The Frail Elderly Functional Assessment Questionnaire: Its ...

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The Frail Elderly Functional Assessment Questionnaire:
Its Responsiveness and Validity in Alternative Settings
F. Michael Gloth, III, MD, Ann A. Scheve, MS, RN-C, Sanjay Shah, MD, Rendell Ashton, BS, Robert McKinney, DO
ABSTRACT. Gloth FM III, Scheve AA, Shah S, Ashton R,
McKinney R. The Frail Elderly Functional Assessment question-
naire: its responsiveness and validity in alternative settings.
Arch Phys Med Rehabil 1999;80:1572-6.
Objective: To test the Frail Elderly Functional Assessment
(FEFA) questionnaire for responsiveness (sensitivity to change)
to low-level functional tasks in a frail elderly cohort and to
evaluate its validity over the telephone or when administered to
a caregiver proxy.
Subjects: Fifty-eight elderly patients from three urban
inpatient rehabilitation settings and an outpatient geriatrics
center.
Methods: A prospective, clinical, comparative trial. The
FEFA questionnaire was administered serially. For validity,
subjects were observed performing the tasks on the question-
naire within 24 hours of each interview. For responsiveness,
repeat measures were performed within a 1- to 2-week period.
Validity and sensitivity to change (responsiveness) of the
questionnaire were determined by correlating patient responses
to direct observations by rehabilitation staff. Responsiveness
was also determined based on the Guyatt technique that divides
clinically significant change by the normal variance, ~/(2×
[mean squared error])!/2, as well as by measures of effect size,
standardized response means, and relative efficiency tests
for responsiveness. To evaluate FEFA validity in alternative
settings, kappa statistic and regression analyses were used
based on the previously validated interviewer-administered
format.
Results: Responsiveness was excellent with effect size (.35),
standardized response means (.48), and relative efficiency
(2.67) tests as well as Guyatt (1.26). There was 83% agreement
when compared with FEFA task performance. Regression
between change in FEFA score versus performance testing was
significant (r 2 = .33;p = .01). ANOVA was significant at ap =
.03 for FEFA scores at first measure in rehabilitation compared
to second. Correlation for caregiver proxy administration was
.92 (p- .0001) and for telephone administration was .99
(p < .0001).
Conclusions: The FEFA questionnaire, previously demon-
strated to be reliable and valid, is sensitive to functional change
From the Division of Geriatrics, The Union Memorial Hospital (Dr. Gloth, Ms.
Sheve, Dr. Shah, Mr. Ashton, Dr. McKinney): the Division of Geriatric Medicine and
Gerontology, Department of Medicine, The Johns Hopkins University School of
Medicine and The Hopkins Bayview Medical Center (Dr. Gloth); and The Johns
Hopkins University School of Medicine (Mr. Ashton), Baltimore, MD.
Submitted for publication January 15, 1999. Accepted in revised form April 5, 1999.
Supported in part through an American Federation for Aging Research grant to Mr.
Ashton and Dr. GIoth.
Presented in part at the 1996 annual meeting of the Gerontological Society of
America Meeting, Washington, DC.
No commercial party having a direct financial interest in the results of tile research
supporting this article has or will confer a benefit upon the authors or upon any
organization with which the authors are associated.
Reprint requests to E Michael Gloth, IIL MD, Chief, Division of Geriatrics, The
Union Memorial Hospital, 201 East University Parkway, Baltimore, MD 21218-2895.
© 1999 by the American Congress of Rehabilitation Medicine and the American
Academy of Physical Medicine and Rehabilitation
0003-9993/99/8012-540953.00/0
Arch Phys Med Rehabil Vol 80, December 1999
(responsive) in frail elderly people. It is also valid when
administered by phone or to a caregiver proxy.
