Health Assessment

I. Objectives

After an hour of class discussion, the MAN students will be able to:
 Explain the concepts of nursing assessment for adults.
 Discuss the uses of the different assessment tools in the nursing practice.
 Apply the concepts in nursing assessment to an actual care situation.

II. Introduction
Assessment is a key component of nursing practice, required for planning and provision of
patient and family centered care.
The assessment not only requires physical data but an integration of biological, psychosocial,
and functional aspects of the person.

Aim
The aim of this is to ensure patients receive consistent and timely nursing assessments. It
specifically seeks to provide nurses with:

 Indications for assessment

 Approach to assessment
 Types of assessments

Types of Assessment:

 Biological assessment – biographic data, health history, personal habits, diet, sleep/rest
patterns, ADLs, IADLs, and recreation/hobbies
 Psychological assessment – major stressors, usual coping pattern, and communication style
 Social assessment – family relationships/friendships, ethnic affiliation, educational history,
occupational history, economic status, and home & neighborhood conditions

As assessment data are obtained, they need to be recorded to allow all members of the health
care team to easily access the information. The family physician can generate a problem list
that includes any condition or event requiring new or ongoing care; the medical, nutritional,
functional, and social implications; and proposed interventions. This type of assessment
allows older patients to benefit from an interdisciplinary team that is effectively assessing and
actively managing their health care.

III. Major Concepts

1. Assessment for General Health

•Nursing assessment of older adult takes longer because of the increased medical and social
complexities of older adults
•Initiation of health history marks the beginning of the nurse-patient relationship and the
assessment process.

Assessment of older adult requires special abilities of the nurse:

–Listen patiently
–Allow for pauses
 –Ask questions that are often not asked
–Observe minute details
–Obtain data from all available sources
–Recognize normal changes associated with late life that might be considered abnormal in
one who is younger

Culturally Sensitive Assessment

•Social organizations and expectations–Roles of family members and friends
•Communication style especially in health care setting
•Use of personal space and eye contact
•General health orientation related to time–Past, present, future
•Appropriate wording of greetings
•Appropriate use of names
•Appropriateness of touch, especially between genders

1.1 Physical Assessment

•Health history is usually followed by the physical assessment

•Manual techniques of the examination do not differ from those used with younger persons

IPPA

 Inspection - is the visual examination, that is , assessing by using the sense of sight.
It should be deliberate, purposeful, and systematic.

 Palpation - is the examination of the body using the sense of touch. It is used to
determine texture, temperature, vibration, position, size, consistency, and mobility of
organs and masses; distention, pulsation, and presence of pain upon pressure.

Types:
Light palpation- superficial
Deep palpation

 Percussion - the act of striking the body surface to elicit sounds that can be heard or
vibrations that can be felt.

Types:
Direct - use pads of two to three, or four fingers
Indirect - striking of an object (e.g. finger)

 Auscultation - is the process of listening to sounds produced within the body.

Types:
Direct - use of unaided ear
e.g. listen to respiration wheeze or grating of moving joint

Indirect - use of stethoscope which transmits sounds to the nurse’s ears.

e.g. Bowel sounds, valve sounds of the heart and BP
FANCAPES

It is an assessment model that can be used with the frail elderly. It uses a survival-needs
framework with an emphasis on functions.

The FANCAPES assessment tool should be used when there appears to be an actual problem
or something is wrong, but what exactly is wrong is unclear. Developed in acute care but
appropriate for long-term care, the FANCAPES acronym is as follows:

F-fluid
A-aeration
N-nutrition
C-cognition, communication
A-activity/abilities
P-pain
E-elimination
S-skin/socialization

Assessment does not conclude with simply stating the finding. Each finding or data bit has to
be followed up with key considerations for further investigation as discussed below.

Fluid: In addition to hydration assessment (orthostatic vital signs, appearance of mucous

membranes, and presence of dry skin), this is an opportunity to consider common vascular
system emergencies such as shock, acute coronary syndrome (ACS), and anemia.

Aeration: A respiratory rate (i.e., aeration) of 20 for at least 1 hour is indicative of probable
pneumonia. Even without the ability to listen to breath sounds (i.e., auscultation), what is
heard simply by standing close to the resident? Is he or she in pain and unable to take a deep
breath? Is breathing noisy? Moist?

Nutrition: Nutrition includes assessment of the oral cavity (e.g., for thrush, xerostomia), as
well as overall nutritional status.

