Comprehensive Functional Assessment for Geriatric Nursing lecture notes (completed)

Definition and Goals of Comprehensive Functional Assessment (CFA)

• Definition of CFA: Comprehensive Functional Assessment (also known as Comprehensive Geriatric Assessment or CGA) is an exhaustive evaluation of an individual's capacity to perform basic self-care tasks and the necessary activities required for independent living.

• Current Statistics on Functional Decline: Functional decline is more prevalent as age advances.

  • $20\%$ of older individuals aged $65+$ years require assistance with Activities of Daily Living (ADLs).

  • $45\%$ of older individuals aged $85+$ years require assistance with ADLs.

• Primary Goals:

  • To improve functional status and individual independence.

  • To enhance the overall quality of life for the older adult.

Common Myths Regarding Functional Ability in Older Adults

• Myth 1: The number of conditions listed on a patient's problem list directly correlates with their degree of functional status.

• Myth 2: Objective indicators of health are the definitive indicators of a person's actual ability.

• Myth 3: The severity of a disease determines the presence or extent of functional impairment.

• Myth 4: All problems experienced by the elderly are simply the natural result of aging or having lived a long life.

Methodologies and Strategies for Performance

• Performance Standard: Functional assessments must be evidence-based and use well-validated, standardized instruments.

• Functions of Assessment Instruments: These tools provide objective measures to screen, describe, monitor, and predict a patient's ability to perform activities essential for daily living.

• Professional Conduct and Strategies:

  • Self-introduction and stating the purpose of the assessment.

  • Addressing the patient by their last name.

  • Facing the patient directly during communication.

  • Conducting the assessment in a well-lit room.

  • Minimizing extraneous noise and interruptions.

  • Inquiring about potential hearing deficits.

  • Allowing ample time for the patient to provide answers.

Comprehensive Functional Assessment (Comprehensive Geriatric assessment)

• A thorough evaluation of a person’s ability to carry out basic tasks for self-care and tasks needed to support independent living.

• Goal of Comprehensive functional assessment:

  • To improve functional status and independence and enhance quality of life.

• How are functional assessments performed?

  • Evidence-based, well-validated standardized functional assessments are used to screen, describe, monitor, & predict one’s ability to perform activities or tasks needed for daily living.

  • Assessment instruments/tools provide:

    • objective measures of the major components of a comprehensive

    • functional assessment.

• Important assessment strategies:

  • Introduce yourself and purpose

  • Address the pt. by last name

  • Face the pt. directly

  • Use a well lit room

  • Minimize extraneous noise

  • Inquire about hearing deficits

  • Minimize interruptions

  • Allow ample time for pt. to answer

Major Components of a Comprehensive Assessment

• Physical Functioning: Assessment of basic and complex movements and health.

• Cognitive Status: Evaluation of mental processing and memory.

• Psychological and Spiritual Status: Assessment of mood, mental health, and belief systems.

• Social Functioning and Support: Evaluation of family dynamics and economic resources.

• Environmental Characteristics: Assessment of the home and surrounding safety.

Multidimensional Assessment Instruments

• Older Americans Resources and Services (OARS) / OMFAQ:

  • Developed at Duke University Center for Study of Aging and Human Development.

  • Updated as the OARS Multidimensional Functional Assessment Questionnaire (OMFAQ).

  • Evaluates ability, disability, functional capacity, and resource utilization.

  • Five Subscales: 1. ADL/IADL, 2. Physical Health, 3. Mental Health, 4. Social Resources, 5. Economic Resources.

  • Rating System: Function is rated from $1$ (excellent) to $6$ (totally impaired).

  • Cumulative Score: Ranges from $6$ to $30$.

  • Administration Time: Approximately $45$ minutes.

  • Requires purchase of the tool and specific training.

• Nursing Facility Resident Assessment Instrument (RAI) - Minimum Data Set (MDS 3.0):

  • Mandated by CMS (Centers for Medicare \& Medicaid Services) for all residents in Medicare/Medicaid approved nursing homes and Skilled Nursing Facilities (SNF).

  • Requirement Intervals: Within $14$ days of admission, upon major permanent change in condition, quarterly (selected items), and annually.

  • Protocols Evaluated: Cognitive ability, communication/hearing, vision, mood/behavior, psychosocial well-being, oral/nutritional status, ADL function/rehab, skin/foot care, urinary incontinence, pressure ulcers, specific treatments, medications, and falls.

  • RN Responsibilities: Coordination, delegation, and attestation of completion.

  • Purpose: Care planning, quality improvement, and Medicare reimbursement.

