The clinical usefulness of performance-based assessments of daily functioning for older adults

Abstract

Clinicians treating older adults are often asked to evaluate the everyday functioning capabilities of their patients. Difficulties with daily functioning are part of the diagnostic criteria for most neuropsychiatric disorders, including dementia. Many methods of assessing daily functioning exist including self- or collateral-reports (through clinical interview or structured rating scales), direct home- or community-based observations, and performance-based measures conducted within the clinic or laboratory. Performance-based measures use simulated or role-play functioning scenarios and have the key advantage of decreasing reporter bias; these instruments may provide complimentary information to subjective reports and/or field observations. Thus, treating clinicians should consider incorporating performance-based assessments as part of the diagnostic process to establish (or rule out) presence of functioning impairments and when developing recommendations about a patient’s capacity for safe independent living.

Introduction

Older adults face a wide range and high prevalence of cognitive and physical health problems that may adversely affect capacity for independent functioning. Caregivers and clinicians who treat older adults with neurocognitive or physical disabilities, as well as the patient’s themselves, need objective information about the individual’s functional capacities in order to make informed decisions regarding the least restrictive but safe level of support or supervision that the individual may require. In that vein, geriatricians and other clinicians specializing in the care of older adults, are frequently asked to make recommendations regarding a patient’s daily functioning capabilities and needs. In some cases, identifying and recommending the appropriate course of action is straightforward, even if the implementation may not be problem free. Decisions about whether a person has the capacity to safely carry out independent living tasks, however, can be less clear among older persons with subtle cognitive impairments.

Many useful everyday functioning instruments exist; however, there is no consensus on which (if any) instrument(s) should represent the “gold standard” for the assessment of everyday functioning among persons with cognitive impairment. Current assessment modalities include self-report, caregiver/collateral reports, informal assessments based on clinical history and exam, performance-based assessments of everyday functioning, and direct observation. Some widely used instruments (e.g., Katz ADL Index, Lawton-Brody Instrumental Activities of Daily Living Scale) have guidelines for defining impairment, but often require the patient to be directly observed in an inpatient setting or depend on the accurate report of the patient or caregiver.^{1, 2} A complementary method is to use performance-based measures in which patients are asked to perform a series of standardized, but ecologically valid, independent living tasks.³

We recently conducted a comprehensive critical review of extant performance-based instruments of everyday functioning, in which we provided a detailed description of the available instruments in regard to the specific functional domains assessed by each, the nature of administration and scoring, administration time, as well as a summary of any empirical data regarding the reliability and validity of each instrument.³ A reader who is interested in a critical review of the instruments in regard to these details is encouraged to consult that paper. However, we also recognize that general practitioners have a pragmatic need for a more general overview of the best candidate and widely used performance-based measures. Thus, the intent of the present article is to expose general practitioners to the nature and implementation of performance based measures, including an overview and general description of some of the more widely used performance-based instruments. This overview will include several case scenarios as well as brief descriptions of some useful instruments. The list of instruments provided herein is in no way intended to be exhaustive.

Case Studies: Implementing performance-based assessment of daily functioning into clinical practice

The need for explicit assessment of everyday functioning capabilities arises frequently in the geriatric population. Among patients with moderate-to-severe cognitive impairments, experienced clinicians are likely to have a good sense of how these deficits may relate to everyday functioning and the associated level of care that may be required for a given patient. Performance-based assessments, however, might still be useful in identifying preserved skills and documenting decline. They may be particularly helpful in distinguishing mild cognitive impairment (MCI) from dementia, in clarifying spared capacities (which may be useful in developing compensatory strategies/environmental modifications), supplementing patient or collateral reports, and supporting recommendations in regard to the need for structured placements/level of supervision. In these subtle situations, performance-based instruments may be worth the extra time and cost, especially when one weighs the potential complications associated with an inaccurate assessment of a person’s daily functioning capabilities (e.g., re-hospitalization, malnutrition, poor control of medical condition because of medication management difficulties).

The administration of performance-based assessments can often fall under the purview of different disciplines (e.g., neuropsychologists, occupational therapists) depending on the structure of a given clinic or care facility. Moreover, these instruments are not used on a routine basis at all clinics; however, assessments similar to those described in the case studies below could likely be requested by an interested clinician and may help to inform decisions about daily functioning.

The following hypothetical case scenarios and recommendations for applicable performance-based assessment instruments are intended to convey just a few examples of the many situations where the use of performance-based measures of everyday functioning may be appropriate.

Case Example 1: Mrs. G.

Detailed testing indicates that Mrs. G. has mild-to-moderate memory and other cognitive impairments. Mrs. G, as well as her husband, Mr. G., report that Mrs. G has no difficulties in the execution of daily functioning activities. However, the patient’s daughter reports that her father has recently taken over many of the tasks that her mother used to do (e.g., shopping, making frequent calls to her grandchildren). These conflicting self- and collateral reports make it unclear whether Mrs. G has significant impairment in daily functioning, which is the key to distinguishing MCI and Alzheimer’s Disease.