Cognition (Delirium): Delirium can be life-threatening. Characteristically presenting as acute

confusion, the following delirium mnemonic can guide assessment:

D Drug use, recent intake of medications

E Electrolyte imbalance
L Lack of drugs, missed medications
I Infection
R Reduced sensory input (blindness, hearing impairment, or speech impairment)
I Intracranial problems (stroke, bleeding, meningitis, postictal state)
U Urinary retention and fecal impaction
M Myocardium problems

The signal criteria of delirium are acute onset and fluctuating course, inability to focus or
maintain attentiveness, disorganized thinking, and altered level of consciousness. The
Confusion Assessment Method (CAM) can specifically describe the observed changes and
guide communication of these changes to the physician or nurse practitioner.
 Activities: This is the domain of activities of daily living (ADLs) and changes in the older
adult’s ability to do self-care. It also includes any recent falls and 72-hour follow-up.

Pain: Chronic pain and the emergence of acute pain need to be described particularly with
regard to its effect on self-care and restriction of desired activity. Consistent use of an
accepted scale can help identify poorly controlled chronic pain or new onset acute pain.

Types of Pain Scales:

1. The pain Visual Analogue Scale is a unidimensional measure of pain intensity, which
has been widely used in diverse adult populations, including those with rheumatic
diseases.

Visual analogue
scale
No pain Worst pain imaginable

Numerical rating scale

No pain Worst imaginable pain

0 1 2 3 4 5 6 7 8 9 10

VAS can be presented in a number of ways, including:

 scales with a middle point,graduations or numbers (numerical rating scales),

 meter-shaped scales (curvilinear analogue scales),
 "box-scales" consisting of circles equidistant from each other (one of which the subject
has to mark), and
 scales with descriptive terms at intervals along a line (graphic rating scales or Likert
scales)

2. Verbal Descriptor Scale (Pain Thermometer)

Pain intensity rating scale recommended for use with all older adults, regardless of cognitive
ability. Often preferred by older adults, and demonstrated good psychometric properties in
older adults with considerable cognitive impairment. This scale requires either verbal ability
or the ability to point to the descriptor on the thermometer most closely representing their
pain.
This tool is formatted for use as a pocket-sized pain scale.
 Used with permission of Keela Herr, PhD, RN, FAAN, AGSF, The University of Iowa

3. Numeric Pain Rating Scale

The Numeric Pain Rating Scale (NPRS) is a segmented numeric version of the visual
analog scale (VAS) in which a respondent selects a whole number (0–10 integers) that
best reflects the intensity of his/her pain.

Response Options/Scale
 The 11-point numeric scale ranges from '0' representing one pain extreme (e.g. “no
pain”) to '10'
 Scores range from 0-10 points, with higher scores indicating greater pain intensity
Administration

The NPRS can be administered verbally (therefore also by telephone) or graphically for
self-completion.As mentioned above, the respondent is asked to indicate the numeric value
on the segmented scale that best describes their pain intensity.

Elimination: Assessment considers changes in continence and bowel pattern. Mental status
change, typically confusion, is associated with constipation. For new-onset abdominal pain, a
first consideration would be impaction or lack of movement of the intestinal wall, known as
an ileus. Appendicitis or an inflamed gall bladder must be considered as well.

Skin and Socialization: This domain covers a multitude of grave scenarios, from decubiti
and pressure ulcers to herpes zoster to suicide. It is alarming that suicidal ideation and
prodromata to suicide attempts are poorly recognized.

Physical Health
The geriatric assessment incorporates all facets of a conventional medical history, including
main problem, current illness, past and current medical problems, family and social history,
demographic data, and a review of systems. The approach to the history and physical
examination, however, should be specific to older persons.

Sample Focused Geriatric Physical Examination

PHYSICAL
SIGNS SIGN OR DIFFERENTIAL DIAGNOSES
SYMPTOM

Vital signs

Blood pressure Hypertension Adverse effects from medication, autonomic dysfunction

Orthostatic Adverse effects from medication, atherosclerosis,

hypotension coronary artery disease

Heart rate Bradycardia Adverse effects from medication, heart block

Irregularly Atrial fibrillation

irregular heart
rate

Respiratory Increased Chronic obstructive pulmonary disease, congestive heart

rate respiratory rate failure, pneumonia
greater than 24
breaths per
minute
 Temperature Hyperthermia, Hyper- and hypothyroidism, infection
hypothermia

