Full text of DOI:10.1093/gerona/56.10.M638

Journal of Gerontology: MEDICAL SCIENCES
Copyright 2001 by The Gerontological Society of America
2001, Vol. 56A, No. 10, M638–M643
The Hierarchy of Functional Loss Associated With
Cognitive Decline in Older Persons
Vesna Njegovan,1 Malcolm Man-Son-Hing,1,2,3 Susan L. Mitchell,1,2 and Frank J. Molnar1,2,3
1Geriatric Assessment Unit, Ottawa Hospital, Ottawa, Ontario, Canada.
2Department of Medicine, University of Ottawa.
3Institute on Health of the Elderly, Sisters of Charity Health Service, Ottawa, Canada.
Objectives. We studied a representative cohort of community-dwelling elderly persons to (i) examine the relation-
ship between the loss of specific functional activities and cognitive status at the time of these losses, (ii) compare the
cognitive status of participants who have and have not lost independence in these functional activities, and (iii) deter-
mine whether a hierarchical scale of functional loss is associated with declining cognitive status.
Methods. A cohort of 5874 community-dwelling persons aged 65 years and older from the Canadian Study of Health
and Aging I and II were analyzed. At baseline and 5 years later, cognitive status with the Modified Mini-Mental State
Examination (3MS) and functional status with 14 Older American Resources and Services (OARS) items were mea-
sured. For each OARS functional item, the mean 3MS scores for persons who lost independence during the 5-year pe-
riod versus those who did not were compared.
Results. For each functional item, the 5-year decline in 3MS scores of persons who lost independence were signifi-
cantly greater than those who remained independent (e.g., ability to do finances), with an 18-point decline for those who
lost independence and a 2-point decline for those who retained independence. A hierarchy of functional items existed,
with instrumental activities of daily living (ADLs) (e.g., shopping, banking, and cooking) being lost at higher cognitive
scores than basic ADL items (e.g., eating, dressing, and walking), although there was some overlap.
Conclusions. This is the first prospective study using a large representative cohort of elderly persons to demonstrate
that progressive cognitive decline is associated with a specific pattern of loss of functional tasks. Clear cognitive thresh-
olds at which development of dependency in OARS functional items occurred. By providing estimates of the cognitive
status of persons at the time at which they developed dependency in specific functional items, a natural hierarchy of
functional loss associated with cognitive decline emerged. For caregivers, clinicians, and health policy makers, this in-
formation can help anticipate the pattern of functional decline and the subsequent care needs of persons with declining
cognition, potentially improving the quality of life of these persons and their caregivers and playing an important part in
health care planning.
NE of the most important health care issues facing to-
day’s elderly population is cognitive impairment and
are also dependent on cognition but to a lesser extent (6).
Also, longitudinal studies as summarized by Barberger-
Gateau and Fabrigoule (7) have demonstrated that poor cogni-
tive status at baseline predicts future functional disability, insti-
tutionalization, and even death. However, these studies were
hampered by their inability to estimate the cognitive status of
persons at the time of incidental loss of functional ability.
When Katz (12) introduced the concept of expressing
functional status in terms of basic activities of daily living
(ADLs), he hypothesized that there is a hierarchical struc-
ture to the specific functional tasks. That is, older persons
with progressive cognitive decline lost the ability to per-
form these tasks in the opposite order to which they ac-
quired them in childhood: bathing, dressing, toileting, trans-
ferring, continence, and feeding. Thus, elderly persons who
are unable to feed themselves should be unable to perform
any other task independently. Lawton (13) expanded our
understanding of functional status by defining more com-
plex functions as IADLs (e.g., shopping, banking, cooking,
cleaning, and telephone use).
O
its implications. The prevalence of dementia, the most com-
mon form of cognitive impairment, is approximately 10%
for persons over 65 years of age, increasing to 30% for
those over 90 years (1). Of all geriatric health care issues,
cognitive decline is the most greatly feared by seniors (2).
Growing evidence suggests that cognitive dysfunction is an
important risk factor in the development of functional dis-
ability and loss of independence (3,4). Thus, further delin-
eating the relationship between cognitive decline and the in-
creased need for assistance with personal care may help
determine future health care needs (5).
