MODULE 4.
FUNCTIONAL ASSESSMENT
Module 4.
Functional Assessment
Sherry Greenberg, MSN, APRN, BC-GNP
Editor: Conchita Rader, MA, RN
Staff Development Partners Edition
Instructor Guide
THIS MODULE INCLUDES:
1. Expected Staff Cognitive Competencies
2. Expected Staff Clinical Competencies
3. Content Outline including Learning Activities
a. REMINDER TO INSTRUCTOR: Read activities in Instructor
Guide and prepare materials for activities in advance
4. Scripted PowerPoint Presentation
5. 10-item Post Test
6. Resources
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MODULE 4. FUNCTIONAL ASSESSMENT
EXPECTED STAFF (Cognitive) COMPETENCIES
1. Define functional assessment and the terminology related to functional assessment.
2. Describe some characteristics of functional decline in older persons.
3. Identify comorbid conditions that might impact negatively on the functional status of an
older adult
4. Assess function using validated tools
5. Plan strategies to promote / maintain optimal function in older adults.
EXPECTED STAFF (Clinical) COMPETENCIES
Behaviors How validated Novice Advanced Competent Proficient Expert
Beginner
1. Long-Term Care Direct observation of
Setting: assessment interview,
techniques (include
Formally assess older family/caregiver/staff if pt
adult’s ability to function unable), accurate use of
upon admission and reassess assessment tool, and
yearly and upon significant documentation
change in clinical status
2. Acute Care Setting: Direct observation of
assessment interview,
Formally assess the patient’s techniques (include
ability to function and family/caregiver/staff if pt
compare it to the baseline unable), accurate use of
(when not acutely ill). assessment tool, and
documentation
3. Home Care Setting: Direct observation of
assessment interview,
Assess the patient’s ability techniques (include
to function in his / her own family/caregiver if pt
home and environment, at unable), accurate use of
every home visit, including assessment tool, and
functional history and documentation
documentation of
observations
4. Tools Direct observation
Correctly use validated tools
in assessing functional status
and determining the degree
of functional decline.
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MODULE 4. FUNCTIONAL ASSESSMENT
Competency 1. Define functional assessment and the terminology related to functional
assessment.
A variety of instruments and methods are available for conducting functional assessment on the
older adult: Katz Activities of Daily Living index (ADL), the Barthel Instrumental Activities of
Daily Living index (IADL), PULSES Profile, SPICES, and the Older American Resources and
Services (OARS) assessment.
A. Functional Assessment is a comprehensive evaluation of the physical and cognitive abilities
required to maintain independence. Assessment tools provide objective measures of physical
health, activities of daily living (ADLs), instrumental activities of daily living (IADLs), and
psychological and social functioning. In a more narrow sense, function can be defined as
“the ability to function in the arena of everyday living”.
B. Activities of Daily Living (ADLs) are the basic daily activities of bathing, dressing, toileting,
continence, transfer / mobility, grooming, and feeding. The Katz ADL Index has been the
most reliable and easy to use. It gathers information by observation on bathing, dressing,
toileting, eating, transferring, continence, and grooming.
C. Instrumental Activities of Daily Living (IADLs) are the basic daily activities needed to live
independently in the community – shopping, food preparation, cooking, using the telephone,
doing laundry, housekeeping, managing medications, managing finances, maintaining a
home and property, performing duties of employment or volunteer work, and traveling
(driving or using public or private transportation systems).
D. Psychological Function is assessed by measuring cognitive mental and affective functions
independently (See Module 5).
E. Social functioning includes social interactions and resources, subjective well-being and
coping, and person-environment fit.
Competency 2. Describe some characteristics of functional decline in older persons.
A. The incidence of chronic conditions increases with age (arthritis, hypertension, heart disease,
hearing impairment, orthopedic impairment, and cataract).
B. Persons over 65 years of age use approximately one-third of available physician resources,
and one-fourth of total medications prescribed, and they constitute more than two-fifths of
acute hospital admissions.
C. In 2002, there were an estimated 35.6 million (12.3%) people age 65 or older, and it was
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MODULE 4. FUNCTIONAL ASSESSMENT
estimated that 2% of the population was age 85 and older. By 2030, there will be about 71.5
million older persons. The 85+ population will increase from 4.6 million in 2002 to 9.6
million in 2030 and 19 million by 2050.
