UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

The development of a geriatric assessment instrument for long term care facilities Buchan, Jane 1979

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1979_A5_7 B93.pdf [ 4.8MB ]
Metadata
JSON: 831-1.0094597.json
JSON-LD: 831-1.0094597-ld.json
RDF/XML (Pretty): 831-1.0094597-rdf.xml
RDF/JSON: 831-1.0094597-rdf.json
Turtle: 831-1.0094597-turtle.txt
N-Triples: 831-1.0094597-rdf-ntriples.txt
Original Record: 831-1.0094597-source.json
Full Text
831-1.0094597-fulltext.txt
Citation
831-1.0094597.ris

Full Text

THE DEVELOPMENT OF A GERIATRIC ASSESSMENT INSTRUMENT FOR LONG TERM CARE FACILITIES by JANE BUCHAN B . S c . N . , McMaster U n i v e r s i t y , 1968 A THESIS SUBMITTED IN PARTIAL FULFTT.TMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n THE FACULTY OF GRADUATE STUDIES (School o f Nursing) We accept t h i s t h e s i s as conforming to the r e q u i r e d standards THE UNIVERSITY OF BRITISH COLUMBIA A p r i l , 1979 (c) Jane Buchan, 1979 . i In presenting th i s thesis in pa r t i a l fu l f i lment of the requirements for an advanced degree at the Univers ity of B r i t i s h Columbia, I agree that the Library shal l make i t f ree ly avai lable for reference and study. I further agree that permission for extensive copying of th i s thesis for scholarly purposes may be granted by the Head of my Department or by his representatives. It i s understood that copying or publ icat ion of th i s thesis for f inanc ia l gain shal l not be allowed without my written permission. Department nf^^^AAXCLO J)J~u.,rAsw "ScAn? / p^f ./\J iAAU) tsryi The Univers ity of B r i t i s h Columbia (J 2075 Wesbrook Place Vancouver, Canada V6T 1W5 Date QUO^AL *4 F / 7 7 ? ABSTRACT The purpose o f the study was to des ign a r e l i a b l e and v a l i d assessment instrument t h a t would prov ide a mult id imens ional p r o f i l e o f the e l d e r l y r e s i d e n t o f a long term care f a c i l i t y . Use o f t h i s '. instrument would be a method o f c o l l e c t i n g and corrmunicating i n f o r -mation concerning the f u l l range o f problems experienced by t h i s group, i n a form t h a t i s s u i t a b l e f o r use a t d i f f e r e n t l e v e l s o f d e c i s i o n -making. The instrument c o n s i s t s o f 31 unweighted"items measuring func t ion ing i n 5 e s s e n t i a l areas - c o g n i t i v e , p h y s i c a l , emotional , s o c i a l , and ins trumenta l . Ratings were based on the observat ions o f long term care s t a f f who were i n c l o s e contact w i th the i n d i v i d u a l over extended p e r i o d s . R e l i a b i l i t y and v a l i d i t y were t e s ted us ing a non randcm sample o f 76 e l d e r l y r e s i d e n t s o f one extended care u n i t . Both t e s t - r e t e s t and inter judge r e l i a b i l i t y proved to be h igh and i tem a n a l y s i s i n d i c a -ted tha t , w i th the except ion o f 2 i tems, the instrument provides l e v e l s o f func t ion ing appropr ia te to the sample popu la t ion . The instrument a l so showed a h igh degree o f i n t e r n a l cons i s tency wi th the 3 major components i d e n t i f i e d as - c o g n i t i v e behaviour, independence i n d a i l y l i v i n g , and p h y s i c a l f u n c t i o n i n g . The v a l i d i t y o f the instrument and i t s subsect ions was demonstrated through s i g n i f i c a n t r e l a t i o n s h i p s wi th ex terna l c r i t e r i a , namely -i i i the number of problems listed on the multidisciplinary problem-oriented record, a health index measure, and a mental status rating. Further evidence of the instrument's validity was its ability to predict, retrospectively, 72 percent of the sample deaths in the f i r s t year following admission. Although only a preliminary form of analysis, this showed that a high level of mental functioning, combined with a low level of independence in daily living, was predictive of death within 3 to 9 months in the sample population. The implications of these results are discussed along with suggestions for further research in the area. Finally, potential uses for the assessment instrument in the field of long term care are provided. Thesis Chairman CONTENTS CHAPTER PAGE I INTRODUCTION 1 The Need f o r a Long Term Care Assessment Instrument Study Questions II LITERATURE REVIEW 6 Assessment Content Assessment Procedure B e h a v i o u r a l Observation Assessments i n Long Term Care I I I METHODOLOGY 2 6 Development of a New Assessment Instrument R e l i a b i l i t y and V a l i d i t y T e s t i n g Assumptions L i m i t a t i o n s IV RESULTS AND DISCUSSION 42 R e l i a b i l i t y V a l i d i t y V CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS 57 C o n c l u s i o n s I m p l i c a t i o n s and Recommendations NOTES 62 BIBLIOGRAPHY 68 APPENDICES :. 73 i i i L I S T OF T A B L E S P a g e I T e s t - R e t e s t a n d I n t e r j u d g e R e l i a b i l i t y o f t h e A s s e s s m e n t S u b s e c t i o n s U s i n g S p e a r m a n Rank O r d e r C o r r e l a t i o n . . . . 43 I I I n t e r n a l C o n s i s t e n c y o f S u b s e c t i o n s a n d T o t a l A s s e s s m e n t I n s t r u m e n t 4 8 I I I C o r r e l a t i o n a l M a t r i x o f S u b s e c t i o n , a n d T o t a l A s s e s s m e n t S c o r e s . 50 i v L I S T OF A P P E N D I C E S P a g e AP PENDIX A - N u r s e s ' O b s e r v a t i o n S c a l e 7 3 B - S a m p l e M u l t i d i m e n s i o n a l P r o f i l e . . . 83 C - M a j o r A d m i t t i n g D i a g n o s e s o f S a m p l e P o p u l a t i o n 84 D - H e a l t h I n d e x 85 E - P l a n n e d A c t i v i t y C h e c k 88 F - M e n t a l S t a t u s Q u e s t i o n n a i r e 90 G - I t e m A n a l y s i s : F r e q u e n c y , D i s t r i b u t i o n , a n d C o r r e l a t i o n s . 91 H - D i s t r i b u t i o n o f S u b s e c t i o n a n d T o t a l S c o r e s 9 5 I - D i s c r i m i n e n t F u n c t i o n A n a l y s i s f o r D e a t h U s i n g S u b s e c t i o n S c o r e s . . 9 7 J - C o m p a r i s o n o f S c o r e D i f f e r e n c e s t o N u r s e C o - o r d i n a t o r a n d R e s i d e n t R a t i n g o f C h a n g e 98 K - C o m p a r i s o n o f N u r s e C o - o r d i n a t o r s ' a n d R e s i d e n t s ' R a t i n g s o f C h a n g e . 9 9 v ACKNOWLEDGEMENTS I wish to express my appreciation to the nursing s t a f f at The University of B r i t i s h Columbia Extended Care Unit for both the intere s t and time they contributed to the completion of t h i s research project. Special thanks go to Dr. John Campbell for his contribution and encouragement i n the development of the instrument, and to Ms. Mary Cruise and Dr. David Lawson for t h e i r continued advice and guidance. vi Chapter I INTRODUCTION The Need For a Long Term Care Assessment Instrument The proportion of the population over 65 i s growing stea d i l y , from one m i l l i o n i n 1971 (7.7 percent of the popu-lation) to a projected three m i l l i o n i n 1980, (11.4 percent of the population)."'" In addition, people are l i v i n g longer and becoming more susceptible to d i s a b i l i t y from chronic diseases and degenerative processes. Despite increased e f f o r t s to provide supportive services i n the community, as many as 7 to 10 percent of the aged w i l l continue to require r e s i -2 3 dential assistance. ' In Canada, as i n many other countries, th i s has resulted i n a rapid expansion in the number of private nursing homes, and government i n s t i t u t i o n s providing basic services such as food, laundry, cleaning, professional and/or lay supervision and care on an extended basis. In 1974, there were 1200 such long term care f a c i l i t i e s providing r e s i d e n t i a l care to 71,000 Canadians through government-sponsored programs. In the United States, long term care f a c i l i t i e s provide twice as many days of care o v e r a l l than short-stay hospitals, and 5 the demand for more beds i n c r e a s e s . Admission to such a f a c i l i t y occurs, not as the r e s u l t 1 2 of a short-term disease from which the person hopes soon to recover, but following an accumulation of events such as physical, mental, and s o c i a l losses, family disunity, and i n s u f f i c i e n t environmental and personal resources for con-tinued community l i v i n g . ^ In addition, the i l l n e s s e s experienced by t h i s age group are c h a r a c t e r i s t i c a l l y multiple i n o r i g i n , chronic and i r r e v e r s i b l e i n nature, and i n t e r -7 acting i n manifestation. Once the move to a long term care f a c i l i t y has been made, return to the community i s unli k e l y and the f a c i l i t y becomes the person's permanent place of residence. Under such circumstances, emphasis on medical conditions alone i s inadequate. Successful management of care hinges upon a m u l t i d i s c i p l i n a r y approach and the i n t e -gration of a variety of services for an i n d e f i n i t e period. Yet assessments and information-gathering procedures upon which care i s based within the f a c i l i t i e s have not r e f l e c t e d the unique problems of the e l d e r l y c l i e n t , nor have they f a c i l i t a t e d a m u l t i d i s c i p l i n a r y , integrated approach. Instead they have been based on single d i s c i p l i n e perspectives, or on the acute care model which emphasizes curing and reversal of medical conditions. Commonly global ratings or labels replace any form of assessment. E r i c P f e i f f e r describes the f i r s t s i t u a t i o n accurately: The physician finds his disease and treats i t and so does the health care worker. The s o c i a l worker determines e l i g i b i l i t y for f i n a n c i a l assistance and leaves i t at that. Placement w i l l occur without major consideration for alternative provisions.8 3 S u c h a p p r o a c h e s a r e c o u n t e r p r o d u c t i v e w i t h any p r o b l e m o r g r o u p , b u t a r e p a r t i c u l a r l y so w i t h t h e a g e d whose p h y s i c a l , s o c i a l , a n d p s y c h o l o g i c a l c o n d i t i o n s a r e so i n e x t r i c a b l y i n t e r w o v e n t h a t a n y • u n i d i m e n s i o n a l i n f o r m a t i o n - g a t h e r i n g c a n o n l y be m i s l e a d i n g . T h e m e d i c a l m o d e l t h a t i s t r a d i t i o n a l l y u s e d i n a c u t e c a r e d e a l s w i t h s t r u c t u r a l l o s s e s a n d d i s e a s e e n t i t i e s f r o m w h i c h i n f e r e n c e s a r e made as t o t h e p o t e n t i a l c a p a b i l i t i e s a n d p r o b l e m s e x p e r i e n c e d b y t h e i n d i v i d u a l . Y e t d i a g n o s t i c c l a s s i f i c a t i o n d o e s n o t a c c u r a t e l y p r e d i c t f u n c t i o n i n g c a p a c i t y o r l e v e l o f d i s a b i l i t y a n d i n many c a s e s t h e a g e d i n d i v i d u a l w i l l be s u f f e r i n g f r o m a number o f m e d i c a l c o n d i t i o n s . O v e r -e m p h a s i z i n g t h e s e c o n d i t i o n s c a n l e a d t o n e g l e c t o f i m p o r t a n t c o n c u r r e n t s o c i a l a n d e m o t i o n a l p r o b l e m s a n d i s s u e s r e l a t i n g t o i n d e p e n d e n c e a n d q u a l i t y o f l i f e . D i f f i c u l t i e s a l s o e n s u e when p r o f e s s i o n a l s a s s e s s r e h a b i l i t a t i v e p o t e n t i a l w i t h e x p e c t a t i o n s f o r m e d w i t h y o u n g e r c l i e n t s . I n a p p r o p r i a t e i n t e r v e n t i o n s a r e i n s t i t u t e d w i t h 9 l i m i t e d o r e v e n n e g a t i v e r e s u l t s . A s a c o n s e q u e n c e , h e a l t h p r o f e s s i o n a l s become f r u s t r a t e d a n d d i s c o u r a g e d a n d t h e a g e d a r e s e e n t o be s u f f e r i n g f r o m an i n e v i t a b l e d e t e r i o r a t i o n t h a t c a n n o t be a l t e r e d t h r o u g h t h e i r i n t e r v e n t i o n . A n a t t i t u d e o f " t h e r a p e u t i c n i h i l i s m " s e t s in."*"^ A c c o r d i n g t o L o w e n t h a l , t h i s i s l a r g e l y r e s p o n s i b l e f o r t h e l a c k o f i n f o r m a t i o n - g a t h e r i n g i n l o n g t e r m c a r e f a c i l i t i e s a n d t h e r e s u l t a n t c u s t o d i a l a p p r o a c h t o c a r e . T h e m o s t common r e p l a c e m e n t f o r a d e t a i l e d a s s e s s m e n t , 4 p a r t i c u l a r l y among nursing s t a f f , consists of global ratings or labels such as "regressed" and " s e n i l e . " Even though such labels are extensively used, they convey l i t t l e i f any useful information. Wolanin i l l u s t r a t e d t h i s fact by examining the 12 use of the word "confused" on charts. There was no clear operational d e f i n i t i o n of the term found and very l i t t l e agreement among s t a f f concerning i t s appropriate usage. She concluded that i t was a meaningless term r e f l e c t i n g s t a f f discomfort. In a s i m i l a r vein, a study by Harris et a l . indicated that nurses tend to l a b e l e l d e r l y residents on the basis of 13 very l i t t l e information. Such p o t e n t i a l l y i n v a l i d diagnoses by s t a f f members had devastating e f f e c t s on the i n d i v i d u a l s , who were thereafter segregated from other residents and a c t i v i t i e s . The r e s u l t , of course, was increased deterioration 14 and withdrawal. Others have found that, once such l a b e l l i n g occurs, subtle changes i n behaviour are ignored as being part of the individual's "condition," even though i t may be i n d i -cative of an undetected physical problem, drug reaction, or depressive state. Despite the obvious dangers of acute care assessments, single d i s c i p l i n e perspectives, and global l a b e l s , no a l t e r -native method has yet been devised to c o l l e c t and communicate information concerning the f u l l range of problems experienced by the elderly i n d i v i d u a l i n a manner that i s both meaningful and concise. Basic assessment information needs to be outlined that provides an overview of the person's condition i n a l l 5 s i g n i f i c a n t areas. This i s es s e n t i a l information needed to plan, provide, and evaluate long term care so that i t w i l l be comprehensive :in scope and focussed upon the o v e r a l l needs of the c l i e n t . Considering the extended duration of care, the pervasiveness of the impairments, and the large number of professionals involved, a standard assessment would serve both as a means of monitoring progress over time, and as a focal point for the integration of services. Problem Statement Can a r e l i a b l e and v a l i d assessment instrument be designed that w i l l provide a multidimensional p r o f i l e of the elderly resident of a long term care f a c i l i t y ? Study Questions 1. What content areas are relevant to the needs of the long term care resident and likewise, the goals of long term care? 2. What method of information-gathering w i l l be r e l i a b l e , v a l i d and p r a c t i c a l enough for use in a variety of f a c i l i t i e s and geographic locations? 3. Can t h i s information be organized i n a form that i s suitable for use not only i n decision-making concerning the i n d i v i d u a l resident, but also for administrative, planning, and research purposes? Chapter II LITERATURE REVIEW Assessment Content The assessment instrument must provide information that i s relevant to the needs of the aged person and the goals of long term care. A review of the l i t e r a t u r e suggests that the problems encountered by the elde r l y can be viewed in terms of multiple losses that produce a cumulative disabling e f f e c t . Although there i s wide in d i v i d u a l v a r i a t i o n , insidious changes occur with age throughout a l l body structures that reduce optimal physiological performance. In addition, the aging process renders the person less able to deal with stress." 1"^ This means that there i s a heightened v u l n e r a b i l i t y to disease and many conditions such as heart f a i l u r e , atherosclerotic vascular disease, diabetes, hearing loss, and c o l i t i s , for example, may combine to produce a general state of i l l - h e a l t h and reduce the person's a b i l i t y to cope independently. This decrease i n e f f e c t i v e response extends to cognitive and s o c i a l functioning as well. Research indicates that there i s a general slowing i n the- speed -.'of, i n f 6'rmatioh-pr.ocessing 7 ( i n c l u d i n g p r o b l e m - s o l v i n g ) , g r e a t e r a n x i e t y i n t h e f a c e o f new l e a r n i n g s i t u a t i o n s , a n d a l o w e r e d t e n d e n c y t o r e s p o n d 17 a p p r o p r i a t e l y t o e n v i r o n m e n t a l s t i m u l i . R e a c t i o n t o s t r e s s a l s o becomes l e s s s p e c i f i c a n d more d i s s e m i n a t e d t h r o u g h o u t t h e b o d y . A g e n e r a l i z e d r e s p o n s e e x i s t s s i m i l a r t o t h a t f o u n d i n t h e v e r y y o u n g . C l a s s i c s i g n s 18 o f d i s e a s e become u n r e l i a b l e i n d i c a t o r s . I l l n e s s , o r g a n d y s f u n c t i o n , a n d t h e l i k e may p r o d u c e s u b t l e , n o n s p e c i f i c c h a n g e s i n b e h a v i o u r a n d f u n c t i o n t h a t seem t o t a l l y u n r e l a t e d t o t h e u n d e r l y i n g c a u s e . F o r e x a m p l e , t h e f i r s t m a n i f e s t a t i o n o f m e t a b o l i c i n b a l a n c e , m y o c a r d i a l i n f a r c t , o r d r u g i d i o -s y n c r a s y may be memory l o s s , d i s o r i e n t a t i o n , o r a n o v e r a l l d e c l i n e i n a b i l i t y t o p e r f o r m t h e a c t i v i t i e s o f d a i l y l i v i n g -e a t i n g , d r e s s i n g , g r o o m i n g , walking."*"^ T h e s e a g e - r e l a t e d a n d d i s e a s e - r e l a t e d c h a n g e s a r e f u r t h e r e x a c e r b a t e d by s o c i a l a l t e r a t i o n s i n t h e p e r s o n ' s l i f e . C o n s i d e r f o r i n s t a n c e , t h e i m p a c t o f t h e l o s s o f " u s e f u l " f u n c t i o n when work a n d p r o d u c t i v i t y a r e h i g h l y v a l u e d , a d e c r e a s e i n s p e e d o f r e s p o n s e i n a f a s t - p a c e d s o c i e t y , a n d i n c r e a s e d d e p e n d e n c y n e e d s when s p o u s e a n d f r i e n d s may be d e c e a s e d , t h e f a m i l y s p r e a d a f a r , o r e c o n o m i c s t a t u s l o w e r e d . Upon e n t e r i n g t h e l o n g t e r m c a r e f a c i l i t y , t h e p e r s o n i s f a c e d w i t h a d d i t i o n a l f o r m s o f s o c i a l a n d e n v i r o n m e n t a l s t r e s s . I n m o s t f a c i l i t i e s , m e d i c a l a n d p e r s o n a l c a r e a r e o b t a i n e d a t t h e e x p e n s e o f s t r a n g e s u r r o u n d i n g s , i n s t i t u t i o n a l d e c o r , r i g i d r u l e s , l a c k o f p r i v a c y , a n d c o n f u s e d , d e t e r i o r a t e d 20 c o m p a n i o n s . I n a d d i t i o n , o l d s u p p o r t s a n d s o c i a l r o l e s may 8 be disrupted and opportunities to exercise competency limited. There frequently seems to be a conspiracy i n p o l i cy and practice for nursing home s t a f f to assume r e s p o n s i b i l i t y for such things as housekeeping, care of clothes, and scheduling of the resident's day... Such decrements i n function as may r e s u l t from physical and mental disorders are further amplified by disuse. The loss of instrumental roles i s one of the most devastating aspects of becoming an institutionalized.person.21 2 Eld e r l y people view the f a c i l i t y as t h e i r " l a s t home." From there, the prospect of imminent death must be faced and 2 3 some perspective acquired on t h e i r past l i f e . At a time when maintaining a sense of i n t e g r i t y and worth i n the face of increasing dependency i s one of the l a s t developmental tasks, the means to achieve i t may be absent. These multiple losses, a r i s i n g from the aging process, from inter a c t i n g disease states, from s o c i a l " l i f e " changes, and from the i n s t i t u t i o n a l environment i t s e l f , constitute the major problems with which the el d e r l y c l i e n t must cope and to which long term care must be directed. In that i t i s not always possible to reverse such losses, the primary goal of care becomes helping residents cope with them so that they are able to reach f u l l functioning potential in a l l dimensions while maintaining the highest possible sense of i n t e g r i t y and worth. Although expressed i n a variety of ways, the maximization of c l i e n t functioning i s how the most frequently expressed theme i n long term care. There are three basic components to t h i s goal: 9 1. A d a p t a t i o n - T h e i n d i v i d u a l ' s r e a l i z a t i o n o f c h a n g e o r l o s s a n d t h e a l t e r a t i o n o f b e h a v i o u r t o s u i t t h a t c h a n g e . 2. I n d e p e n d e n c e - T h e m i n i m i z a t i o n o f d e p e n d e n c e on o t h e r s a n d t h e r e d u c t i o n o f e x c e s s d i s a b i l i t i e s ( t h e d i f f e r e n c e b e t w e e n a c t u a l a n d p o t e n t i a l f u n c t i o n i n g ) . 