Nr 1-2011 - sformatowany

Medical Rehabilitation 2011, 15 (1), 12-15

Contemporary methods in the evaluation of activities in daily living with Alzheimer disease Aktualne metody oceny czynności Ŝycia codziennego w chorobie Alzheimera Józef Opara 1(A,E,F), Waldemar Brola 2(F) 1 2

The Jerzy Kukuczka Academy of Physical Education in Katowice, Poland The St. Luke District Hospital in Konskie, Poland

Key words ADL, activities of daily living, Alzheimer disease, disability, instrumental ADL scales Abstract Alzheimer disease is known for placing a great burden on caregivers which include the social, psychological, physical and/or economic aspects. The disease diminishes patients` independence in activities of daily living (ADL). Home care is usually preferred by patients and families. The role of the main caregiver is often taken by the spouse or a close relative. Dementia caregivers are subject to high rates of physical and mental disorders. ADL scales are useful for the evaluation of patients` capacity and their needs for care and burden. Those scales enable one also to arrive ar the outcome measure of rehabilitation. One can divide them into three parts: universal (generic) basic ADL scales, basic scales which are specific for Alzheimer disease and instrumental - extended (expanded) ADL scales. In this paper the most commonly used scales evaluating activities of daily living in Alzheimer disease, including as equally basic as well as instrumental ADL scales, have been presented. Due to the systematic review we were able to present their psychometric properties: content validity, internal consistency, construct validity, criterion validity, reliability, responsiveness, floor-and ceiling effects, and interpretability. Those scales that received positive ratings have been presented. Słowa kluczowe choroba Alzheimera, czynności Ŝycia codziennego, ADL Streszczenie Starzenie się społeczeństw doprowadzi do wzrostu zapadalności na chorobę Alzheimera. W zaawansowanym stadium choroba uniemoŜliwia samodzielne wykonywanie nawet prostych czynności codziennych i osoba chorująca na chorobę Alzheimera wymaga stałej opieki. Ocena samodzielności osób z otępieniem jest bardzo waŜna – pozwala ona na oszacowanie potrzeb dotyczących opieki nad chorymi, gdyŜ pociąga to za sobą koszty i obciąŜenie opiekunów. W artykule przeglądowym przedstawiono aktualne moŜliwości oceny samodzielności w wykonywaniu czynności Ŝycia codziennego u osób z otępieniem – słuŜą do tego skale oceniające czynności podstawowe (ADL) i skale nazwane instrumentalnymi lub rozciągniętymi skalami ADL.

INTRODUCTION Alzheimer disease (AD) is the most frequent cause of dementia in individuals over the age of 65. It is estimated that around 200000 people suffer from the disease in Poland. Given the ageing of societies within Industrialised countries it is predicted that the number of suffers will treble by the year 2050. The incidence of AD increases with age – in individuals

over 65 years old a rate of 14% has been confirmed while in those over 80 the percentage is around 40%1. With time, besides memory disturbances, mood changes, cognitive functional and behavioural disorders there also appears apraxia. In the advanced stage of the disease this results in an inability to perform even the simplest day-to-day activities and those who suffer from Alzheimer’s require constant care.

The evaluation of independence in individuals with dementia is extremely important for it allows one to estimate the care needs of those who are ill as this brings with it costs and a burdening of carers. The ADL scales allows one to evaluate the results of rehabilitation2. For an evaluation of independence in the undertaking of daily activities in individuals with dementia scales assessing basic activities (basic ADL) are employed as

The individual division on this paper was as follows: A – research work project; B – data collection; C – statistical analysis; D – data interpretation; E – manuscript compilation; F – publication search; G – grant and funding acquisition Article received 28.04.2011; accepted: 14.06.2011

