,5. no 0 I ‘ ‘ I
5 . .
. ‘ 5 " I
o, ' I. . 0
.. ‘0- .
‘ 0 0555 . >‘
. '0
1 U ’ . "' .'
I
0 o o . .
O 05
' O ' I' "I' i . '
| 4
'1 '“5’. ‘ I '5'
. Q 5 Q.
‘ 00 Ol'
O .'
. 5 5 H ,‘ . .

 

 
   
 
     
  

          
 

  

 
 
 

‘ . '
Q . . {' g '
‘ I . . a t . O
’5
5 . J 5 , ° '
I. ‘ 5' f: lyl . 5 ,5: 5 5 ..
. . .
I . 0| ‘
' 5 ‘ . '5 ' . 155 5 .
t. ' '5 l 5 . ' 5 l '55 5 I .. fl. . U.’
.. 5 ,', ' . . y ' I I ' . ' .. : . . . 'I

4 O 5‘ . .5 I. ." 53-5" 5. ..2.“ 555 ., 5 5‘1““ 5

I I '. I ' ‘ . 5‘ ’ V |.,5 .. I ‘ 5f . 9

.5 " '. ‘ ' 'H .‘ ‘ I] ' “r‘ ‘l 't ' . "H‘ Ir, ‘0" ‘ )55

l , . .5 5 5" ‘ . , '. \ I J .
5‘. 5. 5 .[ '.' .... “ '_ ‘55..a~51‘:"q;‘:-’ .5 5 I I
. 5.. _. '.' ‘ ‘ , .. ‘ . .
. ,. fi‘1'.l5(.‘5..‘5-5'.5:1¥: I L} 155' 5 5 H.375“. .5 [I 5‘ 1'7

‘5' " .’ . ‘ . .l‘ll ‘ “h ,l ‘ 5':. I If V I’.’ I 5“‘1.‘,‘.""* I: '1']... ‘1’. V ‘..| ’ ‘ '

7.5 '2 "' =35 {.555 55555:: 5'“ "'U 5”5.555555.m. 5;? 55W,'.."' 55 .:

.5 ‘ . :5." ‘5 5':' .‘ ":41 1" 155‘; ‘ a4; flfi 5- I 5, ‘: u. {5: ¢ ’5 [I \I ”I“: v.3 , >,55"'"I 1“ .‘ l, . ‘1 '.\. . S
H} l!‘ .\‘ 5 O} 'o ““5 5L. ... ”I‘filfk “ ' . 55_' r..’:?;‘...|“ (‘5’ ;. 4., I‘ 715‘: ‘ 5; . '

”1.5‘ ‘ ,5 5 5'. . ’" "Hg‘lf‘r'fi. .5. :5. ; '5...” ‘23,“! .u' l‘ "L". '.'. 5 " 5‘. ‘ ;{

‘.-'. 4. 5 , 5 ,. .5‘,‘ f 5 I .5 5 ;_.5 ”"255, '1, a." 5,145‘ 'f ‘ 5...

5",5' 5 5 5 . 5, 9" 3:“! I! 5. It: ('1!!! '1 '1'- .o', ‘ '5' . .

5‘ 5-5 1...: 555555555‘”5555 " 551..” """‘§fi"‘ H.455 3:555:55?” ,. 5'. ‘ i
6‘55 WNW ' 5‘5'5 5.555554555m55? 5?? '5"5 5"? .5‘5‘.fi:5»1..5.5' . .2..-5, x..' .
. . . . ‘ ”.5... . I ...‘... ...' I ‘. .'.. ‘

"""l ..‘5 5.5"” """ It! 9‘, ..' 7555;5'5- afihww... 1’ ":55 . I" H.552“. 5w '5 5. ‘ .~ 5

57"“: .55.“ .55 " ‘ 5; 55.015555": 5.5 5"-'55.5’51"5--.~555 5-..55555'5 5 L525.” (55 5,! , 51.. . .

.3 ' ‘ '5’ ' | 1'85”” ' 555"1“-"’~5:|5..'5'.!‘;'5‘n'5.. i“; 952—535; “"J .5553} 5.: H915 5 '[I 5". 5"" I,. 5.5“". »- 5. '

0 ti: 5‘?” " I.. ‘. ,Af- h‘ I’;" , I. ."I 5. : 5 r H“ .lé.‘ "'J’L‘} '. h.5’1‘]}‘?: . ”a 6" \‘k‘.is‘.§;. 1",5'1. ‘2‘."‘5. ' 5 0 b , ‘..5 1" ‘\‘ L, H. x

5. .5 5 .55 ;-..1.‘5'-‘{- 3'55 ... ._.: , ‘ ’ $1355 1. . I

9,3! 2“" 5'5““ Lh' l5" 5 LN?“ we“. _5 5 5 Ht “'5' ' E14“! 4“,}; fiv‘f‘. “ WW4!” ~ ‘55? 533552,!1Hlfiffl“ t)" 55' | .3

'3 E15 .5" L ' 1'" .fl‘5 5'555’3'5'65‘5355" "555 55:55 I-‘L’e #5:“ - 5 ”If. .5 5:755'5’ 5 5.;[5 '5 ,5 . 5. 5

Him '4' I“ (54 I", .‘;5‘:' “1"; .;.(:.. :53,“ ”it. I'] .5 ' ' .5 (1.5 55] P; 9.75: if.“ :/ J. {5‘}: 'If“ :3, ; . 6
II... 5 3-. fi; 5.5”“. ‘1.

~.‘ ’"“v’ V?

  
 

5

35.4.“:
['3‘
>>

  

~

5: 5 , . 1'.
115$ («I {A ‘l(|.‘f;15(%‘ .
.5. 35:55 5' 55.55 .555...55.5i:55'i ..
W555} 555.5555: .515. '

'53‘5 '
I M55555}

 
 
  

'7??? "‘1:

   
 

if.“
'5

‘5
, v

‘p .f. 5"!“ 5.
.5... .5 5.5.
11;“ ‘5’.” 5 “£33; , r .. -". '. l4! ‘ 1'

5551‘."

15L
4.5.35" .

. 3A0":
. fl
‘
. ""‘: . -
, . ;
54 ‘5 - .

   
   

   
  
 

55.55.5555
5-5

    

  
 

‘27

f.

- mt:
H515

 

 

' . ' a ' '3 , I. _:

f. l ‘ 5 .5 > .

O ) [1'5 5 ‘%1:) :0. .1.
5’5 {’4‘ I - . 555'}. 59%;.
"5‘ ‘ ‘ (Myt' .2, .3,
V535 5 .5 thgéfi j

5 ' . :5 ‘. ‘1, '4'

.' . 5;: u.
5.5 .‘m “m' ..5".‘ {l - ‘53:. 5.5.1531.

 

lllllllllllllllllll\\\\\\\\\\\\\\\

This is to "ertify that the

thesis entitled

RELATIONSHIP BETWEEN FUNCTIONAL STATUS,
MENTAL STATUS, AND REVERSIBLE PROBLEMS IN
THE COMMUNITY-DWELLING ELDERLY

presented by

Jean Marie Thiele

has been accepted towards fulfillment
of the requirements for

Master of Science degree in Nursing

 

 

Ken }z£u¢x,m4a

Major professor

Date {A 5‘92,

0-7639 MS U is an Affirmative Action/Equal Opportunity Institution

PM

 

Mlchlgan Stator

HUBBARY
Unlverslty

 

 

PLACE IN RETURN BOX to remove this checkout from your record.

    

TO AVOID FINES return on or before duo duo.

DATE DUE DATE DUE DATE DUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

l

MSU to An Afflrmotivo ActiorVEqual Opportunlty Institution
6W

 

 

RELATIONSHIP BETWEEN FUNCTIONAL STATUS,
MENTAL STATUS, AND REVERSIBLE PROBLEMS IN
THE COMMUNITY-DUELLING ELDERLY

By

Jean Marie Thiele

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing
1992

ABSTRACT
RELATIONSHIP BETWEEN FUNCTIONAL STATUS,

MENTAL STATUS, AND REVERSIBLE PROBLEMS IN
THE COMMUNITY-DWELLING ELDERLY

By
Jean Marie Thiele

The statement of the problem is to determine if community-dwelling
elderly can be categorized into low, moderate, or high risk groups by
using functional status and mental status profiles in order to determine
if an association exists between mental status, functional status, and
reversible problems in the community-dwelling elderly. A retrospective
chart audit was done. The results of the Pearson product moment
correlations between the functional status, mental status, and
reversible problems found no relationship. The results of the two-way
ANOVA found no differences in the mean number of reversible problems in
the low, moderate or high risk community-dwelling elderly. This study
strongly supports the need for comprehensive geriatric assessments to be
utilized on all community-dwelling elderly with the major portion

implemented within the geriatric individuals home environment.

ii

ACKNOWLEDGEMENTS

My sincerest thanks to my parents who taught me the importance of
education and how to utilize my degree to enhance my compassion and E1
concern for all individuals within my life and my nursing profession.

To Scott, my husband, for enduring the hardships placed on our i:3
relationship while achieving my Master's degree education. Thank you
for you never ending love and the freedom to pursue my advanced nursing
career.

To my daughters, Jessica and Christine whom I love dearly. They
helped me to prioritize my work and class schedule which allowed time
for an important part of their lives, playtime. Thank you, girls!

To Linda Allen, my good friend who took good care of my children
when I attended individual and committee thesis meetings. Thank you for
devoting quality time to my children. Thanks also to my babysitters,
Karman Adams and Linda Faulkner who also took good care of my daughters
during the many revisions of my thesis.

To Rachel Schiffman, my committee chairperson who continually
encouraged me to work hard on my thesis. She was the driving force
which allowed me to finish my thesis in a timely manner. Your
compassion and concern toward my future as a geriatric clinical nurse
specialist should be commended. _

To Chris Hough, Joan Hood, Brigid Warren and Muriel Archbold who

continue to inspire me with their enthusiasm for the geriatric

iii

population. Thank you for your strong support during my thesis process.
To Judy Kraska and Kathy Boardman my classmates and my friends who
prayed for me before and during my thesis defense. Your support was
very touching and much appreciated. To Patricia Holfgram, librarian,
who assisted me with my literature search. Finally, many thanks to God
and the constant drive given to me to finish my Masters of

Gerontological Nursing degree. This has been a dream come true.

iv

TABLE OF CONTENTS

Ease

CHAPTER I
Introduction ............................ 1
Purpose ............................... 6
Statement of the Problem ...................... 7
Overview of the Remaining Chapters ................. 8
CHAPTER 11

Introduction ............................ 10
Conceptual Definitions of the Variable ............... 10
Theoretical Framework ........................ 19
Explication of Applicability and Relevance of Conceputal

Framework to Problem Under Study .................. 28
Summary ............................... 29
CHAPTER III

Introduction ............................ 30
Low, Moderate and High Level of Screenig in the

Elderly in the 1990's ....................... 31
Mental Status, Functional Status and Patient Problems ........ 33
Support for the CGA to Maintain Elderly in their Home ....... 38
Mental Status, Functional Status and Risk Level ........... 39
Relationship Between Mental Status and Functional Status ...... 45
Mental Status and Reversible Problems ................ 47
Implications for the Present Study ................. 48
Summary ............................... 49
CHAPTER IV

Introduction ............................ 50
Design ............................... 50
Sample ............................... 51
Operational Definitions of the Variable ............... 51
Instruments ............................. 54
Folstein Min-Mental Status Exam ................... 55
Katz Index ............................. 57
Data Collection Procedures ..................... 58
Data Analysis ............................ 58
Methodological Assumptions and Limitations ............. 59
liuman Rights Protection . . . . . . . . . . . ............ 59
.Summary ............................... 60

CHAPTER V

Results ............................... 61
Description of the Sample ...................... 61
Study Variables ........................... 61
Presentation of Data Related to Research Question .......... 64
Summary ............................... 69
CHAPTER VI

Summary, Interpretation and Conclusions ............... 70
Summary of the Research Study .................... 70
Comparison of Sample Characteristics to the Literature ....... 71
Conclusions Regarding Study Findings ................ 72
Implications for Advanced Nursing Practice ............. 75
Implications for Education ..................... 77
Implications for Nursing Research . . ' ................ 79
REFERENCES ............................. 81
APPENDICES

Appendix A ............................. 86
Appendix B ............................ 110
Appendix C ............................ 112

vi

Table 1:
Table 2:
Table 3:
Table 4:

LIST OF TABLES

Frequency and Percent of Reversible Problems ...... 63
Risk Status Identification ............... 65
Mean Number of Reversible Problems by Risk Status . . . . 67

Comparisons of Living Arrangement with Risk Level
Percentage of Individuals in Each Cell ......... 68

vii

Figure 1:

Figure 2:

LIST OF FIGURES

Andersen/Newman Health Service Utilization Framework

Individual Determinants of Health Service Utilization .

viii

. 12
. 18

CHAPTER I
Introduction
Hith the steady increase in the geriatric population, the steady
decline in their mental and functional well-being and the sudden rise in
health care costs of this population, health care providers are seeking
innovative ways to care for the geriatric population. At present many
health care providers are deeply concerned about the delivery of health

care to the elderly. The geriatric population is expanding. According

{iii mm W

I...._..- -s - '

to the U.S. Department of Commerce the number of Americans aged 65 and
over is projected to double between 1980 and 2020. Persons 65 years of
age and over made up 12 percent of the population in 1982 and are
expected to make up 20 percent by 2020. The number of elderly persons
grew twice as fast as the rest of the population between 1960 and 1980,
and the number of people aged 85 and over increased more than twice as
fast within the elderly population (U.S. Department of Commerce, 1990).

Although the health status of the elderly population is improving,
their functional status is on the decline. As the current population
ages, the remaining years of functional well-being is predicted to
decline from ten years of active living at the age of 65 to two to nine
years at the age of 85 (Katz, Branch, Branson, Papsidero, Beck, & Greer,
1983). In addition, the elderly as a group tend to have multiple
medical problems, longer hospital stays, longer rehabilitation periods,
unrecognized symptomatology and current active problems involving
Inultidimensional spheres, for example biological, psychological, social,
environmental and spiritual. ‘

Mental status is also on the decline especially in the 85 and

older group. Community surveys estimate that severe forms of dementing

I

2
illness affect more than five percent of people of the age of 65 years
(Gottlieb, 1989). The prevalence of severe dementia rises from
approximately one percent at ages 65 to 74 to seven percent at ages 75
to 84, to 25 percent for those over age 85 (U.S. Congress, Office of
Technology Assessment, 1987). Fisk and Pannill (1987) in a two-year
study of 159 community-dwelling Alzheimer's disease patients found a
moderate reduction in cognitive function and physical activities of ”
daily living and a greater dependence in the instrumental activities of
daily living. Abnormalities in mental status are probably the biggest
risk to independent living and quality of life (Burke, Rubin, Zorumski,
& Potter, 1989). Therefore, as a clinician, it is extremely important
to screen for cognitive impairment because it places an individual at
high risk for institutionalization.

Given the decline in functional and mental status in the 75 and
over age group, this population has made significant demands on health
care professionals and facilities. As a group, they had 6.3 physician
visits a year compared to 4.8 visits for the general population and an
admission to nursing home occurs eight times more often than in the
younger population (U.S. Department of Commerce, 1990). The majority of
health care professionals are unprepared for the challenges and demands
that this aging population will place on the health care system in the
United States. Gains have been made over the past decade to increase
geriatric training in the undergraduate medical education and in
residency training. It is discouraging to note, however, that there is
relatively low interest in geriatrics among medical students (Anderson,

Gilcrist, Mondeika, & Schwartzberg, I990).

3
Unfortunately, there was no research to document interest in
geriatrics among nursing students, but one author recognized the
importance of geriatric education among nurses to assess and treat
complex problems in the community-dwelling elderly within a variety of
settings. Increased competency and knowledge in gerontological nursing

are seriously needed now that growing numbers of nurses in a variety of

settings are confronting more elderly people in their case loads in
(Eliopoulos, 1989). t '
Because the elderly have multiple problems that span over the 4

biological, psychological, social, environmental, and spiritual realms,
there is a need in the primary care setting to develop a screening tool
that would provide a systematic way for a primary care provider to
identify these problems. This has been supported by Lachs, Feinstein,
Cooney, Drickamer, Marottoli, Pannill and Tinetti (1990) who present a
discussion about a screening tool utilized to identify problems in the
primary care setting. This tool was developed by these physicians to
evaluate geriatric patients in their office in a short period of time.
Domains assessed included vision, hearing, arm function both distal and
proximal, gait evaluation to identify problems associated with falls and
mobility, urinary incontinence, nutrition, mental status and depression.
No research or testing has been done to establish validity or
reliability but this discussion supports the importance for a brief
screening tool to be developed in order to accurately assess all
community-dwelling elderly.

As documented in research, the most frequent tool utilized to
assess and evaluate the elderly is the comprehensive geriatric

assessment (CGA) (Pace, 1989; Burke et al., 1989; Rubenstein, I987;

4
Bedsine, Wakefield, 8 Williams, 1988; Lachs et al., 1990). The
purported beneficial outcomes of the geriatric assessment include: 1)
improved diagnostic accuracy; 2) improved living arrangement; 3)
improved functional and mental status; 4) reduced polypharmacy; 5)
improved use of nursing resources and acute care services; 6) prolonged
survival; 7) more appropriate use of health care services; 8) family
awareness and involvement; and 9) reduced health care costs
(”Comprehensive Geriatric Assessment,“ 1987). By utilizing this
assessment, problems could be detected early and community resources
implemented to maintain the elderly within their home environment.
Even though the CGA improves health care outcomes effectively
within the hospital geriatric evaluation units targeted for the frail
elderly, these assessments are not recognized by Medicare and third
party payers as a unique procedure (Applegate, Deyo, Kramer, & Meehan,
1991; Lefton, Bonstelle, & Frengley, 1983). More specifically, there
are no diagnostic or treatment codes established for reimbursement.
Hhile certain components of the CGA are similar to the generic history
and physical examination, both of which can be billed to Medicare, the
majority of the CGA which includes assessment of mental, functional,
social, environmental, and spiritual realms is not reimbursable.

In addition to financial reimbursement issues, the implementation

of the CGA is extremely time intensive. Basically all components of the

CGA tool can be administered in approximately three to five hours and
this includes the comprehensive history, physical examination, and
implementing the screening tools for identifying problems in mental
status, functional status, depression, and caregiver burden. Much of

the screening tool looks for preventable problems which could place an

5
individual at high risk for institutionalization. The preventable
problems include issues about falls, unsafe environment, inadequate
social support, depression, malnutrition, and polypharmacy. Most
physicians are unable to take that amount of time with an elderly
individual and therefore some have contracted with registered nurses,
specializing in geriatrics, to perform these CGA's. Unfortunately,

third party payers and Medicare do not recognize the services of the

mw'T’l
a

registered nurse performing the CGA within the home and the cost of the

Fr“?-

geriatric registered nurse is often absorbed by the practice. But not
all physicians involved in the care of the elderly are fortunate enough
to be able to utilize a registered nurse to assess the multiple problems
of the elderly on a home visit. Therefore, it is imperative to develop
a screening tool that could be utilized by all health care providers in
the primary care setting to evaluate the community dwelling elderly more
efficiently without compromising their independence within their home.
The tool would be used to identify individuals who may benefit from
further evaluation in the biological, psychological, social,
environmental, and spiritual realms. The primary care provider then
categorizes the elderly individuals into low, moderate, and high risk
groups and the moderate and high risk groups would be referred to the
geriatric assessment team for further evaluation. If an individual is
in the low risk category it is possible that routine medical care may be
sufficient as long as a brief amount of information is collected within
the psychological, social, environmental, and spiritual realms.

