ASSESSMENT OF THE OLDER PERSON

______________________

A Report Submitted to
DR. SARAH BERNADETTE L. BALEÑA
San Pedro College Graduate School, Davao City
______________________

In Partial Fulfillment
of the Requirements for
NSG 509 ADVANCE ADULT HEALTH NURSING

By

Mae D. Lobaton
 ASSESSMENT OF THE OLDER PERSON

INTRODUCTION

Acute and chronic issues that compound to negatively impact function are common among older adults
seeking healthcare services. Functional decline, loss of independence, and the need for institutional
care are frequent pathways. It should be noted that this procedure is not always inevitable or
irreversible. Interventions that may stop or slow the decline can result from early identification of
functional issues.

Many age-related physiological and metabolic changes, the rise in chronic illnesses with possible
psychiatric manifestations, the side effects of accompanying drugs, and the age-related variations in
the presentation of prevalent mental health issues and disorders make assessing older persons
extremely difficult. Because of the significant interactions that older persons have, a biopsychosocial
approach to evaluation is very crucial.

By considering the biological, psychological and social aspect of an older person’s functioning, a
comprehensive assessment allows for a holistic understanding of their needs and challenges. This
knowledge, in turn, enables the development of individualized care plans and interventions that
effectively address the older person’s functional limitations and promote overall well-being. A term
often used in relation to the assessment of older people with medical needs is comprehensive geriatric
assessment (CGA). This approach is designed to accommodate the multidisciplinary approach that is
so important in the care of the older person in any setting, and the role of nursing assessment within
this is central to planning effective interventions to resolve nursing-focused problems.
What is an assessment of functional status and why does it matter?

Naturally, decline in function itself is linked to higher mortality because it may be a manifestation of
otherwise hidden pathologies. Constipation and other relatively minor insults (like drug changes) can
cause a significant decline in function. Systematic reviews have demonstrated that interventions
based on thorough geriatric assessments can enhance physical function and lower the number of
older adults admitted to hospitals and care facilities. The identification and description of functional
issues is the first step in this process; this is not just a geriatrician's job; it should be a routine task for
all health professionals. It is rare for patients to recognize their own functional decline, and
assessments brought on by "crisis" are still frequently conducted.

The health history

The health history marks the beginning of the nurse-patient relationship in the assessment process. It
is the subjective report of health and is collected through the completion of a form by the patient
in advance of the health care contact, through a face-to-face interview, or, most often, in a combination
of the two. The data needed for the health history include demographic information, a past
medical history, current medications and dietary supplements(prescribed, over-the-counter, “home
remedies,” and herbals), social and functional histories, and finally the review of systems. The health
history in an older adult will take longer because of both the high number of concurrent illnesses and
the unknown etiologies of some of these.

Review of systems (ROS)

The review of systems (ROS) is often conducted immediately before or during a physical exam. In a
younger adult it is likely to be quick and limited to the system involved with the symptom at hand.
However, as one ages and collects health problems, this review becomes more complex and time
consuming because one system affects another. The ROS may be more aptly referred to as a “review
of symptoms,” which becomes the focus of the assessment. When there are no particular presenting
symptoms, the ROS begins with the areas where problems are most likely to be problematic simply
attributable to the normal changes with aging or the health problems most often encountered in the
country, race, ethnicity, or socioeconomic class of the patient.
Functional assessment

A functional assessment is a comprehensive evaluation of the physical and cognitive abilities

required to maintain independence. Other aspects of the functional assessment include the
individual’s ability to negotiate physical and social environments. The functional assessment helps
the gerontological nurse work with the individual to move toward healthy aging by accomplishing
the following:

• Identifying the specific areas in which help is needed or not needed

• Identifying changes in abilities from one time to another
• Providing information that may be useful in assessing the safety of a particular living situation.

Evidence-based instruments are available to screen, describe, monitor, and predict an individual’s
ability to perform the activities or tasks needed for daily living. On most tools the activities are
considered mutually exclusive and the scoring is arbitrary.

Two Levels of Functional Assessment

1. Basic Activities of Daily Living (BADLs)

The BADLs are the day-to-day functions related to personal needs or tasks that patients need to be
able to complete on their own, or have assistance to complete, in order to be able to live in their own
residences such as bathing, dressing, toileting, eating, transferring, continence and grooming. Two
of these tasks (dressing [including grooming] and bathing) require higher cognitive function than the
others. The ability to feed oneself, in at least some rudimentary manner, remains intact until late in
dementia, assuming other health problems do not interfere, such as a dominant-side stroke.

