The assessment of autonomy in elderly people]

The assessment of autonomy in elderly people relies on various instruments that aim to evaluate and follow up patients, to measure the burden of care for the medical staff, or to properly distribute health budgets. In this article, we describe 3 clinical scales traditionally employed by gerontologists and specialists in geriatric rehabilitation. We intentionally left out generic scales such as the Barthel index and the Functional Independence Measure, which are well known by physiatrists. The Katz index is a scale of Activities of Daily Living, and the Lawton test is a scale of Instrumental Activities of Daily Living. We paid special attention to the AGGIR classification, which is the actual legal instrument for evaluating dependency in elderly in France, and whose first application is health resources management.     

Inter-rater reliability of the Barthel Index, the Activity Index, and the Nottingham Extended Activities of Daily Living: The use of ADL instruments in stroke rehabilitation by medical and non medical personnel

This investigation addressed the question whether non-medical personnel could produce similar ratings to physicians when applying ADL scales. A sports scientist was trained in the assessment of stroke patients with the Barthel Index, the Activity Index and the Nottingham Extended Activities of Daily Living Scale. He and a rehabilitation physician assessed 20 stroke patients in first in-patient rehabilitation with these instruments. Measurements of inter-rater reliability were calculated for scores, subscales and single items, and for the latter also rater correspondence. Inter-rater reliability was good to excellent for all scores and subscales (ICC: 0.82-0.99). Reliability and correspondence was good to excellent for the items of the Barthel Scale, satisfactory to excellent for those of the Activity Index. Some 25 % of the items of the Nottingham Extended Activities of Daily Living revealed unsatisfactory reliability but still high inter-rater correspondence. Results indicate that physicians and non-medical personnel are able to apply these scales reliably to stroke patients.     

Is the Barthel Scale appropriate in non-industrialized countries? A view of rural Pakistan

Purpose: To determine if the Barthel Index, a conventional scale for assessing disability, is appropriate for stroke patients in rural Pakistan, rather than an observational study by visiting stroke patients in their homes.

Method: Stroke patients attending hospital out patient clinics in Islamabad, together with others identified in local villages, were assessed to test the validity of the Barthel Activities of Daily Living Scale.

Result: For each item on the disability scale, differences in local customs, lifestyle and architecture meant that the Barthel Scale was not appropriate in rural Pakistan.

Conclusions: There is unlikely to be a disability scale which can be applicable universally. Care must be taken when standard scales are used for international comparisons of stroke disability.     

Quality of life of stroke survivors: a 1-year follow-up study

OBJECTIVES: To examine the changes in and to identify determinants of health-related quality of life (HRQOL) during the first year after stroke. DESIGN: Prospective cohort study. SETTING: Regional university teaching hospital in China. PARTICIPANTS: Chinese survivors of stroke (N=303). Patients who were previously physically handicapped were excluded. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Barthel Index, Lawton Instrumental Activities of Daily Living (IADL), Chinese Mini-Mental State Examination, Geriatric Depression Scale (GDS), and the abbreviated Hong Kong Chinese version of the World Health Organization Quality of Life measure domain scores at 3, 6, and 12 months after the stroke. RESULTS: A total of 268 (88%) subjects completed the study. HRQOL data were available in 247 (82%) subjects at 3 months. Between 3 and 12 months, there was no significant change in Barthel Index and IADL scores, but there was significant increase in GDS scores. On multivariate analysis and multilevel modeling, there was a small but significant decrease in social interaction and environment HRQOL domain scores with time. GDS score was negatively associated with all 4 domains of HRQOL, whereas the Barthel Index score was associated with physical and psychological HRQOL domains only. Female sex, nursing home residence, welfare assistance, pain in affected limbs, soft diet or tube feeding, and lack of physical exercise were associated with poorer HRQOL. CONCLUSIONS: Environment and social interaction HRQOL may decrease after 1 year of stroke among Chinese stroke patients. Depression has a more generalized adverse effect on HRQOL than basic functional disabilities. Health care professionals should focus on treating depression; group exercises and self-help group activities may help in promoting socialization and reintegration into community life.     

