Functional Assessment
Janice E. Knoefel, MD, MPH
Professor of Medicine & Neurology
University of New Mexico
Retired - Geriatrics/Extended Care
New Mexico Veterans Affairs
Healthcare System
Albuquerque, NM
Disclosure Statement:
Dr. Knoefel has nothing to
disclose
Learning Objectives:
1. Understand the principles
of Comprehensive Geriatric
Assessment
2. Develop strategies to adapt
CGA for individual clinical
practices
Functional Assessment
• The model, borrowed from traditional
rehabilitation by the geriatric
community, has developed into the
principle of comprehensive geriatric
assessment (CGA)
• Rehabilitation wishes to identify and
treat patients who benefit from
rehabilitation; the clinician wishes to
identify elderly at risk for functional
decline and treat appropriately.
Functional Assessment
• Developed in the late 1940s in the
United Kingdom as a way to identify
seniors in need of services
• Adapted in the 1970s by US as a way
to screen frail seniors who appeared to
require nursing home care because of
physical or cognitive decline.
• Many undiagnosed illnesses, 15%
mortality at 6 months
• Initially an inpatient model, now
outpatient care
Traditional Rehabilitation
• Disease -> impairment -> disability ->
handicap
• Example: Degenerative joint disease (DJD) ->
pain -> gait disturbance -> unable to access
2nd-floor apartment
• Interventions: Disease-specific (nonsteroidal
anti-inflammatory drugs [NSAIDs], total knee
replacement [TKR]) -> impairment
management (pain control) -> disability
compensation (cane) ->environmental
modification (move to 1st-floor apartment)
Functional Assessment
• Clinicians often back into the issue:
• Patient is failing, family is complaining,
something is changing.
• Why is patient not the same as last
year, 2 years ago?
• ?Undiagnosed new illness
• ?Chronic condition worsening
• ?Deconditioning,?Drug effects,
?Dementia
Functional Assessment: Goals
• Identify limitations of patient ability to
function in daily life.
• Develop strategies/interventions to
improve function.
• In other words: What cannot be done,
why cannot it, what can be done to fix
the limitation (patient-based
intervention) or change task
(environmental remediation)
Functional Assessment
• Dimensions of assessment:
–
–
–
–
–
–
–
Medical, including drug use
Functional
Physical
Cognitive
Sensory
Psychologic
Social
Functional Assessment
• Core team members:
– Physician/healthcare professional
– Nurse/nurse practitioner/home care
nurse
– Social worker
• Makeup of core team members
dependent on setting, specific
goals of assessment team
Functional Assessment
• Ad hoc team members:
–
–
–
–
–
–
–
Dietitian
Pharmacist
Rehabilitation therapist(s)
Psychologist
Dentist
Spiritual counselor
Audiologist
Functional Assessment
• Consultative versus primary care
practice
• Settings:
–
–
–
–
Outpatient clinic
Inpatient unit
Home and community
Long-term care facility
Functional Assessment
• Components of assessment:
– Targeting patients likely to benefit
– Performing the evaluation, making
recommendations
– Implementing recommendations
– Monitoring outcomes
Functional Assessment:
Targeting Frail Elders
• Prevalence of disability increases with
age and some have recommended
using age as one criteria (ie, all
individuals older than 75 years).
• Investigational criteria use a number of
factors: Age, comorbidity, known
functional deficits, psychologic and
social factors (depression, social
isolation), use of health care services
Functional Assessment:
Targeting Frail Elders
• Researchers have proposed using
hospitalizations or ER visits as a proxy
for a high-risk population.
• Post hoc analysis showed that
predictive factors were:
– Number of medical diagnoses
– Number of drugs
– Loss of 2 or more intermediate activities of
daily living (IADLs)
Functional Assessment:
Targeting Frail Elders
• My criteria:
– New drug compliance issues
– Cancellation or no-show for
appointments
– Family members start calling office
– Family members start to accompany
patient to office
– Unexplained weight loss
– Change in appearance or behavior
Functional Assessment:
Targeting New Elders
• New Medicare approved “Welcome to
Medicare” examination - meant as a
screening and preventive examination.
