Ageing results in an increased risk of chronic disease and disability, all of which contributes to the demand for acute and chronic healthcare services
. In Australia, the largest prevalence of disability is seen in groups aged 70 years and older, with the highest number of people with a disability seen in the 90 years and over age group (70.3%)
. Disability is comprised of three areas of functioning: 1) impairment, 2) activity limitations and 3) participation restrictions
. Older adults with a disability often require some form of support to live independently
. As such, reducing functional limitations experienced by older adults is an essential part of healthcare services.
Occupational therapists have long identified the link between engagement in meaningful daily activities and health and well-being
. As such, therapists aim to reduce functional limitations by providing interventions based on activity and participation. Current research has established occupational therapy’s role with older adults in enhancing functional independence in a number of areas for older adults, including community and stroke services, for example,
An important component of therapy is the evaluation of the intervention provided
. With an increasing demand on the healthcare system, it is imperative that services are demonstrating the effectiveness of interventions
. To provide accurate reflections of practice, occupational therapists should use valid and reliable assessments
[11, 12]. Yet, occupational therapists are favouring the use of non-standardised evaluations
[13–15]. With a number of valid and reliable assessments available for use, (for example. the Nottingham Extended Activities of Daily Living Scale
), questions must be raised as to why therapists are not routinely using these. Readiness of therapists to use validated assessment tools, skill, time, motivation, self-confidence, lack of support from management, personal values and beliefs, and lack of knowledge have all been suggested as reasons for limited uptake
[13, 15, 17–19].
There is little information regarding which functional assessment should be used by occupational therapists when working with older adults. Reviews of functional assessments from an occupational therapy perspective are available but lack methodical selection of assessments, leading to inaccurate reflections of assessment use. Law and Letts, 1989, conducted a literature search of assessment tools used to predict or evaluate activities of daily living (ADL). Authors reviewed the: 1) purpose of scale, 2) clinical utility, 3) scale construction, 4) standardisation, and 5) reliability and validity of identified assessments
. The authors concluded that no new ADL assessments should be created; instead, further research should be conducted to enhance current assessments. The Index of ADL, Barthel Index, the revised level of rehabilitation scale and physical maintenance scale were found to have the highest reliability and validity of those reviewed. The population and setting of interest was not specified by authors, which creates difficulty in translating results to practice. A similarly conducted study by Klein et al., 2008, compared 18 functional assessments to the Canadian Model of Occupational Performance to determine whether the assessment measured key occupational therapy perspectives
. Again, no information relating to population of interest or setting was provided, and no decisions relating to which assessment should be used in practice were made. Other research includes a literature review of six assessments (Candian Occupational Performance Measure, Assessment of Motor and Process Skills, McMaster Toronto Arthritis, Goal Attainment Scale, Target Complaints and Patient Specific Function)
. Authors described the measurement properties of each and concluded the need for occupational therapists to use assessments that are psychometrically sound and reflect practice. Since these tools do not measure the same construct, no definitive conclusions regarding use in practice can be drawn. The proposed review will identify functional assessments used in randomised trials to measure the effectiveness of occupational therapy interventions for at-risk older adults. We expect that reviewing randomised trials will capture a comprehensive selection of functional assessments, and that tools used in these trials would be of higher quality than in-house developed assessments of function that therapists favour in practice. In the second phase of this study, a comprehensive review of measurement properties of each assessment will be completed. The results of this study will provide an objective identification and evaluation of measurement properties of functional assessments used with older adults. Without such comparisons, therapists will continue to use a variety of different assessments which makes benchmarking of practice impossible. Identifying assessments used for measuring functional independence in older adults and their measurement properties will provide therapists with information needed to make informed decisions about the choice of assessment tools for practice.
This protocol outlines the methods to be used to systematically identify functional assessments used by occupational therapists with older adults at-risk of activity and participation limitations. The protocol also describes the process for reviewing the measurement properties of each assessment identified.
The review questions are as follows:
Phase one, systematic identification of functional assessments used in randomised trials: What functional assessments are used by occupational therapists to measure the effectiveness of enhancing functional independence for older adults at-risk of activity and participation limitations?
Phase two, measurement properties: Of the identified functional assessments, which is psychometrically superior for use with older adults at-risk of activity and participation limitations?
The definition of older adults at risk of functional limitations that will be applied to the review are: persons aged 70 years and over with one or more functional difficulties, who are transitioning from hospital to home or are community dwelling. Functional limitations and difficulties will be defined as limitations in activity performance and participation as described by the International Classification of Functioning (ICF)
. People with pre-existing functional difficulties are also at risk of further functional decline
 and will be included in this review.
Types of publications/studies
Randomised trials published in peer reviewed literature will be considered for this review. Articles must be published in English.
Settings and participants
Participants will be adults aged 70 years or older. Studies will be included where 50% or more of participants are 70 years and over. Participants will either need to be transitioning from hospital to home, or be community dwelling, and recipients of any occupational therapy intervention that aims to enhance functional independence. An occupational therapy intervention is one that is designed and/or implemented by an occupational therapist, provided solely or within a team setting. For example, if a rehabilitation team was providing functional intervention to an older adult and the occupational therapist had a component of intervention, this study would be included in the review.
Types of methods
Randomised trials in which a functional assessment is administered will be included. If the trial is a cross-over trial, both arms may be considered, if relevant.
Types of outcomes
Assessments will be included that measure activity performance and participation as defined using the ICF
 will be included. Assessment tools which measure ICF impairment will be excluded.
Search methods for the identification of studies
The following electronic databases will be searched: 1) Medline, 2) EBSCO, 3) OTseeker. Medical subject headings (MeSH) and text words will be combined in search strategies (Medline search strategy is attached in Additional file
1). Searches will be restricted to studies published in English. Reference lists of included studies will be independently searched by one reviewer to identify additional studies.