Our nation is aging. By 2030, 20% of the population will be over the age of 65. It is estimated that 1.5 million new cases of cancer were diagnosed in 2009 and over 500,000 cancer-related deaths occurred. Of these, approximately 60% of cancer cases and 70% of cancer-related deaths will occur in individuals aged 60 years and older. As the population ages, it is increasingly important that doctors and oncologists characterize the “functional age” of older patients with cancer in order to tailor treatment decisions and stratify outcomes on the basis of factors other than chronologic age, and develop interventions to optimize cancer treatments.
Mrs. S is an 80-year-old woman with a history of hypertension presenting to her primary care provider. She was recently hospitalized and discharged from a skilled nursing facility due to an ankle fracture received as a result of a car accident in which she was the driver. She completed rehabilitation and has since returned home. Prior to the accident, she was living alone. However, her son now checks in on her more frequently and calls her twice a day. At this point, she is also afraid of driving and has been relying on public transportation and family members.
Over the next year, Mrs. S becomes increasingly anxious and depressed. She describes “not feeling well” and weight loss. Lab tests are unremarkable. Her son brings concerns of depression to her primary doctor’s attention and she is started on Citalopram. Repeat clinical breast exams reveal bilateral breast masses, the right greater than the left.
What information from a geriatric assessment would help guide treatment?
Physiologic reserve, functional status, cognition, and comorbidity vary considerably among older adults as a result of the aging process. Given this heterogeneity of factors, a geriatric assessment (GA) may help in managing the older patient with cancer.
Overview of the Geriatric Assessment
A geriatric assessment includes an evaluation of an older individual’s functional status, medical conditions (comorbidities), cognition, nutritional status, psychological state, and social support, as well as a review of the patient’s medications ( Table 4-1 ). A meta-analysis of 28 controlled trials demonstrated that Comprehensive Geriatric Assessment (CGA), if linked to geriatric interventions, reduced early rehospitalization and mortality in older patients through early identification and treatment of problems. The components examined in GA can predict morbidity and mortality in older patients with cancer, and can uncover problems relevant to cancer care that would otherwise go unrecognized. This approach to cancer care can facilitate individualizing the options for cancer management, quality of life, and prognosis.
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Three fundamental concepts guide geriatric assessment and the resulting medical management. At the core of geriatric assessment is functional status, both as a dimension to be evaluated and as an outcome to be improved or maintained. The maintenance and restoration of functional status is an essential overriding objective of good geriatric and geriatric oncologic care. A second overarching concept guiding geriatric assessment is prognosis, particularly life expectancy. Finally, geriatric assessment must be guided by patient goals.
Physical Function
Functional Status
Functional status and disability reflect the interactions among multiple medical conditions, physiologic aging, psychosocial support, cognitive impairment, and the overall health and vitality of the individual. Functional evaluation can add a dimension beyond the usual medical assessment, providing information on patient care needs and prognosis.
The choice of functional assessment tool depends upon the characteristics of the population (community-dwelling, hospitalized, nursing home residents) and the level of function being assessed. Function can be assessed by self-report, proxy report, performance-based testing, or a combination of these approaches.
