Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA 02114, USA.
J Geriatr Phys Ther. 2013 Apr-Jun;36(2):87-91. doi: 10.1519/JPT.0b013e318268da23.
Nursing facility patients are a population that has not been well studied with regard to functional status and independence previously. As such, the manner in which activities of daily living (ADL) relate to one another is not well understood in this population. An understanding of ADL difficulty ordering has helped to devise systems of functional independence grading in other populations, which have value in understanding patients' global levels of independence and providing expectations regarding changes in function. This study seeks to examine the hierarchy of ADL in the nursing facility population.
Data were analyzed from the 2004 National Nursing Home Survey, a cross-sectional data set of 13 507 skilled nursing facility subjects with functional independence items. The ADL difficulty hierarchy was determined using Rasch analysis. Item fit values for the Rasch model using Mean-Square infit statistics were also determined. The robustness of the hierarchy was tested for each ADL. Two grading systems were devised from the results of the item difficulty ordering. One was based on the most difficult item that he or she could perform, and the other assigned a grade based on the least difficult item that a subject could not perform.
A total of 13 113 patients were included in this analysis, the majority of whom were female and white. They had an average age of 81 years. An ordered hierarchy of ADL was found with eating being the easiest and bathing the most difficult. All items in the Katz index fit the Rasch model adequately well. The majority of patients able to perform any particular ADL were also able to perform all easier ADL. Cohen's κ for the 2 grading systems was 0.73.
This study is the first to show the expected hierarchy of difficulty of the 6 activities of daily proposed in the Katz index in the nursing facility population. The hierarchy found in this population matches the original hierarchy found in older adults in the community and acute care settings. It is also similar to hierarchy found in the inpatient rehabilitation setting. Patients would be expected to lose or gain function based on the order of difficulty, but this remains to be confirmed.
Among the 6 activities of daily living tested here, their order from easiest to most difficult is eating, maintaining continence, transferring, toileting, dressing, and bathing. In addition, the index formed by these 6 items has construct validity in the nursing facility population.
护理院患者在之前的研究中并未很好地研究其功能状态和独立性。因此，在该人群中，日常生活活动（ADL）之间的关系尚不清楚。了解日常生活活动的困难程度有助于制定其他人群的功能独立性分级系统，这些系统在了解患者整体独立性水平和提供功能变化预期方面具有价值。本研究旨在检查护理院人群中的日常生活活动的层次结构。
本研究分析了 2004 年全国护理院调查的数据，该数据是一个包含 13507 名有功能独立性项目的熟练护理院受试者的横断面数据集。使用 Rasch 分析确定日常生活活动的困难程度等级。还使用均方根 infit 统计量确定 Rasch 模型的项目拟合值。对每项日常生活活动的层次结构进行了稳健性测试。根据最困难的项目和受试者无法完成的最容易的项目设计了两种分级系统。
共有 13113 名患者纳入本分析，其中大多数为女性和白人，平均年龄为 81 岁。发现日常生活活动的有序层次结构，其中进食最简单，洗澡最困难。卡茨指数中的所有项目都很好地符合 Rasch 模型。能够执行任何特定日常生活活动的大多数患者也能够执行所有更简单的日常生活活动。两种分级系统的 Cohen's κ值为 0.73。
本研究首次在护理院人群中显示了卡茨指数中提出的 6 项日常生活活动预期的难度层次结构。在该人群中发现的层次结构与社区和急性护理环境中老年人的原始层次结构以及住院康复环境中的层次结构相匹配。在护理院人群中，患者预计会根据困难程度的顺序丧失或获得功能，但这仍有待证实。
在本研究测试的 6 项日常生活活动中，从最简单到最困难的顺序为进食、保持大小便控制、转移、如厕、穿衣和洗澡。此外，该指数在护理院人群中具有结构有效性。
