Revista Brasileira de Psiquiatria.

2014;36:143–152
ß 2014 Associação Brasileira de Psiquiatria
doi:10.1590/1516-4446-2012-1003

ORIGINAL ARTICLE

Development, validity, and reliability of the General

Activities of Daily Living Scale: a multidimensional
measure of activities of daily living for older people
Jonas J. de Paula,1,2,3 Laiss Bertola,1,2 Rafaela T. de Ávila,1,2 Luciana de O. Assis,3,4
Maicon Albuquerque,1,2,5 Maria A. Bicalho,6 Edgar N. de Moraes,6 Rodrigo Nicolato,2,7
Leandro F. Malloy-Diniz1,2,7
1
Laboratory of Research in Clinical Neuroscience (LINC), Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil.
2
National Science and Technology Institute for Molecular Medicine, School of Medicine, UFMG, Belo Horizonte, MG, Brazil. 3Faculdade de
Ciências Médicas de Minas Gerais, Belo Horizonte, MG, Brazil. 4Graduate Program in Neurosciences, Institute of Biological Sciences, UFMG,
Belo Horizonte, MG, Brazil. 5Universidade Federal de Viçosa, Viçosa, MG, Brazil. 6Department of Medical Practice, School of Medicine,
UFMG, Belo Horizonte, MG, Brazil. 7Department of Mental Health, School of Medicine, UFMG, Belo Horizonte, MG, Brazil.

Objective: To propose and evaluate the psychometric properties of a multidimensional measure of

activities of daily living (ADLs) based on the Katz and Lawton indices for Alzheimer’s disease (AD) and
mild cognitive impairment (MCI).
Methods: In this study, 85 patients with MCI and 93 with AD, stratified by age (f 74 years, . 74
years), completed the Mini Mental State Examination (MMSE) and the Geriatric Depression Scale,
and their caregivers completed scales for ADLs. Construct validity (factor analysis), reliability (internal
consistency), and criterion-related validity (receiver operating characteristic analysis and logistic
regression) were assessed.
Results: Three factors of ADL (self-care, domestic activities, and complex activities) were identified
and used for item reorganization and for the creation of a new inventory, called the General Activities
of Daily Living Scale (GADL). The components showed good internal consistency (. 0.800) and
moderate (younger participants) or high (older participants) accuracy for the distinction between MCI
and AD. An additive effect was found between the GADL complex ADLs and global ADLs with the
MMSE for the correct classification of younger patients.
Conclusion: The GADL showed evidence of validity and reliability for the Brazilian elderly population.
It may also play an important role in the differential diagnosis of MCI and AD.
Keywords: Activities of daily living; older people; Alzheimer’s disease; mild cognitive impairment;
functional assessment; psychometric properties

Introduction required for diagnosis, whereas in MCI, functional deficits

are usually mild, compromise complex activities, and do
The population explosion that has occurred in the last not result in expressive limitations in daily life.3
decades and the improvement in overall quality of life and The use of inventories of activities of daily living (ADLs)
health conditions has led to an increase in the proportion is a common method for the assessment of functional
of older people in relation to the general population in status in older patients. These inventories are usually lists
recent years.1 With the continuous enhancement of life of common behaviors that are expected to be performed
expectancy, diseases associated with advancing age, without difficulty by older patients. ADLs are commonly
such as most dementias and other neuropsychiatric divided into ‘‘basic ADLs’’ (BADLs, related to self-care,
conditions, have become more prevalent.2 Dementia such as using the bathroom, bathing, and changing
due to Alzheimer’s disease (AD) and mild cognitive clothes) and ‘‘instrumental ADLs’’ (IADLs, which are
impairment (MCI) are two diagnoses associated with related to more complex activities, such as housekeeping,
advanced aging. Both are characterized by cognitive and financial management, and correct use of medications).
functional impairment and are generally progressive, There is a hierarchy of complexity and cognitive demands
resulting in poorer quality of life, as well as social and between BADLs and IADLs. The latter are usually more
economic burden. In AD, functional impairment is dependent on cognitive aspects, but some overlap occurs,
as indicated by an important study using a general
cognitive measure.4 For IADLs, informant reports have
Correspondence: Jonas Jardim de Paula, Av. Alfredo Balena, 190, commonly been used in the literature as a proxy for real-
CEP 30130-100, Belo Horizonte, MG, Brazil.
E-mail: [email protected] world functioning. This method has distinct advantages
Submitted Sep 16 2012, accepted May 23 2013. and disadvantages. Informant-report questionnaires are
144 JJ de Paula et al.

