Functional assessment is a multidimensional concept. It is used to outline or characterize the ability of individuals to provide for the necessities of life and to perform activities to meet basic needs that are both socially influenced and individually determined (Leidy, 1994). The changing needs of older adults support the importance of functional assessment. In determining health status, people generally assess functional status, rather than use specific diagnostic criteria (Panicucci, 1983). The quantification of what individuals can and cannot do is of critical importance in patient care. In older adults, functional impairment caused by illnesses can range from minor impairment in shopping, cooking, cleaning, and travel skills to the inability to dress, groom, bathe, and feed oneself. Functional decline is related to higher hospital use rates, and improvement is associated with lower rates of hospitalization (Mor, Wilcox, Rakowski, & Hiris, 1994). Estimates of functional status have relevance for determining compensation, predicting outcomes, planning placement, estimating care requirements, and indicating changes in functional status (Heinemann, Hamilton, Linacre, Wright, & Grange, 1994). The quantification of what an individual can and cannot do traverses diagnostic categories, which often are seen as concrete, static states. The reality of medical and functional illnesses clearly is a dynamic state, which varies dependent on the acuity and severity of the diagnosis, and on individual and environmental characteristics. Comprehensive functional assessment can result in targeting appropriate support services and can provide direction in formulating treatment plans; developing effective planning, teaching, and training of care providers; and planning needed facilities and services (Morris et al., 1990).
The Iowa Self- Assessment Inventory (ISAI) is a multidimensional instrument developed to survey systematically the status and resources of community-dwelling older adults. Although the ISAI has demonstrated reliability and validity (Morris et al., 1994), its utility in the hospital setting has not been evaluated. Traditionally, when older adults are hospitalized, the initial history and physical examination focus on the patients' acute health problems. However, older patients are' at high risk for a number of physical, emotional, economic, cognitive, and social problems, and the multidimensional functional assessment of these patients early in the hospital admission process should prove useful for optimal clinical management and appropriate use of scarce resources. The study reported in this article examined the appropriateness of the ISAI in the acute care hospital setting and addressed the efficiency of using the ISAI, a multidimensional assessment, by comparing the ISAI to single dimensional assessments (e.g., the Geriatric Depression Scale [GDS] [Yesavage & Brink, 1983], the Mini-Mental State Examination [MMSE] [Folstein, Folstein, & McHugh, 1975]) in determining the needs of older hospitalized patients.
Research has shown that factors most predictive of 6-month mortality are decreased functional status, admitting diagnosis, and decreased mental status. Those factors most predictive of nursing home admission were decreased functional status, living location (i.e., with an adult child), and decreased mental status. Functional status was a stronger predictor of length of stay, mortality, and nursing home placement than the principal admitting diagnosis (Barberger-Gateau & Fabrigoule, 1997; St. Pierre, 1998; Narain, et al., 1988).
Elderly individuals with serious diseases often have symptoms of depression. Borson, Loebel, Kitchell, Domoto, and Hyde (1997) reported a 24% prevalence rate of significant depressive symptoms in a primary care setting, with 10% of this number suffering from major depressive disorder. In major depression, actual or perceived losses (e.g., illness, impaired mobility, changes in sensory capacity, social isolation, death of a spouse or friends, economic hardship, retirement) are the most frequently associated stresses (Kessler, Zhao, Blazer, & Swartz, 1997). Consistent evidence exists that depressive symptoms combined with medical illnesses (either acute or chronic) have an additive, interactive, reciprocal effect on functional status and well-being (Burvill, 1995; Covinsky, Fortinsky, Palmer, Kresevic, & Landefeld, 1997; Kurlowicz, 1994; Wells et al., 1989).
