Annals of International Occupational Therapy

Original Research 

Occupational Performance and Subclinical Disability in Community-Dwelling Older Adults

Jane Bear-Lehman, PhD, OTR/L, FAOTA; Steven M. Albert, PhD, MSPH

Abstract

Introduction:

The purpose of the study was to examine the usefulness of the Assessment of Motor and Process Skills (AMPS) in epidemiologic studies of the elderly.

Methods:

The validity and sensitivity of the AMPS among a population-based, multiethnic sample of community-dwelling elderly (N = 375) was assessed. Occupational therapists who were blind to the participants' physical, cognitive, and self-report status conducted AMPS evaluations. Participants completed three AMPS assessments over a period of 24 months.

Results:

The study showed that AMPS motor and process scores were significantly related to self-reported functional limitation and disability, such as cognitive and physical performance, and the risk of dementia or death over a 2-year follow-up period.

Conclusion:

Poorer physical performance at baseline was associated with persistent and increasingly poor AMPS performance over the follow-up period. The findings showed that the AMPS is useful for population-level investigations of subclinical disabilities among well elders living in the community. Although our study included a multiethnic cohort, all participants resided in an urban environment; therefore, the study findings may not reflect the outcomes for those living in suburban or rural communities. Also, we did not address physical and social environmental factors that are critical to occupational performance. Use of the AMPS in population research adds an important dimension to research on aging. Our recommendation for future research is to assess the influence of social capital, particularly the effect of the physical environment, including new opportunities available through the Internet, on independence, health status, and occupational performance. [Annals of International Occupational Therapy. 2018; 1(2):61–72.]

Abstract

Introduction:

The purpose of the study was to examine the usefulness of the Assessment of Motor and Process Skills (AMPS) in epidemiologic studies of the elderly.

Methods:

The validity and sensitivity of the AMPS among a population-based, multiethnic sample of community-dwelling elderly (N = 375) was assessed. Occupational therapists who were blind to the participants' physical, cognitive, and self-report status conducted AMPS evaluations. Participants completed three AMPS assessments over a period of 24 months.

Results:

The study showed that AMPS motor and process scores were significantly related to self-reported functional limitation and disability, such as cognitive and physical performance, and the risk of dementia or death over a 2-year follow-up period.

Conclusion:

Poorer physical performance at baseline was associated with persistent and increasingly poor AMPS performance over the follow-up period. The findings showed that the AMPS is useful for population-level investigations of subclinical disabilities among well elders living in the community. Although our study included a multiethnic cohort, all participants resided in an urban environment; therefore, the study findings may not reflect the outcomes for those living in suburban or rural communities. Also, we did not address physical and social environmental factors that are critical to occupational performance. Use of the AMPS in population research adds an important dimension to research on aging. Our recommendation for future research is to assess the influence of social capital, particularly the effect of the physical environment, including new opportunities available through the Internet, on independence, health status, and occupational performance. [Annals of International Occupational Therapy. 2018; 1(2):61–72.]

This study describes the occupational performance of a sample of 375 urban-dwelling adults 70 years or older and identifies the key determinants of performance that account for their expressed functional change over 2 years. Measurement of occupational performance identifies the physical and behavioral capacities that an individual uses to complete daily life tasks. This capacity is reliant on individual needs, wants or expectations for completion of personal activities of daily living (ADLs), and instrumental ADLs for self-management in the living environment. Occupational performance often is regarded as an individual issue, and the perception of one's own occupational performance is an important force that drives the process (Law, 2002). It is this force, in the face of aging, that is germane to the individual's ability to engage in and sustain a productive and safe daily life. Satisfactory occupational performance status is critical for successful aging, and unsatisfactory occupational performance, in particular, a change in the ability to complete components of instrumental ADLs, serves as a signal of subclinical disability (Graff et al., 2006; Mori & Sugimura, 2007).

Kovar and Lawton (1994) describe a variety of issues that must be considered in examining impending subclinical disability among older adults. This is typically expressed as self-reported difficulty in the instrumental (domestic) and basic (personal) ADLs. These issues include deciding which tasks should be assessed by observed performance among the myriad of possible instrumental ADL tasks that could signify a change in subclinical disability. Current studies using the Performance Assessment of Self-care Skills (PASS) show the first discriminative ability of instrumental ADL tasks, namely, declining capacity to balance a checkbook and shop, as key indicators of ensuing disability among individuals with mild cognitive impairment (Rodakowski et al., 2014). Questions are raised as to possible environmental factors or contextual constraints that may further impair expressed disability levels or, in some instances, enhance functional levels. For example, urban living may encourage increased mobility and possibly socialization, with short daily walks to a pharmacy, bank, or grocery store, which can improve or sustain functional status but may not be available to those living in suburban or rural settings. New online services, such as Amazon, which allow delivery of virtually any product to the home, and the greater communication and access to information provided by the Internet (including disease management support groups) may change our understanding of independence, not to mention the introduction of social robots and other home-based monitoring and assistive devices.

In terms of self-report test design, little is known about the ceiling effects of the various ADL and instrumental ADL scales, and many scales seem to do best at identifying the most disabled minority by diagnostic category. Measurement of dependence versus difficulty and limitation may take on different meanings for each individual who is completing the self-report inquiry about functional status. Some may overestimate their capacity and others may underestimate their capacity for a variety of reasons, such as fear of losing independence or lack of awareness of changes in function. Responses also may be influenced by social and cultural differences. Assigned familial and societal roles and expectations are obvious conditioners of instrumental ADL task performance and, conceivably, capability. Cognitive factors in interpreting questions on the self-report instrument are also relevant. For example, “help from another person” can mean ongoing help, occasional help, or indirect help.

