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 in THE FACULTY OF GRADUATE STUDIES (School o f  Nursing)  We a c c e p t t h i s t h e s i s as t o the r e q u i r e d  conforming  standards  THE UNIVERSITY OF BRITISH COLUMBIA April, (c)  1979  Jane Buchan, 1979  i  .  In presenting t h i s thesis in p a r t i a l f u l f i l m e n t of the requirements f o r an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y a v a i l a b l e for reference and study. I further agree that permission f o r extensive copying of t h i s thesis f o r s c h o l a r l y purposes may be granted by the Head of my Department or by his representatives.  It i s understood that copying or p u b l i c a t i o n  of t h i s thesis f o r f i n a n c i a l gain s h a l l not be allowed without my w r i t t e n permission.  Department nf^^^AAXCLO  J)J~u.,rAsw " S c A n ? / p^f  The U n i v e r s i t y of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5  Date  QUO^AL  *4  F  /7 7?  ./\J  iAAU) tsryi  (J  ABSTRACT  The purpose o f t h e s t u d y was t o d e s i g n a r e l i a b l e and v a l i d assessment i n s t r u m e n t t h a t would p r o v i d e a m u l t i d i m e n s i o n a l 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 l o n g term c a r e f a c i l i t y .  Use o f t h i s  '.  i n s t r u m e n t would be a method o f c o l l e c t i n g and corrmunicating i n f o r m a t i o n c o n c e r n i n g the f u l l range o f problems e x p e r i e n c e d by t h i s g r o u p , i n a form t h a t i s making.  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  The i n s t r u m e n t c o n s i s t s o f 31 unweighted"items  functioning i n 5 essential  areas - c o g n i t i v e ,  social,  R a t i n g s were based on the  and i n s t r u m e n t a l .  physical,  decision-  measuring emotional,  observations  o f l o n g t e r m c a r e s t a f f who were i n c l o s e c o n t a c t w i t h t h e i n d i v i d u a l o v e r extended  periods.  Reliability  and v a l i d i t y were t e s t e d u s i n g 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 c a r e u n i t .  Both 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 p r o v e d t o be h i g h and i t e m a n a l y s i s ted that, of  w i t h the e x c e p t i o n o f 2 i t e m s ,  indica-  the i n s t r u m e n t p r o v i d e s  f u n c t i o n i n g a p p r o p r i a t e t o t h e sample p o p u l a t i o n .  levels  The i n s t r u m e n t  a l s o showed a h i g h degree 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 t h e 3 major components i d e n t i f i e d as - c o g n i t i v e b e h a v i o u r , independence living,  in daily  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 t h e i n s t r u m e n t and i t s  s u b s e c t i o n s was  demonstrated  t h r o u g h s i g n i f i c a n t r e l a t i o n s h i p s w i t h e x t e r n a l c r i t e r i a , namely i  -  ii  the number of problems l i s t e d on the multidisciplinary problem-oriented record, a health index measure, and a mental status rating.  Further  evidence of the instrument's validity was i t s a b i l i t y to predict, retrospectively, 72 percent of the sample deaths i n 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 i n daily living, was predictive of death within 3 to 9 months i n 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 i n the f i e l d of long term care are provided.  Thesis Chairman  CONTENTS CHAPTER I  PAGE INTRODUCTION  1  The Need f o r a Long Term C a r e Assessment Instrument Study Q u e s t i o n s II  LITERATURE REVIEW  6  Assessment Content Assessment Procedure B e h a v i o u r a l O b s e r v a t i o n Assessments i n Long Term C a r e III  METHODOLOGY  26  Development o f a New A s s e s s m e n t 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 Limitations IV  RESULTS AND DISCUSSION  42  Reliability Validity V  CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS Conclusions Implications  57  a n d Recommendations  NOTES  62  BIBLIOGRAPHY  68  APPENDICES :.  73  iii  LIST  OF T A B L E S  Page  I  II  III  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 O r d e r C o r r e l a t i o n . . . Internal Consistency of Subsections T o t a l Assessment Instrument  43  and  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 , and T o t a l Assessment Scores  iv  .  48  .  50  LIST  OF A P P E N D I C E S  Page  APPENDIX  A -  Nurses'  B -  Sample  C -  Major  Observation  Multidimensional Admitting  Sample D -  Health  E  -  Planned  F  -  Mental  G H -  I  J  -  -  K -  73  Scale Profile  Diagnoses  .  .  .  83  of  Population  84  Index  85  Activity Status  Check  88  Questionnaire  Item A n a l y s i s : Frequency, D i s t r i b u t i o n , and C o r r e l a t i o n s Distribution of Subsection and Total Scores Discriminent Function Analysis for Death Using Subsection Scores .  90  .  91 95  .  97  Comparison of Score Differences to Nurse C o - o r d i n a t o r and Resident R a t i n g o f Change  98  Comparison of Nurse C o - o r d i n a t o r s ' and R e s i d e n t s ' R a t i n g s o f Change.  99  v  ACKNOWLEDGEMENTS I wish t o express my a p p r e c i a t i o n t o the n u r s i n g s t a f f a t The U n i v e r s i t y o f B r i t i s h Columbia Extended Care Unit f o r both the i n t e r e s t the  and time they c o n t r i b u t e d t o  completion o f t h i s r e s e a r c h p r o j e c t . S p e c i a l thanks go t o Dr. John Campbell f o r h i s  c o n t r i b u t i o n and encouragement  i n t h e development  o f the  instrument, and t o Ms. Mary C r u i s e and Dr. David Lawson f o r t h e i r c o n t i n u e d advice and guidance.  vi  Chapter I INTRODUCTION The Need F o r a Long Term Care Assessment Instrument The p r o p o r t i o n o f the p o p u l a t i o n over 65 i s growing s t e a d i l y , from one m i l l i o n i n 1971 (7.7 percent o f the popul a t i o n ) t o a p r o j e c t e d t h r e e m i l l i o n i n 1980, (11.4 percent of  the population)."'"  In a d d i t i o n , people a r e l i v i n g  and becoming more s u s c e p t i b l e t o d i s a b i l i t y d i s e a s e s and degenerative p r o c e s s e s .  longer  from c h r o n i c  Despite i n c r e a s e d e f f o r t s  to p r o v i d e s u p p o r t i v e s e r v i c e s i n t h e community, as many as 7 t o 10 percent o f the aged w i l l continue t o r e q u i r e r e s i 2 3 dential assistance. '  In Canada, as i n many o t h e r c o u n t r i e s ,  t h i s has r e s u l t e d i n a r a p i d expansion  i n t h e number o f p r i v a t e  n u r s i n g homes, and government i n s t i t u t i o n s p r o v i d i n g b a s i c s e r v i c e s such as food, laundry, c l e a n i n g , p r o f e s s i o n a l and/or lay  s u p e r v i s i o n and care on an extended b a s i s .  In 1974, t h e r e  were 1200 such long term care f a c i l i t i e s p r o v i d i n g r e s i d e n t i a l care t o 71,000 Canadians through government-sponsored programs. In the U n i t e d S t a t e s , long term care f a c i l i t i e s p r o v i d e  twice  as many days o f care o v e r a l l than s h o r t - s t a y h o s p i t a l s , and 5 the demand f o r more beds i n c r e a s e s . Admission t o such a f a c i l i t y o c c u r s , not as the r e s u l t  1  2  of a short-term recover, but  disease  from which the person hopes soon to  f o l l o w i n g an accumulation of events such as  p h y s i c a l , mental, and  s o c i a l l o s s e s , f a m i l y d i s u n i t y , and  i n s u f f i c i e n t environmental and p e r s o n a l t i n u e d community l i v i n g . ^ experienced  by t h i s age  i n o r i g i n , c h r o n i c and  resources  In a d d i t i o n , the  f o r con-  illnesses  group are c h a r a c t e r i s t i c a l l y m u l t i p l e i r r e v e r s i b l e i n nature,  and  inter-  7  acting i n manifestation.  Once the move t o a long term c a r e  f a c i l i t y has been made, r e t u r n to the community i s u n l i k e l y and the f a c i l i t y becomes the person's permanent p l a c e of residence.  Under such circumstances,  c o n d i t i o n s alone  i s inadequate.  emphasis on medical  S u c c e s s f u l 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  inte-  g r a t i o n of a v a r i e t y of s e r v i c e s f o r an i n d e f i n i t e p e r i o d . Yet assessments and  information-gathering  procedures  upon which care i s based w i t h i n 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 , i n t e g r a t e d approach. Instead  they have been based on s i n g l e d i s c i p l i n e  perspectives,  or on the acute care model which emphasizes c u r i n g and r e v e r s a l of medical c o n d i t i o n s . r e p l a c e any  Commonly g l o b a l r a t i n g s or l a b e l s  form of assessment.  E r i c P f e i f f e r d e s c r i b e s the f i r s t s i t u a t i o n a c c u r a t e l y : The p h y s i c i a n f i n d s h i s d i s e a s e and t r e a t s i t and so does the h e a l t h care worker. The s o c i a l worker determines e l i g i b i l i t y f o r f i n a n c i a l a s s i s t a n c e and leaves i t at t h a t . Placement w i l l occur without major c o n s i d e r a t i o n for a l t e r n a t i v e provisions.8  3  Such  approaches  group,  but  social,  are  be  particularly  that  with  level be  of  concurrent to  are  does  these social  independence  not  clients.  as  any  aged  are  so  problem  whose  or  physical,  inextricably  information-gathering  traditionally  by  to  and d i s e a s e  the  the  in  many  a number o f can  emotional  and q u a l i t y also  potential  Inappropriate  of  can  potential  predict cases  Yet  diagnostic  aged  capacity  individual  conditions.  neglect  problems  from  capabilities  the  to  acute  functioning  medical  lead  in  and  of  Over-  important  issues  relating  life.  ensue with  used  entities  individual.  accurately  conditions and  is  losses  and  from  Difficulties rehabilitative  that  made  disability  suffering  emphasizing  model  experienced  classification  will  the  conditions  structural  inferences  and problems  or  with  with  misleading.  deals  which  so  any•unidimensional  The m e d i c a l care  counterproductive  and p s y c h o l o g i c a l  interwoven only  are  when  professionals  expectations  interventions  are  assess  formed w i t h instituted  younger  with  9 limited  or  even  professionals are that  seen  negative  become  frustrated  to  be  suffering  cannot  be  altered  attitude  of  Lowenthal,  is  The  custodial most  in  long  an  inevitable  their  term to  a consequence,  and d i s c o u r a g e d  and  sets  care  in."*"^ for  health  the  aged  deterioration  intervention.  responsible  approach  common  As  nihilism"  largely  information-gathering resultant  from  through  "therapeutic this  results.  the  An  According lack  facilities  to  of and  the  care.  replacement  for  a detailed  assessment,  4  p a r t i c u l a r l y among n u r s i n g  s t a f f , c o n s i s t s of g l o b a l r a t i n g s  or l a b e l s such as "regressed"  and  "senile."  Even though such  l a b e l s are e x t e n s i v e l y used, they convey l i t t l e information.  i f any  useful  Wolanin i l l u s t r a t e d t h i s f a c t by examining  the  12 use of the word "confused" on c h a r t s .  There was  o p e r a t i o n a l d e f i n i t i o n of the term found and agreement among s t a f f concerning She  concluded t h a t i t was  no c l e a r  very  i t s appropriate  little usage.  a meaningless term r e f l e c t i n g  staff  discomfort. In a s i m i l a r v e i n , a study by H a r r i s et a l . i n d i c a t e d t h a t nurses tend to l a b e l e l d e r l y r e s i d e n t s on the b a s i s 13 very by who  little  information.  s t a f f members had  Such p o t e n t i a l l y i n v a l i d  devastating  The r e s u l t , of course, was 14  and withdrawal. occurs,  diagnoses  e f f e c t s on the i n d i v i d u a l s ,  were t h e r e a f t e r segregated from other r e s i d e n t s  activities.  of  and  increased d e t e r i o r a t i o n  Others have found t h a t , once such l a b e l l i n g  s u b t l e changes i n behaviour are ignored  as being  of the i n d i v i d u a l ' s " c o n d i t i o n , " even though i t may  be  part  indi-  c a t i v e of an undetected p h y s i c a l problem, drug r e a c t i o n , or depressive  state.  Despite  the obvious dangers of acute care  single d i s c i p l i n e perspectives,  and  n a t i v e method has yet been devised information  concerning  assessments,  g l o b a l l a b e l s , no t o c o l l e c t and  alter-  communicate  the f u l l range of problems experienced  by the e l d e r l y i n d i v i d u a l i n a manner t h a t i s both meaningful and  concise.  that provides  B a s i c assessment i n f o r m a t i o n  needs to be o u t l i n e d  an overview of the person's c o n d i t i o n i n a l l  5  s i g n i f i c a n t areas.  T h i s i s e s s e n t i a l i n f o r m a t i o n needed t o  p l a n , p r o v i d e , and evaluate long term care so t h a t 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 . C o n s i d e r i n g the extended d u r a t i o n o f c a r e , the pervasiveness  o f the impairments, and the l a r g e number o f  p r o f e s s i o n a l s i n v o l v e d , a standard assessment would  serve  both as a means o f m o n i t o r i n g progress over time, and as a f o c a l p o i n t f o r the i n t e g r a t i o n o f s e r v i c e s .  Problem Statement Can designed  a r e l i a b l e and v a l i d assessment instrument  that w i l l provide a multidimensional  e l d e r l y r e s i d e n t o f a long term care  Study  be  p r o f i l e o f the  facility?  Questions  1. What content areas a r e r e l e v a n t t o the needs o f the long term care r e s i d e n t and l i k e w i s e , the goals o f long term care? 2. What method o f i n f o r m a t i o n - g a t h e r i n g 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 f o r use i n a v a r i e t y o f f a c i l i t i e s and geographic  locations?  3. Can t h i s i n f o r m a t i o n be o r g a n i z e d  i n a form t h a t i s  s u i t a b l e f o r use not o n l y i n decision-making  concerning  the i n d i v i d u a l r e s i d e n t , but a l s o 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 , and r e s e a r c h purposes?  Chapter I I LITERATURE REVIEW Assessment Content The  assessment instrument  must p r o v i d e  information  t h a t i s r e l e v a n t t o the needs o f the aged person goals o f long term c a r e .  and the  A review o f the l i t e r a t u r e  suggests  t h a t the problems encountered by the e l d e r l y can be viewed i n terms o f m u l t i p l e l o s s e s t h a t produce a disabling  cumulative  effect.  Although  t h e r e i s wide i n 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 s t r u c t u r e s t h a t reduce optimal p h y s i o l o g i c a l performance. aging process stress." "^ 1  renders the person  In a d d i t i o n , the  l e s s able t o d e a l with  T h i s means t h a t t h e r e i s a heightened  to d i s e a s e and many c o n d i t i o n s such as heart  vulnerability  failure,  a t h e r o s c l e r o t i c v a s c u l a r d i s e a s e , d i a b e t e s , h e a r i n g l o s s , and colitis,  f o r example, may combine t o produce a g e n e r a l s t a t e  of i l l - h e a l t h and reduce the person's a b i l i t y t o cope independently. T h i s decrease and  i n e f f e c t i v e response extends t o c o g n i t i v e  s o c i a l f u n c t i o n i n g as w e l l .  Research i n d i c a t e s t h a t t h e r e  i s a g e n e r a l slowing i n the- speed -.'of, i n f 6'rmatioh-pr.ocessing  7  (including new  problem-solving),  learning  situations,  greater  and a  anxiety  lowered  in  the  tendency  face  to  of  respond  17 appropriately  to  Reaction  environmental to  stress  stimuli.  also  becomes  less  specific  disseminated throughout the body. A generalized e x i s t s s i m i l a r to t h a t found i n the very young.  and  more  response C l a s s i c signs  18 of  disease  become  dysfunction, changes  in  and the  like  behaviour  to  the  of  metabolic  and  inbalance,  may b e  memory  decline  in  ability  eating,  dressing, These  further  to  function  loss,  function  when  decrease  in  work  speed  by  social  needs  deceased,  the  spread  is  faced  entering  with  additional  stress.  In  most  obtained  at  the  decor,  rigid  the  alterations  rules,  lack  in  when  impact  of  are  unrelated  manifestation  drug  idio-  or  an  overall  of  daily  or  of  and  the  the  living  loss  be  lowered.  the  person  environmental  and p e r s o n a l  and  and  may  status  "useful" a  society,  surroundings,  privacy,  of  valued,  facility, and  are  care  are  institutional  confused,  deteriorated  20 companions.  In  addition,  -  person's  friends  economic  social  medical strange  in  fast-paced  spouse  of  changes  highly  term care  forms  of  a  afar,  long  facilities, expense  or  activities  the  response  dependency  Upon  first  infarct,  and p r o d u c t i v i t y  family  the  and d i s e a s e - r e l a t e d  increased  nonspecific  walking."*"^  instance,  of  organ  seem t o t a l l y  disorientation,  perform the  age-related  Consider for  that  myocardial  Illness,  subtle,  F o r example,  grooming,  exacerbated  indicators.  may p r o d u c e  underlying cause.  syncrasy  life.  unreliable  old  supports  and  social  roles  may  8  be d i s r u p t e d and o p p o r t u n i t i e s to e x e r c i s e competency  limited.  There f r e q u e n t l y seems to be a c o n s p i r a c y i n p o l i c y and p r a c t i c e f o r n u r s i n g home s t a f f to assume r e s p o n s i b i l i t y f o r such t h i n g s as housekeeping, care o f c l o t h e s , and s c h e d u l i n g of the r e s i d e n t ' s day... Such decrements i n f u n c t i o n as may r e s u l t from p h y s i c a l and mental d i s o r d e r s are f u r t h e r a m p l i f i e d by d i s u s e . The l o s s of i n s t r u m e n t a l r o l e s i s one of the most d e v a s t a t i n g aspects of becoming an institutionalized.person.21 2 E l d e r l y people view the f a c i l i t y From t h e r e , the prospect  as t h e i r " l a s t home."  of imminent death must be faced  and  23 some p e r s p e c t i v e a c q u i r e d on t h e i r past l i f e . when m a i n t a i n i n g  At a time  a sense of i n t e g r i t y and worth i n the  of i n c r e a s i n g dependency i s one t a s k s , the means to achieve  of the l a s t  i t may  be  developmental  absent.  