easy to administer and may provide a reasonably accurate analysis20 of independent, partially dependent, and
representation of the real world. They are, however, dependent activities. This may reduce the uniformity of
vulnerable to subjective bias.5 clinical assessment, producing bias for the clinician and
According to the results of a Brazilian review of cognitive limiting the possibility of between-study comparisons in
and functional assessment tools,6 only a few measures of research settings. Therefore, unified scoring criteria for
functional status have undergone formal adaptation and BADL and IADL scales may improve their uses in both
validation procedures for the older population. The Pfeffer contexts. Additionally, these indices refer to a continuum
Functional Activities Questionnaire seems to be one of the of functional abilities, and an integrated interpretation of
most commonly used tools for functional assessment the BADL and IADL scales is necessary for an accurate
aiming at the investigation of IADL performance.7-10 One assessment of patients. Therefore, the present study
study using the Pfeffer scale7 found an additive effect proposes to evaluate the reliability (internal consistency)
between functional scores and the Mini Mental State and validity (construct and criterion) of an objective and
Examination (MMSE) for the diagnosis of AD. The unified scoring system for ADLs. Based on the analysis,
Disability Assessment for Dementia was also adapted for an empirically based inventory of ADLs will be proposed
Brazil11 and seems to be useful for the characterization of for the functional assessment of older Brazilian people.
functionality in frontotemporal dementia and AD, asses- We hypothesize a multifactorial structure for ADLs based
sing both BADLs and IADLs as well as leisure activities, on the complexity of specific activities.
although these two groups do not show differences in
functional performance.12
Methods
The BADL index was developed by Sidney Katz in
196313 to study the results of treatment and prognosis Sample and procedure
among older and chronically ill people. The grades of the
index summarize overall performance in bathing, dressing, The present study included 178 participants: 85 diag-
going to the bathroom, transferring, continence, and nosed with amnestic MCI according to Petersen’s
feeding. During the development of the index, 1,001 criteria3 and 93 patients diagnosed with mild probable
patients were assessed, and the use of the index was AD by the NINCDS-ADRDA21 criteria. The assessment
validated as a survey instrument and as an aid in included an interview with the patient and a close
rehabilitation teaching.13 The Katz Index was culturally caregiver to investigate the symptoms, progression,
adapted and translated to Brazilian Portuguese.14,15 The functional loss, family history, and possible confounders.
reliability and internal consistency of the adapted version Clinical examination and neuroimaging tests were per-
were assessed by independent examiners by retesting formed when necessary. The study included cognitive
patients on the same day (kappa = 0.91; alpha = 0.92/0.91) screening methods (MMSE,22 Verbal Fluency,23 and the
or 7 days after the first interview (kappa = 0.67; alpha = Clock Drawing Test23), psychiatric symptom interviews
0.80/0.83). The final version was considered easy to (including the Geriatric Depression Scale 15-item version
understand and to use with solid evidence of reliability.15 – GDS-1524), an unstructured functional status interview
In 1969, Lawton & Brody developed16 a scale to measure assessing functional complaints based on a caregiver
a somewhat more complex set of behaviors: telephoning, report focusing on lost abilities, a neuropsychological
shopping, food preparation, housekeeping, laundering, use assessment including a brief protocol proposed for
of transportation, medicine management, and financial assessment of working memory, language comprehen-
behavior. They tested the inventory on 265 patients and sion, constructional praxis, and executive functions in
found significant correlations with other functional, beha- older people,23 the Brazilian Portuguese version of the
vioral, and cognitive measures. This IADL scale provides a Rey Auditory-Verbal Learning Test25 to assess episodic
brief and objective assessment and was found to have memory, and the Frontal Assessment Battery26 to assess
practical utility in widely diverse settings, with a range of frontal-executive functions. The Clinical Dementia
population groups and ages, and for a variety of goals.16 In Rating27 was used for staging of AD patients (only mildly
Brazil, a study reported adequate reliability for this index demented patients were invited). The diagnoses were
(0.90 by the same examiner and 0.80 between observers) performed by consensus, including at least one geria-
and a significant correlation with the strength of upper limbs trician and one neuropsychologist, no more than 1 month
(r = 0.530), but not lower limbs (r = 0.270).17 prior to the assessment of the present study. Patients
Adapted versions of the Katz and Lawton indices are with severe sensory or motor impairment, those with
commonly used in Brazilian gerontology centers for the positive psychotic symptoms, and those without care-
functional assessment of older patients.18 These scales givers were not included in this study. Only patients who
are based on components of the classical Katz and met the aforementioned inclusion criteria were invited to
Lawton-Brody Inventories and are designed for the participate. The patients were assessed at the Instituto
assessment of ADL in older adults. However, consensual Jenny de Andrade Faria de Atenção à Saúde do Idoso, a
objective scoring criteria are not available for these secondary/tertiary public health center for older people.
adapted scales, requiring a subjective interpretation of The project was approved by the Research Ethics
symptoms by the health practitioner. In Brazilian studies, Committee of the Federal University of Minas Gerais
the interpretation of these indices is heterogeneous, with (COEP-334/06). All patients and their families gave
adoption of a Likert-like scoring method19 or frequency written consent for participation.

Rev Bras Psiquiatr. 2014;36(2)