Self-Reported Tools to Measure Functional Status
Activities of Daily Living (ADLs and IADLs, Tables 4-2 and 4-3 )
Most commonly, older adults’ functional status is assessed at two levels: activities of daily living (ADLs) and instrumental activities of daily living (IADLs). ADLs are self-care tasks, such as:
| In each category, circle the item that most closely describes the person’s highest level of functioning and record the score assigned to that level (either 1 or 0) in the blank at the beginning of the category. | |
| A. Toilet | _____ |
| 1.Care for self at toilet completely; no incontinence 2.Needs to be reminded, or needs help in cleaning self, or has rare (weekly at most) accidents 3.Soiling or wetting while asleep more than once a week 4.Soiling or wetting while awake more than once a week 5.No control of bowels or bladder | 1 0 0 0 0 |
| B. Feeding | _____ |
| 1.Eats without assistance 2.Eats with minor assistance at meal times and/or with special preparation of food, or help in cleaning up after meals 3.Feeds self with moderate assistance and is untidy 4.Requires extensive assistance for all meals 5.Does not feed self at all and resists efforts of others to feed him or her | 1 0 0 0 0 |
| C. Dressing | _____ |
| 1.Dresses, undresses, and selects clothes from own wardrobe 2.Dresses and undresses self with minor assistance 3.Needs moderate assistance in dressing and selection of clothes 4.Needs major assistance in dressing but cooperates with efforts of others to help 5.Completely unable to dress self and resists efforts of others to help | 1 0 0 0 0 |
| D. Grooming (neatness, hair, nails, hands, face, clothing) | _____ |
| 1.Always neatly dressed and well-groomed without assistance 2.Grooms self adequately with occasional minor assistance, e.g., with shaving 3.Needs moderate and regular assistance or supervision with grooming 4.Needs total grooming care but can remain well-groomed after help from others 5.Actively negates all efforts of others to maintain grooming | 1 0 0 0 0 |
| E. Physical Ambulation | _____ |
| 1.Goes about grounds or city 2.Ambulates within residence on or about one block distant 3.Ambulates with assistance of (check one) a ( ) another person, b ( ) railing, c ( ) cane, d ( ) walker, e ( ) wheelchair 1.__Gets in and out without help. 2.__Needs help getting in and out 4.Sits unsupported in chair or wheelchair but cannot propel self without help 5.Bedridden more than half the time | 1 0 0 0 0 |
| F. Bathing | _____ |
| 1.Bathes self (tub, shower, sponge bath) without help 2.Bathes self with help getting in and out of tub 3.Washes face and hands only but cannot bathe rest of body 4.Does not wash self but is cooperative with those who bathe him or her 5.Does not try to wash self and resists efforts to keep him or her clean | 1 0 0 0 0 |
| In each category, circle the item that most closely describes the person’s highest level of functioning and record the score assigned to that level (either 1 or 0) in the blank at the beginning of the category. | |
| A. Ability to Use Telephone | _____ |
| 1.Operates telephone on own initiative; looks up and dials numbers 2.Dials a few well-known numbers 3.Answers telephone but does not dial 4.Does not use telephone at all | 1 1 1 0 |
| B. Shopping | _____ |
| 1.Takes care of all shopping needs independently 2.Shops independently for small purchases 3.Needs to be accompanied on any shopping trip 4.Completely unable to shop | 1 0 0 0 |
| C. Food Preparation | _____ |
| 1.Plans, prepares, and serves adequate meals independently 2.Prepares adequate meals if supplied with ingredients 3.Heats and serves prepared meals or prepares meals but does not maintain adequate diet 4.Needs to have meals prepared and served | 1 0 0 0 |
| D. Housekeeping | _____ |
| 1.Maintains house alone or with occasional assistance (e.g., domestic help for heavy work) 2.Performs light daily tasks such as dishwashing, bed making 3.Performs light daily tasks but cannot maintain acceptable level of cleanliness 4.Needs help with all home maintenance tasks 5.Does not participate in any housekeeping tasks | 1 1 1 1 0 |
| E. Laundry | _____ |
| 1.Does personal laundry completely 2.Launders small items; rinses socks, stockings, etc. 3.All laundry must be done by others | 1 1 0 |
| F. Mode of Transportation | _____ |
| 1.Travels independently on public transportation or drives own car 2.Arranges own travel by taxi but does not otherwise use public transportation 3.Travels on public transportation when assisted or accompanied by another 4.Travel limited to taxi or automobile with assistance of another 5.Does not travel at all | 1 1 1 0 0 |
| G. Responsibility for Own Medications | _____ |
| 1.Is responsible for taking medication in correct dosages at correct time 2.Takes responsibility if medication is prepared in advance in separate dosages 3.Is not capable of dispensing own medication | 1 0 0 |
| H. Ability to Handle Finances | _____ |
| 1.Manages financial matters independently (budgets, writes checks, pays rent and bills, goes to bank); collects and keeps track of income 2.Manages day-to-day purchases but needs help with banking, major purchases, etc 3.Incapable of handling money | 1 1 0 |
- •
bathing
- •
dressing
- •
toileting
- •
maintaining continence
- •
grooming
- •
feeding
- •
transferring
Questions about functional ability may be valuable if posed in reference to recent activities: for example, “Did you dress yourself this morning?” rather than “Do you dress yourself?”
