ADLs

Min H. Huang, PT, PhD, NCS

Learning Objectives

• Apply tests and measures for the examination of ADLs for a geriatric client

• Interpret and analyze the examination findings of ADLs in geriatric clients

• Formulate hypotheses of the variables associated with limitations in ADLs for geriatric clients

ADLs Outcome Measures References

• Geriatric Examination Tool Kit http://web.missouri.edu/~proste/tool/funct/index.htm

• Rehabilitation Measures Database http

://www.rehabmeasures.org/rehabweb/allmeasures.aspx?PageView=Shared&View={0C859D90-7478-4C9B-9575-784C4A9A2D85}&FilterField1=Journal&FilterValue1=Activities%20of%20Daily%20Living

Progression of loss of ADL ability (Jagger 2001)

• LE strength (bathing, mobility, toileting) appear to be lost before UE strength (dressing, feeding)

• With increase in # of diseases: greater chance of difficulty with ADL completion

• Rates of progressive disability increase with age and are greatest with those >85y.o. (Guralnik et al 2001)

• Increased risk of ADL disability with age

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Age at onset of ADL disability (n=1,344) (Jagger 2012)

Median age in years of onset of disability in ADL by sex

• The order of onset of disability for ADLs is invariant across sex and age group

• Women had a higher risk of disability in bathing (relative risk = 1.6)

Importance of ADLs

• Role of self satisfaction and performance of ADLs

• Many ADLs viewed differently to each person (between patients and also between patient & therapist)

• IADLs more sensitive in detecting dysfunction in elderly than ADLs due to ‘ceiling effect’ (Ward 1998)

J. Blackwood

J. Blackwood

Measuring Independence in the Elderly

• Many different instruments available: Katz Index of ADL Barthel Index FIM (ranges from 1: complete dependence to 7:

complete independence)

• Either: self report, observational ratings, or direct examination by trained professionals.

Implicit Hierarchy of Actions, Tasks, and Activities

• Actions: e.g. rolling, bending, sitting, standing, lifting, and reaching.

• Actions involve multiple systems to maintain a posture, transition to other postures, or perform safe and efficient movements.

• Tasks and Activities: e.g. bathing, dressing, grooming, cooking, and driving.

Breaking Down Tasks and Activities for Analysis

• Some functional tasks and activities may need to be analyzed more precisely Critical element of movement that is needed in order

to carry out the task safely or efficiently

• Example: elements of movement involving in bed mobility (1) scooting in bed (2) rolling onto the side (3)

lowering the legs (4) sitting up (5) balancing at the edge of the bed

A functional loss of independence in bed mobility can result from any of these elements

Key Questions for Interpreting Test Results

• What are the normal movements necessary to perform the task?

• Which impairments inhibit performance or completion of the task?

• Are the patient’s functional deficits the result of impaired communication, perception, vision, hearing, or cognition?

Purpose of Examination of Function

• For setting functional goals and expected outcomes of interventions

• Indicators of a person’s initial abilities• Criteria for placement decisions• Indicators of a person’s level of safety in

performing a task• Evidence of the effectiveness of a specific

intervention on function

Type of Instruments

• Performance-based Observational assessment Administered by a therapist who observes the

patient during the performance of an activity

• Self-Reports The patient is asked directly either by the

therapist or a trained interviewer or through the use of a self-administered report instrument

Performance-Based Tests of ADLs

• What a patient can do under a specific circumstance, which may or may not be similar to the individual’s actual environment.

• Often do not measure a specific BADL or IADL in the real world of the patient.

• Described the patient’s current level of function or the maximum level of function possible.

• e.g. “Push your wheelchair over to that red chair (as quickly as you can) and stop” – testing usual (maximum) capacity; 6-minute walk, Timed up & go.

Self-Reported Assessment of ADLs

• Tests need to be designed in a standard format to measure function accurately and without bias.

• Limited by the patient’s mental capacity and the clinician’s training in administering the test.

• A self-report is a valid method of determining function and may be preferable to performance-based methods In some circumstances.

• Distinguish between “habitual” (e.g. “Do you cook your own meals?) vs. “perceived” (e.g. If you had to, could you cook your own meals?”) capacity of performance.

Self-Reported Assessment of ADLs

• Gives self report of perceptions of disability and may indicate better at how they will function

• Heavily influenced by psychological state during testing.