General Unintentional Cancer, depression

weight loss

Weight gain Adverse effects from congestive heart failure medication

Head Asymmetric Bell palsy, stroke, transient ischemic attack

facial or
extraocular
muscle
weakness or
paralysis

Frontal bossing Paget disease

Temporal artery Temporal arteritis

tenderness

Eyes Eye pain Glaucoma, temporal arteritis

Impaired visual Presbyopia

acuity

Loss of central Age-related macular degeneration

vision

Loss of Glaucoma, stroke

peripheral
vision

Ocular lens Cataracts

opacification

Ears Hearing loss Acoustic neuroma, adverse effects from medication,

cerumen impaction, faulty or ill-fitting hearing aids, Paget
disease

Mouth, throat Gum or mouth Dental or periodontal disease, ill-fitting dentures

sores

Leukoplakia Cancerous and precancerous lesions

Xerostomia Age-related, Sjögren syndrome

 Neck Carotid bruits Aortic stenosis, cerebrovascular disease

Thyroid Hyper- and hypothyroidism

enlargement and
nodularity

Cardiac Fourth heart Left ventricular thickening

sound (S4)

Systolic Valvular arteriosclerosis

ejection,
regurgitant
murmurs

Pulmonary Barrel chest Emphysema

Shortness of Asthma, cardiomyopathy, chronic obstructive pulmonary

breath disease, congestive heart failure

Breasts Masses Cancer, fibroadenoma

Abdomen Pulsatile mass Aortic aneurysm

Gastrointestinal, Atrophy of the Estrogen deficiency

genital/rectal vaginal mucosa

Constipation Adverse effects from medication, colorectal cancer,

dehydration, hypothyroidism, inactivity, inadequate fiber
intake

Fecal Fecal impaction, rectal cancer, rectal prolapse

incontinence

Prostate Benign prostatic hypertrophy

enlargement

Prostate nodules Prostate cancer

Rectal mass, Colorectal cancer

occult blood

Urinary Bladder or uterine prolapse, detrusor instability, estrogen

incontinence deficiency

Extremities Abnormalities Bunions, onychomycosis

 of the feet

Diminished or Peripheral vascular disease, venous insufficiency

absent lower
extremity pulses

Heberden nodes Osteoarthritis

Pedal edema Adverse effects from medication, congestive heart failure

Muscular/skeletal Diminished Arthritis, fracture

range of motion,
pain

Dorsal kyphosis, Cancer, compression fracture, osteoporosis

vertebral
tenderness, back
pain

Gait Adverse effects from medication, arthritis, deconditioning,

disturbances foot abnormalities, Parkinson disease, stroke

Leg pain Intermittent claudication, neuropathy, osteoarthritis,

radiculopathy, venous insufficiency

Muscle wasting Atrophy, malnutrition

Proximal Polymyalgia rheumatica

muscle pain and
weakness

Skin Erythema, Anticoagulant use, elder abuse, idiopathic

ulceration over thrombocytopenic purpura
pressure points,
unexplained
bruises

Premalignant or Actinic keratoses, basal cell carcinoma, malignant

malignant melanoma, pressure ulcer, squamous cell carcinoma
lesions

Neurologic Tremor with Parkinson disease

rigidity

NOTE: When performing a geriatric physical examination, physicians should be alert for
some of these signs and symptoms.
II. Functional Assessment

•Evaluation of a person’s ability to carry out basic tasks for self-care and tasks needed to
support independent living

•Numerous tools are available that describe, screen, assess, monitor, and predict functional
ability

•Most of the tools result in a score of the person’s ability to do the task alone, the person’s
need for assistance, or the person’s inability to perform the task

2. Functional Ability
Functional status refers to a person's ability to perform tasks that are required for living. The
geriatric assessment begins with a review of the two key divisions of functional ability:
activities of daily living (ADL) and instrumental activities of daily living (IADL).

2.1 ADL are self-care activities that a person performs daily (e.g., eating, dressing, bathing,
transferring between the bed and a chair, using the toilet, controlling bladder and bowel
functions).

2.2 IADL are activities that are needed to live independently (e.g., doing housework, preparing
meals, taking medications properly, managing finances, using a telephone).

Physicians can acquire useful functional information by simply observing older patients as
they complete simple tasks, such as unbuttoning and buttoning a shirt, picking up a pen and
writing a sentence, taking off and putting on shoes, and climbing up and down from an
examination table.

Two instruments for assessing ADL and IADL include the Katz ADL scale (Table 1) and the
Lawton IADL scale (Table 2). Deficits in ADL and IADL can signal the need for more in-
depth evaluation of the patient's socio-environmental circumstances and the need for
additional assistance.

