The following nursing care protocol has been designed to help bedside nurses to assess and monitor function in older adults, prevent decline, and maintain the function of older adults during acute hospitalization.
A. Functional status of individuals describes the capacity and performance of safe ADL and IADL (Applegate et al., 1990; Kane & Kane, 2000; Katz et al., 1963; Lawton & Brody, 1969) and is a sensitive indicator of health or illness in older adults. It is, therefore, a critical nursing assessment (Buurman et al., 2011; Byles, 2000; Campbell et al., 2004; Kresevic et al., 1998; Mezey et al., 1993).
B. Some functional decline may be prevented or ameliorated with prompt and aggressive nursing intervention (e.g., ambulation, toileting schedules, enhanced communication, adaptive equipment, attention to medications and dosages, and management of pain [Barnes et al., 2012; Bates-Jensen et al., 2004; Boltz et al., 2010; Brown, Redden, Flood, & Allman, 2009; Counsell et al., 2000; Kalisch, Soohee, & Dabney, 2013; Landefeld et al., 1995; Palmer, Counsell, & Landefeld, 1998; Zisberger et al., 2011]).
C. Some functional decline may occur progressively and is not reversible. This decline often accompanies chronic and terminal disease states such as degenerative joint disease, Parkinson’s disease, dementia, heart failure, and cancer (Hirsch, Sommers, Olsen, Mullen, & Winograd, 1990). Interprofessional team care meetings may be helpful in clarifying the trajectory of illness and referring for appropriate follow-up.
D. Functional status is influenced by physiological aging changes, acute and chronic illness, and adaptation to the physical environment. Functional decline is often the initial symptom of acute illness such as infections (e.g., pneumonia and UTI). These declines are usually reversible and require medical evaluation (Applegate et al., 1990; Sager & Rudberg, 1998). Functional status is contingent on motivation, cognition, and sensory capacity, including vision and hearing (Pearson, 2000).
E. Risk factors for functional decline include frailty injuries, acute illness, medication side effects, pain, depression, malnutrition, decreased mobility, prolonged bed rest (including the use of physical restraints), prolonged use of Foley catheters, and changes in environment or routines (Brown et al., 2009; Counsell et al., 2000; Landefeld et al., 1995; McCusker et al., 2002).
F. Additional complications of functional decline include loss of independence, falls, incontinence, malnutrition, decreased socialization, depression, and increased risk for long-term institutionalization and depression (Covinsky et al., 1998; Creditor, 1993; Landefield et al., 1995; see related chapters).
G. Recovery of function can also be a measure of return to health, such as for those individuals recovering from exacerbations of cardiovascular or respiratory diseases and acute infections, from joint replacement surgery, or from new strokes (Katz et al., 1963).
H. Functional status evaluation assists patients and their families in planning future care needs post hospitalization, such as short-term skilled care, assisted living, home care, and need for community services (Boltz, Resnick, Chippendale, & Galvin, 2014; Graf, 2006; Landefeld et al., 1995), or long-term residential care.
I. Physical environments of care with attention to the special needs of older adults serve to maintain and enhance function (i.e., chairs with arms, elevated toilet seat, levers vs. door knobs, enhanced lighting; Capezuti et al. 2008; Kresevic et al., 1998; Landefeld et al., 1995).
A. Comprehensive functional assessment of older adults includes independent performance of basic ADL, social activities, or IADL, the assistance needed to accomplish these tasks, and sensory ability, pain level, cognition, and capacity to ambulate (Campbell et al., 2004; Doran et al., 2006; Freedman, Martin, & Schoeni, 2002; Kalish et al., 2013; Kane & Kane, 2000; Katz et al., 1963; Lawton & Brody, 1969; Lightbody & Baldwin, 2002; McCusker et al., 2002; Tinetti & Ginter, 1998).
- Basic ADL (bathing, dressing, grooming, eating, continence, transferring)
- IADL (meal preparation, shopping, medication administration, housework, transportation, accounting)
- Mobility (ambulation, pivoting)
B. Older adults may view their health in terms of how well they can function rather than in terms of disease alone. Strengths should be emphasized as well as needs for assistance (Depp & Jeste, 2006; Pearson, 2000).
