Activities of Daily Living (ADLs) are the fundamental, routine tasks that most healthy adults perform independently every day. These activities are crucial for maintaining personal well-being and independence. When individuals face challenges performing ADLs, it can significantly impact their safety, health, and overall quality of life. Healthcare professionals recognize the importance of assessing ADLs to identify patients who require assistance and to develop appropriate care plans.
Objectives:
- Understand the core components of ADLs and Instrumental Activities of Daily Living (IADLs).
- Identify the factors that can limit or impair an individual’s ability to perform ADLs.
- Explore common assessment tools used to measure ADLs and IADLs.
- Recognize the crucial role of interprofessional healthcare teams in assessing and managing patients with ADL limitations.
The Significance of Activities of Daily Living
The term “Activities of Daily Living” (ADLs) encompasses the essential skills needed for self-care and independent living. Introduced by Sidney Katz in 1950, ADLs serve as a key indicator of a person’s functional status. Difficulty performing ADLs often leads to dependence on others or assistive devices. Measuring an individual’s ADL capabilities is essential, as it can predict the likelihood of needing alternative living arrangements, hospitalization, or home care services. ADL assessments can also gauge the effectiveness of treatment programs. Nurses are often the first to observe declines in patients’ functionality during hospital stays, highlighting the importance of routine ADL screenings.
Hospitalization, whether for an acute or chronic condition, can significantly affect a person’s ability to maintain independence. Chronic illnesses often progress gradually, leading to physical decline and loss of ADL capabilities. Data from the United States National Health Interview Survey in 2011 revealed that a significant percentage of older adults require assistance with ADLs: 20.7% of those aged 85 or older, 7% of those aged 75 to 84, and 3.4% of those aged 65 to 74.
Function: Breaking Down ADLs and IADLs
ADLs are broadly divided into two categories: basic ADLs (BADLs) and Instrumental Activities of Daily Living (IADLs).
Basic ADLs (BADLs)
Basic ADLs, also known as physical ADLs, are the fundamental skills required to manage one’s physical needs. These include:
- Ambulating: The ability to move from one position to another and walk independently.
- Feeding: The ability to feed oneself.
- Dressing: The ability to select appropriate clothes and dress oneself.
- Personal Hygiene: The ability to bathe, groom, and maintain dental, nail, and hair care.
- Continence: The ability to control bladder and bowel function.
- Toileting: The ability to get to and from the toilet, use it appropriately, and clean oneself.
Understanding how each basic ADL impacts an individual’s ability to care for themselves is crucial in determining the level of assistance needed. These assessments can also help determine eligibility for state and federal assistance programs.
Instrumental ADLs (IADLs)
Instrumental Activities of Daily Living (IADLs) involve more complex tasks that require cognitive and organizational skills. These activities are essential for independent living within the community:
- Transportation and Shopping: The ability to procure groceries, attend events, and manage transportation, either by driving or arranging alternative transport.
- Managing Finances: The ability to pay bills and manage financial assets.
- Meal Preparation: The ability to plan, shop for, and prepare meals.
- Housekeeping and Home Maintenance: Maintaining a clean and safe living environment.
- Managing Communication: The ability to use the telephone and manage mail.
- Managing Medications: The ability to obtain medications and take them as prescribed.
The key difference between IADLs and ADLs is that individuals often seek external assistance when IADLs become challenging to manage independently. This marks a shift towards needing more comprehensive support.
Causes of ADL Limitations
Impairment in physical function, leading to limitations in ADLs, can stem from various factors. Aging is a natural process that may result in a decline in functional status and subsequent loss of ADLs. Musculoskeletal, neurological, circulatory, or sensory conditions can also contribute to decreased physical function.
A cognitive or mental decline can significantly impair ADLs. Severe cognitive fluctuations in dementia patients are strongly associated with impaired engagement in activities of daily living, negatively impacting their quality of life. Social isolation can also hinder the performance of instrumental activities of daily living. Other factors, such as medication side effects and the patient’s home environment, can also influence ADL capabilities.
Hospitalization and acute illnesses have been linked to a decline in ADLs. Studies have shown that loss of ADL functioning is associated with acute hospital admission and cognitive impairment among older adults. Many hospitalized older individuals are discharged with ADL function that is worse than their baseline function.
Measuring ADLs: Assessment Tools
Accurately defining the extent of ADL and IADL loss is crucial for providing appropriate care and support. Numerous checklists and assessment tools have been developed for this purpose.
The most commonly used checklists are the Katz Index of Independence in Activities of Daily Living and the Lawton Instrumental Activities of Daily Living (IADL) Scale. The Katz scale focuses on basic activities of daily living, while the Lawton IADL Scale evaluates more complex, independent living skills.
The Katz ADL scale is sensitive to changes in declining health status. While it may have limitations in measuring small increments of change seen in rehabilitation, it provides a common language for healthcare providers involved in patient care and discharge planning.