• Outcomes and Assessment Information Set (OASIS D):

  • Used for patients receiving skilled care in the home setting.

  • Effective version as of January 1, 2019.

  • Includes measurement of functional, behavioral, physical status, and service utilization.

  • Focuses on nursing interventions to improve post-acute care, prevent re-hospitalization, and ensure home safety (e.g., falls, medications, weight loss).

  • Information is transmitted directly to CMS.

Physical Assessment Tools and Mnemonics

• FANCAPES (Basic Function Assessment):

  • F: Fluids.

  • A: Aeration and circulation.

  • N: Nutrition.

  • C: Communication.

  • A: Activity.

  • P: Pain.

  • E: Elimination.

  • S: Social skills.

• SPICES (Common Geriatric Syndromes):

  • S: Sleep disorders.

  • P: Problems with eating or feeding.

  • I: Incontinence.

  • C: Confusion.

  • E: Evidence of falls.

  • S: Skin breakdown.

  • Overall assessment for healthy or frail elders

  • Useful in acute, skilled nursing, long-term care facilities or in one’s home.

  • Assesses six common syndromes of the elderly that require nursing intervention

  • Ref Reference: Nurses are encouraged to carry a $3 \times 5$ card as a reference for these syndromes.

• Physical assessment:

  • History & Physical Exam

  • Activities of Daily Living (ADL)

  • Instrumental Activities of Daily Living (IADL)

  • Tinetti Balance & Gait

  • Timed Get Up & Go Test

  • One Leg Stand

  • Functional Reach

  • Fall Risk Assessment

  • Nutrition

• Katz ADL Scale: Measures basic activities: Eating, Bathing, Dressing, Toileting, Transferring, and Urine & Bowel Continence.

• Lawton IADL Scale: Measures instrumental activities: Telephone Use, Shopping, Food Preparation, Housework, Transportation, Medication Use, and Money Management.

Mobility and Fall Risk Assessment

• Timed Get Up & Go (TUG):

  • Procedure: Stand from a chair, walk $10$ feet, turn, walk back, and sit down.

  • Normal performance: < 10 seconds.

• Tinetti Balance & Gait Assessment:

  • Balance Section: Evaluates sitting balance, rising from chair, standing balance ($first 5 seconds$), narrow stance, nudge response, eyes closed, turning $360$ degrees, and sitting down. Max points: $16$.

  • Gait Section: Evaluates indication of gait (hesitancy), step length/height, step symmetry, continuity, path, trunk sway, and walking time. Max points: $12$.

  • Risk Scoring:

    • $\text{High Risk} \le 18 \text{ points}$

    • $\text{Moderate Risk} = 19-23 \text{ points}$

    • $\text{Low Risk} \ge 24 \text{ points}$

  • Total potential combined points: $28$.

• Hendrich II Fall Risk Model:

  • Used to determine high fall risk ($\text{Score} \ge 5$).

  • Factors:

    • Confusion/Disorientation/Impulsivity: $4$

    • Symptomatic Depression: $2$

    • Altered Elimination: $1$

    • Dizziness/Vertigo: $1$

    • Male Gender: $1$

    • Antiepileptics administered: $2$

    • Benzodiazepines administered: $1$

    • Get Up \& Go Test: $0-4$ range based on ability to rise.

Nutritional Assessment Instruments

• Nutrition Screening Initiative (DETERMINE Your Nutritional Health; Used mainly outpatient):

  • Checklist items: Illness affecting food, < 2 meals/day, few fruits/veg/milk, $3+$ drinks daily, tooth/mouth problems, lack of money for food, eating alone, $3+$ drugs/day, weight change of $10$ lbs in $6$ months, physically unable to shop/cook.

  • Scoring:

    • $0-2$: Good.

    • $3-5$: Moderate nutritional risk.

    • $\ge 6$: High nutritional risk.

• Mini Nutritional Assessment (MNA; Used more inpatient/hospital):

  • Screening components: Decline in food intake, weight loss, mobility, psychological stress/acute disease, neuropsychological problems, and BMI.

  • Calf Circumference (CC): If BMI is unavailable, CC is used (\text{CC} < 31 \text{ cm} = 0, \text{CC} \ge 31 \text{ cm} = 3).

  • Scoring (Max 14):

    • $12-14$ points: Normal nutritional status.

    • $8-11$ points: At risk of malnutrition.

    • $0-7$ points: Malnourished.

Cognitive Assessment Tools

• Executive functioning: Ability to plan, problem solve, organize, strategize, pay attention, and manage details.

