Geriatric best practices in nursing: optimizing functional independence

Abstract

Currently, older adults comprise approximately 13% of the population, with projections expected to exceed 20% by the year 2040. This graying of America has serious implications regarding the economic and social costs associated with both agerelated functional limitations and those associated with the sequelae of chronic disease. The ability to perform activities of daily living (ADL) has been identified as an important predictor of age-related disability. In addition, the limitations in the ability to perform ADLs are considered predictors of nursing home placement, increased utilization of physician and hospital services, less use of primary and preventative care, compromised quality of life, and increased mortality. 1 The process of aging is generally associated with a decline in functional independence. Furthermore, the limited functional reserves of the immune, pulmonary, cardiac, and vascular systems frequently predispose older adults to the greatest risk for decline in functional independence, especially when hospitalized. Although this functional decline may be attributed to age-related changes in the ability to adapt to acute illness, this high-risk population is prone to both iatrogenic complications and nosocomial infections. In addition, several other factors that contribute to functional decline are listed in Table 1. 2 The effects of declining physical and cognitive levels of function may be further complicated by the impact of chronic disease. Older patients are at particularly high risk of poor functional outcomes when placed in situations in which there is a loss of function compared with their baseline. Although this frequently occurs in the hospitalized patient, acute illness in any setting poses the same risk of functional decline. Similarly, progressive deteriorating chronic diseases, such as Parkinson’s disease and peripheral arterial disease, are frequently associated with limitations in physical function. Oftentimes the oldest of old are frequently unable to recover ADLs, which may be lost during treatment (ie, inability to ambulate, deconditioning, and medication-induced mental status change). In a prospective observational study of 2293 patients who were older than 70 years and admitted to an acute care facility, Covinsky et al 3 reported that 35% of patients declined in ADL function between baseline and discharge. Although most investigations suggest that a decline in cognitive and physical function is associated with frailty, Black and Rush 4 suggest that the inverse relationship also exists. Loss of independence is the greatest fear frequently reported by older adults. However, nurses often fail to address this fear because most individuals are uncomfortable with the dialogue required to circumvent the problem. Whether clinical practice is in the ambulatory or acute care setting, nurses are uniquely positioned to anticipate and minimize the risks associated with functional decline in the older adult population. The initial step in targeting the problem is assessment. Several useful instruments to assess potential problems and risks are described in Table 2. In order to optimize the level of independence in high-risk patients, more discussion regarding realistic outcomes must occur. In my experience, patients are simply read detailed lists of the complications associated with interventional procedures;