Note from the National Guideline Clearinghouse (NGC): In this update of the guideline, the process previously used to develop the geriatric nursing protocols has been enhanced.
Levels of evidence (I –VI) are defined at the end of the "Major Recommendations" field.
Assessment Parameters
- Comprehensive functional assessment of elders includes independent performance of basic activities of daily living (ADLs), social activities, or instrumental activities of daily living (IADLs), the assistance needed to accomplish these tasks, and the sensory ability, cognition, and capacity to ambulate (Campbell, et al., 2004 [Level I]; Doran et al., 2006 [Level VI]; Freedman, Martin, & Schueni, 2002 [Level I]; Kane & Kane, 2000 [Level VI]; Katz et al., 1963 [Level I]; Lawton & Brody, 1969 [Level IV]; Lightbody & Baldwin, 2002 [Level VI]; McCusker, Kakuma, & Abramowicz, 2002 [Level I]; Tinetti & Ginter, 1988 [Level I]).
- Basic ADL
- Bathing
- Dressing
- Grooming
- Eating
- Continence
- Transferring
- IADLs
- Meal preparation
- Shopping
- Medication administration
- Housework
- Transportation
- Accounting
- Mobility
- Elderly patients may view their health in terms of how well they can function rather than in terms of disease alone. Strengths should be emphasized as well as needs for assistance (Depp & Jeste, 2006 [Level I]; Pearson, 2000 [Level VI]).
- The clinician should document baseline functional status and recent or progressive declines in function. (Graf, 2006 [Level V]).
- Function should be assessed over time to validate capacity, decline, or progress (Applegate, Blass, & Franklin, 1990 [Level VI]; Callahan et al., 2002 [Level VI]; Kane & Kane, 2000 [Level VI]).
- Standard instruments selected to assess function should be efficient to administer and easy to interpret. They should provide useful practical information for clinicians and should be incorporated into routine history taking and daily assessments (Kane & Kane 2000 [Level VI]; Kresevic & Holder, 1998 [Level VI]). (See Function topic at
www.ConsultGeriRN.org for tools.)
- Interdisciplinary communication regarding functional status, changes, and expected trajectory should be part of all care settings (Counsell et al., 2000 [Level II]; Kresevic & Holder, 1998 [Level VI]; Landefeld et al., 1995 [Level II]).
- Multidisciplinary team conferences including patient and family whenever possible (Covinsky et al., 1998 [Level II]; Kresevic & Holder, 1998 [Level VI]).
Care Strategies
Strategies to maximize functional status and to prevent decline:
- Maintain individual's daily routine. Help to maintain physical, cognitive, and social function through physical activity and socialization. Encourage ambulation, allow flexible visitation including pets, and encourage reading the newspaper (Kresevic & Holder, 1998 [Level VI]; Landefeld et al., 1995 [Level II]).
- Educate elders, family, and formal caregivers on the value of independent functioning and the consequences of functional decline (Graf, 2006 [Level V]; Kresevic & Holder, 1998 [Level VI]; Vass et al., 2005 [Level II]).
- Physiological and psychological value of independent functioning.
- Reversible functional decline associated with acute illness (Hirsch et al., 1990 [Level VI]; Sager & Rudberg, 1998 [Level II]).
- Strategies to prevent functional decline: exercise, nutrition, pain management, and socialization (Kresevic & Holder 1998 [Level VI]; Landefeld et al., 1995 [Level II]; Tucker, Molsberger, & Clark, 2004; Siegler, Glick, & Lee, 2002 [Level VI]).
- Sources of assistance to manage decline.
- Encourage activity including routine exercise, range of motion, and ambulation to maintain activity, flexibility, and function (Counsell et al., 2000 [Level II]; Landefeld et al., 1995 [Level II]; Pedersen & Saltin, 2006 [Level I]).
- Minimize bed rest (Bates-Jensen et al., 2004 [Level VI]; Covinsky et al., 1998 [Level II]; Landefeld et al., 1995 [Level II]; Kresevic & Holder, 1998 [Level VI]).
- Explore alternatives to physical restraints use (Covinsky et al., 1998 [Level II]; Kresevic & Holder, 1998 [Level VI]).
- Judiciously use medications, especially psychoactive medications in geriatric dosages (Inouye, 1998 [Level III]).
- Assess and treat for pain (Covinsky et al., 1998 [Level II]).
- Design environments with handrails, wide doorways, raised toilet seats, shower seats, enhanced lighting, low beds, and chairs of various types and height (Kresevic et al., 1998 [Level VI], Cunningham & Michael, 2004 [Level I]).
- Help individuals regain baseline function after acute illnesses by using exercise, physical therapy consultation, nutrition, and coaching (Conn et al., 2003 [Level I]); Engberg et al., 2002 [Level II]; Hodgkinson, Evans, & Woods, 2003 [Level I]; Forbes, 2005 [Level VI]; Kresevic et al., 1998 [Level V]).
- Obtain assessment for physical and occupational therapies needed to help regain function (Covinsky et al., 1998 [Level II]).
Strategies to help older individuals cope with functional decline:
- Help older adults and family members determine realistic functional capacity with interdisciplinary consultation (Kresevic & Holder, 1998 [Level VI]).
- Provide caregiver education and support for families of individuals when decline cannot be ameliorated in spite of nursing and rehabilitative efforts (Graf, 2006 [Level V]).
- Carefully document all intervention strategies and patient responses (Graf, 2006 [Level V]).
- Provide information to caregivers on causes of functional decline related to acute and chronic conditions (Covinsky et al., 1998 [Level II]).
- Provide education to address safety care needs for falls, injuries, and common complications. Short-term skilled care for physical therapy may be needed; long-term care settings may be required to ensure safety (Covinsky et al., 1998 [Level II]).
- Provide sufficient protein and caloric intake to ensure adequate intake and prevent further decline. Liberalize diet to include personal preferences (Edington et al., 2004 [Level II]; Landefeld et al., 1995 [Level II]).
- Provide caregiver support via community services, such as home care, nursing, and physical and occupational therapy services, to manage functional decline. (Covinsky et al., 1998 [Level II]; Graf, 2006 [Level V])
Definitions:
Levels of Evidence
Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)
Level II: Single experimental study (randomized controlled trials [RCTs])
Level III: Quasi-experimental studies
Level IV: Non-experimental studies
Level V: Care report/program evaluation/narrative literature reviews
Level VI: Opinions of respected authorities/Consensus panels
Reprinted with permission from Springer Publishing Company: Capezuti, E., Zwicker, D., Mezey, M. & Fulmer, T. (Eds). (2008) Evidence Based Geriatric Nursing Protocols for Best Practice, (3rd ed). New York: Springer Publishing Company.
