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## Complete Summary

#### GUIDELINE TITLE

Assessment of function. In: Evidence-based geriatric nursing protocols
for best practice.

#### BIBLIOGRAPHIC SOURCE(S)

Kresevic DM. Assessment of function. In: Capezuti E, Zwicker D, Mezey M,
Fulmer T, editor(s). Evidence-based geriatric nursing protocols for best
practice. 3rd ed. New York (NY): Springer Publishing Company; 2008 Jan.
p. 23-40. \[48 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Kresevic DM, Mezey M.
Assessment of function. In: Mezey M, Fulmer T, Abraham I, Zwicker DA,
editor(s). Geriatric nursing protocols for best practice. 2nd ed. New
York (NY): Springer Publishing Company, Inc.; 2003. p. 31-46.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Functional decline

#### GUIDELINE CATEGORY

Evaluation\
Management

#### CLINICAL SPECIALTY

Geriatrics\
Nursing\
Physical Medicine and Rehabilitation

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Health Care Providers\
Nurses\
Occupational Therapists\
Physical Therapists\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To maximize the physical functioning, prevent or minimize decline in
activities of daily living function, and plan for future care needs

#### TARGET POPULATION

Hospitalized older adults

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Assessment**

1.  Comprehensive functional assessment

    -   Basic activities of daily living (ADL)

    -   Instrumental ADL

    -   Mobility

2.  Strengths, need for assistance

3.  Baseline functional status

    -   Katz ADL Index

    -   Functional Independence Measure (FIM™)

    -   Lawton Instrumental Activities of Daily Living (IADL) assessment

    -   \"Get-up and Go\" test for ambulation

4.  Standard instruments to assess function

5.  Interdisciplinary/multidisciplinary collaboration

**Management**

1.  Maximization of function and prevention of decline

    -   Daily routine

    -   Education of elders, family, and formal caregivers

    -   Activity

    -   Minimization of bed rest

    -   Alternatives to physical restraints

    -   Pain

    -   Environmental design

    -   Regaining baseline functional status

    -   Physical and occupational therapies

2.  Helping older individuals cope with functional decline

    -   Determining realistic functional capacity

    -   Caregiver education and support

    -   Community resources

    -   Documentation

    -   Protein and caloric intake

#### MAJOR OUTCOMES CONSIDERED

-   Performance of activities of daily living (ADL)

-   Performance of instrumental activities of daily living (IADL)

-   Functional decline

-   Delirium

-   Use of physical restraints

-   Use of foley catheters

-   Readmission rate

-   Quality of life

-   Morbidity

-   Mortality

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Although the AGREE instrument (which is described in Chapter 1 of the
original guideline document) was created to critically appraise clinical
practice guidelines, the process and criteria can also be applied to the
development and evaluation of clinical practice protocols. Thus the
AGREE instrument has been expanded for that purpose to standardize the
creation and revision of the geriatric nursing practice guidelines.

**The Search for Evidence Process**

Locating the best evidence in the published research is dependent on
framing a focused, searchable clinical question. The PICO format---an
acronym for population, intervention (or occurrence or risk factor),
comparison (or control), and outcome---can frame an effective literature
search. The editors enlisted the assistance of the New York University
Health Sciences librarian to ensure a standardized and efficient
approach to collecting evidence on clinical topics. A literature search
was conducted to find the best available evidence for each clinical
question addressed. The results were rated for level of evidence and
sent to the respective chapter author(s) to provide possible
substantiation for the nursing practice protocol being developed.

In addition to rating each literature citation to its level of evidence,
each citation was given a general classification, coded as \"Risks,\"
\"Assessment,\" \"Prevention,\" \"Management,\"
\"Evaluation/Follow-up,\" or \"Comprehensive.\" The citations were
organized in a searchable database for later retrieval and output to
chapter authors. All authors had to review the evidence and decide on
its quality and relevance for inclusion in their chapter or protocol.
They had the option, of course, to reject or not use the evidence
provided as a result of the search or to dispute the applied level of
evidence.

**Developing a Search Strategy**

Development of a search strategy to capture best evidence begins with
database selection and translation of search terms into the controlled
vocabulary of the database, if possible. In descending order of
importance, the three major databases for finding the best primary
evidence for most clinical nursing questions are the Cochrane Database
of Systematic Reviews, Cumulative Index to Nursing and Allied Health
Literature (CINAHL), and Medline or PubMed. In addition, the PsycINFO
database was used to ensure capture of relevant evidence in the
psychology and behavioral sciences literature for many of the topics.
Synthesis sources such as UpToDate^®^ and British Medical Journal (BMJ)
Clinical Evidence and abstract journals such as *Evidence Based Nursing*
supplemented the initial searches. Searching of other specialty
databases may have to be warranted depending on the clinical question.

