Functional Loss Table 14.1 Combined male and female symbol
MALIGNANT DISORDERS
Impairment Ratings Criteria
NIL Minor symptoms that are easily tolerated.
TEN Mild to moderate symptoms that are irritating or unpleasant but rarely prevent completion of any activity. Symptoms may cause loss of efficiency in some activities.
TWENTY More severe symptoms that are more distressing but prevent few everyday activities. Loss of efficiency is discernible in a good few activities. Self‑care is unaffected and independence is retained.
THIRTY‑FIVE Loss of efficiency discernible in many everyday activities. Some elements of self‑care are restricted but, in most respects, independence is retained.
FIFTY Major restrictions in many everyday activities. Capacity for self‑care is increasingly restricted, leading to partial dependence on others.
SEVENTY Most everyday activities are prevented. Dependent on others for most kinds of self‑care. Able to be maintained at home with considerable assistance and frequent medical care.
No age adjustment permitted for this table
Functional Loss Table 14.2 Combined male and female symbol
LIFE EXPECTANCY
Impairment Ratings Predicted Survival at the Time of Diagnosis or Staging Procedure
NIL Normal, or near‑normal, five year survival.
TEN Five year survival less than 75% of normal.
TWENTY Five year survival less than 50% of normal.
THIRTY‑FIVE Five year survival less than 25% of normal.
FIFTY One year survival less than 50% of normal.
SEVENTY One year survival less than 25% of normal.
No age adjustment permitted for this table
Step 6: Compare the ratings obtained in Steps 4 and 5. Take the higher rating.
The higher of these two ratings will be the rating for the malignant condition on the basis of this chapter.
Step 7: Compare the ratings obtained in Steps 3 and 6. Take the higher rating.
If the rating obtained in Step 3 is higher than that obtained in Step 6, go to Step 8.
If the rating obtained in Step 6 is higher than that obtained in Step 3, then the rating obtained in Step 6 becomes the final rating for the malignant condition and is to be included in the final combining of all ratings.
Step 8: If the rating obtained in Step 3 is higher than the rating obtained in Step 6, separate the components of the rating obtained in Step 3 so that each can be included in the final combining of all impairment ratings.
For example, in the case of an accepted carcinoma of the rectum postulated under Step 1, each of the ratings from Chapters 1, 3, and 6 of the Guide is to be separately included in the final combining of all impairment ratings.
CHAPTER 15
INTERMITTENT IMPAIRMENT
INTRODUCTION
Intermittent disorders are conditions:
that remain at a low level of impairment between discrete episodes of increased impairment;
or
where there is one basic type of impairment on which is superimposed episodes of significantly greater impairment of another type.
A sufferer from epilepsy who remains well between “fits” exemplifies the first type of intermittent disorder. A sufferer from Menière’s disease whose condition is characterised by deafness and occasional episodes of vertigo exemplifies the second type of intermittent disorder. The deafness may be regarded as the basic type of impairment and the episodes of vertigo may be regarded as the superimposed intermittent impairment. Both elements of the condition are to be assessed.
In this chapter, “attacks” refers to the episode may increased or superimposed impairment. Attacks are to be categorised by reference to their severity, duration and frequency:
“severity of an attack” refers to the degree to which self‑care and normal everyday activities are disrupted by the attack;
“duration of an attack” refers to the average length of time for which an attack lasts, that is, seconds, minutes, hours or days; and
“frequency of an attack” refers to the number of affected days in a year.
Intermittent disorders are also disorders that affect one or more body systems. For example, asthma is both an intermittent condition and a cardio‑respiratory condition. Hence, potentially, any intermittent disorder can be assessed by either of two methods:
by applying the system‑specific tables contained in Chapters 1 to 12. Several of those tables should be used if the intermittent disorder causes multiple losses of function; or
by applying this chapter.
In practice, except where the intermittent nature of the condition clearly overwhelms its system specific effects or vice versa, both methods are to be applied for rating the intermittent condition and the higher of those two ratings taken as the final rating for the intermittent condition.
Calculation of the impairment rating for an accepted intermittent condition
Follow the steps below to calculate the impairment rating due to an accepted intermittent condition:
(Each of these steps is elaborated in the following pages.)
STEP 1
Establish which body systems are affected by the intermittent condition.
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STEP 2
Determine the functional impairment ratings for the intermittent condition.
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STEP 3
Determine the total combined impairment rating for the various body system impairments attributable to the intermittent condition.
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STEP 4
Determine whether the attacks are of one or more significant types and group them accordingly.
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STEP 5
Determine the rating for intermittent attack severity.
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STEP 6
Determine the rating for the intermittent attack duration.
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STEP 7
Determine the intermittent grading code for the intermittent attack.
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STEP 8
Determine the impairment rating for the intermittent attack by reference to the number of affected days per year.
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STEP 9
Compare the impairment ratings obtained in Step 3 and Step 8. Take the higher rating.
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STEP 10
Determine the rating for the impairment resulting from the avoidance or preclusion of otherwise normal activities between attacks.
