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

Summary

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.

Abstract

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.

Introduction

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 impairment^2,3, 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 hospitalization^9,10. 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 term^12,13. In a hospitalized population, scores on measures of ADL were associated with muscle oxidative capacity and muscle function¹. Hence, assessing a patient's functional independence at an early stage of hospitalization is a priority; this assessment should then be compared with the patient'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’s ability to carry out basic ADL independently^15,16. 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’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’ 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’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.

Protocol

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 units present with numerous comorbidities and it is recommended that staff assess all such patients. In theory, the Katz ADL could be administered to all patients at risk of losing their independence due to an acute medical problem, which would include some younger patients. However, ADL dependence is infrequent in younger adults, as the prevalence of disabling diseases is low in that population. Nevertheless, the protocol could also be implemented in other departments, particularly internal medicine, cardiology, and neurology.

1. Protocol for administering the Katz ADL before hospitalization

1. Evaluate bathing activity.
   1. To evaluate bathing, ask patients how they bathe and whether they need someone to help them with bathing. If so, ask them which part of the body they require help with. Then, note whether they are independent (1 point) or dependent (0 point) in bathing activities.
      NOTE: Independent patients bathe their entire body alone, with the exception of the back, genital area, or a disabled extremity. Dependent patients need help to bathe several parts of their body, or to get in and out of the shower or bathtub.
2. Evaluate dressing.
   1. Ask patients whether they can dress and undress alone, and whether they can take their clothes out of the closet without help. Ask whether they need help with putting on socks or other items of clothing. Then, note whether they are independent (1 point) or dependent (0 point) in dressing activities.
      NOTE: An independent person gets their clothes out of the closet and puts them on, including fastening them where applicable. Shoe tying is not included among dressing activities. A dependent person needs some help with dressing or needs to be completely dressed by someone else.
3. Evaluate toileting.
   1. Ask patients whether they go to the toilet unassisted at home. Ask 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 (1 point) or dependent (0 point) in toileting.
      NOTE: An independent person goes to the toilet, sits and stands up from the toilet, arranges clothes, and cleans the genital area without help. A dependent person needs help transferring to the toilet and cleaning up, or uses a bedpan or commode.
4. Evaluate transferring.
   1. Ask patients whether they can move from the bed to a chair, and from a chair to the bed, without human assistance. Then, note whether they are independent (1 point) or dependent (0 point) in transferring.
      NOTE: An Independent person moves into or out of a bed or chair unassisted or using a mechanical transferring aid. A dependent individual needs help from another person to move from a bed to a chair or requires a complete transfer.
5. Evaluate continence.
   1. Ask patients whether they have complete self-control over urination and defecation. If not, ask whether they can use a urinary catheter or diaper without help. Then, note whether they are independent (1 point) or dependent (0 point) with respect to continence.
      NOTE: Independent patients exercise complete self-control over urination and defecation, or use a urinary catheter or diapers without help. The dependent person is partially or totally incontinent (bowel or bladder) and needs help to manage these functions.
6. Evaluate feeding.
   1. Ask patients whether they eat without help; if so, ask whether they are able to cut meat or open the lid of a yogurt container. Then, note whether they are independent (1 point) or dependent (0 point) in feeding activities. An independent person can eat a prepared and delivered meal without assistance.
      NOTE: An independent person transfers food from the plate into the mouth without help. A dependent person needs partial or total help with feeding.
7. Calculate the ADL score by summing the scores for all activities.

2. Administration of ADL scale on hospital admission

1. Bathing
   1. 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.
   2. Observe whether patients are able to do this on their own or whether they need guidance or help with certain parts of the body. Then, note whether they are independent or dependent in bathing (following the same definition of independent and dependent as in step 1.1).
2. Dressing
   1. During the first day of hospitalization, propose that patients get dressed. Ask them to choose clothes from the closet and put them on; if patients have difficulty, help them to get dressed.
   2. In the evening, follow the same procedure, but as applied to undressing.
   3. Note whether the patient is independent or dependent in dressing (following the same definition of independent and dependent as in step 1.2).
3. Toileting
   1. During the first few days of hospitalization, check whether patients are able to go to the toilet alone, sit and stand up from the toilet, arrange their clothing, and clean the genital area.
   2. Evaluate whether a commode or bedpan is needed. Note whether patients are independent or dependent in toileting (following the same definition of independent and dependent as in step 1.3).
4. Transferring
   1. On the first day of hospitalization, ask patients to transfer from the bed to a chair and from the chair to the bed. If patients have any difficulty, first offer mechanical transferring aids, and if necessary, help them to make the transfer. Then, note whether patients are independent or dependent for transferring (following the same definition of independent and dependent as in step 1.4).
5. Feeding
   1. 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. Help them if necessary. Then, note whether the patient is independent or dependent for eating (following the same definition of independent and dependent as in step 1.6).
6. Calculate the ADL score by summing the scores for all activities.

3. Compare functional independence scores before the acute medical problem and at the time of hospital admission

1. Identify the activities in which patients have lost independence during the acute medical problem. Identify activities in which patients were dependent prior to the problem.
2. Encourage patients to regain their lost independence through rehabilitative care.
3. Help to maintain any independence that was not lost during the acute medical problem.

4. Recalculate ADL score throughout hospitalization (twice per week)

1. Perform the same assessment steps described in Step 2.
2. Discuss the assessment results during a staff meeting where nurses, nurse assistants, physicians, and physiotherapists are present.
3. Compare ADL scores to identify improvement or deterioration of functional independence.
4. Maintain or modify rehabilitative care according to the evolution of functional independence; the goal is for patients to recover their former level of independence.

5. Evaluate the ADL score at discharge and compare it to the score prior to hospitalization

1. Determine whether patients have lost functional independence as a result of the acute medical problem.
2. Adapt the home help protocol as needed.

Results

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...

Discussion

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 0–6); subtle fluctuations in functional dependence may therefore be overlooked. The Barthel Index, which is generally comparable to the Katz ADL, yields weighted and summe...

Materials

Name	Company	Catalog Number	Comments
Clothing and underwear	Any
Hospital Bathroom with toilet
Meal Tray
Medical Bed	Any
Medical Chair	Any
Papers
Pens
Table Bed	Any