Despite these measurement challenges, self-reports of disability are strongly related to the risk of nursing home admission, hospitalization, and mortality, as shown by the U.S. National Long Term Care Survey (Manton, Corder, & Stallard, 1993). However, imprecision in self-report measures is also apparent, as shown in studies of less disabled elderly. In these cohorts, correlations between self-reports and health indicators (e.g., number of doctor visits, number of nights hospitalized, number of prescriptions, risk of nursing home admission) are low (Albert, Bear-Lehman, & Burkhardt, 2009; Gaugler, Duval, Anderson, & Kane, 2007; Rodgers & Miller, 1997). Compared with self-report alone, standardized performance-based measures are more predictive of the need for assistance or of dependency among community-dwelling older adults (Merritt, 2010, 2011). To examine the risk of disability in high-functioning community-dwelling older adults who are aging in place, it is necessary to examine early-stage limitations in the abilities or skills that individuals use in performing ADLs, in addition to gathering self-report data (Terhorst, Holm, Toto, & Rogers, 2016; Waehrens, Bliddal, Danneskiold-Samsøe, Lund, & Fisher, 2012). Deficit in these skill elements presumably precedes the expression of disability acknowledged in self-reports and may occur before the onset of disability (Terhorst et al., 2016).

For this reason, we investigated the utility of the Assessment of Motor and Process Skills (AMPS) in a population-based sample of urban community-dwelling older adults in New York City who had little or only mild self-reported or documented disability. The AMPS is an observational performance-based functional assessment that rates impairment indicators in the motor and process domains of occupational performance (Fisher, 2001). Motor and process skills are assessed simultaneously to determine the person's probability to perform complex instrumental and personal ADLs successfully. As test developers emphasize, the AMPS is a test of skills needed to perform occupational tasks, not a measure of neuromuscular, biomechanical, cognitive, or psychosocial impairment. Studies have shown that AMPS motor and process skill scores are related to these underlying abilities, for example, global cognitive performance in people with dementia (Bouwers et al., 2008; Graff et al., 2006; Liu et al., 2007; Mori & Sugimura, 2007); severity of intellectual disability (Kottorp, Bernspång, & Fisher, 2003); and impairments related to rheumatoid arthritis, osteoarthritis of the knee, and fibromyalgia (Waehrens et al., 2012), stroke (Rexroth, Fisher, Merritt, & Gliner, 2005), psychiatric conditions (McNulty & Fisher, 2001), frailty (Fisher, Alter, & Potts, 2007), brain injury (Lindén, Boschain, Eker, Schalén, & Nordstrom, 2005), and other medical conditions (Doble, Fisk, Fisher, Ritvo, & Murray, 1994; Poole, Atanasoff, Pelsor, & Sibbitt, 2006). Moreover, the AMPS process scale has been found to be very responsive in detecting change that could be critical in allowing the occupational therapist to effectively plan for older adults to live in the community (Merritt & Fisher, 2003).

The performance-based administration of the AMPS overcomes many of the issues described in examining for ensuing subclinical disability among older adults (Kovar & Lawton, 1994). For example, it is free of gender bias (Fioravanti, Bordignon, Pettit, Woodhouse, & Ansley, 2012), and it offers respondents a wide range of ecologically valid tasks for assessment that are part of their usual and customary ADLs. For community-based administration, respondents are asked to engage in two tasks in their usual and customary home-based context. The AMPS differs from other performance-based assessment tools in its ability to generate continuous measures of skill elements, whatever tasks participants choose. In contrast to other performance-based measures for assessment of daily tasks, occupational therapy practitioners are trained and certified in the use of the AMPS to rate the specific functions that are involved in task performance. Also unlike other performance-based measures, such as the PASS, the AMPS tasks are all statistically calibrated to allow valid estimates of occupational skills after observation of only two tasks. More generally, AMPS ratings allow investigators to determine the probability that respondents can successfully perform household and self-maintenance tasks efficiently and safely. Therefore, they offer insight into performance among those who may not report disability. In contrast, the PASS requires administration of tasks in each of four domains—Functional Mobility, Basic ADL, Instrumental ADL, and Instrumental ADL-Cognitive—to determine independence, safety, and adequacy (Chisholm, Toto, Raina, Holm, & Rogers, 2014).

In this research, we report our experience with the AMPS to assess population-level function in a study of multicultural, urban-dwelling well elderly who were 70 years or older. We examined AMPS motor and process scores relative to sociodemographic status, self-reported function, and performance tests of physical and cognitive function. We also examined changes in AMPS performance relative to physical and cognitive function over 2 years of follow-up.

Methods

Study Population

The Sources of Independence in the Elderly (SITE) project was designed to investigate risk factors for disability as well as factors associated with recovery from disability in older adults at a relatively early stage of disability (Albert et al., 2006). The sample included people 70 years or older who reported difficulty with at least one of the four domains according to the criteria developed in the U.S. Women's Health and Aging Study (Guralnik, Fried, Simonsick, Kasper, & Lafferty, 1995). Two of the four domains address bodily function, specifically, upper body and lower body, and two of the domains are occupationally based, instrumental ADL and personal ADL. Potential participants were excluded from the study if they met the criteria for dementia as determined by a comprehensive cognitive assessment conducted in Spanish or English, according to participant preference, and consensus conference review (measures described in Albert, Simone, Brassard, Stern, & Mayeux, 2005); reported impairment in vision as a source of disability; resided in a skilled nursing facility; received hospice services; required a wheelchair for indoor mobility; or planned to move out of the community within the year. With these exclusions, 350 participants were available for analysis, although some were missing AMPS or other correlates (see later).

The SITE participants were selected from the larger pool of community-dwelling well older adults in New York City participating in the Washington Heights-Inwood Aging Project at Columbia University Medical Center, New York, New York. This project is a triethnic population-based survey of 2,165 Medicare beneficiaries (non-Hispanic White, non-Hispanic Black, and Hispanic), recruited from 1999 to 2001, who reside in northern Manhattan, New York (Albert et al., 2005; Manly et al., 2005; Schupf et al., 2005; Tang et al., 1998). Medicare is health insurance for people 65 years or older, people younger than 65 years who have certain disabilities, and people of any age with end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant). Further information on U.S. Government benefits can be found at https://www.benefits.gov. Of the project participants who were approached, 85% agreed to participate in SITE. The SITE assessments were conducted in respondents' homes between 2000 and 2006. The research protocol and the consent form were approved by the Columbia University-New York Presbyterian Hospital Institutional Review Board. The AMPS assessment procedures were detailed in the informed consent document.

