ORIGINAL ARTICLE

Activities of Daily Living Ratings of Elderly

People Using Katz’ ADL Index and the
GBS-M Scale
Karina Dencker RNT, PhD’,*, and Carl-Gerhard Gottfries MD, PhD’
Department of Clinical Neuroscience, Section of Psychiatry and Neurochemistry’, Goteborg University,
Sweden, and Goteborg College of Health Sciences’, Department of Nursing, Sweden

Scand J Caring Sci 1995; 9: 35-40

Instruments for measuring activities of daily living (ADL) are useful in estimating institutionalized elderly i l l people’s need
of care. The aim of the present study was to investigate to what extent the GBS-M scale measures ADL status, as determined
by Katz’ ADL Index. Forty-two elderly patients in long-term care in a psychiatric hospital were rated independently using
each of the two scales. The correlation coefficient between results of the ratings was r = 0.93, i.e., high scores on one of the
scales gave high scores on the other scale. Fifty per cent of severely demented patients had maximal scores on measures of
ADL.
Key words: ADL, GBS, Katz, long-term care patients, psychiatric patients.

Submitted 9 June 1994

Accepted 21 November 1994

INTRODUCTION A range of available instruments for measuring physi-

The usefulness of tools to measure functional status is
evident to those who are concerned with aged and
chronically ill patients. Those responsible for the care
of such patients need instruments to evaluate the
results of treatments and quantitative information
about changes in functions. Measures of functions
may also be useful in estimating the need of care in
community facilities, such as hospitals, rehabilitation
centres, nursing homes, alternative living arrange-
ments and home care services (Katz 1983, Donaldson
& Jagger 1983, Dencker & Gottfries 1991b). One way
of measuring functions is to measure the patient’s
ability to independently perform activities of daily
living (ADL) or his/her actual performance of these.
The ADL are usually divided into two groups, basic
ADL and instrumental ADL. Assessment of instru-
mental ADL is concerned with people’s ability to cope
with their environment, that is, to do their own shop-
ping, cooking, housekeeping, etc. Basic ADL are ac-
tivities that healthy people perform daily, habitually
and universally, independently of help from others
and include such activities as personal hygiene, dress-
ing, transfer, and eating. Continence is also included.
35
cal functions are documented in reviews, such as those
by Kane & Kane (1981) and Brorsson (1980). The
ADL Index, developed by Katz et al. (1963), is one of
the most well-known, most commonly used in re-
search, and most recommended ones. According to its
originators, it focuses on actual function and not on
ability. The GBS scale, developed by Gottfries et al.
(1982), is a geriatric rating scale including an ADL
subscale called Impairment of motor performance
(GBS-M). It measures motor performance, but, ac-
cording to its originators, not motivation.
An ADL scale can usually predict duration of
disease and mortality. In a group of elderly people
with acute somatic diseases who belonged to the Katz’
grades E-G, the one-year mortality was found to be
55% (Brorsson & Hulter Asberg 1984) and in a group
of elderly people living in a somatic nursing home
60% (Jones et al. 1978). One study (Dencker & Got-
tfries 1991a) found a one-year mortality of 46%
among elderly demented patients who scored a mean
of > 4 on the GBS-M scale, corresponding to levels
VI and VII. Thus, both scales predict one-year mor-
tality in an interesting way.
Scand J Caring Sci
36 K . Dencker, C.-G. Gottfries
The aim of the present study was to investigate to
what extent the GBS-M measures basic ADL status as
determined by Katz’ ADL Index and how these mea-
sures are influenced by dementia.
MATERIAL AND METHODS
Scales
Katz’ ADL Index measures the patient’s independence
in six activities arranged according to a psychobiolog-
ical evolution model: bathing, dressing, toileting,
transfer, continence (for the sake of simplicity also
regarded as an activity by Katz and colleagues), and
feeding. There are three scale steps, defined as inde-
pendent, partly dependent, or dependent on assistance
to perform the activity. In the results of the ratings,
only two steps are used: independent and dependent.
Then partly dependent in bathing, dressing and feed-
ing comes under independent and partly dependent in
toileting, transfer and continence comes under depen-
