FUNCTIONAL CHANGES WITH AGING

Physical functioning, to a great degree, is a requirement for many facets of day-to-day life. For older adults, physical functioning may impact the ability to live alone, where they are able to live, and what amount of assistance is required regardless of living setting. Older adults often define their level of health in terms of how they are physically functioning, i.e., their ability to carry out their normal daily functions.

Alterations in coordination (the ability to execute smooth, accurate, controlled motor responses) occur with aging, including:

• Diminished strength, with greater loss in the muscles of the back and lower extremities and greater loss in the proximal rather than distal muscles
• Slowed reaction time and speed decreases in order to ensure greater accuracy
• Decreased range of motion for multiple joints
• Postural changes that are involved in fall avoidance and successful task engagement

Age-related sensory changes also include altered postural stability and control, diminished response to tactile stimuli, and proprioceptive acuity. These may create a variety of activity limitations in older adults due to:

• Postural instability
• Exaggerated body sway
• Balance problems
• Wide-based gait
• Diminished fine-motor coordination
• Tendency to drop items
• Difficulty in recognizing body position in space

Activity limitations are difficulties an individual may have executing tasks or actions. These can include:

• Cognitive and learning skills
• Communication skills
• Functional mobility skills
• Activities of daily living (ADLs) that include basic self-care
  (O’Sullivan et al., 2019)

Participation restrictions are problems with being involved in daily life situations and societal interactions, including those referred to as instrumental activities of daily living (IADLs), and may include:

• Home management
• Work
• Community/leisure

Performance restrictions involve what a person is able to do in their current living environment, which may require the use of assistive devices or personal assistance (O’Sullivan et al., 2019).

Functional Assessment

Functional assessment is a vital part of a comprehensive geriatric assessment, and various components of the evaluation are completed by different members of the healthcare team. A complete geriatric functional assessment includes:

• Assessing the patient’s physical ability to perform daily activities required to meet basic needs, fulfill usual roles, and maintain health and well-being
• Screening for cognitive impairment
• Screening for depression
• Evaluating gait instability and/or fall risk
• Evaluating for communication barriers
• Assessing urinary and fecal continence
• Assessing oral health
• Assessing skin for bruises, wounds, and other signs of skin breakdown
• Assessing nutritional status
• Evaluating for pain
• Addressing polypharmacy
• Assessing social and financial support
• Evaluating for vision or hearing difficulties
  (Ward & Reuben, 2020)

PHYSICAL ASSESSMENT TOOLS

SPICES and FANCAPES are two assessment tools that are part of a comprehensive geriatric physical assessment.

The acronym SPICES refers to six common geriatric syndromes that require interventions (see table).

SPICES PHYSICAL ASSESSMENT

	Geriatric Syndrome
S	Sleep disorders
P	Problems with eating or feeding
I	Incontinence
C	Confusion
E	Evidence of falls
S	Skin breakdown

FANCAPES is a model for the comprehensive physical assessment of the older adult. This model of assessment focuses on the patient’s basic needs and ability to function independently and is designed for use by various members of the healthcare team (see table).

FANCAPES PHYSICAL ASSESSMENT

Area	Assessed By	Assessment Questions
(Devney, 2018)
F (Fluids)	Registered nurse	What is the patient’s current fluid status? Is the patient able to drink adequate fluids throughout the day? Does the patient have barriers or circumstances that would affect fluid intake or balance (e.g., swallowing problems, diuretic use, cognitive impairments, kidney function)?
A (Aeration)	Respiratory therapist	What is the patient’s oxygen exchange (goal is O2 saturation of at least 96%)? What is the patient’s respiratory rate at rest, while talking, and during activity? Do breath sounds indicate any signs of pneumonia?
N (Nutrition)	Dietitian/nutritionist	What is the patient’s usual food intake? Is the patient able to chew and swallow well? Is the patient on any special diet?
C (Communication)	Speech therapist	Can the patient communicate their needs well? Does their caregiver understand them well? What is the patient’s level of hearing? Is the patient able to speak and be understood (any aphasia)? What is the patient’s literacy level?
A (Activity)	Physical therapist	Is the patient able to meet their basic needs (ADLs)? How much assistance do they need and with what activities? Is the patient able to meet higher level needs for activities (e.g., social outings, attending church)? What is the patient’s level of coordination, balance, dexterity, and strength?
P (Pain)	Palliative care nurse	Is the patient experiencing any level of pain (physical, psychological, or spiritual)? Is the patient able to express pain and their needs for pain relief? How does the patient normally treat their pain? Does the patient have cultural barriers to pain expression?
E (Elimination)	Nurse/occupational therapist	Is the patient having any problems with bladder or bowel function? Are their environmental barriers to adequate toileting (e.g., location of bathroom from bedroom)? Does the patient need any assistive devices in the bathroom (e.g., toilet seat riser, bedside commode)?
S (Socialization and social skills)	Social worker	Is the patient able to negotiate relationships within their family and social circles? Does the patient have a sense of self-worth within their world? Is the patient involved in hobbies or interests outside of their home environment?

