patient-completed screening instrument for functional disability in the elderly

8/13/2019 Patient-Completed Screening Instrument for Functional Disability in the Elderly

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A Pat ient C om pleted Screen ing Instrument forFun ct ional D isabi l i ty in the ElderlyF I T Z H U G H C . P A N N I L L I I I M . D . New Haven and West Haven Connecticut

PURPOSE Although m u l t i - d i s c ip l i n a r y g e r i a t r i ca s s e s s m e n t o f e l d e r l y p a t ie n t s h a s b e e n s h o w n t ob e e f f e c t i v e in i d e n t i f y in g n e w d i a g n o s e s a n dp r e v i o u s l y u n k n o w n d i s ab i li ti e s a n d i n d e c r e a s -i n g h o s p it ~ ii T ~ t io n a n d m o r t a l i t y , t i m e a n d f i -n a n c i a l c o n s t r a i n t s p r e v e n t m o s t i n t e r n is t s a n do f f ic e p r a c t i t i o n e r s f r o m u s i n g t h i s a p p r o a c hw i t h t h e i r o l d e r p a t ie n t s . S e v e r a l i n s t ru m e n t s t os c r e e n o l d e r p e r s o n s f o r f u n c t i o n a l d i s a b il i tyh a v e b e e n p r o p o s e d , b u t t h e r e a r e l i m i t e d d a t ar e g a r d i n g t h e i r u t i l i ty o r e f f e c t i v e n e s s in c l in i -c a l m e d i c i n e . T h i s s t u d y d e v e l o p e d a s h o r t , p a -t i e n t - c o m p l e t e d s c r e e n i n g a s s e s s m e n t i n s t r u -m e n t ( t h e F u n c t i o n a l A s s e s s m e n t S c r e e n ) ,c o m p a r e d i t t o a s t a n d a r d , m u l t i - d i s c ip l i n e r y g e -r i a t r i c e v a l u a t i o n , a n d d e t e r m i n e d t h e s c r e e n i n gi n s t r u m e n t ' s a b i l it y to p r e d i c t f u t u r e u s e o fh o m e c a r e s e r v i c e s i n a g r o u p o f e l d e r lyp a t i e n t s .PATIENTS AND METHODS T h e screening instrum e n t w a s p i l ot e d r e t r o s p e c t i v e l y u s i n g d a t af r o m p a t i e n t s s e e n i n t h e p r e v i o u s 2 y e a r s a t ah o s p i t a l - b a s e d g e r i a t r i c s c l i n ic i n W i s c o n s i n . U s -i n g t h e s e r e s u lt s , a r e v i se d i n s t r u m e n t w a s d e -v e l o p e d a n d m a i l e d t o 8 0 c o n s e c u t i v e n e w p a -t i e n ts w h o p r e s e n t e d t o t h e c li n ic f o rm u l t i - d is c i p l in a ~ T g e r i a t r i c a s s e s s m e n t a n d p r i-m a r y c a r e . T h e s e p a t i e n t s w e r e i n t e r v i e w e d 1 8m o n t h s l a t e r t o d e t e r m i n e u s e o f h o m e s e r v ic e s ,i n s ti t u ti o n a l iT ~ t i o n , a n d d e a t h a f t e r t h e i n i t i a lvisit~R E SU L T S: F i f t y - e i g h t o f 8 0 e l i g i b l e p a t i e n t s( 7 2% ) c o m p l e t e d b e t h t h e c l i ni c e v a l u a t i o n a n d1 8 - m o n th f o l l o w - u p . T h e p a t i e n t s w e r e a n e l d e r -l y ( m e a n a g e o f 76 ), f r a i l ( a v e r a g e o f t h r e e m e d i -c a l d i a g n o s e s ) , f u n c t i o n a l l y d i s a b l e d g r o u p ( d e -p e n d e n t i n a n a v e r a g e o f 3 .7 i n s t r u m e n t a la c t i v i t i e s o f d ~ i l y l i v i n g a n d 2 . 7 a c t i v i t i e s o f d a i l y

From the Department of Medic ine Yale Univers i ty School of Medic ineNew Haven Connecticut and the West Haven Veterans Adminis trationMedical Center West Haven Connecticut.Dr. Panni l l was a fu ll - t ime employee of the V eterans Adminis trationwhen this work was done.Part of th is wo rk was presented a t the Annual Meeting of the S ocietyfor General Internal Medic ine W ashington D.C. 1988.Requests for repr ints should be addressed to F itzhugh C. Panni l l II IM.D. We st Haven Veterans Adminis tration Medical Cen ter /11 1C 752Campbel l Avenue W est Haven Connecticut 06516.Manuscr ipt submitted Mar l :h 15 1990 and accepted in rev ised formNovember 19 1990.

l iv i n g ). N i n e o f th e 5 8 e n r o l l e d p a t i e n t s ( 1 5 % )w e r e i n s t i t u t i o n A l i T ~ d , f i v e ( 9 % ) d i e d , a n d 3 1( 5 3% ) r e q u i r e d n e w h o m e s e r v i c e s a f t e r 1 8m o n t h s . T h e s c r e e n i n g v a r i a b l e s w e r e s e n s i t i v eb u t l e s s s p e ci f ic t h a n c l in i c p r o v i d e r s ' j u d g m e n ti n i d e n t i f y i n g a b n o r m a l i t i e s i n s o c i a l , e c o n o m i c ,o r p h y s i c a l h e a l t h s t a t u s . T h e r e l a t i v e r i s k o fe v e n t u a l h o m e s e r v i c e u s e w a s e l e v a t e d i n p a -t i e n ts r e p o r t i n g p o o r h e a l t h s t a t u s ( r e l a ti v e r i s ko f 3.5 , 9 5 % c o n f i d e n c e i n t e r v a l [ C I ] 9 . 9 t o 1 2 ) ,

