Activities of Daily Living (ADLs)

and Instrumental Activities of Daily Living (IADLs) Issues and Tools of Measurement ; Determinants of those needing assisted living:

Performance of

- Instrumental Activities of Daily Living (IADLs)
- Activities of Daily Living (ADLs)
Cognitive status
- Orientation, registration, attention and calculation, recall, language, judgment, and reasoning.
Mental and behavioral status
Physical health and medical status

Issues in the performance of ADLs (Activities of Daily Living) and IADLs (Instrumental Activities of Daily Living):

Is activity done
- At the appropriate time?
- At the appropriate place?
- In the appropriate manner?
Time required for the activity
Difficulty with the performance of the activity
Changes in function over short periods of time.

Reasons for difficulties with ADLs and IADLs:

Physical impairments/problems
- Reduced Range of Motion (ROM), stiffness, tremors, reduced sensation
- Pain/discomfort
- SOB (shortness of breath), weakness, lack of endurance
- Gait/balance problems
- Sensory impairments
- Eating/Chewing problems
Cognitive limitations
- Memory
- Reasoning ability
- Judgment
Emotional and behavioral factors
- Fear, uncertainty, lack of confidence
- Depression
- Anxiety

Contextual factors in ADL and IADL function:

Personal preferences/decisions
- Motivation
- "Learned dependency"
- Cultural factors
Family dynamics
Environmental fit
- Barriers to accessibility
- Features that increase risks
- Lack of assistive technology

Tools for measuring physical function:

Katz Index of ADL (Activities of Daily Living)
- Specifies some components of activity, but they are aggregated
- Only indicates whether elder receives assistance - not the amount needed
- Uses hierarchy to determine level of dependence
- Good for predictive ability, not applicable for determining needed services
Functional Independence Measure (FIM)
- Considers:
  - Time to accomplish activity
  - Need for assistive device
  - Need for cueing/coaxing
  - Approximate amount of activity person can do
- Does not consider
  - Context - home, hospital, structured environment
  - Resistance - in cognitively impaired

Cognitive assessment tools:

Mini-Mental State Examination (MMS)
- Advantages:
  - Relatively short
  - Well tested
  - Samples the domain of cognitive function relatively well (except for judgment)
- Disadvantages:
  - Educational level may have effect
  - Vision or upper extremity disabilities may interfere (drawing and writing)

Problems with Measurement Tools:

Fail to measure interactions among various domains:
- Examine only physical function or amount of assistance needed, not
  - Cognitive factors
  - Social or cultural factor
  - Contextual factors (environmental barriers)
- Examine only cognitive, mood, or behavior status and do not link to physical function

Implications of limitations in tools:

Good interviewing skills are critical.
Acute observational skills are imperative.
Professional judgment is absolutely necessary.

Source: Dr. Linda Redford, Center on Aging, Kansas University Medical Center, at "Assisted Living Skills Training" sponsored by Nebraska Department of Health and Human Services, January 20, 1999.

Compiled by the Lincoln/Greater Nebraska Chapter of the Alzheimer's Association, 1999.