Which professional often performs the assessment of the advanced activities of daily living

Evaluation Timeline

I.

Nonoperative.

Day 1

Wrist and hand AROM and PROM

Distal edema

Sensory screening

Pain assessment

ADL assessment

Days 3 to 7: evaluate elbow, forearm, and hand AROM and PROM (specific check for nerve compromise)

Weeks 2 to 3: evaluate passive shoulder flexion, scaption and external rotation (passive elevation may be initially limited to 90 degrees and rotation testing may be delayed for 4 to 6 weeks in the case of greater tuberosity fractures)

Week 4: evaluate passive shoulder extension and internal rotation, shoulder A/AROM in gravity eliminated positions

Week 6: evaluate shoulder AROM (may initially be tested in supine position and sidelying with gravity diminished positions)

Weeks 12 to 14: evaluate submaximal strength

Operative: as above, but with variations according to the type of surgical procedure performed (e.g., soft tissue repair).

Friedreich ataxia rating scale

FARS had originally been developed for application in FA (Subramony et al., 2005). The whole FARS protocol can be completed within 30 minutes. The scale includes activities of daily living (ADL) assessment and three timed tests:

a physical examination covering:

bulbar (maximum score 11)

upper (maximum score 36)

lower limb (maximum score 16)

peripheral nerve involvement (maximum score 26)

upright stability/gait (maximum score 28) (maximum sum score 117)

functional staging of overall mobility (score 0–6)

ADL (score 0–36)

three timed activities:

the PATA rate (number of repetitions of the bisyllabic phrase PATA within 10 seconds)

the nine-hole pegboard test (time taken to place and retrieve pegs on a nine-hole pegboard tested for each side)

timed walk of 50 feet/16 meters (25 feet or 8 meters one way, turn and walk back with or without device).

Macro models

Measuring income, SES, or economic development is difficult but less problematic than quantifying ‘health.’ Longevity and mortality rates are clear but crude measures, and neither is applicable to individuals. More detailed, specific, or nuanced assessments (activities of daily living, Euro QoL quality of life measurement-36, quality of life, diabetes prevalence, antidepressant drug expenditures, disability days, cancer survival, hospital utilization, psychiatric visits, etc.) are all sufficiently incomplete or ambiguous that none can be satisfactorily aggregated to macro measures of ‘real’ health outcomes. Analysis of system effects is further complicated by reverse causality between health and income – and also by interactions between marital status and occupation, education, and family size, or almost any set of contributory factors. Although each variable has a distinct connotation that is important in certain contexts, they are almost always acting together in related ways that make it difficult, if not impossible, to decompose a compound total network effect into shares, or to reliably estimate an independent coefficient for each variable.

Empirical analysis of macro determinants is often quite limited by the time frame and number of large-scale long-run observations available to discern diffuse and low-frequency responses. Temporal, spatial, and organizational boundaries must be carefully specified to distinguish and reveal micro and macro effects. Changes in coefficients as the unit of observation expands or contracts can be a key for understanding the underlying structure of the process – opening up the institutional black box of a firm, a hospital, the medical profession, or pharmaceutical discovery. The fact that health care employment adjusts quite slowly to inflation tells us something about wage formation within this industry; a mismatch between price indexes and expenditure patterns suggests that little significance should be attached to publicly listed prices; the fact that pharmaceutical research and development is more strongly correlated with prior firm profits than future prospects suggests something about capital allocation within the industry; disparity between individual cross-sectional expenditure estimates and national time series results may be a useful indicator of the likelihood that a specific policy will be able to ‘bend the (national) cost curve.’

Evaluation of Radial Club Hand: Preoperative and Postoperative

The preoperative evaluation should include assessment of ROM of the elbow, wrist, and hand, noting the position of the forearm, which is usually static. Specific attention should be given to the amount of passive range available in centering the hand on the ulna, noting blanching of the skin and other signs of structural stress. A developmentally appropriate ADL assessment should be done with particular emphasis on self-care. Grasp and release patterns are recorded, looking at the child's ability to manipulate and move objects of various sizes and weights. Children with an absent thumb have creative new prehension patterns that also should be recorded. The length of both extremities is measured because length affects how far the child can reach into the environment. When the elbow is stiff in extension, the radial deviation of the hand is often what allows the child to reach the mouth and perineum for toilet care. The amount of deviation needed for those functions should be recorded.

Careful notation of the child's sensation, ability to follow through with an activity, frustration level, and parental or guardian's participation assists the clinician in treatment planning.

