Assessing when and what kind of additional care might be needed for a loved one or client can be tough. Independence can be difficult to gauge, and decline isn’t always apparent.
The six activities of daily living (ADLs) and the eight instrumental activities of daily living (IADLs) can be helpful in assessing whether seniors can or should continue living on their own, or if some assistance might be needed. In some cases, insurance companies, including Medicaid, might also want to do an ADL or IADL assessment to verify needs before agreeing to pay for additional care or a nursing facility.
Activities of daily living (ADLs) history
ADLs were developed in the 1950s by internationally renowned geriatrician Sidney Katz to help healthcare providers measure changes in physical function for patients being treated for disabling conditions, such as a broken hip or following a stroke. Katz and his multidisciplinary team wanted to restore patients to as much independence as possible, but to do that, they had to first figure out what “independence” looked like.
They developed a tool to assess things that people do on a day-to-day basis to take care of themselves physically like grooming or using the bathroom — personal tasks that are fundamental to being able to care for yourself on your own.
Decades later, the Katz Index of Independence in Activities of Daily Living is still one of the most common instruments used to gauge someone’s independence. Seniors are asked whether they can accomplish six different tasks, and one point is given for each activity they can do without any supervision, direction or assistance.
Defining the six ADLs
Bathing: Bathes completely by oneself, or needs help cleaning only a single part of the body (ex. back, genitals, or injured/disabled extremity).
Dressing: Retrieves clothes from dresser or closet and puts them and outer garments on (ex. sweaters or jackets) using the appropriate fasteners. Help may be used to tie shoes.
Toileting: Goes to the bathroom without help, including getting on and off the toilet, taking off and putting on clothes, and cleaning genitals.
Transferring: Gets in and out of a chair or bed without assistance, except for perhaps a mechanical transferring aid.
Continence: Has complete control over urination and defecation.
Feeding: Transfers food from a plate into the mouth without assistance, though the food may be prepared by another person.
How seniors respond to the assessment can shed light on how much (if any) additional care might be needed. If seniors can do all six of these activities without any help or prompting, they are considered to have “full function,” and can take physical care of themselves on their own. A score of four out of six means they have “moderate impairment” and might need additional care, while two out of six or fewer signals they have “severe functional impairment” and therefore, must rely on other people to care for them.
For many seniors, there’s a general progression for these activities. As they age, harder tasks like bathing tend to become more and more challenging to do on their own, while feeding themselves might be one of the last ADLs where they need physical assistance.
Instrumental activities of daily living (IADLs) history
While ADLs were helpful in revealing areas of physical disability that might impact independence, there’s of course more to taking care of yourself than just hygiene or grooming. The IADLs were developed in the late 1960s to measure a greater range of activities needed for independence and spot disabilities that might not show up using the ADL scale alone — tasks like managing finances and grocery shopping, which are more complex than ADLs but still necessary to live independently in a community.
IADLs are often measured using the Lawton Instrumental Activities of Daily Living Scale, a brief assessment that takes 10-15 minutes to complete. The scale measures to what extent individuals can perform the eight tasks.
Defining the eight IADLs
Using the telephone: Answers the phone, dials well-known numbers and takes initiative to operate phone on their own.
Shopping: Takes care of all purchases without assistance.
Food preparation: Plans, preps and serves all food needed for meals and snacks.
Housekeeping: Does light to heavy home maintenance tasks (ex. washing dishes, making the bed) with or without help.
Laundry: Completes some or all personal laundry.
Mode of transportation: Manages personal travel independently and/or uses public transportation with or without assistance.
Responsibility for own medications: Takes the appropriate amount of medication at the correct time without supervision or prompting.
Managing finances: Handles all or some finances with little to no help, including paying bills, keeping track of income and day-to-day purchases.
Several ability levels are given under each activity, and individuals are asked to select the one that most closely matches what they are able to do. Like the Katz ADL Index, the Lawton IADL Scale assigns a points value to each answer (0 or 1), and all the points are tallied up to give an overall score ranging from 0 (low function) to 8 (high function). Where someone falls on that spectrum can help families figure out just how much (if any) additional help might be needed.
Considerations when assessing ADLs and IADLs
While ADLs and IADLs can be useful tools to assess independence, they aren’t perfect. What someone needs to be able to do to live or function on their own can vary from person to person, and a person’s physical and cognitive abilities can fluctuate from one day to the next or decline incrementally over time. Because of this, ADLs and IADLs should be looked at periodically to spot any changes in function and verify that living and care arrangements are still appropriate.
Likewise, because ADL and IADL assessments depend on personal responses — and not, for example, an unbiased observer — people responding to the questionnaires might misremember or have strong feelings about the outcome, potentially skewing results. Care should be taken to ensure answers are as accurate as possible during each assessment. Lastly, it’s also important to note that ADLs and IADLs are designed for individuals living on their own or with some assistance but are not intended for those already living in long-term care facilities where they require extensive help.