Activities of Daily Living
Every day, individuals need to do certain tasks in order to stay safe, clean, and healthy. These tasks are referred to as the activities of daily living (ADLs). This guide covers the basics of ADLs and long-term care options, including information on adaptive equipment, paying for senior care, and choosing the right provider for your needs.
What are ADLs?
ADLs are tasks that are considered the basic functions of daily life. The ability to do these tasks independently is often considered a baseline for a person’s ability to safely live on their own. ADLs include tasks such as:
- Getting dressed
- Continence (bladder and bowel control)
- Transferring (getting in and out of bed or chairs)
- Self-ambulation (moving around with or without assistive devices, like walkers)
These basic daily tasks are the ones people often first learn as children. When someone is no longer able to perform one or several of these ADLs independently, they may need assistance to continue living safely.
Instrumental activities of daily living
In addition to ADLs, there are other activities an individual needs to do in order to live independently. These tasks are known as the instrumental activities of daily living (IADLs). They include tasks such as:
- Meal preparation
- Medication management
- Telephone and other communication method use
- Money management
These activities help individuals maintain independence as well as
Assessing ADLs and IADLs
Healthcare professionals use scales to measure a person’s independence based on their ability to complete ADLs and IADLs. There are several different assessment tools that may be used by a facility or practitioner. The assessments assign point values to the ability to complete each ADL or IADL.
The Katz Index of Independence in ADLs is a commonly-used assessment that measures a person’s ability to complete their ADLs. It assigns a point for activities done independently or with minimal assistance. For example, a person may get a point for dressing independently even if they require assistance tying their shoes. A person will receive zero points for activities that require assistance to complete. The final score is given an on a scale from zero signifying very dependent to six signifying independence.
For IADLs, the Lawton-Brody IADL Scale is often used. This scale measures eight IADLs and assigns one point for tasks done with no or minimal assistance. For example, the transportation category gives a point for driving or using public transportation independently. It also gives a point
These scales are used to determine how much assistance a person requires. In long-term care facilities, they may be used to let staff know how much help an individual will need throughout the day.
Conditions that make ADLs challenging
As people age, there are several conditions that may cause a decline in ability to independently perform ADLs and IADLs. These conditions may vary and may be acute (having a sudden onset) or chronic (long-lasting). Some common conditions that may result in decreased ability to perform ADLs and IADLs include:
- Dementia (like Alzheimer’s disease)
- Chronic back pain
- Congestive heart failure
- Hip fracture
- Vision loss
Individuals with some of these conditions may not see a decline in function or ADLs, but for some people, they may result in a permanent loss of ability for self-care. While some conditions, such as strokes and hip fractures, may be recovered from, some of these conditions may be degenerative and lead to further decline the longer an individual has them.
Many seniors have multiple diagnoses, which may increase the risk of decreased ability to perform ADLs. For example, an individual with diabetes, vision loss, and dementia may have trouble navigating their home. They would be at risk of serious injury, especially if diabetes had caused neuropathy (a loss of feeling in the extremities). They may not always remember to complete certain self-care tasks and may have extreme difficulty completing them.
In some cases,
Dementia and ADLs
Alzheimer’s disease, along with other forms of dementia is progressive and will likely lead to a significant decline in ability to perform ADLs and IADLs over time. In both degenerative dementia and Alzheimer’s disease, stages of the disease are often measured in 7 stages. These stages are measured on the Global Deterioration Scale for Assessment of Primary Degenerative Dementia (GDS) and the Functional Assessment Staging (FAST).
Both the GDS and the FAST are broken into 7 stages ranging from the stage 1 level of no dementia/normal adult to the stage 7 level of late dementia/severe Alzheimer’s disease. The GDS focuses more on the level of cognitive impairment, while the FAST focuses on functional decline. On both the GDS and the FAST, a decline in ability to perform IADLs begins in stage 3 or in stage 4. In these stages, individuals may no longer be able to handle tasks related to personal finance or travel arrangements. By stage 5, individuals will have trouble completing ADLs such as bathing or dressing independently and need some form of Alzheimer’s care.
Chronic pain and ADLs
For many people with chronic pain, IADLs such as household chores present a significant challenge. Activities such as vacuuming, dusting, cooking, or lifting objects may be very difficult for someone with a chronic pain condition. Maintaining their home may become increasingly challenging, and they may need assistance to keep it clean, safe, and secure.
Some people with chronic pain are able to manage other IADLs such as finances, medications, phone calls, and transportation in the way that they were prior to the onset of pain. However, for some people, the pain coupled with these tasks may be overwhelming and they may no longer be able to handle these IADLs. Chronic pain may also cause depression. Depression may result in difficulties in memory and concentration for some people, making management of IADLs very challenging.