3 . Q u a l i t y o f L i f e - A l t h o u g h d i f f i c u l t t o d e f i n e , t h e a c q u i r i n g a n d m a i n t a i n i n g o f a s e n s e o f w o r t h , i n t e g r i t y , a n d e s t e e m i s o f p a r a m o u n t i m p o r t a n c e t o t h e e l d e r l y , a s t o a l l human b e i n g s , a n d t h e r e f o r e m u s t be a n a c k n o w -24 l e d g e d c e n t r a l g o a l o f c a r e - g i v e r s . To be r e l e v a n t t o t h e g o a l s o f l o n g t e r m c a r e , t h e a s s e s s m e n t s h o u l d p r o v i d e i n f o r m a t i o n a b o u t t h e p e r s o n ' s c u r r e n t l e v e l o f f u n c t i o n i n g i n t h o s e a r e a s w h e r e t h e m a j o r l o s s e s a n d n e e d s o f t h e i n d i v i d u a l e x i s t . T h e s e m a j o r a r e a s , f o r t h e e l d e r l y r e s i d e n t , a r e c o g n i t i v e , p h y s i c a l , s o c i a l . , , .emo-t i o n a l , a n d i n s t r u m e n t a l . C o g n i t i v e F u n c t i o n i n g . T h i s s e c t i o n i n c l u d e s t h e i m p o r t a n t m e n t a l p r o c e s s e s : c o m p r e h e n s i o n , j u d g m e n t , memory , a n d c o m m u n i c a t i o n . L o s s e s w i t h i n t h i s a r e a a r e p a r t i c u l a r l y s i g n i f i c a n t t o t h e e l d e r l y p e r s o n . A s p r e v i o u s l y m e n t i o n e d , d e c r e a s e i n m e n t a l f u n c t i o n i n g c a n r e f l e c t d i s e a s e s t a t e s , o r i n b a l a n c e i n o t h e r s y s t e m s . T h e " n o r m a l " age d e c l i n e i n i n t e l l i g e n c e , t h o u g h t t o a p p l y u n i v e r s a l l y t o a l l a g e d p e r s o n s h a s b e e n f o u n d t o h e r a l d g e n e r a l p h y s i c a l a n d m e n t a l d e c o m p o s i t i o n , e v e n d e a t h w i t h i n two o r t h r e e y e a r s i n a f f e c t e d i n d i v i d u a l s , w h i l e o t h e r s 10 m a i n t a i n a p p r o x i m a t e l y t h e same IQ w e l l i n t o l a t e l i f e . L o s s o f a b i l i t y i n t h e s e p r o c e s s e s c a n be t h e r e s u l t o f s t r o k e , o r g a n i c b r a i n c h a n g e s , o r s o - c a l l e d a f f e c t i v e / f u n c t i o n a l d i s o r d e r s s u c h as n e u r o s e s , p s y c h o s e s , a n d d e p r e s s i o n . I t h a s b e e n f o u n d t h a t d e p r e s s i o n i n t h e e l d e r l y i s e x t r e m e l y common a n d o f t e n o v e r l o o k e d as b e i n g o r g a n i c a l l y 2 6 b a s e d . T h e two o f t e n c o - e x i s t . A c a r e f u l a s s e s s m e n t w i l l h e l p d i s t i n g u i s h t h e t y p e a n d o r i g i n o f t h e l o s s a n d i n c r e a s e o u r u n d e r s t a n d i n g o f t h e p r o g r e s s i o n o f o r g a n i c b r a i n c h a n g e s . P h y s i c a l F u n c t i o n i n g . T h i s a r e a i n v o l v e s t h e f u n c t i o n i n g o f p h y s i c a l s t r u c t u r e s a n d r e f l e c t s l o s s e s due t o age a n d d i s e a s e . I t i n c l u d e s o v e r a l l p h y s i c a l c o n d i t i o n , s t r e n g t h , p a i n , a n d s e n s o r y c a p a b i l i t i e s . P h y s i c a l l o s s e s h a v e o b v i o u s s i g n i f i c a n c e t o t h e e l d e r l y p e r s o n . T h e y a f f e c t s u r v i v a l i t s e l f , as w e l l a s t h e p e r s o n ' s c o m f o r t , t h e d e g r e e t o w h i c h a c t i v i t i e s a r e c u r t a i l e d , a n d t h e amount o f d e p e n d e n c e o n o t h e r p e o p l e . I n f a c t , p h y s i c a l w e l l - b e i n g h a s b e e n f o u n d t o be t h e b e s t i n d i c a t o r o f m o r a l e 27 i n t h e a g e d . P o o r v i s i o n a n d h e a r i n g i n t e r f e r e w i t h c o m m u n i -c a t i o n a n d i n t e r a c t i o n w i t h o t h e r s , l i m i t i n g t h e a v a i l a b l e i n t e l l e c t u a l a n d e m o t i o n a l s t i m u l i t h e p e r s o n r e c e i v e s . T h i s c a n l e a d t o d i f f i c u l t y i n i n t e r p r e t i n g t h e e n v i r o n m e n t , e v e n 2 8 t o t h e p o i n t o f p a r a n o i a a n d c o n f u s i o n . S o c i a l F u n c t i o n i n g . S o c i a l f u n c t i o n i n g i n v o l v e s t h e p r o c e s s o f r e l a t i n g t o o t h e r s o n an i n d i v i d u a l a n d g r o u p b a s i s , b o t h c a s u a l l y a n d 11 i n t i m a t e l y . A l s o i n c l u d e d i n t h i s a r e a a r e a c t i v i t i e s r e l a t i n g t o l e i s u r e t i m e o r o f a c r e a t i v e , p r o d u c t i v e n a t u r e f r o m w h i c h t h e p e r s o n i s l i k e l y t o a c h i e v e some s e n s e o f a c c o m p l i s h m e n t . L o s s i n t h i s a r e a may be d u e t o l i f e c h a n g e s s u c h a s d e a t h o f s p o u s e , d i s t a n c e o f f r i e n d s , o r t h e i n s t i t u -t i o n a l e n v i r o n m e n t . S t u d i e s i n d i c a t e t h a t s p a t i a l a r r a n g e m e n t o f c h a i r s , f o r e x a m p l e , c a n i n h i b i t s o c i a l i n t e r a c t i o n w i t h i n 29 an i n s t i t u t i o n , a s c a n l a c k o f p r i v a c y . F e e l i n g s o f e s t e e m a n d l o v e r e q u i r e human i n t e r a c t i o n , w h i l e w i t h d r a w a l f r o m human c o n t a c t c a n p r o d u c e d e p r e s s i o n a n d d i s o r i e n t a t i o n . T h e n e g a t i v e i m p a c t o f l o s s o f s o c i a l r o l e s i s w e l l d o c u m e n t e d . F e e l i n g s o f l o n e l i n e s s a n d e s t r a n g e -ment a c c o m p a n i e d b y f e e l i n g s o f b e i n g i n a m a r g i n a l s o c i a l p o s i t i o n , l e a d t o g r e a t l y i n c r e a s e d s u i c i d e r a t e s i n t h e -| n , 30 e l d e r l y . E m o t i o n a l F u n c t i o n i n g . T h i s c a t e g o r y r e f l e c t s how t h e p e r s o n r e s p o n d s e m o t i o n a l l y t o d i s a b i l i t i e s a n d s t r e s s e s i n t h e e n v i r o n m e n t . Does h e / s h e l a s h o u t - w i t h d r a w i n t o p a s s i v i t y - become d e p r e s s e d ? B e h a v i o u r t h a t r e p r e s e n t s e x t r e m e e m o t i o n a l m a l -a d a p t i o n i s a l s o i n c l u d e d i n t h i s s e c t i o n ( f o r e x a m p l e , h a l l u c i n a t i o n s a n d p a r a n o i a ) . O t h e r i m p o r t a n t a s p e c t s o f e m o t i o n a l f u n c t i o n i n g a r e t h e f e e l i n g s t a t e s a n d s e l f - p e r c e p t i o n s o f the . i n d i v i d u a l -e s t e e m , i d e n t i t y , h a p p i n e s s , m o r a l e , s e l f - i m a g e , a n d o t h e r s -t h a t m i g h t be c o n s i d e r e d t o come u n d e r t h e b r o a d c o n c e p t o f 12 "quality of l i f e " . These feeling states have been demonstrated to be 31 closely linked to survival and adjustment in the institutional setting. As such, they are as crutial to prediction of future progress as physical functioning. The elderly themselves are known to judge the adequacy of 32 an instutution in terms of its humanitarian effectivenes.,. Instrumental Functioning. This category includes the person's ability to maintain independence in performing the activities of daily living.,- grooming, dressing, toileting, walking, and eating. Although more of an integrating than a basic functioning component, this information reflects how the person copes with losses in a l l other areas. It also reflects environmental factors such as obstacles to performance, staff encouragement, and rehabilitative efforts. With the addition of this knowledge, i t may be possible to identify discrepancies in actual versus potential per-formance . Summary. These categories outline the essential content areas for assessment of the elderly client, based on the special needs and goals of long term care. The following section examines the various methods of gathering the assessment information. Assessment Procedure Self-Report Methods. There are two main sources of information concerning the aged individual's current condition, the person him/herself or an observer. (There may also be a combination of the two.) Obviously, 13 u t i l i z i n g the i n d i v i d u a l as source has d i s t i n c t advantages; information can be obtained about feelings such as self-esteem, s a t i s f a c t i o n , morale, and i d e n t i t y , along with perceptions of events. Desirable as t h i s information i s , however, attempts to measure these abstract f e e l i n g states through s e l f - r e p o r t have met with considerable d i f f i c u l t y i n long term care. This i s understandable i n that such procedures, whether of an interview, t e s t , or questionnaire nature, require at least minimal p a r t i c i p a t i o n and co-operation from the i n d i v i d u a l who may suffer limited attention span, language function, or comprehension. A survey by Whanger and Lewis showed that 71 percent of the i n s t i t u t i o n a l e l d e r l y were s i g n i f i c a n t l y mentally-impaired, rendering self-reports very d i f f i c u l t to 33 obtain and of questionable v a l i d i t y . Of those remaining, many had sensory impairments of a magnitude to exclude them from d i r e c t p a r t i c i p a t i o n . In that assessment information i s needed for a l l residents and not merely for those with minimal sensory and mental loss, s e l f - r e p o r t procedures are of l i t t l e value i n long term care. Behavioural Observation Methods. Another person may provide the assessment information based on observations of the el d e r l y i n d i v i d u a l . This, too, poses some d i f f i c u l t i e s . Reports of behaviour may be biased due to the observer's feelings toward the person, stereotyped concepts of the e l d e r l y , or by unresolved personal c o n f l i c t s about aging and death. In addition, observational powers vary 14 f r o m i n d i v i d u a l t o i n d i v i d u a l , d e p e n d i n g o n p e r s o n a l i t y , p r o f e s s i o n a l a t t i t u d e s , a n d e d u c a t i o n . M o s t o b s e r v a t i o n s o f b e h a v i o u r r e q u i r e some d e g r e e o f i n t e r p r e t a t i o n a n d i n f e r e n c e o n t h e p a r t o f t h e p e r s o n m a k i n g t h e o b s e r v a t i o n s . P o w e r s . o f i n f e r e n c e a r e b o t h t h e s t r e n g t h 34 a n d w e a k n e s s o f b e h a v i o u r a l o b s e r v a t i o n p r o c e d u r e s . A n o b s e r v e r c a n r e l a t e b e h a v i o u r t o c o n c e p t s , s u c h as c r y i n g t o s a d n e s s , t h e r e b y p r o v i d i n g v a l u a b l e i n f o r m a t i o n a n d i n s i g h t . On t h e o t h e r h a n d , two o b s e r v e r s c a n made t o t a l l y d i f f e r e n t i n f e r e n c e s f r o m t h e same b e h a v i o u r . A c c u r a t e o b s e r v a t i o n s r e q u i r e c o m p e t e n t o b s e r v e r s a n d a c l e a r d e f i n i t i o n o f w h a t i s t o be o b s e r v e d . D e s p i t e s u c h d r a w b a c k s , o b s e r v e r d a t a h a s t h e c r u c i a l a d v a n t a g e o f b e i n g a v a i l a b l e f o r a l l i n d i v i d u a l s r e g a r d l e s s o f t h e i r m e n t a l a n d e m o t i o n a l s t a t u s , l a n g u a g e s k i l l s , a n d s e n s o r y c a p a b i l i t i e s . A s s e s s m e n t s , b a s e d o n b e h a v i o u r a l o b s e r v a t i o n , c a n be made r e p e a t e d l y w i t h o u t p u t t i n g t h e p e r s o n t h r o u g h r e p e t i t i o n s o f b o r i n g o r p o t e n t i a l l y a n x i e t y - p r o d u c i n g p r o c e d u r e s . K a s t e n b a u m a n d S h e r w o o d , r e c o g n i z i n g t h e v a l u e o f t h i s s o u r c e o f i n f o r m a t i o n , d e c i d e d t o u s e t h e o b s e r v a t i o n s o f t h e i n t e r v i e w e r o r t e s t e r c o n c e r n i n g t h e n a t u r e o f t h e a g e d p e r s o n ' s b e h a v i o u r d u r i n g t h e t e s t p e r i o d . T h e y r e c o g n i z e d t h a t , I n s t e a d o f h a v i n g an u n s c o r a b l e t e s t p r o t o c o l o r i n c o m p l e t e p e r c e p t u a l - m o t o r t a s k p e r f o r m a n c e t o show as a s o u v e n i r o f t h e e n c o u n t e r , we m i g h t a l s o h a v e a n a c c u r a t e a s s e s s m e n t o f t h o s e b e -h a v i o u r s t h e s u b j e c t d i d e x h i b i t d u r i n g t h e s e s s i o n . ^ To t h a t e n d t h e y d e s i g n e d t h e V I R O s c a l e . T h e i n s t r u m e n t 15 consists of 13 scales y i e l d i n g scores on 4 dimensions - vigour, intactness, relationship, and orientation. It i s based on the interviewer's perception of the rela t i o n s h i p that developed during the encounter, and the receptiveness, t r u s t -fulness, and energy-level exhibited by the e l d e r l y person. Po t e n t i a l l y t h i s procedure taps both sources of information, the eld e r l y resident and an observer. However, i t does not eliminate the fact that the aged person w i l l undoubtedly show d i f f e r e n t responses, openness, and anxiety depending on the type of encounter ( r i g i d test or relaxed interview), time of day, c h a r a c t e r i s t i c s of the interviewer, and so on. Observations may be accurate but aty p i c a l of the person's behaviour o v e r a l l . If the rater has had opportunities to observe and interact with the in d i v i d u a l over long periods and under d i f f e r e n t circumstances, the information that becomes available i s more extensive than that obtained from a single examination or interview s i t u a t i o n . Long term personal care s t a f f , for example, are i n a position to observe the aged person over 24 hours, to see him/her i n d i f f e r e n t s o c i a l r o l e s , under stress or relaxed, interacting with v i s i t o r s , and performing the a c t i v i t i e s of d a i l y l i v i n g . Though such f a m i l i a r i t y may d u l l the o b j e c t i v i t y of the observer, i t enables information about emotional status, patterns of behaviour, a c t i v i t i e s , f r i e n d -ships, and energy-level to become part of the assessment data. If a standard assessment becomes a useful and i n t e g r a l part of care, s t a f f w i l l become f a m i l i a r with i t s use and 16 skilled in its completion. In this way, assessments can be obtained on a l l persons repeatedly in an unobtrusive, economical, and potentially reliable manner. The following section traces the development and use of behavioural observation assessments in long term care. Behavioural Observation Assessments in Long Term Care, The first standard assessment procedures to tap the observations of personnel in daily contact with an institutionalized person were developed in psychiatric hospitals. These instruments were able to 36 differentiate patients in "open" versus "closed" wards, to differentiate 37 patients xn remission from a psychiatric problem, and to predict 38 length of hospital stay. In the past, psychiatric hospitals contained a significant number of elderly, schizophrenic patients, those with organic brain syndrome, and many who simply could not return to the community for a variety of reasons. As a consequence, standard assessments of the elderly in long term care facilities, prior to the late 1960's, utilized procedures designed specifically for the nongeriatric, psychiatric patient. One of the most popular tools of this nature was the N.O.S.I.E. Scale (Nurses' Observation Scale for Inpatient Evaluation), published 39 by Honxgfeld and Klett in 1965. It was designed specifically to measure improvement in chronic schizophrenics. Originally consisting of 80 items, 17 the questionnaire was eventually shortened to what the authors describe as 30 " s p e c i f i c actions which the nurse 40 should look for i n the way a p s y c h i a t r i c patient behaves." For example: "The.patient i s sloppy." "The patient i s quick to f l y o f f the handle." The r e s u l t i n g score represents 7 f a c t o r s — s o c i a l competence, s o c i a l i n t e r e s t , co-operation, neatness, i r r i t a b i l i t y , manifest psychosis, and psychotic depression. Validating information was obtained through ratings of 300 chronic schizophrenics who had been continually h o s p i t a l i z e d for over 2 4 years. As such, i t s a p p l i c a b i l i t y to a broader g e r i a t r i c population i s questionable. Absence of a n t i s o c i a l , b e l l i g e r e n t , or aggressive behaviour, which forms a large part of the t o o l , produces a high l e v e l score. However, t h i s may mean the person has withdrawn into p a s s i v i t y , a s i t u a t i o n which augurs poorly for his/her continued s u r v i v a l , 41 according to studies by MacDonald. Research that explores personality t r a i t s of the el d e r l y as predictors of adaptation have pointed to vigorous, h o s t i l e , n a r c i s s i s t i c styles as being related to intactness one year a f t e r admission to a r e s i d e n t i a l f a c i l i t y . Those who become docile and passive and exert l i t t l e control over t h e i r s i t u a t i o n are more l i k e l y to d e t e r i -42 orate quickly." Considering these facts, the N.O.S.I.E. would have very l i t t l e v a l i d i t y as an o v e r a l l measure of the person's well-being. The N.O.S.I.E. has been frequently used with the el d e r l y to evaluate the e f f e c t s of drugs on behaviour. While the originators of the t o o l were able to demonstrate some 18 behavioural improvement using the scale, other researchers have found i t too global to be of use and not applicable to 44 the general g e r i a t r i c population. Meer and Krag, recognizing the l i m i t a t i o n s of one assessment procedure for a l l age groups, created the Stockton G e r i a t r i c Rating Scale on the basis of studies with the older 45 population of Stockton State Mental Hospital. Again the focus i s on psychopathology, but with the addition of questions r e l a t i n g to physical d i s a b i l i t y . The 35 items, each with 3 response categories, are designed to measure a l l ward behaviour considered to be s i g n i f i c a n t of the el d e r l y psychiatric patient's improvement upon discharge. For example, "The patient i s objectionable to others on the ward." Items c l u s t e r around 4 factors - apathy, s o c i a l l y - i r r i t a t i n g behaviour, physical d i s a b i l i t y , and communication f a i l u r e . The s o c i a l l y - i r r i t a t i n g behaviour factor was only very weakly associated with the other three factors and with patient outcome c r i t e r i a . Again, t h i s r e f l e c t s the fact that conformity to ward routine, while highly desirable to s t a f f , i s not necessarily i n d i c a t i v e of a healthy unimpaired person. Despite t h i s evidence, the factor accounts for 9 items on the scale, whereas a factor such as confusion i s rated on a single item. Although Plutchik et a l . revised the scale i n 1970, the psychiatric approach continued, confusion was s t i l l rated globally, and perception of willingness to help around the 46 ward remained a large portion of the instrument. Assessments such as the N.O.S.I.E. and the Stockton 19 Scale concentrate primarily i f not exclusively, on psycho-l o g i c a l impairment and have ignored many aspects of the person's functioning such as physical health, s o c i a l and emotional components. Other instruments have gone to the opposite extreme of dealing with physical impairment, c l a s s i f i c a t i o n of disease states, or ratings of d i s a b i l i t y i n self-ca r e to the exclusion of mental and s o c i a l processes. In 196 8, Linn, Linn, and Gurel published t h e i r Cumu-l a t i v e I l l n e s s Rating Scale designed to assess physical 47 impairments. The instrument i s based on ratings of severity of impairment i n 5 body systems - cardiovascular, gastro-i n t e s t i n a l , musculo-skeletal-integument, neuropsychiatric, and general. It represents a f a i r l y r e l i a b l e and rapid assessment of pathology. However, st r u c t u r a l losses, as mentioned, may bear l i t t l e r elationship to functioning i n the el d e r l y person. Likewise, i t i s d i f f i c u l t to separate one body system from another. Considering i t s s t r u c t u r a l basis, the instrument would be primarily useful i n planning medical interventions, but severely l i m i t e d as a comprehensive assessment of the person. Other instruments such as Rosencranz and Pihlbald's Health Index (1970) l i s t medical conditions and attempt to 48 weight the severity of each. Such attempts have been largely unsuccessful due to the d i f f i c u l t i e s inherent i n the diagnostic c l a s s i f i c a t i o n system, namely the d i f f e r e n t impact of the same disease on d i f f e r e n t i n d i v i d u a l s , and the wide range of seriousness within one diagnostic category. 