Primary tabs

Introduction

The ability to manage activities of daily living (ADLs) is a major signifier of health for older adults. As individuals age or become ill, they increasingly require assistance in completing basic tasks. Over one third of older adults suffers a decline in ADL function after a period of acute hospitalization, with adults over age 85 experiencing the greatest loss in function.1,2 Functional status is influenced by the physiological changes a patient undergoes as result of aging, his or her comorbid acute and chronic illnesses, and how well he or she adapts to the physical environment.1 For an older adult, early recognition of subtle changes in function, such as altered mental status, dehydration, decreased appetite, pain, dizziness, falls and incontinence, offers an opportunity to initiate treatment for underlying health problems while recovery is still possible.3 Often, these symptoms point to acute illness such as pneumonia infection and urinary tract infection, which are usually reversible but require prompt medical evaluation.1 Complaints of fatigue or decreased ability to complete one’s daily activities may signal anemia, thyroid dysfunction, depression, neurologic, or cardiac issues.3 If not addressed, patients are apt to lose physical function permanently, which carries a higher likelihood of being discharged to a long-term care facility.2

Interprofessional Assessment and Collaborative Interventions

A primary goal for health care professionals in the acute care setting is to preserve older adults’ pre-existing functional capabilities and prevent further decline during hospitalization. It is important that the interprofessional team establish a baseline of patient function and reassess periodically to determine whether patient is experiencing normal changes secondary to aging, a chronic disability, or new-onset illness. Failure to assess function can result in further decline, decreased quality of life, and need for institutionalized care.1 Timely referral to rehabilitation programs may allow older adults to regain prior function before the onset of permanent decline.3

Common risk factors associated with functional decline include history of falls, acute illness, delirium, cognitive impairment, depression, medication side effects, malnutrition, pressure ulcers, and decreased mobility secondary to incontinence.1 Patients who are particularly vulnerable to functional decline following hospitalization are those with impaired functional status pre-hospitalization, multiple comorbid chronic conditions, multiple prescription medications, and history of frequent hospitalizations. The experience of hospitalization is especially dangerous for older adults at risk for functional decline given negative effects of bed rest and restricted activity.2 Baseline physical and functional assessments should be gathered upon admission to a facility and with every change in the patient’s condition. Assessments should include evaluation of patient’s ability to complete activities of daily living, instrumental activities of daily living, and general mobility.1,3  Current guidelines suggest that community-dwelling older adults be assessed at least once a year, with more frequent evaluations recommended for patients with chronic disease such as dementia and joint disease.3

It is important that the interprofessional team use standardized functional assessments when evaluating a patient’s functional status to allow for systematic communication across providers and settings.1 The Katz Index of Independence in Activities of Daily Living and Lawton Instrumental Activities of Daily Living Scale are well-validated and commonly used assessment tools across settings.1,3  Nurses can provide valuable information during daily assessment about patients’ ability to perform self-care activities such as bathing, dressing, grooming, toileting, transferring, and ambulation.1 Nurses can encourage patients to independently complete ADLs as much as possible and help ensure that patients’ sensory devices, such as glasses and hearing aids, are kept within reach.2 All instances of functional decline should be assessed for underlying reversible causes, such as acute illness and delirium, with the aid of an acute care provider.1 Pain specialists and neurologists can evaluate patients for underlying pain or an acute neurological even that may have caused sudden changes in function.3

Functional decline may also occur progressively and be irreversible, such in the case of patients with degenerative joint disease, dementia, Parkinson’s disease, heart failure, and cancer.Primary care providers can assist in coordinating services for these patients, including utilization of physical therapists and occupational therapists, to encourage activity with routine exercise, range of motion activities, and regular ambulation.1,2 Pharmacists can be consulted when reviewing patients’ medications to monitor for any negative effects of polypharmacy, particularly with psychoactive medications, sedatives, antihypertensives, and drugs that carry risk of hypoxia and hypoglycemia.1,3 Nutrition consultation with a registered dietitian can guide alterations to patient’s diet to ensure sufficient protein and calorie intake.1 At time of discharge, social workers can use functional status evaluations to plan care outside of the hospital, including short-term skilled care, home care, ongoing physical and occupational therapy, and utilization of community services.1 Health care organizations and agencies as a whole can focus on providing staff with adequate education to prevent hospital-acquired functional deconditioning among older adults. All members of the interprofessional team can advocate for avoidance of prolonged bed rest and reduce use of physical restraints, indwelling urinary catheters, and sedative-hypnotics to improve outcomes for elderly patients.1,2

Interprofessional contacts for this topic:

Acute care providers

Neurologists

Pain specialists

Registered nurses

Primary care providers

Pharmacists

Social workers

Physical therapists

Occupational therapists

Registered dietitians

Link to the following evidence-based protocols:

Assessing cognition

Atypical presentation

Function

References

1Kresevic, D. M. (2012). Assessment of physical function. In M. Boltz, E. Capezuti, T. Fulmer, & D. Zwicker (Eds.), Evidence-based geriatric nursing protocols for best practice (4th ed., pp. 89-103). New York, NY: Springer Publishing Company.

2Boltz, M., Resnick, B., & Galik, E. (2012). Interventions to prevent functional decline in the acute care setting. In M. Boltz, E. Capezuti, T. Fulmer, & D. Zwicker (Eds.), Evidence-based geriatric nursing protocols for best practice (4th ed., pp. 104-121). New York, NY: Springer Publishing Company.

3Amella, E. J. (2006). Presentation of illness in older adults: If you think you know what you're looking for, think again. AORN Journal, 83(2), 372-389.