# Presentation: 517104

## Thomas Edes, MD, FACP
Geriatrics and Extended Care
VACO

- Geriatrics and Extended Care
- VACO

-           OFFICE   BASED FUNCTIONAL   ASSESSMENT

## Office –Based Functional Assessment

- What is functional assessment?
- Why perform functional assessment?
- How to perform functional assessment in less than 10 minutes?

## WHAT IS FUNCTIONAL ASSESSMENT?

## Domains of Function

**Physical**
**Social**
**Emotional**
**Cognitive**
**Mobility**

**Vocational**
**Sexual**
**Self Care**
**Communication**
**Sensory**

## Domains of Function

**Physical**
**Social**
**Emotional**
**Cognitive**
**Mobility**

**Vocational**
**Sexual**
**Self Care**
**Communication**
**Sensory**

*Think Impairment*

## What is FRAILTY ?

- Weakness?
- Unable to care for self?
- VERY REDUCED ABILITY TO ADAPT TO CHANGE

## ELDERLY AS A SHARE OF     THE POPULATION

-                              		_**1990**__**	**__**	**__**	**__**	**__**2030**_

-   **Age > 65****	****	****33 mil****	****	****	****70 mil**
**	****	****	****	****13%****	****	****	****	****20%**
**Disabilities****	****	****4.9 mil****	****	****	****15 mil**
**Severe Disability****	****1.5 mil****	****	****	****5 mil**
**Nursing Home****	****	****1.4 mil****	****	****	****5 mil**

## ELDERLY AS A SHARE OF THE U.S. VETERAN POPULATION

**	****	****	**_**1990**__**	**__**	**__**	**__**2010**__**	**__**	**__**%Change**_
**Total Veteran ****	****27 mil****	****	****20 mil****	****--  26%      Population **
**Age 65 +****	****	****7.16 mil****	****	****8.5 mil****	****+  19%**
**Age 85 +****	****	****154 k****	****	****	****1.3 mil****	****+  744%**

## WHY IS FUNCTIONAL ASSESSMENT IMPORTANT?

- FUNCTION PREDICTS NURSING HOME NEED AND NURSING HOME MORTALITY

- D. REUBEN, Am J Med 93:663, 1992

-   M. LICHTENSTEIN, JAGS 33:315, 1985

## Why is Functional Assessment Important?

- Function predicts hospital survival better than medical diagnosis does.
- A.Incalzi, J.Am.Gen.Soc. 40:34, 1992
- P.Narain, J.Am.Gen.Soc. 36:775, 1988

## Why is Functional Assessment Important?

- Quality of Life
**Vision**
**Hearing**
**Get yourself out of bed**
**Interaction with others**
**Use telephone**
**Travel**

## What is the biggest fear among the Elderly?

- Medical Illness?
- Death?

## Biggest Fear?

- Loss of Independence
- Becoming a Burden

## VA Continuum of Care

**	****     ****Home-Based****	****      Community**
**	****Primary Care****	****	****   Home Health**
**Occupational ****	****	****	****        Homemaker/Home**
**Therapy****	****	****	**** ****	****	****      Health Aide**
***	******	******      ***_***Independence***_**	****	**** ****Primary**
**Geriatric ****	****	****	****	****             Mental Health &**
**Evaluation****	****	****	****	****	****Specialty Clinics**
**Acute Care ****	****	****	****	****      Subacute Care**
**      ****State Homes****	****	****	****	****Adult Day **
**	****	****	****	****	****	****Health Care**
**	****	****Respite****	****	****Hospice****	****	**
**	****	****	****Nursing Home**

**Notes:**
Home care is one small component of the continuum of care needed by our complex veteran population.  Telehealth may contribute to healthcare delivery for many patient sectors and in a variety of ways.  Marlis and Mike will expand into some of the other areas and needs.

## COMPRESSION OF MORBIDITY

**HTN          MI                     CHF         COPD    AFIB      CVA     PR      CA**

**   ****28               44                        52             55         56           58       62         70**

**HTN                                                                MI                      CHF AFIB  HFX**

**CVA**

**28                                                                   56                        62    67 68  70**

## FUNCTIONAL ASSESSMENT SCREENING POTENTIAL VALUE

**1.Identify those at  risk**
**2.Improve quality of life - independence and function**
**3.Reduce cost of care by prevention of serious injury**
**4.Reduce or delay disability by prevention - compression of morbidity**
**5.Delay nursing home placement**
**6.Improve hospital outcomes**

## AMBULATORY GERIATRIC SCREENING

- What components are often missed in routine exams?
- Visual Impairment
- Hearing Deficit
- Malnutrition
- Cognitive Impairment
- Depression
- Mobility
- Urinary Incontinence
- Physical Disabilities