The geriatric clinical nurse specialist (GCNS) is an important
asset to the primary care setting because a nurse in advanced geriatric

practice can implement the CGA, is reimbursed by third party payers and

6
Medicare for home visits, has the knowledge to identify community
dwelling elderly at high risk and the clinical expertise to care for and
help community dwelling elderly maintain their independence within their
home environment. Thus, the unsolved issue is: How can a GCNS
efficiently utilize time in the primary care setting to thoroughly
assess the elderly without compromising quality of care? More
specifically: Hhat kind of assessment tool can be developed by the GCNS
which would identify frail elderly in need of further assessment? One
possibility would be to take a portions of the CGA, specifically the
Folstein mini-mental status tool and the functional status tool, to
categorize community dwelling elderly into low, moderate, and high risk
groups. By doing so it may be possible that certain screening criteria
could be devel0ped for the primary care setting to predict which
geriatric individuals in the community would most benefit from the
complete CGA process.
Purpose

As stated above, the CGA has many components. The components most
important to this research study are mental status and functional
status. Because the implementation of the CGA is so time consuming and
yet so important to accurately diagnosing the problems of the community
'dwelling elderly, the purpose of this study is to identify levels of
risk according to the geriatric individual's mental status and
functional status and to determine if a correlation exists between
Inental status, functional status and reversible problems. Mental status
is defined as an ability of the individual to use appropriate language,
be oriented to person, place, and time, have short-term and long-term

memory, have visual and spatial orientation, arithmetic and reasoning

7
ability. Functional status is defined as a person's ability to perform
activities of daily living (ADL), i.e., eating, dressing, toileting,
continence, mobility, and bathing, and instrumental activities of daily
living (IADL), i.e., transportation, shopping, cooking, housekeeping,
doing laundry, managing money, taking medication, and using the
telephone. Reversible problems for this study are defined as those
problems which may lead to a community dwelling elderly's
hospitalization or institutionalization if not corrected, such as
polypharmacy, malnutrition, inadequate social support, unsafe
environment, and altered vision.

By investigating mental status, functional status and reversible
problems, the physician and/or GCNS may be able to identify the
community dwelling elderly at low, moderate, or high risk for having or
developing reversible problems. Practical outcomes of this research for
the GCNS would be to establish specific criteria that would help all
health care professional screen the community dwelling elderly to
determine if their patients were at low, moderate or high risk for
reversible problems. Soon after mental and functional deterioration
occur, health care providers could provide the community dwelling
elderly at risk with a variety of interventions specifically targeted to
these individuals. Identification of risk factors for the elderly could
stimulate the development of specific strategies designed to reverse or
forestall progressive deterioration (Williams & Hornberger, 1984).

Statement of the Problem

The statement of the problem is to determine if community dwelling

elderly can be categorized into low, moderate, or high risk groups by

using functional status and mental status profiles in order to determine

8
if an association exists between mental status, functional status, and
reversible problems in the community dwelling elderly. Reversible
problems is the dependent variable and mental status, functional status,
and risk level are the independent variables. The research questions
are as follows: 1) Can a combined score of mental status and functional
status predict the number of reversible problems in the comnunity
dwelling elderly?; and 2) Are there differences in the number of .
reversible problems identified in the low, moderate and high risk
comunity dwelling elderly?

The relationship of the concepts of mental status, functional
status and reversible problems will be described in Roy's adaptation
framework. Briefly, the concept of the mental status and functional
status is defined in the physiologic needs mode and reversible problems
are identified after the patient is assessed for behaviors manifested by
stimuli. Risk level then is an. outcome of combined information from the
functional status and mental status obtained in the physiologic needs
mode. All reversible problems become a maladaptive response. Finally,
risk level is an adaptation to Roy's framework and is determined by
combining functional status and mental status. This study will be a
secondary analysis of data in the records of comunity dwelling elderly
with completed comprehensive geriatric assessments.

Overview of the Remaining Chapters

The introduction, background, purpose of this study and statement
of the problem are described in Chapter I. In Chapter II the conceptual
framework and its relationship to the study variables is described. The
study variables are functional status, mental status, risk level, and

reversible problems. Also described are the assumptions, limitations

9
and scope of the framework. In Chapter III a review of the literature
and research pertaining to the framework is presented. Research design,
methodology and technique for analyzing data are described in Chapter
IV. The results are presented in Chapter V and implications for

practice and research are included in Chapter VI.

CHAPTER II
. Introduction

In this chapter the conceptual framework of Roy's adaptation model
as it relates to portions of the CGA is presented. The concepts of
mental status, functional status, reversible problems and level of risk
in the elderly are examined and defined within the framework. The
relevance of the conceptual framework to the research question is
discussed. An explanation of the model for nursing practice is
described as it applies to this investigation. Finally, the scope and
delimitation of the study based on the framework are described.

Conceptual Definitions of the Variable

The major concepts of this study are as follows: 1) mental
status; 2) functional status; 3) reversible problems; and 4) risk status
in the community dwelling elderly.

We

Mental function explicitly influences all other areas of
individual function. The abilities to interact, communicate
autonomously and manage personal affairs are concretely controlled by
higher—order cortical function and virtually all activities of daily
living are subject to limitation when cognitive or emotional status is
disturbed (Gottlieb, 1989).

Normal changes in functional ability of the neurologic system are
related to general slowing and wasting of the nervous system which
produce a decrement in the ability to react quickly to stimuli (Matteson
& McConnell, 1988). Reaction time, or the lag between the stimulation
and the initiation of a response increases with age (Hendricks &

Hendricks, 1981). It appears that the simpler the movement or action

10

11
required the less change in reaction noted. 0n the other hand, more
complex movement requires greater reaction time because more choices are
required between two or more responses to various stimuli. Therefore, a
normal mental status for the elderly would be one where all cognitive
abilities are present but the reaction time to response for certain
stimuli would be decreased.

To many, the mental status examination consists solely of a few
questions about orientation, for example calculations and the ability to
remember three items. But the complete mental status examination
encompasses an assessment of the level of consciousness, attention,
language capabilities, memory, proverb interpretation, similarities,
calculations, writing and construction ability (Gallow, Reichel, &
Anderson, 1988). Therefore, mental status of the community dwelling
elderly involves higher cortical function which would include
information about memory, the capacity to solve day-to-day living
situations, the performances of learned perceptual motor skills, the
correct use of social skills and the control of emotional reactions.
Thus, it is imperative that mental status be screened in the age 65 and
older population in primary care settings because the loss of mental
- status begins to affect many activities of daily living and hinders an
elderly individual's ability to remain independent.

In this study mental status is defined as a higher level of
cortical functioning which involves short-term and long-term memory, the
capacity to solve day—to-day living situations, the correct use of
social skills and the control of emotional reactions. The assessment

involves areas of attention, level of consciousness, language

12
capabilities, memory, proverb interpretation, similarities,
calculations, writing, and construction ability.
Eunstjmlitam

M.E. Hilliams (personal communication, Sept., 1991) describes
functional status as a decrease in muscle weight relative to total body
weight and as a characteristic sign of advanced age. There is now data
to suggest that late onset of loss of muscle mass suggests that loss of
muscles may not be caused by normal aging but rather a result of
nutritional deficiency, chronic disuse or other chronic conditions (M.E.
Hilliams, personal communication, Sept., 1991). This perspective shows
that functional status is a compilation of physical functioning,
physical exercise and nutritional intake.

The domain of functional status includes two elements of physical
function: I) self-care activities, such as hygiene and mobility; and 2)
the more complex activities required to maintain the person in the I
community, such as shopping and food preparation (Johnson & Mezey,
1989). Physical self-care activities have been referred to as
activities of daily living (AOL) and more complex self-maintenance
functions as instrumental activities of daily living (IADL) (Lawton &
Brody, 1971).

In the literature, assessment of AOL include six functions:
toileting, feeding, dressing, grooming, physical ambulation and bathing.
The assessment of IADL includes eight skills: telephone use, shopping,
food preparation, housekeeping, laundry, use of transportation,
responsibility for taking medication and ability to manage finances
(Johnson a Mezey, 1989). Therefore, it is imperative for a GCNS and

health care providers to screen for functional status because it will

13

establish a baseline of function in all geriatric individuals and will
identify need for resources that will help them remain independently
within their home. In this study, functional status is defined as the
community-dwelling elderly's ability to provide physical self-care
activities as well as more complex self-maintenance functions which are
labeled as instrumental activities of daily living.
W

In this study, reversible problems in the community—dwelling
elderly are those problems identified from the CGA that a clinician can
reverse or identify community resources to address the problems, thereby
assisting this population in maintaining their independence in their
home. Without the reversal of these problems, the elderly may need
placement in a long-term care facility (i.e., congregate housing, adult
foster care or nursing home). There was no literature that defined
reversible problems. The majority of literature stated that the CGA
identified new or unique problems but never defined them specifically as
the researcher has done in this study. But in clinical practice, this
researcher has seen many relationships between mental status and the
problems which could be reversed. Cognitive impairment has been shown
to affect nutritional status when the individual does not remember to
eat or eats many of the same food repetitively. Cognitive impairment
affects polypharmacy when the individual cannot remember to take
medication. Cognitive impairment affects social support when the
individual is reluctant to socialize secondary to wanting to hide memory
loss problems. Cognitive impairment can also affect an individual's
environment when they forget to turn off appliances or cannot remember

their way around their familiar environment. Finally, cognitive

l4

impairment can affect an individual's functional capacity when they do
not remember how to use the stove for cooking, how to dress
appropriately for warm weather and how to manage their finances. In
this study the following reversible problems will be addressed.

Polypharmagy. Terezhalmy (1989) and Goldberg and Roberts (1983)
describe the risk for polypharmacy in the elderly as compared to the
younger population. The elderly absorb, distribute, metabolize, and r
excrete medications differently compared to the younger population. ;
They need less medication to cause the same effect in the younger i1
population and they are prescribed more medications related to the
multiple chronic problems associated with increasing age. It is
estimated that as many as 75 percent of the office visits to general
medicine practitioners and internists are associated with initiation or
continuation of medications (Terezhalmy, 1989). Therefore the elderly
are at high risk for polypharmacy related to the number of medications
prescribed by different health care providers, having more chronic
illness and the possible interaction with over-the—counter medications.

Lavizzo-Mourey (1989) discusses the adverse drug reactions caused
by polypharmacy. Many adverse reactions are related to interactions
among medication and medicine misuse. Therefore, the potential for
adverse reactions would logically increase with the number of consumed
medications. Surveys indicate that the community—dwelling elderly take
between five to eight prescription medications regularly, and may take
as many or more nonprescription medications (Vener, 1979). Given the
documented positive correlations between the number of medications and

the risk of adverse reactions, the elderly have increased incidence of

15
adverse drug reactions related to chronic illness and consumption of
medications (Klein, 1984; Lavizzo-Mourey, 1989).

Therefore, polypharmacy is defined as the use of prescribed and
over-the-counter medication of greater than four in total number that
can cause adverse reaction in the elderly related to the physical
changes of the aging body, multiple chronic illnesses, and ambiguous
guidelines for prescribing medications in the elderly. Thus,
polypharmacy was considered a reversible problem because all chronic
illnesses do not need treatment with medication but if medication needs
to be prescribed, then attempts to reverse polypharmacy should be
followed.

Malnutrition. There is some controversy from scientists about
what constitutes appropriate nutritional status in the elderly and
whether or not the recommended daily allowance requirements should
differ from the younger population. Studies conducted in the U.S.,
(Yearick, Hang, & Pisias, 1980; and McGandy, Russell, 8 Hartz, I986)
demonstrate that adult energy intakes decline linearly from about 2700
kilocalories per day at age 30 to 2100 kilocalories per day at age 80.
This age related reduction in energy was linked to few possibilities
such as a decline in the basal energy metabolism which was parallel to
the reduction in lean body mass and a reduction in energy expenditures
of about 400 kilocalories per day was related to decreases in physical
activity with age. Serum albumin levels are lower in the elderly and do
not seem to be related to inadequate protein intake but an increase
protein requirement in the elderly due to less effective utilization of

amino acids for protein synthesis and slightly higher rate of protein

I6
breakdown per unit body cell mass in the elderly (Zheug a Rosenberg,
1989).

In order to make a judgment about the need for nutritional
interventions or the possibility of malnutrition in the elderly, it is
necessary for the GCNS to conduct a thorough, multidimensional
nutritional assessment because each elderly individual has a different
effect on the biochemical and hematologic test used to measure
nutrition. To evaluate the elderly adequately, a thorough nutritional
assessment should include: 1) appraisal of physical appearance; 2) oral
health; 3) social and environmental situation; 4) potential physical and
psychological disabilities; 5) medical and drug history including
performance of anthropometric measurement; 6) evaluation of biochemical
hematologic and immune function; and 7) obtainment of comprehensive
dietary history (Mitchell & Chernoff, I991).

Malnutrition is the consequence of chronically inadequate intake
of essential nutrients. Essential nutrients are defined as food from
the four basic food groups, vitamins, minerals and fluid. Malnutrition
is considered a reversible problem because the GCNS could utilize Roy's
adaptation framework to identify stimuli that would lead to a decrease
in nutritional status. Then appropriate resources would be ordered to
assist the elderly patient in maintaining or improving their nutritional
status. In this study, malnutrition is defined as inadequacies in
physical appearance, social and environmental situations, medical
history and polypharmacy, and inadequacies in food intake from the four
basic food groups.

Inageggate_§ggial_§gppgrt. Social functioning is a broad concept

that embraces all human relationships and activities in society (Kane &

17

Kane, 1989). Social functioning is correlated with physical and mental
functioning and changes in patterns of activities or relationships
adversely affect physical or mental health. Social well-being enhances
the ability to cope with health problems and to maintain autonomy
despite functional limitations (Kane & Kane, 1981).

Inadequate social supports are defined, in this study, as the lack
of physical or emotional help from family, friends and the community.

Essential elements in the social assessment should include the

T-“ .,._—n -—H

individual, family and community (Matteson a McConnell, 1988).

Essential content in the assessment of the individual includes: 1)
perception of current life situation; 2) current roles and recent role
changes; 3) life-style; 4) culture background; 5) location; 6) financial
resources; 7) mental status; and 8) goals and plans for the future
(Matteson & McConnell, 1988). Important content for assessment of
family and friends include: I) perception of the family or caregiver of
the client's life situation and goals; 2) family structure; 3) family
patterns of functioning; and 4) role of client's friends. Essential
content in the assessment of the client's community includes: 1)
special resources in the environment; and 2) special demands of the
current environment. Therefore, inadequate social support is considered
a reversible problem because the GCNS can identify a problem in the
elderly individual's support system and prescribe appropriate community
resources available or communicate with family and friends on how they
can help to improve the inadequacy.

nm n . Environment, as defined geographically, may
be as large as a community, neighborhood or institution or as small as a

ward, home or an individual room. Environment includes quantity and

18
quality of various objects and people within a geographic boundary.
Examples would include frequency of interaction, lighting intensity,
noise level, colors, temperature and spatial arrangements, and size and
type of specific objects such as furniture (McConnell, 1988). Unsafe
environment in the elderly is considered a reversible problems because
fractures are the twelfth leading cause of death in the United States
and people over 65 years of age represent three quarters of all fatal
falls (Louis, 1983; Notelwicz & Hare, 1982). It has been documented
that fifty percent of all falls are caused by environmental factors such
as floor obstacles (electrical cords, scatter rugs, low or broken
furniture), poor lighting, improper fitting shoes or clothes and
congested traffic patterns (Galton, 1976).

Therefore, an unsafe environment would be defined as those areas
within an elderly individual's home environment that would place this
individual at high risk for falls. A thorough assessment of the home
environment would be necessary by the GCNS looking at conditions in the
home which are hazardous to the elderly in a variety of ways. Once
these conditions are identified, the GCNS makes recommendations to the
elderly and their family to make some changes. If the individual is no
longer to remain in their environment, then appropriate referrals would
be made to other areas where the individual could live within the
community with some supervision.

Altered_11§1gn. Altered vision, as it pertains to the elderly, is
related to normal changes in vision in the elderly. These include
decreased visual acuity, decreased tolerance of glare, decreased ability
to adapt to dark and light and decreased peripheral vision. Matteson &
McConnel (1988) observed visual acuity longitudinally in almost five

l9

hundred subjects ranging in age from 63 to 90 over a five-year period.
It was found that visual acuity became worse in 26 percent and actually
improved in 25 percent of the subjects. These are not considered
reversible eye problems in the elderly but cataracts are considered the
most common cause of adult blindness. Therefore, altered vision could
be considered a reversible problem because once the diagnosis of
cataracts is made, extraction can improve vision immediately providing
that no other causes for loss of vision are present (Matteson, 1988).
W

There is no literature to define level of risk in the community-
dwelling elderly as it relates to this study. For the purposes of this
study, to have a low level of risk would mean that the individual is
functionally and cognitively unimpaired, for an individual to be at high
risk means that the individual has an impairment of their mental and
functional abilities in that they cannot think for themselves and cannot
function by themselves without the assistance of another individual, and
moderate risk level is defined as the area in between low and high risk
which is considered somewhat of a gray area clinically speaking. The
moderate risk level could include either difference in mental or
functional status or both but not to the extent as in the high risk
group.

Theoretical Framework

To determine an approach to the research questions, a framework
that allows the GCNS to gather data about mental status, functional
status and reversible problems must be utilized. The framework must
also allow the GCNS the freedom to categorize geriatric individuals into

low, moderate and high risk groups by using mental status and functional

20

status. This information could later be used to predict the number of
reversible problems present in the community-dwelling elderly.

A brief discussion follows to demonstrate the applicability of
Roy's conceptual framework to the problem under study. Figure l is the
model for the application of Roy's adaptation framework to this study.
The GCNS utilizes Roy's adaptation model to establish an association
between mental status, functional status, reversible problems and level
of risk. Hithin Figure 1, labeled input on Roy's adaptation framework,
information about the internal and external environment of the geriatric
individual is present. Adaptation level is defined from the combination
of external and internal stimuli. It is important to note that the
adaptation level according to Roy is constantly changing which
represents the person's own standard and range of stimuli that can be
tolerated with ordinary stress. People have biologic and psychologic
abilities to cope with a changing environment. Some biologic measures
are genetically determined and others are acquired through the process
of learning. Therefore, whatever the change in the environment, the
elderly individual has mechanisms to cope with the changing environment.

