How do you use the FAST Scale?

marachne · Oct 22, 2008

We seem to be disagreeing at work on how this scale is used. I use it just for alzheimer's/dementia and start at the top and work my way down only ranking them on the decline that is related to their alzheimer's/dementia. Another nurse that I work with is telling me that I am wrong. She rates them on the lowest that they can score, regardless of wether or not they have alzheimer's/dementia or not. For example:
89 y/o female with CHF. A&O x 3. Bed to w/c bound, needs assistance with transfers, etc d/t weakness. She would give them a FAST of 7C unable to ambulate without assistance. Without a dx of alzheimer's or dementia I would not use the FAST scale to document any of her confusion/forgetfulness, etc. d/t it just being from regular old age.
Which is correct?

You are correct. The FAST is a prognosis tool for dementia, and the trajectory of dementia. Using it for someone w/o dementia if not as the main diagnosis, as a co-morbidity makes no sense.

Here's a quote from EPERC Fast Fact and Concept #150: Prognostication in Dementia:

NHPCO guidelines state that a FAST stage 7A is appropriate for hospice enrollment, based on an expected six month or less prognosis, if the patient also exhibits one or more specific dementia-related co-morbidities (aspiration, upper urinary tract infection, sepsis, multiple Stage 3-4 ulcers, persistent fever, weight loss >10% within six months).

Now she can use any kind of changes to note decline in a patient, but you can't use the FAST scale with it for a person w/o dementia.

I am a little concerned about your comment that confusion/forgetfulness was "d/t regular old age." If someone is having mental status changes, it could indicate any number of things: infection, hypoxia, drug reaction/toxicity, decline in health status...

NurseAlwaysNForever · Oct 23, 2008

There is a such thing as Normal Age Associated Memory Impairment and Age Related Cognitive Decline. And that is precisely what I am talking about. Not every elderly person that is not quite as sharp as they once were has alzheimer's or dementia. Some memory loss and mild confusion are just because of changes in the brain and neurotransmitters related to old age. I was trying to get across that yes, she does have some memory deficit, however mild, and that it was just the typical stuff related to aging. You know, the stuff they joke about and call "old timers".

marachne · Oct 23, 2008

There is a such thing as Normal Age Associated Memory Impairment and Age Related Cognitive Decline. And that is precisely what I am talking about. Not every elderly person that is not quite as sharp as they once were has alzheimer's or dementia. Some memory loss and mild confusion are just because of changes in the brain and neurotransmitters related to old age. I was trying to get across that yes, she does have some memory deficit, however mild, and that it was just the typical stuff related to aging. You know, the stuff they joke about and call "old timers".

Oh, ok. You just got my radar up with the original statement, b/c I've seen too many times things that can be fixed (or at least managed) ignored under the rubric "oh, that's just part of what happens with age."

The truth, at least as I understand it from the literature is that while there are "age related changes," they mostly have to do with processing time and not being able to multi-task (and important thing to remember when trying to share information w/an OA -- wait until they're not doing something else if you want them to attend to your words!).

So a healthy older adult (i.e. no other co-morbidities) should not be experiencing noticible loss of cognitive function. Now heart failure, for example can cause problems with oxygenation (hypoxia = mental confusion) as well as sleep, and probably other things so yeah, I might expect some changes.

Sorry, but you just hit on a hot button for me.

I hope you have better luck w/your co-worker. Using a FAST for someone w/o a clear dementia dx is just wrong.

NurseAlwaysNForever · Oct 24, 2008

That is what I have been trying to explain. I even asked her if I broke both of my legs and was in traction would I be a 7c? She said yes, you wouldn't be able to walk without assistance. I tried to explain that with the FAST score is only appropriate with Alzheimer's, however she still doesn't see it my way. We are an RN, LVN team and we are documenting completely differently on our FAST, Karnofsky, and PPS. The only thing we seem to agree on is the NYHA. I don't know what to do and I can't find any directions on actually how to use the FAST score to print out for my job. My boss even is now thinking that she may be right in using it her way.

marachne · Oct 24, 2008

This could lead to serious problems for your agency if you're not using the tools the same (which means at least one of you is using it wrong!) And I'm assuming these instruments are being used as part of the continuing certification as well as to document decline from a clinical stand point.

I'm attaching "Fast Fact #150, Prognostication of Dementia" it should help with your documentation. I found it pretty easy just by putting into Google "Dementia Prognostication FAST score" it was the first hit. I guess I've just gotten good at doing searches.

But you should also know about the "Fast Facts" in general -- there's even a downloadable version for a PDA! You can find them here: http://www.eperc.mcw.edu/ff_index.htm

And there's even a search function now.

The PPS is discussed in FF #125

Also, Growth House has a link to various tools here: http://www.growthhouse.org/promotingexcellence/

But it sounds like the issues are even more than just your use of tools. Are you able to get support to mediate between the two of you? I hope I don't sound out of bounds, but your working relationship doesn't sound like it's the greatest...

Good luck. I hope these documents help

Concept 150 Dementia Formatted.pdf

marachne · Oct 24, 2008

One other thing: I have a photocopy of just part of a booklet, but this part is titled: Hospice -- Determining Terminal Status and is published by the United Government Services

Centers for Medicare & Medicaid Services

I would hope your agency has this or something like it. It includes Alzheimer's (note, not even dementia, specifically AD), and discusses the use of the FAST scale. It's the only dx that does.

I wish you luck!

