Functional Ability, ADLs and Screening Tools

• Functional ability exists on a continuum from full function to disability, varying among individuals and at different life stages.
• Health and disability interaction involves developmental, biological, psychological, sociocultural, environmental, and socioeconomic factors.

ADLs (Activities of Daily Living)

• Basic ADLs (BADLs) involve personal care and mobility, including bathing, dressing, eating, toileting, transferring, continence, and ambulating.
• Instrumental ADLs (IADLs) involve complex skills for community living, such as meal preparation, finance management, shopping, transportation, housekeeping, medication management, communication, and home maintenance.

Screening Tools

• These tools are used to assess functional and cognitive abilties
• The choice of tool depends on the specific needs of the assessment

MoCA (Montreal Cognitive Assessment)

• A screening tool for mild cognitive impairment and early dementia signs.
• Assesses attention, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation.
• Takes approximately 10 minutes with a score of 26 or higher out of 30 considered normal.
• Has a high sensitivity (90%) for detecting mild cognitive impairment.
• Used to assess cognitive function in conditions like Alzheimer’s, Parkinson’s, and stroke.

MMSE (Mini-Mental State Examination)

• A screening tool to assess cognitive function and detect impairment, especially in older adults.
• Originally for differentiating between organic and functional psychiatric disorders.
• Takes about 5 to 10 minutes to administer.
• Scoring: 24-30 is normal, 18-23 indicates mild impairment, 10-17 moderate, and below 10 severe.
• Assesses orientation, registration, attention, calculation, recall, language, and visuospatial skills.
• Used to screen for cognitive impairment, estimate severity, and monitor changes but does not diagnose specific dementias.

TUG (Timed Up and Go)

• Evaluates mobility, balance, and fall risk by timing how long it takes an individual to stand from a chair, walk 3 meters, turn around, walk back, and sit.
• Easy to administer
• Shorter times indicate better mobility.
• Normal mobility: less than 10 seconds (healthy), up to 12 seconds (frail/disabled).
• Over 12 seconds indicates increased fall risk; 30 seconds or more suggests severe mobility issues.
• Used in geriatric populations and those with Parkinson’s, stroke, and multiple sclerosis.
• High reliability for assessing changes over time.

Katz Index of Independence in ADL

• Assesses the ability to perform basic ADLs independently.
• Assesses bathing, dressing, toileting, transferring, continence, and feeding.
• Each activity is scored as 1 (independent) or 0 (dependent), with total scores from 0 (very dependent) to 6 (fully independent).
• A score of 6 indicates full function, 4 moderate impairment, and 2 or less severe impairment.
• Used to assess functional status, plan care, and monitor changes, particularly identifying areas needing assistance.
• Limitations: does not assess IADLs and has limited ability to detect small changes in rehabilitation.

PHQ-9 (Patient Health Questionnaire-9)

• Screens, diagnoses, monitors, and measures depression severity based on DSM criteria.
• Self-administered, taking a few minutes, or can be administered by a clinician.
• Each of the nine items is scored from 0 (not at all) to 3 (nearly every day), with a total score range of 0 to 27.
• Score interpretations: 0-4 (none to minimal), 5-9 (mild), 10-14 (moderate), 15-19 (moderately severe), 20-27 (severe).
• Used to identify and diagnose major depression, assess symptom severity, and monitor treatment response.
• A score of 10 or higher has 88% sensitivity and specificity for diagnosing major depressive disorder.
• Brief, validated in many populations, and comprehensive in assessing depressive symptoms

Morse Fall Scale (MFS)

• Evaluates a patient’s risk of falling in healthcare settings, especially useful in acute and long-term care.
• Six factors assessed: fall history, secondary diagnosis, ambulatory aid, IV therapy, gait, and mental status.
• Scoring ranges from 0 to 125, with risk levels categorized as:
• 0-24 (low risk)
• 25-45 (moderate risk)
• 46-125 (high risk).
• Used to identify patients at risk and guide personalized fall prevention strategies.
• Should be used with clinical judgment and facility-specific policies for effective fall prevention.

Risk Recognition

• Recognition is key for early identification of functional deficits, which impacts health outcomes.
• Situations increasing risk include developmental abnormalities, trauma, disease, social/cultural factors, advanced age, cognitive function, mental health issues, comorbidities, and socioeconomic factors.

Assessment Approaches

• Self-reporting tools gather patients' perceptions.
• Performance-based tools involve observation, measuring with repetition, and timed tasks.
• Performance tools are preferred over self-reporting due to potential inaccuracies.
• The same tool should be used for re-evaluation.

Roper-Logan-Tierney Model of Nursing

• Focuses on health promotion and wellness rather than illness.
• Includes 12 ADLs essential to life: maintaining a safe environment, communication, breathing, eating/drinking, elimination, washing/dressing, controlling temperature, mobilization, working/playing, expressing sexuality, sleeping, and death/dying.
• Assesses dependence and independence levels on admission and throughout care.
• By monitoring changes in the dependence-independence continuum, nurses can adjust care based on the evidence.

Nursing Interventions

• Educate patients and families on maintaining functional ability through balanced nutrition, physical activity, routine checkups, stress management, meaningful activity, fall prevention, and avoiding substance abuse.
• Provide self-care assistance for ADLs and teach the proper use of assistive devices.

Meaningful Measurement (EHR Documentation)

• Should address dependency and difficulty levels.
• Dependency levels: no assistance, partial assistance, or total assistance.
• Difficulty levels: no difficulty, some difficulty, or unable to perform.
• Care delivery aims to maintain optimal independent function and prevent functional decline.
• Reduce risk through early detection, screening, and multidisciplinary interventions based on the cause of impairment.