dent. The patients are assigned to seven ADL grades,
called A, B, C, D, E, F, and G. Grade A is indepen-
dent in all six activities; grade B independent in all but
one; grade C independent in all but bathing and one
more activity; grade D independent in all but bathing,
dressing, and one more activity; grade E independent
in all but bathing, dressing, toileting, and one more
activity; grade F independent in all but bathing, dress-
ing, toileting, transfer, and one more activity; and
grade G dependent on all six activities. Patients who
are dependent in two or more activities but not
classified as C, D, E, or F are called Others.
When presenting results of ratings by Katz’ ADL
Index, scores can be used instead of grades. On each
item 1 represents independence, 2 partial dependency
in bathing, dressing or feeding, 4 partial dependency
in toileting, transfer or continence, and 5 dependency
(personal communication with Dr. S. Katz). Thus, the
score on each activity can vary between 1 and 5 and
the total score between 6 and 30. Katz’ ADL index is
recommended for description, screening, following the
development of a disease and prediction of functional
status of elderly ill patients in institutions (Katz et al.
1970).
The validity and inter-rater reliability of Katz’ ADL
Index, which was developed in the US, has been
studied in a Scandinavian population. Its inter-rater
reliability coefficients were found to be high (0.81 -
0.88) for nurses and its validity to be good (Brorsson
& Hulter Asberg 1984). The index can be used by
registered nurses or nurses’ assistants who know the
patient well.
The GBS scale is a geriatric rating scale, divided
into three subscales: GBS-M (6 items) measuring im-
pairment of motor performance, GBS-I (11 items)
measuring impairment of intellectual functions, and
GBS-E (3 items) measuring impairment of emotional
functions. In addition to the subscales, 6 individual
symptoms are included: confusion, irritability, anxi-
ety, fear-panic, depressed mood, and restlessness. The
GBS-M subscale comprises six activities; dressing/un-
dressing, food intake, physical activity, spontaneous
activity, personal hygiene, and control of bladder and
bowel. Each item has 7 scale steps, of which steps 0, 2,
4 and 6 are clearly defined. Zero represents normal
function and means that the patient can perform the
activity in question independently. Six means that the
patient is totally dependent on assistance to perform
the activity and does not participate at all. Two means
partly dependent, and 4 that the patient is dependent
but participates a little. Thus, the score on single
activities varies between 0 and 6 and the total score
between 0 and 36.
To make the two scales comparable, we divided the
possible total GBS-M score into 7 levels built in
principle on multiples of 6: 0-3, >3-6, >6-12,
> 12-18, > 18-24, >24-30 and >30-36. As a total
GBS-M score of 0-6 can be equivalent to normal
function, but allows more than 3 scores (which means
dependent) on one of the items, we made two levels of
0-6. The limit was drawn at a total score of 3. This
division appears appropriate, since Katz’ grade A
does not allow any dependency and grade B allows
dependency in one activity. The levels are referred to
as levels I-VII. The GBS scale is recommended for
screening, characterization, and evaluation of changes
over time in elderly patients. The inter-rater reliability
coefficients for registered nurses using the GBS-M
were 0.90 and 0.93 respectively in two patient groups
previously studied (Gottfries et al. 1982) and the
validity has been shown to be satisfactory (Brine
1989).
Patients
Forty-two patients participated in the study. Nine of
these were temporarily admitted to a diagnostic psy-
chogeriatric ward, but were otherwise living in their
homes. From the patient records, data were gathered
about age, sex, length of stay, and diagnosis (accord-
ing to ICD 9). The most common diagnosis was
organic dementia disorders (ICD number 290 and
294) (n = 26), followed by chronic psychoses (ICD
numbers 295, 296 and 297) (n = lo), dementia related
to alcoholism (ICD number 291) (n = 3), and miscel-
laneous chronic psychiatric disorders ( ICD numbers
301, 790, 794) (n = 3). The median age was 78 years
(range 46-95); only four patients were under 65 years
old. They had stayed in the hospital for 6.5 years
(range 1-57) on average; 25% had stayed less than
one year and 25% thirteen years or more. The major-
ity (59%) were men.
Scand J Caring Sci
 ADL rating scales 37

