A Re-validation of the Rivermead ADL

Scale for Elderly Patients with Stroke

N. B. LINCOLN, J. A. EDMANS

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Summary
The Rivermead ADL scale was developed for assessing activities of daily living in stroke patients but was
not validated for elderly subjects. This study was designed to validate the scale for patients aged over 64
years. A series of 150 stroke patients was assessed on the scale, of whom 103 were aged over 64 years. The
coefficients of reproducibility and 'scalability' were within acceptable limits both for patients aged under
65 and over 64 years. A revised order of assessment is suggested based on the order of difficulty of items.
The two original household scales were combined to give an overall household scale which was validated
as a unidimensional Guttman scale.

Introduction English, were unable to see or hear sufficiently to be

In 1980, Whiting and Lincoln [1] described the
development of a scale for assessing activities of
daily living in patients following a stroke or
head injury. This assessment was shown to be
hierarchical, so that successive items were pro-
gressively more difficult. The advantage of this
scaling is that the total score obtained reflects
not only the severity of disability but also the
actual items which are passed and failed. It is
thus possible to describe patients' abilities on
the basis of their total scores. The reliability was
checked and found to be satisfactory both
between observers and over time. One possible
limitation of the scale was that it was developed
with patients aged under 65 years, yet most
stroke patients are older. The aim of the present
study was to check the scaling for patients aged
over 64 years.
Methods
The Rivermead ADL assessment was administered
to 150 stroke patients admitted consecutively to
Nottingham hospitals who were included in a study
of the frequency of perceptual deficits after stroke [2].
Patients were excluded if they did not understand
assessed on the Rivermead Perceptual Assessment
Battery [3] or had previous history of stroke, head
injury or dementia documented in the medical notes.
Each patient was assessed one month after onset of
the stroke by an occupational therapist (J.A.E.) who
was experienced in working with stroke patients.
There were 1 50 patients of whom 75 had right and
75 left hemisphere stroke. Patients were aged 39-89
years with 47 under 65 years and 103 65 years and
over.
Results
Guttman scaling [4] was performed separately
on young (under 65 years) and old (65 years and
over) patients. The coefficients of reproducibi-
lity (CR) and 'scalability' (CS) were calculated
for each section and are shown in Table I.
Conventionally a CR of 0.9 or greater and a
CS of 0.6 or greater are used as a basis for
accepting the existence of a valid cumulative
and unidimensional Guttman scale. The coeffi-
cients obtained were all within these limits with
the exception of the Household 1 scale for
young patients.
Analysis of individual items revealed that this
Age and Ageing 1990:19:19-24
 Table I. Guttman scaling of Rivermead ADL Scale

Coefficient of Coefficient of
reproducibility scalability
Young patients ( < 65 years)
Self care 0.92 0.79
Household 1 0 .89 0.82
Household 2 0..94 0.91
Old patients ( > 64 years)
Self care 0 .92 0.81
Household 1 0.,91 0.87
Household 2 0..95 0.93

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Table II. Order of difficultyof items; on Rivermead ADL scale

Patients assessed
Young Old Combined
Rivermead ADL Scale n = 47 n=103 n = 150
Self care
1 Drinking 1 1 1
2 Clean teeth 5 4= 5
3 Comb hair 2 2 2
4 Wash face/hands 3 3 3
5 Make up or shave 4 4= 4
6 Eating 6 6 6
7 Undress 7 7 7
8 Indoor mobility 11 = 10 10
9 Bed to chair 8= 8= 8
Q
10 Lavatory O — 8= 8
11 Outdoor mobility 15 = 14 15
12 Dressing 8= 11 11
13 Wash in bath 11 = 13 12 =
14 In/out of bath 15 16 16
15 Overall wash 13 12 12 =
16 Floor to chair 14 15 14
Household 1
1 Preparation of hot drink 2= 2 2
2 Preparation of snack 4 3 4
3 Cope with money 1 1 1
4 Get in/out of car 2= 4 3
5 Prepare meal 5= 5 5
6 Carry shopping 7 6 6
7 Crossing roads 5= 7= 7
8 Transport self to shop 8= 7= 8
9 Public transport 8= 9 9
Household 2
1 Washing 1 1 1
2 Ironing 4 4 4
3 Light cleaning 2 2 2
4 Hang out washing 5 5 5
5 Bed making 3 3 3
6 Heavy cleaning 6 6 6
 A RE-VALIDATION OF THE RIVERMEAD ADL SCALE

