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Geriatric Principles

Maintenance of function is a main goal of geriatric care and is an important element of successful aging. Like other geriatric syndromes, functional decline is multifactorial; medical, psychological, social, and environmental factors can all contribute to impaired functional status. The revised World Health Organization’s International Classification of Functioning, Disability and Health (ICF) provides a framework for the evaluation of function and the prevention and treatment of functional decline that emphasizes the interrelation of contributing factors. The ICF classifies abnormalities in organ system structure or physiologic function as impairments. These impairments lead to difficulties with individual activities, and the limitations and barriers associated with those difficulties lead, in turn, to reduced participation in society. Environmental factors (eg, ramps and grab-bars) and personal factors (eg, education or social support) that do nothing to address underlying impairment can nonetheless influence the effect of impairments on activities and social participation. For example, a woman with severe benign essential tremor (impairment) may have difficulty eating (activity) and therefore not go out to lunch with friends (participation). Interventions to improve function in older adults can address not only the underlying impairments, but also the relevant personal and environmental factors.

Clinicians often think of function in terms of specific important activities, such as the basic and instrumental activities of daily living (ADLs, Box 2–1). Basic ADLs refer to capacities required for personal care, including walking, dressing, bathing, using the toilet, transferring from the bed to a chair, grooming, and eating. Instrumental ADLs, such as shopping, housework, transportation, using the telephone, managing finances, and managing medications, are necessary for living independently in the community. Awareness of functional deficits that often precede ADL problems can help clinicians anticipate potential ADL difficulties. In particular, problems with mobility, such as walking a quarter mile or climbing stairs, and upper-extremity limitations, such as difficulty lifting an object over one’s head or grasping small objects, often precede difficulty in ADLs and put older adults at risk for further functional decline. Early detection of mobility difficulty, upper-extremity limitations, or declines in performance measures, such as gait speed, may allow for interventions to prevent progression to ADL disability.

Box 2–1.Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) Sample Form

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