DEMOGRAPHIC CHARACTERISTICS (N = 98)
Cognitive impairment is prevalent in elderly patients in every clinical setting (Brayne, Best, Muir, Richards, & Gill, 1997; Espino & Lewis, 1998; Stephen & Williamson, 1984, Warshaw et al., 1982). In a study by Folstein, Bassett, Romanoski, and Nedstadt (1991) cognitive status proved to be an independent predictor of functional ability, along with physical illness, emotional distress, neurological status, and use of medications. Early identification of patients at risk for cognitive impairment, depression, or functional impairment lead to earlier and more appropriate treatment, intervention, and discharge planning for elderly hospitalized patients. Maintenance of optimum functional independence also can improve quality of life. Thus, gerontological nurses are challenged to identify and evaluate systematically multidimensional screening tools, such as the ISAI, for their utility and effectiveness in a variety of clinical settings.
PEARSON PRODUCT-MOMENT CORRELATIONS AND CRONBACH'S ALPHAS
A sample of patients age 60 and older admitted to medical, cardiac, and cardiothoracic units, and to psychiatric inpatient, consultation, and outpatient units were recruited to participate in this study. The use of psychiatric and nonpsychiatric patients allowed a wide sampling of conditions, which was optimal to establish concurrent validity of the Emotional Balance (EB) and Cognitive Status (CS) subscales of the ISAI with scores on the MMSE and the short form of the GDS (SGDS). Participants were recruited within 3 days of admission or consultation. Approximately 25% of the eligible patients refused enrollment in the study, while 111 patients agreed to participate, and 13 patients were excluded because of missing data. The final study sample consisted of 98 patients. Data from these patients were used in the analysis.
Demographic characteristics of the sample are presented in Table 1 . The average age of patients included in this study was 70. Patients were predominandy women (60%); most lived with a spouse (56%), approximately half reported daily visits from family members or friends; and 42% had graduated from high school.
On enrollment in the study, each patient was administered the ISAI (Morris et al., 1994), the SGDS (Yesavage & Brink, 1983), and the MMSE (Folstein et al., 1975) by a trained research assistant.
Iowa Self Assessment Inventory (ISAI). The ISAI consists of 56 items - 8 Likert-type items on each of 7 subscales. Each item is scored ranging from 1 (true) to 4 (false). The items of each subscale are added to produce a subscale score ranging from 8 to 32. These subscales are:
* Economic resources (ER): High scores are obtained by individuals who perceive their income and assets to be adequate. Individuals who perceive their economic status to be inadequate or impaired obtain low scores.
* Emotional balance (EB) (anxiety or depression): Individuals with high scores are relatively worryfree, more or less calm, sleep well, and enjoy tranquil lives. Low scores indicate the opposite states, especially the presence of anxiety or depression.
* Physical health (PH) status: High scores are obtained by individuals who profess excellent health, seldom see a doctor, and take few prescribed medications. Individuals with low scores have more physical illnesses, disabilities, and health problems than others, and their performance of daily activities has declined during resent years.
* Trusting others (TO) (alienation): Individuals with high scores believe they have good, trustworthy friends, are friendly toward others, and generally are amiable and affable in their interpersonal relationships. Low scores indicate the individuals question the motives of others and believe others are against them. They are alienated from others.
AVERAGES AND STANDARD DEVIATIONS OF THE IOWA SELF-ASSESSMENT INVENTORY SUBSCALE SCORES
* Mobility (MO): High scores are obtained by individuals who are mobile enough to perform the usual activities of daily living and are able to visit friends and participate in other social activities. Low scores represent a lack of such mobility.
* Cognitive status (CS): Individuals who score high perceive themselves as intellectually intact and possessing good memory, orientation, and a continued ability to learn. Individuals with low scores tend to have trouble remembering things, forget appointments, and suffer a short attention span.
* Social support (SS): High scores are obtained by individuals who believe they live in a comfortable social environment, peopled with friends and relatives with whom they enjoy close relationships. Low scores indicate a less supportive social environment.