The association between cognitive impairment and func-
tional disability has been examined extensively over the past
two decades. Numerous cross-sectional studies (3–10) have
demonstrated a relationship between cognitive status and
functional ability that is independent of demographic, medi-
cal, and social factors. Instrumental activities of daily living
(IADLs), such as doing one’s finances and shopping,
are highly dependent on adequate cognitive ability (9,11),
whereas well-learned activities, such as dressing and bathing,
Attempts have been made to try to combine all ADLs and
IADLs to define a hierarchical scale from which loss of
M638

FUNCTIONAL LOSS AND COGNITIVE DECLINE
M639
function could be predicted. There has been considerable
controversy over whether such a hierarchy can be con-
structed (6,14–18). Whereas some have confirmed this no-
tion (18,19), others have refuted it (6,15,17), and others
have shown that the hierarchy is only one of many ap-
proaches that are possible (20). Other studies (6,14,16,17)
have examined the relationship of specific IADLs (e.g.,
telephone use, finances, shopping, cooking, and cleaning)
within the hierarchy of basic functional activities. Several
groups have proposed measurement scales that combine
ADLs and IADLs into a single hierarchical structure, but
these groups have achieved varying degrees of success, pos-
sibly due to the different patient populations studied. For
example, a distinct hierarchy is difficult to determine using
study populations in which the prevalence of physical dis-
ability and medical illness vary because these will confound
the effect of cognition on function (6,14,17,18).
The Canadian Study of Health and Aging (CSHA) I mea-
sured both the cognitive and functional status of a represen-
tative sample of elderly persons at baseline. Five years later,
a second study (CSHA II) remeasured these variables. This
provided a unique opportunity to estimate the cognitive sta-
tus of persons at the time of the loss of independence of spe-
cific ADLs and IADLs. Within the cohort of community-
dwelling CHSA participants, the objectives of this study
were to (i) examine the relationship between the loss of spe-
cific functional activities and cognitive status during the
time period these losses occurred, (ii) compare the cognitive
status of participants who had loss of specific functional ac-
tivities with those who did not, and (iii) determine whether
there is a predictable hierarchical scale of functional loss as-
sociated with declining cognitive status.
of education. Prospective data regarding the cognitive status
of the participants were collected using the Modified Mini-
Mental State Examination (3MS) (21). The 3MS cognitive
screen was derived from the Mini-Mental State Examina-
tion (MMSE). The 3MS screen includes four additional
items and a score up to 100 points, which improves its abil-
ity to discriminate between those with and without demen-
tia. However, with a cut-off score of 77 (out of 100), the
3MS cognitive screen has a better sensitivity and specificity
than the MMSE in identifying persons with dementia (22).
The functional status of participants was followed using the
Older Americans Resources and Services (OARS) question-
naire (23). The OARS consists of 14 items pertaining to
level of independence in both ADL and IADL (see Appen-
dix). The ADLs were eating, dressing, grooming, walking,
transferring in and out of bed, taking a bath or shower, and
going to the bathroom. The IADLs were telephone use,
transportation out of walking distance, shopping, preparing
meals, doing housework, and taking medication. Each func-
tional item can be categorized as independent, partially de-
pendent, or completely dependent. The CSHA modified the
OARS by substituting a single question regarding the “use
of the bathroom” for two original OARS questions regard-
ing continence.
Statistical Analysis
Only persons who were independent in a given ADL/
IADL at baseline were included in the analyses. This cohort
was then classified into the following two groups: those
who remained independent at 5-year follow-up or those
who became partially or completely dependent at 5-year
follow-up.
In the first analysis, the objective was to describe the
level of cognition associated with a loss of independence in
a specific ADL/IADL. Therefore, subjects who were inde-
pendent at baseline but who became dependent (partially or
completely) in a given functional activity were identified.
We assumed that functional loss occurred at the mid-point
of the 5-year period. Therefore, the best estimate of their
cognitive status at the time of this loss was the mean of their
baseline and 5-year 3MS scores. Standard deviations (SD)
and 95% confidence intervals (CIs) were calculated for each
mean 3MS score.
In the second analysis, the objective was to compare the
change in cognitive status between persons who remained
independent in a specific ADL/IADL task and those who
did not. Thus, for specific functional activities, the mean
change in the 3MS score for each group was calculated by
subtracting the mean 3MS score at baseline from that at 5
years. Analysis of covariance (ANCOVA) was used to com-
pare the mean change 3MS score (dependent variable) be-
tween those who did and those who did not lose indepen-
dence in a specific ADL/IADL (independent variable) while
adjusting for mean baseline 3MS score in each cohort (co-
variate). We felt it was important to adjust for baseline cog-
nitive status because this may affect the degree to which
3MS scores could change over time. Means, SD, and p val-
ues were generated from these analyses. All data were ana-
lyzed using SPSS software (SPSS Inc., Chicago, IL).