An inability to perform basic ADLs alone implies a higher risk for functional decline, hospitalization, and poor outcomes leading to delirium and or death. Dependency in these tasks, which is present in up to 10% of persons aged 75 years or older, usually requires full-time help at home or placement in a nursing home.
IADLs are tasks that are integral to maintaining an independent household, such as:
- •
using the telephone
- •
shopping for groceries
- •
preparing meals
- •
performing housework
- •
doing laundry
- •
driving or using public transportation
- •
taking medications
- •
handling finances
Asking “Did you drive here today?” or “When did you last drive? (rather than “Do you drive?”) may elicit a more useful answer. IADLs are more likely than ADLs to be influenced by factors other than capacity, such as cultural and gender roles and learned skills.
Basic ADLs (BADLs) and IADLs are commonly reported as total scores (see Tables 4-2 and 4-3 ). The total score for BADLs is 0 to 6; for IADLs it is 0 to 8. In some categories of IADLs, only the highest level of function receives a 1; in others, two or more levels have scores of 1 because each describes competence at some minimal level of function. When these screens are used over time, they serve as documentation of a person’s functional improvement or deterioration. It is worth noting that the description of the functional capabilities is more important than the number total score, especially when monitoring function over time.
A longitudinal analysis of older adults that characterized functional states between independent in ADLs and mobility, dependent on mobility but independent in ADLs, and dependent in ADLs translated to diminished survival and more of that survival spent in disabled states. For example, the life expectancy of an ADL-disabled 75-year-old is similar to that of an 85-year-old independent person; thus the impact of the disability approximates being 10 years older with much more of the remaining life spent disabled.
Advanced Activities of Daily Living (AADLs)
Advanced activities of daily living represent the highest level of function and are comprised of vocational, social, or recreational activities that reflect personal choice and add meaning and richness to a person’s life. The AADLs include employment, attending church, volunteering, going out to dinner or the theater, participating in physical recreational activities, and the like. Changes in these activities may reflect a precursor to IADL or ADL dysfunction.
Karnofsky and Eastern Cooperative Oncology Group (ECOG) Performance Status (PS)
Traditionally, the oncologist’s assessment of functional status includes an evaluation of Karnofsky or Eastern Cooperative Oncology Group (ECOG) performance status (PS), Table 4-4 . In older adults, particularly those with multiple chronic diseases, the prognostic ability of ECOG-PS may not relate to the specific impact of cancer and may be insensitive to functional impairment. Although 70% to 80% of older adults with cancer present with ECOG PS of 0 to 1 (normal or symptomatic but ambulatory), greater than half require assistance with IADLs. Furthermore, studies have shown that physicians’, nurses’, and patients’ assessments of performance status using these measures may be discordant.
