Figures

Content may be subject to copyright.
LETTERS TO THE EDITORS
Confirmatory factor analysis
of the general activities of
daily living scale: further
evidences of internal validity
Rev. Bras. Psiquiatr. 2017;39:379–380
doi:10.1590/1516-4446-2017-2256
The assessment of older adults with neurocognitive dis-
orders involves the investigation of functional impairment.
Usually, this is conducted by examining activities of daily
living (ADL), everyday activities that should be performed
without great difficulties by the patients.
1
The most com-
mon method for measuring ADL is the use of scales and
questionnaires, since they are mainly brief, low cost,
and accurate.
2
In a previous issue of Revista Brasileira de Psiquiatria,
we presented the General Activities of Daily Living Scale
(GADL),
3
an instrument to assess different aspects of ADL
in older adults. The GADL emphasized activities commonly
assessed in clinical/research settings in Brazil, showing
evidence of validity and reliability. At the time, an explo-
ratory factor analysis suggested a three-factor structure
based on activity complexity (self-care, domestic, and
complex activities) as the latent structure of ADL in our
sample. The GADL three-factor structure also met evi-
dence of external validity, with each GADL factor differen-
tially associated with complex (i.e., cognitive functioning)
and more simple (i.e., finger dexterity) tasks.
4
However,
Confirmatory Factor Analysis (CFA) can provide further
evidence for the suggested three-factor GADL model.
In this letter, we tested the GADL three-factor hypoth-
esis in a larger and more heterogeneous sample of older
adults (n=578: 369 women) using CFA. We used a con-
joined dataset of three research projects, approved by the
local ethics committees of two universities in Belo Horizonte,
Brazil. Participants or their caregivers, in the case of demen-
tia, gave written consent for participation. Mean participant
age was relatively high (76.067.0 years) and mean educa-
tion predominately low (4.3364.21 years). Participants had
a diagnosis of minor (n=247) or major neurocognitive dis-
order (n=228) irrespective of etiological stratification, other
mental disorders coursing with cognitive-functional com-
plaints (n=46), or were considered healthy controls (n=66).
We stratified the sample based on clinical dementia rating
5
(CDR) scores. Table 1 shows a brief description of the
sample, according to CDR and GADL scores.
Confirmatory analysis was performed using MPlus 6.1
software. We used a diagonally weighted least squares
method, which is commonly adopted to analyze ordinal
data. Factors were defined as in the original study
3
: Self-
care (dressing/undressing, using the toilet, showering,
transferring to toilet, feeding), Domestic (washing/ironing,
household chores, using the telephone, preparing meals),
and complex (financial control, shopping, controlling
medication, using transportation). As expected in CFA,
6
we used different fit indexes to test the model: the root
mean square error of approximation (RMSEA, desired
values o0.06), the comparative fit index and the Tucker-
Leis index (CFI and TFI, desired values 40.95), and
w
2
/degrees of freedom (w
2
/df, desired values o3).
Standardized estimates (R
2
) and factor correlations are
shown in Figure 1. Our results indicated an adequate model
fit for the three-factor model: RMSEA = 0.059, CFI/TLI =
0.984/0.980, and w
2
/df = 2.83, showing convergence with
our previous research.
3,4
Most factor loads were above
0.6, showing a strong relationship with each factor. The only
Table 1 Participants description (percentiles 25, 50, 75)
Group GADL Total GADL Selfcare GADL Domestic GADL Complex
CDR = 0
Percentile 25 23 10 6 6
Percentile 50 25 10 8 8
Percentile 75 26 10 8 8
CDR = 0.5
Percentile 25 21 10 6 5
Percentile 50 25 10 8 7
Percentile 75 26 10 8 8
CDR = 1
Percentile 25 18 10 5 2
Percentile 50 22 10 7 5
Percentile 75 25 10 8 7
CDR = 2
Percentile 25 10 9 0 0
Percentile 50 12 10 2 0
Percentile 75 13 10 3 1
CDR = Clinical Dementia Rating (0 = no dementia; 0.5 = questionable dementia; 1 = mild dementia; 2 = moderate dementia); GADL = General
Activities of Daily Living Scale.
Revista Brasileira de Psiquiatria. 2017;39
&2017 Associac¸a
˜o Brasileira de Psiquiatria
item with a lower factor load was ‘‘The patient is able to feed
himself/herself with tableware’’. This probably occurred due
to the low variance of the measure, since our sample only
included patients with moderate or milder dementia, and this
activity is usually impaired in advanced stages of dementia.
7
Therefore, GADL is a brief, easy to use, and well-
validated measure of functional performance for the asses-
sment of older adults as increasing evidence suggests.
Future studies should attempt to replicate these results in
other samples, thus heightening the reliability and consis-
tency of GADL for clinical use.
