ADLs and IADLs
Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) are helpful tools for caregivers and clinicians to evaluate the autonomy and independence of seniors.
Learn more about what these terms mean and how to apply them to everyday situations.
What Are ADLs and IADLs?
The concept of Activities of Daily Living (ADLs) and tracking a persons ability to complete them as a means to assess their overall health and functional status, was developed in the 1950s by Sidney Katz and his team at the Benjamin Rose Hospital in Cleveland, Ohio. The ADL Index that Katz created is still an effective assessment tool used today.
Basic ADLs, or BADLs, “include six essential skills typically needed to manage basic physical needs,” as outlined by the Katz “Index of Independence in Activities of Daily Living,” including:
- Bathing and showering: Bathing self completely, or requiring assistance with only one area of the body including, hair and skin and oral care
- Continence: Having complete control of bowels and bladder
- Dressing: Including selecting appropriate clothes and outerwear and donning them independently, including fasteners
- Functional mobility: Including walking or transferring from one place to another, specifically in and out of a bed or chair
- Self-feeding (not meal preparation): Moving food from plate to mouth or having the ability to chew and swallow
- Toileting: Including getting on/off the toilet and cleaning oneself
While BADLs represent a person’s fundamental functioning skills, Instrumental Activities of Daily Living, or IADLs, are more complex activities required for independent living, as outlined by the Lawton-Brody “IADL scale,” including:
- Cleaning and housekeeping: Including maintenance and other home care chores
- Managing money
- Medication management: Taking prescribed medications
- Preparing meals: Including food preparation
- Shopping: For groceries and other necessities
- Transportation: Including changing residences and moving
- Using communication devices: Including the computer or telephone
It is especially important that people living on their own can complete IADLs as they are generally not receiving daily support from professional caregivers or family members and can go several hours or even days without interaction with another individual.
As with BALDs, a person’s ability to compete IADLs – or their lack of ability – can represent mental or physical health conditions. A decline in IADL performance is often the first sign that a person may be experiencing mild or early cognitive impairment, whereas a decline in BALD performance may not be noticeable until later stages of dementia or physical disability.
Why ADLs Are a Sound Assessment Tool
Activities of Daily Living challenge both our mental and physical capabilities – not only do ADLs require a person to have the physical ability and manipulation needed to perform the tasks themselves; they also require the forethought and mental capacity to conceptualize the tasks and understand that they need to be completed.
This makes ADLs a great assessment tool for healthcare professionals as they represent the “first signs of diminished functionality” and are often indicators of physical issues and memory-related diseases, such as dementia.
According to Oxford Academic, “declined or inability to achieve one or more ADLs should motivate a primary provider to routinely check on and determine a patient’s independence and evaluate the need for physical therapy or placement in an assisted community.”
Ideally, a physician should check-in with patients on ADLs and IADLs during their annual wellness visit (it’s a small part of the Medicare Annual Wellness Visit tool for physicians). However, it’s unclear how many physicians are discussing ADLs with patients, or how many older adults are having an annual wellness visit. Even if not all physicians are using them, there’s no doubt that ADLs and IADLs are a vitally important assessment tool for healthcare professionals, caregivers and seniors alike to help them understand and determine a person’s functional status and abilities. They help to predict and piece together the puzzle of a person’s long-term health.
In fact, according to Oxford Academic, the less capable someone is at performing their own ADLs, the more likely they are to experience “poorer quality of life, increased health care costs, increased risk of mortality and increased institutionalization.”
Why ADLs and IADLs Are Important for Caregivers
According to Dr. Leslie Kernisan, MD MPH, a geriatric expert and author of GeriatricsForCaregivers.net despite their importance, the average person isn’t aware of ADLs. Even as a practicing geriatrician with a special interest in family caregivers, Dr. Kernisan is rarely asked questions about ADLs from families until the subject is broached when eligibility for long-term care through Medicare/Medicaid becomes a pressing issue.
However, ADLs are extremely important for caregivers to consider. If you’re caring for an elderly parent or loved one, then talking with your physician in terms of ADLs is useful. “If someone is concerned about their mom, then knowing how they’re doing with ADLs is important, it can educate a person and take them from feeling like ‘Mom needs help I’m worried,’ to being able to answer questions like, “Okay, where does she need help?” Dr. Kernisan explains.
The average physician might not be tuned into ADLs and IADLs unless there’s a specific situation like post-surgery rehab or post-stroke.
