Assessment: functional​

Beyond cognition: Five critical areas to assess

Assess the caregiver

While collateral information from the caregiver is essential in assessing dementia, be sure also to assess caregiver stress and implement strategies to help caregivers cope. Here are some strategies to help reduce stress:

• Enlist additional supports, both informal and formal, through referral to home care agencies.
• Help caregiver manage challenging behaviours in the patient.
• Discuss the role of respite care.
• Identify and treat caregiver depression.
• Provide psychoeducation and direct caregivers to self-help and psychoeducational materials such as The 36-Hour Day. 

Assess functional abilities

Any change in functional abilities in older adults should trigger an evaluation for dementia.

Assessing functional abilities is important because dementia and comorbid medical conditions may affect functioning. The levels of support necessary to care for the individual in the community will depend on how functional abilities affect self-care.

Obtain caregiver and patient reports of any change in activities of daily living. Instrumental activities (see below) are impaired before basic activities of daily living.

Review changes in basic activities of daily living:

• ambulation
• bathing
• continence
• dressing
• eating
• toileting
• transfers

Review changes in instrumental activities of daily living:

• shopping
• household maintenance
• finance management
• meal preparation
• telephone use (especially knowledge of emergency contacts)
• transportation
• medication management

Assess driving

Cessation of driving is inevitable for all older adults with progressive dementia. Discussions about driving cessation should begin early in the course of the illness.

With patients who have early dementia, discuss strategies to reduce the risk of accidents, such as limiting driving to familiar environments, driving while supervised, driving only in the daytime and minimizing distractions in the vehicle.

Moderate to severe dementia is a contraindication to driving. Moderate dementia is the loss of two or more instrumental activities of daily living. Severe dementia indicates the inability to perform one or more of the basic activities of daily living.

Canadian guidelines suggest that cognitive impairment associated with loss of ability to complete two instrumental activities of daily living means that the individual is likely unfit to continue driving.

Review the Canadian Medical Association's publication Determining Medical Fitness to Operate Motor Vehicles.

In general:

• Consider medical problems and medications that may elevate the risk for unsafe driving.
• Be familiar with your province's or territory's requirements for reporting fitness to drive.
• Beyond dementia, assess other critical factors required for driving (i.e. mobility, vision, emotional stability, other medical conditions).

Review by history:

• Ask the patient about:
  • recent accidents or near misses
  • incidents of becoming disoriented or lost while driving
  • previous driving habits

Assess capacity around treatment, finances and personal care

Capacity refers to a person's ability to understand information regarding decisions and appreciate how that information applies to their situation. Capacity is task- and situation-specific. Incapacity in one area does not necessarily mean that the individual is incapable in all areas of decision making.

It is important to assess capacity around various issues:

• treatment decisions
• consent to long-term care
• testamentary capacity (ability to complete a will)
• capacity to assign a power of attorney

Assess future planning

If the patient is capable, discuss matters such as:

• writing a will
• making advanced directives
• assigning powers of attorney for care and finances

Involve the family in discussions about the course of dementia and long-term care planning.