C. The clinician should validate, document, and communicate baseline functional status and recent or progressive decline in function (Boltz, Chippendale, Resnick, & Galvin, 2015; Gillis, MacDonald, & MacIssac, 2008; Graf, 2006).
D. Function should be assessed over time to validate capacity, decline, or progress (Applegate et al., 1990; Callahan, Thomas, Goldhirsh, & Leipzig, 2002; Kane & Kane, 2000).
E. Standard instruments selected to assess function should be efficient to administer and easy to interpret. They should provide useful practical information for clinicians and be incorporated into routine history taking and daily assessments, and documentation including electronic medical records (Hoogerduijn et al., 2006; Kane & Kane, 2000; Kresevic et al., 1998; see “Function” topic at www.consultgerirn.org for tools).
F. Interprofessional communication regarding functional status, changes, and expected trajectory should be part of all care settings and should include the patient and family whenever possible (Counsell et al., 2000; Covinsky et al., 1998; Kresevic et al., 1998; Landefeld et al., 1995).
G. Interprofessional rounds support promotion of function by addressing functional assessment (baseline and current), evaluating potential interventions, and helping develop a plan of care with measurable goals (Kresevic & Holder; 1998).
H. Patient’s perceptions of function, quality of life, and goals of care should be assessed, documented, and communicated to the care team across all settings (Liebzeit et al., 2018).
A. Strategies to maximize functional status and to prevent decline
- Maintain individual’s daily routine. Help to maintain physical, cognitive, and social function through physical activity and socialization. Encourage ambulation, encourage the individual to get out of bed for meals, allow flexible visitation, including pets, and encourage reading the newspaper. Encourage adjunctive interventions such as relaxation and music therapy (Boltz et al., 2015; Kresevic & Holder, 1998; Landefeld et al., 1995; Resnick et al., 2011).
- Educate older adults, family, and formal caregivers on the value of independent functioning and the consequences of functional decline (Graf, 2006; Kresevic & Holder, 1998; Vass, Avlund, Lauridsen, & Hendriksen, 2005); increased risk for complications such as malnutrition, falls, hospital readmissions, increased likelihood of being discharged to a nursing home setting (Fortinsky et al., 1999); increased mortality (Boyd et al., 2005; Rozzini et al., 2005); and decreased functional recovery (Boltz et al., 2015; Boyd et al., 2005, Boyd, Ritchie, et al., 2008; Gill et al., 2004; Gillis et al., 2008; Volpato et al., 2007), ultimately decreasing quality of life.
- Physiological and psychological value of independent functioning
- Reversible functional decline associated with acute illness (Hirsch et al., 1990; Sager & Rudberg, 1998)
- Strategies to prevent functional decline: exercise, nutrition, pain management, and socialization (Boltz, Resnick, Capezuti, Shuluk, & Secic, 2012; de Morton, Keating, & Jeffs, 2007; Kresevic & Holder, 1998; Landefeld et al., 1995; Siegler, Glick, & Lee, 2002; Tucker, Molsberger, & Clark, 2004)
- Sources of assistance to manage decline
- Encourage activity, including routine exercise, range of motion, and ambulation to maintain activity, flexibility, and function (Counsell et al., 2000; Landefeld et al., 1995; Pedersen & Saltin, 2006).
- Minimize bed rest (Bates-Jensen et al., 2004; Covinsky et al., 1998; Kresevic & Holder, 1998; Landefeld et al., 1995).
- Explore alternatives to physical restraint use (e.g., cover tubings; use distraction; Covinsky et al., 1998; Kresevic & Holder, 1998; see Chapter 23, Assessing, Managing, and Preventing Falls in Acute Care).
- Judiciously use medications, especially psychoactive medications, in geriatric dosages (Inouye, Rushing, Foreman, Palmer, & Pompei, 1998; see Chapter 17, Advance Care Planning).
- Assess and treat for pain (Covinsky et al., 1998). Consider alternative and nonpharmacological interventions.
- Design environments with handrails; wide doorways; raised toilet seats; shower seats; enhanced lighting; low beds; and chairs of various types and height, including recliners and rocking chairs (Cunningham & Michael, 2004; Kresevic et al., 1998).