ASSESSMENT TOOLS:

1.1 Katz index.

Activities of daily living (ADLs) were first classified as such by Sidney Katz and colleagues
in 1963 (Katz et al, 1963). The Katz index has served as a basic framework for most of the
subsequent measures. On the Katz index the ADLs are considered only in dichotomous
terms: the ability to complete the task independently (1 point) or the complete inability to do
so (0 points). With equal weight on all activities, this index cannot be used to identify the
particular areas of need and cannot show change in any one task. Over the years this
instrument has been refined to afford more sensitivity to the nuances of, and changes in,
functional status (Nikula et al, 2003).

1.2 Barthel index (BI).

 The Barthel index (BI) (Mahoney and Barthel, 1965; Wade and Collin, 1988) is a quick and
reliable instrument for the assessment of both mobility and the ability to perform ADLs. It
can be completed in 2 to 3 minutes using self-report or in about 20 minutes when direct
observation is necessary. The items are rated in various ways, depending on the item. The BI
has been found to be sensitive enough to identify when a person first needs help and to
measure progress or decline, especially following a stroke (Quinn et al, 2011).

1.3 Functional independence measure (FIM).

The functional independence measure (FIM) was designed to assess a person’s need for
assistance with ADLs during inpatient stays and for discharge planning, especially following
a stroke (Cournan, 2011). In some studies the BI and FIM were found to be comparable
(Sangha et al, 2005). In others the FIM was deemed preferable (Kidd et al, 1995). The FIM is
a highly sensitive functional assessment tool and includes measures of ADLs, mobility,
cognition, and social functioning. The tasks are rated using a seven-point scale from totally
independent to totally dependent. Although it is commonly used in acute rehabilitation and
veterans administration hospitals in the United States and several other countries, it cannot
yet be applied across all countries (Lundgren-Nilsson et al, 2005; Ottenbacher et al, 1996)

1.4 FAST

FAST (functional assessment staging tool) is unique in that it is descriptive in nature and
specific to the functional changes seen and anticipated in persons with a progressive dementia
such as Alzheimer’s disease. It was designed by geriatrician Barry Reisberg (1988) to assist
clinicians to identify the level (stage) of ability and, in doing so, help the family know what
to expect and how to prepare for the changes ahead. It uses an ordinal scale from stage 1 (no
functional impairment associated with any cognitive impairment) to 7 (unable to perform any
ADLs associated with very severe [late stage] cognitive impairment). It has been found to be
a reliable and valid instrument for the evaluation and staging of functional decline in persons
with Alzheimer’s disease (Sclan and Reisberg, 1992).

2. Instrumental activities of daily living (IADLs)

These are the basic daily activities needed to live independently in the community. This does not
mean that the person performs the tasks, just that he or she could perform them if called upon to do
so. It is generally agreed that the ability to perform IADLs requires higher cognitive and physical
functioning than do the ADLs.

Assessment tool:

2.1 The Lawton IADL scale

The original Lawton IADL scale rated the IADLs from zero (lowest functioning) to eight
(highest functioning) (Lawton and Brody, 1969). The level of functioning is determined by a
summary score. It may be useful as a screening tool to establish an overall baseline of general
functioning, but like the Katz index, it is not sensitive to changes in any one area. The
original tool and the subsequent iterations take about 15 minutes to administer using self-
report, proxy, or observation. Persons with dementia will progressively lose the ability to
perform IADLs beginning with those associated with the highest neuropsychological
functioning, such as handling finances and shopping.
 DOMAINS OF COMPREHENSIVE GERIATRIC ASSESSMENT

1.Biological Assessment

This includes evaluating the person’s overall health and physical functioning. It involves assessing
factors such as medical history, chronic conditions, medical use, sensory impairments (e.g., vision
and hearing, mobility limitations, strength, balance, and nutritional status. Assessments may involve
medical professionals, such as physicians, physiotherapist and nutritionists, and may include medical
tests, physical examinations, and objective measurements.

1.1 Medication Review

Increasing numbers of prescribed medications correlate with frailty, falls and hospital
admissions, and substantial numbers of older people’s admissions to hospital are caused by or
related to their medications.

