Measurement Properties of the Barthel Index in Geriatric Rehabilitation

doi:10.1016/j.jamda.2018.09.033

Journal of the American Medical Directors Association

Volume 20, Issue 4, April 2019, Pages 420-425.e1

https://doi.org/10.1016/j.jamda.2018.09.033 Get rights and content

Abstract

Objective

The Barthel index (BI) is a widely used observer-based instrument to measure physical function. Our objective is to assess the structural validity, reliability, and interpretability of the BI in the geriatric rehabilitation setting.

Design

Two studies were performed. First, a prospective cohort study was performed in which the attending nurses completed the BI at admittance and discharge (n = 207). At discharge, patients rated their change in physical function on a 5-point Likert rating scale. To assess the internal structure of the BI, a confirmatory factor analysis was performed. Unidimensionality was defined by comparative fit index and Tucker-Lewis index of >0.95, and root mean square error of approximation of <0.06. To evaluate interpretability, floor/ceiling effects and the minimal important change (MIC) were assessed. Predictive modeling was used to calculate the MIC. The MIC was defined as going home and minimal patient-reported improvement defined as slightly or much improved physical function, which served as anchors to obtain a clinical- and patient-based MIC. A second group of 37 geriatric rehabilitation patients were repeatedly assessed by 2 attending nurses to assess reliability of the BI. The intraclass correlation coefficient, standard error of measurement, and smallest detectable change were calculated.

Setting and Participants

Patients receiving inpatient geriatric rehabilitation admitted to 11 Dutch nursing homes (n = 244).

Results

Confirmatory factor analysis showed partly acceptable fit of a unidimensional model (comparative fit index 0.96, Tucker-Lewis index 0.95, and root mean square error of approximation 0.12). The clinical-based MIC was 3.1 [95% confidence interval (CI) 2.0–4.2] and the patient-based MIC was 3.6 (95% CI 2.8–4.3). The intraclass correlation coefficient was 0.96 (95% CI 0.93–0.98). The standard error of measurement and smallest detectable change were 1.1 and 3.0 points, respectively.

Conclusions/Implications

The structural validity, reliability, and interpretability of the BI are considered sufficient for measuring and interpreting changes in physical function of geriatric rehabilitation patients.

Section snippets

Methods

We studied 2 similar groups of geriatric rehabilitation patients to evaluate the measurement properties of the BI. Data collection took place between June 2016 and June 2017. The Medical Ethics Committee of the VU University Medical Center approved the study with a waiver of informed consent (FWA00017598).

Study 1

In study 1, 207 patients were included with a mean age of 80 years and 42% was male. The median length of stay was 35 days (Table 1, Figure 1).

Discussion

Our study expanded the evidence regarding the structural validity, reliability, and interpretation of changes in BI-scores in individual geriatric rehabilitation patients. The BI possesses sufficient measurement properties for clinical application in geriatric rehabilitation. The shorter 5-item version of the BI seems to perform less well than the original BI.

Two out of 3 fit indices showed that the structural validity of the BI was sufficient (ie, it measures 1 construct in the setting of

Conclusions/Relevance

Our results demonstrated that the BI is suitable to measure changes in physical function of individual geriatric rehabilitation patients, irrespective of their clinical condition. The BI is, therefore, suitable to be clinically applied as a general measure of physical function of inpatient geriatric rehabilitation patients. The results indicate the measurement properties, which were previously unknown in this setting, namely the reliability when used by untrained nursing assistants, and

Acknowledgments

We thank Ms S Keyner for her contribution in the data collection.