Procedures

Occupational therapists completed the 5-day AMPS training program and calibration period. During the course of the study, four AMPS-certified occupational therapists conducted assessments, with ongoing calibration and oversight through review of assessments and weekly feedback.

The occupational therapists followed the AMPS protocol for selecting tasks (Fisher, 2001). Therapists considered the overall ability of the study participants, the tasks that participants were likely to perform, and participants' familiarity with potential tasks. A key consideration was to avoid tasks that were likely to be too easy for the respondents. All respondents were told in advance during an initial telephone screening that they would be asked to perform household tasks and would be observed by an occupational therapist. Therapists conducted a preassessment interview, either at the time of screening or during a separate telephone contact, to determine tasks that the participants performed on a regular basis. Respondents often timed their performance of these tasks (e.g., making a meal, cleaning a bathroom) so that therapists could observe them. When necessary, the research team brought objects needed for tasks (e.g., bread, cleaning supplies). In each case, the goal was to narrow the potential tasks to three to five choices selected by therapists as appropriate, habitual, and adequately challenging. Therapists established a “specific task contract” before the assessments were started. Mean time to complete preinterviews and AMPS evaluations was 35 minutes.

The AMPS assessment was conducted after the research evaluation but on the same day. Research assistants administered questionnaires and completed cognitive and performance assessments. Occupational therapists were blind to these assessments.

Instruments

Assessment of Motor and Process Skills

Occupational therapists followed the AMPS protocol. They observed participants perform the two prespecified tasks and made ratings. Motor skill ratings included posture, mobility, coordination, strength and effort, and energy. Process skill ratings included energy, knowledge use, temporal organization, handling space and objects, and spontaneous use of adaptation or modification. In each domain, occupational therapists made multiple ratings on a 4-point scale (competent, questionable, ineffective, deficit). The test developers reported high test-retest reliability (0.90 for the motor skill scale and 0.87 for the process skill scale) (Fisher, 2001). Occupational therapists completed the AMPS with all but 10 respondents. In these cases, the participants refused or the therapist and the participant could not agree on a task.

Self-Report Measures

In addition to demographic features, including age, education level, ethnicity, and gender, participants were asked about their medical history. This information included physician diagnoses of myocardial infarction, angina, congestive heart failure, hypertension, diabetes, arthritis, stroke, cancer, hip fracture, chronic obstructive pulmonary disease, and Parkinson's disease. Information on medications was also obtained, and this information suggested the validity of self-reports of chronic conditions. For example, all but 1 of 66 participants who reported diabetes also reported that they were taking prescription medication for diabetes.

Self-reports of functional limitation were assessed twice, once by telephone as part of a screening interview to determine eligibility and again during the home visit. Fewer than 2% of participants changed their report between assessments, which occurred an average of 1 week apart.

Clinical Physical Assessments

Lower body performance was assessed with the Short Physical Performance Battery (SPPB). The SPPB assesses gait speed, balance, and lower extremity strength (Guralnik, Ferrucci, Simonsick, Salive, & Wallace, 1995). Within each domain, respondents receive a score of 0 to 3 based on quartile of performance derived from the Established Populations for the Epidemiologic Study of the Elderly (Guralnik, Ferrucci, et al., 1995). These scores are then summed and divided into four categories to yield a lower body performance composite score (0–3, 4–6, 7–9, or 10–12, where 12 represents superior performance). Because of the small numbers of people with scores of 0 to 3 (n = 24), in some analyses, we combined the groups with scores of 0 to 3 and 4 to 6. At baseline, all respondents completed the timed gait assessment, and fewer than 10% were unable to complete other elements of the SPPB. Participants who did not complete tests were assigned a score that corresponded to the poorest 1% of performance in the sample distribution (Onder et al., 2002).

Cognitive Assessments

At the baseline assessment, participants completed a 45-minute neuropsychological evaluation to determine whether deficits in memory and other intellectual functions were sufficient to meet the criteria for dementia. Cognitive impairment was diagnosed according to a paradigm-based approach to dementia (Stern et al., 1992). Although attempts were made to exclude those with dementia from SITE, subsequent analyses showed that a small number did meet the criteria for dementia over the follow-up period and were excluded from some analyses.

Cognitive assessments were conducted by Spanish-English bilingual testers and covered the domains of memory (Selective Reminding Test: total recall, delayed recall; Benton Visual Recognition Test); language (Boston Naming Test; Boston Diagnostic Aphasia Examination: repetition and comprehension); and executive function (letter and category fluency). Test scores within each domain were converted to z-scores based on the sample distribution and were summed to develop composite scores for each domain. Each composite was then converted to a T-score using a regression procedure to adjust for age, gender, race and ethnicity, and education (Manly et al., 2005). In the current sample, 52 people (15.3%) scored 1 SD below sample-based means in one or more domains and were considered to meet the criteria for mild cognitive impairment. An additional 25, or 6.7%, met the criteria for dementia during the course of the study, as determined by cognitive assessment and consensus conference.

Analyses

To assess performance of the AMPS for estimating population-level function, AMPS motor and process scores were compared for respondents with different sociodemographic features, self-reported functional limitations and disability, and performance-based assessments of lower body strength and cognition. For these analyses, t tests and analysis of variance were used, with p < .05 considered significant. We also used linear ordinary least squares regression models to examine the association between AMPS motor and process composites and performance-based assessment of physical and cognitive performance, adjusting for the effect of age and other sociodemographic indicators. Analyses were conducted with the Statistical Package for the Social Sciences (SPSS), version 22.0.

