When it becomes clear that a loved one can’t get through their daily routines without assistance, the logical next step is to begin looking into resources that can provide the support they need. One of the first things a long-term care insurance company, home care company, adult day care center, or assisted living community will ask about is the senior’s ability to perform basic activities of daily living (ADLs) and instrumental activities of daily living (IADLs).
What are activities of daily living?
The Katz Index of Independence in Activities of Daily Living defines ADLs as basic skills needed to properly care for oneself and meet one’s physical needs. There are six activities of daily living:
- Eating — the ability to move food and drink successfully to one’s mouth
- Dressing — the ability to select appropriate clothing and put it on
- Bathing — the ability to maintain good personal hygiene practices, including nail care, hair care, and oral hygiene
- Toileting — the ability to use the toilet and cleanse oneself
- Continence — the ability to control bladder and bowel function
- Ambulating — the ability to walk and transfer to and from a bed or chair
What are instrumental activities of daily living?
Instrumental activities of daily living are more complex tasks necessary for truly independent living. These require certain levels of both physical and cognitive ability. According to the Lawton-Brody Scale, IADLs fall into the following eight categories:
- Cooking — the ability to plan, prepare, and serve adequate meals
- Managing medications — the ability to take correct doses of medications at the right times
- Shopping — the ability to shop for all one’s needs, including clothing, personal care items, and groceries
- Communicating — the ability to use a phone, computer, or other methods of communication
- Managing money — the ability to make and follow a budget, write checks, pay bills on time, make trips to the bank, and monitor one’s income and expenses
- Housekeeping — the ability to clean and maintain one’s home
- Transportation — the ability to drive, use public transportation, or arrange other means of transport
- Laundering clothing — the ability to wash and dry personal laundry
What do activities of daily living measure?
Both basic and instrumental activities of daily living measure a person’s functional status.
It’s important to understand that functional abilities can vary across all ADLs and IADLs. For example, a senior who can’t walk without a mobility aid may be dependent on another person for IADLs that are more physically taxing like housekeeping and laundry. Yet they may be able to perform basic ADLs like bathing, toileting, and dressing without assistance. Even if a person needs some help with IADLs and/or ADLs, they might still be capable of participating in their own care.
In each area, a person may:
- Be totally independent
- Require prompting, reminders, or supervision
- Rely on durable medical equipment or other assistive devices
- Require moderate hands-on assistance
- Be completely dependent on another person
How do age and health conditions affect functional abilities?
Advancing age can naturally cause functional decline or ADL impairment in otherwise healthy individuals. According to the American Psychological Association, “fewer than one-fifth of older adults between ages 65 and 74 need assistance with activities of daily living.” However, individuals over age 85 generally need some assistance with daily living tasks.
Health conditions that affect musculoskeletal, neurological, circulatory, or sensory systems can also affect a senior’s ability to perform IADLs and ADLs. More subtle factors — such as social isolation, medication side effects, and certain characteristics of a senior’s home — may make self-care increasingly difficult and unsafe as well.
Because of their complex nature, IADLs tend to weaken in the earlier stages of illness or cognitive decline, while ADLs often weaken in the middle and later stages of impairment.
Why are ADLs and IADLs important?
Functional status and the ability to care for oneself have a significant impact on a senior’s quality of life. Changes in ADLs and IADLs can be caused by underlying medical conditions, but failing to recognize these growing needs can also contribute to a cycle of physical and mental health problems. Unmet needs for help with activities of daily living may contribute to the following:
- Poor personal hygiene
- Illnesses like urinary tract infections (UTIs)
In fact, studies have shown that ADL disabilities are associated with an increased risk for mortality. Ensuring a senior has the ADL care they need can help prevent new and worsening health issues, keep overall care costs down, and delay or eliminate the need for institutional care. Therefore, a senior’s medical needs and functional abilities should both factor into important care decisions.
Additionally, many elder care services, benefits programs, and insurance providers use basic ADLs as eligibility criteria. For example, a senior must have a documented need for a nursing home level of care to qualify for long-term care Medicaid programs. Although the exact definition varies by state, this level of care often includes an inability to perform a certain number of ADLs, among other requirements. ADL needs are also one of the eligibility criteria for the VA Aid and Attendance pension. Applicants for Social Security disability benefits must submit an ADL questionnaire demonstrating how their condition affects their daily life. A firm understanding of a loved one’s functional abilities and limitations will make it easier to find care options that match their needs and supportive services they qualify for.
Assessing activities of daily living
Health care professionals and long-term care providers conduct activities of daily living assessments to gauge a person’s daily functioning and determine the level of care they require. Functional abilities often influence common care decisions such as these:
- Whether an older adult can still live independently at home
- The type and amount of in-home care services a senior needs
- Hospital discharge instructions
- The type of senior living community that fits an older adult’s needs
Seniors are often reluctant to admit they’re having trouble with self-care tasks and their daily routines. However, Carmel Froemke, program director at the Community Action Partnership of North Dakota, stresses that assessing ADLs is crucial. The results can be used to develop a customized plan of care that enables older adults to continue living as safely and independently as possible while ensuring their needs are met.