D. Functional decline, as measured in Activities of Daily Living (ADLs) and Instrumental
Activities of Daily Living (IADLs), is more prevalent with age (20% of older persons over
65 years require assistance with ADLs; 45% of older persons over 85 years require
assistance with ADLs).
Competency 3. Identify comorbid conditions that might impact negatively on the
functional status of an older adult.
A. Acute illness
B. Alteration in nutrition and / or hydration
C. Chronic illness
D. Delirium
E. Dementia
F. Economics
G. Environment
H. Medications
I. Psychiatric comorbidities, especially depression
J. Psychological / social stressors.
Competency 4. Assess function using validated tools.
A. The Katz ADL Index has established reliability and is easy to use. It was first developed in 1963
by Dr. Sidney Katz, who wanted to find a way to measure function and how it changed over time
in older people who had progressive chronic illnesses. It has been modified and simplified and
different approaches to scoring were used from categorical scoring (yes/no), to point scaling
(independent, some assistance, or dependent). There were no formal reliability and validity
reports in the literature; however, it is used extensively to assess functional capabilities of older
adults at home and in the clinical setting. The Katz inventory is useful in creating a common
language about a patient’s function for all care givers involved, evaluating older adults according
to levels of independence. A number of adapted versions are in use today.
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MODULE 4. FUNCTIONAL ASSESSMENT
KATZ ACTIVITIES OF DAILY LIVING1
ACTIVITIES INDEPENDENCE DEPENDENCE
(1 point) (0 points)
NO supervision, direction or WITH supervision, direction,
personal assistance personal assistance or total care
BATHING (1 POINT) Bathes self completely (0 POINT) Needs help in bathing
or needs help in bathing only a more than one part of the body
Point: ______ single part of the body such as the getting out of the tub or shower.
back, genital area, or disabled Requires total bathing.
extremity.
DRESSING (1 POINT) Gets clothes from (0 POINTS) Needs help with
closets and drawers and puts on dressing self or needs to be
Point: ______ clothes and other garments completely dressed.
complete with fasteners. May have
help tying shoes.
TOILETING (1 POINT) Goes to toilet, gets on (0 POINTS) Needs help
and off, arranges clothes, cleans transferring to the toilet, cleaning
Point: ______ genital area without help. self or uses bedpan or commode.
TRANSFERRING (1 POINT) Moves in and out of (0 POINTS) Needs help in
bed or chair unassisted. moving from bed to chair or
Point: ______ Mechanical transferring aides are requires a complete transfer.
acceptable.
CONTINENCE (1 POINT) Exercises complete (0 POINTS) Is partially or totally
self control over urination and incontinent of bowel or bladder.
Point: ______ defecation.
FEEDING (1 POINT) Gets food from plate (0 POINTS) Needs partial or total
into mouth without help. help with feeding or requires
Point: ______ Preparation of food may be done parenteral feeding.
by another person.
TOTAL POINTS= _____ 6 = High(patient independent) 0 = Low (patient very dependent)
1
Adapted with permission from Gerontological Society of America. Katz, S., Down, T. D., Cash, H., R. et al.
(1970). Progress in the development of the index of ADL. Gerontologist, 10, pp. 20 – 30.
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MODULE 4. FUNCTIONAL ASSESSMENT
B. Lawton Instrumental Activities of Daily Living (IADL) has been useful in rehabilitation
settings to monitor improvements over time. IADLs are those activities whose
accomplishment is necessary for continued independent residence in the community. The
independent activities of daily living are more sensitive for subtle functional deficiencies
than the ADLs. It differentiates among task performances including the amount of help and
amount of time needed to accomplish each task.
Lawton Instrumental Activities of Daily Living (IADL)
INSTRUCTIONS: Ask the patient to describe her / his functioning in each category; then
complement the description with specific questions as needed.