© 1999 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
HERE ARE FEW INSTRUMENTS available to measure
T function in frail elderly subjects, l The Frail Elderly Functional
Assessment (FEFA) questionnaire (appendix 1) is a
19-item questionnaire that focuses on lower-level functioning
in areas that also affect caregiver burden. 2 The instrument is
weighted toward declining function (ie, the instrument's design
will not distinguish between various grades of higher function).
Inability to perform more basic functions leads to a higher score
and therefore greater functional impairment.
The FEFA Questionnaire has been proven a valid and reliable
instrument for measuring function in frail, elderly subjects. 2
Determining this instrument's sensitivity to change is an
important feature of standardization if the FEFA is to be a useful
clinical and research tool. Furthermore, demonstrating validity
when the instrument is administered by phone or to a caregiver
proxy should also be helpful. This study addressed these
additional issues for the FEFA in three frail, elderly cohorts.
METHODS
Subjects
Fifty-eight subjects over the age of 65 years, with Mini-
Mental State Examination 3 scores above 18, were studied.
Subjects had multiple comorbid conditions and comprised three
subgroups from three urban inpatient rehabilitation settings in
Baltimore (Union Memorial Hospital, Harford Gardens Nurs-
ing Center, and Johns Hopkins Geriatrics Center) and an
outpatient setting (the Union Memorial Hospital Geriatrics
Center Outpatient Program). For responsiveness testing, the
FEFA questionnaire (appendix 1) was administered to 18 frail,
elderly subjects, who represented a convenience sample from
the Johns Hopkins Geriatrics Center (rehabilitation residents)
and the rehabilitation unit at the Union Memorial Hospital (both
inpatient settings). The rehabilitation setting was used because
this is an environment where relatively rapid change in function
is fairly predictable in a functionally impaired population.
For the validity testing a convenience sample of 40 (20 in
each group) subjects was obtained from the ambulatory geriat-
rics center and the inpatient nursing center.
Data Collection and Analysis
Interviewers consisted of physical and occupational thera-
pists, medical students, and physicians. Each interviewer re-
ceived one-on-one instruction on test administration.
Sample sizes were calculated based on acceptable and
conventional type I and type II statistical error, using an oL error
of .05 and a power of .80.
Responsiveness. Responsiveness, the instrument's sensitiv-
ity to changes in function, was determined using 18 homebound
elderly subjects dwelling in the community or in the inpatient
rehabilitation settings. Responsiveness of the FEFA instrument

was assessed by correlating patient responses with direct
observations by the investigators regarding the tasks addressed
in the questionnaire. Subjects were administered the FEFA
questionnaire 2 to 7 days after admission on the rehabilitation
unit and again 1 to 2 weeks later. Subjects were observed
performing the tasks on the FEFA questionnaire within 24 hours
of each interview. Information for responsiveness was calcu-
lated by determining effect size, 4 standardized response means, 5
and relative efficiency. 5 The effect size establishes a relation-
ship between the degree of change in test scores to the
variability in those scores:
Difference in Means/Standard Deviation of Baseline Scores
FRAIL ELDERLY FUNCTIONAL ASSESSMENT, Gloth 1573
= (X ..... t baseline -- X .... at foil .... p)/SObaseline-
The standardized response means 5 is similar to effect size but
uses the standard d~viation of the mean of differences in scores:
(Xmean at baseline -- Xmean at follow-up)/SD(mean of ..... differences)"
The relative efficiency compares questionnaire t scores to
performance test t scoresS:
(Iquest/tquest) 2 VS (tperf/tquest) 2
with the lower value being less responsive. Further responsive-
ness testing included the clinically significant change divided
by the normal variance,
(cr/(2 × [mean squared error]) v2,
a technique that has been described previously by Guyatt and
colleagues 6 in measuring change over time or responsiveness
for an instrument.
Validity and sensitivity to change of the FEFA questionnaire
was determined by correlating patient responses with direct
observations by rehabilitation staff. When evaluating responsive-
ness of the instrument, the change in FEFA scores was
compared with thg change in ability to perform the tasks
described on the FEFA.
