Table 2.

Occupational Therapy Initial Evaluation Findings for Malcom

Assessment	Findings
Barthel Index (Mahoney, 1965)	The Barthel Index is an interval scale used to measure performance in activities of daily living. ∘ Each area of performance is scored in increments of 5, up to a score of 15 on select items, depending on the difficulty of the task. 0 = dependence; 100 = independence Malcom’s scores: ∘ Bowels: Continent (10) ∘ Bladder: Continent (10) ∘ Grooming: Needs help (0) ∘ Toileting: Needs some help (5) ∘ Feeding: Help/set up (5) ∘ Transfers: Minor help (10) ∘ Mobility: Walks with help of one person (10) ∘ Dressing: Needs help of one person (5) ∘ Stairs: Needs help (5) ∘ Bathing: Dependent (0) ∘ Total Score: 60/100
Global Deterioration Scale (GDS) (Reisberg, 1982)	The GDS is used to assess degenerative dementia and the current stage of the individual’s cognitive decline. ∘ 1 = no cognitive impairment; 7 = very severe cognitive impairment Malcom’s cognitive decline is consistent with a score of 5, indicating moderate cognitive decline; he requires assistance in completing ADLs.
Berg Balance Scale (Berg, 1992)	The Berg Balance Scale is used to measure balance in older adults. ∘ Total score = 56 points; 41–56 = low fall risk, 21–40 = medium fall risk, 0–20 = high fall risk Malcom scored a 36/56, indicating a medium fall risk.
Montreal Cognitive Assessment (MoCA; Julayanont, 2013)	The MoCA is used to evaluate memory loss or other symptoms of cognitive decline. ∘ Total score = 30 points; 18–25 points = mild cognitive impairment, 10–17 points = moderate cognitive impairment, <10 points = severe cognitive impairment Malcom scored 16/30, indicating moderate cognitive impairment. ∘ Visuospatial/executive function: 1/5 ∘ Naming: 3/3 ∘ Attention: 1/2 ∘ Numbers: 2/3, 1/1, 2/3 ∘ Language: 2/2, 1/1 ∘ Abstraction: 2/2 ∘ Delayed recall: 0/5 ∘ Orientation: 1/6
Observation and caregiver report	Malcom requires cues for body mechanics and hand placement when transferring to the toilet. Betty reports feeling depressed.

Note. ADLs = activities of daily living.