To assess the predictive value of the AMPS, we examined baseline AMPS performance among people who survived or were known to have died (n = 25) during the 24-month follow-up period. We performed a similar analysis for people who had incident dementia (n = 25) during the follow-up period. We also developed repeated measures analysis of variance models to examine the change in motor and process scores over the 2-year follow-up period relative to baseline performance. We asked whether participants with less lower extremity strength continued to do more poorly on AMPS assessments at 12 and 24 months and whether they were also more likely to have a steeper decline in AMPS performance.

Results

Excluding the 25 (6.7%) participants who met the criteria for dementia during the course of follow-up left 350 participants. In total, 69.7% were women, with average age of 78.8 years (SD = 5.7), and 31.6% had completed high school. The sample included 99 White participants (29.1%), 60 Black participants (17.6%), 176 Hispanic participants (51.8%), and 5 participants (1.5%) with other self-reported race or ethnicity. Spanish speakers were mostly from the Dominican Republic or Puerto Rico. More than 44.1% reported that they lived alone, and a majority of participants had been born outside of the United States.

At baseline, participants reported the following diagnoses from physicians: arthritis (63.1%); hypertension (63.1%); cancer (19.0%); diabetes (17.4%); myocardial infarction (9.7%), angina (7.7%), and congestive heart failure (4.3%); chronic obstructive pulmonary disease (9.1%); stroke (7.7%); and hip fracture (1.7%).

Of the 350 respondents, 340 completed AMPS examinations at baseline, 312 at 12 months, and 263 at 24 months. At 24 months, 25 respondents (7.1%) were known to have died, and 2 had entered nursing homes for long-term care. Of the participants who survived the 24-month follow-up period, 81% (263 of 325) completed all three AMPS assessments.

Assessment Performance and Sociodemographic Status

The AMPS performance was significantly lower at older ages for both motor skills (p < .001) and process skills (p < .05), as shown in Table 1. The AMPS performance did not differ significantly according to other sociodemographic factors, including gender, education, race and ethnicity, or living arrangement.

Association Between Assessment of Motor and Process Skills Performance and Sociodemographic Indicators

Table 1:

Association Between Assessment of Motor and Process Skills Performance and Sociodemographic Indicators

Assessment Performance and Self-Reported Medical Conditions

When respondents with and without self-reported medical conditions were compared, only those who reported having a hip fracture performed more poorly (motor score: 1.21 [1.6] vs. 2.68 [1.3]; p < .001), and performance was not significantly different among groups according to the summed number of reported medical conditions.

Assessment Performance and Self-Reported Disability

Participants who reported a limitation in either upper or lower body function scored significantly lower on AMPS performance (Table 2). Of six different functions, motor scores were significantly lower for three (lifting the arms over the head, using the fingers to grasp, and walking ¼ mile). In addition, AMPS process performance was poorer only for those who self-reported difficulty with lower body function (difficulty walking ¼ mile).

Association Between Assessment of Motor and Process Skills Performance and Self-Reported Impairment

Table 2:

Association Between Assessment of Motor and Process Skills Performance and Self-Reported Impairment

As shown in Table 3, differences in AMPS performance were greater for those who reported difficulty with personal or instrumental ADLs. For instrumental ADLs, motor and process scores were significantly poorer among those reporting difficulty with light shopping, light housekeeping, and meal preparation. Post hoc tests showed that participants who reported that they did not perform the tasks had poorer performance than those who performed the tasks. For ADL tasks, motor and process scores were significantly lower among those reporting difficulty bathing, and motor scores were significantly lower among those reporting difficulty using utensils.

Association Between Assessment of Motor and Process Skills Performance and Self-Reported IADL and ADL Disability

Table 3:

Association Between Assessment of Motor and Process Skills Performance and Self-Reported IADL and ADL Disability

Assessment Performance and Performance on Tests of Physical and Cognitive Function

Lower extremity performance was strongly associated with both motor and process scores (Table 4), as shown by decreasing mean AMPS scores by one-way analysis of variance across categories of SPPB performance. Mean motor scores ranged from 0.93 (1.4) for participants with the poorest performance (SPPB score 0–3) to 3.26 (0.9) for those with the best performance (SPPB score 10–12) (p < .001); process scores ranged from 1.27 (1.0) to 2.38 (0.8) over the same range (p < .001).

Association Between Assessment of Motor and Process Skills Performance and Physical and Cognitive Function

Table 4:

Association Between Assessment of Motor and Process Skills Performance and Physical and Cognitive Function

Similarly, participants who met the criteria for mild cognitive impairment also scored more poorly on motor and process indicators. The AMPS motor score was 2.76 (1.2) for participants who did not meet the criteria for mild cognitive impairment and 2.15 (1.6) for those who did (p < .01). Similar differences were evident for process scores (2.16 vs. 1.83, p < .05).

In regression models that controlled for the effect of age and other sociodemographic indicators, lower extremity performance and mild cognitive impairment were significant independent predictors of AMPS motor performance. Lower extremity performance also was a significant predictor of the process score with the same set of covariates. Regression models that included this set of predictors explained 33% of the variance in motor scores and 11% of the variance in process scores (results available on request).

Change in Assessment Performance Over 2 Years

At baseline, AMPS performance was significantly lower among respondents who died over the 2-year follow-up period. The mean AMPS motor score among survivors at baseline was 2.70 (1.3) and 2.01 (1.2) among those who later died during the follow-up period (p = .01). Process scores were 2.12 (0.9) among survivors and 1.83 (0.8) among those who died during the follow-up period (p = .11). In addition, respondents who were diagnosed with dementia during the follow-up period had lower AMPS scores at baseline. Motor composite scores were 1.94 (1.3) among participants who subsequently met the criteria for dementia and 2.65 (1.3) among those who appeared to remain dementia-free (p = .01). Process score differences were similar (1.62 [0.9] vs. 2.10 [0.9], respectively; p = .02).

