Alzheimer's disease is now recognized as a major health problem for the aging population in the United States, affecting more than 1.5 million persons over the age of 65 . ' Because it is viewed as a terminal disease with a poor prognosis and minimal rehabilitation potential, little attention has been given to the restorative care possibilities for the patient with Alzheimer's disease (AD). There is a paucity of information in the literature regarding the use of standardized assessment tools to describe the functional ability of the AD patient. Without adequate assessment, it is difficult to determine the self-care and mental status function of patients with AD in order to implement restorative interventions. In this article, one method of functional assessment using two tools is described as conducted on an Alzheimer's unit in a skilled nursing facility.
Families tend to provide most of the care for individuals with Alzheimer's disease.2 Institutionalization is usually sought only when problems become so overwhelming that they affect the family's ability to provide care at home.3 It is at this point that many of these individuals are placed within the general population of skilled nursing facilities, state hospitals, or nursing homes.
Recent advances have altered the knowledge base related to AD, and new concepts have evolved for care of the effected patient. Among these advancements is the development of special units designed to provide care in a less restrictive, though protected, environment in which the psychosocial needs of the patient are emphasized.4*6 On these special units, physical needs are met according to the individual patient's ability or lack of ability to provide for these needs for him- or herself. Experience has shown that if information about a person's capability is provided, a maximal level of functional ability can be promoted within mese units. However, in a review of the literature, no formal studies were found to demonstrate this potential.
When a newly developed Alzheimer's unit opened in northern California, an additional method of assessment was needed; one which would be feasible, quick to use, appropriate for setting and would provide comprehensive information about newly admitted patients. The need for information based on functional assessment was twofold:
1 . To assist the nurses in explaining to the staff the different mental and physical characteristics of each patient; and
2. To permit the nursing staff to individualize care appropriately for each patient.
SUMMARY OF CADET SCORES
The staff consisted of a gerontological clinical specialist program director, charge nurses, and certified nursing assistants (CNAs) who had volunteered for this special care unit. The CNAs were familiar with the general skilled nursing facility philosophy and were oriented toward providing handson, skilled care for persons with many physical disabilities. Traditionally, many nurses have been oriented toward "doing for" the patient rather than assisting the patient to "do for him- or herself."7
An objective method of differentiating between self-care deficits related to mental status dysfunction and those related to physical disability was needed to avoid having the staff misinterpret mental dysfunction as physical incapability. Standardized assessment tools could provide an accurate method of measuring the capabilities of the individual afflicted with Alzheimer's disease. Information obtained would also assist the charge nurses in planning and individualizing appropriate restorative care interventions.
Choke of Assessment Tools
Although there are many types of assessment tools currently in use to measure functional ability, the literature usually refers to their usefulness in the areas of diagnosis, placement, care plan development, and use of services.8 The choice of an assessment tool depends on its purpose and the expected outcome of the assessment process. Since the need on the Alzheimer's unit was for descriptive data to assist the staff in individualizing care, the main criteria for choosing assessment tools were that they provide quantifiable, yet descriptive, data about self-care and mental status function. Additionally, because staff time was limited in the skilled nursing facility setting, the secondary criteria included both a reasonable time involvement and ease of administration.
The search for an appropriate tool that would meet the above criteria led to the selection of the CADET to measure self-care function and the FROMAJE to measure mental status function.9,10 Both of these tools had been previously used in a large, geriatric institutional setting. Both had been demonstrated to have a high internal consistency, interrater reliability, and construct validity.
The internal consistency and interrater reliability coefficients of CADET are exceptionally high: .984 and .936, respectively. All items contribute strongly to the total instrument and in the following rank order: transfer, daily activities, elimination, communication, and ambulation. The same test coefficients for FROMAJE arc almost as high: .942 and .689. The interrater reliability coefficient of .689 for FROMAJE reflects the degree of consistency between nurses and other caregiving staff members - not exclusively among nurses. As such, it is a very high coefficient.11
The CADET and FROMAJE also met the secondary criteria because they were easy to administer, required a minimum amount of orientation to the tool prior to use, and would take no more than 20 minutes each per person to administer.12 Either tool could be administered with a fairly high consistency in rating by various types of healthcare personnel despite differences in educational preparation.