FUNCTIONAL ASSESSMENT TOOLS

Whereas the emphasis in FANCAPES and SPICES is on physical criteria and those associated with geriatric syndromes, a full functional assessment is broader and evaluates the person’s ability to carry out basic tasks for self-care and tasks needed to support independent living. The purpose of functional assessment is to focus on identification of pertinent activities and measurement of the person’s ability to successfully engage in them. It is important to know the person’s baseline functional status and to make comparisons over time.

Functional testing is used to measure how a person does certain tasks or fulfills certain roles. It includes performance-based tests that involve observing the patient performing an activity and self-reports in which the patient is asked directly.

The Functional Status Questionnaire (FSQ)is a functional assessment tool that provides information about the patient’s physical, psychological, social, and role functions. Areas of assessment include:

• Activities of daily living
• Mental health
• Negative affect
• Depression
• Stress and coping
• Occupational performance
• Social support
• Social relationships
• Life participation
• General health
• Quality of life
  (Abilitylab, 2020)

The Functional Independence Measure (FIM) is an 18-item performance instrument used to assess a person’s level of disability as well as changes in patient status in response to rehabilitation or medical intervention (see table).

FUNCTIONAL INDEPENDENCE MEASURE (FIM)

Category	Elements
(Physiopedia, 2021b)
Self-care	Eating Grooming Bathing Dressing (upper) Dressing (lower) Toileting
Sphincter control	Bowel Bladder
Transfers	Bed Chair Wheelchair
Locomotion	Walk Wheelchair Stairs
Communication	Auditory comprehension Verbal expression
Social cognition	Social activity Problem solving Memory

Examples of performance tests include:

• 6-Minute Walk Test, an exercise test used to assess aerobic capacity and endurance
• Functional Reach Test, a single-item test developed as a quick screen for balance problems in older adults
• Timed Up and Go (TUG) Test, an assessment conducted as part of a routine evaluation of older persons in order to assess mobility and both static and dynamic balance
• Berg Balance Scale, an assessment that determines a patient’s ability or inability to safely balance during a series of predetermined tasks
  (Physiopedia, 2021a)

Examples of self-reports include:

• Functional Independence Measure Self-Report (FIM-SR)
• Functional Status Questionnaire
• Activity Measure for Post and Acute Care (AM-PAC), a measure of difficulty, assistance, and limitation in ADLs
• Life Space Questionnaire, a measure of the extent of mobility of older adults
• Late-Life Function and Disability Instrument (LLFDI), an evaluative outcome instrument for community-dwelling older adults that assesses function and disability

It has been shown that physical performance and self-report measures of mobility/function do not provide equivalent information about a patient’s functional status. Consequently, it has been overwhelmingly recommended that both types of assessment be completed, as they provide complementary information that allows for a more accurate account of mobility/function (Fulmer & Chernof, 2019).

PLAN OF CARE

The plan of care is an essential element of the functional assessment process. Once an assessment is completed, a plan of care can be developed that specifies the type of support services and equipment that might be appropriate, including home care and/or modification of the home (i.e., occupational therapy) or possible placement in assisted living or other long-term care facility (i.e., social work). Those who need assistance only with IADLs may continue to live independently with the help of family caregivers; a financial/legal consultant (accountant, attorney, or family member with durable power of attorney); a cleaning service; and/or someone to drive, shop, and run errands.