• Folstein Mini-Mental Status Exam (MMSE): Includes Orientation, Registration, Attention/Calculation (Serial $7$s or spelling "world" backward), Recall, and Language (naming objects, repeating phrases, $3$-stage commands, reading/writing, copying design).

• The Mini Cog: Involves a three-item word recall and a clock-drawing test (serving as an informative distractor).

  • $\text{Recall } 0 = \text{ Demented}$

  • $\text{Recall } 3 = \text{ Nondemented}$

  • $\text{Recall } 1-2 + \text{ Abnormal Clock} = \text{ Demented}$

  • $\text{Recall } 1-2 + \text{ Normal Clock} = \text{ Nondemented}$

• Clock Drawing: Screening for dementia and testing constructional apraxia, visual-spatial skills, abstract thinking, numerical knowledge, and motor execution.

• Time & Change Test: Tell time on a clock set to $11:10$; count out $\$1.00$ in change using $3$ quarters, $7$ dimes, and $7$ nickels.

• Montreal Cognitive Assessment (MoCA): Screens for Mild Cognitive Impairment (MCI) and early Alzheimer's. Assesses attention & concentration, executive functions, memory, language, visuo-constructional skills, conceptual thinking, calculations, & orientation.

  • Max score: $30$.

  • $\text{Normal} \ge 26$.

  • $\text{MCI range} = 19 - 25.2$.

  • $\text{Alzheimer's range} = 11.4 - 21$.

  • Education adjustment: Add $2$ points for $4-9$ years of education; add $1$ point for $10-12$ years.

• Saint Louis University Mental Status (SLUMS): More sensitive than MMSE for detecting MCI and dementia. Free to use.

  • Normal score (High School Education): $27-30$.

  • Normal score (Less than High School): $25-30$.

• Functional Assessment Staging Tool (FAST): Stages of decline from $1$ (No difficulty) to $7$ (Loss of ability to smile, hold up head, or walk).

• Confusion Assessment Method (CAM): Assessment for delirium.

  • Diagnosis suggested if: Both components of Box 1 (Acute onset/fluctuating course and Inattention) are present AND at least one item from Box 2 (Disorganized thinking or Altered level of consciousness) is present.

Psychological, Spiritual, and Social Assessment

• Geriatric Depression Scale (GDS): Short ($15$-item) and long ($30$-item) forms assessing life satisfaction, activities, boredom, and feelings of helplessness.

• Caregiver Strain Index: $13$ Yes/No items including sleep disturbance, physical/emotional strain, behavior concerns, and financial adjustments.

• FICA Spiritual History Tool:

  • F: Faith and Belief.

  • I: Importance.

  • C: Community.

  • A: Address in care.

• Jarel Spiritual Well-Being Scale: $21$ items using a Likert scale.

• Stoll's Guidelines for Spiritual Assessment: $17$ open-ended questions covering the Concept of God, Sources of Hope/Strength, Religious Practices, and Relationship between beliefs and health.

• Family APGAR: Measures satisfaction with family help, communication, support of new activities, affection, and shared time.

Environmental, Sleep, and Skin Assessment

• Home Safety Checklist: Includes Lighting, Floors, Kitchen Appliances, Rugs & Extension cords, Furniture, Temperature/Ventilation, Bathroom grab bars, Outdoor areas, and Footwear.

Examples of tools to use as trigged by SPICES:

• S - The Pittsburgh Sleep Quality Index (PSQI)

• P - Mini Nutritional Assessment (MNA) or Nutrition Screening Initiative

• I - Urinary Incontinence Assessment in Older Adults –Part I (Transient) or Part 2     (Established)

• C - Mental Status Assessment (MMSE, Mini Cog, MoCA, CAM)

• E - Fall Risk Assessment (Hendrich II or other)

• S - Pressure Ulcer Risk Assessment   

• Pittsburgh Sleep Quality Index (PSQI): Measures subjective sleep quality, latency, duration, efficiency, disturbances, medication use, and daytime dysfunction.

  • Total score of $5$ or greater indicates poor sleep quality.

• Urinary Incontinence Tools:

  • UDI-6 (Urogenital Distress Inventory): Focuses on symptoms like frequent urination and leakage.

  • IIQ-7 (Incontinence Impact Questionnaire): Measures impact on travel, social activities, and emotional health.

• Braden Scale (Pressure Sore Risk):

  • Categories: Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction & Shear.

  • Each category scored $1-4$ (except Friction & Shear which is $1-3$).

Clinical Outcomes of Comprehensive Functional Assessment

• Reduced hospital use.

• Reduced mortality rates.

• Improved mental status.

• Consumption of fewer medications.

• Improved functional ability.

• Lower hospital readmission rates.