• Susceptible to bias (say what you want to hear, fears of institutionalization)

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Self-Reported Walking Ability Predicts Functional Mobility Performance in Frail Older Adults

• Self-reported physical function Katz activities of daily living (ADL) items Rosow-Breslau items: ability to do heavy work

around the house, walk up stairs, and walk a half mile

Nagi items: difficulty stooping, crouching, kneeling, reaching above shoulder level, pushing or pulling a large object, lifting or carrying weights over 10 lb, writing or handling small objects.

www.ncbi.nlm.nih.gov/pubmed/11083316 Alexander 2000

Alexander 2000

Self-Reported Walking Ability Predicts Functional Mobility Performance in Frail Older Adults

• Performance measures (ability and time taken to perform the task) Walking tasks: walk 10 ft, turn 180 degrees, and

return 10 ft, tandem walk, walk up and down 2 steps, 360 degree turn.

Maintaining stance: bipedal stance with eyes open/closed, lean as far forward/backward as possible, tandem stance, one leg stance with eyes open/closed.

Chair rise: from a variety of seat heights with and without the use of hands for assistance.

www.ncbi.nlm.nih.gov/pubmed/11083316 Alexander 2000

Alexander 2000

Self-Reported Walking Ability Predicts Functional Mobility Performance in Frail Older Adults

• Self-reported items related to walking, such as self-report on Katz ADL walking item and the Rosow-Breslau items (the ability to do heavy work around the house, walk up stairs, and walk a half mile), are better predictors of functional performance of the mobility tasks of walking, maintaining stance and chair rise.

ActivitiesPoints (1 or 0)

Independence(1 Point)

NO supervision, direction or personal assistance

Dependence(0 Points)

WITH supervision, direction, personal assistance or total care

BATHING  Points: __________

(1 POINT) Bathes self completely or needs help in bathing only a single part of the body such as the back, genital area or disabled extremity

(0 POINTS) Need help with bathing more than one part of the body, getting in or out of the tub or shower. Requires total bathing

DRESSING  Points: __________

(1 POINT) Get clothes from closets and drawers and puts on clothes and outer garments complete with fasteners. May have help tying shoes.

(0 POINTS) Needs help with dressing self or needs to be completely dressed.

TOILETING  Points: __________

(1 POINT) Goes to toilet, gets on and off, arranges clothes, cleans genital area without help.

(0 POINTS) Needs help transferring to the toilet, cleaning self or uses bedpan or commode.

TRANSFERRING  Points: __________

(1 POINT) Moves in and out of bed or chair unassisted. Mechanical transfer aids are acceptable

(0 POINTS)Needs help in moving from bed to chair or requires a complete transfer.

CONTINENCE  Points: __________

(1 POINT) Exercises complete self control over urination and defecation.

(0 POINTS) Is partially or totally incontinent of bowel or bladder

FEEDING   Points: __________

(1 POINT) Gets food from plate into mouth without help. Preparation of food may be done by another person.

(0 POINTS) Needs partial or total help with feeding or requires parenteral feeding.

Katz Index

Barthel Index

• 10 activities of ADLs• Items are rated based on the amount of

assistance required to complete each activity

• 3 point scale 0, 5, 10 or 15 which gives more weight to

mobility & continence over others

• Modified Barthel Index Changes scoring system (1-5) and better

operational definitions J. Blackwood

Barthel Index scoring form

Barthel Index scoring form

FIM (Functional Independence Measure)

• Not free• 18 items (13 motor tasks, 5 cognitive tasks)• Rated on 7 point scale from complete

independence to total assistance• Scores range from 18 (lowest) to 126 (highest)

indicating level of function• Assess ADL deficits, motor, and cognition• More application for institutionalized persons• Scores are generally rated at admission and

discharge (often daily at inpatient rehab)

Suggestions for safety of ADLs

• Evaluate the pt and determine the safest way to perform the activity.

• Give training in the method and use of equipment.

• Determine if the client can consistently perform the activity safely and any assistance needed.

• Arrange for supervision if not Independent with task.

• Help arrange for someone to check up on pt if they live alone.

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Interventions to assist with ADLs

• 3 options modify behavior use assistive devices accept assistance from caregivers

• Values, lifestyle, cost & degree of disability play a role in accepting interventions

• Barriers and poor maintenance of outdoor environments can impede mobility.

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Assessing independence with ADLs

• In order for a person to be truly independent with an ADL or IADL they must function at all arenas independently. This presents a challenge in the geriatric population because although they may be independent with one area of an ADL, in the total picture they might not be. e.g. food prep (making a list=>shopping=>)

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Types of Interventions to Assist with ADLs

• Assistive devices Physical and sensory Stigma may be attached

• Environmental modifications e.g. raised toilet seat, grab bars, ramps ‘Homey’ factors impact compliance Barriers in the home highly underreported

with self-report ADL assessments

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Pulling it all together: Association between Impairments, Activity, and Participation

• How do we formulate a hypothesis on the causes underlying an observed functional impairment?

• Studies have examined various variables measured at each ICF domain and analyzed the correlation between these variables.

• More research work needs to be done…..