How many and which items of activities of daily living (ADL) and instrumental activities of daily living (IADL) are necessary for screening

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Abstract

Geriatric assessment (GA) in elderly cancer patients serves as screening instrument to identify patients who are vulnerable or frail. To reduce the diagnostic burden for patients and caregivers, we asked how many and which items of ADL and IADL questionnaires are necessary to identify those patients with limitations in the sum score of ADL or IADL. Data of 327 elderly patients (age  60 years), of whom 27.9% had limitations in ADL and 36.0% in IADL score, were entered in a forward selection model. Four out of ten items of ADL identified 95.3% of patients with limitations in ADL. Two out of eight items of IADL identified 97.4% of patients with limitations in IADL. The combined use of these items recognised 98.5% of patients with limitations in ADL or IADL score. If ADL and IADL scores are used for screening, we recommend an abbreviated version with 6 instead of 18 items.

Introduction

Cancer is a major public health problem in the United States and other developed countries. Currently, one in four deaths in the United States is due to cancer. Cancer has surpassed heart disease as the leading cause of death for those younger than age 85. About 30% of all cancer deaths occur in patients aged 80 and older [1]. About 60% of patients diagnosed with cancer are older than 65 years of life. Due to the demographic changes, the number of elderly people will increase within the next decades. Together with the age associated rise in incidence of malignant tumours, this will lead to a substantial increase in the number of elderly people with cancer [2].

Geriatric assessment (GA) in elderly cancer patients shall identify those patients who are vulnerable or frail. Among other instruments (e.g. timed up&go test, mini-mental state examination (MMSE), mini-nutritional assessment (MNA), geriatric depression scale (GDS), etc.) GA includes activities of daily living (ADL) and instrumental activities of daily living (IADL) [3], [4].

ADL describe activities essential for self-care like bathing, dressing and feeding. The ADL scale represents the most basic activities involved in everyday independent function. IADL describe activities necessary for adaptation to the environment and emphasise community activities like shopping, cooking, transportation and housekeeping. The activities of IADL are more cognitively influenced [5].

To conduct a complete GA is time consuming and a burden for patients and caregivers. A screening tool allows to recognise patients with limitations and reduces the number of patients with the need for a complete GA. Therefore the selection of the most sensitive items of the ADL and IADL scales seems reasonable. Overcash et al. described in a population of elderly cancer patients (>70 years, any diagnosis and stage of disease) the construction of an abbreviated comprehensive geriatric assessment (aCGA) with a reduced number of items for MMSE, GDS, ADL and IADL. They selected three out of six ADL items and 4 out of 10 IADL items. Their criterion for selection of an item was highest item-to-total correlation [6].

The aim of the presented study is to predict the dichotomous appraisal (i.e. patient ‘with limitations’ or ‘without limitations’) for the ADL and IADL sum score on the basis of a preferably low number of items. In a second step, the selected items are added to a combined score.

Section snippets

Methods

Within a larger prospective trial on decision making in elderly cancer patients, we have full data of ADL or IADL of 327 patients, thereof 198 elderly cancer patients and 129 elderly non-cancer patients, admitted for acute medical problems as in-patients to our hospital. The trial was approved by the ethical committee of Friedrich-Schiller-University in Jena and supported by the German Cancer Aid (Grant: 70-2445-Hö-3). Written informed consent was obtained after patients had been informed on

Patients’ characteristics

From 327 patients data of ADL or IADL items were available, thereof 198 ECP and 129 EMP. Characteristics of patients are summarised in Table 1. More men took part in the group of ECP (55.6%) compared to EMP (34.1%). The mean age of ECP was 70.3 (S.D. = 6.9) and of EMP 71.5 (S.D. = 7.1) years. Diagnoses of EMP were diabetes mellitus (43.4%), heart disease (13.2%), disorder of liver/gall bladder/pancreas (12.4%), benign haematological disease (10.1%), gastrointestinal tract disease (7.8%) and others

Discussion

GA is part of an integral care for elderly patients. It is a diagnostic tool, which recognises deficits and resources of the old patient. Detected deficits have to be addressed by more detailed diagnostic procedures, which enable a precise diagnosis and then treatment or interventions. Within the last years, data on its integration into the care for elderly patients with cancer have been published [17]. Limitations in IADL and ADL have been identified as of prognostic significance for survival

Reviewers

Jean-Pierre Droz, Professor, Centre Léon Bérard, Department of Medical Oncology, 28 rue Laennec, Lyon 29008, France.

Johann W.R. Nortier, Professor, Leiden University Medical Center (LUMC), Department of Clinical Oncology, K1-P, P.O. Box 9600, Leiden 2300 RC, The Netherlands.

Ulrich Wedding is physician (general internal medicine) and is specialist in haematology, oncology, and palliative care. He serves as a consultant at the Department of Haematology and Medical Oncology at the University Hospital of the Friedrich-Schiller-University Jena in Germany. Currently, he is research fellow of the Robert Bosch Foundation. His main interest in clinical research is geriatric oncology. He is active member of national and international working parties in the field of

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    Ulrich Wedding is physician (general internal medicine) and is specialist in haematology, oncology, and palliative care. He serves as a consultant at the Department of Haematology and Medical Oncology at the University Hospital of the Friedrich-Schiller-University Jena in Germany. Currently, he is research fellow of the Robert Bosch Foundation. His main interest in clinical research is geriatric oncology. He is active member of national and international working parties in the field of geriatric oncology.

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