The information from the input system is then processed through
the control primary functional subsystem (Figure I). The regulatory
subsystem receives input from the external and internal environment.
This regulatory subsystem processes the changes through the
neurochemical endocrine channels to produce a response which is only
manifested in the physiologic needs adaptive mode. The cognator
subsystem also takes information from the internal and external stimuli.
These inputs from the cognator involve psychological, social and

physiological realms. These stimuli are processed through perceptual

21

“—001— M0<m Dmmm

.rszZOEEm

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mmmzé
5.2m:
e __I oamxbz I_
_
_
mmmZOmmmM _ 33:00.23
m>_.E<o< _ coco—5m 20m
_
_
_
_
_
L.
as
I 838882 .33
zo§> mg . . maps—h .2...sz
E. .2 z
.268 B§0ma<a 5.2 no H93 may m zoco a...
ezmzzoa>2m m3 _
205252.22 _ 8520823.:
>U<Zm<xm>40m " 28oz Fugue—3mm:
mmmzoamm _ moo: m>E<n<
m>E<D< 2 _
5.56 _ .gm $9383
_ 2. a momem
_I mmzoxamx E5288

 

 

 

 

 

 

 

 

" zommmm
" 8525 2a .5532. 20m 80.: 2256
”5.53 BEBE
_ 38385
_ eéaaaoeoa
_ 33:30
_ e
_
_
_
_
A? u .
_ .35 £523 .323
_ €35.80 Boob
_ < Ema m>E<Q<
_
_ EoEcoeém
_ Auctooncm _8_Eo:u-8=ozv so:
“ >m8<50mm :33 .255
_ v3.5.5
_ -mDm £20523 EDS—Hm u Sni— ,
I.— >MS>=~E 40500

 

 

I aim

22
and information processing, learning, judgment and emotional processes.
Perceptual information processing is the person's internal activity of
selective attention, coding and memory. Learning is the process of
imitation, reinforcement and insight. Judgment process includes problem
solving and decision making. Emotional pathways include the use of
defense to seek relief and affective appraisal. The input system is
defined as the elderly individual's physical being (Roy, 1976).

In the secondary effector subsystem (Figure I), the response to
the stimuli from the cognator and the regulatory subsystem within the
primary functional subsystem are manifested in the adaptive modes
labelled physiologic, self—concept, role function and interdependence.
Physiologic needs mode contains information about oxygenation,
nutrition, elimination, rest and activity, skin integrity, protection,
the senses, fluid and electrolytes, neurological function and endocrine
function. The self-concept mode contains information about physical
self, self-consistency, self-ideal and moral ethical spiritual self.
Role function contains information about primary role, secondary role
and tertiary role in society. Interdependence contains information
about contributive behaviors and recessed behaviors. Functional and
mental status as it is defined in this study is a response that is
manifested in the physiological needs mode and the interdependence mode
only.

After a nurse gathers information about behaviors manifested in
the secondary effector subsystem, then a judgment is made about the
behaviors as to whether or not they are maladaptive or adaptive. This
judgment in Roy's adaptation framework is not labelled; therefore, the

framework was modified (Figure I) to better explain how a GCNS could

23
utilize Roy's adaptation framework to make a judgment about an
individual's risk level. The level of risk was defined by combining the
assessment of mental status and functional status from the physiologic
needs mode and interdependence mode. A low, moderate and high risk
level would be assigned to each geriatric individual according to the
mental status and functional status score. By categorizing the
community-dwelling elderly into low, moderate and high risk levels, the H
GCNS utilizes Roy's adaptation framework to predict the number of

reversible problems present in the geriatric individual. The area in

 

Figure 1 labelled output defines health and illness for the elderly
individuals and includes the dependent variables of the study which are
reversible problems (polypharmacy, malnutrition, inadequate social
support, unsafe environment and altered vision). The next area of this
chapter is the scope and delimitation of the study based on theory.
The Scope and Delimitation of the Study Based on Theory

Although all portions of Roy's nursing model are pertinent to
obtaining a comprehensive and holistic assessment of the elderly
‘ individual, only certain areas will be utilized to describe how
information will be gathered about an elderly individual. For purposes
of this study, only information gathered under the secondary effector
subsystem and the output will be utilized (Figure 2). Nithin the
secondary effector subsystem, the only adaptive modes that will be
utilized to determine an individual's mental status and functional
status will be within the physiologic needs mode and the interdependence
mode. As stated before, an addition to this framework has been
identified as a level of risk which will be determined by the GCNS after

obtaining information from the secondary effector subsystem (mental

24

mmzommmm m>Ham¢a< .Awu

onmH> ammmaqa

emommsm 4<Hoom meaaomnazH
pzmzzomH>zm mmamzb
onaHmangaz

woazm<xquom

ran-IIII IIIII llll'llll'llJ

 

ewfim
uumuuuoz
304

 

 

 

mmzommmm M>HHm<Q<A<Z .A HSmHDo

MmHm
mo qm>ma

 

 

 

Uszmnz

 

mDH<Hm A<Hzmz
mDH<Hm AdZOHHUZDm

ouaevcunuvumucH
c mvuuz HeufimOHOAmmsm

moo: M>HHN<Q<

 

 

 

HADZHHm Suwmrmmsm
OH I .moaommhm
mmzommmm wm<azoumm

HZMmemwm< UHMH<HMmu

Vary; _ 2 £2 .l.:$ .o........4

25
status and functional status). Once the levels of risk are determined
as low, moderate or high, then differences in the number of reversible
problems found in the output section can be identified for each risk
group. If the GCNS is successful through research in demonstrating that
a combined score of functional status and mental status can predict the
number of problems in the community-dwelling elderly by establishing a
correlation, this would assist health care providers in categorizing all
elderly individuals who come into the primary care setting. Therefore,
the elderly population would be taken care of efficiently and quality of
care would not be affected. This screening procedure would possibly
save the health care system the cost of doing a comprehensive geriatric
assessment which is a time intensive procedure on all geriatric
individuals.

Since this research study only includes a retrospective chart
audit, a brief description of how a GCNS would utilize this framework to
collect data and make diagnoses about a geriatric individual will be
described by using Roy's adaptation framework. Initially, the GCNS will
receive information about the individual's internal and external
environment and their adaptation level relative to the situation. As
these stimuli enter the person, the control process of regulatory and
cognator coping mechanisms are activated. These processes involve
chemical, neuroendocrine and cognitive emotional pathways. This
includes information that will determine the individual's mental status.
Response to these stimuli then are classified into four categories and
for purposes of this study, the physiologic needs mode and the
interdependence mode from Roy's adaptation framework will be described.

The GCNS in the first level of assessment systematically looks at

26
behaviors in these two adaptive modes. In the physiologic needs mode,
information would be gathered about neurological functioning (mental
status) and functional status (responses to the individual's ability to
perform ADL's). Specifically, information about eating, dressing,
toileting, continence, mobility and bathing. Information out of the
interdependence mode would include information about an individual's
functional status as it relates to IADL's, for example transportation,
shopping, cooking, housekeeping, doing laundry, managing money, taking
medications and using the telephone.

Hhen the first level of assessment is completed, a tentative
judgment is made about whether or not the behavior of mental status or
functional status is adaptive or maladaptive. Criteria according to Roy
in making this judgment include: 1) whether or not the behavior
promotes integrity of the individual; 2) whether or not there is a
regulatory or cognator effectiveness; and 3) whether or not the patient
perceives the behavior as being adaptive. Hhen the GCNS uses Roy's
adaptation framework to make this judgment, the nurse, along with the
family, is looking at the risk level for a particular geriatric
individual. Once the risk level is determined, then individuals in the
moderate and high risk would have a second level of assessment which
involves the assessment of the stimuli that influences the behaviors for
functional status and mental status. For purpose of this study,
information would be gathered on polypharmacy, malnutrition, inadequate
social supports, unsafe environment and altered vision which all could
have an effect on functional status and mental status.

Hhen the nurse has set priorities and identifies the most

significant behaviors related to these five reversible problems, then

27
identification of focal, contextual and residual stimuli influencing or
contributing to these behaviors are identified. Focal stimuli are
described as a degree of change that precipitate the behavior being
observed and is also the stimuli that is most immediately confronting
the person. It is the assumption of the researcher here that the nurse
and the geriatric physician have made accurate decisions about the
external and internal stimuli which were affecting the geriatric
individual going through the comprehensive geriatric assessment.
Contextual stimuli are also identified and these are all other stimuli
present that affect the behavior being observed. For example, these may
have to do with cultural beliefs.

The third step of the nursing process is nursing diagnosis. After
the nursing assessment has been obtained by the GCNS, the nurse then
makes a nursing diagnosis. Nursing diagnosis, as it relates to this
research study, would be considered a maladaptive response which
includes the five reversible problems.

The remaining portions of the nursing process labelled planning,
intervention and evaluation will not be utilized within this study since
the information had already been gathered by the geriatric nurse and
physician at the MidMichigan Regional Medical Center. Therefore, Roy's
adaptation framework will be used by the GCNS in this study to determine
if a combined functional status score and mental status score can
categorize individuals into a low, moderate or high risk group and then
further assessment would be done to determine if these individuals have

problems that are reversible.

28
Explication of Applicability and Relevance of Conceptual
Framework to Problem Under Study

The outcomes of the geriatric assessment that pertain to this
study are mental status, functional status, number of reversible
problems and level of risk in the elderly. The main goal of the
geriatric assessment process is to gather a comprehensive data base and
determine if a geriatric individual is coping effectively or
ineffectively. If they are coping ineffectively, the geriatric
assessment team identifies personal and community resources to maintain
or improve the individual's functional well-being on the biological,
psychological, social, environmental and spiritual realms. The
similarities between the comprehensive geriatric assessment and Roy's
adaptation model are the following: 1) information is gathered
systematically; 2) information is holistic in the biological,
psychological, social, environmental and spiritual realms; 3) mental
status is assessed; 4) functional status is assessed; 5) behaviors are
assessed as response to internal and external stimuli both in the home
and in the office; and 6) both Roy's model and the CGA process allow for
conclusions of effective (adaptive) or ineffective (maladaptive)
responses to be drawn after information is gathered.

Therefore, the condensed version of the Roy's adaptation framework
for this research study allows the GCNS to accurately assess functional
and mental status within the physiologic needs mode and the
interdependence mode. Once this assessment is done, the nurse then
diagnoses an individual and categorizes them into low, moderate or high
risk. Once the risk levels are determined, information, which is

pertinent to maintaining an elderly individual within the home, is

29
assessed. The ability to maintain or improve their mental status and
functional status would be the information found in the output section
in Figure 2 of Roy's adaptation models, specifically the maladaptive
responses of polypharmacy, malnutrition, unsafe environment, inadequate
social support and altered vision.
Summary

In this chapter the conceptual framework of Roy's adaptation model
as it related to portions of the CGA was presented. The concepts of
mental status, functional status, reversible problems, and level of risk
in the elderly were examined and conceptually defined within the
framework related to current research. The research questions were
discussed with their relationship to the conceptual framework and an
explanation of the model for nursing practice was described as it
applied to this investigation. Finally, the scope and delimitation of

the study framework was described.

CHAPTER 111
Introduction

This chapter includes a discussion of major research findings
related to the concepts under investigation and an examination of the
strengths and weaknesses of the studies. First, a discussion about a
paper written by a task force to determine recommendations for screening
the geriatric population in the 1990's will be outlined. The next set
of studies that follow will establish a relationship between using
functional status and mental status which are components of the
comprehensive geriatric assessment to identify problems in the community
dwelling elderly and the institutionalized elderly. None of these
studies identify problems as being reversible. There was only one
research study (Ramsdell, Swart, Jackson, & Renvall, 1989) that utilized
all concepts except risk level to look at unique problems found in the
home. Other studies (Currie, Moore, Friedman, & Warshaw, 1981;
Williams, Hilliams, Zimmer, Hall, & Podgorski, I987) lend support to
performing a home visit along with the CGA. Still other studies
(Altkorn, Ramsdell, Jackson & Renvall, 1991; Fisk & Pannill, 1987;
Scholer, Potter & Burke, 1990; Williams, 1987; Williams, Hadler & Earp,
1982) include concepts to establish risk levels which were determined by
mortality and use of long-term care services to identify problems in the
community-dwelling elderly and the institutionalized elderly. A few
other studies (Aske, 1990; Nolen, 1987) established a correlation
between mental status and functional status. Finally, one study
(Larson, Kukull, Buchner, a Reifler, 1987) established a relationship

between mental status and polypharmacy.

30

31
Low, Moderate and High Level of Screening in the Elderly for the 1990's

In examining the previous work done with the comprehensive
geriatric assessment (CGA), which includes all of the concepts
investigated in this study, it is difficult to draw similarities and
conclusions between studies due to the broad application of the CGA in
multiple and diverse settings. This does not seem to be related to
problems in any individual study but in the broad application of the
comprehensive geriatric assessment in multiple and diverse settings.
Heterogeneity, which forms the very heart and soul of geriatrics,
creates the problem (Cohen, 1991). Therefore, the heterogeneity is in
the patient population, the settings where geriatric care is provided
and the variety of health care professionals involved.

Rubenstein, Applegate, Burton, Hyer, Pawlson, and Winograd (1991)
convened on three occasions over a two-year period to prepare a report
recommending guidelines to Medicare for the possible establishment of
reimbursement for geriatric assessment. One recommendation was the need
to identify low, moderate and high levels of screening for problems in
the elderly in the biological, psychological, social, spiritual,
environmental and functional realms. It also described major sites for
conducting geriatric assessment within the hospital, office, home and
nursing home. For purposes of this study, since the interest is on
community-dwelling elderly, a description of how the author defines low,
moderate and high risk level of screening will be discussed in the
outpatient setting.

Outpatient geriatric screening was considered the lowest level of
screening which involved a 30 to 60 minute office visit utilizing

screening tools like the Folstein mini-mental status exam, Katz AOL and

32
the depression scale to determine if a geriatric individual would be
eligible for an intermediate or CGA. This required a nurse, social
worker or physician. Intermediate outpatient geriatric assessment was
considered to be similar to the outpatient CGA but less time intensive.
It would be done by a physician, nurse and social worker and take
approximately three hours. Patients requiring an intermediate
assessment are usually impaired in two or more domains but have less co-
morbid illness and are less frail (Rubenstein et al., 1991). Therefore,
intermediate level screenings are based on impairment in mental status,
functional status or one other domain and few medical diagnoses. The
age range for having an intermediate outpatient CGA may be from 65 to 75
and older.

The outpatient CGA requires collaboration by a physician, nurse
and social worker utilizing a variety of multidimensional tools. The
entire process may take up to six hours. To be eligible for outpatient
CGA, an elderly person should have impairment in two or more domains and
presence of functional impairment, sentinel event or syndrome (i.e.,
falls, confusion, post-hospitalization, incontinence, death of spouse,
polypharmacy, failure to thrive); or use of formal in-house services,
adult day care, or board and care facilities (Rubenstein et al., 1991).
Exclusion criteria is urgent need for hospitalization and absence of
functional impairment.

It was also interesting to note that Rubenstein et al., (1991)
perceived the home visit as a useful part of any CGA. Specifically,
indications for a home visit were included and were similar to the CGA
criteria: 1) recent change in physical, mental or functional status; 2)

recent change in caregiver situation; 3) dementia and patient living

33
alone or with compromised support/caregiver; 4) major
mobility/disability problems; 5) frequent emergency room or hospital
admissions; 6) major sensory impairment; 7) temporary hospice care; and
8) suspected psychological and social problems such as depression or
social isolation (Rubenstein, 1991). Rubenstein (1991) supports the
importance of utilizing two assessment tools that measure two separate
domains. Unfortunately, it was not specified which domains to assess ,
when screening for problems that would place community-dwelling elderly
into a low, moderate or high risk screening process.

Mental Status, Functional Status and Patient Problems

 

Ramsdell, Swart, Jackson and Renvall (1989) utilized the concepts
of mental status, functional status and problems in the community-
dwelling elderly to test the hypothesis that a home visit would detect a
greater number of problems and result in more specific recommendations
than an office visit. The sample included 154 frail elderly with a mean
age of 75. Problems were identified by a geriatric nurse practitioner
in the home visit and an internist/geriatrician in an outpatient office
setting. Patient records were the source of data. Mental status was
measured by using the Mini-Mental Status Exam (MMSE) and functional
status was measured with the Katz Index which measured AOL and IADL.

The number, the type and frequency of each problem and the
recommendations for the internist and nurse practitioner were recorded
for each patient. The findings in this study indicated that a home
visit by a nurse practitioner during the course of an interdisciplinary
assessment identified important problems that were not noted at the
initial physician's office evaluation. These problems related directly

to the patient's medical care and well-being, for example, 22.8 percent

34
could have resulted in death or serious morbidity and 74.5 percent had
less serious morbidity or loss of functional ability.

Social or environmental problems identified by physicians in
Ramsdell et al. (1989) were seldom specific enough to permit the
development of a meaningful treatment plan. In contrast, the home visit
record contained significant recommendations pertaining to such things
as patient safety issues in 81 percent of the patients and caregiver T"
issues in 52 percent of the patients. There were also no factors .

apparent in the clinic visit that predicted major risk factors in the i.

 

home but the presence of important risk factors in the home increased
with the number of problems detected during the home visit. This
suggests that it is very difficult to predict the yield of a home visit
based on a regular history and physical done in the office setting. But
when problems are found, they are often serious and the risk associated
with each individual problem increases with the total number of
problems.

Katz, Dube and Calkins (1985) explored the extent to which the
physician-administered multifaceted assessment could meet the needs of a
geriatric assessment team and also provide for the comprehensive
functional assessment for the elderly patient. Fifty-one consecutive
consultation patients with a mean age of 78 were evaluated. The
majority of consultations were to transfer presumably stable patients to
low-cost housing. The domains measured were physical health, mental
health, socioeconomic resources and activities of daily living.

Findings from assessments in the above domains were that 45 percent of
the cases had potentially harmful drug interactions. Assessment of each

patient's medical problems resulted in previously unrecognized problems

35
in 57 percent of the subjects studied. Cognitive dysfunction was noted
in 22 percent of the subjects; depression, social isolation and visual
impairment were detected in 28 percent of the subjects and additional
findings were: a) 18 percent of the patients were incontinent; and b)
39 percent needed strength and social support. Therefore, the majority
of the problems identified appeared to be reversible and this study
lends support to performing assessments in the physical, psychological,
socioeconomic and functional realms to identify substantial numbers of
reversible problems in the hospital patient. However, this does not
support the notion that information collected about functional status
and mental status could be used to predict the number of problems in an
individual in the community. The screening tool helps to identify
problems but not predict them.
S Epstein, Hall, Fretwell, Feldstein, DeCiantis, Tognetti, Cutler,
Constantine, Besdine, Rowe and McNeil (1990) evaluated the effectiveness
of consultive geriatric assessment and limited follow-up for ambulatory
patients. They randomized 600 elderly into three groups: I)
consultation by a geriatric assessment team; 2) consultation by a
second-opinion internist; and 3) only traditional health maintenance
organization services (control patients). The study population was
fairly healthy, and about one fourth of the sample (N-BO) scored less
than 25 on a Folstein test meaning that the large majority had no
impairments. Both the geriatric assessment team and the internist
identified new diagnosis in 30 percent of the patients and changes in
medications in 30-40 percent of the patients., The significant
differences between the internist and the geriatric assessment team were

that the geriatric assessment team made more new diagnoses and provided

‘WLQ-A. 13..

