Stuart Moore, a 79-year-old retired locksmith, comes to the ED with severe left hip pain. (This case is a composite based on my experience.) Four years ago Mr. Moore was diagnosed with prostate cancer, which was treated with radiation therapy (the cancer is currently in remission), and osteoarthritis; 18 months ago he was diagnosed with Alzheimer's disease. His regular medications are donepezil (Aricept) 10 mg orally once a day and acetaminophen (Tylenol) 650 mg orally every four to six hours as needed for pain, not to exceed 4 g per day; he also takes one multivitamin tablet daily. He and his wife have participated in a walking and weight-lifting program that they say has minimized his arthritis pain. But two weeks ago he fell in their home. "Now I have to hold onto the furniture or get my wife to help me, just to cross the room," he says, because of hip pain. And he hasn't been able to exercise at all. He rates his current pain as 8 on a 0-to-10 pain-rating scale, and adds, "Nothing helps." He's spent most of the past week in bed or in a chair; his wife says that his memory has worsened noticeably.
Mr. Moore's vital signs are normal, except for his blood pressure, which is 158/88 mmHg. His hemoglobin level and hematocrit are in the low-normal range; results of a complete blood count, comprehensive metabolic profile, and urinalysis are within normal limits. X-rays of his left hip are pending. His prostate-specific antigen level is elevated. He's alert and oriented to place and circumstances. A dose of morphine 4 mg iv lowers his pain level to 4, and he's admitted to a medical unit for further workup.
But the stress of transferring from the ED takes its toll. His hip pain is back up to 8, making him unable to stand up to void. He agrees to another dose of morphine (2 mg iv). His wife reports that recent inactivity and constant pain have affected his appetite and sleep, which are both poor. He says he feels extremely weak and wonders whether he'll be able to resume exercising. Once his pain is better managed, he falls asleep. The staff nurse, Melissa Brownlee, is concerned about his risk of functional decline and plans to perform a functional assessment when he awakens. (For more on the causes and prevalence of functional decline in older adults, and the value of screening, see Why Screen Hospitalized Older Adults for Functional Decline?1-13 page 64.)
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Web Video
Watch a video demonstrating the use and interpretation of the Hospital Admission Risk Profile at http://links.lww.com/A286.
A Closer Look
Get more information on why it's important for nurses to screen older patients for functional decline at hospital admission, as well as why the Hospital Admission Risk Profile is the right tool for the job.
Try This: The Hospital Admission Risk Profile
This is the tool in its original form. See page 67.
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THE HOSPITAL ADMISSION RISK PROFILE
Clinicians and researchers haven't agreed on how best to predict who is at greatest risk for functional decline. One method is the Hospital Admission Risk Profile (HARP), which was designed for screening older, medically ill patients at the time of hospital admission.14 It was developed as part of a larger multicenter study, the Hospital Outcomes Project for the Elderly (HOPE).15 Sager and colleagues, its developers, found that three variables predict functional decline in patients during and after hospitalization: older age, diminished cognitive function on admission, and reduced ability to perform independent activities of daily living (IADLs) at two weeks before admission.14
Administering the HARP. Accordingly, the HARP assesses patients in these three areas. Age is recorded. Cognition is assessed using the abbreviated 21-question Folstein Mini-Mental State Exam (MMSE), which consists of 10 orientation questions, three registration (immediate memory) items, five attention items, and three recall items. Preadmission function in seven IADLs-telephoning, cooking, shopping, using transportation, housekeeping, and managing medication and finances-is evaluated by asking whether each can be performed and if so, whether assistance is needed (the HARP's IADL assessment isn't based on a particular tool). The HARP uses IADL assessment because a loss of ability to perform IADLs usually precedes a loss of ability to perform activities of daily living (ADLs). Each area yields a subscore that correlates with a risk score; the three risk scores are then tallied to get the total score. (See The Hospital Admission Risk Profile, page 68.) Because the HARP was developed for use at hospital admission, reassessment during the same hospital stay generally isn't necessary.