The entire team brings coordinated efforts to reducing the morbidity and mortality associated with caring for the aging patient. Some expected patient outcomes include:

• Maintaining a safe level of ADLs and ambulation in their particular environment
• Making necessary adaptations to maintain safety and independence, including assistive devices
• Decreasing the incidence and prevalence of functional decline
• Decreasing readmission rates
• Maintaining access to rehabilitative therapies (i.e., occupational, physical, speech, etc.)
  (Fulmer & Chernof, 2019)

Management of Functional Deficits

Management of older adults with functional deficits requires knowledge and input from a team of practitioners, with a focus on maintaining functional status and intervening when signs of decline become evident.

The intent of management is primarily centered on the person’s specific functional deficits, with additional aims such as reducing the need for premature placement into residential care or delaying or reducing the need for community support services. Management can also address the broader social and psychological needs of the older adult through group-based programs and opportunities to connect with the community.

A function-focused approach looks holistically at the nature of, and contributors to, an older person’s functional decline and then applies strategies to improve functional ability by maximizing intrinsic capacity and using environmental modifiers when necessary and available. A systematic approach includes these elements:

1. Clinical assessment and optimal disease management
2. Functional assessment looking at physical, mental, and social domains
3. Collaborative goal setting, with goals that are meaningful to the person and achievable
4. Evidence-based, goal-oriented allied health and nursing therapeutic and lifestyle interventions targeted at improving intrinsic capacity and functional ability
5. Use of assistive technologies and/or environmental modifications to compensate for remaining deficits
6. Provision of community support services to address persisting deficits that affect daily living
7. Supporting the health and wellness of family caregivers
8. Provision of alternative or supported accommodation when living at home remains unsafe or too difficult
   (Poulos & Poulos, 2019)

AMBULATION AND MOBILITY INTERVENTIONS

Being able to ambulate safely within their homes and communities is often a crucial factor in older adults’ ability to continue living an independent lifestyle. Community ambulation refers to an individual’s ability to successfully walk at least 300 meters (984 feet) independently without a rest. To walk within the community for shopping or leisure and to ambulate around the home environment is vital to the socialization and quality of life of the older adult.

Mobility is the capacity one has for movement within the personally available environment. While many mobility issues in older adults cannot be treated medically or surgically, they sometimes can be compensated for by the use of ambulatory assistive devices. There are a number of assistive devices available that may be of assistance to older adults with mobility impairments. Physical therapists provide selection of and training on the use of appropriate assistive devices, and nurses supervise the correct use.

Assistive mobility devices offer a wide range of levels of support based on a patient’s individual needs. When fitted correctly and used properly, assistive devices may increase base of support, improve stability with standing or walking, and increase activity and independence level.

• Standard/straight cane: Lightweight and inexpensive, generally crafted from wood or aluminum. A cane may help improve stability in a patient who does not need the upper extremity to bear weight.
• Offset cane: This type of cane distributes the patient’s weight over the cane’s shaft. An offset cane is often indicated for patients who require their upper extremity to bear weight at times (i.e., due to gait problems caused by pain from knee or hip osteoarthritis).
• Quadripod cane (“quad” cane): A four-legged cane that provides a larger base of support. This type of cane can stand freely if the patient needs to use upper extremities for other tasks momentarily and may be useful for some patients with hemiplegia. For safe and proper use, all four points of the cane must contact the ground at the same time.
• “Smart” canes: A cane that is capable of sensing movement, position, orientation, and force that provides feedback to the user through the use of electronic sensors (Arefin et al., 2020).
• Crutches: Useful for a patient who must use their upper extremities for purposes of both weight bearing and propulsion. Due to the significant energy requirements for their use, as well as the level of arm and/or shoulder strength needed, crutches are infrequently indicated for the majority of older adults, particularly frail elders.
• Standard walker: The most stable walker. However, since the patient must completely lift the walker off ground with each step, it results in a slower gait. This may be challenging for frail older patients with decreased upper body strength.
• Front-wheeled walker (two-wheeled walker): Less stable than a standard walker but maintains a more natural gait pattern. This is an alternative for older adults who cannot lift a standard walker.
• Four-wheeled walker (rollator): Potentially useful for higher-functioning patients who do not require a walker to serve weight-bearing purposes. This type of walker is easy to propel but not generally appropriate for patients with significant balance or cognitive impairment because it may roll forward unexpectedly. May include a seat and baskets but must be used with caution. Brakes should always be engaged and the rollator positioned against a wall or other solid object before the patient sits.