20 The d i f f i c u l t i e s i n r e p r e s e n t i n g h e a l t h i n t h i s way l e d t o t h e a d o p t i o n o f " d i s a b i l i t y " as a b e t t e r o v e r a l l m e a s u r e o f h e a l t h . M o s t o f t h e e a r l y d i s a b i l i t y s c a l e s w e r e g l o b a l i n n a t u r e . F o r e x a m p l e , Waldman a n d F r y m a n (1964) d e v e l o p e d a 6 - c a t e g o r y c l a s s i f i c a t i o n s y s t e m f o r i m p a i r m e n t r a n g i n g f r o m " c a p a b l e o f u n s u p e r v i s e d a c t i v i t y " t h r o u g h t o " p e r s o n s r e q u i r i n g 49 h o s p i t a l c a r e . " N a t u r a l l y s u c h g l o b a l r a t i n g s a l l o w f o r c o n s i d e r a b l e b i a s a n d c o n f u s i o n i n j u d g i n g t h e i m p o r t a n c e o f d i s e a s e o r d i s a b i l i t y o v e r t h e p e r s o n ' s r e m a i n i n g c a p a b i l i t i e s , o r w h e t h e r , f o r e x a m p l e , d i s o r i e n t e d b e h a v i o u r i s more d e b i l i -t a t i n g t h a n m u s c u l a r w e a k n e s s . A s a r e s u l t , m e a s u r e s o f d i s a b i l i t y g r a d u a l l y became more d e t a i l e d . I n 1967 L i n n d e v i s e d t h e R a p i d D i s a b i l i t y R a t i n g S c a l e w h i c h c o n t a i n s 16 i t e m s d e s c r i b i n g d i s a b i l i t y i n s p e c i f i c a r e a s 50 on a 3 - p o i n t f r e q u e n c y - o f - o c c u r r e n c e s c a l e . A l t h o u g h d e s i g n e d f o r r e s e a r c h p u r p o s e s a n d n o t d e t a i l e d e n o u g h t o o b t a i n a c o m p r e h e n s i v e p r o f i l e o f t h e i n d i v i d u a l , i t i s c o n s i d e r e d 51 a d e q u a t e f o r g r o s s s c r e e n i n g a n d w a r d c l a s s i f i c a t i o n . F u r t h e r b r e a k d o w n o f d i s a b i l i t y i n t o i t s c o m p o n e n t p a r t s 52 was r e p r e s e n t e d i n K a t z ' A c t i v i t y o f D a i l y L i v i n g S c a l e . T h i s m e a s u r e s t h e p e r s o n ' s i n d e p e n d e n c e i n p e r f o r m i n g s u c h t a s k s as e a t i n g , d r e s s i n g , g r o o m i n g , a n d a m b u l a t i o n , a n d h a s b e e n w i d e l y u s e d i n r e h a b i l i t a t i o n a s s e s s m e n t s . L o w e n t h a l a d d e d f u r t h e r d e t a i l t o t h e m e a s u r e m e n t by e x p a n d i n g t h e l e v e l s 53 o f d e p e n d e n c e w i t h i n e a c h a r e a . R e l i a b l e a s t h e s e m e a s u r e s a r e , t h e y , l i k e t h e m e d i c a l l y o r p s y c h i a t r i c a l l y - b a s e d t e s t s , d o c u m e n t o n l y one a s p e c t o f t h e 21 p e r s o n ' s b e h a v i o u r . No i n f o r m a t i o n i s p r o v i d e d t h a t w o u l d i n d i c a t e t h e s o u r c e o f p o o r p e r f o r m a n c e , w h e t h e r i t i s t h e r e s u l t o f i m p a i r e d m e n t a l o r p h y s i c a l f u n c t i o n i n g , s e v e r e d e p r e s s i o n , o r m e r e l y c o n f l i c t w i t h t h e s t a f f . I n 19 72, G u r e l , L i n n , a n d L i n n made a m a j o r a d v a n c e b y c o m b i n i n g a l l o f t h e s e a p p r o a c h e s i n a s c a l e c a l l e d t h e P h y s i c a l a n d M e n t a l I m p a i r m e n t o f F u n c t i o n E v a l u a t i o n o f t h e 54 A g e d ( P . A . . M . I . E . ) • C l o s e l y r e l a t e d t o t h e S t o c k t o n s c a l e , i t i s d e s i g n e d t o q u a n t i f y a w i d e r a n g e o f b e h a v i o u r s r e l e v a n t t o t h e i n s t i t u t i o n a l i z e d e l d e r l y . T h e 77 i t e m s b r e a k down i n t o t h e f o l l o w i n g c a t e g o r i e s : (a) p h y s i c a l i n f i r m i t y ( a m b u l a t i o n , s e n s o r i - m o t o r i m p a i r m e n t a n d b e d f a s t - m o r i b u n d s t a t u s ) , (b) p s y c h o l o g i c a l d e t e r i o r a t i o n ( m e n t a l d i s o r g a n i z a t i o n , c o n f u s i o n , w i t h d r a w a l , a p a t h y , a n d b e h a v i o u r a l d e t e r i o r a t i o n ) , a n d (c) s e l f -c a r e d e p e n d e n c y ( c h a r a c t e r i z i n g b o t h p h y s i c a l a n d m e n t a l d e t e r i -o r a t i o n ) . A l t h o u g h i t shows c o n s i d e r a b l e p r o m i s e t o w a r d a m o r e t o t a l e v a l u a t i o n a p p r o a c h t o t h e a g e d p e r s o n , t h e i n s t r u m e n t s u f f e r s some m e t h o d o l o g i c a l s h o r t c o m i n g s . E a c h i t e m d e s c r i b e s a s p e c i f i c b e h a v i o u r o n a y e s - n o d i c h o t o m y . T h i s s e v e r e l y l i m i t s t h e i n s t r u m e n t ' s s e n s i t i v i t y a n d t h e i d e n t i f i c a t i o n o f c h a n g e o v e r t i m e . A s i n o t h e r s c a l e s , 24 o f t h e 77 i t e m s r e l a t e t o t h e p e r s o n ' s c o n f o r m i t y t o w a r d r o u t i n e , c o - o p e r a t i o n , a n d h e l p f u l n e s s a r o u n d t h e h o s p i t a l . By so d o i n g , t h e s c a l e a p p r o a c h e s a d j u s t m e n t f r o m t h e i n s t i t u t i o n ' s r a t h e r t h a n t h e i n d i v i d u a l ' s p o i n t o f v i e w . I n 19 74 B r o d y e t a l . t o o k t h e a s s e s s m e n t p r o c e d u r e one 22 s t e p f u r t h e r by m e a s u r i n g w h a t t h e y c a l l e d e x c e s s d i s a b i l i t i e s , w h i c h w e r e d e f i n e d as " t h e d i s c r e p a n c y e x i s t i n g when f u n c t i o n a l 55 i n c a p a c i t y i s g r e a t e r t h a n t h a t w a r r a n t e d by i m p a i r m e n t . E v a l u a t i o n o f b a s e l i n e f u n c t i o n i n g i n a r e a s o f s e l f - c a r e , i n t e r p e r s o n a l r e l a t i o n s h i p s , p h y s i c a l s t a t u s , m e n t a l s t a t u s , a n d p e r s o n a l i t y c h a r a c t e r i s t i c s w e r e t a k e n . A t t h e e n d o f a p e r i o d o f i n t e n s i v e t h e r a p y t h e i n d i v i d u a l was a g a i n r a t e d o n t h o s e f a c t o r s u t i l i z i n g a 7 - p o i n t s c a l e r a n g i n g f r o m " c o n s i d e r -a b l e d e c l i n e " t o " c o n s i d e r a b l e i m p r o v e m e n t . " U n f o r t u n a t e l y t h e r e was no s t a n d a r d i z e d o r s t r u c t u r e d m e t h o d o l o g y u s e d i n t h e c o l l e c t i o n o f p r e o r p o s t d a t a . I n a d d i t i o n , t h o s e i n v o l v e d i n t h e t h e r a p y were a l s o t h o s e d o i n g t h e r a t i n g o f i m p r o v e m e n t . E v e n i f t h i s h a d n o t b e e n t h e c a s e , s u c h r a t i n g s a r e h i g h l y s u b j e c t i v e a n d i n v i t e b i a s , i n c o n s i s t e n c y , a n d u n r e l i a b i l i t y . N e v e r t h e l e s s , t h e a u t h o r s r e f l e c t e d an a d v a n c e i n t h i n k i n g by e v a l u a t i n g i m p r o v e m e n t i n t e r m s o f r e a c h i n g t h e i n d i v i d u a l ' s p o t e n t i a l r a t h e r t h a n c o m p l y i n g w i t h s t a f f d e m a n d s . T h e n e x t m a j o r a d v a n c e i n a s s e s s m e n t m e t h o d o l o g y came w i t h t h e d i f f e r e n t i a t i o n o f l o n g t e r m c a r e f a c i l i t i e s i n t o d i s t i n c t l e v e l s f o r t h e p u r p o s e o f g o v e r n m e n t f u n d i n g . T h i s move n e c e s s i t a t e d t h e d e v e l o p m e n t o f p r e c i s e p a t i e n t c l a s s i -f i c a t i o n s y s t e m s a n d i t i s t h e s e s y s t e m s t h a t r e p r e s e n t t h e m o s t w i d e l y u s e d p r o c e d u r e s t o d a t e . The e a r l y p r o c e d u r e s c o n c e n t r a t e d o n d e t e r m i n i n g t h e i n d i v i d u a l ' s m e d i c a l a n d n u r s i n g n e e d s so t h a t a d m i n i s t r a t o r s c o u l d a s s u r e a p p r o p r i a t e c l i e n t p l a c e m e n t a n d a d j u s t s t a f f i n g p a t t e r n s t o n e e d s . F o r e x a m p l e , R A P I D S , a g e n e r a l c l a s s i f i c a t i o n 23 scheme d e v e l o p e d i n C a l i f o r n i a i n 1966 by S a l m o n e t a l . , r a t e d 6 a r e a s c o n s i d e r e d o f p r i m a r y i m p o r t a n c e i n d e t e r m i n i n g , 56 n u r s i n g n e e d s . R - R e s t o r a t i v e P r o c e d u r e s A - A c t i v i t i e s o f D a i l y L i v i n g P - P r o b l e m B e h a v i o u r I - I l l n e s s D - D e p e n d e n c y - G e n e r a l S - S o c i a l S e r v i c e s E a c h i s s c a l e d f r o m 1 t o 5 d e p e n d i n g o n t h e amount o f p r o f e s -s i o n a l e f f o r t e x p e n d e d o r r e q u i r e d i n t h e a r e a . 57 S i m i l a r s y s t e m s w e r e d e v e l o p e d b y B u r r a c k (1958) , A s h t o n ( 1 9 6 8 ) , 5 8 a n d t h e B o s t o n C o l l e g e o f N u r s i n g ( 1 9 6 8 ) . 5 9 A l l r e p r e s e n t j u d g e m e n t s o f s t a f f i n g r e q u i r e m e n t s b a s e d o n t h e number o f t a s k s a n d p r o c e d u r e s n e e d e d a n d g l o b a l r a t i n g s o f t h e p e r s o n ' s p o t e n t i a l f o r r e h a b i l i t a t i o n . T h i s a g a i n f o c u s s e s on t h e n e e d s o f t h e f a c i l i t y r a t h e r t h a n t h e e l d e r l y p e r s o n a n d r e v e r t s b a c k t o a c o n c e n t r a t i o n o n p h y s i c a l f u n c t i o n i n g . The n e e d f o r s u p e r v i s i o n i n t h e p r o b l e m b e h a v i o u r c a t e g o r y i s t h e s o l e i t e m i n t h e RAPIDS scheme t h a t r e f l e c t s t h e p e r s o n ' s m e n t a l c o n d i t i o n o r s o c i a l b e h a v i o u r . I n 1 9 7 3 , J o n e s , M c N i t t , a n d M c K n i g h t ^ p u b l i s h e d w h a t i s a c c l a i m e d t o be t h e m o s t p r o g r e s s i v e p a t i e n t c l a s s i f i c a t i o n 61 62 s y s t e m f o r l o n g t e r m c a r e t o d a t e . ' T h i s m u l t i p u r p o s e a s s e s s m e n t p r o c e d u r e i s t h e r e s u l t o f a c o l l a b o r a t i v e e f f o r t b y f o u r m a j o r r e s e a r c h g r o u p s f r o m C a s e W e s t e r n R e s e r v e , H a r v a r d , J o h n H o p k i n s , a n d S y r a c u s e U n i v e r s i t i e s . The s c a l e 24 i s constructed so that information can be expanded or contracted into three d i f f e r e n t l e v e l s of d e t a i l , depending on the purpose of the assessment. I t i s based on objective ratings of 64 items divided into 5 areas: demographic information, functioning status, impairment items, medical status/risk factor items, and medically-defined conditions. Some of the information required for the assessment depends on up-to-date, accurate records or must be obtained d i r e c t l y from the in d i v i d u a l or a r e l a t i v e . Also, the medical information category requires a physician's assessment. Though more complete than many, t h i s assessment procedure requires more time, personnel, and i s less p r a c t i c a l than one that depends s o l e l y on s t a f f observations. This assessment r e f l e c t s a m u l t i d i s c i p l i n a r y approach and i s oriented toward the aged i n d i v i d u a l . However, few, i f any items concentrate on the psychosocial aspects of the person's l i f e . The one item that may be considered as such, concentrates on the appropriateness of behaviour, c a l l i n g for judgments from the f a c i l i t y ' s point of view, again. The authors themselves, admit that there i s a need to develop detailed psychosocial descriptors, but suggest that assessments 6 3 cannot await t h e i r appearance. Obviously, whether designed for psychogeriatric patients of State Mental Hospitals or for the c l a s s i f i c a t i o n and place-ment of a broader aged group, the presently available assessment instruments suffer considerable short-comings. They emphasize psychiatric/mental functioning to the exclusion of physical 25 functioning or vice versa, or they re l y on a single c r i t e r i o n such as A.D.L. to r e f l e c t the combined e f f e c t of a l l impair-ments. Although great s t r i d e s have taken place recently i n combining the physical and mental, components of functioning, much remains to be accomplished with respect to the s o c i a l / adaptive and emotional components. On the basis of t h i s analysis, a number of guidelines can be established for the development of a more comprehensive assessment procedure. 1. The focus of the assessment should be on the needs of the aged person rather than those of the f a c i l i t y . 2. The assessment should provide information concerning the elder l y person's functioning i n a l l areas - cognitive/ mental, emotional, s o c i a l , physical, and instrumental, so that a complete p r o f i l e of the in d i v i d u a l i s obtained. 3. Information should be such that the indi v i d u a l ' s strengths and weaknesses can be i d e n t i f i e d , rather than providing a l i s t of impairments. 4. The instrument should c a l l f o r observations that demand minimal subjective interpretation. In t h i s way, r e l i a -b i l i t y or consistency of the assessment i s enhanced. 5. The assessment should use terms and c l a s s i f i c a t i o n s readily understood by a l l professionals working i n long term care. 6. The assessment should be applicable to the defined group of e l d e r l y l i v i n g i n long term care f a c i l i t i e s . To be accurate and sensitive to subtle changes, i t must r e f l e c t the special conditions and problems of that group within the environmental opportunities and c a p a b i l i t i e s they possess. C h a p t e r I I I METHODOLOGY D e v e l o p m e n t o f a New A s s e s s m e n t I n s t r u m e n t I t e m S e l e c t i o n F o l l o w i n g t h e g u i d e l i n e s d e r i v e d f r o m t h e l i t e r a t u r e r e v i e w , a new g e r i a t r i c a s s e s s m e n t i n s t r u m e n t u t i l i z i n g t h e o b s e r v a t i o n s o f l o n g t e r m c a r e s t a f f was d e s i g n e d (See A p p e n d i x A ) . I n i t i a l l y , t h e r e v i e w e d i n s t r u m e n t s w e r e e x a m i n e d a n d a p o o l o f i t e m s g a t h e r e d t h a t r e p r e s e n t e d t h e c o m p l e t e r a n g e o f c o n t e n t f o u n d i n t h e v a r i o u s a p p r o a c h e s . T h e s e i t e m s w e r e t h e n c l a s s i f i e d i n t o f i v e b a s i c a r e a s , : c o g n i t i v e , p h y s i c a l , s o c i a l , e m o t i o n a l , a n d i n s t r u m e n t a l o r i n d e p e n d e n t f u n c t i o n i n g . S e l e c t i o n o f i t e m s f r o m t h i s p o o l f o r i n c l u s i o n i n t h e new i n s t r u m e n t was b a s e d o n t h e s i g n i f i c a n c e o f t h e i t e m ' c o n t e n t s t o t h e i n d i v i d u a l a s o u t l i n e d i n C h a p t e r I . F o r e x a m p l e , t h e c o g n i t i v e f u n c t i o n i n g s u b s e c t i o n i s i n t e n d e d t o m e a s u r e t h e p e r s o n ' s i m p o r t a n t m e n t a l p r o c e s s e s : c o m p r e -h e n s i o n , j u d g m e n t , memory , a n d c o m m u n i c a t i o n . T h i s a r e a o f f u n c t i o n i n g h a s g r e a t s i g n i f i c a n c e t o t h e i n d i v i d u a l i n t e r m s 64 65 o f d a i l y l i f e a n d i n p r e d i c t i n g f u t u r e p r o g r e s s . I t e m s i n c l u d e d i n t h i s s e c t i o n r e f e r t o o r i e n t a t i o n ( to t i m e , p l a c e p e r s o n ) , c o m p r e h e n s i o n , memory ( r e c e n t a n d r e m o t e ) , j u d g m e n t , 27 a t t e n t i o n s p a n , a n d s p e e c h ( i n c l u d i n g a p h a s i a , s p e e c h p r o b l e m s r e s u l t i n g f r o m c e r e b r a l i n j u r y s u c h as s t r o k e ) . D e t a i l e d i n f o r m a t i o n a b o u t t h e d i f f e r e n t a r e a s i s e s s e n t i a l t o t h e i d e n t i f i c a t i o n o f p a t t e r n s o f c h a n g e a n d p r o b l e m a r e a s , a n d t o t h e p l a n n i n g o f s u p p o r t i v e m e a s u r e s . The i t e m s w i t h i n t h e s o c i a l f u n c t i o n i n g s e c t i o n m e a s u r e t h e p e r s o n ' s a b i l i t y t o r e l a t e t o o t h e r s o n a n i n d i v i d u a l a n d g r o u p b a s i s . I t e m s i n c l u d e p a r t i c i p a t i o n ( t h e i n d i v i d u a l ' s p a t t e r n s o f p a r t i c i p a t i o n i n g r o u p a c t i v i t i e s o r i n d i v i d u a l f o r m s o f s t i m u l a t i o n ) , i n t e r a c t i o n ( r e f e r s t o t h e p e r s o n ' s r e s p o n s e t o a n o t h e r p e r s o n o n a o n e - t o - o n e b a s i s ) , a n d c o - o p e r a t i o n (how c o - o p e r a t i v e t h e p e r s o n i s p e r c e i v e d t o be by o t h e r s ) . T h i s f i n a l i t e m h a s g r e a t p o t e n t i a l s i g n i f i c a n c e i n t h e m a n n e r t o w h i c h t h e a g e d i n d i v i d u a l i s a p p r o a c h e d a n d t r e a t e d by s t a f f a n d o t h e r r e s i d e n t s . I t e m s w i t h i n t h e a d a p t i v e b e h a v i o u r s e c t i o n m e a s u r e t h e i n d i v i d u a l ' s p a t t e r n o f e m o t i o n a l r e s p o n s e t o s t r e s s e s w i t h i n t h e e n v i r o n m e n t . T h e y i n c l u d e - t r u s t i n g / s u s p i c i o u s , r e l a x e d / a n x i o u s , p a s s i v e / a g g r e s s i v e , a n i m a t e d / d e p r e s s e d , a n d r e c o g -n i t i o n / d e n i a l o f i l l n e s s . T h e s e i t e m s may r e f l e c t l i f e t i m e p e r s o n a l i t y p a t t e r n s o r w a r n o f a n u n h e a l t h y e m o t i o n a l r e s p o n s e . T h e a r e a o f p h y s i c a l , w e l l - b e i n g a t t e m p t s t o i d e n t i f y t h e d e g r e e o f p h y s i c a l d e t e r i o r a t i o n a n d d i s c o m f o r t t h e p e r s o n i s e x p e r i e n c i n g f o r w h a t e v e r r e a s o n . T h e s e i t e m s i n c l u d e e n e r g y l e v e l , c o m f o r t l e v e l , b o d y i n t a c t n e s s , v i s i o n a n d h e a r i n g . The a c t i v i t i e s o f d a i l y l i v i n g ( A . D . L . ) s e c t i o n m e a s u r e s t h e p e r s o n ' s a b i l i t y t o m a i n t a i n i n d e p e n d e n t f u n c t i o n i n g i n t h e 28 face of multiple losses or d i s a b i l i t i e s . Items include d e t a i l s of dressing, eating, grooming, ambulating, chewing, bowel and bladder functioning. Subjective assessment of the e l d e r l y person's f e e l i n g state or self-perceptions could not be included except when they were considered to be connected d i r e c t l y to observable behaviour (such as aggression and depression). In t h i s , as in other areas, additional information may be required to manage the i n d i v i d u a l case. The instrument provides an out-l i n e of the basic content areas for assessment and i s not intended to be the sole source of professional knowledge about the aged i n d i v i d u a l . Format Selection Items selected were then rewritten i n a form that would r e f l e c t the f u l l range of potential functioning for e l d e r l y persons l i v i n g i n a long term care f a c i l i t y . The graphic rating scale was chosen for t h i s purpose because i t provides quantifiable information of a rank or ordinal nature, i n a form that i s quickly and e a s i l y completed. (4 3 2 1). _i I i L The v i s u a l graph represents behaviours i n a form that i s readily understood, necessitating very l i t t l e explanation or d i r e c t i o n to raters. Nevertheless, such scales are prone to a number of sources of bias, such as the "halo e f f e c t or tendency to rate 6 7 an object i n the constant d i r e c t i o n of a general impression." This may r e s u l t i n a s t a f f member rating the aged i n d i v i d u a l 29 c o n t i n u a l l y h i g h o n a l l i t e m s b e c a u s e h e / s h e i s f e l t t o be a n i c e p e r s o n who i s v e r y l i t t l e t r o u b l e a r o u n d t h e f a c i l i t y . A n o t h e r d i f f i c u l t y i s t h e t e n d e n c y o f r a t e r s t o r e s p o n d 6 8 d i s p r o p o r t i o n a t e l y i n t h e m i d d l e c a t e g o r y . By p r o v i d i n g 4 r a t i n g p o s i t i o n s i n s t e a d o f 5 , t h i s n e u t r a l c h o i c e i s e l i m i -n a t e d . A l t h o u g h some s e n s i t i v i t y may be l o s t , t h e r a t e r i s f o r c e d t o t a k e a p o s i t i o n i n one d i r e c t i o n o r t h e o t h e r . D e s p i t e t h e s e p o s s i b l e s o u r c e s o f b i a s , t h e g r a p h i c r a t i n g s c a l e i s b o t h i n t e r e s t i n g a n d e a s y f o r o b s e r v e r s t o u s e , a n d i t a l l o w s a l a r g e number o f i t e m s t o be r a t e d i n a s h o r t t i m e . I n t h e new a s s e s s m e n t i n s t r u m e n t , e a c h i t e m t o be o b s e r v e d i s b r o a d l y d e f i n e d a n d t h e n t h e b e h a v i o u r s t o be c o n s i d e r e d a r e r a t e d o n a n u m e r i c a l s c a l e . F o r e x a m p l e ; V i s i o n : The a b i l i t y t o s e e ( w i t h t h e a i d o f g l a s s e s , i f n e c e s s a r y ) . 4 3 2 1 i 1 1 - I 4 = No p r o b l e m o r v e r y 1 = S e v e r e p r o b l e m . U n a b l e s l i g h t d i f f i c u l t y t o s e e a n y t h i n g b u t s e e i n g . v a g u e o u t l i n e s , s h a d o w s . F u n c t i o n a l l y b l i n d . The s t a f f member p l a c e s a c h e c k mark o r c i r c l e s t h e p o i n t i n t h e s c a l e t h a t m o s t c l o s e l y r e p r e s e n t s t h e e l d e r l y p e r s o n ' s b e h a v i o u r . E a c h i t e m r e p r e s e n t s a l a r g e number o f p o s s i b l e b e -h a v i o u r s , t h u s e x h a u s t i v e s p e c i f i c a t i o n s c o u l d n o t be p r o v i d e d 30 f o r e a c h p o i n t o n t h e s c a l e . C o n s e q u e n t l y , e x a m p l e s o f t y p i c a l b e h a v i o u r w e r e o u t l i n e d t o a n c h o r t h e e x t r e m e e n d s o f t h e s c a l e . I n t h i s way t h e s t a f f a r e p r o v i d e d w i t h g u i d e -l i n e s c o n c e r n i n g w h a t i s t o be o b s e r v e d w i t h o u t so s e v e r e l y r e s t r i c t i n g them t h a t t h e v a l i d i t y o f o b s e r v a t i o n s i s l o s t . I n f o r m a l f e e d b a c k f r o m s e n i o r n u r s e s a n d p s y c h o l o g i s t s i n g e r o n t o l o g y a l s o w e r e o b t a i n e d a t t h i s i n i t i a l d e v e l o p m e n t s t a g e . On t h e b a s i s o f t h e i r s u g g e s t i o n s t h e i n s t r u m e n t was f u r t h e r r e f i n e d a n d a p r e l i m i n a r y i n s t r u m e n t c o n s t r u c t e d . I t c o n t a i n s 31 i t e m s d i v i d e d i n t o 5 s u b s e c t i o n s . E a c h i t e m h a s a r a t i n g f r o m 1 t o 4 w i t h 4 r e p r e s e n t i n g t h e h i g h e s t l e v e l o f f u n c t i o n i n g a n d 1 t h e l o w e s t . T h e A . D . L . s e c t i o n was a d o p t e d f r o m a p r o g r a m d e v e l o p e d 70 a n d t e s t e d by D r . J . C a m p b e l l . I t i s a p i c t o r i a l m e t h o d o f e v a l u a t i n g a n d c o m m u n i c a t i n g A . D . L . p e r f o r m a n c e t h a t f o r m s t h e b a s i s o f a r e h a b i l i t a t i v e a p p r o a c h i n l o n g t e r m c a r e . S i n c e i t h a s d e m o n s t r a t e d r e l i a b i l i t y a n d v a l i d i t y a n d i s one o f t h e m o s t c o m p r e h e n s i v e o f p o p u l a r A . D . L . c h a r t s , i t was a d d e d t o t h e a s s e s s m e n t i n s t r u m e n t . T h i s s e c t i o n r e t a i n e d i t s o r i g i n a l s c o r i n g f o r t h i s d a t a c o l l e c t i o n ( 1 - f o r c o m p l e t e i n d e p e n d e n c e , 2 - f o r p a r t i a l d e p e n d e n c e , a n d 3 - f o r c o m p l e t e d e p e n d e n c e ) . A l t h o u g h i t w o u l d be d e s i r a b l e t o h a v e t h e s c o r i n g i n t h e same d i r e c t i o n as t h e o t h e r s e c t i o n s o f t h e i n s t r u m e n t (and t h i s i s r ecommended f o r f u t u r e u s e o f t h e s c a l e ) , i t was f e l t t h a t i t w o u l d be t o o c o n f u s i n g t o s t a f f a t t h e t e s t i n g f a c i l i t y who were f a m i l i a r w i t h t h e A . D . L . c h a r t i n i t s o r i g i n a l f o r m . To r e v e r s e i t may h a v e r e s u l t e d i n many 31 misrated items. Therefore i t was deemed easier to invert the scoring at the data analysis stage. In t h i s form, the instrument i s able to provide information concerning s p e c i f i c functions such as memory, or speech. A l t e r -natively, i t can be aggregated into a multidimensional p r o f i l e of the in d i v i d u a l (Appendix B), or compiled into a composite assessment score, depending on the use for which i t i s intended. P i l o t Testing. I n i t i a l impressions from four experienced g e r i a t r i c nurses confirmed that the instrument was considered compre-hensive and p o t e n t i a l l y useful i n long term care. A b r i e f pretest was then conducted to i d e n t i f y gross d i f f i c u l t i e s i n wording and item inter p r e t a t i o n , i n preparation for the major test of r e l i a b i l i t y and v a l i d i t y to follow. Five nurses at the extended care unit assessed one resident with whom they were f a m i l i a r using the new assessment instrument. From the i r ratings i t appeared that the item r e l a t i n g to aphasia was being marked i n c o r r e c t l y . However, since t h i s area of functioning i s so important to the in d i v i d u a l and l i k e l y to af f e c t many other areas., i t was retained for further analysis. Great d i f f i c u l t y was encountered i n the scaling of aggression and p a s s i v i t y . In order to be consistent with the other items, one end of the scale must represent the highest l e v e l of functioning and the other the lowest. Therefore, aggression and p a s s i v i t y could not be placed as p o l a r i t i e s of the same behaviour, as neither represents high l e v e l 32 functioning. I n i t i a l l y , 2 scales were presented and the rater asked to mark one or the other. . Passive/ Aggressive: N.B. Mark only one of the scales below. The score of 4 on each i s i d e n t i c a l , i n d i c a t i n g a good balance of p a s s i v i t y and aggressiveness. (a) Passive 4 3 2 1 4 = Well-balanced. Shows s u f f i c i e n t assertiveness and independence. Not too passive. 