These m u l t i p l e l o s s e s , a r i s i n g from the aging from i n t e r a c t i n g d i s e a s e s t a t e s , from s o c i a l and  face  "life"  from the i n s t i t u t i o n a l environment i t s e l f ,  process, changes,  c o n s t i t u t e the  major problems w i t h which the e l d e r l y c l i e n t must cope  and  to which long term care must be d i r e c t e d . In t h a t i t i s not always p o s s i b l e t o r e v e r s e  such  l o s s e s , the primary g o a l of care becomes h e l p i n g r e s i d e n t s cope with them so t h a t they are able to reach  full  p o t e n t i a l i n a l l dimensions w h i l e m a i n t a i n i n g  the  p o s s i b l e sense of i n t e g r i t y and worth.  functioning highest  Although expressed  in  a v a r i e t y of ways, the maximization of c l i e n t f u n c t i o n i n g i s how  the most f r e q u e n t l y expressed  theme i n long term care.  There are three b a s i c components to t h i s g o a l :  9  1.  Adaptation loss  2.  individual's  and the  Independence and  the  between 3.  The  Quality of  -  alteration  of  behaviour  The m i n i m i z a t i o n o f  reduction actual Life  -  of  of  excess  a  esteem  is  to  human b e i n g s ,  sense  paramount  to  change suit  dependence  or  that  on  change.  others  (the  difference  functioning).  Although d i f f i c u l t of  of  disabilities  and p o t e n t i a l  and m a i n t a i n i n g  all  realization  of  to  define,  worth,  importance  integrity,  to  and t h e r e f o r e  the  the  must  acquiring and  elderly, be  an  as  acknow-  24 ledged To be assessment level  of  should  of  elderly  tional,  and  Cognitive  the  of  information  those  are  areas  cognitive,  this  includes  judgment,  area  are  long  term  about  care,  the  where  the  These  major  the  person's  major  physical,  " n o r m a l " age  universally  disease  to  physical three  memory,  states,  aged  in  in  or  current  losses  areas,  for  social.,,  .emo-  mental  decrease  inbalance  has  been  in  in  to  mental  other  found  individuals,  Losses  the  thought  decomposition,  affected  processes:  and communication.  intelligence,  persons  and m e n t a l  years  important  mentioned,  decline  all  the  particularly significant  As p r e v i o u s l y  The  or  goals  individual exist.  section  reflect  two  in  care-givers.  instrumental.  can  general  the  provide  resident,  comprehension,  person.  to  of  Functioning.  This  within  goal  relevant  functioning  and needs the  central  even  to  functioning  systems. to  apply  herald  death  while  elderly  within  others  10  maintain  approximately  Loss of  stroke,  of  ability  organic  functional  the in  brain  disorders  these  IQ w e l l  such been  as  or  found  is  common a n d o f t e n  that  late  can  life.  be  so-called  neuroses,  It  into  processes  changes,  depression. extremely  has  same  the  affective/  psychoses,  depression  overlooked  as  result  and  in  the  being  elderly  organically  26 based. help our  T h e two  distinguish  type  of  area  the  A careful  assessment  and o r i g i n  of  the  progression  of  organic  reflects  involves  losses  physical  condition,  Physical  losses  person.  They a f f e c t  comfort,  the  the  co-exist.  loss  and  will  increase  brain  changes.  Functioning.  This and  the  understanding  Physical  often  amount  degree  of  well-being  have  due  to  obvious  which  been  on  found  physical  and d i s e a s e . pain,  and  itself,  be  as  to  are  best  structures  includes  as  elderly the  person's  curtailed, In  overall  capabilities.  the  well  people.  the  It  sensory  activities other  to  of  significance  survival to  functioning  age  strength,  dependence  has  the  fact,  indicator  and  physical of  morale  27 in  the  cation  aged. and  Poor v i s i o n  interaction  intellectual can to  lead the  Social  to  and  point  in  paranoia  others, stimuli  limiting the  interpreting and  interfere  confusion.  the  person the 28  with  communi-  available  receives.  environment,  This even  Functioning. Social  to  of  with  emotional  difficulty  and h e a r i n g  others  on  functioning an  involves  the  i n d i v i d u a l and group  process  basis,  of  both  relating casually  and  11  intimately. relating  Also  to  from which  included  leisure  or  this  of  a  person  is  likely  accomplishment.  Loss  in  this  such  spouse,  as  tional of  the  time  in  death  of  environment.  chairs,  for  example,  to  achieve  area  may b e of  inhibit  activities productive  nature  some  of  sense  due  to  life  friends,  or  the  indicate  can  are  creative,  distance  Studies  area  that  spatial  social  changes institu-  arrangement  interaction  within  29 an  institution,  as  can  Feelings  of  esteem  while and  is  well  ,  elderly.  lead  greatly  of  can  of  being  increased  interaction,  produce  impact  Feelings  feelings  category  emotionally  to  Does  lash  he/she  out  Behaviour  adaption  also  is  hallucinations Other feeling  -  of  depression  loss  of  loneliness in  and  a marginal  suicide  rates  social estrange-  social  in  the  be  that  the  person  and s t r e s s e s into  this  the  passivity  represents in  in  responds  extreme  section  environment. -  become  emotional  (for  mal-  example,  paranoia).  important states  how  withdraw  included  and  identity,  might  reflects  disabilities  depressed?  that  human c o n t a c t  human  Functioning.  This  esteem,  require  30  Emotional  the  privacy.  The n e g a t i v e  by  to  of  and love  documented.  accompanied  position, -| n  from  disorientation.  roles ment  withdrawal  lack  and  aspects  of  emotional  self-perceptions  happiness,  considered  to  morale, come  of  functioning the.  individual  self-image,  under  the  are  broad  -  and o t h e r s concept  of  -  12  "quality of l i f e " .  These feeling states have been demonstrated to be  closely linked to survival and adjustment i n the institutional setting. 31 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 i n terms of i t s humanitarian effectivenes.,. Instrumental Functioning. This category includes the person's ability to maintain independence i n 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 i n 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 i n actual versus potential performance .  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  utilizing  the i n d i v i d u a l as source has d i s t i n c t advantages;  i n f o r m a t i o n can be o b t a i n e d about f e e l i n g s  such as s e l f - e s t e e m ,  s a t i s f a c t i o n , morale, and i d e n t i t y , along w i t h p e r c e p t i o n s of events.  D e s i r a b l e as t h i s i n f o r m a t i o n i s , however, attempts  to measure these a b s t r a c t f e e l i n g s t a t e s through have met  with c o n s i d e r a b l e d i f f i c u l t y  T h i s i s understandable  self-report  i n long term care.  i n t h a t such procedures,  whether of  an i n t e r v i e w , t e s t , or q u e s t i o n n a i r e nature, r e q u i r e a t l e a s t minimal p a r t i c i p a t i o n and c o - o p e r a t i o n from the i n d i v i d u a l may  who  s u f f e r l i m i t e d a t t e n t i o n span, language f u n c t i o n , or  comprehension.  A survey by Whanger and Lewis showed t h a t 71  percent o f 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 s e l f - r e p o r t s  very d i f f i c u l t to  33 o b t a i n and o f q u e s t i o n a b l e v a l i d i t y . many had  sensory  Of those  remaining,  impairments o f 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 t h a t assessment i n f o r m a t i o n i s  needed f o r a l l r e s i d e n t s and not merely f o r those w i t h minimal sensory  and mental l o s s , s e l f - r e p o r t procedures  are of  little  value i n long term c a r e . B e h a v i o u r a l Observation Methods. Another person may  p r o v i d e the assessment i n f o r m a t i o n  based on o b s e r v a t i o n s of the e l d e r l y i n d i v i d u a l . poses some d i f f i c u l t i e s . due to the observer's  Reports  feelings  of behaviour may  toward the person,  T h i s , too, be b i a s e d stereotyped  concepts o f the e l d e r l y , o r by u n r e s o l v e d p e r s o n a l c o n f l i c t s about aging and death.  In a d d i t i o n , o b s e r v a t i o n a l powers vary  14  from  i n d i v i d u a l to  professional Most  attitudes,  and  observations  of  interpretation the  individual,  and  observations.  depending  on  personality,  education. behaviour the  require  inference  on  part  Powers.of  inference  of  are  some  the  degree  person  both  the  of  making  strength  34 and weakness  of  observer  can  relate  sadness,  thereby  On t h e  other  inferences require is  to  their  of  two  concepts,  observers  observers  can  and a  such  made  clear  crying  and  totally  Accurate  An  as  information  same b e h a v i o u r .  such  being  mental  drawbacks, available  can  be  repetitions  observer  for  and e m o t i o n a l  capabilities.  observation, through  to  procedures.  to  insight.  different  observations  definition  of  what  observed.  advantage  sensory  behaviour  from the  competent  be  observation  providing valuable  hand,  Despite  of  behavioural  all  made of  boring or  language  based  repeatedly  has  the  individuals  status,  Assessments,  data  on  without  regardless  skills,  and  behavioural putting  potentially  crucial  the  person  anxiety-producing  procedures. Kastenbaum source  of  information,  interviewer behaviour  and Sherwood,  or  tester  during the  decided  recognizing to  concerning test  use the  period.  the  the  value  of  observations  nature  of  the  They r e c o g n i z e d  this  of  aged  the person's  that,  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 or incomplete perceptual-motor task performance t o s h o w a s 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 have an 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 the s u b j e c t d i d e x h i b i t d u r i n g the session.^ To  that  end  they  designed  the  VIRO  scale.  The  instrument  15  c o n s i s t s o f 13 s c a l e s y i e l d i n g scores on 4 dimensions - v i g o u r , i n t a c t n e s s , r e l a t i o n s h i p , and o r i e n t a t i o n .  I t i s based on  the i n t e r v i e w e r ' s p e r c e p t i o n o f the r e l a t i o n s h i p t h a t developed d u r i n g the encounter, and the r e c e p t i v e n e s s ,  trust-  f u l n e s s , and e n e r g y - l e v e l e x h i b i t e d by the e l d e r l y person. P o t e n t i a l l y t h i s procedure taps both sources o f i n f o r m a t i o n , the e l d e r l y r e s i d e n t and an observer. it  However,  does not e l i m i n a t e the f a c t t h a t the aged person w i l l  undoubtedly show d i f f e r e n t responses, depending on the type of encounter  openness, and a n x i e t y  ( r i g i d test or relaxed  i n t e r v i e w ) , time o f day, c h a r a c t e r i s t i c s o f the i n t e r v i e w e r , and  so on.  Observations  may be accurate but a t y p i c a l o f the  person's behaviour o v e r a l l . I f the r a t e r has had o p p o r t u n i t i e s t o observe and i n t e r a c t w i t h the i n d i v i d u a l over long p e r i o d s and under d i f f e r e n t circumstances,  the i n f o r m a t i o n t h a t becomes a v a i l a b l e  i s more e x t e n s i v e than t h a t o b t a i n e d or i n t e r v i e w s i t u a t i o n .  from a s i n g l e examination  Long term p e r s o n a l care s t a f f , f o r  example, are i n a p o s i t i o n t o observe the aged person over 24 hours, t o 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 s t r e s s  or r e l a x e d , i n t e r a c t i n g with v i s i t o r s , and performing t h e 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  the o b j e c t i v i t y o f the observer, emotional  i t enables  s t a t u s , p a t t e r n s o f behaviour,  i n f o r m a t i o n about  activities,  friend-  s h i p s , and e n e r g y - l e v e l t o become p a r t o f the assessment I f a standard  dull  data.  assessment becomes a u s e f u l and i n t e g r a l  p a r t o f 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 i n i t s completion.  In this way, assessments can be obtained  on a l l persons repeatedly i n an unobtrusive, economical, and potentially reliable manner. The following section traces the development and use of behavioural observation assessments i n long term care.  Behavioural Observation Assessments i n Long Term Care,  The f i r s t standard assessment procedures to tap the observations of personnel i n daily contact with an institutionalized person were developed i n psychiatric hospitals.  These instruments were able to 36  differentiate patients i n "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 f a c i l i t i e s , prior to the late 1960's, u t i l i z e d 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 i n 1965.  I t was designed specifically to measure  improvement i n chronic schizophrenics. Originally consisting of 80 items,  17  the q u e s t i o n n a i r e was  e v e n t u a l l y shortened  to what the  authors d e s c r i b e as 30 " s p e c i f i c a c t i o n s which the nurse should look f o r i n the way  a p s y c h i a t r i c p a t i e n t behaves."  For example:  i s sloppy."  "The.patient  to f l y o f f the handle." factors— neatness,  p a t i e n t i s quick  r e s u l t i n g score r e p r e s e n t s 7  s o c i a l competence, s o c i a l i n t e r e s t , irritability,  depression. ratings  The  "The  Validating  of 300  40  manifest  co-operation,  p s y c h o s i s , and  i n f o r m a t i o n was  psychotic  obtained  c h r o n i c s c h i z o p h r e n i c s who As such,  through  had been  hospitalized  f o r over 2 4 y e a r s .  to a broader  g e r i a t r i c population i s questionable.  continually  i t s applicability Absence  of a n t i s o c i a l , b e l l i g e r e n t , or a g g r e s s i v e behaviour,  which  forms a l a r g e p a r t of the t o o l , produces a high l e v e l s c o r e . However, t h i s may  mean the person has withdrawn i n t o  a s i t u a t i o n which augurs p o o r l y f o r h i s / h e r continued  passivity, survival,  41 a c c o r d i n g to s t u d i e s by MacDonald. personality  Research t h a t e x p l o r e s  t r a i t s of the e l d e r l y as p r e d i c t o r s of  adaptation  have p o i n t e d to v i g o r o u s , h o s t i l e , n a r c i s s i s t i c s t y l e s as being r e l a t e d t o i n t a c t n e s s one year a f t e r admission facility. little  Those who  to a r e s i d e n t i a l  become d o c i l e and p a s s i v e and  exert  c o n t r o l 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." have very l i t t l e  C o n s i d e r i n g these  f a c t s , the N.O.S.I.E. would  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 f r e q u e n t l y used with the t o e v a l u a t e the e f f e c t s of drugs on behaviour. originators  elderly  While the  of the t o o l were a b l e to demonstrate some  18  b e h a v i o u r a l improvement u s i n g the s c a l e , have found  other  researchers  i t too g l o b a l to be of use and not a p p l i c a b l e t o 44  the g e n e r a l g e r i a t r i c  population.  Meer and Krag, r e c o g n i z i n g the l i m i t a t i o n s of  one  assessment procedure f o r a l l age groups, c r e a t e d the  Stockton  G e r i a t r i c Rating S c a l e on the b a s i s o f s t u d i e s with the o l d e r 45 p o p u l a t i o n of Stockton S t a t e Mental H o s p i t a l .  Again  focus i s on psychopathology, but with the a d d i t i o n of r e l a t i n g to physical d i s a b i l i t y .  The  response c a t e g o r i e s , are designed  to measure a l l ward  psychiatric  Items c l u s t e r around  4 f a c t o r s - apathy, s o c i a l l y - i r r i t a t i n g behaviour,  behaviour  communication f a i l u r e .  f a c t o r was  behaviour  For example, "The p a t i e n t  i s o b j e c t i o n a b l e t o others on the ward."  d i s a b i l i t y , and  questions  35 items, each w i t h 3  c o n s i d e r e d to be s i g n i f i c a n t of the e l d e r l y p a t i e n t ' s improvement upon d i s c h a r g e .  the  The  physical  socially-irritating  o n l y very weakly a s s o c i a t e d w i t h the  three f a c t o r s and w i t h p a t i e n t outcome c r i t e r i a .  Again,  other this  r e f l e c t s the f a c t t h a t conformity t o ward r o u t i n e , w h i l e h i g h l y d e s i r a b l e to s t a f f , i s not n e c e s s a r i l y i n d i c a t i v e o f a h e a l t h y unimpaired  person.  Despite t h i s evidence,  the f a c t o r  f o r 9 items on the s c a l e , whereas a f a c t o r such as i s r a t e d on a s i n g l e Although  accounts  confusion  item.  P l u t c h i k e t a l . r e v i s e d the s c a l e i n 1970,  p s y c h i a t r i c approach continued,  c o n f u s i o n was  still  rated  g l o b a l l y , and p e r c e p t i o n of w i l l i n g n e s s to h e l p around the 46 ward remained a l a r g e p o r t i o n of the instrument. Assessments such as the N.O.S.I.E. and the Stockton  the  19  Scale concentrate p r i m a r i l y i f not e x c l u s i v e l y , on psychol o g i c a l impairment  and have ignored many aspects o f the person's  f u n c t i o n i n g such as p h y s i c a l h e a l t h , s o c i a l and emotional components.  Other instruments have gone t o the o p p o s i t e  extreme o f d e a l i n g w i t h p h y s i c a l impairment, of  classification  disease states, or ratings of d i s a b i l i t y i n s e l f - c a r e to  the e x c l u s i o n o f mental In  and s o c i a l p r o c e s s e s .  196 8, L i n n , L i n n , and Gurel p u b l i s h e d t h e i r Cumu-  l a t i v e I l l n e s s R a t i n g S c a l e designed t o assess p h y s i c a l 47 impairments. of  The instrument i s based on r a t i n g s o f s e v e r i t y  impairment  i n 5 body systems - c a r d i o v a s c u l a r , g a s t r o -  i n t e s t i n a l , musculo-skeletal-integument, n e u r o p s y c h i a t r i c , and general. of  I t r e p r e s e n t s a f a i r l y r e l i a b l e and r a p i d  pathology.  bear l i t t l e  assessment  However, s t r u c t u r a l l o s s e s , as mentioned, may  r e l a t i o n s h i p t o f u n c t i o n i n g i n the e l d e r l y  L i k e w i s e , i t i s d i f f i c u l t t o separate one body system another.  