 The GADL index for older people 145

Inventories of activities of daily living structure was used for the development of a new
inventory, grouping the ADL of each factor on new
The BADL and IADL inventories based on the Katz and functional performance indices. For the assessment of
Lawton indices and adopted by the Instituto Jenny de the reliability of the new variables, Cronbach’s alpha was
Andrade Faria de Atenção à Saúde do Idoso were used to investigate the internal consistency of each
selected as candidate measures of ADLs.18 After minor component. Correlational analysis was performed (using
adjustments of the items aiming at better comprehension Spearman’s rank-order correlation) between the encoun-
by the caregiver, an adapted version was used in the tered factors, the MMSE, GDS-15, age, and education.
present study (Appendices 1 and 2). Responses were For the assessment of criterion-related validity, con-
provided by a relative (usually the spouse, son, or sibling) sidering the encountered factor division, a ROC curve
living with the patient and accompanying the patient’s analysis was performed for the differential diagnosis of
performance in daily life. By combining the two indices, MCI and AD patients stratified by age group with each of
14 ADLs were evaluated and divided into six basic and the functional measures. A sensitivity and specificity ratio
eight instrumental activities. Objective scoring criteria close to 1 was adopted for the selection of cutoff scores,
were adopted for the evaluation of each activity according offering a conservative diagnostic approach. Because
to the following procedure: 1) independent: performs the functional and cognitive assessments are relevant for the
activity in question spontaneously, independently, safely, diagnosis of AD and MCI, binomial logistic regression
and without the need for supervision by others or models were created for the assessment of a possible
additional technological resources (score = 2); 2) partially additive effect between the functional components
dependent: requires some degree of supervision or created after the factor analysis and the MMSE on the
assistance, human or technological, for the safe perfor- differential diagnosis of AD and MCI. The regression
mance of the proposed activities (score = 1); 3) models were built by first including the MMSE (used as a
dependent: requires constant human assistance to per- base for the others), then combining it with each of the
form the tasks (score = 0). Based on this scoring system, factors encountered and, finally, the total score of the new
BADL scores range from a minimum of 0 (worst) to a inventory. These regression analyses were performed
maximum of 12 (best). The IADL score, following the independently for young and old participants. A model
same method, ranges from 0 to 16. Together, the items was developed for each combination (five models per age
range from 0 to 28 points. group), thus reducing multicollinearity. All statistical
procedures were performed in SPSS version 17.0.30
Statistical procedures

Because age is an important factor for the performance of Results

ADLs,28 MCI and AD patients were divided by the sample
median (74 years), creating the subgroups young (f 74) Considering the AD and MCI patients without stratifying
and old (. 74). According to a chi-square statistic, no for age, this factor did not differ between the two groups
differences were found between the proportion of AD and (U = 4448.50, Z = 1.44, p = 0.148). When the participants
MCI patients between the two age groups (chi-square = were stratified by age, there were no differences
2.05, p = 0.203). In addition to the results of the MMSE, concerning education (chi-square = 3.80, p = 0.284) or
the GDS-15, BADL, and IADL, the demographic char- the proportion of men and women (chi-square = 3.27, p =
acteristics of the participants were assessed by descrip- 0.352). The groups differed in terms of total MMSE score
tive statistics. The general analysis of data distribution, (chi-square = 23.55, p , 0.001) and GDS-15 (chi-square
performed by the Kolmogorov-Smirnov test (n . 50), = 9.17, p = 0.027). These comparisons and the post-hoc
showed predominantly non-parametric distributions. analysis are reported in Table 1.
Differences between the four groups (MCI young, AD The factor analysis procedure for the ADL indices was
young, MCI old, and AD old) were analyzed by non- adequate, considering the sample size and character-
parametric tests: the Kruskal-Wallis test for general group istics (Kaiser-Meyer-Olkin sample adequacy = 0.871;
comparisons and Bonferroni-corrected (p = 0.008) Mann- Bartlett’s test of sphericity, p , 0.001). The scree plot of
Whitney tests for specific group comparisons. Differences factor extraction is available from the authors on request.
in the distribution of men and women among the groups After factor extraction and orthogonal rotation, a three-
were assessed by chi-square tests. factor structure (Table 2) was considered the most
The analysis of construct validity was performed first by suitable for the participants’ data. Together, these factors
an exploratory factor analysis of all ADLs. Principal axis accounted for 53% of the explained variance. The first
factoring was chosen for the factor extraction, and an factor, self-care ADLs (eigenvalue: 4.97), accounts for
orthogonal rotation design (varimax) was adopted for 33% of the total variance and involves basic ADLs. The
better interpretation of the components. The criteria for second factor, complex ADLs (eigenvalue: 2.30),
factor extraction were eigenvalues larger than 1 and a accounts for 13% of the total variance and contains
convergent scree plot analysis by two experienced items related to more complex ADLs, such as financial
researchers. To determine significant factor loadings on and medication management. The last factor, domestic
each item, parameters based on sample size were ADLs (eigenvalue: 1.32), accounts for 7% of the total
adopted.29 Based on our sample size, factor loadings of variance and contains items more closely related to
0.45 or higher can be considered significant. The factor domestic ADLs, such as housekeeping and cooking. In

Rev Bras Psiquiatr. 2014;36(2)

 146
JJ de Paula et al.

Rev Bras Psiquiatr. 2014;36(2)