Frequency Katz’ADL
0 Index
11-
GBS-M
10-
9-
8-
7-
6-
5-
4-
3-
2-
1-
0-
A
I
B
II
C
Ill
D
IV
E
V
d F
VI
G Katz’ADL Index grades
VII GBS-M levels
Fig. 1 . Results of ratings of 38 elderly psychiatric patients using Katz’ ADL Index in grades and GBS-M divided into levels.

Procedure GBS-M (total score)

All the patients were first rated by a registered nurse

(KD) using the GBS scale. This nurse did not work
at the study wards and therefore had to rely on
nursing staff members for information about the pa-
tients’ ADL status. In every case, the nursing staff
36
30

24
c $
/
e
10

member who provided information about a patient

belonged to the team that was in charge of that 18
patient. One or two days later, the registered nurses
in charge of the study wards rated their respective
patients using Katz’ ADL Index. These nurses knew /
the patients well and needed no information from the
other staff members. To ensure that the ratings were 6
done independently, without influence from the nurs- 0 .

ing staff involved in the GBS ratings, the staff had I 1 I I

been told not to discuss the patients’ ADL status 6 12 18 24 30

between them during the study period. However,
sudden important changes, such as flu, fever, or a
broken leg, had to be reported. There were no such
reports. All the raters worked in the hospital and
were trained in psychiatry. Since 1985, one of the
raters (KD)-who is also one of the authors of this
article- had regularly provided both information
about the scales and individual practical training in
rating. One patient was not rated on the GBS-M
item of spontaneous activity but was given a score
that was the mean value of the scores on the other 5
items.
The Ethics Committee of Goteborg University ap-
proved the ratings. The Spearman rank correlation
test was used to analyse the correlations between the
GBS-M scale and Katz’ ADL Index items.
Katz’ADL (total score)
Fig. 2. Correlations between total scores on the Katz’ ADL
scale and the total scores on the GBS-M scale for 42 psychi-
atric long-term care patients, r = 0.93.
RESULTS
Katz’ ALIL Index
Results of the ratings using Katz’ ADL Index showed
that 90% of the patients could be assigned to index
grades A to G. Seven (16.7%) patients were assigned
to grade A, 5 (1 1.9%) to grade B, 2 (4.8%) to grade C,
4 (9.5%) to grade D, 8 (19%) to grade E, 1 (2.3%) to
grade F, and 1 1 (26.2%) to grade G (Fig. 1). Four
(loo/,) patients were classified as Others. One was a
Scand J Caring Sci
38 K . Dencker, C . 4 . Got fries

Table 1. Correlations (Spearman’s rank correlation test) between all items of the Katz’ ADL Index and the GBS-M scale
(n = 42: two indenendent rates: r > 0.52 D < 0.001)
GBS-M
_ _ ~ ~ ~
Control of
Dress/ Food Physical Spontaneous Personal bladder and
undress intake activity activity hygiene bowel

Katz’ ADL
Bathing 0.60 0.36 0.42 0.55 0.66 0.56
Dressing 0.80 0.57 0.66 0.74 0.76 0.74
Toileting 0.78 0.69 0.54 0.71 0.75 0.87
Transfer 0.62 0.68 0.85 0.65 0.54 0.50
Continence 0.71 0.66 0.49 0.57 0.66 0.88
Feeding 0.69 0.83 0.65 0.72 0.65 0.71

GBS Intellectual functions vs Katz‘ADL

6

4
c
m
2
-3
-
0

v)
m 0
c!Y
2

0
1 2 3 4 5
Katz ADL (mean)
Fig. 3. Correlations between mean scores on Katz’ A D L scale and those on the GBS-I scale for 26 demented patients, r = 0.69.

