Clinical Nurse Specialist:
Using Research to Advance Nursing Practice
Measuring Functional Status in Older Adults With Dementia
MAYO, ANN M. DNSc, RN
Section Editor(s): Buelow, Janice PhD, RN, Column Editor; Chamberlain, Barbara DNSc, APN, C, CCRN, WCC, Column Editor
Author Affiliations: Department of Physiological Nursing, University of California, San Francisco
Support for this work includes the John A. Hartford Foundation & Atlantic Philanthropies.
Corresponding author: Ann M. Mayo, DNSc, RN, 806 Vanitie Court, San Diego, CA 92109 (firstname.lastname@example.org; email@example.com).
Functional activities are paramount to preserving independence among older adults. Examples include maintaining one's finances, bathing, getting around, shopping, and preparing balanced meals. Functional decline can result in expensive direct and indirect care costs for patients, families, and healthcare organizations. Especially for persons with dementia, functional disability directly accounts for most of the care costs.1,2 Reported dementia prevalence rates range from 4.3% to 9.4% overall,3,4 doubling for every 5 years of age after age 60 years.5 For those older than 80 years, rates range from 12% to 40%.6,7 For those in nursing homes, rates are as high as 67%.8 Thus, clinical nurse specialists (CNSs) and the nurses they lead are encountering older adults with dementia in ever-increasing numbers.
FUNCTIONAL ABILITY AND DEMENTIA
Functional ability can be conceptualized as activities of daily living (ADLs) (eg, bathing and mobility) and as instrumental ADLs (IADLs) (eg, shopping and managing finances). Functional ability correlates with dementia pathology, and not surprisingly, patients with dementia show earlier deficits in IADLs than in ADLs.9-11 A number of studies have shown that functional ability can be directly affected by executive function (ie, ability to set goals, plan, and multitask),12,13 memory, and mental status.14-16 Findings from these studies, primarily conducted among adults without dementia and limited to discrete aspects of cognition such as concentration and attention, have been mixed.14,17 In other studies, functional ability has been found to be associated with global dementia severity (r = −0.48; P < .01).18 As this neurodegenerative disease progresses, functional ability declines. One group of investigators has suggested that functional status might be an indicator of dementia.19
ASSESSING FUNCTIONAL ACTIVITIES
Many professional nurses routinely and formally assess the functional activities (ADLs and IADLs) of their older adult patients. Accurately determining the functional ability of older adult patients, especially those with dementia, is critical in determining their care needs. Clinical nurse specialists can take the lead in forming an accurate assessment as well as educating other nurses in how to do so.
Assessing the IADL functional status of persons with dementia can be efficiently accomplished using the Functional Activities Questionnaire (FAQ). The instrument reflects more socially oriented independent ADLs like shopping rather than the less complicated ADLs like bathing.
The FAQ can be used in acute care, clinic, and home settings. The FAQ has only 10 items. It uses a 4-point ordinal rating scale (0 = normal or if does not do regularly, could do normally; 1 = has difficulty but does by self or if does not do regularly, would find difficult; 2 = requires assistance; 3 = dependent on others) and is completed by someone who knows the patient well (not the patient). A total score for each patient can be calculated from individual item scores.
The reliability of the FAQ is high. The reliability of the FAQ for measuring functional status has been determined by examining how items correlate among themselves (exceeds 0.80).20 Interrater reliability is also strong, ranging from 0.802 (physicians and nurses) to 0.97 (examining and reviewing neurologists) (P < .001),21 meaning that different professionals using the FAQ on the same patients would get very similar results. In practical terms, the FAQ is straightforward to administer and gives consistent results.
The FAQ also has strong validity. Pfeffer et al21 established that the FAQ has the ability to discriminate among different functional levels of patients (discriminate validity) and to predict neurological examination ratings as well as certain cognitive scores (predictive validity).20 Thus, knowing a patient's FAQ total score will give the nurse an idea of what the patient's neurological examination rating might be, in addition to the patient's Mini Mental Status Exam score. Conveniently for CNSs involved in research, the FAQ is valid for the bedside as well as for research.
The FAQ has been evaluated as consistently performing better than the Instrumental Activities of Daily Living (IADL) Scale (another widely used instrument) in regression analyses as a predictor of mental status and functional assessment.19 The FAQ was sensitive (85%) to identifying patients who had functional impairment and specific to identifying those who did not (81%) when the FAQ was compared with neurologists' diagnoses of functional impairment.20
Because it can be anticipated that functional ability in persons with dementia will decline over time, and because diminished functional ability is costly to families and healthcare organizations, a reliable and effective method of testing functional ability is an important nursing tool. The FAQ can be used by CNSs for such purposes as research, evidence-based practice projects, and, most importantly, the clinical assessment of their patients. The resulting clinical information can be used to provide for specific care needs, thereby promoting the safe and appropriate level of independence for persons with dementia.
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