When comparing actual performance of tasks to responses
given on the FEFA, subjects were observed performing the
FEFA-based tasks within 48 hours of responding to the
questionnaire. In most circumstances the specific tasks were
observed by one 0f the investigators. In some instances a
simulation of the task was observed by an investigator. For
example, subjects ~vere observed preparing a hot mean using
the oven, stove, or ]microwave oven. If actual meal preparation
was not feasible, a ~imulation of the task was witnessed, ie, the
patient would fill a pot with hot water, turn on a mock stove, add
pasta to the pot, arid turn off the stove after 5 minutes. For the
sixth question, "Are you able to manage money (paying bills,
keep checkbook, etc)?" the patient was asked to write a check
for $14, record the iamount in a mock checkbook, and calculate
the new balance, tf a caregiver had not observed a task, the
investigator obser'~ed the attempted activity or simulation. If a
subject lived alone at home, an investigator visited the home to
observe tasks. If subjects had no one to help them dress, the fact
that a patient was dressed attested to the ability to perform that
task.
As part of the e,~aluation of the FEFA's sensitivity to change
in function, the change FEFA interview scores were compared
with the change i~ the observed performance of the FEFA-
based tasks usingOinear regression techniques. To this end,
analysis of variance (ANOVA) was included as an additional
means of evaluatin~ the FEFA's sensitivity to change.
Validity. To te~t the validity of the FEFA over the phone,
the instrument was prospectively administered to a cohort of 20
elderly volunteers who were scheduled for outpatient geriatric
assessment. Within the next 10 days, the subjects were adminis-
tered the same instrument in a previously validated, person-to-
person interview during their office visit. Validity of phone
administration for the FEFA was determined by direct compari-
son and correlation of responses in the two different interview
formats. Responses to FEFA questions were also analyzed
using the kappa statistic.
To test the validity of the FEFA when administered to a
patient's care provider, we asked the questions of patients' care
providers at a nursing home. In this study, a care provider was
defined as anyone directly involved with the patient's care. The
FEFA questionnaire was then administered to the patients in the
previously validated, interview format. The validity of care-
giver administration was then determined by direct correlation
with individual responses using the standard interviewer admin-
istered format. Kappa analysis was also performed. A kappa
score below 0.4 was considered to demonstrate poor agreement.
This study was approved by the Johns Hopkins University
School of Medicine Joint Committee for Clinical Investigation,
the Johns Hopkins Bayview (formerly Francis Scott Key
Medical Center) Institutional Review Board, the Johns Hopkins
Geriatrics Center Research Review Committee, and the Union
Memorial Hospital Institutional Review Board.
RESULTS
Responsiveness effect size (.35), standardized response means
(.48), and relative efficiency (2.67) tests showed consistently
high levels of responsiveness. Additional testing using Guyatt's
method was excellent at 1.26. Regression between change in
FEFA score versus performance testing was significant (r 2 = .33;
p = .01; fig 1). ANOVA was significant at ap = .03 for FEFA
scores at first measure in rehabilitation compared with second.
Agreement between telephone results and interview results
was excellent with kappa scores of ->0.7 for 15 of 19
questionnaire items and -->0.4 for 18 of the 19 (fig 2).
Correlation scores were also highly significant, with overall R 2
of .98 (p < .0001; fig 2). Care provider scores and interviewer
scores demonstrated nonrandom agreement (kappa ->0.4) in 16
of 19 items with 6 having kappa of -->0.7. Correlation for
caregiver proxy administration was .84 (p -< .0001, fig 3).
DISCUSSION
This study indicates that the FEFA questionnaire is valid
when administered by phone or to a caregiver proxy and is
20
15.
10.
Change in
Performance of 5
FEFA tasks 0i
-5-
-10-
-10
.../.