n d d e p e n d e n c y i n h o u s e w o r k ( r e l a t i v e r i s k o f3 .0 , 9 5 % C I 5 .1 to 1 .7 ), s h o p p i n g ( r e l a t i v e r i s k o f2 .6 , 95% CI 4 .7 t o 1 .5 ), m ea l s ( r e l a t i v e r i s k o f 2 .4 ,9 5 % C I 3 . 4 t o 1 . 7) , d r e s s i n g ( r e l a t i v e r i s k o f 2 2,9 5 % C I 3 . 0 t o 1 . 6) , o r b a t h i n g ( r e l a t i v e r i s k o f 2.2 ,9 5 % C I 3 .2 t o 1 .5 ). H o m e s e r v i c e s w e r e u s e d i n1 6 % o f p a t i e n t s w i t h n o p o s i t i v e r e s p o n s e s t o as u b s e t o f f o u r o f t h e s c r e e n i n g q u e s ti o n s ; u s a g er o s e t o 2 2 % w i t h o n e p o s i t i v e r e s p o n s e , a n d t o8 9 % ( r e l a t i v e r i s k o f 4 .5 , 9 5 % C I 9 . 2 t o 2 .1 ) w i t ht w o o r m o r e p o s i ti v e r e s p o n se s .C O NC LU SIO N S: T h i s s c r e e n i n g i n s t r t u n e n t i d e n -t if f e d a g r o u p o f e l d e r l y p a t i e n ts a t m u c h h i g h e rr i s k fo r i n c r e a s e d h o m e s e r v i c e u s e t h a n o t h e rp a t i e n t s i n a g e r i a t r i c s c l in i c . I f v a l i d a t e d i n o t h -e r p o p u l a ti o n s , s u c h a n i n s t r u m e n t m a y i d e n t if yf r a i l, e l d e r l y p a t i e n t s i n o f f i c e p r a c t i c e a t h i g hr i s k f o r u s e o f h o m e s e r v i c e s . T h e s e p a t i e n t sc o u l d b e t a r g e t e d f o r m o r e c o m p l e t e m u l ti - d is c i -p l i n n ry g e r i a t r i c a s s e s s m e n t t o i d e n t if y a n d t r e a td i s e as e a n d d i s a b il i ty r e s p o n s i b l e f o r i n c r e a s e ds e r v i c e u s e n d d e c l in i n g h e a l t h .

eriatric ss essment has bee n s ho wn to be effec-tive in identifying significant e w diagnoses

an d previously n k n o w n functional disabilities 1-5]. Thi s process identifies lderly patients at highrisk for institutionalization nd ot he r adve rse o ut-comes an d has been sh ow n to decrease hospital sea n d m o r ta l i t y c o m p a r e d w i t h th a t i n c o n tr o lg r o u p s [ 1 -5 ]. T h e s e a s s e ss m e n ts h a v e n o t b e e nstandardized but usually include an evaluation ofmedical conditions functional mental an d emo -tional tatus nd ec ono mic an d social ell-being ya multi-disciplinary ea m of physicians urses o-cial ork ers an d other professionals. h es e special-ized assessments are usually time- a nd personnel-

3 2 0 M a r c h 1 9 9 1 T h e A m e r i c a n J o u r n a l o f M e d i c i n e V o l u m e 9 0


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i n t en s i v e, a n d n o t r e i m b u r s e d b y t h i r d - p a r t ypayors [2,3] . Cur ren t ly , however , the vast major i tyof o lder pa t ien ts who may need these evalua t ionsrece ive the i r care in p r iva te , o f f ice-based medica lp r ac t i ce s t h a t a r e u n eq u ip p ed to acco m m o d a tesuch a compre hensive 3 - o r 4 -hour mul t i -d isc ip l in -ary approach .Severa l studies [6,7] have sh own off ice practi t io-ners do a re la t ive ly poor job of iden t i fy ing funct ion-a l d isab i l i t ies in the i r o lder pa t ien ts . Therefore ,t rea tab le funct ional d isab i l i t ies may go unrecog-n ized in o f f ice p rac t ice , resu l t ing in increasedheal th serv ice use , ins t i tu t ionaliza t ion , a nd m or ta l -iW tha t cou ld be p reven ted by ger ia t r ic assessment .A shor t , s imple , and ef fec t ive screen ing ins t r ume ntfor ger ia t r ic assess ment i s neede d to iden t i fy func-t ional ly d isab led pa t ien ts who are a t h ighest r i sk fo rhea l th serv ice use , ins t i tu t ional iza t ion , and adverseoutcomes.As a f irst step in designing such a screening in-s t rum ent , th is s tu dy had th r ee purposes: (1 ) to de-ve lop a shor t , pa t ien t -comple ted , 'ger ia t r ic assess-m e n t s c r e e n i n g i n s t r u m e n t i n c o r p o r a t i n gm easu r e m en t s o f f u n c tio n a l an d h ea l th s t a tu s an deconomic and social resources; (2) to validate then ew in s t r u m en t ag a in s t c li n ica l j u d g m en t ( d e f in edas the resu l t o f a s tandard comprehensive ger ia tr icassessment) in iden t i fy ing funct ional d isab i l i ty ,poor physica l hea l th , and poor soc ia l o r economicresources; and (3) to de termin e the va l id i ty o f thescreen ing ins t rument fo r p red ic t ing use o f homecare serv ices and fu ture ins t i tu t ional iza t ion in agroup of frail patie nts in a geriatr ics clinic.P TIENTS ND METHODS

Th e screening instrumen t wa s deve loped in a ret-rospective pilot tudy an d tested prospectively. Th edata came from patients attending the geriatricsclinic of Sinai Sam arit an Medic al Center, the Mil-wa uk ee Clinical Ca mp us of the University of Wis-consin Medical School. Staffed by fellowship-trained geriatricians, internists, nurses, an d socialworkers, this clinic rovid es multi-disciplinary, pri-ma ry health care to over 1,000 elderly patients insoutheastern Wisconsin.