36
psychological and social evaluations more frequently, suggested changes
in medications, regimen, problems of the home and community services
more often as compared to consultation by a second-opinion internist
giving traditional health maintenance organization services. In
summary, the Epstein et al. (1990) study showed that the single
consultive geriatric assessment with telephone call follow-up did not
produce any substantial health benefits for the ambulatory elderly !
population. But it did lend support to this research in that the data

collection in the multidimensional fields could help the health care

 

a- _. _

provider to identify problems in the ambulatory elderly. The limitation
of the Epstein et al. (1990) study is that it does not specifically
support the ability to use functional status and mental status alone to
predict number of problems in the elderly and its main purpose was to
identify differences in the outcomes of the geriatric assessment
administered by a geriatric team versus an internist.

Fields, MacKenzie, Charlson and Sax (1986) conducted a prospective
study to analyze whether clinical outcomes differed between patients
with or without cognitive impairment when modifying variables of
severity of illness, sex and age were controlled. The prevalence of
cognitive impairment was 20 percent (Folstein < 24). The in-hospital
mortality and morbidity rates were higher in the cognitively impaired
patients than the cognitively unimpaired patients. This could be
explained by greater severity of illness, instability and co-morbidity.
The cognitive impaired patients had longer length of stay, related to
awaiting placement. These findings suggest that cognitive impairment on
admission may be regarded as a marker for patients with poor prognosis.

Therefore, the strength of this study is that the mini-mental status

37

exam (MMSE) could identify individuals with cognitive impairment and
predict that their length of stay and complications may be greater
especially if the cognitive impairment is associated with severe
illness. The limitation is that the information could not be
generalized to the community-dwelling elderly.

Williams and Horneberger (I984) evaluated the contributions of
other functional measurements such as lower extremity performance,
mental status and overall strength to provide a more useful tool for

anticipating change in the status of institutionalized older people.

1 ..

The purpose of this study was to evaluate the contribution of other
functional measures such as lower extremity performance, mental status
and overall strength to predict stability and chronic deterioration in a
cohort of frail older persons. The sample consisted of 40 patients who
resided in either the community or an institution and who were 65 and
older. The variables of manual ability, mental status, upper extremity
strength, mobility, activity, active and resolved medical problems,
current medications, performance of AOL's and change in care
requirements. Subjects were evaluated and followed over a two-year
period. The change in care needs were defined as: 1) patients who
maintained long-term care needs; 2) patients whose extreme irreversible
acute events result in death or transfer to skilled care unit; and 3)
patients who require transfer to skilled nursing home for all reasons
except acute events. The results showed that at least four dimensions
of functional measurement, i.e., upper extremity performance,
ambulation, grip strength and mental status can be used to make accurate
predictions regarding overall stability of an institutionalized frail

older person. Other observations, such as number of medications used,

38
number of diagnoses or findings on physical exam, were not associated
with changes in level of care. The findings supplement the observations
by showing that individuals who require intermediate level care exhibit
less than optimal manual skill. The researchers concluded that
predictions may improve by adding measurements of ambulation, grip
strength and mental status.

Currie, Moore, Friedman and Warshaw (1981) support the practice
and importance of home visits for the elderly. Their sample consisted
of 50 high—risk patients as evidenced by frailty, need for overall
assessment or overall decline leading to placement in a long-term
facility. Mental status and functional status were evaluated along with
physical health, and environmental status, and living arrangements. The
_ mean age was 78; 36 patients were female and 19 lived alone. The
maximum mean number of problems identified was 3.8. The outcome of the
assessment was that 36 percent had new diagnoses; the most common being
depression and dementia. Adjustment in medication schedule and advice
about support and placement were given. No predictions were made about
the home visit, decreasing mortality, or institionalization, but
screening for mental status, functional status, physical, environmental
and living arrangements resulted in the identification of 36 percent new
diagnoses.

Support for the CGA to Maintain Elderly in their Home

The next set of studies demonstrates the importance of the home
visit. Williams, Williams, Zimmer, Hall and Podgorski (1987), conducted
a randomized control clinical trial to evaluate the effectiveness of the
team-oriented geriatric assessment approach versus the traditional care.

One hundred seventeen subjects 65 years and over were randomly assigned

Wynn—ink;
._,

39
to receive CGA's by a multi-disciplinary team (treatment) or by one of a
panel of community internists (controls). The screening criteria
included frail older persons with changing medical and social needs. No
differences were found between groups. The treatment group had slightly
more hospital admissions than the control group but used less hospital
days. Overall institution costs were reduced by 25 percent in the
treatment group. Therefore, people in the treatment group were able to
stay in their homes. However, no significant differences were noted in
the patient's or caregiver's satisfaction with the evaluation process,
functional ability or health status.

This study supports the idea of screening frail elderly in the
multidimensional domains to maintain them within their home. Although
Williams et al. (1987) did not link mental status and functional status
with identified reversible problems, the study did show that hospital
length of stay decreased. In addition, problems to prevent those issues
from occurring were identified and interventions were implemented to
prevent long-term care admissions.

Mental Status, Functional Status, and Risk Level

The next set of articles mentions a risk level not as it is
defined in the present research study but as the risk for long-term care
service use and mortality. Altkorn, Ramsdell, Jackson and Renvall
(1991) determined the frequency of recommendations regarding home health
and the change in residence resulting from a comprehensive geriatric
assessment. The association of risk factors to a recommendation for a
change in living situation was used to determine the usefulness of the
risk factors in screening for the need for further home evaluation. The

mean age of patients was 75 years (s.d. 7.3). Two-thirds were females

 

40
and 62 percent had memory problems. A mean Folstein score of 19.1 (s.d.
8.8) was reported. Seventy-four percent of the subjects had a diagnosis
of dementia, the mean number of medical diagnoses was 5.6 and the mean
number of medications as 2.5. In the findings, 58 percent of the
recommendations were for no change in living situation, 20 percent were
for increase in home support, and the remaining 22 percent were for
placement.

The major finding was that most patients evaluated in an
outpatient geriatric assessment clinic required no changes in living
situations. Risk factors involved in recommendations for change in
living situation were dementia, an increase in number of diagnoses, a
high school education or less, vision defects and functional limitations
on the Katz score. The strength in the Altkorn et al. (1991) study, as
it relates to the present research study, is that mental status and
functional status were utilized to determine the risk level in addition
the study lends support to holistic data collection.

Williams (1987) conducted a study to determine if a clinician
could utilize the manual test to objectively measure function in elderly
called the Williams Manual Test (WMT). The WMT consists of determining
time opening and closing of different doors, fasteners and other
subtests that measure gross and fine motor skills (Scholer, 1990). The
test would also classify geriatric individuals at high risk so that the
clinician could identify in advance specific interventions that would
reverse or forestall the progressive deterioration. The sample included
86 individuals undergoing geriatric evaluation (76% female, 89% white,
32% married and 38% widowed, 44% lived alone).

w-‘qu-u
. D

41

The results showed that timing manual performance in vulnerable
older persons allowed prospective identification of geriatric
individuals likely to require long-term care services. Other health
observations, such as age, sex, type or number of medical problems in
medication use were not as discriminating. Independent persons
performed the WMT quickly while persons requiring services took more
time to complete tasks. Risk factors for increasing long-term care
services were determined by retrospective analysis of a sample of
elderly in hospitals and inpatient geriatric evaluation units.
Increasing age and impaired mental status were most frequently
associated with the use of additional post-hospital care. This research
showed that objective measurement of functional status can be used as a
predictor for long-term care service needs.

In the research study by Williams, Hadler and Earp (1981), the
goal was to discover markers associated with institutional placement.
Domains that were assessed were manual ability, morale, social support,
mental status, medical problems, current medications, rheumatology, and
neurological abnormalities for the relationship to dependency.
Specifically, the purpose was to determine the degree to which manual
skills were a marker of dependency when compared with other
characteristics such as mental status or social support. The sample
included 56 white females over the age of 60 who were ambulatory, fully
continent and could use one upper extremity. There were three groups of
dependency, i.e., most dependent, intermediate dependent, and least
dependent. Dependency was defined as the need for supervision or
assistance to perform the AOL. The high dependency group included

individuals who were institutionalized, the low dependency group

42
included women who had total self-maintenance, and the intermediate
level of dependence group included women who needed support for
continued living outside an institution.

The results showed that age, strength of social network, level of
income, number of past medical problems, and number of abnormalities on
physical exam did not contribute to an explanation of dependency. When
manual skill index was used as a covariate with degree of dependence,
the total number of drugs used remained significant. Therefore, if an
individual's manual skill index is known, no other variable except the
number of medications taken as information provides an explanation of
the difference between dependency and groups. Manual ability is a very
sensitive measure of dependency in the study population. Three specific
manual skills (the time to close the door on a panel, the time to write
a simple sentence with a nondominant hand, and the time to perform the
simulated task using the dominant hand) accurately distinguished the
three groups. By timing the manual skills, the authors felt that a
prolongation of skilled time was missed by traditional ADL assessments.
In fact, all patients evaluated in this study could perform all ADL
tasks. The added sensitivity that timing normal skills is important for
judging progress and deterioration of a function. Social network
strength did not vary between groups. This was a mysterious finding
since dependency implied an imbalance between environmental demands and
individual resources.

Using the findings of Williams et al. (1981), Scholer, Potter and
Burke (1990) hypothesized that the Williams Manual Test (WMT) would
predict which older adults would increase their use of long-term care

services and that the tests would be reproducible. A hundred and

43
seventeen subjects met the criteria for analysis. Domains assessed were
manual ability, mental status, morale, functional abilities, physical
health, and caregiver stress. The use of long-term care services was
ascertained by a social worker during an interview on an initial visit
and by a phone interview at six and twelve months to determine if the
patient was dead, institutionalized or residing in the community with
what services were being used (formal support). Following Williams .
protocol, it was predicted that an individual would use additional
formal services by the time of the six and twelve month follow-up phone
call if he or she took more than 350 seconds to complete the WMT during
the initial visit. Study results revealed that the greater caregiver
stress and poor cognitive function would increase service utilization in
subjects with good hand function (as determined by WMT). Better
performances on the IADL scale reduced service use among subjects with
poor hand function; however, 74 percent of the subjects who took longer
than 350 seconds to complete the test were utilizing services by the
twelfth month follow-up visit. This supports the WMT as a predictor of
service use.

In order to identify the best predictors of service use in the
study, subjects were divided into service users and non-service users at
twelve months. Only baseline Family Burden Interview and mini-mental
status exam scores were significant predictors of service use at twelve
months. The WMT was not an independent discriminator of service use but
it may have been the best assessment of objective need. As measures of
function, the AOL and IADL scales measured the patient's reported
capacity to perform those tasks, whereas the WMT measured actual

performance. Therefore, Scholer et al. (1990) supported utilizing

44
objective measurement of function to predict possible service use in the
future.

Finally, a study by Fisk and Pannill (1987) described the
management of community-dwelling elderly with dementia and the
assistance that could be given to the family and caregivers. The sample
was comprised of 1,028 patient who were seen at an outpatient clinic and
156 of these were diagnosed with dementia. The mean age was 77; 73
percent were female; 44 percent were widowed; 84 percent were white.

The mean Folstein score was 15.3, they had 3.4 medical problems, and 2.2
medications per patient were documented. Seventy-four percent of the
patients had mildly impaired social supports, 47 percent lived alone,
and the mean value for physical activities of daily living was 3.2 with
the highest score being four. There was a significant reduction in IADL
with a mean value of 1.7 and the highest possible score being 3.3.

An eighteen month follow-up on 159 patients revealed that 51
percent were living at home, 35 percent in a nursing home, and 13
percent had died. Not being married significantly increased the
likelihood of nursing home placement. The mental status score was lower
for patients who later went into a nursing home (12.4 versus 16.6) and
there was no difference between groups and patient function.

The Fisk and Pannill (1987) study found that appropriate treatment
of associated medical illness determined after a thorough medical
evaluation was critical to maintain patients in their homes.

Elimination of a number of unnecessary medications and a reduction of
the dosage of medications increased cognitive function. The initial
assessment of patients who later went into a nursing home was surprising

because their mean AOL and IADL scores were not significantly different

 

45
from the non-nursing home patients. They were not seriously impaired,
cognitive or functionally, when first seen. They may have deteriorated
rapidly by the time of nursing home placement, which the author doubted,
but not being married may have had a major influence on
institutionalization. This Fisk and Pannill (1987) study is important
to the current study because it defines community-dwelling elderly who
have dementia and what factors are important in having them lose their
independence within the home environment. In summary, community-
dwelling elderly are at risk for losing their independence within the
home when they have a loss of mental status and an objective loss of
functional status. Level of risk was not determined by combining
functional status and mental status but was determined by use of long-
term care services or mortality.
Relationship Between Mental Status and Functional Status

Nolen (1987) found a direct correlation between mental status and
functional status in the elderly with late stages of dementia. Nolen
(1987) looked at whether the regression noted in elderly persons with
dementia bears any similarity to normal childhood development. The
assumption was that dependencies in eating, mobility, and self-care are
not isolated events tied to physical limitations or to behaviors of
caregivers to encourage helplessness. Instead dependencies seem to be
tied to cognitive and sensory motor changes which occur with dementia.
The study's purpose was to demonstrate that loss of sensory motor
function and activities of daily living skills can be anticipated in the
late stages of dementia and can be tied to the easily recognizable
pattern of childhood development. This finding would make care planning

easier for the caregiver of patients with dementia in institutions or

46

communities. One hundred and fifty-two patients made up of 138 women
and 14 men from a long-term facility were included in this study. The
Geriatric Functional Developmental Screening Scale was utilized to
examine mobility, hand use, sensory motor status, cognition,
socialization, repetitive language (comprehension), expressive language,
feeding, toileting, and self-care skills. This scale can be compared to
the Katz tool in that it measures some of the similar things in both the
AOL and IADL tools, socialization, mobility, and hand use. The scale
included seven developmental levels, i.e., 0 months, 2 months, 6 months,
18 months, 48 months, 72 months, and 96 months. An occupational
therapist did the rating. The average functional age was highly
correlated with the dependent variables. Feeding, cognition, and
mobility affected this result the most and socialization the least. The
MMSE also showed a high degree of correlation with function. The most
significant contributing variables were receptive language, mobility,
sensory motor status, and cognition. Toileting and self-care skills
were least related. Therefore, there was a negative correlation between
mental status and functional status in that the most severely impaired
person showed the lowest functional age in months. A major limitation
of this study was that the sample was predominantly women. The direct
correlation occurred only when MMSE scores were below 19. The direct
correlation was that functional status declined as mental status
declined only when the scores for mental status were 19 or below.
Therefore, generalizing to the community-dwelling elderly could not be
done, since their scores are generally above 19.

Another study by Aske (1990) examined the correlation between MMSE

score and the Katz ADL status score among dementia patients to determine

 

47
a way of screening veterans for participation in the Veterans Affairs
Adult Day Health Care Center. Subjects had to be male veterans, nursing
home bound without day care centers and dependent in two or more
functional activities of daily living. Because of these requirements,
it was important for the interdisciplinary staff to determine if the
Mini-Mental Status Score correlated with the patient's Katz ADL status.
If so, this should give the clinician a broader picture of how the
patients would function at the day care center. There was significant
negative correlation between Mini-Mental Status Scores and Katz index
scores among the 37 demented subjects at the day care center.
Limitations of this sthdy were small sample size, convenience sample,
one-half to one—third of the population had dementia, and this group had
a high degree of dependence compared to the general population.
Mental Status and Reversible Problems

Much of the research done that would describe a relationship
between mental status and nutrition, polypharmacy, inadequate social
support, unsafe environment, and altered vision were descriptive
studies. Only one study showed a correlation between mental status and
polypharmacy. Larson, Kukull, Buchner, and Reifler (1987) studied 308
patients who were enrolled prospectively in ongoing studies of the
diagnostic evaluation of outpatients with suspected dementia. Criteria
for enrollment were: age greater than 60 years, global cognitive
impairment, and willingness to undergo a diagnostic evaluation. The
evaluation included a clinical exam as well as laboratory tests and x-
ray tests. The results showed that 35 patients were found to have
adverse drug reactions causing cognitive impairment. Twenty-seven

patients were taking only one drug that classified as primarily

48
responsible, whereas the others were judged to have potentially
contributed to the patient's problem. In all cases cognition improved
when the drugs were withdrawn. It was also found that adverse drug
reactions not only caused cognitive impairment in these patients but
also exacerbated underlying dementia. Most demographic variables were
not significantly different for patients with adverse drug reactions
compared with patients without adverse drug reactions. Patients with
adverse drug reactions took an average of four prescription drugs per
patient compared with two in the group without adverse drug reactions.
A step-wise multiple logistic regression process identified use of
sedatives and use of antihypertensives adding significantly to
predictions of adverse drug reactions after adjusting for age duration
of dementia symptoms in a number of prescription drugs. And finally as
the number of prescription drugs increased, so did the relative odds of
adverse drug reaction. This study clearly shows a relationship between
polypharmacy and mental status.
Implications for the Present Study

There is very little literature which attempts to demonstrate the
relationship between mental status, functional status, and reversible
problems through the use of empirical methods. Many of the studies did
discuss the number of problems or unique problems found within the home
and utilized functional status and mental status as screening tools to
identify problems within the home. But no conclusions were made about
using mental status and functional status to predict the number of
reversible problems within the home environment. Risk levels were
looked at in a number of articles but their definition of risk included

things such as mortality and use of long-term services in that people in

49
the high risk categories had a higher mortality and used more long-term
care services. Therefore, these articles did not describe risk level as
the researcher did in this study. It is certain that more research
needs to be done on the clinical benefits of utilizing portions of the
comprehensive geriatric assessment as a screening tool so that health
care providers can better identify individuals at low, moderate or high
risk and prescribe community resources that would assist these elderly n

in maintaining independence within their home environment.

 

 

Summary E
In summary, no literature supports the utilization of mental 9
status and functional status screening tools to predict the number of
reversible problems in the community-dwelling elderly. The literature
does support utilizing the CGA to assess the community-dwelling elderly
because multiple problems are identified by the health care provider
that would have been missed using traditional medical assessment.
Mental status and functional status are considered risk factors when
determining recommendations for relocation from the home environment.
Objective measures of functional status can be used to predict long-term
care service utilization which would decrease the need to
institutionalize an elderly person from their home environment.

Finally, mental status is the greatest risk to independent living.

CHAPTER IV
Introduction

This chapter includes a description of the design, the sample and
the operational definitions of the variables. Instrumentation including
a description of the Katz tool, Folstein tool, and their known validity
and reliability is also described. Data collection procedures, data
analysis, assumption and limitations, and human rights protection are
discussed.

Design

The research design utilized in this study is a retrospective
chart audit of a portion of the comprehensive geriatric assessment. It
is an ex post facto investigation of the relationship and association
between mental status, functional status, reversible problems and risk
level.