person. from  C o n s i d e r i n g i t s s t r u c t u r a l b a s i s , t h e instrument  would be p r i m a r i l y u s e f u l i n p l a n n i n g medical but s e v e r e l y l i m i t e d as a comprehensive  interventions,  assessment  of the  person. Other instruments such as Rosencranz Health Index  and P i h l b a l d ' s  (1970) l i s t medical c o n d i t i o n s and attempt t o 48  weight the s e v e r i t y o f each.  Such attempts have been l a r g e l y  u n s u c c e s s f u l due t o the d i f f i c u l t i e s  i n h e r e n t i n the d i a g n o s t i c  c l a s s i f i c a t i o n system, namely t h e d i f f e r e n t impact o f the same d i s e a s e on d i f f e r e n t i n d i v i d u a l s , and t h e wide range o f s e r i o u s n e s s w i t h i n one d i a g n o s t i c category.  20  The  difficulties  to  the  of  health.  Most o f  in  nature.  For example,  a  adoption  6-category  "capable  of  of  in  representing  "disability" the  early  as  unsupervised  a better  disability  Waldman  classification  health  activity"  for  this  overall  scales  and Fryman  system  in  global  developed  impairment ranging  through to  led  measure  were  (1964)  way  "persons  from  requiring  49 hospital  care."  considerable disease or  or  In  on  a  for  and c o n f u s i o n  for  over  example,  the  person's  Linn  contains  3-point  16  more  devised  items  As  the  a  purposes  comprehensive  represented  This tasks been added  of  measures as  the  eating,  widely  used  the  Katz'  capabilities, more  measures  debiliof  Disability Rating  disability 50  in  scale.  detailed  person's  in  to  dependence  within  each  as  grooming,  rehabilitation  detail  these  Daily  independence  dressing,  the  it  to  Scale  specific  Although  enough  individual,  A c t i v i t y of  further  Reliable or  in  of  is  of  obtain  areas  designed a  considered 51 adequate f o r gross s c r e e n i n g and ward c l a s s i f i c a t i o n . F u r t h e r breakdown o f d i s a b i l i t y i n t o i t s component p a r t s 52 was  profile  remaining  result,  for  importance  behaviour  Rapid  describing  and not  the  allow  detailed.  frequency-of-occurrence  research  ratings  judging  disoriented  g r a d u a l l y became 1967  global  in  than muscular weakness.  disability  which  bias  disability  whether,  tating  N a t u r a l l y such  in  is  Living  Scale.  performing  and a m b u l a t i o n ,  assessments.  measurement 53  by  such and  has  Lowenthal  expanding  the  levels  area. measures  psychiatrically-based tests,  are,  they,  document  only  like one  the  medically  aspect  of  the  21  person's  behaviour.  indicate  the  result  of  source  In  or  merely  poor  a l l  of  or  and Mental  physical  Linn,  these  is  provided that  performance,  conflict  Gurel,  19 72,  combining  Physical  of  information  impaired mental  depression,  by  No  with  the  approaches of  it  is  functioning,  and L i n n  Impairment  whether  would the  severe  staff.  made in  a  a major scale  advance  called  the  Function Evaluation of  the  54 Aged  (P.A..M. I . E . ) •  it  is  to  the  the  designed  to  Closely quantify  institutionalized categories:  sensori-motor  impairment  psychological  deterioration  care  apathy,  dependency  a wide  (a)  to  range  elderly.  following  withdrawal,  related  The  the of  77  physical  Stockton  behaviours items  and b e h a v i o u r a l  (characterizing  down  status),  deterioration), physical  into  (ambulation,  disorganization,  both  relevant  break  infirmity  and b e d f a s t - m o r i b u n d (mental  scale,  (b) confusion,  and  (c)  and mental  self-  deteri-  oration) . Although total  evaluation  suffers a  shows  considerable  approach to  some m e t h o d o l o g i c a l  specific  behaviour  limits  the  change  over  to  person's  the  it  time.  in  other  conformity  adjustment point  of  19 74 B r o d y  the  to  the  Each  and the  scales,  24 o f  ward r o u t i n e ,  hospital. from  person,  dichotomy.  sensitivity  around the  individual's In  As  aged  toward  shortcomings.  a yes-no  instrument's  helpfulness approaches  on  the  promise  By so  more  instrument  item  This  describes  severely  identification the  77  items  co-operation,  doing,  institution's  a  the  rather  of relate and  scale than  the  view. et  al.  took  the  assessment  procedure  one  22  step  further  which  were  by m e a s u r i n g what  defined  as  "the  they  called  discrepancy  excess  existing  disabilities,  when  functional 55  incapacity  is  greater  Evaluation  of  baseline  interpersonal  those able  in  was  no  to  Even  this  subjective  a  pre  were  or  had not  the  by  improvement  potential  rather  The with  the  distinct move  major  levels  for  systems  widely The  the and  ratings  of  in  staff  procedures  concentrated  appropriate needs.  For example,  those  of  in involved  improvement.  are  highly  unreliability. in  thinking  the  individual's  came into  funding. patient  that  This classi-  represent  the  determining  the  date.  and n u r s i n g needs client  used  facilities  precise  systems  on  "consider-  methodology  government of  rated  a  demands.  term care of  these  reaching  assessment  long  purpose  and  advance  early  assure to  terms  of  Unfortunately  such  to  could  end  from  rating  an  status,  again  the  procedures  medical  A t the was  inconsistency,  in  is  mental  addition,  used  individual's  patterns  doing  development it  self-care,  ranging  In  case,  advance  the  taken.  data.  reflected  of  status,  scale  complying with  differentiation  necessitated  fication most  next  than  of  s t r u c t u r e d methodology  the  authors  impairment.  improvement."  those  Nevertheless, evaluating  or  bias,  areas  individual  7-point  been  and i n v i t e  were  the  post  also  in  physical  "considerable  of  therapy  i f  therapy  standardized  collection the  functioning  utilizing  decline"  w a r r a n t e d by  characteristics  intensive  factors  there the  of  that  relationships,  and p e r s o n a l i t y period  than  so  placement RAPIDS,  on  that  administrators  and a d j u s t a general  staffing classification  23  scheme 6  developed  areas  considered  is  sional  California of  primary  in  1966  by  importance  Salmon in  et  a l . ,  rated  determining  , 56 needs.  nursing  Each  in  scaled effort  R -  Restorative  A -  Activities  P  -  Problem Behaviour  I  -  of  Daily  Living  Illness  D -  Dependency  S  Social  -  Procedures  from 1 to expended  -  General  Services 5 depending  or  on  required in  the  the  amount  of  profes-  area. 57  Similar Ashton  systems  (1968),  5 8  were  and the  All  represent  judgements  the  number o f  tasks  of  the  person's  focusses person  on  the  functioning. category the  is  person's In  is  needs  of  back  acclaimed  sole  mental  1973, to  of  staffing  for the  to  item  of  needed  rather  supervision  in  based  This than  on the  or  social  behaviour.  be  most  progressive  again elderly  problem  scheme  and M c K n i g h t ^  on  physical  RAPIDS  McNitt,  5 9  ratings  the  the  Jones,  (1968).  and g l o b a l  concentration  in  (1958) ,  Nursing  rehabilitation.  condition  the  Burrack  requirements  facility  a  for  by  College  and procedures  The need the  Boston  potential  and r e v e r t s  developed  that  behaviour  reflects  published  patient  what  classification  61 62 system  for  assessment by  four  Harvard,  long  term  procedure  major  care is  research  John Hopkins,  to  the  date.  '  result  of  groups  This a  from Case  and S y r a c u s e  multipurpose  collaborative Western  Universities.  effort  Reserve, The  scale  24  i s c o n s t r u c t e d so t h a t i n f o r m a t i o n can be expanded o r c o n t r a c t e d i n t o three d i f f e r e n t l e v e l s o f d e t a i l , depending on the purpose of the assessment.  I t i s based on o b j e c t i v e r a t i n g s o f 64 items  d i v i d e d i n t o 5 areas:  demographic i n f o r m a t i o n , f u n c t i o n i n g  s t a t u s , impairment items, medical  s t a t u s / r i s k f a c t o r items,  and m e d i c a l l y - d e f i n e d c o n d i t i o n s . Some o f the i n f o r m a t i o n r e q u i r e d f o r the assessment depends on up-to-date, accurate records o r must be obtained d i r e c t l y from the i n d i v i d u a l o r a r e l a t i v e . i n f o r m a t i o n category  A l s o , the medical  r e q u i r e s a p h y s i c i a n ' s assessment.  Though more complete than many, t h i s assessment procedure r e q u i r e s more time, p e r s o n n e l , t h a t depends s o l e l y on s t a f f  and i s l e s s p r a c t i c a l than one  observations.  T h i s 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 and  i s o r i e n t e d toward the aged i n d i v i d u a l .  any  items concentrate  person's l i f e . concentrates  However, few, i f  on the p s y c h o s o c i a l aspects  o f the  The one item t h a t may be c o n s i d e r e d  on the appropriateness  o f behaviour,  as such,  calling for  judgments from the f a c i l i t y ' s p o i n t o f view, again. authors  approach  The  themselves, admit t h a t there i s a need t o develop  d e t a i l e d p s y c h o s o c i a l d e s c r i p t o r s , but suggest t h a t assessments 63 cannot await t h e i r appearance. Obviously,  whether designed  for psychogeriatric patients  of State Mental H o s p i t a l s o r f o r t h e c l a s s i f i c a t i o n and p l a c e ment o f a broader aged group, the p r e s e n t l y a v a i l a b l e assessment instruments  s u f f e r c o n s i d e r a b l e short-comings.  They emphasize  p s y c h i a t r i c / m e n t a l f u n c t i o n i n g t o the e x c l u s i o n o f p h y s i c a l  25  f u n c t i o n i n g o r v i c e v e r s a , o r they r e l y on a s i n g l e c r i t e r i o n such as A.D.L. t o r e f l e c t the combined e f f e c t o f a l l impairments.  Although great s t r i d e s have taken p l a c e r e c e n t l y i n  combining the p h y s i c a l and mental, components o f f u n c t i o n i n g , much remains t o be accomplished with r e s p e c t adaptive  t o the s o c i a l /  and emotional components.  On the b a s i s o f t h i s a n a l y s i s , a number o f g u i d e l i n e s can be e s t a b l i s h e d f o r the development o f a more comprehensive assessment procedure. 1. The focus o f the assessment should be on the needs o f the aged person r a t h e r than those o f the f a c i l i t y . 2. The assessment should provide  information  concerning the  e l d e r l y person's f u n c t i o n i n g i n a l l areas - c o g n i t i v e / mental, emotional, s o c i a l , p h y s i c a l , and i n s t r u m e n t a l , so t h a t a complete p r o f i l e o f the i n d i v i d u a l i s obtained. 3. Information should be such t h a t the i n d i v i d u a l ' s s t r e n g t h s and weaknesses can be i d e n t i f i e d , r a t h e r than p r o v i d i n g a l i s t o f impairments. 4. The instrument should  c a l l f o r observations  minimal s u b j e c t i v e i n t e r p r e t a t i o n . b i l i t y or c o n s i s t e n c y 5. The assessment should  t h a t demand  In t h i s way,  relia-  o f the assessment i s enhanced. use terms and c l a s s i f i c a t i o n s r e a d i l y  understood by a l l p r o f e s s i o n a l s working i n long term 6. The assessment should  be a p p l i c a b l e t o the d e f i n e d  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 . accurate the  care.  group  To be  and s e n s i t i v e t o s u b t l e changes, i t must r e f l e c t  s p e c i a l c o n d i t i o n s and problems o f t h a t group w i t h i n  the environmental o p p o r t u n i t i e s  and c a p a b i l i t i e s they possess.  Chapter  III  METHODOLOGY  Development  Item  of  review,  a new  observations  the  of  long  A).  examined  and a p o o l  complete  range  These  items  cognitive,  of  to  example,  the the  daily  of  the  instrument  staff  was  designed  (See were  instruments  items  gathered  that  found  in  classified social,  the  into  represented  various five  emotional,  literature  utilizing  reviewed  items was  based  cognitive person's  has  life  64  this  from  individual  judgment,  functioning  the  the  approaches.  basic  and  the  areas,:  instrumental  or  functioning.  instrument  contents  hension,  then  from  the  content  physical,  Selection  measure  term care  of  derived  assessment  Initially,  were  independent  new  guidelines  geriatric  Appendix  of  Instrument  Selection Following  the  a New A s s e s s m e n t  this  on  as  the  pool  great  included  in  person),  comprehension,  predicting  section  refer memory  to  to  I.  in  the  item'  For  is  intended  processes:  compre-  the  future  This  individual 65  progress.  orientation  (recent  of  Chapter  and c o m m u n i c a t i o n .  significance  and i n  in  subsection  important mental  memory,  inclusion  significance  outlined  functioning  for  (to  area in  of terms  Items  time,  and r e m o t e ) ,  to  place  judgment,  27  attention  span,  resulting  from  information  the  about  the  group  within  Items  forms  stimulation), another  co-operation by  others).  in  the  (how  manner  treated  by  staff  Items  The degree  They  area of  of  aged  ability  (the  the  person  great  individual person's  basis), is  and  perceived  potential is  and  individual's  (refers  to  measure  individual  to  be  significance  approached  behaviour  -  response  section to  and  trusting/suspicious,  These  items  may  body  maintain  to  items  intactness,  living  response.  identify the  person  include  vision  (A.D.L.)  independent  recog-  lifetime  and d i s c o m f o r t These  within  emotional  attempts  the  relaxed/  and  reflect  an u n h e a l t h y  reason.  daily  measure  stresses  animated/depressed,  level,  to  an  or  deterioration  of  and  residents.  whatever  comfort  the  section  activities  physical, well-being  for  on  individual  o r warn o f  activities  person's  has  include  physical  to  and problem a r e a s ,  others  the  emotional  illness.  essential  a one-to-one  adaptive  of  patterns  level, The  the  of  experiencing  energy  the  passive/aggressive,  personality  is  item  the  pattern  nition/denial  to  group  on  and o t h e r  environment.  anxious,  the  which  within  individual's the  to  final  is  problems  Detailed  functioning  interaction  person  stroke).  participation  in  speech  measures.  co-operative  This  as  change  social  include  aphasia,  areas  relate  participation  to  of  the  to  of  response  such  different  patterns of  injury  supportive  ability  basis.  (including  patterns  of  items  person's  the  of  planning The  speech  cerebral  identification to  and  and  section  hearing.  measures  functioning  in  the  28  face o f m u l t i p l e l o s s e s or d i s a b i l i t i e s .  Items i n c l u d e  d e t a i l s of d r e s s i n g , e a t i n g , grooming, ambulating, chewing, bowel and bladder Subjective  functioning. assessment o f the e l d e r l y person's f e e l i n g  s t a t e o r s e l f - p e r c e p t i o n s c o u l d not be they were c o n s i d e r e d behaviour i n other  to be connected d i r e c t l y to o b s e r v a b l e  (such as aggression areas,  i n c l u d e d except when  and d e p r e s s i o n ) .  a d d i t i o n a l information  manage the i n d i v i d u a l case.  The  may  In t h i s ,  be r e q u i r e d  instrument p r o v i d e s  l i n e o f the b a s i c content areas f o r assessment and intended  as  to  an  out-  i s not  to be the s o l e source of p r o f e s s i o n a l knowledge about  the aged i n d i v i d u a l . Format S e l e c t i o n Items s e l e c t e d were then r e w r i t t e n i n a form t h a t would r e f l e c t the  f u l l range of p o t e n t i a l f u n c t i o n i n g f o r 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 . r a t i n g s c a l e was  The  graphic  chosen f o r t h i s purpose because i t p r o v i d e s  q u a n t i f i a b l e information  of a rank or o r d i n a l nature, i n a  form t h a t i s q u i c k l y and  e a s i l y completed.  The  v i s u a l graph represents  (4  3  2  _i  I  i  1). L  behaviours i n a form t h a t i s r e a d i l y  understood, n e c e s s i t a t i n g very  little  explanation  or d i r e c t i o n  to r a t e r s . Nevertheless,  such s c a l e s are prone t o a number o f  sources o f b i a s , such as the an o b j e c t i n the constant T h i s may  "halo e f f e c t or tendency to r a t e  d i r e c t i o n of a g e n e r a l  impression."  r e s u l t i n a s t a f f member r a t i n g the aged i n d i v i d u a l  67  29  continually a nice  h i g h on  p e r s o n who Another  all  is  items  very  difficulty  because  he/she  little  trouble  is  tendency  the  is  felt  around of  the  raters  to  be  facility. to  respond  68 disproportionately rating  positions  nated.  Although  forced  to  Despite scale it  take  these  is  both  allows  a  In observed  is  considered Vision:  some  middle of  possible  in  assessment defined  r a t e d on to  may b e  bias, for to  lost,  the  be  and then  (with  each  in  to a  item  For  aid of  is  other.  behaviours  scale.  the  the  4  elimi-  rater  graphic  rated  the  is  the  observers  instrument,  a numerical see  choice  d i r e c t i o n or  of  items  By p r o v i d i n g  neutral  and easy  number o f  The a b i l i t y  this  one  sources  interesting  new  5,  category.  sensitivity  a position  broadly are  the  instead  large  the  in  rating use,  and  short to to  time.  be be  example;  glasses,  if  necessary).  4  3  2  i  1  1 -  4 = No p r o b l e m o r v e r y slight difficulty seeing.  The  staff  member p l a c e s  the  scale  that  most  a  1  I  1 = Severe problem. Unable t o see a n y t h i n g b u t vague o u t l i n e s , shadows. Functionally blind.  c h e c k mark  closely  or  represents  circles the  the  elderly  point  in  person's  behaviour. Each haviours,  item  thus  represents  exhaustive  a  large  number o f  specifications  possible  c o u l d not  be  beprovided  30  for  each  typical of  the  lines  point  on  behaviour scale.  In  them  Informal gerontology On t h e  further  refined  has of  contains a  outlined  this  way  rating  the  were  and  of  A.D.L.  to  anchor  staff  be  are  observed  validity  of  the  extreme  without  obtained  this  divided 4 with  1 the  ends  and  the  guide-  severely is  lost.  psychologists  initial  suggestions  into  so  observations nurses  their  of  provided with  from senior at  examples  development  instrument  a preliminary instrument  from 1 to and  the  to  feedback  items  functioning The  is  that  basis  31  Consequently,  were  also  stage.  