Department of General Medicine

Guidelines On Functional Assessment

1. The following simple template can enable queries on the pre-morbid

functional status of the patient to be more systematic and thorough:
a) Physical function

- Mobility
- Basic activities-of-daily-living
b) Mental function

- Cognition
- Behavior
c) Bladder and Bowel functions

d) Miscellaneous

- Swallowing
- Vision
- Hearing

2. Notes

a) Pre-morbid means prior to the latest round of illness

b) For all functional parameters, what the doctor is most interested in is not so
much whether an impairment is now present; rather the more important query
is whether a change in functional status has occurred

c) If a change in functional status has occurred, related queries are how suddenly
and for how long. The nature of onset gives a clue to the underlying illness that
produced the functional impairment while the duration of the impairment alerts
the clinician whether there will be discharge issues to be potentially worried
about. Generally, a new and serious functional deterioration will often delay
discharge. Calling in the discharge coordinator early for such patients is always
important.

d) For cognition changes, a clinical distinction must be made between delirium

and dementia. Diagnosis of dementia is clinical (purely through history-taking,
with attention to DSM-IV features); blood tests and brain scans done as dementia
workup is only for establishing the cause of dementia (and not its presence)

e) For behavioral changes, ask for depression, anxiety, agitation, psychosis

(hallucinations, delusions, paranoia), insomnia and appetite problems.
Psychotropic medications can usefully help patients (and relatives) for this
category of problems

f) For bladder and bowel problems, ask about incontinence as well as

constipation.
g) For swallowing impairments, over and above its onset and duration, ask about
whether it is worse with liquids or solid food. For those with swallowing
impairment and/or whose bedside swallowing assessment indicates risk of
aspiration, consider nil-by-mouth or consider blended diet with thickened fluids
(ranging from nectar-thickened fluids which has the thinnest consistency to
honey-thickened fluids to pudding-thickened fluids which has the thickest
consistency) till formal review by the speech therapist. If nil-by-mouth is
considered better, and patient has oral medications to be served, then a naso-
gastric tube needs to be ordered.
h) For patients with functional impairments, consider early referral to the
therapists as the patients acute medical conditions are beginning to stabilize.
Consider also sitting these patients out of bed (if appropriate) as being out of bed
can hasten the recovery process.