Last Updated: 2013-10-04
Functional status is measured by the ability of people to perform basic and instrumental activities of daily living (ADLs). Basic activities of daily living (BADLs) consist of self-care tasks and include feeding, bathing, dressing, using the toilet, personal hygiene, ability to transfer from bed to chair and back again, and walking.  Instrumental activities of daily living (IADLs) are not fundamental for functioning but allow a person to live independently in a community. They include the ability to use the telephone, perform housework and laundry, shop, prepare meals, manage finances, take medications, and arrange appropriate transportation.  More advanced ADLs include hobbies and leisure activities.
Information on functional status can be obtained during a patient interview and typically does not require a questionnaire. Screening for geriatric syndromes helps to identify risk factors for and causes of functional impairment. Identification of such syndromes and initiation of appropriate assessment and management strategies may also foster preservation of function. Several validated screening tools have been published to screen for many of these syndromes:
Delirium: Confusion Assessment Method
Dementia: Short Portable Mental Status Questionnaire, AD8
Depression: Geriatric Depression Scale, PHQ-9, Cornell Scale for Depression in Dementia
Malnutrition: Mini Nutritional Assessment (MNA)
Pain: Verbal Pain Descriptors, Pain Thermometer, Faces Scale for Pain
Falls: Get-Up-and-Go (timed and modified), Single Limb Stance Test, Functional Reach. 
Functional decline in and of itself should not be considered a geriatric syndrome but rather an indicator of the negative impact that geriatric syndromes and acute/chronic medical conditions may have on an individual. Threats to functional independence arise from physical and cognitive limitations as a process of normal aging or the accumulation of chronic illness. Management of chronic illness is a key factor in preserving function. To optimize function as a result of the aging process, physical and cognitive interventions may be used when possible. Counseling patients regarding exercise and following up with them regularly has been shown to have a positive effect on mobility and helps preserve independence in community-dwelling elders.  In one meta-analysis, participation in exercise was shown to increase gait speed, balance, and performance in ADLs in frail older adults.  Physical interventions include regular exercise, balance training, participation in resistance training, and endurance training. Cognitive interventions include participating in leisure activities and in cognitively stimulating activities (cognitive training). Despite the focused nature of many of these activities, their benefits may overlap. For example, participating in cardiovascular physical activities may also benefit cognitive function. The evidence for many of the interventions remains unclear, and longitudinal studies are required. However, given the potential benefit of preserving and optimizing the functional status of older people, there appears to be limited risk in implementing these interventions. Guidelines supporting such interventions have been published. 
Increased physical activity has been associated with a reduced risk of dementia.  For example, participating in higher levels of physical activity (reported as exercising 3 or more times a week at an intensity greater than walking) was associated with a lower risk of developing Alzheimer disease in 5 years when compared with no exercise.1[A] Evidence Evidence In patients with dementia, exercise programs with multiple components (e.g., gait, balance, strengthening) have been shown to preserve physical function and BADLs, regardless of the stage of the disease.  Improvements in balance and performance of ADLs have been seen in women participating in exercise programs.   Participating in physical activity has also been associated with positive impacts on mortality, with the greatest benefit achieved at high levels of activity.    In one study, men who maintained or improved levels of physical activity were less likely to die (from all causes and cardiovascular disease) than were unfit men.2[A] Evidence Evidence Even when started later in life, physical activity can improve mortality.  Participation in structured physical activities may continue to provide benefits for up to 2 years after such activities have ceased.   A study of disability rates showed that people who are physically active are more likely to die without a disability than are sedentary people.  This provides further support that physical activity can preserve function.  Research also suggests that any individual, regardless of their current level of function, can expect such participation to help preserve their current functional status    and potentially reduce the risk of nursing home placement.    These benefits occur regardless of whether activities take place at home or at a center where such activities are provided. 
Impaired balance has been shown to increase the risk of falls, with an associated relative risk of 1.42 for falls in such individuals.  Studies of multicomponent behavioral interventions have shown these to improve balance confidence.  The exercise tai chi has been shown to be beneficial in reducing the risk of falls by improving balance.  Participating in these exercises for 15 weeks confers benefit.3[B] Evidence Evidence
Several professional societies have provided specific recommendations for resistance training. The American Heart Association recommends engaging in 8 to 10 different exercises, with a minimum of one exercise per major muscle group: chest press, shoulder press, triceps extension, biceps curl, pull-down (upper back), lower-back extension, abdominal crunch/curl-up, quadriceps extension or leg press, leg curls (hamstrings), calf raise. The recommendation is for 8 to 12 repetitions per exercise for those age <50 years, and 10 to 15 repetitions for those age 50 to 60 years.  The American Geriatrics Society has further classified the intensity of exercises. They define a maximum repetition as the maximum weight at which a particular exercise can be done only once (1 RM). They further define exercise as low (40% of 1 RM, performed 10-15 times), medium (40% to 60% of 1 RM, 8-10 repetitions), and high (>60% of 1 RM, 6-8 repetitions).  Gains have been reported over short periods of time. A meta-analysis looking at the benefits of progressive resistance training has demonstrated its effectiveness in maintaining physical function in older individuals, particularly in strength and performance of simple and complex tasks.   However, longitudinal studies demonstrating sustained benefit are required. Continued participation in such exercises should be emphasized to maintain benefit.