Activities of daily living as quantitative indicators of nursing effort

Functional assessments of elderly or disabled people requiring long-term care have been used by clinicians for many years, and functional assessment instruments are now being used as indicators of required nursing care and its cost. The authors examine the ability of functional assessment items and instruments to measure accurately the variation in nursing care used by nursing home patients, with analysis of 290 patients. Nursing times, measured for each patient by nurse category (registered and all other) and type of care (skilled and personal) measure resource consumption. Activities of daily living (ADLs): eating, bathing, dressing, toileting, transferring, and continence are used to measure functional abilities on a four-point scale: independent, supervised, assisted or helped, and dependent, as well as two derived scales: Katz's Index and Resource Utilization Groups. The four-point measurement scales for ADLs are found to be necessary as indicators of nursing time required by patients. As a consequence, the three-point scales used for ADLs in the Long-term Care Minimum Data Set are not adequate, at least in nursing homes, for resource allocation. The relationship of nursing times with individual ADLs is nonlinear, so linear statistical techniques such as principal components, canonical correlations, or linear regression are inappropriate to produce patient classification systems based on ADLs. Individual ADLs do not explain use of registered nursing care time as well as they do care time by other nursing staff. Therefore, resource allocation and staffing for registered nurses must be done separately from nursing personnel, using indicators other than ADLs.     

WHO NEEDS A NURSING HOME? A SIMPLE AND EFFECTIVE SCREENING TEST

SUMMARY The aim of this study was to determine whether the Barthel Index (BI) or Folstein's Mini-Mental State Examination (MMSE) could distinguish between patients who might continue at home with domiciliary care and those requiring institutional long-term care. The results of the BI and the MMSE were compared with decisions made by an expert multidisciplinary team, including geriatricians. A Barthel score of 15 or less had a sensitivity of 90%, a specificity of 83% and a predictive value of 84% for determining those patients requiring nursing home placement. The BI proved to be a simple, accurate and reliable indicator of patients requiring nursing home care. The MMSE was of no predictive value in distinguishing the patients' discharge destinations.     

Monitoring functional status in hospitalized older adults

The Katz Index of Independence in Activities of Daily Living can help nurses detect subtle changes in health and prevent functional decline. OVERVIEW: Created 45 years ago, the Katz Index of Independence in Activities of Daily Living has shown itself to be an important tool in measuring an older adult's capacity to care for her- or himself. When a nurse using the tool notes a diminishment in the patient's ability to perform any of six activities-bathing, dressing, toileting, eating, transferring, or remaining continent-further assessment may uncover a reversible cause, such as a chronic or acute condition requiring treatment. A video demonstrating the use of the Katz index is available for free online at http://links.lww.com/A241.     

Psychometric properties of the extended Care Dependency Scale for older persons in Egypt

Aim. The aim of this study was to determine the validity and reliability of the modified Arabic Care Dependency Scale for self‐assessment of older persons in Egypt and to compare these self‐assessments to proxy assessments by care givers and family members. Background. The Care Dependency Scale is an internationally used instrument to measure care dependency. The Arabic version may improve data collection on this phenomenon in the Middle East where the population is ageing. Design. A cross‐sectional study with a sample of 611 older persons living in Greater Cairo. Participants belonged to three groups: nursing home residents, home care recipients and non‐care recipients; 459 participants were also rated by proxies and 171 repeated their self‐assessment after two weeks. Methods. The correlation between sum scores of the Care Dependency Scale and the Activities of Daily Living scale was calculated to establish criterion validity. Construct validity was determined by comparing care recipients and non‐care recipients with regard to their Care Dependency Scale sum scores and by exploratory factor analysis. Intraclass coefficients were used to assess test‐retest reliability of self‐ratings for each item. Mean differences between self and proxy assessment were calculated. Results. The Care Dependency Scale had a strong correlation to the Activities of Daily Living scale and is able to distinguish between care recipients and non‐care recipients. Factor analysis revealed one factor for basic needs and one factor for psychosocial needs. ICC values were >0·7 for most items related to the factor for basic needs among care recipients. Proxy assessment yielded higher care dependency than self assessment. Conclusion. Care Dependency Scale items for basic needs are suitable to assess care dependency among Egyptian care recipients. Relevance to clinical practice. Assessment of care dependency is useful to obtain data for appropriate resource allocation among care recipients.     