METHODS
Study Population
The study population was drawn from the CSHA I and II
studies, which prospectively followed up a randomly se-
lected, representative sample of 10,263 elderly Canadians
for 5 years. A detailed description of CSHA methods has
been reported previously (1). In summary, the CSHA was a
multi-center study of the epidemiology of dementia, health,
and disability among Canadians aged 65 years and over. It
included elderly persons living both in the community and
institutions. Only the community-dwelling sample (n ꢀ
9008) was included in our analysis, which was stratified by
age (65–74 years, 75–84 years, and 85 years and older),
with over-sampling of the older cohorts. Study nurses con-
ducted face-to-face interviews with subjects and/or proxies
in the subjects’ own environment with demographic, medi-
cal, social, cognitive, and functional information systemati-
cally collected.
Definition of Variables
During face-to-face interviews, measurements of baseline
clinical data, including cognitive and functional status, were
obtained. Approximately 5 years later, repeat data collec-
tion was performed on available study participants. Demo-
graphic variables collected included gender, age, and level

M640
NJEGOVAN ET AL.
Table 1. Subject Characteristics at the Time of CSHA I (n ꢀ 5874)
Mean Age, y (SD)
Women, %
75.7 (7.1)
59.5
Percentage With Self– or Proxy-reported
Cardiac and circulation problems
Diabetes
30.2
9.7
Lung problems
Vision problems
Previous stroke
17.3
28.7
4.9
Arthritis
Parkinson’s disease
Renal disease
Previous fracture
Urinary incontinence
Bowel incontinence
Dementia
56.4
1.4
12.2
5.9
12.2
4.8
13.8
Note: CSHA I ꢀ Canadian Study of Health and Aging I.
Figure 1. Mean ꢀ (
95% confidence intervals) Modified Mini-
Mental State (3MS) scores for persons with incidental loss in Older
American Resources and Services (OARS) functional items over a
5-year period.
RESULTS
Population
From the total community cohort in CSHA I (n ꢀ 9008), a
total of 5874 persons were independent in at least 1 of the 14
OARS functional items and available for follow-up 5 years
later. Within this cohort, there were some missing data for
each functional item; however, the percentage never exceeded
4% of the total. Subject characteristics are shown in Table 1.
DISCUSSION
This study is the first to demonstrate that progressive
cognitive decline is associated with a specific pattern of loss
of functional tasks among a large prospective cohort of
community-dwelling elderly persons. For all ADLs and
IADLs examined over the 5-year study period, persons who
lost independence in a particular task had lower 3MS scores
and significantly greater declines in cognition than those
who retained independence. The strong relationship be-
tween cognitive status and functional ability persisted even
after adjusting for baseline cognitive status.
Descriptive Analysis
The mean 3MS scores and 95% CIs for persons during
the time period of incidental loss of the 14 specific func-
tional activities (ADLs and IADLs) are shown in Figure 1.
The order of loss of independence in ADLs, from the least
to the most impaired cognitive status, was bathing, walk-
ing, toileting, transferring, dressing, grooming, and eating.
Again on the basis of cognitive status, the order of loss of
independence in IADLs was homemaking, shopping, ability
to use transportation, meal preparation, telephone use, fi-
nances, and medication use. For the seven IADL tasks, the
3MS scores at the time of dependency overlapped with
those associated with the ADL tasks. However, there was a
tendency for dependency for IADL activities to occur at
higher 3MS scores (mean 84/100) compared with ADLs
(mean 67/100). Furthermore, a greater number of persons
became dependent in at least one IADL (n ꢀ 5218) com-
pared with ADLs (n ꢀ 2652) over the 5 years.
By prospectively estimating the cognitive status of per-
sons before and after the loss of ability to perform specific
functional tasks, this study furthers previous work examin-
ing the relationship between cognitive status and functional
ability. The precision (i.e., 95% CIs) of the estimates of
cognitive status at the time of incidental loss of specific
functional items supports the concept of a hierarchical
structure to functional loss associated with cognitive de-
cline. Our results confirm that there is a tendency for IADLs
to be lost at higher cognitive levels compared with ADLs,
but there is overlap. There appeared to be three levels of
functioning ability associated with cognitive ability. The
first level corresponded to 3MS scores of 75 or greater (out
of 100) and included mostly IADL items (housework, shop-
ping, outside transportation, and meal preparation). The sec-
ond level corresponded to 3MS scores between 70 and 75
(out of 100) and included a mixture of IADL and ADL
items (toileting, telephone use, finances transfers, medica-
tion use, and dressing). The third level corresponded to
3MS scores of less than 70 (out of 100) and included only
ADL items (grooming and feeding). To capture a greater
range of functional disability, these results support the view
that a composite measure of IADLs and ADLs may be best
measured on one scale (12,24).