75-year-old demented woman, admitted to the diag- The GBS scale

nostic psychogeriatric unit, who could dress, transfer
The results of the GBS-scale ratings showed that
and eat independently. Two were schizophrenic men,
among the patients with a diagnosis of dementia 3
84 and 81 years old, who had been in the hospital
were mildly, 5 moderately and 18 severely impaired in
for 50 years. One of them could dress and eat inde-
intellectual functions (mean 3.17 SD 2.05). The symp-
pendently and was continent; the other could dress,
tom of confusion was present to a moderate degree,
transfer and eat independently. The fourth patient
while the other 5 symptoms were present to a mild
was a mentally retarded 68-year-old man who had
degree or absent.
been in institutions during all his adult life and could
only transfer independently. Expressed in scores,
the results of the Katz’ ADL ratings of the 42
The GBS-M scuie
patients showed a mean total score of 18.9 8.6. The results of the ratings (Fig. 1) showed that 9
The mean score for bathing was 4.4 & 1.5, for dress- (21.4%) patients belonged to level I on the GBS-M
ing 3.6 f 1.8, for toileting 3.5 & 1.8, for transfer scale, 2 (4.8%) to level 11, 4 (9.5?4) to level 111, 6
2.3 f 1.8, for continence 2.9 f 1.9, and for feeding (14.30/0) to level IV, 5 ( 1 1.9%) to level V, 2 (4.8%) to
2.2 f 1.8. level VI and 10 (23.8%) to level VII. The four patients
Scand J Caring Sci

