A patient-completed screening instrument for functional disability in the elderly

Although multi-disciplinary geriatric assessment of elderly patients has been shown to be effective in identifying new diagnoses and previously unknown disabilities and in decreasing hospitalization and mortality, time and financial constraints prevent most internists and office practitioners from using this approach with their older patients. Several instruments to screen older persons for functional disability have been proposed, but there are limited data regarding their utility or effectiveness in clinical medicine. This study developed a short, patient-completed screening assessment instrument (the Functional Assessment Screen), compared it to a standard, multi-disciplinary geriatric evaluation, and determined the screening instrument's ability to predict future use of home care services in a group of elderly patients.

The screening instrument was piloted retrospectively using data from patients seen in the previous 2 years at a hospital-based geriatrics clinic in Wisconsin. Using these results, a revised instrument was developed and mailed to 80 consecutive new patients who presented to the clinic for multi-disciplinary geriatric assessment and primary care. These patients were interviewed 18 months later to determine use of home services, institutionalization, and death after the initial visit.

Fifty-eight of 80 eligible patients (72%) completed both the clinic evaluation and 18-month follow-up. The patients were an elderly (mean age of 76), frail (average of three medical diagnoses), functionally disabled group (dependent in an average of 3.7 instrumental activities of daily living and 2.7 activities of daily living). Nine of the 58 enrolled patients (15%) were institutionalized, five (9%) died, and 31 (53%) required new home services after 18 months. The screening variables were sensitive but less specific than clinic providers' judgment in identifying abnormalities in social, economic, or physical health status. The relative risk of eventual home service use was elevated in patients reporting poor health status (relative risk of 3.5, 95% confidence interval [CI] 9.9 to 1.2), and dependency in housework (relative risk of 3.0, 95% CI 5.1 to 1.7), shopping (relative risk of 2.6, 95% CI 4.7 to 1.5), meals (relative risk of 2.4, 95% CI 3.4 to 1.7), dressing (relative risk of 2.2, 95% CI 3.0 to 1.6), or bathing (relative risk of 2.2, 95% CI 3.2 to 1.5). Home services were used in 16% of patients with no positive responses to a subset of four of the screening questions; usage rose to 22% with one positive response, and to 89% (relative risk of 4.5, 95% CI 9.2 to 2.1) with two or more positive responses.

This screening instrument identified a group of elderly patients at much higher risk for increased home service use than other patients in a geriatrics clinic. If validated in other populations, such an instrument may identify frail, elderly patients in office practice at high risk for use of home services. These patients could be targeted for more complete multi-disciplinary geriatric assessment to identify and treat disease and disability responsible for increased service use and declining health.