It  scale.  c o n c e r n i n g what  restricting  in  the  was  constructed.  5 subsections.  4 representing  Each  the  item  highest  level  lowest.  section  was  adopted  from a program  developed  70 and of the  tested  by  Dr.  J .  evaluating  and  communicating A . D . L .  basis  Since of  it  the  added  of  to  original  a rehabilitative  has  most  Campbell.  demonstrated comprehensive  the  assessment  scoring  scale),  it  (and was  at  the  testing  in  its  original  in  popular A.D.L.  data  This  p a r t i a l dependence,  felt  is  form.  as  it who  would were  To r e v e r s e  (1and  the  be  other for too  it  is  one  was  retained  for  to  have  sections  its  complete  3-  complete the of  the  use  of  the  confusing  to  staff  familiar with it  and  for  future  forms  care.  charts,  desirable  recommended  that  facility  be  term  section  collection  would  same d i r e c t i o n this  long  method that  and v a l i d i t y  for  Although i t  instrument  performance  this  dependence). the  reliability of  a pictorial  for  2-  in  is  approach  instrument.  independence,  scoring  It  may h a v e  the  A.D.L.  resulted  in  chart many  31 m i s r a t e d items.  T h e r e f o r e i t was deemed e a s i e r t o i n v e r t the  s c o r i n g a t the data a n a l y s i s stage. In t h i s form, the instrument  i s able t o p r o v i d e i n f o r m a t i o n  concerning s p e c i f i c f u n c t i o n s such as memory, o r speech. n a t i v e l y , i t can be aggregated of the i n d i v i d u a l  into a multidimensional  (Appendix B ) , o r compiled  Alterprofile  i n t o a composite  assessment score, depending on the use f o r which i t i s intended. P i l o t Testing. I n i t i a l impressions nurses confirmed  from f o u r experienced  geriatric  t h a t the instrument was c o n s i d e r e d compre-  hensive and p o t e n t i a l l y u s e f u l i n long term c a r e . p r e t e s t was then conducted  t o i d e n t i f y gross  A brief  difficulties  i n wording and item i n t e r p r e t a t i o n , i n p r e p a r a t i o n f o r the major t e s t o f r e l i a b i l i t y and v a l i d i t y t o f o l l o w .  F i v e nurses  at the extended care u n i t assessed one r e s i d e n t w i t h whom they were f a m i l i a r u s i n g the new assessment instrument.  From t h e i r  r a t i n g s i t appeared t h a t the item r e l a t i n g t o aphasia was being marked i n c o r r e c t l y . f u n c t i o n i n g i s so important  However, s i n c e t h i s area o f to the i n d i v i d u a l and l i k e l y t o  a f f e c t many other areas., i t was r e t a i n e d f o r f u r t h e r a n a l y s i s . Great d i f f i c u l t y was encountered a g g r e s s i o n and p a s s i v i t y .  i n the s c a l i n g o f  In order t o be c o n s i s t e n t w i t h the  o t h e r items, one end o f the s c a l e must r e p r e s e n t the 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 and the o t h e r the lowest.  Therefore,  a g g r e s s i o n and p a s s i v i t y c o u l d not be p l a c e d as p o l a r i t i e s of the same behaviour,  as n e i t h e r r e p r e s e n t s h i g h  level  32  functioning.  Initially,  2 s c a l e s were presented and the r a t e r  asked t o mark one o r the o t h e r . .  Passive/ Aggressive:  N.B. Mark o n l y one o f the s c a l e s below. The score o f 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 o f p a s s i v i t y and a g g r e s s i v e n e s s .  (a) P a s s i v e 4  3  2  1  4 = Well-balanced. Shows s u f f i c i e n t a s s e r t i v e n e s s and independence. Not too p a s s i v e . 1 = Extremely p a s s i v e and dependent. W i l l not attempt anything on h i s own. Makes no attempt t o c o n t r o l what happens o r events around him/her.  or  (b) A g g r e s s i v e 4  3  2  1  11 4 .= Well-balanced. or a s s e r t i v e .  Not too a g g r e s s i v e  1 = Extremely a s s e r t i v e and o v e r l y aggress i v e t o the p o i n t o f being h o s t i l e o r threatening. T r i e s t o c o n t r o l the environment t o t a l l y .  However, t h i s format was c o n f u s i n g t o s t a f f and r e s u l t e d i n no r a t i n g a t a l l o r incompatible r a t i n g s on both s c a l e s .  Finally,  a s c a l e was c o n s t r u c t e d t h a t was c o n s i s t e n t w i t h the o t h e r and r e a d i l y understood  by s t a f f members.  items  33  1  Passive  Well-balanced  Aggressive 3  2  4  3  4=Well-balanced. l=Extremely a s s e r t i v e Not too a g g r e s s i v e and o v e r l y a g g r e s s i v e or p a s s i v e . to the p o i n t o f 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 .  I t was  2  1  _l_  !  l=Extremely p a s s i v e and dependent. W i l l not attempt anything alone. Makes no attempt to c o n t r o l events around him/ her.  a l s o noted d u r i n g the p i l o t t e s t i n g t h a t  staff  were unable to s p e c i f y the r e s i d e n t ' 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. c h a r t .  That i s , they  were a b l e to s t a t e the r e s i d e n t ' s o v e r a l l l e v e l of dependence and independence  i n d r e s s i n g , e a t i n g , grooming, or ambulating,  but not h i s / h e r 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 , o n l y one score was  the four areas.  T h i s was  used f o r each of  c a l c u l a t e d by averaging the  specific  items t h a t were r a t e d w i t h i n each area and rounding to the n e a r e s t whole number. Completion to be 15 minutes 5 to 10  time f o r the i n i t i a l assessment and f o r second and subsequent  was  estimated  assessments,  minutes.  With these changes,  the new  assessment  instrument  was  c o n s i d e r e d ready to be submitted to more r i g o r o u s r e l i a b i l i t y and v a l i d i t y  testing.  34 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  Sample Assessments were o b t a i n e d at d i f f e r e n t time for  76 r e s i d e n t s o f a 300-bed extended  the f i r s t  intervals  care u n i t d u r i n g  two years of i t s o p e r a t i o n . (1977,1978).  Admission  to  the f a c i l i t y  of  p h y s i c a l and p e r s o n a l f u n c t i o n i n g , communication,  medical  i s based on c r i t e r i a of need i n the areas and  problems.  The assessments  were o b t a i n e d as p a r t of the informa-  t i o n - g a t h e r i n g of a major r e s e a r c h p r o j e c t examining  the  71 s t r e s s o f r e l 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 r e q u i r e d the r e s i d e n t s to be a t l e a s t  moderately  o r i e n t e d t o p l a c e and person, and be capable of i n t e r a c t i n g i n an i n t e r v i e w s i t u a t i o n w i t h some degree  of comprehension.  S u b j e c t s were r e f e r r e d by the u n i t ' s admission s c r e e n i n g committee i f they met  the study's requirements.  were v i s i t e d by a r e s e a r c h e r who consent.  Then they  o b t a i n e d informed w r i t t e n  Most s u b j e c t s were o b t a i n e d d u r i n g the f i r s t  few  months of the u n i t ' s o p e r a t i o n w i t h the h i g h e s t frequency of  admissions o c c u r r i n g i n June and J u l y of The  average  1977.  sample r e s i d e n t s were aged 44 to 99 years w i t h an age of 80.  S i x t e e n of the r e s i d e n t s assessed were  men  35  (21  percent)  and  the  facility  as  percent  of  disease the  of  major medical  their  were of  are  percent  for  all  were  (See  from  the  frequency  It  is  most  study.  and  is  77. some  heart for  interesting  to  to  of  problems  the  severely  This  68  having or  to  Appendix C  relating  56 percent  who w e r e  as  disorder,  problem.  comprise  male  residents  diagnosed  both  compares  gives  total mentally-  some  and p e r v a s i v e n e s s  of  such  problems  obtained  facility  facilities.  Conditions staff  subject  Follow-up after  rating  resided  admission.  2-3  during  weeks?"  most  Raters  and have  the  provide  In  positively  well  late  were each to  moving  then case  the  to  feedback  about  term care  equally aides.  to  staff  time  the  the  U.B.C. 3,  members  question,  hours  have  from  obtained, at  worked w i t h  evening  informal  long  to  The m a j o r i t y  likely  were  was  prior  assessments  responded  were  32  diagnoses).  residents  excluded the  This  2 categories,  though  residential  past  admitting  first  percent).  a behavioural  functioning,  even  One  and  of  the  indication  the  subjects  as  cognitive  Test  of  age  injury,  impaired  in  i n which  cerebral  that  sample,  (79  The a v e r a g e  majority  frequency  note  women  a whole  female. The  form  sixty  of  assessments  when to  staff  complete  concerning  its  d i v i d e d between The purpose  of  form  used they  the  obtained  felt  they and  content.  registered the  know  assessment and  months  who  during  were  members the  a n d 12  were  him/her d i r e c t l y  which  unit.  6,  "Who f e e l s  in  nurses  research  and  the  36  nature  of  the  assessment  was  of  completion  time.  estimation  participation  was  voluntary  explained  to  staff,  They were  and  could  be  including  informed  that  terminated  at  an  any  time.  Reliability Test-Retest assessment unit  each  through  instrument assessed  daily  reassessed time  less  fresh  In  order over  one  than  same ten  Ten to  in  the  minds  increase  the  likelihood  change  in  the  of  to  another  was  familiar  with  them.  different  assessments  nurses.)  The two was  was  render  the  explored  simultaneously  it  that  nurses  whom t h e y  fourteen  days felt  the  while  a  of  at  were  later, that  first  person's  The c o n s i s t e n c y  assessed  cause  staff  raters,  stability  the  the  U.B.C.  familiar they  each  a period  of  assessment  longer  period  condition  would  would  interim.  Inter-rater rater  30  It  would  the  the  with  residents. days  test  time,  resident  contact.  the  to  and  (That  essential  the  having  each  instrument  each  independently is,  done  nurses  by  of  by  the  same t i m e  were  not  the  both  same  raters  30  two  resident  at  that  of  in  staff  nurses  have  two  two  different  each  know t h e  one  residents  would by  from  case  be-  elderly  person  well. Item item  was  provided items  Analysis  analyzed were  should  to  The d i s t r i b u t i o n assess  appropriate have  a mean  to  that the  score  the  ratings  levels  sample  that  of  of  for  functioning  population.  falls  near  each  the  Ideally, middle  of  37  the  potential  indicates  choices  the  raters  available have  made  and have use  of  a distribution  the  entire  range  that of  72 the  continuum. Internal  its  Consistency  relationship  score. the  In  this  instrument  classified total  or  to way,  that  assessment  be  internal  structure  exploring  the  of  the  and the  and  be  and t o t a l of  that  to  was  The  also  test  assessment  items were  significantly  identified.  between  total  analyzed  items  assessment  relationship  subsections  score  contribute  could  was  consistency  evaluated  d i d not  score  item  subsection  the  could  component  the  the  Each  within mis-  to  the  underlying  analyzed  subsections  and  by  between  score.  Validity Validity test the  that  the  expected  assessment the  to  (c)  and  participation period,  structured based  show  on  in (e)  information.  (a)  a weighted  nurse  with  (b)  the  all  or  of  number o f physical  observations  structured  and  was,  being/impairment.  index  (d)  a brief  fact,  were  used  to  measuring Those  part  that  of  the  A m u l t i d i s c i p l i n a r y summary  problems,  interview,  the  well  in  a relationship  symptoms,  measures  instrument,  of  were:  resident's  diagnoses  week  level  score  prescribed,  A number o f  assessment  individual's  were  of  Criteria  activities  evaluation (f)  of  a valid  on  of  medications health  the  the  mental  based  on  resident's  unit  over  status  diagnosis  co-ordinator/physician  list  of  a  two  using  a  aphasia  and/or medical  record  38  1. Problem-Oriented  Record - T h i s method o f record-keeping i s  designed f o r m u l t i d i s c i p l i n a r y use and o u t l i n e s t h e i n d i v i d u a l ' s problems  (both o f permanent and temporary  nature) as the b a s i s  73 of  care-giving.  In the U.B.C. u n i t , an i n i t i a l  l i s t of  permanent or c h r o n i c problems i s made on the person's r e c o r d f o l l o w i n g the f i r s t admission.  i n t e r d i s c i p l i n a r y care conference  As such, i t can be expected t o enumerate the  major problems and impairments of  functioning.  o f t h e i n d i v i d u a l i n a l l areas  I f the assessment instrument i s an a c c u r a t e  measure o f t h e e l d e r l y person's w e l l - b e i n g and it  after  impairment,  should be h i g h l y r e l a t e d t o the number o f problems  listed  on t h e P.O.R. 2. M e d i c a t i o n - Since m e d i c a t i o n i s p r e s c r i b e d f o r lowered f u n c t i o n i n g i n many areas  ( p h y s i c a l , emotional, mental) i t was  hypothesized t h a t the number o f medications p r e s c r i b e d f o r each i n d i v i d u a l would be r e l a t e d t o t h e l e v e l o f h i s / h e r w e l l being or. impairment.  T h e r e f o r e , scores on t h e assessment  instrument were compared t o the number o f medications r e c e i v e d by each r e s i d e n t i n the sample. 3. Health Index S c a l e - T h i s s c a l e was adapted  from t h e Health  74 Index developed by Rosencranz and P i h l b l a d i n 1970 and Linn's 75 Cumulative  Index S c a l e  (196 8).  The instrument  classifies  diagnoses, symptoms, and problems o f a p h y s i c a l nature  into  c a t e g o r i e s w i t h each item a s s i g n e d a weight  o f 2 o r 4 depending  on the degree o f s e r i o u s n e s s i t r e p r e s e n t s .  (See Appendix D).  S p e c i a l c a r e requirements  and problems o f t h e e l d e r l y were  39  added  to  bility they  make  applicable  and v a l i d i t y  have  been  represent using  it  a  useful  medical  correlate  used  term  care.  is  limited  extensively  in  gerontology  method  record  of  indexing  information. with  subsection  subscale  long  information  negatively  functioning  to  the  The score  resident's health  and a  high  score  ratings  4.  Planned A c t i v i t y Check  -  This  is  together  illness  was on  the  dimensions  expected the  produces on  relia-  scales,  2  and  score  poor  the  the  physical  (since  on  on  While  a  physical low  health  a technique  of  to  score  index).  observing  V6 subject It and  was  behaviour developed  has  person  a high is  for  (between  11:30  4 and  during et for  degree  10  4:40  these  cetera). 2 weeks,  times  is  These  observations  the  the  two  of  the  observed  conversation,  the  that in  of  total  therapy  w e e k p e r i o d was compared t o  for  than  activity  4 days  a  will those  be  have  observed  who  each  are  less  resident  (writing,  assessment  week  per  who  group meeting)  his/her  3 p.m.,  solitary/group,  times  activity or  day  and  residents  areas  number o f  such  independent  observations  those  frequently  in  person's  32  all  by  2:30  Mills  elderly  during a  2 p.m.,  w e r e made  a total  less  possible  (active/passive,  functioning  activity  was  in  hypothesized  Therefore,  sample  recreation,  is  recorded  of  and S. The  (0.95).  periods  and  1:30  Appendix E ) .  Campbell  as  4 time  The n a t u r e  level  in  for  (See  J .  reliability  p.m.)  the  impaired.  Dr.  unobtrusively  seconds  resulting  structured  by  a.m.,  It  in  as  of  sampling.  a n d 12  resident. lowest  time  and t e s t e d  observed  observers  and  using  reading,  during score.  40  5.  Mental  Status  performed 10  by  specific  independent questions  functioning. by  Kahn,  sively  Questionnaire  (See  Goldfarb  used  in  -  During  interviewers,  designed  to  Appendix F ) . et  al.  in  geriatrics  test This  1960,  structured  the  resident  his/her  been  gained  interview was  asked  mental  instrument,  has  and has  a  designed  widely  and  acceptance  exten-  as  a  77 reliable  and v a l i d  expected  that  highly  with  the  the  measure score  of  on  cognitive  gross  this  mental  status.  questionnaire  functioning  score  It  will  on  is  correlate  the  assessment  instrument. 6.  Valid  speech  Aphasia  problems  Diagnosis was  and/or medical  tested  accuracy  Predictive assessment death died  within  died  shortly  or  to  one  acute  instrument  can  of  be  then  over  used the  to  resident's  co-ordinator, r a t i n g was  analyzed  to  for  its  of  the  - T h r e e . o f ,:the  scores  on  make  high  instrument  ability  Twelve  another  a  then  long  the  5  term  76  predict residents  twelve care  subsections  percentage  c a n be  to  the  of  considered  facility of  the  correct a  valid  well-being.  that  time.  the  each  The i n f o r m a t i o n p r o v i d e d by  transfer If  of  measure.  admission.,  Sensitivity changes  this  year  after  nurse  The s t a f f  residents.  of  diagnosis  the  elderly  care.  predictions, measure  Validity was  from  record.  against  instrument  among t h e  A valid  obtained  physician, for  -  have In  The i n s t r u m e n t occurred in  order  to  test  the the  must  be  person's  able level  instrument's  to of  identify well-being  sensitivity  to  41  change,  differences  in  3-month  assessments  were  and  residents'  the  period  (improved,  scores  between  compared  overall  to  the the  estimation  deteriorated,  or  of  the  12-month nurse change  and  the  co-ordinators' during  that  same).  Assumptions  1.  The e l d e r l y  the 2.  range  described  Information  staff  person's  who  are  in  the  demanded in  level  daily  of  functioning  assessment  by  the  contact  scale with  will  fall  within  instrument. is  the  readily  observable  by  individual.  Limitations  1.  The d a t a  long 2.  term  care  their  to  in  facility  The r e s i d e n t s  ability to  provided  in  surroundings. of  the  test  a n a l y s i s aire b a s e d  on  one  only.  selected  interact  representative  the  an As  for  the  study  interview such,  population  the of  must  and be sample the  possess  the  moderately cannot  facility  as  be a  oriented considered whole.  