778

CLINICAL PRACTICE

Framework for medical assessment of functional

performance

"An important part of training is to help students to see old people in functional terms. It is vital to establish what an old person is capable of doing, rather than merely to attach a diagnostic label to his disease."-R. E. Irvine,] R Coll Physicians Land 1984.’

Medical history-taking and examination does not usually include an assessment by the doctor of the patient’s ability to perform everyday tasks. Such functional performance assessment (FPA) is necessary for evaluation and management of any patient whose functional ability is impaired or threatened: it should be mandatory for all elderly patients since they are especially susceptible to a deterioration of everyday function. Furthermore, because of the predicted increase in the number of very old people in the UK, FPA is an essential skill for all graduating doctors. Lately, a World Health Organisation report emphasised the importance of teaching providers of primary care how to assess, record, and identify changes in a patient’s functional abilities.2 We here propose a framework for the easy incorporation of an FPA into the conventional medical history-taking and examination.

FPA is not done

Although FPA is simply

a formally recorded extension of the conventional history-taking and examination, it is usually absent from medical records. The check-list offered by the Royal College of Physicians of London for an audit of casenotes does not include any FPA items.3 Additionally, FPA is often not recorded in clinical practice even for patients who have a high risk of functional disabilities. We assessed the casenotes of 104 inpatients in a district general hospital who had been consecutively referred to geriatric medicine from other specialties. Documentation of three basic functions was usually incomplete: continence, transfers (ie, movements between any two of bed, chair, wheelchair, commode/toilet, and a standing position), and walking ability were not recorded in 95%, 94%, and 61% of casenotes, respectively. Even in an academic department of geriatric medicine, an audit disclosed that 46% of notes did not mention continence and 78% did not record examination of the patient’s mobility: this led to the introduction of a standardised form for recording the medical history and examination which reflected the importance of functional history, assessment of mobility, and recording of multidisciplinary case conferences.4 We

a similar change in clinical practice must be encouraged within all specialties that deal with elderly patients. Commonly used British textbooks on clinical skills5-11 (including student textbooks on geriatric medicinel2-14) give no guidance about FPA. Moreover, while teaching the geriatric medicine course at this medical school, we have

believe that

found that the concept of FPA is new students and has to be formally taught.

even to

final year

Why do it? Firstly, FPA helps to identify, diagnose, and objectively quantify functional disabilities. For example, any change in the patient’s usual level of functional performance prompts a search for underlying health disorders. At presentation, the clinician can use the FPA to quantify the rate of decline and so obtain diagnostically valuable information. The premorbid functional performance can be used as a standard against which subsequent progress can be evaluated and as a guide to realistic rehabilitation goals. Thus, medical and other interventions can be selected and targeted according to the initial FPA, and their efficacy can be monitored by repeated FPA. Secondly, the FPA points to the need for specific support services and allows fine tuning of their provision. When patients are unable to remain in their own homes, the FPA can be used to help them to choose accommodation. Finally, such assessment may give the doctor some sense of a person’s quality of life. FPA is central to good clinical

practice. How is it done? Checklist The doctor should inquire about most functions and should personally assess some of them (varying the emphasis with the importance of the function and the clinical situation) (table). Expert, in-depth assessment of selected functions can then be obtained from other members of the

ADDRESS Academic Department of Geriatric Medicine, Royal Free Hospital School of Medicine, London NW3 2QG, UK (E J Dickinson, MRCP, Prof A. Young, FRCP) Correspondence to Prof A Young

779

CHECKLIST FOR FPA

I

I

I

Corroboration. Histories must also be obtained from other people-eg, from a relative, neighbour, home help, or district nurse. It is vital to liase with all those involved since important differences in actual performance (or in the perception of performance) refine the overall assessment and may also highlight discrepancies, some of which will be especially relevant to planning services. What a patient can do occasionally may differ from what the patient does regularly. What a patient can or will do for a physiotherapist, may be different from what happens with a member of the family. Corroborative data are devalued if their sources are not identified.

included FT physiotherapist; ST =speech therapist

OT = occupational

therapist,

-=not

CA=continence

usually advisor,

team. The doctor must decide which should be requested and must have a sound working knowledge of FPA to integrate the fmdings.

