Translation and Validation of the Activities of Daily Living Scale with Iranian Elderly Cancer Patients Treated in an Oncology Unit

  • Khoei, Mahtab Alizadeh (School of Public Health, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences) ;
  • Akbari, Mohammad Esmail (Cancer Research Center, Shahid Beheshti University of Medical Sciences) ;
  • Sharifi, Farshad (Elderly Health Research Center, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences) ;
  • Fakhrzadeh, Hossein (Elderly Health Research Center, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences) ;
  • Larijani, Bagher (Elderly Health Research Center, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences)
  • Published : 2013.05.30


Background: This study evaluated the validity and reliability of applying the Katz's Activities of Daily Living (ADL) scale in an Iranian sample of elderly oncologic patients following initial cancer treatment. Materials and Methods: The scale was translated with the forward-backward procedure to give an Iranian version. The ADL scale was then applied in a random sample of 400 oncologic patients aged 60 and older following initial cancer treatment. Assessment of the scale stability was twice, with a 14-days (two weeks) interval, to 30 (of the 400) eligible elderly cancer patients in March 2012. To measure treatment effects, the index was run with 150 patients in a three month recall, following oncology processing. Exploratory and confirmatory factor analysis was performed for assessment of construct validity of the Katz's ADL. Reliability was measured with internal consistency (Cronbach's alpha co-efficient), and test/retest (Spearman's r value) of the instrument. Criterion validity was evaluated by comparing the Katz with Physical Function (PF) subscale of SF 36. Known-group validity was approved by comparing of Katz' ADL between quartile groups of PF subscale of SF 36. Results: In our study the ADL demonstrated a high degree of internal homogeneity (Cronbach's alpha 0.923). There was a high correlation between scores of two time measurement of Katz's ADL (p value of two- related- samples test was 0.3). Construct validity showed a correlation coefficient of 0.572 between the ADL and PF scores. In factor analysis, 2 factors were extracted. Evidence for the reliability of the questionnaire was good and known group validity was approved by significant differences of ADL score between quartiles of the PF subscale of SF36. Conclusions: The results suggest that the Iranian version of ADL applied for oncologic older adult patients following initial cancer treatment is a reliable and a valid clinical instrument and comparable to those reported in other studies.


  1. Aapro M, Extermann M, Repetto L (2000). Evaluation of the elderly with cancer. Ann Oncol, 11, 223-9.
  2. Allen SM, Mor V, Raveis V, et al (1993). Measurement of need for assistance with daily activities: quantifying the influence of gender roles. J Gerontol Ser B Psychol Sci Soc Sci, 48, 204-11.
  3. Alvarez M, Alaiz AT, Bru E, et al (1992). Capacidad functional de pacientes mayores de 65 anos, segun el indice de Katz. Fiabilidad del metodo. Aten Primaria, 10, 812-6 (in Spanish).
  4. Balducci L, Extermann M (2000). Cancer and aging. An evolving panorama. Hematology-Oncology Clinics North Am, 14, 1-16.
  5. Brorsson B, Asberg K (1984). Katz index of independence in ADL. Reliability and validity in short-term care. Scan Med D J Rehabil, 16, 125-32.
  6. Ciesla JR, Shi L, Stoskopf CH, et al (1993). Reliability of Katz's Activities of Daily Living Scale when used in telephone interviews. J Educ Eval Health Prof, 16, 190-203.
  7. Cohen ME, Marino RJ (2000). The tools of disability outcomes research functional status measures. Arch Phys Rehabil, 81, 21-8
  8. Cummings SM, Neff JA, Ban H, et al (2003 ). Functional impairment as a predictor of depressive symptomatology: The role of race, religiosity, and social support. Health Soc Work, 28, 23-32.
  9. Darzin P (2004). Personal care participation and resource tool (PC 548Q4 PART). Greythorn.
  10. Eshaghi SR, Ramezani MA, Shahsanaee A, et al (2006). Validity and reliability of the short form-36 item questionnaire as a measure of quality of life in elderly Iranian population. Am J Applied Sci, 21, 1763-6.
