Delirium — an acute but treatable syndrome — must be differentiated from dementia, which has a slow and chronic progression. A history of rapid functional change or change in patient behavior (e.g., increased lethargy, confusion, or agitation) is often the first sign of an acute problem. Such infections as UTI or pneumonia are common causes of delirium. Fluid and electrolyte imbalances, constipation/impaction, and adverse drug reactions are other common differentials. Approaches to evaluating rapid functional change should focus on identifying acute causative factors.

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.


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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.

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

Constipation and impaction from such common causes as limited fluid intake, decreased activity, and medication side effects are also important elimination concerns to discuss, as they can lead to discomfort and decreased appetite as well as acute symptoms.4 Clarify what constipation means to the patient, and determine an appropriate follow-up plan.

Social support/environmental resources. Support from people and environmental resources becomes increasingly important with the illnesses and frailties common in advanced age. There is often a loss of these resources for the oldest old, as friends and family precede in death. Particularly for those declining in function, it is important to determine whether the individual has consistent support and a safe environment. A basic screening question asks, “Who would help you if you got sick or had an emergency?”

Consideration of the patient’s usual living arrangements or environmental setting is part of a functional screen. While the benefits of environmental observation may be limited in primary care, ask, “Do you have trouble with stairs, lighting, bathroom, or other home hazards?” Often such simple environmental adaptations as revised room arrangements or grab bars can make a difference in functional abilities. If screening suggests problems, further evaluation can include referral to an appropriate specialist.

Visit closure

Because of the unique qualities of older adults, this patient population requires individualized treatment plans. The best plans find a balance among the older adult’s functional abilities, needs, and resources. The optimal care plan also may vary by environmental setting.2 There are some simple tips to consider as the visit concludes.

Prioritize and treat what is easily treatable. Some conditions commonly occur (e.g, UTIs). After determining care priorities, consider best treatments in light of other comorbidities and functional deficits. Gain best evidence from research, expert clinician practice, and patient preference. Focus in particular on steps that promote functional ability and quality of life.

Consider physical aging changes when prescribing medications. Whenever possible, avoid prescribing high-risk drugs to elders. Provide older patients with clear written guides for taking medications, and alert them to potential side effects.

Keep the treatment plan simple. The treatment plan should fit the patient’s abilities. Written follow-up care guides and patient reminders should contain simple bulleted information in large-font print.

Refer those who need to be referred. A team approach that includes physical, occupational, and speech therapists can enhance a function-oriented plan. The problem-oriented plan should be available to all providers.9

Guide families to needed support resources. Provide contact information for such groups as the local Area Agencies on Aging and the American Association of Retired Persons. Such specialty organizations as the Alzheimer’s Association or the Parkinson’s Disease Foundation provide educational resources and support groups that many patients and family members find beneficial.

Target the most complex cases. Once the patients that require the most involvement have been identified, determine what type of further monitoring (if any) is needed. Consider the benefits of a case manager, and include family caregivers in developing strategies for the coordination of support services.

Health promotion and disease prevention is important for people of all ages. Basic principles of improved nutrition and adequate exercise—related to functional level—apply. Health promotion diagnostic screening guides differ for those of advanced age with limited predicted longevity. Age-appropriate screening, counseling, and preventive-services guidelines can be accessed through the Agency for Healthcare Research and Quality (www.ahrq.gov).10

Summary

Screening for functional deficits provides the PCP with a good starting point in caring for older adults with long health histories and comorbidities. Functional screening allows for further systematic assessment and helps clarify patient strengths. Consider functional screens the first step in establishing a realistic and patient-focused care plan. By promoting optimal functional abilities, PCPs can help elders maintain independence with a focus on safety and quality of life.

Dr. Bonnel is an associate professor at the University of Kansas School of Nursing, Kansas City. The author has no relationships to disclose regarding the content of this article.

HOW TO TAKE THE POST-TEST: To obtain CME/CE credit, please click here after reading the article to take the post-test on myCME.com.

References

1. Administration on Aging. Profile of older Americans: 2010.

2. Kane RL. Ouslander JG, Abrass IB, Resnick, B. Essentials of Clinical Geriatrics, 6th ed. New York, N.Y.: McGraw-Hill Professional; 2009.

3. Leipzig RM, Granville L, Simpson D, et al. Keeping granny safe on July 1: a consensus on minimum geriatrics competencies for graduating medical students. Acad Med. 2009;84:604-10.

4. Ham RJ, Sloane PD, Warshaw GA. Primary Care Geriatrics: A Case-Based Approach. St. Louis, Mo.: Mosby; 2006.

5. Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res. 1982-1983;17:37-49.

6. National Institute of Mental Health. Older adults: Depression and suicide facts.

7. Reuben DB. Geriatrics at Your Fingertips, 13th ed. Belle Meade,N.J.: American Geriatrics Society; 2011:60-65.

8. Alzheimer’s Association. Diagnostic procedures. 

9. Elsawy B, Higgins KE. The geriatric assessment. Am Fam Physician. 2011;83:48-56.

10. Agency for Healthcare Research and Quality. Electronic preventive services selector helps clinicians deliver prevention at the point of care.

All electronic documents accessed August 15, 2011


HOW TO TAKE THE POST-TEST: To obtain CME/CE credit, please click here after reading the article to take the post-test on myCME.com.