1. Sandra Qaseem MD UNM SOM 8/4/17
Functional Assessment in the Elderly
Sandra Qaseem MD UNM SOM 8/4/17

2. Goals and Objectives
Enable learners to assess functional, cognitive and affective status of older adults
To assess and determine appropriate level of care for elder with functional and or cognitive deficits
Know what is available in terms of placement/ care for elders in the community

3. Case Scenario- Mrs G
You are on inpatient service with 15 patients you have just rounded on- you have about an hour to complete usual tasks – order tests, prepare for teaching/ work rounds, write daily orders
Mrs G is an 85 y/o scheduled for discharge today, looked fine on rounds and all dc orders were written last night-
RN reports to you that dtr has just called and said she cannot take the patient home because she “couldn’t handle her” and the patient would be “too much to take care of at home” The dtr is on jury duty and cannot be reached until 5 pm
What next?

4. Goal Understand what problems Mrs G might have had functioning at home
Patient is dressed and ‘ready to go’
What is your approach??

5. Communication
Well lit room but do not sit in front of window or light source
Facilitate wearing glasses
Reduce extraneous noise- hearing aids/ pocket amplifier
Speak slowly in an even tone and check that patient can hear you
Face patient at eye level
Use paper/ white board to write questions in large block print
Take your time- leave enough pauses for patient to answer

6. Assessment of function
ADL’s
IADL’s
Gait Impairment
Cognition- mini-cog, MOCA
Affect- depression screen

7. DEATTH SHAFTTT
ADL’s and IADL’s

8. Basic ADLs D Dressing E Eating A Ambulation T Transfers T Toileting
H Hygiene
Grooming
Bathing

10. Advanced ADLs (IADLs) S Shopping H Housekeeping A Accounting = $
Cleaning
Laundry
A Accounting = $
F Food Preparation
T Telephone
T Transportation
T Taking Medications

12. Clinical Implications
75% of 75 and older limit their activities due to functional impairment
Almost 50% of 85 + require assistance in 1 or more ADL’s
ADL impairment is a stronger predictor of hospital outcomes than admitting diagnosis, DRG, illness burden etc.
25-35% of older patients admitted for treatment of acute medical illness lose independence in 1 or more ADL- risk factors being cognitive impairment, advanced age and IADL impairment on admission

13. Screening for Cognitive Impairment
Mini- Cog- 3 item recall and clock drawing
MOCA- 30 items
R/O delirium- inattention, acute onset, disorganized thinking or altered level of consciousness
R/O depression
Diagnosis of dementia is more involved but screening is fairly predictive
Score of less than 3 indicative of need for further dementia screening
Patients who score + for any screen for dementia should be further evaluated
Neg likelihood ration is likelihood of having disease if screen -

14. Mini Cog Contents Advantages +3 +2 Verbal Recall (3 points)
Clock Draw (2 points)
Advantages
Quick (2-3 min)
Easy
High yield (executive fx, memory, visuospatial)
Subject asked to recall 3 words
Leader, Season, Table +3
Subject asked to draw clock,
set hands to 10 past 11 +2
Speaker Notes:
Ask the audience why setting the time for “ten past eleven” is a sensitive marker of cognitive decline? Answer: time is an abstract concept. Ten after is symbolically represented by the 2. Our brains do this type of mental gymnastic easily because we do not have dementia. But, patients with early Alzheimer’s disease lose symbolic, abstract thinking. A common response on this part of the task is to draw one line to the ten and one line to the eleven because those are the two numbers you mentioned in the instructions. Their thinking becomes more concrete.
The clock is scored all or nothing, 0 or 2 points, because it has been shown to be a very sensitive marker of early cognitive decline.
Borson et al., 2000

16. Prevalence and clinical implications
3% sig cognitive impairment at age 65 and doubles every 5 years 50% in 90 year old
Patients do not complain of memory loss
Often undiagnosed
Effects are poor med compliance, poor compliance with behavioral recommendations, difficulty navigating health system, and caregiver stress

17. Screening for Depression
2 question screen
GDS short/ long
PHQ-9
Medical disorders can mimic – hypothyroidism, PD, dementia, malignancy and depression likewise accompanies many major illnesses
GDS less than 6 depression less likely, 6-9 possible/ probable greater than 9 depression likely

18. PHQ-2

20. Prevalence and clinical implications
6-10% in ambulatory clinic elderly- major depression
11-45% inpatient elderly- major depression
65 and older less than 13% of population but 25% of suicides
More than 75% of people who commit suicide suffered major depression and majority have seen a physician in the last month
Subsyndromal depressions even more common
Depression lowers QOL and leads to poor adherence

