The Texas Functional Living Scale (TFLS) by Cullum et al. (2001) is a performance-based assessment that measures instrumental activities of daily living (IADLs) across 4 subscales: time, money and calculation, communication, and memory. Initially designed for those with neurocognitive disorders (NCDs), subsequent studies suggest that it may be useful across a number of diagnoses where IADL engagement is of primary concern (Binegar, 2007). The TFLS contains 24 activities that assess various aspects of IADLs such as using an analog clock, calendar, check book, phone, and setting a microwave. Other tasks include calculations involving time and money as well as recall of information within a 15-minute span (Drozdick & Cullum, 2011). Scores range from 0 to 5 for each activity with a maximum possible score of 52. Total scores and cumulative percentages are recorded for each of the 4 subscales and an overall T-score is calculated for the entire test. The TFLS takes approximately 15 to 20 minutes to administer and higher scores are suggestive of better IADL functioning.
Original research by the authors of 21 subjects with NCD of the Alzheimer’s type and 21 controls demonstrated a strong correlation between the TFLS and the Mental State Examination at r = 0.92, whereas the TFLS was only moderately correlated with the Blessed Dementia Rating Scale (Cullum et al., 2001). The same study showed 1-month test-retest reliability to be high as well as a strong correlation between the subscale scores and the total score at r = > 0.90 for most items was noted (Cullum et al., 2001). Another study by Binegar, Hynan, Lacritz, Weiner, and Cullum (2009), in their examination of individuals with mild cognitive impairment, found no significant relationship between TFLS and Mini Mental State scores for either intervention or control group at r = 0.26 for the intervention group while the normal control group the relationship was r = 0.25; however, a moderate correlation was noted when both groups scores were combined at r = 0.34. Further analyses determined the sensitivity and specificity scores for the observed cohort ranged from 40 to 52 where a cutoff score of 48 represented the highest combination of sensitivity (0.57) and specificity (0.63), yielding a percent accurate group classification of 0.60. Lyon (2012) found that correlations between TFLS T-Score and Wechsler Memory Scale (WMS–IV) subtest scores ranged from 0.46 (Logical Memory II) to 0.60 (Logical Memory I, Verbal Paired Associates II, and Visual Reproduction I) suggesting that memory is moderately related to IADLs performance. Drozdick and Cullum (2011) found that the correlations between the TFLS T-score and the Wechsler Adult Intelligence Scale (WAIS-IV) were higher in the overall clinical sample (i.e., traumatic brain injury, NCD, autism, or major depression) than in the normative group where the subtest scores of the WAIS were moderate to highly correlated (range = 0.63 to 0.80).
The TFLS is a brief and easily administered performance-based measure of daily functional capabilities that is sensitive to level of cognitive impairment and has shown to be applicable in patients with varying degrees of NCD (Cullum et al., 2001). Initial research has also demonstrated good reliability, internal consistency, and convergent and discriminant validity with several measures of global cognitive status and behavioral functioning (Cullum et al., 2001). No special training or certifications are required for its administration. The TFLS is managed by and can be purchased from Pearson Psych Corp.
The TFLS is a relatively new outcome measure and more supportive data is needed to ascertain its utility in a variety of clinical populations (Drozdick & Cullum, 2011). Another potential downside may be found in the design of the cue card system used where Lindsey-Glenn and Strang (2010) note that the black-and-white line drawings may be difficult for some people to use or interpret. For example, the microwave oven may be suggestive of a poor representation where using real objects or models of real objects might be more effective. A similar argument can be made concerning those cue cards provided for the water bill, writing a check, and addressing an envelope in which their appearance may make it difficult for persons with developmental disabilities to make accurate inferences.
During administration the client may be asked to respond to items containing oral and visual cues depending on the nature of the particular item being assessed, such as writing a check or looking up information in a phone book (Lindsey-Glenn & Strang, 2010). For example, a client may be asked to point to the date on a calendar. A correct response given would earn 3 points, whereas 2 points would be given if they point to only the correct week but not the correct day, and 1 point if they point to the correct month only, etc. (Binegar, 2007). Other activities include telling time on a traditional clock, making change, paying a bill, using a phone and phonebook, managing medications, and making a snack. The test kit contains stimulus cards for some of the items as well as a list of other items needed, which includes a calendar, stop watch, and various coin and bill denominations. Explicit instructions and scoring interpretation guidelines are included in the manual.
The TFLS is an assessment battery that can be purchased from Pearson at the information that follows for a cost of $163. Use in research or publication can also be obtained by contacting Pearson or its creators at the addresses below. Further information can be found in the following original journal article.
Cullum, C., Saine, K., Chan, L., Martin-Cook, K., Gray, K., & Weiner, M. (2001). Performance-based instrument to assess functional capacity in dementia: The Texas Functional Living Scale. Neuropsychiatry, Neuropsychology, and Behavioral Neurology, 14(2), 103-108.
|POPULATION||NCD, suspected cognitive impairment|
|TYPE OF MEASURE||Performance-based|
|WHAT IT ASSESSES||Abilities relative to time, money and calculation, communication, and memory|
|TIME||15 to 20 minutes|
Munro Cullum, PhD.
University of Texas Southwestern Medical Center
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