The feasibility and reliability of
videoconferencing assessments of autonomy, mobility, and nutrition in seniors
versus traditional medical assessments.
Bernard,
M., Fruhwirth, M., Janson, F., Burzillo, L., Meunier, L.
Abstract
The feasibility and reliability of videoconferencing assessments of autonomy, mobility, and nutrition in seniors versus traditional medical assessments was conducted using 38 seniors, 21 of which were found to evaluable, with an average age of 78, from two long-term healthcare facilities managed by the City of Ottawa, and one independent assisted-living community in Ottawa, Ontario, Canada. Subjects were randomized to two study arms, whereby the order of videoconferencing and traditional medical assessments varied. Autonomy, mobility, and nutrition, were measured using the standard of care assessments AGGIR, Tinetti, and AQRD, respectively. Each assessment was conducted twice for each subject in random order. The percent agreement between videoconferencing or telemedicine and traditional medical assessments for the respondents using the three standard of care assessments was 89.4% with an associated 10.6% variability, 3.5% of which was attributed to fluctuations in the physical health of the subjects during the study.
Such promising results from videoconferencing assessments of autonomy, mobility, and nutrition in seniors versus traditional medical assessments, are encouraging for the future use of telemedicine to reduce the soaring costs of healthcare among seniors.
Introduction
A challenge facing seniors in the future is managing the costs and securing the needs associated with long-term healthcare in an exploding senior population. Based on a report from the American Association for Retired Persons [1], approximately 7 million Americans over the age of 70 require long-term healthcare in 2001, and this figure is estimated to increase to 12 million by 2020. In particular, the demand for both home-based services and community healthcare for seniors is the strongest force propelling growth in Canada’s health sector [2]. The principle reasons are that the exploding senior population would prefer to receive healthcare at home than in an institution [3], and would like to reduce the dependence of handicapped seniors on institutions [3].
A promising solution to these aforementioned growing demands for home-based healthcare is the employment of telecommunications, in particular videoconferencing, which is well adapted to provide quality healthcare in a number of medical disciplines [2,4]. Considering that isolation of individuals is a source of increasing morbidity and mortality [5,6], in 1996, Programs for Autonomy and Communication for the Elderly (PACE) 2000 International Foundation developed an easy-to-use resource for home-based intergenerational telecommunication and applied it to recreational, cultural, linguistic, educational, and telemedicine initiatives. In 1998, PACE 2000 developed a VC product to respond to the intergenerational demand, particularly those affected by physical and mental handicaps, who are often restricted to their homes [2,7,8,]. In order to maximize the use of this VC product among home-bound seniors, PACE 2000, guided by the results from its ongoing intergenerational project, defined and established standardized user criteria for their VC product.
1. The disposition of the VC product must not be intrusive: It can not require a technician or other person to participate in a videoconferencing session. Notwithstanding, the VC system must be discrete enough to keep in an office or living room, and must be easy to use (no PC monitor, no keyboard, no complex remote control).
2. The VC product must be as easy as a telephone to use, and must not require previous computer knowledge or technical aptitude. Rather, a short demonstration should be sufficient for the user to operate the product independent of others.
3. The VC product must satisfy the non-verbal demands of the users, a necessary condition for teleconsultations, including VC-based continuing education, and must allow the user to adapt well to a new method of communication. The size of the projected image should be of approximate life-size human dimensions, in accord with the dimensions provided a living room television screen.
Having used this desirable set of standards for videoconferencing and intergenerational programs, PACE 2000 decided to launch other videoconferencing service programs for seniors, exercise and physiotherapy, respectively. In 2002, in conjunction with the Ottawa General Hospital, PACE 2000 launched a study to compare traditional in-clinic physiotherapy sessions, using a goniometer, to videoconferencing-based physiotherapy sessions using a patented videoconferencing goniometer, based on diagnostic software developed by PACE 2000. The results suggested that no significant difference exists between medical evaluations using tradition in-clinic approaches and videoconferencing.
Wanting to further validate videoconferencing medical evaluation initiatives, for the purpose of reducing high overhead costs associated with medical centers used in the future healthcare of senior, PACE 2000 set out to compare in-clinic and videoconferencing medical evaluations for assessing the balance, mobility, gait, nutrition, and autonomy of seniors. Two long-term healthcare facilities, Perley-Rideau and Champlain Center, respectively, and one assisted-living community for seniors on Walkley Road in Ottawa, Ontario, Canada participated in the study.
