Name: assessment of dependence in activities of daily living among older patients in an acute care unit
Uploaded: 2020-09-30T13:00:00
Description: Watch this Scientific Journal Video about Assessment of Dependence in Activities of Daily Living Among Older Patients in an Acute Care Unit at JoVE.com

The University of Bordeaux and University Hospital of Bordeaux supported this publication.

The protocol has been approved by the human research ethics committee of the University Hospital of Bordeaux.
NOTE: The protocol described in this section involves evaluation of ADL dependence using the Katz ADL. The six activities assessed are described above18. The Katz ADL is administered at the Bordeaux University Hospital, on admission and discharge, to all patients over 75 years of age, i.e., all those in acute geriatric medicine wards. Inpatients in geriatric uni...

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E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reliability+of+Katz's+Activities+of+Daily+Living+Scale+when+used+in+telephone+interviews.">Reliability of Katz's Activities of Daily Living Scale when used in telephone interviews.</a> Evaluation &amp; the Health Professions. 16 (2), 190-203 (1993).</li><li>Carvalho, T., Polachinido Valle, A., Ferrari Jacinto, A., Ferreira de S&#225; Mayoral, V., Fortes Villas Boas, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impact+of+hospitalization+on+the+functional+capacity+of+the+elderly:+A+cohort+study.">Impact of hospitalization on the functional capacity of the elderly: A cohort study.</a> Revista Brasileira de Geriatria e Gerontologia. 21, 134-142 (2018).</li><li>Mahoney, F. I., Barthel, D. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Functional+Evaluation:+The+Barthel+Index.">Functional Evaluation: The Barthel Index.</a> Maryland Medicine Journal. 14, 61-65 (1965).</li><li>Peres, K., Verret, C., Alioum, A., Barberger-Gateau, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+disablement+process:+factors+associated+with+progression+of+disability+and+recovery+in+French+elderly+people.">The disablement process: factors associated with progression of disability and recovery in French elderly people.</a> Disability and Rehabilitation. 27 (5), 263-276 (2005).</li><li>Lawton, M. P., Brody, E. 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The protocol is not appropriate in all situations 
Our protocol was designed for patients who have been hospitalized for an acute medical problem. However, other tools, such as the Barthel Index, should be used in rehabilitation centers. The original Katz ADL scale scores functional ability only on a 7-point scale (scores of 0&#8211;6); subtle fluctuations in functional dependence may therefore be overlooked. The Barthel Index, which is generally comparable to the Katz ADL, yields weighted and summe...

Medical problems can cause older people to lose functional independence, rendering them unable to carry out activities of daily living (ADL) without assistance from others. This loss of independence, which often results from cardiovascular comorbidities1, cognitive impairment2,3, and visual impairment4, impacts patient quality of life5 and life expectancy6, and increases healthcare costs7. Functional independence may progressively deteriorate, or be lost completely, with more severe comorbidities (cognitive impairment, heart failure, etc.). It may also worsen during an acute medical problem, such as stroke, myocardial infarction, lower limb fracture, or chest infection8. About 30% of patients aged between 70 and 80 years, and 60% of those aged over 80 years, experience such a loss of independence during hospitalization9,10. Patients may recover the functional independence they enjoyed prior to the acute medical problem, or it may persist thereafter despite appropriate treatment.
It is widely accepted that treatment aimed at maintaining or restoring functional independence during hospitalization for an acute medical problem is most effective if it is started as soon as possible11. Physical exercise during hospitalization improves function in the short and medium term12,13. In a hospitalized population, scores on measures of ADL were associated with muscle oxidative capacity and muscle function1. Hence, assessing a patient&#39;s functional independence at an early stage of hospitalization is a priority; this assessment should then be compared with the patient&#39;s level of ADL independence before hospitalization (baseline). Medical care, particularly nursing care, is aimed at restoring any loss of independence or maintaining the existing level thereof. This requires a reliable and reproducible assessment method; the most commonly used measure for this purpose is the Katz Index of Independence in Activities of Daily Living (Katz ADL).
The Katz ADL, developed in 1970, allows assessment of a patient&#8217;s ability to carry out basic ADL independently15,16. The scale measures patient independence in six activities: bathing, dressing, toileting, transferring, continence, and feeding. Each activity is scored as 0 or 1, where a score of 0 indicates dependence on another person, and 1 indicates independence. A total Katz ADL score of 6 denotes full independence, a score of 4 moderate dependence, and a score of 2 or less severe dependence.
For many years, the Katz ADL has proven useful in the assessment of functional status in older people. First, the Katz ADL assessment is very simple to perform and involves interviewing the patient or family members about the patient&#8217;s ability to perform the six ADL activities, or directly observing how well the patient performs these activities17. Furthermore, during an acute medical problem, the Katz ADL Index is sensitive to major, but not to minor, changes in health status. Thus, this tool is ideal for assessing the impact of an acute medical problem on patients&#8217; functional status, whatever their chronic morbidities.
When initiating rehabilitation within the first days of an acute medical problem, it is necessary to determine the extent of the patient&#8217;s functional decline. For this purpose, we propose that the functional status of each patient should be assessed before hospitalization via interview, and that the ability to perform ADL be assessed within the first days of hospitalization via observation. These two assessments could guide early preventive and rehabilitative measures in parallel with a care plan for the acute event. The effectiveness of these measures for promoting recovery of functional independence can be monitored by repeated ADL assessment until discharge.

