Nephrology - Original Paper

International Urology and Nephrology

, Volume 45, Issue 1, pp 259-264

First online:

Routine use of an abbreviated 4-item scale to assess dependence in essential activities of daily living amongst elderly hemodialysis patients: a validation study

  • Farhat FarrokhiAffiliated withInstitute of Health Policy, Management and Evaluation, University of Toronto
  • , Sarbjit V. JassalAffiliated withInstitute of Health Policy, Management and Evaluation, University of TorontoDivision of Nephrology, University Health NetworkDepartment of Medicine, University Health Network Email author 

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Poor functional status is associated with reduced survival and poor outcomes in older dialysis patients. The Geriatric Nephrology Advisory Group recommends routine evaluation of functional status on all older patients; however, assessments can be time consuming and burdensome to clinical care providers. The objective of this study was to validate an abbreviated 4-item self-report screening tool for use in elderly hemodialysis patients.


The functional dependence of community-dwelling hemodialysis patients, aged ≥65 years, was measured by trained evaluators. The accuracy of a 4-item self-report activities of daily living (ADL) score was compared against formal evaluation by the Barthel Index and the outcomes using agreement statistics and Cox regression analysis.


The cohort included 167 patients with a mean age of 74.8 ± 5.9 years (57 % males). The 4-item scale correctly identified 83 % of the patients dependent in ≥1 ADL. Those incorrectly identified as independent on the abbreviated scale were uniformly unable to climb stairs without assistance. The sensitivity and specificity, and coefficient for agreement between the 4-item scale and the Barthel Index were 83.2, 100 and 0.78 %, respectively. The positive and negative predictive values of the 4-item scale were 100 and 76.9 %, respectively. Using the 4-item scale, the presence of severe disability was predictive of increased mortality (HR 12.5; 95 % CI 2.5–65.0; P = 0.03).


The 4-item scale is a simple, valid screening test for disability which can be used in the elderly population on dialysis as a screening tool. Difficulties with stair climbing may be overlooked using this score.


Hemodialysis Functional impairment Barthel Index