1 = Extremely passive and dependent. W i l l not attempt anything on his own. Makes no attempt to control what happens or events around him/her. or (b) Aggressive 4 1 3 2 1 1 4 .= Well-balanced. Not too aggressive or assertive. 1 = Extremely assertive and overly aggres-sive to the point of being h o s t i l e or threatening. Tries to control the environment t o t a l l y . However, t h i s format was confusing to s t a f f and resulted i n no rating at a l l or incompatible ratings on both scales. F i n a l l y , a scale was constructed that was consistent with the other items and rea d i l y understood by s t a f f members. 33 Aggressive 1 2 Well-balanced 3 4 3 2 _ l _ Passive 1 ! l=Extremely assertive and overly aggressive to the point of being h o s t i l e or threatening. Tries to control the environment t o t a l l y . 4=Well-balanced. Not too aggressive or passive. l=Extremely passive and depen-dent. W i l l not attempt anything alone. Makes no attempt to control events around him/ her. It was also noted during the p i l o t t e s t i n g that s t a f f were unable to specify the resident's a b i l i t y i n the d e t a i l demanded by the v i s u a l A.D.L. chart. That i s , they were able to state the resident's o v e r a l l l e v e l of dependence and independence i n dressing, eating, grooming, or ambulating, but not his/her a b i l i t y to do up buttons, take o f f a s h i r t , and so on. As a r e s u l t , only one score was used for each of the four areas. This was calculated by averaging the s p e c i f i c items that were rated within each area and rounding to the nearest whole number. Completion time for the i n i t i a l assessment was estimated to be 15 minutes and for second and subsequent assessments, 5 to 10 minutes. With these changes, the new assessment instrument was considered ready to be submitted to more rigorous r e l i a b i l i t y and v a l i d i t y t e s t i n g . 34 R e l i a b i l i t y and V a l i d i t y Testing Sample Assessments were obtained at d i f f e r e n t time i n t e r v a l s for 76 residents of a 300-bed extended care unit during the f i r s t two years of i t s operation. (1977,1978). Admission to the f a c i l i t y i s based on c r i t e r i a of need i n the areas of physical and personal functioning, communication, and medical problems. The assessments were obtained as part of the informa-tion-gathering of a major research project examining the 71 stress of rel o c a t i n g e l d e r l y persons. P a r t i c i p a t i o n i n the study required the residents to be at least moderately oriented to place and person, and be capable of i n t e r a c t i n g in an interview s i t u a t i o n with some degree of comprehension. Subjects were referred by the unit's admission screening committee i f they met the study's requirements. Then they were v i s i t e d by a researcher who obtained informed written consent. Most subjects were obtained during the f i r s t few months of the unit's operation with the highest frequency of admissions occurring i n June and July of 1977. The sample residents were aged 44 to 99 years with an average age of 80. Sixteen of the residents assessed were men 35 (21 p e r c e n t ) a n d s i x t y women (79 p e r c e n t ) . T h i s c o m p a r e s t o t h e f a c i l i t y as a w h o l e i n w h i c h 32 p e r c e n t a r e m a l e a n d 6 8 p e r c e n t f e m a l e . T h e a v e r a g e age f o r a l l r e s i d e n t s i s 7 7 . T h e m a j o r i t y o f s u b j e c t s were d i a g n o s e d as h a v i n g some f o r m o f c e r e b r a l i n j u r y , a b e h a v i o u r a l d i s o r d e r , o r h e a r t d i s e a s e as t h e i r m a j o r m e d i c a l p r o b l e m . (See A p p e n d i x C f o r t h e f r e q u e n c y o f a d m i t t i n g d i a g n o s e s ) . I t i s i n t e r e s t i n g t o n o t e t h a t t h e f i r s t 2 c a t e g o r i e s , b o t h r e l a t i n g t o p r o b l e m s o f c o g n i t i v e f u n c t i o n i n g , c o m p r i s e 5 6 p e r c e n t o f t h e t o t a l s a m p l e , e v e n t h o u g h r e s i d e n t s who w e r e m o s t s e v e r e l y m e n t a l l y -i m p a i r e d w e r e e x c l u d e d f r o m t h e s t u d y . T h i s g i v e s some i n d i c a t i o n o f t h e f r e q u e n c y a n d p e r v a s i v e n e s s o f s u c h p r o b l e m s i n r e s i d e n t i a l f a c i l i t i e s . T e s t C o n d i t i o n s One s t a f f r a t i n g was o b t a i n e d f r o m t h e f a c i l i t y i n w h i c h t h e s u b j e c t r e s i d e d p r i o r t o m o v i n g t o t h e U . B . C . u n i t . F o l l o w - u p a s s e s s m e n t s w e r e t h e n o b t a i n e d , a t 3 , 6 , a n d 12 m o n t h s a f t e r a d m i s s i o n . I n e a c h c a s e s t a f f members w e r e u s e d who r e s p o n d e d p o s i t i v e l y t o t h e q u e s t i o n , "Who f e e l s t h e y know w e l l a n d h a v e w o r k e d w i t h h i m / h e r d i r e c t l y d u r i n g t h e p a s t 2 -3 w e e k s ? " T h e m a j o r i t y o f a s s e s s m e n t s w e r e o b t a i n e d d u r i n g t h e l a t e e v e n i n g h o u r s when s t a f f members f e l t t h e y were m o s t l i k e l y t o h a v e t i m e t o c o m p l e t e t h e a s s e s s m e n t a n d p r o v i d e i n f o r m a l f e e d b a c k c o n c e r n i n g i t s f o r m a n d c o n t e n t . R a t e r s w e r e a b o u t e q u a l l y d i v i d e d b e t w e e n r e g i s t e r e d n u r s e s a n d l o n g t e r m c a r e a i d e s . T h e p u r p o s e o f t h e r e s e a r c h a n d t h e 36 n a t u r e o f t h e a s s e s s m e n t was e x p l a i n e d t o s t a f f , i n c l u d i n g a n e s t i m a t i o n o f c o m p l e t i o n t i m e . T h e y w e r e i n f o r m e d t h a t p a r t i c i p a t i o n was v o l u n t a r y a n d c o u l d be t e r m i n a t e d a t any t i m e . R e l i a b i l i t y T e s t - R e t e s t I n o r d e r t o t e s t t h e s t a b i l i t y o f t h e a s s e s s m e n t i n s t r u m e n t o v e r t i m e , 30 s t a f f n u r s e s a t t h e U . B . C . u n i t e a c h a s s e s s e d one r e s i d e n t w i t h whom t h e y w e r e f a m i l i a r t h r o u g h d a i l y c o n t a c t . T e n t o f o u r t e e n d a y s l a t e r , t h e y e a c h r e a s s e s s e d t h e same r e s i d e n t s . I t was f e l t t h a t a p e r i o d o f t i m e l e s s t h a n t e n d a y s w o u l d r e n d e r t h e f i r s t a s s e s s m e n t f r e s h i n t h e m i n d s o f t h e r a t e r s , w h i l e a l o n g e r p e r i o d w o u l d i n c r e a s e t h e l i k e l i h o o d t h a t t h e p e r s o n ' s c o n d i t i o n w o u l d c h a n g e i n t h e i n t e r i m . I n t e r - r a t e r T h e c o n s i s t e n c y o f t h e i n s t r u m e n t f r o m one r a t e r t o a n o t h e r was e x p l o r e d by h a v i n g e a c h o f 3 0 r e s i d e n t s a s s e s s e d s i m u l t a n e o u s l y a n d i n d e p e n d e n t l y by two s t a f f n u r s e s f a m i l i a r w i t h t h e m . ( T h a t i s , e a c h r e s i d e n t w o u l d h a v e two d i f f e r e n t a s s e s s m e n t s d o n e a t t h e same t i m e by two d i f f e r e n t n u r s e s . ) The two n u r s e s w e r e n o t t h e same i n e a c h c a s e b e -c a u s e i t was e s s e n t i a l t h a t b o t h r a t e r s know t h e e l d e r l y p e r s o n w e l l . I t e m A n a l y s i s The d i s t r i b u t i o n o f r a t i n g s f o r e a c h i t e m was a n a l y z e d t o a s s e s s t h a t t h e l e v e l s o f f u n c t i o n i n g p r o v i d e d w e r e a p p r o p r i a t e t o t h e s a m p l e p o p u l a t i o n . I d e a l l y , i t e m s s h o u l d h a v e a mean s c o r e t h a t f a l l s n e a r t h e m i d d l e o f 37 t h e p o t e n t i a l c h o i c e s a v a i l a b l e a n d h a v e a d i s t r i b u t i o n t h a t i n d i c a t e s t h e r a t e r s h a v e made u s e o f t h e e n t i r e r a n g e o f 72 t h e c o n t i n u u m . I n t e r n a l C o n s i s t e n c y E a c h i t e m was a n a l y z e d t o t e s t i t s r e l a t i o n s h i p t o t h e s u b s e c t i o n s c o r e a n d t o t a l a s s e s s m e n t s c o r e . I n t h i s w a y , t h e i n t e r n a l c o n s i s t e n c y o f i t e m s w i t h i n t h e i n s t r u m e n t c o u l d be e v a l u a t e d a n d i t e m s t h a t w e r e m i s -c l a s s i f i e d o r t h a t d i d n o t c o n t r i b u t e s i g n i f i c a n t l y t o t h e t o t a l a s s e s s m e n t s c o r e c o u l d be i d e n t i f i e d . T h e u n d e r l y i n g c o m p o n e n t s t r u c t u r e o f t h e a s s e s s m e n t was a l s o a n a l y z e d by e x p l o r i n g t h e r e l a t i o n s h i p b e t w e e n s u b s e c t i o n s a n d b e t w e e n t h e s u b s e c t i o n s a n d t h e t o t a l s c o r e . V a l i d i t y V a l i d i t y C r i t e r i a A number o f m e a s u r e s w e r e u s e d t o t e s t t h a t t h e a s s e s s m e n t i n s t r u m e n t , i n f a c t , w a s , m e a s u r i n g t h e i n d i v i d u a l ' s l e v e l o f w e l l b e i n g / i m p a i r m e n t . T h o s e t h a t w e r e e x p e c t e d t o show a r e l a t i o n s h i p w i t h a l l o r p a r t o f t h e a s s e s s m e n t s c o r e w e r e : (a) A m u l t i d i s c i p l i n a r y summary l i s t o f t h e r e s i d e n t ' s p r o b l e m s , (b) t h e number o f m e d i c a t i o n s p r e s c r i b e d , (c) a w e i g h t e d i n d e x o f p h y s i c a l h e a l t h b a s e d o n d i a g n o s e s a n d s y m p t o m s , (d) o b s e r v a t i o n s o f t h e r e s i d e n t ' s p a r t i c i p a t i o n i n s t r u c t u r e d a c t i v i t i e s o n t h e u n i t o v e r a two week p e r i o d , (e) a b r i e f e v a l u a t i o n o f m e n t a l s t a t u s u s i n g a s t r u c t u r e d i n t e r v i e w , a n d (f) a v a l i d d i a g n o s i s o f a p h a s i a b a s e d o n t h e n u r s e c o - o r d i n a t o r / p h y s i c i a n a n d / o r m e d i c a l r e c o r d i n f o r m a t i o n . 38 1. Problem-Oriented Record - This method of record-keeping i s designed for m u l t i d i s c i p l i n a r y use and outlines the individual's problems (both of permanent and temporary nature) as the basis 73 of care-giving. In the U.B.C. unit, an i n i t i a l l i s t of permanent or chronic problems i s made on the person's record following the f i r s t i n t e r d i s c i p l i n a r y care conference a f t e r admission. As such, i t can be expected to enumerate the major problems and impairments of the in d i v i d u a l i n a l l areas of functioning. If the assessment instrument i s an accurate measure of the el d e r l y person's well-being and impairment, i t should be highly related to the number of problems l i s t e d on the P.O.R. 2. Medication - Since medication i s prescribed for lowered functioning i n many areas (physical, emotional, mental) i t was hypothesized that the number of medications prescribed for each i n d i v i d u a l would be related to the l e v e l of his/her well-being or. impairment. Therefore, scores on the assessment instrument were compared to the number of medications received by each resident i n the sample. 3. Health Index Scale - This scale was adapted from the Health 74 Index developed by Rosencranz and Pihlblad i n 1970 and Linn's 75 Cumulative Index Scale (196 8). The instrument c l a s s i f i e s diagnoses, symptoms, and problems of a physical nature into categories with each item assigned a weight of 2 or 4 depending on the degree of seriousness i t represents. (See Appendix D). Special care requirements and problems of the elde r l y were 39 a d d e d t o make i t a p p l i c a b l e t o l o n g t e r m c a r e . W h i l e r e l i a -b i l i t y a n d v a l i d i t y i n f o r m a t i o n i s l i m i t e d o n t h e 2 s c a l e s , t h e y h a v e b e e n u s e d e x t e n s i v e l y i n g e r o n t o l o g y a n d t o g e t h e r r e p r e s e n t a u s e f u l m e t h o d o f i n d e x i n g p h y s i c a l i l l n e s s d i m e n s i o n s u s i n g m e d i c a l r e c o r d i n f o r m a t i o n . T h e s c o r e was e x p e c t e d t o c o r r e l a t e n e g a t i v e l y w i t h t h e r e s i d e n t ' s s c o r e o n t h e p h y s i c a l f u n c t i o n i n g s u b s e c t i o n ( s i n c e p o o r h e a l t h p r o d u c e s a l o w s c o r e on t h e s u b s c a l e r a t i n g s a n d a h i g h s c o r e o n t h e h e a l t h i n d e x ) . 4. P l a n n e d A c t i v i t y C h e c k - T h i s i s a t e c h n i q u e o f o b s e r v i n g V 6 s u b j e c t b e h a v i o u r u s i n g t i m e s a m p l i n g . (See A p p e n d i x E ) . I t was d e v e l o p e d a n d t e s t e d b y D r . J . C a m p b e l l a n d S . M i l l s a n d h a s a h i g h d e g r e e o f r e l i a b i l i t y (0.95). T h e e l d e r l y p e r s o n i s o b s e r v e d as u n o b t r u s i v e l y a s p o s s i b l e b y i n d e p e n d e n t o b s e r v e r s f o r 10 s e c o n d s f o r 4 t i m e p e r i o d s d u r i n g a d a y (be tween 11:30 a n d 12 a . m . , 1:30 a n d 2 p . m . , 2:30 a n d 3 p . m . , and 4 a n d 4:40 p . m . ) T h e n a t u r e o f t h e p e r s o n ' s a c t i v i t y d u r i n g t h e s e t i m e s i s r e c o r d e d ( a c t i v e / p a s s i v e , s o l i t a r y / g r o u p , e t c e t e r a ) . T h e s e o b s e r v a t i o n s w e r e made f o r 4 d a y s a week f o r 2 w e e k s , r e s u l t i n g i n a t o t a l o f 32 o b s e r v a t i o n s p e r r e s i d e n t . I t i s h y p o t h e s i z e d t h a t t h o s e r e s i d e n t s who h a v e t h e l o w e s t l e v e l o f f u n c t i o n i n g i n a l l a r e a s w i l l be o b s e r v e d i n s t r u c t u r e d a c t i v i t y l e s s f r e q u e n t l y t h a n t h o s e who a r e l e s s i m p a i r e d . T h e r e f o r e , t h e t o t a l number o f t i m e s e a c h r e s i d e n t i n t h e s a m p l e was o b s e r v e d i n s u c h a c t i v i t y ( w r i t i n g , r e a d i n g , r e c r e a t i o n , c o n v e r s a t i o n , t h e r a p y o r g r o u p m e e t i n g ) d u r i n g t h e two week p e r i o d was compared t o h i s / h e r a s s e s s m e n t s c o r e . 40 5. M e n t a l S t a t u s Q u e s t i o n n a i r e - D u r i n g a s t r u c t u r e d i n t e r v i e w p e r f o r m e d b y i n d e p e n d e n t i n t e r v i e w e r s , t h e r e s i d e n t was a s k e d 10 s p e c i f i c q u e s t i o n s d e s i g n e d t o t e s t h i s / h e r m e n t a l f u n c t i o n i n g . (See A p p e n d i x F ) . T h i s i n s t r u m e n t , d e s i g n e d b y K a h n , G o l d f a r b e t a l . i n 1 9 6 0 , h a s b e e n w i d e l y a n d e x t e n -s i v e l y u s e d i n g e r i a t r i c s a n d h a s g a i n e d a c c e p t a n c e a s a 77 r e l i a b l e a n d v a l i d m e a s u r e o f g r o s s m e n t a l s t a t u s . I t i s e x p e c t e d t h a t t h e s c o r e o n t h i s q u e s t i o n n a i r e w i l l c o r r e l a t e h i g h l y w i t h t h e c o g n i t i v e f u n c t i o n i n g s c o r e o n t h e a s s e s s m e n t i n s t r u m e n t . 6. V a l i d A p h a s i a D i a g n o s i s - A v a l i d d i a g n o s i s o f e a c h r e s i d e n t ' s s p e e c h p r o b l e m s was o b t a i n e d f r o m t h e n u r s e c o - o r d i n a t o r , p h y s i c i a n , a n d / o r m e d i c a l r e c o r d . T h e s t a f f r a t i n g was t h e n t e s t e d f o r a c c u r a c y a g a i n s t t h i s m e a s u r e . P r e d i c t i v e V a l i d i t y The i n f o r m a t i o n p r o v i d e d by t h e a s s e s s m e n t i n s t r u m e n t was a n a l y z e d f o r i t s a b i l i t y t o p r e d i c t d e a t h among t h e e l d e r l y r e s i d e n t s . T w e l v e o f t h e 76 r e s i d e n t s d i e d w i t h i n one y e a r o f a d m i s s i o n . , - T h r e e .of ,:the t w e l v e d i e d s h o r t l y a f t e r t r a n s f e r t o a n o t h e r l o n g t e r m c a r e f a c i l i t y o r t o a c u t e c a r e . I f t h e s c o r e s o n t h e 5 s u b s e c t i o n s o f t h e i n s t r u m e n t c a n be u s e d t o make a h i g h p e r c e n t a g e o f c o r r e c t p r e d i c t i o n s , t h e n t h e i n s t r u m e n t c a n be c o n s i d e r e d a v a l i d m e a s u r e o f w e l l - b e i n g . S e n s i t i v i t y The i n s t r u m e n t mus t be a b l e t o i d e n t i f y c h a n g e s t h a t h a v e o c c u r r e d i n t h e p e r s o n ' s l e v e l o f w e l l - b e i n g o v e r t i m e . I n o r d e r t o t e s t t h e i n s t r u m e n t ' s s e n s i t i v i t y t o 41 c h a n g e , d i f f e r e n c e s i n s c o r e s b e t w e e n t h e 1 2 - m o n t h a n d t h e 3 - m o n t h a s s e s s m e n t s w e r e c o m p a r e d t o t h e n u r s e c o - o r d i n a t o r s ' a n d t h e r e s i d e n t s ' o v e r a l l e s t i m a t i o n o f c h a n g e d u r i n g t h a t p e r i o d ( i m p r o v e d , d e t e r i o r a t e d , o r t h e s a m e ) . A s s u m p t i o n s 1. The e l d e r l y p e r s o n ' s l e v e l o f f u n c t i o n i n g w i l l f a l l w i t h i n t h e r a n g e d e s c r i b e d i n t h e a s s e s s m e n t i n s t r u m e n t . 2 . I n f o r m a t i o n demanded b y t h e s c a l e i s r e a d i l y o b s e r v a b l e by s t a f f who a r e i n d a i l y c o n t a c t w i t h t h e i n d i v i d u a l . L i m i t a t i o n s 1. The d a t a p r o v i d e d i n t h e t e s t a n a l y s i s aire b a s e d o n on e l o n g t e r m c a r e f a c i l i t y o n l y . 2 . T h e r e s i d e n t s s e l e c t e d f o r t h e s t u d y mus t p o s s e s s t h e a b i l i t y t o i n t e r a c t i n an i n t e r v i e w a n d be m o d e r a t e l y o r i e n t e d t o t h e i r s u r r o u n d i n g s . A s s u c h , t h e s a m p l e c a n n o t be c o n s i d e r e d r e p r e s e n t a t i v e o f t h e p o p u l a t i o n o f t h e f a c i l i t y a s a w h o l e . Chapter IV RESULTS AND DISCUSSION R e l i a b i l i t y f Test-Retest Measurement instruments, according to the Standards for Tests published by the American Psychological Association, should be stable over time and show consistent results when 7 8 used by d i f f e r e n t i n d i v i d u a l s . The t e s t - r e t e s t r e l i a b i l i t y of the 5 subsections of the assessment instrument was analyzed using the Spearman 79 rank order co r r e l a t i o n c o e f f i c i e n t and Kendall's tau. Although there i s some debate concerning the superiority of the d i f f e r e n t methods, both provide a c o e f f i c i e n t that i s an estimate of the extent to which 2 sets of measurements are 8 0 related to each other, using the ranking of the scores. Zero represents no relat i o n s h i p and +1 or -1 perfect p o s i t i v e and negative c o r r e l a t i o n , respectively. As reported i n Table I, a l l subsections of the i n s t r u -ment were found to be highly stable, attaining Spearman corr e l a t i o n c o e f f i c i e n t s from 0.6 to 0.83 with the t o t a l score r e l i a b i l i t y being equal to 0.61. The pr o b a b i l i t y of these correlations occurring by chance alone i s less than 42 43 0.001 i n a l l c a s e s (P<0.001), ( K e n d a l l ' s t a u c o e f f i c i e n t s w e r e b a s i c a l l y e q u i v a l e n t w i t h P<0.001). I n t e r - J u d g e T h e i n t e r - j u d g e r e l i a b i l i t y o f t h e i n s t r u m e n t s u b -s e c t i o n s was a n a l y z e d u s i n g t h e S p e a r m a n r a n k o r d e r c o e f f i c i e n t s a n d K e n d a l l ' s t a u . ( T a b l e I ) . A l l s u b s e c t i o n s a t t a i n e d h i g h l y s i g n i f i c a n t c o r r e l a t i o n s , i n d i c a t i n g c o n s i s t e n c y o f r a t i n g s u s i n g d i f f e r e n t s t a f f m e m b e r s . S p e a r m a n c o e f f i c i e n t s r a n g e d f r o m 0.47 t o 0.87 (P<0.004). A g a i n , K e n d a l l ' s t a u v a l u e s showed s i m i l a r r e s u l t s w i t h P<0.006). SPEARMAN S I G N I F I C A N C E ASSESSMENT S U B S E C T I O N C O E F F I C I E N T L E V E L C o g n i t i v e F u n c t i o n i n g 0. 83 P<0.001 S o c i a l F u n c t i o n i n g 0.64 P<0.001 T E S T -A d a p t i v e B e h a v i o u r 0. 60 P<0.001 R E T E S T P h y s i c a l F u n c t i o n i n g 0.60 P<0.001 (N=30) A . D . L . 0.75 P<0.001 T o t a l A s s e s s m e n t 0. 