Medication review is, put simply, a process by which a patient’s use of medication is
carefully reviewed to ensure that each medication taken is used appropriately, optimally, and
that its benefits outweigh its harms. It is a key part of a comprehensive geriatric assessment.
Polypharmacy is a term commonly used in this context though it simply means the patient is
on many medications (typically a cut-off of 4 or 5 is accepted as a threshold suggesting
increased risk of interactions and complications). Polypharmacy and inappropriate
prescribing (IP) are well-known risk factors for ADRs, which commonly cause adverse
clinical outcomes in older people (Onder G, 2013)]. IP encompasses potentially inappropriate
medications (PIMs) and potential prescribing omissions (PPOs) (O'Connor, 2012). One
patient may be taking only 3 medications, all of which are unnecessary or detrimental, while
another may be taking 10, completely appropriate medications at optimal doses with
evidence-based indications.

1.2 Frailty Syndromes

‘Frailty’ is theoretically defined as a clinically recognizable state of increased vulnerability

resulting from aging-associated decline in reserve and function across multiple physiologic
systems that the ability to cope with every day or acute stressors is comprised. In the absence
of gold standard, frailty has been operationally defines by Fried et al. reported a clinical
definition of frailty based on the presence of three or more frailty indicators: unintentional
weight loss, slow walking speed, subjective exhaustion, low grip strength and low levels of
physical activity. Frailty, based on these criteria, was predictive of poor outcome including
institutionalization and death .

MODELS OF FRAILTY

2.1.1 Phenotypic frailty, comprising three or more cardinal features of weight loss, self-
reported exhaustion, weak grip, slow gait, and low physical activity, independently predicts
adverse outcomes and death in persons over the age of 65 . This establishes frailty as
recognizable clinical entity, but without accounting for other factors that increase risk of
adverse outcomes, such as dementia . Approximating biological age obliges a graded, rather
than binary, method of measuring frailty; for the frailty phenotype, six grades are possible
(i.e., no to all five features being present). More commonly, however, two distinctions are
made in addition to being frail: “robust” (no features) and “pre-frail” (one or two features).

2.1.2 The deficit accumulation model of frailty reflects that at any age, as a person
accumulates health deficits, they become more likely to experience a range of adverse
outcomes, including death . Interestingly, these health deficits can be signs, symptoms,
laboratory markers, disease states, or functional impairments, so long as they are associated
with health, increase with age, are not ubiquitous, and cover a range of physiologic systems.
The ratio of deficits present to deficits assessed is a frailty index (FI), ranging anywhere from
0 (no deficits present) to, in theory, 1 (all deficits present), allowing frailty to be graded

2.1 Falls/Gait Disturbance

More than one-third of community-dwelling older persons fall each year, and falls are
independently associated with functional decline. Also, patients who have fallen are at
high risk for falling again and having resulting injuries. Because older persons frequently
attribute falls to normal aging, it is very important to ask older patients if they have fallen in
the last year, at their initial visit and at least annually. The use of a pre-visit questionnaire can
help elicit this information efficiently. Tests of gait, balance, and functional reach help
to assess patients’ risk of falling. Underlying balance and gait disorders can best be
detected by observing patients walking and performing balance maneuvers. To save
time, this evaluation can be performed while the patient is entering or leaving the
examining room. Several additional simple tests of balance and mobility can also be
performed quickly, including the ability to maintain a side-by-side, semi-tandem, and
full-tandem stance for 10 seconds each; resistance to a nudge; and stability during a 360-
degree turn. One Underlying balance and gait disorders can best be detected by observing
patients walking and performing balance maneuvers can assess quadriceps strength by
observing an older person arising from a hard armless chair without the use of his or her
hands. Slow gait speed is also a helpful marker for recurrent falls as well as reduced survival.
Patients whose gait speed exceeds 0.8 m per second are likely to live beyond the median
life expectancy for age and sex, whereas those whose gait speed is<0.8 m per second are
likely to have shorter survival. The timed ‘‘up and go’’ test is a measure of the
patient’s ability to rise from an arm chair, walk 3 m (10 feet), turn, walk back, and sit
down again; those who take longer than 20 seconds to complete the test should receive
further evaluation as well. For patients who have tested positive for falls, a structured visit
note can be used at follow-up visits. Physicians should then inquire about the
circumstances of the fall. Patients with recurrent falls or falls with any injury should receive a
more detailed evaluation, including assessment of all medications, gait and balance,
orthostatic blood pressure readings, and vision testing.