Table 1 Sample profile stratified by diagnosis and age group, with comparisons of sociodemographic, clinical, and functional variables
Lawton GADL GADL
Diagnosis/age group Age Education MMSE GDS-15 Katz (BADLs) (IADLs) self-care domestic GADL complex GADL global
MCI
Young (1)
Mean (SD) 67.04 (4.53) 5.13 (4.29) 23.89 (3.74) 3.69 (3.10) 11.93 (0.33) 14.26 (2.25) 9.97 (0.14) 7.35 (1.28) 6.86 (1.57) 24.2 (2.44)
Median (SE) 68 (0.67) 4 (0.64) 24 (0.55) 3 (0.46) 12 (0.04) 15 (0.33) 10 (0.02) 8 (0.19) 8 (0.23) 25 (0.36)
Range 60-74 0-17 17-30 0-13 10-12 8-16 9-10 2-8 2-8 16-26
Old (2)
Mean (SD) 81.17 (5.10) 3.92 (3.40) 23.06 (3.62) 2.22 (2.33) 11.91 (0.36) 14.44 (2.32) 10.00 (0.01) 7.47 (1.15) 6.97 (1.40) 24.44 (2.32)
Median (SE) 81 (0.85) 4 (0.56) 24 (0.60) 2 (0.38) 12 (0.06) 15 (0.38) 10 (0.01) 8 (0.19) 8 (0.23) 25 (0.38)
Range 75-95 0-15 16-29 0-12 10-12 6-16 10-10 3-8 3-8 16-26
AD
Young (3)
Mean (SD) 68.97 (4.13) 4.68 (3.92) 21.47 (3.53) 4.82 (3.88) 11.94 (0.23) 11.47 (4.05) 9.97 (0.17) 6.58 (2.06) 4.94 (2.41) 21.44 (4.05)
Median (SE) 70 (0.70) 4 (0.67) 22 (0.60) 3 (0.66) 12 (0.04) 11 (0.69) 10 (0.02) 7 (0.35) 4 (0.41) 21 (0.69)
Range 60-74 0-15 14-29 0-14 11-12 0-16 9-10 0-8 1-8 10-26
Old (4)
Mean (SD) 79.47 (3.40) 5.26 (3.61) 19.88 (4.36) 3.33 (2.48) 11.41 (1.33) 9.34 (4.46) 9.58 (1.23) 5.18 (2.44) 3.83 (2.94) 18.41 (5.39)
Median (SE) 79 (0.51) 4 (0.55) 19 (0.66) 2 (0.37) 12 (0.20) 9 (0.68) 10 (0.18) 6 (0.37) 4 (0.44) 19 (0.82)
Range 75-88 0-11 12-28 0-10 5-12 0-16 3-10 0-8 0-8 3-26
Group comparisons*
K-W 119.26 3.80 21.21 10.32 16.17 45.41 12.86 37.10 39.81 49.25
p-value { , 0.001 0.284 , 0.001 0.016 , 0.001 , 0.001 0.005 , 0.001 , 0.001 , 0.001
Post-hoc 1 , 3, 2 , 4 - 1 . 3, 2,3 1 . 4, 2 . 4, 1 . 3, 1 . 4, 1 . 4, 2 . 4 1 . 3, 1 . 4, 1 . 3, 1 . 4, 1 . 3, 1 . 4,
1 . 4, 2 . 4 3.4 2 . 3, 2 . 4, 2 . 3, 2 . 4, 3.4 2 . 3, 2 . 4 2 . 3, 2 . 4,
3.4 3.4
AD = Alzheimer’s disease; BADLs = basic activities of daily living; GDS-15 = Geriatric Depression Scale; IADLs = instrumental activities of daily living; GADL = General Activities of Daily Living
Scale; K-W = Kruskal-Wallis test; MCI = mild cognitive impairment; MMSE = Mini Mental State Examination; SD = standard deviation; SE = standard error.
* Specific group comparisons (Mann-Whitney U tests and effect sizes) are available from the authors on request.
{
Bonferroni-corrected p-values for specific comparisons (p = 0.008).
 Table 2 Factor structure of ADLs and comparisons between participants according to age/diagnosis groups
Factor structure Median (SE) Comparisons* {
Activities of daily living Post-hoc
MCI young MCI AD AD
Self-care Complex Domestic (1) old (2) young (3) old (4) K-W p-value
The patient is able to choose and change clothes 0.858 0.163 0.124 2 (0.00) 2 (0.00) 2 (0.00) 2 (0.07) 10.90 0.012 1.4
(dress and undress) by himself/herself.
The patient is able to make his/her way to the 0.677 0.219 0.091 2 (0.00) 2 (0.00) 2 (0.00) 2 (0.04) 9.12 0.430 -
bathroom, undress, clean him/herself, and dress
again.
The patient is able to use the shower, soap, and 0.663 -0.055 0.105 2 (0.00) 2 (0.00) 2 (0.05) 2 (0.06) 10.90 0.012 1.4
bath sponge properly.
The patient is able to transfer from his/her bed or 0.657 0.167 0.066 2 (0.02) 2 (0.00) 2 (0.00) 2 (0.04) 5.24 0.155 -
chair unaided.
The patient is able to feed himself/herself with 0.584 0.061 0.078 2 (0.00) 2 (0.00) 2 (0.03) 2 (0.03) 2.17 0.537 -
tableware.
The patient is able to manage his/her own 0.112 0.833 0.106 2 (0.07) 2 (0.07) 2 (0.12) 1 (0.14) 28.32 , 0.001 1 . 3, 1 . 4,
money or financial matters. 2 . 3, 2 . 4
The patient is able to run simple errands by 0.091 0.824 0.345 2 (0.08) 2 (0.07) 1 (0.14) 1 (0.13) 41.32 , 0.001 1 . 3, 1 . 4,
himself/herself. 2 . 3, 2 . 4
The patient is able to take his/her medication at 0.120 0.631 0.329 2 (0.06) 2 (0.11) 2 (0.10) 1 (0.25) 25.16 , 0.001 1 . 3, 1 . 4,
the correct dose and time by himself/herself. 2 . 4, 2 . 4
The patient is able to go to distant places by 0.091 0.469 0.304 2 (0.06) 2 (0.10) 2 (0.10) 1 (0.14) 31.30 , 0.001 1 . 3, 1 . 4,
himself/herself using some form of 2 . 4, 3 . 4
transportation.
The patient is able to do his/her own washing 0.128 0.165 0.924 2 (0.06) 2 (0.08) 2 (0.12) 1 (0.13) 19.39 , 0.001 1 . 4, 2 . 4,
and ironing.
The patient is able to do minor household 0.088 0.168 0.861 2 (0.05) 2 (0.06) 2 (0.13) 2 (0.12) 14.92 0.002 1 . 4, 2 . 4
chores.
The patient is able to use the telephone (make 0.126 0.437 0.502 2 (0.05) 2 (0.08) 2 (0.10) 1 (0.13) 21.57 , 0.001 1 . 4, 2 . 4,
and receive calls). 3.4
The patient is able to prepare his/her own meals. 0.240 0.322 0.456 2 (0.07) 2 (0.04) 2 (0.11) 1 (0.13) 37.83 , 0.001 1 . 4, 2 . 4,
3.4
The patient is able to control urination and bowel 0.042 0.220 0.002 2 (0.04) 2 (0.07) 2 (0.03) 2 (0.09) 12.54 0.006 1.4
movements completely by him/herself.
AD = Alzheimer’s disease; ADLs = activities of daily living; K-W = Kruskal-Wallis test; MCI = mild cognitive impairment; SE = standard error.
* Data from Mann-Whitney U tests are available from the authors on request.
{
Bonferroni-corrected p-values for specific comparisons (p = 0.008).
The GADL index for older people