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Medical Rehabilitation e ISSN 1896-3250 © ELIPSA-JAIM & WSA Bielsko-Biała


well as scales referred to as instrumental or expanded ADL scales. In many works a correlation has been shown between ADL and the results of neuropsychological tests diagnosing dementia. Rosenthal et al.3 have shown a mutual connection between cognitive functions and independence in ADL performance. On the other hand, a routine evaluation of independence in ADL may result following a suspicion of dementia4. UNIVERSAL SCALES EVALUATING BASIC EVERYDAY ACTIVITIES Widely known scales are very helpful in an evaluation of ADL in dementias: the Barthel Index – (BI), the Katz Basic ADL Index or the Functional Independence Measure (FIM)5,6. The FIM may also be successfully applied 7 . For unknown reasons the universal scale that is Sheikh et al’s ADL Index, originally created for the evaluation of ADL in post-stroke patients, enjoys particular success amongst researchers into AD. The ADL Rivermead Scale described in 1980 and rehabilitated in 1990 is de facto an instrumental scale of day-to-day activities9,10. This scale is composed of three sections: looking after oneself, housework 1 and housework 2, comprising, in total, 31 activities. THE SCALE OF EVERYDAY LIFE ACTIVITIES SPECIFIC FOR ALZHEIMER’S DISEASE The three specific scales serve in the evaluation of basic ADL in dementias. These are: the ADL Scale in Blessed ADL Scale, the Bristol Scale and the Functional Activities Questionnaire (FAQ). The Blessed ADL Scale (DS) was described by Blessed, Tomlinson and Roth in 1965. In the modified version of 1988 by Erkinjuntti et al.12 the Revised Dementia Scale (RDS) comprises an evaluation of 13 ADL activities divided into two parts: in the first part, covering 10 activities, there is in force a points system of 0, 0.5 and 1, in the second part there are four possible points to select, from 0

to 311,12. The scale also allows patients to be differentiated with regard to the degree of dementia. In screening tests the cut off point 4 in the DS gave for a 90% rate of sensivity and 84% of specificity. In RDS the cut off point 1.5 gave a sensivity of 93% and a specificity of 97% in relation to the neuropsychological tests confirming dementia. These scales may be helpful in the evaluation of the degree of disability as well as in the planning of social support. The DS scale has its own Polish language version. The ADL Bristol scale described by Hughes et al.13 in 1982 was composed of an evaluation of 20 activities. In the modified version of 1996 developed by Bucks et al.4 of the Frenchay Hospital in Bristol the assessment involved 14 activities conducted on a 4-point scale from 0 to 3 points. Its high correlation with the Mini-Mental State Examination – MMSE14 – was shown . The research of Umayal et al.15 comparing the Bristol scale and the Blessed scale showed an optimal cut off point of 20 in the modified Bristol scale, which resulted in 100% sensivity and 74.2% specificity while the optimal cut off point in the modified Blessed scale was 10.5 resulting in a sensivity of 100% and specificity of 71%. Pfeffer et al.16 in 1982 developed the Functional Activities Questionnaire (FAQ). This came about through the selection of the most representative 10 activities for dementia from Lawton’s Instrumental Scale (ADL). The evaluation system ranges from 0 to 3 points. The scoring may be from 0 to 30 points, wherein 0 points constitute total independence from one’s surroundings while 30 total dependence16,17. Gélinas et al.18 created in 1999 a scale for Disability Assessment for Dementia (DAD). This assesses in the simplest system of zero-unary (yes or no) 40 activities of which 17 are connected with basic ADL, while 23 with instrumental ADL18. In 2009 Graessel et al.19 advanced the Erlangen Test of Activities of Daily Living (E-ADL-Test) evaluating the completion of 5 simple activities (the pouring of a drink, the cut-