<table>
	<tbody>
		<tr>
			<td>Clothing and underwear</td>
			<td>Any</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Hospital Bathroom with toilet</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Meal Tray</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Medical Bed</td>
			<td>Any</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Medical Chair</td>
			<td>Any</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Papers</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Pens</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Table Bed</td>
			<td>Any</td>
			<td></td>
			<td></td>
		</tr>
	</tbody>
</table>

assessment of dependence in activities of daily living among older patients in an acute care unit

During an acute medical problem, older people may lose functional independence. ADL scales are used to assess this loss of independence. The simplest and most convenient ADL scale is the Katz Index, which measures six ADL: bathing, dressing, toileting, transferring, continence, and feeding. A lower ADL score indicates greater loss of functional independence. The ADL score prior to the acute medical problem (baseline) is estimated by questioning the patient or the caregivers, and this score is then compared with that on hospital admission. The ADL score should be monitored from hospital admission until discharge to allow early detection of changes in functional independence. Identifying any loss of functional independence before and during hospitalization provides information to caregivers regarding the risk of short-term mortality risk and complications, and the prognosis after hospitalization.

Here, we consider two example cases after completion of the protocol: one with full recovery of the baseline level of ADL function at discharge, and one with no or partial recovery.
Discharged with baseline level of ADL function 
In this group of patients, two ADL function trajectories were possible, as shown in Figure 1: patients who maintained their ADL score throughout hospitalization (Trajectory A) and those whose score at hospitalization...

Watch this Scientific Journal Video about Assessment of Dependence in Activities of Daily Living Among Older Patients in an Acute Care Unit at JoVE.com

Assessment of Dependence in Activities of Daily Living Among Older Patients in an Acute Care Unit

During acute medical problems, older people may lose independence in activities of daily living (ADL). Assessment of baseline ADL and ADL on admission can guide personalized treatment plans aimed at preventing nosocomial dependence and ensuring better functional outcomes.

During an acute medical problem, older people may lose functional independence. ADL scales are used to assess this loss of independence. The simplest and ...

Our protocol make it possible to assess the evolution of functional independence of elderly patients during hospitalization for an acute medical episode. The ADL score is reproducible, easy to use, and can be used to join as a loss of functional independence at an early stage to allow adaptation of the rehabilitation care plan. To evaluate bathing, ask patients how they bathe and whether they need someone to help them with bathing.If so, ask which part of the body they require help with and note whether they're independent or dependent in bathing activities. Ask patients whether they can dress and undress alone and whether they can take their clothes out of the closet without help. Then ask whether they need help with putting on socks or other items of clothing and note, whether they are independent or dependent in dressing activities.Ask patients whether they go to the toilet unassisted at home and whether they can sit down and stand up from the toilet, arrange their clothing as needed, and clean the genital area without help. Then note whether they are independent or dependent in toileting. To evaluate transferring, ask patients whether they can move from bed to chair and from chair to bed without human assistance and note whether they are independent or dependent in transferring.Then ask patients whether they have complete self control over urination and defecation, and whether they can use a urinary catheter or diaper without help. Note whether the patients are independent or dependent with respect to continence. Finally, ask patients whether they eat without help and if they're able to cut meat or to open the lid of a yogurt container, and note whether they are independent or dependent in feeding activities.Then sum of the scores for all of the activities to determine the ADL score. During the first day of hospitalization, offer patients a shower. If they feel able to take one, accompany them to the bathroom and check whether they are able to wash by themselves.If patients do not feel able to do this, offer to wash them in bed or at the basin. After observing whether the patient can breathe alone or if they need guidance or help with certain parts of the body, note whether they are independent or dependent in bathing. During the first day of hospitalization, propose that patients get dressed, asking them to select clothes from the closet and to put them on.If patients have difficulty help them to get dressed. In the evening, follow the same procedure, but as applied to undressing. Then note whether the patients are independent or dependent in dressing.During the first few days of hospitalization, check whether patients are able to go to the toilet alone, sit upon, and stand up from the toilet, arrange their clothing, and clean the genital area. Note whether patients are independent or dependent in toileting. Evaluate whether a commode or bedpan is needed and note whether patients are independent or dependent in continence.On the first day of hospitalization, ask patients to transfer from the bed to a chair and from the chair to a bed, offering mechanical transferring aids and helping them to make the transfer as necessary. Note whether patients are independent or dependent for transferring. During the first meal at the hospital, observe whether patients are able to eat alone, including cutting meat and opening the lid of a yogurt container, and help if necessary.Note whether the patient is independent or dependent for eating. Then sum the scores for all of the activities to determine the ADL score. In this group of patients with favorable ADL dependence trajectories, two ADL function trajectories were possible.Patients who maintained their ADL score throughout hospitalization and those who's score at hospitalization was lower than at baseline, but who regained their baseline level of function by discharge. Patients were discharged when their baseline ADL function had an 83.8%or 67%chance of maintaining function for one month and one year after discharge, respectively. The mortality rate for both groups was 17.8%In this group of patients with unfavorable ADL dependence trajectories, three types of cases were identified.Patients who retained their baseline independence on admission to the hospital, but showed deterioration during hospitalization and did not regain full independence thereafter, patients who lost their baseline independence prior to hospitalization and did not regain it during hospitalization, and patients who showed deterioration of independence both prior to and during hospitalization and who did not regain full independence. Of the patients discharged with new or additional disability in ADL, 33.5%recovered their baseline level of ADL function within the first month after discharge, and 30.1%did so within the first year. The one year mortality rate was 41.3%for these patients.The most important thing to remember is that for the protocol to be effective, the score must be noted regularly during hospitalization. Our protocol allows us to identify patients who should receive rehabilitation care on the priority as is in order to start them in the program as soon as possible.

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