Repeated measures analyses for motor skills over the three assessments indicated significant main effects for age and physical performance at baseline. Stratifying by lower body performance at baseline, as seen in the Figure, showed a marginally significant interaction (p = .07) between SPPB status and time. That is, those with poorer lower body performance at baseline were likely to have a steeper decline in AMPS motor skills over 2 years. The same model did not provide a good fit for change in process scores over the follow-up period. Mild cognitive impairment at baseline was not associated with a decline in AMPS scores.

Assessment of Motor and Process Skills motor composite scores: 2-year follow-up. Repeated measures analysis of variance. SPPB = Short Physical Performance Battery (Guralnik, Ferrucci, Simonsick, Salive, & Wallace, 1995). Mean scores adjusted for age, SPPB, and presence of mild cognitive impairment. Age effect, p < .01; SPPB effect, p < .001; interaction between time trend and SPPB, p = .07. No other significant main or interaction effects.

Figure:

Assessment of Motor and Process Skills motor composite scores: 2-year follow-up. Repeated measures analysis of variance. SPPB = Short Physical Performance Battery (Guralnik, Ferrucci, Simonsick, Salive, & Wallace, 1995). Mean scores adjusted for age, SPPB, and presence of mild cognitive impairment. Age effect, p < .01; SPPB effect, p < .001; interaction between time trend and SPPB, p = .07. No other significant main or interaction effects.

Discussion

In this population-based, multicultural sample of community-dwelling older adults, AMPS motor and process scores were significantly related to self-reported functional limitations and disability, observed cognitive and physical performance, and risk of dementia or death over a 2-year follow-up period. In addition, poorer physical performance at baseline was associated with persistent and increasingly poor AMPS performance over the 2-year follow-up period. The findings suggest the utility of the AMPS for identifying subclinical disability in studies of population health.

This research also provides reassuring support for the AMPS as a gender-free and culturally unbiased assessment. The AMPS performance did not differ significantly between men and women; White, Black, or Hispanic older adults; or those who completed more or less education.

A key finding is the poorer AMPS performance among people with mild cognitive impairment. Although earlier research has shown poorer performance among people with dementia (Bouwers et al., 2008; Graff et al., 2006; Liu et al., 2007; Mori & Sugimura, 2007), our results are consistent with findings reported from geriatric rehabilitation (Douglas, Letts, Eva, & Richardson, 2012). The poorer performance of elders with mild cognitive impairment suggests that cognitive impairment that does not meet the criteria for dementia may be detectable with structured functional assessments, although people may not be aware of these mild deficits.

Results from this population-based study suggest that the motor composite score may be a more useful measure for population research than the process composite score. The AMPS motor scores were more likely to be significantly correlated with underlying measures of ability, such as lower extremity function and mild cognitive impairment.

Is the AMPS a useful measure for population-based research? Use of the AMPS added an extra 35 minutes to each home visit and required the equivalent of one additional member of the research team. However, as mentioned earlier, the AMPS offers a number of advantages that are not available with other performance-based measures. It provides a guided measure of the central occupational domains of motor and process skills, with continuous measures and norms for performance, standardized training for raters, and ecologically valid tasks. Still, it would be valuable to conduct head-to-head tests of different occupational therapy performance measures in population-based studies. A key opportunity for the use of occupational therapy performance measures in population research would be better delineation of subclinical disability to allow effective targeting of prehabilitation (Gill et al., 2002) and other primary prevention measures, such as strength training and lifestyle preparation, to keep older adults safe from injury.

Limitations

Although our study included a multiethnic cohort, all participants resided in a very large, densely populated urban environment; thus, the findings cannot be extrapolated to community-dwelling well older adults who live in smaller cities or suburban or rural areas. A limitation of the study is the absence of alternative occupational therapy performance measures to assess the sensitivity of the AMPS in population-based studies. Future studies should include head-to-head comparison of occupational therapy measures in epidemiologic research. A second limitation of the study is that we did not address physical and social environmental factors that are considered critical to achieving successful behavioral change. Our findings support the need to advance the line of inquiry to identify how the determinants of health that we measured are affected by the community environment. In addition, greater ease in accessibility to goods, services, and other supports through the Internet and other media may be changing the landscape for assessing independent living. New forms of Internet-based social capital may affect health and occupational performance (Murayama, Fujiwara, & Kawachi, 2012). The findings of this study need to be aligned with current public health models for assessment of aspects of the physical environment that are likely to hinder or facilitate healthy behavior and health expectancy.

Conclusion

We conclude that the AMPS is a valid assessment of everyday higher-level functional competencies that is useful in the epidemiologic study of aging or, broadly, large-scale occupational assessment of older people in the community, that offers insight into sources of disability and barriers to participation. Disability and barriers to social participation are now recognized as key elements of health expectancy or life span. These measures assess population health much more broadly than standard measures of morbidity and mortality. New research on behavioral interventions suggests that disability and barriers to social participation are more remediable than expected, even for those with dementia (Gitlin, Winter, Dennis, Hodgson, & Hauck, 2010). To assess the effects of policy and environmental changes on health expectancy, we need better measures of occupational performance and the skills that people draw on to participate in the spheres of life that matter to them. Epidemiologic research, combined with occupation-based assessments, can play a key role in the effort to support prevention with behavioral interventions throughout the life span. A key consideration for future research is the development of tools to assess independence in light of the growing use of technology, from home-based monitoring and cognitive prostheses to self-driving cars, that will likely change the nature of independence in old age.

