Mohammed T. Abou-Saleh

ASSESSMENT OF DAILY LIVING 167and rheumatoid arthritis, and mentally impaired people improvedand deteriorated in the same way 9 . The instrument has been usedfor a number of purposes among elderly and disabled people inmany countries 10 . In Sweden, it is used in clinical practice bymedical and geriatric departments and in home care to communicateinformation about the patients’ ADL ability. The level ofADL performance has been shown to predict survival and death,length of hospital stay and type of hospital discharge in acutemedical care 11,12 .The cumulative order of items was found to correspond to theobservations made by Gesell of the ADL development in smallchildren during their first 7 years. This sociobiological origin mayexplain the good predictive validity of the instrument. Thelimitation of the scale is primarily a ceiling effect. It does notdifferentiate among less disabled persons, who are independent inbathing. But the small child does not stop developing at age 7, andthe very existence of a cumulative scale evoked the question ofwhat comes after bathing.From population studies, it was possible to derive scales ofpercentages of the population with activity limitations. Lawtonand Brody 13 formed hierarchical scales of personal and instrumentalitems. These cumulative ADL items were incorporated in acomprehensive multidimensional scale, the Older AmericanResearch and Service Center (OARS) instrument 14 . In order toprovide shortened measures, Fillenbaum formed a five-itemcumulative instrumental ADL scale out of the OARS instrument15 . Spector and Katz 16 reported that the instrumental items ofcooking and shopping were ranked higher than personal items.From the Gothenburg population study 17 , ADL reduction wasfound in about 30% of 70 year-old people, mostly due todependence in the personal items of the ADL.To understand further the cause of disability in old age, it wasnecessary to formulate exact definitions for instrumental activities,which could be ordered into an extended cumulative scale.Sonn and Hulter Asberg 18 found that the items of cooking,transportation, shopping and cleaning could be defined andordered next to bathing in Katz’s Index of ADL. The ADL‘‘staircase’’ now consists of 10 items: feeding, continence, movementof the body (e.g. getting out of bed), going to the toilet,dressing, bathing, cooking, transportation, shopping, cleaning.This ADL staircase can be used for observation and documentationof the different levels of disability for individuals, groups ofpatients and for population studies. For individuals, it can besupplemented by test situations according to the occupationaltherapists’ assessment of the need for rehabilitation. For groups ofpatients, it can be supplemented by disease- or symptom-specificscales, and populations can be assessed by interviews, where theinterviewer also assesses whether or not the answer seems areasonable one.There may be special reasons for choosing other ADLinstruments than the one described above, such as historicalreasons, instruments that include more items and are moresensitive to small changes in disability and that offer thepossibility of comparison with earlier studies. Furthermore,important research work by occupational therapists is now inprogress, attempting to develop special ADL instruments forpatients with psychiatric problems. The field is, as it were,‘‘preadolescent’’. In order to achieve a general standard for ADLassessments, it would be valuable to use the ADL staircasealongside other instruments. This would facilitate comparisonsbetween different studies and help promote knowledge about, andunderstanding of, the ADL status of elderly patients.REFERENCES1. World Health Organization. International Classification ofImpairments, Disabilities, and Handicaps: A Manual of ClassificationRelating to the Consequences of Disease. Geneva: World HealthOrganization, 1980.2. Wood PHN, Badley EM. Setting disablement in perspective. IntRehab Med 1978; 1: 32–7.3. Eakin P. Problems with assessments of activities of daily living. Br JOccup Therapy 1989; 52(2): 50–4.4. Kane RA, Kane RL. Assessing the Elderly. Lexington, MA: DCHeath, 1981.5. Skurla E, Rogers JC, Sunderland T. Direct assessment of activities ofdaily living in Alzheimer’s disease. J Am Geriat Soc 1988; 36: 97–103.6. Hawkins Watts J, Keilhofner G, Bauer DF et al. The assessment ofoccupational functioning: a screening tool for use in long-term care.Am J Occup Therapy 1986; 4: 231–40.7. Katz S, Ford AB, Moskowitz RW et al. 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MultidimensionalFunctional Assessment: the OARS Methodology, 2nd edn. Durham,NC: Duke University, 1978.15. Fillenbaum GG. Screening the elderly: A brief instrumental activitiesof daily living measure. J Am Geriatr Soc 1985; 33: 698–706.16. Spector WD, Katz S, Murphy JB, Fulton JP. The hierarchicalrelationship between activities of daily living and instrumentalactivities of daily living. J Chron Dis 1987; 40: 481–90.17. Gosman-Hedstrom G, Anianson A, Persson GB. ADL-reduction andneed for technical aids among 70 year-olds. From the populationstudy of 70 year-olds in Gothenburg. Comp Gerontol B 1988; 2: 16–23.18. Sonn U, Hulter Asberg K. Assessment of activities of daily living inthe elderly. A study of a population of 76 year-olds in Gothenburg,Sweden. Scand J Rehab Med 1991; 23: 193–202.19. American Psychiatric Association. Diagnostic and Statistical Manualof Mental Disorders, 4th edn. Washington, DC: American PsychiatricAssociation, 1994.