The purpose of this study was to determine if a combination of
mental status and functional status could be utilized to determine a
low, moderate and high risk level and predict the number of reversible
problems found in the community-dwelling elderly. Reversible problems
is the dependent variable and mental status, functional status and risk
level are the independent variables. The research questions were as
follows: I) can a combined score of mental status and functional status
be used to predict the number of reversible problems in the community-
dwelling elderly? and 2) are there differences in the number of
reversible problems identified in the low, moderate and high risk

community-dwelling elderly?

50

51
Sample

The sample was comprised of 64 records identified from an audit
performed by the business manager of the geriatric assessment program at
MidMichigan Regional Medical Center. From the 100 medical records of
patients seen between April 1, 1990, and April 1, 1991, 64 charts met
the screening criteria chosen for this investigation. These criteria
were: 1) home visit conducted to obtain medical, nursing and
environmental history; 2) physical examination performed in the office i
setting by a geriatric physician; 3) demographic information such as :
age, sex and living arrangements available; 4) medical diagnoses
documented; 5) Folstein mini-mental status score recorded; 6) Katz AOL
and IADL functional status score recorded; 7) vision score recorded; and
8) reversible problems, for example polypharmacy, malnutrition,
inadequate social support, unsafe environment and altered vision
documented.

Operational Definitions of the Variable

Mental status, functional status, risk level and reversible
problems were operationally defined in the following manner:
new

Mental status was defined as the documented score of the Folstein
mini-mental status questionnaire, which had been administered by the
geriatric nurse in the home setting. Possible scores range from 0-30.
A documented score of 30 describes an individual who is cognitively
unimpaired and a score of 24 or less describes an individual who is
cognitively impaired. The lower the score, the worse the impairment.
When administering the Folstein mini-mental status screening tool,

special adjustments in the scores were made to allow for sensory loss

52

related to vision, hearing or inability to write with a pen related to a
functional loss of the hands.
W

Documented score on the Katz functional questionnaire which was
also administered in the home was utilized to define an elderly
individual's functional status. The instrument was a measure of an
individual's ability to independently accomplish 14 basic and

instrumental activities of daily living. A score of 6 out of 6 in the

 

ADL test identified independence in those six activities while a score

of 8 out of 8 identified an individual who was independent in all eight

activities.
BMW

These are those problems identified by the nurse or physician
after completing the geriatric assessment process on the geriatric
individual. These problems were documented under the analysis portion
of the nurse's or physician's dictation note. The criteria utilized to
define the reversible problems in the study are the same criteria
utilized by the nurse and the physician on the geriatric assessment team
to determine the reversible problems. The criteria for identification
of individual reversible problems are as follows:
Enlynnnnnnty. Polypharmacy was defined as greater than four
medications, either prescription or over-the-counter, or an abnormal
blood level for Digoxin, Dilantin, Theophylline and Synthroid.
Malnutrition. Malnutrition was defined by an albumin level of less than
3.5 and/or documentation of malnutrition in the nursing diagnosis. The

following information was considered by the nurse in determining

53

malnutrition: height, weight, diet recall, food in the cupboard and
refrigerator and use of Meals on Wheels or restaurant use.
inaaegnata_§ntia1_§nnnant. Inadequate social support was determined by
utilizing the information in the following areas: name of family
members, address, phone and relationship, available friends, daily
routine, life stressors (i.e., death, change in living arrangement,
change in financial arrangement, change in health), use of community
resources, and transportation ability. These areas were assessed and
difficulties noted in the record.
Unsafe Envinnnment. Unsafe environment was identified by utilizing
information in the home assessment and/or an elderly individual's
history of falls. Information on unsafe environment was documented on
the environmental assessment. The categories assessed include number of
rooms available to the individual, stairs used, home cleanliness, home
ventilation, insulation and heat, signs of neglect, overloaded
electrical outlets, poor lighting, cluttered furniture, frayed carpets,
use of throw rugs, missing or broken smoke alarms and safety equipment
installed in the bathroom.
Altanaa_!iainn. Altered vision was defined as a score of less than
20/50 for both eyes as determined with a Snellen eye chart. There was
no attempt made to test the left eye and the right eye separately. The
results were documented in the record.
Risk Level

There was no literature available on the community-dwelling
elderly population that categories them into-low, moderate or high risk
levels by utilizing Folstein, mini-mental status exam score and Katz

functional status scores. The risk levels were developed by the

54
researcher and the geriatrician at the MidMichigan Regional Medical Care
Center by utilizing knowledge of dementia, functional impairment and
clinical judgment in evaluating many geriatric patients. A combined
mental status and functional status score was utilized to operationally
define risk level. Low risk was a Folstein score of 30 and a Katz score
of 6 on the ADL measure and more than 6 on the IADL measure, meaning
that there was no mental or functional impairment. Moderate risk was
defined as a Folstein score between 25 and 29 and a Katz score of 6 on
the ADL measure and 1-6 on the IADL measure, meaning that there was
moderate functional and mental impairment. A high risk level was
defined as a Folstein score of 24 or less and a Katz score of 0 on the
IADL measure and 5 or less on the ADL measure, indicating a low level of
cognitive and mental impairment. The rationale for allowing higher ADL
levels in determining risk level is that individuals who are unable to
perform IADL's are at higher risk for loss of independence within the
home environment provided that appropriate community resources cannot be
utilized for financial reasons or reasons related to cognitively
impaired individual forbidding community resources in the home
environment.
Instruments

Copies of the Folstein instrument, the Katz instrument and the
data collection tool developed for the study and a copy of the geriatric
assessment tool are included in Appendix A. Two instruments were
utilized in clinical practice to determine mental status and functional
status in the charts audited for this research study. The Folstein or

mini-mental status exam (MMSE) was used to document mental status in the

55
record and the Katz functional status instrument was used to document
functional status in the record.
Folstein Mini-Mental Status Exam

The accuracy and specificity for the Folstein (MMSE) exam to
predict dementia for a score of less than 24 is about 90 percent
(Anthony, LeResche, Niaz, VonKorf & Folstein, 1982; Can, Jackson &
Alguire, 1990). In a validation study (Anthony et al., 1982) a cutoff
score of 23 or below was used to demonstrate cognitive impairment. The
MMSE has a sensitivity of 87 percent and a specificity of 82 percent, a
false-positive ratio of 39.4 percent and a false-negative ratio of 4.7
percent. All subjects with false-positives had less than nine years of
education and many were 60 years or older. The sample subjects were not
seeking psychological help and also contain subjects with low
socioeconomic status and education level. The sample subjects were
patients on a general medical ward. Folstein, Anthony, Parhad, Duffy, &
Gurenberg, (1985) administered the MMSE to two groups of subjects; one
group was 18-64 years and the other group included those over 65 years
of age (from the Eastern Baltimore area). No differences were found
between males and females and blacks and whites of equal education.
When comparing the 65 and over group to the 18-64 age groups, the 65 and
over sample had lower scores on the MMSE (between 0 and 23). The 65 and
over population also had lower educational levels, but the low scores on
the MMSE were not related to the educational effects alone. The
researchers could not be confident that the education of the old was
comparable to the young. Many elderly with low scores had a mental
disorder. Thirty-three percent of the elderly scored high on the

Folstein mini-mental status exam and did not have a mental disorder and

56
therefore prevalence of dementia from all causes was six percent of the
population over 65.

Carr, Jackson and Alguire (1990) used the MMSE to screen for
cognitive impairment. A score of 27 or more out of a possible 30 is
found in normal adults and a score of less than 20 has been shown to
identify dementia with concurrent validity of 78 percent and 66 percent
when compared to the Wechsler Adult Intelligence Scale (WAIS) verbal and
performance score, respectively. Horton, Sloan and Shapiro (1987)
demonstrated that neuropsychometrics correlated with the MMSE. The
Pearson product correlation suggested a moderate association of the MMSE
with the Wechsler memory scale (r-.17). Small sample size was a
limitation to this study. Therefore, the MMSE has been used in other
correlation studies and has been a reliable and valid tool.

It is important to note that the validity of the mental status
examination depends on the clinician's ability to accurately judge the
constructs measured (Kane & Kane, 1988). Validity is affected if the
sample of behaviors observed during the testing procedures does not
accurately reflect the elderly individual's capabilities. For example,
elderly persons may become anxious and unable to accurately answer
questions from the MMSE especially if the test is administered in
surroundings other than their own home. Other things that could hamper
validity and reliability is failure by the examiner to distinguish
apparent cognitive and affective disturbances that one actually has
sensory deficits (for example, loss of vision or loss of hearing). For
the original data collection, in the present study the Folstein exam was
administered by one nurse who had been trained and was also aware of

sensory perceptual problems that are often present in the elderly.

57
Katz Index

For the Katz index of AOL, the validity and reliability are quite
good. The index has been carefully studied and is well known (Brorrson
& Asberg, 1984; Kane & Kane, 1988). Katz and his colleagues (Kane &
Kane, 1988) have shown a natural progression in the loss of AOL capacity
and return of these abilities with recovery after going through a
rehabilitation program. The pattern of recovery from a disabling
illness in later life was similar to the order of development of primary
function in children (feeding, continence, transfer, toileting, dressing
and bathing) which supports its validity. Staff of the Hebrew
Rehabilitation Center for Aged report in unpublished data that the Katz
index utilizing a Guttman Scale is highly reproducible with coefficients
of reproducibility of .948 for patients in the home care study and .976
for the patients in a sheltered housing sample. Brorrson and Asberg
(1984) conducted a study on 100 patients at a general hospital in
Sweden. The results indicated that activities are ranked according to a
cumulative scale and the index is reliable. The patients independent in
AOL had shorter hospitalization and were discharged home more often than
were the dependent party. This indicates that this score was valid.

It is important to note that a three tiered scale (independent,
needs some assistance, and dependent) for the ADL was found to be more
reliable and is reproducible even when scored by personnel with minimal
training (Gallow, Reichel & Anderson, 1988). It is also important to
note that the ADL scale is used for assessing individuals classified
into the frail elderly group because most community-dwelling elderly

would be able to perform the activities without much difficulty.

58

No reliability or validity studies have been done on the IADL
scale used within this study. It is important to note though that
special consideration needs to be taken when measuring IADL's because
these were the tasks that were commonly performed by women and may put
males at a disadvantage because of social roles (Matteson & McConnell,
1988). Therefore, adjustments may be needed in the tool when assessing
males secondary to their social roles preventing them from performing
such activities such as shopping, cooking cleaning and laundering.

Data Collection Procedures

A data collection tool was developed after obtaining information
from the original chart audit. Information in the areas of
demographics, functional status, mental status, medical diagnoses,
reversible problems specifically polypharmacy, malnutrition, inadequate
social support, unsafe environment and vision were documented. Refer to
a copy of the data collection tool in Appendix A.

Data Analysis

Frequency and appropriate measures of central tendencies on
modifying variables and each study variable (mental status, functional
status and reversible problems) were done.

A description of the sample included information on age, sex,
living arrangements and medical diagnoses. Pearson product moment
correlations between a combined functional status score and mental
status score and each individual reversible problem and mean number of
reversible problems were calculated. The actual mental status score and
functional status score were added together to obtain a total risk
level. A two-way ANOVA was utilized to compare the mean number of

reversible problems within the risk levels determined by mental status

59

and functional status. Low risk was a high mental status and a high
functional status. Moderate risk was a moderate mental status and a
moderate functional status. High risk was a low mental status and a low
functional status. Low, moderate and high mental status and functional
status were operationalized previously within this chapter. Mean number
of reversible problems was determined by taking the average of all
reversible problems (polypharmacy, malnutrition, inadequate social
support, unsafe environment and altered vision) for each of the 64
cases.

Methodological Assumptions and Limitations

The major assumption of this study was that data and records were
accurate.

The limitations of the study were small sample size, retrospective
chart audit, and selection of a convenience sample. The researcher was
unable to actively manipulate the independent variables and unable to
randomly assign individuals to experimental groups. Therefore, the
possibility of faulty interpretation was present. The results of the
study cannot be generalized to other groups.

Human Rights Protection

When the patient comes to the MidMichigan Regional Medical Center
for a geriatric assessment, an individual sheet is signed stating they
will release the records to the insurance company and any other

referring physicians who request information on their chart. Patients

consented to the home assessment and to release of information to others .

as necessary. This researcher did the review of records and did not
identify individuals in any way. No risk or harm to the patient was

done as a result of the chart review. Approval of proposed methods to

60
protect the rights and welfare of human subjects was obtained from the
Michigan State University Committee on Research Involving Human Subjects
(See Appendix A).
Summary

In summary, a description of the research design was discussed and
included a retrospective chart review, independent variables, dependent
variables, statement of the problems, and research questions.
Operational definitions were discussed and included mental status,
functional status, reversible problems, and risk level. Instruments
were identified and known reliability and validity were discussed and
supported by the literature for the Folstein Mini-Mental Status Exam and
the Katz functional tool. The sample selection was described and
included information regarding sample size, demographics, modifying
variables, Folstein score, functional score, and reversible problems.
Data collection procedures, data analysis, assumptions, limitations, and

human rights protection were also discussed.

CHAPTER V
Results
Overview
The results of the analysis of data are presented in this chapter.
The study sample is described and descriptive data is provided for all
variables. Analysis of the data to answer the research questions is
emphasized.
Description of the Sample
The sample was comprised of 64 charts with information about
geriatric individuals who went through a comprehensive geriatric
assessment at the MidMichigan Regional Medical Center between April of
1990 and April of 1991. The subjects represented by the records ranged
in age from 58 to 87 with a mean age of 80.2 years (s.d. 7.2). Twenty-
nine percent (n-19) were male. Most subjects were living alone (n=31,
48%) while 25 percent (n-17) were living with spouse, 17.2 percent
(n-Il) were living with a relative and 5 percent (n=5) were living in
congregate housing in the community. Of the 64 charts audited,
hypertension was reported in 35.9 percent of the records (n-23),
coronary artery disease was reported in 45.3 percent of the records
(n-29), arthritis was reported in 51.6 percent of the records (n-33), GI
problems were reported in 40 percent of the records (n-26), sensory
problems were reported in 56 percent of the records (n=36), and
depression was reported in 35 percent of the records (n-23). The mean
number of medical diagnoses per individual chart was 3.5 (s.d. 1.7).
Study Variables _
Means and standard deviations were computed for each study

variable. The actual range of values for Folstein score was from 0—30

61

62
with a mean score of 22.2 (s.d. 8.0). Katz AOL scores ranged from 2-6
with a mean score of 5.2 (s.d. 1.2). Katz IADL score ranged from 0-8
with one IADL score missing and a mean score of 4.6 (s.d. 2.7). If data
was missing, this meant that the researcher could find no reference to
the variable within the record. Frequencies were calculated on all
reversible problems (Table 1). The percentage of charts found to have
polypharmacy was 70.3 (n-45). Abnormal laboratory values for Digoxin,
Dilantin, Synthroid and Theophylline were reported in few cases (Table
1). Regarding the number of medications taken, 68.8 perCent (n=44) were
documented to be taking greater than four medications including over the
counter medications. Charts with documented malnutrition problems were
59.4 percent (n=38). Of these charts only 6.6 percent (ne4) had an
abnormal albumin level and there were three records that had missing
data. Problems with inadequate social support were documented in 59.4
percent of the records (n-38). Charts with documented unsafe
environment were 79.7 percent (n-51) and only 21 percent (n-13) had
problems with vision documented.

When determining problems documented in the area of polypharmacy,
malnutrition and unsafe environment, at least two areas of information
determine their definition. As can be seen in Table 1, generally the
problem with polypharmacy was related to the number of medications
rather than to abnormal blood levels. Fewer cases of malnutrition were
documented by abnormal albumin level but more than half of the problems
related to malnutrition were documented by the geriatric nurse on
initial assessment. Finally, either a history of falls or an unsafe
environment were equally considered when unsafe environment was

documented by the nurse or the physician. There were few missing data.

63
Table 1

WWW

 

Emblem Erenuencx Lenten;
Polypharmacy 45 70.3
Abnormal Digoxin 2
Abnormal Dilantin 0
Abnormal Theophylline 3
Abnormal Thyroid 8
Greater than 4 medications 44
Over-the-counter medications 45
Malnutrition 38 59.4
Abnormal Albumin 4
Malnutrition 37
Inadequate Social Support 38 59.4
Unsafe Environment 51 79.7
History of Falls 41
Environment 42
Altered Vision . 13 21.7

 

Nate: Some records documented more than one area for polypharmacy,
malnutrition and unsafe environment.

64
Presentation of Data Related to Research Question

In this section the data analysis procedures used to answer the
research questions are presented. The research questions are: 1) Can
the combined score of mental status and functional status be utilized to
predict reversible problems in the community-dwelling elderly? and 2)
Are there differences in the number of reversible problems identified a
with high, moderate and low risk community-dwelling elderly? i

Pearson product moment correlations were calculated to answer the i
first question and no significant correlations were found between mental
status scores and the number of reversible problems (r--.02), functional
status scores and the number of reversible problems (r=.04), or a
combined functional and mental status score and number of reversible
problems (r=.01). Therefore, the functional status and mental status
cannot be utilized to predict the number of reversible problems in the
community—dwelling elderly. Thus, the screening tool that measures
mental status and functional status cannot be utilized within the
primary care setting either separately or combined to determine or
identify how many reversible problems the community-dwelling elderly
would possess.

In order to answer the second research question, the risk levels
were identified using functional status score and mental status score as
defined in Chapter IV. A cross-tabulation was done (Table 2) using the
mental status score and the functional status scores to determine the
number of cases in the low, moderate and high risk groups. The
definition of low, moderate and high risk classified only 25 cases into
clearly identified low, moderate and high risk groups. Four cases were

identified as having high functional status and high mental status and

65
Table 2

WM

 

 

MENTAL RISK

 

 

 

 

 

 

 

FUNCTIONAL RISK High Risk Moderate Risk Low Risk
Hi h Risk 14¥(87.§%) 2 (12.5%) 0

Moderate Risk 12 (54.5%) 7 (31.8%) 3 (13.6%)

I Low Risk 3 (12.0%) 18 (72.0%) 4 16.0%

 

66
therefore were low risk. Seven cases were identified as having moderate
functional status risk and moderate mental status risk and were
classified as moderate risk and fourteen cases were identified as having
low functional status and low mental status that were classified as high
risk. The rest of the sample was put into a variation of these risk
levels. For example, eighteen cases fell into a category of moderate
mental status risk with high functional status risk, and three cases
were categorized having low mental status risk and high functional
status risk. Refer to Table 2 for the risk level of the remaining
cases. Therefore, 39 cases would be lost to further analysis if the
method risk status identified was not altered. The researcher's
question was then altered to observe mean differences for any
combination of risk status.

