Activities of Daily Living: Measuring Senior Independence

ADLs are basic tasks a person needs to be able to do on their own to live independently. Health issues and aging may make it difficult for seniors to complete certain everyday self-care tasks. Research shows that individuals over age 85 generally need assistance with daily living, with more than 20% of seniors over 85 requiring help with ADLs.^[01]

Basic ADLs, as outlined by the Katz Index of Independence in Activities of Daily Living, ^[02] include six essential skills:

1. Bathing and showering — the ability to bathe and maintain personal hygiene, which can include tasks like brushing teeth, combing hair, and nail care
2. Continence — having complete control of bowels and bladder
3. Dressing — the ability to select appropriate clothes and outerwear for the weather or occasion, and to get dressed independently
4. Mobility — being able to walk or transfer from one place to another, specifically in and out of a bed or chair
5. Feeding (excluding meal preparation) — the ability to get food from plate to mouth, and to chew and swallow
6. Toileting — the ability to get on and off the toilet and clean one’s self without assistance

Instrumental activities of daily living (IADLs) require planning, problem solving, and organizational skills. While ADLs are very fundamental, IADLs are skills that allow seniors to function independently and manage their own affairs. IADLs, as outlined by the Lawton-Brody scale ^[03], include the following:

• Cleaning and housekeeping, including maintenance and other home-care chores
• Doing laundry
• Managing money
• Managing medications and taking medicines as directed
• Preparing meals
• Shopping for groceries and other necessities
• Transportation, including changing residences and moving
• Using communication devices, including the telephone or computer

Let our care assessment guide you

As a family caregiver, you have the power to give your loved one the best life possible. When you track your loved one’s health and functional capabilities, it will become easier to notice signs of deterioration and improvement. Knowing what ADL and IADL changes to look for will help you know what level of care your loved one needs.

Understanding the functions of ADLs and IADLs can help you take note of what activities of daily living your loved one can and cannot do. Ideally, they should have the physical and mental capabilities to conceptualize and carry out the tasks on their own or with minimal assistance.

Changes in these capabilities occur gradually over time. Often, a decline in the ability to complete basic ADLs may not be noticeable until later stages of physical or mental disability. Assistance with daily activities from senior communities and in-home care services can provide individuals with help to complete ADLs and IADLs.

Knowing your loved one’s ability to complete ADLs and IADLs can help you, with the input of a doctor, answer the following questions:

• Do you or a neighbor need to check on your aging parent routinely?
• Does your aging loved one need physical, occupational, or speech therapy?
• Is your aging parent able to continue living independently?
• Would moving to an assisted living community eliminate chores and tasks that frustrate or are beyond your loved one’s ability?

Assessing ADLs can also help caregivers and health care professionals understand the level of care needed. The level of care for someone who can’t complete IADLs is different from the care needed by someone who can’t complete basic ADLs.

As you track your loved one’s status and plan for future steps, keep in mind that ADLs require more intensive, hands-on care. In some cases, IADL deficiencies may be managed by different service providers, such as a senior meal preparation or delivery service, a housekeeper, or a money management professional. If you find that in-home services are not enough to help your parent complete a key ADL, assisted living communities offer facility-based support for seniors who need daily assistance.

Families rarely ask about ADLs until a parent or senior loved one is going through the process of assessment for long-term care, says Dr. Leslie Kernisan, a geriatric expert.^[04]

“If someone is concerned about their mom, then knowing how they’re doing with ADLs is important,” she says. “It can educate a person and take them from feeling like ‘Mom needs help, I’m worried,’ to be able to answer questions like, ‘OK, where does she need help?’”

She recommends bringing up changes in a loved one’s ability to do these tasks when talking with a physician.

According to Kernisan, it’s a good idea to share changes in ADLs or other medical statuses with your loved one’s medical team. Before your next clinician visit, consider the following:

• A change in the ability to perform ADLs can trigger medical evaluations that may uncover a medical issue. It’s important to understand the root cause of the problem or change in ability.
• Understanding root causes can help you and your loved one’s doctor work together to find ways to improve function. Some common ways to improve function include medical treatment, mobility devices, and specialized therapy. Occupational therapists can specifically assess and treat ADLs and IADLs. Speech language pathologists can understand how communication and understanding affect a person’s ability to complete ADLs and IADLs. Physical therapists can treat pain, imbalance, or range of motion that can hinder completion of ADLs.
• Understanding ADLs is critical to having an accurate care plan. If your parent’s doctor doesn’t realize there’s a functional problem, the care plan they create may not be in line with your loved one’s abilities. For example, if the doctor isn’t aware that your loved one is sometimes forgetful, then their expectation that your parent can regularly monitor their blood sugar on their own may not be realistic.