Rev Bras Psiquiatr. 2014;36(2)

147
148 JJ de Paula et al.

this analysis, sphincter control did not show relevant 2 contain the English and Portuguese versions of the
factor loadings for any component and was excluded from inventory, respectively.
the subsequent analysis. ROC curve analysis was performed independently on
New variables were created that summed the ADL items young and older participants. Results are presented in
related to each factor. The descriptive data and group Table 4. Considering the younger patients, only the
comparisons for these new measures are shown in Table curves for GADL complex ADLs and GADL global ADLs
1. Cronbach’s alpha was used to estimate the reliability of were significant (both p , 0.001). Considering the
the three factors reported in the previous results. The guidelines most commonly adopted in neuropsychology,
results show good internal consistency for self-care ADLs the accuracy of the functional measure for these
(0.806), domestic ADLs (0.810), complex ADLs (0.822), participants (0.736 and 0.725, respectively) can be
and the sum of all items (0.849), indicating that the considered only moderate. The suggested cutoffs were
encountered factors and the global score of ADL are highly 6/7 and 23/24 (case/non-case). The accuracy of the
reliable. The correlational analysis showed significant GADL in the older group showed a different pattern, in
associations between domestic and global measures of which the GADL domestic ADL, complex ADL, and global
ADL with age, but not education. The domestic, complex, ADL scores showed significant areas under the curve (p
and global measures were significantly related to MMSE , 0.001). Accuracy in this older group was higher (0.810,
scores. Only domestic and complex ADL were weakly 0.810, and 0.862) compared with the analysis of younger
correlated with depressive symptoms. Considering the patients. The recommended cutoff scores were 7/8 for
three inventory components, all were related to the global GADL domestic ADL, 6/7 for the GADL complex ADL,
score. Weak associations were found between the self- and 23/24 for the inventory total score.
care component and the other two measures. However, We tested five independent regression models for
when these latter two measures were correlated, a young and old participants, beginning with the MMSE
moderate association was observed between them. (model 1), adding one of the GADL components (models
These data are shown in Table 3. 2, 3, and 4), and finally using the GADL global score. The
Based on this new distribution, we called the new model results are shown in Table 5. For younger
inventory Escala Geral de Atividades de Vida Diária / participants, an additive effect of functional measures
General Activities of Daily Living Scale. Appendices 1 and on cognitive screening for diagnosis was observed only

Table 3 Spearman rank-order correlations between GADL factor scores, sociodemographic variables, MMSE, and GDS-15
(1) (2) (3) (4) (5) (6) (7) (8)
(1) Age 1
(2) Education -0.008{ 1 {
(3) MMSE -0.215{ 0.396 1
(4) GDS-15 -0.298 0.075 0.134 1
(5) GADL – self-care ADLs -0,089{ -0.170 0.146{ -0.098 1
(6) GADL – domestic ADLs -0.206 0.037 0.320{ -0.169* 0.201*{ 1 {
(7) GADL – complex ADLs -0.126 -0.021 0.322{ -0.158* 0.230{ 0.610{ 1 {
(8) GADL – global ADLs -0.174* -0.004 0.360 -0.149 0.290 0.820 0.932 1
ADLs = activities of daily living; GDS-15 = Geriatric Depression Scale; GADL = General Activities of Daily Living Scale; MMSE = Mini Mental
State Examination.
* Correlation significant at 0.05.
{
Correlation significant at 0.001.

Table 4 Area under the curve, cutoff values, sensitivity, and specificity of the functional measures
MCI young x AD young
Functional measure Area (SE) p-value 95%CI Cutoff Sensitivity Specificity
GADL – self-care ADLs 0.504 (0.07) 0.728 0.394-0.638 - - -
GADL – domestic ADLs 0.624 (0.06) 0.061 0.508-0.744 - - -
GADL – complex ADLs 0.736 (0.06) 0.001 0.586-0.812 6/7 0.689 0.588
GADL – global ADLs 0.725 (0.06) 0.001 0.599-0.818 23/24 0.689 0.618

MCI old x AD old

Functional measure Area (SE) p-value 95%CI Cutoff Sensitivity Specificity
GADL – self-care ADLs 0.581 (0.06) 0.215 0.456-0.707 - - -
GADL – domestic ADLs 0.810 (0.05) , 0.001 0.713-0.907 7/8 0.750 0.791
GADL – complex ADLs 0.810 (0.05) , 0.001 0.715-0.905 6/7 0.722 0.767
GADL – global ADLs 0.862 (0.04) , 0.001 0.781-0.944 23/24 0.806 0.791
95%CI = confidence interval; AD = Alzheimer’s disease; ADLs = activities of daily living; GADL = General Activities of Daily Living Scale; MCI
= mild cognitive impairment; SE = standard error.