Comparison of Subjects Who Remained Independent
Versus Those Who Lost Independence
Figure 2 illustrates that there was a significantly greater
5-year decline in cognitive scores for persons who became
dependent in each functional task compared with those who
remained independent (p ꢁ .001). For all 14 functional
tasks, the change in cognitive scores over the 5-year study
period reflected a similar hierarchy of losses as the previous
analysis. For ADLs, the decline in cognition for subjects
who lost the ability to perform a functional item indepen-
dently was (greatest to least) eating, grooming, transferring,
dressing, toileting, walking, and bathing. These differences
remained significant even after adjustment for baseline cog-
nitive scores (p ꢁ .001).
The hierarchy of functional items found in this study was
also similar but not identical to others that have been re-
ported (14–18). For the seven specific ADL tasks, the hier-
archy found in this study differed from the one proposed by

FUNCTIONAL LOSS AND COGNITIVE DECLINE
M641
Figure 2. Comparison of mean absolute declines in Modified Mini-Mental State (3MS) scores for subjects who did and did not lose indepen-
dence for individual Older American Resources and Services (OARS) functional items over a 5-year period. Scores were adjusted for baseline
3MS score. ꢀ persons who lost independence; ꢁ persons who did not lose independence.
Katz (12). Most notably, the onset of the inability to dress
independently occurred much earlier in the process of cog-
nitive decline than Katz described. For specific IADL tasks,
dependency for activities outside the home (shopping and
walking outside) tended to occur at higher cognitive scores
than activities within the home (medication management
and telephone use). A reason for this inconsistency may be
that different studies examined varied populations of elderly
persons. Another possible reason may be the availability of
resources for assistance with each of the functional tasks.
For example, in Canada, home care services for house
cleaning, shopping, and bathing are relatively readily avail-
able to all elderly persons regardless of socioeconomic sta-
tus. This ease of access may explain the earlier than ex-
pected dependency for housework and shopping (IADLs)
and bathing (ADLs) in our population. Future studies are
needed to examine the relationship between dependency in
functional activities and the availability of formal and infor-
mal support for these activities.
cognitive and functional status of the participants at two time
points that were 5 years apart. Thus, we needed to assume
that the decline in cognition over the 5-year period was linear.
Our estimates of the cognitive status of persons at the time of
functional dependency would have been even more precise if
we had been able to follow participants with greater fre-
quency. Considering the costs associated with following such
a large cohort, feasibility issues prevented performing more
repeated measures of cognition and function. If this assump-
tion of linearity was not correct, the relationship between
cognitive decline and functional status would not have been
as strong. However, we believe that the pattern of functional
decline found in the study would have remained intact.
Additionally, we used the 3MS to measure the cognitive
status of patients, a scale not as widely used clinically as the
MMSE. However, given its superior measurement proper-
ties and that it can significantly improve the accuracy of
screening elderly persons for dementia (22), use of the 3MS
may have significant clinical benefit despite its slightly
greater response burden.
Our study has several limitations. Besides cognitive func-
tion, other factors, such as patients’ physical abilities, motiva-
tion, and environment, have an impact on their functional sta-
tus. Thus, it is inappropriate to use the results of our study to
predict the functional status of individual patients from their
cognitive test scores. Also, we were only able to measure the
Another limitation is that the assessment of individuals’
“functional abilities” using the OARS scale relied on proxy
reports. Therefore, informants’ perceptions and not the ac-
tual ADL abilities of the subjects were assessed. Moreover,
with the use of globally defined ADL task categories, items

M642
NJEGOVAN ET AL.
5. Fillenbaum GG. Screening the elderly: a brief instrumental activities
of daily living measure. J Am Geriatr Soc. 1985;33:698–705.
6. Reed BR, Jagust WJ, Seab JP. Mental status as a predictor of daily
function in progressive dementia. Gerontologist. 1989;29:804–807.
7. Barberger-Gateau P, Fabrigoule C. Disability and cognitive impair-
ment in the elderly. Disabil Rehabil. 1997;19:175–193.
8. Barberger-Gateau P, Chaslerie A, Dartiques J, et al. Health measures
correlates in a French elderly community population: the PAQUID
study. J Gerontol Soc Sci. 1992;47:S88–S95.
