Impairment Evaluation

Aka: Impairment Evaluation, Geriatric Functional Screening, Functional Decline in Older Adults

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II. Approach

  1. Determine third party requesting the evaluation
    1. Examples: Employer, insurer, judge, family
  2. Determine nature of the request
    1. Examples: Diagnosis, cause, treatment, work capacity, disposition
  3. Determine physician's role
    1. Examples: Second opinion, independent medical examiner, facilitator
  4. Identify specific medical Impairments (condition diagnoses)
    1. Diagnoses and severity
    2. Overall functional impact
  5. Characterize the Disability (Impairments precluding specific tasks)
    1. Time course (gradual or rapid)
    2. Associated symptoms
    3. Specific activities affected
    4. Compensatory measures

III. History

  1. Comorbidity
    1. Cardiopulmonary disease (e.g. CAD, CHF, COPD)
    2. Musculoskeletal Conditions (e.g. Rheumatoid Arthritis, Osteoarthritis, Spinal stenosis)
    3. Mood Disorders (e.g. Schizophrenia, Bipolar Disorder, Severe Major Depression)
    4. Cognitive disorders (e.g. Dementia)
    5. Neurologic conditions (e.g. Cerebrovascular Accident, Seizure Disorder)
    6. Endocrine conditions (e.g. Diabetes Mellitus)
    7. Hematologic conditions (e.g. Anemia)
  2. Sensory deficits
    1. Hearing Impairment
    2. Visual Impairment
  3. Cognitive and perceptual history
    1. Addiction
    2. Planning
    3. Conscientiousness, honesty and trustworthiness
    4. Interpersonal functioning
    5. Motivation and Reliability
    6. Pace, persistence and stress tolerance
    7. Mood
    8. Pain
  4. Activities of Daily Living (ADL)
    1. Katz ADL Scale
    2. Barthel Index
    3. Ambulation and Transfers
    4. Bathing and Toileting
    5. Dressing and Grooming
    6. Eating
      1. See Geriatric Nutrition Checklist
  5. Instrumental Activities of Daily Living (IADL)
    1. Shopping
    2. Transportation
    3. Telephone
    4. Managing money and medication
    5. Cleaning house
    6. Cooking
  6. Mobility
    1. Balance and coordination
    2. Strength and endurance
    3. Stair climbing
  7. Environment
    1. Home (Family factors and expectations)
      1. See Caregiver Burden Scale
    2. Work or School
    3. Community
  8. Resources
    1. Communication
    2. Vocational status
      1. Work training and experience
      2. Opportunities
    3. Financial status
    4. Educational status
    5. Recreational needs
    6. Transportation needs
    7. Community interaction
    8. Social support (e.g. family or friends in time of emergency)

IV. Examination

  1. Cognition and mental status
    1. See Mental Status Exam
    2. Time and Change Test
    3. Six Item Cognitive Impairment Test (6CIT)
    4. Blessed Orientation Memory Concentration (BOMC)
    5. Copland's Short-Test of Mental Status
    6. Short Test of Mental Status (STMS)
    7. Blessed Information Memory Concentration (BIMC)
    8. Saint Louis University Mental Status (SLUMS)
  2. Mood and Affect
    1. See Depression Screening Tools
    2. Patient Health Questionaire 9 (PHQ-9)
    3. Geriatric Depression Scale
  3. Sensory
    1. Vision
      1. See Vision Screening
      2. Near: Read newsprint or a child's book (11 to 12 point type)
      3. Far: Snellen Chart
    2. Hearing
      1. See Hearing Testing
      2. Whisper test
      3. Audioscope or Audiogram
    3. Special senses
      1. Proprioception
      2. Vibration sense
      3. Temperature sense
  4. Functional Range of Motion
    1. Shoulder Range of Motion
      1. Hands clasped behind head
      2. Hands clasped behind back
    2. Hip and knee raneg of motion
      1. Place ankle on opposite knee
    3. Back range of motion
      1. Touch toes while sitting
  5. Coordination, Gait and Balance
    1. Gentle nudge to Sternum (while patient is standing)
    2. Romberg Test
    3. Tinetti balance Test
    4. Gait evaluation Scale
  6. Motor Strength and Functional Testing
    1. Squeeze or grip two fingers
    2. Pinch paper
    3. "Get up and go" test (Mobility, agility, and aerobic capacity)
    4. Get up from floor
    5. Chair Stand Test (rise from chair without using arms)
    6. Climb stairs
    7. Pick Up A Penny from the floor
    8. Functional Independent Measure

V. Grading: Severity

  1. Asymptomatic
  2. Mild
  3. Moderate
  4. Severe
  5. End-Stage

VI. Management: Increase capacity

  1. See Disability Management
  2. Medication management
    1. Examples: Supplemental Oxygen for COPD
  3. Surgery
    1. Examples: Hip Replacement, Cataract replacement
  4. Nutrition
    1. Examples: Consider nutrition supplements
  5. Prosthetics
    1. Examples: Hearing Aid
  6. Exercise
    1. See Exercise Prescription
    2. See Exercise in Chronic Pain
    3. See Exercise in COPD
    4. See Exercise in Diabetes Mellitus
    5. See Exercise in Obesity
    6. See Exercise in Osteoporosis
    7. See Exercise in Patients with Arthritis
    8. See Exercise in the Elderly
    9. See Exercise Participation in Hypertensive Patients

VII. Management: Decrease Task Demand

  1. Environmental modification
    1. See No-fail Environment in Dementia
    2. See Home Adaptations for the Elderly
    3. See Fall Prevention
  2. Assistive Devices
    1. See Assistive Technology
    2. See Ambulatory Assistive Device
  3. Human Resources
    1. Home Health Aids
    2. Assisted Living
  4. Adaptive Training
    1. Energy conservation

VIII. References

  1. (1997) Can Med Assoc J 156:680A-C [PubMed]
  2. Barron (2001) Am Fam Physician 64(9): 1579-86 [PubMed]
  3. Colon-Emeric (2013) Am Fam Physician 88(6): 388-394 [PubMed]
  4. Derebry (1983) J Occup Med 25:829-35 [PubMed]
  5. McGrail (2001) Am Fam Physician 63(4):679-84 [PubMed]

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