Ability to Telephone
1. Operates telephone on own initiative: looks up and dials number, etc.
2. Answers telephone and dials a few well-known numbers.
3. Answers telephone but does not dial.
4. Does not use telephone at all.
Shopping
1. Takes care of all shopping needs independently.
2. Shops independently for small purchases.
3. Needs to be accompanied on any shopping trip.
4. Completely unable to shop.
Food Preparation
1. Plans, prepares, and serves adequate meals independently.
2. Prepares adequate meals if supplied with ingredients.
3. Heats and serves prepared meals, or prepares meals but does not maintain adequate diet.
4. Needs to have meals prepared and served.
Housekeeping
1. Maintains house alone or with occasional assistance (e.g. heavy work done by domestic
help).
2. Performs light daily tasks such as dishwashing and bed making.
3. Performs light daily tasks but cannot maintain acceptable level of cleanliness.
4. Needs help with all home maintenance tasks.
5. Does not participate in any housekeeping tasks.
Laundry
1. Does personal laundry completely
2. Launders small items; rinses socks, stockings, and so on.
3. All laundry must be done by others.
Mode of Transportation
1. Travels independently on public transportation, or drives own car.
2. Arranges own travel via taxi, but does not otherwise use public transportation.
3. Travels on public transportation when assisted or accompanied by another
4. Travel limited to taxi, automobile, or ambulette, with assistance.
5. Does not travel at all.
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MODULE 4. FUNCTIONAL ASSESSMENT
Lawton Instrumental Activities of Daily Living (IADL) (continued)
Responsibility for Own Medication
1. Is responsible for taking medication in correct dosages at correct time.
2. Takes responsibility if medication is prepared in advance, in separated dosages.
3. Is not capable of dispensing own medication.
Ability to Handle Finances
1. Manages financial matters independently (budgets, writes checks, pays rent and bills, goes
to bank); collects and keeps track of income.
2. Manages day-to-day purchases but need help with banking, major purchases, controlled
spending, and so on.
3. Incapable of handling money.
Scoring: Circle one number for each domain. Total the numbers circled. The lower the score,
the more independent the older adult is. Scores are only good for individual patients. It is useful
to see the score comparison over time.
______________________
Figure 1. The Lawton Scale for Instrumental Activities of Daily Living (IADL) of M.P. Lawton,
“Functional Assessment of Elderly People” from the Journal of the American Geriatrics Society,
1971; 9(6): 465-481. Reprinted by permission of Blackwell Science, Inc.
C. PULSES Profile. This instrument measures general functional performance in mobility and
self-care, medical status, and psychosocial factors. The acronym is useful for remembering
the components:
P = Physical Condition
U = Upper Limb Function
L = Lower Limb Function
S = Sensory Components
E = Excretory Functions
S = Support Factors
D. SPICES is an acronym for the common syndromes of the older adult requiring nursing
intervention: S is for Sleep Disorders; P is for Problems with eating or feeding; I is for
Incontinence; C is for Confusion; E is for Evidence of Falls; and S is for Skin Breakdown.
Developed by Terry Fulmer, PhD, RN, FAAN, at New York University, Division of Nursing,
SPICES is an appropriate instrument for obtaining the information necessary to prevent
health alterations. Psychometric testing has not been done. The instrument has been used
extensively to assess and prevent most frequent health problems of older adults at the
following healthcare facilities: Yale University Medical Center, and the New York
University Medical Center.2 Scoring: If the syndrome screens positive, refer to evidence-
based practice protocol.
2
Adapted from Fulmer. T. (1991). The geriatric nurse specialist role: A new model. Nursing Management, 22(3),
pp. 91-93. Used by permission from Lippincott Williams & Wilkins.
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MODULE 4. FUNCTIONAL ASSESSMENT
Fulmer SPICES: An Overall Assessment Tool of Older Adults
Patient Name Date
SPICES EVIDENCE
Sleep Disorders
Problems with eating or feeding
Incontinence
Confusion
Evidence of Falls
Skin Breakdown
E. The Older American Resources and Services (OARS) assessment for physical function is
similar in scope of measurement to the Katz scale, including bathing, dressing, grooming,
and continence. However, unlike the Katz instrument, OARS relies on self report, therefore,
this tool may be less valid than observations of performance.