Patient selection
A randomized, two-way, cross-over study was conducted in seniors aged 65 and over. A total of 15 residents from two long-term care facilities chosen to participate and 6 individuals from an assisted-living community were invited to participate in the study, yielding 21 evaluable subjects. Thirty-eight seniors were originally recruited for the study. Of those 38 seniors, a total of 21 completed the entirety of the study (15 females and 6 males). 7 people experienced a scheduling conflict, 4 did not feel comfortable with the study, 3 did not feel well enough to continue onto the second interview, 2 did not show up for one or more of the interviews, and 1 was unable to communicate effectively as a result of a medical condition. The average age among these seniors was 78. Participants had to be over the age of 65 and able to communicate in English or French. Functional deficiencies and visual impairments in seniors were included in the study. Exclusion criteria comprised persons with hearing deficiencies, bed-ridden seniors, and those diagnosed with cognitive disorders (Alzheimer and related disorders).
Procedure
Participants were invited to participate in two separate
interviews (one face-to-face and one via videoconference [VC]). The volunteers
were randomized into two groups and underwent a sequence of two evaluations; VC
followed by conventional evaluations in group one, and conventional followed by
VC evaluations in group two. The cross-over was performed after the first
interview and a wash-out period of at least two days was implemented. Each
volunteer underwent a series of three tests, which were performed twice on two
separate dates, in the following order: Tinetti Balance Test & Tinetti Test
for Mobility/Gait (1st), AQRD [Nutritional Assessment] (2nd),
AGGIR [Autonomie Gérontologique Groupe Iso-Ressources] (3rd). AGGIR
was used for the assessment of autonomy; Tinetti’s test with a timed “Get up
and Go” was used for the evaluation of mobility and balance, and the AQRD scale
assessed the risk of malnutrition. The Tinetti test was to be conducted first,
in order to provide the evaluator with an indication of the person’s
mobility/gait and balance. Both the AQRD and AGGIR evaluations have components
that are dependent on mobility/gait and balance. The AQRD and AGGIR evaluation
questions require reliable answers for an accurate assessment. By conducting
the Tinetti test first, the evaluator had a better indication of the
reliability of the answers provided to the AQRD and AGGIR questions. Therefore,
the evaluator was able prompt the person to provide the most accurate response.
An example of the Tinetti, AQRD, and AGGIR assessments are found in Appendix A,
B, and C, respectively.
Results
Table 1: The average percent agreement between medical
evaluations using traditional in-clinic and videoconferencing-based telemedicine
methods for Tinetti, AQRD, and AGGIR.
|
Evaluation Scale |
Respondent |
Caregiver |
|
Evaluation Scale |
Respondent |
Caregiver |
|
Tinetti Balance Assessment |
86.6 |
N/A |
|
AGGIR: (IVc) Dressing and Undressing Mid
Body |
81.0 |
100 |
|
Tinetti Mobility and Gait Assessment |
84.1 |
N/A |
|
AGGIR: (IVd) Dressing and Undressing
Lower Body |
95.2 |
100 |
|
AQRD Nutritional Assessment |
85.7 |
N/A |
|
AGGIR: (V) Preparing, Serving, and
Eating Food |
94.0 |
100 |
|
AGGIR: (I) Coherence |
95.2 |
95.2 |
|
AGGIR: (VIa) Elimination of Urine |
85.7 |
95.2 |
|
AGGIR: (II) Orientation |
92.9 |
100 |
|
AGGIR: (VIb) Elimination of Stool |
95.2 |
100 |
|
AGGIR: (IIIa) General Bathroom Hygiene |
77.8 |
98.4 |
|
AGGIR: (VII) Lying and sitting down,
standing and getting up. |
94.0 |
96.4 |
|
AGGIR: (IIIb) Washing Upper Body |
81.9 |
100 |
|
AGGIR: (VIIIa) Displacement Inside |
70.2 |
97.6 |
|
AGGIR: (IIIc) Washing Lower Body |
90.5 |
85.7 |
|
AGGIR: (VIIIb) Displacement Outside |
100 |
100 |
|
AGGIR: (IVa) General Dressing and
Undressing |
88.9 |
100 |
|
AGGIR: (X) Distance Communication |
100 |
99.2 |
|
AGGIR: (IVb) Dressing and Undressing
Upper Body |
88.9 |
95.2 |
|
AGGIR: Subgroup Value Assessment |
100 |
100 |
Discussion
Table 1 illustrates the data for traditional on-site medical evaluations versus videoconferencing off-site medical evaluations for comparison. Note, unlike the Tinetti balance, mobility, and gait assessments, the AQRD nutritional and the AGGIR autonomy assessments do not grade based on observed physical performance assessments. Rather, these subjective assessments employ an honor-based system whereby subjects are asked to answer questions about their autonomy truthfully. Occasionally, the answers provided by the subjects during the non-physical or subjective performance assessments were contradicted by observations of inability recorded by the Tinetti physical assessment, contradictions that required study nurses to contact the primary caregiver to resolve the contradictions using the caregiver section of the AGGIR assessment. However, some caregivers were unable to replicate their evaluations of subjects during the course of the study. The variability or error observed in the comparison of the average percent agreement between videoconferencing and traditional medical evaluations is thought to be associated with, but not limited to, fluctuations in physical and/or mental health affecting performance, the sensitivity of subjects and their caregivers to answering certain personal questions, the ability of subjects and their caregivers to recall facts based on memory, opposition to non-traditional medical evaluations using videoconferencing technology, and experimental error.
