Transcript ADLs - University of Michigan–Flint

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/allmeasure
s.aspx?PageView=Shared&View={0C859D90-74784C9B-9575784C4A9A2D85}&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)
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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
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•
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•
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 performancebased 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.
Activities
Points (1 or 0)
BATHING
Points: __________
Katz Index
DRESSING
Points: __________
TOILETING
Points: __________
TRANSFERRING
Points: __________
CONTINENCE
Points: __________
FEEDING
Points: __________
Independence
(1 Point)
NO supervision, direction or
personal assistance
Dependence
(0 Points)
WITH supervision, direction,
personal assistance or total care
(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
(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.
(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.
(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.
(1 POINT) Exercises complete
self control over urination and
defecation.
(0 POINTS) Is partially or totally
incontinent of bowel or bladder
(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.
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
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operational definitions
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
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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
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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…..