Integral evaluation in the elderly is a multidimensional and multidisciplinary process centred on the detection of the underlying problems which can make the physiological process of ageing worse.
The method used to diagnose dependency is functional evaluation, in the context of a geriatric evaluation, and is currently based on the evaluation of the capacity to perform, independently, the basic activities of daily living (BADL). It is common, in elderly people, that the first warning sign of an approaching and progressive deterioration can be a slight loss of functional independence. This impairment can be demonstrated in the social area as well in cognitive capacity, or with the appearance of a small limitation in mobility or another physical problem. Only if these risk factors are detected in their earlier stages can the health professionals carry out specific preventive and rehabilitation measures to the affected dimension, and it is in the diagnosis of this incipient fragility where the evaluation of the degree of independence is shown to be more useful with the person carrying out the instrumental activities of daily living (AIDL).1
The independent performance of these activities has a significant impact on the health of the elderly. It has been associated with higher levels of self-perceived health and a direct association with mortality has also been shown.
There is also other evidence that the lack of independence in carrying out AIDL can be associated with sensory problems, lack of physical exercise, falls, difficulties in mobility, the lack of leisure activities and, above all, poorer quality of life.
The American Academy of Family Physicians, in their recommendations of preventive activities in primary care, revised in August 2005, did not include the functional evaluation of the elderly. However, other consulted sources of similar fields, the US Preventive Services Task Force and the Canadian Task Force of the Periodic Health Examination do recommend the periodic evaluation of the ABDL and the AIDL, although without quoting any particular scale or questionnaire.
The tool most used in our country to evaluate AIDL is the Lawton and Brody index. It scores if the individual performs the activity, not if he/she declares they can do it. It gives great importance to domestic tasks, therefore women normally obtain a better score. However, it evaluates the capacity to carry out an activity in circumstances of living alone, as in the case of widows/widowers.
The availability of electrical appliances and other tools could also influence the score. There have been many applications of this scale: it has been used as an indicator to determine the type and level of care necessary, to decide to admit to an institution, to evaluate intervention treatment, to train personnel, and plan and provide care services, as well as in research.
The Pfeffer-FAQ2 questionnaire is used as a cognitive screening test, although its format is that of a tool for activities of daily living for normal individuals or with slight functional changes. It measures the functional capacity to be able to carry out the AIDL. It has a high correlation with cognitive deterioration, as well as with the Lawton and Brody scale.
The Rapid Disability Rating Scale-23 is another one of the AIDL used in clinical practice, although it is directed more towards the co-evaluation of the mental state. It can be used in institutionalised subjects as well as those in the community. It consists of 18 questions classified into 3 groups: an aid in the activities of daily living (8 items), degree of incapacity (7 items), and 3 questions on specific problems (mental confusion, cooperation, and depression). It has 4 response options, with a score range between 18 and 72 points. The authors obtained mean values of 21-22 in non-domiciliary residents in the community. It has been suggested that in moderate-acute states of cognitive deterioration it yields better results than other scales, such as Pfeffer-FAQ or that of Lawton and Brody, which are more sensitive in mild cases of deterioration.
The COOP-WONCA4 charts evaluate the functional state and quality of life associated with health. It requires that the subject evaluates his/her state of health in the previous 15 days (physical, feelings, daily activities, social activities, changes in state of health, state of health, pain, and social support).
There are also other questionnaires on motor capacity, manual ability, self-care, scales for direct measurement of functional state, batteries of structured measurements of independence in daily activities and measurement of complex abilities, which provide more information on specific aspects in the evaluation of functional independence.5
A simple way of combining any of these tools could be the Functional Capacity Index of Sánchez Colodrón of 1997 (Faculty of Psychology, Autonomous University of Madrid), constructed by adding the 6 evaluation items of the ABDL of the Katz Index, the 8 of the Lawton and Brody scale, and 2 added activities, due to the importance that some authors have attributed to them, which are going to the toilet and combing hair.6 It can also be useful to evaluate the potential functional activity with the question: "If you did not have help to carry out the task, could you do it yourself?," with the hypothesis that sometimes the elderly do not carry out an activity, not because they cannot, but for convenience or too much protection by their carers. Along this line, perhaps an adaptive approach, with a combination and a selection of different items, among those already available, to evaluate the AIDL in our environment in a more sensitive or specific manner would be a more efficient task than starting creating a new tool from zero, taking into account the extensive scientific evidence available on the subject. There are currently 8833 literature references indexed on Medline with the criteria "Geriatric Assessment[MeSH]" of which 30% also have the criteria "Activities of Daily Living[MeSH]". This percentage is lower (25.3%; 22/87) when the same strategy applies with the language filter in Spainsh. This difference may support the hypothesis that the use of these scales is qualitatively different in our environment, which could be due to the majority of them have not having been adapted nor validated for use in our cultural environment. This, then, justifies the need to investigate the creation of new scales for evaluating AIDL, more suited to our primary care, and any attempt to advance this subject is followed with interest due to the expectations that it generates.