:/"
-5 0 5 10 15 20
Change in FEFA
Fig 1. Change in performance of tasks on the FEFA was significantly
associated with changes in FEFA responses (r 2 = .33; p < .01).
Arch Phys Med Rehabil Vol 80, December 1999

1574 FRAIL ELDERLY FUNCTIONAL ASSESSMENT, Gloth
Telephone
FEFA
4°1 /
30
20
10
0
0 10 20 30 40
Interview FEFA
Fig 2. FEFA responses by telephone interview correlated strongly
with responses in the previously validated interviewer administered
format (r 2 = .98; p < .0001).
responsive to functional change in frail elderly people. The
validity of the telephone-administered FEFA for evaluating the
functional level of frail older patients should allow clinicians to
use this tool with greater confidence when face-to-face inter-
views are not possible. These results are not surprising given
the previous reliability and validity results in the FEFA
questionnaire. 2
The FEFA stands out from other instruments for several
reasons. The "can you" rather than a "do you" question format
may leave less room for indecision on the part of respondents
and a greater likelihood of agreement between caregiver and
subject. The FEFA is more discriminating, with a focus on very
low functional level. This contrasts to relatively broad instru-
ments like Katz's instrument for Activities of Daily Living, v
which is a broader instrument originally designed to assess
individuals who had incurred a stroke or hip fracture. Another
factor is that the FEFA is not a performance-based measure,
thus is less time consuming, requires less space (or equipment),
can be administered in most settings, and has little inherent risk
for injury. Also, the activities measured generally apply directly
to usual activities in the daily environment. 8
The instrument, designed to assess activities that would
Caregiver
FEFA
35
30-
25
20
15-
10
5
J
0 ''''1''''1''''1''''1''''1''''1''''
0 5 10 15 20 25 30 35
Interview FEFA
Fig 3. Interviewer administered responses also correlated well with
FEFA responses from a caregiver proxy (r 2 = .84; p < .0001).
Arch Phys Med Rehabil Vol 80, December 1999
affect caregivers, is reliable and valid when administered to
caregivers. Nonetheless, care should be exercised in interpretat-
ing FEFA results obtained from a patient's care provider. Since
fairly loose criteria for defining a "care provider" were used in
this study, studies are needed to more strictly define criteria for
providers capable of giving optimal FEFA results. There are
data to indicate that for more basic activities, in more debili-
tated subjects self-report correlates better with caregiver reports
of functional status. 9
Interpretation of the study may also be somewhat limited by
the relatively small number of subjects. Although the study
population is believed to be representative of frail older patients
elsewhere, studies with larger populations are needed to verify this.
Responsiveness to change is important in evaluating and
standardizing measures of function, but such testing is often not
reported in studies assessing instruments. 1° The fact that the
FEFA achieved acceptable responsiveness offers clinicians and
researchers a degree of comfort when it is used to follow
changes in function in a frail older adult. The FEFA also seemed
to be useful in following specific tasks over time (responsive-
ness). The overall design of the questionnaire, however, was to
use the instrument as a whole, thus giving a wider appreciation
of functional capabilities. Without further evaluation on a larger
scale, the value of separating the questionnaire into sections as
an indicator of overall functional status can not be addressed.
Furthermore, FEFA has the potential to help classify people as
"frail." Although not evaluated in this study, that potential
should be a focus of future research.
The FEFA questionnaire has been shown to be reliable, valid,
and sensitive to changes in functional status in frail, mature
adults. These factors and the versatility with telephone and
proxy standardization should warrant its use as an instrument to
measure function and follow its change in frail older adults in
both clinical and research arenas.
Acknowledgments: The authors thank Charles Smith, and David
Gloth for their diligent technical assistance with this study and express
their gratitude to the study subjects for their interest in contributing to
such research efforts.
References
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2. Gloth III FM, Walston JD, Meyers JM, Pearson J. Reliability and
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questionnaire. Am J Phys Med Rehabil 1995;74:45-53.
