INTRODUCTION
============

The preservation of functional abilities in older adults is associated with cultural and social values.^(^ [@B1] ^-^ [@B3] ^)^ Self-care is a significant aspect of ageing, as it is thought to be the best healthcare strategy to preserve the ability to perform Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) in this stage of life.^(^ [@B4] ^-^ [@B9] ^)^ Self-care aims to prevent injuries and conditions leading to hospitalization of older adults, which may reduce ambulatory ability, promote functional decline and affect health dynamics in this population, with significant impacts on the routine of relatives and caregivers.^(^ [@B4] ^-^ [@B9] ^,^ [@B10] ^)^

Caregivers play a pivotal role in bridging the gap between dependent elderly and the health care team. The ability to judge information contributed by both parties enhances the team\'s capacity to prevent diseases and promote health among ageing adults.^(^ [@B11] ^,^ [@B12] ^)^

Health care delivered to the elderly should be targeted at comorbidities, such as hypertension, diabetes, rheumatologic conditions, heart diseases, dementia, and others. These are indicators of common conditions in this age group, which must be monitored by health care teams so that proper preventive and therapeutic interventions can be implemented.^(^ [@B13] ^-^ [@B15] ^)^ Assessment tools employed by nursing teams lack sensitivity and are often unable to capture valuable information that supports better health planning for older adults.^(^ [@B7] ^,^ [@B14] ^,^ [@B15] ^)^

Subjective and objective assessment strategies can be used to compare reported and observed ability of geriatric patients to perform a given task.^(^ [@B7] ^,^ [@B15] ^)^ Objective assessment provides practical information on the performance of ALD and IADL, thus enabling early detection of disorders and proper planning aimed to overcome functional impairment and promoting self-care.^(^ [@B7] ^,^ [@B15] ^)^

The Performance Test of Activities of Daily Living (PADL) is a sensitive tool for identification of patients suffering from organic or nonorganic disorders, and may be used to measure the progression of hospitalized patients in the short-term. Furthermore, PADL is thought to be one of the best tools for this type of assessment, since it is based on objective and accurate tasks, being the gold-standard test.^(^ [@B16] ^)^ The IADL assessment scale provides data on the ability of older adults to perform certain tasks.^(^ [@B7] ^,^ [@B14] ^,^ [@B15] ^)^ In contrast, objective assessment consists of face-to-face interviews held over the course of hospital stay to investigate self-care performance.

OBJECTIVE
=========

To identify the functional status in performance of self-care of hospitalized older adults by means of subjective and objective assessments based on the Performance Test of Activities of Daily Living and items in the Instrumental Activities of Daily Living scale.

METHODS
=======

An observational, cross-sectional cohort study carried out at the geriatric inpatient unit of a quaternary care university hospital, located in the state of São Paulo, from August 2013 through March 2014. Data collection consisted of the applicacation of subjective elderly (ES) and subjective caregivers (SC) and objective evaluation (OB) respectively. The sample included 55 elderly patients-caregiver pairs, regardless of gender. The patients in this study were aged 60 years or over.

However, only geriatric patients were submitted to objective assessment. Assessments were carried out in an individualized manner (*i.e.*, in the absence of the second element of a pair), within two days of hospital admission. In ES and CS, the subjects were asked to rate self-care skills using an assessment scale. In objective assessments, the ability of patients to perform a given simulated task was judged by a rater. The PADL (Performance Test of Activities of Daily Living) scale containing 16 items was used by the author.^(^ [@B7] ^)^

Data collected were stored in Excel spreadsheets and analyzed using the Statistical Package for the Social Sciences (SPSS) for Windows, version 17.0. Patients were quantitatively described using summary measures (mean, median, standard deviation, minimum and maximum value). Absolute and relative frequencies were used to describe qualitative data. Associations between selected characteristics and questionnaires responses were investigated using the χ^2^ test. The level of agreement between subjective and objective assessments was measured using Kappa (K) coefficients, and the agreement index was employed to estimate the percentage of identical responses across different assessments. The study was approved by the Research Ethics Committee, protocol 497.440, CAAE: 15546013. 3.0000.0068.

RESULTS
=======

Socio-functional characteristics of the 55 pairs studied are shown in [table 1](#t1){ref-type="table"}. Most geriatric patients and caregivers were women (58.2% and 83.6%, respectively). The mean age of elderly was 80 years, and 58.7 years for caregivers. Most geriatric patients (65.4%) had elementary education, while 32.7% of caregivers had complete higher education. Geriatric patients had 3.15 children on average, compare to 2 children per caregiver. As to kinship, caregivers were the spouse or daughters in 20.7% and 53.4% of cases, respectively.