Rev Bras Psiquiatr. 2014;36(2)

 The GADL index for older people 149

Table 5 Logistic regression models assessing the differential diagnosis of MCI and AD for young and old participants
MCI x AD (young participants)
Model Chi-square p-value R2 MCI % AD % Overall % Variables b Wald p-value
Model 1 8.13 0.004 0.13 67 44 62 MMSE -0.181 7.22 0.007
Model 2 8.14 0.017 0.13 77 44 62 MMSE -0.181 7.19 0.008
GADL self-care 0.119 0.01 0.936
Model 3 11.26 0.004 0.18 77 53 66 MMSE -0.173 6.46 0.011
GADL domestic -0.272 2.73 0.099
Model 4 21.95 , 0.001 0.33 84 65 76 MMSE -0.172 5.45 0.020
GADL complex -0.380 11.46 0.001
Model 5 19.34 , 0.001 0.29 84 68 77 MMSE -0.169 5.55 0.018
GADL global -0.270 0.78 0.003

MCI x AD (old participants)

Model Chi-square p-value R2 MCI % AD % Overall % Variables b Wald p-value
Model 1 11.36 , 0.001 0.18 61 72 67 MMSE -0.194 9.62 0.002
Model 2 19.08 , 0.001 0.29 69 67 68 MMSE -0.195 8.56 0.003
GADL self-care -18.980 0.00 0.998
Model 3 28.45 , 0.001 0.49 89 74 81 MMSE -0.109 2.49 0.114
GADL domestic -0.654 9.96 0.002
Model 4 31.77 , 0.001 0.44 81 72 76 MMSE -0.112 2.45 0.118
GADL complex -0.518 13.13 , 0.001
Model 5 37.97 , 0.001 0.51 86 81 84 MMSE -0.070 0.95 0.330
GADL global -0.409 14.93 , 0.001
AD = Alzheimer’s disease; GADL = General Activities of Daily Living Scale; MCI = mild cognitive impairment; MMSE = Mini Mental State
Examination.

when GADL complex ADLs or GADL global ADLs were functioning) for the characterization and staging of
added to the MMSE (models 4 and 5), increasing the cognitive impairment in patients with MCI and AD.
classification rate of MCI and AD patients from 62 to 76 Especially in younger participants, ADLs related to
and 77%, respectively. A different pattern was observed complex activities were a useful component for the
in older patients. In these participants, when the GADL distinction of these two conditions. In MCI, impairment
domestic ADLs, GADL complex ADLs, or GADL global is generally restricted to more complex ADLs, which
ADLs were added to the initial model, the MMSE total involve social interpretation, prospective memory, and
score lost significance, but the models were able to executive functioning.3,32 This may explain the lack of
correctly classify 81, 76, and 84% of subjects, respec- significance of more basic ADLs for the differential
tively, increasing from 67% (MMSE alone). diagnosis. Our data and other studies are in agreement
with the proposal of Thomas et al.,33 according to which
Discussion ADLs should not be addressed as a unitary construct.34
This may be particularly relevant when MCI and AD are
This study analyzed the psychometric characteristics of considered as a continuum. The division of ADLs into
two indices commonly adopted in clinical gerontology levels of complexity may help clinicians track the
practice in Brazil to evaluate ADLs in older people. Based progression of dementia when combined with cognitive
on this analysis, a new inventory was proposed that measures. However, as stated previously, although the
considered BADLs and IADLs as a continuum of division of ADLs may be interesting for this purpose,
complexity for the assessment and diagnosis of MCI some overlap may occur concerning the complexity of
and AD patients stratified by age group. Internal specific ADLs.4
consistency and construct- and criterion-related validity The present study attempts to contribute to previous
were analyzed. The GADL, our proposed new inventory, reports of functional measures for the assessment of
showed significant evidence of these properties. older Brazilian people by developing a quick, objective,
The division of the spectrum of ADLs into three specific and clinically guided index that can be available to any
components was found to be useful for classifying the health professional and is based on questions commonly
functional impairment of AD and MCI patients. Our data used in the evaluation of ADL. The GADL provides
sustain a three-component division of ADLs based on two empirical evidence for this purpose. Possible advantages
different methods, one related to construct validity (three of the GADL are that it works with commonly assessed
components found in factor analysis) and the other to ADLs, improving its clinical applicability for clinicians of
criterion-related validity (because in younger patients, different professional backgrounds, and it includes a
complex but not domestic ADLs were helpful for the broad range of ADLs of different complexities. In the
correct classification of MCI/AD). A recent study31 found context of Brazilian studies, to our knowledge, this is the
satisfactory validity for functional measures (related to first work to investigate the role of functional measures on
advanced ADLs with greater involvement of executive the differential diagnosis of AD and MCI. In addition, we

Rev Bras Psiquiatr. 2014;36(2)