An individual with chronic pain’s ability to perform ADLs may also decline. The individual may have difficulty pulling shirts over their head, reaching some buttons, or standing for long enough to pull on pants. They may no longer be able to keep their balance in the shower and may be unable to reach all the parts of their body that need to be cleaned. Additionally, depending on where the pain is, they may find it challenging to get up from a seated position, making it difficult to use the bathroom.
Medications and ADLs
Many seniors are on several medications. In fact, it is estimated that 25 percent of seniors take at least five prescription medications. These medications may also result in a decreased ability to perform ADLs and IADLs, often by causing symptoms such confusion or dizziness. Some of the most commonly-prescribed medications for seniors include:
- Hydrocodone with acetaminophen for pain reduction
- Simvastatin for lowering cholesterol
- Lisinopril for lowering blood pressure
- Levothyroxine sodium for thyroid regulation
- Omeprazole for acid reflux
- Metformin for diabetes
- Hydrochlorothiazide for lowering blood pressure
For some seniors, these medications may help treat conditions but cause a decrease in ability to perform ADLs and IADLs. If an elderly individual is on a new medication and notices a decline in their ability to perform IADLs or ADLs, they should report this change to their doctor right away.
Adaptive equipment and ADLs
When an individual requires assistance with ADLs, adaptive equipment may be ordered. Adaptive equipment may be able to help individuals continue to perform some ADLs on their own. Some examples of adaptive equipment include:
- Shower handrails — For an individual who is having trouble showering due to balance issues, shower handrails may be able to help them keep their balance and shower independently
- A shower chair or bench — As with shower handrails, a shower chair helps with balance. For an individual who is unable to stand for long enough to shower, a shower chair allows them to sit while bathing
- Front-buttoning or velcro tops and bottoms — For individuals who are no longer able to reach back buttons, clothing that is made with adaptations for easier self-dressing may be useful
- Raised chair cushions or toilet seats — Standard height chairs and toilet seats may be difficult to get in and out of. Raising the height may make it possible for getting in and out of these seated positions to be done independently for longer
- Walkers or other mobility devices — Devices to assist in ambulation such as walkers and canes may help an individual maintain independence. When an individual needs a walker or cane, a physical therapist will teach them how to use it. In some cases this device may only be needed for a short time, in others, it is meant as a long-term solution
- Adaptive silverware — Adaptive silverware is generally larger and heavier than regular silverware. It may help individuals with arthritis who are no longer able to grip standard silverware continue to eat on their own
When an individual needs adaptive equipment for ADLs or IADLs, physical or occupational therapists may recommend the equipment that would be the most beneficial. For many people, adaptive devices are able to help them care for themselves and remain independent for much longer than they would have been able to otherwise. In many cases, even when an elderly individual is no longer able to use the equipment themselves for ADLs, the adaptive devices may be able to help caregivers perform them.
Assistance with ADLs
When an individual is no longer able to perform ADLs on their own, they may need help to maintain their safety. They may need assistance in their home or in a long-term care facility. What level of help a senior requires will depend on their specific circumstances and level of decline.
Many individuals are able to remain at home, even when they require assistance with ADLs and IADLs. In these cases, in-home care may be able to provide the care these individuals need. Care available in the home is often divided into home care, non-medical care that includes tasks such as homemaking and personal care services, and home health care, which includes skilled medical care.
Either type of home-based care will provide help with ADLs. Home health care will also provide nursing care and therapy services. A home healthcare team will oversee the individual’s care and make sure they are safe in the home. They will report back to the patient’s doctor about any changes. The individual will receive treatments and therapy sessions in the home.
Some home health care agencies may provide assistance with IADLs, but some may not. Home care agencies generally do provide these services but do not provide skilled nursing or therapy services.
Home care services options are generally best for people who do not need around-the-clock care. They may be helpful for individuals who live with a spouse, adult child, or another caregiver. They may also be helpful for individuals who are unable to do some ADLs (such as showering independently) but are still able to be safe in their home most of the time.
For individuals with conditions such as dementia who are unable to be in their homes unattended, home-based care may not be the most appropriate choice. While some agencies may able to arrange around-the-clock care for the elderly, this may be difficult and costly to set up.
Assisted living facilities
If a person needs help to be safe in their home and care for themselves on a continuous, around-the-clock basis, home-based care may no longer be an option and senior housing may be the right choice. In these cases, an individual and their family may want to consider inpatient facilities such as assisted living facilities (ALFs). ALFs are meant to be long-term solutions for individuals. In an ALF, a person will receive assistance with their ADLs and IADLs.