O n the first isit, very ne w patient had a com -prehensive ass essment by a registered nurse an d ageriatric social wor ker using a structured interviewderived fro m the Functional Assessm ent Inventoryof Pfeiffer [8]. hi s asse ssmen t focused on social,econo mic, an d physical health function. Specificquestions we re directed at dep end enc y in instru-me nta l activities of daily living (IA DLs ) an d ac-tivities f daily living (ADL s). T he I AD L s includ-ed travel, hous ekeep ing, shopping , me alpreparation, finances, medications, an d telepho ne

FUNCTIONALDISABILITYSCREENING PANNILL

use. Th e A D L s included eating, bathing, dressing,groomi ng, walking, toileting, nd transferring abili-ty, Ea ch patient was rated on three su m ma ry scoresof social resources, eco nom ic resources (rated by asocial worker), an d physical health status (rated bythe nurse). Th es e ratings consisted of a five-pointscale: excellent, good, fair, ode ratel y impaired, orpoor (scales available fr om the author).

A pilot stud y w as designe d to test the utility f aset of eight questions for geriatric sse ssm ent devel-ope d by Pea rlm an [9] in a Delphi survey of 20 geri-atric clinicians in six subspecialties. M y colleaguesan d I identified eight questions o n the clinic's s-sessme nt instrument that were identical or closeapproxi mations to these consensus questions.Th es e eight questions w ere tested for validity inpredicting the clinician-generated s u mm a r y ratingsof f ive areas (social resources, econom ic resources,physica l hea l th s ta tus , and IADL and ADL aver -ages) , using data from patients seen in the clinicbetw een 1983 and 1985. Base d on this analysis, were ta ined a l l the o r ig ina l quest ions and added oneaddi t ional economic quest ion ( luxur ies ) , th reeaddi t ional IADL quest ions ( shopping , housework ,and ge t t ing around) , and two addi t ional ADL ques-t ions (dress ing and ba th ing) . The f ina l Funct io nalAssessm en t Sc r een i s sh o wn in th e Ap p en d ix . Th eeigh t pilot que stio ns a re nu mb ers 1, 2, 3, 5, 6, 7, 8, 9-6, and 9-7.Prospective Study

Th e sam ple for the prospective evaluation con-sisted of 80 commu nity-living patients wh o pre-sented consecutively to the geriatrics clinic fr omMa rc h 1, 1985, to M a y 15, 1985, for ne w patientevaluations and ongo ing care. Patients wh o pre-sented specifically for assistance in nursing ho m eplace ment we re excluded. T w o week s before thefirst isit, ll ew patients wer e mail ed the one-p agescreening instrum ent with a n introductory letter.Patients were requested to get assistance fro m fam-ily me mb er s to complete the screen if necessary.Family me mb er s were asked to complete the screenfor their relatives if the a pp oi ntm en t wa s for theevaluation of m e m o r y loss, onfusion, or dementi a.Th es e instru ments were collected by the clinic ec-retary at the first isit, nd not available to clini-cians. Th e nurse a nd social worker performing thecompre hensiv e clinic assessment were un awa re ofthe study's purpose an d did not see the complet edscreening questionnaire. Th e data fro m the com-prehensive assessment were used extensively to de-velop plans for ongo ing care and in multi-disciplin-ary staffing meeti ngs held for all patients. Thi s wa sstandard clinic practice before and during thestudy. T he clinic e rved as the majo r source of pri-

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FUNCTIONAL DISABILITY SCREENING PANNILL

mar y care for almost all (90%) of the patie nts. Clinicstaff arranged hospitalization, specialty referrals,home care services, and nur sing home placemen t, ifneeded.Eighteen months after the initial clinic visit, atrained research assistant, unaware of both thescreen and comprehensive clinic assessment data,att empt ed to contact all patients by telephone. Af-ter obtaining pat ient consent, the research assistantdetermined the patient's current living situation,use of help or services in the home, and the typesand sources of both formal (by paid agencies or non-family members) and informal (family member orfriend) daily assistance used since the patient 's firstclinic visit. The interviewer also inquired abouthospitalizations, and changes in place and type ofresidence, and specifically asked if the patientneeded or had used additional help at home withany dhily tasks such as housework, transport ation,meals, shopping, chores, medications, personalcare, walking, health problems, or money manage-ment. P atient s who indicated such use were askedabou t the types o f service and how it was provided.The families were interviewed if the patient wasdead or institutionali zed or had memory loss or de-mentia. Interviews were conducted with a standar dprotocol.A blinded chart review was conducted to deter-mine medical diagnoses and hospitalizations sincethe first clinic visit. All provider notes were re-viewed for mention of the use of formal services.Char t copies of records from visiting nursin g agen-cies were reviewed when available. Services in placebefore the first clinic visit were specifically docu-ment ed by the assessment on the first visit and wereexcluded from analysis. A specific search\was notmade for services delivered at other hospitals orhospit al clinics not r ecorded in our chart , or by pro-viders unknown to our clinic staff or not ment ionedin the interviews. As Almost all patients attendedthe clinic for primar y care and had no other provid-ers, information on most major services were avail-able. The procedures and interview protocol wereapproved by the Clinical Investigations Committeeof Mount Sinai Medical Center, Milwaukee,Wisconsin.Data nalysis

Th e prospective analysis xam ine d the validity ofthe screening instrument to predict provider-deter-mi ne d abnormalities in the corresponding are as ofthe co mpre hens ive assessment (social, economic,physical health, IA DL s, an d ADL s) , an d the utilityof the screen to predict use of formal h o m e servicesand nursing ho me placement. Abn orm al providerratings wer e defined as mode ratel y impaired or

worse social or economic resources (a score of 4 orhigher) or fai r physical heal th or worse (a score of4 or higher). IADL or ADL impairments were de-fined as the need for assistance in any two of theseven IADLs or ADLs. A formal service was defi nedas a service provided by a paid third party otherthan immediate family members for support inIADL or ADL functions or patient supervision, aliving situation with such IADL or ADL assistance(senior apartm ent with meals, for example), or anin-home evaluation by a health care professionalother t han clinic staff (nurse or therapist, for exam-ple). Institutionalization was defined as nursinghome placement at skilled, intermediate, or domi-ciliary (board and care) levels.