The time it takes to complete the HARP hasn't been described. In my experience, it takes 10 to 15 minutes: IADLs can be assessed in about five minutes, either verbally or by using a written checklist; the cognitive screening generally takes five to 10 minutes. Some data from the admission examination may also be available. (To view the portion of the video in which nurses discuss assessment and care planning, go to http://links.lww.com/A287
ASSESSING MR. MOORE
When Mr. Moore awakens two hours later, he says that his pain level is down to 2. Ms. Brownlee tells him she wishes to begin the functional assessment; he asks whether his wife can help to answer the questions, and the nurse assures him she can.
To establish a baseline, Ms. Brownlee asks Mr. Moore about his ability to perform ADLs by using the Katz Index of Independence in Activities of Daily Living. He says that he can bathe, dress, use the toilet, remain continent, transfer, and feed himself without assistance. Ms. Brownlee also knows that Mr. Moore was mobile without the use of an assistive device until his fall two weeks ago.
IADLs. Next Ms. Brownlee asks Mr. Moore to think back to two weeks before admission, just before his fall, and describe his ability to perform each of the seven IADLs. She asks, "Do you use the telephone, and if so, do you have any difficulty making or receiving phone calls?" Mr. Moore says that he uses both a landline and a cell phone but has some trouble using the latter: "I have a hard time dialing because the numbers are too small, so my wife usually helps me." Although he rarely shops for groceries, he says, he sometimes takes the bus to the mall. Although his wife usually cooks for them, he can prepare his meals without her help. When the nurse asks whether he does any of the housework, his wife says, "He's always taken care of the car and the yard. But he hasn't been able to do anything since the pain started two weeks ago." She also says that for the past several months, she has "put out his pills every day because he was forgetting to take his medicine" and that since his Alzheimer's diagnosis 18 months ago, she's been handling their finances.
Cognition. Ms. Brownlee begins the cognitive assessment by asking several questions about Mr. Moore's orientation to time and place. She says, "Please tell me today's date, including the day of the week." Mr. Moore says, "I know we just talked about it, but I can't remember the exact date. I know it's November 2007. I don't know what day of the week it is." Ms. Brownlee continues, "Please tell me where we are-the name of this place and the floor we're on, and the city, state, and country." (There is disagreement among practitioners over whether patients should be asked which country they live in or which county, hence the discrepancy between this assessment and the discussion of the MMSE in the original Try This tool on page 68.) Mr. Moore replies, "I'm at the hospital, UCSF. We're in San Francisco, California; the United States." Asked again if he knows what floor he's on, Mr. Moore says, "No."
Next Ms. Brownlee assesses his immediate memory. She says, "I'm going to say three words. Please repeat them back to me and then try to remember them, because I'm going to ask you to repeat them again in a moment. Hat, ball, tree." Mr. Moore says: "Hat, ball, [horizontal ellipsis] I can't remember the last one." Ms. Brownlee again: "Hat, ball, tree." Mr. Moore repeats them. To assess attention, Ms. Brownlee asks Mr. Moore to spell the word world backwards. Mr. Moore answers, "D-R-O-L-W." To test recall, Ms. Brownlee asks Mr. Moore to recite the three words once more; again, he can't remember the last word.
SCORING AND INTERPRETATION
The HARP provides risk scores in the three categories of age, cognitive function, and IADL status, which are added to get the total score. Total score ranges and their meaning are as follows: 0 or 1, low risk of a loss of ability to perform ADLs; 2 or 3, intermediate risk; and 4 or 5, high risk. Using these scores, nurses can identify which patients are likely to benefit from targeted interventions such as inpatient physical and occupational therapy, care on a geriatrics unit, or discharge planning that includes restorative care.14
Mr. Moore, day 1. Mr. Moore's age, 79 years, correlates to a risk score of 1. His cognitive function subscore is 14 of 21, which correlates to a risk score of 1. (He scores 7 of 10 points on the orientation questions, missing the date, day, and floor number; 3 of 3 points on registration [for example, recall of three unrelated items]; 2 of 5 points on attention, misspelling world backwards; and 2 of 3 points on recall, forgetting the third word.) He can perform four of seven IADLs independently, which correlates to a risk score of 2. His total HARP score is 4, indicating that he's at high risk for functional decline during or after his hospitalization.