Katz Index of Independence in Activities of Daily Living

It is commonly referred to as the Katz ADL, is the most appropriate instrument to assess
functional status as a measurement of the client’s ability to perform activities of daily
living independently. Clinicians typically use the tool to detect problems in performing
activities of daily living and to plan care accordingly.

Table 1

Katz Index of Independence in Activities of Daily Living

ACTIVITIES
INDEPENDENCE
DEPENDENCE (0 POINTS) †
(1 POINT)*
(1 OR 0 POINTS)
Bathing Bathes self Needs help with bathing more than one part of the
completely body, getting in or out of the bathtub or shower;
or needs requires total bathing
Points:_____ help in
bathing only
a single part
of the body,
such as the
back, genital
area, or
disabled
extremity

Dressing Gets clothes Needs help with dressing self or needs to be

from closets completely dressed
and drawers,
Points:_____ and puts on
clothes and
outer
garments
complete
with
fasteners;
may need
help tying
shoes

Toileting Goes to Needs help transferring to the toilet and cleaning self,
toilet, gets or uses bedpan or commode
on and off,
Points:_____ arranges
clothes,
cleans
genital area
without help

Transferring Moves in Needs help in moving from bed to chair or requires a

and out of complete transfer
bed or chair
Points:_____ unassisted;
mechanical
transfer aids
are
acceptable

Fecal and urinary Exercises Is partially or totally incontinent of bowel or bladder

continence complete
self-control
over
Points:_____ urination
and
defecation
Feeding Gets food Needs partial or total help with feeding or requires
from plate parenteral feeding
into mouth
Points:_____ without
help;
preparation
of food may
be done by
another
person

Total points‡: _____

*—No supervision, direction, or personal assistance.

†—With supervision, direction, personal assistance, or total care.
‡—Score of 6 = high (patient is independent); score of 0 = low (patient is very
dependent).
Adapted with permission from Katz S, Downs TD, Cash HR, Grotz RC. Progress in
development of the index of ADL. Gerontologist. 1970;10(1):23.

Table 2

Lawton Instrumental Activities of Daily Living Scale (Self-Rated Version)

For each question, circle the points for the answer that best applies to your situation.

1. Can you use the telephone?

Without help 3

With some 2
help

Completely 1
unable to use
the telephone

2. Can you get to places that are out of walking distance?

Without help 3
 With some 2
help

Completely 1
unable to
travel unless
special
arrangements
are made

3. Can you go shopping for groceries?

Without help 3

With some 2
help

Completely 1
unable to do
any shopping

4. Can you prepare your own meals?

Without help 3

With some 2
help

Completely 1
unable to
prepare any
meals

5. Can you do your own housework?

Without help 3

With some 2
help

Completely 1
unable to do
any
 housework

6. Can you do your own handyman work?

Without help 3

With some 2
help

Completely 1
unable to do
any
handyman
work

7. Can you do your own laundry?

Without help 3

With some 2
help

Completely 1
unable to do
any laundry

8a. Do you use any medications?

Yes (If “yes,” 1

answer
question 8b)

No (If “no,” 2
answer
question 8c)

8b. Do you take your own medication?

Without help 3
(in the right
doses at the
right time)
 With some 2
help (take
medication if
someone
prepares it
for you or
reminds you
to take it)

Completely 1
unable to
take own
medication

8c. If you had to take medication, could you do it?

Without help 3
(in the right
doses at the
right time)

With some 2
help (take
medication if
someone
prepares it
for you or
reminds you
to take it)

Completely 1
unable to
take own
medication

9. Can you manage your own money?

Without help 3

With some 2
help

Completely 1
unable to
handle
money
 NOTE: Scores have meaning only for a particular patient (e.g., declining scores over time reveal
deterioration). Some questions may be sex-specific and can be modified by the interviewer.

Adapted with permission from Lawton MP, Brody EM. Assessment of older people: self-
maintaining and instrumental activities of daily living. Gerontologist. 1969;9(3):181.

INSTRUMENTAL ACTIVITIES OF DAILY LIVING SCALE (IADL)

M.P. Lawton & E.M. Brody

A. Ability to use telephone E. Laundry

1. Operates telephone on own initiative; 1 1. Does personal laundry completely 1

looks up and dials numbers, etc. 2. Launders small items; rinses stockings, etc. 1
2. Dials a few well-known numbers 1 3. All laundry must be done by others. 0
3. Answers telephone but does not dial 1
4. Does not use telephone at all. 0

