Barthel Index: what is it, how is it used and what does it evaluate?

Let's take a look at the characteristics of this psychological assessment tool.

Let's think for a moment about what the vast majority of people do every day from the moment they wake up. We get up, shower and wash, get dressed, eat breakfast, go to work/study, eat... these are apparently simple activities that we have automated and that we do not usually stop to think about.

But these are basic activities that we all have to do simply to stay healthy and have a certain autonomy, and that we have been learning and developing throughout life.

However, in some cases (accidents, dementia and other neurological illnesses, disability...) it is possible that a person loses the ability to do them on his or her own or may not be able to develop them at all. Bearing in mind that these are basic skills, this implies that in order to achieve an adaptive daily functioning, the subject will need help to carry them out: he/she will have a certain level of dependence, either temporarily or permanently.

Assessing when a person is dependent and the degree to which he/she needs specific help is not as simple as it may seem at first glance, but fortunately there are different assessment tools that allow us to make such an assessment. One of them is the Barthel Index or scale.which we are going to talk about in this article.

The Barthel Index

The Barthel Index or Barthel Scale, which is sometimes also called the Maryland Disability Index, is an assessment instrument in the form of a scale widely used by various professionals in the social and health care field to evaluate or assess the level of independence that a person has when it comes to performing basic activities.

This measure allows to evaluate the existence of a physical or neurological disability that entails a difficulty in the performance and accomplishment of fundamental tasks in our day to day life.

Specifically, this index assesses the so-called basic activities of daily lifewhich are understood as the set of actions and activities that a person needs to do in order to maintain adequate self-care and stay healthy and active. That is to say, unlike other activities that are linked more to the relationship of the subject with the surrounding environment, the basic ones focus on how the subject maintains himself.

Not being able to perform these activities is clearly detrimental to the physical and mental integrity of the subject and could even lead to death if not helped.

The application of the Barthel index, which began to be used in hospitals in 1955, seeks to evaluate the performance in a total of ten of these basic activities in such a way that The Barthel Index, which began to be used in hospitals in 1955, seeks to evaluate how the individual can perform them without any problem.The Barthel Index is used in hospitals since 1955.

Its total score (with a maximum of 100 and a minimum of 0) gives us a general idea of the need for external support, although each of the available items can give us relevant information on which areas or types of activities are problematic or whether a particular type of support can be provided.

It should be borne in mind that this index should be passed at the initial moment in order to assess whether or not the subject has problems in daily life, but also during and after any rehabilitation intervention that is used. This will allow us to see whether or not such intervention has been successful and at what level, as well as to adjust the type and level of help provided to the patient's needs. It is also important to bear in mind that we evaluate what the subject does, not what he/she could do..

Basic activities evaluated

The Barthel Index or Barthel Scale evaluates a total of ten basic activities of daily living, which can be divided mainly into feeding, hygiene, movement and sphincter control. The specific activities that are observed are as follows.

1. Eating

This item assesses whether the subject is able to eat by him/herself. It involves being able to put food in the mouth, chew and swallow.. In addition, it also assesses whether the subject is able to perform actions such as cutting the food or pouring water, although if despite not being able to do these last actions he/she can eat by him/herself, he/she will also have a score other than zero (10 if he/she can do everything independently, 5 if he/she needs help to cut, use cutlery, etc.). If he needs complete help to be able to eat, the score is 0.

It is important to bear in mind that what is valued is the act of eating itself: it does not matter for this valuation whether the person has cooked the food or whether someone else has prepared and served it.

2. Washing/Personal hygiene

This activity involves being able to maintain bodily hygiene on one's own, so that one is able to shower and clean oneself independently.

It also takes into account whether you are able to get in and out of the bathroom. It is assessed whether he/she needs help or supervision (0) or whether he/she can do it independently (10)..

3. Dressing

Dressing is another basic activity. Here it is assessed whether the subject can put on and take off clothes independently and without help (10 points), has to be helped at some times but can do most things by himself (5 points) or needs someone to help him at all times (0 points).

