Continence is a part of Activities of Daily Living. Fifteen percent to 30% of adults living in the community and almost 50% of nursing home residents are affected by urinary incontinence. The prevalence in older women is twice that of prevalence in older men. Pregnancy, childbirth, menopause, and the anatomy of a woman’s urinary tract are all factors that increase the likelihood of incontinence.
Despite the fact that incontinence is common in aging, it should never be considered a normal condition of aging. Various methods of managing and reducing incontinence have been developed, and many older persons have been assisted with incontinence so that the quality of their lives is not so greatly affected.
Because of embarrassment and worry about appearance and odor, an older person may not report incontinence unless asked directly. Incontinence can be isolating and has a major impact on quality of life. It also increases the risk of falls in older persons. Rushing to the bathroom to avoid urge incontinent episodes most likely increase the risk of falling, which then results in falls and fractures. The development of incontinence is often the final factor influencing family caregivers to institutionalize those they care for.
Assessing fall risk is a big part of assessing client mobility. Every year, approximately 30% of older persons living at home fall. In fact the Center for Disease Control says every year 1 in 3 older adults has a fall . Getting more information about where falls occur is vital. A practical mnemonic for reviewing the actual fall is as follows:
S ‑Symptoms experienced at the time of fall
P ‑Previous number of falls or near-falls
L ‑Location of falls
A ‑Activity engaged in or attempted at time of fall
T ‑Time (hour) of fall
T ‑Trauma (e.g., physical or psychological) associated with falls
Prevention of falls is of utmost importance because after a fall the fear of another fall can become a vicious cycle. Fear leads to inactivity that then results in decreased strength that then leads to increased risk of another fall.
Many falls by older persons occur in the bathroom, the most dangerous room in the house. Adaptations in the environment can decrease the risk. If your client is falling at night, ask about the use of sedating medications at bedtime. Or perhaps does the person fall because he or she ambulates slowly and needs to rush to answer the only phone in the home, which is located on the kitchen wall? Getting a portable telephone may decrease the risk of another fall. Was the person experiencing specific symptoms secondary to medical problems, for example, dizziness or postural hypotension? Reviewing these symptoms with the physician can result in treatment or change in medications that will reduce the risk of a repeat fall.
Changes in the environment, attention to adaptations, and medical evaluation will make it safer for a person with impaired mobility to get around the home. In addition, with the goal of improved mobility and balance, the care manager should think about the possibility of physical therapy for strength training, personal trainers who can come to the home or the assisted living facility to do light exercise, or even a membership at a local senior-friendly gym that offers tai chi classes, which are known to improve balance. In addition, for clients in nursing homes the care manager needs to advocate for needed therapies and medical evaluations to improve mobility and decrease falls.
One factor influencing ADL performance is mobility. Direct observation can identify problems in gait and balance. Early detection of deficits in mobility can identify those clients at risk of injury. Whenever possible, rehabilitation can then assist in restoring functional losses and reduce the risk of falls. For those deficits that cannot be rehabilitated, assistive equipment such as a cane or walker can be provided.
Immobility and inactivity can lead to the older person becoming chair- or bed-bound. These older persons often go on to develop edema, contractures, incontinence, or pressure sores. These complications place them at increased risk of falls and nursing home placement. It is important to inquire about recent falls and the circumstances under which they occurred and to test gait performance in all older adults. One tool, is the Tinetti Balance and Gait Evaluation tool . Those at high risk can be identified so that preventive measures can be taken as part of care planning. Factors increasing risk include confusion, incontinence, impaired mobility, generalized weakness, use of sedating medications and alcohol, postural hypotension, and history of previous falls.
To note the character of the gait it is best for the geriatric care manager to observe the person ambulating. Is the gait slow and shuffling or too fast and without concern for the environment? Note the person’s balance. Did the person need to grab onto the furniture to prevent a fall? Can he or she walk up the flight of steps to get to the bedroom or even up the two steps from the living room to the kitchen? Would a stair lift provide improved safety? It is important to observe footwear. Is the stylish older woman still wearing a shoe with a raised heel? Is the stylish older man still wearing a slip-on shoe that does not provide proper support? Recommending proper footwear can be the first step in preventing falls. Asking the person for a tour of the home is an excellent way to observe how he or she gets around and to make observations regarding home safety.
What about ambulating outside? Does the person need adaptive equipment outside because of uneven surfaces even if he or she is fine when ambulating on a smooth floor inside? Is the person able to get up the outside stairs? Are there railings to keep the person safe? Does the person need a ramp? Is the person cognitively intact enough to use a scooter for longer distances traveled in the nursing home? Does the person need a prescription for a wheelchair because he or she is unable to walk the long distance to the doctor’s office?
Today we are going to again cover activities of daily living. Why? Because I have been blogging about a geriatric assessment and we are now covering a functional assessment. This is the second part of a geriatric assessment, with the first part a psychosocial assessment, which you can review in former blogs.
The term Activities of Daily Living was coined in 1949 by Edith Buchwald in Physical Therapy Review
In 1950 Katz and colleagues came up with scale in Cleveland at Benjamin Rose Hospital and designed Katz scale
Designed 6 indexes
v Feeding- late loss
v Continence- late loss
v Transferring- late loss
v Toileting early loss
v Dressing –early loss
v Bathing – early loss
Today we are covering mobility
q As a geriatric care manager, you are looking for
q Ability to transfer
q Joint function
Early detection of mobility problems and assistive devices, rehab prevent falls
Ø Observation- watch him/her walk, get up out of chair, listen to talking for clarity cognitive problem (not making sense)
Ø Ask caregiver or family member to confirm if cognitively impaired
Ø Reframe question say “ Did you drive here” instead of “ Are you still driving?”
Ø 30% of older adults living at home fall each year- makes them at risk for nursing home placement
Ø Ask them to get you a drink of water (you can watch them get out of chair and walk)
Ø Observe the older person sitting balance, transfer from supine to sitting, and sit to chair sit to stand
Ø If in bed watch transfer from one surface to another
Ø Ask client if they have shoulder pain
Ø Ask them to lift and rotate each arm
Ø As the client to two of the GCM’s fingers – measure grasp
Ø Ask client to pick up small object like toothbrush, penny, and spoon- measuring dexterity
Ø 1-5 older adults have a gait disorder, which is an excellent reason to administer the activities of daily living test.
Ø More on this tomorrow