The University of Bordeaux and University Hospital of Bordeaux supported this publication.

The protocol has been approved by the human research ethics committee of the University Hospital of Bordeaux.
NOTE: The protocol described in this section involves evaluation of ADL dependence using the Katz ADL. The six activities assessed are described above18. The Katz ADL is administered at the Bordeaux University Hospital, on admission and discharge, to all patients over 75 years of age, i.e., all those in acute geriatric medicine wards. Inpatients in geriatric units present with numerous comorbidities and it is recommended that staff assess all such patients. In theory, the Katz ADL could be administered to all patients at risk of losing their independence due to an acute medical problem, which would include some younger patients. However, ADL dependence is infrequent in younger adults, as the prevalence of disabling diseases is low in that population. Nevertheless, the protocol could also be implemented in other departments, particularly internal medicine, cardiology, and neurology.
1. Protocol for administering the Katz ADL before hospitalization
<ol>
	<li>Evaluate bathing activity.
	<ol>
		<li>To evaluate bathing, ask patients how they bathe and whether they need someone to help them with bathing. If so, ask them which part of the body they require help with. Then, note whether they are independent (1 point) or dependent (0 point) in bathing activities. 
		NOTE: Independent patients bathe their entire body alone, with the exception of the back, genital area, or a disabled extremity. Dependent patients need help to bathe several parts of their body, or to get in and out of the shower or bathtub.</li>
	</ol>
	</li>
	<li>Evaluate dressing.
	<ol>
		<li>Ask patients whether they can dress and undress alone, and whether they can take their clothes out of the closet without help. Ask whether they need help with putting on socks or other items of clothing. Then, note whether they are independent (1 point) or dependent (0 point) in dressing activities. 
		NOTE: An independent person gets their clothes out of the closet and puts them on, including fastening them where applicable. Shoe tying is not included among dressing activities. A dependent person needs some help with dressing or needs to be completely dressed by someone else.</li>
	</ol>
	</li>
	<li>Evaluate toileting.
	<ol>
		<li>Ask patients whether they go to the toilet unassisted at home. Ask whether they can sit down and stand up from the toilet, arrange their clothing as needed, and clean the genital area without help. Then, note whether they are independent (1 point) or dependent (0 point) in toileting. 
		NOTE: An independent person goes to the toilet, sits and stands up from the toilet, arranges clothes, and cleans the genital area without help. A dependent person needs help transferring to the toilet and cleaning up, or uses a bedpan or commode.</li>
	</ol>
	</li>
	<li>Evaluate transferring.
	<ol>
		<li>Ask patients whether they can move from the bed to a chair, and from a chair to the bed, without human assistance. Then, note whether they are independent (1 point) or dependent (0 point) in transferring. 
		NOTE: An Independent person moves into or out of a bed or chair unassisted or using a mechanical transferring aid. A dependent individual needs help from another person to move from a bed to a chair or requires a complete transfer.</li>
	</ol>
	</li>
	<li>Evaluate continence.
	<ol>
		<li>Ask patients whether they have complete self-control over urination and defecation. If not, ask whether they can use a urinary catheter or diaper without help. Then, note whether they are independent (1 point) or dependent (0 point) with respect to continence. 
		NOTE: Independent patients exercise complete self-control over urination and defecation, or use a urinary catheter or diapers without help. The dependent person is partially or totally incontinent (bowel or bladder) and needs help to manage these functions.</li>
	</ol>
	</li>
	<li>Evaluate feeding.
	<ol>
		<li>Ask patients whether they eat without help; if so, ask whether they are able to cut meat or open the lid of a yogurt container. Then, note whether they are independent (1 point) or dependent (0 point) in feeding activities. An independent person can eat a prepared and delivered meal without assistance. 
		NOTE: An independent person transfers food from the plate into the mouth without help. A dependent person needs partial or total help with feeding.</li>
	</ol>
	</li>
	<li>Calculate the ADL score by summing the scores for all activities.</li>
</ol>
2. Administration of ADL scale on hospital admission
<ol>
	<li>Bathing
	<ol>
		<li>During the first day of hospitalization, offer patients a shower. If they feel able to take one, accompany them to the bathroom and check whether they are able to wash by themselves. If patients do not feel able to do this, offer to wash them in bed or at the basin.</li>
		<li>Observe whether patients are able to do this on their own or whether they need guidance or help with certain parts of the body. Then, note whether they are independent or dependent in bathing (following the same definition of independent and dependent as in step 1.1).</li>
	</ol>
	</li>
	<li>Dressing
	<ol>
		<li>During the first day of hospitalization, propose that patients get dressed. Ask them to choose clothes from the closet and put them on; if patients have difficulty, help them to get dressed.</li>
		<li>In the evening, follow the same procedure, but as applied to undressing.</li>
		<li>Note whether the patient is independent or dependent in dressing (following the same definition of independent and dependent as in step 1.2).</li>
	</ol>
	</li>
	<li>Toileting
	<ol>
		<li>During the first few days of hospitalization, check whether patients are able to go to the toilet alone, sit and stand up from the toilet, arrange their clothing, and clean the genital area.</li>
		<li>Evaluate whether a commode or bedpan is needed. Note whether patients are independent or dependent in toileting (following the same definition of independent and dependent as in step 1.3).</li>
	</ol>
	</li>
	<li>Transferring
	<ol>
		<li>On the first day of hospitalization, ask patients to transfer from the bed to a chair and from the chair to the bed. If patients have any difficulty, first offer mechanical transferring aids, and if necessary, help them to make the transfer. Then, note whether patients are independent or dependent for transferring (following the same definition of independent and dependent as in step 1.4).</li>
	</ol>
	</li>
	<li>Feeding
	<ol>
		<li>During the first meal at the hospital, observe whether patients are able to eat alone, including cutting meat and opening the lid of a yogurt container. Help them if necessary. Then, note whether the patient is independent or dependent for eating (following the same definition of independent and dependent as in step 1.6).</li>
	</ol>
	</li>
	<li>Calculate the ADL score by summing the scores for all activities.</li>
</ol>
3. Compare functional independence scores before the acute medical problem and at the time of hospital admission
<ol>
	<li>Identify the activities in which patients have lost independence during the acute medical problem. Identify activities in which patients were dependent prior to the problem.</li>
	<li>Encourage patients to regain their lost independence through rehabilitative care.</li>
	<li>Help to maintain any independence that was not lost during the acute medical problem.</li>
</ol>
4. Recalculate ADL score throughout hospitalization (twice per week)
<ol>
	<li>Perform the same assessment steps described in Step 2.</li>
	<li>Discuss the assessment results during a staff meeting where nurses, nurse assistants, physicians, and physiotherapists are present.</li>
	<li>Compare ADL scores to identify improvement or deterioration of functional independence.</li>
	<li>Maintain or modify rehabilitative care according to the evolution of functional independence; the goal is for patients to recover their former level of independence.</li>
</ol>
5. Evaluate the ADL score at discharge and compare it to the score prior to hospitalization
<ol>
	<li>Determine whether patients have lost functional independence as a result of the acute medical problem.</li>
	<li>Adapt the home help protocol as needed.</li>
</ol>