  11. Extermann M, Aapro M, Bernabei R, et al (2005 ). Use of comprehensive assessment in older cancer patients: Recommendations from the task force on CGA of the International Society of Geriatric Oncology (SIOG). Crit Rev Oncol Hematol, 55, 241-52.
  12. Fisher A (1995). Assessment of motor and process skills (AMPS): Three Star Press, Colorado.
  13. Fitzgerald JF, Smith DM, Martin DK, et al (1993). Replication of the multidimensionality of activities of daily living. J Gerontol, 48, 28-31.
  14. Frick J (1993). Measuring outcomes in rehabilitation: a review. Br J Occup Ther, 56, 217-21.
  15. Gilbertson-White S, Aouizerat B, Jahan T, et al (2011). A review of the literature on multiple symptoms, their predictors, and associated outcomes in patients with advanced cancer. Palliat Supp Care, 9, 81-102.
  16. Given CW, Given BA, Stommel M, et al (1994). The impact of age, treatment, and symptoms on the physical and mental health cancer patients. Cancer Supplement J, 74, 2128-38.<2128::AID-CNCR2820741721>3.0.CO;2-J
  17. Hamrin E, Lindmark B (1988). Evaluation of functional capacity after stroke as a basis for active intervention. Scand J Caring Sci, 2, 113-22.
  18. Ingram S, Seo P, Martell R, et al (2002). Comprehensive assessment of the elderly cancer patient: The feasibility of self-report methodology. J Clin Oncol, 20, 770-5.
  19. Inouye SK, Peduzzi PN, Robison JT, et al (1998). Importance of functional measures in predicting mortality among older hospitalized patients. JAMA, 279, 1187-93
  20. Jette AM, Haley SM (2005). Contemporary measurement techniques for rehabilitation outcomes assessment. J Rehabil Med, 37, 339-45.
  21. Jitapunkul S, Kamolratanakul P, Ebrahim S, et al (1994). The meaning of activities of daily living in a Thai elderly population: development of a new index. Age Ageing J, 23, 97-101.
  22. Kagawa-Singer M, Blackhall LJ (2001). Negotiating crosscultural issues at the end of life: “You got to go where he lives”. JAMA, 286, 2993-3001.
  23. Katz S (1983). Assessing self maintenance: activities of daily living, mobility and instrumental activities of daily living. J Am Geriatr Soc, 31, 721-7.
  24. Katz S, Downs TD, Cash HR, et al (1970). Progress in development of the index of ADL. Gerontologist, 10, 20-30
  25. Katz S, Ford AB, Moskowitz RW, et al (1963). Studies of illness in the aged. The Index of ADL: a standardized measure of biological and psychosocial function. JAMA, 185, 914-9.
  26. Katz S, Vignos PJ , Moskowitz RW,et al (1968). Comprehensive outpatient care in rheumatoid arthritis, a controlled study. JAMA, 206, 1249-54.
  27. Kempen GIJM, Surrmeijer TPBM (1990). The development of a hierarchical polychotomous ADL-IADL scale for noninstitutionalized elders. Gerontologist, 30, 497-502.
  28. Law M, Baum CM, Dunn W, et al (2005). Measuring occupational performance: supporting best practice in occupational therapy: SLACK Inc, Thorofare.
  29. Lawton MP, Brody EM (1969). Assessment of older people: selfmaintaining and instrumental activities of daily living. Gerontologist, 9, 179-86.
  30. Lewinter M, Kesmez SS, Gezgin K, et al (1993). Self-reported health and functional status of elderly Turkish immigrants in Copenhagen, Denmark. Scand J Soc Med, 21, 159-63.
  31. Maione P, Perrone F, Ciro G, et al (2005). Pretreatment quality of life and functional status assessment significantly predict survival of elderly patients with advanced non-small-cell lung cancer receiving chemotherapy: a prognostic analysis of the multicenter italian lung cancer in the elderly study. J Clin Oncol, 23, 6865-72.
