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.

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.

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

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.

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

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 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.

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

* Reliability has not been described.

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?