A decision was made to utilize the nine-cell matrix that would
classify all cases according to their functional and mental status and
risk status. This analysis was done by two-way ANOVA which compared the
dependent variables of mean number of reversible problems by the
independent variables of functional status and mental status score (Risk
Status). Table 3 shows the mean number of reversible problems within
each risk level. There was some missing data in the high risk category
and three cases were dropped from this risk level. The range of the
mean number of reversible problems was 2.33 to 4.00. The highest mean
number of reversible problems (4.0) was found in two cases with low
functional risk and moderate mental risk. The next highest number of
reversible problems (3.5) was found in the four cases in the lowest risk

group. The remaining risk groups had an average of 3.0 reversible

67

 

 

 

 

 

 

Table 3
er v i
MENTAL STATUS RISK
FUNCTIONAL High Risk Moderate Risk Low Risk I
STATUS RISK
I High Risk 2.64 4.00 0
11 2
3.09 2.71 3.00
Moderate Risk 11 7 3
2.33 2.61 3.50
LOW RISK 3 18 4

 

 

 

 

 

 

 

 

.maumum Hmucwe top use HaccHuucam :oHummex
.meL magnum Hmucme wuagovce new HacoHuu:=$ :cHnwmea
.meL mauaam Haynes gap; cam HugoHHucam 3oHu~me¢
.meg magma” Fences 3oH can Hacopuucam ouagmnoEuome¢
.xmpg macaw Hmacms mamgouce was anopuuczm muagmvosumxmwa
.xmpg mauaum pauses amp; van HacoHuuczm maugwcosu¢xmpm
.xmwg magnum Hmucme zo— van Hacopuucam gmngmme¢
.mes nausea Haucwe uuagmuce tea HacoHuu==$ gmngNmem
.xm_e magma” Page»; gm.; ecu H~=°_au==e gu.;.me.¢

 

 

 

 

 

 

 

 

 

 

 

 

:. in.wH.IIIIIIIII4IIIIIIlIIIIIIIANWMWIEIIIIquflmI :. T .u T. T [wwww;:lé . a

.e N c o H H o o H o
ao.m~ mom xmm am.¢H uo.m

v H o m H o o H o m
Rom new RH.sm Rm.mm x~.wH amw

s H o o v o H m H ,
aH.~ x~.mo am.¢H xooH as.om x~.- xms
H o o m H m N mH m

3.2;- 9.5. mu:— mflfl. iwflyr .lflwyh -mfldi- .Iwwml- 1%: T

g . cp mpaavH>Hcc we m.~a=m gm. m>m Hz «a 3 case. . .c 5.. .

w «Hank

69
problems. There were no differences in the mean number of reversible
problems within each risk level (F-.269, NS). Although there was no
significant difference in the mean number of reversible problems, it was
interesting that the cases with some of the highest mean number of
problems were those in the lowest risk group.

A follow-up analysis utilizing the variables of living arrangement
to describe a possible relationship that might exist between risk status
and whether an individual lived alone or not. A cross—tabulation of the
nine risk status categories with the four areas of living arrangement
was calculated (Table 4). As seen in Table 4 seventy-five percent of
the cases (n=3) with the lowest risk status (Risk I) lived alone while
93 percent of the cases (n=13) in the highest risk category lived with
other individuals. By looking at Table 4, it appears that almost half
of the people lived alone regardless of what their functional status and
mental status were.

Summary

Therefore, in this chapter the study sample was described and
answers were given to the first and second research questions. Further
analysis was done on the second research question when 39 of the cases
were lost by the researcher's definition of risk level. The next
chapter will have interpretation of the data and how these findings will
be utilized in advanced nursing practice, education, and nursing

research.

CHAPTER VI
Summary, Interpretation and Conclusions
Overview

In this study a summary of the study results are presented. The
summary and interpretation includes a review of previous chapters
followed by a discussion of the characteristics of the sample. Findings
for the research questions are discussed within the context of previous
related research and limitations of the study are addressed.
Interpretation of the data and implications of the study for nursing
practice, nursing education and nursing research are presented.

Summary of the Research Study

A descriptive study of the relationship between mental status,
functional status, level of risk and reversible problems in the
community-dwelling elderly was conducted to determine if the Folstein
screening tool and the Katz functional screening tool could be
administered to categorize the population into low, moderate and high
risk groups. Once the population was categorized, the study was also
conducted to determine if there was a difference in the number of
reversible problems between each group. A modification of Roy's
adaptation nursing theory provided a framework in which to examine a
relationship between mental status, functional status and reversible
problems and the combination of mental status and functional status
variables to determine a risk level. Data was collected from 64
geriatric assessment charts between April of 1990 and April of 1991.
Data was analyzed utilizing descriptive studies, Pearson product moment
correlation and two-way ANOVA. According to the study results, there

were no significant relationships between mental status, functional

70

71
status and reversible problems. Therefore, mental status and functional
status could not be utilized to predict the number of reversible
problems found in the community-dwelling elderly. A combination of
mental status and functional status was used to determine low, moderate
and high risk levels and to identify mean number of reversible problems
within each level. On average, the same mean numbers of reversible
problems were found in all risk levels.
Comparison of Sample Characteristics to the Literature

The community-dwelling elderly represented by the records had
similar sample characteristics compared to other studies reported in the
literature. The range in the number of years in age was from 58 to 87
with a mean age of 80.2. The mean age was slightly higher than the mean
age in the Katz et al. (1985), Fisk et al. (1987), Ramsdell et al.
(1989), and Altkorn et al. (1991) studies. Twenty-nine percent of the
population were male and 70 percent were female. There were a few more
females in this study compared to the Ramsdell et al. (1989) and
Williams et al. (1987) studies. Forty-eight percent lived alone and
three percent lived with spouse, 17 percent lived with a relative and
five percent lived in congregate housing. Compared to Ramsdell et al.
(1989), the percent of elderly living alone was considerably higher and
the percent of elderly living with spouse was considerably lower in this
study. The living arrangement compared to subjects in the Currie et al.
(1981) study were very similar. The number of diagnoses compared to the
Ramsdell et al. (1989) study were quite a bit higher at 4.5. The mean
value for Folstein scores in this study was 22.2. This was similar when
compared to the subjects in the Nilliams et al. (1982), Scholar et al.
(1990) and Altkorn (1991) studies but were significantly higher than

72
subjects in the Katz et al. (1985) and Fisk et al. (1987) studies. A
mean score of 5.2 on the ADL tool and 4.6 on the IADL tool were
documented. These scores were similar to those documented in the Fisk
et al. (1987) study. Studies used different functional status tools and
it was difficult to compare these to the present study. The mean number
of reversible problems per risk level was approximately 3.0 for this
study. But the researchers in other studies did not define reversible
problems as the researcher in this study and therefore no comparisons
will be made. The combined score of mental status and functional status
could not be used to predict the number of reversible problems found
within the community-dwelling elderly. This outcome is similar to
Ramsdell et al. (1989) in that no variables or a combination of
variables were associated with one or more risk level at the home visit.
There was no literature to support or criticize the definition of risk
level and therefore no comparisons were made with other studies.
Conclusions Regarding Study Findings

Study findings related to reversible problems support utilizing
the CGA compared to the traditional medical review of systems to
identify but not predict reversible problems. Seventy percent of charts
had polypharmacy, 59 percent had malnutrition, 59 percent had inadequate
social support, 80 percent had unsafe environment and 21 percent had
altered vision. These problems are reversible and if not recognized by
a health care provider could jeopardize the independent home life of the
community-dwelling elderly. These problems were found on a home visit
and not in the office setting. Thus, it is extremely important to
utilize the home visit as part of the CGA.

73

Related to the first research question, there are many
explanations for the lack of relationship between mental status,
functional status and reversible problems. A simple quantitative
screening tool may be unable to predict complex problems in the
community-dwelling elderly. For example, the Folstein (MMSE), that
measure areas an elderly individual may not utilize in their every day
life like mathematics and spelling may not accurately reflect their
mental status. Also the Katz index has limitations when measuring
function in that the information is subjective and many of the IADL
tasks such as shopping, cooking and housekeeping are performed by a
female spouse providing biased results for female subjects. Therefore,
documentation of an individuals functional level may be higher for women
when measuring function with the Katz tool. Statistically speaking, by
utilizing these two screening tools, combined scores may have been
higher causing less variability in the 64 cases and thus no statistical
significance. The ranges utilized to operationally define low, moderate
and high risk using mental status and functional status may not have
been correct. If ranges utilized to define low, moderate and high risk
were adjusted to include lower scores than more variability may have
been found between groups leading to greater statistical significance.
Fewer problems may have been identified by the patient and the
nurse/physician related to different perceptions of the problems defined
in this study. Overall, the range for possible reversible problems was
small (0-5), resulting in potential decreased variability among
subjects. The timing of the CGA may have been crucial to the number of

reversible problems found because community resources may have already

 

74
been implemented and adjustments made by caregivers to reverse problems
and therefore causing fewer problems to be identified.

Related to the second research question, mean number of reversible
problems were identified in the low, moderate and high risk groups and
living arrangement was examined to determine a cause for small
differences among risk levels. In the lowest risk group with 3.5
reversible problems three lived alone and one with a spouse. In the
moderate risk group with 2.71 reversible problems one lived alone, four
with a spouse and two in congregate housing. In the high risk group
with 2.64 reversible problems, one lived alone, seven with spouse, four
with relative and two in congregate housing. In Risk level 8 which was
defined as a moderate mental status and a low functional status, these
cases had the highest mean number of reversible problems (4.0) where one
lived alone and one lived with spouse. Risk level 6 which was defined
as moderate functional status and low mental status had 3.09 reversible
problems and living arrangement showed that eight lived alone, none with
a spouse, three with relatives and one in congregate housing. Finally,
in Risk level 4, defined as high mental status and moderate functional
status, 3.00 reversible problems were found and all cases (n23) lived
alone. Therefore, on average, there were small differences in the mean
number of reversible problems between all risk levels and these
differences were not significant. It was also interesting to note that
living risk level did not have any effect on arrangement. More
specifically, a community-dwelling elderly individual could have a low
mental status and a moderate functional status and still live alone.
This lends support to utilizing Roy's Adaptation model because many of

these individuals or their caregivers adapt before receiving help from

75
their health care provider. Therefore, it is extremely important to
assess all community—dwelling elderly by utilizing the CGA within the
home environment to objectively assess their living situation.

Given the above information, the following changes could be made
within Roy's Adaptation Model to improve the study. Other modifying
variables could be considered that may have an effect on the
relationship between these study variables. The modifying variables are %
socioeconomic status, educational level and finances, community ;”
resources utilized and caregiver burden. Roy's Adaptation Model would I

be revised by redefining the concept of risk level and changing the if

 

dependent variable to mental status and functional status and the
independent variable to reversible problems. The concept of risk would
include objective measurements of polypharmacy, malnutrition, inadequate
social support, unsafe environment, altered vision, and the objective
measurement of functional status. The outcome or adaptive response
would be independence within the home environment and the maladaptive
response-would be use of adult foster care or institutionalization
related to their functional and mental status.
Implications for Advanced Nursing Practice

Since there were no relationships found between mental status,
functional status, risk level, and reversible problems, the Folstein
screening tool and Katz screening tool could not be utilized in the
office setting to predict the number of problems in the community-
dwelling elderly. In clinical practice, the implication for the GCNS is
that screening tools should be utilized to establish a baseline to
assess change and to identify the need for further evaluation of

reversible problems in the community-dwelling elderly. Also, this

 

76
finding strongly supports the need to assess the elderly across multiple
domains utilizing the CGA. The need still exists to develop a screening
tool that is more practical but just as comprehensive as the CGA. Some
of the domains to be screened for in the primary care setting should
include vision, hearing, upper and lower extremity range of motion,
presence of urinary incontinence, nutrition status, mental status,
depression, Nilliams Manual Test for functional level, home environment,
and social support.

When utilizing the mental status screening tool and the functional
status screening tool certain rules should be followed when evaluating
the elderly. Hhen utilizing the mental status tool a brief description
of hearing and vision sensory losses as well as educational level should
be documented. When utilizing the functional status tool, documentation
should be made about assistance with independent activities of daily
living; for example, shopping, cooking, preparing meals, or finances.
All of these issues could cause the score on the MMSE and the functional
status tool to be different if not taken into consideration.

When the community-dwelling elderly are placed into low, moderate
and high risk categories by utilizing mental status and functional
status, the lowest risk group had the highest mean number of reversible
problems. This strongly supports the need to assess all elderly in the
primary care setting. Hhen living arrangement had no effect on risk
level this finding emphasized the importance of the home visit on all
elderly because many of the problems were reversible and could have an
impact on maintaining an individual's independence in the home
environment. The home visit also allows for an objective assessment of

the patient and caregiver relationship, specifically caregiver

.

77
responsibilities and relationship with spouse and caregiver burden
issues. The home visit allows the GCNS to objectively assess the home
environment of an individual who is cognitively impaired, living alone
and unable to express his/her reversible problems. It is imperative
that a home visit be done on those individuals with memory loss because
their health history information is questionable. In this situation it
is also important to contact the spouse or other family members to
contribute objective information about the cognitively impaired elderly
individual. This research study lends support to the home visit and
these findings improve the chances of demonstrating to Medicare and
other third party payers that identifying reversible problems must be
done in the home and also earlier identification can result in savings
to the health care system and insurance companies.
Implications for Education

Implications for education would involve the community-dwelling
elderly, family members and the health care providers performing CGA's
in the primary care settings. Related to the findings already stated,
the implications for community-dwelling elderly are to educate
individuals and their families about what constitutes a problem and when
to contact a health care professional for assistance with a problem.
When these two issues are identified, they will become more aware of
changes in their health care status and how to deal with them. The
majority of problems caused by misdiagnosis of problems in the elderly
could be related to the lack of communication between the patient and
the health care provider. The key issue is to establish a rapport over
time so a level of trust develops. If there is no rapport established

between patient, family, and health care provider, then information may

 

78
not be as accurate and problems may not be identified for fear that the
individual may become more dependent and closer to needing community
resources. The fear that is generated by the individual and family is
that they may not be able to afford community resources and the
alternative than would be institutionalization which is not a
consideration for these individuals. Therefore, it is important to
educate the health care providers about establishing a rapport with the
community-dwelling elderly and their caregivers and also make the health
care providers aware of the fears associated with admitting to problems
that may require a change in living situation.

Education for physicians and other health care providers about the
role of the GCNS is also imperative. This description should include
the many roles of the GCNS which are consultant, collaborator, assessor,
researcher, clinician, educator, and patient advocate and how these
roles are implemented during the assessment process of all community-
dwelling elderly.

Education would also involve information to other health care
providers on how to administer screening tools to the elderly population
in order to obtain the most accurate baseline data. The information
taken by the primary care provider could then be used as baseline data
to monitor patients' functional improvements or declines over time
within the primary care setting. Education should also include the
importance of assessing the population over 65 in the biological,
'psychological, social, spiritual, and environmental realms to make a
diagnosis more accurate and to individualize treatment plans.

Finally, this research should be used to educate hospital

administrators and the nursing home administrators that shortcuts for

79
assessment of the elderly should not be utilized with the geriatric
population secondary to the complex nature of their health status.
CGA's may be the best way to accurately diagnose problems and in the
future would be cost effective for third party payers and Medicare to
reimburse for these services. Utilizing CGA's, the community-dwelling
elderly may remain independent longer within their home environment.
Implications for Nursing Research

In terms of implications for nursing research, this investigation
was done to determine if two screening tools which measure mental status
and functional status could be utilized on the community-dwelling
elderly to predict the number of reversible problems they possess and to
determine an individual's risk level (low, moderate, or high). The
limitation in this research is that the complex problems of the
geriatric population could not be screened by utilizing the mental
status tool and the functional status tool alone. Therefore, this
researcher recommends looking at another investigation in the future
that would include multiple tools for screening the community-dwelling
elderly and assessing their risk level. Reliability and validity would
need to be determined with these screening tools. The domains that
should be assessed include vision, hearing, upper and lower extremity
functioning, gait assessment, urinary incontinence, nutrition, mental
status, polypharmacy, social assessment, legal issues, and evidence of
depression. The tool would be developed so that it could be
administered by nurses, physicians, and social workers, and administered
in less than twenty minutes. Number of problems would be identified and
a greater range of problems would be utilized in order to possibly

increase the variability and the number of problems identified.

80

Other research to be done by the GCNS would be an experimental
design targeted to a specific group of geriatric community-dwelling
elderly that is prospective in nature. Screening criteria would include
community-dwelling elderly over the age of 80, degree of functional
impairment, presence of geriatric conditions (i.e., incontinence and
confusion), particular diagnostic information, psychological
information, social and environmental information, living arrangement,
recent stressors present in the individual's life, and economic status.
Exclusion criteria would include individuals with severe dementia,
terminal illness, or inevitable nursing home placement. This study
would take place over a time which would include a longitudinal study
and also a cohort study.

In conclusion, because functional status and mental status
screening tools could not be used to predict the number of reversible
problems within the community-dwelling elderly or allow the GCNS to
categorize individuals into low, moderate and high risk groups, it is
imperative that the GCNS continue research within this area with the
community-dwelling elderly population. Because of the expansion in the
geriatric population, the increase in health care costs, the functional
and mental status decline, and the lack of interest in geriatrics, it is
imperative that the GCNS find ways that the geriatric community-dwelling
elderly can be screened to identify problems in the primary care setting
by all health care professionals. The GCNS must continually educate
families, individuals and health care providers about the GCNS role and
about the unique problems in the geriatric population so that these

individuals may receive better care in the future.

REFERENCE LIST

Altkorn, D.L., Ramsdell, J.N., Jackson, J.E., 8 Renvall, M. (1991).
Recommendations for a change in living situation resulting from an
outpatient geriatric assessment. Type, frequency and risk factors.
Qeurnel ef the Amerjeen Gerjetrje Sec jety, 32, 508-512.

Anderson, M.S., Gilchrist, A., Mondeika, T., 8 Schwartzberg, J.G.
(1990). American Medical Association white paper on elderly

health. Archives 9f Internal Medicine, 150, 2459-2473.

Applegate, Deyo, Kramer 8 Meehan. (1991). Geriatric evaluation and
management: Current status and future research directions.

Qegrgel ef Ameriean Gerietrje Seeiety, 32, 25-75.

American Psychiatric Association. (1987). Diagnostic and statistical
manual of mental disorders (3rd ed., revised), Hashington, D.C.:
Author.

Anthony, J.C., LeResche, L, Niaz, U. VonKorff, M. R, 8 Folstein, M. F.
(1982). Limits of the Mini-Mental State as a screening test for
dementia and delirium among hospital patients. Eeyehelegieel
$1193.12. 397- 408

Aske, D. (1990). The correlation between Mini—Mental State Examination
scores and Katz ADL Status among dementia patients. Behebiljtetjgn
M51113. .15. 140-142.

Bedsine, R.H., Hakefield, K.M., 8 Nilliams, T.F. (1988). Assessing
function in the elderly. ,Eetient_§ere, 69-79.

Brorsson, 8., 8 Asberg, K. H. (1984). Katz Index of Independence in AOL:
Reliability and validity in short- term care. Seegdjneyjee Qeurnal
ef Rehabiljtetjee Mediejne, 16, 125- 132.