  32. Mystakidou K, Tsilika E, Parpa E, et al (2012). Activities of daily living in Greek cancer patients treated in a palliative care unit. Support Care Cancer, 21, 1497-5
  33. Portney LG, Watkins Mp (2009). Foundations of clinical research: Applications to practice: Pearson,Prentice Hall.
  34. Portney LG, Watkins MP. Foundations of clinical research: Applications to practice. edn r, editor: Pearson/Prentice Hall; 2009.
  35. Repetto L, Fratino L, Audisio RA, et al (2002). Comprehensive geriatric assessment adds information to eastern cooperative oncology group performance status in elderly cancer patients: an italian group for geriatric oncology study. J Clin Oncol, 20, 494-502.
  36. Repetto L, Venturino A, Vercelli M, et al (1998). Performance status and comorbidity in elderly cancer patients compared with younger patients with neoplasia and elderly patients without neoplastic conditions. Cancer, 82, 760-5.<760::AID-CNCR20>3.0.CO;2-V
  37. Reuben DB, Valle LA, Hays RD, et al (1995). Measuring physical function in community-dwelling older persons: a comparison of self-administered, interviewer-administered, and performance-based measures. J Am Geriatr Soc, 43, 17-23
  38. Sainsbury A, Seebass G, Bansal A, et al (2005). Reliability of the Barthel Index when used with older people. Age Ageing, 34, 228-32.
  39. Sands LP, Landefeld CS, Ayers SM, et al (2005). Disparities between black and white patients in functional improvement after hospitalization for an acute illness. J Am Geriatr Soc, 53, 1811-6.
  40. Sands LP, Yaffe K, Covinsky K, et al (2003). Cognitive screening predicts magnitude of functional recovery from admission to 3 months after discharge in hospitalized elders. J Gerontol A Biol Sci Med Sci, 58, 37-45.
  41. Spector WD, Fleischman JA (1998). Combining activities of daily living with instrumental activities of daily living to measure functional disability. J Gerontol, 53, 46-57.
  42. Spector WD, Kat S, Murphy JB, et al (1987). The hierarchical relationship between activities of daily living and instrumental activities of daily living and instrumental activities of daily living. J Chron Dis, 40, 481-9.
  43. Stafford RS, Cyr PL (1997). The impact of cancer on the physical function of the elderly and their utilization of health care. Cancer, 80, 1973-80.<1973::AID-CNCR15>3.0.CO;2-V
  44. Stewart MA, Ware JE, Brook RH (1981). Advances in the measurement of functional status: construction of aggregate indexes. Medical Care J, 14, 437-88.
  45. Unsworth CA, Duncombe D, Duncombe E (2004). AusTOMs for Occupational Therapy: La Trobe University, Melbourne.
  46. Wade DT (1992). Measurement in neurological rehabilitation: Oxford Univ. Press, Oxford.
  47. Wallace M, Shelkey M (2008). Monitoring functional status in hospitalized older adults. AJN: Am J Nurs, 108, 65-71.
  48. Ware JE, Sherbourne CD (1992). The MOS 36-Item Short-Form health survey (SF-36), conceptual framework and item selection. Med Care J, 30, 473-481.
  49. Wilkins M (1991). Cancer in the elderly patient. In Pathy MSJ, Sinclair AJ & Morley JE (Eds.), Principles and Practices of Geriatric Medicine. (pp. 1385-1396). Chichester: Wiley.
  50. World Health Organization ( 2001 ). International classification of functioning, disability and health (ICF): World Health Organization, Geneva.
  51. Yancik RM, Ries L (1998). Cancer and age: magnitude of the problem. In Balducci L, Lyman GH & E. WB (Eds.), Comprehensive geriatric oncology (pp. 95-104): Harwood Academic Publishers, London.
  52. Zustovich F, Shams M, Anselmi P, et al (2009). Cognitive and emotive state in elderly treatment naive patients with advanced cancer compared with an elderly healthy control population. Cancer Ther, 7, 149-52.

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