Functional Disability Screening

1. Functional Disability Screening Brenda K. Keller, M..D. Section of Geriatrics, Dept. of Internal Medicine University of Nebraska Medical Center

6. Disability Screening • Two realms of Abilities: • Activities of Daily Living • Instrumental Activities of Daily Living

7. Activities of Daily Living • Activities needed to prepare for the day • Toileting Dressing Bathing Feeding Grooming Ambulation

8. Activities of Daily Living

9. Shopping Transportation Housekeeping Telephone Use Food preparation Laundry Medications Finances Instrumental Activities of Daily Living

10. Instrumental Activities of Daily Living

12. Disability Screening:Who Needs It? • All asymptomatic elderly outpatients Initial Visit Annual H&P • Not done during acute illness

13. 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

14. Vision Hearing Arm & Leg function Urinary Incontinence Mental Status Nutrition Depression Home Safety Social Support Disability Screening:Target Areas

15. Vision • 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

16. Vision Screening • Jaeger card • 14 inches from face • Well lit room, minimize glare • If unable to read 20/40 or better refer to ophthalmologist

17. Hearing • Hearing Loss is prevalent among elderly. • Associated with: isolation, confusion, depression • High frequency hearing loss common • Affects conversation

18. Hearing 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

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

20. Hearing Loss Options for Treatment • Prosthesis: hearing aides • Assistive listening devices • Environmental Changes

21. Hearing Aides

22. Hearing Aides

25. 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

26. Arm Function Screening • Proximal Function“Touch the back of your head with both hands.” • Distal Function “Pick up a pen.”

27. Arm Function Evaluation • If difficulties, then full neuromuscular exam: • pain • Range of motion • weakness

28. Arm Function DisabilityOptions for Treatment • Treat underlying medical condition • Occupational therapy consultation • Assistive devices

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

33. Leg Function Evaluation • If unable to walk or transfer: • full neuromuscular exam, • focus on pain • Range of motion • Balance and Gait

34. Leg Function DisabilityOptions for Treatment • Initiation of exercise program • Physical Therapy consult for:Gait Training, Strengthening Assistive Devices

38. 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

39. Mental 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

40. Mental 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

41. Depression • Affects over 1 million over age 65 • 13% of community dwelling elderly • 25% of all suicides committed by old

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

43. Urinary 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

44. 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

45. Nutrition • Poor nutrition in the elderly can be a reflection of: Concurrent Illness Depression Poor dentition Financial Hardship Inability to shop or cook Inability to feed oneself

46. Nutrition 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

47. Food Pyramid for the Elderly

48. NutritionEvaluation of Weight Loss • H & P • Investigate Abnormalities • Lab evaluation for occult malignancy and metabolic disturbances

49. Home 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.

50. Home Safety Screening • Have you had any falls at home? • Identify potential fall hazards: • # Stairs Throw Rugs Bath rails