was due to item 3 (coping with money) being
passed by more subjects than item 1 (preparing
a hot drink), and item 2 (preparing a snack).
Changing the order of this scale so that item 3
becomes the first item brings the CR within
acceptable limits.
The order of difficulty of items was checked
and compared with the original order. The
orders obtained with young and old subjects are
shown in Table II. On the Self-care scale, item
2 (cleaning teeth), was more often failed than
items 3 and 4. Item 8 (indoor mobility), was
more often failed than items 9 (transferring bed by a higher proportion of patients than items 12,
Household scales may be combined to give an
overall Household score. The revised order is
shown in the Appendix.
Discussion
The Self-care section was found to be accept-
able for use with elderly stroke patients. There
were slight discrepancies between the order of
difficulty of items in this group compared to the
original validation samples. Item 11 was failed

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to chair), and 10 (lavatory). Item 11 (outdoor 13, 15 or 16, suggesting that its position in the
mobility) was more often failed than items scale is too high. One reason for this discre-
occurring later. Item 14 (getting in and out of a pancy may be the differences in the assessment
bath) was the most frequently failed. On settings. Patients in the original sample were all
Household 1, the order obtained was equivalent attending Rivermead Rehabilitation Centre in
to the original sample except that item 3 (coping Oxford. In this unit, when patients move
with money) was the easiest and item 2 (prepar- between departments they have to go outside.
ing a snack) was more often failed than item 4 They therefore acquire outdoor mobility skills
(getting in and out of a car). This latter order relatively early. In contrast, most of the Nott-
difference did not occur when only young ingham patients were assessed in general hospi-
subjects were considered. The Household 2 tals. They did not need to go outside between
section showed a different hierarchy of diffi- departments and this was not an integral part of
culty which was consistent between both young their rehabilitation. There is also controversy
and elderly. whether patients should learn to propel a wheel-
The CR and CS were calculated for the chair independently early in their rehabilitation
revised orders based on the frequency of each [5]. In 1980, the policy at Rivermead was for
item for the total sample. These are shown in patients to propel themselves in a wheelchair as
Table III. soon as possible. This was not the policy in the
The two Household scales were separated in Nottingham hospitals in 1985, when the pre-
the original study because, when the two sec- sent assessments were carried out.
tions were combined, a valid Guttman scale was Another discrepancy of order arose on the
not obtained. The two scales were combined to Household 1 section. Coping with money (item
check whether, in this sample, results could be 3) was found to be the simplest item, yet in the
amalgamated to form a valid, unidimensional original sample it was third in the Household 1
Household scale. The CR obtained was 0.93 section. Some of the patients in the present
and the CS was 0.90. This indicates that the two sample were at home and therefore would have
been using money, whereas in the original
Rivermead sample all were inpatients and
Table III. Guttman scaling of revised order for therefore less likely to use money regularly.
Rivermead ADL Scale The present sample is probably more repre-
sentative of stroke patients seen in most hospi-
Coefficient of Coefficient of tals in the UK. It is therefore suggested that the
reproducibility scalability revised scaling is adopted unless there are clear
indications to the contrary. The suggested
Self care 0.99 0 97 revised assessment form is shown in the Appen-
Household 1 0.89 0.98 dix. This scale is suggested as appropriate for
Household 2 0.92 0.89 use with stroke patients in hospital and at home.
It has the advantage over other ADL scales for
22 N. B. L I N C O L N , J. A. EDMANS

stroke patients [6, 7] that it covers a wide range
of A D L skills and therefore is appropriate both
during inpatient rehabilitation and after dis-
charge from hospital. However, unlike the
Nottingham 10-point ADL scale [6], there has
been no comparison between formal testing on
the activities and administration by verbal
report. Although not as extensive as the
extended A D L scale [8] and Frenchay Activi-
ties Index [9], it is more comprehensive than
others which are completed by asking patients
to perform each item instead of describing what
they do. The present results indicate the scale is
appropriate for elderly stroke patients and this
will mean that it can be used for both research
and clinical practice as a measure of activities of
daily living,