Bivariate analysis compared the association be-tween clinical characteristics, comprehensive pro-dder assessment, and the screen variables and theoutcomes of formal service use and institutionaliza-tion. Sta tisti cal significance (p -- 0.05) was evaluat-ed using the Mann- Whit ney U test, or the t-test , asappropriate. For statistically significant variables,the relative risk was calculated to determine theassociation of the presence of a parti cular f eature(i.e., living alone) wit h home services use an d insti-tutionalization. Relative risks are reported with95% confidence intervals (CI) [10]. A short index ofspecific screening instrument questions with thehighest relative risks was developed to predict for-real home service use. The variables were addedincrementally, based on highest relative risk, tomaximize the number of patients with service useidentified.R SULTS

Two patients were excluded from the analysis fornot completing the comprehensive assessment. Thecharacteristics of all 78 patients and their outcomesafter 18 months are shown in Table I. These pa-tients' characteristics are not significantly differ entfrom those of patients seen in the clinic in the previ-ous 3 years and seem a suitably repres entati ve sam-ple. O f-t he 78 patients, 58 (74%) retur ned thescreening instrument. The 20 patients who refuseddid not differ significantly from the group as awhole, in general demographic data, assessment re-sults, medical diagnoses, or outcome.The 78 patients were a frail, elderly group withfrequent medical problems and a high prevalence offunctional disability. Major medical diagnoses in-cluded cardiac disease (59%), dementia (26%), ar-thritis (19%), diabetes (18%), and other neurologicdisease (14%). Almost 60% were rat ed by th e n urseas having fair or worse physical health. Impairedsocial and economic resources were common. Thepati ents were depe nden t in 3.8 of seven IADL items

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and 2 .2 o f seven ADL i tems on average. Thirty -fourpercent had urinary incont inence . Thirty -two per-cent were fo l lowed in the c l in ic for more than 18months , and 55 o f the pat ients had v is i ted thecl in ic w i thin 6 mon ths o f the end o f the s tudy , indi -cating m ost were sti l l regular cl inic patients . Forty-three (55 ) reported or had chart docume ntat ion o fformal serv ice use during the 18 months . Eleven o fthe 78 (14 ) required nurs ing home placem ent dur-ing the 18 months , and seven (9 ) o f the pat ientsdied. These outcomes are not mutual ly exclus ive ,but o f the 17 pat ients who died or were ins t i tut ion-alized, 11 (65 ) had received hom e services. Thefo rma l s erv i ce s req u i red i n c l u d ed h o me h ea l thaides, day care, and other major services (Table I).Use of Meals on W heels , a senior center, or a seniorapartment were each reported by four o f 78 pat ients(5 ) . Evalu ations by home physical therapists orsocia l workers , Ti t le X IX or Ti t le X X eva luat ion, orhelp wi th f inances were each reported by three o fthe 78 pat ients (4 ) . One pat ient used te lephonereassurance.Validation of the Functional ssessment Screen

The screening ins trument was compared with theprovider's rating of the p atients based on the fivesummary areas o f the comprehens ive assessment .The resul ts show that the screen was genera l ly moresensitiv e than specific for the five areas of provider-ident i f ied abnormal i t ies (Table I I ) . Overa l l , thescreen was 91 sensitive and 64 specific for anabnor mality in any of the five areas on the provider-cond ucte d assessm ent. On ly four of the 47 (9 ) pa-t ients w i th one or more pos i t ive screen quest ionswere judged by the nurse an d social worker to benorm al in al l f ive areas (false positives). Four of 11pat ients (36 ) judged to be abnormal by the nurseor social worker had no positive answer on thescreen (false negatives).

Table I II shows the c l in ica l and comprehens iveassessment summary variables from the prov iderassessment that had a statistical ly s ignificant asso-c ia t ion between pat ients who used formal serv icesand those who did not . The re la t ive r i sk o f formalservice use was s ignificantly incr eased (relative riskof 1 .6 to 2 .1 ) w i th a prov ider-determined ADL orIADL impairment , a prov ider rat ing o f impairedsocial resources, or a diagnosis of dementia. Im-paired physical health status was marginally s ignif-icant (p = 0.03). Age, sex, number o f med ical diag-noses, economic resources rating, or other mddicaldiagnoses did not show a statistical ly s ignificantrelationship. R elative risks were 1.3 or less with theother variables.

The screen variables c lose ly reproduced these as -socia t ions . Ta ble IV l i s ts the screen variables w i th

FUNCTIONAL DISABILITY SCREENING / PANNILL

TABLE ICharacteristics of 78 Patients on Admission to Clinic*

Completed Did NotScree n Complete creen(n -- 58) (n = 20)

Mean age 76.8=1=8.3 75.7 =E 10.1Mean number of admission diagnoses 2.9 =t= 1.4 3.1 4- 1.2Abnormal socialresources 18 (31 ) 7 (35 )(moderate or greater impairment)Abnormal economic resources 16 (27 ) 7 (35 )(moderate or greater impairment)Abnormal physical health status 33 (57 ) 13 (65 )(fair or worse health)Average number of IADLdependencies 3.8 + 4.7 3.7 -4- 3.5Average number of ADL dependencies 1.9 =t= 2.3 2.7 4- 3.8Average mental statusscore 22.7 =t= 7.3 21.5 =t= 8. IPatient outcomes at 18 monthsPatients requiring ormalservices 31 (53 ) 12 (60 )Patients hospitalized 24 (41 ) 7 (35 )Patients institutionalized 9 (15 ) 2 (10 )Deaths 5 (9 ) 2 (10 )Home care servicesHomehealth aide ]7 (29 ) 5 (25 )Registerednurse 9 (16 ) 4 (20 )Day care 9 (16 ) 0 (0 )Transportation 6 (10 ) 0 (0 )Homemaker 5 (9 ) I (5 )Shoppingassistance 4 (7 ) 2 (10 )

IADL= instrumental ctivitiesof daily iving;ADL = activitiesof daily iving.' Resultsexpressedas mean~ SD.

