Elham Al-Shorman, PT, PhD

» The Ultimate goal of all physical therapist intervention

with the elderly is to restore or maintain the highest level
of function possible for individuals, particularly function
associated with movement

» Functional Assessment: is particular to the individuals

and a measure of those activities by which an individuals
judges the quality of life.
» Functional assessment data can be useful to
physical therapist in several way:
1. On the individuals level a functional assessment can be used as a quick
screen to identify the need for more extensive evaluation by a physical or
other practitioners
2. If an elder who has functional deficits becomes a patient, these data
determine the overall goal of physical treatment
3. Organizing and analyzing functional data by types of patients or patient’s
problems can provides valuable documentation of the needs of a group
for a treatment
» Physical therapist must review the functional
limitation in light of other clinical findings that
identify the patients impairments along with
psychological, social, and environmental factors

» The therapist then hypothesize which findings

contribute to the patients functional deficits which
will be the focus of patients- related instruction and
direct intervention

» Example: inability to transfer from bed to chair

» In general: the ability to function independently decline with age
and influenced by a host of biological, psychological and social
factors.

» Epidemiological studies of functional limitations in the elderly

provide a group of context into which a physical therapist can
place an individual’s level of function

 The Supplement on Aging (SOA)

 1985 National Nursing Home Survey (NNHS)
 1987 National Medical Expenditure Survey (NMES)
 1982 and 1984 National Long Term Care Survey (NLTCSs)
 Establishment of Populations for the epidemiological Study of the Elderly (EPESE)
project in 1982

 It is important to note that each of these data set yields some how
different rate on the incidence and prevalence of functional
limitations and disability in the elderly
 For example : National Long Term Care Survey:
http://www.nltcs.aas.duke.edu/

» It is a longitudinal survey designed to study changes in the health and

functional status of older Americans (aged 65+). It also tracks health
expenditures, Medicare service use, and the availability of personal,
family, and community resources for caregiving. The survey began in
1982, and follow-up surveys were conducted in 1984, 1989, 1994,
1999, and 2004.
» The NLTCS survey population consists of a sample of 35,789 people
drawn from national Medicare enrollment files in 1982 that has been
augmented with subsequent samples of approximately 20,000 Medicare
enrollees obtained by adding 5,000 people passing age 65 between
successive surveys done approximately every five years. This technique
ensures a large, nationally-representative sample at each point in
time. Both elderly in the community (including those not impaired) and
those residing in institutions are represented in the samples.
» Community-dwelling older adults: those who are not in
assisted living or nursing homes

» Institutionalized elders: elders who live in a nursing

home

» Data from NNHS compare nursing home residents with

non institutionalized and clearly indicate differences In
their functional level

» This differences in functional level encourage physical

therapist to do a functional assessment for an
individuals patient
» To assess the functional status we include: physical, psychological,
and social dimensions

» Physical therapist are most often concerned with evaluating and

diagnosing physical function limitation and then treat the
impairments underlie them

» Physical functional assessment:

 Mobility: transfer and ambulation

 Basic self care and personal hygiene activities of daily living (ADL)

 More complex activities essential to an adult’s living in the

community, known as instrumental ADL(IADL)
First Component: Mobility
 The main concern of physical therapists in
performing a physical functional assessment of an
elderly is to identify any functional limitation in
mobility:
 ambulation on level surfaces within the home
 Stair climbing
 Walking for long distance in the community
 Second component: Basic Activities of Daily Living (ADL)
 Basic ADL include all of the fundamental tasks and activities necessary for
survival, hygiene, and self care within home

 A typical ADL battery, which may administered by the physical therapist

covers: eating, bathing, grooming, dressing, bed mobility, and transfer

 Incontinence and the ability to use a bathroom are very important

components in assessing the physical function

 Even Three aspect of toileting may each need explanation:

 Ability to get to bathroom in appropriate time
 Move safely
 Perform self hygiene
 Third component: Instrumental Activities of
Daily Living (IADL)

 Addresses multiple areas that are essential to

living independently such as cooking,
shopping, housekeeping, ability to use public
transportation
» Fourth component: Work
 One measure of adults capability is employment

