Optimizing functional status in the elderly

Functional status is measured by the ability of people to perform basic and instrumental activities of daily living (ADLs). Basic activities of daily living (BADLs) consist of self-care tasks and include feeding, bathing, dressing, using the toilet, personal hygiene, ability to transfer from bed to chair and back again, and walking. [1] Katz S, Ford AB, Moskowitz RW, et al. Studies of illness in the aged: the index of ADL, a standardized measure of biological and psychosocial function. JAMA. 1963;185;914-919. http://www.ncbi.nlm.nih.gov/pubmed/14044222?tool=bestpractice.com Instrumental activities of daily living (IADLs) allow a person to live independently in a community. They include the ability to use the telephone, perform housework and laundry, shop, prepare meals, manage finances, take medications, and arrange appropriate transportation. [2] Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9:179-186. http://www.ncbi.nlm.nih.gov/pubmed/5349366?tool=bestpractice.com More advanced ADLs include hobbies and leisure activities.

Information on functional status can be obtained during a patient interview and typically does not require a questionnaire. Screening for geriatric syndromes helps to identify risk factors for and causes of functional impairment. Identification of such syndromes and initiation of appropriate assessment and management strategies may also foster preservation of function. Several validated screening tools have been published to screen for many of these syndromes:

• Delirium: Confusion Assessment Method (CAM), Richmond Agitation Sedation Scale (RASS)

• Dementia: Short Portable Mental Status Questionnaire, AD8, Mini-Cog

• Depression: Geriatric Depression Scale, PHQ-9, Cornell Scale for Depression in Dementia

• Malnutrition: Mini Nutritional Assessment (MNA)

• Pain: Verbal Pain Descriptors, Pain Thermometer, Faces Scale for Pain

• Falls: Get-Up-and-Go (timed and modified), Single Limb Stance Test, Functional Reach. [3] American Geriatrics Society. AGS/BGS clinical practice guideline: prevention of falls in older persons. 2010. http://www.medcats.com/ (last accessed 19 December 2016). http://www.medcats.com/FALLS/frameset.htm

Functional decline in and of itself should not be considered a geriatric syndrome but rather an indicator of the negative impact that geriatric syndromes and acute/chronic medical conditions may have on an individual. Threats to functional independence arise from physical and cognitive limitations as a process of normal aging or the accumulation of chronic illness. Management of chronic illness is a key factor in preserving function. To optimize function as a result of the aging process, physical and cognitive interventions may be used when possible. Counseling patients regarding exercise and following up with them regularly has been shown to have a positive effect on mobility and helps preserve independence in community-dwelling elders. [4] Mänty M, Heinonen A, Leinonen R, et al. Long-term effect of physical activity counseling on mobility limitation among older people: a randomized controlled study. J Gerontol A Biol Sci Med Sci. 2009;64A:83-89. http://biomedgerontology.oxfordjournals.org/content/64A/1/83.full http://www.ncbi.nlm.nih.gov/pubmed/19164270?tool=bestpractice.com In one meta-analysis, participation in exercise was shown to increase gait speed, balance, and performance in ADLs in frail older adults. [5] Chou CH, Hwang CL, Wu YT, et al. Effect of exercise on physical function, daily living activities, and quality of life in the frail older adults: a meta-analysis. Arch Phys Med Rehabil. 2012;93:237-244. http://www.ncbi.nlm.nih.gov/pubmed/22289232?tool=bestpractice.com Physical interventions include regular exercise, balance training, participation in resistance training, and endurance training. Cognitive interventions include participating in leisure activities and in cognitively stimulating activities (cognitive training). Despite the focused nature of many of these activities, their benefits may overlap. For example, participating in cardiovascular physical activities may also benefit cognitive function. [ ] In people without known cognitive impairment, does aerobic exercise help to maintain good cognitive function? /cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.886/full Show me the answer The evidence for many of the interventions remains unclear, and longitudinal studies are required. However, given the potential benefit of preserving and optimizing the functional status of older people, there appears to be limited risk in implementing these interventions. Guidelines supporting such interventions have been published. [6] National Institute for Health and Care Excellence. Mental wellbeing in over 65s: occupational therapy and physical activity interventions. October 2008. https://www.nice.org.uk/ (last accessed 19 December 2016). https://www.nice.org.uk/guidance/PH16