150 JJ de Paula et al.

developed preliminary cutoff scores for this purpose, References

which should allow clinicians to perform a brief functional
assessment and allow health professionals to make 1 Lin RT, Chen YM, Chien LC, Chan CC. Political and social
determinants of life expectancy in less developed countries: a
better use of consultation time (which is generally scarce longitudinal study. BMC Public Health. 2012;12:85.
in public health care in Brazil). 2 Lopes MA, Bottino CM. Prevalência de demência em diversas
However, there are important limitations when adopting regiões do mundo: análise dos estudos epidemiológicos de 1994 a
reporting scales for the functional assessment of patients. 2000. Arq Neuropsiquiatr. 2002;60:61-9.
3 Petersen RC, Doody R, Kurz A, Mohs RC, Morris JC, Rabins PV,
First, low ecological validity is common for self-reported
et al. Current concepts in mild cognitive impairment. Arch Neurol.
questionnaires, perhaps due to the anosognosia pre- 2001;58:1985-92.
sented by these patients or to loss of insight when faced 4 Njegovan V, Hing MM, Mitchell SL, Molnar FJ. The hierarchy of
with social demands.35 In such cases, scales are more functional loss associated with cognitive decline in older persons. J
effective if they are based on the report of a caregiver Gerontol A BiolSci Med Sci. 2001;56:M638-43.
5 Schmitter-Edgecombe M, Parsey C, Cook DJ. Cognitive correlates
close to the patient who shares his or her daily life and is of functional performance in older adults: comparison of self-report,
aware of his or her main difficulties, as is common in direct observation, and performance-based measures. J Int
inventories of behavioral assessment.36 Although this Neuropsychol Soc. 2011;17:853-64.
method is often more precise than self-evaluation (and is 6 Vasconcelos LG, Brucki SMD, Bueno OFA. Cognitive and functional
the method adopted in our research), it has limitations dementia assessment tools: Review of Brazilian literature. Dement
Neuropsychol. 2007;1:18-23.
because the caregiver’s perceptions and reports of the 7 Aprahamian I, Martinelli JE, Cecato J, Yassuda MS. Screening for
patient’s behavior may be biased by the caregiver’s Alzheimer’s disease among illiterate elderly: accuracy analysis for
relationship to the patient. Caregivers who are over- multiple instruments. J Alzheimers Dis. 2011;26:221-9.
burdened and experience socioeconomic problems and 8 Laks J, Batista EM, Guilherme ER, Contino AL, Faria ME, Rodrigues
CS, et al. Prevalence of cognitive and functional impairment in
psychological disorders tend to provide biased
community-dwelling elderly: importance of evaluating activities of
responses, diminishing the accuracy of these instruments daily living. Arq Neuropsiquiatr. 2005;63:207-12.
for assessment of ecological functioning.23,37 9 Laks J, Coutinho ES, Junger W, Silveira H, Mouta R, Baptista EM,
The gold standard for functional evaluation is the et al. Education does not equally influence all the Mini Mental State
ecological examination, which uses contextual tasks that Examination subscales and items: inferences from a Brazilian
community sample. Rev Bras Psiquiatr. 2010;32:223-30.
explore components of the verisimilitude of ecological 10 Sanchez MA, Correa PC, Lourenço RA. Cross-cultural adaptation of
validity.38 In Brazil, only a few structured instruments are the ‘‘Functional Activities Questionnaire – FAQ’’ for use in Brazil.
available for such examinations, such as the Rivermead Dement Neuropsychol. 2011;5:322-7.
Behavioral Memory Test39 (a measure of episodic 11 Carthery-Goulart MT, Areza-Fegyveres R, Schultz RR, Okamoto I,
Caramelli P, Bertolucci PH, et al. [Cross-cultural adaptation of the
memory that demands complex ADL functioning).
Disability Assessment for Dementia (DAD)]. Arq Neuropsiquiatr.
However, this instrument demands expertise and experi- 2007;65:916-9.
ence in the application, scoring, and interpretation of its 12 Bahia VS, Silva MM, Viana R, Smid J, Damin AE, Radanovic M, et al.
results and requires time and material resources that are Behavioral and activities of daily living inventories in the diagnosis of
usually unavailable to the average health professional. It frontotemporal lobar degeneration and Alzheimer’s disease. Dement
Neuropsychol. 2008;2:108-13.
is more appropriate in the context of a more thorough 13 Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of
assessment (usually performed by a neuropsychologist, illness in the aged; The Index of ADL: A standardized measure of
occupational therapist, or physical therapist). Further biological and psychosocial function. JAMA. 1963;185:914-9.
studies that aim to identify a correlation between GADL 14 Lino VTS, Pereira SRM, Camacho LAB, Filho STR, Buksman S.
components and such measures are needed to establish Adaptação transcultural da Escala de Independência em Atividades
da Vida Diária (Escala de Katz). Cad Saúde Pública. 2008;24:103-
the ecological validity of the reports obtained by the 12.
inventory. 15 Duarte YAO, Andrade CL, Lebrão ML. O Índex de Katz na avaliação
In conclusion, the present study provides a synthetic da funcionalidade dos idosos. Rev Esc Enferm USP. 2007;41:317-
tool for the evaluation of ADLs in older people and makes 25.
16 Lawton MP, Brody EM. Assessment of older people: self-monitoring
it available to Brazilian health professionals. Further and instrumental activities of daily living. Gerontologist.1969;9:179-
studies should consider other psychometric properties 86.
of the GADL, such as its predictive validity, its correlation 17 Santos RL, Virtuoso Júnior JS. Confiabilidade da versão brasileira
with specific cognitive measures (for instance, episodic da escala de atividades instrumentais da vida diária. Rev Bras Prom
memory, executive functions, visuospatial abilities, lan- Saude. 2008;21:290-6.
18 Secretaria de Estado de Saúde de Minas Gerais (SESMG) [Internet].
guage, and processing speed), and its applicability and 2012. http://www.hc.ufmg.br/geriatria/img/galeria_fotos/Protocolo.
diagnostic power for other types of dementia. pdf
Additionally, to improve the external validity of our results, 19 Oliveira DLC, Goretti LC, Pereira LSM. O desempenho de idosos
other studies in different contexts should attempt to institucionalizados com alterações cognitivas em atividades de vida
diária e mobilidade: estudo piloto. Rev Bras Fisioter. 2006;10:91-6.
replicate our findings in larger and more heterogeneous
20 Lebrão ML, Laurenti R. Saúde, bem-estar e envelhecimento: o
samples involving patients with different ranges of estudo SABE no Municı́pio de São Paulo. Rev Bras Epidemiol.
cognitive impairment and diagnoses. 2005;8:127-41.
21 McKhann G, Drachman D, Folstein M, Katzman R, Price D, Stadlan
EM. Clinical diagnosis of Alzheimer’s disease: report of the NINCDS-
Disclosure ADRDA Work Group under the auspices of Department of Health
and Human Services Task Force on Alzheimer’s. Neurology.
The authors report no conflicts of interest. 1984;34:939-44.