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Pre-stroke activities of daily living do not predict functional decline after stroke in a cohort of community dwelling older subjects at risk for vascular disease
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Pre-stroke impairment of activities of daily living (ADL) is considered a major determinant for functional outcome after stroke. However, findings are based on studies in stroke patients in which pre-stroke information is gathered retrospectively, with inherent risks of selection and recall bias. The objective of this study was to verify the predictive value of pre-stroke ADL with respect to ADL decline in a large prospective cohort of community dwelling older subjects with known vascular risk factors or vascular disease, thereby minimizing selection and recall bias.
Within the four-year study follow-up of a cohort including 5,804 community dwelling older subjects from three countries at risk for vascular disease, incident stroke survivors were identified. Incident myocardial infarction (MI) survivors and the remaining study survivors without incident vascular events served as comparison groups. Multivariate logistic regression analyses for each of the aforementioned groups were performed to assess associations between pre-stroke ADL by the Barthel Index (BI) and Instrumental Activities of Daily Living (IADL) scale and risk for ADL decline.
In stroke survivors, neither pre-event BI (n = 230, OR 1.00 (95% CI 0.83–1.23)) nor IADL (OR 1.07 (95% CI 0.94 – 1.20)) predicted risk of post-stroke ADL decline in contrast to ADL decline after MI (n = 443, OR 0.83 (95% CI 0.70–0.98) and 0.87 (95% CI 0.78–0.97) respectively) and the group without vascular events (n = 4336, OR 0.85 (95% CI 0.78–0.92) and 0.87 (95% CI 0.83–0.92) respectively).
In the present prospective cohort of community dwelling older subjects with known vascular risk factors, pre-stroke ADL measured by BI and IADL scale did not predict post-stroke ADL decline.
Effects of physical exercise on physical function in older adults in residential care: a systematic review and network meta-analysis of randomised controlled trials
2023, The Lancet Healthy Longevity
Physical exercise is effective at attenuating ageing-related physical decline in general, but evidence of its benefits for older adults in residential care, who often have functional dependency, multimorbidity, and polypharmacy, is inconclusive. We aimed to establish the effects of exercise interventions on the physical function of this population.
For this systematic review and network meta-analysis, we searched PubMed, Web of Science, Cochrane Library, Rehabilitation & Sports Medicine Source, and SPORTDiscus to identify randomised controlled trials assessing the effects of exercise interventions (vs usual care) on physical function (ie, functional independence, physical performance, and other related measures, such as muscle strength, balance, or flexibility) in adults aged 60 years or older living in residential care. Relevant studies published in English or Spanish up to Jan 12, 2023, were included in the systematic review. The quality of studies was assessed using the Tool for the Assessment of Study Quality and Reporting in Exercise (TESTEX) score. A network meta-analysis was performed for physical function-related outcomes reported in at least ten studies, with subanalyses for specific intervention (ie, exercise type, training volume, and study duration) and participant (eg, having cognitive impairment or dementia, pre-frail or frail status, and being functionally dependent) characteristics. The study protocol was registered on PROSPERO (CRD42021247809).
147 studies (11 609 participants, with mean ages ranging from 67 years [SD 9] to 92 years [2]) were included in the systematic review, and were rated as having overall good quality (median TESTEX score 9 [range 3–14]). In the meta-analysis (including 105 studies, n=7759 participants), exercise interventions were associated with significantly improved overall physical function, with a standardised mean difference [SMD] of 0·13 (95% credible interval [CrI] 0·04–0·21), which was confirmed in all analysed subpopulations. The strongest association was observed with 110–225 min per week of exercise, and the greatest improvements were observed with 170 min per week (SMD 0·36 [95% CrI 0·20–0·52]). No significant differences were found between exercise types. Subanalyses showed significant improvements for almost all analysed physical function-related outcomes (Barthel index, five-times sit-to-stand test, 30-s sit-to-stand test, knee extension, hand grip strength, bicep curl strength, Short Physical Performance Battery, 6-min walking test, walking speed, Berg balance scale, and sit-and-reach test). Large heterogeneity was found between and within studies in terms of population and intervention characteristics.
Exercise interventions are associated with improved physical function in older adults in residential care, and should, therefore, be routinely promoted in long-term care facilities.
None.
For the Spanish translation of the abstract see Supplementary Materials section.
Efficacy of Therapeutic Exercise on Activities of Daily Living and Cognitive Function Among Older Residents in Long-term Care Facilities: A Systematic Review and Meta-analysis of Randomized Controlled Trials
2023, Archives of Physical Medicine and Rehabilitation
Citation Excerpt :
Group interventions aimed at improving function require narrowing down the target population and interventions according to functional abilities,58 and novel intervention methods may be needed.59–61 ADL change scores associated with the minimal clinically important difference62 were 17 for the motor FIM, and BI score (0-20 scale) associated with the minimally important change63 was 3.1; these scores were for stroke and geriatric rehabilitation, respectively. The improvement value of the present results was relatively smaller than these values.
This study aimed to systematically analyze the efficacy of therapeutic exercise on activities of daily living (ADL) and cognitive function among older residents in long-term care facilities.
PubMed, Cochrane Central of Register Trials, Physiotherapy Evidence Database, OTseeker, and Ichushi-Web were searched from inception until December 2018.
Databases were searched to identify randomized controlled trials (RCTs) of therapeutic exercise for long-term care facility residents aged 60 years and older, focusing on ADL and cognitive function as outcomes.
Two independent reviewers extracted the key information from each eligible study. Two reviewers independently screened and assessed all studies for eligibility, extracting information on study participants, details of interventions, outcome characteristics, and significant outcomes. Any discrepancies were resolved by a third reviewer.
A total of 11 RCTs with 1280 participants were eligible for analyses. Therapeutic exercise had a significant benefit on ADL (standard mean difference [SMD]=0. 22, 95% confidence interval [CI]: 0.02, 0.42, P=.03). Subgroup analyses indicated that interventions conducted ≥3 days per week [SMD=0.42, 95% CI 0.02, 0.82, P=.04] had a significant benefit on ADL. For cognitive function, group exercise and ≥3 days/week of intervention had a significant benefit (group exercise: mean difference [MD]=3.36, 95% CI 0.91, 5.80, P=.007; ≥3 days/week of intervention: MD=2.28, 95% CI 0.07, 4.49, P=.04).
Therapeutic exercise conducted 3 or more days per week may be effective for improving ADL and cognitive function among older residents in long-term care facilities. This meta-analysis suggested that group exercise for cognitive functions was effective. However, the effective method of intervention delivery for ADL was unclear.
Characteristic of process analysis on instrumental activities of daily living according to the severity of cognitive impairment in community-dwelling older adults with Alzheimer's disease
2024, International Psychogeriatrics
Risk factors for post-cerebral infarction cognitive dysfunction in older adults: a retrospective study
2024, BMC Neurology
Do physical fitness and cognitive function mediate the relationship between basic activities of daily living and quality of life in older adults with dementia?
2024, Quality of Life Research

