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HarrietFinne-Soveri

Assessment of Functional Capacity in the Elderly

Assessment of functional ability and care needs Comprehensive Geriatric Assessment for Older Adults Admitted to Hospital, Informant Questionnaire on Cognitive Decline in the Elderly (Iqcode) for the Diagnosis of Dementia Within a Secondary Care Setting

  • Assessment of functional capacity in the elderly is an extensive, multiprofessional task. In addition to physical performance and coping in daily life, cognitive and psychosocial functioning, at least, must be considered and an idea formed about the person's age-related frailty.
  • Many different measuring instruments are used. The choice of the instrument depends on
    • the group of people to which it is applied (elderly people living independently at home with support from home services or residents of assisted living facilities with advanced services)
    • the variables that the instrument is intended to quantify (functional deficits, care needs, results of therapy or rehabilitation, need for preventive measures)
    • the purpose of use of the instrument.
  • When functional capacity is still well preserved, emphasis is placed on detection and follow-up of an early memory disorder or functional impairment in the choice of the measuring instrument. When functional capacity is reduced, the significance of being able to handle basic daily routines increases.
  • Use of such measuring instruments does not replace normal interviewing and hearing of the person through free conversation. The measuring instruments are there to help with drawing conclusions and making decisions. A physician must interpret how the results are related to any diseases.
  • Use of measuring instruments and familiarity with them is useful for screening for functional impairment and diseases or their risk as well as for epidemiological research.
  • Notice that the official versions of many instruments are not freely available online. In such cases the links provided below point to sites that provide more information on or display a specific version of the instrument. Find out about local availability of official versions and relevant language versions of the instruments.
  • See also local recommendations concerning the use of measuring instruments in various settings.

Physical performance and coping in daily life

Tests for memory and information processing

Tests for mental and social performance

  • When assessing depression, in addition to using scales, the person should be asked whether he/she feels depressed and, if so, how severe they consider the depression. This will not exclude the use of scales.
  • There are scales suitable for screening for depression, such as the Geriatric Depression Scale (GDS) http://web.stanford.edu/~yesavage/GDS.html. It is frequently used in many countries. The Montgomery-Åsberg Depression Rating Scale (MÅDRS) http://www.mdcalc.com/calc/4058/montgomery-asberg-depression-rating-scale-madrs is more accurate in following up the effects of treatment.
  • The Cornell Scale or the depression scales in the RAI system should be used for assessing depression in patients with memory disorder (Table T1 and aforementioned links).
  • As behavioural symptoms in patients with a memory disorder are a significant predictor of the need for institutional care or assisted living facilities, they should be examined when following up on pharmacotherapy or other forms of treatment. The Neuropsychiatric Inventory (NPI) http://npitest.net/about-npi.html is a useful test. Instruments of the equivalent area in the RAI system can also be used to assess and follow up on behavioural symptoms (Table T1 and aforementioned links).
  • So far, there are very few measures available for the assessment of social performance. In addition to RAI tools, the Social Provision Scale (see e.g. http://chipts.ucla.edu/wp-content/uploads/downloads/2012/01/Social-Provisions-Scale.pdf) may be feasible with regard to loneliness and deteriorating social networks.

Tests for assessing service needs

  • Find out about local policies concerning the use of tests and other instruments for assessing service needs. In some countries there may be legal requirements
    • In Finland, for example, there is a legal obligation to use instruments of the RAI system to assess service needs concerning
      • an elderly person's need for regular home care or round-the-clock treatment and care in an assisted living facility.
        • In these cases, functional ability is defined multidimensionally and multiprofessionally, taking into account at least daily functional capacity, cognition and the psychosocial dimension of functional capacity. A physician assesses the prognosis of any diseases and whether therapeutic measures applied before assessment were appropriate and effective.
      • any essential change in functional ability in regular home care customers
      • any essential change in functional ability in round-the-clock care customers, and
      • the need for long-term follow-up of functional ability of the elderly in home care, assisted living facilities with advanced services and in institutional care settings, as well as for comparison of the effectiveness of care in different care settings.
  • People seeking or referred to assessment of service needs have a wide spectrum of functional deficits. In some cases, it is essential to recognize physical or psychosocial frailty even if regular services are not started.

Utilization of multidimensional comprehensive assessment tools

  • When utilizing multidimensional comprehensive assessment tools, computerized use of scales and a multiprofessional approach promote cooperation between various professional groups and may reduce duplicate entries.
  • The International Classification of Functioning, Disability and Health (ICF) describes how the consequences of a disease or injury affect a person's life http://www.who.int/classifications/icf/en/ .
  • The RAI system http://interrai.org/ is an international method for evaluating the quality and cost-effectiveness of care, based on individual comprehensive evaluation and a care plan that is based on the evaluation. Table T1 shows some of the instruments included in the RAI system with other equivalent instruments for the same areas.
  • The use of comprehensive evaluation systems requires training. When used within an outpatient appointment, reserving separate time for the testing is recommended.

Example of RAI system instruments suitable for services for the elderly

Purpose of use of the instrumentsName and scale of the RAI toolOther instruments for the same area of use
Daily coping, basic activitiesADL Short Form (ADL-S), 0-16Barthel Index, Katz ADL Index
Hierarchic ADL (ADL-H), 0-6
ADL Long Form (ADL-L), 0-28
Daily coping, instrumental activitiesIADL Performance (IADLP), 0-48Lawton IADL Index
IADL Capacity (IADLC), 0-48
CognitionCognitive Performance Scale (CPS1), 0-6MMSE, Cornell
Cognitive Performance Scale 2 (CPS2), 0-8MMSE, CERAD (MoCA)
Mental performance capacityDepression Rating Scale (DRS), 0-14GDS, MARDS (also MÅRDS)
Aggressive Behavior Scale (ABS), 0-12NPI
Social engagementIndex for Social Engagement (ISE), 0-6Not available yet

References

  • Guralnik JM, Simonsick EM, Ferrucci L et al. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol 1994;49(2):M85-94 [PubMed]
  • Montgomery SA, Asberg M. A new depression scale designed to be sensitive to change. Br J Psychiatry 1979;(134):382-9 [PubMed]
  • Alexopoulos GS, Abrams RC, Young RC et al. Cornell Scale for Depression in Dementia. Biol Psychiatry 1988;23(3):271-84. [PubMed]
  • Cummings JL, Mega M, Gray K et al. The Neuropsychiatric Inventory: comprehensive assessment of psychopathology in dementia. Neurology 1994;44(12):2308-14. [PubMed]
  • Searle SD, Mitnitski A, Gahbauer EA et al. A standard procedure for creating a frailty index. BMC Geriatr 2008;(8):24 [PubMed]

Evidence Summaries ⬆