multidisciplinary assessments

Method Quantification. A common pitfall is to record that the patient receives "help" without stating how much and what kind of help. Reductions in the amount or type of help required may be sensitive indicators of therapeutic effect and may also have important implications for the provision of services. The amount of help can be scored with a simple scale which can be applied to any function—eg, independent; supervision required; prompting required; physical help of one person needed; physical help of two people needed. Validated (but more complex) research methods for FPA such this concept.

as

the Barthel indexl5

Information about a patient’s social valuable in its own right but is also an is support system indicator of habitual functional performance. The exact frequency of services, and family and voluntary assistance should be recorded. It is crucial to know whether "daily" mean 5 or 7 days a week. When the system of social support is complex a timetable of a typical week may be helpful.

Support systems.

I

+++=essential; + + = important; evidence;

are

based

on

Observation. There is ample opportunity for FPA in the conventional physical examination (eg, walking, sitting down, standing up, undressing, getting on and off the bed or couch). For an adequate FPA, the patient must not be helped, so extra time should be allowed. There may be circumstantial evidence of incontinence and difficulty in washing and bathing. All observations must be recorded.

Safety. The FPA should comment on safety. For example, does the patient fall or seem to be at risk of falling while walking? Aids. Many people rely on aids to maintain their independence--eg, walking sticks, walking frames, toilet raises, and kitchen adaptations. The clinician should be aware of which aids are being used by the patient, although judgments about their suitability and efficacy are usually the province of the therapist.

FPA form. Form is completed with following key: I = independent; S = supervision needed; P = prompting needed, +11 = help of1 person needed; + 2 = help of 2 people needed.

We are currently using a standardised form to that the most common FPA items are recorded (figure). Each item is scored as previously described; whether aids are needed (walking frame, stick, toilet frame) is also indicated. The forms can be stamped or attached to the clinical notes for easy reference and comparison of serial

Recording. ensure

assessments.

Conclusions The need for FPA is growing rapidly. Unfortunately, such assessment is rarely taught and rarely recorded; we suspect it is not widely practised. FPA should be included in the undergraduate curriculum to equip all future doctors with skills appropriate to the increasing number of very old

patients.

REFERENCES 1. Irvine RE. Geriatric medicine and Physicians Lond 1984; 18: 21-24.

general

internal

medicine. J R Coll

2. WHO Technical Report Series No 779. Health of the World Health Organisation, 1989.

elderly.

Geneva:

Report of the Royal College of Physicians. Medical Audit. A first report. What, why and how? London: The Royal College of Physicians of London, 1989. 4. Dunn RB, Day RWB, Hall MRP. Medical audit in geriatric medicine. Age Ageing 1987; 16: 225-28. 5. Ogilvie C, Evans CC, eds. Chamberlain’s symptoms and signs in clinical medicine. 11th ed. Bristol: John Wright, 1987. 6. Bouchier IAD, Morris JS. Clinical skills. 2nd ed. London: WB Saunders, 3.

1982. 7. Turner R, Blackwood R. Lecture notes on history taking and examination. Oxford: Blackwell, 1983. 8. Pappworth MH. A primer of medicine, 5th ed. London: Butterworth, 1984. 9. Swash M, Mason S, eds. Hutchinson’s clinical methods. 18th ed. London: Baillière Tindall, 1984. 10. MacLeod J, French EB, Munro JF, eds. Introduction to clinical examination. 4th ed. Edinburgh: Churchill Livingstone, 1985. 11. MacLeod J, Munro J, eds. Clinical examination. 7th ed. Edinburgh: Churchill Livingstone, 1986. 12. Coni N, Davison W, Webster S. Lecture notes on geriatrics. 3rd ed. Oxford: Blackwell, 1988. 13. Adams GF. Essentials of geriatric medicine. 2nd ed. Oxford: Oxford University Press, 1981. 14. Brocklehurst JC, Allen SC. Geriatric medicine for students. 3rd ed. Edinburgh: Churchill Livingstone, 1987. 15. Mahoney FI, Barthel DW. Functional evaluation: the Barthel Index. Maryland State Med J 1965; 14: 61-65.

Framework for medical assessment of functional performance.

778 CLINICAL PRACTICE Framework for medical assessment of functional performance "An important part of training is to help students to see old peo...
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