Burke, H.J., Rubin, E.H., Zorumski, C. F. 8 Potter, J. F. (1989).
Geriatric assessment. MW 11. 28- 41

Carr, D. Jackson, T. 8 Alguire, P. (1990). Characteristics of an
elderly driving population referred to a geriatric assessment

center MW. 38. 1145-1150

Cohen. H J (1991) Commentary. MW
51:13:21.3. 175-185

81

82

Currie, C. T, Moore, 0. T. Friedman, S. H., 8 Harshaw, G.A. (1981).
Assessment of elderly patients at home. A report of fifty cases.

Jngrnel of th e Anerjeen fieri etrjes 3o ejeLy, 23, 398-401.

Eliopoulos, C. (1989). Caring for the elderly in diverse care settings.
In c. Eliopoulos (Ed-i. MW. (pp. 3-
10). Philadelphia, PA: 0.8. Lippincott Company.

Epstein, A.M., Hall, 0.A., Fretwell, M., Feldstein, M., DeCiantis, M.L.,
Togretti, 0., Cutler, C., Constantine, M., Besdine, R., Rowe, 0., 8
McNeil, 8.0. (1990). Consultative geriatric assessment for
ambulatory patients. JAMA, 2§3, 538-544.

Comprehensive geriatric assessment improves care. (1987) Eenjly

Erastise. §§. 239-240.

Fields, S.D., MacKenzie, C.R., Charlson, M.E., 8 Sax, F.L. (1986).
Cognitive impairment: Can it predict the course of hospitalized

patients? Journal ef Amerjeen Qerjetrje Sneiety, 35, 579-585.

Fisk, A.A., 8 Pannill, F.C. (1987). Assessment and care of the
community-dwelling alzheimer's disease patient. Qenrnel ef the

Amerjeen Gerjatrje §eeiety, 35, 307-311.

Folstein, M. Anthony, 0. L, Parhad, 1., Duffy, 8H8 Gurenberg, E. M.
(1985). The meaning of cognitive impairment in the elderly.

WM. 33. 228- 235

Fretwell, M.D. (1990). The Merck manual of geriatrics: Comprehensive
functional assessment. Rahway, NJ: Merck, Sharp, 8 Dohme Research
Laboratories.

Gallo, 0.0., Reichel, N., 8 Anderson, L. (1988). Handbook of Geriatric
Assessment. Rockville, MD: Royal Tunbridge Hells--Aspen
Publishers, Inc.

Galton, L. (1976). Drugs and the elderly. unrejng lg, 33, 43.

Goldberg, P. 8., 8 Roberts, 0. (1983). Pharmacologic basis for
developing rational drug regimens for elderly patients. Menjeel
WM. 61. 315-331.

Gottlieb, G.L. (1989). Optimizing mental function of the elderly. In
R. Lavisso-Movrey, S.C. Day, 0. Diserens and 0.A. Grisso (Eds.),

v on f . (pp. 141-152).
Philadelphia, PA: Hanley 8 Beltus, Inc.
Hendricks, 0., 8 Hendricks, C.D. (1981). Aging jn Mess Soejety (2nd

Edition). Cambridge, MA: Hinthrop Publishers.

Horton, A.M. Jr., Slone, D.G., 8 Shapiro, S. (1987). Neuropsychometric
correlates of the Mini-Mental State Examination: Preliminary Data.

W. 33. 64-66.

83

Johnson, 0.C., 8 Mezey, M.D. (1989). Functional status: An approach to
tertiary prevention. In R. Lavizzo-Mourey, S.C. Day, D. Diserens

and 0.A. Grisso (Eds.), Preetiejng preventjen fer Lhe elderly.
Philadelphia, PA: Hanley 8 Belfus, Inc.

Kane, R.A. 8 Kane, R. (1981). Aeeeeeing_1he_e1denly. Lexington, MA.

The Rand Corporation.

Katz, P. PH Dube, D. H. 8 Calkins, E. (1985). Use of a structured
functional assessment format in a geriatric consultative service.

029W. 3.3. 681- 686.

Katz, S, Branch, L. GH Branson, M. H. Pasidero, 0. A, Beck, 0. C, 8

Greer, D. S. (1983) Active life expectancy. Neu_£_gleeg_flee_nel_e_
Medicine. 392. 1218- 1224

Klein, L. (1984). Medication problems among outpatients. Arehiyee_ef
Internel Medieine, 155, 1185-1188.

Kurfees, 0.F. 8 Dotson, R.L. (1987). Drug interactions in the elderly.
W1 of Fa_miLv PM. 25. 477-488.

Lachs, M.S., Feinstein, A.R., Cooney, L.M., Drickamer, M.A., Marottoli,
R.A., Pannill, F.C., 8 Tinetti, M.E. (1990). A simple procedure
for general screening for functional disability in elderly

patients. Angels ef Intennel Mediejne, 112, 699-706.

Larson, E. 8., Kukull, H. A, Buchner, DH 8 Reifler, 8. V. (1987).
Adverse drug reactions associated with global cognitive impairment
in elderly persons We. 101. 169-173

Lavizzo-Mourey, R. (1989). Preventing Adverse Drug Reactions in the
Elderly. In R. Lavizzo-Mourey, S.C. Day, D. Diserens, and 0.A.
Grisso (Eds.), r ct i v tio f r ld r , (pp. 47-62).
Philadelphia, PA: Hanley 8 8elfus, Inc.

Lawton, M.P., 8 Brody, E.M. (1969). Assessment of older people: Self
maintaining and instrumental activities of daily living.

Gerontelegist, 2, 179-185.

Lefton, E., Bonstelle, S., 8 Frengley, 0.0. (1983). Success with an
inpatient geriatric unit: A controlled study of outcome and

follow-up. W. 31. 149-155.

Lekan-Rutledge, D. (1988). Gerontological Nursing in Long-Term Care
Facilities. In M.A. Matteson and E.S. McConnell (Eds.),
i n P ' , (pp. 721-762).
Philadelphia, PA: 8.8. Saunders Company.

Lother, C.P., MacLeod, R.D.M., 8 Hilliamson, D. (1970). Evaluation of
early diagnostic services for the elderly. firitj§h_flegjeel

1198111881. :9 275-277 0

84

Louis, M. (1983). Falls and their causes. Qgurna1_gf_§g[gntglggiga1
rinsing. 1. 143-149. .

Matteson, M.A. (1988). Age related changes in the neurological system.
In M.A. Matteson and E.S. McConnell (Eds. ), r
, (pp. 241-264). Philadelphia, PA: H.B.
Saunders Company.

Matteson, M. A. (1988). Age related changes in the special senses. In
M. A. Matteson and E. S. McConnell (Eds. ), e n

W
;g_gept§_and_pragtige, (pp. 311- 326). Philadelphia, PA: H.B.

Saunders Company.

Matteson, M.A., a McConnell, E.S. (1988). Psychosocial problems
associated with aging. In M.A. Matteson and E.S. McConnell (Eds.),
WW. (pp. 481-528).
Philadelphia, PA: N.B. Saunders Company.

McConnell, E.S. (1988). A conceptual framework for gerontological
nursing practice. In M.A. Matteson and E.S. McConnell (Eds.),

fiargntglggigal nagging gggggpts and practice, (pp. 5-55).
Philadelphia, PA: ".8. Saunders Company.

McGandy, R.B., Russell, R.M., Hartz, S.C. (1986). Nutritional status
survey of healthy non-institutionalized elderly: Energy and
nutrient intakes from three-day diet records and nutrient

supplements. mm. 6. 785-798.

Mitchell, C.O. & Chernoff, R. (1991). Nutritional assessment of the
elderly. In R. Chernoff (Ed.), fig;iatnig_ngtgitign, (pp. 363-396).
Gaithersburg, MD: Aspen Publishers, Inc.

Nolen, N.R. (1988). Functional skill regression in late— —stage

dementias. lhg American figurnal of Qggupatjgnal lhgzapy, 52, 666-
669.

Notelewitz, M. & Ware, M. (1982). fitand_1a11. Gainsville, FL: Triad
Publications.

Pace, M.D. (1989). Geriatric assessment in the office setting.
, 55, 29-35.

Ramsdell, J.N., Swart, J., Jackson, J.E., & Renvall, M. (1989). The
yield of home visit in the assessment of geriatric patients.

gogrnal 9f thg Amarjgan figrjatrjg Sggjgty, 31, 17-24.
Roy. S c. (1976) W (2nd

EditionL Englewood Cliffs, NJ: Prentice-Hall Inc.

Rubenstein, L. 2. (1987). Geriatric assessment: An overview of its

impacts. Cljn njgs jn figri 91:19 Magi cine, 3, 1-15.

 

 

 

85

Rubenstein, L.Z., Applegate, W.B., Burton, J.R., Hyer, J., Pawlson,
L.G.. & Winograd. CAL (1991). MW
5.03.1311. 12. 926-931.

Scholer, S.G., Potter, J.F., & Burke, W.J. (1990). Does the Williams
Manual Test predict service use among subjects undergoing geriatric

assessment? MW. 3.8. 767-
772.

U.S. Department of Commerce. (1990).
. Washington, D.C.: U.S. Bureau of the Census
Current Population Reports.

Terezhalmy, G.T. (1989). Rational pharmacotherapy for the elderly.
Qantal tlinigg 9f North Amgrjga, 3;, 59-67.

U.S. Congress, Office of Technology Assessment. (1987). Lgaing_a
Million Mi 5: Confron in h T ed Al ' ers i n
chg: Damgntiaa. Washington D.C.: U.S. Government Printing
Office.

Vener, A. (1979). Drug usage and health characteristics in non—

institutionalized retired persons. Journal of the Amgrjgan
Wu. 2§. 83-90.

Wenk, G.L. (1989). Nutrition, cognition and memory. logic; of
figrjatrjc Rehabilitation, 5, 79-87.

Williams, M.E. (1987). Identifying the older person likely to require

long-term care services. Jggrnal gf tug Amerigan Geriatrig
1mm. 15. 761-766.

Williams, M.E., Hadler, N.M., G Earp, J.L. (1982). Manual ability as a
marker of dependency in geriatric women. Journal of chronic

D.Ls_e_a_s_e. 35. 115-122.

Williams, M.E., & Hornberger, J.C. (1984). A quantitative method of
identifying older persons at risk for increasing long term care

services. Jgurgal gf Chronit Diaaaae, 31, 705-711.

Williams, M.E., Williams, T.F., Zimmer, J.G., Hall, W.J., G Podgorski,
C.A. (1987). How does the team approach to outpatient geriatric
evaluation compare with traditional care: A report of a randomized
controlled trial. MW. 35.
1071-1078.

Yearick, E.S., Wang, M.L., & Pisias, S.J. (1980). Nutritional status of
the elderly: Dietary and biochemical findings. Jog:na1_gf

Gem. :5. 663-671.

Zheng, J.T., & Rosenberg, I.H. (1989). What is the nutritional status
of the elderly? Geriatrigs, 15, 57-64.

APPENDIX A

]. Christopher Hongb. .ll.D. ——MIDMCHIGAN—
REGIONAL MEDICAL CENTER

FAMILY AND ADULT MEDICINE

5912 Eastman Road

 

Midland. Michigan 48640

517 ' 839 ° 00.78 hr 517 ° 839 ° 0.336

May 4th, 1992

Rachelle Schiffman, Ph.D.
College of Nursing

Michigan State University
A230 Life Sciences Building
East Lansing, Michigan

Dear Dr. Schiffman:

I have been informed that Jean Thiele has referenced MidMichigan
Regional Medical Center in her thesis as the source of the charts
from which her research data was collected. She has received my
permission to cite our organization specifically in her work.

Please let me know if there is anything further you need in this
regard.

'ncerely,

[m

Diane K. Welk
Manager, Geriatric Services
Business Manager, Physician Service Division

86

]. Christopher Hougb, M.D. —MIDMICHIG7AxN_
' REGIONAL MEDICAL CENTER

FAMILY AND ADULT MEDICINE

 

5912 Eastman Road

 

Midland, Michigan 48640

517' 839 ° 0023 Fax 517 ' 839 ° 0336

AUTHORIZATION FOR PAYMENT

l have' granted permission for a. home visit to

be done by the geriatric nurse from Family and
Adult Medicine. I understand that the charge for
this visit is included in the total assessment

fee. If, for whatever reason, I do not undergo

a comprehensive assessment, I agree to pay for the
home visit as a separate charge. I have been
informed that home visits are not a covered Medicare
benefit and I will personally be responsible for

the bill. ’

Witness Date

87

 

 

SENIOR ASSESSMENT INTAKE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

'DAIE
KANE PaoNE
ADDRESS
ACE DAIE or BIRTH SEX §__§. MARITAL SIAIUS M s v D
REFERRED BY A PHYSICIAN
NEXT or RIN - RELAIIONSEIP
ADDRESS
PHONE
INSURANCE INPoRNAIION
NAME POLICY Nos.
ADDRESs .
MEDICARE MEDICAID

 

 

SOCIAL SECURITY NO.

 

RELEASE OF INFORMATION-CONSENT FOR SERVICES

I AUTHORIZE FAMILY AND ADULT MEDICINE TO RELEASE MY COMPLETE MEDICAL RECORDS TO
HOSPITALS, PHYSICIANS. AND OTHER SOCIAL AGENCIES OR INSTITUTIONS AS NECESSARY.
I ALSO AUTHORIZE MY PHYSICIAN. HOSPITAL. OR OTHER AGENCIES TO RELEASE TO THE
FAMILY AND ADULT MEDICINE ANY PORTION OF MY MEDICAL RECORDS WHICH MAX BE DEEMED
NECESSARY.

 

 

CLIENT OR PERSON LEGALLY RESPONSIBLE DATE

 

 

WITNESS DATE

88

REASON FOR REFERRAL:

 

 

 

R.N. ASSESSMENT
DR. ASSESSMENT

FAMILY CONE.

DICTATED

TC

FOLLOU-UP VISIT

 

DR. LETTER
REFERRED TO: HOME CARE
LAB X-RAY

TRAVEL INSTRUCTIONS:

ADULT DAY CARE COA

PHYSICIAN OTHER

 

 

COMMENTS:

 

 

 

 

 

 

 

89

COMPREHENSIVE GERIATRIC ASSESSMENT
SUMMARY SHEET

NAME AGE ___ DOB Z A INITIATED g A
PROBLEM. RECOMMENDATION

 

PROBLEMS

 

 

 

 

 

 

 

 

 

 

 

 

MENTAL

 

SOCIAL

 

LEGAL

 

ECONOMIC

 

ENVIRONMENT

 

ADL / IADL

HEALTH MAINT. FLU z A PNEUMO 4 4 TE‘I‘ ; 4 PPD _L.L__
PAP_/__/_NAms _LL_SIG__L_¢_BCLT_L_L_
ngEEAR 4; PE 44DENI44

VALUES CODEY/.N HOSPY/N MEDY/N INVESTY/N TU/VENTY/N

LTCAREPLAN

 

 

90

COMPREHENSIVE GERIATRIC ASSESSMENT
NAME AGE _ DOB _L__[__ INITIATED __LL__

CURRENT MAJOR COMPLAINT:

 

 

W (CIRCLE AND DESCRIBE ABNORMALITIES IF NECESSARY)

W

81‘: 1 WT: TEMP:_____ PULSE:__ RESP:
SITTING B? A STAND 3P _[__ VISUAL WI 00+ “/0 00 Z
HEARING SCIEEN: NORMAL VOICE Y / N WHISPER Y / N WATCH TICKING Y / N

' APPEARANCE: HYGIENE DRESS GROG‘IING POSTURE EYE CONTACT CACHEXIA OBESITY
HOOD/AFFECT: APPROPRIATE LABILE DEPRESSED AGITATED ANXIOUS HOSTILE

 

W
SYMMETRY SHAPE DISTRIBUTION BALDNESS HAIR LOSS
DESCRIBE

 

EAQE
EXPRESSION MUSCLE NEARNESS PALSY STARE

DESCRIBE

 

m
COLOR VISION PTOSIS PUPILS VISUAL FIELDS EOM NYSTAGMUS STRABISMUS

CONJUNCTIVA SCLERA LIDS CATARACT GLASSES FUNDI ARCUS SENILIS
DESCRIBE

 

 

91

EAR
AURICLES CANALS TM CERUMEN IMPACT HEARING AID AC>BC RT AC>BC LT WEBER

DESCRIBE

 

m: .
PATENCY SEPTUM DEVIATION MUCOSA POLYPS
DESCRIBE

 

W .
TEETH EDENTULOUS PARTIAL DENTURE FULL DENTURE DENTURE FIT ORAL HYGIENE

LIPS MUCOSA TONGUE PHARYNX GAG .PHONATION UVULA/TONGUE MIDLINE TESTING
DESCRIBE

 

 

NECK
RANGE OF MOTION THYROID BRUIT CAROTID PULSE ADENOPATHY MASS

DESCRIBE

 

 

BREAST
SYMMETRY SKIN NIPPLE DISCHARGE MASS AXILLARY NODES TENDER MASTECTOMY
DESCRIBE

 

W

5mm ucmzsxous AP mm maosxs scouoszs moatczc SPINE ROM
30m! munmss cu mms _

3mm SOUNDS ms wmzmc RHONCBI BASILAR cmruuous RUBS
DESCRIBE

 

 

92

W
LIFT THRILL PMI LBCD RUB RATE RHYTHM SI 52 SPLIT MURMUR GALLOP
S3 84 JVD HEPATOJUGULAR REFLUX CYANOSIS PREMATURE CONTRACTIONS

 

 

 

 

EDEMA: PEDAL SACRAL HANDS GRADE: +

DESCRIBE

WI!

CONTOUR SCARS HERNIA PULSATIONS SOUNDS LIVER SIZE ___ CM ABD AORTA

BRUIT FEMORAL BRUIT MASS TENDERNESS SPLENOMEGALY KIDNEY
DESCRIBE

 

 

W
RASH FORESKIN TESTICLE MASS VARICOCELE TENDERNESS DISCHARGE HERNIA
DESCRIBE

m

VULVAR SKIN CHANGES URETHREAL MEATUS VAGINA VAGINITIS ATROPHY CERVIX
CERVICITIS. POLYP PROLAPSE HYSTERECTOMY UTERUS ADNEXA CYSTOCELE
RECTOCELE MASS TENDERNESS. SUPPORT PAP DONE ____

DESCRIBE

 

 

329nm

TAGS SPHINCTER TONE FISSURE HEMORRHOIDS RECTAL MASS PROSTATE ENLARGED
PROSTATE MASS FECES FECAL IMPACTION PROLAPSE HEMOCULT

DESCRIBE

 

 

93

(
pea-es reflexes

W7???

musculoskeletal - ROM
right left comments

upper extrem

‘ lower extrem
hand funaion
tee:

other neurologic

m: CALUSES BUNIONS NAILS ULCERS DEFORMITY HAMMER TOES

DESCRIBE:

 

WED

O
1
2

SCORE

C ’ T DO
LIMITED
NORMAL

 

DESCRIBE

BALANCE GAIT

SITTING __ INITIATION OSTEOARTHRITIS
RAISING _ STEP LENGTH RHEUMATOID ARTHRITIS
IMED STAND _ STEP HEIGHT VASCULAR DEFICIENCY
PROL STAND _ STEP CONTINUITY ONYCHOGRYPHOSIS
NUDGE _ STEP SYMMETRY

RQIBERG _ NALK STANCE _ UP FROM FLOOR
TURNING 360 _ TRUNK SHAY __ CABINET REACH

SIT DOWN _ PATH DEVIATE __ FLOOR REACH

 

 

94

 

 

MEAL
PATHOLOGIC REFLEXES: BABINSKI SNOUT/SUCK GRASP

SENSATION: VIBRATION L / R UP / DOWN POSITION L / R UP / DOWN
DESCRIBE

 

 

CRANIAL NERVES: 1 2 3 4 5 6 7 8 9 10 11 12 NORMAL I ABNORMAL

COORDINATION: FINGER-TO-NOSE HEEL-TO-SHIN RHOMBERG RAPID FINGER MOVEMENT

MOVEMENT DISORDER: PARKINSON RESTING TREMOR TARDIVE DYSKINESIA BRADYKINESIA
INTENTION TREMOR COGWHEEL REGIDITY HEMIPARESIS OTHER

DESCRIBE

 

 

§KIN
COLOR TURGUR HART LESION SEBORRHEIC KERATOSES NEVI ACTINIC KERATOSES

STASIS DERMATITIS
DESCRIBE

 

 

COMMENT:

 

 

 

 

 

 

95

(mill-“_._.
_._ - .