ADLs and IADLs can be assessed in a variety of ways. Caregiver input can be helpful in creating a bigger picture of your loved one’s functional capabilities. Family or hired caregivers are often able to notice when a senior needs more assisted daily living support than they used to — for example, a parent may start asking for help in situations they could once tackle alone. However, caregiver burnout, the tendency to overestimate or underestimate someone’s true abilities, or a change in the caregiver’s ability to provide adequate care can make this method less accurate than others.

Self-reporting can also help get the conversation about ADLs started. No one understands a situation better than the person experiencing it. Self-reporting is especially helpful when individuals have minimal cognitive decline. However, self-reporting can introduce bias, as your loved one may not feel an incident is really worth recording.

While a health care professional’s report is often believed to provide the most objective view of a person’s functional status, a combination of assessments may fully capture the picture of disability for a given individual.

The 3 types of ADL assessments health care professionals use

Health care professionals commonly use these tools to assess ADLs:

• The Katz Index of Independence in Activities of Daily Living. This is the best choice for patients in long-term care, where disability is generally more severe but stable. In this assessment, you gain one point for each ADL your loved one can complete independently. The total number of points you have tallied at the end of the assessment is indicative of how independent your loved one is and what level of care they may need.
• The Barthel ADL Index.^[05] This assessment covers two additional domains, including grooming and stairs. It’s best suited to acute care settings as it is more detailed and better detects subtle changes in a person’s health. In this assessment, the task levels are on a scaled point system. As with the Katz assessment, the more points you have in total, the more independent your loved one likely is.
• The Functional Independence Measure (FIM).^[06] This option is more comprehensive, combining ADLs with IADLs and other social domains. This assessment tool comprises 18 items divided into motor and cognitive categories. Each item is scored on a scale. The higher the score, the more independent your loved one is at performing the task.

Keep track at home

To help you assess and monitor your loved one’s activities of daily living, download A Place for Mom’s ADL and IADL checklists. These are great tools to take with you the next time your loved one has a medical checkup.

As you assess your loved one’s ability to complete ADLs and IADLs, follow these tips:

• Ask for other opinions. Check with siblings, neighbors, and friends. Inquire about any changes you’ve noticed in your loved one’s abilities. Pick two or three people to discuss your concerns with.
• Assess on a spectrum. Ask yourself whether your loved one can do the task a little bit, sometimes, or often rather than a simple “yes, they can do the task,” or “no, they can’t.”
• 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 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, your loved one’s abilities can be momentarily impaired.
• 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,” Kernisan says.
• 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. 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,” Kernisan says. Caregivers should “be discreet and empathetic” when assessing for ADLs, she suggests.

If your loved one is unable to independently perform daily ADLs and IADLs, or if you have other safety concerns, it may be time to discuss increasing their level of support or moving to an assisted living community.

Talk with a Senior Living Advisor

Kernisan suggests keeping an eye out for specific safety factors when visiting a senior relative:

• 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 answered “yes” to any of the above questions, it may be time to assess your aging loved one’s ADLs and IADLs, either by a medical professional or from your perspective as a family member.

Navigating changes

When it comes to assessing ADLs and IADLs, there’s a lot of technical information about different assessments. This can be overwhelming for families to navigate.

Dr. Kernisan understands this struggle and recommends the following:

• Ask your aging parent’s doctor if a change in medical plan is required as your parent’s ability to complete ADLs decreases. 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.

Following the tips described in this article may help your loved one to be as independent as possible so they can enjoy a greater quality of life. In some cases, simple lifestyle adjustments such as hearing or vision aids, therapy treatments, or assistive devices to make bathing, transferring on and off furniture, or using the toilet easier can help your loved one perform ADLs independently.

Read related article:Do You Need a Geriatric Care Manager?

If you’re worried about your loved one’s ability to perform everyday tasks, connect with their doctor to discuss your concerns. It’s important to identify any limitations your aging parent may have, but it’s even more critical to support them by finding solutions to help solve or alleviate those limitations, or by finding the care they need. If your loved one needs help with even one ADL, assisted living or home care services could be helpful possibilities to consider.

When you’re ready to explore senior support options, reach out to one of A Place for Mom’s Senior Living Advisors. At no cost to you, an advisor will work to understand your parent’s unique situation and needs, compare different senior living options, and offer personalized referrals. We’ve helped more than two million families along their journey to find senior living, and we’re ready to help you start the search today.