The result of the average percent agreement between videoconferencing medical evaluations and conventional medical evaluations using all three assessments and based on the performance of the respondents was 89.4%, with an associated error of 10.6%. In contrast, the average percent agreement for the performance of the subjects as determined by the caregivers was 97.8% with an error of 2.4%. The error difference between the responses provided by the caregivers and respondents was 8.4%. In summary, with the average percent agreement for respondents approximately equal to the 90th percentile, the future looks very promising for future videoconferencing-based medical evaluations.
The results of the average percent agreement between videoconferencing medical evaluations and conventional medical evaluations using the Tinetti test for balance, mobility and gait were 86.6% and 84.1%, respectfully, representing an error of 13.4% and 15.9%, respectfully.
Although the definition of error, as described above, includes fluctuations in mental and cognitive performance, the bulk of this error is assumed to be associated with fluctuations in physical function, as subjects were either independently able, dependently able, or unable to perform certain physical requests associated with basic physical autonomy. Collectively, the average percent agreement between videoconferencing medical evaluations and conventional medical evaluations using the two Tinetti tests for physical performance is equal to 85.3%, with an associated 14.7% variability.
The result of the average percent agreement between videoconferencing medical evaluations and conventional medical evaluations using the nutritional assessment AQRD was 85.7%, with an associated 14.3% variability, not statistically different from the physical performance evaluation. However, the error associated with the nutritional assessment is not thought to be primarily associated with fluctuations in physical performance, but rather is thought to be associated to other sources of error as defined above.
The results of the average percent agreement between videoconferencing medical evaluations and conventional medical evaluations using the AGGIR assessment for autonomy when surveying subjects only was 90.1%, representing 9.9% variability. Again, the reported variability from the respondent’s subjective AGGIR assessment is less than the observed variability from their Tinetti physical performance assessment. Comparatively, the average percent agreement between videoconferencing medical evaluations and conventional medical evaluations using the AGGIR assessment for autonomy when surveying primary caregivers only was 98.0%, representing 2.0% variability. Therefore, the primary care providers were more capable of responding to the traditional and videoconferencing assessments with similar results than were the subjects themselves. However, primary caregivers, most often in the presence of the patients during the subjective and physical assessments, provided responses that also contradicted the observed ability of subjects during the Tinetti physical assessment. For example, a number of primary caregivers and subjects reported that the subjects did not need help going to the bathroom, but during the Tinetti physical assessment, many of those same subjects were unable to get out of a chair and walk across the room, without assistance, making the claims of autonomy unrealistic from an obligate perspective. However, employing a fluctuating physical performance rational provides room for facultative realistic autonomy, with occasional assistance from the primary care provider, but not more assistance than independence, resulting in an explanation for the discrepancy between the reported physical abilities and the observed physical abilities.
The gross observation, when compared to the average percent agreement between videoconferencing medical evaluations and conventional medical evaluations using all three assessments, 89.4%, the physical assessment, 85.3%, was considered to be the most accurate assessment, as the research nurse was able to verify that each subject possessed the physical ability or inability to complete basic physical tasks associated with autonomy. The AGGIR assessment was considered the next most accurate assessment because primary caregivers provided more consistent information regarding patient information, 98.0%, than the subjects 90.1%. The AQRD nutritional assessment reporting, 85.7%, was considered to be the least accurate of the three assessments, as this assessment employs neither a physical assessment nor input from primary caregivers. Fortunately, the Tinetti physical assessment provided a means from which to identify conflicts in subjective reporting.
