Author's reply : Journal of Family and Community Medicine

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Keshari, Priya; Shankar, Hari

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Journal of Family and Community Medicine: Jan–Apr 2018 - Volume 25 - Issue 1 - p 54-55
doi: 10.4103/2230-8229.222253
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We thank the researchers most sincerely for their interest in our study and appreciate their comments on the article entitled, “Prevalence and spectrum of functional disability of urban elderly subjects: A community-based study from Central India.” by Keshari and Shankar.[1] The strength of any article is based on the objectives of the study and methodology as well as subsequent research. While contemplating this study, we recognized that an assessment of the functional status of the study participants would be a critical input for the provision of their care. This also would predict the need for assistance for this age group. This study examined the performance of the participants on ten Activities of Daily Living (ADLs) which were grouped according to self-care (namely, feeding, grooming, bathing, dressing, bowel and bladder care, and toilet use) and mobility restriction (namely, mobility, transfer, and climbing of stairs).

The result of the study showed significantly higher involvement in activities belonging to the domain of mobility restriction in comparison to domain of self-care. This was confirmed by applying Z-test in the proportions of domain-wise involvement and made a case for prioritization of interventions for the improvement of activities pertaining to mobility. The study has also pinpointed the level of dependency, namely, total dependency, severe dependency, moderate dependency, slight dependency, and no dependency assessed on scoring of Barthel's Index based on the criteria suggested by Shah et al.[23] The spectrum of disability revealed by this study can serve as the basis for focused/targeted interventions and prioritization of resources. The results of the study in terms of patterns of activity of daily living [Table 1] and dependency status [Table 3] have been considered as an approach for vulnerability analysis of elderly participants and assistance for identified groups for focused interventions.

The major purpose of the study was to capture the overall situation of functional disability in elderly participants and predict the need for assistance for this group as a whole with regard to ADL. There are various tools for assessing the functional status of the elderly in a community setting. In adopting Barthel Index, we took into account the limitation of Katz Index, which lacks comprehensiveness, as it assesses only six basic functions of the ADL, whereas the ADLs covered by Barthel Index are representative of overall functional abilities of disabled persons. It thus met the requirement of the study, the objective of which was to assess functional disability in urban elderly participants.

The study adopted standard methodology for the selection of representative adequate sample. It is interesting to note that sample size estimation is done by taking a prevalence of 40% whereas our study revealed that 53.6% of the study participants had some functional disability. This amply underscores the adequacy of the sample size for summative (overall) estimate of functional disability in the elderly of urban Varanasi.

Assessment of association of functional disability with factors mentioned by researchers was not the purpose/objective of this communication.

We appreciate the concern of researcher about the use of Instrumental ADL (IADL) for the comprehensive assessment of functional status of the elderly. It is worth noting that Lawton's IADL Scale was developed to assess more complex activities necessary for functioning in community settings (e.g. shopping, cooking, and managing finances). The capacity to handle these complex functions is normally lost before basic “activities of daily living” (e.g. eating and bathing) which are measured by ADL scales.[4] Barthel index which was used in this study has been extensively tested for validity and has been found to be comparable with other measures of ability.[5]

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Conflicts of interest

There are no conflicts of interest.

1. Keshari P, Shankar H. Prevalence and spectrum of functional disability of urban elderly subjects: A community-based study from central India J Family Community Med. 2017;24:86–90
2. . The Original Barthel Index of ADLsLast accessed on 2016 Apr 24 Available from:
3. Shah S, Vanclay F, Cooper B. Improving the sensitivity of the Barthel index for stroke rehabilitation J Clin Epidemiol. 1989;42:703–9
4. . American Psychological Association Instrumental Activities of Daily Living Scale. Construct: Assessment of Complex Activities of Daily LivingLast accessed on 2017 Oct 09 Available from:
5. Granger CV, Albrecht GL, Hamilton BB. Outcome of comprehensive medical rehabilitation: Measurement by PULSES profile and the Barthel index Arch Phys Med Rehabil. 1979;60:145–54
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