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The authors have no conflicts of interest to disclose.

The protocol is not appropriate in all situations 
Our protocol was designed for patients who have been hospitalized for an acute medical problem. However, other tools, such as the Barthel Index, should be used in rehabilitation centers. The original Katz ADL scale scores functional ability only on a 7-point scale (scores of 0&#8211;6); subtle fluctuations in functional dependence may therefore be overlooked. The Barthel Index, which is generally comparable to the Katz ADL, yields weighted and summed scores. The six activities included in the Katz ADL scale are also evaluated by the Barthel Index, but with several differences: bowel and bladder control are considered separately, and mobility is addressed in greater detail (i.e., both on level surfaces and when climbing stairs). Also, the total score is based on 10 activities, each of which is scored as 0, 5, 10 or 15 points. Transferring and mobility are the only activities scored on 15 points. The maximal overall score is 100 points, with higher scores indicating greater independence. The Barthel Index should ideally be scored during a multidisciplinary meeting involving the physician, nurse, physiotherapist, and occupational therapist, because the score guides the rehabilitation plan20.
Furthermore, the Katz ADL score is not pertinent during follow-up assessment of cognitive impairment. ADL dependence, as assessed by the Katz ADL score, occurs at a late stage in the treatment of major cognitive problems. The hierarchical model of functional dependence was developed for epidemiological population-based studies. Older subjects may become dependent, in terms of the performance of basic ADL activities, at the stage considered as severe dependence based on the Katz index. Prior to that stage, moderate dependence is indicated by the need for help from another person to perform instrumental activities of daily living (IADL), which include household activities, making telephone calls, shopping, transferring, and managing medications or finances without help21. IADL dependence is included among the criteria for diagnosis of major cognitive disabilities.
The questionable &#34;continence&#34; item 
In our protocol, we modified the evaluation of &#34;continence.&#34; Incontinence is an impairment rather than a disability; therefore, unlike the original ADL scoring system, we award the patient 1 point if they can manage their incontinence on their own. A patient can be incontinent and still be functionally independent.
The 12-item ADL scale: an alternative 
An ADL scale with 12 items (and thus a maximum possible score of 12 points) is currently preferred for comprehensive gerontological assessments performed in a day hospital, to ensure precise evaluation of functional independence outside of the context of an acute problem22. The 12-item ADL scale is more sensitive to changes in ADL dependence than the 6-point version but is still less sensitive than the Barthel Index. It may be instructive to apply the 12-item scale after the 6-item version for patients who exhibit no change between their baseline and admission ADL scores. The 12-item ADL scale evaluates the same six activities as Katz&#39;s ADL scale; the difference lies in the scoring system. In the case of the former instrument, a score of 0 indicates independence, 1 corresponds to moderate dependence, and 2 indicates dependence. Thus, the feeding item is scored as 1 if the subject is able to eat alone but needs help to cut meat or to open the lid of a yogurt container. Several elements are considered by the 12-item ADL scale that do not decrease the ADL score, such as the need for assistance when using the toilet for only one part of the body, or the need for assistance when tying one&#39;s shoes. We have not yet tried to incorporate the 12-item ADL scale into our protocol; combining multiple tools may prove disruptive for health care teams, where efficient prevention of ADL dependence relies on simple tools that are easy to memorize and apply as frequently as necessary.