called Others on the Katz’ Index were not included.
The mean total value of all 6 items was 17.4 & 13.2 for
the whole patient group (n = 42). Dressing/undressing
had a mean score of 3.2 2.5, food intake 1.9 f 2.6,
physical activity (e.g., walking) 2.1 2.6, spontaneous
activity 2.8 f 2.6, personal hygiene 3.9 k 2.3, and con-
trol of bladder and bowel 3.2 k 2.7.
Correlation between Katz’ A D L Index and GBS-M
The correlation coefficient between results of ratings
by Katz’ ADL Index (total score) and the GBS-M
scale (total score) was 0.93 (Fig. 2). Table 1 shows
correlations between all individual activities on the
Katz’ and GBS-M scales. The Katz’ activity Dressing
correlated well (0.80) with GBS-M Dress/undress.
The Katz’ activity Toileting correlated well (0.87)
with GBS-M Control of bladder and bowel. The
Katz’ activity Transfer correlated well (0.85) with
GBS-M Physical activity. The Katz’ activity Conti-
nence correlated well (0.88) with GBS-M Control of
bladder and bowel. The Katz’ activity Feeding corre-
lated well (0.83) with GBS-M Food intake. The Katz’
activity Bathing did not correlate closely with any of
the GBS-M items; the strongest correlation (0.66) was
with Personal hygiene. GBS-M Spontaneous activity
did not correlate closely with any of the Katz’ activi-
ties; the strongest correlation was with the Katz’
activity Dressing (0.74).
When studying the correlations between GBS-M
and Katz’ ADL on one hand and intellectual impair-
ment (GBS-I) on the other, significant correlations
were found (GBS-I/GBS-M r = 0.80, GBS-I/Katz’
ADL r = 0.69). As is evident from Fig. 3, 50% of the
severely demented patients were maximally impaired
according to the ratings on both instruments.
DISCUSSION
The present study was part of a large study including
ratings of long-term care patients twice a year and a
check of the inter-rater reliability once a year. The
raters were all registered nurses with long practice in
using scales for research purposes.
Katz’ ADL Index is constructed in such a way that
95% of hospitalized, elderly, ill patients should fit into
the grades A-F. In the present study, however, only
90% of the patients fitted into these grades. Four
patients were classified as Others. Katz et al. (1963)
have stressed that if more than 5% of a group of
elderly people are classified as Others, either there are
specific disabilities among the patients, such as blind-
ness, deafness, or an amputated leg, or the definitions
have been misunderstood. A review of our data
showed that one patient had a specific disability: he
was blind. The other three patients had no such
disabilities. As both GBS ratings and Katz’ ADL
ADL rating scales 39
ratings showed the same inabilities in all three pa-
tients, there appears to be no doubt about their ADL
status. The presence of three Others (besides the blind
patient) may well be accidental in as small a sample as
42 patients, or there might be other specific disabilities
among the patients than those mentioned by Katz and
colleagues. Katz’ ADL Index was developed on the
basis of observations of hospitalized elderly patients
with mainly somatic diseases, whereas the patients in
the present study were suffering from various psychi-
atric diseases. The three Others in question were all
chronic psychotics with extremely long stays in hospi-
tal. It seems reasonable that, for instance, the uncon-
cern for grooming that is characteristic of this type of
patients could influence the ratings in the same way
as, for instance, an amputated leg.
The arrangement of the Katz’ items that allows a
division into 7 grades representing increasing degrees
of severity is based on a special system. The GBS-M
scale does not have a similar arrangement, but based
on the possible total score, the results can be divided
into 7 levels. On comparison, the grades/levels of the
two scales showed quite good agreement, that is, a
patient who was assigned to a certain Katz’ grade was
usually also assigned to the corresponding GBS-M
level.
A significant and positive correlation between Katz’
ADL total scores and GBS-M total scores ( r = 0.93)
was also found. Thus, there was a nearly linear corre-
lation between total scores on Katz’ ADL Index and
total scores on the GBS-M scale, i.e., high scores on
one of the scales gave high scores on the other scale.
Ninety-one per cent of the observations were within a
confidence interval of 95%.
Patients with very low (6) or very high total scores
(30) on Katz’ ADL Index also had very low or very
high scores on the GBS-M scale, but patients with
scores between the extreme points were more fre-
quently found to diverge from the regression line.
Those patients had often lower scores on the GBS-M
scale than on the Katz’ ADL Index. This reflects one
of the main problems with all scales: the two extreme
points are readily identified, but the intermediate steps
are much more difficult to define (Bruett & Overs
1969).
The strong significant correlation between the
scores rated on the two scales was not surprising, as
the activities included in the scales are very similar.
There was only one activity, Spontaneous activity, on
the GBS-M scale that had no equivalent on the Katz’
ADL Index and one activity, Toileting, on the Katz’
ADL Index that had no equivalent on the GBS-M
scale. Five of the activities on the Katz’ ADL Index,
Bathing, Dressing, Transfer, Continence, and Feed-
ing, were also on the GBS-M scale, even though the
designations and definitions differed slightly. The
Scand J Caring Sci
40 K. Dencker. C.-G. Gottfries
Katz’ activities Toileting and Continence correlated
both closely with the GBS-M Control of bladder and
bowel.
It is obvious that the degree of dementia influences
the outcome of the ratings on Katz’ A D L and on
GBS-M. In ratings of patients with mild to moderate
dementia, the influence does not seem to be important
(Fig. 3), but 50%) of severely demented patients were
rated as maximally impaired on Katz’ ADL. The aim
of the ratings with Katz’ A D L is often to measure
work load. For such measurements, however, the
validity of the ratings in patients with severe dementia
ought to be further investigated.
CONCLUSION
The GBS-M scale includes activities considered to
represent A D L functions; only one activity differs from
those included in Katz’ A D L Index. The comparison
between total scores on Katz’ ADL Index and total
scores on the GBS-M scale showed a very strong cor-
relation (0.93). If results from the GBS-M ratings are
divided into 7 levels, that is, as many as the Katz’ A D L
grades, levels and grades show very good agreement. We
therefore conclude that the GBS-M scale measures
A D L function and can be used as an A D L scale.
ACKNOWLEDGEMENTS
We are grateful to Goran Lingstrom for help with statistical
analysis and to lngrid Larsson for valuable linguistic advice.
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