When Ms. Brownlee calls others on Mr. Moore's health care team to report her findings, she learns that Mr. Moore's bone scan results suggest bone metastasis in his left hip, although he's able to tolerate bearing some weight on standing. The entire team agrees to meet shortly to develop a plan of care. Because there's evidence of current functional decline, Ms. Brownlee requests orders for evaluation and treatment by the physical and occupational therapists. She schedules the appointment at a time when she'll be available to give Mr. Moore analgesia to facilitate his participation.
Mr. Moore, day 2. By the next morning orders have been given to start Mr. Moore on a pain regimen of controlled-release morphine (MS Contin) 30 mg orally twice daily and acetaminophen 650 mg orally every six hours as needed. He's also started on a bowel regimen to prevent constipation and encouraged to drink to prevent dehydration. He remains on self-imposed bed rest. Ms. Brownlee comes by and explains that physical and occupational therapists will be coming within the hour to assess him (she'll stay and observe) and that it's important to lower his pain level as much as possible. Mr. Moore rates his current pain as 6, but after he takes the controlled-release morphine, his score goes down to 2. The physical therapist will be assessing his mobility, including his ability to transfer from bed to chair and to walk, as well as his gait and balance; the occupational therapist will be evaluating his ability to perform ADLs such as feeding himself and using the bathroom.
COMMUNICATING THE RESULTS
Ms. Brownlee has notified Mr. Moore's health care team of his HARP results and has discussed interventions aimed at restoring his function with the physical and occupational therapists. She talks with Mr. Moore and his wife about the importance of his mobility and ability to independently perform ADLs while hospitalized. She posts Mr. Moore's daily activity plan in his room, which lists daily tasks such as transfers from bed to chair at mealtimes, and shows him where to check off each task as he accomplishes it. To prevent falls, Ms. Brownlee recommends nonskid footwear and reminds Mr. Moore to use the call light to alert the staff when he's getting out of bed. The activity plan details the assistance he'll need, as determined during his assessment by the physical and occupational therapists: moderate assistance from two people for bed-to-chair transfers and during ambulation with the walker. By posting this information in Mr. Moore's room, staff, family, and friends can be aware of these precautions. The activity plan will be updated daily by nursing and physical therapy staff as Mr. Moore progresses.
The plan of care also includes management of acute and chronic pain. Ms. Brownlee is concerned that Mr. Moore might develop delirium because of his preexisting dementia and the opiate just added to his drug regimen for pain management, and discusses this with the Moores. Ms. Moore says she'll spend the rest of the day and evening with her husband, helping to keep him oriented and encouraging him to use the walker and drink adequate fluids. She places photographs of family members near his bedside, as well as his reading glasses and a CD player with his favorite music.
Ms. Brownlee also discusses the plan of care with the nursing assistant assigned to Mr. Moore. The nursing assistant will make rounds every two hours to offer to help with using the bathroom and other out-of-bed activities and will alert the nurse if Mr. Moore appears to be in pain or confused, isn't eating or drinking, or is having difficulty with continence. Ms. Brownlee includes Mr. Moore's HARP score and daily activity plan in her nursing "handoff," noting the need for pain medication before physical and occupational therapy. She also shares this information during multidisciplinary rounds and, when discharge planning begins, with the case manager.
CHALLENGES AND DISCHARGE
If a care facility doesn't routinely and formally assess cognitive status and IADL function in its older patients, these must be added to assessment protocols, and staff must be taught how to administer and interpret the HARP. The tool's developers caution that although the HARP can identify patients at various risk levels for functional decline, it doesn't necessarily identify those "most likely to benefit from geriatric interventions."14 That said, the HARP score supplies additional data needed by patients and families to make decisions about goals of care.