B. Shopping F. Mode of Transportation

1. Takes care of all shopping needs 1 1. Travels independently on public 1

Independently transportation or drives own car.
2. Shops independently for small purchases 0 2. Arranges own travel via taxi, but does not 1
3. Needs to be accompanied on any shopping 0 otherwise use public transportation.
trip. 3. Travels on public transportation when 1
4. Completely unable to shop. 0 accompanied by another.
4. Travel limited to taxi or automobile with 0
C. Food Preparation assistance of another.
5. Does not travel at all. 0
1. Plans, prepares and serves adequate meals 1
Independently
2. Prepares adequate meals if supplied with 0 G. Responsibility for own medications
Ingredients
3. Heats, serves and prepares meals or prepares 0 1. Is responsible for taking medication in 1
meals but does not maintain adequate diet. correct dosages at correct time.
4. Needs to have meals prepared and 0 2. Takes responsibility if medication is 0
served. prepared in advance in separate dosage.
3. Is not capable of dispensing own 0
D. Housekeeping medication.

1. Maintains house alone or with occasional 1 H. Ability to Handle Finances

assistance (e.g. “heavy work domestic help”)
2. Performs light daily tasks such as dish- 1 1. Manages financial matters independently 1
washing, bed making (budgets, writes checks, pays rent, bills goes to
3. Performs light daily tasks but cannot 1 bank), collects and keeps track of income.
maintain acceptable level of cleanliness. 2. Manages day-to-day purchases, but needs 1
4. Needs help with all home maintenance tasks. 1 help with banking, major purchases, etc.
5. Does not participate in any housekeeping 0 3. Incapable if handling money. 0
tasks.

Source: Lawton, M.P., and Brody, E.M. “Assessment of older people: Self-maintaining and instrumental
activities of daily living.” Gerontologist 9:179-186, (1969).
Copyright (c) The Gerontological Society of America. Used by permission of the Publisher.
3. Functional Performance Test

BALANCE AND FALL PREVENTION

Impaired balance in older persons often manifests as falls and fall-related injuries.
Approximately one-third of community-living older persons fall at least once per year, with
many falling multiple times. Falls are the leading cause of hospitalization and injury-related
death in persons 75 years and older.

3.1 The Tinetti Balance and Gait Evaluation is a useful tool to assess a patient's fall risk. This
test involves observing as a patient gets up from a chair without using his or her arms, walks
10 ft, turns around, walks back, and returns to a seated position. This entire process should
take less than 16 seconds. Those patients who have difficulty performing this test have an
increased risk of falling and need further evaluation.

Older persons can decrease their fall risk with exercise, physical therapy, a home hazard
assessment, and withdrawal of psychotropic medications. Guidelines addressing fall
prevention in older persons living in nursing homes have been published by the American
Medical Directors Association and the American Geriatrics Society.

3.2 Get Up and Go Test

The “Get Up and Go Test” is an assessment that should be conducted as part of a

routine evaluation when dealing with older persons. Its purpose is to detect “fallers”
and to identify those who need evaluation.

The staff should be trained to perform the “Get Up and Go Test” at check-in and query
those with gait or balance problems for falls.

INITIAL CHECK

All older persons who report a single fall should be observed as they:

• From a sitting position, stand without using their arms for support.
• Walk10 feet, turn, and return to the chair.
• Sit back in the chair without using their arms for support.

Individuals who have difficulty completing the above in less than 10 seconds or
demonstrate unsteadiness performing this test require further assessment.

FOLLOW-UP ASSESSMENT

In the follow-up assessment, ask the person to:

• Sit.
• Stand without using their arms for support.
• Close their eyes for a few seconds, while standing in place.
• Stand with eyes closed, while you push gently on his or her sternum.
• Walk a short distance and come to a complete stop.
• Turn around and return to the chair.
 • Sit in the chair without using their arms for support.

When conducting the test, pay attention to any abnormal movements. As you observe,
answer the questions below. Record your assessment in the Yes or No boxes provided
and/or on the “Falls Evaluation: Initial Visit” form.

Follow-Up Assessment Observations

• Is the person steady and balanced when sitting upright? Yes No

• Is the person able to stand with the arms folded? Yes No

• When standing, is the person steady in narrow stance? Yes No

• With eyes closed, does the person remain steady? Yes No

• When nudged, does the person recover without difficulty? Yes No

• Does person start walking without hesitancy? Yes No

• When walking, does each foot clear the floor well? Yes No

• Is there step symmetry, with the steps equal length and regular? Yes No

• Does the person take continuous, regular steps? Yes No

• Does the person walk straight without a walking aid? Yes No

• Does the person stand with heels close together? Yes No

• Is the person able to sit safely and judge distance correctly? Yes No

• Is the person obviously fearful or anxious during assessment? Yes No

Table 1: Mobility & Functional Assessment Tools

TOOL DESCRIPTION STRENGTH LIMITATION
Berg 14-item scale designed to Easy measure Not practical in acute
Balance assess balance and risk of administered in 15-20 (needs
Scale falling of older people in minutes equipment)
the community
Good community 20 minutes to administer,
predictor of falls
not practical in acute