BARTHEL SELF-CARE INDEX AND GERIATRIC HOME CARE PATIENTS

Barthel Self-care Index scores were recorded at 6-month intervals for patients in a geriatric home care program by an occupational therapist in cooperation with an interdisciplinary health care team. Scores ranged from 10 to 100 with an overall mean score of 83.9. Lowest score for a patient living alone was 75 and that patient required extensive social services to remain in the community. The data suggest that the Barthel Index may be useful in helping to define the personal care needs of the frail community elderly and in identifying the need to consider institutional placement.     

Differences between patient and proxy reports in the assessment of disability after stroke

OBJECTIVE: To determine whether the assessment of disability level including basic activities of daily living (ADL) and instrumental ADL varies between patients' and proxy respondents' reports, and to explore the factors influencing proxy agreement. DESIGN: Patient-proxy agreement study. SETTING: Hospital settings. SUBJECTS: Fifty-two stroke patients with mild or without cognitive impairments and their primary caregivers voluntarily participated in this study. MAIN MEASURES: The self-administered versions of the Barthel Index and Frenchay Activities Index were completed by the patients and their proxy respondents concurrently, yet separately, to assess the level of disability. RESULTS: The proxy agreement on total scores of the self-administered Barthel Index and self-administered Frenchay Activities Index demonstrated moderate to good agreement (self-administered Barthel Index: intraclass correlation coefficient (ICC) = 0.71; self-administered Frenchay Activities Index: ICC = 0.6). There were no significant differences between patient and proxy reports on self-administered Barthel Index and self-administered Frenchay Activities Index scores (paired t = -0.22, P = 0.83; paired t = 0.88, P = 0.39, respectively). However, limits of agreement of patient and proxy reports on the self-administered Barthel Index and self-administered Frenchay Activities Index were notable. Stepwise regression analysis found no significant variables associated with proxy agreement. CONCLUSIONS: These results indicate that it is appropriate for research purposes, but not appropriate for clinical usage, to use proxy reports to measure disability levels in patients with stroke. Furthermore, the two methods should not be used interchangeably to monitor patients because of the wide limits of agreement between patient and proxy reports on the self-administered Barthel Index and self-administered Frenchay Activities Index.     

Functional ability and health complaints among older people with a combination of public and informal care vs. public care only

The aim of the study was to investigate functional ability and health complaints of people, 65+, living in special accommodation (equivalent to nursing home) and their counterparts who live at home and receive municipal care or a combination of municipal and informal care. Persons (n = 1958) receiving municipal care were assessed in terms of functional ability, health complaints, and level of informal and municipal care and services. The results showed that more home care, services and help with Instrumental Activities of Daily Living (IADL) were provided to those receiving only municipal care at home, while more home care and services associated with Personal Activities of Daily Living (PADL) as well as nursing care were provided to those receiving informal care in addition to formal care. Cohabitation was a predictor of a combination of municipal and informal care in the home (OR: 5.935), while assistance with IADL provided by municipal home care and services predicted municipal care only (OR: 0.344). Care in special accommodation was predicted by advanced age (OR: 1.051), dependency in IADL (OR: 19.883) and PADL (OR: 2.695), and impaired cognitive ability (OR: 3.849) with receiving municipal care only as a reference. Living alone (OR: 0.106), dependency in IADL (OR: 11.348) and PADL (OR: 2.506), impaired cognitive ability (OR: 3.448), impaired vision or blindness (OR: 1.812) and the absence of slowly healing wounds (OR: 0.407) were predictors of special accommodation with a combination of informal and municipal care at home as a reference. The distribution of municipal care divided older people into three distinct groups. The most frail and elderly people who had no cohabitants received care in special accommodation, determined by their level of physical and cognitive dependency. The frailest individuals living at home were cohabiting and received a combination of municipal and informal care, while those who were less dependent mainly had help with IADL from municipal care only. The results indicate that there is a shift from the substitution to the complementary model and highlights that attention to the family carers is needed.     