21. Evaluating Gait Instability or Falls
8-19% of non- institutional older adults have difficulty walking or require assistance of another person or special equipment to walk
Walking disability increases with age 6% of 65 y/o and to 40% in 85 or older
30-40% of community dwelling elders fall each year, increases to 60% in those with a previous fall in prior year
Complications from falls are leading cause of death from injury in elders
10-15 % falls result in serious injury
40-70% of fallers develop fear of falling

22. All elderly patients should be asked about falls
If they report a single fall should undergo the Timed up and Go

23. Timed Up and Go
Place a marker on the floor ten feet from patient’s chair
Instructions:
Rise from chair
Walk 10 feet
Turn
Return to chair
Sit down
Score is time in seconds, should use regular aids

24. Results Normal is less than ten seconds
Further evaluation required if not performed in 20 seconds
Patients who require 20 s or more are at greater risk from falls and may require assistance of others.
Patients with abnormal gait should be further evaluated
Patients who have fallen require further evaluation and should be referred to those with skills to evaluate and manage appropriately

25. Other tests of mobility
Chair sit to stand
Get up and go
Gait speed
Functional reach
PT assessment is invaluable

27. Timed up and go

28. 30 second chair stand test

29. 4 stage balance test

30. Where do the elderly live?
Own home independently
Senior living
Own home with assistance
Child’s home
Assisted living
Small group or shelter care home
Nursing home
All except nursing home can be +/- adult day care

31. PACE- Program All Inclusive Care of Elderly- Innovage
Non-residential
Patient lives at home/ ALF
Dual eligible Medicaid /Medicare
“managed care”
Provides transportation/ MD/ Pharmacy/ PT/ OT/ ST/ SW
Includes home health aids etc to help patient maintain independence at home
Nursing home eligible patient

32. Paid Caregivers Private- can do whatever you require
Through agency- agency will decide
Medicaid Waiver Program- meals, bathing, light housework
Driving to appointments- often not available

33. Senior Living Primarily room and board
Some contract with agencies to provide medication management/ toileting/ mobility at extra and significant cost

34. Assisted Living
Various options range from small number of beds to multi story
Will distribute meds
Toileting
Bathing
Mobility
Transport to meals
Feeding
Transport to appointments
These are usually add ons- the more dependent you are the more costly

35. Small Group or Shelter Care Homes
Usually around 8 beds, private or semi- private
In a regular home
1-2 caregivers present
Give full assistance including feeding if necessary
Need high school diploma to manage a home- very variable
Regulated as ALF

36. Nursing Home
Skilled care 30 days Medicare/ days copay and Medicare
Custodial care- private pay or Medicaid
Full assistance- highest level of dependency
Regulated by state and federal government, must have medical director/ RN

37. THE NURSING HOME POPULATION
Need assistance with 3+ ADLs
80%
Dependent on assistance for eating
57%
Incontinence
>60%
Hearing and Visual Impairments
33%
Ambulate without assistance
9.4%
Rely on chair for mobility
60.6%
ADLs = activities of daily living
Functional disability is prevalent in nursing-home residents. More than half of long-stay nursing-home residents require supervision or hands-on assistance from another person in 5 ADLs (ie, eating, dressing, bathing, transferring, and toileting).
Topic

40. Financing options
Medicare- DOES NOT pay for custodial care, only skilled
Medicaid- if qualify due to ADL deficiency Medicaid will pay for a number of hours of assistance in home or a contribution to board in select ALF.
When all funds depleted elders will often end up in Nursing Home with institutional Medicaid- this is the most expensive option for state

41. Back to our case……

42. Case Scenario- Mrs. G
You are on inpatient service with 15 patients you have just rounded on- you have about an hour to complete usual tasks – order tests, prepare for teaching/ work rounds, write daily orders
Mrs. G is an 85 y/o scheduled for discharge today, looked fine on rounds and all dc orders were written last night-
RN reports to you that dtr has just called and said she cannot take the patient home because she “couldn’t handle her” and the patient would be “too much to take care of at home” The dtr is on jury duty and cannot be reached until 5 pm
What next?

43. What do you do? Background if possible
H+P including social hx- hopefully should be available
USE TEAM
Social work consult- use IDT
PT/ OT assessment
Dietary/ Speech
Options for care
Skilled nursing placement- requirement for 3 x midnight in hospital

44. Case Resolution Pt was discharged to NH for PT/ OT
Further evaluation showed deficits in cognition and difficulty with independent ambulation, deficits in ADL’s
After 3 weeks was discharged to Small Group Shelter Care Home close to dtr
Private pay----until funds are depleted then usually custodial care is in NH Medicaid funded
Many agencies exist to assist families in finding placement for loved ones, “A Place for Mom” , office of senior affairs

45. Summary
Functional assessment very important involves evaluation of ADL’s, IADL’s, cognition, mobility, mood
Many options for placement determined by availability, funding, physical/ mental capacity of pt