5.3 Functional & Cognitive Assessment
Key Takeaways
- Functional assessment measures what the patient can do: basic activities of daily living (Katz index: bathing, dressing, toileting, transferring, continence, feeding), instrumental activities (Lawton scale: tasks such as shopping, medications, and finances), mobility, and cognition.
- Mobility and fall-risk tests guide offloading and device choices; a Timed Up and Go of 12 seconds or longer suggests increased fall risk in older adults, and slow gait speed predicts disability.
- Performance scales such as the Karnofsky Performance Status (0–100), ECOG (0–5), and Palliative Performance Scale (0–100%) summarize overall function and help frame prognosis and goals of care.
- Brief cognitive screens such as the Mini-Cog and Montreal Cognitive Assessment identify patients who need caregiver involvement, simplified regimens, and teach-back before they are expected to manage dressings, NPWT, or offloading on their own.
- Functional findings determine the level of care and services, such as home health eligibility for homebound patients, skilled nursing, physical and occupational therapy referrals, and whether a patient can safely use a total contact cast or knee scooter.
5.3 Functional & Cognitive Assessment
Core Clinical Principle: A treatment plan only works if the patient can carry it out. Functional assessment shows whether a patient can change a dressing, walk safely in an offloading device, get to clinic, and recognize warning signs, and it shows how the wound itself is limiting daily life.
The CWSP outline lists functional assessment in the Assessment and Diagnosis domain, and determining the appropriate level of care and identifying the need for referrals are listed professional tasks. Functional findings connect assessment to realistic care planning.
Core Components
| Domain | Tool or Measure | What It Tells You |
|---|---|---|
| Basic activities of daily living (ADLs) | Katz Index: bathing, dressing, toileting, transferring, continence, feeding | Need for hands-on help; pressure injury and incontinence risk |
| Instrumental ADLs | Lawton Scale: telephone, shopping, food preparation, housekeeping, laundry, transportation, medications, finances | Ability to live independently, obtain supplies, and manage medications |
| Global function | Functional Independence Measure (FIM): 18 items scored 1–7, total 18–126 | Rehabilitation needs and progress |
| Mobility and balance | Timed Up and Go (TUG), gait speed, Berg Balance Scale (0–56), 30-second chair stand | Fall risk, device safety, need for physical therapy |
| Performance status | Karnofsky (0–100), ECOG (0–5), Palliative Performance Scale (PPS, 0–100%) | Overall function, prognosis, and goals of care |
| Cognition | Mini-Cog, Montreal Cognitive Assessment (MoCA), Mini-Mental State Examination (MMSE) | Ability to learn and follow a regimen |
| Wound-related quality of life | Wound-QoL questionnaire, Cardiff Wound Impact Schedule | Effect of pain, odor, exudate, and restrictions on daily life |
Mobility and Fall Risk
- Timed Up and Go: The patient rises from a chair, walks 3 meters, turns, walks back, and sits. In the CDC STEADI program, 12 seconds or longer suggests increased fall risk.
- Gait speed: Walking slower than about 0.8 m/s is associated with disability and poor outcomes in older adults; below about 1.0 m/s suggests risk.
- Berg Balance Scale: 14 tasks scored 0–4 (maximum 56); scores in the low to mid 40s or below indicate increased fall risk.
- 30-second chair stand: Counts how many times the patient stands from a chair without using the arms; low counts reflect leg weakness.
These results matter for offloading. A total contact cast or knee-high walker changes balance and limb length, so patients with poor balance may need gait training, an assistive device, a shoe lift on the other foot, or a different offloading strategy. Neuropathy, visual impairment, orthostatic hypotension, and sedating medications add to fall risk.
Upper Extremity, Vision, and Reach
Self-care of a foot wound requires the patient to see and reach the foot. Obesity, arthritis, low vision (such as diabetic retinopathy), tremor, and hand weakness can make daily foot inspection, dressing changes, and donning compression garments impossible. Occupational therapy can supply long-handled mirrors, stocking donners, and adaptive techniques, or a caregiver may need to take over.
Cognitive Screening
| Tool | Format | Interpretation |
|---|---|---|
| Mini-Cog | Three-word recall plus clock drawing (about 3 minutes) | Total 0–5; a score below 3 suggests cognitive impairment |
| MoCA | 30-point test of attention, executive function, memory, language, and orientation | 26 or more is generally considered normal |
| MMSE | 30-point test | Scores below about 24 suggest impairment; less sensitive for mild impairment |
Cognitive impairment does not mean a patient cannot take part in decisions, but it does call for simpler regimens, written and pictorial instructions, caregiver involvement, teach-back to confirm understanding, and a separate decision-making capacity assessment for major choices.
Performance Status and Goals of Care
- Karnofsky Performance Status: 100 (normal) to 0 (dead); 40 or below means disabled and needing special care.
- ECOG: 0 fully active; 1 restricted in strenuous activity; 2 ambulatory and capable of self-care but unable to work, up more than 50% of waking hours; 3 limited self-care, in bed or chair more than 50% of waking hours; 4 completely disabled; 5 dead.
- Palliative Performance Scale: Rates ambulation, activity, self-care, intake, and consciousness in 10% steps; low scores are associated with short survival and help shift wound goals from healing to comfort when appropriate.
From Function to Level of Care
| Finding | Implication |
|---|---|
| Independent in ADLs and IADLs, good cognition | Outpatient care with self-management teaching |
| Leaving home takes considerable and taxing effort, and the patient needs skilled nursing | May qualify as homebound for Medicare home health services |
| Needs daily skilled wound care or IV antibiotics and cannot manage at home | Skilled nursing facility or inpatient rehabilitation |
| Severe infection, sepsis, acute ischemia, or need for urgent surgery | Hospital admission |
Referrals follow the gaps: physical therapy for gait and transfers, occupational therapy for ADLs and adaptive equipment, social work for supplies, transportation, and caregiver support, and home health for skilled dressing changes or NPWT.
Clinical Traps
Trap 1: Prescribing a Device the Patient Cannot Use
A removable walker boot for a patient who cannot reach the straps, or NPWT for a patient who cannot recognize an alarm, sets up failure. Match the device to measured function.
Trap 2: Skipping the Cognitive Screen
Patients with mild cognitive impairment often appear to understand instructions in clinic. A quick Mini-Cog and teach-back reveal gaps before the first missed dressing change.
A wound center wants a standardized way to document whether patients can bathe, dress, use the toilet, transfer, maintain continence, and feed themselves independently. Which tool is designed for this purpose?
A 76-year-old woman with a stage 4 sacral pressure injury is bedbound, needs total care for all activities, eats only a few mouthfuls a day, and is drowsy most of the time. Her Palliative Performance Scale score is 20%. How should this finding shape her wound care plan?
A 69-year-old man with a new diabetic foot ulcer is being considered for home negative pressure wound therapy. He appears to follow the teaching, but scores 2 of 5 on the Mini-Cog and cannot explain what to do when the device alarms. What is the most appropriate next step?