Rev Bras Psiquiatr. 2014;36(2)

 The GADL index for older people 151

22 Brucki SM, Nitrini R, Caramelli P, Bertolucci PH, Okamoto IH. 32 Brown PJ, Devanand DP, Liu X, Caccappolo E, Alzheimer’s Disease
[Suggestions for utilization of the Mini-Mental State Examination in Neuroimaging Initiative. Functional impairment in elderly patients
Brazil]. Arq Neuropsiquiatr. 2003;61:777-81. with mild cognitive impairment and mild Alzheimer disease. Arch
23 de Paula JJ, Schlottfeldt CG, Moreira L, Cotta M, Bicalho MA, Gen Psychiatry. 2011;68:617-26.
Romano-Silva MA, et al. Psychometric properties of a brief 33 Thomas VS, Rockwood K, McDowell I. Multidimensionality in
neuropsychological protocol for use in geriatric populations. Rev instrumental and basic activities of daily living. J Clin Epidemiol.
Psiquiatr Clin. 2010;37:246-50. 1998;51:315-21.
24 Almeida OP, Almeida SA. Short versions of the geriatric depression 34 Royall DR, Lauterbach EC, Kaufer D, Malloy P, Coburn KL, Black
scale: a study of their validity for the diagnosis of a major depressive KJ, et al. The cognitive correlates of functional status: a review
episode according to ICD-10 and DSM-IV. Int J Geriatr Psychiatry. from the Committee on Research of the American Neuro-
1999;14:858-65. psychiatric Association. J Neuropsychiatry Clin Neurosci. 2007;19:
25 Malloy-Diniz LF, Lasmar VA, Gazinelli L de S, Fuentes D, Salgado 249-65.
JV. The Rey Auditory-Verbal Learning Test: applicability for the 35 Starkstein SE, Jorge R, Mizrahi R, Robinson RG. A diagnostic
Brazilian elderly population. Rev Bras Psiquiatr. 2007;29:324-9. formulation for anosognosia in Alzheimer’s disease. J Neurol
26 Dubois B, Slachevsky A, Litvan I, Pillon B. The FAB: a Frontal Neurosurg Psychiatry. 2006;77:719-25.
Assessment Battery at bedside. Neurology. 2000;55:1621-6. 36 Cummings JL. The Neuropsychiatric Inventory: assessing psycho-
27 Morris JC. The Clinical Dementia Rating (CDR): current version and pathology in dementia patients. Neurology. 1997;48:10-6.
scoring rules. Neurology. 1993;43:2412-4. 37 Schulz R, Cook TB, Beach SR, Lingler JH, Martire LM, Monin JK,
28 Hogan DB, Ebly EM, Fung TS. Disease, disability, and age in et al. Magnitude and Causes of Bias Among Family Caregivers
cognitively intact seniors: results from the Canadian Study of Health Rating Alzheimer Disease Patients. Am J Geriatr Psychiatry. 2012
and Aging. J Gerontol A Biol Sci Med Sci. 1999;54:M77-82. Jan 10. [Epub ahead of print]
29 Hair Jr J, Anderson RE, Tatham RL, Black WC. Análise multivariada 38 Chaytor N, Schimitter-Edgecombe M. The ecological validity of
de dados. Porto Alegre: Bookman; 2005. neuropsychological tests: a review of the literature on everyday
30 SPSS Inc. Statistical Package for the Social Sciences (SPSS Base) cognitive skills. Neuropsychol Rev. 2003;13:181-97.
17.0 for Windows User’s Guide. Chicago: SPSS; 2008. 39 Yassuda MS, Flaks MK, Viola LF, Pereira FS, Memória CM, Nunes
31 Bombin I, Santiago-Ramajo S, Garolera M, Vega-González EM, PV, et al. Psychometric characteristics of the Rivermead Behavioural
Cerulla N, Caracuel A, et al. Functional impairment as a defining Memory Test (RBMT) as an early detection instrument for dementia
feature of: amnestic MCI: cognitive, emotional, and demographic and mild cognitive impairment in Brazil. Int Psychogeriatr.
correlates. Int Psychogeriatr. 2012;24:1494-504. 2010;22:1003-11.

Rev Bras Psiquiatr. 2014;36(2)

152 JJ de Paula et al.

Rev Bras Psiquiatr. 2014;36(2)