Acute Functional Decline
A sudden change in ability to function at baseline.
Acute functional decline is an important presenting complaint in the ED. It sometimes gets lost under unhelpful misleading terms like “weak and dizzy” or “failure to cope” or “the dwindles.” Like delirium or increasing falls, acute functional decline must be considered a symptom of some underlying medical problem.
- Metabolic problem – hypothyroid, hyponatremia, hypercalcemia
- Neuro or cardiac events (TIA, ACS)
- Medication mix-up
- Untreated pain – especially in a cognitively impaired person
This acute change will not be uncovered unless the simple question – “What has changed?” – is asked.
A musculo-skeletal injury – even trivial, like a wrist sprain, shoulder hematoma, hip bruise – can have a significant effect on ability to function at the previous level which will need to be addressed to ensure successful ED discharge:
Assessing Risk of Functional Decline:
Some older patients are at risk of significant functional decline after a visit to the ED – but there is a lot of heterogeneity among older patients. The 82 year old man who broke his left wrist while playing tennis may only have to give up his 2 km daily swim until his cast comes off but otherwise have no problems! How do you decide who is at risk of significant functional decline? Is there a way of predicting those at most risk?
Identifying seniors at Risk (ISAR) (McCusker et al, 1999) – View the NCBI Journal Article
- Before the illness or injury that brought you to the Emergency, did you need someone to help you on a regular basis?
- Since the illness or injury that brought you to the Emergency, have you needed more help than usual to take care of yourself?
- Have you been hospitalized for one or more nights during the past 6 months (excluding a stay in the Emergency Department)?
- In general, do you see well?
- In general, do you have serious problems with your memory?
- Do you take more than three medications every day?
Any score >1 puts the older patient at risk of prolonged hospitalization, functional decline after discharge, and early return to ED.
In some departments this risk-stratification tool is built into the initial RN assessment. To view a Nursing Assessment with ISAR click here.
In practice most of the issues should likely be covered in a complete medical history of the older patient. The management of the patient is going to be influenced by the results of that information. For example: an ISAR score of 0/6 (functionally robust) with a lobar pneumonia may be a candidate for outpatient management with some home supports; ISAR 5/6 with even a trivial injury (soft tissue injury of hip) may need hospital or transitional care.
Discussion: Acute Functional Decline
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Good tool for disposition
good assessment strategy
I like the ISAR. Easy fast questions providing crucial information.
Good to know.
I like the ISAR tool
important not to forget
good to assess risk
isar is ok but it can miss stuff
In the ISAR Score, does it’s 3 different medication like in this module or 6 different medication like in the printed Emergency Nursing Care Record sheet from Mont Sinai Hospital ? Confusing …
again call a member of family or home nurse to verify info
complete history is important
acute changes have a cause
ISAR very helpful
Good to know about Isar
Excellent summary. Of further note, a very recent (Dec. 2016) systematic review of 32 validation studies found that the ISAR had “modest predictive accuracy and may serve as a decision-making adjunct when determining which older adults can be safely discharged.” Among other things, the authors found that an ISAR of ≥2 had a pooled sensitivity of 0.87 and a pooled specificity of 0.35 for predicting mortality (95% CI 0.75-0.94 and 0.26-0.44 respectively).
Galvin R, Gilleit Y, Wallace E, Cousins G, Bolmer M, Rainer T, Smith SM, Fahey T. Adverse outcomes in older adults attending emergency departments: a systematic review and meta-analysis of the Identification of Seniors At Risk (ISAR) screening tool. Age Ageing. 2016 Dec 17. [Epub ahead of print]
We used ISAR test in my hospital.
I noticed the ISAR score as described on this page awards a point if the patient is on greater than three medications, but the nursing assessment record provided awards a point if the patient is on six or more medications. Is there a reason for this discrepancy?
Very observant! Although 3 or more was the original criterion, many sites have found that that is overly sensitive (e.g. an aspirin, acetaminophen and a bisphosphonate would generate a +). At our site we arbitrarily established six or more as our cut off.
no es poco frecuente pero si se tomo muy poco en cuenta
ISAR is a good tool to assess seniors at ER.
Agree that the early ISAR testing will help alert the MD/Allied health team re disposition earlier.
i think that having the ISAR test as part of the initial nursing assessment in the Er is very helpful it will raise flags so that the gem nurse and other resources can be contacted as well
Interesante bloq en un tema que se vuelve cada día más vulnerable