References

  • Albert, S. M., Bear-Lehman, J. & Burkhardt, A. (2009). Lifestyle-adjusted function: Variation beyond BADL and IADL competencies. Gerontologist, 49(6), 767–777. doi:10.1093/geront/gnp064 [CrossRef]
  • Albert, S. M., Bear-Lehman, J., Burkhardt, A., Merete-Roa, B., Noboa-Lemonier, R. & Teresi, J. (2006). Variation in sources of clinician-rated and self-rated instrumental activities of daily living disability. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 61(8), 826–831. doi:10.1093/gerona/61.8.826 [CrossRef]
  • Albert, S. M., Simone, B., Brassard, A., Stern, Y. & Mayeux, R. (2005). Medicaid home care services and survival in New York City. Gerontologist, 45(5), 609–616. doi:10.1093/geront/45.5.609 [CrossRef]
  • Bouwers, S. F., van Heugten, C. M., Aalten, P., Wolfs, C. A., Baarends, E. M., van Menxel, D. A. & Verhey, F. R. (2008). Relationship between measures of dementia severity and observation of daily life functioning as measures with the Assessment of Motor and Process Skills (AMPS). Dementia and Geriatric Cognitive Disorders, 25(1), 81–87. doi:10.1159/000111694 [CrossRef]
  • Chisholm, D., Toto, P., Raina, K., Holm, M. & Rogers, J. (2014). Evaluating capacity to live independently and safely in the community: Performance Assessment of Self-care Skills. British Journal of Occupational Therapy, 77(2), 59–63. doi:10.4276/030802214X13916969447038 [CrossRef]
  • Doble, S. E., Fisk, J. D., Fisher, A. G., Ritvo, P. G. & Murray, T. J. (1994). Functional competence of community-dwelling persons with multiple sclerosis using the Assessment of Motor and Process Skills. Archives of Physical Medicine and Rehabilitation, 75(8), 843–851. doi:10.1016/0003-9993(94)90107-4 [CrossRef]
  • Douglas, A., Letts, L., Eva, K. & Richardson, J. (2012). Use of the cognitive performance test for identifying deficits in hospitalized older adults. Rehabilitation Research and Practice, 2012, 638480. doi:10.1155/2012/638480 [CrossRef]
  • Fioravanti, A. M., Bordignon, C. M., Pettit, S. M., Woodhouse, L. J. & Ansley, B. J. (2012). Comparing the responsiveness of the assessment of motor and process skills and the functional independence measure. Canadian Journal of Occupational Therapy, 79(3), 167–174. doi:10.2182/cjot.2012.79.3.6 [CrossRef]
  • Fisher, A. G. (2001). Assessment of motor and process skills (5th ed., Vols. 1–2). Fort Collins, CO: Three Star Press.
  • Fisher, A. G., Alter, K. & Potts, A. (2007). Effectiveness of occupational therapy with frail community living older adults. Scandinavian Journal of Occupational Therapy, 14(4), 240–249. doi:10.1080/11038120601182958 [CrossRef]
  • Gaugler, J. E., Duval, S., Anderson, K. A. & Kane, R. L. (2007). Predicting nursing home admission in the U.S.: A meta-analysis. BMC Geriatrics, 7(1), 13. doi:. doi:10.1186/1471-2318-7-13 [CrossRef]
  • Gill, T. M., Baker, D. I., Gottschalk, M., Peduzzi, P. N., Allore, H. & Byers, A. (2002). A program to prevent functional decline in physically frail, elderly persons who live alone. New England Journal of Medicine, 347(14), 1068–1074. doi:10.1056/NEJMoa020423 [CrossRef]
  • Gitlin, L. N., Winter, L., Dennis, M. P., Hodgson, N. & Hauck, W. W. (2010). A biobehavioral home-based intervention and the well-being of patients with dementia and their caregivers: The COPE randomized trial. Journal of the American Medical Association, 304(9), 983–991. doi:10.1001/jama.2010.1253 [CrossRef]
  • Graff, M. J. L., Vernooij-Dassen, M. J. M., Thijssen, M., Dekker, J., Hoefnagels, W. H. L. & Rikkert, M. G. (2006). Community based occupational therapy for patients with dementia and their care givers: Randomised controlled trial. British Medical Journal, 333(7580), 1196–1198. doi:10.1136/bmj.39001.688843.BE [CrossRef]
  • Guralnik, J. M., Ferrucci, L., Simonsick, E. M., Salive, M. E. & Wallace, R. B. (1995). Lower extremity function in persons over the age of 70 years as a predictor of subsequent disability. New England Journal of Medicine, 332(9), 556–561. doi:10.1056/NEJM199503023320902 [CrossRef]
  • Guralnik, J. M., Fried, L. P., Simonsick, E. M., Kasper, J. D. & Lafferty, M. E. (Eds.). (1995). The Women's Health and Aging Study: Health and social characteristics of older women with disability (NIH Publication No. 95–4009). Bethesda, MD: National Institute on Aging.
  • Kottorp, A., Bernspång, B. & Fisher, A. G. (2003). Validity of a performance assessment of activities of daily living for people with developmental disabilities. Journal of Intellectual Disability Research, 47(Pt. 8), 597–605. doi:10.1046/j.1365-2788.2003.00475.x [CrossRef]
  • Kovar, M. G. & Lawton, M. P. (1994). Functional disability: Activities and instrumental activities of daily living. In Lawton, M. P. & Teresi, J. A. (Eds.), Annual review of geriatrics and gerontology (Vol. 14). New York, NY: Springer.
  • Law, M. (2002). Participation in the occupations of everyday life. American Journal of Occupational Therapy, 56(6), 640–649. doi:10.5014/ajot.56.6.640 [CrossRef]
  • Lindén, A., Boschain, K., Eker, C., Schalén, W. & Nordstrom, C. H. (2005). Assessment of motor and process skills reflects brain-injured patients' ability to resume independent living better than neuropsychological tests. Acta Neurologica Scandinavica, 111(1), 48–53. doi:10.1111/j.1600-0404.2004.00356.x [CrossRef]