It bears noting that the database architecture can be exploited to limit
the search to articles tagged with the publication type
\"meta-analysis\" in Medline or \"systematic review\" in CINAHL.
Filtering by standard age groups such as \"65 and over\" is another
standard categorical limit for narrowing for relevance. A literature
search retrieves the initial citations that begin to provide evidence.
Appraisal of the initial literature retrieved may lead the searcher to
other cited articles, triggering new ideas for expanding or narrowing
the literature search with related descriptors or terms in the article
abstract.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

**Level I**: Systematic reviews (integrative/meta-analyses/clinical
practice guidelines based on systematic reviews)

**Level II**: Single experimental study (randomized controlled trials
\[RCTs\])

**Level III**: Quasi-experimental studies

**Level IV**: Non-experimental studies

**Level V**: Care report/program evaluation/narrative literature reviews

**Level VI**: Opinions of respected authorities/Consensus panels

Reprinted with permission from Springer Publishing Company: Capezuti,
E., Zwicker, D., Mezey, M. & Fulmer, T. (Eds). (2008) *Evidence Based
Geriatric Nursing Protocols for Best Practice*, (3^rd^ ed). New York:
Springer Publishing Company.

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Note from the National Guideline Clearinghouse (NGC)**: In this update
of the guideline, the process previously used to develop the geriatric
nursing protocols has been enhanced.

Levels of evidence (I --VI) are defined at the end of the \"Major
Recommendations\" field.

**Assessment Parameters**

-   Comprehensive functional assessment of elders includes independent
    performance of basic activities of daily living (ADLs), social
    activities, or instrumental activities of daily living (IADLs), the
    assistance needed to accomplish these tasks, and the sensory
    ability, cognition, and capacity to ambulate (Campbell, et al., 2004
    **\[Level I\]**; Doran et al., 2006 **\[Level VI\]**; Freedman,
    Martin, & Schueni, 2002 **\[Level I\]**; Kane & Kane, 2000 **\[Level
    VI\]**; Katz et al., 1963 **\[Level I\]**; Lawton & Brody, 1969
    **\[Level IV\]**; Lightbody & Baldwin, 2002 **\[Level VI\]**;
    McCusker, Kakuma, & Abramowicz, 2002 **\[Level I\]**; Tinetti &
    Ginter, 1988 **\[Level I\]**).

-   Basic ADL

    -   Bathing

    -   Dressing

    -   Grooming

    -   Eating

    -   Continence

    -   Transferring

-   IADLs

    -   Meal preparation

    -   Shopping

    -   Medication administration

    -   Housework

    -   Transportation

    -   Accounting

-   Mobility

    -   Ambulation

    -   Pivoting

-   Elderly patients may view their health in terms of how well they can
    function rather than in terms of disease alone. Strengths should be
    emphasized as well as needs for assistance (Depp & Jeste, 2006
    **\[Level I\]**; Pearson, 2000 **\[Level VI\]**).

-   The clinician should document baseline functional status and recent
    or progressive declines in function. (Graf, 2006 **\[Level V\]**).

-   Function should be assessed over time to validate capacity, decline,
    or progress (Applegate, Blass, & Franklin, 1990 **\[Level VI\]**;
    Callahan et al., 2002 **\[Level VI\]**; Kane & Kane, 2000 **\[Level
    VI\]**).

-   Standard instruments selected to assess function should be efficient
    to administer and easy to interpret. They should provide useful
    practical information for clinicians and should be incorporated into
    routine history taking and daily assessments (Kane & Kane 2000
    **\[Level VI\]**; Kresevic & Holder, 1998 **\[Level VI\]**). (See
    Function topic at [www.ConsultGeriRN.org](http://consultgerirn.org/)
    for tools.)

-   Interdisciplinary communication regarding functional status,
    changes, and expected trajectory should be part of all care settings
    (Counsell et al., 2000 **\[Level II\]**; Kresevic & Holder, 1998
    **\[Level VI\]**; Landefeld et al., 1995 **\[Level II\]**).

-   Multidisciplinary team conferences including patient and family
    whenever possible (Covinsky et al., 1998 **\[Level II\]**; Kresevic
    & Holder, 1998 **\[Level VI\]**).