2.2 Hearing Impairment

Hearing impairment affects up to one-third of persons aged >65 years. Independently, it is

associated with reduced cognitive and physical function, and reduced social involvement. It
is also often under-recognized and therefore undertreated, and again often not self-reported
by patients. There are several methods to help screen for hearing loss. One simple
method for a busy practitioner is simply to rely on the patient’s own subjective
report of hearing loss. This involves asking patients whether they feel they have
hearing impairment. An affirmative answer is considered a positive test for hearing loss, and
patients should be referred to an audiologist. Another alternative is the whisper voice test,
administered by whispering 3 to 6 random words at a set distance from the patient’s
ear and then asking the patient to repeat the words. Patients fail the screening if they are
unable to repeat half of the words correctly. This should be done out of the patient’s sight
line to prevent lip reading, and the other ear should be covered. The most accurate office
test is the AudioScope 3(Welch Allyn, Inc., Skaneateles Falls, NY), a handheld otoscope
with a built-in audiometer. It should be set at 40 dB to evaluate hearing loss in older persons.
A pre tone at 60 dB should be delivered, with 4subsequent tones (500, 1000, 2000, and
4000 Hz), all at 40 dB. If patients cannot hear the 1000 or 2000 Hzin both ears or
both in one ear, they then need more formal audiometric testing.

2.3 Visual Impairment

Visual impairment is a common sensory deficit in the older population; all 4 major eye
diseases (cataracts, macular degeneration, diabetic retinopathy, and glaucoma) increase in
prevalence with age. Most older persons have presbyopia and require corrective lenses.
Visual deficiencies are also independently associated with increased risk of falling,
functional decline, and depression. The Snellen eye chart is standard method of screening
for visual impairment. This requires the patient to stand 20 feet from the chart and read
letters, using corrective lenses. Patients fail the screening if they are unable to read all of the
letters on the 20/40line with their eyeglasses on, and should then be referred for further
evaluation by an ophthalmologist. Given the high prevalence of eye diseases in the older
population and the potential for adverse health consequences of impaired vision, a visit
with an optometrist or ophthalmologist is recommended every 1 or 2 years by the American
Academy of Ophthalmology and the American Optometric Association.

2.4 Urinary Incontinence

Urinary incontinence is under-reported as well, often due to patients’ embarrassment or

belief that incontinence is a normal part of aging. In fact, it is a very common problem
in both older men and women, and can have deleterious effects on their lives, including
urinary tract infections, sleep disruption with subsequent falls, and pressure ulcers. It is also
a marker for higher mortality in older adults. There are many treatment options available,
including behavioral, pharmacologic, and surgical. Therefore, a good continence assessment
should be an essential component for any older people admitted to hospital to ensure good-
quality person-centered care, promoting independent living. Assessment of precipitating
factors and identification of treatable, potentially reversible conditions are essential steps.
Continence problems can be secondary to drug side effects, constipation, impaired mobility,
arthritic pain, inappropriate clothing or dexterity.

2.2 Bone Health Assessment

The most common bone problems found in older people are osteoporosis and vitamin D
deficiency, which are typically clinically silent. Other diseases may present, such as Paget’s
disease of the bone, osteomalacia (clinically evident vitamin D deficiency), and
hyperparathyroidism. Bone pain or hypercalcaemia raises the suspicion of fractures, bony
metastases or primary malignancy of the bone. Because of increased bone loss after the
 menopause in women, and age-related bone loss in both women and men, the prevalence of
osteoporosis increases markedly with age, from 2% at 50 years to more than 25% at 80 years
in women. The comprehensive assessment of an older person with regard to bone health
should include: History: previous fractures, bony pain, loss of height or change of posture,
weight loss, diet, alcohol and smoking history, current level of exercise and approximate
exposure to sunlight, current or previous use of glucocorticoids, family history of fracture or
osteoporosis and age at menopause. Examination on height, weight and posture, evidence of
arthritis and muscle strength.

2.3 Nutritional Assessment

The term ‘‘malnutrition’’ has been used to refer to a wide spectrum of deficiencies
(eg, protein-energy, vitamins) and excesses (eg, obesity, hypervitaminosis)that place
older persons at risk for other health conditions, functional decline, and death. Nutritional
disorders are very common in older persons, the most common one being obesity (body mass
index>30 kg/m2) in community- older persons. Obesity is associated with functional
decline and more comorbidities, such as type 2 diabetes mellitus and osteoarthritis. Weight
loss has commonly been used to define undernutrition and also predicts increased mortality.
Although weight loss may be voluntary, any weight loss in an older person raises concern
for underlying illnesses (eg, malignancy, depression) or social/functional barriers(poverty,
inability to shop or prepare meals).