- Help individuals regain baseline function after acute illnesses by using exercise, physical or occupational therapy consultation, nutrition, and coaching (Conn, Minor, Burks, Rantz, & Pomeroy, 2003; Covinsky et al., 1998; Engberg, Sereika, McDowell, Weber, & Brodak, 2002; Forbes, 2005; Hodgkinson, Evans, & Wood, 2003; Kresevic et al., 1998).
B. Strategies to help older individuals cope with functional decline
- Help older adults and family members determine realistic functional capacity based on health trajectory with interprofessional consultation (Kresevic & Holder, 1998).
- Provide caregiver education and support for families of individuals when decline cannot be ameliorated in spite of nursing and rehabilitative efforts (Graf, 2006). Palliative care consultation may offer the family and team important management strategies, particularly postacute care.
- Carefully document all intervention strategies and patient response (Graf, 2006).
- Provide information to caregivers on causes of functional decline related to acute and chronic conditions (Covinsky et al., 1998; Resnick et al., 2016).
- Provide education to address safety care needs for falls, injuries, and common complications. Short-term skilled care for physical therapy may be needed; long-term care settings may be required to ensure safety (Covinsky et al., 1998).
- Provide sufficient protein and caloric intake to ensure adequate intake and prevent further decline. Liberalize diet to include personal preferences (Edington et al., 2004; Landefeld et al., 1995).
- Provide caregiver support and community services, such as senior centers, meals on wheels, home care, nursing, and physical and occupational therapy services to manage functional decline (Covinsky et al., 1998; Graf, 2006).
A. Patients can
- Maintain safe level of ADL and ambulation.
- Make necessary adaptations to maintain safety and independence, including assistive devices and environmental adaptations.
- Strive to attain highest quality of life despite low functional level.
- Communicate preferences for care.
B. Providers can demonstrate
- Increased assessment, identification, and management of patients susceptible to or experiencing functional decline. Provide routine assessment of functional capacity despite level of care.
- Ongoing documentation (electronic medical record) and communication of capacity, interventions, goals, and outcomes
- Competence in preventive and restorative strategies for function
- Competence in assessing safe environments of care that foster safe independent function
C. Institution will experience
- System-wide incorporation of functional assessment into routine assessments
- A reduction in incidence and prevalence of functional decline
- A decrease in morbidity and mortality rates associated with functional decline
- Reduction in the use of physical restraints, prolonged bed rest, and Foley catheters use falls
- Decreased incidence of delirium
- An increase in prevalence of patients who leave the hospital with baseline or improved functional status
- Decreased readmission rate
- Increased early utilization of nutritional and rehabilitative services (occupational and physical therapy)
- Evidence of geriatric-sensitive physical care environments that facilitate safe, independent function such as low beds, comfortable chairs, and caregiver education on safe environmental design and exercise programs
- Evidence of continued interprofessional assessments, care planning, and evaluation of care related to function, including posthospital follow-up planning such as leadership support for interdisciplinary communication
- Leadership commitment to patient-centered care
RELEVANT PRACTICE GUIDELINES
Several resources are now available to guide adoption of evidence-based nursing interventions to enhance function in older adults.
A. Agency for Healthcare Research and Quality and National Guideline Clearinghouse: www.guideline.gov
B. McGill University Health Centre Research and Clinical Resources for Evidence Based Nursing: www.muhc-ebn.mcgill.ca
C. National Quality Forum: www.qualityforum.org/Home.aspx
D. Registered Nurses Association of Ontario. (2005). Clinical practice guidelines. Retrieved from www.rnao.org/Page.asp?PageID=861&SiteNodeID=270&BL_ExpandID
E. University of Iowa Hartford Center of Geriatric Nursing Excellence. (n.d.). Evidence-based practice guidelines. Retrieved from www.nursing.uiowa.edu
ADL Activities of daily living
IADL Instrumental activities of daily living
UTI Urinary tract infection
Updated: November 2020
Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description
Chapter 10: Kresevic, D. (2021) Assessment of Physical Function in the Older Adult. In M. Boltz, E. Capezuti, D. Zwicker & T. Fulmer (eds.). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed. pp 133-148). New York: Springer.
Applegate, W. B., Blass, J., & Franklin, T. F. (1990). Instruments for the functional assessment of older patients. New England Journal of Medicine, 322(17), 1207–1214. doi:10.1056/NEJM199004263221707. Evidence Level I.