  • Liu, K. P., Chan, C. C., Chu, M. M., Ng, T. Y., Chu, L. W., Hui, F. S. & Fisher, A. G. (2007). Activities of daily living performance in dementia. Acta Neurologica Scandinavica, 116(2), 91–95. doi:10.1111/j.1600-0404.2007.00800.x [CrossRef]
  • Manly, J. J., Bell-McGinty, S., Tang, M. X., Schupf, N., Stern, Y. & Mayeux, R. (2005). Implementing diagnostic criteria and estimating frequency of mild cognitive impairment in an urban community. Archives of Neurology, 62(11), 1739–1746. doi:10.1001/archneur.62.11.1739 [CrossRef]
  • Manton, K. G., Corder, L. S. & Stallard, E. (1993). Estimates of change in chronic disability and institutional incidence and prevalence rates in the U.S. elderly population from the 1982, 1984, and 1989 National Long Term Care Survey. Journal of Gerontology, 48(4), S153–S166. doi:10.1093/geronj/48.4.S153 [CrossRef]
  • McNulty, M. C. & Fisher, A. G. (2001). Validity of using the Assessment of Motor and Process Skills to estimate overall home safety in persons with psychiatric conditions. American Journal of Occupational Therapy, 55(6), 649–655. doi:10.5014/ajot.55.6.649 [CrossRef]
  • Merritt, B. K. (2010). Utilizing AMPS ability measures to predict level of community dependence. Scandinavian Journal of Occupational Therapy, 17(1), 70–76. doi:10.3109/11038120903165107 [CrossRef]
  • Merritt, B. K. (2011). Validity of using the Assessment of Motor and Process Skills to determine the need for assistance. American Journal of Occupational Therapy, 65(6), 643–650. doi:10.5014/ajot.2011.000547 [CrossRef]
  • Merritt, B. K. & Fisher, A. G. (2003). Gender differences in the performance of activities of daily living. Archives of Physical Medicine and Rehabilitation, 84(12), 1872–1877. doi:10.1016/S0003-9993(03)00483-0 [CrossRef]
  • Mori, A. & Sugimura, K. (2007). Characteristics of Assessment of Motor and Process Skills and Rivermead Behavioral Memory Test in elderly women with dementia and community-dwelling women. Nagoya Journal of Medical Science, 69(1–2), 45–53.
  • Murayama, H., Fujiwara, Y. & Kawachi, I. (2012). Social capital and health: A review of prospective multilevel studies. Journal of Epidemiology, 22(3), 179–187. doi:10.2188/jea.JE20110128 [CrossRef]
  • Onder, G., Pennix, B. W., Lapuerta, P., Fried, L. P., Ostir, G. V., Guralnik, J. M. & Pahor, M. (2002). Change in physical performance over time in older women: The Women's Health and Aging Study. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 57(5), M289–M293. doi:10.1093/gerona/57.5.M289 [CrossRef]
  • Poole, J. L., Atanasoff, G., Pelsor, J. C. & Sibbitt, W. L. Jr.. (2006). Comparison of a self-report and performance-based test of disability in people with systemic lupus erythematosus. Disability and Rehabilitation, 28(10), 653–658. doi:10.1080/09638280500264691 [CrossRef]
  • Rexroth, P., Fisher, A. G., Merritt, B. K. & Gliner, J. (2005). ADL differences in individuals with unilateral hemispheric stroke. Canadian Journal of Occupational Therapy, 72(4), 212–221. doi:10.1177/000841740507200403 [CrossRef]
  • Rodakowski, J., Skidmore, E. R., Reynolds, C. F. III. , Dew, M. A., Butters, M. A., Holm, M. B. & Rogers, J. C. (2014). Can performance on daily activities discriminate between older adults with normal cognitive function and those with mild cognitive impairment?Journal of the American Geriatrics Society, 62(7), 1347–1352. doi:10.1111/jgs.12878 [CrossRef]
  • Rodgers, W. & Miller, B. (1997). A comparative analysis of ADL questions in surveys of older people. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 52, 21–36. doi:10.1093/geronb/52B.Special_Issue.21 [CrossRef]
  • Schupf, N., Tang, M. X., Albert, S. M., Costa, R., Andrews, H., Lee, J. H. & Mayeux, R. (2005). Decline in cognitive and functional skills increases mortality risk in nondemented elderly. Neurology, 65(8), 1218–1226. doi:10.1212/01.wnl.0000180970.07386.cb [CrossRef]
  • Stern, Y., Andrews, H., Pittman, J., Sano, M., Tatemichi, T., Lantigua, R. & Mayeux, R. (1992). Diagnosis of dementia in a heterogeneous population: Development of a neuropsychological paradigm-based diagnosis of dementia and quantified correction for the effects of education. Archives of Neurology, 49(5), 453–460. doi:10.1001/archneur.1992.00530290035009 [CrossRef]
  • Tang, M. X., Stern, Y., Marder, K., Bell, K., Gurland, B., Lantigua, R. & Mayeux, R. (1998). The APOE-epsilon4 allele and the risk of Alzheimer disease among African Americans, whites, and Hispanics. Journal of the American Medical Association, 279(10), 751–755. doi:10.1001/jama.279.10.751 [CrossRef]
  • Terhorst, L., Holm, M. B., Toto, P. E. & Rogers, J. C. (2016). Performance-based impairment measures as predictors of early-stage activity limitations in community-dwelling older adults. Journal of Aging and Health, 29(5), 880–892. doi:10.1177/0898264316648113 [CrossRef]
  • Waehrens, E. E., Bliddal, H., Danneskiold-Samsøe, B., Lund, H. & Fisher, A. G. (2012). Differences between questionnaire- and interview-based measures of activities of daily living (ADL) ability and their association with observed ADL ability in women with rheumatoid arthritis, knee osteoarthritis, and fibromyalgia. Scandinavian Journal of Rheumatology, 41(2), 95–102. doi:10.3109/03009742.2011.632380 [CrossRef]

