Author: Margaret (Meega) Wells, PhD, RN, NP
Nurse practitioners in the primary care setting in both rural and urban areas are in ideal positions to provide quality care to older adult patients to help them maintain independence and function. According to the U.S. Census Bureau (2010), it is estimated that 13% of the U.S. population is 65 years and older. Most of these older adults reside in the community and receive health care in outpatient settings. Older adult patients are often complicated to manage and nurse practitioners must be systematic and thorough in providing care to this group. A comprehensive geriatric assessment (CGA) should be performed once a year along with periodic focused assessments for the management of chronic illnesses. Ideally, performing a CGA on a regular basis will allow the nurse practitioner to detect subtle changes in older adults and intervene before major problems occur. Components of the comprehensive geriatric assessment should include medical, psychosocial, cognitive, and functional assessments. Assessing functional assessment of older adults using physical performance measures will be the focus of this article.
Functional Component
The functional assessment should include self-reported measures as well as an objective physical performance measure. First, it is necessary to ask patients if they have any difficulties with activities of daily living (ADL). ADL include eating, dressing, ambulating, and toileting. Next, patients should be asked about their ability to perform instrumental activities of daily living (IADL). IADL include shopping, managing finances, housekeeping, taking medications, using the telephone, and driving or using public transportation and this requires higher executive functioning. Inability to perform IAD is also associated with cognitive impairment. (Reppermund et al., 2011)
It is important that nurse practitioners watch their patients’ walk and this is often omitted from the geriatric assessment. Patients are usually put in the exam room and assisted to the exam table prior to the nurse practitioner’s arrival to the room. Nurse practitioners may not have the opportunity to observe patients walk unless they incorporate it into the physical exam. There are several physical performance measures that can be used to objectively measure physical function. Gait speed and Timed Up and Go (TUG) are two measures that will be discussed in this article and both of these measures include observation of gait.
In many cohort studies, gait speed, or the rate in which one walks, has been found to be associated with survival in older adults. (Cesari et al., 2005; Cesari et al., 2009; Ostir, Kuo, Berges, Markides, & Ottenbacher, 2007; Rolland et al., 2006; Rosano et al., 2008) Walking requires energy, movement control, and support, which put a demand on multiple organ systems, and this is why gait speed is thought to predict survival. (Abellan van Kan et al., 2009) Gait speed is usually calculated using time in seconds to walk 4 meters and is reported in meters per second. Gait speeds of 1 m/s or faster suggest healthier aging, while gait speeds of 0.6 m/s or slower increase the likelihood of poor health and function. (Viccaro, Perera, & Studenski, 2011)
In a systematic review of 9 cohort studies for a total of 34,485 community-dwelling older adults who had gait speed measured at baseline, and survival monitored for at least 5 years, the overall 5-year survival rate for participants was 84% and the 10-year survival rate was 59.7%. (Abellan van Kan et al., 2009) The mean gait speed of the participants was 0.92 meters per second (m/s) and it was associated with survival in all studies using hazard ratios. Survival increased as gait speed increased in 0.1 m/s increments.
Gait speed measurement has a place in the clinical setting because it may help identify older adults who have a high probability of living for 5 or 10 years and would benefit from more intensive preventative interventions. Further, gait speed may be used to help stratify risks of the patient for surgery or chemotherapy. Gait speed is relatively easy to measure and only requires a stopwatch and a 4-meter course. Patients are instructed to walk at usual pace, as if walking down the street, with no further encouragement or instructions. A gait speed less than 1 m/s or a declining gait speed over time may indicate a new health problem that requires evaluation. A physical therapy referral may be needed at this time. A recent systematic review of frail older adults found that an exercise intervention improved gait speed and performance on ADLs; however, the type of exercise was not specified nor was the effect on mortality. (Chou, Hwang, & Wu, 2012) Hardy and colleagues found that improved gait speed significantly reduced mortality in a sample of community-dwelling adults 65 years and older. (Hardy, Perera, Roumani, Chandler, & Studenski, 2007)
The TUG test can also be used to assess balance and gait. The TUG measures some aspects of balance such as rising, walking, turning, and sitting and is correlated with functional mobility. (Podsiadlo & Richardson, 1991) The TUG is quick, requires no special equipment, and can be done in about 1-2 minutes during an office visit. The TUG is the time it takes a patient to rise from a standard height chair with arms, walk 10 feet (3 meters), turn around, walk back to the chair and sit down. Patients may use their arms or an assistive device when rising from the chair; however, another person may not assist them. This screening test is timed and using assistive devices or the arms of the chair to rise may slow down the time it takes to complete the task. An independently mobile adult should be able to complete the TUG in less than 10 seconds. A TUG time of 15 seconds or greater requires further evaluation to determine the cause of the mobility impairment. If a musculoskeletal problem is found to be the problem, a referral to physical therapy may be appropriate.
Gait speed and TUG both were found to predict health decline, ADL difficulty, and falls in older adults living the community. (Viccaro et al., 2011) However, both tests were found to be more useful in predicting recurrent falls rather than first-time falls. (Viccaro et al., 2011)According to the Panel on Prevention of Falls in Older Persons, TUG is recommended to evaluate gait and balance in patients with a positive fall screen or those at risk for falling. (Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 2011) Evidence exists that supports using gait speed or the TUG to screen for mobility impairment; however, more research is needed is support interventions that can improve or maintain physical function.
Summary
It is essential that nurse practitioners perform a comprehensive geriatric assessment as least once a year on all older adult patients. The four components of this evaluation include medical, psychosocial, cognitive, and functional assessments. In the primary care setting, many nurse practitioners do not always objectively evaluate the physical functional ability of patients. Either gait speed or TUG can be used to measure functional ability in older adults. Both are easy to perform and do not require special equipment other than a chair, a measured distance, and a stopwatch. Both tests require patients to follow direction to carry out the task. The nurse practitioner can obtain much information from watching the patient perform these tasks. Maintaining independence is important to older adults and detecting subtle changes in functional ability can help nurse practitioners to manage the care older adult patients more effectively. The nurse practitioner should perform a comprehensive geriatric assessment that includes either gait speed or the TUG. If either is found to be slow or declined from the previous year, careful evaluation of the patient is needed and an intervention such as physical therapy or an individualized exercise program may be an appropriate addition to the treatment plan prescribed by the nurse practitioner.
References
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