Chapter IV RESULTS AND  DISCUSSION  Reliability  f  Test-Retest Measurement instruments, for  a c c o r d i n g t o the Standards  T e s t s p u b l i s h e d by the American P s y c h o l o g i c a l A s s o c i a t i o n ,  should be s t a b l e over time and show c o n s i s t e n t r e s u l t s when 78 used by d i f f e r e n t  individuals.  The t e s t - r e t e s t r e l i a b i l i t y the assessment instrument  o f the 5 s u b s e c t i o n s o f  was analyzed u s i n g the Spearman 79  rank order c o r r e l a t i o n c o e f f i c i e n t and K e n d a l l ' s t a u . Although  t h e r e i s some debate concerning  the s u p e r i o r i t y o f  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 t h a t i s an estimate o f the extent t o which 2 s e t s of measurements are 80 r e l a t e d t o each o t h e r , u s i n g the r a n k i n g o f the s c o r e s . Zero r e p r e s e n t s no r e l a t i o n s h i p and negative c o r r e l a t i o n ,  and +1 o r -1 p e r f e c t  positive  respectively.  As r e p o r t e d i n Table I, a l l s u b s e c t i o n s o f the i n s t r u ment were found t o be h i g h l y s t a b l e ,  attaining  Spearman  c o r r e l a t i o n c o e f f i c i e n t s from 0.6 t o 0.83 with the t o t a l score r e l i a b i l i t y these c o r r e l a t i o n s  being equal t o 0.61.  The p r o b a b i l i t y o f  o c c u r r i n g42 by chance alone i s l e s s  than  43  0.001 were  in  all  cases  basically  (P<0.001),  equivalent  (Kendall's  with  tau  coefficients  P<0.001).  Inter-Judge The sections and  inter-judge  was  analyzed  Kendall's  highly  tau.  significant  ratings  reliability  using  (Table  from  values  showed  different  similar  results  Social  (N=30)  I:  members.  SUBSECTION  attained  consistency  Spearman  Again,  coefficients  of  coefficients  Kendall's  tau  P<0.006). SPEARMAN COEFFICIENT  Functioning  SIGNIFICANCE LEVEL  0. 83  P<0.001  0.64  P<0.001  0. 60  Physical  Functioning  0.60  P<0.001 P<0.001  0.75  P<0.001  0. 62  P<0.001  0. 87  P<0.001  0. 52  P<0.002  A.D.L. Assessment  Functioning  Functioning  Adaptive  Behaviour  0.48  P<0.003  Physical  Functioning  0.47  P<0.004  0.67  P<0.001  0.66  P<0.001  A.D.L. Total  TABLE  indicating  with  order  sub-  Behaviour  Social  (N=30)  rank  subsections  Functioning  Cognitive  JUDGE  A l l  instrument  Adaptive  Total  INTER-  the  Spearman  0.87 (P<0.004).  Cognitive  RETEST  I).  staff  ASSESSMENT  TEST-  the  correlations,  0.47 t o  ranged  using  of  Assessment  TEST-RETEST  AND  INTERJUDGE R E L I A B I L I T Y  ASSESSMENT  SUBSECTIONS  RANK ORDER  CORRELATION.  USING  SPEARMAN  OF T H E  44  Item  Analysis Average  and  frequency  Appendix  G.  Ratings of  ratings  The i t e m  recognition/denial  the  rater  could  mean  aggressive where is  to  only  should  one be  given  be  able  to  The  from  lowest  that 1 to  average  for  the  last  4  the  sample  a  on  for  H.  showed staff  by  confused area  of  4  in  items  are  the  is  4-point  scale  (2.5).  T h e mean  the  some  any in  decide this  indicate  the  same p e r s o n . item  The  were  members  item  indicating for  occurred  chewing  A.D.L.  them  higher  2).  This  slightly  seen  in  the  rated  The than  rating  higher the  that  than  the  instrument.  histograms  and d i s t r i b u t i o n o f  the  for  suggests  c o n t i n u u m p r o v i d e d by is  (3.7).  are  separately.)  The a v e r a g e =  in  ability  subsection  slightly  functioning  scores  to  and  consideration  uncommunicative  2.8,  (midpoint  this  this  Although  will  staff  considered  items  of  that  by  passive  unable  and  made  item,  both  continuum.  the  for  highest  evidence  of  rating  functioning.  rating  behavioural  was  exists  or  and t h e  is  comment  member was  in  in  missing  recognition/denial  comments  2.14  displayed  had one  signs  the  all  is  are  deviations,  passive/aggressive  behaviour  the  too  population  Further Appendix  of  average  last  items  the  the  possibility  3 and t h e r e f o r e  rating  of  the  this  (2.4)  the  midpoint  middle  was  standard  A l t h o u g h no  and the  types  rate  participation (Note  mark  by w r i t t e n  person  item  p r o v i d i n g an o p t i o n  ratings  accompanied  to  to  both  two.  i n d i v i d u a l on  rating,  of  the  the  each  resident  behaviour  missing  that  the  place  presence two  d i d not  that  for  score,  passive/aggressive  and  who  T h e mean  scores  in for  45  the  subsections  higher  than  the  functioning the  were  oriented  sample  the  in  addition produce  one  item  with  the  changed  was of  be  sample  (0.48).  rating  for  average or  to  the  item  be  chewing  of the  concluded population  of  functioning  in  the  the  With  scales  and wide  that  the  and a b l e the  to  A.D.L.)  expected  scores. on  suggests and  in  for  that  should  the  from  the 0.74  ratings  are  both  This  scales  mean  rating  points  Average  scores  away  approaching  different is  also  rating.  assessment.  appropriate to  discriminate  be  ratings,  4-point  was  lowest  the. a p h a s i a  staff  item  any  combined  individual variations,  residents.  histograms.  of  the  away  average  items  be  per-  (1.23) a n d t h e  true  average  2.14.  among  subsection  scales  and  ratings  ability  to  elderly  lowered  subsection  ratings  1 point  the  adaptive,  in  who  comprehend  have  information  also  of  to  narrow v a r i a t i o n  significant  approximately  mean  to  in  residents  sample c o u l d  and  according  a  expected  Since  variation  This  is  variation  For 3-point  of  This  be  and a b l e  s h o r t - t e r m memory  aphasia,  The  midpoints can  of  seldom  the  to  slightly  cognitive  from  (social,  The w i d e s t  eliminated.  too  2.8.  well  mean  could  tend  providing discriminating  or  0.94,  from  in  ability  diagnosis  occurs  as  the  situation.  would  residents  decrease  weighted  selected  interview  areas  h i g h mean  not  was  functioning  such  result  surroundings  occurred with  chewing  is  an  Variance  with  The  in  of  a  This  their  other  Item  it  to  are  particularly in  population  poor mental  formance  to  midline,  participate  with  assessment  subsection.  that  and  and the  the it the  levels  illustrated  approach  the  46  midpoint  of  deviations indicate  the for  wide  Internal  possible each  individual  was  of  the is  of  each  examined  ten  section  is  score  and the  standard  sufficiently  large  to  differences.  Consistency  relationship  out  range  subsection  Item-to-Subscale  score  score  of  the  and  Item-to-Total  to  is  its  also  in  highly  assessment  internally  related  item  items  correlate  total  and  with  score.  consistent  subsection  reported  the  Correlations  in  cognitive both  This  and t h a t  the  and t h e  The  total  Appendix G.  functioning  subsection  indicates  that  the  are  items  Nine  sub-  score the  and  subsection  measuring  behaviours. Items-to-subscale  desirable  in  that  the  correlations  items  would  between  then  be  0.4  and  measuring  0.6  are  related  81 but in  different the  and  social  for  the  very  high  that  the  items  items  behaviours  have  majority  could  halo  of  be  may b e used  raters  the  the  and the  with  was poor  the  the  the  A.D.L.  the  limited  to  for  all  subsection.  and the  resident  has  item-to-subsection  fewer Alter-  between  ratings  been  therefore  and r a t e d  and  information.  differentiate  assumed  The  suggest  same p h e n o m e n o n  person  items  subsections  subsection  identical  aged  rater  case  behaviour  cognitive  failed  For example,  functioning  in  produce  by  is  and a d a p t i v e  measuring  may h a v e  memory  Items  This  items in  to  exhibited  effect.  poor  mental  functioning  correlations  natively,  a  behaviours.  the  indicate  observed  that  to  all  accordingly. correlations  include  47  aphasia and  (in  the  hearing  (in  bowel The  small  The the in  This  their  low  bowel  adaptive highly total  On  the  instrument indices  considered factors, items cantly  items  with to  and  low an  assessment may p r o v i d e  the not  of  If  they  are  health  indicate  to  the  were  there  should  the  the  measure  a l l  are  these  items  of  and t o t a l  in  were the  simply  not  information  correlate that  than  the  toward to  so.  physical the signifi-  Comparison of validity to  do  subsection,  contribute  with  on which  functioning,  Therefore  well-being. scores  all  A.D.L.  score.  is  independent,  designed  and  It  adequately  evidence rather  the  hearing,  cognitive  emotional,  total  may  some  with  case.  not  items  items  mis-  measuring  Since  indeed,  the  that  other  simply  vision,  that  is  toward and,  correlations  not  functioning  mental,  with  additional  related  assessment.  health,  of  items  intactness,  social  most  other  ability)  of  subsections  items  is  weighted  overall  the  this  score,  correlate  that  reflect identified  However,  is  hand,  ability  correlations  (body  total  reflective  do  indication  ability,  subsection).  high  physical  total  A.D.L.  have  and e a t i n g  the  other  s t i l l  score.  the  the  and chewing  subsections.  behaviour,  with  physical  measure  of  and chewing  vision,  assessment.  would  aspects in  further  are  the  (in  intactness,  d i s c r i m i n a t i n g power  they  function,  represented  aphasia  of  assessment  unrelated  ability  correlations  they  that  a  body  subsection)  and poor  the  respective  classified,  possible  for  is  from  behaviours  total  and e a t i n g  variance  eliminated  subsection),  physical  correlations  previously. be  the  function,  low  their  cognitive  base  the  criteria  the  decision  48  to  add more  eliminate  items  those  This to  the  the  of  level  section of  examination  the of  of  internal  and the  total  reliability,  little  to  each  assessment  is  or  overall of  to  score.  high  with  internal  of  possible  A summary  by  p r o v i d e d by  items  degree  the  subsection. attained  to  individual  a  subsection,  consistency  of  the  points  functioning  a measure  functioning  relationship  scores  within  physical  physical  the  and t o t a l  consistency  exception  to  contributing  subsection  internal  of  relating  each  sub-  Hoyt s  estimate  1  consistency  using  82 analysis-of-variance  techniques.  Maximum c o n s i s t e n c y ,  the  the  same  where  each  produces range  thing,  a  produces  item  is  f r o m 0.49  a  for  of  0.  physical  The t o t a l  where  each  coefficient  measuring  coefficient  functioning.  case  (Represented  something  item  of  1,  is  has  a  to  II).  measuring  completely  functioning  Table  and no  The s u b s e c t i o n  assessment  in  consistency,  different,  coefficients 0.95  for  consistency  cognitive value  of  83 0.93  using  Hoyt s 1  method  SUBSECTION  and  0.73  using  HOYT'S  ESTIMATE  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  0.79  Functioning  3) A d a p t i v e  Behaviour  0.81  4) P h y s i c a l  Functioning  0.49  TABLE  II:  Alpha.  CRONBACH S ALPHA 1  0. 74  5) A . D . L . 6) T o t a l  Cronbach's  0. 93  Score  INTERNAL CONSISTENCY ASSESSMENT  OF S U B S E C T I O N S  INSTRUMENT.  0. 73  AND T O T A L  49  Component assessment  was  Structure  analyzed  subsections  and between  illustrated  in  The adaptive each are  behaviour  suggests  the  three  account  for The  total This but  to  in  subsection  it  all is  A.D.L.  reflects  total  (Table  III).  errors of  the  score,  and  correlated  of  overlap the  with  in  same  other  the  social,  and  content  factor  with  may  the  subsections.  contributes  assessment  correlations  scores.  correlated  the  with  measurement,  subsection  highly  mental,  between  functioning,  highly  section  the  the  Although these  degree  moderately the  all  score.  a  and t h e  social  are  of  relationship  Alternatively,  variation  that  matrix  identical  is  information to  that  different  supports  and p h y s i c a l  the components  behaviour. The  the  total  highly  physical score  The  fact  that  is  it  (P<0.002)  is  independent From  consists  of  importance  this  the  of  to  that the  the  the  lowest  it  other it  score,  the  score  correlated  contributing  is  that  the  factors.  In  they  are:  with  s t i l l  subsection  is  variation. with  the  other  information  measures.  appears or  that  overall  is  correlation  relationship  poorly  components  total  the  suggesting  very  analysis,  3 major to  only  indicates  has  However,  substantially  subsections  that  subsection  (0.4).  significant  contributing  4  due there  and o n l y  related  total  structure  the  subsections  the  subsections.  indicates  belief of  that  A.D.L.  score  the  subsections  high  the  examining  functioning,  and w i t h  spuriously  by  internal  correlational  cognitive  other  this of  the  The  instrument order  of  50  1.  a  cognitive  or  2.  a  component  relating  daily 3.  behavioural to  component  independence/dependence  in  activities  a physical  functioning  component.  SUBSECTION  COGNITIVE  SOCIAL  ADAPTIVE  COGNITIVE  1.00  0.63  0.68  1.00  0.76  SOCIAL  PHYSICAL  1.00  ADAPTIVE PHYSICAL  A.D.L  TOTAL  0.13  0.43  0.89  0.36.  0.37  0.83  0.22  0.40  0.84  1.00  0.32  0.40  1.00  0.64  A.D.L.  1.00  TOTAL  TABLE  C O R R E L A T I O N A L M A T R I X OF S U B S E C T I O N  III:  ASSESSMENT  AND  TOTAL  SCORES.  Validity  Criterion-Related The measures  instrument's  was  tested  to  relationship evaluate  its  to  a number o f  validity  as  other  a measure  of  well-being/impairment. Problem-Oriented total the  assessment  number o f  score  problems  list.  The r e s i d e n t s  listed  on  their  Record would  be  listed  sampled  record with  It  on  was  hypothesized  negatively the  had an a range  that  correlated  the  with  m u l t i d i s c i p l i n a r y problem average  of  5  of  12  and a  0 to  problems standard  51  d e v i a t i o n o f 2.5.  The Spearman rank order  correlation  c o e f f i c i e n t was -0.26, s u p p o r t i n g the hypothesis a t the 0.01 l e v e l of significance.  T h i s i n d i c a t e s t h a t the lower the score  on the assessment instrument,  the higher the number o f  problems o f a permanent nature found on the medical Medication expected  The number o f medications  record.  p r e s c r i b e d was  t o show an i n v e r s e r e l a t i o n s h i p t o the score on the  assessment instrument. 5 medications  The r e s i d e n t s r e c e i v e d an average o f  each, ranging from 0 t o 11 and standard  d e v i a t i o n , 2.8.  Contrary t o the h y p o t h e s i s , 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 r e l a t i o n s h i p between assessment score and number o f m e d i c a t i o n s .  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 o f medications  p r e s c r i b e d and the h e a l t h index s c a l e  0.39, P<0.003).  From t h i s evidence  of medical diagnoses  (coefficient  i t seems t h a t the number  and symptoms p r o v i d e a b e t t e r p r e d i c t i o n  of the number o f medications  than the i n d i v i d u a l ' s  overall  l e v e l of functioning. Health Index S c a l e  The H e a l t h Index S c a l e , being a  measure o f p h y s i c a l i l l n e s s based on diagnoses was expected  and symptoms,  t o show an i n v e r s e r e l a t i o n s h i p t o the r e s i d e n t ' s  score on the 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 .  The average  score on the h e a l t h index was 2 5 w i t h a range o f 6 t o 4 0 and a standard d e v i a t i o n o f 8.6.  The Spearman rank order  coefficient  f o r t h i s r e l a t i o n s h i p was -0.25, s u p p o r t i n g the hypothesis a t the 0.02 l e v e l o f s i g n i f i c a n c e . Planned A c t i v i t y Check  On the average,  each r e s i d e n t  52  was observed t o be i n v o l v e d i n s t r u c t u r e d a c t i v i t y 1.8 times out o f 32 o b s e r v a t i o n  periods  (range from 0 t o 11,  standard  d e v i a t i o n 2.4). Those r e s i d e n t s w i t h low l e v e l s o f funct i o n i n g on the assessment instrument were expected t o p a r t i c i p a t e less frequently i n structured unit Therefore,  activities.  a p o s i t i v e c o r r e l a t i o n was hypothesized between  the 2 s c o r e s . The  rank-order c o e f f i c i e n t s i n d i c a t e d no 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 assessment score and r e s i d e n t nor between s o c i a l f u n c t i o n i n g score  and r e s i d e n t  ( c o e f f i c i e n t s = 0.1 and 0.05 r e s p e c t i v e l y ) .  activity,  activity  The frequency  of a c t i v i t y was, however, r e l a t e d t o the r e s i d e n t ' s l e v e l o f physical functioning  ( c o e f f i c i e n t = 0.23, P<0.05),  suggesting  t h a t r e s i d e n t s are excluded or exclude themselves p r i m a r i l y on the b a s i s o f l i m i t e d p h y s i c a l  capacity.  Mental Status Q u e s t i o n n a i r e mental s t a t u s u s i n g  T h i s gross measure o f  s t r u c t u r e d r e s i d e n t i n t e r v i e w s was compared  to s t a f f r a t i n g s o f c o g n i t i v e f u n c t i o n i n g on the assessment instrument.  The two scores were expected t o show an i n v e r s e  r e l a t i o n s h i p i n t h a t low scores on the mental s t a t u s n a i r e and high scores  on the c o g n i t i v e f u n c t i o n i n g  i n d i c a t e good mental performance. was -0.65, supporting  question-  subsection  The c o r r e l a t i o n c o e f f i c i e n t  the h y p o t h e s i s a t the 0.001 l e v e l ,  thereby i n d i c a t i n g t h a t the c o g n i t i v e f u n c t i o n i n g items are indeed v a l i d measures o f mental s t a t u s . V a l i d Aphasia Diagnosis  Since  some q u e s t i o n  existed  d u r i n g the p r e t e s t o f the v a l i d i t y o f s t a f f r a t i n g s on t h i s  53  item,  accurate  resident, were as  and  found  having  rated  as  diagnoses compared  in  15  some  of  no  aphasic.  valid,  poor  form and  suggests treated  other  A using  a  ratings.  Of the  aphasia  when  when  should  separate  they  they  power  be  of  yes/no  item  at  the  15,  did  of  13  not,  to  each ratings  were and  rated  2  were  diagnosed  the  the  excluded  for  Incorrect  had been  80 percent  information  ratings  item  in  from the  scale subsection  be.included  beginning  are  with  of  the  assess-  analysis  was  performed  Validity  step-wise  the  death.  Each  function.  