###### Socio-functional characteristics of the study sample in hospitalized patients in the geriatric ward and their caregivers

  Variables                               Elderly (n=55)                  Caregivers (n=55)                          
  --------------------------------------- ------------------------------- ------------------- ------- -------------- -------
  Sex                                                                                                                
                                          Female                          32 (58.2)           0.864   46 (83.6)      0.817
                                          Male                            23 (41.8)                   9 (16.4)       
  Age                                                                                                                
                                          Mean (SD)                       80 (7.24)                   58.7 (11.96)   
                                          Median (minimum; maximum)       80(64:99)                   58 (37:84)     
  MMSE                                                                                                               
                                          Mean (SD)                       22 (4.99)           0.891   \- -           
                                          Median (minimum; maximum)       23(9:30)                    \- -           
  Katz                                                                                                               
                                          Mean (SD)                       9.42 (3.13)         0.503   \- -           
                                          Median (minimum; maximum)       10 (6:16)                   \- -           
  Lawton                                                                                                             
                                          Mean (DP)                       15.80 (4.56)        0.329   \- -           
                                          Mean (DP)                       16 (9:27)                   \- -           
  Children                                                                                                           
                                          Mean (DP)                       3.15 (1.80)                 2 (1.64)       
                                          Mean (DP)                       3 (0:6)                     2 (0:7)        
  Race                                                                                                               
                                          White                           40 (72.7)                   38 (69.1)      
                                          Non-white                       14 (25.5)                   16 (29.1)      
                                          Yellow                          1 (1.8)                     1 (1.8)        
  Schooling level                                                                                                    
                                          Illiterate                      7 (12.7)                    \-             
                                          Primary education               36 (65.4)                   7 (12.7)       
                                          Secondary education             5 (9.1)                     17 (30.9)      
                                          Secondary education             6 (10.9)                    13 (23.6)      
                                          Complete university education   1 (1.8)                     18 (32.7)      
  Marital status                                                                                                     
                                          Married                         21 (38.2)                   34 (61.8)      
                                          Single                          3(5.5)                      8 (14.5)       
                                          Widower                         27 (49.1)                   3 (5.5)        
                                          Divorced                        3 (5.5)                     7 (12.7)       
                                          Others                          1 (1.8)                     3 (5.5)        
  Kinship elderly patient and caregiver                                                                              
                                          Wife                                                        12 (20.7)      
                                          Husband                                                     3 (5.2)        
                                          Daughter                                                    31 (53.4)      
                                          Son                                                         7 (12.1)       
                                          Daughter-in-law/son-of-law                                  1 (1.7)        
                                          Grandchild                                                  2 (3.4)        
                                          Others (friends)                                            2 (3.4)        

SD: standard deviation; MMSE: Mini-mental State Examination.

[Table 2](#t2){ref-type="table"} shows the distribution of ES, CS and objective assessments of self-care performance scored according to the functional status in tasks listed in the PADL and IADL scales. For example, 27.3% of elderly (ES) and 21.8% of caregivers (CS) reported inability to complete task 4. However, objective assessment revealed that 41.8% were not able to complete that particular task. As for remaining items, the patients were rated unable to perform all three IADL tasks by caregivers, while objective assessment revealed difficulties with some tasks only. Means obtained from different assessment strategies (ES, CS and objective) were compared and graded according to three levels of functional status; similar responses were given by patients and caregivers, while results obtained via objective (rater) assessment differed from both ([Figures 1](#f1){ref-type="fig"} e [2](#f2){ref-type="fig"}).

###### Subjective assessments of elderly and caregivers and objective assessment about self-care performance in geriatric inpatients

