3. Activities of Daily Living (ADL) | Points | | | | |
Bathing (sponge bath, tub bath, or shower) | | | | |
Receives no assistance (gets in and out of the tub by self if tub is usual means of bathing) | 1 | | | | |
Receives no assistance in bathing only one part of the body (such as back or leg) | 1 | | | | |
Receives assistance in bathing more than one part of the body (or not bathed) | 0 | | | | |
Dressing (gets clothes from closets and drawers, including underclothes/outer garments and using fasteners/braces, if worn) | | | | |
Gets clothes and gets completely dressed without assistance | 1 | | | | |
Gets clothes and gets dressed without assistance except for assistance in tying shoes | 1 | | | | |
Receives assistance in getting clothes or in getting dressed, or stays partly or completely undressed | 0 | | | | |
Toileting | | | | |
Goes to “toilet room” cleans self, and arranges clothes without assistance (may use object for support such as cane, walker, or wheelchair and may manage night bedpan or commode, emptying same in morning) | 1 | | | | |
Receives assistance in going to “toilet room” or in cleaning self or in arranging clothes after elimination or in use of night bedpan or commode | 0 | | | | |
Doesn’t go to room termed “toilet” for the elimination process | 0 | | | | |
Transfer | | | | |
Moves in and out of bed as well as in and out of chair without assistance (may be using object for support such as cane or walker) | 1 | | | | |
Moves in and out of bed or chair with assistance | 0 | | | | |
Doesn’t get out of bed | 0 | | | | |
Continence | | | | |
Controls urination and bowel movement completely by self | 1 | | | | |
Has occasional “accidents” | 0 | | | | |
Supervision helps keep urine or bowel control, catheter is used, or is incontinent | 0 | | | | |
Feeding | | | | |
Feeds self without assistance | 1 | | | | |
Feeds self except for getting assistance in cutting meat or buttering bread | 1 | | | | |
Receives assistance in feeding or is fed partly or completely by using tubes or intravenous fluids | 0 | | | | |
Max ADL score (best performance): | 6 | | | | |
4. Instrumental Activities of Daily Living Scale (IADL) | | | | |
Ability to use telephone | | | | |
Operates telephone on own initiative: Iooks up and dials numbers, etc. | 1 | | | | |
Dials a few well-known numbers | 1 | | | | |
Answers telephone but does not dial | 1 | | | | |
Does not use telephone at all | 0 | | | | |
Shopping | | | | |
Takes care of all shopping needs independently | 1 | | | | |
Shops independently for small purchases | 0 | | | | |
Needs to be accompanied on any shopping trip | 0 | | | | |
Completely unable to shop | 0 | | | | |
Food preparation | | | | |
Plans, prepares and serves adequate meals independently | 1 | | | | |
Prepares adequate meals if supplied with ingredients | 1 | | | | |
Heats, serves and prepares meals or prepares meals but does not maintain adequate diet | 0 | | | | |
Needs to have meals prepared and served | 0 | | | | |
Housekeeping | | | | |
Maintains house alone or with occasional assistance (e.g. “heavy work domestic help”) | 1 | | | | |
Performs light daily tasks such as dishwashing, bed-making | 1 | | | | |
Performs light daily tasks but cannot maintain acceptable level of cleanliness | 1 | | | | |
Needs help with all home maintenance tasks | 0 | | | | |
Does not participate in any housekeeping tasks | 0 | | | | |
Laundry | | | | |
Does personal laundry completely | 1 | | | | |
Launders small items; rinses stockings, etc. | 1 | | | | |
All laundry must be done by others | 0 | | | | |
Mode of transportation | | | | |
Travels independently on public transportation or drives own car | 1 | | | | |
Arranges own travel via taxi, but does not otherwise use public transportation | 1 | | | | |
Travels on public transportation when accompanied by another | 1 | | | | |
Travel limited to taxi or automobile with assistance of another | 0 | | | | |
Does not travel at all | 0 | | | | |
Responsibility for own medications | | | | |
Is responsible for taking medication in correct dosages at correct time | 1 | | | | |
Takes responsibility if medication is prepared in advance in separate dosage | 0 | | | | |
Is not capable of dispensing own medication | 0 | | | | |
Ability to handle finances | | | | |
Manages financial matters independently (budgets, writes checks, pays rent, bills, goes to bank), collects and keeps track of income | 1 | | | | |
Manages day-to-day purchases, but needs help with banking, major purchases, etc | 1 | | | | |
Incapable if handling money | 0 | | | | |
Max IADL score (best performance): | 8 | | | | |
5. Short Portable Mental Status Questionnaire (SPMSQ) | | | | |
What is the date today? (Correct only when the month, date, and year are all correct) | If incorrect: 1 | | |
What day of the week is it? | If incorrect: 1 | | |
What is the name of this place? (Correct if any of the description of the location is given) | If incorrect: 1 | | |
What is your street address? | If incorrect: 1 | | |
How old are you? | If incorrect: 1 | | |