Frenchay活动量表对于我国脑卒中患者评定的效度研究

目的探讨Frenchay活动量表在我国脑卒中患者应用中的效度。方法选取脑卒中患者和正常人各39例。由同一评定者用Frenchay活动量表分别对两组受试者评定2次。首次评定患者时,评定Barthel指数1次。两个量表比较采用Spearman相关系数检验,两组Frenchay活动量表评分比较采用配对t检验。结果在脑卒中组中,Frenchay活动量表与Barthel指数的相关系数为0.727(P<0.001),各项得分和总分明显低于正常对照组(P<0.01)。结论Frenchay活动量表适用于我国脑卒中的评定。     

Functional status in older women following hip fracture

BACKGROUND: Women aged 65 years and over are at high risk for a fractured hip because of osteoporosis. One of the devastating effects of a fracture is the loss of ability to live independently. AIM: The major aim of this study was to describe the functional status, or ability to perform activities of daily living, of women aged 65 years and older who had experienced a fractured hip in the recent past and to explore possible differences in selected variables (e.g. age and length of rehabilitation) for those who were fully performing activities of daily living at least 6 months after fracture and those who were not. DESIGN: Following Institutional Review Board approval, data were collected from 23 Caucasian women ranging from 65 to 95 years of age (M = 82, SD = 6.83) who had experienced fractured hips related to a fall in the recent past (6 months to 4 years). All were living independently prior to their fractures. Three Registered Nurses, in a structured interview, collected the data using a Demographic Data Form, an Osteoporosis Risk Factor Checklist, the Katz Index of Independence in Activities of Daily Living, and the Lawton Instrumental Activities of Daily Living Scales. RESULTS: Nine of the participants reported prior fractures, suggesting that this could have been a risk factor for this group. Eighteen achieved the maximum independence score of six on the Katz Index of Independence in Activities of Daily Living; help with bathing was required by the other five. Of the Instrumental Activities of Daily Living, those requiring physical activity for home maintenance were the most problematic. Ability to perform Instrumental Activities of Daily Living was significantly related to ability to perform the activities required to live independently. CONCLUSIONS: Results suggest that achieving a functional level that will support independence is possible for older women who were residing independently prior to a hip fracture.     

Stroke patients and long-term training: is it worthwhile? A randomized comparison of two different training strategies after rehabilitation

OBJECTIVE: To find out if there were any differences in improvement and maintenance of motor function, activity of daily living and grip strength between patients with first-ever stroke receiving two different strategies of physical exercise during the first year after stroke. DESIGN: A longitudinal randomized controlled stratified trial. SETTING: Rehabilitation institutions, community, patients' homes and nursing homes. SUBJECTS: Seventy-five male and female first-time-ever stroke patients: 35 in an intensive exercise group and 40 in a regular exercise group. INTERVENTION: The intensive exercise group received physiotherapy with focus on intensive exercises in four periods during the first year after stroke. The regular exercise group patients were followed up according to their subjective needs during the corresponding year. MAIN OUTCOME MEASURES: Motor Assessment Scale, Barthel Index of Activities of Daily Living, and grip strength. RESULTS: Both groups improved significantly up to six months when function stabilized. The groups did not differ significantly on any test occasions. The difference of improvement from admission to discharge was significant in favour of the intensive exercise group, in the Motor Assessment Scale total score (intensive exercise group 7.5; regular exercise group 1.7, P = 0.01), and in the Barthel Index of Activities of Daily Living total score (17.4 versus 8.9, P = 0.04). CONCLUSION: Motor function, activities of daily living functions and grip strength improved initially and were maintained during the first year after stroke in all patients irrespective of exercise regime. This indicates the importance of motivation for regular exercise in the first year following stroke, achieved by regular check-ups.     

Katz index of independence in ADL. Reliability and validity in short-term care

This article deals with the Katz Index of Independence in Activities of Daily Living and presents a study of its reliability and validity carried out at a Department of Internal Medicine in Sweden. Enrolled nurses assessed independently 100 aged patients. Scalability and interobserver variability were tested with Guttman scale-analysis. The results indicated that the activities are ranked according to a cumulative scale and that the index is reliable. Patients independent in ADL had shorter hospitalization and were discharged home more often than were the dependent patients. This indicates that the scale is valid. One year later most dependent patients were either dead or living in institutions: thus the index has a predictive potential. The systematic errors of scale were used to refine the index for use in short-term care. It is recommended as a basic measure of functional ability among aged abled or disabled patients also in short-term care.     