The goal of assessment should be not only to gather information but also to accurately reflect the patient's optimal functioning. In some cases-for example, when a patient has pain, dyspnea, or fatigue-assessment might require additional time and might best be completed over several sessions. Knowledge of the normal changes associated with aging is essential, as is knowledge of the often atypical presentation of disease in older adults. For example, older adults who are depressed may not have typical symptoms such as sadness or withdrawal; rather, they might present with memory or attention deficits or increased somatic complaints.16
If possible, prepare the assessment environment ahead of time by reducing ambient noise, enhancing room light, and providing seating or positioning aids so that nurse and patient can easily make eye contact. Attention to sensory deficits is critical. If the patient routinely uses glasses or hearing aids, these should be available; page magnifiers or personal sound amplifiers may also prove useful. If the patient routinely uses or would benefit from using a walker or cane, these should be available; in some cases lifting equipment might be helpful. To ensure the patient's safety when testing gait and balance, have someone nearby to provide hands-on guarding or more extensive assistance if needed.
Hospital admission can be especially stressful for older adults, who may be facing not only an acute illness but also a potential move to an assisted-living facility or nursing home. They might be reluctant to disclose difficulties with ADLs or IADLs. Cognitive testing can cause frustration and anxiety if patients feel rushed or are unable to answer a question. It's important to explain that assessments are routine and that the goal is to provide the patient with the best possible care during hospitalization and after discharge.
Demographic considerations. The HARP instrument hasn't been tested except in the original development and validation study cohorts. Demographic data show that all participants in both cohorts were ages 70 and older; 63% in the developmental cohort and 62% in the validation cohort were female; and 80% in the developmental cohort and 75% in the validation cohort were white (no additional racial data were reported). But data are available regarding the impact of culture and sex on the assessment tools that the HARP incorporates (any of several IADL assessment tools and the abbreviated MMSE). (To view the portion of the video in which a nursing expert answers question on the HARP, go to http://links.lww.com/A288
Mr. Moore, day 4. By the afternoon of day 4, Mr. Moore is ready for discharge. He has participated in daily mobility and strengthening exercises. Although there is some improvement, he hasn't reached his prefall level of IADL performance. He feels more comfortable using a walker, and he can't climb stairs well enough to return home. But he can perform ADLs independently and moves around his hospital room on his own. His pain is well managed, and he's eating and sleeping better. He'll be discharged to an acute rehabilitation facility for physical therapy.
CONSIDER THIS
What is the evidence supporting the use of the HARP in clinical practice? The HARP was developed with a cohort of 448 medically ill patients ages 70 and older who were enrolled in the control arm of the HOPE clinical trial.14 The purpose of the development phase was to identify which risk factors were predictive of a loss of ability to perform ADLs during a medical illness requiring hospitalization. The analysis revealed that older age, cognitive impairment, and lower preadmission IADL scores each independently predicted new losses in the ability to perform ADLs. A risk-scoring system was created that categorized patients as at low, intermediate, or high risk for experiencing a new decrease in the ability to perform ADLs.
* Reliability has not been described.
* Validity. The HARP was validated with a separate cohort of 379 patients enrolled in the HOPE trial. The rates of decline in ADL performance at discharge were similar across groups in the two cohorts: 17% and 19% in the low-risk groups, 28% and 31% in the intermediate-risk groups, and 55% and 56% in the high-risk groups. Patients in the high-risk groups were three times more likely to lose ADL-related function than those in the low-risk groups; they were also more likely to be discharged to a nursing home. (For further details on the validity of the HARP, go to http://links.lww.com/A497
[white circle] Sensitivity and specificity have not been described.
It's important to note that only patients admitted with medical illnesses participated in the validation and development study. The tool hasn't been tested in patients admitted for surgery or with a terminal illness, those living in nursing homes before admission, or those admitted from an ICU. The developers caution that, without further testing, their findings aren't generalizable to populations different from the study sample.14 Despite this, I believe it would be reasonable to use the instrument to screen older adults admitted for surgery. Such patients may also be at increased risk for functional decline associated with surgery and complications, as well as related pain and pain management.
The HARP's developers have also proposed that it may prove useful in outpatient settings to identify patients who, if hospitalized, would be at risk for functional decline.
Why Screen Hospitalized Older Adults for Functional Decline?
