The ability to perform basic daily activities in and around the house was assessed by self report. A questionnaire assessing independence in activities o f daily living (annex 5.7) was used based on the K atz scale (1989), one o f the most widely used and validated scales. The scale aims to appraise the degree o f independence in six basic activities: eating, transferring6, dressing, bathing, toileting and continence7. Subjects would report on w hether they w ere able to perform a particular task independently, or whether they required partial o r total assistance. The answer was recorded as a score ranging from 0 to 2. Further the questionnaire included questions on basic mobility. In addition mobility was also recorded as observed by the interviewer. The wording was amended from the questionnaire used in India to adapt to the different cultural context.
5.5.3 Physical performance tests
The Indian protocol (M anandhar, 1999) was also largely followed for the physical tests. It included tests described in the N H ANES III physical function examination protocol (1990) and by Bassey (1990). The tests were selected on th e basis o f suitability for community studies in developing countries (simplicity, involvement o f minimum equipment, cultural appropriateness, low risk o f falling/injuries) and measured the following dimensions: manual dexterity, flexibility, muscular strength, psychom otor co ordination and cognitive function. The subjects were encouraged to perform to the best o f their ability. The tests are described in the following sections.
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6 The ability to transfer oneself from the bed to a chair, from the floor to standing etc.
Continence is quite distinct from the other ADLs in the sense that it refers to the ability to control particular muscles rather than (independence in a certain activity.
Cognitive function
Short term m em ory was assessed by the object recall and w ord recall tests. F o r the object recall test, the subject was asked to look carefully for 1 minute at a tray w ith fifteen familiar objects8. In order to make subjects concentrate, they were asked to nam e the objects out loud. Then the tray was covered and after all other tests were finished, the subject w as given 1 minute to recall as many objects as possible.
The word recall test also aims to measure short term memory with special em phasis on the ability to process and retain verbal information, an aspect that may be o f specific interest in the daily life o f illiterate people. A fter explaining the test, three w o rd s9 referring to familiar things in their daily life, w ere mentioned slowly and clearly. The words were to be repeated by the subject immediately. The recalled num ber was recorded and after seven other questions w ere asked (approximately 10 m inutes), the subject was asked to mention the w ords again. T he second score was also recorded.
Cognitive function as observed by the nurse w as recorded as well as assessed by a set o f questions about the day, month and religious festivals (annex 5.8). Appropriate questions were formulated by the team after exploring the relevance in group discussions.
Manual dexterity
Manual dexterity was measured by the lock and key test. A simple padlock w a s held upright at the edge o f a table by the observer. T he key was on the table next to th e lock10 in such position that it did not need to be turned before insertion into the lock. The subject was seated on a chair in front o f the lock and key, and was allowed to u s e only one hand. Timing was started as soon as the subject touched the key and ended at the moment the lock opened.
Flexibility
Flexibility o f shoulder joints w as assessed by tw o simple exercises: internal and external shoulder rotation. The exercises were dem onstrated by the measurer and copied by the
’ The following objects were selected by the team: pen, comb, lantern, straw, spool of thread, pipe, big nail, spoon, wrist watch, big coin, box of matches, battery, piece of soap, cup, key.
The three words selected by the team were: moon, water, fire.
subject, if possible in a standing position. For the external shoulder rotation the hands were put behind the neck at ear level, w ith the arm s parallel to the floor and elbows pointed outwards (plate 5.7). F o r the internal rotation the arms were put behind the back at waist level, with fingers touching in the middle o f the back near the spine and elbows pointing outwards.
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P late 5.7 External shoulder rotation
Muscle strength
Repeated chair rises" m easured lower body muscle strength. The subject w as seated on a chair o f 47 cm height (placed against a wooden pole to steady it) with feet slightly apart on the floor and arm s folded across the chest. The subject would first be asked to move forward while seated until half-way along the chair seat (arms remain folded) to assess trunk control. Then (s)he was asked to stand up once (with folded arms). If this
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did not give problems, the subject would be tim ed doing this five times as fast as possible.
Upper body muscle strength w as measured by the handgrip test for which a mechanical Harpenden handgrip dynam ometer was used. B oth hands were alternately m easured in triplicate, with a final extra attem pt on the preferred hand. This allowed the technique to become familiar and the subject to be given several chances to improve the reading. The measurements w ere taken in sitting position w ith the fore-arm resting across the stomach. After an explanation and adjustment o f th e dynamometer to the size o f the hand, the subject squeezed the handle as forcefully as possible for a few seconds and released (plate 3.2).
Psychomotor coordination
A plate tapping exercise w as used to measure speed and coordination skills. The equipment was a table o f 82 cm height with tw o circular discs (20 cm in diam eter) fixed on to the table to p with the centre o f the discs 80 cm apart, and a rectangular shape fixed in between the disks. The subject would stand in front o f the table (or sit if standing gave problems) in front o f the rectangular shape, the feet slightly apart. The non-preferred hand would be placed on the rectangular shape and stay there. The other hand was moved as quickly as possible back and forward betw een the circular discs, touching them in the centre. The time to com plete 25 laps was measured and inappropriate ta p s were excluded (plate 3.1).
The tests were taken in the following order: first part o f mem ory test (looking at objects), lock and key test, external and internal shoulder rotations, chair stands, first plate tapping, handgrip test, second plate tapping, last part o f m emory test (recalling objects).