62 P<0.001 C o g n i t i v e F u n c t i o n i n g 0. 87 P<0.001 S o c i a l F u n c t i o n i n g 0. 52 P<0.002 I N T E R -A d a p t i v e B e h a v i o u r 0.48 P<0.003 JUDGE P h y s i c a l F u n c t i o n i n g 0.47 P<0.004 (N=30) A . D . L . 0.67 P<0.001 T o t a l A s s e s s m e n t 0.66 P<0.001 T A B L E I : T E S T - R E T E S T AND I N T E R J U D G E R E L I A B I L I T Y OF THE ASSESSMENT SUBSECTIONS USING SPEARMAN RANK ORDER C O R R E L A T I O N . 44 I t e m A n a l y s i s A v e r a g e R a t i n g s T h e mean s c o r e , s t a n d a r d d e v i a t i o n s , a n d f r e q u e n c y o f r a t i n g s f o r e a c h i t e m a r e d i s p l a y e d i n A p p e n d i x G . T h e i t e m p a s s i v e / a g g r e s s i v e h a d one m i s s i n g r a t i n g a n d r e c o g n i t i o n / d e n i a l t w o . A l t h o u g h no comment was made by t h e r a t e r who d i d n o t m a r k t h e p a s s i v e / a g g r e s s i v e i t e m , t h i s c o u l d mean t h a t t h e r e s i d e n t showed s i g n s o f b o t h p a s s i v e a n d a g g r e s s i v e b e h a v i o u r a n d t h e s t a f f member was u n a b l e t o d e c i d e w h e r e t o p l a c e t h e i n d i v i d u a l o n t h e c o n t i n u u m . A l t h o u g h t h i s i s o n l y one r a t i n g , t h e p o s s i b i l i t y e x i s t s a n d some c o n s i d e r a t i o n s h o u l d be g i v e n t o p r o v i d i n g a n o p t i o n t h a t w i l l i n d i c a t e t h e p r e s e n c e o f b o t h t y p e s o f b e h a v i o u r i n t h e same p e r s o n . T h e two m i s s i n g r a t i n g s o n t h e r e c o g n i t i o n / d e n i a l i t e m w e r e a c c o m p a n i e d by w r i t t e n comments by t h e s t a f f members i n d i c a t i n g t h a t t h e p e r s o n was t o o c o n f u s e d o r u n c o m m u n i c a t i v e f o r t h e m t o b e a b l e t o r a t e t h i s a r e a o f f u n c t i o n i n g . T h e l o w e s t a v e r a g e r a t i n g f o r any i t e m o c c u r r e d i n p a r t i c i p a t i o n (2 .4 ) a n d t h e h i g h e s t i n c h e w i n g a b i l i t y ( 3 . 7 ) . (Note t h a t t h e l a s t 4 i t e m s i n t h e A . D . L . s u b s e c t i o n a r e r a t e d f r o m 1 t o 3 a n d t h e r e f o r e a r e c o n s i d e r e d s e p a r a t e l y . ) The a v e r a g e r a t i n g f o r a l l i t e m s i s 2 . 8 , s l i g h t l y h i g h e r t h a n t h e m i d p o i n t f o r a 4 - p o i n t s c a l e ( 2 . 5 ) . The a v e r a g e r a t i n g f o r t h e l a s t 4 i t e m s i s 2 . 1 4 ( m i d p o i n t = 2 ) . T h i s s u g g e s t s t h a t t h e s a m p l e p o p u l a t i o n i s f u n c t i o n i n g s l i g h t l y h i g h e r t h a n t h e m i d d l e o f t h e b e h a v i o u r a l c o n t i n u u m p r o v i d e d by t h e i n s t r u m e n t . F u r t h e r e v i d e n c e o f t h i s i s s e e n i n t h e h i s t o g r a m s i n A p p e n d i x H . T h e mean s c o r e s a n d d i s t r i b u t i o n o f s c o r e s f o r 45 t h e s u b s e c t i o n s a n d t h e a s s e s s m e n t a r e w e i g h t e d s l i g h t l y h i g h e r t h a n t h e m i d l i n e , p a r t i c u l a r l y i n t h e c o g n i t i v e f u n c t i o n i n g s u b s e c t i o n . T h i s r e s u l t c o u l d be e x p e c t e d i n t h a t t h e s a m p l e p o p u l a t i o n was s e l e c t e d f r o m r e s i d e n t s who w e r e o r i e n t e d t o t h e i r s u r r o u n d i n g s a n d a b l e t o c o m p r e h e n d a n d p a r t i c i p a t e i n an i n t e r v i e w s i t u a t i o n . S i n c e t h e e l d e r l y w i t h p o o r m e n t a l f u n c t i o n i n g w o u l d t e n d t o h a v e l o w e r e d p e r -f o r m a n c e i n o t h e r a r e a s a s w e l l ( s o c i a l , a d a p t i v e , a n d A . D . L . ) t h e a d d i t i o n o f s u c h r e s i d e n t s t o t h e sample c o u l d be e x p e c t e d t o p r o d u c e a d e c r e a s e i n mean i t e m a n d s u b s e c t i o n s c o r e s . I t e m V a r i a n c e T h e w i d e s t v a r i a t i o n i n r a t i n g s o n any one i t e m o c c u r r e d w i t h s h o r t - t e r m memory (1.23) a n d t h e l o w e s t w i t h c h e w i n g a b i l i t y (0.48). T h i s n a r r o w v a r i a t i o n c o m b i n e d w i t h t h e h i g h mean r a t i n g f o r c h e w i n g a b i l i t y s u g g e s t s t h a t i t i s n o t p r o v i d i n g d i s c r i m i n a t i n g i n f o r m a t i o n a n d s h o u l d be c h a n g e d o r e l i m i n a t e d . T h i s i s a l s o t r u e o f t h e . a p h a s i a r a t i n g . The d i a g n o s i s o f a p h a s i a , a c c o r d i n g t o t h e s t a f f r a t i n g s , o c c u r s t o o s e l d o m t o be a s i g n i f i c a n t i t e m i n t h e a s s e s s m e n t . T h e a v e r a g e v a r i a t i o n o f r a t i n g s f o r 4 - p o i n t s c a l e s was 0.94, o r a p p r o x i m a t e l y 1 p o i n t away f r o m t h e mean r a t i n g o f 2.8. F o r 3 - p o i n t s c a l e s t h e a v e r a g e was 0.74 p o i n t s away f r o m t h e mean o f 2.14. W i t h a v e r a g e r a t i n g s a p p r o a c h i n g t h e m i d p o i n t s o f t h e s c a l e s a n d w i d e i n d i v i d u a l v a r i a t i o n s , i t c a n be c o n c l u d e d t h a t t h e i t e m s a r e b o t h a p p r o p r i a t e t o t h e s a m p l e p o p u l a t i o n a n d a b l e t o d i s c r i m i n a t e d i f f e r e n t l e v e l s o f f u n c t i o n i n g among t h e r e s i d e n t s . T h i s i s a l s o i l l u s t r a t e d i n t h e s u b s e c t i o n h i s t o g r a m s . A v e r a g e s c o r e s a p p r o a c h t h e 46 m i d p o i n t o f t h e p o s s i b l e s c o r e r a n g e a n d t h e s t a n d a r d d e v i a t i o n s f o r e a c h s u b s e c t i o n i s s u f f i c i e n t l y l a r g e t o i n d i c a t e w i d e i n d i v i d u a l s c o r e d i f f e r e n c e s . I n t e r n a l C o n s i s t e n c y I t e m - t o - S u b s c a l e a n d I t e m - t o - T o t a l C o r r e l a t i o n s T h e r e l a t i o n s h i p o f e a c h i t e m t o i t s s u b s e c t i o n a n d t h e t o t a l s c o r e was e x a m i n e d a n d i s a l s o r e p o r t e d i n A p p e n d i x G . N i n e o u t o f t e n o f t h e i t e m s i n t h e c o g n i t i v e f u n c t i o n i n g s u b -s e c t i o n c o r r e l a t e h i g h l y w i t h b o t h t h e s u b s e c t i o n s c o r e a n d t h e t o t a l a s s e s s m e n t s c o r e . T h i s i n d i c a t e s t h a t t h e s u b s e c t i o n i s i n t e r n a l l y c o n s i s t e n t a n d t h a t t h e i t e m s a r e m e a s u r i n g r e l a t e d b e h a v i o u r s . I t e m s - t o - s u b s c a l e c o r r e l a t i o n s b e t w e e n 0 .4 a n d 0 . 6 a r e d e s i r a b l e i n t h a t t h e i t e m s w o u l d t h e n be m e a s u r i n g r e l a t e d 81 b u t d i f f e r e n t b e h a v i o u r s . T h i s i s t h e c a s e f o r a l l i t e m s i n t h e s o c i a l f u n c t i o n i n g a n d a d a p t i v e b e h a v i o u r s u b s e c t i o n s a n d f o r t h e m a j o r i t y o f i t e m s i n t h e A . D . L . s u b s e c t i o n . T h e v e r y h i g h c o r r e l a t i o n s i n t h e c o g n i t i v e s u b s e c t i o n s u g g e s t t h a t t h e i t e m s may be m e a s u r i n g t h e same phenomenon a n d f e w e r i t e m s c o u l d be u s e d t o p r o d u c e i d e n t i c a l i n f o r m a t i o n . A l t e r -n a t i v e l y , r a t e r s may h a v e f a i l e d t o d i f f e r e n t i a t e b e t w e e n t h e b e h a v i o u r s e x h i b i t e d b y t h e a g e d p e r s o n a n d t h e r a t i n g s i n d i c a t e a h a l o e f f e c t . F o r e x a m p l e , t h e r e s i d e n t h a s b e e n o b s e r v e d t o h a v e p o o r memory a n d t h e r a t e r a s s u m e d t h e r e f o r e t h a t a l l m e n t a l f u n c t i o n i n g was l i m i t e d a n d r a t e d a c c o r d i n g l y . I t e m s w i t h p o o r i t e m - t o - s u b s e c t i o n c o r r e l a t i o n s i n c l u d e 47 a p h a s i a ( i n t h e c o g n i t i v e s u b s e c t i o n ) , b o d y i n t a c t n e s s , v i s i o n , a n d h e a r i n g ( i n t h e p h y s i c a l s u b s e c t i o n ) a n d c h e w i n g a b i l i t y , b o w e l f u n c t i o n , a n d e a t i n g a b i l i t y ( i n t h e A . D . L . s u b s e c t i o n ) . T h e l o w c o r r e l a t i o n s f o r a p h a s i a a n d c h e w i n g a b i l i t y r e f l e c t t h e i r s m a l l v a r i a n c e a n d p o o r d i s c r i m i n a t i n g p o w e r i d e n t i f i e d p r e v i o u s l y . T h i s i s a f u r t h e r i n d i c a t i o n t h a t t h e i t e m s s h o u l d be e l i m i n a t e d f r o m t h e a s s e s s m e n t . T h e l o w c o r r e l a t i o n s o f t h e o t h e r i t e m s i n d i c a t e t h a t t h e b e h a v i o u r s t h e y m e a s u r e a r e n o t r e l a t e d t o t h e o t h e r i t e m s i n t h e i r r e s p e c t i v e s u b s e c t i o n s . I f t h e y w e r e s i m p l y m i s -c l a s s i f i e d , t h e y w o u l d s t i l l h a v e h i g h c o r r e l a t i o n s w i t h t h e t o t a l a s s e s s m e n t s c o r e . H o w e v e r , t h i s i s n o t t h e c a s e . I t i s p o s s i b l e t h a t t h e i t e m s (body i n t a c t n e s s , v i s i o n , h e a r i n g , b o w e l f u n c t i o n , a n d e a t i n g a b i l i t y ) a r e a l l m e a s u r i n g i n d e p e n d e n t , u n r e l a t e d a s p e c t s o f p h y s i c a l h e a l t h t h a t a r e n o t a d e q u a t e l y r e p r e s e n t e d i n t h e t o t a l a s s e s s m e n t . S i n c e c o g n i t i v e f u n c t i o n i n g , a d a p t i v e b e h a v i o u r , a n d s o c i a l f u n c t i o n i n g i t e m s a l l c o r r e l a t e h i g h l y w i t h t h e t o t a l s c o r e , t h e r e i s some e v i d e n c e t h a t t h e t o t a l i n s t r u m e n t i s w e i g h t e d t o w a r d t h e s e r a t h e r t h a n t o w a r d p h y s i c a l i n d i c e s o f h e a l t h , a n d , i n d e e d , w e r e d e s i g n e d t o do s o . On t h e o t h e r h a n d , m o s t o f t h e i t e m s i n t h e A . D . L . s u b s e c t i o n , c o n s i d e r e d r e f l e c t i v e o f m e n t a l , e m o t i o n a l , a n d p h y s i c a l f a c t o r s , do c o r r e l a t e w i t h t h e t o t a l s c o r e . T h e r e f o r e t h e i t e m s w i t h low c o r r e l a t i o n s may s i m p l y n o t c o n t r i b u t e s i g n i f i -c a n t l y t o a n o v e r a l l m e a s u r e o f w e l l - b e i n g . C o m p a r i s o n o f t h e a s s e s s m e n t s u b s e c t i o n s a n d t o t a l s c o r e s w i t h v a l i d i t y c r i t e r i a may p r o v i d e a d d i t i o n a l i n f o r m a t i o n o n w h i c h t o b a s e t h e d e c i s i o n 48 t o a d d more i t e m s r e l a t i n g t o p h y s i c a l f u n c t i o n i n g o r t o e l i m i n a t e t h o s e c o n t r i b u t i n g l i t t l e t o t h e o v e r a l l s c o r e . T h i s e x a m i n a t i o n o f t h e r e l a t i o n s h i p o f i n d i v i d u a l i t e m s t o t h e s u b s e c t i o n a n d t o t a l s c o r e s p o i n t s t o a h i g h d e g r e e o f i n t e r n a l c o n s i s t e n c y w i t h i n e a c h s u b s e c t i o n , w i t h t h e p o s s i b l e e x c e p t i o n o f t h e p h y s i c a l f u n c t i o n i n g s u b s e c t i o n . A summary o f t h e l e v e l o f i n t e r n a l c o n s i s t e n c y a t t a i n e d by e a c h s u b -s e c t i o n a n d t h e t o t a l a s s e s s m e n t i s p r o v i d e d by H o y t 1 s e s t i m a t e o f r e l i a b i l i t y , a m e a s u r e o f i n t e r n a l c o n s i s t e n c y u s i n g 82 a n a l y s i s - o f - v a r i a n c e t e c h n i q u e s . ( R e p r e s e n t e d i n T a b l e I I ) . Maximum c o n s i s t e n c y , t h e c a s e w h e r e e a c h i t e m i s m e a s u r i n g t h e same t h i n g , p r o d u c e s a c o e f f i c i e n t o f 1, a n d no c o n s i s t e n c y , w h e r e e a c h i t e m i s m e a s u r i n g s o m e t h i n g c o m p l e t e l y d i f f e r e n t , p r o d u c e s a c o e f f i c i e n t o f 0. T h e s u b s e c t i o n c o e f f i c i e n t s r a n g e f r o m 0.49 f o r p h y s i c a l f u n c t i o n i n g t o 0.95 f o r c o g n i t i v e f u n c t i o n i n g . T h e t o t a l a s s e s s m e n t h a s a c o n s i s t e n c y v a l u e o f 8 3 0.93 u s i n g H o y t 1 s m e t h o d a n d 0.73 u s i n g C r o n b a c h ' s A l p h a . S U B S E C T I O N H O Y T ' S E S T I M A T E C R O N B A C H 1 S A L P H A 1) C o g n i t i v e F u n c t i o n i n g 0.95 2) S o c i a l F u n c t i o n i n g 0.79 3) A d a p t i v e B e h a v i o u r 0.81 4) P h y s i c a l F u n c t i o n i n g 0.49 5) A . D . L . 0. 74 6) T o t a l S c o r e 0. 93 0. 73 T A B L E I I : I N T E R N A L C O N S I S T E N C Y OF SUBSECTIONS AND T O T A L ASSESSMENT INSTRUMENT. 49 Component S t r u c t u r e T h e i n t e r n a l s t r u c t u r e o f t h e a s s e s s m e n t was a n a l y z e d b y e x a m i n i n g t h e r e l a t i o n s h i p b e t w e e n s u b s e c t i o n s a n d b e t w e e n t h e s u b s e c t i o n s a n d t h e t o t a l s c o r e , i l l u s t r a t e d i n t h e c o r r e l a t i o n a l m a t r i x ( T a b l e I I I ) . T h e c o g n i t i v e f u n c t i o n i n g , s o c i a l f u n c t i o n i n g , a n d a d a p t i v e b e h a v i o u r s u b s e c t i o n s a r e a l l h i g h l y c o r r e l a t e d w i t h e a c h o t h e r a n d w i t h t h e t o t a l s c o r e . A l t h o u g h t h e s e c o r r e l a t i o n s a r e s p u r i o u s l y h i g h due t o i d e n t i c a l e r r o r s o f m e a s u r e m e n t , t h i s s u g g e s t s t h a t t h e r e i s a d e g r e e o f o v e r l a p i n t h e c o n t e n t o f t h e t h r e e s u b s e c t i o n s . A l t e r n a t i v e l y , t h e same f a c t o r may a c c o u n t f o r t h e v a r i a t i o n i n a l l t h e s u b s e c t i o n s c o r e s . T h e A . D . L . s u b s e c t i o n i s h i g h l y c o r r e l a t e d w i t h t h e t o t a l s c o r e a n d o n l y m o d e r a t e l y w i t h t h e o t h e r s u b s e c t i o n s . T h i s i n d i c a t e s t h a t t h e A . D . L . s e c t i o n c o n t r i b u t e s d i f f e r e n t b u t r e l a t e d i n f o r m a t i o n t o t h e a s s e s s m e n t a n d s u p p o r t s t h e b e l i e f t h a t i t r e f l e c t s m e n t a l , s o c i a l , a n d p h y s i c a l c o m p o n e n t s o f b e h a v i o u r . T h e p h y s i c a l s u b s e c t i o n h a s t h e l o w e s t c o r r e l a t i o n w i t h t h e t o t a l s c o r e ( 0 . 4 ) . H o w e v e r , t h e r e l a t i o n s h i p i s s t i l l h i g h l y s i g n i f i c a n t (P<0.002) s u g g e s t i n g t h a t t h e s u b s e c t i o n i s c o n t r i b u t i n g s u b s t a n t i a l l y t o t h e o v e r a l l s c o r e v a r i a t i o n . T h e f a c t t h a t i t i s o n l y v e r y p o o r l y c o r r e l a t e d w i t h t h e o t h e r 4 s u b s e c t i o n s i n d i c a t e s t h a t i t i s c o n t r i b u t i n g i n f o r m a t i o n t h a t i s i n d e p e n d e n t o f t h e o t h e r m e a s u r e s . F r o m t h i s a n a l y s i s , i t a p p e a r s t h a t t h e i n s t r u m e n t c o n s i s t s o f 3 m a j o r c o m p o n e n t s o r f a c t o r s . I n o r d e r o f i m p o r t a n c e t o t h e t o t a l s c o r e , t h e y a r e : 50 1. a c o g n i t i v e o r b e h a v i o u r a l c o m p o n e n t 2. a c o m p o n e n t r e l a t i n g t o i n d e p e n d e n c e / d e p e n d e n c e i n d a i l y a c t i v i t i e s 3. a p h y s i c a l f u n c t i o n i n g c o m p o n e n t . SUBSECTION COGNITIVE SOCIAL ADAPTIVE PHYSICAL A . D . L TOTAL COGNITIVE 1.00 0.63 0.68 0.13 0.43 0.89 SOCIAL 1.00 0.76 0.36. 0.37 0.83 ADAPTIVE 1.00 0.22 0.40 0.84 PHYSICAL 1.00 0.32 0.40 A . D . L . 1.00 0.64 TOTAL 1.00 T A B L E I I I : C O R R E L A T I O N A L MATRIX OF S U B S E C T I O N AND T O T A L ASSESSMENT S C O R E S . V a l i d i t y C r i t e r i o n - R e l a t e d T h e i n s t r u m e n t ' s r e l a t i o n s h i p t o a number o f o t h e r m e a s u r e s was t e s t e d t o e v a l u a t e i t s v a l i d i t y a s a m e a s u r e o f w e l l - b e i n g / i m p a i r m e n t . P r o b l e m - O r i e n t e d R e c o r d I t was h y p o t h e s i z e d t h a t t h e t o t a l a s s e s s m e n t s c o r e w o u l d be n e g a t i v e l y c o r r e l a t e d w i t h t h e number o f p r o b l e m s l i s t e d o n t h e m u l t i d i s c i p l i n a r y p r o b l e m l i s t . T h e r e s i d e n t s s a m p l e d h a d a n a v e r a g e o f 5 p r o b l e m s l i s t e d o n t h e i r r e c o r d w i t h a r a n g e o f 0 t o 12 a n d a s t a n d a r d 51 deviation of 2.5. The Spearman rank order c o r r e l a t i o n c o e f f i c i e n t was -0.26, supporting the hypothesis at the 0.01 l e v e l of signi f i c a n c e . This indicates that the lower the score on the assessment instrument, the higher the number of problems of a permanent nature found on the medical record. Medication The number of medications prescribed was expected to show an inverse rel a t i o n s h i p to the score on the assessment instrument. The residents received an average of 5 medications each, ranging from 0 to 11 and standard deviation, 2.8. Contrary to the hypothesis, the Spearman rank order c o e f f i c i e n t was 0.13, i n d i c a t i n g no relat i o n s h i p between assessment score and number of medications. However, there was a s i g n i f i c a n t r e l a t i o n s h i p between the number of medications prescribed and the health index scale ( c o e f f i c i e n t 0.39, P<0.003). From t h i s evidence i t seems that the number of medical diagnoses and symptoms provide a better prediction of the number of medications than the individual's o v e r a l l l e v e l of functioning. Health Index Scale The Health Index Scale, being a measure of physical i l l n e s s based on diagnoses and symptoms, was expected to show an inverse r e l a t i o n s h i p to the resident's score on the physical functioning subsection. The average score on the health index was 2 5 with a range of 6 to 4 0 and a standard deviation of 8.6. The Spearman rank order c o e f f i c i e n t for t h i s relationship was -0.25, supporting the hypothesis at the 0.02 l e v e l of signi f i c a n c e . Planned A c t i v i t y Check On the average, each resident 52 was observed to be involved i n structured a c t i v i t y 1.8 times out of 32 observation periods (range from 0 to 11, standard deviation 2.4). Those residents with low leve l s of func-tioning on the assessment instrument were expected to pa r t i c i p a t e less frequently i n structured unit a c t i v i t i e s . Therefore, a po s i t i v e c o r r e l a t i o n was hypothesized between the 2 scores. The rank-order c o e f f i c i e n t s indicated no s i g n i f i c a n t r elationship between the assessment score and resident a c t i v i t y , nor between s o c i a l functioning score and resident a c t i v i t y (coefficients = 0.1 and 0.05 re s p e c t i v e l y ) . The frequency of a c t i v i t y was, however, related to the resident's l e v e l of physical functioning ( c o e f f i c i e n t = 0.23, P<0.05), suggesting that residents are excluded or exclude themselves primarily on the basis of lim i t e d physical capacity. Mental Status Questionnaire This gross measure of mental status using structured resident interviews was compared to s t a f f ratings of cognitive functioning on the assessment instrument. The two scores were expected to show an inverse relationship i n that low scores on the mental status question-naire and high scores on the cognitive functioning subsection indicate good mental performance. The c o r r e l a t i o n c o e f f i c i e n t was -0.65, supporting the hypothesis at the 0.001 l e v e l , thereby i n d i c a t i n g that the cognitive functioning items are indeed v a l i d measures of mental status. V a l i d Aphasia Diagnosis Since some question existed during the pretest of the v a l i d i t y of s t a f f ratings on t h i s 53 i t e m , a c c u r a t e d i a g n o s e s o f a p h a s i a w e r e o b t a i n e d f o r e a c h r e s i d e n t , a n d c o m p a r e d t o t h e s t a f f r a t i n g . I n c o r r e c t r a t i n g s w e r e f o u n d i n 15 o f t h e 75 r a t i n g s . O f t h e 1 5 , 13 w e r e r a t e d as h a v i n g some f o r m o f a p h a s i a when t h e y d i d n o t , a n d 2 w e r e r a t e d as h a v i n g no a p h a s i a when t h e y h a d b e e n d i a g n o s e d e x p r e s s i v e a p h a s i c . A l t h o u g h 8 0 p e r c e n t o f t h e r a t i n g s a r e v a l i d , t h e p o o r d i s c r i m i n a t i n g p o w e r o f t h e i t e m i n s c a l e f o r m s u g g e s t s t h a t i t s h o u l d be e x c l u d e d f r o m t h e s u b s e c t i o n a n d t r e a t e d as a s e p a r a t e y e s / n o i t e m t o b e . i n c l u d e d w i t h o t h e r i d e n t i f y i n g i n f o r m a t i o n a t t h e b e g i n n i n g o f t h e a s s e s s -ment f o r m . P r e d i c t i v e V a l i d i t y A s t e p - w i s e d i s c r i m i n a n t f u n c t i o n a n a l y s i s was p e r f o r m e d u s i n g t h e r e s i d e n t s ' s c o r e s on t h e 5 s u b s e c t i o n s t o p r e d i c t d e a t h . E a c h s u b s e c t i o n was e n t e r e d a n d t h o s e m i n i m i z i n g t h e u n e x p l a i n e d v a r i a t i o n w e r e r e t a i n e d t o f o r m a d i s c r i m i n a n t f u n c t i o n . (See A p p e n d i x I ) . A d i s c r i m i n a n t f u n c t i o n i s a r e g r e s s i o n e q u a t i o n w i t h a d e p e n d e n t v a r i a b l e t h a t r e p r e s e n t s 84 . . g r o u p m e m b e r s h i p . S c o r e s o n t h e s u b s e c t i o n s c o g n i t i v e f u n c t i o n i n g a n d A . D . L . w e r e f o u n d t o p r o v i d e t h e b e s t p r e d i c t i o n o f g r o u p m e m b e r s h i p (dead o r a l i v e ) a n d w e r e c o m b i n e d t o p r o -d u c e one d i s c r i m i n a n t f u n c t i o n e q u a t i o n . T h e a d d i t i o n o f o t h e r s u b s e c t i o n s c o r e s d i d n o t s i g n i f i c a n t l y i m p r o