TABLE IISensitivit y and Specific ity of Screen Items Compared wi thComprehensive Pr ovider Assessment

Sensitivity SpecificityProvider-determinedabnormality in:Socialresources 72 (13 18) 60 (21 35)Economic resources 88 (14/1 6) 30 (11/3 7)Physical health 88 (29/33) 43 (10/23)IADLs 73 (19/2 6) 74 (23/3 1)ADLs 79 (15/1 9) 67 (26/3 9)Any of the above 91 (43/47) 64 (7/1 I)

Abbreviations s n Table .

TABLE IIIRelationship Betwe en Clinical and Comprehensive AssessmentVariables and Formal Service Use

Number 95of Ser vic e se Rel ative ConfidenceVariable Patients Number ( ) Risk Interval

ADLsHelp with>2 22 19 (86) 2.1 (3.0- 1.5)Help with _2 37 27 (73) 2.0 (3.2-1 .3)Help with _


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FUNCTIONAL DISABILITY SCREENING / PANNI LL

T BLE IVRelationship etween Screening Instrument Variables andFormal Service Use

Number 95of Service Use Re lat ive ConfidenceVariable Patients Number ( ) Ri sk Interval

Health status(self-reported)Poor 40 26 (65) 3.5 (9. 9-1 .2)Normal 16 3 (19)HouseworkDependent 24 21 (87) 3.0 (5. 1-1 .7)Independent 34 10 (29)ShoppingDependent 28 22 (79) 2.6 (4. 7-1 .5)Independent 30 9 (30)MealsDependent 12 12 (100) 2.4 (3. 4-1 .7)Independent 46 19 (41)DressingDependent 9 9 (100) 2.2 (3. 0-1 .6)Independent 49 22 (45)BathingDependent 13 12 (92) 2.2 (3. 2-1 .5)Independent 45 19 (42)BathroomDependent 5 5 (100) 2.0 (2. 7-1 .5)Independent 53 26 (49)Hospital days>1 5 5 (100) 2.0 (2.7- 1.5)< 1 53 26 (49)Getting aroundDependent 16 13 (81) 1.9 (2. 8-1 .2)Independent 42 18 (43)

TABLE VMultivariate Index for Determining Need for Increased FormalServices tn 58 Ge riatric PatientsNumber ofIndex Number 95Features of Service Use+ Relative ConfidencePresent* Patients Number ( ) Risk Interval

0 12 2 (16) 1.0 \ --1 18 4 (22) 1.3 (6. 2-0 .3)2 5 5 (100) 5.9 (21. 0-1 .7)3 14 11 (79) 4.7 (17. 2-1 .3)4 9 9 (100) 5.9 (21 .1- 1.7 )2- 4 28 25 89) 4.5 9.2-2.1)Index eatures nclude:health roublesprevented oing hings, or neededassistance nany of housework, hopping,or meals.t X2 or linear rend = 26.2, p < 0.00001.

s ignificant associat ion by descending relat ive r iskof fo rmal serv ice use fo r the 58 pa t i en t s who com-p le ted the screen . Poor se l f - repor ted hea l th s t a tus ,dependency in housework , shopp ing , meal s , d ress -ing , ba th ing , and ba th room, a repor ted hosp i t a ls t ay in the l as t 6 months , and depe nden cy in ge t tingaround dem ons t ra ted re l a t ive r i sks over o r c lose to2.0, al l s tat is t ical ly s ignificant. Living alone, lack ofavai lable help, home ownership, income, luxuries ,and s i ck days d id no t dem ons t ra te s ign if i can t as so-ciat ions . The screen as a whole had a sensi t ivi ty of94% (29 of 31) and a spec ifici ty of 33% (nine o f 27)fo r p red ic t ion o f any fo rmal serv ice use .

Us ing the n ine screen var i ab les wi th s ign i f i can t lyincreased re la t ive r i sks , an index was dev eloped tos t ra t i fy pa t i en t s in to g roups wi th and wi thou t ser -v ice use . The resu l t s o f th is ana lys i s a re shown inTab le V. Pa t i en t s wi th two o r more pos i t ive an-swers o f poor se l f - repor ted hea l th s t a tus , o r as s i s -t ance in shopp ing , housekeep ing , o r meal s demon-s t ra t ed a marke d ly increased l ike l ihood o f us ingforma l services (relat ive r isk of 4 .7 to 5 .9) com par edto pat ien ts w ith no posi t ive answers . Overal l , a posi-t ive response to any two o r more o f the fou r ques -t ions iden t i f i ed a g roup tha t accoun ted fo r 89% ofthe formal service use, wi th an overal l relat ive r iskof 4 .5 (95% CI, 9 .2 to 2 .1) . An analysis u sing jus t th eIADL var iab les ( shopp ing , housekeep ing , and mealp repara t ion) dem ons t ra ted mu ch lower re l a t iverisks of 2 .4 to 2 .8 corresponding to two to threepos i t ive answers . Addi t ion o f any o f the o ther f ives ign if i can t screen i t ems d id no t increase the accura-cy of the index.