  Instrument         ES - FN                                               CS - FN     OB - FN                                                                            
  ------------------ ----------------------------------------------------- ----------- ---------- ----------- ----------- ----------- ----------- ----------- ----------- -----------
  PADL                                                                                                                                                                    
                     Drink from a cup                                      1 (1.8)     \-         54 (98.2)   \-          \-          55 (100)    2 (3.6)     3 (5.5)     50 (90.9)
                     Use a tissue to wipe nose                             1 (1.8)     \-         54 (98.2)   \-          \-          55 (100)    1 (1.8)     1 (1.8)     53 (96.4)
                     Comb hair                                             1 (1.8)     1 (1.8)    53 (96.4)   1 (1.8)     2 (3.6)     52 (94.5)   5 (9.1)     4 (7.3)     46 (83.6)
                     File nails                                            15 (27.3)   4 (7.3)    36 (65.5)   12 (21.8)   3 (3.6)     40 (76.4)   23 (41.8)   5 (9.1)     27 (49.1)
                     Shave/make up                                         8 (14.5)    2 (3.6)    45 (81.8)   10 (18.2)   4 (7.3)     41 (74.5)   19 (34.5)   5 (9.1)     31 (56.4)
                     Lift food onto spoon and to mouth                     1 (1.8)     1 (1.8)    53 (96.4)   \-          1 (1.8)     54 (98.2)   2 (3.6)     1 (1.8)     52 (94.5)
                     Turn faucet on and off                                1 (1.8)     2 (3.6)    52 (94.5)   \-          2 (3.6)     53 (96.4)   5 (9.1)     6 (10.9)    44 (80)
                     Turn light switch on and off                          1 (1.8)     1 (1.8)    53 (96.4)   \-          1 (1.8)     54 (98.2)   5 (9.1)     7 (12.7)    43 (78.2)
                     Put on and remove a jacket                            1 (1.8)     4 (7.3)    50 (90.9)   \-          4 (7.4)     51 (92.6)   3 (5.5)     5 (9.1)     47 (85.5)
                     Put on and remove shoes                               1 (1.8)     3 (5.5)    51 (92.7)   \-          5 (9.1)     50 (90.9)   3 (5.5)     6 (10.9)    46 (83.6)
                     Brush teeth                                           1 (1.8)     3 (5.5)    51 (92.7)   1 (1.8)     2 (3.6)     52 (94.5)   2 (3.6)     5 (9.1)     48 (87.3)
                     Make a phone call                                     2 (3.6)     8 (14.5)   45 (81.8)   1 (1.8)     12 (21.8)   42 (76.4)   6 (10.9)    17 (30.9)   32 (58.2)
                     Sign name                                             2 (3.6)     2 (3.6)    51 (92.7)   2 (3.6)     3 (5.5)     50 (90.9)   3 (5.5)     4 (7.3)     48 (87.3)
                     Turn key in lock                                      2 (3.6)     1 (1.8)    52 (94.5)   \--         6 (10.9)    49 (89.1)   7 (12.7)    6 (10.9)    42 (76.4)
                     Tell time                                             4 (7.3)     \-         51 (92.7)   2 (3.6)     4 (7.3)     49 (89.1)   4 (7.3)     7 (12.7)    44 (80)
                     Stand up and walk a few steps, and sit back down      1 (1.8)     \-         54 (98.2)   \-          1 (1.8)     54 (98.2)   1 (1.8)     5 (9.1)     49 (89.1)
  IADL scale items                                                                                                                                                        
                     Medications: able to store, recognize and take them   1 (1.8)     11 (20)    43 (78.2)   \-          18 (32.7)   37 (67.3)   2 (3.6)     18 (32.7)   35 (63.6)
                     Handling money                                        1 (1.8)     6 (10.9)   48 (87.3)   \-          13 (23.6)   42 (76.4)   2 (3.6)     11 (20)     42 (76.4)
                     Shopping                                              1 (1.8)     9 (16.4)   45 (81.8)   1 (1.8)     17 (30.9)   37 (67.3)   3 (5.5)     13 (23.6)   39 (70.9)

FN: 1 - unable to perform task; 2 - able to perform task with assistance; 3 - able to perform task unassisted. K: Kappa; Agreement rate (%); McNemar test. (-) Caselas test with data equal to zero. PADL: Performance Test of Activities of Daily Living; FN: Functional level and IADL: Instrumental Activities of Daily Living; ES: subjective of elderly; SC: subjective of caregivers; OB: objective.

![Distribution of mean responses from assessments of elderly subjective, caregiver subjective and objective in the Performance Test of Activities of Daily Living scale](1679-4508-eins-16-01-eAO3987-gf01){#f1}

![Distribution of mean responses from assessments of elderly subjective, caregiver subjective and objective in Instrumental Activities of Daily Living items](1679-4508-eins-16-01-eAO3987-gf02){#f2}