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Step 1: Establish which body systems the intermittent condition affects.
Before an intermittent condition is assessed, information regarding the extent of the condition must be available. From that information, the affected body systems are to be established and the applicable chapters of this Guide applied.
Step 2: Determine the functional impairment ratings attributable to the intermittent condition for each affected body system.
Use the relevant chapters and determine the appropriate rating.
Chapter 19 (Partially Contributing Impairment) or Chapter 20 (Apportionment) may also have to be applied to allow for the effect of other accepted conditions or non‑accepted conditions respectively.
Step 3: Determine the total combined impairment rating for the various body system impairments attributable to the intermittent condition.
Combine the attributable impairment ratings obtained in Step 2 by applying Table 18.1 (Combined Values Chart) in Chapter 18.
The combined value so obtained is for use only in Step 9.
Step 4: Determine whether the attacks are of one or more significant types and group them accordingly.
If attacks vary in severity, duration or frequency, an average for each parameter is to be established except when the attacks fall naturally and very clearly into groups. In such cases separate the attacks into one or other of these groups. Determine the average severity, duration and frequency of the attacks in each group.
Perform the following four steps separately for each identified group of attacks.
Step 5: Determine the rating level for intermittent attack severity using Table 15.1.
Table 15.1 Combined male and female symbol
INTERMITTENT ATTACK SEVERITY
Level Criteria
0 Minor symptoms that are easily tolerated.
I Mild to moderate symptoms that are irritating or unpleasant but that rarely prevent completion of any activity. Symptoms may cause loss of efficiency in some activities.
II More severe symptoms, that are distressing, but prevent few everyday activities. Loss of efficiency is discernible elsewhere. Self‑care is unaffected and independence is retained.
III Loss of efficiency is discernible in many everyday activities. Some elements of self‑care are restricted but, in most respects, independence is retained. Bed‑rest is often necessary during an attack.
IV Major restrictions in many everyday activities. Capacity for self‑care is increasingly restricted, leading to partial dependence on others.
V Most everyday activities are prevented. Dependent on others for many kinds of self‑care. Able to be maintained at home only with considerable difficulty, or hospital admission is required.
VI Total incapacity. Unconscious or delirious. Self‑care is impossible.
No age adjustment permitted for this table
Ratings are based on the activities that the veteran is physically unable to perform. For conditions in which it is common practice to lie down during attacks, it may be inappropriate to rate at level III if symptoms are mild and cause little restriction to activity.
Attacks of some intermittent conditions necessitate hospital admission. Hospital admissions commonly, but not invariably, call for level V or VI rating. It is important to rate self‑care capacity. To be rated at Level V severity, a condition must render the veteran incapable of caring for himself or herself.
Hospital admission for surgery is not to be used as a basis for ratings from Table 15.1.
Step 6: Determine the rating for duration of the intermittent attacks using Table 15.2.
Attacks that last for more than 24 hours are to be classified as prolonged for the purposes of Table 15.2. Because they affect the veteran for more than one day per attack, the number of affected days per year will be greater than the number of attacks.
Table 15.2 Combined male and female symbol
INTERMITTENT ATTACK DURATION
Description Duration
Transient Lasting up to and including five minutes.
Short Lasting more than five minutes but less than 30 minutes.
Medium Lasting from 30 minutes to four hours.
Prolonged Lasting more than four hours.
No age adjustment permitted for this table
Step 7: Determine the intermittent grading code for the intermittent attack using Table 15.3.
Table 15.3 Combined male and female symbol
INTERMITTENT GRADING CODE
Description Severity Level
0 I II III IV V VI
Transient A A A B C C F
Short A A C C D E H
Medium A B C D E H I
Prolonged A C D F G I J
No age adjustment permitted for this table
Step 8: Determine the impairment rating for the intermittent attack by reference to the number of affected days per year and by using Table 15.4.
Using the intermittent grading code determined in Step 7, determine the impairment rating appropriate to the intermittent grading code and frequency by applying Table 15.4.
Functional Loss Table 15.4 Combined male and female symbol
INTERMITTENT IMPAIRMENT
Frequency (affected days/year)
2+ 5+ 10+ 20+ 40+ 70+ 100+
Intermittent Grading Code Impairment Rating
A – – – – – 2 2
B – – – – 2 5 5
C – – – 2 5 10 10
D – – 2 5 10 15 20
E – – 2 5 10 20 30
F – 2 5 5 10 20 30
G – 2 5 10 20 25 30
H – 2 5 10 30 40 50
I 2 5 10 30 50 60 70
J 5 10 20 40 70 80 90
No age adjustment permitted for this table
If the attacks were separated into groups in Step 4, a separate rating is to be obtained for each group of attacks.
Those ratings are not to be combined at this stage but are to be included in the final combining of all ratings.
Step 9: Compare the impairment ratings obtained in Step 3 and Step 8. Take the higher rating.