3. Folstein MF, Folstein SE, McHugh PR. "Mini-Mental State": a
practical method for grading the cognitive state of patients for the
clinician. J Psychiatr Res 1975; 12:189-98.
4. Kazis LE, Anderson JJ, Meenan RF. Effect size for interpreting
changes in Health Status. Med Care 1989;27 Suppl:S 178-89.
5. Liang MH, Larson MG, Cullen KE, Schwartz JA. Comparative
measurement efficiency and sensitivity of five health status
instruments for arthritis research. Arthritis Rheum 1985;28:542-7.
6. Guyatt G, Walter S, Norman G. Measuring change over time:
Assessing the usefulness of evaluative instruments. J Chron Dis
1987;40:171-8.
7. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies
of illness in the aged. The index ofADL: a standardized measure of
biological and psychological function. JAMA 1963; 185:914-9.
8. Guralnik JM, Branch LG, Cummings SR, Curb DJ. Physical perfor-
mance measures in aging research. J Geronto11989;44:M141-6.
9. Weinberger M, Samsa GP, Schmader K, Greenberg SM, Carr DB,
Wildman DS. Comparing proxy and patients' perceptions of
patients' functional status: results from an outpatient geriatric
clinic. J Am Geriatr Soc 1992;40:585-8.
10. Gerety MB, Cornell JE, Mulrow CD, Tuley M, Hazuda HE
Lichtenstein M, et al. The Sickness Impact Profile for Nursing
Homes (SIP-NH). J Gerontol 1994;49:M2-8.

Name of the participant:.
ID #:.
Date:
APPENDIX 1: FEFA QUESTIONNAIRE
1. Are you able to walk?
_ _ a. Yes, without help
_ _ b. Yes, with a cane or walker
c. Yes, with the help of another person
__d. Not at all
2. Can you transfer out of bed?
a. Yes, alone without a transfer board or other assis-
tive device
_ _ b. Yes, with the help of a transfer board or other device
_ _ c. Yes, With the help of one or more than one person
_ _ d. Yes, with the help of both another person and some
assistive device
e. Not at all
3. Are you able to turn over on your side in bed?
_ _ a. Yes, without help
_ _ b. Yes, with assistive device(s)
_ _ c. Yes, with some help from another person
d. No, must beturned
4. Are you able to wash dishes?
__a. Yes
__b. No
5. Are you able to prepare your own hot dinner?
__a. Yes
_ _ b. No, but am able to heat up already prepared meals
_ _ c. No, but am able to make a peanut butter and jelly
sandwich
_ _ d. Not at all
6. Are you able to manage money (paying bills, keep check-
book, etc)?
__a. Yes
_ _ b. Partially, but not major bills and balancing a check-
book
_ _ c. Sign checks but unable to handle even minor trans-
actions
__d. No
7. Are you able to use the telephone?
_ _ a. Yes, !ncluding dialing and answering the phone
_ _ b. Yes, but unable to dial
_ _ c. Yes, but am not able to dial or pick up receiver
__d. No
8. Are you able to eat by mouth, including feeding your-
self?.
_ _ a. Yes, without help
_ _ b. Yes, with assistive device(s)
_ _ c. No, but can eat iffed
d. No, but can give own tube feeding
_ _ e. No, must be tube fed
/
9. Are you able to dress yourself in pants, shirt or blouse, slip
on shoes, and socks if clothes are placed out?
_ _ a. Yes, without help of either a person or assistive
device
_ _ b. Yes, Wth assistive device(s)
_ _ c. Part!ally, but some help is required from another
person
d. No, Completely dependent on another person
FRAIL ELDERLY FUNCTIONAL ASSESSMENT, Gloth 1575
APPENDIX 1: FEFA QUESTIONNAIRE (Cont'd)
10. Are you able to dress yourself in a robe and slippers if
both are placed out?