Comparative analysis of data derived from ES and objective assessments are displayed in [table 3](#t3){ref-type="table"}. The levels of agreement were reasonable (tasks 1, 3, 4, 5, 7, 8, 13, 15 and 16; 02.0≥K≤0.39), moderate (tasks 6, 9, 10 and 12; 0.40≥K≤0.59) or substantial (task 2; 0.60≥K≤0.79). Comparisons between CS and objective assessment of performance in the same tasks revealed reasonable (tasks 3, 4, 5, 6, 7, 10, 13, 14, 15 and 16; 0.20≥K≤0.39) or moderate (task 12; 0.40≥K≤0.59) correlation; the p-value was non-significant and the index of agreement ranged from 58.0 to 96.4%. In ES *versus* CS comparisons, correlation was regular (tasks 4, 7, 11 and 14; 0.20≥K≤0.39), moderate (tasks 10, 12, 13 and 15; 0.40≥K≤0.59) or substantial (tasks 3 and 6; 0.60≥K≤0.79); the p-value was also non-significant and the index of agreement ranged from 65.4 to 98.1%. Overall, performance in the above-mentioned tasks differed between ES, CS and objective assessment. Despite reported ability to perform these tasks, the patients showed difficulties when it came to actually performing these same tasks. As regards remaining items in the IADL scale, ES and objective and ES and SC comparisons produced Kappa coefficients of (0.20≥K≤0.39) for task one (1) and (0.40≥K≤0.59) for tasks 2 and 3. The p-value remained non-significant and the index of agreement ranged from 58 to 96.4%. The level of agreement between different assessment strategies (ES, CS and objective) across the various tasks can be appreciated in [figures 3](#f3){ref-type="fig"} and [4](#f4){ref-type="fig"}.

###### Subjective assessments of elderly and caregivers compared to objective assessment about self-care performance in Performance Test of Activities of Daily Living tasks and items of Instrumental Activities of Daily Living in inpatients

  Instrument   Performance assessment                                                                                                         
  ------------ --------------------------------------------------------- ------- --------- ------ ------- --------- ------ -------- --------- ------
  PADL                                                                                                                                        
               1\. Drink from a cup                                      0.316   0.027     93.0   \-      \-        91.0   \-       \-        98.1
               2\. Use a tissue to wipe nose                             0.661   0.007     98.2   \-      \-        96.4   \-       \-        98.1
               3\. Com hair                                              0.330   0.033     87.2   0.378   0.011     87.0   0.784    0.002     98.1
               4\. File nails                                            0.315   0.039     62.0   0.378   0.033     58.0   0.248    0.121     65.4
               5\. Shave/make up                                         0.287   0.009     65.4   0.252   0.168     62.0   0.043    0.772     65.4
               6\. Lift food onto spoon and to mouth                     0.580   0.002     96.3   0.233   0.027     94.5   0.661    0.007     98.1
               7\. Turn faucet on and off                                0.388   0.006     85.4   0.271   0.008     84.0   0.373    0.104     94.5
               8\. Turn light switch on and off                          0.249   0.056     82.0   0.130   0.119     80.0   -0.04    0.963     94.5
               9\. Put on and remove a jacket                            0.494   0.004     87.0   0.187   0.198     82.0   0.165    0.478     87.2
               10\. Put on and remove shoes                              0.496   0.001     89.0   0.370   0.013     85.4   0.403    0.032     90.0
               11\. Brush teeth                                          0.606   \<0.001   93.0   0.041   0.294     84.0   0.252    0.457     90.0
               12\. Make a phone call                                    0.425   \<0.001   73.0   0.477   \<0.001   74.5   0.417    0.003     80.0
               13\. Sign name                                            0.318   0.009     87.2   0.361   0.022     87.2   0.526    0.001     93.0
               14\. Turn key in lock                                     0.197   0.032     78.1   0.229   0.001     76.3   0.301    0.031     89.0
               15\. Tell time                                            0.352   0.001     84.0   0.339   0.002     82.0   0.469    0.001     90.0
               16\. Stand up and walk a few steps, and sit back down     0.270   0.007     91.0   0.263   0.082     91.0   -0.010   0.847     96.3
  IADL items                                                                                                                                  
               1\. Medications: able to store, recognize and take them   0.542   \<0.001   80.0   0.609   \<0.001   82.0   0.510    \<0.001   80.0
               2\. Handling money                                        0.356   0.003     80.0   0.556   \<0.001   84.0   0.232    0.064     76.3
               3\. Shopping                                              0.380   0.009     76.4   0.474   \<0.001   76.3   0.360    0.006     74.5

McNemar test. (-) Caselas test with data equal to zero.

PADL: Performance Test of Activities of Daily Living; IADL: Instrumental Activities of Daily Living.

