The comprehensive assessment of community dwelling elderly: why functional status is not enough

Development and Validation of a Performance-Based Test to Assess Instrumental Activities of Daily Living in Spanish Older Adults

Abstract. A key feature of the autonomy and quality of life of the elderly is their ability to perform instrumental activities of daily living (IADLs). When older people have difficulty in performing IADLs, many of their social and community activities may be affected, leading to their progressive isolation from society. This study describes the development and validation of a test that assesses six areas of daily functioning in the elderly: use of medication and healthcare management, administrative, financial management, transportation, meal preparation, and shopping. The study evaluated 164 healthy individuals without cognitive impairment using an extensive cognitive battery. The construct validity and reliability of test were examined. Findings revealed a good internal consistency and high inter-rater and test-retest reliability. As for construct validity, the instrument tasks were grouped into two dimensions, based on the cognitive components involved in each task: fluid and episodic memory tasks and crystallized tasks. The developed instrument may be useful for evaluating IADLs in those elderly who live at home and are somewhat dependent.

Cognitive correlates of functional performance in older adults: comparison of self-report, direct observation, and performance-based measures

Neuropsychologists are often asked to answer questions about the effects of cognitive deficits on everyday functioning. This study examined the relationship between and the cognitive correlates of self-report, performance-based, and direct observation measures commonly used as proxy measures for everyday functioning. Participants were 88 community-dwelling, cognitively healthy older adults (age 50-86 years). Participants completed standardized neuropsychological tests and questionnaires, and performed eight activities of daily living (e.g., water plants, fill a medication dispenser) while under direct observation in a campus apartment. All proxy measures of everyday function were sensitive to the effects of healthy cognitive aging. After controlling for age, cognitive predictors explained a unique amount of the variance for only the performance-based behavioral simulation measure (i.e., Revised Observed Tasks of Daily Living). The self-report instrumental activities of daily living (IADL) and the performance-based everyday problem-solving test (i.e., EPT) did not correlate with each other; however, both were unique predictors of the direct observation measure. These findings suggest that neuropsychologists must be cautious in making predictions about the quality of everyday activity completion in cognitively healthy older adults from specific cognitive functions. The findings further suggest that a self-report of IADLs and the performance-based EPT may be useful measures for assessing everyday functional status in cognitively healthy older adults.

Cognitive predictors of everyday functioning in older adults: results from the ACTIVE Cognitive Intervention Trial

OBJECTIVE

The present study sought to predict changes in everyday functioning using cognitive tests.

METHODS

Data from the Advanced Cognitive Training for Independent and Vital Elderly trial were used to examine the extent to which competence in different cognitive domains--memory, inductive reasoning, processing speed, and global mental status--predicts prospectively measured everyday functioning among older adults. Coefficients of determination for baseline levels and trajectories of everyday functioning were estimated using parallel process latent growth models.

RESULTS

Each cognitive domain independently predicts a significant proportion of the variance in baseline and trajectory change of everyday functioning, with inductive reasoning explaining the most variance (R2 = .175) in baseline functioning and memory explaining the most variance (R2 = .057) in changes in everyday functioning.

DISCUSSION

Inductive reasoning is an important determinant of current everyday functioning in community-dwelling older adults, suggesting that successful performance in daily tasks is critically dependent on executive cognitive function. On the other hand, baseline memory function is more important in determining change over time in everyday functioning, suggesting that some participants with low baseline memory function may reflect a subgroup with incipient progressive neurologic disease.

Word list memory predicts everyday function and problem-solving in the elderly: results from the ACTIVE cognitive intervention trial

Data from the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) trial (N = 2,802) were analyzed to examine whether word list learning predicts future everyday functioning. Using stepwise random effects modeling, measures from the modified administrations of the Hopkins Verbal Learning Test (HVLT) and the Auditory Verbal Learning Test (AVLT) were independently predictive of everyday IADL functioning, problem-solving, and psychomotor speed. Associations between memory scores and everyday functioning outcomes remained significant across follow-up intervals spanning 5 years. HVLT total recall score was consistently the strongest predictor of each functional outcome. Results suggest that verbal memory measures are uniquely associated with both current and future functioning and that specific verbal memory tests like the HVLT and AVLT have important clinical utility in predicting future functional ability among older adults.

Abstinence versus alcohol use among elderly rural Baptists: a test of reference group theory and health outcomes

Reference groups, such as religious groups, are thought to provide individuals with normative frameworks which set and maintain standards for them. Persons who belong to a reference group, yet do not comply with the standards of that group, i.e. non-conformists, are thought to experience cognitive dissonance which in turn may lead to psychological discomfort and adverse physical health outcomes. In a community-based, racially mixed sample of elderly Baptists in the rural south of the United States (n = 1155), where Baptist churches proscribe alcohol use, we studied whether alcohol use was associated with adverse physical and mental health assessments. No relationship was found between non-conformist behavior among rural Baptists and adverse health outcomes for either Whites or African-Americans in controlled analyses. More frequent church attendance among African-American Baptists, but not for White Baptists, was strongly associated with abstinence from alcohol.