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Appendix: Rivermead ADL Scale (Revised)
Name: Date:
Self care Score Aids/Comments
Drinking
Comb hair
Wash face/hands
Make up or shave
Clean teeth
Eating
Undress
Bed to chair
Lavatory
Indoor mobility
Dressing
Wash in bath
Overall wash
Floor to chair
Outdoor mobility
In/out of bath
Household
Cope with money
Preparation of hot drink
Washing
Get in/out of car
Preparation of snack
Light cleaning
Prepare meal
Bedmaking
Ironing
Carry shopping
Hang out washing
Crossing roads
Transport self to shop
Heavy cleaning
Public transport
Score
1 Independent with or without aids. Ov Needs verbal supervision.
0 Dependent.
 A RE-VALIDATION OF THE RIVERMEAD ADL SCALE
ADL Assessment: Instructions
All aids supplied or recommended to be stated on the
form.
Decide where to start. If patient can do that item, go
back three to make sure patient can do these as well,
and forward until three consecutive failures—then
stop. This applies to each section.
Instructions should be strictly followed.
Self care
Drinking A full cup of hot liquid, not spilling more
than one eighth of the contents.
Comb hair To be presentable on completion.
Wash face and hands At basin (not with bowl),
including putting in plug and managing taps and
patient drying self (all materials to hand).
Make up or shave Shaving to be done by patient's
preferred method.
Clean teeth Unscrewing toothpaste—putting tooth-
paste on brush. Managing tap.
Eating A slice of cheese on toast eaten with knife and
fork (this was chosen as being reasonably tough to cut
and an easy snack to prepare).
Undress Dressing gown, pyjamas, socks and shoes to
be taken off.
Bed to chair From lying covered, to chair with arms
within reach.
Lavatory Mobility to WC (less than 10 metres). To
include managing pants and trousers, cleaning self
and transferring.
Indoor mobility Moving from one room to another—
turns must be to left. Distance of 10 metres.
Dressing Does not involve fetching clothes. Clothes
to be within reach in a pile but not in any specific
order. All essential fastenings to be done up by
patient.
Wash in bath Showing movements, i.e. ability to
wash all over. Ability to manage taps and plugs.
Overall wash Not in bath—at basin (not with bowl).
Patient must be able to wash good arm, stand up, and
touch toes from sitting, in order to be able to wash
overall.
Outdoor mobility To cover a distance of 50 metres and
to include going up a ramp and through a door.
Acknowledgement
We would like to thank the Chest, Heart and Stroke
Association for financial support.
References
1. Whiting SE, Lincoln NB. An ADL assessment
Floor and chair From lying, to upholstered chair
without arms, seat 15 in high.
In and out of bath A dry bath.
Household
Cope with money Match coins to packet of sugar,
cornflakes and margarine. Ask for change of 34p from
50p (16p); 72.5p from £1 (27.5p); £3.21 from £5
(£1.79p).
Preparation of hot drink Fill electric kettle, every-
thing to be ready on working surface.
Washing Handwash smalls at sink.
Get in and out of car Front seat of any car except
sports model.
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Preparation of snack Making a sandwich—materials
to be easily reached. Washing and clearing work
surface to be done afterwards.
Light cleaning Cleaning and tidying surfaces—height
13-37 in.
Preparation of a meal Peel a potato, fry sausage.
Frozen vegetable from fridge. Open tin.
Bedmaking Putting on sheet and blanket, straighten-
ing and tucking in. Bed 21 inches high.
Ironing Not with steam iron. Organize ironing sur-
face (board or table).
Carry shopping \\b butter, 14 oz tin and money.
Hang out washing On rail indoors, away from sink, no
pegs.
Crossing roads Cross at traffic lights with kerbs—no
pedestrian crossing.
Transport self to shop and back—distance of 1 mile.
Public transport Travel on bus (not Park and Ride).
Distance at least 1 mile with minimum three stops
before destination.
Heavy cleaning Vacuum, sweep and dustpan/brush
in 1 1 ft square room, moving dining-room chairs
only.
Scoring
1 Independent, with or without aid. All aids
should be listed on each page of form.
Ov Verbal assistance only.
0 Dependent (if not assessable, if patient medically
unfit, if not safe to try, or too soon to try, if time
taken is beyond practical bounds).
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Windsor: XFER-Xelson, 1985.
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