| Percentage (%) | Karnofsky Performance Scale | Score | ECOG Performance Scale |
|---|---|---|---|
| 100 | Normal, no complaints, no evidence of disease | 0 | Normal activity; asymptomatic |
| 90 | Able to carry on normal activity; minor signs or symptoms of disease | 1 | Symptomatic; fully ambulatory |
| 80 | Normal activity with effort; some signs or symptoms of disease | ||
| 70 | Cares for self, unable to carry on normal activity or to do active work | 2 | Symptomatic; in bed <50% of time |
| 60 | Requires occasional assistance, but is able to care for most of his/her needs | ||
| 50 | Requires considerable assistance and frequent medical care | 3 | Symptomatic; in bed 50% of time; not bedridden |
| 40 | Disabled, requires special care and assistance | ||
| 30 | Severely disabled, hospitalization indicated; death not imminent | 100% bedridden | |
| 20 | Very sick, hospitalization indicated; death not imminent | 4 | |
| 10 | Moribund, fatal processes, progressing rapidly | ||
| 0 | Dead | 5 | Dead |
Use of Self-Reported Functional Status Measures in Cancer Patients
Older patients with cancer, both during initial diagnosis and as cancer survivors, are more likely to require functional assistance than those without cancer. Functional status may be dependent on cancer stage, with observational studies showing this dependency is more commonly found in hospitalized patients with metastatic disease as compared with patients with nonmetastatic disease. IADL impairment predicted postoperative complications (P = .043) in a series of older adults undergoing cancer-related surgery and functional status predicted risk of treatment-related toxicity in studies of ovarian cancer patients receiving standard cytotoxic chemotherapy. In addition, the need for assistance in IADLs has been reported to correlate with psychological distress in older adults with cancer.
The need for assistance with IADLs has been shown to have the same predictive capability for mortality among older adults with cancer. Functional limitations in cancer survivors also persist.
Because functional status changes over time and is affected by other conditions as well as cancer and by the patient’s social needs, accurate assessments at multiple time points over the course of the cancer patient’s life are valuable in monitoring response to treatment and can provide prognostic information that is useful in short- and long-term care planning. Acute or subacute changes in functional status are important to elicit as they may be a marker of underlying medical illness, including recurrence of cancer, cognitive losses, or other psychosocial issues. Health care providers can promote their patients‘ autonomy by mobilizing appropriate medical, social, and environmental supports.
Performance-Based Instruments of Physical Function
Performance-based instruments can provide additional information beyond an older adult’s self-reported perception of difficulty.
Get-up-and-Go Test
Ambulation is an essential prerequisite for completing many of the activities of daily living and slowing of gait speed is an indicator of future morbidity. For example, gait speeds of 1 m/s or less, and especially those less than 0.6 m/s, predict hospitalization, cognitive impairment, and mortality.
The “Get-up and Go Test” has been recommended. This assessment tool does not require specialized equipment, but uses an armless chair and has the individual stand up from the chair, walk 3 meters and sit back down. ( Table 4-5 ) It can be performed by the physician, nurse, or other trained health care provider. Severe abnormalities are considered present if the subject appears at risk for a fall at any time during the test. The time needed to complete this task is used to score the test; greater than 15 seconds is considered a positive screen. Also, ranges of times required to complete the task correlate with independence in some functional tasks. ( Table 4-5 )
Examiner asks the patient to:
| ||||
Factors to note:
| ||||
Positive screen:
| ||||
| Timed Get Up and Go (secs) | ||||
| 10-19 | 20-29 | 30+ | ||
| Tub or shower transfers | Self | 59% | 60% | 23% |
| Climbs stairs | Self | 77% | 60% | 4% |
| Goes outside alone | Yes | 82% | 50% | 15% |
| Chair transfer | Self | 100% | 93% | 62% |
∗ Proportion able to complete mobility tasks, according to “Timed Get Up and Go” times
Functional Status
Functional status and disability reflect the interactions among multiple medical conditions, physiologic aging, psychosocial support, cognitive impairment, and the overall health and vitality of the individual. Functional evaluation can add a dimension beyond the usual medical assessment, providing information on patient care needs and prognosis.
The choice of functional assessment tool depends upon the characteristics of the population (community-dwelling, hospitalized, nursing home residents) and the level of function being assessed. Function can be assessed by self-report, proxy report, performance-based testing, or a combination of these approaches.