The purpose of resistance training is to enhance muscle mass, strength, and endurance, and to have a positive effect on functional status and quality of life.  In older men, resistance training for at least 12 weeks has been shown to increase muscle mass and quality (defined as increased strength for the same amount of muscle mass).4[B] Evidence Evidence In people with sarcopenia (loss of muscle mass related to aging), resistance training can increase muscle mass and quality.  The benefits tend to be less in women than in men, but muscle mass increases were not age dependent.5[C] Evidence Evidence Resistance training may maintain or increase basal metabolic rate, which may contribute to increased caloric expenditure when combined with aerobic exercise, and may lead to loss of body fat while body weight is preserved.    Bone mass remains unchanged or increases after applying substantial force.  This benefit is specific to bones related to the exercised muscle groups.6[B] Evidence Evidence In a study of older patients in a nursing home who followed a 10-week program of resistance training, their increase in strength, gait velocity, and stair-climbing power was associated with an increase in their thigh muscle cross-sectional area.7[B] Evidence Evidence Resistance training also improved walking endurance, walking speed, and dynamic balance, and reduced falls in men and women.       8[A] Evidence Evidence
By increasing strength and stamina, the purpose of endurance training is to improve aerobic capacity (including associated cardiopulmonary and metabolic variables), reduce associated risk factors for cardiovascular disease, and promote cognitive health.   Reports of improved function after endurance exercises (e.g., walking or bicycling) leading to improved morbidity and mortality have been mixed.  In studies where function improved after endurance exercises, resistance training was also a component of the exercise program. Function improved most in the frailest people, while smaller improvements were noted in the more functionally intact, healthy older people.  7[B] Evidence Evidence
Contraindications to resistance and endurance training
People with the following conditions should not undertake resistance or endurance training: unstable CHD; decompensated heart failure; uncontrolled arrhythmias; severe pulmonary hypertension (mean pulmonary arterial pressure >55 mmHg); severe and symptomatic aortic stenosis; acute myocarditis, endocarditis, or pericarditis; uncontrolled hypertension (>180/110 mmHg); aortic dissection; Marfan syndrome; and proliferative retinopathy, or moderate or severe nonproliferative diabetic retinopathy. 
People with the following conditions should be thoroughly evaluated before participating in endurance or resistance training: major risk factors for CHD; diabetes; uncontrolled hypertension (>160/>100 mmHg); low functional capacity (<4 metabolic equivalents [METs]); musculoskeletal limitations; and implanted pacemakers or defibrillators.  The MET of a task is a physiologic concept expressing the energy cost of a physical activity. One MET is defined as the resting metabolic rate obtained during quiet sitting. http://www.umce.ca/utano_recherche/ProjetEtude/ExerciceforOestoporosePat.pdf [Exercise for older adults with osteoarthritis pain]
Observational studies have identified that leisure activities have a protective effect and are associated with a lower risk of developing dementia compared with not participating in these activities. People who frequently participated (i.e., several times a week) in leisure activities obtained more benefit than those who participated in activities rarely (i.e., up to once a week).  Leisure activities can be divided into cognitive and physical. Cognitive activities that have been found to confer protection include playing board games, reading, and playing a musical instrument. The only leisure physical activity that has been shown to confer protection is dancing.9[B] Evidence Evidence
Cognitive stimulating activities (cognitive training)
These seem to have positive benefits for preserving cognitive function in later life. Educational attainment is a factor associated with risk of dementia, with lower levels of education associated with a higher risk of developing dementia.   In the US, attaining a high school education has been associated with maintaining cognitive function in late life.10[B] Evidence Evidence The level of complexity of an occupation has also been associated with the level of intellectual functioning in late life.11[B] Evidence Evidence The ability to maintain a ninth grade literacy level later in life has also been associated with maintenance of cognitive function. 