Medical problems can cause older people to lose functional independence, rendering them unable to carry out activities of daily living (ADL) without assistance from others. This loss of independence, which often results from cardiovascular comorbidities1, cognitive impairment2,3, and visual impairment4, impacts patient quality of life5 and life expectancy6, and increases healthcare costs7. Functional independence may progressively deteriorate, or be lost completely, with more severe comorbidities (cognitive impairment, heart failure, etc.). It may also worsen during an acute medical problem, such as stroke, myocardial infarction, lower limb fracture, or chest infection8. About 30% of patients aged between 70 and 80 years, and 60% of those aged over 80 years, experience such a loss of independence during hospitalization9,10. Patients may recover the functional independence they enjoyed prior to the acute medical problem, or it may persist thereafter despite appropriate treatment.
It is widely accepted that treatment aimed at maintaining or restoring functional independence during hospitalization for an acute medical problem is most effective if it is started as soon as possible11. Physical exercise during hospitalization improves function in the short and medium term12,13. In a hospitalized population, scores on measures of ADL were associated with muscle oxidative capacity and muscle function1. Hence, assessing a patient&#39;s functional independence at an early stage of hospitalization is a priority; this assessment should then be compared with the patient&#39;s level of ADL independence before hospitalization (baseline). Medical care, particularly nursing care, is aimed at restoring any loss of independence or maintaining the existing level thereof. This requires a reliable and reproducible assessment method; the most commonly used measure for this purpose is the Katz Index of Independence in Activities of Daily Living (Katz ADL).
The Katz ADL, developed in 1970, allows assessment of a patient&#8217;s ability to carry out basic ADL independently15,16. The scale measures patient independence in six activities: bathing, dressing, toileting, transferring, continence, and feeding. Each activity is scored as 0 or 1, where a score of 0 indicates dependence on another person, and 1 indicates independence. A total Katz ADL score of 6 denotes full independence, a score of 4 moderate dependence, and a score of 2 or less severe dependence.
For many years, the Katz ADL has proven useful in the assessment of functional status in older people. First, the Katz ADL assessment is very simple to perform and involves interviewing the patient or family members about the patient&#8217;s ability to perform the six ADL activities, or directly observing how well the patient performs these activities17. Furthermore, during an acute medical problem, the Katz ADL Index is sensitive to major, but not to minor, changes in health status. Thus, this tool is ideal for assessing the impact of an acute medical problem on patients&#8217; functional status, whatever their chronic morbidities.
When initiating rehabilitation within the first days of an acute medical problem, it is necessary to determine the extent of the patient&#8217;s functional decline. For this purpose, we propose that the functional status of each patient should be assessed before hospitalization via interview, and that the ability to perform ADL be assessed within the first days of hospitalization via observation. These two assessments could guide early preventive and rehabilitative measures in parallel with a care plan for the acute event. The effectiveness of these measures for promoting recovery of functional independence can be monitored by repeated ADL assessment until discharge.