## HOW LONG WOULD IT TAKE ?

- EVALUATE EVERY NEW ELDERLY PATIENT TO DETERMINE
**VISUAL  IMPAIRMENT**
**HEARING  IMPAIRMENT**
**COGNITIVE  IMPAIRMENT**
**LEG  MOBILITY**
**SEXUAL  DYSFUNCTION**

## HOW LONG WOULD IT TAKE ?

- EVALUATE EVERY NEW ELDERLY PATIENT TO DETERMINE
**SELF-CARE DEFICITS**
**DEPRESSION**
**MALNUTRITION**
**URINARY INCONTINENCE**
**JOINT PAIN LIMITING ACTIVITY**

## Accuracy of Functional Assessment

- Self-Ratings tend to overestimate ability.
- Caregiver ratings tend to underestimate.
- Observation identifies what they CAN do.
- Opportunity demonstrates what they WILL do.

## Focus on Function

- What is Important to the Patient?
- How to Maximize Independence.
- When Are Support Services Needed?

## Key Question...

- Does this ___________ keep you from doing things that are important to you?
- Joint pain
- Chest pain
- Shortness of breath

## FUNCTIONAL DISABILITY SCREENING

- Focused on 8 problems often missed
- Identified or modified known screening measures
- Tested the battery - UCLA Geriatric Clinic
- Moore & Siu, _Am J Med_ 100:438, 1996

## FUNCTIONAL DISABILITY SCREENING

- _METHODS_
**109 Consecutive new patients to geriatric clinic**
**Screened by trained research assistant**
**Routine comprehensive screening by geriatrician **
**unaware of results of initial screen**
- Moore & Siu, _Am J Med_ 100:438, 1996

## FUNCTIONAL DISABILITY SCREENING

- OUTCOMES - AGAINST GOLD STANDARD
**Positive Predictive Value 0.60 to 0.91**
**Negative Predictive Value 0.77 to 0.96**
**COST:  $530 one-time cost  for  equipment  plus  $7  per  patient  screened (10 minutes)**
-       Moore & Siu, _Am J Med_ 100:438, 1996

## FUNCTIONAL DISABILITY SCREENING

- _METHODS OF ASSESSMENT_
**PROBLEM:  VISUAL IMPAIRMENT**
** ****INTERVENTION****	****	****	****	****GERIATRICIAN**
**Q: Do you have difficulty****	****    Snellen Eye Chart **
**driving, watching TV, or****	****       or Jaeger Card**
**reading?**
**If YES, Snellen Eye Chart**
- 	Moore & Siu, _Am J Med_ 100:438, 1996

## FUNCTIONAL DISABILITY SCREENING

- _METHODS OF ASSESSMENT_
- PROBLEM:  HEARING  				**	****	****	****	****	****	****      **_**INTERVENTION**__**	**__**	**__**GERIATRICIAN**_
**	****Audioscope at 40 dB ****	****	****Whisper Test  **
**	****1000 and 2000 Hz**
- Moore & Siu, _Am J Med_ 100:438, 1996

## FUNCTIONAL DISABILITY SCREENING

- _METHODS OF ASSESSMENT__	__	__	_PROBLEM:	COGNITIVE IMPAIRMENT
_**INTERVENTION**__**	**__**	**__**GERIATRICIAN**_
**3 item recall****	****	**** ****	****Folstein  MMSE**
**    ****at 1 minute****	**
- Moore & Siu, _Am J Med_ 100:438, 1996

## FUNCTIONAL DISABILITY SCREENING

- _METHODS OF ASSESSMENT _
- PROBLEM:  LEG MOBILITY
_**INTERVENTION**__**	**__**	**__**GERIATRICIAN**_
**	****Complete within****	****	****Performance- **
**   ****15 sec: rise from ****	****	****based**
**	**** ****chair, walk 20 ft, ****	****	****mobility ****	****	**** return and sit ****	****	****assessment **
**	****	**	 Moore & Siu, _Am J Med_ 100:438, 1996

## FUNCTIONAL DISABILITY SCREENING

**PROBLEM:  PHYSICAL DISABILITY**
_**	**__**INTERVENTION**__**	**__**	**__**	**__**GERIATRICIAN**_
**    “****Yes” if unable to:****	****	****	****Katz ADL:**
**	****Walk fast or bicycle****	****	****	****Toilet**
**	****Do heavy work - wash****	****	****	****Bathe**
**	****windows or floors****	****	****	****	****Feed**
**	****Shop for groceries or clothes****	****	****Dress**
**	****Go beyond walking distance****	****	****Ambulate****	****	****Bathe or shower****	****	****	****Instrumental ADL**
**	****Fully dress**
**	****	****	****	****Moore & Siu, **_**Am J Med**_** 100:438, 1996**

