Mobility and function. Overall mobility and function are critical factors affecting elders’ capacity for self-care and ability to stay safely and independently in their homes. Such standardized scales addressing activities of daily living (ADLs) and instrumental activities of daily living (IADLs) as the Katz ADL and the Lawton IADL are recommended for those having difficulties.2 ADLs are self-care activities that a person performs daily, whereas IADLs relate to more detailed activities of daily home management. While function includes interaction of such factors as cognition and motivation, simple upper- and lower-body screens provide useful indicators to assess need for further screening.
To identify basic functional range of motion in the upper body, ask the patient to move his or her arms in three positions: (1) arms stretched up toward the ceiling; (2) hands lowered to touch the back of the neck; and (3) hands brought together to touch the lower back. Picking up such small objects as a paper clip or penny provides a further screen of manual dexterity.
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For assessment of the lower body, the individual’s gait provides an initial indicator of function. Early indicators of such diagnoses as Parkinson disease may be detected. Specifically, the Timed Up and Go (TUG) Test is recommended. The TUG screens strength, coordination, and walking ability. In this test, the patient is asked to rise from an armless chair, walk three meters, return, and sit down while the provider observes.4 Inability to complete in 14 seconds is considered a positive finding.
Falls or the fear of falling are often major factors in older adults’ loss of independence. Falls can be symptomatic of specific disorders or attributed to a combination of factors. After hearing a positive response to the question, “Have you had any falls in the past year?” the clinician should obtain from the patient a detailed fall history, including frequency and circumstances. Reports of repeated falls indicate the need to determine contributing intrinsic or extrinsic factors.2 Asking patients to remove shoes and socks provides an additional opportunity to identify functional deficits and is a useful screen for foot problems. Such problems as improper footwear or foot disorders can lead to functional deficits.
Eating and nutrition. Dental problems, which PCPs often miss, are common and can lead to infections and systemic disorders. Some medications can lead to decreased saliva and altered taste. Meal management and self-care eating abilities may be overlooked. Nutritional screening and follow-up assessments can address the following possible issues:
- weight changes
- adverse effects of medication on appetite
- eating-related self-care deficits
- oral health deficits (e.g., dental problems or dry mouth)
- chewing or swallowing disorders
- eating problems of those with such specific diagnoses as Alzheimer disease.
Questions more detailed than, “Are you eating?” are required to determine diet patterns. For example, asking, “What is a normal breakfast or dinner for you?” elicits a more detailed response. Changes in weight patterns are another important indicator. Although the discussion relevant to frail elders is often limited to weight loss and problems of underweight, obesity remains a major concern with many health-care implications and should not be overlooked.
Incontinence/elimination issues. Elimination concerns can be embarrassing and uncomfortable for elders. Urinary incontinence in particular can lead to social isolation or even physical injury caused by falls from hurrying to the bathroom and slipping. Incontinence relates to function in that it is a factor in activity choices and can even affect living arrangements.
The question, “Have you lost your urine and gotten wet in the past year?” can be followed up with more detailed questions regarding frequency and severity.4 Determining such iatrogenic factors as lack of ability to manage clothing or access toilet facilities is particularly relevant in a functional screen.2 A new medication may lead to incontinence in individuals with no previous episodes. Diuretics can lead to urgency and frequency; narcotics and sedative-hypnotics can lead to sedation and decreased mobility; and drugs with anticholinergic effects can lead to retention and overflow incontinence. The embarrassment, health risks, and decreased quality of life for patients make urinary incontinence an important issue to address.2