Geriatric Depression Scale. The GDS (Yesavage & Brink, 1983) assesses depression in older individuals. A shorter version of the GDS, the SGDS, consisting of 15 selfadministered yes or no items that distinguish nondepressive from depressive individuals, was used in this study.
Internal consistency for the GDS, measured by Cronbach's coefficient alpha, was .94, suggesting a high degree of internal consistency. With administrations separated by 1 week, a test-retest yielded a reliability of .85. Validity studies also were supportive of the ability of both the GDS and the SGDS to distinguish between nondepressed, mildly depressed, and severely depressed older adults. A correlation coefficient of .84 between the GDS and SGDS indicated successful differentiation of depressed and nondepressed patients (Sheikh & Yesavage, 1986). For the purposes of this study, scores on the SGDS were dichotomized: Individuals with scores of 5 or below were included in a nondepressed group, while individuals with scores of 6 or above were included in a depressed group.
Mini-Mental State Examination. The MMSE (Folstein et al., 1975) is designed to assess cognitive impairment objectively. The MMSE is administered by an examiner and has been found reliable and valid for distinguishing cognitive ability. The test-retest reliability coefficient was .89. In addition, the MMSE classification agreed with clinical opinion of the presence of cognitive difficulty. In general use, if the MMSE score is less than 24, causes of dementia should be sought. In this study, a score of 24 or above was used to represent a "cognitively intact" group, whereas a score of less than 24 represented a "cognitively impaired" group.
After the data were collected, item scores on the ISAI were combined and converted to subscale t scores (Gilmer et al., 1991). The reliability of each subscale was examined through Cronbach's alphas, which measure internal consistency. To further evaluate the reliability of the subscales, interitem correlations were computed to identify items that were redundant (i.e., those with an interitem correlation greater than .70) (Kerlinger, 1973). When reliability coefficients were between .30 and .70, the interitem correlations were used to assess the relationship between the items within the scale. Interitem correlations less than .30 were considered to measure different concepts (Kerlinger, 1973). The correlations of the subscales also were examined to determine the extent to which they measured the same concept.
Construct validity of the ISAI for screening older hospitalized patients for depression and cognitive impairment was examined through correlation of the ISAI subscales with the SGDS and the MMSE. The ISATs sensitivity to levels of depression and cognition was reflected in differences in the ISAI subscale means across levels of the SGDS and AlMSE. Means and standard deviations were computed for each of the seven subscales. The ANOVA was used to assess the significance of the differences between means across the levels of the SGDS and the MMSE.
RESULTS AND DISCUSSION
Cronbach's alphas for internal consistency for the ISAI subscales are reported in Table 2. Reliability estimates ranged from .67 (PH) to .84 (ED). All reliability estimates were greater than .70, with the exception of the PH subscale. These data are similar to reliability estimates reported for the ISAI by the developers (Morris et al., 1994). Most of the interitem correlations of the PH scale were less than .30, indicating the items were not measuring a similar concept of PH in this hospitalized sample.
Correlations among the ISAI scales are shown in Table 2 and ranged from .06 (between TO and SS) to .61 (between CS and EB) The moderately high correlations between the psychological scale (EB) and the cognitive scale (CS) suggests those subscales overlap to some extent, which makes intuitive sense.
Correlations of the ISAI scales and the SGDS and the MMSE also are presented in Table 2. All ISAI scales had a mild to moderate negative correlation with SGDS scores. Correlations ranged from -.28 (TO) to -.49 (EB). Most scales were correlated mildly with MMSE scores. Correlations ranged from .08 (PH) to .40 (MO). The low correlation (r = .25) between MMSE and CS suggests the self-report measure of cognition in the ISAI is not measuring the same concept as the more objective measure of cognition, the MMSE. Recently, this finding has been replicated in other samples (Daly, Buckwalter, Morris, & Crowe, 1999), suggesting that older individuals' perceptions of their cognitive status may differ from performance measures.