Only 11 pa t i en t s were ins t i tu t iona l i zed dur ingthe 18-month fo l low-up per iod , l imi ting the usefu l -ness o f any ana lys is . These pa t i en t s were more l ike-ly to be dependen t in IADLs and ADLs , to have areduced phys ica l hea l th ra t ing , and to su f fer f romdement ia . No d i f fe rences were seen in o ther c l in ica lvariables , or in any screening quest ionnaire vari -ab le excep t se l f - repor ted depe nden cy in ge t t ingaro und (relat ive r isk = 5.3). Th e infrequ enc y ofnurs ing home p lace ment l imi ted the s ign i fi cance o ffurther analysis .OMMENTSThe resu l t s ind ica te tha t the Funct ional Assess -

me nt Screen i s a sens i t ive bu t so mew hat nonspeci f -i c mea surem ent o f hea l th p rov ider ra t ings o f im-pai red soc ia l, economic , and phys ica l hea l th s t a tusand func t ional d i sab i l i ty in very f rai l pa t i en t s f roma geriat r ics cl inic. This screening quest ionnaire,and a subse t o f four ques t ions in par t i cu lar , i den t i -f i ed fra il , e lder ly pa t i en t s who were muc h more l ike-ly to require home services .

I t i s -no t su rp r i s ing tha t IADL var iab les were sos t rong ly assoc ia ted wi th hom e serv ices use , as p re-vious s tudies have shown s ignificant relat ionshipsb e t w e e n A D L o r I A D L d e p e n d e n c e a n d h o me s e r-vices use [11], hospi tal izat ion [12], ins t i tut ional iza-t ion [13], and mortal i ty [12,14-16]. In a s tudy ofhome serv ice requ i rements in communi ty e lder ly[1 1], A D L o r I A D L d e p e n d e n c e , h o me b o u n d s t a tu s ,social isolat ion, and mental s tatus were s ignificantpredic tors of ut il izat ion. The frail , cl inical ly il l pa-t i en t s repor ted here had a much h igher inc idence o fabnormal i t i es than those in th i s communi ty s tudy ,perhaps exp la in ing the adde d impo r tance o f a g lob-a l h e a l t h me a s u r e - - s e l f - p e r c e i v e d h e a l t h s t a t u s - -

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FUNCTIONAL DISABILITY SCREENING PANNILL

an d the relative ack of impo rtan ce of social r eco-no mi c variables. Ba se d on our results, I A D L vari-ables, althou gh important, do not se em to be suffi-cient as the only com po ne nt of a screeningexa min ati on in this frail opulation.

Several caveats are in order. Alt hou gh the screensee med to be widely accepted and was easily com-pleted by patients or family me mb er s, significantothers m ay not always be reliable informantsab ou t patient function [17]. Fur the r evaluation isne ede d to deter mine if ur practice of allowing fam-ily me m be rs to answe r for the patient is reasonableor mak es som e patients appear more dependent.Wh ile it is unlikely we miss ed data on h om e servicesin patients with nor mal functioning, thus introduc-ing significant bias, future studi es of larger, lessfrail populations ma y need a more comprehe nsiveme asu re of h o m e service use such as direct inter-views or patient diaries. T h e generalizability ofthese results m a y be limited until the usefulness ofthe sc reen in predic ting us e of other.services, nsti-tutionalization, ortality, or preven table function-al disability s studied . Its validity n other pop ula -tions wit h a low er prevalence of disability an ddisease suc h as tho se in typical office practice alsoneeds to be determined.

On e of the mo st significant bstacles to the wide-spr ead use of geriatric sse ssm ent b y private, ffice-base d practitioners m a y be the ab sence of a clearconsensus on ho w this assessment process can betargeted to patients wh o need it the most and ho wto best re cognize these patient s in office practice.Physicians, in general, are not v ery g oo d at recog-nizing functional disability in their ow n patients[6,7]. Identif ying ol der p ers ons at highe st risk forfunctional deterioration an d increasing ne ed for ex-pensi ve he alth services an d institutionalization illrequire a simple, effective, an d well-validatedscreening inst rum ent that is not n o w available.

Thi s screen sho uld (1) be sensitive o patient ab-normalities, while being specific en ou gh to avoididentifying a large nu mb er of false positives w hone ed further evaluation, (2) require little r no pro-vider time to administer a nd be readily integratedinto current office ractice, 3) be easily nde rst oodby patients and their families and, ideally, quallyvalid if omp let ed either by a patient or by a familysurrogat e, an d (4) poi nt to different, pecific nter-ventions that can be easily intro duced into officepractice, or indicate wh ic h patients should be re-ferred for mo re intensive assessment.

T h e exact target areas of suc h a screening in-st ru men t are unclear. It m a y be difficult r impossi-ble to design a screening questionnaire that cancover all of the areas ev aluate d in the usual geriatricassessment. S om e, like dementia, depression, an d

incontinence, hav e a clearly defined me tho dol ogyavailable for evaluation an d tre atm ent that officepractitioners are familiar with an d can proba blyinstitute by themselves, using existing inst rume nts[18]. thers, suc h as poo r social esources or im-paired sho ppi ng ability, re ma rk ers for underly-ing processes or specific diseases that m a y nee dmo re in-depth, multi-disciplinary evaluation. Ascreening instrument m a y not be able to cover thewaterfront an d deal wit h all these areas at once.The re are limited data, however, on the perfor-ma nc e of screening in struments for specific dis-eases in am bu la to ry geriatric atients [7], n d e venless dat a on screening for less specific conditions.Referral for a geriatric assess ment m a y be m or eapprop riate for all positives.

Gi ve n this uncertainty, it is not surprising that awide variety of screening evaluations hav e bee npr opo sed [15,18-24], esig ned for different op ula-tions, target conditions, and settings. F e w havebee n tested for validity against patient out comes,however.