Different ALFs provide different levels of service, but most can assist with medication management and personal care. Nursing staff will provide medications and some treatments. Personal care aides will provide assistance with ADLs and IADLs. In an ALF, services such as housekeeping, laundry meals, transportation, and activities are generally also provided.
In an ALF, an individual will likely take an assessment before moving in. This assessment will measure the individual’s ability for self-care. If an ALF is unable to accommodate the individual's needs, they will tell the individual and their family this after the assessment.
Some ALFs are part of communities known as Continuing Care Retirement Communities (CCRCs), which offer multiple levels of care all in one building or on one campus. An individual may be able to start out in the ALF level of care and move back and forth to a skilled nursing facility (SNF) level as needed. In an SNF, an individual may receive therapy, wound care, or other skilled services. After finishing their care in the SNF, an individual in a CCRC will return to their room in the ALF. These communities can help ensure residents feel at home and secure as their care needs change.
Paying for long-term senior care
All types of long-term care for assistance with ADLs will have associated costs. Different home-based care providers, SNFs, ALFs, and CCRCs will accept different forms of payment. The level of care the individual needs may increase costs in certain facilities or with certain providers.
Medicare will pay for all home health care costs as long as the agency is Medicare-certified and as long as the doctor ordering the care certifies that there is a skilled need. Medicare will cover the costs for services needed on a part-time (less than 8 hours a day) and temporary (for less than 21 days) basis. Medicare will not pay IADL services, such as housekeeping, transportation, and meal preparation. Different agencies will accept different payment forms, but common payment options include Medicaid, private pay, and long-term care insurance.
Skilled nursing facilities
Medicare will cover nursing home costs for up to 20 days as long as there has been a qualifying hospital stay. On days 21 through 100, Medicare will pay a portion of the costs and the individual will be responsible for a copay amount. After 100 days, Medicare will no longer cover the costs of care in an SNF and the individual will be responsible for the entire amount. Most SNFs accept payments such as long-term care insurance, Medicaid, and private pay.
Assisted living and continuing care communities
These facilities are considered custodial care and not medical care. They are not covered by Medicare. The cost of these facilities will need to be paid by other methods. Staff at the ALF or CCRC may be able to assist an individual and their family determine the best payment option for them. Medicaid is accepted at some facilities, while others require private pay. Methods such as home equity loans, reverse mortgages, and immediate annuities are often used to help cover this cost.
Activities of Daily Living FAQs
- Why are ADLs so important?
ADLs are a measure of an individual’s ability to care for themselves independently. When an individual is no longer able to perform their ADLs, this is a sign they need assistance to be safe. An individual who is unable to perform their ADLs independently cannot live completely independently. They will need some help to accomplish these tasks and maintain a quality of life.
Neglecting any of the ADLs may lead to infection, injury, or death.
- Why is making phone calls considered an IADL?
Being able to communicate with the community is an important part of independent living. An individual who is unable to use the phone or another communication device to talk to family and loved ones, make orders for medication or food, or call a doctor may not be safe in their homes. Additionally, if an individual is unable to call 911 in the case of an emergency, the emergency situation may worsen significantly before help is able to arrive.
There are many programs that may be available to provide free or low-cost cell phones to seniors. Some of these programs are income-based, but others are not. Having a cell phone available at all times for any needed emergencies may help seniors run errands and live active lives. When a senior lives in an ALF or another long-term care facility, they may have the ability to call for help from a call light in their rooms. This may provide additional peace of mind that assistance will always be reached.
- If a person is unable to cook their own meals, can they still live alone?
Yes. There are many programs available to help seniors have nutritious meals when they cannot prepare them on their own. Many of these programs will help seniors stay with a doctor-prescribed diet plan, such as a heart-healthy diet. Some options for seniors who need meals prepared for them include paid services, free community-based care services, meals provided at senior centers, and meals prepared by home care agencies.
Proximity of care is very important when considering options
Research care options that are nearby when thinking about the next step for your loved ones.
Leona J. Werezak RN, BSN, MN is a registered nurse and adjunct nursing professor. She has 24 years experience working in a variety of healthcare settings including such remote locations as the Arctic Circle. Her research in early stage dementia was published in the Canadian Journal of Nursing Research and re-published in their 40th anniversary issue which showcased exceptional research published since the journal began. Her work in dementia care has also been published in the Journal of Gerontological Nursing. She currently teaches surgical nursing care on a thoracic/vascular unit to baccalaureate nursing students. Her clinical work with nursing students involves extensive work with older adults who have multiple chronic health conditions.