2. Psychological Assessment

The main health problems affecting older people in this domain are cognitive impairment, depression
and delirium. Although these are different health issues, their symptoms overlap and may present
simultaneously (Baquero and Martín, 2015; Fong et al, 2015); this complicates diagnosis and the
choice of treatment. Careful assessment is key to reach the correct diagnosis, provide appropriate
treatment and understand the patient’s care needs. Successful ageing is contingent upon three
elements : avoiding disease and disability, sustaining high cognitive and physical function, and
engaging with life (Rowe JW, 1997). Because of their coexisting physical conditions, older adults
are significantly more likely to seek and accept services in primary care versus specialty mental
health care settings (IOM, 2012). GPs are often the first and only mental healthcare contact that older
people actively seek (AIHW, 2002 ).

The factors that affect mental health and mental illness occur in biological, psychological and social
domains (Engel G, 1980). Older adults who have experienced a lifetime of chronic or relapsing
mental illness have special needs. These people are often uniquely disabled by a combination of
personal, social, mental and physical health disadvantage (Jolley D, 2004).

2.1 Cognitive Decline

Cognition is easily threatened by any disturbance in health or homeostasis. Altered mental

status, including reduced cognitive abilities, may be the first sign of anything from a heart
attack to a reversible condition such as a urinary tract infection. In a comprehensive
assessment, baseline measures of cognition are obtained.
Assessment Tools for Cognitive Decline:

1.1 Mini-mental state examination (MMSE)

For many years the MMSE has been the mainstay for the gross screening of cognitive status
(Folstein et al, 1975; Mitchell, 2009). It is a 30-item instrument that is used to screen for and
monitor orientation, short-term memory and attention, calculation ability, language, and
construction (Wattmo et al, 2011).

1.2 Clock drawing test

The Clock Drawing Test, in use since 1992, is reported to be used second most often as the
MMSE across the world (Aprahamian et al, 2010; Ehreke et al, 2010). It is not appropriate
for use with those who are blind or who have limiting conditions such as tremors, or a stroke
that affects their dominant hand. While reading fluency is not necessary, completion of the
Clock Test requires number fluency, the ability to hear and see, manual dexterity adequate to
hold a pencil, and experience with analog clocks. Scoring is based on the position of both the
numbers and the hands. This tool cannot be used as the sole measure for dementia, but it does
test for constructional apraxia, an early indicator (Shulman, 2000) (The Clock Test is an
evidence-based instrument that has been found to be useful across cultures and languages
(Borson et al, 1999).

1.3 Mini-Cog
In some settings the use of the Mini-Cog has replaced the MMSE as a screening tool for
cognitive impairment (Borson et al, 2000). It has been found to be as accurate and reliable as
the MMSE but less biased, easier to administer, and possibly more sensitive to dementia
(Mitchell and Malladi, 2010). The Mini-Cog combines the test of short- term memory in the
original MMSE with the Clock Test. It has been found to be equally reliable with English-
speaking and non– English-speaking individuals (Borson et al, 2003). It takes 3 to 5 minutes
to administer and like the other screening tools discussed in this chapter, only serves as an
indicator of the need for more detailed assessments leading to diagnosis. It requires number
fluency and the ability to hear and see, hold a pencil, and have experience with analog clocks.

2.2 Delirium

Delirium is an acute confusional state, usually with a fluctuating course, characterized by

disturbed consciousness, cognitive function or perception (NICE CG103, 2010)

The Confusion Assessment Method (CAM) is widely used to screen for the presence of
delirium ((Inouye SK, 1990) ( Wong CL, 2010).

The only instrument available for family screening for delirium, the Family Confusion
Assessment Method (FAM-CAM), was developed by Inouye and colleagues to screen for
delirium by interviewing family caregivers (Inouye SK, 1996) (inouye SK, 1999). Derived
from the original 10-item CAM instrument, the FAM-CAM was adapted to maximize
detection of delirium (i.e., acute onset and fluctuating course, inattention, disorganized
thinking, altered level of consciousness, disorientation, perceptual disturbances, and
psychomotor agitation) from the observations of family caregivers. While relatively
uncommon in delirium, “inappropriate behavior” and perceptual disturbances such as
hallucinations were included in the FAM-CAM to maximize sensitivity and specificity.
 2.1 Dementia

Dementia is a progressive and largely irreversible clinical syndrome that is characterized by a

widespread impairment of mental function. Although many people with dementia retain
positive personality traits and personal attributes, as their condition progresses they can
experience some or all of the following: memory loss, language impairment, disorientation,
changes in personality, difficulties with activities of daily living, self-neglect, psychiatric
symptoms (for example, apathy, depression or psychosis) and out-of-character behavior (for
example, aggression, sleep disturbance or disinhibited sexual behavior, although the latter is
not typically the presenting feature of dementia). (NICE CG42, 2006). Making a diagnosis of
dementia in the early stages can be a clinical challenge. The insidious and variable emergence
of dementia symptoms makes recognition of the syndrome problematic, particularly in the
primary care setting, with the often limited time available for consultation (Iliffe S, 2009)
In addition, physicians need to be wary of patients' ability to hide their symptoms. In the
early stages of dementia, accommodation to or denial of changes in cognition, functional
ability, mood, or behavior are common coping strategies (Woods RT, 2003). As the person's
denial strengthens, the concerns of the family become more pressing, with the physician often
caught in between and faced with apparently irreconcilable needs.

