Functional Assessment in an 85-Year-Old Lady

Functional Assessment in an 85-Year-Old Lady A. 20 High-Yield Points Why Function Matters at 85

Functional assessment means measuring what the person actually does in daily life, not just listing her diseases. In geriatrics, function is the common language and assessment is the core method.

In an 85-year-old, function predicts outcome better than diagnosis. There is no direct relationship between disease and functioning — the same illness produces very different disability in different people, so function must be measured separately.

Functional decline is caused by medical, functional, psychological, social and environmental risk factors acting together. Hence assessment must be multidimensional, not just physical.

A baseline functional measure is essential so that progress can be monitored and the effect of treatment or rehabilitation judged.

Three levels are assessed: impairment (the deficit) → activity restriction (ADL/IADL loss) → participation restriction (loss of social role). Participation restriction is unique to the individual and depends largely on her ability to adapt.

Mobility must always be tested at this age — about half of people aged 85 and over report difficulty walking, and gait disorders threaten independence and cause falls.

The functional "review of systems" rests on three measures: frailty, basic ADLs, and IADLs.

Principle of hierarchy: if she is severely ADL-dependent, do not test frailty; if she is robust or pre-frail, do not test basic ADLs. Match the depth of assessment to the patient and the setting.

Basic ADLs (personal care): bathing, dressing, toileting, transferring, continence, feeding, grooming. Tools — Katz Index, Barthel Index, Lawton Personal Self-Maintenance Scale.

IADLs (tasks needing "instruments"): cooking, shopping, housework, laundry, telephone, public transport, managing money and medicines. Tools — Lawton IADL scale, OARS-MFAQ.

IADLs are lost first, ADLs later — so IADL loss is the earlier warning sign. If difficulty is reported, always ask "how does she manage?" — is the task neglected, or is someone else doing it?

Always record premorbid function as well as present function, especially after an acute illness, fall or hospital admission.

Mobility, gait and balance — the high-yield numbers: - Gait speed over a 4 m track: below 0.6 m/s is abnormal; 0.6–0.8 m/s is high-risk. Each 0.1 m/s fall in gait speed equals a 7% rise in fall risk. - Timed Get-Up-and-Go: more than 12 seconds equals high fall risk (sensitivity 77%, positive predictive value 93% in the community). - Tinetti Mobility Scale: 14 tasks, score below 24 of 28 indicates fall risk (10–15 minutes). - 30-second chair stand and 4-stage balance test (hold each position 10 seconds); both feed into the Short Physical Performance Battery (SPPB). - Berg Balance Scale: 14 items, 0–56 (0–20 wheelchair-bound, 21–40 walks with assistance, 41–56 independent).

Two screens are mandatory in any older person with functional disability: cognition (Folstein MMSE) and depression (Yesavage GDS or Zung). Both are common, treatable causes of apparent functional loss.

Other essential domains: nutrition (MNA, SNAQ, BMI, weight loss), special senses (whispered voice test or Hearing Handicap Inventory; Snellen chart), oral health (GOHAI), continence, and social network and support (Lubben Social Network Scale, OARS social resources section).

RCP/BGS endorsed scales — memorise this table:

Quick screening questions usable at the bedside: "Do you need help at home?" (function) · "Do you have trouble walking or lose your balance? Have you had a fall? Are you afraid of falling?" (mobility) · "Are you sad?" (mood) · "Have you lost weight?" (nutrition) · "Are you on seven or more medicines?" (polypharmacy) · "Do you wet yourself?" (continence).

Use both report and performance. Reports (from her or a proxy) tell you what she does under real living conditions; performance tests tell you what she can do under standard conditions. Discrepancies between the two are common and informative.

Grade each task into: independent without difficulty / independent but with difficulty or an aid / needs human help / unable even with help. Distinguishing "independent with difficulty" adds prognostic value.

Do a task analysis of the specific problem, then look for a reversible cause and act on it: - Example: "difficulty dressing" may be due to choosing clothes, remembering to finish, buttoning, reaching overhead, or bending for shoes — pointing respectively to cognitive impairment, poor finger mobility, or shoulder, back or hip disease. Each demands a different treatment. - Always correlate new functional loss with new drugs or dose changes (including over-the-counter), changes in living conditions, and intercurrent acute illness (even mild). - Remember the cascade: impaired gait leads to depression and social withdrawal; immobility of any cause causes deconditioning and loss of musculoskeletal flexibility that persists after the cause is removed. - Assessment without a plan is worthless — link findings to the rehabilitation steps: assessment → goal setting → therapy → aids and adaptations → education → psychological support → evaluation → follow-up.

WHO ICOPE and "intrinsic capacity" — the major conceptual shift. The ICOPE 5-step pathway is: screening, in-depth assessment of those screening positive, person-centred interventions, long-term follow-up, and community engagement with caregiver support. The screening tool assesses six functional domains — mobility, cognition, nutrition/vitality, vision, hearing and psychological well-being — and can be done by a professional or by self-assessment through the ICOPE Monitor application; a confirmed deficit triggers full assessment and a personalised care plan. Reference centiles for intrinsic capacity were published in Nature Aging (2023, 2024).

German DGG S3 Guideline on CGA in Hospital (2024). Minimum requirements are defined as six core dimensions — self-help ability, mobility, cognitive function/delirium, affect, nutrition and social situation — with a minimum CGA duration of 15 minutes. This is the first guideline to set a floor standard for functional assessment.

Age-Friendly Health Systems "4Ms" framework. The 4Ms are What Matters, Medication, Mentation and Mobility. In an eight-hospital 2024 evaluation of 3,103 admissions, patients receiving all 4Ms had fewer 30-day emergency visits (16% vs 22%) and a trend to lower readmissions; Mobility generated the highest "act-on" rate of all four Ms (83%).

Gait speed is being repositioned as the single best functional marker. A 2025 longitudinal study of about 3,600 older adults found that among all components of frailty and sarcopenia, low physical performance (slow gait speed) was the best single predictor of incident basic and instrumental ADL disability, and sarcopenia as a whole construct was not associated with increased disability risk. EWGSOP2 defines low physical performance as gait speed of 0.8 m/s or less.

Italian National CGA Guideline (2024). Across 117 studies, CGA was shown to maintain functional activities and to reduce hospitalisation, mortality, institutionalisation and delirium risk.

Oncology — ASCO 2023. Geriatric assessment including all essential domains, of which physical function is one, should be used in all patients over 65 with cancer, with the Practical Geriatric Assessment (PGA) as the recommended tool.

Indian context. Functional assessment tools are being adapted for low-resource, high-volume settings under NPHCE. Evidence remains predominantly from high-income countries and hospitalised patients. Short multidimensional community tools such as EHSAS, deliverable by community health workers, have been validated for rural India precisely because full CGA is impractical with the available workforce. LASI provides the national ADL/IADL disability estimates.