## FUNCTIONAL DISABILITY SCREENING

**PROBLEM:  DEPRESSION**
_**	**__**INTERVENTION**__**	**__**	**__**GERIATRICIAN**_
**     ****Q:  “Do you often feel ****	****	****Yesavage ****	****	****	****  sad or depressed?”****	****	****Depression Scale**
**	****	****	****Moore & Siu, **_**Am J Med**_** 100:438, 1996**
**	****	****	****Mahoney & Drinka, JAGS 42:1006, 1994**

## FUNCTIONAL DISABILITY SCREENING

**PROBLEM:  MALNUTRITION**
_**	**__**INTERVENTION**__**	**__**	**__**GERIATRICIAN**_
**	****1) Have you lost 10 LB****	****	****History and ****	****     ****	****in past 6 months?****	****	****	****Weight**
**	****	****OR**
**	****2) Weight less than 100 LB**
**	****	****	****	****	****	**
**	****	****	****Moore & Siu, **_**Am J Med**_** 100:438, 1996**

## FUNCTIONAL DISABILITY SCREENING

**PROBLEM:  URINARY INCONTINENCE**
_**	**__**INTERVENTION**__**	**__**	**__**GERIATRICIAN**_
**       ****Q: In  past  year, have ****	****	****      History**
**	****you ever had urinary**
**	****leakage?**
**        ****IF YES:**
**	**** ****Has this happened **
**	**** ****at least 6 times?**
**	**
**	****	****Moore & Siu, **_**Am J Med**_** 100:438, 1996**

## BUT CAN WE FIX IT ?

## SUMMARY

- 1.  IF WE FOCUS ON WHAT IS IMPORTANT TO OUR ELDERLY PATIENTS, WE WILL FOCUS ON FUNCTION.
- 2.   Biggest fear is not death, but loss of independence and becoming a burden.
- 3.  Function impacts hospital mortality, NH placement, quality of life, and health care cost.

## SUMMARY

- 4.  Many of the “Missed” domains of assessment in routine physical exam can be assessed in 10 minutes.
- 5.  We can improve many of the functional deficits.
- 6.  You now have the ability to impact quality of life through function.

## Slide 37

## COMPREHENSIVE GERIATRIC ASSESSMENT IN THE HOME

**visits on disability development in community elderly**
_**DESIGN**_**: Randomized controlled trial, 3 years**
**	****	****	****	****AE Stuck, NEJM 333:1184, 1995**

## CGA IN THE HOME

**	****414 community-living elderly  (age **_**>**_** 75 yrs)**
**	****Excluded:****	****Severe cognitive impairment**
**	****	****	****Severe functional impairment**
**	****	****	****Language problems**
**	****	****	****Plans for nursing home care**
**	****	****	****Terminal illness**
**	****	****	****	****AE Stuck, NEJM 333:1184, 1995**

## CGA IN THE HOME

**CGA in the home annually by GNP****	****Gait and Balance**
**Medical History and Examination****	****Vision and Hearing**
**Functional Status****	****	****	****Social Network & Support**
**Cognitive Status****	****	****	****	****Home Safety**
**Oral Health****	****	****	****	****Medications**
**	****	****	****	****	****Body Weight**
**Consultation with Geriatrician for plan**
**Follow-up every 3 months**
**	****	****AE Stuck, NEJM 333:1154, 1995**

## CGA IN THE HOME

**Higher functional status scores (p < .03)**
**Fewer patients admitted to long-term**
**NH4% vs. 10%, p = .02**
**No difference in acute CARF admissions**
**	****	****AE Stuck, NEJM 333:1184, 1995**

## SELF-ADMINISTERED FUNCTIONAL ASSESSMENT

**Dartmouth COOP Charts**
**Cartoon figures depicting functions and levels**
**Assess physical, emotional, social, health change, daily routine/work, overall condition**
**E.C. Nelson, **_**Med Care**_** 27:S77-90, 1989**

## SELF-ADMINISTERED FUNCTIONAL ASSESSMENT

**OUTCOMES:****	**
**Increased orders for tests in women**
**Increased help for pain-related impairments****	****in men**
**E.C. Nelson, **_**Med Care**_** 27:S77-90, 1989**

## SELF-ADMINISTERED FUNCTIONAL  ASSESSMENT

- FSQ = Functional Status Questionnaire
- 34 items, computer scored
- Assesses physical, psychological, social, functional
- General Internists trained in use (2 hrs)
- OUTCOME:  No impact on physician management
- A.M. Jette, J Gen Int Med 1:143, 1986

## WHY HAVE FUNCTIONAL ASSESSMENT SCREENS FAILED?

- Information to physicians broad and nonspecific
- Physicians have difficulty recognizing the impact of functional impairments (physical, social, emotional) on daily routine

## AMBULATORY GERIATRIC SCREENING

- What components are often missed in routine exams?
- Visual Impairment
- Hearing Deficit
- Malnutrition
- Cognitive Impairment
- Depression
- Mobility
- Urinary Incontinence
- Physical Disabilities