Types of dementia :
Progressive dementias
Types of dementias that progress and aren't reversible include:

• Alzheimer's disease.
o In people age 65 and older, Alzheimer's disease is the most common cause of
dementia.
o Although the cause of Alzheimer's disease isn't known, plaques and tangles are
often found in the brains of people with Alzheimer's. Plaques are clumps of a
protein called beta-amyloid, and tangles are fibrous tangles made up of tau protein.
o Certain genetic factors might make it more likely that people will develop
Alzheimer's.

• Vascular dementia.
o This second most common type of dementia occurs as a result of damage to the
vessels that supply blood to the brain.
o Blood vessel problems can be caused by stroke or other blood vessel conditions.
Lewy body dementia.

• Lewy bodies dementia.

o Lewy bodies are abnormal clumps of protein that have been found in the brains of
people with Lewy body dementia, Alzheimer's disease and Parkinson's disease.
o This is one of the more common types of progressive dementia.

• Frontotemporal dementia.
o This is a group of diseases characterized by the breakdown (degeneration) of nerve
cells in the frontal and temporal lobes of the brain, the areas generally associated
with personality, behavior and language.
o As with other dementias, the cause isn't known.
 • Mixed dementia.
o Autopsy studies of the brains of people 80 and older who had dementia indicate
that many had a combination of Alzheimer's disease, vascular dementia and Lewy
body dementia.
o Studies are ongoing to determine how having mixed dementia affects symptoms
and treatments.

2.2 Depression
Depression in older people has a prevalence of 5-10% over those aged over 65, but is
frequently under-recognized. It is associated with higher morbidity and poorer outcomes
from physical illness. Older people under-report symptoms of depression, and may attribute
them to the effects of ageing. Somatic symptoms are more common than in younger people
with depression.

3. Social assessment

Social assessment is an integral part of a comprehensive multidimensional assessment of older adult

patients. Social assessment is a broad construct, encompassing many aspects of an older individual’s
life. It includes assessment of functional ability, as measured by the ability to perform the basic
activities of daily living (adls) and instrumental activities of daily living (iadls), social functioning (the
older adult’s social network and support system), the need for supportive services, screening for
cognitive function, and an assessment of psychological well-being (e.g. Mood, quality of life, life
satisfaction). Regardless of whether an older person lives in the community or in an institution,
supportive activities provided by social networks are key to ensuring adequate care and maintaining
well-being. Social functioning encompasses many aspects of a person’s relationships and activities,
and a social assessment provides a snapshot of the resources and risks related to health and wellness
experienced by an older patient.

Impact of Social Functioning on Health and Well-Being

A large body of research exists on the impact of social functioning on the health and well-being of
older adults. Research on older adults in several countries (Denmark, Holland, Japan, Britain, and the
United States) has found that social isolation and loneliness are associated with increased mortality.
Multiple studies have found greater level of social support to be related to better self-management of
diabetes and dietary and exercise behaviors. Furthermore, social relationships such as marital status
and friendship networks influence the practice of healthy behaviors such as smoking, alcohol use,
physical activity, and dental visits, where dissolution of marriage or weaker social networks are
associated with lower levels of healthy behaviors. In a meta-analysis of available studies, Barth and
colleagues noted that good evidence exists for the positive relationship between lower perceived social
support and a poorer prognosis for coronary heart disease (CHD). They suggested that an important
step in increasing the survival of patients after a cardiac event might be a more thorough monitoring
of patients with low social support to improve compliance with medication and adherence to healthy
behaviors.

Finally, most older patients receive some level of care and support from family and friends, and for
many this constitutes their sole source of support. Many caregivers of older persons are themselves
older (typically a spouse or adult child). Caregiving for older persons with limitations in ADLs, chronic
illnesses, or dementia is physically and emotionally challenging and has been documented to have
serious adverse physical and mental health consequences, such as declining health and increased
mortality among older caregivers. The experience of caregiver burden can result in impaired ability to
provide adequate care to the older patient and may lead to medication errors, elder mistreatment or
neglect, and family conflict. Caregiver strain or burden is also associated with increased likelihood of
institutionalization for the older patient. Therefore, including an assessment of an older adult’s ADL
and IADL functioning, social functioning, including met and unmet need for services, and status of
the caregiver(s) are critical components of a social assessment.

