Functional Assessment in the Elderly

Functional assessment means measuring what the person actually does in daily life. In geriatrics, function is the common language and assessment is the core method.

In an older person, function predicts outcome better than diagnosis. There is no direct relationship between disease and functioning — the same illness produces very different disability in different people, so function must be measured separately.

Functional decline results from medical, functional, psychological, social and environmental risk factors acting together. Hence assessment must be multidimensional.

A baseline functional measure is essential so that progress can be monitored and the effect of treatment or rehabilitation judged. Reassess at least weekly during rehabilitation.

Three levels are assessed: impairment (the deficit) → activity restriction (ADL/IADL loss) → participation restriction (loss of social role). Participation restriction is unique to the individual and depends largely on the ability to adapt.

Mobility must always be tested — about half of people aged 85 and over report difficulty walking, and gait disorders threaten independence and cause falls.

The functional "review of systems" rests on three measures: frailty, basic ADLs, and IADLs.

Principle of hierarchy: if the patient is severely ADL-dependent, do not test frailty; if robust or pre-frail, do not test basic ADLs. Match the depth of assessment to the patient and the setting.

Basic ADLs (personal care): bathing, dressing, toileting, transferring, continence, feeding, grooming — Katz, Barthel, Lawton PSMS.

IADLs (tasks needing instruments): cooking, shopping, housework, laundry, telephone, transport, money, medicines — Lawton IADL, OARS.

IADLs are lost first, ADLs later, so IADL loss is the earlier warning sign. Always ask "how does she manage?"

Always record premorbid function as well as present function, especially after acute illness, a fall or hospital admission.

Mobility, gait and balance: gait speed (below 0.6 m/s abnormal; 0.6–0.8 high-risk), TUG above 12 seconds, Tinetti below 24 of 28, 30-second chair stand, 4-stage balance test, SPPB, Berg Balance Scale.

Two screens are mandatory in any older person with functional disability: cognition (MMSE) and depression (GDS or Zung).

Other essential domains: nutrition (MNA, SNAQ, weight loss), special senses (whispered voice test, Snellen), oral health (GOHAI), continence, and social network and support (Lubben Social Network Scale).

Also assess: pain, polypharmacy (Beers/STOPP-START), continence, sleep, alcohol (CAGE, SMAST-G), caregiver capacity, financial resources, and home environment.

Use both report and performance. Reports tell you what the person does under real living conditions; performance tests tell you what they can do under standard conditions.

Grade each task as: independent without difficulty / independent but with difficulty or an aid / needs human help / unable even with help. Distinguishing "independent with difficulty" adds prognostic value.

Perform a task analysis of the specific problem. Example: "difficulty dressing" may be due to choosing clothes, remembering to finish, buttoning, reaching overhead, or bending for shoes — pointing respectively to cognitive impairment, poor finger mobility, or shoulder, back or hip disease. Each demands a different treatment.

Correlate any new functional loss with new drugs or dose changes (including over-the-counter), changes in living conditions, and intercurrent acute illness (even mild). Remember the cascade — impaired gait leads to depression and withdrawal, and immobility of any cause produces deconditioning that persists after the cause is removed. Finally, link assessment to a plan: rehabilitation steps of assessment, goal setting, therapy, aids and adaptations, education, psychological support, evaluation and follow-up.

continence · drugs (including over-the-counter) · nutrition and weight change · mood and motivation · social support and caregiver capacity · housing and environment. Step 2 — Examination Postural blood pressure · vision and hearing screening · observation of gait · musculoskeletal (tone, power, joint range of motion, feet) · neurological (focal signs, sensation, proprioception) · skin over pressure areas · cognition (MMSE/MoCA) and mood (GDS). Step 3 — Performance testing Gait speed over 4 metres · Timed Up-and-Go · 30-second chair stand · 4-stage balance · grip strength · observed transfer and stair climbing. Step 4 — Baseline investigations Complete blood count, blood chemistry, serum calcium (mg/dL), sodium (mEq/L), creatinine (mg/dL), thyroid function, vitamin B12, 25-hydroxy vitamin D, haemoglobin (g/dL), fasting glucose or HbA1c, urinalysis. Step 5 — Formulate and act Identify reversible causes → treat disease and pain → deprescribe → refer to physiotherapy, occupational therapy, dietician and social work → prescribe aids and adaptations → set goals with the patient → arrange follow-up and case management.

WHO ICOPE and intrinsic capacity. The five-step pathway screens six domains — mobility, cognition, nutrition/vitality, vision, hearing and psychological well-being — and can be done by a professional or by self-assessment through the ICOPE Monitor app. Reference centiles for intrinsic capacity and real-world screening data were published in Nature Aging (2023, 2024).

German DGG S3 Guideline (2024) defines minimum requirements — six core dimensions in at least 15 minutes — the first guideline to set a floor standard for functional assessment in hospital.

Age-Friendly Health Systems "4Ms." What Matters, Medication, Mentation and Mobility. In an eight-hospital 2024 evaluation of 3,103 admissions, patients receiving all 4Ms had fewer 30-day emergency visits (16% vs 22%); Mobility generated the highest "act-on" rate (83%) of the four.

Gait speed as the single best marker. A 2025 longitudinal study found slow gait speed the best single predictor of incident ADL and IADL disability, outperforming both frailty and sarcopenia as constructs.

Italian CGA guideline (2024) — across 117 studies, CGA maintains functional activities and reduces hospitalisation, mortality, institutionalisation and delirium.

Oncology. ASCO 2023 requires geriatric assessment including physical function in all patients over 65 on systemic cancer therapy, using the Practical Geriatric Assessment.

Indian data. LASI wave-1 (31,464 adults aged 60 and above) found about 3% with severe ADL disability and about 6% with severe IADL disability, with 7.4% ADL dependency. Rural surveys show far higher figures — ADL disability 13.7% and IADL disability 38.7% in rural Goa — associated with sex, education, financial dependence, comorbidity, alcoholism and sensory impairment. Functional tools are being adapted for community health worker delivery under NPHCE.