v e p r e d i c t i v e a b i l i t y so w e r e n o t i n c l u d e d . T h e e q u a t i o n , w h i c h i n c l u d e d c o g n i t i v e f u n c t i o n i n g a n d A . D . L . s u b s e c t i o n s c o r e s , was t h e n u s e d t o a s s i g n r e s i d e n t s t o groups. The discriminant function was able to c o r r e c t l y predict 72 percent of the sample population, i n d i c a t i n g that i t i s a v a l i d measure of the person's well-being. It further indicates that cognitive functioning and independence i n d a i l y a c t i v i t i e s are better predictors of death than physical functioning. In t h i s sample, cognitive functioning scores were p o s i t i v e l y correlated with death and A.D.L. negatively, meaning that those with high l e v e l s of mental functioning and who were dependent i n A.D.L. were most l i k e l y to die. This i s a curious finding and contrary to previous research that 85 suggests a drop i n i n t e l l i g e n c e predicts imminent death. However, t h i s assessment was taken once and i s not a measure of change. Also, the residents i n t h i s sample do not include those who have very low l e v e l s of i n t e l l e c t u a l functioning. The addition of such subjects may a l t e r the predictive nature of t h i s subsection. At present, the data are based on 12 deaths out of a sample of 76 (4 men, 8 women). A larger sample would increase the power of the discriminant function. Also, the technique employed i n the analysis i s necessarily only preliminary. The derived equation would need to be applied to a new sample of residents to confirm i t s v a l i d i t y . The fact that a l l but 2 of the deaths occurred within 3 to 9 months of admission suggests the p o s s i b i l i t y that the deaths may be related to relocation. The combination of early post-admission death, high cognitive and low A.D.L. functioning 55 may be e v i d e n c e o f w h a t S c h m a l e , E n g e l a n d o t h e r s t e r m t h e ' g i v i n g - u p , g i v e n - u p 1 s y n d r o m e . T h i s phenomenon i s c h a r a c -t e r i z e d by f e e l i n g s o f h e l p l e s s n e s s a n d h o p e l e s s n e s s a n d was f i r s t r e c o g n i z e d i n r e l a t i o n t o c o n c e n t r a t i o n c a m p s . T h e s e f e e l i n g s w e r e s e e n b y t h e a u t h o r s t o be a p s y c h o l o g i c a l s e t 86 8 7 t h a t p r e c e d e d b o t h p h y s i c a l a n d p s y c h i a t r i c d i s o r d e r s . ' I t i s w e l l - k n o w n t h a t a d m i s s i o n t o a l o n g t e r m c a r e f a c i l i t y i s o f t e n p e r c e i v e d as t h e b e g i n n i n g - o f - t h e - e n d b y a n e l d e r l y 8 8 p e r s o n . P e r h a p s t h o s e w i t h h i g h m e n t a l f u n c t i o n i n g a b i l i t i e s who a r e u n a b l e t o c a r e f o r t h e m s e l v e s a n d a r e , t h e r e f o r e , m o s t d e p e n d e n t o n o t h e r s , s u f f e r m o s t s e v e r e l y . A l t h o u g h much m o r e e v i d e n c e i s n e e d e d , t h i s d o e s p r o v i d e some t e n t a t i v e s u p p o r t f o r w h a t many n u r s e s h a v e f e l t i n t u i t i v e l y . S e n s i t i v i t y A n a l y s i s o f t h e i n s t r u m e n t ' s a b i l i t y t o d e t e c t c h a n g e was made by c o m p a r i n g t h e d i f f e r e n c e i n t h e r e s i d e n t ' s s c o r e s o v e r 9 m o n t h s t o t h e n u r s e c o - o r d i n a t o r ' s a n d t h e r e s i d e n t ' s a s s e s s m e n t o f o v e r a l l c h a n g e . T h e s a m p l e was d i v i d e d i n t o 3 g r o u p s a c c o r d i n g t o w h e t h e r t h e y h a d b e e n r a t e d i m p r o v e d , d e t e r i o r a t e d , o r t h e same. T h e c h a n g e i n s c o r e f o r e a c h g r o u p was a n a l y z e d u s i n g O n e - w a y a n a l y s i s - o f - v a r i a n c e . T h e r e s u l t s a r e r e p o r t e d i n A p p e n d i x J . T h e n u r s e c o - o r d i n a t o r s ' r a t i n g o f o v e r a l l c h a n g e f o l l o w e d t h e p a t t e r n o f a s s e s s m e n t s c o r e d i f f e r e n c e s more c l o s e l y t h a n t h e r e s i d e n t s ' r a t i n g o f c h a n g e . H o w e v e r , n e i t h e r r e l a t i o n s h i p r e a c h e d s i g n i f i c a n c e (P>0.1). 56 I n t e r e s t i n g l y , t h e n u r s e c o - o r d i n a t o r s a n d t h e e l d e r l y r e s i d e n t s r e a c h e d a g r e e m e n t o n t h e d i r e c t i o n o f c h a n g e o n l y 4 0 p e r c e n t o f t h e t i m e , w i t h t h e n u r s e s t e n d i n g t o s e e m o r e i m p r o v e m e n t t h a n t h e i n d i v i d u a l s t h e m s e l v e s . (A d e t a i l e d c o m p a r i s o n o f t h e s e r a t i n g s i s f o u n d i n A p p e n d i x K . ) T h e two g r o u p s o b v i o u s l y h a v e v e r y d i f f e r e n t p e r s p e c t i v e s o n w e l l - b e i n g . The n u r s e may be f o c u s s i n g o n p h y s i c a l p a r a m e t e r s a n d t h e a g e d p e r s o n o n q u a l i t y - o f - l i f e p a r a m e t e r s . T h e p e r c e i v e d l a c k o f i m p r o v e m e n t may be an i n d i c a t i o n o f t h e h o p e l e s s n e s s o f t h e i n s t i t u t i o n a l i z e d e l d e r l y p r e v i o u s l y d i s c u s s e d . F r o m t h e n u r s e s ' s t a n d p o i n t , c l i e n t i m p r o v e m e n t may be n e c e s s a r y t o j o b s a t i s f a c t i o n a n d f e e l i n g s o f c o m p e t e n c y . T h i s may l e a d t o an o v e r l y - o p t i m i s t i c r a t i n g o f p r o g r e s s . T h e f a c t o r s i n v o l v e d i n t h e p e r c e p t i o n o f c h a n g e by b o t h g r o u p s a r e v e r y c o m p l e x . W h e t h e r e i t h e r i s a v a l i d m e a s u r e a g a i n s t w h i c h t o t e s t t h e s e n s i t i v i t y o f t h e a s s e s s m e n t i n s t r u m e n t i s d e b a t a b l e . On t h e b a s i s o f t h i s a n a l y s i s , i t c a n o n l y b e c o n c l u d e d t h a t t h e a s s e s s m e n t i s n o t s e n s i t i v e t o c h a n g e a s i t i s p e r c e i v e d by t h e n u r s e c o - o r d i n a t ' o r o r t h e e l d e r l y i n d i v i d u a l . Chapter V CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS Conclusions A short, p r a c t i c a l assessment instrument has been developed based on the observations of long term care s t a f f that has demonstrated r e l i a b i l i t y and v a l i d i t y i n an extended care unit. Of course, the study was conducted i n only one f a c i l i t y with a sample that excluded mentally-impaired i n d i -viduals. As such, the r e s u l t s cannot be generalized to other settings or groups of e l d e r l y . However, the high r e l i a b i l i t y of ratings obtained i n the study setting i s p a r t i c u l a r l y encouraging i n the l i g h t of previous research reports of low 89 90 agreement among s t a f f nurse ratings of behaviour. ' One area of concern i s the high degree of i n t e r c o r r e l a t i o n among the ten items measuring cognitive functioning. A very high i n t e r c o r r e l a t i o n suggests that a l l the items are measuring the same thing and there i s no d i s t i n c t i o n between the various processes as ennumerated i n the instrument. However, t h i s i s contrary to current gerontological l i t e r a t u r e which states that a l l mental functions usually are not l o s t simultaneously or globally and that remaining strengths often can be used 91 92 to support other f a i l i n g processes. ' This leads to 57 58 s p e c u l a t i o n t h a t t h e s t a f f r a t e r s w e r e u n a b l e t o d i f f e r e n t i a t e among t h e v a r i o u s a s p e c t s o f f u n c t i o n i n g a n d a r e c o n t i n u i n g t o p e r c e i v e c o g n i t i v e b e h a v i o u r i n g l o b a l t e r m s . A d d i t i o n a l i n v e s t i g a t i o n i s n e e d e d b e f o r e t h e i t e m s i n t h e s u b s e c t i o n a r e a l t e r e d o r c o m p r e s s e d f u r t h e r . T h e i n t e r r e l a t i o n s h i p o f t h e v a r i o u s d i m e n s i o n s o f w e l l - b e i n g a r e i l l u s t r a t e d i n t h e s t u d y r e s u l t s , p a r t i c u l a r l y i n r e l a t i o n t o t h e h i g h i n t e r n a l c o n s i s t e n c y a t t a i n e d . A s m i g h t be e x p e c t e d , t h e w i d e s t d i v e r g e n c e a n d t h e l e a s t r e l a t i o n s h i p o c c u r r e d b e t w e e n c o g n i t i v e a n d p h y s i c a l f u n c t i o n i n g w i t h i n d e p e n d e n c e i n A . D . L . s i g n i f i c a n t l y r e l a t e d t o b o t h . T h i s s u p p o r t s t h e b e l i e f t h a t A . D . L . r e f l e c t s b o t h m e n t a l a n d p h y s i c a l a b i l i t i e s a s w e l l a s a number o f e n v i r o n m e n t a l f a c t o r s . D a t a a n a l y s i s s u g g e s t e d t h a t t h e r e may be a n e e d f o r a d d i t i o n a l i t e m s t o i n c r e a s e t h e c o n t r i b u t i o n o f p h y s i c a l f u n c t i o n i n g t o t h e o v e r a l l a s s e s s m e n t s c o r e . T h e p o o r p r e -d i c t i v e p o w e r o f t h i s s u b s e c t i o n a l s o i n d i c a t e s t h a t i t may n o t be a d e q u a t e l y r e p r e s e n t i n g t h o s e p h y s i c a l p a r a m e t e r s t h a t a r e s i g n i f i c a n t t o h e a l t h . H o w e v e r , c o r r e l a t i o n s b e t w e e n t h e i n s t r u m e n t a n d v a l i d i t y c r i t e r i a d i d n o t p r o v i d e d i r e c t i o n f o r t h e a d d i t i o n o f s u c h i t e m s . A l s o , no a t t e m p t was made t o a d j u s t t h e s c o r e s o v e r t h e 5 s u b s e c t i o n s a t t h i s t i m e . A l t h o u g h s u g g e s t i v e e v i d e n c e h a s b e e n p r o v i d e d , t h e r e l a t i v e s i g n i f i c a n c e o f e a c h o f t h e d i m e n s i o n s t o t h e p e r s o n ' s w e l l -b e i n g h a s n o t b e e n e s t a b l i s h e d a d e q u a t e l y . O t h e r r e s e a r c h e r s h a v e f o u n d , i n s i m i l a r c i r c u m s t a n c e s , t h a t a t t e m p t s t o w e i g h t s p e c i f i c s e c t i o n s h a v e n o t c h a n g e d r e s u l t s s i g n i f i c a n t l y n o r 59 a d d e d t o t h e v a l i d i t y o f t h e i n s t r u m e n t . ^ P e r h a p s t h e m o s t s i g n i f i c a n t f i n d i n g f r o m t h e d a t a a n a l y s i s i s t h e r e l a t i o n s h i p b e t w e e n h i g h c o g n i t i v e f u n c t i o n i n g , h i g h l e v e l s o f d e p e n d e n c y a n d d e a t h . A s m e n t i o n e d , t h i s may r e p r e s e n t a l o s s o f hope a n d a " g i v i n g u p , " by e l d e r l y i n d i -v i d u a l s e v e n t o t h e p o i n t o f w i l l i n g d e a t h . T h e i m p l i c a t i o n s o f t h i s a n d o t h e r f i n d i n g s a r e d i s c u s s e d b e l o w . I m p l i c a t i o n s a n d R e c o m m e n d a t i o n s The s t u d y r e s u l t s h a v e c o n f i r m e d t h a t n u r s i n g s t a f f w i t h i n a l o n g t e r m c a r e f a c i l i t y a r e a b l e t o p r o v i d e e c o n o m i -c a l l y b o t h a n a c c u r a t e a n d c o n s i s t e n t a s s e s s m e n t o f t h e e l d e r l y i n d i v i d u a l s w i t h whom t h e y come i n c l o s e c o n t a c t . T h e i n f o r m a t i o n , s o p r o v i d e d , h a s v a s t p o t e n t i a l u s e i n l o n g t e r m c a r e . T h e a s s e s s m e n t c a n be d u p l i c a t e d a t d i f f e r e n t t i m e p e r i o d s , m a k i n g i t p o s s i b l e t o i d e n t i f y a n d a n a l y z e i n d i v i d u a l c h a n g e s w i t h a min imum o f b i a s a n d e r r o r . T h i s , i n t u r n , p r o v i d e s t h e b a s i s f o r e v a l u a t i o n o f p r o g r e s s a n d e f f e c t i v e n e s s o f s p e c i f i c i n t e r v e n t i o n s . C o m p a r i s o n s c a n be made b e t w e e n i n d i v i d u a l s , g r o u p s , p r o v i d e r s , a n d t r e a t m e n t m e t h o d s . P r o g r a m s a n d b r o a d t h e r a p e u t i c a p p r o a c h e s , s u c h as r e a l i t y o r i e n t a t i o n , c a n be e m p i r i c a l l y t e s t e d o n t h e b a s i s o f a c c u r a t e o u t c o m e m e a s u r e s r a t h e r t h a n i n t u i t i v e i m p r e s s i o n s o f s u c c e s s . A g g r e g a t e d a t a o n t h e w e l l - b e i n g o f t h e e l d e r l y i n d i v i d u a l c a n a l s o be u s e d f o r a d m i n i s t r a t i v e p l a n n i n g a n d e v a l u a t i o n p u r p o s e s , p a r t i c u l a r l y i n t h e a p p r o p r i a t e a l l o c a t i o n o f r e s o u r c e s a n d s e r v i c e s . 60 However, before these uses can be contemplated, further research i s needed to esta b l i s h the instrument's r e l i a b i l i t y and v a l i d i t y i n other settings and with other groups of eld e r l y , including those who are severely mentally impaired. In addition, s t a f f ratings of cognitive functioning need to be examined very c a r e f u l l y . I f the ratings do r e f l e c t an inadequate l e v e l of awareness and knowledge of the person's functioning, then i t follows that l i t t l e or no attempt i s being made to c a p i t a l i z e on remaining mental strengths or to compensate for areas of loss . Without such important i n t e r -ventions we are providing l i t t l e more than custodial care. The connection between mental a b i l i t y , dependency and death., also warrants further investigation. However, even the tentative evidence that has emerged from t h i s study should be s u f f i c i e n t to increase e f f o r t s at promoting maximum independence i n the el d e r l y . I n a b i l i t y of the nursing s t a f f to i d e n t i f y s p e c i f i c functional a b i l i t i e s i n the a c t i v i t i e s of d a i l y l i v i n g , noted early i n the study, again suggests a lack of systematic r e h a b i l i t a t i v e e f f o r t . Others have found that, not only are such programs frequently absent i n long term care, but s t a f f have a tendency to "do for" the aged person, thereby undermining any remaining c a p a b i l i t i e s they might have and creating an a r t i f i c i a l l y high l e v e l of 94 dependency. Considering the possible re l a t i o n s h i p between dependency and death, these a c t i v i t i e s have very ominous implications. This study has made a beginning at i d e n t i f y i n g and 61 v e r i f y i n g the e s s e n t i a l assessment information relevant to the aged i n d i v i d u a l i n a long term care setting. It has also been able to demonstrate the potential value such information could have i n the f i e l d of gerontology. Much more work i s now needed to expand the application of the instrument to other groups and to determine the r e l a t i v e significance of the various dimensions of well-being. If the predictive power of cognitive functioning and dependency i n d a i l y l i v i n g i s v e r i f i e d , the goals and o v e r a l l approach to long term care w i l l have to be reconsidered with greater p r i o r i t y being given to r e h a b i l i t a t i v e and q u a l i t y of l i f e issues. NOTES "'"H. W e a v e r , M . M c P h e e , a n d P . L a m b e r t , G e r i a t r i c s R e p o r t ( V a n c o u v e r , B . C . : V a n c o u v e r H o s p i t a l D i s t r i c t , 1 9 7 5 ) , p . 5 . 2 S . B l a n d , " L o n g T e r m C a r e P r o g r a m f o r B . C . , " R e g i s t e r e d N u r s e s ' A s s o c i a t i o n o f B . C . M e e t i n g , S h a u g h n e s s y H o s p i t a l , N o v e m b e r , 19 7 7 . ^ W e a v e r , p . 6. W e a v e r , p . 5 . 5 " L o n g T e r m C a r e D a t a , " P r o c . o f a C o n f e r e n c e o n L o n g T e r m H e a l t h C a r e D a t a h e l d a t T u c s o n , A r i z o n a , 1 2 - 1 6 M a y , 1 9 7 5 , M e d i c a l C a r e , 1 4 , N o . 5 ( 1 9 7 6 ) , l - 2 3 0 , : B . M . G r e e n b e r g , " M e d i c a l M o d e l - N u r s i n g M o d e l : A G e r o n t o l o g i c a l D i l e m m a , " J o u r n a l o f G e r o n t o l o g i c a l N u r s i n g , 1, N o . 4 ( 1 9 7 4 ) , p p . 6 - 8 . 7 M e d i c a l C a r e , p . x i i . g M e d i c a l C a r e , p . 1 0 . 9 M . P . L a w t o n , " C o p i n g B e h a v i o u r a n d t h e E n v i r o n m e n t o f O l d P e o p l e , " i n P r o f e s s i o n a l O b l i g a t i o n s a n d A p p r o a c h e s t o  t h e E l d e r l y , e d . A . S c h w a r t z a n d I . M e n s h ( S p r i n g f i e l d : C h a r l e s T h o m a s , 1 9 7 4 ) , p . 6 0 . 1 ( ^ M . F . L o w e n t h a l a n d A . S i m o n , " M e n t a l C r i s e s a n d I n s t i t u t i o n a l i z a t i o n Among t h e A g e d , " J o u r n a l o f G e r i a t r i c  P s y c h i a t r y , 4 , N o . 1 ( 1 9 7 0 ) , p . 1 6 5 . " ^ L o w e n t h a l , p . 16 7. 12 M . 0 . W o l a n i n , " C o n f u s i o n i n t h e E l d e r l y , " G e r o n t o -l o g i c a l S o c i e t y M e e t i n g , F l o r i d a , N o v e m b e r , 1 9 7 3 . 13 H . H a r r i s , A . L i p m a n , a n d R. S l a t e r , " A r c h i t e c t u r a l D e s i g n : T h e S p a t i a l L o c a t i o n a n d I n t e r a c t i o n s o f O l d P e o p l e , " G e r o n t o l o g i s t , 23 ( 1 9 7 7 ) , p . 3 9 0 . 14 H a r r i s , p . 3 9 1 . 15 I . B u r n s i d e , N u r s i n g a n d t h e A g e d (New Y o r k : M c G r a w -H i l l , 1 9 7 6 ) , p . 1 5 7 . 62 63 16 U . B r a n t 1 a n d M . R . B r o w n , e d . , R e a d i n g s i n G e r o n t o l o g y (New Y o r k : C . V . M o s b y , 1 9 7 3 ) , p . 2 3 . 17 C . E x s d o r f e r a n d M . P . L a w t o n , e d . , T h e P s y c h o l o g y o f  A d u l t D e v e l o p m e n t a n d A g i n g ( W a s h i n g t o n , D . C . : A m e r i c a n P s y c h o l o g i c a l A s s o c i a t i o n , 1 9 7 3 ) . 18 L . M . G u n t e r a n d J . C . M i l l e r , " T o w a r d a N u r s i n g G e r o n t o l o g y , " N u r s i n g R e s e a r c h , 26 ( J u n e , 1 9 7 7 ) , p p . 2 0 8 - 2 2 0 . 19 S . L . R o b e r t s , " C a r d i o p u l m o n a r y A b n o r m a l i t i e s i n A g i n g , " i n N u r s i n g a n d t h e A g e d , I . B u r n s i d e (New Y o r k : M c G r a w - H i l l , 1 9 7 6 ) , p p . 2 8 6 - 3 1 6 . 20 M . K . L a u r e n c e , " P r i n c i p l e s a n d P r a c t i c e s o f M i l i e u T h e r a p y w i t h t h e E l d e r l y , " C a n a d i a n A s s o c i a t i o n o f G e r o n t o l o g y M e e t i n g , V a n c o u v e r , B . C , N o v e m b e r , 1 9 7 6 . 21 L a w t o n , C o p i n g B e h a v o u r s , p . 76 . 22 S . T o b m a n d M . L i e b e r m a n , L a s t Home f o r t h e A g e d (San F r a n c i s c o : J o s s e y - B a s s , 1 9 7 6 ) . 23 P . P . E b e r s o l e , " D e v e l o p m e n t a l T a s k s i n L a t e L i f e , " i n N u r s i n g a n d t h e A g e d , I . B u r n s i d e (New Y o r k : M c G r a w - H i l l , 1 9 7 6 ) , p p . 6 9 - 8 0 . 24 A . S c h w a r t z a n d I . M e n s h , P r o f e s s i o n a l O b l i g a t i o n s a n d  A p p r o a c h e s t o t h e A g e d ( S p r i n g f i e l d : C h a r l e s T h o m a s , 1 9 7 4 ) , p . 6. 25 J . B i r r e n , " P s y c h o l o g i c a l A s p e c t s o f A g i n g , " i n A g i n g  i n A m e r i c a , e d . C . K a r t a n d B . M a n a r d (New Y o r k : A l f r e d 1 9 7 6 ) , p . 1 9 0 . 2 6 E . B u s s e a n d E . P f e i f f e r , B e h a v i o u r a n d A d a p t a t i o n i n  L a t e L i f e ( B o s t o n : L i t t l e B r o w n , 1 9 6 9 ) . 27 M . P . L a w t o n , " F u n c t i o n a l A s s e s s m e n t o f t h e E l d e r l y P a t i e n t , " i n R e a d i n g s i n G e r o n t o l o g y , e d . U . B r a n t l a n d M . R . Brown (New Y o r k : C . V . M o s b y , 19 7 3 ) , p . 4 3 . 2 8 C . E i s d o r f e r , " D e v e l o p m e n t a l L e v e l s a n d S e n s o r y I m p a i r m e n t i n t h e A g e d , " J o u r n a l o f P r o j e c t i v e T e c h n i q u e s , 24 ( 1 9 6 5 ) , p p . 1 2 9 - 1 3 2 . 29 L . A . P a s t a l a n a n d D . H . C a r s o n , e d . S p a t i a l B e h a v i o u r  o f O l d e r P e o p l e (Ann A r b o r , M i c h . : U n i v e r s i t y o f M i c h i g a n P r e s s , 1 9 7 0 ) . 30 I . B u r n s i d e , " D e p r e s s i o n a n d S u i c i d e i n t h e E l d e r l y , " i n N u r s i n g a n d t h e A g e d , I . B u r n s i d e (New Y o r k : M c G r a w - H i l l , 1 9 7 6 ) , p p . 1 6 5 - 1 8 1 . 64 31 T o b i n a n d L i e b e r m a n , p . 100. 32 R . C . A t c h l e y , T h e S o c i a l F o r c e s i n L a t e r L i f e ( C a l i f o r n i W a d s w o r t h , 1972), p . 127. 3 3 A . W h a n g e r a n d P . L e w i s , " S u r v e y o f I n s t i t u t i o n a l i z e d E l d e r l y , " i n M u l t i d i m e n s i o n a l F u n c t i o n a l A s s e s s m e n t : Th e OARS  M e t h o d o l o g y , E . P f e i f f e r (Durham: Duke U n i v e r s i t y , 1975) , p . 2 34 F . N . K e r b i n g e r , F o u n d a t i o n s o f B e h a v i o u r a l R e s e a r c h (New Y o r k : H o l t , R i n e h a r t a n d W i n s t o n , 1964), p . 538. 35 R . K a s t e n b a u m a n d S . S h e r w o o d , " V I R O : A S c a l e f o r A s s e s s i n g t h e I n t e r v i e w B e h a v i o u r o f E l d e r l y P e o p l e , " i n R e s e a r c h , P l a n n i n g a n d A c t i o n f o r t h e E l d e r l y , e d . D . K e n t , R. K a s t e n b a u m , a n d S . S h e r w o o d (New Y o r k : B e h a v i o u r a l . P u b l . , 1972), p p . 144-165. 3 6 R. B . E l l s w o r t h , MACC B e h a v i o u r a l A d j u s t m e n t S c a l e ( C a l i f o r n i a : W e s t e r n P s y c h o l o g y S e r v i c e s , 1962) , p . 14. 37 R . B . E l l s w o r t h a n d W. H . C l a y t o n , " M e a s u r e m e n t o f I m p r o v e m e n t i n M e n t a l I l l n e s s , " J o u r n a l o f C o n s u l t i n g P s y c h o - l o g y , 23 (1957), p p . 15-20. 3 8 E l l s w o r t h a n d C l a y t o n , p . 15. 39 G . H o n i g f e l d a n d J . K l e t t , "The N u r s e s ' O b s e r v a t i o n S c a l e f o r I n p a t i e n t E v a l u a t i o n , " J o u r n a l o f C l i n i c a l P s y c h o l o g y , 21 (1965), p p . 65-71. 40 A . P i n t o a n d E . D e R o s a , NOSIE-30: P r o g r a m m e d I n s t r u c t i o n ( M a r y l a n d : (1977)). 