Jonas Jardim de Paula,
1,2
Maicon Rodrigues Albuquerque,
1
Maria Aparecida Camargos Bicalho,
1
Marco Aure
´lio Romano-Silva
1
1
Universidade Federal de Minas Gerais (UFMG), Belo Horizonte,
MG, Brazil.
2
Faculdade de Cie
ˆncias Me
´dicas de Minas Gerais,
Belo Horizonte, MG, Brazil
Submitted Feb 16 2017, accepted Apr 18 2017.
Acknowledgements
This study was supported by Fundac¸a
˜o de Amparo a
`
Pesquisa do Estado de Minas Gerais (FAPEMIG; grants
INCT-MM FAPEMIG CBB-APQ-00075-09, APQ-01972/
12-10, APQ-02755-10, APQ-04706-10, APQ-02662-14)
and by Conselho Nacional de Desenvolvimento Cientifico
e Tecnolo
´gico (CNPq; grants 573646/2008-2, 474208/
2013-3).
Disclosure
The authors report no conflicts of interest.
References
1 Lawton MP. Scales to measure competence in everyday activities.
Psychopharmacol Bull. 1888;24:609-14.
2 Gold DA. An examination of instrumental activities of daily living
assessment in older adults and mild cognitive impairment. J Clin Exp
Neuropsychol. 2012;34:11-34.
3 de Paula JJ, Bertola L, A
´vila RT, Assis Lde O, Albuquerque MR,
Bicalho MA, et al. Development, validity, and reliability of the General
Activities of Daily Living Scale: a multidimensional measure of acti-
vities of daily living for older people. Rev Bras Psiquiatr. 2014;36:143-52.
4 de Paula JJ, Albuquerque MR, Lage GM, Bicalho MA, Romano-Silva
MA, Malloy-Diniz LF. Impairment of fine motor dexterity in mild cog-
nitive impairment and Alzheimer’s disease dementia: association with
activities of daily living. Rev Bras Psiquiatr. 2016;38:235-8.
5 Morris JC. The Clinical Dementia Rating (CDR): current version and
scoring rules. Neurology. 1993;43:2412-4.
6 Hu LT, Bentler PM. Cutoff criteria for fit indexes in covariance struc-
ture analysis: conventional criteria versus new alternatives. Struct
Equ Modeling. 1999;6:1-55.
7 Wajman JR, Bertolucci PH. Comparison between neuropsychological
evaluation instruments for severe dementia. Arq Neuropsiquiatr.
2006;64:736-40.
Figure 1 Confirmatory factor analysis of the General Activities of Daily Living Scale.
Rev Bras Psiquiatr. 2017;39(4)
380 Letters to the Editors
... Activity of daily living was assessed by the Activity of Daily Living scale (ADL) [12], which covers ten parameters i.e. defecation, urination, self-feeding, toilet hygiene, activities, dressing, grooming, transferring, bathing and showering, and stair activity. The total score of the scale was 100 points, and the higher the score, the better the activity of daily living. ...
Article
Purpose: To study the efficacy of glucocorticoid combined with hyperbaric oxygen therapy for the treatment of delayed encephalopathy after carbon monoxide poisoning (DEACMP), and its effect on the expression of immune-associated cytokines. Methods: A total of 102 DEACMP patients in PLA General Hospital, Haidian, China were divided into two groups of 51 patients each, namely, observation group (glucocorticoid + hyperbaric oxygen therapy), and control group (hyperbaric oxygen only). The clinical data for each group was retrospectively analyzed. Clinical efficacy, improvement time, hospitalization time, cognitive function, activities associated with daily living, changes in immunity-associated cytokines, and incidence of adverse reactions were compared for the two groups. Results: Following treatment, the time taken for improvement, duration of hospitalization, cognitive function, daily living activity and total effectiveness in the observation group were significantly higher than those for the control group (p < 0.05). In addition, the levels of transforming growth factor beta 1 (TGF-β1), interleukin 4 (IL-4) and interferon-gamma (IFN-γ) in the observation group were significantly greater than for the corresponding control group levels (p <0.05). There was no significant difference in incidence of adverse reactions between the two groups (p > 0.05). Conclusion: These results suggest that a combination therapy of glucocorticoid and hyperbaric oxygen therapy for the treatment of DEACMP is more eutherapeutic in the improvement of cognitive function and activities of daily living in DEACMP patients than hyperbaric oxygen therapy. The mechanism of this combination therapy may be related to the improvement in immunity-related cytokine levels. © Pharmacotherapy Group, Faculty of Pharmacy, University of Benin, Benin City, 300001 Nigeria and 2018 The authors.