• This is a one-time comprehensive
medical review and physical
examination in the first 6 months that
patient has Part B Medicare coverage.
• Good way to get baseline on patients
newly eligible for Medicare, however,
few meet the frail elderly designation.
Functional Assessment:
Outcomes
•
•
•
•
•
Decreased NH admissions
Decreased drug use
Major and minor new diagnoses
Decreased annual medical cost of care
Decreased mortality rate, no loss of
quality of life (QOL)
• Increased independent function
• Increased patient/family satisfaction
Functional Assessment
• Medical assessment:
– Current condition
– Medical and surgical history
– Drugs: Prescriptions, herbal supplements,
and over-the-counter (OTC) drugs
– Allergies
– Habits: Tobacco, alcohol, diet, exercise
– Health maintenance: Immunizations;
dental, eye and hearing examinations;
Fecal Occult Blood; mammogram; Pap test;
breast examination
– Family history
Functional Assessment
• Social assessment:
–
–
–
–
–
–
–
Marital status, family members
Educational and occupational history
Housing status
Financial concerns, income status
Hobbies and activities
Sexual history
Religious preferences
Functional Assessment
• Functional status: Activities of daily
living (ADL)
–
–
–
–
–
–
–
–
Bathing
Dressing
Personal grooming
Eating
Transfers
Toileting
Continence
Ambulation
Functional Assessment
• Functional status: IADL
–
–
–
–
–
–
–
–
Shopping
Meal preparation
Taking drugs
Housekeeping
Laundry
Transportation
Telephone use/communication
Managing personal finances
Functional Assessment
• Functional status review counts as
review of systems (ROS)
• Supplement for additional ROS as
needed
• Advance directives
• Driving:
–
–
–
–
Still driving?
Any accidents?
Change of driving habits?
Gotten lost, lost the car?
Functional Assessment
• Physical examination:
– Need to include some measure of visual
and auditory acuity
– Cognitive examination: Mini-Mental State
Examination (MMSE)
– Psychiatric examination: Geriatric
Depression Scale
– Performance examination: Get-up-and-go
test
– Neurologic examination: Other measures of
balance and gait
Functional Assessment
• Coding: Use evaluation and
management (E/M) codes, aim for level
5
• History:
–
–
–
–
–
Chief report, history of present illness
Medical and surgical history
Drug review
Family and social history
ROS need to review 10+ systems
• Examination: Multisystem examination
needs to look at 8 of the 12 areas
Functional Assessment
• Decision-making needs to be high
complex:
– 8 or more diagnoses
– Review management of all
diagnoses, but do not need to
change if in agreement.
– Diagnoses include constipation, pain,
hearing loss, skin dx, dry eyes, etc.
• Counseling can upgrade 1 level:
Include time in minutes and subject of
discussion
Functional Assessment
• Delegate data collection
• Minimize data recording time
• Keep information needed for decisionmaking readily available
• Delegate plan execution
Strategies for Saving Time
• Previsit questionnaire:
– Medical history:
o Current drugs
o Drug allergies
o Surgical and medical diagnosis and
procedures
o Social history
o Health maintenance and preventive services
– Home safety checklist
– Advance directives
Strategies for Saving Time
• Specific questions on:
–
–
–
–
–
–
–
–
Vision
Hearing
Dentition
Falls
Urinary incontinence
Nutrition
Depression symptoms
Functional status
Strategies for Saving Time
• Minimize data recording time:
–
–
–
–
Dictation
Templates
Word processing programs
Computerized medical records
Strategies for Saving Time
• Keep information needed for decisionmaking readily available:
– Pocket guides
– PDA programs
– Useful books and charts
– Computer retrieval system
Strategies for Saving Time
• Delegate plan execution:
– Network of health professionals
– Health educators
– Patient education handouts
Assessing Care of the
Vulnerable Elderly
• Assessing Care of the Vulnerable
Elders (ACOVE)
• http://www.geronet.ucla.edu/centers/ac
ove/index.htm
• Can find:
–
–
–
–
Office forms
Physician education
Patient education
More information and reprints