Selection of an appropriate assistive device for mobility is contingent on a patient’s strength, endurance, balance, cognitive status, and environmental demands. All ambulatory assistive devices should be fitted to the individual patient, who will likely need training in using the device. However, not all older adults are candidates for ambulatory assistive devices. For example, those with serious impairments in cognition, judgment, vision, or upper body strength may not be able to use one of these devices safely.

It is important to bear in mind that a wheelchair may be the safest mobility option for patients who can no longer ambulate safely or who have severe lower extremity weakness that does not respond to therapeutic interventions (Odebiyi & Adeagbo, 2020).

FALL PREVENTION INTERVENTIONS

A comprehensive geriatric assessment for older adults includes assessment of risk for falls. More than 1 of 4 older people fall each year, but less than half inform their healthcare provider. One out of five falls causes a serious injury such as broken bones or head injury, and over 800,000 patients a year are hospitalized because of a fall injury, mostly due to head injury or hip fracture. The greatest majority of hip fractures are caused by falling, usually by falling sideways and falls are the most common cause of traumatic brain injuries (CDC, 2020f).

Many factors—both intrinsic and extrinsic—contribute to the risk of falls. Most of them can be changed or modified to help prevent falls. These include:

• Age 65 and older
• Lower body weakness
• Vitamin D deficiency
• Dehydration
• Difficulties with walking and balance, gait disorders
• Use of medicines, such as tranquilizers, sedatives, or antidepressants
• Polypharmacy
• Postural hypotension
• Chronic conditions (arthritis, CVA, incontinence, neurologic conditions, etc.)
• Dementia
• Vision problems
• Fear of falling
• Foot pain or poor footwear
• Improper use of an assistive device
• Alcohol or substance use
• Home hazards or dangers, such as:
  • Broken or uneven steps
  • Lack of stair handrails
  • Lack of bathroom grab bars
  • Dim lighting or glare
  • Obstacles and tripping hazards
  • Slippery or uneven surfaces

Most falls are caused by a combination of these risk factors. The more risk factors, the greater the chances of falling (CDC, 2020e).

Falls Assessment

The CDC and the American Geriatric Society recommend yearly fall assessment screening for all adults 65 years of age and older. A person may also need additional assessments if at higher risk due to:

• Dizziness
• Light-headedness
• Tachycardia or arrhythmia

A fall assessment is done to determine how likely the risk is for a patient to fall. It includes:

• An initial screening that includes a series of questions about overall health, if the patient has had previous falls or problems with balance, standing, and/or walking
• A set of tasks (fall assessment tools) that test strength, balance, and gait, which may include:
  • Timed Up and Go (TUG) Test to assess risk for falling
  • 30-second chair stand test to test leg strength and endurance
  • 4-stage balance test to evaluate static balance based on the ability to hold four progressively more challenging positions

Many providers use an approach developed by the CDC called STEADI (Stopping Elderly Accidents, Deaths, and Injuries). STEADI includes screening, assessment of modifiable risk factors, and interventions using effective clinical and community strategies. Some interventions that may be recommended include:

• Referral to physical therapist for evaluation and treatment to improve strength and balance
• Changing or reducing the dosage of medications
• Prescribing vitamin D
• Prescribing medications such as bisphosphonates (e.g., Fosamax) for osteopenia and osteoporosis
• Recommending a vision examination
• Assessing footwear
• Reviewing the home for potential hazards
  (NIH, 2020j; CDC, 2020f; Godfrey et al., 2019)

Falls and Traumatic Brain Injury (TBI)

Adults ages 75 and older have the highest incidence of TBI. Falls, largely from standing height, are the leading mechanism of TBI in older adults, with more women than men being affected. Intracranial changes occurring with aging and the increasing use of anticoagulant medications (e.g., warfarin/Coumadin, aspirin) put older adults at increased risk of intracranial bleeding, even with TBIs that would otherwise be classified as mild.