variation  equation  group one  subsection  scores  ability  were  The A.D.L.  equation,  subsection  5  on  were  subsections  the  found  or  alive)  function  predict  minimizing  to  discriminant  form a  function  variable  that  provide and were  equation.  significantly  is  the  a  represents  . . cognitive  subsections to  to  and t h o s e  A discriminant  a dependent  d i d not  not  the  retained  I).  (dead  discriminant  function  entered  Scores  and A . D . L .  membership  so  were  with  84  on  was  Appendix  membership.  functioning  scores  subsection  (See  regression group  discriminant  residents'  unexplained  duce  rating.  Although  it  obtained  form.  Predictive  of  that  as  75  were  staff  discriminating  identifying  ment  the  aphasia  the  aphasia  expressive the  to  form of  having  of  the  best  combined  The a d d i t i o n improve  prediction to  pro-  of  other  predictive  included. which  scores,  included was  then  cognitive used  to  functioning  assign  and  residents  to  groups. predict it  The  discriminant  72 percent  of the  f u n c t i o n was  able to c o r r e c t l y  sample p o p u l a t i o n ,  i n d i c a t i n g that  i s a v a l i d measure of the person's w e l l - b e i n g .  i n d i c a t e s t h a t c o g n i t i v e f u n c t i o n i n g and  It further  independence i n  d a i l y a c t i v i t i e s are b e t t e r p r e d i c t o r s o f death than p h y s i c a l functioning.  In t h i s sample, c o g n i t i v e f u n c t i o n i n g  scores  were p o s i t i v e l y c o r r e l a t e d w i t h death and A.D.L. n e g a t i v e l y , meaning t h a t those w i t h high l e v e l s o f mental f u n c t i o n i n g who  were dependent i n A.D.L. were most l i k e l y to d i e .  i s a curious  f i n d i n g and  contrary  to p r e v i o u s  research  and  This that 85  suggests a drop i n i n t e l l i g e n c e p r e d i c t s imminent death. However, t h i s assessment was of change. those who The  taken once and  A l s o , the r e s i d e n t s i n t h i s sample do not have very  low  l e v e l s of i n t e l l e c t u a l  a d d i t i o n of such s u b j e c t s may  of t h i s  sample of 76  functioning.  a l t e r the p r e d i c t i v e nature  the data are based on  (4 men,  8 women).  the power of the d i s c r i m i n a n t  12 deaths out of a  A l a r g e r sample would function.  A l s o , the  employed i n the a n a l y s i s i s n e c e s s a r i l y o n l y  of residents to confirm  increase  technique  preliminary.  d e r i v e d equation would need to be a p p l i e d to a new  The  include  subsection.  At present,  The  i s not a measure  sample  i t s validity.  f a c t t h a t a l l but  2 of the deaths o c c u r r e d  within  3 to 9 months of admission suggests the p o s s i b i l i t y t h a t deaths may  be r e l a t e d to r e l o c a t i o n .  The  post-admission death, high c o g n i t i v e and  the  combination o f e a r l y low A.D.L. f u n c t i o n i n g  55 may b e  evidence  'giving-up, terized first  by  what  given-up feelings  recognized  feelings that  of  relation  seen  by  preceded  both  physical  is  well-known  is  often  the  that  perceived  This  helplessness  were  It  Engel  syndrome.  1  of  in  Schmale,  to  authors  the  phenomenon  to  be  is  a  the  characand  camps.  long  disorders.  term care  beginning-of-the-end  by  was  These  a psychological  and p s y c h i a t r i c to  term  and h o p e l e s s n e s s  concentration  admission  as  and o t h e r s  set  86 8 7 '  facility  an  elderly  88 person. who  Perhaps  are  unable  dependent  on  to  those care  others,  for  is  needed,  this  for  many n u r s e s  high mental  themselves  suffer  evidence what  with  most  does  have  and a r e ,  severely.  provide  felt  functioning  abilities  therefore,  most  A l t h o u g h much  some t e n t a t i v e  more  support  intuitively.  Sensitivity Analysis was over  made  by  3 groups  the  instrument's  comparing the  9 months  assessment  of  of  to  the  overall  according  deteriorated,  or  to  the  difference  nurse  The  whether  they  same.  analyzed  using  are  reported  i n Appendix J .  followed closely  nurse  the than  relationship  One-way  the  of  reached  to  detect  and the was  had been in  rating  rating  significance  score of  rated  resident's  each  The  group  results  change  differences  (P>0.1).  into  improved,  for  overall  change.  scores  divided  score  of  change  resident's  analysis-of-variance.  assessment  residents'  the  sample  The change  co-ordinators'  pattern  in  co-ordinator's  change.  was  The  ability  more  However,  neither  56  Interestingly, residents  reached  40 percent  of  improvement comparison groups The  of  nurse  person  on  these  to  complex. the  On t h e the by  very  in  the  of  assessment the  nurse  not  found  of  is the  of  or  the  to  detailed The  on  may b e  and the lack  by  measure  change  elderly  are  against  as  the  may  groups  be  to lead  is  very  which  is  to  debatable.  concluded it  of  factors  instrument only  aged  the  necessary  The  both  of  From  This  two  well-being.  hopelessness  discussed.  can  see  The p e r c e i v e d  assessment  sensitive  more  parameters  the  change  it  to  Appendix K.)  progress.  a valid  only  (A  competency.  of  analysis,  co-ordinat'or  of  elderly  change  perspectives  improvement  of  of  tending  in  previously  rating  and the  themselves.  physical  feelings  either  this  is  on  perception  is  nurses  different  client  sensitivity  basis  the  direction  parameters.  elderly  and  Whether  the  indication  overly-optimistic  involved  test  an  standpoint,  satisfaction an  ratings  quality-of-life  institutionalized  job  with  focussing  may b e  on  co-ordinators  individuals  have  may b e  improvement  nurses'  time, the  obviously  nurse  agreement  the  than  the  that  perceived  individual.  Chapter  V  CONCLUSIONS, IMPLICATIONS AND  RECOMMENDATIONS  Conclusions A s h o r t , p r a c t i c a l assessment instrument developed  has been  based on the o b s e r v a t i o n s o f long term care  t h a t has demonstrated r e l i a b i l i t y care u n i t .  and v a l i d i t y i n an extended  Of course, the study was  conducted  i n only  f a c i l i t y w i t h a sample t h a t excluded m e n t a l l y - i m p a i r e d viduals.  one indi-  As such, the r e s u l t s cannot be g e n e r a l i z e d t o other  s e t t i n g s or groups of e l d e r l y . of  staff  However, the h i g h  reliability  r a t i n g s o b t a i n e d i n the study s e t t i n g i s p a r t i c u l a r l y  encouraging  i n the l i g h t of p r e v i o u s r e s e a r c h r e p o r t s o f 89  agreement among s t a f f nurse r a t i n g s of behaviour. One  area of concern  i s the high degree o f  90 '  intercorrelation  among the ten items measuring c o g n i t i v e f u n c t i o n i n g . high i n t e r c o r r e l a t i o n suggests  low  A very  t h a t a l l the items are measuring  the same t h i n g and t h e r e i s no d i s t i n c t i o n between the v a r i o u s processes as ennumerated i n the instrument.  However, t h i s  i s c o n t r a r y to c u r r e n t g e r o n t o l o g i c a l l i t e r a t u r e which s t a t e s t h a t a l l mental f u n c t i o n s u s u a l l y are not l o s t or g l o b a l l y and t h a t remaining to  support o t h e r f a i l i n g  simultaneously  s t r e n g t h s o f t e n can be used 91 92 processes. ' T h i s leads to  57  58  speculation among to  the  that  various  perceive  altered The  be  is  or  before  the  high  relationship  the  in  This  supports  belief  abilities  Data additional  dictive  items to  power  are  significant  addition the  Although  scores  suggestive  significance being have  has  not  found,  specific  of  in  been  of  have  Additional subsection  that  the  However,  items.  the  been  dimensions  changed  a need  of  physical  The poor that  it  may that  between  the  direction  this  the  pre-  parameters  provided,  results  and  for  at  that  mental  may b e  attempt  adequately.  both.  factors.  provide  to  to  both  correlations  no  functioning  environmental  physical  5 subsections  circumstances, not  related  indicates  d i d not  As  least  and p h y s i c a l  score.  Also,  has  attained.  contribution  also  of  particularly  and the  there  those  criteria  the  results,  a number o f  established  similar  continuing  dimensions  reflects  assessment  evidence  each  sections  as  health.  over  are  consistency  A.D.L.  subsection  such  study  cognitive  representing  of  differentiate  the  various  significantly  increase  and v a l i d i t y  to  terms. in  divergence  suggested  overall  to  items  the  the  that  well  this  adequately  the  adjust  to  of  be  for  as  the  not  instrument  A.D.L.  analysis  functioning  in  widest  independence  and  global  the  of  o c c u r r e d between  the  in  internal  with  unable  further.  illustrated  to  were  functioning  behaviour  needed  expected,  physical  of  compressed  are  relation  might  aspects  raters  interrelationship  well-being in  staff  cognitive  investigation are  the  was  made  to  time. the  relative  person's  Other  well-  researchers  attempts  to  weight  significantly  nor  59  added  to  the  validity  Perhaps analysis high  is  the  levels  represent  the  loss to  of  even  of  and o t h e r  hope  the  within cally  a  study  long  point  of  findings  both  term care  an  accurate  individuals  with  information,  so  care.  periods, changes  with  provides of  basis  for  groups,  and b r o a d t h e r a p e u t i c can  be  empirically  measures Aggregate can  also  rather data be  has  on  used  the for  in  to  and  services.  indi-  of  nursing  staff  provide  economi-  of  use  in  progress can  and  be  of  accurate  appropriate  effectiveness between Programs  orientation, outcome  success.  elderly  planning  turn,  methods.  basis  of  individual  made  reality  term  time  in  as  the  long  and a n a l y z e This,  elderly  The  such  of  the  different  error.  administrative  resources  at  impressions  well-being  the  may  implications  contact.  and treatment  the  intuitive  to  potential  and  approaches,  particularly in  The  that  close  identify  providers,  purposes,  this  elderly  assessment  Comparisons  on  functioning,  below.  able  duplicated  evaluation  tested  than  are  vast  bias  interventions.  individuals,  confirmed  come  possible  a minimum o f  the  specific  it  by  death.  consistent  be  up,"  discussed  facility  can  cognitive  data  Recommendations  have  and  from the  As mentioned,  willing  and  provided,  making  high  "giving  are  whom t h e y  The assessment  between  and a  results  finding  and d e a t h .  Implications  The  instrument.^  significant  dependency  viduals this  most  the  relationship  of  a  of  and  individual evaluation  allocation  of  60  However, b e f o r e these uses can be contemplated, r e s e a r c h i s needed t o e s t a b l i s h the instrument's  further  reliability  and v a l i d i t y i n other s e t t i n g s and w i t h other groups o f e l d e r l y , i n c l u d i n g those who are s e v e r e l y m e n t a l l y impaired. In  a d d i t i o n , s t a f f r a t i n g s o f c o g n i t i v e f u n c t i o n i n g need t o  be examined very c a r e f u l l y .  I f the r a t i n g s do r e f l e c t an  inadequate l e v e l o f awareness and knowledge o f t h e person's f u n c t i o n i n g , then i t f o l l o w s t h a t l i t t l e  o r no attempt i s  being made t o c a p i t a l i z e on remaining mental compensate f o r areas o f l o s s .  Without  s t r e n g t h s or t o  such important  inter-  v e n t i o n s we are p r o v i d i n g l i t t l e more than c u s t o d i a l c a r e . The connection between mental a b i l i t y , dependency and death., a l s o warrants f u r t h e r i n v e s t i g a t i o n .  However, even  the t e n t a t i v e evidence t h a t has emerged from t h i s study should be s u f f i c i e n t t o i n c r e a s e e f f o r t s a t promoting maximum independence  i n the e l d e r l y .  I n a b i l i t y o f the n u r s i n g s t a f f  to  i d e n t i f y s p e c i f i c f u n c t i o n a l 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 e a r l y 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  t h a t , not o n l y are such programs f r e q u e n t l y absent i n long term c a r e , but s t a f f have a tendency person, thereby undermining  t o "do f o r " the aged  any remaining c a p a b i l i t i e s they  might have and c r e a t i n g an a r t i f i c i a l l y h i g h l e v e l o f 94 dependency.  C o n s i d e r i n g the p o s s i b l e r e 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. T h i s study has made a beginning a t 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 i n f o r m a t i o n r e l e v a n t to the aged i n d i v i d u a l i n a long term care s e t t i n g .  I t has  a l s o been able t o demonstrate the p o t e n t i a l value  such  i n f o r m a t i o n c o u l d have i n the f i e l d of gerontology.  Much  more work i s now  the  instrument  needed to expand the a p p l i c a t i o n of  to other groups and  to determine the  relative  s i g n i f i c a n c e of the v a r i o u s dimensions of w e l l - b e i n g . the p r e d i c t i v e power of c o g n i t i v e f u n c t i o n i n g and  If  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 g o a l s and o v e r a l l approach to long term care w i l l have t o be r e c o n s i d e r e d with  greater  p r i o r i t y being given t o r e h a b i l i t a t i v e and q u a l i t y of issues.  life  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 (Vancouver, 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 , "Long Term C a r e P r o g r a m f o r B . C . , " Registered Nurses' A s s o c i a t i o n o f B . C . Meeting, Shaughnessy H o s p i t a l , November, 19 7 7 . ^Weaver,  p.  6.  Weaver,  p.  5.  5 "Long Term 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 on Long Term H e a l t h C a r e Data h e l d a t T u c s o n , A r i z o n a , 12-16 May, 1975, M e d i c a l C a r e , 14, No. 5 (1976), l-230, :  B. M. Greenberg, "Medical 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 Dilemma," J o u r n a l of G e r o n t o l o g i c a l Nursing, 1, N o . 4 ( 1 9 7 4 ) , p p . 6 - 8 . 7  Medical  Care,  p.  x i i .  Medical  Care,  p.  10.  g 9 M. P . Lawton, "Coping B e h a v i o u r and t h e E n v i r o n m e n t o f Old People," 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 and Approaches to the E l d e r l y , e d . A . Schwartz a n d I . Mensh (Springfield: C h a r l e s Thomas, 1974), p . 60. ^M. F . Lowenthal and A . Simon, "Mental C r i s e s and 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 Psychiatry, 4, No. 1 (1970), p . 165. 1 (  "^Lowenthal,  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 , November, 1973. 13 H. H a r r i s , A . L i p m a n , and R. S l a t e r , "Architectural Design: The S p a t i a l L o c a t i o n and I n t e r a c t i o n s o f O l d P e o p l e , " Gerontologist, 23 ( 1 9 7 7 ) , p . 3 9 0 . 14 H a r r i s , p . 391. 15 Hill,  I. Burnside, Nursing 1976), p . 157.  and the  62  Aged  (New Y o r k :  McGraw-  63  16 (New  U. B r a n t 1 and M. R. Brown, e d . , Readings York: C . V . Mosby, 1973), p . 23.  in  Gerontology  17 C. E x s d o r f e r and M. P. Lawton, e d . , The P s y c h o l o g y o f A d u l t Development and A g i n g (Washington, D . C . : American Psychological Association, 1973). 18 L . M. Gunter and J . C . M i l l e r , "Toward 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 : McGraw-Hill, 1976), pp. 286-316. 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 Therapy with the E l d e r l y , " Canadian A s s o c i a t i o n of Gerontology M e e t i n g , V a n c o u v e r , B . C , November, 1976. 21 Lawton, 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 ( S a n Francisco: Jossey-Bass, 1976). 23 P. P. E b e r s o l e , "Developmental Tasks i n Late L i f e , " in 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 : McGraw-Hill, 1976), pp. 69-80. 24 A. Schwartz and I . Mensh, P r o f e s s i o n a l O b l i g a t i o n s and Approaches to the Aged ( S p r i n g f i e l d : C h a r l e s Thomas, 1974), p. 6. 25 J. Birren, "Psychological Aspects of Aging," i n Aging 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 : Alfred 1976), p . 190. 26 E . Busse and E . P f e i f f e r , B e h a v i o u r and A d a p t a t i o n i n Late L i f e (Boston: L i t t l e Brown, 1969). 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 Readings i n G e r o n t o l o g y , e d . U . B r a n t l and M. R. B r o w n (New Y o r k : C . V . M o s b y , 19 7 3 ) , p . 4 3 . 28 C. E i s d o r f e r , "Developmental L e v e l s and Sensory Impairment 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 (1965), pp. 129-132. 29 L . A . P a s t a l a n and 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 . : University of Michigan Press, 1970). 30 I. B u r n s i d e , "Depression and S u i c i d e i n the 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 : McGraw-Hill, 1976), pp. 165-181.  64  31  Tobin  and  Lieberman,  p.  100.  32 R. C . Wadsworth,  Atchley,  The  Social  Forces  in  Later  Life  (Californi  1972), p . 127.  33 A . Whanger and P. L e w i s , "Survey o f Institutionalized E l d e r l y , " i n Multidimensional Functional Assessment: T h e OARS Methodology, E. Pfeiffer (Durham: Duke U n i v e r s i t y , 1975) , p . 2  34  F. N. York:  (New  35  Kerbinger, Foundations of Behavioural H o l t , R i n e h a r t a n d W i n s t o n , 1964), p .  Research  538.  R. Kastenbaum and S. S h e r w o o d , "VIRO: A Scale for A s s e s s i n g the Interview Behaviour of E l d e r l y People," in R e s e a r c h , P l a n n i n g and A c t i o n f o r the 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 : Behavioural.Publ.,  1972), p p . 144-165. 36 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 Scale (California: 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 Improvement in Mental l o g y , 23 (1957), p p .  38  Ellsworth  and  a n d W. H . Illness,"  Clayton, Journal  "Measurement of of Consulting Psycho-  15-20.  Clayton,  p.  15.  39 for  G. H o n i g f e l d and J . K l e t t , "The N u r s e s ' Observation Inpatient Evaluation," Journal of C l i n i c a l Psychology,  (1965), p p . 65-71. 40 A.  Pinto  (Maryland:  41  and  E.  DeRosa,  NOSIE-30:  Instruction  (1977)).  M. L . M a c D o n a l d , "The F o r g o t t e n l o g i c a l A n a l y s i s o f A g i n g and N u r s i n g  of  Programmed  Scale 21  Community P s y c h o l o g y ,  42  1, N o .  