Explanation of the Tools
The first of these assessment tools, the CADET, was used by Rameizl in 1981. The acronym CADET represents five functions that most persons perform independently: C-communication; ?-ambulation; D-daily activities such as grooming, dressing, hygiene, feeding; ?-elimination; and T-transfer. The scoring is rated for each function with: 1 = independence in self-care; 2 = moderate dependence, needs some assistance; and 3 = total dependence, total assistance required. The rating may fall between one and two or two and three, or the decision to rate only as a one, two, or three must be made. The total score is the sum of all function ratings and is ranked to indicate an overall functional level. The total scores indicate:
5-6 = essentially no impairment
7-8 = mild impairment
9-10 = moderate impairment
11+ = severe impairment
Thus, an individual who is impaired in one area of self-care function may not be impaired in other areas of self-care function or in overall self-care function. Rameizl found the CADET, in conjunction with the FROMAJE, a mental status test, to be a successful predictor and indicator of change in a geriatric population. Additionally, the CADET facilitated communication about a patient's self-care abilities between nurses and other healthcare workers.9
The second assessment tool, the FROMAJE, was initally developed by Libow in 1981. 10 FROMAJE is an acronym representing seven aspects of mental status: F-function; R-reason; O-orientation; M-memory; ?-arithmetic; Jjudgment; and ?-emotional status.10 Because the questions used in the FROMAJE examine several aspects of mental status, it has a broader scope than basic mental status tests of memory and orientation. Rameizl used the FROMAJE in conjunction with the CADET to screen a geriatric population for evidence of mental impairment and its relationship to self-care function.12
Like the CADET, each aspect of FROMAJE mental status function is given a score of one, two, or three with: 1 = no significant impairment in function; 2 = moderate impairment, some impairment; and 3 = severe or total impairment. The total of individual scores is used as a screening guide for evidence and degree of dementia. On a ranked scale, the scores indicate:
7-8 = essentially no impairment
9-10 = mild impairment, possible mild dementia or depression
11-12= moderate impairment; moderate dementia or depression
13+ = severe impairment; severe dementia or depression
Although the FROMAJE itself is not diagnostic of dementia or depression, it was felt that it might prove useful to measure the degree of impairment in persons already diagnosed as having a Senile Dementia of the Alzheimer's Type (SDAT).10 Following the selection of these tools, they were used to assess newly admitted patients on the unit.
Findings of the CADET and FROMAJE
Twenty-five patients, 11 males and 14 females, on an Alzheimer's unit in a skilled nursing facility were assessed with the CADET and FROMAJE between February 19, 1985 and May 10, 1985. The age of the patients ranged from 67 to 91 years, with a mean age of 80.6 years and a standard deviation of 5.974. More than 80% (N = 21) of the 25 patients were Caucasian, and 23 of 25 were either married or widowed. Educational level was determined for only 12 of the 25 patients and, of these, all but one had completed high school, and four had baccalaureate or advanced degrees. Educational level was determined and verified by family members. Most of the patients with Alzheimer's disease were able to recall their occupational background, although recall for recent events was impaired. Some occupations mentioned by both males and females included secretary, railroad worker, sales, police work, teacher, registered nurse, bookbinder, business, beautician, and bank teller.
SUMMARY OF FROMAJE SCORES
The CADET test showed a mean score of 9.04 with a standard deviation of 2.791. This score indicated a moderate impairment in self-care function. However, the mean score for the FROMAJE was 16.92 with a standard deviation of 2.308. This score indicated a severe level of dementia. In fact, 24 or 25 patients had total mental status scores ranging from 13 to 19, indicating that almost the total population assessed was severely impaired in mental function.
When each of the self-care function scores on the CADET was reviewed individually, the areas of greatest independence in function were in communication (64%), ambulation (52%), and transfer (52%). These functions were apparently maintained in over half the population on the unit despite a severe level of dementia. The most severely impaired functions were those daily living activities requiring more complex movements such as grooming, dressing, hygiene, and eating. Twenty-one of 25 patients also showed occasional to frequent loss of bowel or bladder control. Twenty-one of 25 patients required moderate assistance with activities of daily living, and three patients required total care in this area (see Table 1).
When scores for each category of the FROMAJE were analyzed, 92% of patients showed a severe impairment in overall function. The next most impaired areas were orientation (84%) and memory (84%), and arithmetic (80%) and reason (68%). Least impaired functions were emotional status and judgment (see Table 2).
Discussion of Findings and Assessment Tools
Both tools used on the special care unit were valuable in determining mental and physical function. The tools were especially valuable because the scores provided both descriptive and quantifiable data about newly admitted patients. Despite severe dementia, many patients were found to retain the ability to communicate, ambulate, and transfer. This is perhaps the most interesting finding demonstrated by the relationship between the CADET and FROMAJE scores. CADET scores showed that the most impaired functions found in this population were those that commonly require fine motor skills, memory, and recognition; whereas skills requiring gross motor ability, such as the act of walking and transfer, appear to remain intact at this phase of the disease, despite severe mental deterioration.
In this pilot project, the FROMAJE served to verify that patients with a diagnosis of Alzheimer's disease who are placed on special Alzheimer's units have, for the most part, a severe level of dementia. Within the group of patients characterized as having severe dementia, there is a tremendous range of selfcare ability, as demonstrated by the CADET scores.
Although the CADET scores obtained in this pilot study indicated that 52% of the population of patients on the Alzheimer's unit showed no functional impairment requiring physical assistance from others, the FROMAJE revealed that instruction related to verbal cues for memory, orientation, and reason would need to be addressed in the nursing care plan.
CADET- Scores on the CADET were valuable in this initial attempt to assess functional ability on an Alzheimer's unit. However, the effectiveness of this tool for assessment of patients with Alzheimer's disease cannot be generalized until further studies have been done. The tool also needs to be tested on a larger population of AD patients in a more formal study. Comparative studies using the CADET on specialized Alzheimer's units and other general units in the larger, skilled nursing population might be valuable in helping to determine if the specific interventions provided within Alzheimer's units significantly affect the functional level of patients on the unit.