![Distribution of agreement between patient and caregiver data and caregivers as compared to objective assessments in Performance Test of Activities of Daily Living scale](1679-4508-eins-16-01-eAO3987-gf03){#f3}

![Distribution of agreement between patient and caregiver data as compared to objective assessments in Instrumental Activities of Daily Living scale](1679-4508-eins-16-01-eAO3987-gf04){#f4}

DISCUSSION
==========

Objective assessment of performance in daily living activities was not consistent with subjective reports provided by patients or respective caregivers. This gave us some insight into the extent to which elderly patients are able to accurately rate their own ability to perform essential, as well as and more complex, instrumental activities of daily living. Objective assessment is thought to be the gold-standard to assess ability of the elderly when performing these activities, allowing better classification of functional status, which favors the implementation of actions aimed to address the specific needs of this population.

The sociodemographic and functional profiles of the 55 elderly-caregiver pairs in this sample reflected those reported in other studies.^(^ [@B17] ^-^ [@B19] ^)^ Prevailing low levels of education among elderly patients contrast with the higher levels of education among caregivers (*e.g.*, complete higher education), as reported in literature.^(^ [@B17] ^-^ [@B19] ^)^

Some data used in this study, such as the systematic evaluation Mini-Mental State Examination (MMSE), were extracted from the database derived from the Comprehensive Geriatric Assessment (CGA),^(^ [@B20] ^)^ carried out in the geriatric inpatient unit prior to admission of the elderly. Mini-Mental State Examination data were used to score elderly patients in this sample according to cognitive function; the mean score was 22 points, compared with 21.4 points reported in literature. Activities of Daily Living and IADL scale means (9.42 and 15.80 points, respectively) were similar to those reported in previous studies,^(^ [@B17] ^-^ [@B21] ^)^ indicating that most elderly patients in this sample had preserved functional status.

Comparisons between objective, ES and CS assessments revealed reasonable agreement between responses, with reasonable Kappa coefficients for most PADL tasks and a non-significant p-value. The agreement rate pointed to greater mismatch between responses in some tasks. When ES and CS were compared, the elderly rated themselves higher than their caregivers did. Similar data have been reported in literature in most cases, showing that caregivers tend to underestimate the functional abilities of geriatric patients.^(^ [@B22] ^)^ A different study reported substantial kappa values for PADL, confirming that caregivers must be more aware of the functional and health status of their patients.^(^ [@B23] ^)^ Agreement between ES and CS data regarding PADL performance has also been reported.^(^ [@B24] ^)^

Kappa values associated with items in the IADL scale were either reasonable (tasks 2 and 3) or moderate (task 1). In one study comparing ES and CS, Kappa values were moderate ("managing money") or equal to zero ("managing medication" and "shopping").^(^ [@B22] ^)^ In contrast, the index of agreement varied between "shopping" and "managing money".^(^ [@B24] ^)^

Self-care performance of PADL tasks 1 to 16 was associated with reasonable to substantial Kappa values. The agreement rate revealed discrepancies between self-rated and objectively assessed skills. These results show that self-rated performance differed significantly from performance *in loco* under the supervision of a rater, as previously reported.^(^ [@B7] ^)^

Subjective information given by caregivers was not consistent with self-reported data, since geriatric patients tended to rate themselves higher than their caregivers did. Similar differences have been described in literature.^(^ [@B17] ^)^

Comparisons between CS and objective assessment of self-care skills yielded reasonable kappa values for some PADL tasks (1 to 16) and items in the IADL scale. Despite reported ability by caregivers, patients were unable to perform the tasks during objective assessment in some cases. Instrumental Activities of Daily Living scale items 1 to 3 were associated with moderate or substantial kappa values, and the agreement rate revealed slight inconsistency with the objective assessment of task 3. The comparative analysis of ES, CS and objective assessments showed that elderly patients overestimated their functional status as compared to caregivers, while objective rating was comparatively poorer. There is a need to extend public policies targeted at older adults and respective caregivers, so as to provide them with care and self-care guidance. Also, further studies are warranted to detect and develop better self-care strategies for older adults.

CONCLUSION
==========

This study emphasized the importance of approaches comparing self-reported data with data provided by caregivers, or collected via objective assessment for improved understanding of self-care skills in geriatric patients. Data contributed by caregivers are important, given they are in charge of elderly patients and, therefore, in a position to observe gradual changes taking place over the ageing process course.

Agreement between data contributed by patients and respective caregivers, and those collected via objective assessment, was poor. This fact should be taken into account in care planning in hospitals or nursing homes, since geriatric patients and respective caregivers tend to overestimate true self-care skills, with potential safety and health risks for patients. Therefore, systematic, objective assessment of major feeding and hygiene tasks is recommended to ensure these will be performed safely and effectively.

[^1]: **Conflict of interest:** none.