<table><tbody><tr><td>Clothing and underwear</td><td>Any</td><td></td><td></td></tr><tr><td>Hospital Bathroom with toilet</td><td></td><td></td><td></td></tr><tr><td>Meal Tray</td><td></td><td></td><td></td></tr><tr><td>Medical Bed</td><td>Any</td><td></td><td></td></tr><tr><td>Medical Chair</td><td>Any</td><td></td><td></td></tr><tr><td>Papers</td><td></td><td></td><td></td></tr><tr><td>Pens</td><td></td><td></td><td></td></tr><tr><td>Table Bed</td><td>Any</td><td></td><td></td></tr></tbody></table>

assessment of dependence in activities of daily living among older patients in an acute care unit

During an acute medical problem, older people may lose functional independence. ADL scales are used to assess this loss of independence. The simplest and most convenient ADL scale is the Katz Index, which measures six ADL: bathing, dressing, toileting, transferring, continence, and feeding. A lower ADL score indicates greater loss of functional independence. The ADL score prior to the acute medical problem (baseline) is estimated by questioning the patient or the caregivers, and this score is then compared with that on hospital admission. The ADL score should be monitored from hospital admission until discharge to allow early detection of changes in functional independence. Identifying any loss of functional independence before and during hospitalization provides information to caregivers regarding the risk of short-term mortality risk and complications, and the prognosis after hospitalization.

Here, we consider two example cases after completion of the protocol: one with full recovery of the baseline level of ADL function at discharge, and one with no or partial recovery.
Discharged with baseline level of ADL function 
In this group of patients, two ADL function trajectories were possible, as shown in Figure 1: patients who maintained their ADL score throughout hospitalization (Trajectory A) and those whose score at hospitalization was lower than at baseline, but who regained their baseline level of function by discharge (Trajectory B). Patients of either trajectory discharged with their baseline ADL function (had an 83.8% and 67% chance of maintaining it 1 month and 1 year after discharge, respectively. In this study, the 1-year mortality rate was 17.8% in this group of patients and there was no difference therein between patients who followed trajectory A and those who followed trajectory B11.
Discharged with new or additional disability in ADL 
In our cohort, three types of cases were identified, as shown in Figure 2: patients who retained their baseline independence on admission to the hospital but showed deterioration during hospitalization and did not regain full independence thereafter (trajectory C); patients who lost their baseline independence prior to hospitalization for the acute problem and did not regain it during hospitalization (trajectory D); and patients who showed deterioration of independence both prior to and during hospitalization, and did not regain full independence (trajectory E)19. Of the patients discharged with new or additional disabilities in ADL, 33.5% recovered their baseline level of ADL function within the first month after discharge, and 30.1% did so within the first year. The 1-year mortality rate was 41.3% for these patients. There was no significant difference between patients who followed trajectory C and those who followed trajectory D11.
Possible errors during execution of the protocol 
Our protocol is simple to implement. Errors are most likely to occur when determining the baseline ADL score, especially when it is obtained through interviews with patients. Some patients may underestimate or overestimate their prior level of functional independence at home. Furthermore, patient recall may be distorted by cognitive impairment. Considering the high prevalence of cognitive impairment among those in geriatric acute care wards, we recommend questioning the family, nurses working in the home or nursing home, or the attending physician to obtain the most accurate baseline ADL score. This questioning is mostly done by telephone after hospital admission.
Examples of results obtained at Bordeaux University Hospital 
The present protocol was implemented in 2017 and applied to all patients over 75 years of age. During the year since the implementation of the protocol, loss of functional independence was observed less often. In 2016, of the 699 hospitalized older patients to whom the protocol was applied, 25.97% showed a loss of functional independence, compared to 19.48% of 852 patients in 2019.
Although systematic application of the protocol to all hospitalized geriatric patients was required, data were not consistently entered in the medical records. In 2017, only 36.78% of medical records mentioned ADL data; in 2019, these data were present in 51.26% of medical records. Thus, health professionals in the hospital should be encouraged both to carry out the protocol and record the patient outcomes.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/61249/61249fig01.jpg" /> 
Figure 1: Favorable trajectories of ADL dependence during an acute medical problem, from baseline to post-event status.&#160;Trajectory A: Mild baseline ADL dependence with no decline at any point during the event; Trajectory B: Mild baseline ADL dependence, decline during the acute event, and recovery before discharge. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/61249/61249fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/61249/61249fig02.jpg" /> 
Figure 2: Unfavorable trajectories of ADL dependence during an acute medical problem, from baseline to post-event status.&#160;Trajectory C: Mild baseline dependence, no decline noted on admission but decline during hospital stay. Trajectory D: Mild baseline dependence, decline noted on admission, no recovery during hospital stay or at discharge. Trajectory E: Moderate baseline dependence, decline noted on admission, further decline during hospital stay, no recovery before discharge. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/61249/61249fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

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Assessment of Dependence in Activities of Daily Living Among Older Patients in an Acute Care Unit

During acute medical problems, older people may lose independence in activities of daily living (ADL). Assessment of baseline ADL and ADL on admission can guide personalized treatment plans aimed at preventing nosocomial dependence and ensuring better functional outcomes.