Activities specifically designed to improve cognitive function have been studied longitudinally. In one study, at the end of a 14-year period, a cohort of older people was divided into 2 groups: large or small decline in inductive reasoning or spatial cognition. They participated in 5 hours of activities related to inductive reasoning or spatial orientation training. Overall, 40% of those who showed substantial decline in these cognitive areas over the 14-year period returned to a level equivalent to their original performance following the 5-hour training activities.  Another prospective study assigned 2832 people aged 65 to 94 years to one of 4 different groups: 3 consisting of 10 sessions of group training in either verbal episodic memory, inductive reasoning, or speeded processing in a divided attention task, and a fourth no contact control group.  At 11 months, 60% of participants received 4 hours of booster training. Immediate benefits in the trained ability were noted and benefits were maintained over the 2 years of the study. It appears that focused cognitive training produces improvements or gains in cognition specifically in the areas that are trained, and the effects can be long-lasting, but these specific training exercises do not seem to affect normal daily activities. 
More recent studies have demonstrated a positive effect on function. In one study of 908 community-dwelling older drivers who were randomized to 3 different forms of cognitive training (memory, reasoning, and speed of processing), the at-fault rate of motor-vehicle collision accidents was approximately 50% lower in the cohort of individuals randomized to the reasoning and speed of processing arms of the study compared with the controls. 
It appears that focused cognitive training produces long-lasting improvements or gains in cognition specifically in the areas that are trained. As research progresses, the impact of these interventions on function will continue to be studied.
Generally, chronic illnesses and acute events that have the greatest potential for affecting functional status are those with the highest probability of limiting mobility (e.g., falls and fracture from osteoporosis, osteoarthritis) or have the potential to reduce cognitive function (e.g., depression) and physical function (e.g., stroke from atrial fibrillation). Issues related to sensory impairment (vision, hearing), immunization, cancer, nutritional status (specifically obesity and malnutrition), appropriate prescribing, and substance use (tobacco, alcohol) are also important and can affect daily functioning. Therefore, they should be addressed as a part of routine medical care.
Assessments for sensory impairment
Visual impairment can reduce the ability to perform ADLs and limit the ability to participate in leisure activities. Commonly encountered causes of vision impairment in older people include macular degeneration, glaucoma, cataracts, and diabetic retinopathy. Impairment of vision can also increase the risk of falls. Visual acuity can be assessed in an office setting with a Snellen chart at 6 m or a Rosenbaum card at 36 cm, but the patient would likely benefit from an ophthalmologic evaluation to screen for glaucoma and to visualize the retina for pathology.
Hearing impairment can lead to social isolation and impair function. History from the patient and the family may indicate significant hearing impairment (e.g., reports that a person is turning up the volume on the television, does not hear the telephone ringing, or has difficulty hearing conversations). Patients can be screened in the office using a whisper test or hand audiometry. Referral to an audiologist would not only allow for more detailed assessment of hearing, but may also prompt discussion regarding use of a hearing amplification device. Use of a hearing aid in such people may improve social, emotional, and communicative function. 
Peripheral neuropathy can impair a person's ability to walk and increase the risk of falls. It can be identified in the office setting by assessing the Romberg sign and light touch, pinprick, proprioception, and vibratory sense in the lower extremities (evaluation may show a pattern of distribution of sensory impairment). Causes of peripheral neuropathy include diabetes, vitamin B12 deficiency, and spinal stenosis. The discovery of peripheral neuropathy should prompt a targeted evaluation to identify a possible reversible cause.
In the US, it is recommended that older people receive vaccines for pneumonia, influenza, herpes zoster, and tetanus/diphtheria as part of an immunization schedule to prevent morbidity and mortality associated with these particular disease entities. Risks and benefits of these interventions should be discussed individually with the patient. http://www.cdc.gov/vaccines/schedules/hcp/adult.html [CDC: adult immunization schedule - US, 2013]
Several professional societies have developed guidelines for cancer screening. In older people, the decision to implement these cancer screening guidelines should be individualized and made in the context of life expectancy and functional status of the individual person.  http://onlinelibrary.wiley.com/doi/10.3322/caac.20008/full [Cancer screening in the US, 2009]
Older people commonly have adverse events due to prescribed medications.  Many people accumulate chronic illnesses as they age, and so determining the risks and benefits of prescribed medications is important. Selecting appropriate medications with the most favorable adverse-effect profile and avoiding those medications that are more likely to cause harm is more critical in older people. Several recommendations have been published for this purpose and can be integrated into clinical practice.  Aside from discontinuing potentially inappropriate medications, it is also necessary to ensure that appropriate standards of medical care are provided to elders. In chronic medical conditions for which evidence-based treatments exist, medication should not be withheld from older patients. One example is the withholding of anticoagulation with warfarin in patients at risk of falls. The benefits of medical interventions should be considered on an equal basis with their associated risks before a decision is made to forgo them.