3. Grooming

This activity involves in part personal grooming, e includes actions such as combing your hair, washing your face or hands, shaving or putting on make-up. It is assessed whether the subject can do it by him/herself (10) or needs help to do it (0).

4. Continence/fecal incontinence

On this occasion we are talking about a basic activity in which the subject eliminates the residues of digestion by fecal means. It is assessed whether the subject is able to hold the stool (10 points), whether he/she has an occasional episode of incontinence or needs help from time to time (5) or whether he/she is unable to control the sphincters by him/herself, having incontinence on a regular basis (0).

This assessment is made taking into account the performance during the week prior to the assessment..

5. Urinary incontinence/continence

In the same way that fecal incontinence is evaluated, urinary incontinence is also assessed.

In this regard, also taking into account the performance in the week prior to the evaluation, it will be observed if the subject can hold urine and/or take care of the operation of a possible catheter (10 points), if he/she has episodes (maximum 1 daily) of incontinence (5) or if he/she is habitually unable to hold urine (0 points).

6. Toilet use

Linked to the previous two points, in this case it is assessed whether the subject is able to use the toilets (0 points). whether the subject is able to use the toilets by himself/herself.. If he/she can go to the toilet, take off his/her clothes, relieve him/herself and clean him/herself, 15 points are given.

If he/she needs help but is able to clean him/herself, 5 points will be given and if he/she needs help for both aspects, the item will be valued with 0 points.

7. Transferring to chair or bed

This activity would be among those that assess the subject's ability to move, specifically if he/she is able to sit or get up by him/herself or get in and out of bed.

The subject can be totally independent (15 points), need little help (10 points), need someone specialized and with great strength (something that implies that a great part of the effort is made thanks to such help) to help him although he can remain seated by himself (5 points) or need total help in which either a crane or several people move him and he cannot be seated (0 points).

8. Ambulation

Another of the basic activities that are evaluated in the Barthel Index or Barthel Scale is the ability to ambulate and move short distances.. It is assessed if the subject is able to walk 50 meters without the help of another person or walkers (although he/she may use crutches or canes). If he/she is able to walk independently, the score is 15 points, if he/she needs help or a walker, 10 points, and if he/she depends on help to move around, the score is 0.

In the case of persons in wheelchairs who are able to move independently with the wheelchair, 5 points will be awarded.

10. Using stairs

In most of our housing developments and houses we can find stairs, steps and changes in height, so that being able to use them is considered a basic activity of daily life when moving around.

A subject who can go up or down stairs independently is scored 10 points for this item, if he/she needs someone to help or supervise him/her 5 points and if he/she is not able to use the stairs the item is scored 0 points.

Scoring and significance

The Barthel Index or Barthel Scale is easy to apply and score.. Mainly note that the maximum score is 100 (90 in the case of wheelchair users) and that each item can be scored with 0, 5 or 10 points. Ten points are given when the subject is totally independent for the action referred to in the item, five points when he/she needs help for specific aspects or when he/she occasionally has difficulties and zero points are given when the subject is dependent in that activity.

It should also be noted that some items such as washing or grooming only have scores of 5 (independent) or 0 (dependent), and in the cases of moving or wandering a score of 15 is added to reflect that the subject can move without help (10 would imply minimal help or supervision).

The score obtained from this scale gives us an idea of the subject's degree of dependence. an idea of the degree of dependence of the subject being evaluated..

Scores of 100 imply total independence, and lower scores would reflect increasing dependence for activities of daily living. Scores between 100 and 60 indicate the existence of a slight dependence or need for help, between 55 and 40 a moderate dependence, between 35 and 20 would indicate a severe dependence and scores below 20 points would indicate that the subject has a total dependence.

Bibliographical references:

• Cid-Ruzafa, J. and Damián-Moreno, J. (1997). Assessment of physical disability: the Barthel index. Revista Española de Salud Pública, 71 (2). Madrid, Spain.
• Barrero Solís, C.L., García Arrioja, S. and Ojeda Manzano, A. (2005). Barthel Index (BI): An essential instrument for functional assessment and rehabilitation. Plasticity and Neurological Restoration, 4 (1-2). International Association for Brain Plasticity.