Assessments and Screenings

Fried’s Frailty Phenotype

low physical activity

exhaustion/fatigue

unintentional weight loss

weakness (grip)

slow walking speed

Fried’s Frailty Phenotype Criteria

robust = 0 criteria

pre-frail = 1-2 criteria

frail = 3+ criteria

Low Complexity: Profile and History

brief history

Moderate Complexity: Profile and History

expanded history

High Complexity: Profile and History

extensive history

Low Complexity: Assessment and Determination of Deficits

1-3 performance deficits

Moderate Complexity: Assessment and Determination of Deficits

3-5 performance deficits

High Complexity: Assessment and Determination of Deficits

5 or more performance deficits

Low Complexity: Clinical Decision Making

problem focused assessments

limited number of treatment options

modifications are not necessary

Moderate Complexity: Clinical Decision Making

detailed assessments

several treatment options

minimal to moderate modification

High Complexity: Clinical Decision Making

comprehensive assessments

multiple treatment options

significant modifications are necessary to enable patient to complete evaluation component

Katz

measurement of client’s ability to perform ADLs independently

administer: 5 minutes

Katz Items

bathing

dressing

toileting

transferring

continence

feeding

Katz Scoring

1: independent (no supervision, direction or personal assistance)

0: dependent (with supervision, direction, personal assistance or total care)

total score: 6 (high: independent) - 0 (low: dependent)

Lawton

measures the extent to which somebody can function independently and has mobility in their iADLs

ideal for community dwelling older adults, as well as those who have been admitted to hospital, short term SNF or rehabilitation facility

administer: 10-15 minutes

Lawton Items

ability to use telephone

shopping

food preparation

housekeeping

laundry

mode of transportation

responsibility for own medications

ability to handle medications

ability to handle finances

Lawton Scoring

1: independent

0: dependent

total score: 8 (high function: independent) - 0 (low function: dependent)

The 4AT

screens for delirium

alertness

the AMT4 (age, date of birth, place, current year)

attention

acute change or fluctuation course

The Confusion Assessment Method (CAM)

standardized evidence based tool that enables non-psychiatrically trained clinicians to identify and recognize delirium quickly and accurately in bout clinical and research settings

The Confusion Assessment Method Severity (CAM-S)

quantifies the intensity of delirium symptoms and patient experiences

will not yield a delirium diagnosis and is intended to be used in addition to the original CAM (CAM first then this assessment)

short (4 items) or long forms

administer: 5-10 minutes

Delirium Rating Scale (DRS)

used for initial assessment and repeated measurements of delirium symptom severity

13 items

all available sources of information are used to rate the items in addition to examination of the patient

SLUMS, MMSE

11 item tests with some questions having multiple parts

scoring provides with 3 categories of cognitive functioning

MoCA

examines 8 areas of cognition

scoring provides you with 2 categories of cognitive functioning

BIMS

required for all patients using Medicare or Managed medicaid insurance in acute care (adult rehabilitation facility, skilled nursing facilitation)

tests attention, immediate and delayed recall, orientation

scoring provides you with a range of 3 categories for cognitive functioning

E-ADL

assessment of functional cognition

AniP-DT Gait Test

novel dual task gait testing method can be used to screen MCI

could be easy and reliable for community dwelling older adults

Westmead Home Safety Assessment (WeHSA)

gold standard for home assessment

72 items over 1+ home visits

costly

Comprehensive Assessment and Solution Process for Aging Residents (CASPAR)

“is the home a good fit for the person?”

does not have to be an OT to use this assessment

Home Falls and Accidents Screening Tool (Home FAST)

25 items for environmental hazards in the home

emphasizes functional tasks and behaviors/interactions

Falls Behavioral Scale (FaB)

behavioral factors that protect against (or increase risk for) falling within the context of environment and occupations

Range of Motion (ROM)

test before testing strength

make sure there is no pain, joint instability or rigidity

discover compensatory strategies

note where there are limitations affecting functional performance

determine if we can proceed with the manual muscle testing

Manual Muscle Test (MMT)

evaluate function a strength of muscles

manual resistance, dynamometer, functional

important factors: fatigue, pain, fear, communication, recent sutures, test positions

precautions: inflammation, pain, healing tissue, setting, cardiovascular conditions

procedure: proximal stability to reduce compensatory action, resistance opposite the pull of the muscle, gradual application of pressure using the long lever

Manual Muscle Test (MMT) Grades

0: no contraction visible

1: trance, contraction can be felt when palpated

2: poor, person can move through complete ROM without gravity (gravity eliminated)

3: fair, person can move through full ROM and hold position against gravity

4: good, person can move through full ROM against gravity and hole the body part against moderate pressure

5: normal, person can hold body part against strong pressure/resistance

most of well community dwelling older adults will be 3,4,5

plus and minus can be added to the grade for further description but this can be very subjective

Borg Rating of Perceived Exertion Scale

uses rating of perceived exertion to monitor and guide exercise intensity

original: 6-20

modified dyspnoea: 0-10

both are used in clinical practice to measure perceived exertion, but modified one ism commonly used to measure breathlessness

roughly correspond to heart rate

Aerobic Assessments

short physical performance better test

METS

borg rating of perceived exertion scale

Balance Assessments

functional reach test

30 second

TUG

berg balance scale

4 stage balance

Static and Dynamic Balance Grades: Normal

maintains balance even with a maximum challenge without any support

static: patient able to maintain steady balance without handhold support

dynamic: patent accepts maximal challenge and can shift weight easily within full range in all directions

