What is functional decline (FD)?
Why is FD a “hot topic" in health?
What does iCAHE do?
iCAHE research
Latest findings in FD
iCAHE  compendium of FD tools

What is functional decline?

Functional decline (FD)

  • Functional decline (FD) is when people lose their physical, social and/or thinking capacity. It can have an impact on people living safely and independently in the community.
  • FD is commonly associated with getting older but FD is not inevitable.
  • FD is often preventable and always manageable – with good planning and support.

Why is FD a “hot topic’ in health?

Functional Decline (FD) is such a ‘hot topic’ internationally because of the worldwide ageing of populations; however, there is no clear-cut definition, with variations between clinical practice and the research literature1-4.  In the literature, FD has been broadly defined as the loss of ability to perform everyday tasks without assistance (such as bathing, dressing, feeding oneself, continence, transferring (walking), toileting) and higher-functioning tasks (such as food shopping, driving or managing personal finances)5,6.

FD is associated with increased mortality, frequent unplanned health service use, and high health care costs.  Undetected and unaddressed FD in older community-dwelling adults will inevitably result in large direct primary and sub-acute healthcare costs (e.g. ambulance and police call outs, regular GP visits for health crisis management, and short- and long-term provision of community care and supports) and high (but frequently unmeasured) indirect costs (such as opportunity costs to family, friends and neighbours in providing crisis supports for older people not coping at home). 

Older people in FD usually to come the attention of the tertiary health sector (Hospital/Emergency Department) when FD manifests as a serious health crisis such as after a fall, or due to infection/disease resulting from poor self-care.  By this stage it is often too late to do anything to arrest the progression of FD1-8. Thus the opportunity to intervene effectively has generally been lost.

Findings from our systematic literature review9, which were applied in our recently-completed longitudinal study of FD in older adults presenting to ED9,10, indicate that relevant measures of late-detected FD are loss of independence in activities of daily living, loss of morale and increasing frequency of falls, poly-pharmacy (the use of multiple and potentially conflicting medications), emergency events of: hospitalisation; prolonged hospital stays; frequent presentations at ED and/or regular hospital readmissions, and increasing consumption of healthcare services. 

If FD is not detected early enough in its trajectory in primary and sub-acute healthcare sectors, then associated costs to society to deal with resultant disability will not be sustainable in the next few years, and community safety and independence cannot be assured for ageing people in the community.

Currently, FD is detected too late1-8,11, in settings such as tertiary hospitals. We aim to provide new knowledge that will assist in the early, and more sensitive identification of FD in the community, via primary and sub-acute health sectors, than is currently happening. This will empower the community to take ownership of identifying early FD whilst older people are still managing at home.

  1. Fortinsky, R.H., Covinsky, K.E., Palmer, R.M., & Landefeld, C.S. (1999). Effect of functional changes before and during hospitalization on nursing home admission of older adults. Journal of Gerontology: Biological Sciences, 54A, M521. doi: 10.1093/gerona/54.10.M521.
  2. Inouye, S.K., Wagner, D.R., Acampora, D., Horwitx, R.I., Cooney, L.M., Hurst, L.D., & Tinetti, M.E. (1993). A predictive index for functional decline in hospitalized elderly patients. J Gen Intern Med, 8, 645-652.
  3. Boyd, C. M., Landefeld, C. S., Counsell, S. R., Palmer, R. M., Fortinsky, R. H., Kresevic, D., . . . Covinsky, K. E. (2008). Recovery of activities of daily living in older adults after hospitalization for acute medical illness. Journal of the American Geriatrics Society, 56(12), 2171-2179.
  4. Brand, C. A., Martin-Khan, M., Wright, O., Jones, R. N., Morris, J. N., Travers, C. M., . . . Gray, L. C. (2011). Development of quality indicators for monitoring outcomes of frail elderly hospitalised in acute care health settings: study protocol. BMC Health Services Research, 11(1), 281-281. doi: 10.1186/1472-6963-11-281.
  5. Covinsky, K. E., Justice, A. C., Rosenthal, G. E., Palmer, R. M., & Landefeld, C. S. (1997). Measuring prognosis and case mix in hospitalized elders. The importance of functional status. Journal of General Internal Medicine, 12(4), 203-208. doi: 10.1046/j.1525-1497.1997.012004203.x
  6. Mehta, K. M., Yaffe, K., & Covinsky, K. E. (2002). Cognitive impairment, depressive symptoms, and functional decline in older people. Journal of the American Geriatrics Society, 50(6), 1045-1050. doi: 10.1046/j.1532-5415.2002.50259.x
  7. Hoogerduijn, J. G., Buurman, B. M., Korevaar, J. C., Grobbee, D. E., E, & Schuurmans, M. J. (2012). The prediction of functional decline in older hospitalised patients. Age & Ageing, 41(3), 381-387.
  8. Bortz, W. M., II. (2002). Conceptual framework for frailty: a review. Journals of Gerontology: Series A: Biological Sciences and Medical Sciences, 57A(5), M283-M288.
  9. Beaton, K., & Grimmer, K. (2013). Tools that Assess Functional Decline: Systematic Literature Review Update. Clinical Interventions in Ageing, 8, 485–494.
  10. Grimmer, K., Beaton, K., Kumar, S., Hendry, K., Moss, J., Hillier, S., . . . Gordge, L. (2013). Estimating the risk of functional decline in the elderly after discharge from an Australian public tertiary hospital emergency department. Aust Health Rev, 37(3), 341-347. doi: 10.1071/AH12034
  11. Woods, M., Fitzgerald, R., & Macri, S. (2011). Caring for Older Australians: Final Inquiry Report. Canberra.