Self-Reported Tools to Measure Functional Status
Activities of Daily Living (ADLs and IADLs, Tables 4-2 and 4-3 )
Most commonly, older adults’ functional status is assessed at two levels: activities of daily living (ADLs) and instrumental activities of daily living (IADLs). ADLs are self-care tasks, such as:
| In each category, circle the item that most closely describes the person’s highest level of functioning and record the score assigned to that level (either 1 or 0) in the blank at the beginning of the category. | |
| A. Toilet | _____ |
| 1.Care for self at toilet completely; no incontinence 2.Needs to be reminded, or needs help in cleaning self, or has rare (weekly at most) accidents 3.Soiling or wetting while asleep more than once a week 4.Soiling or wetting while awake more than once a week 5.No control of bowels or bladder | 1 0 0 0 0 |
| B. Feeding | _____ |
| 1.Eats without assistance 2.Eats with minor assistance at meal times and/or with special preparation of food, or help in cleaning up after meals 3.Feeds self with moderate assistance and is untidy 4.Requires extensive assistance for all meals 5.Does not feed self at all and resists efforts of others to feed him or her | 1 0 0 0 0 |
| C. Dressing | _____ |
| 1.Dresses, undresses, and selects clothes from own wardrobe 2.Dresses and undresses self with minor assistance 3.Needs moderate assistance in dressing and selection of clothes 4.Needs major assistance in dressing but cooperates with efforts of others to help 5.Completely unable to dress self and resists efforts of others to help | 1 0 0 0 0 |
| D. Grooming (neatness, hair, nails, hands, face, clothing) | _____ |
| 1.Always neatly dressed and well-groomed without assistance 2.Grooms self adequately with occasional minor assistance, e.g., with shaving 3.Needs moderate and regular assistance or supervision with grooming 4.Needs total grooming care but can remain well-groomed after help from others 5.Actively negates all efforts of others to maintain grooming | 1 0 0 0 0 |
| E. Physical Ambulation | _____ |
| 1.Goes about grounds or city 2.Ambulates within residence on or about one block distant 3.Ambulates with assistance of (check one) a ( ) another person, b ( ) railing, c ( ) cane, d ( ) walker, e ( ) wheelchair 1.__Gets in and out without help. 2.__Needs help getting in and out 4.Sits unsupported in chair or wheelchair but cannot propel self without help 5.Bedridden more than half the time | 1 0 0 0 0 |
| F. Bathing | _____ |
| 1.Bathes self (tub, shower, sponge bath) without help 2.Bathes self with help getting in and out of tub 3.Washes face and hands only but cannot bathe rest of body 4.Does not wash self but is cooperative with those who bathe him or her 5.Does not try to wash self and resists efforts to keep him or her clean | 1 0 0 0 0 |
| In each category, circle the item that most closely describes the person’s highest level of functioning and record the score assigned to that level (either 1 or 0) in the blank at the beginning of the category. | |
| A. Ability to Use Telephone | _____ |
| 1.Operates telephone on own initiative; looks up and dials numbers 2.Dials a few well-known numbers 3.Answers telephone but does not dial 4.Does not use telephone at all | 1 1 1 0 |
| B. Shopping | _____ |
| 1.Takes care of all shopping needs independently 2.Shops independently for small purchases 3.Needs to be accompanied on any shopping trip 4.Completely unable to shop | 1 0 0 0 |
| C. Food Preparation | _____ |
| 1.Plans, prepares, and serves adequate meals independently 2.Prepares adequate meals if supplied with ingredients 3.Heats and serves prepared meals or prepares meals but does not maintain adequate diet 4.Needs to have meals prepared and served | 1 0 0 0 |
| D. Housekeeping | _____ |
| 1.Maintains house alone or with occasional assistance (e.g., domestic help for heavy work) 2.Performs light daily tasks such as dishwashing, bed making 3.Performs light daily tasks but cannot maintain acceptable level of cleanliness 4.Needs help with all home maintenance tasks 5.Does not participate in any housekeeping tasks | 1 1 1 1 0 |
| E. Laundry | _____ |
| 1.Does personal laundry completely 2.Launders small items; rinses socks, stockings, etc. 3.All laundry must be done by others | 1 1 0 |
| F. Mode of Transportation | _____ |
| 1.Travels independently on public transportation or drives own car 2.Arranges own travel by taxi but does not otherwise use public transportation 3.Travels on public transportation when assisted or accompanied by another 4.Travel limited to taxi or automobile with assistance of another 5.Does not travel at all | 1 1 1 0 0 |
| G. Responsibility for Own Medications | _____ |
| 1.Is responsible for taking medication in correct dosages at correct time 2.Takes responsibility if medication is prepared in advance in separate dosages 3.Is not capable of dispensing own medication | 1 0 0 |
| H. Ability to Handle Finances | _____ |
| 1.Manages financial matters independently (budgets, writes checks, pays rent and bills, goes to bank); collects and keeps track of income 2.Manages day-to-day purchases but needs help with banking, major purchases, etc 3.Incapable of handling money | 1 1 0 |
- •
bathing
- •
dressing
- •
toileting
- •
maintaining continence
- •
grooming
- •
feeding
- •
transferring
Questions about functional ability may be valuable if posed in reference to recent activities: for example, “Did you dress yourself this morning?” rather than “Do you dress yourself?”