The discrepancy between the accuracy appropriated by each assessment and the observed average percent agreement between videoconferencing medical evaluations and conventional medical evaluations is assumed to be associated with, but not limited to, fluctuations in physical and/or mental health affecting performance, the sensitivity of subjects and their caregivers to answering certain personal questions, the ability of subjects and their caregivers to recall facts based on memory, opposition to non-traditional medical evaluations using videoconferencing technology, and/or experimental error. This rationalization was employed because a number of subjects and primary caregivers answered that the subjects were able to perform basic physical tasks on their own, but when assessed by the Tinetti physical assessment, these same subjects were not capable of performing the basic physical tasks on their own.
Only two situations arose where the primary caregivers responded less consistently than the subjects, the washing of the lower body component of AGGIR, whereby the primary caregivers reported an average percent agreement between videoconferencing medical evaluations and conventional medical evaluations equal to 85.7% versus 90.5% agreement reported by the subjects, and the distance communication component of AGGIR, where by the caregivers’ input was 99.2% and the respondents’ input was 100%, respectively. Although sensitivity to questions regarding lower body washing are possible, the perhaps less hygienic, more sensitive, questions, regarding assistance with the elimination of stool provided contrasting data, such that subjects reported an average percent agreement between videoconferencing medical evaluations and conventional medical evaluations equal to 95.2% for stool elimination assistance versus 100% reported by the primary caregiver. The respective 9.6% reporting discrepancy, the sum of difference between the average percent agreement reported between the subject and caregiver for stool elimination, 4.8%, and the difference between the average percent agreement reported between the subject and caregiver for lower body washing, also 4.8%, provides evidence against inconsistent reporting from either the subject or the caregiver based on sensitive questions alone, as neither the subject or caregiver responded in a similar manner to both sets of sensitive questions. Furthermore, it is seemingly unlikely that a caregiver would be more sensitive to washing the subject’s lower body, than helping the subject to eliminate stool, returning back to the notion that sensitivity, on the part of the caregiver, is not a likely explanation of the variance that was reported. Therefore, this variance is thought to be associated with the caregiver’s recent memory of providing assistance, assistance that is dependent on the observed fluctuating physical health of the subjects reported during the Tinetti assessment, requiring facultative or intermittent, and not obligate or constant assistance. Based on the above argument and on the recorded observations, it is more likely that the subjects were more sensitive to assistance eliminating stool than to assistance washing the lower body, as greater variance was observed for the stool elimination assistance than for the washing of the lower body, as reported by the subjects during the two sessions, the traditional assessment and videoconferencing assessment, respectively.
In summary, if the variability for the average percent agreement between videoconferencing medical evaluations and conventional medical evaluations is approximately equal to 10.6% only, and that variability is entirely appropriated by aversion to videoconferencing medical evaluations, then videoconferencing medical evaluations present great potential as a medical diagnostic devices, a function of reporting medical assessment information in the range of 90% accuracy.
However, as the discussion has revealed, the variance associated with the Tinetti physical assessments of balance, mobility, and gait, are more likely dependent on fluctuations in physical health, a function of ability or inability. As this physical assessment weighs heavy on the general assessment of autonomy, the 10.6% variance entirely appropriated by aversion to videoconferencing medical evaluations, is significantly reduced. Aversion variance to videoconferencing is still further reduced, as the recent memory of primary caregivers regarding assistance is dependent on fluctuations in the physical health and independent ability of the subjects, as was the case for lower body washing and stool elimination. Sensitivity to questions on behalf of subjects was proposed, specifically for questions regarding lower body care, further reducing the aversion variance to videoconferencing medical evaluations. Given the multiple rationales for accounting for and partitioning the observed 10.6% total variance reported by subjects, it would not be unreasonable to reduce the burden of the appropriated subject aversion variability from 10.6% to 7.1%, on the low end and with good measure, as aversion variability is likely significantly less than one third, 3.5%, correlating to the three medical assessments employed in the study, and given the weight and reach of the Tinetti physical assessment. Therefore, subtracting this conservative estimate of non-aversion variance, based on fluctuations of physical health, 3.5%, to the total respondent variance of 10.6% appropriated to aversion towards telemedicine assessments, reduces the aversion towards telemedicine assessments 7.1%, effectively increasing non-aversion to 92.9%, the sum of the average percent difference reported by subjects, 89.4%, and the 3.5% variance associated with fluctuations in physical health. Furthermore, as it is not likely that aversion to telemedicine accounts for the entire 7.1%, the variance between traditional medical assessments and telemedicine assessments is likely even less than 7.1%, further supporting the hypothesis that telemedicine is an acceptable and valid alternative to traditional in-clinic medical assessments. As telemedicine operations are significantly less expensive than traditional healthcare institution operations, employment of telemedicine technology, provided by organizations like PACE 2000 International, are likely to significantly reduce healthcare costs in the future with increased acceptance by both patients and medical practitioners.