Scree ning inst rume nts desi gned solely or geriat-ric pati ents include questionnaires [15,19,21-24]an d perfo rmanc e-ba sed instruments [18,20]. il-le nb au m [15], sing three existing atabases, fou ndthat five I A D L items--transportation, shopping,mea l preparation ability, house work , and fi-nance s-dem onstr ated good reproducibility andconstruct a nd predictive validity in reference toIADL funct ion ing and m or ta l i ty a year la t e r . Thesei t ems were no t t es t ed p rospec t ive ly o r in a c l in icalse t ting . Freer [19] has p ropo sed n ine ques t ions touse in ident i fying elderly pat ients in general prac-t i ce who need more de ta i l ed assessments . Theseques t ions had m any s imi lar i ti es wi th the Funct ion-a l Assessme nt Screen descr ibe d here , bu t no spec i f -ic val idat ion was repor ted. In a geriat r ic cl inic simi-l a r t o o u r s , W i l l i a m s [ 20 ] f o u n d t h a t aper fo rm ance-ba sed eva lua t ion cons i s ting o f t iminghand funct ion was more usefu l than IADL or ADLvar iab les in p red ic t ing nurs ing ho me u t i l iza t ion andserv ice use . Th i s hand funct ion eva lua t ion mayhave l imited appl ica bi l i ty in general office set t ingsbecause o f the need fo r spec ia l equ ip men t and ex-per t superv i s ion . Wi l l i ams p roposed s impler mea-s u remen t s o f h an d fu n c t i o n t h a t m ay b e mo re u s e -fu l , bu t these s t i l l seem more compl ica ted than as imple mai l ed ques t ionnai re . Th i s may be a p rob-lem wi th a l l p er fo rm ance -base d ins t ruments .Lachs et l [18] proposed a series of 11 i tems forident i fying poor physical funct ion, vis ion, hearing,IADLs , ADLs , menta l s t a tus , and soc ia l funct ion ingin o lder pa t i en t s . The i t ems are l a rge ly per fo r -mance-based , bu t inc lude s imple ques t ions and aredes igned to be incorpora ted in to phys ic ians ' p rac-



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t i ces . Th i s i s a comprehens ive approach t ry ing toiden t i fy d i seases dement ia , depress ion) , func t ionald i sab i l i ty , and poor resources . The va l id i ty andprac t i ca l i ty o f these i t em s in the iden t i f i ca t ion o ffrai l, elderly pat ien ts in office pract ic e have no tbeen s tud ied .Severa l shor t ques t ionnai res have been des ignedto measure phys ica l , psycho log ic , and soc ia l func-t ion ing in genera l popu la t ions [21-24] , bu t cou lda l so have app l i cab i l i ty to the f ra i l e lder ly . Two ofthese inc lude i t ems on genera l hea l th percep t ionsand soc ia l ro le funct ion ing th a t would seem to havel imited relevance to older adul ts [21,23], but theFunct ion al S ta tus Ques t ionnai re FSQ) [22 ,24] hasan emph as i s on ques t ions fo r as sessmen t o f theelderly .The FSQ cons i s ts o f 34 se l f -admin i s t e red ques -t ions covering physical , psychologic, and socialro les , some o f which c lose ly resemble A DL, IADL,and hea l th eva lua t ion i t ems on ger i a t r i c as sess -ments . Val ida t ion o f the F SQ has shown i t i s a goodmarker o f d i sab i l i ty as measured by age , bed days ,res t r i c t ed ac t iv i ty days, and work l imi ta t ions , b u t i thas no t been t es t ed as a measu re o f hea l th ou tcomesor dea th o r compared to c l in ica l judgm ent . TheFSQ has been t es t ed p rospec t ive ly [24] and foundto be accep tab le to pa t i en t s and phys ic ians . Unfor -tunate ly , when phys ic ians were g iven the add i t iona l

, i n fo rmat ion on funct ional s t a tus f rom the FSQ,there was l i t t l e d i f fe rence in therapy o r serv icesprescr ibed o r even tua l pa t i e n t funct ion . Th i s ra i sesthe ser ious i ssue o f the capac i ty and in teres t o f o f -f i ce p rac t i t ioners to ac t on in fo rmat ion a bou t func-t iona l d i sab i l i ty . I t a l so s t reng thens con ten t ionstha t a screen shou ld p rompt re fer ra l fo r spec i f i cger i a tr i c as sessme nt and man ageme nt , ,and tha t re -l i ance on nonger ia t r ic p rac t i t ioners to m anage func-t iona l d i sab i l i t i es may be p rob lemat ic .None o f the p ropo sed ins t ruments , inc luding ourFunct ional Assessment Screen , can be recommend-ed wi thou t reserva t ions fo r widespread use . Theapproaches tha t have been mos t thorough ly va l i -da ted seem e i ther too compl ica ted fo r widespreadphys ic ian acc ep tance o r , if easi ly accep ted b y phys i -c ians , have no t been t es t ed as p red ic to rs o f fu tu reserv ice use in e lder ly pa t i en t s and may have l i t t l ei mp a c t o n p a t i e n t c a r e . T h e p e r f o r ma n c e - b a s e dscreen o f Lachs et l [18] is properly focused onger ia t r i c pa t i en t s bu t needs to be va l ida ted . Thedata p resen te d here es t ab l i sh the va l id i ty o f theFunct ion al Assessm ent Screen comp ared to p rov id -er judg me nt a nd fu tu re serv ice use , bu t these con-c lus ions a re l imi ted as to se t t ing and popu la t ion .Fu t u r e e v a l u a ti o n s o f t h e F u n c t i o n a l A s s e s s me n tSc r e e n n e e d t o b e p e r f o r me d t o d e t e r mi n e a c c e p t-

ab i l i ty to l a rger num bers o f pa t i en t s and phys i -c ians , re li ab i l i ty when com par ing pa t i en t and su r ro -ga te responden t s , va l id i ty in o ther c l in ical se t t ings,espec ia l ly in nonger ia t r i c p rac t i ce , and va l id i ty inpred ic t ing ins t i tu t iona l i za t ion , dea th , and o therservice use in larger populat ions with fewer frai le lderly . Wi thou t these and o ther s tud ies o f screen-ing ins t ruments in genera l o f f ice p rac ti ce , the i r use-fu lness in the m ains t ream of medic ine wi ll go un-tes t ed and ger i a t r i c serv ices may never be wide lyaccep ted by o f f ice genera li s t s.