NurseAlwaysNForever · Oct 25, 2008

In general we get along great. We make a good team in the care for our patients, are able to discuss and come to agreement in their treatment and interventions. The main problem is that we see the scales differently. She's a great nurse and she is also very knowledgeable. I have been with the hospice company for 2 years, she is new to it and doesn't quite get the grasp of the scales, but she also has a lot more nursing experience than I do and is a lot older than I am. I am only a 3 year nurse with experience only in hospice and LTC. She has a vast array of experience. Anyway. Thanks for all the help. This is exactly how I thought things were.

marachne · Oct 25, 2008

In general we get along great. We make a good team in the care for our patients, are able to discuss and come to agreement in their treatment and interventions. The main problem is that we see the scales differently. She's a great nurse and she is also very knowledgeable. I have been with the hospice company for 2 years, she is new to it and doesn't quite get the grasp of the scales, but she also has a lot more nursing experience than I do and is a lot older than I am. I am only a 3 year nurse with experience only in hospice and LTC. She has a vast array of experience. Anyway. Thanks for all the help. This is exactly how I thought things were.

I'm glad you work well together -- that means everyone (especially the patients) win!

Don't sell your own knowledge, intelligence and experience short. I know it's easy to second guess yourself when your ideas and/or understanding are challenged, especially when you're a relatively new nurse.

Appreciate, honor and take advantage of her strengths and knowledge and experience -- it sounds like it's part of what makes you a good team, but don't let yourself be cowed. New things come out all the time -- new medications (or new uses for older meds), new scales, new regulations, new approaches to practice. Being knowledgeable and experienced only goes so far if you also don't stay aware of what is current best practice.

If you're not sure about something, coming to someplace like AN is a good tactic, so is checking out reputable sites like EPERC and Growth house and the like.

NurseAlwaysNForever · Oct 25, 2008

I didn't want to make this an RN vs LVN thread so that is not where I am going with this at all. I truly respect my RN and acknowledge that she has had much more training and experience than I have and I recognize that 100%, but at my place of work as the LVN my opinion is less valued. My boss does not ever want to disagree with the RN's because 1, he is afraid of losing them, they are much harder to come by, and 2 he is an LVN himself. Whenever I or any other LVN raise a question we are told not to be "insubordinate" to our RN. So, that is my problem. I want to approach this very carefully so as not to ruffle any one's feathers. I have had 4 RN's in 2 years at this company and would not want to lose the one I have for anything. She is the first one that has truly helped me and been kind and compassionate to my patients. I do feel blessed to have her. She doesn't think that she is any better than me, but does tend to "mother/mentor" me as she is much older than I am and much more experienced. Maybe I am am a little hesitant to truly "argue" my opinion out of respect for her. I don't know how to put it. It's kind of complicated I guess.

marachne · Oct 25, 2008

i didn't want to make this an rn vs lvn thread so that is not where i am going with this at all. i truly respect my rn and acknowledge that she has had much more training and experience than i have and i recognize that 100%, but at my place of work as the lvn my opinion is less valued. my boss does not ever want to disagree with the rn's because 1, he is afraid of losing them, they are much harder to come by, and 2 he is an lvn himself. whenever i or any other lvn raise a question we are told not to be "insubordinate" to our rn. so, that is my problem. i want to approach this very carefully so as not to ruffle any one's feathers. i have had 4 rn's in 2 years at this company and would not want to lose the one i have for anything. she is the first one that has truly helped me and been kind and compassionate to my patients. i do feel blessed to have her. she doesn't think that she is any better than me, but does tend to "mother/mentor" me as she is much older than i am and much more experienced. maybe i am am a little hesitant to truly "argue" my opinion out of respect for her. i don't know how to put it. it's kind of complicated i guess.

all makes perfect sense, really. and i had no idea who was the rn and who was the lvn before you told me.

i know the issues of hierarchies and power can be tricky indeed.

as i said, i'm glad you mostly get along, and are doing well and right by your patients.

i'm just curious -- were you able to present the info i gave you to your partner and your boss? has it made any difference?

please, let me know if there is anything else i can do.

oh, did a quick lit search and here's one more bit to add. here is the abstract, and i've attached the full .pdf

again, i hope this helps you make your point.

diagnosis of alzheimer's disease

functional and global evaluations

[color=#336699]the gds/fast staging system

stefanie auer a1 and barry reisberg a1

a1 aging and dementia research center, new york university medical center, new york, new york, usa

abstract

staging methodologies are an essential tool in the assessment of disease severity in progressive dementing illness. several different instruments have been developed for this purpose. one of the most widely used methodologies is the global deterioration scale/functional assessment staging (gds/fast) system. this system has been studied extensively and proven to be reliable and valid for staging dementia in alzheimer's disease (ad) in diverse settings. one of the major advantages of this system is that it spans, demarcates, and describes the entire course of normal aging and progressive ad until the final substages of the disease process. other advantages include: (a) greatly enhanced ability to track the longitudinal course of ad, (b) improved clinicopathologic observations of ad interrelationships, and © enhanced diagnostic, differential diagnostic, and prognostic information. this article presents a brief overview of the gds/fast staging system

FAST Staging .pdf

NurseAlwaysNForever · Oct 27, 2008

I have not broached the subject with them as of yet, but I did send an e-mail to the compliance officer asking for clarification. I did not mention to her where the confusion was coming from, or mention any names, but did state that "we" were having some confusion, could she please clarify for us. This way I am not actually confronting any one in the office with the information. I felt it would be easier this way. you have been very helpful and I am very grateful. I will be printing off this information and leaving it in places they are sure to see it.

Thanks!!!!