Pre-existing medical conditions are associated with worse outcomes after TBI in older adults. Older adults with TBI experience higher morbidity and mortality, slower recovery trajectories, and worse functional, cognitive, and psychosocial outcomes than younger individuals. TBI also significantly increases the risk of new onset depression, anxiety, and/or PTSD in older adults, with evidence of under-recognition and under-treatment (Narapareddy et al., 2019).

Traumatic brain injuries have physical, sensory, and cognitive or mental signs and symptoms that appear immediately after a traumatic event, but some may appear days or weeks later.

Symptoms of mild TBI may include:

• Loss of consciousness for a few seconds to a few minutes
• No loss of consciousness but a state of being dazed, confused, or disoriented
• Headache
• Nausea or vomiting
• Fatigue or drowsiness
• Problems with speech
• Difficulty sleeping or sleeping more than usual
• Dizziness or loss of balance
• Sensory problems, such as blurred vision, ringing in the ears, a bad taste in the mouth, or changes in the ability to smell
• Sensitivity to light or sound
• Memory or concentration problems
• Mood changes or mood swings
• Feeling depressed or anxious
  (Mayo Clinic, 2019d)

Signs and symptoms of moderate to severe TBI include any of the signs and symptoms of mild injury, as well as these symptoms that may appear within the first hours to days after head injury:

• Loss of consciousness from several minutes to hours
• Persistent headache or headache that worsens
• Repeated vomiting or nausea
• Convulsions or seizures
• Dilation of one or both pupils of the eyes
• Clear fluid draining from the nose or ears
• Inability to awaken from sleep
• Weakness or numbness in fingers and toes
• Loss of coordination
• Profound confusion
• Agitation, combativeness or other unusual behavior
• Slurred speech
• Coma and other disorders of consciousness
  (Mayo Clinic, 2019d)

The Glasgow Coma Scale is the most widely used clinical assessment tool to determine TBI severity at the time of initial presentation, but it may not be able to accurately assign TBI severity in older adults. Older adults with pre-existing dementia may have an abnormal GCS at baseline, and others may have comorbid medical conditions or medication side effects that may complicate accurate diagnosis.

Following a blunt head trauma, older adults may produce a completely normal neurological examination yet still have evidence of intracranial trauma on head CT scan. Age-related atrophy may provide space for an intracranial hemorrhage to expand substantially before it leads to clinically apparent signs or symptoms that would be detected by the GCS (Gardner et al., 2018).

Studies have assessed but not validated the use of various acute neurosurgical interventions, including intracranial pressure monitoring, craniotomy, and decompression craniectomy in older adults with moderate to severe TBI. There is, however, substantial evidence that intensive inpatient rehabilitation greatly benefits older adults with TBI, with the majority showing functional gains and achieving discharge to home. Although gains are slower, necessitating longer lengths of stay, overall functional gains did not significantly differ between older versus younger patients after accounting for TBI severity (Gardner et al, 2018).

HOME SAFETY INTERVENTIONS

Older adults are at greater risk for various home safety issues. In comparison to the population-at-large, people from the ages of 65 to 74 are nearly twice as likely to die in a fire, those between 75 and 84 nearly four times, and those ages 85 and older more than five times as likely. Cooking fires are the number one cause of home fires, and smoking is the leading cause of home fire deaths for adults 65 and over (Age Safe America, 2020).

Older adults are also at a higher risk for accidental poisoning. Most (>90%) happen in the home, specifically the kitchen, bathroom, and bedroom. Medication mishaps are a major cause of poisonings, and older adults are twice as likely to visit the emergency department for problems related to their medicines and seven times more likely to be hospitalized after such a visit. Other sources of accidental poisoning include chemicals, household cleaners, and sprays (Pathways, 2020).

Home safety interventions to address a variety of risks are described below:

Keeping emergency numbers handy:

• Call 911 for emergencies.
• Call poison control at 800-222-1222.
• Keep a list of family members’ and friends’ numbers.
• Keep a list of all healthcare providers’ phone numbers.

