1. 
   

   How is functional ability assessed?

   
   
2. 
   

   What is functional decline?

   
   
3. 
   

   What are the risk factors for developing functional decline?

   
   
4. 
   

   How does hospitalization contribute to functional decline?

   
   
5. 
   

   How can functional decline be prevented?

Approximately 30% of people living in the community that are older than 65 fall each year and more than half of these people will fall again. The yearly costs for acute hospital care for fall-related fractures are estimated in the billions in the United States; and lifetime costs associated with fall injuries for this age group is rising as the U.S. population ages. Falls are the 6th leading cause of death and a common reason for loss of independent living. Some of these falls occur within 30 days of admission to the hospital, and may be the result of deconditioning that occurred during the index hospitalization.

Many hospital environments are not designed for maintaining or improving patient function. Hospitalization is often associated with bed rest, decreased mobility, sleep deprivation, and poor nutritional intake. These factors can cause a cascade of events that reduce functional ability in a patient of any age including a decrease in cardiovascular conditioning. Older patients, in particular, tend to be more vulnerable to functional disability and are particularly susceptible to loss of functional independence during hospitalization. This frequently results in placement upon discharge in nursing facilities, sometimes for short-term rehabilitation, but often for long-term residence.

Today, approximately half of all hospitalized adults are over the age of 65 and this proportion will likely increase as the overall number of elderly increases. Mitigating the factors that contribute to functional decline during hospitalization will improve the quality of care provided to patients, reduce readmissions, and decrease the disability and cost that extends well beyond hospitalization.

Inpatient physicians should perform a functional assessment on all patients. Oftentimes, it is inferred—a middle-aged mother of three admitted for gallstones is assumed to be independent. A 60-year-old employed carpenter with angina is assumed to be fully independent. These assumptions are usually right. However, as patients age, assumptions are often incorrect. Clinicians may care for a 72-year-old fully dependent nursing home resident and at the same time care for a 94-year-old fully independent resident living at home alone.

There is no all-purpose test to determine a patient’s functional abilities. Rather, clinicians must rely upon yes/no questions around specific tasks as well as bedside assessment tools.

Several assessment tools have been developed to aid clinicians in determining a patient’s functional status (Table 168-1). The Activities of Daily Living (ADLs) have been used for the past 30 years to assess a patient’s ability to feed and clean themselves, dress, transfer from bed to chair, maintain continence, and toilet independently. The Instrumental Activities of Daily Living (IADLs) include the ability to use the telephone, take transportation, manage finances, shop, cook, clean, do laundry, and take medications.

While ADLs and IADLs can give a clinician a good sense of how a patient functions with life tasks, clinicians should also assess gait, hearing, vision, and nutritional status. The Get Up and Go Test is useful to determine how well a patient can walk. Ask the patient to stand from a seated position without using her arms, walk 10 feet, turn around, and return to the chair and sit down. The inability to get up without using one’s arms, trouble with balance or turning, using adaptive devices, or taking longer than 15 seconds are markers for increased risk of falling. Also note whether these tests are associated with an abnormal cardiac response: systolic blood pressure drops or heart rate increases abnormally. Orthostatic changes from the sitting to standing position are likely to have a negative impact on the patient’s mobility. Likewise, for a patient with lung disease, significant hypoxia during walking should be noted and corrected.

Gross testing of auditory and visual acuity can be easily performed at the bedside. Test vision at the bedside with the Snellen chart. Assess hearing with the Whisper Test.

While physical function is important, a cognitive evaluation should also be performed. A patient’s cognitive function is critical to understanding whether the patient will be able to adhere to recommended therapies, participate in informed consent, and take prescribed medications correctly. Clinicians should not make assumptions about a patient’s cognitive ability since there can be wide variations that are not predicted by age or other factors. Chapter 165 addresses formal assessment of cognition.

A patient’s nutritional status impacts physical and cognitive function. For instance, poor nutritional status negatively impacts immune function. All patients should be screened for malnutrition by calculating their body mass index (BMI) and should be questioned about weight loss and access to food. See Chapter 54.