When to get an ADL assessment
If you’re noticing even minor changes in a loved one’s functional abilities, then it’s time to act. Early intervention can help you establish a baseline and find solutions that prolong their independence, improve their safety, and prevent further decline.
“Most family members pick up on a loved one’s decline through secondary signs of a problem, such as changes in their routines or appearance,” Froemke says. “These red flags typically indicate there is a more serious underlying issue that is interfering with their ability to perform self-care.”
Use our activities of daily living PDF below as a starting point to assess ADLs and determine the kind of assistance a senior might require.
Printable: Activities of Daily Living Checklist
How to get an ADL assessment
A variety of elder care experts and medical professionals perform official ADL assessments. However, most programs that provide or cover long-term care services have their own processes, assessors, rules, and guidelines. For instance, long-term care insurance companies typically employ private assessors to make eligibility determinations for policyholders who wish to use their long-term care benefits.
If you’d like to arrange an independent assessment of a loved one’s needs, Froemke says it’s best to see a specialist, such as a geriatric care manager, a nurse, an occupational therapist, or a social worker. These professionals should be able to identify areas of concern and recommend potential solutions. A comprehensive geriatric assessment conducted by a physician can also evaluate both ADLs and IADLs, lifestyle factors, medications, and physical and mental health to get a more complete picture of a senior’s circumstances and needs.
One of the best resources for beginning this process is a senior’s local Area Agency on Aging (AAA). AAAs can provide referrals to providers and, in some cases, may actually be able to conduct functional assessments. These offices can also recommend support programs and benefits and assist with applications.
Sources of IADL and ADL assistance
Family caregivers are a common source of help with daily living tasks for older adults. But there’s a limit to the amount of assistance busy family members and friends can provide.
Sometimes durable medical equipment or home modifications can help facilitate activities of daily living for elderly individuals. However, if there’s still a need for support after modifications are put in place, Froemke says it may be time for outside help. Fortunately, there are many options available to support seniors and minimize the burden on caregivers.
One option is for your loved one to work with a physical therapist, occupational therapist, and/or speech therapist. These professionals are trained to help people restore their functional abilities. Sometimes ADLs and IADLs can’t be improved due to a degenerative disease like dementia. But in other cases, seniors may benefit from a therapist’s support and guidance. Medicare may cover these services, which can be provided in a senior’s own home by a home health care agency, in an outpatient setting, and in a skilled nursing facility for short-term rehabilitation following a hospital stay.
Another option is seeking out formal assistance. Help with most instrumental ADLs is referred to as companion care or homemaker services. This type of nonmedical support can be provided in a senior’s home by a home care company. But if a loved one only needs help with one or two IADLs, standalone services may be a better fit. For example, a ride-hailing service could meet their transportation needs, and a regular cleaning service could handle housekeeping tasks.
Assistance with ADLs is referred to as personal care or custodial care. For seniors who wish to age in place but need help with ADLs, home care is an excellent fit. Assisted living communities provide ADL support in a residential setting. So do memory care communities, a specialized senior living option for older adults with Alzheimer’s disease or other forms of dementia. Nursing homes provide ADL support along with 24/7 skilled nursing care for individuals who require the highest levels of assistance and medical monitoring.
Navigating care decisions and comparing care types can be difficult. If your loved one’s needs are increasing and you’re ready to explore your options, begin a no-cost consultation with one of our advisors. We can help you find local home care providers or senior living communities that meet their unique needs, care goals, and budget.
Reviewed by dementia care expert Adria Thompson, M.A., CCC-SLP.
Studies of Illness in the Aged: The Index of ADL: A Standardized Measure of Biological and Psychosocial Function (https://doi.org/10.1001/jama.1963.03060120024016)
StatPearls: Activities of Daily Living (ADLs) (https://www.ncbi.nlm.nih.gov/books/NBK470404/)
Lawton-Brody Instrumental Activities of Daily Living Scale (https://geriatrictoolkit.missouri.edu/funct/Lawton_IADL.pdf)
Older Adults' Health and Age-Related Changes (https://www.apa.org/pi/aging/resources/guides/older)
Unmet Need for ADL Assistance Is Associated With Mortality Among Older Adults With Mild Disability (https://doi.org/10.1093/gerona/glv028)
Medicaid Nursing Facilities (https://www.medicaid.gov/medicaid/long-term-services-supports/institutional-long-term-care/nursing-facilities/index.html)
VA Aid and Attendance benefits and Housebound allowance (https://www.va.gov/pension/aid-attendance-housebound/)
Function Report-Adult Form SSA-3373-BK (https://www.ssa.gov/forms/ssa-3373-bk.pdf)
Geriatric Assessment: An Office-Based Approach (https://www.aafp.org/pubs/afp/issues/2018/0615/p776.html)