_ _ a. Yes, without help of either a person or assistive
device
_ _ b. Yes, with assistive device(s)
c. Partially, but some help is required from another
person
d. No, completely dependent on another person
11. Are you able to bathe in a tub or shower yourself?
_ _ a. Yes, without help
_ _ bo Yes, with assistive device(s), eg, tubchair or grab
bar
_ _ c. Partially, but some help is required from another
person
_ _ d. Partially, but some help is required from another
person and assistive device(s)
_ _ e. No, completely dependent on another person
12. If the answer to #11 was 'e' (completely dependent on
another person), are you able to sponge bathe yourself?
_ _ a. Yes, without help
_ _ b. Partially, but some help is required from another
person
_ _ c. No, completely dependent on another person
_ _ d. Not applicable (#11 was a, b, c, or d)
13. Are you able to use the toilet, including getting to the
bathroom?
_ _ a. Yes, without help
_ _ b. Yes, with assistive device(s)
_ _ c. Yes, with some help from another person
_ _ d. Yes, with help from another person and assistive
device(s)
_ _ e. No, unable to use toilet in the bathroom
If you answered #13 as 'a' (yes, without help) skip to #15.
14. If you answered #13 above as 'e' (unable to use toilet in
the bathroom) are you able to use a bedside commode?
_ _ a. Yes, without help
_ _ b. Yes, with assistive device(s)
_ _ c. Yes, with some help from another person
d. Yes, with help from another person and assistive
device(s)
_ _ e. No, unable to use bedside commode
_ _ f. Not applicable (#13 was a, b, c, or d)
If you answered #14 as 'a' (yes, without help) skip to #16
15. If you answered #14 above as 'e', unable to use bedside
commode, are you able to use a bedpan/urinal?
_ _ a. Yes, without help
_ _ b. Yes, with help
_ _ c. No, am unable to recognize bladder fullness or
bowel movement
d. No, have an ostomy (who cares for the site and
empties the bag?. )
_ _ e. Not applicable (#13 or #14 was a, b, c, or d)
16. Are you ableto sit up?
_ _ a. Yes, without help
_ _ b. Yes, with assistive device(s)
_ _ c. Yes, but some help is required from another
person
__d. No
Arch Phys Med Rehabil Vol 80, December 1999

1576 FRAIL ELDERLY FUNCTIONAL ASSESSMENT, Gloth
17. Are you
__a.
__b.
__c,
18. Are you
__a.
__b,
__c,
19. Are you
day?
__a.
__b,
APPENDIX 1: FEFA QUESTIONNAIRE (Cont'd}
d.
able to grasp a cup or a cloth with your hands?
Yes, either hand
Yes, but only with one hand
No
able to reach out past your nose?
Yes, with arm fully extended at shoulder level
Yes, but can not fully extend at shoulder level
No
usually able to take your own medications every
Yes, without help
Yes, if medication doses are set out by another
person
No, must have medication administered by
another person
No, do not take medication on a daily basis
Arch Phys Med Rehabil Vol 80, December 1999
APPENDIX 2: FEFA QUESTIONNAIRE SCORING INSTRUCTIONS
1. a) 0; b) l; c) 2; d) 3
2. a) 0-d) 3
3. a) 0-d) 3
4. a) 0-b) 1
5. a) 0-d) 3
6. a) 0-d) 3
7. a) 0-d) 3
8. a) 0-e) 4
9. a) 0-d) 3
10. a) 0-d) 3
11. a) 0-e)4
12. a) 0-c) 2; d) 0
13. a) 0-d) 3; e) 0
14. a) 0-e) 4; f) 0
15. a) 0-d) 3; e) 0; if answer is d and patient cares for and
empties ostomy without help score as 0
16. a) 0-d) 3
17. a) 0-c) 2
18. a) 0-c) 2
19. a) 0-c) 2; d) 0
Total 0 to 55 (low scores infer better function).