 

EAST—SEALS

NO FUNCTIONAL DECREMENT SUBJECTIVELY
OR OBJECTIVELY

COMPLAINS OF FORGETTING LOCATION OF
OBJECTS/SUBJECTIVE WORK DIFFICULTIES

DECREASED FUNCTIONING IN DEMANDING WORK
SETTING EVIDENT TO COWORKERS/DIFFICULTY

TRAVELING TO NEW LOCATIONS

DECREASED ABILITY TO PERFORM COMPLEX

TASKS

 

STAGE

2

DDX CONSIDERATIONS

ANXIETY NEUROSIS. DEPRESSION

DEPRESSION / SUBTLE MANIFESTA-
TION OF MEDICAL PATHOLOGY

DEPRESSION. PSYCHOSIS. FOCAL

 

 

 

(PLANNING. FINANCES. SHOPPING) 4 CEREBRAL PROCESS (GERSTMANN)
REQUIRES ASSISTANCE SELECTING ATTIRE
MAY REQUIRE COAXING TO BATHE PROPERLY 5 DEPRESSION
DIFFICULTY DRESSING PROPERLY 6A ARTHRITIS. SENSORY DEFICIT.
STROKE. DEPRESSION
REQUIRES ASSITANCE BATHING. FEAR OF BATH BB SAME AS 8A
DIFFICULTY WITH MECHANICS OF TOILETING BC SAME AS 6A
URINARY INCONTINENCE - 6D URINARY TRACT INFECTION. OTHER
CAUSES OF INCONTINENCE
FECAL INCONTINENCE 6E INFECTION. MALABSORPT ION.
OTHER CAUSE OF INCONTINENCE
VOCABULARY LIMITED TO 1'5 WORDS 7A STROKE. OTHER DEMENTIAS
INTELLIGIBLE VOCABULARY LOST VB SAME AS 7A
AMBULATORY ABILITY LOST 7C PARKINSONISM. NEUROLEPTIC
INDUCED OR OTHER EXTRAPYRAM-
IDAL SYNDROME. CREUTZFELDT-
‘JAKOB DISEASE. NORMAL PRESSURE
HYDROCEPHALUS. HYPONATREMIC
DEMENTIA. STROKE. ARTHRITIS.
HIP FRACTURE. OVERMEDICATION
ABILITY TO SIT LOST 7D ARTHRITIS. CONTRACTURES
ABILITY TO SMILE LOST 7E STROKE
ABILITY TO HOLD UP HEAD LOST 7F HEAD TRAUMA

ULTIMATELY. STUPOR OR COMA

 

METABOLIC ABNORMALITY. OTHER
MEDICAL ABNORMALITY. OVER-
MEDICATION. ENCEPHALITIS
OTHER CAUSES

 

 

 

 

96

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME: ' DATE INITIATED _LL.
TELEPHONE: DOB: 1. 1 AGE _ u/F RACE: C/B/A/I
W
W
W
W
DIAGNOSIS 1 SURGERY HOSPITAL DATE
1 J
J 1
1 1
1 1
1 1
1 4
1 1
1 1

 

97

W LAST COMPLETE PHYSICAL _Z_L
PAP SMEAR z [ MAMMO [ [ SIG L l HCLT A z

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DA 11 DENTAL 11EYE11HEAR11
FLU 119NEUH011I'FD11TET11
SMOKER: NEVER QUIT (YR) __ YES RFD x YRS = max YRS i
ALCOHOL HISTORY
DIET: REGULAR Low FAT Low CHOLESTEROL DIABETIC Low FIBER HIGH FIBER 5
OTHER EXERCISE
SEAT BELT USE: ' FALLS/ACCIDENTS
SELF mus: MENOPAUSE/OSTEO
W
NAME DOSE FREQUENCY PURPOSE
1
2
3
4
s
s
7
8
9
10
u
12
13
14

 

 

98

 

NAME DOSE FREQUENCY PURPOSE

 

 

 

 

 

 

 

» O: NO I»

 

 

PRESCRIBING PHYSICIAN:
PHARMACY & PHONE: °
MEDICATION ALLERGIES:

 

 

 

 

PATIENT CAN PREPARE AND TAKE MEDS RELIABLY BY SELF: YES / NO

99

 

 

W (CIRCLE ABNORMALITIES AND EXPLAIN)
man: HEIGHT CHANGE. FATIGUE. FEVER/CHILLS. INSOMNIA
EXPLAIN:

 

 

fiEEflI: HEADACHES VISUAL CHANGES. CATARACT. GLAUCOMA. DIZZINESS. VERTIGO
GLASSES Y I N HEARING IMPAIRMENT: NONE SOME TOTAL. TINNITUS.

HEARING AID: Y / N DENTURES= Y / N U / L DRY MOUTH. EPISTAXIS
SWALLOWING NECK MASS. BRUIT. ADENOPATHY. THYROID ENLARGEMENT

EXPLAIN:

 

 

 

B§§£LBAIQEI: DYSPNEA. COUCH. WHEEZING. HEMOPTYSIS. SPUTUM
EXPLAIN:

 

 

HARDIQEA§§ELAB= CHEST PAIN. ORTHOPNEA. PND. CLAUDICATION. PALPITATIONS
ORTHOSTATIC HYPOTENSION, SOB. SYNCOPE. EDEMA: PEDAL SACRAL HANDS.
PHLEBITIS. HYPERTENSION

EXPLAIN:

 

 

EASIBQIEIE§IIEAL: DYSPHAGIA. ABDOMINAL PAIN. CONSTIPATION. DIARRHEA.
BLOOD IN STOOL. DYSPEPSIA. N/V. HEMORRHOIDS
BOWEL HABITS:

 

EXPLAIN:

 

 

100

m: APPETI'I'E: G F P
HEIGHT: GAIN / LOSS AHOUNT

 

24 HR DIET RECALL:
BREAKFAST LUNCH DINNER

 

 

 

SNACKS FLUID INTAKE OTHER

 

EHLAIN:

 

W: DYSURIA. NOCTURIA. POLYURIA. HEMATURIA. HESITANCY. STREAM.
STRAINING. FREQUENCY. URGENCY. VAGINAL BLEEDING. DISCHARGE

GRAVIDA _. PARA _. AB _. HYSTERECTOMY __L__L__
BREAST: MASS. DISCHARGE. RASH. ABNORMAL SHAPE/CONTOUR. SURGERY '
EXPLAIN:

 

 

INCONTINENCE: BLADDER I BOWEL STRESS / URGE / OVERFLOW / FUNCTIONAL
EXPLAIN:

 

 

W: STIFFNESS. JOINT PAIN. LIMITATION OF MOTION. DEFORMITY.
ATROPHY. MUSCLE PAIN. WEAKNESS. SWELLING. ROM. ARTHRITIS

JOINTS INVOLVED:
EXPLAIN:

 

 

MOVEMENT EQUIPMENT: CANE WALKER WHEELCHAIR SPECIAL BED CRUTCHES
EXPLAIN:

 

 

101

§K1§: RASH. ITCHING. DECUBITUS. LUMPS. DERMATITIS. PSORIASIS. BRUISING
EXPLAIN:

 

 

fiEflBQLQgIQAL: VERTIGO. SYNCOPE. DIZZY / LIGHTHEADED. TIA. SEIZURE.
APHASIA. APRAXIA. TREMOR. BLACK OUTS. AMNESIA. DIPLOPIA. MEMORY LOSS.
MOOD SWINGS. VISUAL DISTURBANCE. WEAKNESS. PARALYSIS. DEPRESSION.
DISRUPTIVE BEHAVIOR. WANDERING. MEMORY IMPAIRMENT. HALLUCINATIONS. ANXIETY
EXPLAIN:

 

 

NURSING DIAGNOSIS / RECOMMENDATIONS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

102

W
FAMILY MEMBERS .
NAME ADDRESS PHONE RELATIONSHIP

 

 

 

 

 

 

 

 

 

 

 

 

 

HOBBIES AND INTERESTS (INCLUDING OUTSIDE ACTIVITIES):

 

 

DAILY ROUTINE:

 

 

 

WHO DO YOU FEEL YOU ARE CLOSE TO AND HOW IS THAT DEMONSTRATED?

 

LIFE STRESSORS:

DEATH(S)
'CHANGES IN LIVING ARRANGEMENTS
CHANGES IN FINANCIAL STATUS
CHANGES IN HEALTH

 

 

 

 

 

COMMUNITY RESOURCES USED (AGENCY AND PHONE):

 

 

 

 

103

 

FINANCIAL SITUATION (IS MONEY A PROBLEM FOR YOU?)

 

 

LEGAL ISSUES - DPA. GUARDIANSHIP. CONSERVATOR (NAME AND ADDRESS):

 

 

LIVING WILL ISSUES (CODE STATUS):

 

 

DO YOU OWN OR OPERATE A AUTOMOBILE?

 

 

 

 

 

 

 

 

 

 

 

 

 

INCOME: MONTHLY EXPENSES:
SOCIAL SECURITY FOOD
SSI - HOUSING
PENSION HEATING
OTHER TRANSPORTATION
MEDICATION
OTHER

 

104

W

ADL SCALE Independent
1. Bathing Receives either no assistance or assistance in

bathing only one part of the body. Y / N
2. Dressing Gets clothes and dresses without any assistance

except for tying shoes. Y / N

'3. Toileting Goes to toilet room. uses toilet. arranges clothes.
and returns without any assistance. May use cane or walker

for support and may use bedpan/urinal at night. Y / N
4. 1133;13:1133 Moves in and out of bed and chair without

assistance. but may use cane or walker. Y / N
5. antingngg Controls bowel and bladder completely by self.

without occasional accidents. Y / N
6. tagging Feeds self without assistance. except for help with

cutting meat or buttering bread. Y / N
' SCORE 1 5

IADL SCALE
AhiliEz_ER_Ess_EslsnhRns .Lsnndrz
Operates phone on own initiative 1 Does personal laundry completely 1
Dials a few well-known numbers 1 Launders small items 1
Answers phone but does not dial 1 All laundry must be done by other 0
Does not use phone at all 0
§h9221n8 lkukLsuLjransngrzaEign
Takes care of all shopping needs 1 Travels independently or drives 1
Shops independently for small items 0 Travels via taxi. not public 1
Needs assistance for any shopping 0 Travels public when accompanied 1
Completely unable to shop 0 Travel limited taxi/car w assist 0
Does not travel at all 0
Plans. prepares. and serves on own 1 Takes correct dose on time 1
Prepares meals if supplied w items 0 Takes if prepared in advance 0
Prepares meals. but inadequate diet 0 Is not capable of dispensing meds 0
Needs to have meals prepared/served 0
OP WW.
Maintains house alone w occas asist 1 Manages financial matters independ 1
Performs light daily tasks 1 Manages purchases. needs help bank 1
Light daily tasks. but inadequate 1 Incapable of handling money 0
1
0

Needs help with all maintenance
Does not participate in hskeeping

SCORE ________4_§

105

MENTAL STATUS
FOLSTEIN

DATE
YEAR
MONTH
DAY
SEASON
HOSPITAL
FLOOR
TOWN/CITY
COUNTY
STATE
BALL
FLAG
TREE

OR
WORLD = DLROW
NUMBER PLACED CORRECTLY
BALL
FLAG
TREE
WATCH
PENCIL/PEN
NO IFS. ANDS. 0R BUTS.
TAKES IN RIGHT
FOLDS
PLACES ON FLOOR
CLOSE YOUR EYES
SENTENCE
DRAWS PENTAGONS

SCORE

(DGQOICDAUNH

106

POPOFF INDEX

1.

10.

11.

12.

13.

02130 (1100 0.03 0:130 (1390 00:13 0.530 {1200 09:1: 0320 {1300 COD! OCEO

. EVERYTHING IS AN EFFORT

I HAVE A LOT OF ENERGY

. MAYBE I’M JUST GETTING OLDER

I'VE GOT A LOT OF PEP
I TIRE EASILY
I’M TIRED ALL THE TIME

I’M IN'A RUT
THINGS ARE NOT GOING WELL
I’M PLEASED WITH THE WAY THINGS ARE GOING

I DON’T HAVE MUCH TO LOOK FORWARD TO
I LOOK FORWARD TO THE FUTURE
I GO ALONG AS BEST I CAN

I ENJOY GETTING UP IN THE MORNING
I PUSH MYSELF To GET GOING IN THE MORNING
I FIND IT HARD To FACE THE DAY

I DON’T FEEL RESTED AFTER SLEEPING
I’VE BEEN HAVING TROUBLE SLEEPING LATELY
I SLEEP FINE AND FEEL RESTED

I HAVEN'T BEEN EATING AS WELL LATELY
I ENJOY EATING
FOOD DOESN’T TASTE AS GOOD AS IT USED TO

SEX IS PLEASURABLE TO ME

. SOMETIMES I’M TOO TIRED FOR SEX

I’VE LOST SOME INTEREST IN SEX LATELY

FORCE MYSELF TO DO MY WORK
DON’T HAVE MUCH AMBITION
AM ABITIOUS

DON’T FEEL LIKE DOING MUCH LATELY
ENJOY DOING A LOT OF THINGS
DON’T GO OUT MUCH BECAUSE I AM TOO TIRED

HHH HHH

. THINGS ARE GOING GOOD

SOMETIMES EVERYTHING GOES WRONG
I CAN’T COPE WITH THINGS VERY WELL LATELY

I'D DO BETTER IF I FELT BETTER
SOMETIMES I CAN’T DO ANYTHING RIGHT
THINGS ARE RUNNING SMOOTHLY

I’M DEPRESSED
I'M HAPPY
I DON’T LET MYSELF GET DEPRESSED

107

14.

15.

OHIO COD:

0

I’M HAPPY WITH THE WAY I’M DOING THINGS
EVERYBODY FEEL THEY COULD DO BETTER
I’M NOT DOING THINGS AS WELL AS I USED TO

SOMETIMES I FEEL LIKE GIVING UP
I’M ENJOYING MY LIFE
I FIGHT IT WHEN I FEEL DISCOURAGED

 

 

108

 

S SS

1. How many rooms are available to the patient?

Own bedroom If shared. with whom?

Bathroom
Kitchen
Living/sitting room

3. Is the house clean? Y / N

Unwashed dishes?

Other:

 

 

 

6. Safety checklist

Can the patient?

2. Must patient use stairs in house? Y / N If yes. how many?
4. Does the house seem adequately?
Insulated Y / N
Ventilated? Y / N
Heated Y / N
5. Are there signs of neglect?
Old toad in the refrigerator? Y / N
Y / N
Accumulated dirty clothes? Y / N
Call for help with phone Y / N
Sately transfer all locations Y / N

Are there obvious dangers?
Overloaded electrical outlets
Poor lighting

Cluttered furniture

Frayed carpets or broken floors
Missing or broken smoke alarm

EXPLAIN:

t<NU*~<N
\\\\\
22222

 

 

109

 

APPENDIX B

DATA COLLECTION INSTRUMENT
A.

2) Sex

APPENDIX

Demographics 1) Age

3) Living Arrangement
a) Alone

b) With spouse
c) With relative

d) With other

 

 

8. Kat: Score
ADI. _
l3
IADL __
14
c. Folstein Score

 

 

D. Vision (00),,
E. Medical Diagnoses
1) Hypertension
. 20
2) can __
21
3) Arthritis __
22
4) DM _
23
5) Stroke __
24
6) 0090 _
25
?. Reversible problems

1) Polypharmacy

a) Abnormal values for one or more

1) DigOMLn
2) Dilantin
3) Theophylline

4) Thyroid

1) Parkinson's

8) 61 problems
9) ASHD
10) Sensory loss

11) Depression

12) Other (list out)

3‘? 5
E
3
36
II
""" ‘13
I? i?
I? IS 33
Yes No

 

 

 

 

110

ID

fl!
”1

N
0‘

2” SN 8!

UI

OI

2)

3)

4)

5)

APPENDIX B
Page 2

b) More than 4 medications prescribed
Yes No

if

c) Documentation OTC Yes No

'—

Malnutrition
a) Abnormal albumin level <3.S

b) Documentation of Malnutrition in Nursing Diagnosis

Inadequate Social Supports
a) Documented in Nursing or Medical Diagnosis

Unsafe Environment

a) History of falls

b) Documented in nursing or medical diagnosis
under environment

Vision
a) DOCumented problem if less than 20/50

111

 

 

 

 

 

 

ID _ _‘_ _
l 2 3 4
Yes No
Yes No
Yes no
Yes No

 

 

APPENDIX C

MICHIGAN STATE UNIVERSITY

 

OFFICE OF VICE man POI RESEARCH EAST LANSING 0 MICHIGAN 0 “814-10“
AND DEAN OF THE GRADUATE SCHOOL

March 6, 1992

Jean M. Thiele
1514 Bookness St.
Midland, MI 48640

RE: RELATIONSHIP BETWEEN FUNCTIONAL STATUS, MENTAL STATUS AND REVERSIBLE
PROBLEMS IN COMMUNITY DWELLING ELDERLY, IRB #92-057

Dear Ms. Thiele:

The above project is exempt from full UCRIHS review. The proposed research
protocol has been reviewed by another committee member. The rights and welfare
of human subjects appear to be protected and you have approval to conduct the

research.

You are reminded that UCRIHS approval is valid for one calendar year. If you
plan to continue this project beyond one year, please make provisions for
obtaining appropriate UCRIHS approval one month prior to March 5, 1993.

Any changes in procedures involving human subjects must be reviewed by UCRIHS
prior to initiation of the change. UCRIHS must also be notifed promptly of any
problems (unexpected side effects, complaints, etc.) involving human subjects
during the course of the work.

Thank you for bringing this project to my attention. If I can be of any future
help, please do not hesitate to let me know.

Sincerely,

1

David E. wright, .
University Committe- on Research lnvolvwng

Human Subjects (UCRIHS)

       

DEN/deo
cc: Dr. Rachel Schiffman

112

"III'LTIITIITTIIT