Domain 3 - Functioning (Primary Domain)

Overview

This domain considers functional impairment associated with or exacerbated by mental health issues. While some types of illnesses and disabilities experienced by the older adult may play a role in determining what types of support services may be required, they should not be considered in determining mental health service intensity within a stepped care continuum.

Assessment of an older adult on this domain should consider the impact of the mental health issues on:

  • Their ability to fulfil usual roles/responsibilities appropriate to their age, capability, and cultural background.

  • Their functioning within the family or home environment, vocational or social settings, caregiving roles, and in the community.

  • Their ability to undertake basic activities of daily living appropriate to their age and capability (e.g., self-care, mobility, toileting, nutrition, and personal hygiene).

PRACTICE POINT - functional decline in later life

Some gradual functional decline can be expected in later life, particularly beyond the age of 80 or for older adults with multiple co-occurring issues. A reduction in function can be associated with illness, a decline in physical health, and the older person’s environment, among other factors. This domain is concerned with functional impairment associated with or exacerbated by mental health issues.

Understanding the timeline and trajectory of functional change from baseline (i.e., what is usual for the person) is necessary for accurately rating this domain.

If there is uncertainty about the factors contributing to functional impairment (e.g., underlying medical causes of functional decline) a comprehensive functional assessment is recommended. A functional assessment considers the physical, psychological, and social factors influencing function. Some older adults may benefit from a care plan focused on reablement and restorative care.

Scoring

0 = No problem in this domain

1 = Mild impact

  1. Mildly diminished ability to function in one or more of their usual roles (e.g., at home, vocational or social settings, caregiving roles or in the community), but without significant or adverse consequences.

  2. Mental health issues contribute to brief and transient disruptions in one or more areas of functioning.

2 = Moderate impact

  1. Moderate functional impairment in more than one of their usual roles (e.g., at home, vocational or social settings, caregiving roles or in the community) to the extent that they are reasonably frequently unable to meet the requirements of those roles but without significant or adverse consequences.

  2. Mental health issues contribute to occasional difficulties with basic activities of daily living (e.g., eating, mobility, bathing, getting dressed, toileting) or instrumental activities of daily living (e.g., preparing food, cleaning, transportation, managing money) but without threat to health.

3 = Severe impact

  1. Significant difficulties with functioning, resulting in disruption to many areas of the person’s life (e.g., limited participation in vocational or social activities, deterioration in or some withdrawal from community or relationships). The person requires treatment, family, and community support to maintain independent functioning.

  2. Mental health issues contribute to frequent difficulties with basic activities of daily living (e.g., eating, mobility, bathing, getting dressed, toileting) or instrumental activities of daily living (e.g., preparing food, cleaning, transportation, managing money) on a consistent basis but without threat to health.

4 = Very severe impact

  1. Profound difficulties with functioning, resulting in significant disruption to virtually all areas of the person’s life (e.g., unable to participate in vocational or social activities, complete withdrawal from the community).

  2. Mental health issues contribute to severe and persistent self-neglect that poses a threat to health.