9. Scherr PA, Albert MS, Funkenstein HH, et al. Correlates of cognitive
function in an elderly community population. Am J Epidemiol. 1988;
128:1084–1101.
10. Barberger-Gateau P, Commenges D, Gagnon B, et al. Instrumental ac-
tivities of daily living as a screening tool for cognitive impairment and
dementia in elderly community dwellers. J Am Geriatr Soc. 1992;40:
1129–1134.
11. Fillenbaum GG, Hughes DC, Heyman A, et al. Relationship of health
and demographic characteristics to mini-mental state examination
score among community residents. Psychol Med. 1988;18:719–726.
12. Katz S, Ford AB, Moskowitz RW, et al. The index of ADL: a stan-
dardized measure of biological and psychosocial function. JAMA.
1963;185:914–919.
13. Lawton MP, Brody EM. Assessment of older people: self-maintaining
and instrumental activities of daily living. Gerontologist. 1969;9:179–186.
14. Spector WD, Katz S, Murphy JB, Fulton JP. The hierarchical relation-
ship between activities of daily living and instrumental activities of
daily living. J Chron Dis. 1987;40:481–489.
15. Kovar MG, Lawton MP. Functional disability: activities and instru-
mental activities of daily living. Ann Rev Gerontol. 1994;14:57–75.
16. Norstrom T, Thorslund M. The structure of IADL and ADL measures:
some findings from a Swedish study. Age Ageing. 1991;20:23–28.
17. Thomas VS, Rockwood K, McDowell I. Multidimensionality in in-
strumental and basic activities of daily living. J Clin Epidemiol. 1998;
51:315–321.
18. Kempen GI, Suurmeijer TP. The development of a hierarchical polychot-
omous ADL-IADL Scale for noninstitutionalized elders. Gerontologist.
1990;30:497–502.
such as meal preparation may be interpreted quite differ-
ently by different raters. For example, a rating of “indepen-
dent” may be viewed by some as the ability to prepare full-
course meals but by others as the ability to heat frozen
foods. Whereas both individuals may be independent in pre-
paring meals, they do not have the same level of ADL inde-
pendence. In addition, informants’ ratings may be influ-
enced more by what they allow individuals to perform than
by the individuals’ actual level of ADL ability. That is, in-
formants who perceive family members as forgetful may re-
duce their opportunities to perform ADL tasks.
Finally, the generalizability of our results to other coun-
tries is not known. Clearly, the availability of different for-
mal and informal supports may have an influence on the hi-
erarchy of functional loss. Finally, from the data set, we
could not determine the cause of functional or cognitive de-
cline. However, the intent of the analyses was to describe
the association between incidental functional loss and cog-
nitive decline regardless of the etiology.
This study also has some strengths. Using a very large
representative cohort of elderly persons followed prospec-
tively over 5 years, this study describes a natural hierarchy
of functional loss associated with cognitive decline. For
caregivers, clinicians, and health policy makers, this pattern
of loss can help anticipate the pattern of functional decline
and the subsequent care needs of persons with declining cog-
nition. Thus, this information could potentially improve the
quality of life of these persons and their caregivers and could
play an important part in the health care planning process.
19. Ford GR, Haley WE, Thrower SL, et al. Utility of Mini-Mental State
Exam scores in predicting functional impairment among White and
African American dementia patients. J Gerontol Med Sci. 1996;51A:
M185–M188.
20. Lazardis EN, Rudberg MA, Furner SE, Cassel CK. Do activities of
daily living have a hierarchical structure? An analysis using the Longi-
tudinal Study of Aging. J Gerontol Med Sci. 1994;49:M47–M51.
21. Teng EL, Chui HC. The modified mini-mental state (3MS) examina-
tion. J Clin Psychiatr. 1987;48:314–318.
Acknowledgments
We thank Ian McDowell, PhD, and Richard Aylesworth for providing
CSHA I and II data and for their helpful comments. We also thank Dan
Harper, PhD, and Paddi O’Hara, PhD, for providing statistical help.
Address correspondence to Malcolm Man-Son-Hing, MD, Geriatric As-
sessment Unit, Ottawa Hospital–Civic Campus, 1053 Carling Avenue,
Ottawa, Ontario, Canada K1Y 4E9. E-mail: mhing@ottawahospital.on.ca
22. McDowell I, Kristjansson B, Hill GB, Hebert R. Community screen-
ing for dementia: the Mini-Mental State Examination (MMSE) and
Modified Mini-Mental State Exam (3MS) compared. J Clin Epide-
miol. 1997;50:377–383.