Barnes, D. E., Palmer, R. M., Kresevic, D. M., Fortinsky, R. H., Kowal, J., Chren, M.-M., & Landefeld, C. S. (2012). Acute care for elders units produced shorter hospital stays at lower cost while maintaining patients’ functional status. Health Affairs, 31(6), 1227–1236. doi:10.1377/hlthaff.2012.0142. Evidence Level I.
Bates-Jensen, B. M., Alessi, C. A., Cadogan, M., Levy-Storms, L., Jorge, J., Yoshii, J., … Schnelle, J. F. (2004). The minimum data set bedfast quality indicators: Differences in nursing homes. Nursing Research, 53(4), 260–272. doi:10.1097/00006199-200407000-00009. Evidence Level V.
Boltz, M., Capezuti, E., Shabbat, N., & Hall, K. (2010). Going home better not worse: Older adults’ views on physical function during hospitalization. International Journal of Nursing Practice, 16(4), 381–388. doi:10.1111/j.1440-172X.2010.01855.x. Evidence Level IV.
Boltz, M., Chippendale, T., Resnick, B., & Galvin, J. (2015). Testing family centered, function-focused care in hospitalized persons with dementia. Neurodegenerative Disease Management, 5(3), 203–215. doi:10.2217/nmt.15.10. Evidence Level III.
Boltz, M., Resnick, B., Capezuti, E., Shuluk, J., & Secic, M. (2012). Functional decline in hospitalized older adults: Can nursing make a difference? Geriatric Nursing, 33(4), 272–279. doi:10.1016/j.gerinurse.2012.01.008. Evidence Level IV.
Boltz, M., Resnick, B., Chippendale, T., & Galvin, J. (2014). Testing a family-centered intervention to promote functional and cognitive recovery in hospitalized older adults. Journal of the American Geriatrics Society, 62(12), 2398–2407. doi:10.1111/jgs.13139. Evidence Level III.
Boyd, C. M., Ritchie, C. S., Tipton, E. F., Studenski, S. A., & Wieland, D. (2008). From bedside to bench: Summary from the American Geriatrics Society/National Institute on Aging Research Conference on comorbidity and multiple morbidity in older adults. Aging Clinical and Experimental Research, 20(3), 181–188. doi:10.1007/bf03324775. Evidence Level V.
Boyd, C. M., Xue, Q. L., Guralnik, J. M., & Fried, L. P. (2005). Hospitalization and development of dependence in activities of daily living in a cohort of disabled older women: The Women’s Health and Aging Study I. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 60(7), 888–893. doi:10.1093/gerona/60.7.888. Evidence Level IV.
Brown, C. J., Redden, D. T., Flood, K. L., & Allman, R. M. (2009). The underrecognized epidemic of low mobility during hospitalization of older adults. Journal of the American Geriatrics Society, 57(9), 1660–1665. doi:10.1111/j.1532-5415.2009.02393.x. Evidence Level IV.
Buurman, B. M., van Munster, B. C., Korevaar, J. C., de Haan, R. J., & de Rooij, S. E. (2011). Variability in measuring (instrumental) activities of daily living functioning and functional decline in hospitalized older medical patients: A systematic review. Journal of Clinical Epidemiology, 64, 619–627. doi:10.1016/j.jclinepi.2010.07.005. Evidence Level I.
Byles, J. E. (2000). A thorough going over: Evidence for health assessments for older persons. Australian and New Zealand Journal of Public Health, 24(2), 117–123. doi:10.1111/j.1467-842x.2000.tb00131.x. Evidence Level I.
Callahan, E. H., Thomas, D. C., Goldhirsh, S. L., & Leipzig, R. M. (2002). Geriatric hospital medicine. Medical Clinics of North America, 86(4), 707–729. doi:10.1016/j.emc.2016.06.002. Evidence Level VI.
Campbell, S. E., Seymour, D. G., Primrose, W. R., & ACMEPLUS Project. (2004). A systematic literature review of factors affecting outcome in older medical patients admitted to hospital. Age and Ageing, 33(2), 110–115. doi:10.1093/ageing/afh036. Evidence Level I.