ting of bread, the opening of a small cupboard, washing one’s hands, tying a bow). The way in which each activity is carried out is assessed on a scale of 0 to 6. The Erlangen Test turned out to be a useful instrument particularly in the evaluation of patients with moderate and severe dementia. Its displayed a high rate of reliability (Cronbach’s alpha = 0.77) as well as a high correlation with other scales: NOSGER (Nurse’s Observational Scale for Geriatric Patients – 0.60) and MMSE (0.72)19. INSTRUMENTAL (EXTENDED) ADL SCALES In the evaluation of more complicated daily activities in dementia cases the Instrumental (Extended) Activities of Daily Living Scales (ADL) are used. We have Sikkes et al.20 to thank for a systematic review of the ADL and IADL scales applied in the diagnosis and assessment of the results of dementia treatment. The authors, after the introduction of the key words: activities of daily living, dementia, Alzheimer, IADL, extended ADL, functional ability, everyday functioning and activities of daily living, searched the computer databases of PubMed (1950–2007), PsycINFO (1887–2007) as well as Embase (1996–2007)20. Several dozen publications describing the application of ADL questionnaires were subjected to analysis. Each of the 8 features on the scale was evaluated: content validity, internal consistency, construct validity, criterion validity, reliability, responsiveness, floor-and ceiling effects as well as interpretability20. After a selection was made 12 scales were evaluated altogether. Two ADL scales: the DAD and the Bristol ADL received two positive evaluations and were classified as being of moderate quality. Five scales: Activities of Daily Living Prevention Instrument (ADL-PI), Alzheimer Disease Activities of Daily Living International Scale (ADL-IS), Bayer Activities of Daily Living Scale (B-ADL), Cleveland Scale for Activities of Daily Living (CSADL) and Lawton IADL received a single positive evaluation. The results show that for the substan13


tiation of their use improvement is necessary and more data on the subject of the psychometric properties of the ADL scales in dementia is required. The Activities of Daily Living Prevention Instrument (ADL-PI) questionnaire comprises 20 positions, of which 15 evaluate daily activities, while 5 physical states. There was confirmed an ADL-PI correlation with the results of the CDR test (Clinical Dementia Rating)21. The Alzheimer Disease Activities of the Daily Living International Scale (ADL-IS) arose as a result of many years of inter-institutional cooperation. ADL-IS is composed of 40 positions formulated in 13 ADL categories. This scale shows high (> 0,80) correlations with the Global Deterioration Scale (GDS), with the MiniMental State Examination scale and with the Short Cognitive Performance Test (SKT) – a short cognitive test which is a screening test for testing memory disturbances, in a similar way to MMSE22. Another international scale, the Bayer Activities of Daily Living Scale (B-ADL) arose as a result of pilot tests conducted in the USA, Germany, Great Britain, Russia and Greece. B-ADL is composed of 25 positions23. In research conducted in Brazil B-ADL displayed a sensivity of 97% and a specificity of 88.1% at a cut off point of 2.58; while at a cut off point of 3.12 the sensivity was 87.9%, while the specificity 96.6%24. The Cleveland Scale for Activities of Daily Living (CSADL) evaluates 47 activities on a four-point scale 0, 1, 2 and 3. A high internal consistency is shown for the scale (Cronbach’s alpha = 0.98) for the general result and a high CSADL correlation with the Blessed Scale (0.88) and the evaluation of the cognitive functions by means of the MMSE (0.6)25. The Lawton & Brody Instrumental ADL published in 1969 evaluates on a three-level, four-level and five-level scale independence in carrying out eight activities: the ability to use the telephone, do the shopping, prepare meals, maintain the house, wash, travel, take medicines and the ability to deal with one’s finances26. The ac14

curacy of the scale was assessed by comparing it with 4 scales measuring similar features and showing a high coefficient correlation as well as a high internal consistency (0.85). Equally the reliability of the Lawton & Brody Scale was high (0.87–0.91)27. The scale has its own Polish-language adaptation with the testing of psychometric properties28. In 1999 Géelinas et al.18 described the Disability Assessment for Dementia (DAD). DAD covers 40 positions: 17 connected with basic functions done on one’s own and 23 instrumental daily activities. There was shown the high level of internal consistency (Cronbach’s alpha = 0.96), the excellent reliability of measurements conducted by various researchers (ICC = 0.95) and repeatability (test-retest = 0.96 ICC)18. Farina et al.29 applied the Functional Living Skills Assessment (FLSA). This is composed of 41 activities covering 8 ADL instrumental spheres evaluated on a scale of from 2 to 20 points. The maximum number of FLSA points is 135 29. The five-level Nurses’ Observation Scale for Geriatric Patients (NOSGER) was developed in Basle. This was chiefly designed for nursing staff and carers of geriatric patients. It comprises 30 positions covering 6 dimensions: memory, instrumental activities of daily life, being able to help oneself, mood, social behaviour and behaviour disorders (disturbing behaviours). An analysis of the reliability of the scale showed its large amount of internal consistency (Cronbach’s alpha for all the evaluated areas > 0.8)30,31. By way of the authors’ commentary on the subject of the practical selection of a scale for utilisation by a doctor in everyday practice: depending on the requirements and qualifications of the evaluator then we would recommend the Bristol scales with the goal of basic ADL evaluation and the Disability Assessment for Dementia (DAD) scales where there exists the need for instrumental evaluation. The first is short and easy to complete, while DAD contains equally various elements of basic evaluation as well as instrumental ADL in a zero-unary system.