Preventing falls:

• If balance or walking is difficult, complete a risk assessment and evaluation.
• Use special alarms, such as a bracelet or necklace that can be worn continually, to call for emergency services after a fall.
• Do not rush to answer the phone; let the answering machine or voicemail answer, or carry a cordless or cell phone.
• When walking on smooth floors, wear rubber, nonslip footwear that fits well.
• If using a cane or walker, employ it at all times instead of hanging on to walls or furniture.
• Remove throw rugs, decrease clutter, and keep electrical cords out of pathways.
• Assure hallways, stairs, and pathways are well lit and clear of objects.
• Have rails and banisters installed on all stairways.
• Tape area rugs to the floor so they do not move when walked upon.

Protecting against fire and related dangers:

• If a fire occurs, escape the area and then call 911.
• Know at least two ways to get out of the apartment or home.
• For those who smoke, smoke outside and extinguish butts in a can of water or sand.
• Check furniture and places where people smoke before leaving home or going to bed.
• Do not wear loose clothes or long sleeves when cooking.
• Replace appliances that have frayed or damaged cords.
• Do not put too many electric cords into one socket or extension cord.
• Install a smoke detector and replace the battery twice a year.
• Never smoke in bed or leave candles burning in an empty room, even for a short time.
• Make sure heaters are at least 3 feet away from anything that can burn; turn off space heaters when leaving the room.

Avoiding bathroom hazards:

• Set the water heater to 120 °F to prevent scalding.
• Install grab bars in the shower and near the toilet.
• Use rubber-backed rugs to prevent slipping.
• Place nonslip mats in the shower.
• For those having trouble getting in and out of the tub, install a special tub chair or bench.
• For those having trouble getting on or off the toilet, install a raised toilet seat.

Preventing poisoning:

• Never use a stove, oven, or grill to heat the home since these can give off carbon monoxide.
• Make sure there is a working carbon monoxide detector near all bedrooms and replace batteries twice yearly.
• Keep medications in the original containers and make sure they are labeled properly.
• Store medicines and household products in a different place than food.
• Ask the pharmacist to use large print on medication containers.
• Take medications in a well-lit room in order to see the labels clearly.
• Bring all pill bottles to healthcare appointments for verification that they are being taken correctly.
• If forgetful, set alarms as medication reminders.
• Use pill separators and containers to keep track of daily doses.
• Never mix bleach, ammonia, or other cleaning liquids together, as they can form deadly gases.

Protecting against victimization:

• Keep windows and doors locked.
• Never let a stranger into the home when alone.
• Talk over offers made by telephone salespeople with a friend or family member.
• Do not share personal information, such as Social Security number, credit card numbers, bank information, or account passwords, with unknown people.
• Always ask for written information about any offers, prizes, or charities and wait to respond until reviewing the information thoroughly.
• Do not succumb to pressure to make purchases or donations over the phone; it is never rude to wait to discuss such decisions with a family member or friend.
• Keep phone numbers for consumer resources, the local police, bank (if money has been taken from your accounts), etc.

(Health in Aging Foundation, 2019)

SAFE DRIVING AND TRANSPORTATION INTERVENTIONS

Age-related physical, vision, and cognitive decline negatively impact functional ability and some older adults’ driving abilities. Determining when driving is a risk and whether driver retraining is indicated is best done by occupational therapists with specialized training. This training helps to optimize and prolong an older driver’s ability to drive safely, but also can ease the emotional transition to other forms of transportation if limiting or stopping driving becomes necessary (AOTA, 2021b).

Families are usually the first to notice unsafe driving behaviors in their older loved one but often find it difficult to convince the person to stop driving. Some patients willingly stop driving; others are reluctant to give up the independence that driving represents, thereby creating a significant threat to personal and public safety. Those who refuse to quit driving even though they pose a hazard must be prevented from driving by other means, either by hiding the car keys or disabling the car. If family members cannot convince the impaired driver to stop driving, their physician must intervene.

Patient and family strategies for managing the older adult’s transportation and driving needs include:

• Seeking a referral to occupational therapy for a comprehensive driving examination
• Asking a friend or neighbor for a ride and/or carpooling
• Utilizing religious and civic groups who arrange for volunteers to provide transportation
• Visiting a local drivers licensing agency for an evaluation of driving skills
• Using taxis and public transportation
• Attending a CarFit event (see box below)
• Avoiding driving during evenings or rush hour
  (NIA, 2018)