Capezuti, E., Wagner, L. M., Brush, B. L., Boltz, M., Renz, S., & Secic, M. (2008). Bed and toilet heights as potential environmental risk factors. Clinical Nursing Research, 17(1), 50–66. doi:10.1177/1054773807311408. Evidence Level IV.
Conn, V. S., Minor, M. A., Burks, K. J., Rantz, M. J., & Pomeroy, S. H. (2003). Integrative review of physical activity intervention research with aging adults. Journal of the American Geriatrics Society, 51(8), 1159–1168. doi:10.1046/j.1532-5415.2003.51365.x. Evidence Level I.
Counsell, S. R., Holder, C. M., Liebenauer, L. L., Palmer, R. M., Fortinsky, R. H., Kresevic, D. M., … Landefeld, C. S. (2000). Effects of a multicomponent intervention on functional outcomes and process of care of hospitalized older patients: A randomized controlled trial of acute care for elders (ACE) in a community hospital. Journal of the American Geriatrics Society, 48(12), 1572–1581. doi:10.1111/j.1532-5415.2000.tb03866.x. Evidence Level II.
Covinsky, K. E., Palmer, R. M., Kresevic, D. M., Kahana, E., Counsell, S. R., Fortinsky, R. H., & Landefeld, C. S. (1998). Improving functional outcomes in older patients: Lessons from an acute care for elders unit. Joint Commission Journal on Quality Improvement, 24(2), 63–76. doi:10.1016/S1070-3241(16)30362-5. Evidence Level II.
Creditor, M. C. (1993). Hazards of hospitalization of the elderly. Annals of Internal Medicine, 118(3), 219–223. doi:10.7326/0003-4819-118-3-199302010-00011. Evidence Level VI.
Cunningham, G. O., & Michael, Y. L. (2004). Concepts guiding the study of the impact of the built environment on physical activity for older adults: A review of the literature. American Journal of Health Promotion, 18(6), 435–443. doi:10.4278/0890-1171-18.6.435. Evidence Level I.
de Morton, N., Keating, J. L., & Jeffs, K. (2007). The effect of exercise on outcomes for older acute medical inpatients compared with control or alternative treatments: A systematic review of randomized controlled trials. Clinical Rehabilitation, 1, 3–16. doi:10.1177/0269215506071313. Evidence Level I.
Depp, C. A., & Jeste, D. V. (2006). Definitions and predictors of successful aging: A comprehensive review of larger quantitative studies. American Journal of Geriatric Psychiatry, 14(1), 6–20. doi:10.1097/01.JGP.0000192501.03069.bc. Evidence Level I.
Doran, D. M., Harrison, M. B., Laschinger, H. S., Hirdes, J. P., Rukholm, E., Sidani, S., … Tourangeau, A. E. (2006). Nursing-sensitive outcomes data collection in acute care and long-term-care settings. Nursing Research, 55(Suppl. 2), S75–S81. doi:10.1097/00006199-200603001-00012. Evidence Level VI.
Edington, J., Barnes, R., Bryan, F., Dupree, E., Frost, G., Hickson, M., … Coles, S. J. (2004). A prospective randomised controlled trial of nutritional supplementation in malnourished elderly in the community: Clinical and health economic outcomes. Clinical Nutrition, 23(2), 195–204. doi:10.1016/S0261-5614(03)00107-9. Evidence Level II.
Engberg, S., Sereika, S. M., McDowell, B. J., Weber, E., & Brodak, I. (2002). Effectiveness of prompted voiding in treating urinary incontinence in cognitively impaired homebound older adults. Journal of Wound, Ostomy, and Continence Nursing, 29(5), 252–265. doi:10.1097/00152192-200209000-00008. Evidence Level II.
Forbes, D. A. (2005). An educational programme for primary healthcare providers improved functional ability in older people living in the community. Evidence-Based Nursing, 8(4), 122. doi:10.1136/ebn.8.4.122. Evidence Level VI.
Fortinsky, R. H., Covinsky, K. E., Palmer, R. M., & Landefeld, C. S. (1999). Effects of functional status changes before and during hospitalization on nursing home admission of older patients. Journals of Gerontology. Series A, Biological Sciences & Medical Sciences, 54A, M521–M526. doi:10.1093/gerona/54.10.m521. Evidence Level IV.