The overall means and standard deviations of the ISAI scales are reported in Table 3. The norms for community-dwelling older adults for the ISAI subscales scores are: 27 for ER, 25 for EB, 21 for PH, 30 for TO, 27 for MO, 23 for CS, and 29 for SS. On average, the hospitalized patients in this study were below the norms on all subscale scores.
Comparison of the means, standard deviations, and results of the t tests between cognitively intact and cognitively impaired patients for each scale also are presented in Table 3. In general, patients classified as cognitively impaired scored lower on the ISAI than cognitively intact patients. Two ISAI scales, MO and SS, were below the normal range for impaired patients. Statistically significant differences between intact and impaired patients were found for MO (p < .001) and SS scales (p = .003). No other scale scores differed statistically (ER p = .16; EB p = .28; PH p = .61; TO p = .64; CSp = .09). Overall, the ISAI scales did not detect differences in cognition.
Table 3 also includes means, standard deviations, and results of the t tests for depressed and nondepressed patients. Statistically significant differences between depressed and nondepressed patients were found for all scales (ER p > < .001; EB p < .001; PHp = .01; TO p = .02, MO p< .001; CS p = .001, SSp = .02). Most scale scores for depressed patients (ER, PH, TO, and MO) were borderline normal, whereas EB and MO scores were below the normal range. Scores for nondepressed patients were within the normal range, suggesting the ISAI is able to differentiate between depressed and nondepressed older hospitalized patients.
The multidimensional assessment of functional status and resources provides a broader, more comprehensive view of older hospitalized patients and their problems, generating more information about patients than usually is acquired through standard admission procedures. Thus, clinicians are able to develop treatment plans that address patients in a more holistic manner.
In this study, the ISAI demonstrated it is useful for screening for depression in hospitalized older adults. However, while the ISAI detects differences in functional status between depressed and nondepressed patients, it is not as efficient as the SGDS, which is shorter and requires less time to complete. The ISAI also does not detect differences in cognition as well as the MMSE. This may be because of the subjective nature of the ISAI items and the tendency of cognitively impaired patients to minimize or hide their losses and degree of impairment. The low correlation between CS and MMSE scores also suggests self-reported cognition measured on the ISAI is not the same construct as that measured by the MMSE. The ISAI CS assesses individuals' self-perceptions of the quality of their intellectual functioning, whereas the MMSE measures individuals' cognitive ability more objectively in domains such as orientation, recall, and ability to calculate and construct geometric figures. Finally^ cognitively impaired patients often lack insight into their own diminished levels of cognitive function, and scores on this subscale of the ISAI may be inflated.
Although the ISAI assists in determining the needs of older hospitalized patients, the SGDS and the MMSE (i.e., unidimensional tools) are more efficient in screening for depression and cognition, respectively. With the exception of the EB and CS subscales, the remaining subscales can assist clinicians in estimating care requirements and planning placement. By viewing the scores on the SS, MO, TO, and ER subscales, clinicians can determine more appropriate referrals for patients during their hospital stay and after discharge.
Further work on the ISAI is necessary before it is maximally useful for the assessment of hospitalized older individuals, including its evaluation as a screening tool for other aspects of treatment of older patients. In addition, research is needed on health care providers' use of the information provided by the ISAI for determining patient needs at discharge and after hospitalization. With more research and refinement, the ISAI may be a helpful tool to assist accurate functional assessment which is necessary to improve patient outcomes.
The research supporting the impact of functional status, cognitive statusy and depressive symptoms on the outcome of medical care demands gerontological nurses continue to develop and refine screening tools that may contribute to the development of psychosocial assessment standards across settings in general hospitals.
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DEMOGRAPHIC CHARACTERISTICS (N = 98)
PEARSON PRODUCT-MOMENT CORRELATIONS AND CRONBACH'S ALPHAS
AVERAGES AND STANDARD DEVIATIONS OF THE IOWA SELF-ASSESSMENT INVENTORY SUBSCALE SCORES