Functional Disability ScreeningFunctional Disability Screening

Brenda K. Keller, M..D.Section of Geriatrics, Dept. of Internal Medicine

University of Nebraska Medical Center

Disability ScreeningDisability Screening

Two realms of Abilities:

Activities of Daily Living Instrumental Activities of Daily Living

Activities of Daily LivingActivities of Daily Living

Activities needed to prepare for the day Toileting

DressingBathingFeedingGroomingAmbulation

Activities of Daily LivingActivities of Daily Living

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Instrumental Activities of Daily LivingInstrumental Activities of Daily Living Shopping Transportation Housekeeping Telephone Use

Food preparation Laundry Medications Finances

Instrumental Activities of Daily LivingInstrumental Activities of Daily Living

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Disability Screening:Who Needs It?Disability Screening:Who Needs It?

All asymptomatic elderly outpatientsInitial Visit Annual H&P

Not done during acute illness

Disability Screening:What do we Want?Disability Screening:What do we Want? Incorporate into General Exam Target Common problems Keep it simple Screens should be of high yield Clear next step to treatment

Disability Screening:Target AreasDisability Screening:Target Areas

Vision Hearing Arm & Leg

function Urinary

Incontinence

Mental Status Nutrition Depression Home Safety Social Support

VisionVision

Visual impairment, particularly from decreased accommodation and cataracts, is more common with age.

Role of the primary care MD is identification of vision loss and f/u of care plan outlined by eye specialist

Vision ScreeningVision Screening

Jaeger card 14 inches from face Well lit room, minimize glare If unable to read 20/40 or better refer to

ophthalmologist

HearingHearing

Hearing Loss is prevalent among elderly. Associated with: isolation, confusion,

depression High frequency hearing loss common Affects conversation

Hearing ScreeningHearing Screening

Whisper Test: consistent with a 30 Db. Loss. Validated against audiometry

Stand 2 feet behind patient and whisper a series of 3 numbers into each ear

Hearing ScreeningHearing Screening

If unable to respond: check for wax Wax in ears: remove and repeat test If still fails -- refer for audiogram

Hearing Loss Options for Treatment Hearing Loss Options for Treatment

Prosthesis: hearing aides Assistive listening devices

Environmental Changes

Hearing Aides

Hearing Aides

Arm Function Decrease in arm function leads to difficulty

Gross tasks such as dressing, Fine tasks such as writing and eating

Community dwelling elderly, this increases reliance on family, formal services

Arm Function ScreeningArm Function Screening

Proximal Function“Touch the back of your head with both hands.”

Distal Function “Pick up a pen.”

Arm Function Evaluation If difficulties, then full neuromuscular

exam: pain Range of motion weakness

Arm Function DisabilityOptions for TreatmentArm Function DisabilityOptions for Treatment

Treat underlying medical condition

Occupational therapy consultation Assistive devices

Leg Function Screening Get Up and Go Patient arises from chair, walks 10 ft., turns

& returns to chair

Leg Function Evaluation If unable to walk or transfer: full neuromuscular exam,

focus on pain Range of motion Balance and Gait

Leg Function DisabilityOptions for TreatmentLeg Function DisabilityOptions for Treatment

Initiation of exercise program Physical Therapy consult for:Gait

Training, StrengtheningAssistive Devices

Mental Status Dementia is the most common important

disturbance in mental status in elderly persons Older people compensate well for the problem,

so it may be missed if not specifically tested Short term memory and calculations are sensitive

indicators of cognitive decline

Mental Status ScreeningMental Status Screening

Three item recall Names of three items presented to pt. Pt. asked to repeat 3 items immediately and

remember them for later Recall at 1 minute If unable to recall any at 1 minute, then

MMSE

Mental StatusFurther EvaluationMental StatusFurther Evaluation Folstein MMSE < 24 Ascertain onset, duration, and fluctuation of

overt symptoms Complete Neuro Exam Assess Affect, level of consciousness Med review, appropriate lab, x-ray

DepressionDepression

Affects over 1 million over age 65

13% of community dwelling elderly

25% of all suicides committed by old

Depression ScreeningDepression Screening

Do you often feel sad or depressed? If yes, then: Geriatric Depression Scale Score > 10 Check meds, labs. Consider

counseling or antidepressant Rx.

Urinary IncontinenceUrinary Incontinence

Ten million Americans suffer from urinary incontinence

30% of community dwelling elderly 50% of people in Nursing Facilities Over half of those afflicted have had no

treatment or evaluation 75-90% of individuals can be helped

Urinary IncontinenceScreening Urinary IncontinenceScreening Ask “Do you ever lose urine and get wet? If yes, then: Ascertain frequency, amount,

circumstances, time of day Look for acute reversible causes for

incontinence

NutritionNutrition

Poor nutrition in the elderly can be a reflection of:

Concurrent IllnessDepressionPoor dentitionFinancial HardshipInability to shop or cookInability to feed oneself

Nutrition ScreeningNutrition Screening

Have you lost more than 10 lbs in the past year.?

If yes, or if appears of low body weight, then:

Evaluate intake with food diaries If inadequate, dietitian to see If adequate, evaluate for medical cause

Food Pyramid for the Elderly

NutritionEvaluation of Weight Loss NutritionEvaluation of Weight Loss H & P Investigate Abnormalities Lab evaluation for occult malignancy

and metabolic disturbances

Home SafetyHome Safety

Environmental hazards lead to increased risk of falls

Hip Fx in 1% of falls in community dwellers and 5% of NH residents

Falls cause 70% of accidental deaths Stairs and bathrooms are likely sites for

falls.

Home Safety ScreeningHome Safety Screening

Have you had any falls at home?

Identify potential fall hazards: # Stairs Throw Rugs Bath rails

Home Safety EvaluationHome Safety Evaluation OT or PT Home

visit to identify and change hazards

Supply patient or family with safety checklist

Social SupportSocial Support

Degree of social support has been associated with survival, morbidity and quality of life

Breadth and depth of social circle are important factors in determining need for formal support

ID of potential caregivers in the medical record facilitates interactions

Social Support ScreeningSocial Support Screening

Who would be able to help you in case of illness or emergency?

Who would make health decisions for you if you were unable to make them for yourself?

Inquire about current advanced directives Document these individuals in the medical record Become familiar with community services for the

elderly

Helping the Elderly Stay ActiveConclusionsHelping the Elderly Stay ActiveConclusions Functional Disability is common in the

elderly Search of Target areas for disability can

lead to early identification and Rx Screens can be easily incorporated into H &

P or can be done by office personnel prior to MD visit