Detection of depressive symptomatology in elderly people: a short version of the CES-D scale

This study aims to test a short form of the Center for Epidemiological Studies--Depression Scale (CES-D) which can be a useful screening tool for depressive symptomatology in epidemiological studies of elderly patients. The study was conducted on 2792 subjects from the PAQUID (Personnes Agées QUID?) cohort, an epidemiological survey of community dwellers living in South-West France. CES-D items with high sensitivity and good specificity were selected for the short form, then the best cut-off scores were determined with Receiver Operating Characteristics (ROC) curves. The external validity of the 5-item scale was then assessed against the full scale at different PAQUID follow-ups. Sensitivity was 99% and specificity 81% for detecting depressive symptomatology when compared to the 20-item scale. The external validity on the different follow-ups was good, yielding a sensitivity varying from 95 to 100%, and a specificity from 83 to 89%. In conclusion, the 5-item CES-D is a simple, rapid and reliable tool which could be useful for screening depressive symptoms in epidemiological studies of the elderly.

Aging, health, and the "electronic church"

We tested whether elders substitute religious media use for church attendance when health declines (using multidimensional disengagement theory) with data from a multiracial, population-based sample in the Bible Belt (N = 2,971). In adjusted models, 3-year declines in functional status were significantly associated with concurrent reduction in frequency of church attendance but not with any change in rates of religious media (TV/radio) use. Age-related declines in church attendance were substantively explained by declining functional ability. Changes in religious media use were independent of age and less sensitive to declining functional status or service attendance than to cultural heritage such as race, socioeconomic status, and rural upbringing. Our data do not support the hypothesis that elders with deteriorating health substitute increased engagement with religious media as their participation in organizational religious activities is reduced. However, applicability of the substitution hypothesis to other dimensions of nonorganizational religiousness (e.g., prayer) awaits similar scrutiny.

Comprehensive clinical assessment in community setting: applicability of the MDS-HC

OBJECTIVE

To describe the results of an international trial of the home care version of the MDS assessment and problem identification system (the MDS-HC), including reliability estimates, a comparison of MDS-HC reliabilities with reliabilities of the same items in the MDS 2.0 nursing home assessment instrument, and an examination of the types of problems found in home care clients using the MDS-HC.

DESIGN

Independent, dual assessment of clients of home-care agencies by trained clinicians using a draft of the MDS-HC, with additional descriptive data regarding problem profiles for home care clients.

SETTING AND PARTICIPANTS

Reliability data from dual assessments of 241 randomly selected clients of home care agencies in five countries, all of whom volunteered to test the MDS-HC. Also included are an expanded sample of 780 home care assessments from these countries and 187 dually assessed residents from 21 nursing homes in the United States.

MEASUREMENTS

The array of MDS-HC assessment items included measures in the following areas: personal items, cognitive patterns, communication/hearing, vision, mood and behavior, social functioning, informal support services, physical functioning, continence, disease diagnoses health conditions and preventive health measures, nutrition/hydration, dental status, skin condition, environmental assessment, service utilization, and medications.

RESULTS

Forty-seven percent of the functional, health status, social environment, and service items in the MDS-HC were taken from the MDS 2.0 for nursing homes. For this item set, it is estimated that the average weighted Kappa is .74 for the MDS-HC and .75 for the MDS 2.0. Similarly, high reliability values were found for items newly introduced in the MDS-HC (weighted Kappa = .70). Descriptive findings also characterize the problems of home care clients, with subanalyses within cognitive performance levels.

CONCLUSION

Findings indicate that the core set of items in the MDS 2.0 work equally well in community and nursing home settings. New items are highly reliable. In tandem, these instruments can be used within the international community, assisting and planning care for older adults within a broad spectrum of service settings, including nursing homes and home care programs. With this community-based, second-generation problem and care plan-driven assessment instrument, disability assessment can be performed consistently across the world.

Disability and cognitive impairment in the elderly

Disability and cognitive impairment show similar patterns of increasing frequency with ageing. A review of the published literature shows that there is a cross-sectional relationship between cognitive impairment and disability, independent of demographic, medical, and lifestyle factors. Some instrumental activities of daily living (IADL) items appear more specifically related to cognitive impairment, but cognition and functional impairment are distinct concepts requiring separate assessments. Subjects with low cognitive performances are at higher risk of functional impairment in the following years. Cognitive impairment as well as disability increase the risk of death and institutionalization. Preventive strategies could be directed against the risk factors of cognitive impairment and disability, and would aim to delay the onset of dementia. Prevention of disability associated with cognitive impairment needs further assessment in elderly community-dwellers. Further research is needed to better identify the specific areas cognition involved in the disablement process.

Physical Performance Measures for Characterizing High Functioning Older Persons

The goal of this study was to identify methods for characterizing high-functioning older adults living in the community. The subjects were 495 older adults from the Longitudinal Interdisciplinary Study on Aging conducted by the Tokyo Metropolitan Institute of Gerontology. Physical performance measures included grip strength, walking at preferred and maximum speeds, one-leg standing with eyes open, and finger tapping rate. Performance scores were created by summing each categorical score. Consistent differences were found among age groups and genders. Scores were lower in subjects who had stroke or diabetes than in those without these conditions. These results suggest that physical performance measures have both discriminant validity and construct validity, which make them useful methods for characterizing high-functioning older persons.