What does iCAHE do?

The research group at the International Centre for Allied Health Evidence (iCAHE) have a 15 year collaborative history of aged care research, longitudinal epidemiological studies and cross-sector research into discharge planning quality (engaging tertiary, sub-acute and primary sectors). With extensive experience in research into quality care, evidence-based practice implementation and policy development, and networks that include Australian health policy experts and local healthcare networks to bring evidence translation experience across the healthcare sector. Our findings will underpin future research into timely and appropriate community-based interventions to arrest or slow the progress of early FD, before the changes become irreversible. Not only will this reduce high (and avoidable) tertiary healthcare costs, but it will enrich communities by having healthier, higher-functioning older people contributing to community life, for longer.

iCAHE research

Grimmer K, Kennedy K, Milanese S, Price K, Kay D. 2015. The Australian 75+ Health Assessment: could it detect early functional decline better? CSIRO Publishing. Australian Health Review.  http://dx.doi.org/10.1071/AH15011.    Published online: 9 June 2015

Beaton K, McEvoy C, Grimmer K. 2015. Identifying indicators of early functional decline in community‐dwelling older people: A review. Geriatrics & gerontology international, 15(2), 133-140.

link to full text

Beaton, K., & Grimmer, K. (2013). Tools that assess functional decline: systematic literature review update. Clin Interv Aging, 8, 485-494. doi: 10.2147/CIA.S42528

link to full text

Grimmer, K., Beaton, K., & Hendry, K. (2013). Identifying functional decline: a methodological challenge. Patient Relat Outcome Meas, 4, 37-48. doi: 10.2147/prom.s42474

link to full text

Grimmer, K., Beaton, K., Kumar, S., Hendry, K., Moss, J., Hillier, S., . . . Gordge, L. (2013). Estimating the risk of functional decline in the elderly after discharge from an Australian public tertiary hospital emergency department. Aust Health Rev, 37(3), 341-347. doi: 10.1071/AH12034

link to full text

Grimmer, K., Luker, J., Beaton, K., Kumar, S., Crockett, A., & Price, K. (2013). TRialing individualized interventions to prevent functional decline in at-risk older adults (TRIIFL): study protocol for a randomized controlled trial nested in a longitudinal observational study. Trials, 14(1), 266. doi: 10.1186/1745-6215-14-266

link to full text

Grimmer, K., Milanese, S., Beaton, K., & Atlas, A. (2014). Additional measures do not improve the diagnostic accuracy of the Hospital Admission Risk Profile for detecting downstream quality of life in community-dwelling older people presenting to a hospital emergency department. Clinical interventions in aging, 9, 233. 

link to full text 


Latest findings in FD

Early detection of functional decline in community-dwelling older adults is essential, given the increasing ageing population in Australia, and the cost of undetected decline to the Australian health system.  Early detection of decline in primary care settings will improve the delivery of appropriate services that support older people to age in place safety and independently.  Most knowledge on functional decline comes from assessments taken in secondary or tertiary healthcare settings, when older people are in a health crisis, and an unfamiliar environment.  There is a lack of knowledge about early functional decline as measured in the community. 

iCAHE recently undertook a comprehensive systematic review of both peer reviewed literature to identify a comprehensive pool of relevant articles identifying features, measures and/or manifestations of early functional decline or frailty in a community setting, and grey literature to identify core elements and features of primary care geriatric assessment in older people internationally

Data was extracted on the measurement tools and the context in which they were administered.  The tools were then grouped by constructs of measurement, and the broader domains measured.  

Puzzle pieces set to constructs and domains


These were positioned in a hypothesised time-sequence of decline.


 proposed time sequence of early functional decline

There is no standard approach either in the published literature, or the grey literature, on items for geriatric assessment.  Early functional decline can manifest as many things and in many ways.  The comprehensive pool of data assessment items identified in the review suggests that the geriatric assessment approaches described in the current practice do not necessarily reflect all the important domains and constructs of primary care, early functional decline.   In Australia, the Medicare ’75 plus’ health assessment provides a structured way of identifying health issues and conditions that are potentially preventable or amenable to health interventions in order to improve health and/or quality of life. While it reflects all the major domains and subdomains reported in the first review, it does not assess all the important constructs. Thus, locally and internationally, aged care assessments conducted in primary care may miss opportunities to comprehensively measure early functional decline, as it manifests in different people. 

Link to the iCAHE final 25 page report for APHCRI.

Link to the iCAHE final 3 page report summary for APHCRI.

Link to the iCAHE final 1 page key messages for APHCRI.


iCAHE Compendium of tools to detect early functional decline

A compendium of tools to detect early functional decline was produced as a spin-off of a research project funded by The Australian Primary Health Care Research Institute (APHCRI) Research stream: Relationship between sub-acute and primary health care: Older people living in the community: 75+ health checks and functional decline (FD) (2013-2015)
The Compendium provides information on freely-available assessment tools; the psychometric properties, the tool itself, and the scoring properties. 

Access the compendium (pdf 24mb)