Evaluation of this population ideally should be preoperative, with the therapist contributing to the surgical decisions. The therapist has an unusual opportunity to supply the surgical team with functional information that can help in the algorithm of treatment. Often, surgery is contraindicated if the child has adapted to the condition. When surgery is appropriate, preoperative and postoperative evaluations should be done to record progress and be repeated at regular intervals. Care must be given not to make surgical decisions based on aesthetic pressure from the family that will not improve the child's function.

Postoperative evaluation differs slightly with the type of surgery performed. Examples of common surgical procedures are Ilizarov placement and centralization or pollicization for an absent or hypoplastic thumb. In each situation, the evaluation should record the child's physical limitations (impairment level) and how they affect their function.

Assessments of activities of daily living

Functional assessment of a client’s abilities to perform ADLs and IADLs involves a therapist’s ability to simultaneously analyze the biomechanics of an activity while assessing and integrating the multiple dimensions of a client’s performance skills. This information allows the therapist to appropriately prescribe a treatment intervention (exercise, activity, or task) to remediate and/or develop skills required for activity performance.

There are multiple instruments used to assist occupational therapists in this process. ADL assessments are used to quantify levels of independence versus burden of care and to identify occupational performance deficits. Letts and Bosch73 performed a systematic review of 83 ADL instruments. A list of 15 instruments was identified to meet the following criteria: clinical usefulness, current use for clinical or research purposes, existence of reliability and validity testing, and availability of information about the instrument through peer-reviewed publications. Box 8-7 is a summary of their findings (with the exception of pediatric-specific instruments not applicable to this chapter).

ADL instruments may involve self-reporting, direct observation, and standardized assessments to evaluate functional abilities. Among the various methods, literature shows self-reporting to be the least accurate assessment of actual burden of care,26 but self-reporting tools can provide value in recognizing the client’s perception, insights into what motivates the client, and quality-of-life information.

One of the most commonly used tools is the Functional Independence Measure (FIM), which was developed in 1996 by the Uniform Data System of Medical Rehabilitation (UDS).124 It is an 18-item ordinal rating scale that was developed in an effort to resolve the problem of lack of uniform measurement and data on disability and rehabilitation outcomes. The FIM has been adopted by the CMS as the official tool for determining functional status of clients for reimbursement in in-patient rehabilitation facilities (IRFs).

Stamm et al.113 compared the content of occupation-based instruments used in adult rheumatology and musculoskeletal rehabilitation to the conceptual framework regarding function and disability of the International Classification of Impairment, Disability, and Handicap (ICIDH). In this study, the following seven instruments were identified as occupation-based assessments: the Canadian Occupational Performance Measure, the Assessment of Motor and Process Skills, the Sequential Occupational Dexterity Assessment, the Jebson Taylor Hand Function Test, the Moberg Picking Up Test, the Button Test, and the Functional Dexterity Test. Stamm et al. state that the main focus of these instruments is on the ICF components of activities and participation.113

8.20.4.5 Care Planning

As individuals with dementia increasingly need assistance managing their daily lives, it is important to assess their needs and values to provide suitable care. Dementia can impair an individual's activities of daily living (ADL). These include basic functions to take care of oneself, such as dressing, toileting, and eating. In the beginning stages of dementia, ADLs tend to remain intact. However, instrumental activities of daily living (IADL), which include more complex activities such as managing finances or medications, can suffer in the early stages of cognitive decline (Mlinac and Feng, 2016). There are many measures available to assess daily functioning. The Physical Self-Maintenance Scale (PSMS) and IADL scale by Lawton and Brody (1969) are commonly used to assess ADL and IADL functioning separately. Moore et al. (2007) provides a review of available ADL assessment tools and their psychometric support.

Assessing an individual's values gives caregivers the information they need to make care decisions and facilitate an appropriate lifestyle. For example, if an individual with dementia values autonomy, it may be appropriate to provide home-based care. On the other hand, if they prioritize social interactions and safety, it may be more suitable for the person to be living in an assisted living facility. Family caregivers may not reliably relay the values of individuals with dementia, so patients should be given the opportunity to communicate their care preferences (Geshell et al., 2019; Van Haitsma et al., 2013; Whitlatch, 2010). Personal preferences can be ascertained via a qualitative interview, or measures have been developed to assess patient values. Some commonly used measures include the Values and Preferences Scale and the Preferences for Everyday Living Inventory, which were designed specifically for use in populations with cognitive impairment (Van Haitsma et al., 2013; Whitlatch et al., 2005).