Appendix A – Tinetti
TINETTI BALANCE TEST
1. Sitting balance: 0 or 1
2. Arising from chair: 0, 1, or 2
3. Trying to arise from a chair: 0, 1, or 2
4. Immediate standing balance: 0, 1, or 2
5. Standing balance: 0, 1, or 2
6. Nudge on sternum: 0, 1, or 2
7. Neck turning: 0, 1, or 2
8. Eyes closed: 0 or 1
9. Pivot 360° :
(a) 0 or 1
(b) 0 or 1
10.One leg standing balance:
(a) 0 or 1
(b) 0 or 1
11. Back extension: 0, 1, or 2
12. Reaching up: 0 or 1
13. Bending down: 0 or 1
14. Sitting down: 0, 1, or 2
TINETTI MOBILITY/GAIT TEST
1. Initiation of gait: 0 or 1
2. Step height:
(a) 0 or 1
(b) 0 or 1
3. Step Length:
(a) 0 or 1
(b) 0 or 1
4. Step symmetry: 0 or 1
5. Step continuity: 0 or 1
6. Path deviation: 0, 1, or 2
7. Trunk stability: 0, 1, or 2
8. Walk stance: 0 or 1
9. Turning while walking: 0, 1, or 2
10. Capable of augmenting a change in walking speed: 0, 1, or 2
Appendix B – AQRD
NUTRITIONAL ASSESSMENT (AQRD)
1. Do you always feel able to run errands, cook for yourself, or set the table?
2. On a daily basis, do you eat fruits, vegetables, and dairy products?
3. Have you lost 2 kgs or more in the last month or 4 kgs or more in the last six months?
4. Do you have a handicap or sickness that inhibits your ability to feed yourself?
5. Have you had surgery or a new medical condition in the last month?
6. Have you lost your appetite, your desire to eat, or feel that you are never hungry at meal times?
7. Do you frequently eat alone?
8. Do you drink 3 or more glasses of wine, beer or alcohol on a daily basis?
9. Do you eat 3 meals a day?
10. Do you take more than 3 medications a day?
Appendix C – AGGIR
AGGIR
(I) COHERENCE
RESPONDENT
1. Do you have the chance to leave your residence? A, B, OR C.
2. When do you usually leave your residence? A, B, OR C.
3. Where do you normally go when you leave your residence?A, B, OR C.
4. What are you going to do today? A, B, OR C.
5. When are you going to eat? A, B, OR C.
OR
CAREGIVER
1. Does the person frequently conduct themselves in a manner that is logical and reasonable, according to social norms? A, B, C, OR N/A.
2. Does the person conform to social norms? A, B, C, OR N/A.
(II) ORIENTATION
RESPONDENT
1. What season are we in?
3. What time of the day is it?
4. Where do you live?
5. What time is dinner served?
OR
CAREGIVER
1. Does the person frequently forget to go to the right room?
2. Must the person be reminded of meal times?
3. Does the person frequently lose themselves in the time of day or seasons?
AGGIR: (III) BATHROOM HYGIENE
General bathroom hygiene
RESPONDENT
1. Do you need help taking a bath or a shower?
2. Does anyone need to remind you to take your bath or shower?
3. Do you bathe or shower by yourself?
Washing Upper Body
4. Without help can you wash your:
- face?
- torso?
- arms?
- hands?
5. Can you comb your hair and can you shave yourself?
Washing Lower Body
6. Without help do you wash your:
- intimate regions?
- legs?
- feet?
OR
CAREGIVER
General bathroom hygiene
1. Does the person bathe or shower by themselves?
2. Does the person bathe or shower without being reminded to do so?
3. Does the person require help to bathe or shower?
Washing Upper Body
4. Without help can they wash their:
- face?
- torso?
- arms?
- hands?