An inability to perform basic ADLs alone implies a higher risk for functional decline, hospitalization, and poor outcomes leading to delirium and or death. Dependency in these tasks, which is present in up to 10% of persons aged 75 years or older, usually requires full-time help at home or placement in a nursing home.
IADLs are tasks that are integral to maintaining an independent household, such as:
- •
using the telephone
- •
shopping for groceries
- •
preparing meals
- •
performing housework
- •
doing laundry
- •
driving or using public transportation
- •
taking medications
- •
handling finances
Asking “Did you drive here today?” or “When did you last drive? (rather than “Do you drive?”) may elicit a more useful answer. IADLs are more likely than ADLs to be influenced by factors other than capacity, such as cultural and gender roles and learned skills.
Basic ADLs (BADLs) and IADLs are commonly reported as total scores (see Tables 4-2 and 4-3 ). The total score for BADLs is 0 to 6; for IADLs it is 0 to 8. In some categories of IADLs, only the highest level of function receives a 1; in others, two or more levels have scores of 1 because each describes competence at some minimal level of function. When these screens are used over time, they serve as documentation of a person’s functional improvement or deterioration. It is worth noting that the description of the functional capabilities is more important than the number total score, especially when monitoring function over time.
A longitudinal analysis of older adults that characterized functional states between independent in ADLs and mobility, dependent on mobility but independent in ADLs, and dependent in ADLs translated to diminished survival and more of that survival spent in disabled states. For example, the life expectancy of an ADL-disabled 75-year-old is similar to that of an 85-year-old independent person; thus the impact of the disability approximates being 10 years older with much more of the remaining life spent disabled.
Advanced Activities of Daily Living (AADLs)
Advanced activities of daily living represent the highest level of function and are comprised of vocational, social, or recreational activities that reflect personal choice and add meaning and richness to a person’s life. The AADLs include employment, attending church, volunteering, going out to dinner or the theater, participating in physical recreational activities, and the like. Changes in these activities may reflect a precursor to IADL or ADL dysfunction.
Karnofsky and Eastern Cooperative Oncology Group (ECOG) Performance Status (PS)
Traditionally, the oncologist’s assessment of functional status includes an evaluation of Karnofsky or Eastern Cooperative Oncology Group (ECOG) performance status (PS), Table 4-4 . In older adults, particularly those with multiple chronic diseases, the prognostic ability of ECOG-PS may not relate to the specific impact of cancer and may be insensitive to functional impairment. Although 70% to 80% of older adults with cancer present with ECOG PS of 0 to 1 (normal or symptomatic but ambulatory), greater than half require assistance with IADLs. Furthermore, studies have shown that physicians’, nurses’, and patients’ assessments of performance status using these measures may be discordant.