PPENDIXFunctional ssessmentScreening nstrument__ 1. Who lives with you? (circle right answer )* 1. no one 4. friends2. husband or wife 5. non-relat ed paid helper3. othe r relative(s ) 6. reside in an institution__ 2. Is there someone who would give you help if you were sick ordisabled (for example, your hu sband/wif e, a member of yourfamily, or a friend?)1. yes * 2. no__ 3. Do you own your own home?1. yes * 2. no4. Do you usually have enough to buy those little ex tras , that is,small luxuries?1. yes * 2. no__ 5. What is your household income?* 1. under $5,000 3. $15,00 0-$25,0 002. $5,OOO-$15,O00 4. ove rS25 ,00 0__ 6. During the past 6 months, how many days were you so sick thatyou were unable to carry on your usual activities--such asgoing to work or working around the house? (do not includedays in hospital or nursing home)__ number of days * more than 1__ 7. During the past 6 months, how many days were you in thehospital ?__ number of days * more than I__ 8. How much do your health troubles stand in the way of your doingthe things you want to do --n ot at all, a l ittle (some), or a greatdeal?1. not ata ll =2. a l ittle (some) '=3. agre atde al__ 9. Do you need any help with such things as: (check) (Any *)1. shopping 5. _ _ dressing2. housework 6. __ going to the bathroom3. __ getting around 7. __ meals4. bathingPositive answer.

CKNOWLEDGMENTI wish to-t hank the staff of the Geriatrics Institute, Sinai Samaritan MedicalCenter, Milwaukee, Wisconsin, for patient evaluations, Lee Ellington for assis-tance with data collection and analysis, Nancy Hetmanski for expe rt secretarialservices, and Mary Tinetti, M.D., and Alvan Feinstein, M.D., for reviewing themanuscript.REFERENCES1. Williams TF. Comprehensive funct ional assessment: an ove rview . J Am Ger-iatr Soc ]983; 3]: 637-4].2. Rubenstein LZ. Comprehensive geria tric assessment. In: Solomon DH, mod-erator. New issues in geriatric care. Ann Intern Med 1988; 108: 718-32.3. Rubenstein 17, Josephson KR, Wieland GD, et al Effectiveness of a geriatricevaluation unit: a randomized clinical trial. N Engl J Med 1984; 31 ]: ].66 4-7 0.4. Rubenstein 17. Geriatric assessment: an overview of its impacts. Clin GeriatrMed ]987; 3: 1-15.5. Williams TF, Hill JG, Fairbank MF, et al Appropriate placement of the chroni

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cally ill and aged: a successful approach by ev aluation. JAMA 1973; 226 : 13 32-5.6. Pinholt EM, Kroenke K, Henley JF, et al Functional assessmentof the elderly;a comparison of standard instruments with clinical udgem ent. Arch Intern Med1987: 147: 484-8.7. Miller DK, M orley JM, Rubenstein LZ, et al Form al geriatric assessmentinstruments and th e care of older general medical outpatients. J Am Geriatr Soc1990; 38: 645-51 .8. Barton B, Cairl R, Keller D, et a/ Functional assessment inventory trainingmanual. Tampa, Florida: Suncoast Gerontology Center, University of SouthFlorida, 1983.9. Pearlman RA. Development of a functional assessment questionnaire forgeriatric patients: the comprehensive older person s evaluation (COPE). JChronic Dis 1987; 40 (Suppl): 85S-94S.10. Freeman DH. Applied categorical data analysis. New York: Marcel Dekker,1987: 63-4.11. Branch LG, Wetle l-r, Scherr P, eta/ A prospective study of incident com-prehensive medical home care use among the elderly. Am J Public Health 1988;78: 255-9.12. Spector WD, Katz S, Murphy JB, F ulton JP. The hierarchical relationshipbetween activities of daily living and instrumental activities of daily living. JChronic Dis 1987; 40: 481-9.13. Branch LG, Jette AM . A prospective study of long term care institutionaliza-tion among the aged. Am J Public Health 1982; 72: 1373-9.14. Katz S, Branch LG, Branson MH, eta/ Active life expectancy. N Engl J M ed

1983; 309: 1218-24.15. Fillenbaum GG. Screening h e elderly: a brief instrumental activities of da ilyliving measure. J Am Geriatr Soc 1985; 33: 698-706.16. Manton KG. A longitudinal study of functional c hange and mortality in theUnited States. J Gerontol 1988; 43: S153-61.17. Rubenstein LZ, Schairer C, Wieland GD, Kane R. Systematic biases n func-tional status assessment of elderly adults: effects of different data sources. JGerontol 1984; 39: 686-91.18. Lachs MS, Feinstein AR, Cooney LM, et a/ A simple procedure for generalscreening for functional disability in elderly patients. Ann Intern Med 1990; 112:699-706.19. Freer CB. Consultation-based screening of the elderly in general practice: apilot study. J R Coil Gen Pract 1987; 37: 455-6.20. Williams ME. Identifying the older person likely to require long-term careservices. J Am Geriatr Sac 1987; 35: 761-6.21 MackenzieCR, Charlson ME, D iGioia D, Kelley K A patient-specific measureof change in maximal function. Arch Intern Med 1986; 146: 1325-9.22 Jett e AM, Davies AR, Cleary PD, eta/ The functional status questionnaire:reliability and validity when used in primary care. J Gen Intern Med 1986: 1:143-9.23 Stewart AL, H ays RD, Ware JE. The MOS short-form general health survey.Med Care 1988; 26: 724-35.24. Rubenste in LV, Caulkins DR, Young RT, et al Improving patient function: arandomized trial o f functional disability screening. Ann Intern Med 1989; 111:836-42.


patient-completed screening instrument for functional disability in the elderly

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