Section 2 - Assessment of Activities of Daily Living

WHAT ARE THE ACTIVITIES OF DAILY LIVING?

Function is the ability to adapt to the environment and perform activities of daily living, or the things that people
need to do every day. Doctors think about activities of daily living in three levels:

1. Advanced activities of daily living. These include such high-level functions as:
o Being gainfully employed
o Hobbies
o Socializing and involvement in activities in the community
2. Intrumental activities of daily living. These mid-level day-to-day tasks including:
o Shopping
o Cleaning
o Cooking
o Driving
o Managing financial matters
3. Basic activities of daily living. Examples include:
o Eating
o Dressing
o Bathing
o Toileting
For people to do all of these activities well, they have to have the mental and physical abilities to do them.
They must also have access to resources and opportunities that allow them to do these activities. Some
resources and opportunities may help to compensate for lost abilities, such as when a spouse cooks for a
person who can no longer do this alone. Finally, in order to do these activities of daily living, people must be
motivated to do them.

ASSESSING FUNCTIONAL STATUS

Observing the Patient
In evaluating a patient's function, doctors should consider the circumstances of the patient's visit. For example,
does the patient complain about problems with any activities? Does the patient appear well dressed and
groomed, or does the patient's appearance raise questions about the ability to do these activities? Does
someone accompany the patient, possibly because of concern about the patient's ability to get to or participate
in the clinic visit alone? Often, the doctor may ask the patient a general question, such as "How are you doing
in your daily activities?"
Taking a Functional History
Based on these circumstances, the doctor should ask more focused questions about how well the patient is
doing in the activities of daily living. For example, if the patient appears underdressed or poorly groomed, the
doctor might ask about basic activities. If the patient is well groomed, and accompanied to the visit by a family
member, the doctor might ask about instrumental activities of daily living. If the patient has come alone, the
doctor might ask about advanced activities.

The doctor should begin my asking about the most appropriate activites of daily living, based on the observed
circumstances. For example, asking about BADLs when a patient comes to the office appropriately dressed
and groomed would probably be inefficient.

ASSESSING PHYSICAL ABILITY

The Six-Maneuver Physical Function Screen
By having the patient perform six simple movements, the physician can learn much about his or her function.
This will help to focus any further physical examination. The six maneuvers are the following:
1. Put both hands together behind the head
2. Put both hands together in back of the waist
3. While sitting, touch each great toe with the opposite hand
4. Squeeze the examiner's two fingers with each hand, and resist the attempt to pull them out
5. Hold a paper between the thumb and index finger on each hand, and resist the attempt to pull it out.
6. Place the arms across the chest and stand from the chair
Launch the video clip to the right to see these maneuvers performed, along with an explanation of the activities
of daily living that each assesses.
ASSESSING PHYSICAL ABILITY
The Six-Meter Walk
The doctor may want to assess how well the patient is able to walk by having the patient stand up from a chair,
walk to a point about three meters away, turn around, walk back to the chair, turn around again, and sit back
down.
The Five-Second Stand
The doctor can assess balance by asking the patient to stand on one leg for five seconds.
The Sternal Nudge Test
Another way to assess balance and reflex, to evaluate fall risk, is the sternal nudge test. In this test, the doctor
asks the patient to stand with the feet about shoulder width apart. Then, with one hand behind the patient to
catch him or her if needed, the doctor pushes on the patient's chest just hard enough to knock him or her off
balance. The normal response is to put one leg back to stop one's self from falling. Failure to do so may reveal
a problem that puts the patient at an increased risk of falling.

An alternative way of doing this test is to push the patient from behind, catching him or her with the other hand
in the event of a forward fall. The normal response to this would be to put one leg forward.
The video link to the right demonstrates the six-meter walk, five-second stand, and sternal nudge test.
The Whispered Word
If hearing loss is a possible concern, the doctor may whisper a word in the patient's ear, and then ask him or
her to repeat the word.