| Percentage (%) | Karnofsky Performance Scale | Score | ECOG Performance Scale |
|---|---|---|---|
| 100 | Normal, no complaints, no evidence of disease | 0 | Normal activity; asymptomatic |
| 90 | Able to carry on normal activity; minor signs or symptoms of disease | 1 | Symptomatic; fully ambulatory |
| 80 | Normal activity with effort; some signs or symptoms of disease | ||
| 70 | Cares for self, unable to carry on normal activity or to do active work | 2 | Symptomatic; in bed <50% of time |
| 60 | Requires occasional assistance, but is able to care for most of his/her needs | ||
| 50 | Requires considerable assistance and frequent medical care | 3 | Symptomatic; in bed 50% of time; not bedridden |
| 40 | Disabled, requires special care and assistance | ||
| 30 | Severely disabled, hospitalization indicated; death not imminent | 100% bedridden | |
| 20 | Very sick, hospitalization indicated; death not imminent | 4 | |
| 10 | Moribund, fatal processes, progressing rapidly | ||
| 0 | Dead | 5 | Dead |
Activities of Daily Living (ADLs and IADLs, Tables 4-2 and 4-3 )
Most commonly, older adults’ functional status is assessed at two levels: activities of daily living (ADLs) and instrumental activities of daily living (IADLs). ADLs are self-care tasks, such as:
| In each category, circle the item that most closely describes the person’s highest level of functioning and record the score assigned to that level (either 1 or 0) in the blank at the beginning of the category. | |
| A. Toilet | _____ |
| 1.Care for self at toilet completely; no incontinence 2.Needs to be reminded, or needs help in cleaning self, or has rare (weekly at most) accidents 3.Soiling or wetting while asleep more than once a week 4.Soiling or wetting while awake more than once a week 5.No control of bowels or bladder | 1 0 0 0 0 |
| B. Feeding | _____ |
| 1.Eats without assistance 2.Eats with minor assistance at meal times and/or with special preparation of food, or help in cleaning up after meals 3.Feeds self with moderate assistance and is untidy 4.Requires extensive assistance for all meals 5.Does not feed self at all and resists efforts of others to feed him or her | 1 0 0 0 0 |
| C. Dressing | _____ |
| 1.Dresses, undresses, and selects clothes from own wardrobe 2.Dresses and undresses self with minor assistance 3.Needs moderate assistance in dressing and selection of clothes 4.Needs major assistance in dressing but cooperates with efforts of others to help 5.Completely unable to dress self and resists efforts of others to help | 1 0 0 0 0 |
| D. Grooming (neatness, hair, nails, hands, face, clothing) | _____ |
| 1.Always neatly dressed and well-groomed without assistance 2.Grooms self adequately with occasional minor assistance, e.g., with shaving 3.Needs moderate and regular assistance or supervision with grooming 4.Needs total grooming care but can remain well-groomed after help from others 5.Actively negates all efforts of others to maintain grooming | 1 0 0 0 0 |
| E. Physical Ambulation | _____ |
| 1.Goes about grounds or city 2.Ambulates within residence on or about one block distant 3.Ambulates with assistance of (check one) a ( ) another person, b ( ) railing, c ( ) cane, d ( ) walker, e ( ) wheelchair 1.__Gets in and out without help. 2.__Needs help getting in and out 4.Sits unsupported in chair or wheelchair but cannot propel self without help 5.Bedridden more than half the time | 1 0 0 0 0 |
| F. Bathing | _____ |
| 1.Bathes self (tub, shower, sponge bath) without help 2.Bathes self with help getting in and out of tub 3.Washes face and hands only but cannot bathe rest of body 4.Does not wash self but is cooperative with those who bathe him or her 5.Does not try to wash self and resists efforts to keep him or her clean | 1 0 0 0 0 |
| In each category, circle the item that most closely describes the person’s highest level of functioning and record the score assigned to that level (either 1 or 0) in the blank at the beginning of the category. | |
| A. Ability to Use Telephone | _____ |
| 1.Operates telephone on own initiative; looks up and dials numbers 2.Dials a few well-known numbers 3.Answers telephone but does not dial 4.Does not use telephone at all | 1 1 1 0 |
| B. Shopping | _____ |
| 1.Takes care of all shopping needs independently 2.Shops independently for small purchases 3.Needs to be accompanied on any shopping trip 4.Completely unable to shop | 1 0 0 0 |
| C. Food Preparation | _____ |