In addition to assessing the patient's values to guide daily care, a comprehensive dementia assessment may include advanced care planning, which involves making decisions about end-of-life care. Having these conversations early is particularly important for an individual with dementia, as deteriorating cognition may mean the person cannot meaningfully engage in such planning later in the disease course. Individuals with dementia often do not initiate advanced care planning, so clinicians should facilitate these conversations early and often (Piers et al., 2018). A systematic review of individuals with dementia and advanced care planning found mixed results, with some studies showing that individuals were able to meaningfully participate in discussions or thought they were helpful, while other studies found individuals with dementia thought the conversations were challenging or had negative attitudes toward advanced care planning (Geshell et al., 2019).

When considering care planning, there may be concern that an individual with dementia lacks the ability to make reasonable decisions, which casts doubt on whether they have capacity to be involved in the planning process. Clinicians should start with the assumption that individuals with dementia have full capacity to engage in care planning. If an individual with dementia does demonstrate compromised ability to make reasonable decisions, that does not mean the person cannot engage in any part of the planning process. Decisional capacity should be seen as task-specific (Geshell et al., 2019) and can be evaluated. Full procedures for capacity evaluations are described by the American Psychological Association and American Bar Association (2008) in their publication Assessment of older adults with diminished capacity: A handbook for psychologists. Although patients' ability to answer factual questions might decline, individuals with dementia may still be able to consistently relay their preferences (Whitlatch, 2010).

Validity

Validity is the extent to which an assessment reflects the concept or quantity that it is intended to measure. The assessment should be considered a surrogate or proxy for the entity we really want to understand. If that surrogate or proxy is a good indicator of the underlying entity, then the assessment is valid. A measure can be reliable but not valid, but a valid assessment must always be reliable. Otherwise, error from the assessment itself (i.e., poor reliability) will make it difficult to gauge how well the assessment measures the clinical condition or concept in question.

Just as reliability takes many forms, so too does validity. Face (or content) validity suggests that a measure includes a reasonable set of indicators to assess the concept or clinical condition we seek to measure. Construct (or convergent) validity indicates that an assessment is highly correlated with other indicators of the underlying clinical condition. Divergent validity is indicated by a low or absent correlation between the assessment and indicators not hypothesized to be related to the underlying condition. Criterion validity assesses the extent to which a measure correlates with another indicator of some underlying true value. External validity, or generalizability, suggests that an assessment may be useful across different client or clinical settings.

As an example, think of the occupational therapist–elicited report of activities of daily living (ADLs), originally developed by Katz and colleagues.19 The ADL assessment identifies the individual’s ability to perform competencies considered essential for personal self-maintenance. Older adults self-report their degree of difficulty with bathing, dressing, personal grooming, transfer, continence, and use of the toilet. The underlying measurement quantity or concept is “personal self-maintenance competency,” and the assessment is a count of the number of ADL tasks older adults report they have difficulty performing. The measure has face or content validity in that it elicits the degree of difficulty in performing a wide range of basic adult competencies. The tasks are not gender specific, optional, or subject to variation in lifestyle. The measure has construct validity in that people reporting ADL disability are likely to have motor, cognitive, or psychiatric conditions that compromise a person’s ability to perform self-maintenance activities without difficulty; indeed, ADL disability is correlated with severity of these disease conditions. The measure has criterion validity to the extent that ADL disability increases the risk of mortality, hospitalization, and nursing home placement. Finally, the ADL measure has external validity in that the measure correlates with these indicators both in community and long-term care populations.19

The ADL measure yields ordinal data. That is, ADL tasks can be numerically ranked. The tasks differ in levels of complexity, and in motor and cognitive demand. As a result, ADL competencies appear to be gained and lost in a generally consistent (but not necessarily fixed) order. Early on, Katz et al.19 suggested that the order in which ADL tasks are acquired in childhood development (first, feeding and transfer; later, toileting and dressing; last, bathing) is the reverse of the order in which they are lost in chronic disease (so that the first lost is bathing, the most complex of the tasks). He noted as well that the order in which they are regained in recovery from stroke or brain injury repeats the sequence for childhood development (so that the last competency reacquired is again bathing).

Katz’s early research showed that the disability status of almost all older adults in a skilled care setting adhered to this rough hierarchy of preservation and loss of task ability. That is, people who were unable to do just one task from this set of tasks almost always had lost the ability to bathe. People who could perform only one task independently from the set of ADLs were likely to have retained the ability to feed themselves. The ability to group tasks according to complexity suggests a particular approach to scale development, with meaningful thresholds. It is no accident that variants of the ADL measure have become standard in gerontological assessment.