5. Can they comb their hair and can they shave themselves?
Washing Lower Body
6. Does the person need help washing their lower body, totally, partially, or not at all (please explain)?
AGGIR: (IV) DRESSING AND UNDRESSING
RESPONDENT
Dressing (General)
1. Do you need help getting dressed?
2. Do you need help getting undressed?
3. Does someone help you in taking your clothes out of the closet or drawers?
Dressing Upper Body
1. Are you able to put on a sweater, vest or dress by yourself?
2. Are you able to put on undergarments by yourself?
3. Are you able to undo your clothes by yourself?
Dressing Mid Body
Do you need help clasping straps, buttoning clothes, doing/undoing zippers, putting on belts or suspenders?
Dressing Lower Body
Do you need help putting on shoes, socks, pants, shorts, leotards, or pantyhose?
OR
CAREGIVER
Dressing (General)
Do you need to gather clothes for the person from the closets and drawers and do you need to help them get dressed or undressed?
Dressing Upper Body
Is the person able to put on a sweater, shirt, dress or undergarments by themselves?
Dressing Mid Body
Does the person need help clasping straps, buttoning clothes, doing/undoing zippers, putting on belts or suspenders?
Dressing Lower Body
Do you need to help putting on shoes, socks, pants, shorts, leotards, or pantyhose?
AGGIR: (V) PREPARING/SERVING, AND EATING FOOD
RESPONDENT
1. Do you cut meat by yourself? Do you peel fruit, open yogurt and canned food by yourself (preparing food)?
2. Do you require any assistance pouring liquids into a glass (serving food)?
3. Do you eat/drink without being asked to do so and without help?
4. Do you frequently find it difficult to swallow food or drink?
OR
CAREGIVER
1. Does the person frequently spill food or drink on the table?
2. Does the person need help eating and drinking?
3. Does the person need to be reminded to eat or drink?
(VI) ELIMINATION OF URINE AND STOOL
RESPONDENT
Elimination of urine
1. Do you need assistance urinating, or emptying the urinal?
2. Do you need to urinate frequently so that it becomes a limitation or nuisance to going out?
Elimination of stool
3. Do you need assistance depositing stool?
OR
CAREGIVER
Elimination of urine
1. Do you need to assist patient in urination?
2. Does the person need to urinate frequently and does she become home bound for that reason?
Elimination of stool
3. Do you need to assist patient in depositing stool, emptying colostomy bag, reminding the person to go to the bathroom?
(VII) LYING AND SITTING DOWN, STANDING, AND GETTING UP
RESPONDENT
1. Do you require assistance lying down?
2. Do you require assistance sitting down?
3. Do you require assistance getting out of a chair or from your bed?
4. Do you require assistance getting up from a chair/wheel chair and going to another chair/bed?
OR
CAREGIVER
1. Does the respondent require assistance lying down?
2. Does the respondent require assistance sitting down?
3. Does the respondent require assistance getting out of a chair or from their bed?
4. Does the respondent require assistance getting up from a chair/wheel chair and going to another chair/bed?
(VIII) DISPLACEMENT (INSIDE)
RESPONDENT
1. Do you use anything/anyone to help you walk?
2. Do you require assistance to move from room to room?
3. Do you require assistance to move from floor to floor?
4. Do you need any help with your wheelchair?
OR
CAREGIVER
1. Does the person use anything/anyone to help them walk?
2. Does the patient require assistance moving from room to room?
3. Does the patient require assistance moving from floor to floor?
4. Does the person need any help with their wheelchair?
(IX)AGGIR DOMESTIC SUBGROUP VALUE (DSV) ASSESSMENT
RESPONDENT
1. Do you live at home (X) or do you live in a care center (Y)? X=continue with questions, Y=finished with questions.
OR
CAREGIVER
1. Does the person live at home (X) or does the person live in a care center (Y)? X=continue with questions, Y=finished with questions.
Displacement (exterior)
RESPONDENT
1. Do you frequently require assistance leaving the house?
2.Can you leave your residence alone to run errands?
OR
Displacement (exterior)
CAREGIVER
1. Are you frequently required to assist the patient in leaving their residence?
2. Can the person leave their residence alone to run errands?
AGGIR: (X) Distance communication
RESPONDENT
1. Do you have a telephone that you can use?
2. Are you able to activate an alarm or contact someone in case of an emergency?
3. Do you know when to use an alarm system or an emergency contact person?
4. Do you know when/how to activate an alarm or emergency response system?
OR
CAREGIVER
1. Does the person have a telephone that they can use?
2. Is the person able to activate an alarm or contact someone in case of an emergency?
3. Does the person know when to use an alarm system or an emergency contact person?
4. Does the person know when/how to activate the emergency response system?