F. Timed “Get-Up and Go” Test measures the ability to walk. This is a simple, validated, and
practical assessment of balance function, yielding information on independence in
ambulation with efficiency and ease of use.. Subjects are asked to rise from a chair, stand
still momentarily, then walk toward the wall and turn around, walk back to the chair, turn
around and sit down. Undue slowness, hesitancy, abnormal movements, staggering, and
stumbling are considered abnormal and indicate that the patient is at risk of falling. Other
investigators have categorized this test by time requirement (<20 seconds; 20 – 39 seconds;
>40 seconds). Physical performance tests have some advantages over self-report measures
such as the ADLs and IADLs) including better reproducibility, greater sensitivity to change
and ability to predict pre-clinical impairment.3 4
3
Mathias, S., Nayak, U.S., Isaacs, B. (1986). Balance in elderly patients: The “Get Up and Go” test. Archives of
Physical Medicine and Rehabilitation, 67: pp. 387 – 389.
4
Podsiadlo, D., Richardson, S. (1991). The timed “Up and Go”: A test of basic functional mobility for frail elderly
persons. Journal of the American Geriatrics Society. 29 (2), pp. 142-148.
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MODULE 4. FUNCTIONAL ASSESSMENT
Competency 4. . Plan strategies to promote / maintain optimal function in older adults.5
1. Exercise and physical activity help to prevent heart disease, hypertension, depression, and a
tendency toward diabetes.
2. Design environments with handrails, wide doorways, raised toilet seats, shower seats,
enhanced lighting, low beds, and chairs of various types and height
3. Schedule regular examinations for prevention and early detection of cancer; prevention of
heart disease and stroke; and prevention and treatment of osteoarthritis.
4. Judicious assessment and monitoring of medications and their dosages, especially
psychoactive medications.
5. Maintain vaccination status.
6. Optimize nutritional patterns. Provide sufficient protein and caloric intake to ensure adequate
intake and prevent further decline. Liberalize diet to include personal preferences.
7. Maintain and enhance mental functioning.
8. Minimize bed rest.
9. Explore alternatives to physical restraints use
10. Obtain assessment by physical and occupational therapists as needed to help regain function.
11. Maintain and enhance social relationships and support.
12. Provide information to caregivers on causes of functional decline related to acute and chronic
conditions.
13. Help them access counseling and resources remaking physical modifications to the
environment or gaining access to equipment. (Rowe & Kahn, 1998)
5
Kresevic, D. M., & Mezey, M. (2003). Assessment of function. In M. Mezey, T. Fulmer, I. Abraham, & D. S.
Zwicker (Eds.), Geriatric nursing protocols for best practice. (2nd ed., pp. 31-46). New York: Springer.
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MODULE 4. FUNCTIONAL ASSESSMENT
RESOURCES
Abraham, I., Bottrell, M., Dash, K., Fulmer, T., Mezey, M., O’Donnell, L., & Vince-Whitman,
C. (1999, March.). Profiling care and benchmarking best practices in care of hospitalized
elderly: The geriatric institutional assessment profile. In The Nursing Clinics of North
America (pp. 239-255). Philadelphia: Saunders.
Assessment of the Older Adult. (1996). [Video, Two-part series]. Philadelphia: Lippincott,
Williams, & Wilkins.
Beers, M., & Berkow, R. (2000). The merck manual of geriatrics (3rd ed.). Whitehouse Station,
NJ: Merck and Co.
Binstock, R. H., Cluff, L. E., & Von Mering, O. (1996). The future of long-term care: Social
and policy issues. Baltimore: Johns Hopkins University Press.
Fulmer, T. (1991). The geriatric nurse specialist role: A new model. Nursing Management,
22(3), 91-93.
Fulmer, T. (1993, March/April). Grow your own experts in hospital elder care. Geriatric
Nursing, 12(2), 64-66.
Fulmer, T. (2001). The Geriatric resource nurse: A model of caring for older patients. American
Journal of Nursing, 102(5), 62.
Gallo, J. J., Fulmer, T., Paveza, G. J., & Reichel, W. (2000). Handbook of geriatric assessment.
(3rd ed.). Gaithersburg, MD: Aspen.