During an acute medical problem, older people may lose functional independence. ADL scales are used to assess this loss of independence. The simplest and ...

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9.7K Views.  CHU Bordeaux. Ons protocol maakt het mogelijk om de evolutie van de functionele onafhankelijkheid van oudere patiënten te beoordelen tijdens ziekenhuisopname voor een acute medische episode. De ADL-score is reproduceerbaar, gebruiksvriendelijk en kan worden gebruikt om in een vroeg stadium deel te nemen aan het verlies van functionele onafhankelijkheid om aanpassing van het revalidatiezorgplan mogelijk te maken. Om het baden te evalueren, vraag patiënten hoe ze baden en of ze iemand nodig hebben om hen t...

Video: Assessment of Dependence in Activities of Daily Living Among Older Patients in an Acute Care Unit

Development of a Virtual Reality Assessment of Everyday Living Skills

Cognitive impairments affect the majority of patients with schizophrenia and these impairments predict poor long term psychosocial outcomes.&#160; Treatment studies aimed at cognitive impairment in patients with schizophrenia not only require demonstration of improvements on cognitive tests, but also evidence that any cognitive changes lead to clinically meaningful improvements.&#160; Measures of &#8220;functional capacity&#8221; index the extent to which individuals have the potential to perform skills required for real world functioning. &#160;Current data do not support the recommendation of any single instrument for measurement of functional capacity.&#160; The Virtual Reality Functional Capacity Assessment Tool (VRFCAT) is a novel, interactive gaming based measure of functional capacity that uses a realistic simulated environment to recreate routine activities of daily living. Studies are currently underway to evaluate and establish the VRFCAT&#8217;s sensitivity, reliability, validity, and practicality.&#160;This new measure of functional capacity is practical, relevant, easy to use, and has several features that improve validity and sensitivity of measurement of function in clinical trials of patients with CNS disorders.

A challenge for proving treatment efficacy for cognitive impairments in schizophrenia is finding the optimizing measurement of skills related to everyday functioning.&#160; The Virtual Reality Functional Capacity Assessment Tool (VRFCAT) is an interactive gaming based computerized measure aimed at skills associated with everyday functioning, including baseline impairments and treatment related changes.

Cognitive impairments affect the majority of patients with schizophrenia and these impairments predict poor long term psychosocial outcomes.&#160; ...

Behavior

Community-based Adapted Tango Dancing for Individuals with Parkinson's Disease and Older Adults

Adapted tango dancing improves mobility and balance in older adults and additional populations with balance impairments. It is composed of very simple step elements. Adapted tango involves movement initiation and cessation, multi-directional perturbations, varied speeds and rhythms. Focus on foot placement, whole body coordination, and attention to partner, path of movement, and aesthetics likely underlie adapted tango&#8217;s demonstrated efficacy for improving mobility and balance. In this paper, we describe the methodology to disseminate the adapted tango teaching methods to dance instructor trainees and to implement the adapted tango by the trainees in the community for older adults and individuals with Parkinson&#8217;s Disease (PD). Efficacy in improving mobility (measured with the Timed Up and Go, Tandem stance, Berg Balance Scale, Gait Speed and 30 sec chair stand), safety and fidelity of the program is maximized through targeted instructor and volunteer training and a structured detailed syllabus outlining class practices and progression.

Adapted tango has demonstrated efficacy for improving mobility and balance. We describe the dissemination of adapted tango teaching methods to dance instructor trainees and the implementation of adapted tango by the trainees in the community for improving mobility and balance in older adults and individuals with Parkinson&#8217;s disease.

Adapted tango dancing improves mobility and balance in older adults and additional populations with balance impairments. It is composed of very simple ...