Freedman, V. A., Martin, L. G., & Schoeni, R. F. (2002). Recent trends in disability and functioning among older adults in the United States: A systematic review. Journal of the American Medical Association, 288(24), 3137–3146. doi:10.1001/jama.288.24.3137. Evidence Level I.
Gill, T. M., Allore, H., & Guo, Z. (2004). The deleterious effects of bed rest among community-living older persons. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 59(7), 755–761. doi:10.1093/gerona/59.7.m755. Evidence Level IV.
Gillis, A., MacDonald, B., & MacIsaac, A. (2008). Nurses’ knowledge, attitudes, and confidence regarding preventing and treating deconditioning in older adults. Journal of Continuing Education in Nursing, 39(12), 547–554. doi:10.3928/00220124-20081201-07. Evidence Level IV.
Graf, C. (2006). Functional decline in hospitalized older adults. American Journal of Nursing, 106(1), 58–67. doi:10.1097/00000446-200601000-00032. Evidence Level V.
Hirsch, C. H., Sommers, L., Olsen, A., Mullen, L., & Winograd, C. H. (1990). The natural history of functional morbidity in hospitalized older patients. Journal of the American Geriatrics Society, 38(12), 1296–1303. doi:10.1111/j.1532-5415.1990.tb03451.x. Evidence Level IV.
Hodgkinson, B., Evans, D., & Wood, J. (2003). Maintaining oral hydration in older adults: A systematic review. International Journal of Nursing Practice, 9(3), S19–S28. doi:10.1046/j.1440-172X.2003.00425.x. Evidence Level I.
Hoogerduijn, J. G., Schuurmans, M. J., Duijnstee, M. S. H., de Rooij, S. E., & Grypdonck, M. F. H. (2006). A systematic review of predictors and screening instruments to identify older hospitalized patients at risk for functional decline. Journal of Clinical Nursing, 16, 45–57. doi:10.1111/j.1365-2702.2006.01579.x
Inouye, S. K., Rushing, J. T., Foreman, M. D., Palmer, R. M., & Pompei. P. (1998). Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study. Journal of General Internal Medicine, 13(4), 234–242. doi:10.1046/j.1525-1497.1998.00073.x. Evidence Level III.
Kalisch, B. J., Soohee, L., & Dabney, B. W. (2013). Outcomes of inpatient mobilization: A literature review. Journal of Nursing Scholarship, 23, 1486–1501. Evidence Level II.
Kane, R. A., & Kane, R. L. (Eds.). (2000). Assessing older persons: Measures, meaning, and practical applications. New York, NY: Oxford University Press. Evidence Level VI.
Katz, S., Ford, A. B., Moskowitz, R. W., Jackson, B. A., & Jaffe, M. W. (1963). Studies of illness and the aged. The index of ADL: A standardized measure of biological and psychosocial function. Journal of the American Medical Association, 185, 914–919. doi:10.1001/jama.1963.03060120024016. Evidence Level I.
Kresevic, D. M., Counsell, S. R., Covinsky, K., Palmer, R., Landefeld, C. S., Holder, C., & Beeler, J. (1998). A patient-centered model of acute care for elders. Nursing Clinics of North America, 33(3), 515–527. Evidence Level VI.
Kresevic, D. M., & Holder, C. (1998). Interdisciplinary care. Clinics in Geriatric Medicine, 14(4), 787–798. doi:10.1016/S0749-0690(18)30091-0. Evidence Level VI.
Landefeld, C. S., Palmer, R. M., Kresevic, D. M., Fortinsky, R. H., & Kowal, J. (1995). A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. New England Journal of Medicine, 332(20), 1338–1344. doi:10.1056/NEJM199505183322006. Evidence Level II.
Lawton, M. P., & Brody, E. M. (1969). Assessment of older people: Self-maintaining and instrumental activities of daily living. The Gerontologist, 9(3), 179–186. doi:10.1093/geront/9.3_Part_1.179. Evidence Level IV.
Liebzeit, D., King, B., Bratzke, L., & Boltz, M. (2018). Improving functional assessment in older adults transitioning from hospital to home. Professional Case Management, 23(6), 318–326. doi:10.1097/NCM.0000000000000293
Lightbody, E., & Baldwin, R. (2002). Inpatient geriatric evaluation and management did not reduce mortality but reduced functional decline. Evidence-Based Mental Health, 5(4), 109. doi:10.1136/ebmh.5.4.109. Evidence Level VI.