Granger, C. V., Albrecht, G. L., & Hamilton, B. B. (1979). Outcomes of comprehensive medical
rehabilitation: Measures of PULSES profile and the Barthel index. Archives of Physical
Medicine and Rehabilitation, 60, 145-154.
Greenberg, S. A., Ramsey, G., Mitty, E., & Fulmer, T. Elder mistreatment: Case law and ethical
issues in assessment, reporting and management. Journal of Nursing Law, 6(3), 7-20.
Hanson, C. (1996, January). Instant nursing assessment: Gerontologic. New York: Delmar.
Kane, R. A., & Kane, R. L. (1981). IAssessing the elderly: A practical guide to measurement,
Lexington, MA: Lexington Books.
Kane, R. L., Ouslander, J. G., & Abrass, I. B. (1994). Essentials of clinical geriatrics (3rd ed.).
New York: McGraw Hill.
Katz, S. (1983). Assessing self-maintenance: Activities of daily living, mobility, and
instrumental activities of daily living. Journal of the American Geriatrics Society, 3(12).
Katz, S. (1989). Functional assessment in geriatrics: A review of progress and directions.
Journal of the American Geriatrics Society, 37.
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MODULE 4. FUNCTIONAL ASSESSMENT
Katz, S., Down, T. D., & Cash, H. R. (1970). Progress in the development of the index of ADL.
Gerontologist, 10, 20-30.
Kresevic, D. M., & Mezey, M. (2003). Assessment of function. In M. Mezey, T. Fulmer, I.
Abraham, & D. S. Zwicker (Eds.), Geriatric nursing protocols for best practice. (2nd ed.,
pp. 31-46). New York: Springer.
Kresevic, D., Mezey, M., & the NICHE Faculty. (1999). Assessment of function: Critically
important to acute care of elders (pp. 1-12). In Abraham, I., Bottrell, M., Fulmer, T., &
Mezey, M. (Eds.). Geriatric nursing protocols for best practice. New York: Springer
Publishing Company.
Lawton, M. P. (1971). The functional assessment of elderly people. Journal of the American
Geriatrics Society, 19(6). 465-481.
Lueckenotte, A. G., (1990). Pocket guide to gerontologic assessment. Philadelphia: Mosby.
Luggen, A. S. (1996). Core curriculum for gerontological nursing (pp. 370-371). St. Louis,
MO: Mosby Year Book.
Maddox, G., et al (Eds.). (2001). The encyclopedia of aging (3rd ed.). New York: Springer
Publishing Company.
Mathias, S., Nayak, U.S., Isaacs, B. (1986). Balance in elderly patients: The “Get Up and Go”
test. Archives of Physical Medicine and Rehabilitation, 67, 387 – 389.
Matteson, M. A., McConnell, E. S., & Linton, A. D. (1997). Gerontological nursing concepts
and practice (2nd ed.). Philadelphia: Saunders.
Mezey, M. et al. (Eds.). (2001). The encyclopedia of elder care. New York: Pantheon Books.
Mezey, M., Rauckhorst, L., & Stokes, S. (1993). Health assessment of the older individual. New
York: Springer.
Podsiadlo, D., Richardson, S. (1991). The timed “Up and Go”: A test of basic functional
mobility for frail elderly persons. Journal of the American Geriatrics Society, 29(2), 142-
148.
Rowe, J. W., & Kahn, R. L. (1998). Successful aging. New York: Pantheon Books.
Shelkey, M., & Wallace, M. (1998, October). Katz index of independence in activities of daily
living. Try this, 1(2).
Wallace, M. & Fulmer, T. (1998). SPICES: An overall assessment tool of older adults. Try This,
1(1). New York: Hartford Institute for Geriatric Nursing. New York University, Division
of Nursing.
Wallace, M., Fulmer, T. (2000). Fulmer SPICES: An overall assessment tool of older adults.
Geriatric Nursing, 21(3), 147.
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Other Resources
Videotape:
Video Workshop # 1 Case Study Marie 3 Parts
Center for Assistive Technology at the University of Buffalo.
UB/CAT Products
515 Kimball Tower
University of Buffalo
Buffalo, NY 14214-3079
Phone: 716-829-3141; Fax: 716-829-3217
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