Ultimately, when it comes to ADLs and IADLs, “caregivers have more information about how a senior loved one is doing than the doctor does,” Dr. Kernisan says, and if family members “notice a difference, then they should bring the change up when talking with a physician,” she says.
Dr. Kernisan notes that it’s important to share changes in ADLs with your loved one’s medical team because:
- It’s important to understand the root cause of the problem or change in ability. A change in ADL can trigger medical evaluations that can uncover a medical issue.
- Once the root cause is understood, then you and your physician can work together to find ways to improve function, sometimes with medical treatment or with a compensatory device (like a walker).
- Alignment on Activities of Daily Living is critical to having an accurate care plan. If your physician doesn’t realize there’s a functional impairment, then the care plan they create for your loved one may not be in line with their abilities. In some cases, this could mean that your loved one isn’t covered for the assistance they need or is being expected to do more than they can. For example, if your physician isn’t aware that your loved one is sometimes forgetful then their expectation that your loved one can regularly monitor their blood sugar on their own may not be realistic.
When Should Caregivers Consider an ADL Assessment?
Dr. Kernisan refers to ADLs and IADLs as “life tasks” and suggests keeping an eye out for specific safety factors when visiting a senior loved one, including:
- Driving: Have there been any accidents or close calls? Do passengers feel worried?
- Elder abuse: Do you have any concerns about emotional, financial, physical or verbal abuse?
- Finances: Are there problems paying bills? Are you concerned about scams?
- Health: Has your loved one had any falls? Have there been repeated trips to the ER or hospital?
- Memory and thinking: Have there been problems with forgetting, getting lost or wandering? Is there concern about poor awareness or poor judgment?
If you notice that any of the above concerns apply to your parent or senior loved one, it may be time to assess their ADLs and IADLs, either by a medical professional or from your perspective as a family member.
Their ability to perform daily tasks outlined in the ADLs and IADLs, in conjunction with other safety factors, may indicate that it is time to discuss increasing their level of support or moving to an assisted living community. For help in navigating this delicate conversation, check out our “Ask an Advisor Series: When Is the Right Time to Move?“
The 3 Types of Formal ADL Assessments Physicians Use
ADLs and IADLs can be assessed in a variety of ways, including:
- Caregiver or family member report: Caregiver input can be helpful to create a bigger picture of a person’s functional status; however, this method can be more biased than others due to caregiver burnout and the burden of supporting the individual, as well as the tendency to over or underestimate the patient’s true abilities.
- Clinician report: Including nurses, physicians and occupational, physical or speech therapists. This method is often believed to provide the most objective view of a person’s functional status. Commonly used tools healthcare professionals use to assess ADLs include:
- The Barthel ADL Index: Covers two additional domains, including grooming and stairs, and is best suited to acute care settings, as it is more detailed and better detects subtle changes in a person’s health
- The Functional Independence Measure (FIM): More comprehensive, combining basic ADLs with IADLs and other social domains
- The Katz Index of Independence in Activities of Daily Living: The best choice for patients in long-term care, where disability is generally more severe and stable
- Self-report: No one understands a situation better than the person experiencing it, therefore self-report measures can be convenient when individuals have minimal cognitive decline. However, self-report measures leave the results open to a person’s own interpretation or poor insight of their functional impairments. Research has shown that a combination of assessments via a healthcare professional and self-report “may be the best way to fully capture the picture of disability for a given individual.”
There are a variety of helpful, self-report tools available online, including:
- The Direct Assessment of Functional Status: Groups ADLs together with IADLs for a more comprehensive assessment
- The Lawton-Brody IADL Scale: Focuses on IADLs and is easy to self-calculate
- The Physical Self-Maintenance Scale (PSMS): Covers the six ADL domains, with more detailed and user-friendly descriptions than the Katz Index
Ways to Assess ADLs and IADLs as a Caregiver
If you’re concerned about your parent or senior loved one’s abilities, then it’s a good idea to look at an ADL checklist that’s designed for caregivers, like Dr. Kernisan’s “Quick Start Guide to Checking Older Parents for Health and Safety Problems.” You can use this checklist to assess your loved one’s abilities.
Such an assessment should be done respectfully and in a thoughtful way. If your loved one feels like they’re being evaluated, they may become defensive. Instead, quietly observe how your loved one is getting along on their own. You may need to ask some questions (like whether it’s difficult to get in and out of the bathtub).