When were you born? | If incorrect: 1 | | |
Who is the president (or the Pope) now? (Requires only the correct last name) | If incorrect: 1 | | |
Who was president (or the Pope) just before him? | If incorrect: 1 | | |
What was your mother’s maiden name? | If incorrect: 1 | | |
Subtract 3 from 20 and keep subtracting 3 from each new number at least for 3 times (the entire series must be performed correctly to be scored as correct) | If incorrect: 1 | | |
Max SPMQ score (worst performance): | 10 | | | | |
6. Exton-Smith Scale (ESS) | | | | |
General Condition | | | | |
Bad | 1 | | | | |
Poor | 2 | | | | |
Fair | 3 | | | | |
Good | 4 | | | | |
Mental State | | | | |
Stuporous | 1 | | | | |
Confused | 2 | | | | |
Apathetic | 3 | | | | |
Alert | 4 | | | | |
Activity | | | | |
In bed all day | 1 | | | | |
Chairfast | 2 | | | | |
Walks with help | 3 | | | | |
Ambulant | 4 | | | | |
Incontinence | | | | |
Doubly incontinent | 1 | | | | |
Usually of urine | 2 | | | | |
Occasional | 3 | | | | |
None | 4 | | | | |
Mobility in Bed | | | | |
Immobile | 1 | | | | |
Very limited | 2 | | | | |
Slightly limited | 3 | | | | |
Full | 4 | | | | |
Max ESS score (best performance): | 20 | | | | |
7. Cumulative Illness Rating Scale |
| Point allocation based on disease severity |
| None | Mild | Moderate | Severe | Extremely severe |
Cardiac (heart only) | 1 | 2 | 3 | 4 | 5 |
Hypertension (rating is based on severity) | 1 | 2 | 3 | 4 | 5 |
Vascular (arteries, veins, lymphatics) | 1 | 2 | 3 | 4 | 5 |
Respiratory (lungs, bronchi, trachea) | 1 | 2 | 3 | 4 | 5 |
EENT (eye, ear, nose, throat, Iarynx) | 1 | 2 | 3 | 4 | 5 |
Upper GI (esophagus, stomach, duodenum, biliary and pancreatic trees) | 1 | 2 | 3 | 4 | 5 |
Lower GI (intestines, hernias) | 1 | 2 | 3 | 4 | 5 |
Hepatic (liver only) | 1 | 2 | 3 | 4 | 5 |
Renal (kidneys only) | 1 | 2 | 3 | 4 | 5 |
Other GU (urethers, bladder, urethra, prostate, genitals) | 1 | 2 | 3 | 4 | 5 |
Musculo-skeletal-integumentary (muscles, bone, skin) | 1 | 2 | 3 | 4 | 5 |
Neurological (brain, spinal cord, nerves) | 1 | 2 | 3 | 4 | 5 |
Endocrine-metabolic (including diabetes, hyperlipidemia, infections, toxicity) | 1 | 2 | 3 | 4 | 5 |
Psychiatric (dementia, depression, anxiety, agitation, psychosis) | 1 | 2 | 3 | 4 | 5 |
Max comorbidity index (number of items with a score of ≥3; excluding the psychiatric item; most severe): | 13 | | | | |
8. Mini Nutritional Assessment (MNA) | Points | | | | |
Anthropometric Assessment | | | | |
Body Mass Index | | | | |
< 19 | 0 | | | | |
19–20 | 1 | | | | |
21–22 | 2 | | | | |
≥ 23 | 3 | | | | |
Mid-arm circumference (cm) | | | | |
< 21 | 0 | | | | |
22 | 0.5 | | | | |
> 22 | 1 | | | | |
Calf circumference (cm) | | | | |
< 31 | 0 | | | | |
> 31 | 1 | | | | |
Weight loss (last 3 months) | | | | |
Loss of >3 kg | 0 | | | | |
Do not know | 1 | | | | |
Loss between 1 and 3 kg | 2 | | | | |
No weight loss | 3 | | | | |
General Assessment | | | | |
Lives independently (not in a nursing home or hospital) | | | | |
No | 0 | | | | |
Yes | 1 | | | | |
Takes more than 3 prescription drugs per day | | | | |
Yes | 0 | | | | |
No | 1 | | | | |
Has suffered psychological stress or acute disease in the past 3 months | | | | |
Yes | 0 | | | | |
No | 1 | | | | |
Mobility | | | | |
Bed/chair-bound | 0 | | | | |
Able to get out of bed / chair but does not go out | 1 | | | | |
Goes out | 2 | | | | |
Neuropsychological problems | | | | |
Severe dementia/depression | 0 | | | | |
Mild dementia | 1 | | | | |
Psychological problems | 2 | | | | |
Pressure sores or skin ulcers | | | | |
Yes | 0 | | | | |
No | 1 | | | | |
Dietary Assessment | | | | |
How many full meals does the patient eat daily? | | | | |
1 meal | 0 | | | | |
2 meals | 1 | | | | |
3 meals | 2 | | | | |
Consumes at least 1 serving of dairy products (milk, cheese, yogurt) per day | | | | |
No | 1 | | | | |
Yes | 0 | | | | |
Consumes 2 or more servings of Legumes or eggs per week | | | | |
No | 0 | | | | |
Yes | 0.5 | | | | |
Consumes meat, fish or poultry every day | | | | |
No | 0 | | | | |
Yes | 1 | | | | |
Consumes 2 or more servings of fruits or vegetables per day? | | | | |
No | 0 | | | | |
Yes | 1 | | | | |
Has food intake declined over the past 3 months due to loss of appetite? | | | | |
Severe loss of appetite | 0 | | | | |
Moderate loss of appetite | 1 | | | | |
No loss of appetite | 2 | | | | |
How much fluids consumed per day? | | | | |
< 5 glasses | 0 | | | | |
5–9 glasses | 0.5 | | | | |
> 9 glasses | 1 | | | | |
Mode of feeding | | | | |
With assistance | 0 | | | | |
Self-feed with some difficulty | 1 | | | | |
Self-feed without any problem | 2 | | | | |
Self Assessment | | | | |
Do they view themselves as having nutritional problems? | | | | |
Major malnutrition | 0 | | | | |
Does not know | 1 | | | | |
No nutritional problems | 2 | | | | |
In comparison with other people of same age, how they consider their health status? | | | | |
Not as good | 0 | | | | |
Does not know | 0.5 | | | | |
As good | 1 | | | | |
Better | 2 | | | | |
Max MNA score (best-nourished) | 30 | | | | |