Static and Dynamic Balance Grades: Good

maintains balance with moderate challenge

static: patient able to maintain balance without handhold support, limited postural sway

dynamic: patient accepts moderate challenge, able to maintain balance while picking object off floor or reaching for something

Static and Dynamic Balance Grades: Fair

requires supervision or contact guard assistance (cga) to maintain balance

static: patient able to maintain balance without handhold support, may require occasional minimal assistance

dynamic: patient accepts minimal challenge; able to maintain balance while turning head/trunk; may require handheld support

Static and Dynamic Balance Grades: Poor

requires minimal to maximum assistance to maintain position and not lose balance

static: patient requires handhold support and moderate to maximal assurance to maintain position

dynamic: patient unable to accept challenge or move without loss of balance

Fear of Falling Scale

uses yes/no

liket scale

Activities-Specific Balance Confidence (ABC) Scale

confidence without feeling unsteady

16 or 6 items

Falls Self-Efficacy Scale International (FES-I)

concern about falling

Survey of Activities and Fear of Falling in the Elderly (SAFEE)

fear of falling within context

do you avoid __ in case you fell?

Mini Mental Satus Exam (MMSE)

orientation, registation, attention and calculation, recall and langage

Barthel Index for Activities of Daily Living

measures the extent to which somebody can function independently and has mobility in their ADLs

developed for use in rehabilitation patients with stroke and other neuromuscular or musculoskeletal disorders

administer: 20 minutes

Barthel Index for Activities of Daily Living Items

feeding

bathing

grooming

dressing

bowel control

bladder control

toileting

chiar transdermal

ambulation

stair climbing

Barthel Index for Activities of Daily Living Scoring

10: independent

5: needs help

0: dependent

higher the number is the more dependent one is

Barthel Index for Activities of Daily Living Interpreting Scores

0-20: total dependency

21-60: severe dependency

61-90: moderate dependency

91-99: slight dependency

100: independence

Modified Barthel Index

collin version: 0 (complete dependent) to 20 (functional independence)

shah version: each item has 5 scoring categories to improve reliability and sensitivity

Malnutrition Screening Tools (MST)

2 steps

takes less than 5 minutes

stratified risk

ficus on unintended weight loss and appetite

Malnutrition Universal Screening Tool

takes less than 5 minutes

based on BMI and weight loss

accounts for some effects of acute illness

Mini Nutrition Assessment Short Form (MNA-SF)

developed specifically for adults > 65 years old

short form is as reliable as long form

asks about: food intake, weight loss, mobility, illness, mental health and BMI

DETERMINE Checklist

disease

eating poorly

tooth loss

economic hardship

reduced social contact

multiple medicines

involuntary weight loss

needs assistance with self care

elders years about age 80

Brief Pain Inventory (BPI)

evaluates the severity and impact of pain in individual, particularly those with chronic pain conditions

questionnaire

two major components: pain severity and pain interference

Numeric Rating Scale (NRS)

assesses pain intensity and allowing individuals to quantify their pain levels

11 point numerical scale

how would you rate your pain RIGHT NOW?

how would you rate your BEST pain in the last 24 hours?

how would you rate your WORST pain in the last 24 hours?

time to administer: less than 1 minute

Verbal Pain Intensity Scale

measures and categorizes the intensity of a person’s pain based on verbal descriptors

clients are asked to select a descriptor that matches current pain level

time to administer: less than 1 minute

Verbal Pain Intensity Scale: Descriptors

no pain/none

mild pain

moderate pain

severe pain

worst possible pain/excruciating pain

Wong Baker Faces Pain Scale

assesses and quantifies pain in individuals

time to administer: less than 1 minute

The Occupational Understanding of Challenges Chronic Pain Questionnaire (OUCH-CPQ)

explores the influence of chronic pain on daily activities, occupations and overall well being

made specifically for OT

administration: interview or self report

The Occupational Understanding of Challenges Chronic Pain Questionnaire (OUCH-CPQ) Items

pain location

pain description

occupations

goals

Chronic Pain Acceptance Questionnaire (CPAQ)

measures acceptance of pain in order to focus on meaningful activities

administration: interviews

items: activity engagement (11 items) and pain willingness (9 items)

scoringL higher the score indicates higher level of acceptance

Elder Abuse Screenings

no universally accepted screening tool

occupational therapy elder abuse checklist

elder abuse suspicion index (EASI)

hwalek sengstock elder abuse screening test (H-S/EAST)

vulnerability to abuse screening scale (VASS)

EM-SART brief screening tool

Columbia Suicide Severity Rating Scale (C-SSRS)

supports suicide risk screening through a series of simple, plain language that anyone can ask

the answers help users identify whether someone is at risk for suicide, determine the severity and immediacy of that risk and gauge the level of support that the person needs

Loneliness Screening Tools

UCLA Loneliness Scale

Dejong Gierveld Loneliness Scale

Depression Screening Tool

patient health questionnaire (PHQ-9)

geriatric depression scale (short form)