CONCLUSIONS 1. From amongst the scales serving to evaluate independence in Activities of Daily Living (ADL) within the framework of Alzheimer’s Disease, first and foremost recommendation should be given to two scales: Disability Assessment for Dementia (DAD) and Bristol ADL. 2. In utilising the scales: Activities of Daily Living Prevention Instrument (ADL-PI), Alzheimer Disease Activities of Daily Living International Scale (ADL-IS), Bayer Activities of Daily Living Scale (B-ADL), Cleveland Scale for Activities of Daily Living (CSADL) and Lawton IADL it follows to be aware of their limitations. 3. A constant improvement in scales is evident as well as the conducting of further research with the aim of enriching the data on the subject of the psychometric properties of ADL scales as used in dementia. References 1. Szczudlik A., Liberski P., Barcikowska M. (ed.): Otępienie. Wyd. UJ, Kraków, 2004 2. Opara J.: NeuroRehabilitacja. ELAMED, Katowice, 2011 3. Rosenthal E., Brennan L., Xie S., Hurtig H., Milber J., Weintraub D. et al.: Association between cognition and function in patients with Parkinson disease with and without dementia. Mov. Disord., 2010; 25(9): 1170– 1176 4. Juva K., Mäkelä M., Erkinjuntti T., Sulkava R., Ylikoski R., Valvanne J., Tilvis R.: Functional assessment scales in detecting dementia. Age Ageing,1997; 26(5): 393–400 5. Gresham G.E., Duncan P.W., Stason W.B.: Rehabilitacja po udarze mózgu: ocena stanu pacjenta, wskazania do rehabilitacji i sposób postępowania. Rehab. Med., 1997; 1(2): 13– 25 (przedruk z: Topics in Stroke Rehabilitation, 1996, 3 (2), 1–25) 6. Opara J.: Klinimetria w udarach mózgu. Wydanie II rozszerzone. Wydawnictwo AWF, Katowice, 2010 7. Opara J., Szeliga-Cetnarska M., Chromy M., Dmytryk J., Ickowicz T.: SKALE UDARÓW „REPTY”. Wskaźnik funkcjonalny „Repty” dla oceny czynności Ŝycia codziennego u chorych z niedowładem połowiczym po udarze mózgowym. Część II. Neurol. Neurochir. Pol., 1998; 4: 813- 822 8. Sheikh K., Smith D.S., Meade T.W., Goldenberg E., Brennan P.J., Kinsella G.: Repeatability and validity of a modified activities of daily living (ADL) index in studies of chronic disability. Int. Rehabil. Med., 1979; 1(2): 51–58 9. Whiting S., Lincoln N.: An ADL assessment for stroke patients. Br. J. Occup. Ther., 1980; 2: 44–46 10. Lincoln N.B., Edmans J.A.: A re-validation of the Rivermead ADL scale for elderly patients with stroke. Age Ageing, 1990; 19(1): 19–24 11. Blessed G., Tomlinson B.E., Roth M.: The association between quantitative measures


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Address for correspondence Prof. Józef Opara Akademia Wychowania Fizycznego im. J. Kukuczki ul. Mikołowska 72b, 40–065 Katowice, Poland e-mail: [email protected]

Translated from the Polish by Guy Torr

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