23. Fillenbaum GG. Multidimensional Functional Assessment of Older
Adults: The Duke Older Americans Resources and Services Proce-
dures. Hillsdale, New Jersey: Lawrence Erlbaum Associates; 1988.
24. Sonn U, Svensson E. Measures of individual and group changes in or-
dered categorical data: application to the ADL staircase. Scand J
Rehabil Med. 1997;29:233–242.
References
1. Canadian Study of Health and Aging Working Group. Canadian Study
of Health and Aging: study methods and prevalence of dementia. Can
Med Assoc J. 1994;150:899–913.
2. Jagger C, Clarke M, Cook A. Mental and physical health of elderly
people: five-year follow-up of a total population. Age Ageing. 1989;
18:77–82.
3. Herzog AR, Wallace RB. Measures of cognitive functioning in the
AHEAD study. J Gerontol Psychol Sci Soc Sci. 1997;52B(special is-
sue):37–48.
4. Moritz DJ, Kasl SV, Berkman LF. Cognitive functioning and the inci-
dence of limitations in activities of daily living in an elderly
community sample. Am J Epidemiol. 1995;141:41–49.
Received April 19, 2000
Accepted September 29, 2000
Decision Editor: John E. Morley, MB, BCh

FUNCTIONAL LOSS AND COGNITIVE DECLINE
M643
Appendix
Canadian Study of Health and Aging OARS Questionnaire
Now, I would like to ask you a few questions about activities of daily living, things that we all need to do as a part of our daily lives. I would like to know if, today, you
can do these activities without any help, or if you need some help to do them, or if you can’t do them at all. Please tell me about your situation today when answering
these questions.
(For each item, show the cue card and ask them to select the best answer. If the respondent has difficulty in selecting a response category, you can read the
examples in parentheses below each option. Use these only when help is required, however: do not read them routinely).
a. Can you eat . . .
2. without any help?
1. with some help (need some help with cutting, etc)? 0. or are you completely unable to feed yourself?
b. Can you dress and undress yourself . . .
2. without any help (pick out clothes, dress and
undress self)?
1. with some help?
0. or are you completely unable to dress yourself?
c. Can you take care of your own appearance, for example, combing your hair and (for men) shaving . . .
2. without any help?
1. with some help?
0. or are you completely unable to take care of your
own appearance?
d. Can you walk . . .
2. without any help (except for a cane)?
1. with some help (from a person or using a walker,
crutches or chair)?
0. or are you completely unable to walk?
e. Can you get in and out of bed . . .
2. without help?
1. with some help (from a person or device)?
0. or can’t you get in and out of bed unless someone
lifts you?
f. Can you take a bath or shower . . .
2. without help?
g. Can you go to the bathroom or a commode . . .
2. without any help?
1. with some help (from a person or device)?
1. with some help?
0. or are you completely unable to bathe yourself?
0. or are you completely unable to use the bathroom
or commode unless someone helps you?
h. Can you use the telephone . . .
2. without help (including looking up numbers and
dialing)?
1. with some help (can answer phone, dial operator in 0. or are you completely unable to use the phone?
an emergency, but needs a special phone or help in
getting numbers or dialing)?
i. Can you get to places out of walking distance . . .
2. without help (can travel alone on buses, taxis, or
drive your own car)?
1. with some help (need someone to help you or go
with you when travelling)?
0. or are you completely unable to travel unless
special arrangements are made?
j. Can you go shopping for your groceries or clothes . . . (assuming they have transportation)
2. without help (can you take care of all your
shopping yourself)?
k. Can you prepare your own meals . . .
2. without help (can plan and cook full meals)?
1. with some help (need someone to go with you on
all shopping trips)?
0. or are you completely unable to do shopping?
0. or are you completely unable to prepare meals?
0. or are you completely unable to do housework?
1. with some help (can do some things but not full
meals)?
l. Can you do your housework . . .
2. without help (can scrub floors, etc)?
1. with some help (can do light work but not heavy
work)?
m. Can you take your own medicine . . .
2. without help (in the right doses at the right time)? 1. with some help (can take medication if someone
prepares it for you and/or reminds you to take it)?
0. or are you completely unable to take your own
medicine?
n. Can you handle your own money . . .
2. without help (write cheques, pay bills, etc.)?
1. with some help (can manage day-to-day buying but 0. or are you completely unable to handle money?
need help with your cheque book and paying
bills)?