**Care Strategies**

Strategies to maximize functional status and to prevent decline:

-   Maintain individual\'s daily routine. Help to maintain physical,
    cognitive, and social function through physical activity and
    socialization. Encourage ambulation, allow flexible visitation
    including pets, and encourage reading the newspaper (Kresevic &
    Holder, 1998 **\[Level VI\]**; Landefeld et al., 1995 **\[Level
    II\]**).

-   Educate elders, family, and formal caregivers on the value of
    independent functioning and the consequences of functional decline
    (Graf, 2006 **\[Level V\]**; Kresevic & Holder, 1998 **\[Level
    VI\]**; Vass et al., 2005 **\[Level II\]**).

    -   Physiological and psychological value of independent
        functioning.

    -   Reversible functional decline associated with acute illness
        (Hirsch et al., 1990 **\[Level VI\]**; Sager & Rudberg, 1998
        **\[Level II\]**).

    -   Strategies to prevent functional decline: exercise, nutrition,
        pain management, and socialization (Kresevic & Holder 1998
        **\[Level VI\]**; Landefeld et al., 1995 **\[Level II\]**;
        Tucker, Molsberger, & Clark, 2004; Siegler, Glick, & Lee, 2002
        **\[Level VI\]**).

    -   Sources of assistance to manage decline.

-   Encourage activity including routine exercise, range of motion, and
    ambulation to maintain activity, flexibility, and function (Counsell
    et al., 2000 **\[Level II\]**; Landefeld et al., 1995 **\[Level
    II\]**; Pedersen & Saltin, 2006 **\[Level I\]**).

-   Minimize bed rest (Bates-Jensen et al., 2004 **\[Level VI\]**;
    Covinsky et al., 1998 **\[Level II\]**; Landefeld et al., 1995
    **\[Level II\]**; Kresevic & Holder, 1998  **\[Level VI\]**).

-   Explore alternatives to physical restraints use (Covinsky et al.,
    1998 \[Level II\]; Kresevic & Holder, 1998 **\[Level VI\]**).

-   Judiciously use medications, especially psychoactive medications in
    geriatric dosages (Inouye, 1998 **\[Level III\]**).

-   Assess and treat for pain (Covinsky et al., 1998 **\[Level II\]**).

-   Design environments with handrails, wide doorways, raised toilet
    seats, shower seats, enhanced lighting, low beds, and chairs of
    various types and height (Kresevic et al., 1998 **\[Level VI\]**,
    Cunningham & Michael, 2004 **\[Level I\]**).

-   Help individuals regain baseline function after acute illnesses by
    using exercise, physical therapy consultation, nutrition, and
    coaching (Conn et al., 2003 **\[Level I\]**); Engberg et al., 2002
    **\[Level II\]**; Hodgkinson, Evans, & Woods, 2003 **\[Level I\]**;
    Forbes, 2005 **\[Level VI\]**; Kresevic et al., 1998 **\[Level
    V\]**).

-   Obtain assessment for physical and occupational therapies needed to
    help regain function (Covinsky et al., 1998 **\[Level II\]**).

Strategies to help older individuals cope with functional decline:

-   Help older adults and family members determine realistic functional
    capacity with interdisciplinary consultation (Kresevic & Holder,
    1998 **\[Level VI\]**).

-   Provide caregiver education and support for families of individuals
    when decline cannot be ameliorated in spite of nursing and
    rehabilitative efforts (Graf, 2006 **\[Level V\]**).

-   Carefully document all intervention strategies and patient responses
    (Graf, 2006 **\[Level V\]**).

-   Provide information to caregivers on causes of functional decline
    related to acute and chronic conditions (Covinsky et al., 1998
    **\[Level II\]**).

-   Provide education to address safety care needs for falls, injuries,
    and common complications. Short-term skilled care for physical
    therapy may be needed; long-term care settings may be required to
    ensure safety (Covinsky et al., 1998 **\[Level II**\]).

-   Provide sufficient protein and caloric intake to ensure adequate
    intake and prevent further decline. Liberalize diet to include
    personal preferences (Edington et al., 2004 **\[Level II\]**;
    Landefeld et al., 1995 **\[Level II\]**).