Aspects of Social Functioning and Assessment Tools

Social functioning is a multidimensional term used broadly to describe the social contexts through
which individuals live out their lives. It includes concepts such as interpersonal relationships, social
adjustment, and spirituality, which have been operationalized in the literature. The assessment of social
functioning may be complicated by personal biases and values (e.g., ageism, stereotypes, culture) that
can influence the practitioner’s and older adult’s assessment. These issues may also influence a
practitioner’s perception of how much social support or how large a social network is needed to protect
an older adult from social isolation. Similarly, satisfaction with one’s level of social support may be
influenced by one’s life experiences, personal values, group membership, and self-concept. Even so,
physicians only need to identify older adults whom they have determined to be at risk for social
isolation. In the following section, we present the most relevant aspects of social functioning to
consider when providing geriatric care, which include the following concepts: social networks, social
support, social roles, and social integration.

1. Social Networks

A social network is an aspect of social functioning that describes a person’s web of social
relationships. It is an objective concept that quantitatively describes a person’s combined social
relationships instead of focusing on more subjective considerations, such as a person’s feelings about
the quality of these relationships. Aspects of a person’s social network include the following: size
(number of people considered to be part of the network); density (connectedness of the members);
boundedness (traditional boundaries that define group members, such as family, neighbors, and
church); homogeneity (similarities of members); frequency of contacts (regularity of member
transactions); multiplexity (single or multiple transactions between members); duration (how long
members have known one another); and reciprocity (the extent to which transactions of the members
are reciprocal).

A person’s social network can be further understood as social relationships that exist along a
continuum of proximity, often referred to as primary and secondary social relationships. A primary
relationships consists of individuals with whom a person has the most frequent interactions, such as
family members, spouses or partners, and good friends, whereas a secondary relationship refers to
people with whom a person interacts less frequently, such as the mail carrier, grocery clerk, and
members of a faith-based congregation. Within a social network, a person’s relationships can also be
classified by degree of formality. Informal social networks are those made up of naturally forming
social relationships, such as that of a friend, child, and spouse or partner. Semiformal networks are
made up of social relationships formed as a result of joining a preexisting social structure, such as a
neighborhood, church, club, or senior center. Finally, formal social networks are those social
relationships or interactions with professional service staff, such as case managers, social workers,
physicians, and nurses found in a formal organization, such as a medical clinic, hospital, or social
welfare agency.

Although there are many aspects included in the concept of social network, it is not necessary for a
physician to obtain such detailed information about a patient’s social relationships during a social
assessment. Instead, a physician can condense his or her knowledge of social networks into several
questions that can identify patients who are risk for social isolation. One way for physicians to
accomplish this is to ask patients about the number and frequency of their social contacts (daily,
weekly, monthly), as well as asking them to identify the nature of these contacts (in person, by
telephone, by mail). Another more structured way to accomplish this is for the physician to administer
a short evidenced-based screening tool, such as the Berkman-Syme Social Network Index, Social
Network List, or Lubben Social Network Scale-6 (LSNS-6). The LSNS-6 contains six questions that
ask patients about the size of their social network and the tangible and emotional support received
through their identified networks. Each of the six questions has a possible score of 0 to 5; a score of 0
indicates a lack of social network, and 5 indicates an above adequate social network, with the lowest
total score being 0 and the highest score being 30. It is recommended that any older adult who scores
at or below 12 on the LSNS-6 be referred to a social worker for a more in-depth social assessment.21

Social Support

Although an understanding of a person’s social network may help the geriatric care team identify
persons at risk for social isolation, this basic understanding does not allow the care team to understand
how well their patients are supported by members within their social networks. For this reason, an
assessment of social support is more important than an assessment of a social network because social
support is more closely related to an older adult’s ability to remain independent in the community. In
spite of a large social network, without adequate social supports in place an older adult who
experiences significant functional decline will be unable to safely remain living outside of an
institutional setting. In addition, studies have shown that without a robust social support system, older
adults are less likely to follow medical advice and are at greater risk for significant negative health
outcomes such as increased comorbidities, cognitive decline, depression, poorer self-rated health, and
mortality. The convoy model of social relations can also help the geriatric care team understand the
concept of social support within the context of their patients’ lives. According to this model, older
adults surround themselves with social supports that move with them throughout their life course and
largely contribute to their well-being. This theory maintains that the quality of social support is more
important than the quantity. The longer the supports have been in place, the more significance they
hold for older adults, and the more likely they will contribute to their satisfaction with social supports
and, as a result, their overall well-being.