Methodology for Establishing a Community-Wide Life Laboratory for Capturing Unobtrusive and Continuous Remote Activity and Health Data

An end-to-end suite of technologies has been established for the unobtrusive and continuous monitoring of health and activity changes occurring in the daily life of older adults over extended periods of time. The technology is aggregated into a system that incorporates the principles of being minimally obtrusive, while generating secure, privacy protected, continuous objective data in real-world (home-based) settings for months to years. The system includes passive infrared presence sensors placed throughout the home, door contact sensors installed on exterior doors, connected physiological monitoring devices (such as scales), medication boxes, and wearable actigraphs. Driving sensors are also installed in participants' cars and computer (PC, tablet or smartphone) use is tracked. Data is annotated via frequent online self-report options that provide vital information with regard to the data that is difficult to infer via sensors such as internal states (e.g., pain, mood, loneliness), as well as data referent to activity pattern interpretation (e.g., visitors, rearranged furniture). Algorithms have been developed using the data obtained to identify functional domains key to health or disease activity monitoring, including mobility (e.g., room transitions, steps, gait speed), physiologic function (e.g., weight, body mass index, pulse), sleep behaviors (e.g., sleep time, trips to the bathroom at night), medication adherence (e.g., missed doses), social engagement (e.g., time spent out of home, time couples spend together), and cognitive function (e.g., time on computer, mouse movements, characteristics of online form completion, driving ability). Change detection of these functions provides a sensitive marker for the application in health surveillance of acute illnesses (e.g., viral epidemic) to the early detection of prodromal dementia syndromes. The system is particularly suitable for monitoring the efficacy of clinical interventions in natural history studies of geriatric syndromes and in clinical trials.

Unobtrusive sensors and pervasive computing technology incorporated into the daily home life of older adults enables meaningful health and activity changes to be recorded continuously for months to years, providing ecologically valid, high frequency, multi-domain data for research or clinical use.

An end-to-end suite of technologies has been established for the unobtrusive and continuous monitoring of health and activity changes occurring in the ...

Measuring the Kinematics of Daily Living Movements with Motion Capture Systems in Virtual Reality

The inability to complete instrumental activities of daily living (IADL) is a precursor to various neuropsychological diseases. Questionnaire-based assessments of IADL are easy to use but prone to subjective bias. Here, we describe a novel virtual reality (VR) test to assess two complex IADL tasks: handling financial transactions and using public transportation. While a participant performs the tasks in a VR setting, a motion capture system traces the position and orientation of the dominant hand and head in a three-dimensional Cartesian coordinate system. Kinematic raw data are collected and converted into &#39;kinematic performance measures,&#39; i.e., motion trajectory, moving distance, and time to completion. Motion trajectory is the path of a particular body part (e.g., dominant hand or head) in space. Moving distance refers to the total distance of the trajectory, and time to completion is how long it took to complete an IADL task. These kinematic measures could discriminate patients with cognitive impairment from healthy controls. The development of this kinematic measuring protocol allows detection of early IADL-related cognitive impairments.

We designed a virtual reality test to assess instrumental activities of daily living (IADL) with a motion capture system. We propose a detailed kinematic analysis to interpret the participant&#39;s various movements, including trajectory, moving distance, and time to completion to evaluate IADL capabilities.

The inability to complete instrumental activities of daily living (IADL) is a precursor to various neuropsychological diseases. Questionnaire-based ...

Using a Real-Time Locating System to Measure Walking Activity Associated with Wandering Behaviors Among Institutionalized Older Adults

A real-time locating system (RTLS) can be used to track the walking activity of institutionalized older adults in long-term care who are at risk for wandering behaviors. The benefits of a RTLS are objective and continuous measurements of activity. Self-report methods of activity, especially wandering, by health care staff are vulnerable to floor effects and recall bias, and continuous clinical or research observation over the long-term can be time-consuming and expensive. Health care staff also fail to recognize the onset and/or duration of wandering behaviors, which are associated with a variety of adverse health outcomes in this population but amenable to intervention. RTLS technologies can measure the walking activity of institutionalized residents with cognitive impairment over time with a high degree of accuracy. This is particularly useful for the study of wandering, defined as walking for at least 60 seconds with few (if any) breaks in activity. Wandering is associated with disease progression, hospitalizations, falls and death. Previous work suggests older adults with poor balance ability and high sustained walking activity may be particularly susceptible to poor health outcomes. RTLS&#39;s are used to assess cognitive impairment and factors associated with gait and balance; however, supplemental paper and pencil gait/balance tools may be used to further refine risk profiles. This project discusses the use of a RTLS to measure walking activity and also gait quality and balance ability measures on this population.

