Assessing health of older adults

The care of older adults is a major component in the health-care world, and two experts recently presented insights on the challenge and an approach to assessing the health of older Americans at the CIMIT Forum at Simches Research Center at Massachusetts General Hospital.

Presenters were Alan M. Jette, PT, PhD, FAPTA, professor of health policy and management, Boston University School of Public Health; director, Health and Disability Research Institute, BU; research director, New England Regional Spinal Cord Center, BUMC; director, post doctoral research fellowship in rehabilitation outcomes and effectiveness research, BU; and Jonathan Bean, MD, MS, MPH, assistant professor, director, Research Training and Education, Department PM&R, Harvard Medical School; medical director, Spaulding Cambridge Outpatient Center.

Dr. Jette's address was titled, “How Are You Really Doing? Innovations in Functional Outcomes Measurement in Rehabilitation.”

He talked about his plans for contemporary techniques for innovative functional outcome assessment instrument in rehabilitation. He has helped develop the Boston University Activity Measure for Post Acute Care (AM-PAC). It compiles and calibrates a set of 269 functional tasks (washing face, walking indoors) likely to be encountered within the context of a day.

The AM-PAC test is designed to be used across patient diagnoses, conditions and rehabilitation sessions. Dr. Jette discussed the promise and challenges of this approach to functional outcome assessment.

Dr. Bean outlined “Three Big Risks for Older Adults: Walking, Climbing Stairs and Rising from a Chair – Evidence-based Rehabilitative Care for Older Adults.”

Dr. Bean said as many as 25 percent of older adults are at increased risk for disability. He discussed the relative importance of rehabilitative impairments in limb power, limb velocity and trunk integrity.

He said that certain capabilities are important for seniors. One of his slides showed a woman about to cross a wide, busy street, and the light indicated she had 54 seconds to traverse it. He said that if the time comes when her propulsion and speed could not get her across, she would have to find a new part of the neighborhood at which to cross the street.

Dr. Bean suggested that older adults should be screened to find out if there is potential to be impaired. If so, there could be a need to change living arrangements.

Rehabilitative care is a major part of the U.S. healthcare system, and from the hospital to the home, clinicians and other caregivers depend on metrics to gauge each patient’s progress.  These measurements promote speedy rehabilitation by providing information that can help guide therapy, but at the moment, there may be too many metrics to choose from.  Most measuring instruments are designed for one setting, but today, one episode of rehabilitative care usually cuts across multiple settings, perhaps from an inpatient facility to a rehab center to the patient’s home.  The healthcare system needs new outcome assessment instruments, and these should cover a broad functional range without sacrificing precision.

Researchers led by Alan M. Jette, PhD, of the Boston University School of Public Health have created a new metric, known as the Activity Measure for Post-Acute Care (AM-PAC), to assess outcomes based on item response theory.  The new metric consists of questions posed by focus groups, care providers, and the scientific literature.  The questions, or items, have been correlated with one another based on the responses of over one thousand trial subjects.  Each item measures a patient’s ability to perform one of 269 functional tasks, and the tasks are divided into three sub-domains: daily activities, mobility, and applied cognitive skills. 

AM-PAC is a computer-adaptive test, so it is fairly easy to administer.  Not all questions in the battery of 269 items are asked to each patient.  Each new question is based on the patient’s previous response.  The computer is able to quickly assess the general area of the scale on which the patient falls, and then it asks questions designed to obtain a precise measure of the patient’s functional abilities.  Because the computerized test tailors itself to each individual patient, a caregiver can obtain measurements in all three AM-PAC sub-domains in around five minutes, yet the test is broad enough to be applicable in many settings.

Despite the advantages of the AM-PAC system, there are still obstacles to be overcome.  The test requires computer platforms that are not available everywhere, and it can present IT challenges.  In some settings, care providers are legally required to use other metrics, and few providers are willing to do “extra” tests.  Finally, the test itself still needs to be made more intuitively interpretable to clinicians.  Nevertheless, computer-adaptive testing seems to be the technology of the future for outcome assessment.                     

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