View all citing articles on Scopus

: The authors declare no conflicts of interest.

View full text

Post-acute Care and RehabilitationOriginal StudyMeasurement Properties of the Barthel Index in Geriatric Rehabilitation

Abstract

Objective

Design

Setting and Participants

Results

Conclusions/Implications

Section snippets

Methods

Study 1

Discussion

Conclusions/Relevance

Acknowledgments

J Clin Epidemiol

J Clin Epidemiol

J Psychiatr Res

J Clin Epidemiol

J Clin Epidemiol

J Clin Epidemiol

Boston Working Group on improving health care outcomes through geriatric rehabilitation

Med Care

Barthel index for stroke trials: Development, properties, and application

Stroke

Validation of International Classification of Functioning, disability, and health (ICF) core sets for early postacute rehabilitation facilities: Comparisons with three other functional measures

Am J Phys Med Rehabil

Functional evaluation: The Barthel index

Md State Med J

Functional assessment in older people

BMJ

Rehabilitation efficiency and destination on discharge after stroke

Eur J Phys Rehabil Med

Long-term prediction of functional outcome after stroke using single items of the Barthel index at discharge from rehabilitation centre

Disabil Rehabil

The five item Barthel index

J Neurol Neurosurg Psychiatry

Comparison of the psychometric characteristics of the functional independence measure, 5 item Barthel index, and 10 item Barthel index in patients with stroke

J Neurol Neurosurg Psychiatry

COSMIN guideline for systematic reviews of patient-reported outcome measures

Qual Life Res

Psychometric characteristics of the Spanish version of the Barthel index

Aging Clin Exp Res

The Barthel ADL index: Factor structure depends upon the category of patient

Age Ageing

Reliability of the Barthel index when used with older people

Age Ageing

Reliability (inter-rater agreement) of the Barthel Index for assessment of stroke survivors: Systematic review and meta-analysis

Stroke

Post-acute Care and Rehabilitation
Original Study
Measurement Properties of the Barthel Index in Geriatric Rehabilitation