Article
Full-text available
Objective:: Cognitive impairment is a hallmark of mild cognitive impairment (MCI) and Alzheimer's disease dementia (AD). Although the cognitive profile of these patients and its association with activities of daily living (ADLs) is well documented, few studies have assessed deficits in fine motor dexterity and their association with ADL performance. The objective of this research paper is to evaluate fine motor dexterity performance among MCI and AD patients and to investigate its association with different aspects of ADLs. Methods:: We assessed normal aging controls, patients with multiple- and single-domain amnestic MCI (aMCI), and patients with mild AD. Fine motor dexterity was measured with the Nine-Hole Peg Test and cognitive functioning by the Mattis Dementia Rating Scale. We analyzed the data using general linear models. Results:: Patients with AD or multiple-domain aMCI had slower motor responses when compared to controls. AD patients were slower than those with single-domain aMCI. We found associations between cognition and instrumental ADLs, and between fine motor dexterity and self-care ADLs. Conclusion:: We observed progressive slowing of fine motor dexterity along the normal aging-MCI-AD spectrum, which was associated with autonomy in self-care ADLs.
Article
Full-text available
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 (≤ 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.
Article
Full-text available
To study the correlation between two tools for cognitive evaluation, Mini-Mental State Examination-severe (MMSE-s) and Severe Impairment Battery (SIB), and the Bristol Daily Activities Functional Scale. 50 patients from the Behavioral Neurology Section--EPM-UNIFESP--were evaluated. Mean age was 76.8+/-7.9 (range 57 to 95); 32% were males; mean education was 5.0+/-2.3 years (range 4 to 15); mean disease duration was 3.9+/-1.5 years (range 2 to 10). Preliminary results in a small sample drawn from the study group do indicate a difference between the three cognitive scales. SIB and MMSE-s had a better correlation with functional score than MMSE, and MMSE-s had a correlation slightly better than SIB. These data indicate that it is possible to follow dementia patients up to severe stage as long as adequate instruments are used, and that there may be differences between scales with regard to sensitivity.
Article
This article examines the adequacy of the “rules of thumb” conventional cutoff criteria and several new alternatives for various fit indexes used to evaluate model fit in practice. Using a 2‐index presentation strategy, which includes using the maximum likelihood (ML)‐based standardized root mean squared residual (SRMR) and supplementing it with either Tucker‐Lewis Index (TLI), Bollen's (1989) Fit Index (BL89), Relative Noncentrality Index (RNI), Comparative Fit Index (CFI), Gamma Hat, McDonald's Centrality Index (Mc), or root mean squared error of approximation (RMSEA), various combinations of cutoff values from selected ranges of cutoff criteria for the ML‐based SRMR and a given supplemental fit index were used to calculate rejection rates for various types of true‐population and misspecified models; that is, models with misspecified factor covariance(s) and models with misspecified factor loading(s). The results suggest that, for the ML method, a cutoff value close to .95 for TLI, BL89, CFI, RNI, and Gamma Hat; a cutoff value close to .90 for Mc; a cutoff value close to .08 for SRMR; and a cutoff value close to .06 for RMSEA are needed before we can conclude that there is a relatively good fit between the hypothesized model and the observed data. Furthermore, the 2‐index presentation strategy is required to reject reasonable proportions of various types of true‐population and misspecified models. Finally, using the proposed cutoff criteria, the ML‐based TLI, Mc, and RMSEA tend to overreject true‐population models at small sample size and thus are less preferable when sample size is small.
Article
Basic activities of daily living (ADL) are self-maintenance abilities such as dressing or bathing. Instrumental ADL (IADL) are more complex everyday tasks, such as preparing a meal or managing finances (Lawton & Brody, 1969). IADL questionnaires play an important role in assessing the functional abilities of older adults and evaluating the impact of cognitive impairment on routine activities. This paper examined the cognitive processes that underlie IADL performance and concluded that the accurate and reliable execution of IADL likely draws upon the integrity of a wide range of cognitive processes. This review examined IADL in mild cognitive impairment (MCI) because of the controversial nature of distinguishing a significant decline in functional abilities in those with MCI versus dementia or MCI versus cognitively normal aging. The challenges of investigating IADL empirically were explored, as well as some of the reasons for the inconsistent findings in the literature. A review of questionnaire-based assessments of IADL indicated that: MCI can be distinguished statistically from healthy older adults and dementia, individuals with multiple domain MCI are more impaired on IADL than those with single domain MCI, mild IADL changes can be predictive of future cognitive decline, and the ability to manage finances may be among the earliest IADL changes in MCI and a strong predictor of conversion to dementia. This paper concluded with recommendations for more sensitive and reliable IADL questionnaires.
Figure 1 Confirmatory factor analysis of the General Activities of Daily Living Scale
Figure 1 Confirmatory factor analysis of the General Activities of Daily Living Scale. Rev Bras Psiquiatr. 2017;39(4)
Scales to measure competence in everyday activities
  • Lawton MP