41 M . L . M a c D o n a l d , "The F o r g o t t e n A m e r i c a n s : A S o c i o -l o g i c a l A n a l y s i s o f A g i n g a n d N u r s i n g H o m e s , " A m e r i c a n J o u r n a l  o f C o m m u n i t y P s y c h o l o g y , 1, N o . 3 (1973), p p . 272-291. 42 B . F . T u r n e r , S . T . S h e l d o n , a n d M . L i e b e r m a n , " P e r s o n a l i T r a i t s a s P r e d i c t o r s o f I n s t i t u t i o n a l ! A d a p t a t i o n Among t h e E l d e r l y , " J o u r n a l o f G e r o n t o l o g y , 21 (1966), p . 392. 4 3 H o n i g f e l d a n d K l e t t , p . 69. 44 A . W o l p e r t , C . S h e p p a r d , a n d S . M e r l i s , " M e t h o d o f E v a l u a t i n g B e h a v i o u r a l C h a n g e s i n A g e d H o s p i t a l P a t i e n t s D u r i n g A n a b o l i c T h e r a p y , " J o u r n a l o f A m e r i c a n G e r i a t r i c s S o c i e t y , 15 (1967), p p . 470-473. 4 5 B . M e e r a n d J . B a k e r , "The S t o c k t o n G e r i a t r i c R a t i n g S c a l e , " J o u r n a l o f G e r o n t o l o g y , 21 (1966), p . 392. 65 46 R . P l u t c h i k , H . C o m t e , M . L i e b e r m a n , M . B a k e r , J . G r o s s m a n , a n d N . L e h r m a n , " R e l i a b i l i t y a n d V a l i d i t y o f a s c a l e f o r A s s e s s i n g t h e F u n c t i o n i n g o f G e r i a t r i c P a t i e n t s , " J o u r n a l o f A m e r i c a n G e r i a t r i c s S o c i e t y , 1 8 , N o . 6 ( 1 9 7 0 ) , p p . 4 9 1 - 4 9 6 . 47 B . S . L i n n , M . W. L i n n , a n d L . G u r e l , " C u m u l a t i v e I l l n e s s R a t i n g S c a l e , " J o u r n a l o f A m e r i c a n G e r i a t r i c s S o c i e t y , 1 6 , N o . 5 ( 1 9 6 8 ) , p p . 6 2 2 - 6 2 6 . 48 * H . A . R o s e n c r a n z a n d C . T . P i h l b l a d , " M e a s u r i n g t h e H e a l t h o f t h e E l d e r l y , " J o u r n a l o f G e r o n t o l o g y , 2 5 , N o . 2 ( 1 9 7 0 ) , p p . 1 2 9 - 1 3 3 . 49 A . Waldman a n d E . F r y m a n , " C l a s s i f i c a t i o n i n Homes f o r t h e A g e d , " i n G e r i a t r i c I n s t i t u t i o n a l M a n a g e m e n t , e d . H . S h o r e a n d M . L e e d s (New Y o r k : P u t n a m , 1 9 6 4 ) , p p . 1 3 1 - 1 3 5 . 50 M . L i n n , "A R a p i d D i s a b i l i t y R a t i n g S c a l e , " J o u r n a l o f  G e r o n t o l o g y , 1 5 , N o . 2 , ( 1 9 6 7 ) , p p . 2 1 1 - 2 1 4 . "*^"J. A . Goga a n d W. O . H a m b a c h e r , " P s y c h o l o g i c a n d B e h a v i o u r a l A s s e s s m e n t s o f G e r i a t r i c P a t i e n t s : A R e v i e w , " J o u r n a l o f A m e r i c a n G e r i a t r i c s S o c i e t y , 2 5 , N o . 5 ( 1 9 7 7 ) , p p . 2 32-2 37 . 52 S . K a t z , T . D . D a u n s , H . R. C a s h , a n d R . C . G r o t z , " P r o g r e s s i n D e v e l o p m e n t o f t h e I n d e x o f A D L , " G e r o n t o l o g i s t , 1 0 , N o . 20 ( 1 9 7 0 ) . 53 M . F . L o w e n t h a l , L i v e s i n D i s t r e s s (New Y o r k : B a s i c B o o k s , 1 9 6 4 ) . 54 L . G u r e l , M . L i n n , a n d B . L i n n , " P h y s i c a l a n d M e n t a l I m p a i r m e n t o f F u n c t i o n E v a l u a t i o n i n t h e E l d e r l y , " J o u r n a l  o f G e r o n t o l o g y , 2 7 , N o . 1 ( 1 9 7 2 ) , p p . 8 3 - 9 0 . 55 E . B r o d y , M . K l e e b a n , M . P . L a w t o n , a n d M . M o s s , "A L o n g i t u d i n a l L o o k a t E x c e s s D i s a b i l i t i e s i n M e n t a l l y I m p a i r e d E l d e r l y , " J o u r n a l o f G e r o n t o l o g y , 2 9 , N o . 1 ( 1 9 7 4 ) , p p . 7 9 - 8 4 . 56 P . S a l m o n , J . M . A t t h o w e , a n d M . R . H a l l o c k , R A P I D S : A  M e t h o d o f C l a s s i f y i n g P a t i e n t s R e c e i v i n g L o n g T e r m C a r e (San M a t e o C o u n t y , C a l i f . : D e p t . o f H e a l t h & W e l f a r e , 1 9 6 7 ) . 57 B . B u r r a c k , " I n t e r d i s c i p l i n a r y C l a s s i f i c a t i o n f o r t h e A g e d , " J o u r n a l o f C h r o n i c D i s e a s e s , 1 8 , N o . 5 ( 1 9 6 5 ) , p p . 1 0 5 9 - 1 0 6 4 . 5 8 R . W. A s h t o n , "An I n t e g r a t e d P a t i e n t C l a s s i f i c a t i o n S y s t e m a n d N u r s i n g A c t i v i t y S t u d y i n a n E x t e n d e d C a r e F a c i l i t y , " D i s s . H a r v a r d , 1 9 6 8 . 59 M . S h a u g h n e s s y , G . O ' B r i e n , T . F i t z p a t r i c k , a n d S . G r o v e , An A p p r o a c h t o D e t e r m i n i n g t h e N u r s i n g N e e d s o f N u r s i n g Home  P a t i e n t s ( B o s t o n : S c h o o l o f N u r s i n g , 1 9 6 8 ) . 66 E . W. J o n e s , B . J . M c N i t t , a n d E . M . M c K n i g h t , P a t i e n t  C l a s s i f i c a t i o n f o r L o n g T e r m C a r e ; U s e r ' s M a n u a l ( H a r v a r d M e d i c a l S c h o o l , B u r e a u o f H e a l t h S e r v i c e s R e s e a r c h , 1 9 7 3 ) . 61 S . S h e r w o o d , e d . , L o n g T e r m C a r e (New Y o r k : S p e c t r u m , 1 9 7 5 ) , p . 2 8 . 6 2 E . B r o d y , " B a s i c D a t a R e q u i r e m e n t s f o r G e r i a t r i c I n s t i t u t i o n s a n d S e r v i c e s , " M e d i c a l C a r e , 1 4 , N o . 5 ( 1 9 7 6 ) , p p . 6 0 - 7 0 . J o n e s , p . 5 2 . 64 B i r r e n , p . 1 9 0 . 65 B u s s e a n d P f e i f f e r , p . 1 0 0 . ^ K e r l i n g e r , p . 5 4 7 . 6 7 K e r l i n g e r , p . 54 8. 6 8 F . A b d e l l a h a n d E . L e v i n e , B e t t e r P a t i e n t C a r e T h r o u g h N u r s i n g R e s e a r c h (New Y o r k : M a c M i l l a n , 1 9 6 5 ) , p . 240 . 69 K e r l i n g e r , p . 5 4 9 . 70 J . C a m p b e l l , " B e h a v i o u r a l I n t e r v e n t i o n i n t h e R e h a b i l i -t a t i o n o f t h e E l d e r l y : a n E c o l o g i c a l A p p r o a c h , " C a n a d i a n A s s o c i a t i o n o f G e r o n t o l o g y M e e t i n g , V a n c o u v e r , November 1 3 , 1 9 7 6 . 71 J . W i l l i s a n d D . L a w s o n , " P r e d i c t i o n a n d P r e p a r a t i o n i n t h e R e l o c a t i o n o f t h e E l d e r l y , " B r i t i s h C o l u m b i a , V a n c o u v e r ( N a t i o n a l H e a l t h a n d W e l f a r e G r a n t : i n p r o g r e s s ) . 72 J . G u i l f o r d , P s y c h o m e t r i c M e t h o d s , 2nd e d . (New Y o r k : M c G r a w - H i l l , 1 9 5 4 ) , c h a p . 1 6 . 73 L . L . Weed , M e d i c a l R e c o r d s , M e d i c a l E d u c a t i o n a n d  P a t i e n t C a r e ( C h i c a g o : Y e a r b o o k M e d i c a l , 1 9 7 1 ) . 74 R o s e n c r a n z a n d P i h l b l a d . 75 L i n n , L i n n , a n d G u r e l . 7 6 G . L a b o u r i e - V i e f , W. J , H a y e r , a n d B . B a l t e s , " O p e r a n t A n a l y s i s o f I n t e l l e c t u a l B e h a v i o u r i n O l d A g e , " Human D e v e l o p m e n t , 1 7 , N o . 5 ( 1 9 7 4 ) , p p . 2 5 9 - 2 7 2 . 77 R . L . K a h n , A . I . G o l d f a r b , M . P o l l a c k , a n d A . P e c k , " B r i e f O b j e c t i v e M e a s u r e s f o r t h e D e t e r m i n a t i o n o f M e n t a l S t a t u s i n t h e E l d e r l y , " A m e r i c a n J o u r n a l o f P s y c h i a t r y , 117 (1960) , p . 326 . 67 7 8 Standards for Educational and Psychological Tests (Washington, D.C: American Psychology Association, 1974). 79 S. Siegel, Nonparametrie S t a t i s t i c s (New York: McGraw-H i l l , 1956), p. 202. 8 0 D. J. Fox, Fundamentals of Research i n Nursing, 3rd ed. (New York: Appleton-Century-Crofts, 1976), p. 106. 81 J. W i l l i s , D. Smithy, and S. Holliday, "Item Level Analysis of the Devereux Elementary School Behaviour Rating Scale," Journal of Special Education, 22 (1978), pp. 81-82. 8 2 L. J. Cronbach, Essentials of Psychological Testing, 3rd ed. (New York: Harper and Row, 1970), p. 159. 8 3 Cronbach, p. 16 0. 84 Kerlinger, p. 650. 8 5 B i r r e n , p. 190. 8 6 J. D. Adamson and A. H. Schmale, "Object Loss, Giving Up and the Onset of Psychiatric Disease," Psychosomatic  Medicine, 27 (1965), p. 557. 87 A. H. Schmale and G. L. Engel, "The Giving Up, Given Up Complex," Archives of General Psychiatry, 17 (1967), pp. 135-145. : : : 8 8 Tobin and Lieberman. 89 M. B. Jensen and W. E. Morris, " R e l i a b i l i t y - U n r e l i a b i l i t y of A n c i l l a r y Psychiatric Evaluations," Journal of C l i n i c a l  Psychology, 16 (1960), pp. 248-252. 90 W. A. Hargreaves, "Systematic Nursing Observation of Psychopathology," Archives of General Psychiatry, 18 (May, 1968), pp. 519-531. 91 P. Arenberg, "Cognition and Aging," i n Eisdorfer and Lawton, pp. 74-97. 92 J. Herr, "Psychology of Aging: An Overview," i n Burnside, p. 40. 93 R. C. Jelinek, R. K. D. Haussman, S. T. Hegyvary, and J. F. Newman, A Methodology for Monitoring Quality of Nursing Care (Maryland: DHEW, 1974), p. 66. 94 T Laurence. BIBLIOGRAPHY Abdellah, F. and E. Levine. Better Patient Care Through Nursing  Research. New York: MacMillan, 1965. Adamson, J.D. and A.H. Schmale. "Object Loss, Giving Up and the Onset of Psychiatric Disease." Psychosomatic MedicineT 27 (1965), 557. Arenburg, P. "Cognition and Aging." in The Psychology of Adult  Development and Aging. Ed. C. Eisdorfer and M.P. Lawton. Washington, D.C: American Psychological As sociation, 1973, 117-45. Ashton, R.W. An Integrated Patient Classification System and Nursing  Activity Study in an Extended Care Facility. Diss. Harvard 1968. Atchley, R.C. The Social Forces in Later Life. California: Wadsworth, 1972. Bland, S. "Long Term Care Program for B.C. Registered Nurses' Association of B.C., Vancouver. November 1978. Birren, J. "Psychological Aspects of Aging." in Aging in America. Ed. C. Kart and B. Manard. New York: Alfred, 1976. Brantl V. and M.R. Brown. Readings in Gerontology. New York: C.V. Mosby, 1973. Brody, E. "Basic Reguirements for Geriatric Institutions and Services." Medical Care, 14, No. 5 (1976), 60-70. , M. Kleeban, M.P. Lawton, and M. Moss. "A Longitudinal Look at Excess Disabilities in Mentally Impaired Elderly." Journal of Gerontology, 29, No.l (1974), 79-84. Burnside, I. Nursing and the Aged. New York: McGraw-Hill, 1976. Burrack, B. "Interdisciplinary Classification for the Aged." Journal of Chronic Diseases, 18, No.5 (1965), 1059-64. 68 69 Busse, E. and E. Pfeiffer. Behaviour and Adaptation in Late Life. Boston: Little Brown, 1969. Campbell, J. "Behavioural Intervention in the Rehabilitation of the Elderly." Canadian Association of Gerontology Meeting, Vancouver. 13 November 1976. Cronbach, L.J. Essentials of Psychological Testing. 3rd ed. New York: Harper and Row, 1970. Eisdorfer, C. "Developmental Levels and Sensory Impairment in the Aged." Journal of Projective Techniques, 24 (1965), 129-132. and M.P. Lawton. The Psychology of Adult Development and Aging. Washington, D.C: American Psychological Association, 1973. Ellsworth, R.B. MACC Behavioural Adjustment Scale. California: Western Psychological Services, 1962. and W.H. Clayton. "Measurement and Improvement in Mental Illness." Journal of Consulting Psychology, 21 (1957), 15-20. Fox, D.J. Fundamentals in Nursing. 3rd ed. New York: Apple ton-Century-Crofts, 1976. Goga, J.A. and W.O. Hambacher. "Psychologic and Behavioural Assessments of Geriatric Patients." Journal of American Geriatrics Society, 25, No.5 (1977), 232-237. Greenberg, B.M. "Medical Model-Nursing Model: A Gerontological Dilemma." Journal of Gerontological Nursing, 1, No.4 (1974), 6-8. Guilford, J. Psychometric Methods. 2nd ed. New York: McGraw-Hill, 1954. Gunter, L.M. and J.C. Miller. "Toward a Nursing Gerontology." Nursing  Research, 26, No. 6 (1977), 208-220. Gurel, L., M. Linn, and B. Linn. "Physical and Mental Impairment of Function Evaluation of the Elderly." Journal of Gerontology, 27, No. 1 (1972), 83-90. Harris, H., A. Lipman, and R. Slater. "Architectural Design: The Spatial Locations and Interactions of Old People." Gerontologist, 23(1977), 390-396. ;Hargreaves, W.A. "Systematic Nursing Observation of Psychopathology." Archives of General Psychiatry, 18, No.5 (1968), 519-531. 70 H o n i g f e l d , G . and J . K l e t t . "The Nurses' Observat ion Scale f o r Inpat i en t E v a l u a t i o n . " J o u r n a l o f C l i n i c a l Psychology, 21 (1965), 65-71. J e l i n e k , R . C . , R. K. D. Haussman, S . T . Hegvary, and J . F . Newman. A Methodology f o r Moni tor ing Q u a l i t y o f Nurs ing C a r e . Maryland: DHEW, 1974. Jensen, M . B . and W.E. M o r r i s . " R e l a i a b i l i t y - U n r e l i a b i l i t y o f A n c i l l a r y P s y c h i a t r i c E v a l u a t i o n s . " J o u r n a l o f C l i n i c a l Psychology,16 (1960), 248-252. Jones, E . W . , B . J . McNi t t , and E . M . McKnight. P a t i e n t C l a s s i f i c a t i o n  f o r Long Term C a r e . Harvard: Bureau o f Hea l th Serv ices Research, 1973. Kahn, R . L . , A . I . G o l d f a r b , M. P o l l a c k , and A . Peck. " B r i e f Objec t ive Measures f o r the Detemdnat ion o f Mental Status i n the E l d e r l y . " American J o u r n a l o f P s y c h i a t r y , 117 (1960), 326-327. Kastenbaum, R. and S. Sherwood. "VTRO: A Sca le f o r Assess ing the Interview Behaviour o f E l d e r l y People ." i n Research, P l a n n i n g , and A c t i o n . E d . D. Kent, R. Kastenbaum, and S. Sherwood. New York: Behavioura l P u b l i c a t i o n s , 1972, 144-165. K a t z , S. T . D . Dauns, H .R . Cash, and R . C . G r o t z . "Progress i n Develop-ment o f the Index o f A D L . " G e r o n t o l o g i s t , 10, No.20 (1970) K e r l i n g e r , F . N . Foundations o f Behavioura l Research. New York: H o l t , R inehart , and Winston, 1964. Long Term C a r e . P r o c . o f a Conference i n Long Term C a r e , D a t a . 12-16 May 1975. Medica l Care , 14, No.5 (1976), 1-230. L a b o u r i e - V i e f , G. W . J . Hayer, and M. B a l t e s . "Operant A n a l y s i s o f I n t e l l e c t u a l Behaviour i n O l d Age." Human Development, 17, No. 5 (1974), 259-272. Laurence, M.K. " P r i n c i p l e s and P r a c t i c e s o f M i l i e u Therapy w i t h the E l d e r l y . " Canadian Conference o f Gerontolgy, Vancouver, B . C . November, 1976. Lawton, M . P . "Coping Behaviour and the Environment o f O l d People ." i n P r o f e s s i o n a l Ob l iga t ions and Approaches t o the E l d e r l y . E d . A . Schwartz and I . Mensh. S p r i n g f i e l d : Char les Thomas, 1974, 60. . "Funct ional Assessment o f the E l d e r l y P a t i e n t . " i n Readings i n Gerontology. E d . V . B r a n t l y and M.R. Brown. New York: C . V . Mosby, 1973, 43-50. 71 Linn, M. "A Rapid D i s a b i l i t y Rating Scale." Journal of Geron- tology, 15, No.2 (1967), 211-4. Linn, B l S . M.W. Linn, and L. Gurel. "Cumulative I l l n e s s Rating Scale." Journal of American G e r i a t i r c s Society.16, No.5 (1968), 622-6 Lowenthal, M.F. Lives i n Distress. New York:Basic Books, 1964. and A. Simon. "Mental Crises and I n s t i t u t i o n a l i z t i o n i n the Eld e r l y . " Journal of G e r i a t r i c Psychiatry, 4, No.l (1970) , 165-170. MacDonald, M.L. "The Forgotten Americans." American Journal of  Community Psychology.!, No.3 (1973), 272-291. Meer, B. and Baker, J. "The Stockton G e r i a t r i c Rating Scale." Journal of Gerontology, 21 (1966), 392-5. Nie, N. , CH. H u l l , J.G. Jenkins, K. Steinbrenner, and D. Kent. S t a t i s t i c a l Package for the Social Sciences.2nd ed. New York: McGraw-Hill Books,]9 75. Pastalan, L.A. and D.H. Carson. Spatial Behaviour of Older P . People. Ann Arbor, Mich.: University Press, 1970. Pinto, A. and E. DeRosa. NOSIE-30: Programed Instruction. Maryland: n.p., 1977. Rosencranz, H.A. and C T . Pihlblad. "Measuring the Health of the Eld e r l y . " Journal of Gerontology. 25, No.2 (1970). Salmon, P. J.M. Atthowe, and M.R. Hallock. RAPIDS: A Methodic: of c l a s s i f y i n g Patients Receiving Long Term Care. C a l i f o r n i a : DHEW, 196 7. Schmale, A.H. and G.L. Engel. "The Giving Up, Given Up Complex." Archives of General Psychiatry. 17 (1967). Schwartz, A. and I. Mensh. Professional Obligations and Approaches to the E l d e r l y . S p r i n g f i e l d : Charles Thomas, 1974. Shaughnessy, M.G., T. O'Brien, G. F i t z p a t r i c k , and S. Grove. An Approach to Determining the Nursing Needs of Nursing Home Patients. Boston: School of Nursing, 1968. 72 Sherwood, S. Long Term Care. New York: Spectrum, 1975. Siegel, S. Nonparametric Statistics. New York: McGraw-Hill, 1956. Standards for Educational and Psychological Tests. Washington, D.C: American Psychological Association, 1974. Tobin, S. and M. Lieberman. Last Home for the Aged. San Francisco: Jossey-Bass, 1976. Turner, B.F. S.T. Sheldon, and M. Lieberman. "Personality Traits as Predictors of Institutional Adaptation Among the Elderly." Journal of Gerontology, 21 (1966), 392-5. Waldman, A. and E. Fryman. "Classification in Homes for the Aged." in Geriatric Institutional Management. Ed. H. Shore and M. Leeds. New York: Putnam, 1964, 131-135. Weaver, H., M. McPhee, and P. Lambert. Geriatrics Report. Vancouver, B.C.: Vancouver Hospital District, 1975. Weed, L.L. Medical Records, Medical Education, and Patient Care. Chicago: Yearbook Medical, 1971. Whanger, A. and P. Lewis. "Survey of Institutionalized Elderly." in MulticILmensionai Functional Assessment: The OARS Methodology. E. Pfeiffer. Durham: Duke University, 1975, 2-10. Willis, J., D. Smithy, and S. Holliday. "Item Level Analysis of the Devereux Elementary School Behaviour Rating Scale." Journal of Special Education, 22 (1978) 81-88. and D. Lawson. "Prediction and Preparation in the Relocation of the Elderly." Vancouver, B.C., National Health and Welfare Grant, in progress. Wolanin, M.O. "Confusion in the Elderly." Gerontological Society, Florida. November, 1973. Wolpert, A., C. Sheppard, and S. Merlis. "Method of Evaluating Behavioural Changes in Aged Hospital Patients During Anabolic Therapy." Journal of the American Geriatrics Society, 15 (1976), 470-3. Appendix A Nurses' Observation Scale R e s i d e n t ' s name Date A i d e , L.P.N., R.N. INSTRUCTIONS FOR COMPLETION OF SCALE: 1. For each i t e m a s c o r e of h i n d i c a t e s the h i g h e s t l e v e l of f u n c t i o n i n g o r a d a p t a t i o n . A s c o r e of 1 r e p r e s e n t s the most s e v e r e l e v e l of i m p a i r m e n t . 2. P l e a s e c i r c l e the number you t h i n k most a c c u r a t e l y e s t i m a t e s the p a t i e n t ' s f u n c t i o n i n g . B e h a v i o u r s t h a t I n d i c a t e a s c o r e of k and 1 ( t h e h i g h e s t and l o w e s t ) have been o u t l i n e d below each i t e m . 3. To o b t a i n a s c o r e of A, a p a t i e n t s h o u l d be c o n s i s t e n t i n h i s b e h a v i o u r . For example, i n s c o r i n g ' o r i e n t a t i o n ' , i f some c o n f u s i o n o c c u r s a t n i g h t or i n f r e q u e n t l y a t o t h e r t i m e s , a s c o r e of 3 s h o u l d be g i v e n . That i s , t h e f r e q u e n c y o f b e h a v i o u r must be t a k e n i n t o a c c o u n t a l o n g w i t h the degree of i m p a i r m e n t . T r y not t o answer i n the way you 'hope' the p a t i e n t w i l l be a b l e to f u n c t i o n , o r what you t h i n k he/she i s a c t u a l l y c a p a b l e of d o i n g . R a t h e r i t i s i m p o r t a n t t o o b t a i n an a c c u r a t e assessment of how the p e r s o n i_s f u n c t i o n i n g based on the e v i d e n c e you have g a t h e r e d i n your day-to-day c o n t a c t . That i s the o n l y way an a c c u r a t e p l a n o f c a r e and subsequent e v a l u a t i o n of p r o g r e s s can be made. 73 74 A. COGNITIVE FUNCTIONING: 1. O r i e n t a t i o n : I n d i c a t e s a r e a l i s t i c awareness o f s e l f and s u r r o u n d i n g s . (a) Time 4 3 2 1 1 1 | | 4= Knows the month, y e a r , 1= Seems t o t a l l y unaware o f whether se a s o n , time o f day i t i s da y t i m e o r n i g h t t i m e . Or-a c c u r a t e l y and c o n s i s t e n t l y . i s l i v i n g i n a n o t h e r t i m e p e r i o d , (eg. t h i n k s he/she i s a c h i l d a g a i n . ) N.B. B e i n g unaware of the exact date o r day of the week does not n e c e s s a r i l y i n d i c a t e d i s o r i e n t a t i o n . (b) P l a c e 4 3 2 1 1 1 1 | 4= Knows where he/she i s and 1= Seems t o t a l l y unaware of i n what t y p e o f p l a c e , (eg. s u r r o u n d i n g s and i s u n a b l e t o a c u t e c a r e h o s p i t a l ) I s a b l e l o c a t e own room, bedroom, o r t o f i n d h i s / h e r way around d i n i n g - r o o m , w i t h o u t g e t t i n g l o s t . (c) P e r s o n 4 3 2 1 1 1 1 | 4= Knows e x a c t age 1= F a i l s t o r e c o g n i z e own name, and r e c o g n i z e s f a m i l y o r t h e f a c e s of s i g n i f i c a n t members, f r i e n d s , s t a f f , o t h e r s i n t h e en v i r o n m e n t , (eg. and o t h e r p a t i e n t s . t he n u r s e who has been i n c l o s e c o n t a c t f o r some t i m e ) . 2. Memory: I n d i c a t e s the a b i l i t y t o r e c a l l i n f o r m a t i o n and e x p e r i e n c e s i n the p a s t , whether an hour b e f o r e o r t e n y e a r s b e f o r e . (a) S h o r t Term ( R e c e n t ) - e v e n t s of the p a s t few m i n u t e s , h o u r s , or days. Remembers where he/she 1= Unable t o remember what meal was p l a c e d p e r s o n a l b e l o n g i n g s s e r v e d l a s t o r f o r g e t s what has and t h e d e t a i l s o f a c t i v i - happened a f t e r a few m i n u t e s , t i e s o f the r e c e n t p a s t . 75 (b) Long Term (Remote)- events of several years a J Is able to r e l a t e the s i g n i -f i c a n t events of his/her l i f e . (eg. the death of a spouse, number of children, main occupation, b i r t h p l a c e , etc.) Cannot remember own name, or those of immediate family. Unable to generate the names of body parts on request, (eg. leg, arm.) Cannot recognize a f a m i l i a r tune, as indicated by humming or singing along. 3 Comprehension: Indicates the a b i l i t y to understand or to obtain a r e a l i s t i c , i n t e l l i g e n t grasp of the s i t u a t i o n . 4= Is able to follow i n s t r u c t i o n s and understand explanations. New s i t u a t i o n s and i n f o r -mation are r e a d i l y grasped. Unable to understand or follow the simplest of i n s t r u c t i o n s . Indicates no a b i l i t y to grasp new s i t u a t i o n s or deal with simple information. 