-   Provide caregiver support via community services, such as home care,
    nursing, and physical and occupational therapy services, to manage
    functional decline. (Covinsky et al., 1998 \[**Level II\]**; Graf,
    2006 **\[Level V\]**)

**Definitions**:

**Levels of Evidence**

**Level I**: Systematic reviews (integrative/meta-analyses/clinical
practice guidelines based on systematic reviews)

**Level II**: Single experimental study (randomized controlled trials
\[RCTs\])

**Level III**: Quasi-experimental studies

**Level IV**: Non-experimental studies

**Level V**: Care report/program evaluation/narrative literature reviews

**Level VI**: Opinions of respected authorities/Consensus panels

Reprinted with permission from Springer Publishing Company: Capezuti,
E., Zwicker, D., Mezey, M. & Fulmer, T. (Eds). (2008) *Evidence Based
Geriatric Nursing Protocols for Best Practice*, (3^rd^ ed). New York:
Springer Publishing Company.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=12259)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for selected
recommendations.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

**Patients**

-   Maintain safe level of activities of daily living and ambulation

-   Make necessary adaptations to maintain safety and independence
    including assistive devices and environmental adaptations

-   Highest quality of life despite functional level

**Providers**

-   Increased assessment, identification, and management of patients
    susceptible to or experiencing functional decline. Routine
    assessment of functional capacity despite level of care

-   Ongoing documentation and communication of capacity, interventions,
    goals, and outcomes

-   Competence in preventive and restorative strategies for function

-   Competence in assessing safe environments of care that foster safe
    independent function

**Institution**

-   System-wide incorporation of functional assessment

-   Reduced incidence and prevalence of functional decline

-   Decreased morbidity and mortality rates associated with functional
    decline

-   Reduced use of physical restraints, prolonged bed rest, foley
    catheters

-   Decreased incidence of delirium

-   Increased prevalence of patients who leave hospital with baseline or
    improved functional status

-   Decreased readmission rate

-   Increased early utilization of rehabilitative services (occupational
    and physical therapy)

-   Support of institutional policies/programs that promote function

-   Evidence of geriatric sensitive physical care environments that
    facilitate safe independent function such as caregiver educational
    efforts and walking programs

-   Evidence of continued interdisciplinary assessments, care planning,
    and evaluation of care related to function

#### POTENTIAL HARMS

Not stated

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Chart Documentation/Checklists/Forms

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Safety

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Kresevic DM. Assessment of function. In: Capezuti E, Zwicker D, Mezey M,
Fulmer T, editor(s). Evidence-based geriatric nursing protocols for best
practice. 3rd ed. New York (NY): Springer Publishing Company; 2008 Jan.
p. 23-40. \[48 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 (revised 2008 Jan)

#### GUIDELINE DEVELOPER(S)

Hartford Institute for Geriatric Nursing - Academic Institution

#### GUIDELINE DEVELOPER COMMENT

The guidelines were developed by a group of nursing experts from across
the country as part of the Nurses Improving Care for Health System
Elders (NICHE) project, under sponsorship of The John A. Hartford
Foundation Institute for Geriatric Nursing.

#### SOURCE(S) OF FUNDING

Supported by a grant from The John A. Hartford Foundation.

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Primary Authors*: Denise Kresevic

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Kresevic DM, Mezey M.
Assessment of function. In: Mezey M, Fulmer T, Abraham I, Zwicker DA,
editor(s). Geriatric nursing protocols for best practice. 2nd ed. New
York (NY): Springer Publishing Company, Inc.; 2003. p. 31-46.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Hartford Institute for Geriatric
Nursing Web
site](http://consultgerirn.org/topics/function/want_to_know_more).

Copies of the book *Geriatric Nursing Protocols for Best Practice*, 3rd
edition: Available from Springer Publishing Company, 536 Broadway, New
York, NY 10012; Phone: (212) 431-4370; Fax: (212) 941-7842; Web:
[www.springerpub.com](http://www.springerpub.com/).

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Katz index of independence in activities of daily living (ADL). Try
    this: best practices in nursing care to older adults. 2007.
    Electronic copies available from the [Hartford Institute for
    Geriatric Nursing Web
    site](http://www.hartfordign.org/publications/trythis/issue02.pdf).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on May 30, 2003. The information was
verified by the guideline developer on August 25, 2003. This guideline
was updated by ECRI Institute on June 18, 2008. The updated information
was verified by the guideline developer on August 4, 2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

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approve, or endorse the guidelines represented on this site.

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under the auspices of medical specialty societies, relevant professional
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Guidelines represented on the NGC Web site are submitted by guideline
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<http://www.guideline.gov/about/inclusion.aspx> .

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008