For the purposes of geriatric assessment, social support is defined as the tangible and intangible
assistance derived from an older adults’ social network and the older person’s satisfaction with that
help. Social support may be given in the form of the following: (1) emotional support (love and caring
most often provided by a family member, spouse, or close friend); (2) instrumental support (tangible
help with ADLs and IADLs); and (3) appraisal or informational support (providing information or
advice to help someone make a decision about something that concerns them). Each of these types of
social support is delivered through the informal, semiformal, or formal networks described earlier and
is subjective, meaning that an older adult’s perception of that help is just as important as the actual
help received. In fact, there is evidence that suggests that a person’s satisfaction with her or his level
of social support is more closely correlated with psychological well-being than the actual help
received.

Similar to the concept of a social network, a physician does not need to master all the concepts
included in the description of social support. Instead, a physician could condense this knowledge to
identify patients who may be at risk of adverse health outcomes or premature institutionalization due
to inadequate social support. One approach would be to ask patients to identify the types of help they
need in ADLs and IADLs, find out who is available to offer the appropriate assistance for these things,
and determine who would be able to step in if this person became unavailable. If the patient is
independent in all ADLs and IADLs, the most appropriate approach would be to pose these questions
hypothetically. Another approach is for physicians to use an evidence-based screening tool to screen
for patients who may need additional interventions from the geriatric team. There are many screening
tools that may be appropriate for this purpose, such as the Social Support Questionnaire, Interpersonal
Support Evaluation List, MOS (Medical Outcomes Study) Social Support Survey, and Enhancing
Recovery in Coronary Heart Disease Patients (ENRICHD) Social Support Instrument (ESSI). A short
instrument developed for use in a medical setting is the ESSI, which is a seven-item self-report
questionnaire. The ESSI was developed to examine the relationship between social support and
cardiovascular disease outcomes because lower levels of perceived functional support and network
support have been found to be associated with increased mortality and morbidity among patients with
cardiovascular disease. The ESSI measures a patient’s perception of his or her emotional, instrumental,
informational, and appraisal social support systems. Possible scores range from 7 to 35, with a score
at or below 18 indicating poor social support. Thus, it is recommended that patients with a score at or
below 18 on the ESSI be referred to a social worker for additional follow-up.

Social Roles

Social role identifies and define individuals position and validate their existence in social groups such
as families, workplace and communities. Social role changes throughout the lives. The different roles
remain in place but the participation in that role generally depends on the health status, financial
resources and mobility in the community. However, older adults continue to participate in way of these
social roles even faced with diminished capacities. Retirement is one of the social changes. It is 10
difficult for older adult to leave the position where they get respect, regular income and social network
of friends, colleagues and acquaintances. Similarly, it causes transition from the daily recognition to
one with limited recognition and possible isolation. It may affect elderly psychologically. Numerous
studies have shown that socialization is important for physical and psychological well-being. But
social relationship gets affected with old age. Personal heath declines and the ability to socialize
reduced. So, only few relationships are maintained. Such relationships are social circle of family
members and close friends. Older adults have strong desire to be independent and do not accept help
from others. Due to decline in the health status they reached at the point where they need to accept
support and help from others. Family member especially children gives assistance to them. (Brossoie,
Nancy 2013.)

Social Integration

Social integration is a process of building values, relations and institutions for a society where all
individuals, regardless of race, sex, age, ethnicity, language or religion, can fully exercise their rights
and responsibilities on an equal basis with others. Every person should be allowed to age in security
and with dignity and be in a position to contribute to society in the most meaningful way. Such an
environment is at the root of stable, safe and just societies where all members, including vulnerable
ones, enjoy equality of opportunities. Integration and participation are therefore closely linked to the
notion of social cohesion, a vital element of a healthy society. It denotes the capacity of a society to
ensure the welfare of its members, minimizing disparities and avoiding polarization and conflict, and
it requires fostering solidarity and reciprocity between generations. Care responsibilities often have
an intergenerational character, with older persons caring for grandchildren and younger adults
providing care for older persons. There is much older and younger persons can learn from each
other. Such processes ultimately help realize the goal of achieving a Society for All Ages (Zelenev
2009). To achieve this goal, concrete action can be taken in three broader areas: functional
participation, infrastructure and intergenerational relationships.
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