ASSESSING MENTAL ABILITY

The Mini Mental State Exam (MMSE)
The first tool the doctor will often use to assess mental, or cognitive, ability is the Mini Mental State Exam. This
screening tool consists of several questions and brief tasks that focus on thinking and memory. A perfect score
is 30 points, but a normal score depends on the patient's age and educational background. Therefore, it is
important that the doctor remember to ask about the patients level of education.

When interpreting the score of a Mini Mental State Exam, it is also important to consider any circumstances
other than cognitive impairment that might affect a patient's performance. For example, if a patient has recently
moved, they might be more likely to give a wrong answer on the question about which county they are in.

Also, when administering the Mini Mental State Exam, it is important to avoid prompting the patient, whether
advertantly or inadvertantly. For example, a common mistake is to present the three-stage command ("Take
the paper in the right hand, fold it in half, and set it on the floor") as three separate directives, with the patient
being allowed to do the given step before being told the next step. All three steps should be presented first,
with the patient then completing all three steps. Another common mistake is to present the paper toward the
patient's right hand, inadvertantly prompting them on which hand to use. As another example, the student
should allow the patient to make up the sentence to write, to assess the patient's ability to form and use
language. It is a mistake to tell the patient what sentence to write.
The Mini Mental State Exam is a good first tool for assessing mental ability because it can give a baseline
score that the doctor can follow over time.
To see how the Mini Mental State Exam should be performed, launch the video clip to the right.
The Clock Drawing Test
The clock drawing test should be used when the Mini Mental State Exam has raised questions about the
patient's mental abilities. The clock drawing test serves to further confirm a deficit in cognition.
To administer the clock drawing test, the doctor gives the patient instructions such as the following: "I want you
to take this paper and pencil, and draw a clock with all the numbers on the face of the clock. Set the time to 10
minutes after 11 o'clock." The instructions should be given in their entirely before the patient begins, although
the examiner may later prompt the patient as explained below.

This screen assesses three major areas. First, it focuses on executive function, or the ability to plan. Can the
patient realize that the circle must be drawn large enough to fit all the numbers and hands in? Second, it
focuses on visual-spatial ability. Can the patient put the numbers in the appropriate places on the clock?
Finally, it focuses on abstraction, or the ability to use symbols. Does the patient realize that on a clock, the
number 2 actually represents 10 minutes?
In this test, if the patient becomes stuck or is unable to do a part of the task, the doctor may prompt the patient,
but notes that the patient needed prompting. For example, if the patient has difficulty drawing the circle for the
clock face, the doctor may draw the circle for them, so that they are able to move on to putting the numbers on
the clock.
The images below show normal and abnormal clocks.

A normal clock: note that the An abnormal clock: the numbers are
numbers are evenly spaced and the not evenly spaced, and the hands
hands set correctly at 11:10. are incorrect for 11:10.

Apraxia Screening
Apraxia means trouble performing purposeful motor tasks, even though the physical ability to move the limbs
and joints is normal. It is caused by deficits in the workings of the brain. If a patient shows problems with
memory through an abnormal Mini Mental State Exam and/or Clock Drawing test, the doctor may assess for
apraxia as part of evaluating the patient for dementia. To do this, the doctor will have the patient perform a
series of finger movements.

ASSESSING MOOD AND MOTIVATION

The Geriatric Depression Scale (GDS)
Depression can affect the patient's motivation to perform activities of daily living, and is therefore important to
consider in functional assessment. The Geriatric Depression Scale (click the link to view the form) is a series of
15 questions that have been shown to be useful in identifying depression in older adults. It avoids certain
questions that sometimes appear in depression screens for younger patients, but which could be less useful
with elderly patients due to changes associated with aging.
When considering whether a particular patient's score on the Geriatric Depression Scale represents a
depressed mood, the doctor must consider factors other than depression that could influence the response.
For example, a patient may say that he or she prefers to stay at home rather than going out. Perhaps this
represents a lifelong preference and habit. Perhaps it is due to physical problems that make it difficult to
navigate the environment outside the home. Or, perhaps it does in fact represent a change in the patient's
behavior that is due to a depressed mood and lack of motivation.

In the absence of other explanations for "depressed" answers, a score of greater than 5 out of 15 on the
Geriatric Depression Scale likely represents a depressed mood.