It’s easy to overestimate a person’s abilities, especially when it comes to IADLs related to cognition (like high-level organizational skills), Dr. Kernisan warns. “Often, we assume everything is fine because it seems to be fine,” she says. “You really need to go take a look for yourself to know how your loved one is doing.”
It’s also easy to underestimate a person’s abilities. Sometimes, when there’s a diagnosis of dementia, caregivers assume the person can no longer do anything or think they need more assistance than they actually do.
Assessment Tips for Caregivers
Here are some tips to help you objectively assess your loved one’s capacity regarding ADLs and IADLs:
- Ask two to three people’s opinions about any changes you’ve noticed in your loved one’s abilities. Siblings, your loved one’s friends, neighbors, etc.
- Assess on a spectrum. It is more useful to use a spectrum to frame questions around abilities. Ask yourself whether your loved one can do the task a little bit, sometimes, or often rather than ‘yes,’ they can do the task or ‘no,’ they cannot.
- Be patient. “If a person is doing a task more slowly than they used to it doesn’t mean they can’t do the task,” says Dr. Kernisan.
- Consider the time of day and how tired they are. Many seniors have sharper cognitive abilities and more energy in the morning.
- Consider their health. If they’re fatigued or fighting a virus, their abilities can be momentarily impaired.
- Consider why you’re doing the assessment. Is it to complete a Medicaid application? Is it a checklist for a long-term care community or is it to prepare for a yearly physical?
- Find the time. “It’s common to be in a hurry and it’s difficult to find the time to observe, but it’s important to take the time and when you do, be patient.” Dr. Kernisan suggests.
- Look at your own preconceived notions about your loved one. Are they interfering with your ability to make an impartial assessment?
- Make the effort to help correct what you can to ensure your loved one can live life to the best of their abilities and as independently as possible.
“It’s very challenging to have people see you as less able,” Dr. Kernisan points out. Caregivers should “be discreet and empathetic” when assessing for ADLs, she suggests. If you feel that a parent or senior loved one’s abilities have declined and they need help, then you may be wondering how to broach this difficult conversation with them. How you talk about it will depend on your relationship with them and their cognitive ability.
A good way to bring up the topic is to “ask them how they feel things are going,” Dr. Kernisan suggests.
An ADL and IADL Checklist for Caregivers
When it comes to ADLs, there’s a lot of technical information out there about different assessments, which can be overwhelming for families to navigate.
Instead of focusing on these technical assessments, Dr. Kernisan recommends for caregivers to:
- Ask if a change in medical plan is required (for example, a complicated diabetes plan may need to be revised)
- Ask if your loved one qualifies for a service like Medicaid
- Ask what’s causing any issues or inabilities
- Be aware of your loved one’s true abilities when it comes to ADLs and IADLs
- Consider whether the limitations have short or long-term implications
- Help your loved one remain independent as long as possible with adaptive assistance
- Seek treatment
Ways for Caregivers to Get ADL Help
If you are concerned about your functional status, or that of a loved one, consider using Dr. Kernisan’s “Quick Start Guide to Checking Older Parents for Health and Safety Problems” to gain a better understanding of your loved one’s current abilities.
Connecting with a healthcare provider to discuss the results and schedule a clinician-reported assessment will ensure that your baseline functional status has been formally documented on your personal health record and can initiate ongoing support with referrals to occupational and physical therapy, home care assistance or long-term care placement.
While it’s important to identify any limitations your loved one may have, supporting them by solving the limitation (if possible) is even more critical. It’s important to enable your loved one to be as independent as possible so they can enjoy the best quality of life possible.
Simple lifestyle adjustments can make it easier to perform ADLs independently. For instance:
- Consider hearing and vision aids. Sometimes a person’s ADLs and IADLs are impaired because they have a hearing or vision issue that has not been corrected.
- Consider therapy. Therapists, including rehabilitation and speech therapists, teach specific muscle-strengthening exercises to improve mobility and speech and build postural muscles to help improve independence while completing ADLs.
- Make accommodations in clothing. Selecting clothing with Velcro or zippers as opposed to buttons can be less cumbersome to put on or remove, especially for individuals with arthritis.
- Eliminate tasks that cause a problem. For instance, eating more finger foods (such as sandwiches) that don’t require the use of a fork or knife may be helpful for individuals with coordination issues.
- Use assistive devices to make bathing, dressing, transferring and using the toilet easier to do independently.
What ADLs and IADLs does your parent or senior loved one need assistance with? We’d like to hear more about the support you provide to them in the comments below.