The Lawton Instrumental Activities of Daily Living (IADL) Scale is a valuable tool for assessing independent living skills and identifying improvement or deterioration over time. It measures eight functional domains, including meal preparation, housekeeping, and laundering. Individuals are scored based on their highest level of functioning in each category. A summary score ranges from 0 (low function, dependent) to 8 (high function, independent). The Lawton scale is easy to administer and provides self-reported information about functional skills needed for community living. Identified deficits can assist nurses and other professionals in planning for safe discharge. However, it’s important to note that the scale is self-administered, potentially leading to overestimation or underestimation of abilities.
Clinical Significance: Why ADL Assessment Matters
Assessing ADLs is a critical component of routine patient assessment, helping healthcare providers understand a patient’s status and develop appropriate plans and interventions. A provider must consider a patient’s overall medical condition when determining their functional capabilities, ensuring independent living and personal care.
ADL assessments help determine if a patient requires further rehabilitation, home assistance, or a skilled nursing facility. The inability to ambulate increases the risk of falls, which are associated with increased mortality. Individuals with multiple falls, especially those aged 65 and older, tend to have poorer prognoses. Such falls also contribute to increased healthcare utilization and costs. Other factors to consider when determining the appropriate living environment include a patient’s ability to cook, clean, shop, use public transportation, or drive.
Understanding the impact of ADL loss on patients is crucial. Independent living is highly valued, and many aging individuals fear losing their autonomy.
Occupational therapists use ADL assessments to determine eligibility for disability and long-term care insurance. The costs associated with home care, skilled care, assisted living, and nursing homes are significant concerns for many families. Since not all supportive care is covered by Medicare or private insurance, financial constraints can impact the level of care a patient receives.
Access to care can also be a barrier. Lower socioeconomic groups often face challenges in accessing quality care due to transportation, distance, and availability. While many placements in care facilities are short-term, most patients stay longer than a year due to the inability to perform more than two of the six ADLs.
Other Issues: Communication and Collaboration
Nurses play a vital role in communicating a patient’s ADL and IADL capabilities to providers, enabling the healthcare team and families to discuss the most appropriate living arrangement. Occupational therapists conduct thorough assessments. Home health nurses develop plans for improvements, assist with medication administration, and provide resources to support independence. Unlicensed assistive personnel provide assistance with bathing, light housekeeping, shopping, and other activities that support the patient’s desire for independent living.
Enhancing Healthcare Team Outcomes Through Collaboration
All members of the interprofessional healthcare team, including clinicians, nurses, physical therapists, and occupational therapists, should collaborate to assess patient functionality before discharge. Patients unable to perform ADLs may require further rehabilitation or home assistance. The inability to dress or toilet can significantly impact quality of life, while difficulty ambulating increases the risk of falls and further decline. Difficulties eating independently can lead to poor nutrition, dehydration, and weakness. Appropriate referrals to OT, PT, and dieticians should be considered. Routine assessment of functionality is essential for patients of all ages. Effective communication and collaboration within the interprofessional team will ensure optimal patient evaluation and discharge planning with comprehensive follow-up care. The nursing staff should promptly report any concerns regarding a patient’s ADL abilities to the medical team.
Interventions by Nursing, Allied Health, and Interprofessional Teams
Changes in ADLs have different implications for various stakeholders in a patient’s care team:
- Case manager, nurse, and social worker: Assess and collect information on a person’s ability to perform ADLs to plan for their continuum of care.
- Primary care clinician: Uses assessments to formulate and plan of care, which is then provided to the home health agency or skilled nursing agency.
- Home health or skilled nursing agencies: Select the appropriate staff needed for each client.
- Physical and occupational therapists: Work with the plan of care and document progress in ADL to ensure rehabilitation goals are achieved to the extent possible.
- Insurance providers and government agents: Use the assessments of ADL to determine the patient’s qualifications and pay for the services rendered.
Monitoring by Nursing, Allied Health, and Interprofessional Teams
Nurses and occupational therapists assess ADLs and IADLs daily in all hospitalized patients. Effective assessment, planning, intervention, and evaluation of ADLs and IADLs can significantly impact a person’s ability to age independently.
While daily shift assessments include various tools, all nurses should be aware of each patient’s need for assistance with ADLs. When a patient is at risk for a change in ADLs or IADLs, the nurse should assist the patient and report to the interprofessional team members to establish a new plan of care.
Possible NANDA nursing diagnoses include altered health maintenance, risk of injury, activity intolerance, social isolation, or ineffective family coping.
Conclusion
Understanding and assessing Activities of Daily Living is essential for healthcare professionals in providing comprehensive patient care. By recognizing the different types of ADLs, identifying potential limitations, and utilizing appropriate assessment tools, healthcare teams can develop effective interventions to support patients’ independence, safety, and overall well-being. Continuous monitoring and collaboration among team members are crucial for ensuring the best possible outcomes for patients with ADL limitations.
References: (Same as original article)