Evaluation of findings of the CADET led to questions about the need to establish further the reliability of the tool for measurement of functional ability in the AD patient. Would the familiarity of the evaluator with specific functional deficits normally characteristic of Alzheimer's disease affect the reliability of rating of functions of the CADET? For example, in this pilot study, communication was found to be impaired in only 36% of the population on the Alzheimer's unit; whereas previous studies have documented some problems in communication in most institutionalized persons with Alzheimer's disease.1415 Though fluency of speech is often retained, comprehension and the ability to read and write are often lost or severely impaired.14 Confabulation, or "I don't know" answers, sometimes cover up these deficits.16 Without this knowledge, the inexperienced person might make mistakes in rating commumcation deficits that occur in a person with Alzheimer's disease.
One way to strengthen the reliability of the tool for use on an Alzheimer's unit would be to apply specific rating criteria to assist the evaluator in scoring each function and have two evaluators screen the same patients, using the same tool. Function ratings with criteria applied could be evaluated and compared against findings of two persons administering the tool without established criteria.
The dual benefits of the CADET as an assessment tool in this pilot study were its usefulness in:
1 . Targeting functional deficits requiring further assessment; and
2. Describing intact functions in persons on the Alzheimer's unit.
As nurses providing care, we are primarily concerned with cognitive, physiological, and functional changes in our clients. Occasionally these changes occur together, but sometimes physiological changes precede functional deficits. For example, Visser studied a population of apparently normal, independent, ambulatory persons with Alzheimer's disease and found that they had impaired performance on tests of gait and balance when compared to normal controls.13 Although the CADET scores in this pilot study did not discriminate subtle changes of gait affected by fine motor control, scores did appear to differentiate gait changes discrete enough to affect patient's safety in ambulation or transfer.
Other areas targeted by the CADET included the need for further assessment of bowel and bladder status, and the need for further evaluation by speech therapy, occupational therapy, or physical therapy. Finally, and perhaps most important for staff working with Alzheimer's disease, the CADET was able to describe intact functions of residents on the Alzheimer's unit. The need to describe intact functions in order to maximize these functions on the unit is crucial for restorative care. For example, the high number of persons on the unit retaining the ability to ambulate should alert all institutions to provide for safe and supervised walking areas and eliminate the use of wheelchairs or geri-chairs as a form of restraint.
FROMAJE - The initial outcome of the pilot use of me FROMAJE is the acknowledgment of its usefulness as an initial assessment tool, especially in conjunction with the CADET. The next step should be to compare it with some other method of quantitative mental status assessment. A definitive tool used for describing mental status function during the later phases of Alzheimer's disease might provide a more valid method to measure the relationship between mental status and self-care function.
Evaluation of the scores obtained in this study indicated that because 36% of the patients on the unit had a known communication impairment, the FROMAJE was probably not a valid mental status test for these patients.
Libow, who developed the tool, recognized that most mental status tests fail to be accurate in any patient with aphasia because most standard mental status tests depend on intact communication skills for their administration and accuracy.10 It is significant that FROMAJE depends on language skills for each function tested.
Functional assessment performed upon arrival on a special unit is important; however, the entry assessment should not take the place of comprehensive testing before placement is made. It remains true that many types of dementia are reversible if detected early, and an accurate workup is always needed.17·18
As healthcare workers, we share the responsibility of ensuring that the patients are thoroughly assessed before the provisional diagnosis of Alzheimer's disease is made and they are assigned to a special care unit.
Restorative interventions are those which can be applied to assist patients to attain an optimal level of function. A determination of self-care deficits can be made through assessment. Nursing care, including planned interventions, must be based on comprehensive assessment. In this pilot project, the CADET and FROMAJE were used to assess patients on a special care Alzheimer's unit in a skilled nursing facility. The CADET appears to have the potential for providing nursing and other healthcare professionals and nonprofessionals with the means to assess abilities and deficits of patients with Alzheimer's disease. It could also be used to measure the effectiveness of their interventions over time in an Alzheimer's unit. The FROMAJE was also helpful; however, further inquiry is needed to determine if it is the best tool for accurately describing the mental status of the patient. Mental status testing for cognitive ability needs to be measured and assessed over time in conjunction with self-care ability. The special advantage of those tools is the clear relationship between the acronyms and characteristics being measured.
Findings for this preliminary use of the CADET and FROMAJE cannot be generalized until a more formal study has been conducted. Specific criteria and written instructions for use with the patient with Alzheimer's disease will increase and strengthen each tool's reliability for use on an Alzheimer's unit. For this pilot project, the scores have been helpful in assisting the staff in understanding the difference between mental functioning and physical abilities and in providing individualized nursing care. It is hoped that future studies will contribute to the scientific knowledge base needed to increase the quality of life for institutionalized persons who have Alzheimer's disease.
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SUMMARY OF CADET SCORES
SUMMARY OF FROMAJE SCORES