 Fifth component: recreation: not limited to sport

There are three primary methods to measure functional
status
- Direct observation: asking the subject to perform a
function under a specific set of condition
- self report or interviewer or administered questioner
» Advantage:
1. Professional judgment of functional status is
based on clear cut objective evidence of the ability
to do the task
2. Physical performance is not limited by language
barriers

» Disadvantages
1. This method assumes that the controlled
environment of a structured situation in the clinic
is similar to the environment in which a person
function

2. Functional performance methods are time

consuming and therefore costly
» Examples: Tests are also referred to performance
measures
1. 6-minutes walk test
2. The physical performance and mobility examination
3. Functional Reach test
4. Get up and go
5. Timed up and go
6. Physical performance battery

» Quantitative measures, give one score, characterized a

person’s functional limitation under controlled
environment
» 6-min walk test:
 The 6MWT was developed in 1963 by Balke to
evaluate functional capacity.
 Different variations of the timed walk have
been tested, and the six minute timed walk was
recommended given its reproducibility and
ease of administration compared to longer
timed test
» Timed Up and Go
 simple test used to assess a person's mobility
and requires both static and dynamic balance
 Gold standard: direct observation
 Self report approaches have become well accepted in
research and in clinical practice
 The most feasible and cost effective method in
gathering functional status data

 Trained interviewer OR read and answer???

 There is little differences in the quality of the data
obtained by self report or face to face interview
 Visual loss, shorter attention spans
 Katz Index of Activities d Daily Living
 Measure the basic ADL
 Six basic ADL: bathing, dressing, toileting, transfer,
continence, and feeding
 The theoretical foundation of the Kats index is
actually taken from a development model of
children: feeding is the most easily acquired function
(lowest), and bathing considered the developing level
of function (highest)
 Functional Independence Measure FIM
 18-item measure of
 Physical
 Psychological
 Social

 FIM uses the level of assistance an individuals needs to grade

functional status from total independence to total assistance

 The FIM lists six self care activities: feeding, grooming,

bathing, upper body dressing, lower body dressing, and
toileting.

 Bowel and bladder control

 Mobility is tested only through 3 items on transfer

 Locomation: walking, using wheelchair

 Stairs
 OARS Multidimensional Functional Assessment Questioner
 The Older American Resources and Services (OARS).
 The first formal approach developed explicitly to assess the function of
elders in multiple domains
 MFAQ is designed to be administered by a trained interviewer
 The items on MFAQ cover basic and instrumental ADL, social interaction,
economic resources, physical health, mental health

 MFAQ is sensitive enough to detect changes over time and can

discriminate between elders who live independently in the community,
need adult daycare, or are institutionalized
 Philadelphia Geriatrics Center Multilevel Assessment Instrument

 There are five behavioral domains represented in the MAI

1. Physical health, cognition, self care, and instrumental ADL
2. Time use: Employment, hobbies, recreation
3. Social interaction
4. Personal adjustment
5. Perceived environment (housing, neighborhood, personal security)

 Can be completed in 1 hour

 There are three methodological issues:
1. Reliability
2. Validity
3. Clinical utility

1. Reliability : It is important to know whether apparent improvement in a patient’s

level of function is a real change or a variation in measurement due to the nature of
the test or skill of the tester.

2. Validity: it is important to know whether the therapist actually gathered the

information that intended to be gathered and what inferences about the patient’s
status or prognosis are appropriate based on the data
Several forms:
Internal consistency: is a measure of the degree to
which items on the test measure the same thing
and yield the same results

1. intra-rater reliability: the degree of agreement

among multiple repetitions of a diagnostic test
performed by a single rater

2. Inter-rater reliability: degree of agreement among

raters.
» Several kinds:
1. Face validity: the extent to which a test is subjectively
viewed as covering the concept it purports to measure
In other words, a test can be said to have face validity if it
"looks like" it is going to measure what it is supposed to
measure.

3. Concurrent validity: is demonstrated where a test

correlates well with a measure that has previously been
validated – Gold standard
» Very important!!!!
» Assignment:
Please choose 3 functional tests listed on slide #
15 and write about it. please include:
1- purpose
2- how to do the test
3- reliability
4- normal scores for older individuals