Association Between Assessment of Motor and Process Skills Performance and Sociodemographic Indicators

Sociodemographic indicatornAssessment of Motor and Process Skills, M (SD)
Motor compositeProcess composite
Age
  70–74 years1012.82 (1.1)2.12 (0.89)
  75–79 years1122.80 (1.1)2.22 (0.84)
  80–84 years742.60 (1.3)2.04 (0.96)
  85+ years531.84 (1.7)***1.71 (0.97)***
Gender
  Male1062.69 (1.2)2.03 (0.89)
  Female2342.57 (1.3)2.09 (0.93)
Education
  0–8 years1462.66 (1.3)2.12 (0.89)
  9–12 years882.72 (1.3)1.93 (0.96)
  Post-high school1062.43 (1.3)2.10 (0.92)
Ethnicitya
  White992.49 (1.4)2.01 (0.97)
  Black602.41 (1.2)2.01 (0.94)
  Hispanic1762.73 (1.3)2.11 (0.89)
Housingb
  Live alone1502.62 (1.3)2.11 (0.95)
  Co-resident1832.58 (1.3)1.99 (0.87)

Association Between Assessment of Motor and Process Skills Performance and Self-Reported Impairment

Self-reported impairmentnAssessment of Motor and Process Skills, M (SD)
Motor compositeProcess composite
Upper body
  Lift arms over head
    No2982.72 (1.3)2.12 (0.9)
    Yes422.17 (1.4)**1.95 (1.0)
  Use fingers to grasp or handle
    No2982.72 (1.3)2.11 (0.9)
    Yes422.17 (1.4)**2.00 (0.9)
  Lift something as heavy as 10 lba
    No2202.72 (1.2)2.11 (0.9)
    Yes1022.51 (1.3)2.10 (0.9)
    Don't do172.45 (1.5)2.05 (1.0)
  Any upper extremity limitation
    No1892.80 (1.2)2.15 (0.9)
    Yes1512.47 (1.4)*2.04 (0.9)
Lower body
  Difficulty walking ¼ milea
    No2242.87 (1.1)2.19 (0.9)
    Yes1152.24 (1.4)***1.94 (1.0)*
  Difficulty walking up a flight of stairs
    No1882.78 (1.2)2.18 (0.9)
    Yes1462.50 (1.3)1.99 (0.9)
    Don't do62.01 (0.7)1.88 (1.2)
  Difficulty transferring
    No2642.71 (1.2)2.13 (0.9)
    Yes762.41 (1.4)1.99 (0.9)
  Any lower extremity impairment
    No1272.93 (1.2)2.27 (0.9)
    Yes2132.48 (1.3)**2.00 (0.9)**

Association Between Assessment of Motor and Process Skills Performance and Self-Reported IADL and ADL Disability

Self-reported IADL and ADL disabilitynAssessment of Motor and Process Skills, M (SD)
Motor compositeProcess composite
Instrumental activities
  Difficulty with light housekeepinga
    No3072.80 (1.1)2.16 (0.9)
    Yes220.96 (0.8)1.30 (1.4)
    Doesn't do112.10 (1.6)***1.94 (0.9)*
  Difficulty with preparing mealsa
    No2922.80 (1.1)2.16 (0.9)
    Yes160.96 (1.6)1.28 (1.4)
    Doesn't do322.08 (1.6)***1.94 (0.9)***
  Difficulty with light shopping
    No2992.85 (1.1)2.16 (0.9)
    Yes261.01 (1.4)1.60 (1.0)
    Doesn't do151.41 (1.8)***1.79 (1.2)**
  Any IADL limitation
    No1243.00 (1.0)2.19 (0.8)
    Yes2162.44 (1.4)***2.05 (0.9)
Basic activities
  Difficulty bathing/showering
    No3232.73 (1.2)2.13 (0.9)
    Yes171.17 (1.6)***1.42 (1.2)**
  Difficulty dressing
    No3272.67 (1.3)2.09 (0.9)
    Yes132.13 (2.0)2.15 (1.4)
  Difficulty using utensils for eating
    No3352.67 (1.3)2.11 (0.9)
    Yes51.16 (2.4)**1.20 (1.9)
  Difficulty getting to/using toilet
    No3372.66 (1.3)2.10 (0.9)
    Yes31.59 (1.4)1.83 (1.0)
  Any ADL limitation
    No3102.73 (1.2)2.12 (0.9)
    Yes301.82 (1.6)***1.88 (1.2)

Association Between Assessment of Motor and Process Skills Performance and Physical and Cognitive Function

Physical and cognitive functionnAssessment of Motor and Process Skills, M (SD)
Motor compositeProcess composite
Short Physical Performance Battery
  0–3240.93 (1.4)1.27 (1.0)
  4–6611.91 (1.2)1.72 (0.9)
  7–91102.62 (1.2)2.11 (0.8)
  10–121453.26 (0.9)***2.38 (0.8)***
Mild cognitive impairmenta
  Unimpaired2882.76 (1.2)2.16 (0.9)
  Mild cognitive impairment522.15 (1.6)**1.83 (1.1)*
Authors

Dr. Bear-Lehman is Professor and Director, Health Science Program, College of Health Professions, Pace University, Pleasantville, New York. Dr. Bear-Lehman is also Adjunct Professor, Psychosocial Research Unit on Health, Aging, and the Community, College of Dentistry, New York University, New York, New York. Dr. Albert is Professor and Chair, Department of Behavioral and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania.

The authors have no relevant financial relationships to disclose.

This study was supported in part by the National Institute on Aging (R01 AG18234).

Address correspondence to Jane Bear-Lehman, PhD, OTR/L, FAOTA, Professor and Director, Health Science Program, College of Health Professions, Pace University, 861 Bedford Road, Pleasantville, NY 10570; e-mail: jbearlehman@pace.edu.

Received: July 12, 2017
Accepted: January 12, 2018
Posted Online: May 02, 2018

10.3928/24761222-20180409-02

Sign up to receive

Journal E-contents