Found to have high Limited to balance

sensitivity for predicting Limited to specific
falls patients, not generic

Ability to identify risk for Does not include measure

falling and used to identify of gait
change in risk following Despite high intra-class
rehabilitation correlation coefficient,
absolute reliability showed
High inter-rater and intra- change of 8 points is
rater reliability required to show change
in function among older
Age-related normative people who are dependent
 values established in activities of daily living
Tested across community, (ADLs)
acute, post-acute,
residential care settings

de Morton 15 hierarchical mobility Simple, quick and easy to New tool (published in
Mobility Index challenges score and administer by August 2008) – limited
(DEMMI) clinician observation interdisciplinary
awareness
No special/expensive
equipment required A one-dimensional
measure of ‘mobility’ so
Can be administered at the other tools required to
patient’s bedside or in a measure other domains.
community setting.

Developed based on the

Rasch model and therefore
provides interval level
data

Overcomes limitations of
existing instruments such
as ceiling and floor
Effects

Extensive clinimetric
evaluation – Rasch,
reliability, validity,
responsiveness to change
and minimally clinically
important difference
(MCID)
Modified 7 item test of motor Quick and easy to Functional Reach
Elderly function of elderly administer component only practical
Mobility patients with a spread of in clinical setting
Scale functional levels Valid and reliable
(MEMS) Needs controlled
Experience of environment and stairs
physiotherapist scoring
patient does not greatly No self-care component
impact reliability of
scoring Needs to be administered
soon after admission
Concurrent validity when
compared to FIM Rural/regional areas may
(Functional Independence find difficult as do not
Measure) have allied health staff
seven days
High inter-rater and test-
retest reliability for each Still reliable but less so for
item and total score, patients of a low
regardless of experience functional
of rater level, but this may be due
to video scoring method
during trial
Timed Up & Assessment of dynamic Quick and easy to Need a chair at the right
Go Test balance and mobility skills administer in less than 3 height
for older people mins.
Difficult for patients with
Can be used across dementia, Parkinsons,
different settings visual impairments
 Suits bedside Only provides information
on a few aspects of
Reliability and validity balance
with community dwelling
older adults Scores do not have depth
of information to
Normative values discriminate between the
established in Steffen et various sources of
al. (2002) and Hill et al. impairment
(1999)
Unable to administer if
High inter and intra-rater person unable to
reliability and sensitivity transfer/mobilise without
and specificity assistance
Tinetti Assessment Tool: Test measuring gait and Simple and easily Not often used in clinical
Balance balance administered in setting
10-15 minutes
No gait or self-care
Shorter than some other components
balance tests
Requires therapist
Good inter-rater reliability interpretation

Not sensitive enough to

pick up some function
changes

Lengthy Validity not

reported
Barthel 15 ADL items; Assesses Widely used in geriatric Community rehabilitation
Index self-care and mobility settings /sub-acute setting focused
activities of daily living
Administered in 5-10 Does not take cognition
minutes into account

Easy and quick to learn May give broad brush

picture, as its ability to
Multidisciplinary reflect change in function
limited by a floor effect
Good snap shot of and lack of sensitivity to
inpatient function and change
covers personal care,
mobility and self-care

Reliability, validity and

overall utility are rated as
good to excellent

Compares favourably with

other ADL scales
Functional Independence 18 items Measures Widely used in general May not be translatable to
Measure (FIM) and functional status of people rehabilitation settings acute 5 hour training
Functional Assessment in rehabilitation required for administration
Measure (FAM) Administration by an with annual refresher
Reflects what person trained assessor of any training (costly)
usually does rather discipline
than what he/she can do Users need to be certified
Includes cognition,
language, continence Cost required for
use/accreditation
Can be used as a
 benchmark Limited focus on physical
health (skin integrity,
Acceptable reliability for nutrition, medical
assessing conditions, pain etc)

ADLs for adults across a

wide variety of settings,
raters and patients

More reliable in detecting

functional change in
inpatient setting
Performance Orientated 18 item mobility Quantitative assessment of Some items appear
Mobility Assessment assessment, usually in the balance and gait subjective
evaluation of fall risk or
falls. Can be performed at the Not well known
bedside in about 5 minutes
Mobility Assessment only,
no functional assessment
Components