McCusker, J., Kakuma, R., & Abrahamowicz, M. (2002). Predictors of functional hospitalized elderly patients: A systematic review. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 57(9), M569–M577. doi:10.1093/gerona/57.9.m569. Evidence Level I.
Mezey, M. D., Rauckhorst, L. H., & Stokes, S. A. (1993). Health assessment of the older individual. New York, NY: Springer Publishing Company. Evidence Level VI.
Palmer, R. M., Counsell, S., & Landefeld, C. S. (1998). Clinical interventions trials: The ACE unit. Clinics in Geriatric Medicine, 14(4), 831–849. doi:10.1016/S0749-0690(18)30094-6. Evidence Level I.
Pearson, V. I. (2000). Assessment of function in older adults. In R. I. Kane & R. A. Kane (Eds.), Assessing older persons: Measures, meanings and practical applications (pp. 17–34). New York, NY: Oxford University Press. Evidence Level VI.
Pedersen, B. K., & Saltin, B. (2006). Evidence for prescribing exercise as therapy in chronic disease. Scandinavian Journal of Medicine & Science in Sports, 16(Suppl. 1), 3–63. doi:10.1111/j.1600-0838.2006.00520.x. Evidence Level I.
Resnick, B., Galik, E., Boltz, M., & Pretzer-Aboff, I. (2011). Restorative care nursing for older adults: A guide for all care settings. New York, NY: Springer Publishing Company. Evidence Level VI.
Resnick, B., Wells, C., Galik, E., Holtzman, L., Zhu, S., Gamertsfelder, E., … Boltz, M. (2016). Feasibility and efficacy of function focused care for orthopedic trauma patients. Journal of Trauma Nursing, 23(3), 144–155. doi:10.1097/JTN.0000000000000203
Rozzini, R., Sabatini, T., & Trabucchi, M. (2005). Hospital organization: General internal medical and geriatrics wards. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 60(4), 535. doi:10.1093/gerona/60.4.535. Evidence Level IV.
Sager, M. A., & Rudberg, M. A. (1998). Functional decline associated with hospitalization for acute illness. Clinics in Geriatric Medicine, 14(4), 669–679. doi:10.1016/S0749-0690(18)30085-5. Evidence Level II.
Siegler, E. L., Glick, D., & Lee, J. (2002). Optimal staffing for acute care of the elderly (ACE) units. Geriatric Nursing, 23(3), 152–155. doi:10.1067/mgn.2002.125411. Evidence Level VI.
Tinetti, M. E., & Ginter, S. F. (1998). Identifying mobility dysfunctions in elderly patients. Standard neuromuscular examination or direct assessment? Journal of the American Medical Association, 259(8), 1190–1193. doi:10.1001/jama.1988.03720080024022. Evidence Level I.
Tucker, D., Molsberger, S. C., & Clark, A. (2004). Walking for wellness: A collaborative program to maintain mobility in hospitalized older adults. Geriatric Nursing, 25(4), 242–245. doi:10.1016/j.gerinurse.2004.06.009. Evidence Level VI.
Vass, M., Avlund, K., Lauridsen, J., & Hendriksen, C. (2005). Feasible model for prevention of functional decline in older people: Municipality-randomized, controlled trial. Journal of the American Geriatrics Society, 53(4), 563–568. doi:10.1111/j.1532-5415.2005.53201.x. Evidence Level II.
Volpato, S., Onder, G., Cavalieri, M., Guerra, G., Sioulis, F., Maraldi, C., … Fellin, R.; Italian Group of Pharmacoepidemiology in the Elderly Study (GIFI). (2007). Characteristics of nondisabled older patients developing new disability associated with medical illnesses and hospitalization. Journal of General Internal Medicine, 22(5), 668–674. doi:10.1007/s11606-007-0152-1. Evidence Level IV.
Zisberg, A., Shadmi, E., Sinoff, G., Gur-Yaish, N., Srulovici, E., & Admi, H. (2011). Low mobility during hospitalization and functional decline in older adults. Journal of the American Geriatrics Society, 59(2), 266–273. doi:10.1111/j.1532-5415.2010.03276.x. Evidence Level IV.