Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly
Assessment of Functioning
A multidimensional holistic assessment of an older person which considers health and wellbeing and
formulates a plan to address issues which are of concern to the older person ( and their family and carers when relevant ) ,
arranges interventions according to the plan and then reviews the impact.
The Assessment of Funtioning is one of 8 domains of the Comprehensive Geriatric Assessment (CGA)
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MODIFIED BARTHEL INDEX
The scale was introduced in 1965, and yielded a score of 0–20 (Mahoney F, 1965).
Although this original version is still widely used, it was modified in 1979, when it came to include 0–10 points for every variable (Granger CV, 1979).
Further refinements were introduced in 1989 in the form of the Modified Barthel Index because the original scale was insensitive to change and had arbitrary scores (Shah S, 1989).
This modified sensitized version yields a score of 0-100, thereby lending itself to expression of the total score as a percentage of dependence or independence. For example, a score of 80/100 represents 80% independence and 20% dependence.
Sequential scoring over time provides a measure of declining or improving degree of dependence.
The Modified Barthel Score has proved itself effective not just with in-patient rehabilitation, but also in home care, nursing care, skilled nursing, and community settings (O'Sullivan SB, 2007).
The following Table sets out the dependency needs and the recommended hours of help required per week for each dependency level
THE LAWTON IADL SCALE
The Lawton IADL scale was developed by Lawton and Brody in 1969 to assess the more complex ADLs necessary for living in the community (Lawton MP, 1969).
The scale had nearly equal validity in a population of rural older adults whether scored with simple or more complex systems (Vittengl JR, 2006).
It is appropriate for use with community dwellers as well as older adults admitted to a hospital, a short-term skilled nursing facility, or a rehabilitation facility.
The scale is generally not useful for older adults in long-term care facilities, where residents perform few IADLs without assistance.
The Lawton IADL scale takes 10 to 15 minutes to administer and contains eight items, with a summary score from 0 (low function) to 8 (high function).
Each ability measured by the scale relies on either cognitive or physical function, though all require some degree of both (Ng TP, 2006).
The scale can be administered with a written questionnaire or by interview. The patient or a knowledgeable family member or caregiver may provide answers.
Older adults may be reluctant to participate in a functional assessment if they fear losing independence as a result. They may report that their living situation is adequate even if it is not.
With all assessments of older adults, taking a "matter-of-fact approach," establishing rapport and explaining that the questions are a normal part of the assessment (Lach HW, 2007).
Asking about a typical day can be helpful for starting the assessment, as can highlighting a person's strengths rather than seeming to focus entirely on functional deficits.
Emphasize that the goal is to work with patients to create the safest possible ongoing plan, which may evolve as they recover, and often a person may be able to remain at home with additional help.
Responses to each of the eight items in the scale will vary along a range of levels of competence-from independence in performing the activity to not performing it at all.
It is not necessary to ask the questions in sequence as they appear on the tool. If a patient is talking about shopping for groceries, it is fine to discuss transportation at that time as well. Or the interviewer may first ask "what is your typical dinner?" before asking how the patient prepares meals.
If the patient (or other informant) identifies independence with an activity, additional questions are unnecessary. If dependence in an activity is identified, additional information is needed to assess the extent of the deficit and how the deficit is accommodated.
The Lawton IADL scale can be scored in several ways.
The most common method is to rate each item either dichotomously (0 = less able, 1 = more able) or trichotomously (1 = unable, 2 = needs assistance, 3 = independent) and sum the eight responses.
The higher the score, the greater the person's abilities.
Women are scored on all 8 areas of function, but, for men, the areas of food preparation, housekeeping, laundering are excluded.
Clients are scored according to their highest level of functioning in that category.
The final total score ranges from 0 (low function, dependent) to 8 (high function, independent) for women, and 0 through 5 for men.
The final total score may be presented as a percentage of function.
For example, a total score of 6 out of 8 would represent 75% function (75% independence, 25% dependence).
Sequential scoring over time provides a measure of declining or improving degree function and dependence.
In the acute care setting it's likely that only one IADL assessment will be needed, unless the patient has confusion that improves during the hospital stay.
In other settings, repeated administration of the Lawton IADL Scale is useful to assess patients' loss of function or recovery of function over time.
When a person has a cognitive impairment such as dementia, explanations should be simple and instructions given in one- or two-part commands. Patients with dementia may mirror your mood. If you are rushed and stressed, they may become agitated.
If possible, information obtained from a person with dementia should be corroborated by speaking (with documented due permission) with family or friends.
The content of IADL measures often reflects specific cultural concerns; for example, British measures frequently include the ability to make a cup of tea (Ward G, 1998).
IADL scales have been said to overemphasize tasks customarily performed by women and so overestimate dependency in men."
Dependence in an IADL may in some cases be "situational" rather than functional, as when a widower can shop and prepare food but needs to be taught how to do so after his spouse's death.
Married men’s need for help in IADL tasks may in some cases be attributable not to functional deficit but to their perceptions that those tasks were "women's work." (Allen SM, 1993).
This Read More page is an extension of
Assessment of Functioning
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