Comparison of nurses' and physicians' documentation of functional abilities of older patients in acute care--patient records compared with standardized assessment

Aim:  To compare nurses' and physicians' documentation of geriatric issues and explore double documentation and undocumented areas of importance in an acute care setting in two Nordic countries.
Method:  158 participants, aged 75+, of whom the Minimum Data Set for Acute Care (MDS-AC) instrument was conducted at admission and from which 56 variables were taken in comparison with notes from patient records documented by nurses and/or physicians in two acute care hospitals, in Finland and Iceland.
Findings:  Documentation of the impairment of personal Activities of Daily Living (ADL) was missing in 40–60% of the nurses' reports and 80–97% of the physician's reports. Even poorer was the documentation of the impairment of Instrumental Activities of Daily Living (IADL), of which 75% was not reported by the nurses and 85–96% by the physicians . Cognitive function was recorded in only 30–40% of the cases.
Conclusions:  The traditional patient record in acute care setting lacks several variables of functional abilities of the older patients. Nurses took more responsibility in the documentation of functional abilities, compared with physicians, but they could improve. Using a standardized instrument such as the MDS-AC can improve documentation and make a basis for a clearer delineation in responsibilities for documentation between nurses and physicians and thereby improve outcome of care.     

A cross-validation of the comprehensive assessment of activities of daily living after stroke.

This study aimed to determine whether the Frenchay Activities Index and the Barthel Index assess different factors in stroke patients who survive for more than one year. The Frenchay Activities Index and the Barthel Index were administered via telephone interview. One hundred and twenty-four patients from the community participated in the study. All items of the Barthel Index and the Frenchay Activities Index, except reading books, were included in a factor analysis to determine the underlying constructs of the items. Four factors were found. One factor comprised all items from the Barthel Index and one item from the Frenchay Activities Index. The rest of the Frenchay Activities Index items loaded on three other factors. The combined scores, using simple transformation, had satisfactory distributions. The results support the hypothesis that the Frenchay Activities Index and the Barthel Index assess different factors in stroke patients who survive for more than one year. The Barthel Index score and the Frenchay Activities Index score could be combined to assess the entire range of activities of daily living functions in stroke.     

The Lawton instrumental activities of daily living scale

By detecting early functional decline, the scale can help nurses with discharge planning. OVERVIEW: Acute illness or a worsening chronic condition can hasten functional decline in older adults. During hospitalization, reduced mobility and other factors may rapidly decrease an older patient's ability to perform activities crucial for independent living, and the effects might be permanent. The Lawton Instrumental Activities of Daily Living (IADL) Scale assesses a person's ability to perform tasks such as using a telephone, doing laundry, and handling finances. Measuring eight domains, it can be administered in 10 to 15 minutes. The scale may provide an early warning of functional decline or signal the need for further assessment. For a free online video demonstrating use of this assessment, go to http://links.lww.com/A246.     

Effectiveness of an Acute Care for Elders unit at a long-term care facility for frail older patients with COVID-19

The Acute Care for Elders (ACE) is a model of care addressed to reduce the incidence of loss of self-care abilities of older adults occurring during hospitalization for acute illness.This observational study aimed to describe the effectiveness of an ACE unit at a long-term care facility to prevent functional decline (decrease in the Barthel Index score of >5 points from admission to discharge) in older adults with frailty (Clinical Frailty Scale score ≥5) and symptomatic COVID-19.Fifty-one patients (mean age: 80.2 + 9.1 years) were included. Twenty-eight (54.9%) were women, with a median Barthel index of 50 (IQR:30–60) and Charlson of 6(IQR: 5–7), and 33 (64.7%) had cognitive impairment.At discharge, 36(70.6%) patients had no functional decline, 6 (11.7%) were transferred to hospital and 4(7.8%) died.An ACE unit at a long-term care facility constitutes an alternative to hospital care to prevent hospital-associated disability for frail older patients with COVID-19.