Dr. Q, the treating clinician has her staff administer the Kohlman Evaluation of Living Skills (KELS), a performance-based battery of functional assessments. Other choices that Dr. Q considered included the Direct Assessment of Functional Status (DAFS) and Structured Assessment of Independent Living Skills (SAILS).^4–6 Both the DAFS and SAILS would be appropriate alternatives because they also assess multiple everyday functioning domains, have been used with older healthy controls and adults with Alzheimer’s Disease and have several articles supporting their reliability and validity. However, Dr. Q ultimately chose the KELS over these other two options because she wanted an assessment of safety, which she suspected might be impaired in Mrs. G. The KELS indicates that Mrs. G. is significantly impaired in the domains of communication, safety, and finances. These findings corroborate the daughter’s report, and the clinician assigns a diagnosis of dementia rather than MCI. As a result of this differential diagnosis, the clinician may choose to order subsequent medical tests, initiate psychopharmacologic treatment and recommend additional assistive care.

Case Example 2: Mr. B.

Mr. B. is a retired accountant who recently had a stroke. He has been adamant that he is able to manage his retirement funds. His wife, who has no experience completing financial tasks, suspects that her husband is no longer capable of managing their complex retirement funds and is thus very concerned. The treating physician notices that Mr. B is still able to do simple math, but decides to administer the Financial Capacity Index (FCI),⁷, a targeted performance-based assessment of financial capacity, for a formal assessment. Results reveal significant impairments on this measure, such as check management, bank statement management, and bill payment, and it is recommended that the patient’s family manage the family finances instead.

Case Example 3: Mr. W.

Mr. W. is a 65-year-old man with schizophrenia who has been living independently in the community. The family is considering transferring him to a structured living facility due to fears that, in his older age, he will not be able to 1) find his way to and from his therapy appointments, 2) interact appropriately in social situations, and 3) manage his medications. The patient reports his own impression is that he has no difficulty in any of these areas. The clinician administers the brief version of the University of California, San Diego, Performance-Based Skills Assessment (UPSA-Brief) and the Medication Management Ability Assessment (MMAA).^{8, 9} His performance on these measures indicates that he does not have current impairments in daily functioning capacity, but that reports from the family indicate the patient does have some difficulties spontaneously performing these tasks in his everyday living. Based on the apparent discrepancy between capacity and spontaneous performance, the treating clinician refers Mr. W to an occupational therapist with expertise in psychiatric conditions, who begins a rehabilitative program to help Mr. W. learn to better utilize his functional capabilities so that he can maintain independent functioning.

These case examples highlight how performance-based assessments can provide additional quantifiable information, resolve discrepancies in self- or collateral-reports, and lead to more informed recommendations from the clinician. Obviously, results may not be as clear cut as in the examples provided; however, clinicians should be aware of these potential tools that may assist in characterizing their patients, especially in situations where major life transitions are being discussed.

Domains of everyday functioning: Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs)

Everyday functioning behaviors are quite individualized, and can vary based on factors such as culture, socioeconomic status, and the presence of medical or psychiatric conditions. Despite the large range of possible daily activities, certain basic behaviors are nearly universal. ADLs are personal care behaviors and basic physical skills necessary for daily life, and they include walking, grooming, bathing, and dressing. Individuals who are unable to complete these basic ADLs require significant assistance and are likely to live in a structured setting (e.g., nursing home) or receive assistance from a full-time caregiver. IADLs are more complex abilities that are required for functioning independently as a member of society. Examples of IADLs include managing medications, balancing a checkbook, and preparing a meal. Community-dwelling older adults typically handle most IADLs independently.

The exact manifestation of cognitive impairment in relation to ADL or IADL impairment is variable. For instance, neuropsychological impairment may manifest before daily functioning impairment or vice versa. Although it is generally posited that IADL impairments will manifest prior to ADL impairments, this is not necessarily the case (e.g., walking may be impaired prior to all IADLs). Furthermore, by making certain modifications to behavior (e.g., increasing the frequency) or altering one’s environment (e.g., using an electronic reminder as a cue to take medications), a cognitively impaired person may be able to compensate for cognitive and daily functioning impairments that may exist. Altering how or how often a task is accomplished without reporting difficulty with the task may represent a form of preclinical disability.^{10, 11} Performance-based measures of everyday functioning may be able to capture some of these more subtle daily functioning difficulties.