Americans: A SocioHomes," A m e r i c a n J o u r n a l  3 (1973), p p .  272-291.  B. F . T u r n e r , S. T . S h e l d o n , and M. L i e b e r m a n , "Personali T r a i t s as 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 , " Journal of Gerontology, 21 (1966), p . 392. 4 3  Honigfeld  and  Klett,  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 , "Method o f E v a l u a t i n g B e h a v i o u r a l Changes i n Aged H o s p i t a l P a t i e n t s D u r i n g Anabolic Therapy," Journal of American G e r i a t r i c s Society, 15  (1967), p p . 470-473. 45  B. Meer and J . B a k e r , "The S t o c k t o n G e r i a t r i c Scale," Journal of Gerontology, 21 (1966), p . 392.  Rating  65  46  R. P l u t c h i k , H . Comte, M . L i e b e r m a n , M . B a k e r , J . Grossman, and N. Lehrman, " R e l i a b i l i t y and 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 the F u n c t i o n i n g of 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 , 18, No. 6 (1970), pp. 491-496. 47 B . S . L i n n , M . W. L i n n , a n d L . G u r e l , "Cumulative I l l n e s s Rating Scale," Journal of American G e r i a t r i c s Society, 16, No. 5 (1968), pp. 622-626. 48 * H. A . Rosencranz and C . T . P i h l b l a d , "Measuring the Health of the E l d e r l y , " J o u r n a l of Gerontology, 25, No. 2 (1970), pp. 129-133. 49 A . Waldman and E . F r y m a n , " C l a s s i f i c a t i o n i n Homes for the Aged," i n G e r i a t r i c I n s t i t u t i o n a l Management, ed. H. Shore and M. Leeds (New Y o r k : Putnam, 1964), pp. 131-135. 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 Gerontology, 15, No. 2, (1967), p p . 211-214. "*^"J. A . G o g a 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 Behavioural Assessments of G e r i a t r i c P a t i e n t s : A J o u r n a l of American G e r i a t r i c s S o c i e t y , 25, No. 5 p p . 2 32-2 37.  and Review," (1977),  52 S. K a t z , T . D . D a u n s , H . R. C a s h , and R. C . G r o t z , "Progress i n Development of the Index of A D L , " Gerontologist, 1 0 , N o . 20 (1970). 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 : Basic Books, 1964). 54 L . G u r e l , M. L i n n , and B. L i n n , " P h y s i c a l and M e n t a l Impairment of F u n c t i o n E v a l u a t i o n i n the E l d e r l y , " J o u r n a l of Gerontology, 27, No. 1 (1972), pp. 83-90. 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 Look at Excess D i s a b i l i t i e s in Mentally Impaired E l d e r l y , " Journal of Gerontology, 29, No. 1 (1974), pp. 79-84. 56 P. Salmon, J . M. Atthowe, and M. R. H a l l o c k , RAPIDS: A Method 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 Long Term C a r e (San Mateo C o u n t y , C a l i f . : Dept. of Health & Welfare, 1967). 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 Classification for the Aged," J o u r n a l o f C h r o n i c D i s e a s e s , 18, No. 5 (1965), pp. 1059-1064. 58 R . W. A s h t o n , " A n I n t e g r a t e d P a t i e n t Classification System and N u r s i n g A c t i v i t y Study i n an E x t e n d e d C a r e F a c i l i t y , " Diss. Harvard, 1968. 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 , A n 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 Patients (Boston: School of Nursing, 1968).  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 , Patient C l a s s i f i c a t i o n f o r Long Term C a r e ; U s e r ' s Manual (Harvard Medical School, Bureau of Health Services Research, 1973). 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 : Spectrum, 1975), p . 28. 62 E. Brody, "Basic Data Requirements f o r G e r i a t r i c I n s t i t u t i o n s and S e r v i c e s , " M e d i c a l C a r e , 14, No. 5 (1976), pp. 60-70. Jones, 64  p.  Birren,  65  Busse  52.  p.  190.  and P f e i f f e r ,  ^Kerlinger,  p.  p.  100.  547.  67 K e r l i n g e r , p . 54 8 . 68 F. A b d e l l a h and E . L e v i n e , B e t t e r N u r s i n g R e s e a r c h (New Y o r k : MacMillan, 69 K e r l i n g e r , p . 549.  P a t i e n t Care Through 1 9 6 5 ) , p . 240.  70 J. Campbell, "Behavioural Intervention i n the R e h a b i l i tation of the Elderly: an 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 13, 1976. 71 J . W i l l i s and D. Lawson, " P r e d i c t i o n and P r e p a r a t i o n i n the R e l o c a t i o n of the E l d e r l y , " B r i t i s h Columbia, Vancouver ( N a t i o n a l H e a l t h and W e l f a r e G r a n t : in progress). 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 , 2 n d e d . (New Y o r k : M c G r a w - H i l l , 1954), chap. 16.  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 and Patient Care (Chicago: Yearbook M e d i c a l , 1971). 74 Rosencranz and P i h l b l a d . 75  Linn,  Linn,  and  Gurel.  76 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 , "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 Old Age," Human D e v e l o p m e n t , 17, No. 5 (1974), p p . 259-272. 77 R. L . Kahn, A . I . G o l d f a r b , M. P o l l a c k , and A . P e c k , " B r i e f O b j e c t i v e Measures f o r the Determination o f Mental Status i n the E l d e r l y , " American Journal of Psychiatry, 117 (1960) , p . 3 2 6 .  67 78 Standards f o r E d u c a t i o n a l and P s y c h o l o g i c a l T e s t s (Washington, D.C: American Psychology A s s o c i a t i o n , 1974). 79 S. S i e g e l , Nonparametrie S t a t i s t i c s (New York: McGrawH i l l , 1956), p. 202. 80 D. J . Fox, Fundamentals of Research i n Nursing, 3rd ed. (New York: A p p l e t o n - C e n t u r y - C r o f t s , 1976), p. 106. 81 J . W i l l i s , D. Smithy, and S. H o l l i d a y , "Item L e v e l A n a l y s i s of the Devereux Elementary School Behaviour R a t i n g S c a l e , " J o u r n a l o f S p e c i a l E d u c a t i o n , 22 (1978), pp. 81-82. 82 L. J . Cronbach, E s s e n t i a l s o f P s y c h o l o g i c a l T e s t i n g , 3rd ed. (New York: Harper and Row, 1970), p. 159. 83 Cronbach, p. 16 0. 84 K e r l i n g e r , p. 650. 8 5  B i r r e n , p.  190.  86 J . D. Adamson and A. H. Schmale, "Object Loss, G i v i n g Up and the Onset o f P s y c h i a t r i c Disease," Psychosomatic Medicine, 27 (1965), p. 557. 87 A. H. Schmale and G. L. E n g e l , "The G i v i n g Up, Given Up Complex," A r c h i v e s of General P s y c h i a t r y , 17 (1967), pp. 135145. : : 88 Tobin and Lieberman. 89 M. B. Jensen and W. E. M o r r i s , " 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 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), pp. 248-252. 90 W. A. Hargreaves, "Systematic Nursing O b s e r v a t i o n of Psychopathology," A r c h i v e s of General P s y c h i a t r y , 18 (May, 1968), pp. 519-531. 91 P. Arenberg, " C o g n i t i o n and Aging," i n E i s d o r f e r and Lawton, pp. 74-97. 92 J . Herr, "Psychology o f Aging: An Overview," i n Burnside, p. 40. 93 R. C. J e l i n e k , R. K. D. Haussman, S. T. Hegyvary, and J . F. Newman, A Methodology f o r M o n i t o r i n g Q u a l i t y o f Nursing Care (Maryland: DHEW, 1974), p. 66. 94 Laurence. :  T  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 Medicine 27 (1965), 557. T  Arenburg, P. "Cognition and Aging." i n 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 i n an Extended Care Facility. Diss. Harvard 1968. Atchley, R.C. The Social Forces i n 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." i n Aging i n America. Ed. C. Kart and B. Manard. New York: Alfred, 1976. Brantl V. and M.R. Brown. Readings i n Gerontology. C.V. Mosby, 1973.  New York:  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 i n 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 i n Late Life. Boston: L i t t l e Brown, 1969. Campbell, J. "Behavioural Intervention i n 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 i n 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 i n Mental Illness." Journal of Consulting Psychology, 21 (1957), 15-20. Fox, D.J. Fundamentals i n Nursing. 3rd ed. New York: Apple ton-CenturyCrofts, 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 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 Evaluation." 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), 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 M o n i t o r i n g Q u a l i t y o f N u r s i n g C a r e . M a r y l a n d : DHEW, 1974. J e n s e n , 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. J o n e s , E . W . , B . J . M c N i t t , and 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 Long Term C a r e . H a r v a r d : Bureau o f H e a l t h S e r v i c e s R e s e a r c h , 1973. Kahn, R . L . , A . I . G o l d f a r b , M . P o l l a c k , and A . P e c k . " B r i e f O b j e c t i v e Measures f o r the D e t e m d n a t i o n o f M e n t a l S t a t u s 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 S c a l e f o r A s s e s s i n g the 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 , and A c t i o n . E d . D. K e n t , R. Kastenbaum, and S. Sherwood. New Y o r k : B e h a v i o u r a 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 . C a s h , and R . C . G r o t z . ment o f the Index o f A D L . " G e r o n t o l o g i s t ,  "Progress i n D e v e l o p 10, No.20 (1970)  K e r l i n g e r , F . N . Foundations o f B e h a v i o u r a l Research. H o l t , R i n e h a r t , and W i n s t o n , 1964.  New Y o r k :  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. M e d i c a l C a r e , 14, N o . 5 (1976), 1-230. L a b o u r i e - V i e f , G . W . J . H a y e r , 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 B e h a v i o u r i n O l d A g e . " Human Development, 17, N o . 5 (1974), 259-272. L a u r e n c e , 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 Elderly." Canadian Conference o f G e r o n t o l g y , V a n c o u v e r , B . C . November, 1976. Lawton, M . P . "Coping B e h a v i o u r and the Environment 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 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 : C h a r l e s Thomas, 1974, 60. . " F u n c t i o n a l Assessment o f the E l d e r l y P a t i e n t . " in Readings i n G e r o n t o l o g y . E d . V . B r a n t l y and M . R . Brown. New Y o r k : C . V . Mosby, 1973, 43-50.  71 L i n n , M. "A Rapid 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 t o l o g y , 15, No.2 (1967), 211-4.  Geron-  L i n n , B l S . M.W. L i n n , and L. G u r e l . "Cumulative 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 of American G e r i a t i r c s S o c i e t y . 1 6 , No.5 (1968), 622-6 Lowenthal, M.F.  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 Books,  1964.  and A. Simon. "Mental C r i s e s and I n s t i t u t i o n a l i z t i o n i n the E l d e r l y . " 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, No.l ( 1 9 7 0 ) , 165-170. MacDonald, M.L. "The F o r g o t t e n Americans." American Community Psychology.!, No.3 (1973), 272-291.  Journal of  Meer, B. and Baker, J . "The Stockton G e r i a t r i c Rating S c a l e . " J o u r n a l o f Gerontology, 21 (1966), 392-5. Nie, N. , C H . H u l l , J.G. J e n k i n s , K. S t e i n b r e n n e r , and D. Kent. S t a t i s t i c a l Package f o r the S o c i a l Sciences.2nd ed. New York: McGraw-Hill Books,]9 75. P a s t a l a n , L.A. and D.H. Carson. S p a t i a l Behaviour o f Older P . People. Ann Arbor, Mich.: U n i v e r s i t y P r e s s , 1970. P i n t o , A. and E. DeRosa. NOSIE-30: Programed I n s t r u c t i o n . Maryland: n.p., 1977. Rosencranz, H.A. and C T . P i h l b l a d . "Measuring the H e a l t h o f the E l d e r l y . " J o u r n a l of Gerontology. 25, No.2 (1970). Salmon, P. J.M. Atthowe, and M.R. H a l l o c k . RAPIDS: A M e t h o d i c : of 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 Long Term Care. C a l i f o r n i a : DHEW, 196 7. Schmale, A.H. and G.L. E n g e l . "The G i v i n g Up, Given Up Complex." A r c h i v e s of General P s y c h i a t r y . 17 (1967). Schwartz, A. and I. Mensh. P r o f e s s i o n a l O b l i g a t i o n s and Approaches t o the E l d e r l y . S p r i n g f i e l d : C h a r l e s 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 o f N u r s i n g Home P a t i e n t s . 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. American Psychological Association, 1974.  Washington, D.C:  Tobin, S. and M. Lieberman. Last Home for the Aged. Jossey-Bass, 1976.  San Francisco:  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 i n Homes for the Aged." i n 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." i n 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 i n the Relocation of the Elderly." Vancouver, B.C., National Health and Welfare Grant, i n progress. Wolanin, M.O. "Confusion i n the Elderly." Gerontological Society, Florida. November, 1973. Wolpert, A., C. Sheppard, and S. Merlis. "Method of Evaluating Behavioural Changes i n Aged Hospital Patients During Anabolic Therapy." Journal of the American Geriatrics Society, 15 (1976), 470-3.  Appendix A Nurses' Observation Scale  Resident's  name  Date A i d e , L.P.N.,  R.N.  INSTRUCTIONS FOR 1.  For  COMPLETION OF  SCALE:  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  or a d a p t a t i o n .  A score of  1 represents  the most s e v e r e  of f u n c t i o n i n g level  of  impairment.  2.  P l e a s e c i r c l e t h e number y o u t h i n k m o s t a c c u r a t e l y e s t i m a t e s t h e p a t i e n t ' s functioning. 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 o f 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 b e l o w each i t e m .  3.  To o b t a i n a s c o r e o f 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 . F o r e x a m p l e , 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 o r 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 o f 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 t h e degree of impairment. T r y n o t t o a n s w e r i n t h e way you 'hope' t h e p a t i e n t w i l l be a b l e t o f u n c t i o n , o r what y o u t h i n k h e / s h e i s a c t u a l l y c a p a b l e o f d o i n g . Rather 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 a s s e s s m e n t o f how t h e p e r s o n i_s f u n c t i o n i n g b a s e d on t h e e v i d e n c e you h a v e g a t h e r e d i n y o u r d a y - t o - d a y c o n t a c t . That i s t h e 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 s u b s e q u e n t e v a l u a t i o n o f p r o g r e s s c a n be made.  73  74  A. COGNITIVE FUNCTIONING:  1. O r i e n t a t i o n :  Indicates 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) T i m e 4  3  1  1  2  |  1  |  4= Knows the m o n t h , y e a r , season, time o f day a c c u r a t e l y and c o n s i s t e n t l y .  1= Seems t o t a l l y u n a w a r e o f w h e t h e r i t i s daytime o r n i g h t t i m e . Ori s l i v i n g i n another time p e r i o d , ( e g . t h i n k s he/she i s a c h i l d again.)  N.B. B e i n g u n a w a r e o f t h e e x a c t d a t e o r d a y o f t h e week d o e s n o t necessarily indicate disorientation.  (b) P l a c e 4  3 1  1  2 1  1 |  4= Knows w h e r e h e / s h e i s and 1= Seems t o t a l l y u n a w a r e o f i n what t y p e o f p l a c e , ( e g . s u r r o u n d i n g s and i s u n a b l e t o acute care h o s p i t a l ) I s able l o c a t e own room, b e d r o o m , o r t o f i n d h i s / h e r way a r o u n d dining-room, without getting l o s t .  (c)  Person 4  3 1  1  2 1  4= Knows e x a c t age and r e c o g n i z e s f a m i l y members, f r i e n d s , s t a f f , and o t h e r p a t i e n t s .  2. Memory:  1 | 1= F a i l s t o r e c o g n i z e own name, or the faces of s i g n i f i c a n t others i n the environment, (eg. t h e n u r s e who h a s b e e n i n c l o s e c o n t a c t f o r some t i m e ) .  I n d i c a t e s t h e 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 p a s t , whether an h o u r 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  (Recent)- events days.  of the past  few m i n u t e s ,  i n the  hours, or  Remembers w h e r e h e / s h e 1= U n a b l e t o remember what m e a l was placed personal belongings s e r v e d l a s t o r f o r g e t s what h a s 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 of the recent past.  75  (b) Long Term (Remote)- events of s e v e r a l years a  J Is a b l e to r e l a t e the s i g n i f i c a n t events of h i s / h e r l i f e . (eg. the death of a spouse, number of c h i l d r e n , main o c c u p a t i o n , b i r t h p l a c e , etc.)  3 Comprehension:  I n d i c a t e s the a b i l i t y to understand grasp of the s i t u a t i o n .  4=  4. A t t e n t i o n Span:  Cannot remember own name, or those of immediate f a m i l y . Unable to generate the names of body p a r t s on r e q u e s t , (eg. l e g , arm.) Cannot r e c o g n i z e a f a m i l i a r tune, as i n d i c a t e d by humming or s i n g i n g along.  or to o b t a i n a r e a l i s t i c ,  Is a b l e to f o l l o w i n s t r u c t i o n s and understand e x p l a n a t i o n s . 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.  I n d i c a t e s the a b i l i t y event.  intelligent  Unable to understand or f o l l o w the s i m p l e s t of i n s t r u c t i o n s . I n d i c a t e s no a b i l i t y to grasp new s i t u a t i o n s or d e a l w i t h simple i n f o r m a t i o n .  to a t t e n d or c o n c e n t r a t e on a s i n g l e s i t u a t i o n  or  J 4= Becomes engrossed i n a c t i v i t y , r e a d i n g , e t c . Is a b l e to f o l l o w c o n v e r s a t i o n , or m a i n t a i n i n t e r e s t i n a task u n t i l completion.  N.B.  5. Judgment:  Is very e a s i l y d i s t r a c t e d by i r r e l e v a n t s t i m u l i or preoccupat i o n w i t h other matters. Not a b l e to a t t e n d to even s h o r t convers a t i o n s or t a s k s without c o n t i n u a l ' c a l l i n g back'.  I f the p a t i e n t i s d i s o r i e n t e d , a b i l i t y t o a t t e n d w i l l be i n d i c a t e d by l i s t e n i n g i n t e n t l y and m a i n t a i n i n g a t t e n t i o n without d i s t r a c t i o n , whether or not the person can take p a r t i n the c o n v e r s a t i o n .  I n d i c a t e s the a b i l i t y to e v a l u a t e a l t e r n a t i v e courses of a c t i o n and t o draw proper c o n l u s i o n s from e x p e r i e n c e . This includes a r e a l i s t i c self perspective and i n s i g h t .  JL Able to make sound j u d g ments on important matters. Recognizes own s t r e n g t h s and l i m i t a t i o n s and a c t s accordingly. Has q u i t e good i n s i g h t i n t o own behaviour.  