4. Attention  Span: Indicates the a b i l i t y to attend or concentrate on a s i n g l e s i t u a t i o n or event. J 4= Becomes engrossed i n a c t i v i t y , reading, etc. Is able to follow conversation, or maintain i n t e r e s t i n a task u n t i l completion. Is very e a s i l y distracted by i r r e l e v a n t s t i m u l i or preoccupa-t i o n with other matters. Not able to attend to even short conver-sations or tasks without continual ' c a l l i n g back'. N.B. If the patient i s disoriented, a b i l i t y to attend w i l l be indicated by l i s t e n i n g i n t e n t l y and maintaining attention without d i s t r a c t i o n , whether or not the person can take part i n the conversation. 5. Judgment: Indicates the a b i l i t y to evaluate a l t e r n a t i v e courses of action and to draw proper conlusions from experience. This includes a r e a l i s t i c s e l f perspective and in s i g h t . JL Able to make sound judg-ments on important matters. Recognizes own strengths and l i m i t a t i o n s and acts accordingly. Has quite good insight into own behaviour. Unaware of a b i l i t i e s and attempts dangerous acts. Has t o t a l l y unrealis-t i c plans for the future. Unable to make day-to-day decisions, such as what clothes to wear. 76 6. Speech: Communicates i n a fluent manner that i s readily understood by others. ( a ) 4 3 2 1 1 1 1 1 4= Speaks c l e a r l y , f l u e n t l y , 1= Unable to communicate in any manner and coherently. Maintains (speech, gesture, w r i t i n g ) . Or-a frame of reference with speech i s such that i t i s impossible clear boundaries. Context to decipher, for whatever reason, of statements i s relevant Or- speech i s t o t a l l y Irrelevant and follows a l o g i c a l and meaningless, sequence. ^ Aphasic- Has disturbances of language due to a s p e c i f i c brain injury such as cerebrovascular accident (stroke), tumour, or accident. 4 3 2 1 1 1 1 1 4= No disturbance i n language of thi s type has been i d e n t i f i e d . 3= Expressive aphasia ( d i f f i c u l t y i n executing speech or expressing oneself.) 2= Receptive aphasia ( d i f f i c u l t y i n understanding speech, or unable to read. 1= Global aphasia ( d i f f i c u l t y i n both speaking and understanding communications. B. SOCIAL FUNCTIONING: 1. Emotional Involvement: Has a close emotional r e l a t i o n s h i p with another person. 4 3 2 1 1 1 1 1 4= Has a close r e l a t i o n s h i p 1» No v i s i t o r s . Lacks r e l a t i o n s h i p with family member, f r i e n d , with any one. Lonely, or s t a f f on a regular basis. 2. P a r t i c i p a t i o n : P a r t i c i p a t e s i n group a c t i v i t i e s with s t a f f , other patients, or u t i l i z e s materials i n a stimulating manner. 4 3 2 1 1 1 1 1 4= Takes part i n group a c t i v i t i e s . 1= Withdrawn from group a c t i v i t i e s Finds stimulation either or programs. Does not take through organized, s t a f f - part i n any form of i n d i v i d u a l directed programs, or through a c t i v i t y or stimulation, s e l f - d i r e c t e d endeavours such as k n i t t i n g , c r a f t wark, hobbies, reading, etc. 77 3. I n t e r a c t i o n : Responds t o a n o t h e r p e r s o n on a one-to-one b a s i s w i t h i n t e r e s t and e n t h u s i a s m . 4 3 2 1 -1 1 L L_ 4= Shows i n t e r e s t , r e s p o n s i v e n e s s 1= I n d i c a t e s a s u s p i c i o u s , w i t h -s p o n t a n e i t y , t r u s t , and drawn, c l o s e d tendency when approach-e a g e r n e s s when approached ed. G i v e s the i m p r e s s i o n of by a n o t h e r p e r s o n . s h r i n k i n g away from p e r s o n a l i n t e r a c t i o n . 4. C o - o p e r a t i o n : A c t s i n a c o n s i d e r a t e , h e l p f u l , and s e n s i t i v e manner t o o t h e r s . 4 3 2 1 J 1 1 I 4= C o n s i d e r a t e , c o - o p e r a t i v e , 1= D i s r u p t i v e o f h o s p i t a l r o u t i n e . h e l p f u l , and s e n s i t i v e t o B e l l i g e r e n t , u n c o - o p e r a t i v e . o t h e r p a t i e n t s . Behaves o b j e c t i o n a b l y o r i n a manner w h i c h i s a n n o y i n g t o s t a f f and/or o t h e r p a t i e n t s . C. ADAPTIVE BEHAVIOUR: 1. T r u s t i n g / S u s p i c i o u s : •A 3 2 1 1 1 I 1 4= I n d i c a t e s openness, t r u s t f u l - 1= I n d i c a t e s s e v e r e s u s p i c i o n o r ness of o t h e r s . p a r a n o i a , ( e g . . T h i n k s t h a t o t h e r s a r e s t e a l i n g o r h i d i n g t h i n g s from him/her.) R e f u s e s t o g i v e i n f o r m a t i o n and eyes s t a f f s u s p i c i o u s l y . 2. R e l a x e d / A n x i o u s : 4 3 2 1 1 1 1 1 4= At ea s e , r e l a x e d , c a l m . Takes 1= S e v e r e l y a g i t a t e d , n e r v o u s , t h i n g s i n s t r i d e . w o r r i e d , r e s t l e s s , o r f i d g e t y . ( p a c i n g , r o c k i n g , n a i l - b i t i n g , e t c . ) . G e n e r a l l y i n d i c a t e s u n s e t t l e d b e h a v i o u r . 78 3. P a s s i v e / A g g r e s s i v e : A g g r e s s i v e 1 W e l l - b a l a n c e d 3 4 P a s s i v e 1 E x t r e m e l y a s s e r t i v e and o v e r l y a g g r e s s i v e to the p o i n t of b e i n g h o s t i l e or t h r e a t e n i n g . T r i e s to c o n t r o l the environment t o t a l l y . 4= W e l l - b a l a n c e d . Not too a g g r e s s i v e o r p a s s i v e . 1= E x t r e m e l y p a s s i v e and dependent. W i l l n o t a t t e m p t a n y t h i n g on h i s own. Makes no attempt t o c o n t r o l what happens or e v e n t s around him/ h e r . 4. Animated/  Depressed: 4= Has e n t h u s i a t i c , o p t i m i s t i c , happy o u t l o o k on l i f e . Shows a c t i v e i n t e r e s t i n s u r r o u n d i n g s . 1= V e r y d e p r e s s e d , despondent. Ex-p r e s s e s e x t r e m e l y s e l f - d e r o g a t o r y h o p e l e s s f e e l i n g s . 5. R e c o g n i t i o n / D e n i a l : 4 3 2 1 1 1 1 1 4= R e c o g n i t i o n and a c c e p t a n c e o f h i s / h e r s t a t e of h e a l t h ( i e . s o c i a l , p h y s i c a l , and f u n c t i o n a l s i t u a t i o n ) . A b l e t o d i s c u s s o p e n l y . 1= D e n i a l of l o s s i n h e a l t h and f u n c t i o n i n g a b i l i t y . Responses w h i c h a r e o b v i o u s l y i n c o n g r u e n t w i t h a c t u a l f e e l i n g s . (eg. S t a t e s t h a t he/she i s not d e p r e s s e d when a l l o t h e r o b s e r v a t i o n s i n d i c a t e o t h e r w i s e . ) D. GLOBAL PHYSICAL WELL-BEING: 1. Energy L e v e l : I n d i c a t e s the c a p a c i t y t o s u s t a i n e f f o r t or e x e r t o n e s e l f . 4= G i v e s the i m p r e s s i o n of 1= m a i n t a i n i n g good s t r e n g t h and power f o r h i s / h e r age. ( e r e c t p o s t u r e , d e c i s i v e movements). A b l e t o m a i n t a i n a c t i v i t i e s most o f the day w i t h o u t r e s t o r s l e e p . G i v e s the i m p r e s s i o n of b e i n g e x t r e m e l y weak and f e e b l e (eg. slumped, c o l l a p s e d p o s t u r e ) . Spends most o f the day on o r i n bed. 79 2. Comfort L e v e l : E x p e r i e n c e s no p a i n or d i s c o m f o r t as a r e s u l t of d i s e a s e or d i s a b i l i t y . 3 . Body I n t a c t n e s s : 4. V i s i o n : 5. H e a r i n g : 4= F r e e from p a i n / d i s c o m f o r t . 1= S u f f e r s from s e v e r e p a i n o r d i s c o m f o r t f r e q u e n t l y . P a i n i s such t h a t i t i n t e r f e r e s w i t h h i s / h e r d a y-to-day a c t i v i t i e s . The body systems have m a i n t a i n e d t h e i r wholeness i n s t r u c t u r e and f u n c t i o n . 4= I n t a c t body. No major d e t e r i o r a t i o n , p a r a l y s i s , a m p u t a t i o n , a r e a s of a n a e s t h e s i s , or l o s s o f body p a r t (eg. mastectomy) o r f u n c t i o n (eg. c o l o s t o m y ) S k i n i s i n good c o n d i t i o n . 1= G i v e s i m p r e s s i o n o f h a v i n g s e v e r e o v e r a l l d e t e r i o r a t i o n i n p h y s i c a l h e a l t h . Has l o s s of body p a r t o r f u n c t i o n , p a r a l y s i s , a m p u t a t i o n , o r a r e a s of a n a e s t h e s i a , e t c . Or-s k i n i s i n v e r y poor c o n d i t i o n w i t h s e v e r e breakdown. The a b i l i t y t o see ( w i t h the a i d of g l a s s e s , i f n e c e s s a r y ) 4= No problem o r v e r y s l i g h t d i f f i c u l t y s e e i n g . 1= Severe problem. Unable t o see a n y t h i n g but vague o u t l i n e s , shadows. F u n c t i o n a l l y b l i n d . The a b i l i t y t o hear ( w i t h the a i d . of a h e a r i n g d e v i c e , i f n e c e s s a r y ) . 4= No p roblem, o r v e r y s l i g h t d i f f i c u l t y h e a r i n g . 1= Severe p r o b l e m . Cannot hear even when spoken t o v e r y l o u d l y . F u n c t i o n a l l y d e a f . 80 E. ACTIVITIES OF DAILY LIVING: 1. Chewing A b i l i t y : I n d i c a t e s the a b i l i t y to e a t a d i e t of normal c o n s i s t e n c y . 4 3 2 1 1 1 1 1 4= Normal d i e t 3= Minced d i e t 2= S o f t d i e t 1= F l u i d d i e t 2. C o n t i n e n c e : I n d i c a t e s t he a b i l i t y t o c o n t r o l b l a d d e r f u n c t i o n a p p r o p r i a t e l y . 4 3 2 1 1 1 h i 4= Has f u l l c o n t r o l . 3= R a r e l y i n c o n t i n e n t . O c c a s i o n a l a c c i d e n t . 2= U s u a l l y or f r e q u e n t l y i n c o n t i n e n t . 1= No c o n t r o l . Always i n c o n t i n e n t . C a t h e t e r , 3. Bowel F u n c t i o n : I n d i c a t e s t he a b i l i t y to pass formed s t o o l s i n d e p e n d e n t l y on a r e g u l a r b a s i s . 4 3 2 1 1 1 1 1 4= Has n o r m a l l y formed s t o o l on r e g u l a r b a s i s w i t h o u t the a i d of m e d i c a t i o n , enema, or manual a s s i s t a n c e . 3= O c c a s i o n a l l y r e q u i r e s the use of l a x a t i v e f o r r e g u l a r e l i m i n a t i o n . 2= Takes l a x a t i v e s r o u t i n e l y . R a r e l y needs enemas o r manual r e m o v a l . 1= I n c o n t i n e n t of s t o o l or t o t a l l y dependent on mechanical/chem-i c a l means of s t o o l e l i m i n a t i o n . 81 A c t i v i t i e s of Daily L i v i n g (ADL) Chart INSTRUCTIONS FOR THE USE OF THE VISUAL CHART: P l e a s e w r i t e a s c o r e of 1, 2, 3 b e s i d e each a r e a of the v i s u a l c h a r t t h a t r e p r e s e n t s p a r t i c u l a r a c t i v i t i e s . 1= T o t a l Independency: Independence means the a b i l i t y t o p e r f o r m an a c t i v i t y w i t h o u t s u p e r v i s i o n , d i r e c t i o n o r p e r s o n a l a s s i s t a n c e . The p a t i e n t who r e f u s e s t o p e r f o r m an a c t i v i t y i s s c o r e d 3, dependent, even though he may be c o n s i d e r e d a b l e t o do i t . He/she may use any method o r a i d to p e r f o r m the a c t i v i t y . The s c o r e of 1 i n the a c t i v i t y of w a l k i n g r e p r e s e n t s the a b i l i t y t o walk a p p r o x i m a t e l y 1 b l o c k i n d e p e n d e n t l y . 2= P a r t i a l Dependence: The p a t i e n t can p e r f o r m the g r e a t e r p a r t of the a c t i v i t y h i m s e l f but needs s u p e r v i s i o n t o complete the a c t i v i t y . I n w a l k i n g a b i l i t y t h i s r e f e r s to the a b i l i t y t o w a l k s h o r t d i s t a n c e s ( t o bathroom) w i t h o u t p e r s o n a l a s s i s t a n c e . May use cane or w a l k e r , e t c . 3= T o t a l Dependence: The a c t i v i t y i s c a r r i e d out f o r the p a t i e n t . I n w a l k i n g t h i s r e f e r s t o w a l k i n g s h o r t d i s t a n c e s w i t h p e r s o n a l a s s i s t a n c e . 82 On Off A p p e n d i x B S a m p l e M u l t i d i m e n s i o n a l P r o f i l e Range o f S c o r e s f o r E a c h S u b s e c t i o n R e s i d e n t 1 s H y p o t h e t i c a l S c o r e V i s u a l P r o f i l e o f P e r f o r m a n c e C o g n i t i v e 10 -40 25 10 40 S o c i a l 4-16 9 4 16 A d a p t i v e 5-20 19 5 .» 2 0 P h y s i c a l 5 -20 15 5 • JL. 20 A . D . L . 24 7-24 14 7 83 Appendix C Major Admit t ing Diagnoses o f Sample Populat ion Diagnoses Number o f Residents Approximate Percent 1. C e r e b r a l In jury (Stroke, P a r k i n s o n ' s , Hemorrhage, e t c . ) 27 36 2. Behavioural Problems ( S e n i l i t y , Organic B r a i n Syndrome, P s y c h i a t r i c Diagnoses) 16 21 3. Heart Disease 9 12 4. M u s c u l o / S k e l e t a l Problems 5 6 5. C i r c u l a t o r y Problems 4 5 6. Metabol ic Disorders 3 4 7. N u t r i t i o n a l Problems 2 3 8. Sensory Problems 2 3 9. Other Diagnoses 8 10 T o t a l 76 100 84 Appendix D Health Index Underline the Appropriate Diagnoses, Problems, and Symptoms Score 4 Points A. Heart Disease: - A.S.H.D. (arteriosclerotic heart disease) - angina/ischemia - block/other conductive problem or pacemaker - arrhythmia (tachycardia, bradycardia, fibrillation episodes) - congestive heart failure - valve insufficiency - infarct B. Circulatory Problems: -— generalized arterio/athero-sclerosis - intermittent claudication & other forms of peripheral arteriosclerosis - hyper/hypotension - embolus, thrombus, artery/ vein occlusion - ttorombophlebitLs C. Cerebral Insult: - cerebrovascular accident - hemorrhage, aneurysm - injury/hematoma/concussion - transient ischemic attacks - tumour - Parkinson's Disease - epilepsy - tardive dyskinesia D. Musculo-Skeletal Problems: - amputations (limb part) - fractures (unresolved) - joint replacements - arthritis (rheumatoid, or severe osteoarthritis) - osteoporosis - contracture or major structural deformity - major spinal problem Score 2 Points mild varicosities mild hyper/hypo-tension not requiring medica-tion . amputation (minor) fratures (resolved) spasm minor contracture mild back ache 85 86 E . Metabo l i c D i s o r d e r s : - d iabetes m e l l i t u s (not c o n t r o l l e d by d ie t ) - d iabetes i n s i p i d u s - adrena l i n s u f f i c i e n c y - hypo/hyperthyroidism - p i t u i t a r y problems F . G a s t r o i n t e s t i n a l Problems: - d i v e r t i c u l i t i s - u l c e r a t i v e c o l i t i s - bowel f i s t u l a / o b s t r u c t i o n G . In fec t ions : - major systemic i n f e c t i o n - o s t e o m y l i t i s - gangrene -pneumonia/bronchit i s - chron ic i n f e c t i o n s H. Organ F a i l u r e : - major organ f a i l u r e o r removal ( k i d n e y , l i v e r , u terus , g a l l b ladder , e t cetera) - stones i n organ or duct - o ther major surgery I . Integument: - open wound ( s u r g i c a l o r decubi t i ) - s t a s i s u l c e r s J . N u t r i t i o n a l Problems: - e l e c t r o l y t e inbalance - dehydrat ion - anemia (severe, progress ive) - progress ive weight l o s s - syirptomatic v i tamin d e f i c i e n c y K. Sensory Impairments: - severe hear ing l o s s - severe v i s i o n l o s s L . Symptomatic Diagnoses: - d i s turbance i n consiousness - p a i n (N.Y.D.) - fever " - jaundice " - d iabetes m e l l i t u s ( c o n t r o l l e d by d ie t ) - m i l d g a s t r o e n t e r i t i s - minor bowel problems - miss ing teeth/dentures - minor l o c a l i z e d i n f e c t i o n - a b s c e s s / b o i l - r e so lved i n f e c t i o n s o f ser ious nature - minor organ f a i l u r e o r removal - p r o s t a t i c hypertrophy - . h e r n i a - minor surgery - minor t o e / n a i l / f o o t problems - p r u r i t i s / p s o r i a s i s - m i l d d i e t a r y i n s u f f i c i e n c y - o b e s i t y anemia (mild) - rninor to moderate hearing or v i s i o n l o s s - d i z z i n e s s / p o s t u r a l hypo-tens ion - m i l d balance d i s turbance 87 M. Miscellaneous: - cancer - tumour/c^st/growth - multiple sclerosis (small or benign) - CO.L.D. (chronic - neuralgia obstructive lung disease) - other disease entities/syndromes N. Special Requirements: - requies oxygen occasionally - special diet modification " suctioning " " tube feeding " - has indwelling catheter - has tracheostomy - has colostomy - has ileostomy - has gastrostomy Total Score: Appendix E Planned A c t i v i t y (PLA) Check Name Date Room No. Observer 11:30-12:00 Observer 1:30-2:00 Observer 2:30-3:00 Observer 4:00-4:30 LOCATION: Dining Room/Activity Physio Room ~ ~ Kitc h e n (Occupational Area) Bedroom Of f i c e s / N u r s i n g S t a t i o n C o r r i d o r Bathroom Classrooms Other: Specify STATE: Walking Standing S i t t i n g : (1) Appar. awake (2) Appar. asleep Wheelchair: (1) Independent (2) Dependent TYPE: Dr i n k i n g E a t i n g : (1) Meals (2) Other than meals Grooming: (1) Oneself (2) By someone (3) Both Dressing: (1) Oneself (2) By someone (3) Both W r i t i n g Reading/Leafing thru magazine 88 89 Observer 11:30-12:00 Observer 1:30-2:00 Observer 2:30-3:00 Observer 4:00-4:30 R e creation: (1) Observer (2) P a r t i c i p a n t Conversation: (1) T a l k i n g (2) L i s t e n i n g Therapy: (1) OT-PT (2) Med. Proc. (3) Counsel. Group Meeting SOCIAL LEVEL: S o l i t a r y Dyad: (1) S t a f f (2) Another P a t i e n t (3) Volunteer (4) Family Group: (1) I n c l . S t a f f / V o l u n . (2) P a t i e n t s only (3) Family COMMENTS! Appendix F Mental Status Questionnaire 1. Where are we now? 2. Where is this place? 3. What is to-day's date? 4. What month is it? 5. What year is it? 6. How old are you? 7. What is your birthday? 8. What year were you born? 9. Who is the Prime Minister of Canada? 10. Who was the Prime Minister before him? 90 s Appendix G Item Analysis: Frequency, Distribution, and Correlations A. Cognitive Functioning Mean Score Correlations Item Rating Number Rated S.D. : with with, subsection Total Score 1. Orienta- 1 '9 tion to 2 14 Time 3 18 3.0 1.0 0.88 0.8 4 35 2. To 1 11 Place 2 10 3 10 3.2 1.1 0.87 0.76 4 45 3. To 1 '2 Person 2 13 3 12 3.4 0.87 0.81 0.74 4 49 4. Short- 1 17 term 2 .9 Memory 3 11 2.9 1.24 0.87 0.78 4 39 5. Long 1 6 term 2 13 Memory 3 10 3.3 1.0 0.75 0.68 4 47 6. Compre- 1 10 hension 2 11 3 23 3.0 1.0 0.88 0.85 ' 4 32 7. Attention 1 14 Span 2 12 3 18 2.9 1.2 0.83 0.86 4 32 . 8. Judgment 1 20 2 11 3 22 2.6 1.2 0.88 0.84 4 23 9. General 1 }P2 Speech 2 20 3 23 3.0 0.88 0.73 0.7 4 31 91 92 Cognitive Functioning (continued) Correlations Item Rating Number Rated Mean Score S.D. with with Subsection Total 10. Aphasia 1 . 1 2 3 .1 17 3.7 0.6 0.33 0.26 4 57 B. Social Functioning 1. Emotional Involvement 1 2 3 4 8 17 11 40 3.1 1.0 0.43 0.5 2. Participation • 1 23 19 14 2 3 2.4 1.2 0.62 0.71 4 20 3. Interaction 1 ,9 2 3 8 . 31 3.0 0.98 0.68 0.71 4 28 4. Co-operation 1 ,8 20 25 2 3 • 2.8 0.98 0.68 0.67 4 23 C. Adaptive Behaviour 1. Trusting/ Suspicious 1 2 3 4 •A 16 24 32 3.1 0.92 0.62 0.61 2. Relaxed/ Anxious 1 2 3 4 10 23 25 18 2.7 0.99 0.67 0.6 3. Passive/ Aggressive 1 2 3 4 12 20 19 24 2.7 1.1 0.6 0.67 4. Animated/ Depressed 1 2 3 4 11 28 24 13 2.5 0.95 0.6 0.59 5. Recognition/ Denial 1 2 3 4 6 14 25 29 2.9 1.0 0.<:52 0.66 93 D. Physical Functioning Correlations Number Mean with with Item Rating Rated Score S.D. Subsection Total 1. Energy 1 13 Level 2 3 4 22 30 11 2.5 0.95 0.4 0.59 2. Comfort 1 10 Level 2 3 4 17 31 18 2.8 0.97 0.43 0.1 3. Body 1 9 Intactness 2 3 4 29 20 18 2.6 0.98 0.2 -0.01 4. Vision 1 4 2 3 11 26 3.2 0.88 0.16 0.26 4 35 5. Hearing 1 2 2 3 "7 21 3.4 0.77 0.14 0.24 4 46 E. A.D.L. 1. Chewing 1 0 Ability 2 3 4 ,2 14 60 3.7 0.49 0.24 0.44 2. Continence 1 6 • 2 3 13 27 3.0 0.94 0.54 0.61 4 30 3. Bowel 1 .'9 Function 2 3 4 9 29 29 3.0 0.99 0.3 0.37 4. Dressing 1 36 2 3 22 18 1.76 0.8 0.59 0.4 94 Correlations A.D.L. ,(cx>ntinued) Number Mean with with Item Rating Rated . Score S.D. Subsection Total 5. Grccming 1 19 2 32 2.0 0.76 0.7 0.5 3 25 6. Eating 1 ,6 2 12 2.7 0.61 0.25 0.1 3 58 7. Ambulating 1 24 2 26 2.0 0.82 0.62 0.34 3 26': Appendix H Distribution of Subsection and Total Scores 1. Cognitive Functioning Subsection: ± i _ 10 * * * * * * * * * ** * **** * **** ** **** **** * ***** * ** *********** ********** ** *********** 20 30 &*j T 40 X Mean= 31.2 S.D.= 8.6 S.E.= 1.82 2. Social Functioning: * * * * *** *• ***** ********* ********* ********* * ********* ************* ************* **** 16 X Mean= 11.4 S.D.= 3.31 S.E.= 1.32 3. Adaptive Behaviour: * * * ** ** ** ** ** * * * * *** * * ** ****** ************ ** ************\| *********.******* 20 Mean= 13.9 S.D.= 3.8 S.E.= 1.48 X 95 96 . Physical Functioning: ** ** ** ** ** *** * ***** ******* ******** ********* ********** *********** ******_****•*•* 20 X Mean= 14.5 S.D.= 2.6 S.E.= 1.67 A.D.L.: * * * * * * *** * *** * *** ** ***** ** ***** ** ***** ** ***** *  * * ** ***** * * ' A ' * * * * * * * * * * * * * * * * * * * * * * * * * 16 t * ^ 24 Mean= 18.4 S.D.= 3.48 S.E.= 1.63 X . Total Score: * ** * * * * * * *** * *** * * * *** *** * * ***** * * **** ******* * * ± ** *************************** 30 60 /90 120 X Mean= 89.5 S.D.= 16.9 S.E.= 4.4 ( Each * = 1 resident) ( N= 76) Appendix I Discriminant Function Analysis For Death Using Subsection Scores Step ^ Number Variable Entered F to Enter Wilk's Lambda 1 Cognitive Functioning 2.88 0.96 2 A.D.L. 1.97 0.94 Standardized Discriminant Function C o e f f i c i e n t v Canonical Correlation Percentage of Known Cases .Correctly Predicted Cognitive Functioning A.D.L. 1.07 -0.7 0.25 72% Subsection scores were included i n the discriminant function analysis i n order of t h e i r a b i l i t y to minimize the residual unexplained v a r i a t i o n . For > ... de t a i l s of t h i s program see,-'N~:,.Nie - et a l , S t a t i s t i c a l  Package for the Social Sciences, 2nd ed.(New York:McGraw-H i l l Books, 1975), p. 447. 97 Appendix J Comparison o f Score Di f ferences To Nurse C o - o r d i n a t o r and Resident Rat ing o f Change Source o f V a r i a t i o n S.S D . F . M . S . F . P . Nurse Rat ing 643 2 321 E r r o r 5052 37 136 2.35 0.1 (N.S.) T o t a l 5695 39 142 Resident 194 2 97 0.65 E r r o r 5501 37 148 T o t a l 5695 39 142 98 Appendix K Ccfmparison of Nurse Co-ordinators' and Residents' Ratings of Change Nurse Co-ordinator Improved Same Deteriorated c - H tn Improved Same Deteriorated 12 22 19 15 40 99 

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0094597/manifest

Comment

Related Items