If the attacks were separated into groups in Step 4, the ratings for the various groups of attacks are to be combined by applying Chapter 18 (Combined Values Chart) before being compared with the rating obtained in Step 3. The combined rating determined under Chapter 18 is to be used only for the purpose of this comparison.
If the combined rating determined under Chapter 18 is higher than the rating obtained in Step 3, then each of the separate ratings for the various groups of attacks is to be included in the final combining of all ratings.
Step 10: Determine the rating for the impairment resulting from the avoidance and preclusion of otherwise normal activities between attacks by using Table 15.5.
Precluded activities refer to ordinary activities. Ratings are to be given on the basis of having to avoid, or of being precluded from undertaking, activities that are common for the veteran’s age group. Ratings are not to be given on the basis of having to avoid only relatively hazardous activities such as rock‑climbing or acrobatics.
Table 15.5 is to be applied only if at least one attack of the condition of severity II or greater has occurred within the last two years.
Functional Loss Table 15.5 Combined male and female symbol
INTERMITTENT IMPAIRMENT: PRECLUDED AND AVOIDED ACTIVITIES
Impairment Ratings Criteria
NIL Not prevented by fear of an attack from any significant activities. Can lead a normal life between attacks without the need to take long term medication.
TWO Must avoid relatively few activities for fear of precipitating an attack.OrCan lead a fairly normal life between attacks but must take long term medication.
FIVE Must avoid some activities such as driving a car, using machinery, using public transport, swimming, travelling, being alone except for short periods of time lest an attack occur.
TEN Must avoid a wide range of activities such as driving a car, using machinery, using public transport, swimming, travelling, being alone except for short periods of time lest an attack occur with possible severe consequences.
Only one rating may be had from this table for any given condition. Intermittent conditions may attract a rating from Table 15.5 as well as a rating or ratings from either Table 15.4 or the system specific tables.
No age adjustment permitted for this table
The rating obtained in Step 10 is not to be compared with the rating obtained in Step 9, nor are ratings to be combined at this stage. Irrespective of the outcome of Step 9 the rating obtained from Table 15.5 is to be included in the final combining of all ratings.
Intermittent Impairment Worksheets
A set of Intermittent Impairment Worksheets (pages 178 to 179) is designed to facilitate the calculation of intermittent impairment rating.
Intermittent Impairment Worksheet (1) is to be used in those cases where all the attacks are grouped into a single type of attack.
Intermittent Impairment Worksheet (2) is to be used in those cases where the attacks are grouped into two or three types.
No worksheet is provided for those cases where more than three types of attacks are involved.
A worksheet for noting assessment details in relation to intermittent impairment
A second worksheet for noting assessment details in relation to intermittent impairment
CHAPTER 16
ACTIVITIES OF DAILY LIVING
INTRODUCTION
The Activities of Daily Living (ADLs) are a defined set of activities necessary for normal self‑care. The activities are movement in bed, transfers, locomotion, dressing, personal hygiene, and feeding.
These six activities are defined as follows:
“movement in bed” means sitting in, rising from, and moving around in, bed;
“transfers” means moving from one seat to another, changing position from sitting to standing, and transferring to and from the toilet and bed;
“locomotion” means walking on the level, on gentle slopes and down stairs;
“dressing” means putting on socks, stockings, and shoes, as well as clothing the upper and lower trunk;
“personal hygiene” means grooming, and washing of face, trunk, extremities and perineum;
“feeding” means eating and drinking, but not the preparation of food.
“Effects on ADLs” is to be used to assess conditions for which criteria do not exist in the system specific tables of Chapters 1 to 12, or are inadequate, or for which the application of the tables in Chapter 14 (Malignant Conditions) or Chapter 15 (Intermittent Impairment) is inappropriate.
Table 16.3 (Other Impairment) covers such non‑specific indicators of disease as pain, lethargy and prognosis.
This chapter is to be applied in the assessment of conditions that result in the veteran being bedfast, chairfast, housebound or nearly housebound. Such conditions include the effects of severe strokes, severe Parkinson’s disease, severe heart failure, severe respiratory disease, severe liver failure, severe kidney failure and some dementias.
ADLs may be used to rate a single condition if its effects are well‑differentiated, or may be used to rate all conditions together if their effects are difficult to differentiate.
When ADLs are used to rate a single condition, an impairment rating or ratings from other chapters may be combined with a rating derived from Chapter 16 provided that the ratings relate to different conditions.
When ADLs are used to rate all conditions together, no ratings from other chapters are to be combined with the rating from Chapter 16.
Calculation of the impairment rating for an accepted condition using ADLs
Follow the steps below to calculate the impairment rating due to an accepted condition using the ADLs.
(Each step is elaborated in the following pages.)
STEP 1
For each of the six ADLs obtain a grading code for that activity.
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STEP 2
Add up the grading codes for each of the six ADLs.
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STEP 3
Using the sum obtained in Step 2, determine a functional impairment rating by applying Table 16.2.
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STEP 4
Determine an Other Impairment rating for the condition by applying Table 16.3.
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STEP 5
Compare the ratings obtained in Steps 3 and 4. Take the higher rating.