Unaware of a b i l i t i e s and attempts dangerous a c t s . Has t o t a l l y u n r e a l i s t i c p l a n s f o r the f u t u r e . Unable to make day-to-day d e c i s i o n s , such as what c l o t h e s to wear.  76 6. Speech:  Communicates i n a f l u e n t manner that i s r e a d i l y understood  ( a )  4  1  3  1  2  1  1  1  4= Speaks c l e a r l y , f l u e n t l y , and c o h e r e n t l y . M a i n t a i n s a frame of r e f e r e n c e w i t h c l e a r boundaries. Context o f statements i s r e l e v a n t and f o l l o w s a l o g i c a l sequence.  ^  by o t h e r s .  1= Unable to communicate i n any manner (speech, g e s t u r e , w r i t i n g ) . Orspeech i s such that i t i s i m p o s s i b l e t o d e c i p h e r , f o r whatever reason, Or- speech i s t o t a l l y I r r e l e v a n t and meaningless,  Aphasic- Has d i s t u r b a n c e s of language due to a s p e c i f i c b r a i n i n j u r y such as c e r e b r o v a s c u l a r a c c i d e n t ( s t r o k e ) , tumour, or accident. 4  1  3  1  2  1  1  1  4= No d i s t u r b a n c e i n language of t h i s type has been i d e n t i f i e d . 3= E x p r e s s i v e aphasia ( d i f f i c u l t y i n e x e c u t i n g speech or e x p r e s s i n g oneself.) 2= R e c e p t i v e a p h a s i a ( d i f f i c u l t y i n understanding speech, or unable to read. 1= G l o b a l a p h a s i a ( 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 c l o s e emotional r e l a t i o n s h i p w i t h another  4  1  3  1  2  1  1  1  4= Has a c l o s e r e l a t i o n s h i p w i t h f a m i l y member, f r i e n d , or s t a f f on a r e g u l a r basis. 2.  Participation:  person.  1» No v i s i t o r s . Lacks r e l a t i o n s h i p w i t h any one. Lonely,  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 w i t h s t a f f , o t h e r p a t i e n t s , or u t i l i z e s m a t e r i a l s i n a s t i m u l a t i n g manner.  4  1  3  1  2  1  1  1  4= Takes p a r t i n group a c t i v i t i e s . Finds s t i m u l a t i o n either through o r g a n i z e d , s t a f f d i r e c t e d programs, or through 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, r e a d i n g , e t c .  1= Withdrawn from group a c t i v i t i e s or programs. Does not take p a r t i n any form of i n d i v i d u a l a c t i v i t y or s t i m u l a t i o n ,  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 o n e - t o - o n e b a s i s w i t h enthusiasm.  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 s p o n t a n e i t y , t r u s t , and e a g e r n e s s when a p p r o a c h e d by a n o t h e r p e r s o n .  4.  Co-operation:  Acts  i n a considerate,  1.  4  3  2  1  J  1  1  I 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 . B e l l i g e r e n t , unco-operative. Behaves objectionably or 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 other p a t i e n t s .  BEHAVIOUR:  Trusting/ Suspicious:  •A  1  3  2  1  1  I  1  4= I n d i c a t e s o p e n n e s s , t r u s t f u l ness of o t h e r s .  2. R e l a x e d / Anxious:  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 d r a w n , c l o s e d t e n d e n c y when a p p r o a c h ed. G i v e s the impression of s h r i n k i n g away f r o m p e r s o n a l interaction.  h e l p f u l , a n d s e n s i t i v e manner t o o t h e r s .  4= C o n s i d e r a t e , c o - o p e r a t i v e , h e l p f u l , and s e n s i t i v e t o other patients.  C. ADAPTIVE  i n t e r e s t and  4  1  3  1  4= A t e a s e , r e l a x e d , things i n stride.  2  1  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 paranoia, (eg..Thinks that others are s t e a l i n g o r h i d i n g things 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 suspiciously.  1  1  calm. 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 , worried, r e s t l e s s , or fidgety. (pacing, rocking, n a i l - b i t i n g , etc.). Generally indicates unsettled behaviour.  78  3.  Passive/ Aggressive:  Aggressive 1  Well-balanced 4  3  Extremely 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.  Well-balanced. Not t o o a g g r e s s i v e or passive.  1= E x t r e m e l y p a s s i v e and d e p e n d e n t . W i l l not attempt a n y t h i n g on h i s own. M a k e s no attempt to c o n t r o l what happens or e v e n t s around him/ her.  Animated/ Depressed:  4=  5.  4=  Passive 1  Recognition/ Denial:  Has e n t h u s i a t i c , o p t i m i s t i c , h a p p y o u t l o o k on l i f e . Shows active interest i n surroundings.  4  3  2  1  1  1  1  1  4=  R e c o g n i t i o n and acceptance of 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 functional situation). Able to d i s c u s s openly.  D.  GLOBAL PHYSICAL WELL-BEING:  1.  Energy Level:  Indicates  4=  1= V e r y d e p r e s s e d , d e s p o n d e n t . Expresses extremely self-derogatory hopeless f e e l i n g s .  1= D e n i a l o f l o s s i n h e a l t h and functioning a b i l i t y . Responses which are o b v i o u s l y incongruent with actual feelings. (eg. States t h a t he/she i s not depressed 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 otherwise.)  the c a p a c i t y to s u s t a i n e f f o r t  G i v e s the i m p r e s s i o n of 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 a g e . (erect posture, decisive movements). A b l e to 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 .  or e x e r t o n e s e l f .  1= G i v e s t h e i m p r e s s i o n o f b e i n g e x t r e m e l y weak and f e e b l e ( e g . slumped, c o l l a p s e d p o s t u r e ) . S p e n d s m o s t o f t h e d a y on o r i n bed.  79  2.  Comfort Level:  Experiences  4=  3.  4.  Body Intactness:  Vision:  Hearing:  p a i n or d i s c o m f o r t  from  as a r e s u l t  pain/discomfort.  1=  of d i s e a s e o r  disability.  S u f f e r s from severe p a i n or discomfort frequently. Pain i s such that i t i n t e r f e r e s w i t h h i s / h e r day-to-day a c t i v i t i e s .  The body s y s t e m s h a v e m a i n t a i n e d function.  t h e i r wholeness i n s t r u c t u r e  4=  1=  The  4=  5.  Free  no  The  4=  I n t a c t b o d y . No m a j o r deterioration, paralysis, amputation, areas of a n a e s t h e s i s , or l o s s of body p a r t (eg. mastectomy) or f u n c t i o n (eg. colostomy) S k i n i s i n good c o n d i t i o n .  ability  t o see  ability  to hear  Gives impression of having severe overall deterioration in physical health. Has l o s s o f body p a r t o r f u n c t i o n , p a r a l y s i s , amputation, or areas of a n a e s t h e s i a , e t c . Ors 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 severe breakdown.  ( w i t h the a i d of g l a s s e s , i f  No p r o b l e m o r v e r y s l i g h t d i f f i c u l t y seeing.  1=  and  necessary)  Severe problem. Unable to see a n y t h i n g but vague o u t l i n e s , shadows. Functionally blind.  ( w i t h the aid. 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 ) .  No p r o b l e m , o r v e r y d i f f i c u l t y hearing.  slight  1=  Severe problem. Cannot hear when s p o k e n t o v e r y l o u d l y . F u n c t i o n a l l y deaf.  even  80  E. A C T I V I T I E S OF D A I L Y L I V I N G :  1.  Chewing Ability:  Indicates  the a b i l i t y  4  3  2  1  1  1  1  1  4= 3= 2= 1=  2. C o n t i n e n c e :  Indicates  3. B o w e l Function:  4  3  1  1h  Indicates  consistency.  Normal d i e t Minced d i e t Soft diet Fluid diet  the a b i l i t y  4= 3= 2= 1=  to e a t a d i e t o f normal  to c o n t r o l bladder  2  function  appropriately.  1  i  Has f u l l c o n t r o l . Rarely incontinent. Occasional accident. Usually or frequently incontinent. No c o n t r o l . A l w a y s i n c o n t i n e n t . Catheter,  the a b i l i t y  4  3  1  1  t o pass formed  2  1  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  basis.  1  1  4= Has n o r m a l l y f o r m e d s t o o l o n r e g u l a r b a s i s w i t h o u t t h e a i d o f m e d i c a t i o n , enema, o r m a n u a l 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 t h e u s e o f l a x a t i v e f o r r e g u l a r elimination. 2= T a k e s l a x a t i v e s r o u t i n e l y . R a r e l y n e e d s enemas o r m a n u a l removal. 1= I n c o n t i n e n t o f s t o o l o r t o t a l l y d e p e n d e n t o n m e c h a n i c a l / c h e m i c a l means o f 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 D a i l y L i v i n g  (ADL)  Chart  INSTRUCTIONS FOR THE USE OF THE V I S U A L CHART:  P l e a s e w r i t e a s c o r e o f 1, 2, 3 b e s i d e e a c h a r e a o f t h e v i s u a l particular activities.  chart  that  represents  1= T o t a l I n d e p e n d e n c y : I n d e p e n d e n c e means t h e a b i l i t y t o p e r f o r m a n 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, d e p e n d e n t , e v e n t h o u g h he may be c o n s i d e r e d a b l e t o do i t . H e / s h e may u s e a n y m e t h o d o r a i d t o p e r f o r m the a c t i v i t y . The s c o r e o f 1 i n t h e a c t i v i t y o f w a l k i n g r e p r e s e n t s t h e a b i l i t y to walk approximately 1 block independently.  2= P a r t i a l D e p e n d e n c e : The p a t i e n t c a n p e r f o r m t h e g r e a t e r p a r t o f t h e 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 . In walking 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 walk 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 u s e c a n e o r w a l k e r , e t c .  3= T o t a l D e p e n d e n c e : The a c t i v i t y this refers  to walking  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 short distances with personal assistance.  82 On  Off  Appendix Sample  Range o f S c o r e s for Each Subsection  B  Multidimensional Profile  Resident s Hypothetical Score 1  Visual Profile of Performance  Cognitive 10-40  25  10  40  9  4  16  19  5  15  5  14  7  Social 4-16 Adaptive 5-20  .»  2  0  Physical 5-20 A.D.L. 7-24  83  •  JL.  20  24  Appendix C Major A d m i t t i n g Diagnoses o f Sample  Population  Number o f Residents  Diagnoses 1. C e r e b r a l I n j u r y (Stroke, P a r k i n s o n ' s , Hemorrhage, e t c . ) 2.  27  B e h a v i o u r a l 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)  Approximate Percent  36  16  21  3. H e a r t D i s e a s e  9  12  4.  5  6  5. C i r c u l a t o r y Problems  4  5  6. M e t a b o l i c  3  4  2  3  2  3  8  10  Musculo/Skeletal Problems  Disorders  7. N u t r i t i o n a l 8.  Problems  Sensory Problems  9. O t h e r Diagnoses  76  Total  84  100  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, f i b r i l l a t i o n episodes) - congestive heart failure - valve insufficiency - infarct B. Circulatory Problems: -— generalized arterio/atherosclerosis - 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 85  Score 2 Points  mild varicosities mild hyper/hypotension not requiring medication .  amputation (minor) fratures (resolved) spasm minor contracture mild back ache  86  E . Metabolic Disorders: - diabetes mellitus (not c o n t r o l l e d by d i e t ) - diabetes insipidus - adrenal insufficiency - 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: - diverticulitis - ulcerative 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. Infections: - major s y s t e m i c i n f e c t i o n - osteomylitis - gangrene -pneumonia/bronchitis - chronic infections H. Organ F a i l u r e : - major o r g a n f a i l u r e o r removal (kidney,liver, uterus, g a l l bladder, e t cetera) - stones i n organ o r duct - o t h e r major s u r g e r y I . Integument: - open wound ( s u r g i c a l or decubiti) - stasis ulcers 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 - dehydration - anemia ( s e v e r e , p r o g r e s s i v e ) - progressive weight l o s s - syirptomatic v i t a m i n deficiency K . Sensory Impairments: - severe hearing l o s s - severe v i s i o n l o s s L . Symptomatic D i a g n o s e s : - disturbance i n consiousness - p a i n (N.Y.D.) - fever " - jaundice "  - diabetes mellitus ( c o n t r o l l e d by d i e t )  - mild gastroenteritis - m i n o r bowel problems - missing teeth/dentures - minor l o c a l i z e d i n f e c t i o n -abscess/boil - resolved infections of serious nature  - minor o r g a n f a i l u r e o r removal - p r o s t a t i c hypertrophy -. hernia - minor s u r g e r y  - minor t o e / n a i l / f o o t problems - pruritis/psoriasis - mild dietary - obesity anemia (mild)  insufficiency  - rninor t o moderate h e a r i n g or v i s i o n loss -  d i z z i n e s s / p o s t u r a l hypotension - m i l d balance disturbance  87  M. Miscellaneous: - cancer - multiple sclerosis - CO.L.D. (chronic obstructive lung disease) - other disease entities/syndromes N. Special Requirements: - requies oxygen occasionally " suctioning " " tube feeding " - has indwelling catheter - has tracheostomy - has colostomy - has ileostomy - has gastrostomy  - tumour/c^st/growth (small or benign) - neuralgia  - special diet modification  Total Score:  Appendix E Planned A c t i v i t y  (PLA) Check  LOCATION: Dining Room/Activity P h y s i o Room K i t c h e n ( O c c u p a t i o n a l Area) Bedroom Offices/Nursing Station Corridor Bathroom Classrooms Other: Specify  ~~  STATE: Walking Standing Sitting:  (1) Appar. awake (2) Appar. a s l e e p Wheelchair: (1) Independent (2) Dependent TYPE: Drinking Eating:  (1) Meals (2) Other t h a n meals Grooming: (1) O n e s e l f (2) By someone (3) Both Dressing: (1) O n e s e l f (2) By someone (3) Both Writing R e a d i n g / L e a f i n g t h r u magazine  88  Observer 4:00-4:30  Observer 2:30-3:00  Observer 1:30-2:00  Observer 11:30-12:00  Name Date Room No.  Recreation:  (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. P r o c . (3) Counsel. Group Meeting SOCIAL LEVEL: Solitary Dyad: (1) S t a f f (2) Another P a t i e n t (3) V o l u n t e e r (4) F a m i l y 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 o n l y (3) F a m i l y COMMENTS!  Observer 4:00-4:30  Observer 2:30-3:00  Observer 1:30-2:00  Observer 11:30-12:00  89  Appendix F Mental Status Questionnaire  1. Where are we now? 2. Where i s this place? 3. What i s to-day's date? 4. What month i s i t ? 5. What year i s i t ? 6. How old are you? 7. What i s your birthday? 8. What year were you born? 9. Who i s 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 Number Mean Item Rating Rated Score 1 1. Orienta'9 2 14 tion to 18 3.0 3 Time 4 35 1 2 3 4  11 10 10 45  To Person  1 2 3 4  '2  4. Shortterm Memory  1 2 3 4  17 .9 11 39  5. Long term Memory  1 2 3 4  6 13 10 47  6. Comprehension  1 2 3 4  10 11 23 32  7. Attention Span  1 2 3 4  14 12 18 32 .  8. Judgment  1 2 3 4  20 11 22 23  1 2 3 4  }P2  2. To Place  3.  9. General Speech  13 12 49  20 23 31  Correlations with with, S.D. :subsection Total Score 1.0  0.88  0.8  3.2  1.1  0.87  0.76  3.4  0.87  0.81  0.74  2.9  1.24  0.87  0.78  3.3  1.0  0.75  0.68  3.0  1.0  0.88  0.85 '  2.9  1.2  0.83  0.86  2.6  1.2  0.88  0.84  3.0  0.88  0.73  0.7  91  92 Cognitive Functioning (continued) Number Mean Rating Rated Item Score 1 10. Aphasia .1 2 .1 3.7 3 17 4 57  S.D.  Correlations with with Subsection Total  0.6  0.33  0.26  B. Social Functioning 1. Emotional Involvement  2. Participation  3. Interaction  4. Co-operation  1 2 3 4  8 17 11 40  3.1  1.0  0.43  0.5  • 1 2 3 4  23 19 14 20  2.4  1.2  0.62  0.71  1 2 3 4  ,9 8. 31 28  3.0  0.98  0.68  0.71  1 2 3• 4  ,8 20 25 23  2.8  0.98  0.68  0.67  3.1  0.92  0.62  0.61  C. Adaptive Behaviour 1. Trusting/ Suspicious  1 2 3 4  16 24 32  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  •A  93  D. Physical Functioning  Number Mean Rated Score 13 22 2.5 30 11  Item 1. Energy Level  Rating 1 2 3 4  2. Comfort Level  1 2 3 4  10 17 31 18  3. Body Intactness  1 2 3 4  4. Vision  1 2 3 4  5. Hearing  S.D.  Correlations with with Subsection Total  0.95  0.4  0.59  2.8  0.97  0.43  0.1  9 29 20 18  2.6  0.98  0.2  -0.01  4 11 26 35  3.2  0.88  0.16  0.26  3.4  0.77  0.14  0.24  1 2 3 4  21 46  1. Chewing Ability  1 2 3 4  0 ,2 14 60  3.7  0.49  0.24  0.44  2. Continence  1 2 3 4  6 • 13 27 30  3.0  0.94  0.54  0.61  3. Bowel Function  1 2 3 4  .'9 9 29 29  3.0  0.99  0.3  0.37  4. Dressing  1 2 3  36 22 18  1.76  0.8  0.59  0.4  2 "7  E. A.D.L.  94  A.D.L. ,(cx>ntinued) Item Rating 5. Grccming 1 2 3 6. Eating  7. Ambulating  Number Mean Rated . Score 19 32 2.0 25  S.D.  Correlations with with Subsection Total  0.76  0.7  0.5  1 2 3  ,6 12 58  2.7  0.61  0.25  0.1  1 2 3  24 26 26':  2.0  0.82  0.62  0.34  Appendix H Distribution of Subsection and Total Scores  1. Cognitive Functioning Subsection:  * * * * * * * * * ** * **** * **** ** **** **** * ***** * ** *&*j ********** * * * * * * * * * * ** *********** 20 30 40  T  ±i _ 10  Mean= 31.2 S.D.= 8.6 S.E.= 1.82  X 2. Social Functioning:  * * * ****** *** *• ********* ********* *********  * ********* ************* * * * * * * ***** ******  Mean= 11.4 S.D.= 3.31 16  S.E.= 1.32  X 3. Adaptive Behaviour:  * * *  ** ** * ** * ** * * ** *  Mean= 13.9  ***  S.D.= 3.8  * ** ****** ************ ** ************\| *********.*******  S.E.= 1.48  20  X 95  96  . Physical Functioning:  ** ** ** ** ** *** * ***** ******* ******** ********* ********** *********** ******_****•*•* 20 X  Mean= 14.5 S.D.= 2.6 S.E.= 1.67  A.D.L.:  ** *** ** *** *** * ***** *** ** ** ***** * ** ** ***** ** ***** * t*^ * 16 ** ***** *24  Mean= 18.4 S.D.= 3.48 S.E.= 1.63  * ' A ' * * * * * * * * * * * * * * * * * * * * * * * * *  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  Step ^ Number  Variable Entered  Scores  F to Enter  Wilk's Lambda  1  Cognitive Functioning  2.88  0.96  2  A.D.L.  1.97  0.94  Standardized Discriminant Function Coefficient Cognitive Functioning A.D.L.  v Canonical Correlation  Percentage of Known Cases .Correctly Predicted  0.25  72%  1.07 -0.7  Subsection scores were i n c l u d e d i n the 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 i n order o f t h e i r a b i l i t y t o minimize the r e s i d u a l unexplained v a r i a t i o n . For > ... d e t a i l s o f t h i s program see,-'N~:,.Nie - e t a l , S t a t i s t i c a l Package f o r the S o c i a l S c i e n c e s , 2nd ed.(New York:McGrawH i l l Books, 1975), p. 447.  97  Appendix J Comparison o f Score  Differences  To Nurse C o - o r d i n a t o r and R e s i d e n t R a t i n g o f Change  Source o f Variation  S.S  D.F.  M.S.  Nurse R a t i n g  643  2  321  Error  5052  37  136  Total  5695  39  142  Resident  194  2  97  Error  5501  37  148  Total  5695  39  142  98  F.  2.35  0.65  P.  0.1 (N.S.)  Appendix K Ccfmparison of Nurse Co-ordinators' and Residents' Ratings of Change  Nurse Co-ordinator Improved  Same  Deteriorated  Improved  12  Same  22  c -H  tn  Deteriorated 19  15  99  40  

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