Cochrane review produced 143 articles from 8653 total available with only one article relevant and applicable to our search topic regarding assessment tools for primary care. The following assessments were excluded. The Kohlman Evaluation of Living (KELS) assessment requires administration at home as well as taking 30 min to 45 min for completion (Hildebrand et al., 2014). The Functional Status Questionnaire (FSQ) assesses psychological and social functions in addition to ADLs (Brach et al., 2002). The Groningen Frailty Indicator focuses on cognitive, social, and psychological domains instead of strictly assessing ADLs (Simone & Haas, 2013), and the Short Form-36 (SF36) tool assesses emotional status, social status, and pain status in addition to physical functional status (Richardson et al., 2008). The Physical Performance Test includes assistive devices, such as a bowl, kidney beans, a book, a shelf, a jacket, and a penny, as well as 30 min for completion of the test (Brach et al., 2002). The Sherbrooke Postal Questionnaire and the Brief Risk Identification of Geriatric Health Tool (BRIGHT) Questionnaire are postal questionnaires that would likely take time and money to send out (Kerse, Boyd, McLean, Koziol-McLain, & Robb, 2008). Bissett, Cusick, and Lannin (2013) discussed the use of the Older American Resources and Services Assessment Questionnaire as a comprehensive functional assessment for older adults, but it is recommended for the emergency room. Other functional assessment tools were eliminated if they were used in environments other than in the primary care office setting such as physical therapy, a specialty office, within the home, at an assisted living facility, or within a nursing home. Studies that included patients having caretakers, either from outside or living within the home, such as a spouse or family member, were excluded from our research. None of the self-reported functional assessment or physical functional tests researched scored men or women differently and none of the articles found showed evidence of cultural insensitivity. The most commonly used assessment tools found within the initial 37-article search then became the focus of the 161
162
Self-reported patient interview or by observation of the patient’s performance in the care setting 10 questions
Self-reported patient interview or rated from observation by healthcare professional Six questions
Katz Index of Independence in Activities of Daily Living (Katz, Downs, Cash, & Grotz, 1970)b
Administration/ number of questions
Barthel Index of Activities of Daily Living (Barthel & Mahoney, 1965)a Adopted modification by Collin and Wade (1988) is more widely used because of scoring range of 0–20
Name/ author/ year
Table 1 Functional assessment questionnaires
− Bowels − Bladder − Grooming − Toilet use − Feeding − Transfer − Mobility − Dressing − Stairs − Bathing Assesses functional ability of elderly at that particular timeb − Bathing − Dressing − Toileting − Transferring − Fecal and urinary incontinence − Feeding
Activities assessed
No particular time found
2–3 min
Time
One point received for being independent, zero points for dependent Questionnaire defines independence versus dependence for each activitya
Each activity scored from completely independent to totally dependent or unable to complete the task
Scoring
Continued
Score of 6 means the patient is highly independent, score of 0 means the patient is very dependent
Adopted modification scores range from 0 (totally dependent) to 20 (completely independent)
Initial Barthel Index scores range from 0 to 100
Scoring interpretation
Functional assessments in elderly K. Roedl et al.
Can be administered by nonmedical personnel in person or over the phone of self-reported activities 13 questions
Vulnerable Elders Survey-13 (Saliba et al., 2001) d
− Telephone − Travel − Shopping − Meal preparation − Housework − Handyman work − Laundry − Medication − Administration (three questions) − Managing finance − Age − Self-rated health − Limitations in physical capability (stooping, lifting, reaching, grasping, walking, heavy housework) − Limitations in functional capability (shopping, managing money, walking, light housework, bathing)
Activities assessed
b
Barthel information from Hartigan (2007) and Sainsbury et al. (2005). Katz information from Suijker et al. (2014), Yang et al. (2014), and Dong et al. (2009). c Lawton information from Iwarsson (2005), Graf (2008), and Fairhall et al. (2013). d Vulnerable Elders Survey from Min et al. (2009), McGee et al. (2008), and Saliba et al. (2001)
a
Administered by written questionnaire or by interview through self-reported activities 11 questions
Administration/ number of questions
Lawton Instrumental Activities of Daily Living Scale (Lawton & Brody, 1969)c
Name/ author/ year
Table 1 (Continued)
4 min
10–15 min
Time
Patients automatically receive one point if aged 75–84, receive three points if 85 years old or more − If the patient answers yes to a question with an asterisk, the patient is given points according to the scale directions
Three points for independent without help of others, two points received for needing some help of others, one point received for completely unable to do the activity on own
Scoring
High scores predictive of poor health Score of 0–1 mean the patient is more likely to be in excellent health
Scores are interpreted based on individual patient with declining scores over time meaning deterioration of function -0 (lower function) to 8 (high function)
Scoring interpretation
K. Roedl et al. Functional assessments in elderly
163
Functional assessments in elderly
K. Roedl et al.
Table 2 Physical functional assessments
Name/author/year Functional Reach Test (Duncan et al., 1990)a
Gait Speed Test (Wells and Wade, 2013)b
Timed Up and Go Test (Podsiadlo & Richardson, 1991)c
Administration Measures maximal distance reached past length of arm. Subject stands with feet comfortable distance apart, forward flex dominant arm to 90°, reach forward as far as possible. Measured by yardstick affixed to wall. Location of the third metacarpal recorded. Three trials were performed with the average of last two noted. 2 m course is measured and marked. Patient instructed to walk at usual pace. When first line reached, clock starts. Clock stopped at second line. Subjects stands up from sitting position in a chair (seat height 44–47 cm), walks 3 m at comfortable pace, turns, walks back to chair and sits down.
Time
Scoring
Scoring interpretation
5 min
Inches reached