| 1.Plans, prepares, and serves adequate meals independently 2.Prepares adequate meals if supplied with ingredients 3.Heats and serves prepared meals or prepares meals but does not maintain adequate diet 4.Needs to have meals prepared and served | 1 0 0 0 |
| D. Housekeeping | _____ |
| 1.Maintains house alone or with occasional assistance (e.g., domestic help for heavy work) 2.Performs light daily tasks such as dishwashing, bed making 3.Performs light daily tasks but cannot maintain acceptable level of cleanliness 4.Needs help with all home maintenance tasks 5.Does not participate in any housekeeping tasks | 1 1 1 1 0 |
| E. Laundry | _____ |
| 1.Does personal laundry completely 2.Launders small items; rinses socks, stockings, etc. 3.All laundry must be done by others | 1 1 0 |
| F. Mode of Transportation | _____ |
| 1.Travels independently on public transportation or drives own car 2.Arranges own travel by taxi but does not otherwise use public transportation 3.Travels on public transportation when assisted or accompanied by another 4.Travel limited to taxi or automobile with assistance of another 5.Does not travel at all | 1 1 1 0 0 |
| G. Responsibility for Own Medications | _____ |
| 1.Is responsible for taking medication in correct dosages at correct time 2.Takes responsibility if medication is prepared in advance in separate dosages 3.Is not capable of dispensing own medication | 1 0 0 |
| H. Ability to Handle Finances | _____ |
| 1.Manages financial matters independently (budgets, writes checks, pays rent and bills, goes to bank); collects and keeps track of income 2.Manages day-to-day purchases but needs help with banking, major purchases, etc 3.Incapable of handling money | 1 1 0 |
- •
bathing
- •
dressing
- •
toileting
- •
maintaining continence
- •
grooming
- •
feeding
- •
transferring
Questions about functional ability may be valuable if posed in reference to recent activities: for example, “Did you dress yourself this morning?” rather than “Do you dress yourself?”
An inability to perform basic ADLs alone implies a higher risk for functional decline, hospitalization, and poor outcomes leading to delirium and or death. Dependency in these tasks, which is present in up to 10% of persons aged 75 years or older, usually requires full-time help at home or placement in a nursing home.
IADLs are tasks that are integral to maintaining an independent household, such as:
- •
using the telephone
- •
shopping for groceries
- •
preparing meals
- •
performing housework
- •
doing laundry
- •
driving or using public transportation
- •
taking medications
- •
handling finances
Asking “Did you drive here today?” or “When did you last drive? (rather than “Do you drive?”) may elicit a more useful answer. IADLs are more likely than ADLs to be influenced by factors other than capacity, such as cultural and gender roles and learned skills.
Basic ADLs (BADLs) and IADLs are commonly reported as total scores (see Tables 4-2 and 4-3 ). The total score for BADLs is 0 to 6; for IADLs it is 0 to 8. In some categories of IADLs, only the highest level of function receives a 1; in others, two or more levels have scores of 1 because each describes competence at some minimal level of function. When these screens are used over time, they serve as documentation of a person’s functional improvement or deterioration. It is worth noting that the description of the functional capabilities is more important than the number total score, especially when monitoring function over time.
A longitudinal analysis of older adults that characterized functional states between independent in ADLs and mobility, dependent on mobility but independent in ADLs, and dependent in ADLs translated to diminished survival and more of that survival spent in disabled states. For example, the life expectancy of an ADL-disabled 75-year-old is similar to that of an 85-year-old independent person; thus the impact of the disability approximates being 10 years older with much more of the remaining life spent disabled.
Advanced Activities of Daily Living (AADLs)
Advanced activities of daily living represent the highest level of function and are comprised of vocational, social, or recreational activities that reflect personal choice and add meaning and richness to a person’s life. The AADLs include employment, attending church, volunteering, going out to dinner or the theater, participating in physical recreational activities, and the like. Changes in these activities may reflect a precursor to IADL or ADL dysfunction.
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