This paper discusses the use of a continuous and objective real-time locating system to measure walking activity associated with wandering behaviors, focusing on older adults with cognitive impairment. Walking activity is measured by walking distance, sustained walking distance, and sustained gait speed. Also assessed are gait quality and balance ability.

A real-time locating system (RTLS) can be used to track the walking activity of institutionalized older adults in long-term care who are at risk for ...

The Immersive Cleveland Clinic Virtual Reality Shopping Platform for the Assessment of Instrumental Activities of Daily Living

A decline in the performance of instrumental activities of daily living (IADLs) has been proposed as a prodromal marker of neurological disease. Existing clinical and performance-based IADL assessments are not feasible for integration into clinical medicine. Virtual reality (VR) is a powerful yet underutilized tool that could advance the diagnosis and treatment of neurological disease. An impediment to the adoption and scaling of VR in clinical neurology is VR-related sickness resulting from sensory inconsistencies between the visual and vestibular systems (i.e., locomotion problem).
The Cleveland Clinic Virtual Reality Shopping (CC-VRS) platform attempts to solve the locomotion problem by coupling an omnidirectional treadmill with high-resolution VR content, enabling the user to physically navigate a virtual grocery store to simulate shopping. The CC-VRS consists of Basic and Complex shopping experiences; both require walking 150 m and retrieving five items. The Complex experience has additional scenarios that increase the cognitive and motor demands of the task to better represent the continuum of activities associated with real-world shopping. The CC-VRS platform provides objective and quantitative biomechanical and cognitive outcomes related to the user&#39;s IADL performance. Initial data indicate that the CC-VRS results in minimal VR-sickness and is feasible and tolerable for older adults and patients with Parkinson&#39;s disease (PD). The considerations underlying the development, design, and hardware and software technology are reviewed, and initial models of integration into primary care and neurology are provided.

Virtual reality (VR) is a powerful yet underutilized approach to advance the diagnosis and treatment of neurological disease. The Cleveland Clinic Virtual Reality Shopping platform combines state-of-the-art VR content with an omnidirectional treadmill to quantify instrumental activities of daily living-a proposed prodromal marker of neurological disease.

A decline in the performance of instrumental activities of daily living (IADLs) has been proposed as a prodromal marker of neurological disease. Existing ...

Engineering

Exergaming in Older People Living with HIV Improves Balance, Mobility and Ameliorates Some Aspects of Frailty

Approximately 1.2 million people in the United States live with HIV infection. Medical advancements have increased the life expectancy and this cohort is aging. HIV-positive individuals have a high incidence of frailty (~20%) characterized by depression and sedentary behavior. Exercise would be healthy, but due to the frail status of many HIV-positive individuals, conventional exercise is too taxing. The aim of this study was to evaluate the effectiveness and acceptability of a novel game-based training program (exergame) in ameliorating some aspects of frailty in HIV-infected individuals. Ten older people living with HIV were enrolled in an exergame intervention. Patients performed balance exercises such as weight shifting, ankle reaching, and obstacle crossing. Real-time visual/audio lower-extremity joint motion feedback was provided using wearable sensors to assist feedback and encourage subjects to accurately execute each exercise task. Patients trained twice a week for 45 min for 6 weeks. Changes in balance, gait, psychosocial parameters and quality of life parameters were assessed at the beginning, midterm and at conclusion of the training program. Ten patients completed the study and their results analyzed. The mean age was 57.2 &#177; 9.2 years. The participants showed a significant reduction in center of mass sway (78.2%, p = .045) during the semi-tandem balance stance with eyes closed and showed a significant increase in gait speed during a dual task motor-cognitive assessment (9.3%, p = .048) with an increase in stride velocity of over 0.1 m/sec. A significant reduction in reported pain occurred (43.5%, p = .041). Preliminary results of this exergame intervention show promise in improving balance and mobility while requiring older people living with HIV to be more active. The exergame can be continued at home and may have long term as well as short-term benefits for ameliorating frailty associated with HIV infection.

Persons infected with HIV are often frail, depressed and live a sedentary lifestyle for which conventional exercise is too taxing. Here, we present an exercise protocol that ameliorates aspects of frailty in HIV-infected persons. An exergame integrating cognitive control was developed using biosensors that measured balance, weight-shifting and obstacle crossing.

Approximately 1.2 million people in the United States live with HIV infection. Medical advancements have increased the life expectancy and this cohort is ...