Lengthy

4. Mental Status Assessment (Cognition and Mental Health)

The main areas considered in a psychological examination are intellectual health and
emotional health. Assessment of cognitive function, checking for hallucinations and
delusions, measuring concentration levels, and inquiring into the client's hobbies and interests
constitute an intellectual health assessment. Emotional health is assessed by observing and
inquiring about how the client feels and what he does in response to these feelings.
The psychological examination may also include the client's perceptions (why they think they
are being assessed or have been referred, what they hope to gain from the meeting). Religion
and beliefs are also important areas to consider. The need for a physical health assessment is
always included in any psychological examination to rule out structural damage or anomalies.
4.1 Mini-Mental State Examination (MMSE)

-Also called as Folstein test is a 30-point questionnaire that is used extensively in clinical and
research settings to measure cognitive impairment.

Instructions for administration and scoring of the MMSE

Orientation (10 points):
• Ask for the date. Then specifically ask for parts omitted (e.g., "Can you also tell me
what season it is?"). One point for each correct answer.
• Ask in turn, "Can you tell me the name of this hospital (town, county, etc.)?" One
point for each correct answer.

Registration (3 points):
• Say the names of three unrelated objects clearly and slowly, allowing approximately one
second for each. After you have said all three, ask the patient to repeat them. The number
of objects the patient names correctly upon the first repetition determines the score (0-3).
If the patient does not repeat all three objects the first time, continue saying the names
until the patient is able to repeat all three items, up to six trials. Record the number of
trials it takes for the patient to learn the words. If the patient does not eventually learn all
three, recall cannot be meaningfully tested.
• After completing this task, tell the patient, "Try to remember the words, as I will ask
for them in a little while."
Attention and Calculation (5 points):
• Ask the patient to begin with 100 and count backward by sevens. Stop after five
subtractions (93, 86, 79, 72, 65). Score the total number of correct answers.
• If the patient cannot or will not perform the subtraction task, ask the patient to spell the
word "world" backwards. The score is the number of letters in correct order (e.g.,
dlrow=5, dlorw=3).

Recall (3 points):
• Ask the patient if he or she can recall the three words you previously asked
him or her to remember. Score the total number of correct answers (0-3).

Language and Praxis (9 points):

• Naming: Show the patient a wrist watch and ask the patient what it is. Repeat with a
pencil. Score one point for each correct naming (0-2).
• Repetition: Ask the patient to repeat the sentence after you ("No ifs, ands, or buts.").
Allow only one trial. Score 0 or 1.
• 3-Stage Command: Give the patient a piece of blank paper and say, "Take this paper in
your right hand, fold it in half, and put it on the floor." Score one point for each part of
the command correctly executed.
• Reading: On a blank piece of paper print the sentence, "Close your eyes," in letters
large enough for the patient to see clearly. Ask the patient to read the sentence and do
what it says. Score one point only if the patient actually closes his or her eyes. This is
not a test of memory, so you may prompt the patient to "do what it says" after the
patient reads the sentence.
• Writing: Give the patient a blank piece of paper and ask him or her to write a sentence
for you. Do not dictate a sentence; it should be written spontaneously. The sentence
must contain a subject and a verb and make sense. Correct grammar and punctuation are
not necessary.
• Copying: Show the patient the picture of two intersecting pentagons and ask the patient to
copy the figure exactly as it is. All ten angles must be present and two must intersect to
score one point. Ignore tremor and rotation.

Interpretation of the MMSE

Method Score Interpretation

Single Cutoff <24 Abnormal

<21 Increased odds of dementia

Range
>25 Decreased odds of dementia
 21 Abnormal for 8th grade education

Education <23 Abnormal for high school education

<24 Abnormal for college education

24-30 No cognitive impairment

Severity 18-23 Mild cognitive impairment

0-17 Severe cognitive impairment

4.2 Clock Drawing Test

A clock drawing test (CDT) is a neurological test used for the assessment of cognitive
impairment based on sketches of a clock completed by a patient. Usually, a medical
expert assesses the sketches to discover any deficiencies in the cognitive processes of
the patient. More recently, automatic tools for assessing such tests have been
developed. However, the problem of automatic interpretation of clock drawings,
especially those sketched by people with cognitive impairment, is not fully solved, and
in more difficult cases, the automatic systems have to revert to the help of human
assessors in labelling the sketched objects forming the clock drawing. Moreover, the
labelling of the sketched objects could be more reliable if prior knowledge of the
expected CDT sketch structure and human reasoning could be integrated into the
drawing interpretation system.