The fast pace of hospital care, with its focus on diagnosis, treatment, and cure, can leave little room for attending to a patient's functional status-even though functional decline may be predictive of subsequent illness or injury,1 nursing home placement,2 and death.3, 4 Defined as "a deterioration in self-care skills"5 and usually assessed in terms of activities of daily living (ADLs) and independent activities of daily living (IADLs), functional decline can occur rapidly in hospitalized older adults. And it's common: a 1996 study found that 31% of 1,279 hospitalized older adults had less ADL ability at discharge than before admission.6 Three months after discharge, 40% of the surviving cohort had new ADL- or IADL-related disabilities. (For more information, see "Monitoring Functional Status in Hospitalized Older Adults," which describes the Katz Index of Independence in Activities of Daily Living, and "The Lawton Instrumental Activities of Daily Living Scale," April.)
Age-related changes in organ systems leave older adults especially vulnerable during hospitalization. Among the most important changes are those affecting the musculoskeletal and cardiovascular systems, such as decreased muscle and bone mass, increased total body fat, decreased stroke volume and cardiac output, and reduced aerobic capacity. When combined with limited mobility, these changes result in deconditioning, muscle atrophy and weakness, and orthostatic hypotension.7 Limited mobility during hospitalization is common in older adults; one 1991 study found that such patients were on strict bed rest (neither walking nor transferring from bed to chair was permitted) for 23% of the 3,500 patient-days studied.8 A 2004 study found a median hallway-ambulation time of just 5.5 minutes in 118 hospitalized older adults deemed able to walk; 73% didn't walk in the hallway at all during each three-hour observation period.9
The hospital environment, with its busy, cluttered hallways; raised beds; absence of orienting cues; and care scheduled according to staff needs, also contributes to functional decline.10 Side rails and restraints are often deployed to prevent falls, but their overuse can result in deconditioning and may actually increase a patient's risk of falling,10 as can bed rest orders,10 the use of indwelling urinary catheters,10 and polypharmacy.11 Other factors contributing to functional decline include reduced sensory input associated with immobilization and inadequate hydration and nutrition.7
The ability to perform ADLs tends to be unstable in this population, either improving or worsening during the period from two weeks before admission through discharge.12, 13 In one recent study of 45 hospitalized older adults, researchers collected data on patients' ability to perform ADLs two weeks before admission (baseline), on admission, and on day 4 of hospitalization.13 Interestingly, more patients had declined in the two-week preadmission period (n = 18) than in the first four days of hospitalization (n = 10). But those who suffered functional decline during hospitalization were more likely to die within three months of discharge, regardless of their baseline status. Most patients who had losses in ability to perform ADLs before admission recovered some-though not all-function during hospitalization. The researchers, noting that all participants were acutely ill, suggested that preadmission decline probably resulted from progression of their illnesses. But declines during hospitalization resulted not only from illness but also from hospital-related factors such as prolonged bed rest. The researchers concluded that while functional changes are common in this population, improvement is possible, suggesting the importance of timely intervention.
Watch It!!
Go to http://links.lww.com/A286 to watch a nurse use the Hospital Admission Risk Profile to screen for functional decline at the time of hospital admission and discuss how to administer the tool and interpret results. Then watch the health care team plan preventive strategies.
View this video in its entirety and then apply for CE credit at http://www.nursingcenter.com/AJNolderadults; click on the How to Try This series link. All videos are free and in a downloadable format (not streaming video) that requires Windows Media Player.
Online Resources
For more information on this and other geriatric assessment tools and best practices go to http://www.ConsultGeriRN.org-the clinical Web site of the Hartford Institute for Geriatric Nursing, New York University College of Nursing, and the Nurses Improving Care for Healthsystem Elders (NICHE) program. The site presents authoritative clinical products, resources, and continuing education opportunities that support individual nurses and practice settings.
Visit the Hartford Institute site, http://www.hartfordign.org, and the NICHE site, http://www.nicheprogram.org, for additional products and resources.
Go to http://www.nursingcenter.com/AJNolderadults and click on the How to Try This link to access all articles and videos in this series.
REFERENCES