A Method for Quantifying Upper Limb Performance in Daily Life Using Accelerometers

A key reason for referral to rehabilitation services after stroke and other neurological conditions is to improve one's ability to function in daily life. It has become important to measure a person's activities in daily life, and not just measure their capacity for activity in the structured environment of a clinic or laboratory. A wearable sensor that is now enabling measurement of daily movement is the accelerometer. Accelerometers are commercially-available devices resembling large wrist watches that can be worn throughout the day. Data from accelerometers can quantify how the limbs are engaged to perform activities in peoples' homes and communities. This report describes a methodology to collect accelerometry data and turn it into clinically-relevant information. First, data are collected by having the participant wear two accelerometers (one on each wrist) for 24 h or longer. The accelerometry data are then downloaded and processed to produce four different variables that describe key aspects of upper limb activity in daily life: hours of use, use ratio, magnitude ratio, and the bilateral magnitude. Density plots can be constructed that visually represent the data from the 24 h wearing period. The variables and their resultant density plots are highly consistent in neurologically-intact, community-dwelling adults. This striking consistency makes them a useful tool for determining if upper limb daily performance is different from normal. This methodology is appropriate for research studies investigating upper limb dysfunction and interventions designed to improve upper limb performance in daily life in people with stroke and other patient populations. Because of its relative simplicity, it may not be long before it is also incorporated in clinical neurorehabilitation practice.

This protocol describes a method to quantify upper limb performance in daily life using wrist-worn accelerometers.

A key reason for referral to rehabilitation services after stroke and other neurological conditions is to improve one's ability to function in daily life. ...

Oral Health Assessment by Lay Personnel for Older Adults

Oral health is an often-undervalued contributor to overall health. The literature, however, underscores the myriad of systemic diseases influenced by oral health, including type II diabetes, heart disease, and atherosclerosis. Thus, assessments of oral health, called oral screenings, have a significant role in assessing risk of disease, managing disease, and even improving disease by oral care. Here we present a method to assess oral health quickly and consistently across time. The protocol is simple enough for non-oral health professionals such as students, family, and caregivers. Useful for any age of patient, the method is particularly key for older individuals who are often at risk of inflammation and chronic disease. Components of the method include existing oral health assessment scales and inventories, which are combined to produce a comprehensive assessment of oral health. Thus, oral characteristics assessed include intraoral and extraoral structures, soft and hard tissues, natural and artificial teeth, plaque, oral functions such as swallowing, and the impact this oral health status has on the patient&#39;s quality of life. Advantages of this method include its inclusion of measures and perceptions of both the observer and patient, and its ability to track changes in oral health over time. Results acquired are quantitative totals of questionnaire and oral screening items, which can be summed for an oral health status score. The scores of successive oral screenings can be used to track the progression of oral health across time and guide recommendations for both oral and overall health care.

The goal of this protocol is to enable non-dental professionals to assess oral health status for research or health-screening purposes. Aspects assessed include lips, tongue, soft and hard tissues, natural and artificial teeth, oral cleanliness, plaque, swallowing, and impact of oral health on quality of life.

Oral health is an often-undervalued contributor to overall health. The literature, however, underscores the myriad of systemic diseases influenced by oral ...

Dual-Task Stroop Paradigm for Detecting Cognitive Deficits in High-Functioning Stroke Patients

General clinical cognitive assessment scales are not sensitive enough to cognitive impairment in high-functioning stroke patients. The dual-task assessment has advantages for identifying cognitive deficits in high-functioning stroke patients and has been gradually applied in clinical assessment and cognitive training. Moreover, the Stroop paradigm has higher sensitivity and specificity for attentional assessment than conventional clinical cognitive assessment scales. Therefore, this study presents the dual-task assessment based on the Stroop paradigm to identify cognitive deficits in high-functioning stroke patients. This study demonstrates a single- and dual-task evaluation based on the Stroop paradigm and confirms its feasibility through case experiments and synchronized functional near-infrared spectroscopy evaluation. The Stroop reaction time and correct rate are used as the main indicators to evaluate the cognitive level of the subjects. This study protocol aims to provide new ideas to figure out the ceiling effect in general clinical assessment failure for high-functioning stroke patients.

Clinical assessment scales are notsensitive enough to cognitive dysfunction in high-functioning stroke patients. The dual-task paradigm presents advantages and potential in the assessment and cognitive training of cognitive dysfunction. The study here proposes a dual-task Stroop paradigm to identify cognitive dysfunction in high-functioning stroke patients.

Assessment of Dependence in Activities of Daily Living Among Older Patients in an Acute Care Unit

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