4.3 Mini-Cog Test

It is a simple diagnostic test that can be carried out by an individual. It can be used if
you are concerned about mild cognitive impairment, dementia, or Alzheimer's.
However, if the results are suspicious, the test should be replicated by a physician or
doctor specialist.

Mini-Cognitive Assessment Instrument

There are three parts to the test.

Step 1. Ask the patient to repeat three unrelated words, such as “ball,” “dog,” and
“window.”

Step 2. Ask the patient to draw a simple clock set to 10 minutes after eleven o'clock
(11:10). A correct response is drawing of a circle with the numbers placed in
approximately the correct positions, with the hands pointing to the 11 and 2.
 Step 3. Ask the patient to recall the three words from Step 1. One point is given for
each item that is recalled correctly

Interpretation

NUMBER OF
CLOCK
ITEMS INTERPRETATION OF SCREEN FOR
DRAWING TEST
CORRECTLY DEMENTIA
RESULT
RECALLED

0 Normal Positive

0 Abnormal Positive

1 Normal Negative

1 Abnormal Positive

2 Normal Negative

2 Abnormal Positive

3 Normal Negative

3 Abnormal Negative

Adapted with permission from Ebell MH. Brief screening instruments for dementia in primary care.
Am Fam Physician. 2009;79(6):500, with additional information from reference 47.

DEPRESSION
-is a common and serious medical illness that negatively affects how you feel, the way you
think and how you act. Fortunately, it is treatable. It causes of feelings of sadness and/or a
loss of interest in activities once enjoyed.

Depression Tool

Geriatric Depression Scale (GDS)

 The Geriatric Depression Scale (GDS) is a self-report measure of depression in older

adults. Users respond in a “Yes/No” format.
  The GDS was originally developed as a 30-item instrument. Since this version proved
both time-consuming and difficult for some patients to complete, a 15-item version
was developed.
 The shortened form is comprised of 15 items chosen from the Geriatric Depression
Scale-Long Form (GDS-L). These 15 items were chosen because of their high
correlation with depressive symptoms in previous validation studies (Sheikh &
Yesavage, 1986).
 Of the 15 items, 10 indicate the presence of depression when answered positively
while the other 5 are indicative of depression when answered negatively. This form
can be completed in approximately 5 to 7 minutes, making it ideal for people who are
easily fatigued or are limited in their ability to concentrate for longer periods of time.

Geriatric Depression Scale (short form)

Instructions: Circle the answer that best describes how you felt
over the past week.

1. Are you basically satisfied with your life? yes no

2. Have you dropped many of your activities and

interests? yes no

3. Do you feel that your life is empty? yes no

4. Do you often get bored? yes no

5. Are you in good spirits most of the time? yes no

6. Are you afraid that something bad is going to

happen to you? yes no

7. Do you feel happy most of the time? yes no

8. Do you often feel helpless? yes no

9. Do you prefer to stay at home, rather than going

out and doing things? yes no

10. Do you feel that you have more problems with

memory than most? yes no

11. Do you think it is wonderful to be alive now? yes no

12. Do you feel worthless the way you are now? yes no

13. Do you feel full of energy? yes no

14. Do you feel that your situation is hopeless? yes no

 15. Do you think that most people are better off
than you are? yes no

Total Score

1 Tools may be copied without permission

Geriatric Depression Scale (GDS)

Scoring Instructions
Instructions: Score 1 point for each bolded answer. A score of 5 or more

1. Are you basically satisfied with your life? yes no

2. Have you dropped many of your activities and

interests? yes no

3. Do you feel that your life is empty? yes no

4. Do you often get bored? yes no

5. Are you in good spirits most of the time? yes no

6. Are you afraid that something bad is going to

happen to you? yes no

7. Do you feel happy most of the time? yes no

8. Do you often feel helpless? yes no

9. Do you prefer to stay at home, rather than going

out and doing things? yes no

10. Do you feel that you have more problems with

memory than most? yes no

11. Do you think it is wonderful to be alive now? yes no

12. Do you feel worthless the way you are now? yes no

13. Do you feel full of energy? yes no

14. Do you feel that your situation is hopeless? yes no

15. Do you think that most people are better off than
you are? yes no

A score of > 5 suggests depression Total Score

suggests depression.

Ref. Yes average: The use of Rating Depression Series in the Elderly, in Poon (ed.): Clinical

Memory Assessment of Older Adults, American Psychological Association, 1986

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