Instruments for assessing everyday functioning

Performance-based measures of everyday functioning are administered under consistent conditions and use standardized instructions, making scoring straightforward. A subset of widely used multi-domain assessment instruments with adequate to good reliability and validity are listed in Table 1. We also list measures for the assessment of financial and medication management ability, as these are two domains that come under frequent consideration in a primary care setting. For a more comprehensive list and for detailed reliability and validity information for the majority of these measures, see our recent review³.

Table 1.

Performance-based assessments of ADLs and IADLs

Multi-domain Assessments
ADLs (eg, transferring, walking, hygiene, bathing, toileting, dressing, eating)	Refined ADL Assessment Scale (RADL) 13
IADLs (eg, financial management, medication management, cooking, laundry, communication, shopping, housekeeping, gardening, driving, hobbies, safety)	Activities of Daily Living Test (ADL-T) 14 Everyday Problems Test for the Cognitively Challenged Elderly (EPCCE) 15a Independent Living Scales (ILS) 16 Revised Observed Tasks of Daily Living (OTDL-R) 17b UCSD Performance-based Skills Assessment (UPSA) 18c
Combined (ADLs + IADLs)	Direct Assessment of Functional Status (DAFS) 4 Direct Assessment of Functional Abilities (DAFA) (Karagiozis, 1998) Structured Assessment of Independent Living Skills (SAILS) 5 Texas Functional Living Scale (TFLS) 19 Kohlman Evaluation of Living Skills (KELS) 6
Single-domain Assessments
Financial skills	Financial Capacity Index (FCI) 7d Time and Change (T&C) 20
Medication management	Medication Management Ability Assessment (MMAA) 9 Drug Regimen Unassisted Grading Scale (DRUGS) 21 Functional Ability to Take Medications (FATM) 22 Medication Administration Test (MAT) 23

^aThere is also the original Everyday Problems Test (EPT) ²⁴

^bThere is an original version Observed Tasks of Daily Living ²⁵

^cThere is also the UPSA-Brief ⁸

^dThere is also the modified FCI-8 ²⁶

Key: ADLs, Activities of Daily Living; IADLs, Instrumental Activities of Daily Living

Performance-based measures may assess ADLs, IADLs, or a combination of the two. In general, these measures use role-play and mock settings to simulate everyday functioning tasks. For instance, rather than having the patient or a collateral informant answer questions about the patient’s medication management skills (which might be limited by the insight, candor, and objectivity of the patient or the informant), the patient can show how he or she organizes and takes his or her medications using a mock medication regimen, or in some cases the actual regimen. Note, however, such performance-based measures assess capacity or what a person can do under standardized, optimal conditions, not what they actually do in the their habitual environment.¹² This distinction is important because in some disorders, it is not a lack of capacity that impairs performance, but rather a failure to translate functional capacity into self-initiated functional performance. For instance, a person may have the capacity to write a check, but fails to actually pay his or her monthly bills.

Notable strengths of performance-based measures of functional capacity include that they 1) directly assess functional capacity (and thus are less dependent on the respondent’s insight or forthrightness than are measures using self- or collateral report); 2) have standardized administration and scoring (leading to good reliability as contrasted with open-ended direct observation or informal assessments based on clinical history and exam); and 3) have greater ecological validity than traditional neuropsychological measures in that the tasks performed have direct analogues with everyday functional tasks.

Some of the key limitations of performance-based measures follow from the use of a simulated environment; doing so may lead to either an overestimation of capacity due to the structured nature of the prompts, or an underestimation of performance since the materials are not the ones patients use in their daily lives and may not allow for environment-driven cues and over-learned behaviors. Also, the content of some performance-based test items may not actually map onto the difficulties that a patient is having in his or her personal environment (e.g., the problem may be remembering to put medications into an organizer, rather than remembering to take the medications once they are in the organizer). Also, performance-based instruments tend to require more time and a more highly trained assessor, as compared to self- or collateral report or a standard interview. Currently available performance-based measures also assess only one given functional domain at a time, and therefore fail to capture the multi-tasking complexity of daily life (e.g., the phone ringing in the middle of cooking dinner). Finally, comprehensive studies of the predictive validity of many of these instruments have yet to be firmly established.

Although the strengths and limitations mentioned above must be kept in mind when considering use of a performance-based measure in any context, it generally appears that the strengths sufficiently outweigh the weaknesses in most situations. We believe that such measures should be at least considered as part of an overall functional assessment.

Summary

Because many conditions that affect older individuals can impair daily functioning abilities, it is important that clinicians, caregivers, and patients themselves, be able to determine how much support the affected individual needs for a least restrictive but safe living environment. Although many different types of assessments exist for the assessment of daily functioning, performance-based measures have proven reliable and have much to offer in their standardized, objective measures of functional capacity. In today’s ever-aging population, clinicians who are unfamiliar with the performance-based assessment methodology may want to consider this under utilized approach in assisting with making daily functioning recommendations.