Learning Objectives
By the end of this section, you will be able to:
- Recognize the types of ADLs
- Describe the causes of limitations with performing ADLs
- Identify measurement tools for the performance of ADLs
A functional performance activity, also called an activity of daily living (ADL), is an essential, routine task that most people can do independently most of the time. If you are reading this and going to nursing school with the intent to practice as a nurse, you probably perform all your ADLs independently. You can dress, shop, and cook for yourself without help. However, perhaps you have had an occasion—maybe during an illness—when you needed help with those basic functions.
A great deal of nursing care, particularly in hospitals and long-term care facilities, is centered around aiding patients with ADLs or completely performing ADLs for patients who cannot perform them independently. Individuals with disabilities or chronic illness, patients recovering from recent surgeries, and even many older adults may regularly require assistance with ADLs. In long-term facilities, staffing decisions are frequently made based on the number of patients needing assistance with ADLs and the number of ADLs each patient needs. Even funding agencies such as the Centers for Medicare & Medicaid Services use ADLs to estimate a patient’s time for rehabilitation after an illness, and the performance measures used to evaluate and rank care facilities are often partly based on ADLs. Many insurers decline to provide permanent nursing home care unless the patient has lost three or more ADL abilities.
The inability to perform basic routine tasks can lead to safety and health risks for individuals and decrease their quality of life (QoL). Even in outpatient care, regular assessment of ADL ability is an important part of ensuring that patients receive the care they need. Gradual decline in ADLs over a long period of time is not unusual, particularly in patients over 85 years—sometimes called the oldest old. The 2011 U.S. National Health Interview Survey revealed that 20.7 percent of all adults over 85 required ADL assistance, whereas only 3.4 percent of those between 65 and 74 required help (Edemekong et al., 2022). However, a rapid decline in ADL ability in any patient is cause for alarm. Thus, understanding and recognizing ADL ability is important in all healthcare settings.
Types of ADLs
There are two types of ADLs: basic and instrumental. A physical ADL is also considered a basic activity of daily living (BADL). They are things that most individuals learn as children when they are reaching various developmental milestones, and they make up the basic skills necessary to manage one’s physical body. A complex activity called an instrumental activity of daily living (IADL) makes up the skills required to live independently in community settings. These are everyday activities typically learned as adolescents.
Basic ADLs
Healthcare providers generally recognize the following BADLs:
- Transferring: the ability to move one’s body from one location to another, such as from a bed to a wheelchair and vice versa.
- Continence: the ability to maintain control of one’s own bowel and bladder functions.
- Eating: the ability to feed oneself and use utensils without assistance from others.
- Dressing: the ability to make appropriate clothing choices for the occasion or weather and put on the clothes (including zippers and buttons) without assistance.
- Bathing: the ability to wash oneself and provide for one’s basic cleanliness.
- Grooming: the ability to brush one’s teeth and care for one’s nails and hair.
- Toileting: the ability to move to and from the toilet, use it correctly, and clean oneself afterward.
Note that there are some variations in BADLs depending on the source or the measurement instrument being used. For example, some agencies combine toileting and continence or list walking as a separate BADL.
When a patient begins to lose their BADLs, the chances of gaining a nursing home admission increase dramatically—especially upon loss of the abilities to bathe, feed, or dress oneself. It is very difficult for families to provide full-time care for individuals who need extensive assistance with their BADLs. In a 2018 study of long-term care providers in the United States, 251,100 individuals were using an adult day service to meet their needs when their caregivers are working. Of those individuals, 64 percent needed help with three or more BADLs (Lendon & Singh, 2021).
Instrumental ADLs
IADLs are higher-order skills requiring complex physical or mental processes. They include the following:
- Transportation: the ability to either arrange for transportation, such as a cab or bus, or provide one’s own transportation.
- Shopping: the ability to acquire items needed for daily life, such as food, medication, and clothing.
- Managing finances: the ability to pay bills and manage bank accounts.
- Meal preparation: the ability to plan meals and cook for oneself.
- House cleaning: the ability to maintain one’s living space by completing tasks such as cleaning dishes after eating, taking out the trash, and straightening up living areas.
- Laundry: the ability to wash and dry one’s clothing.
- Home maintenance: the ability to keep one’s home in good repair, either by performing tasks oneself or by arranging for others to do them.
- Managing communication: the ability to communicate as needed via phone, mail, or computer.
- Managing medications: the ability to obtain medications and take them as ordered.
The loss of an individual’s ability to perform IADLs is often the trigger when families recognize a cognitive decline in their loved ones; it may be one of the first noticeable signs of dementia.
Limitations with Performing ADLs
Individuals who cannot perform ADLs independently and lack assistance are at risk for a variety of health and safety concerns, including malnutrition, poor hygiene, illnesses such as urinary tract infections, and injuries from falls. Unidentified ADL limitations are associated with higher chances of mortality, added healthcare costs, and admission to institutional care (Huntsberry-Lett, 2023). These limitations can have many causes, including musculoskeletal, CNS, circulatory, sensory, and respiratory disorders; impairment can also result from aging, medication side effects, and cognitive decline (such as dementia). Regular physical activity can prevent or delay the loss of ADL functioning (DHHS, 2021).
Aging
By 2030, there will be seventy-two million people in the United States over age 65—that will be 20 percent of the population (Tatum et al., 2018). As individuals live longer, their chances of experiencing multiple chronic illnesses and disabilities also increase. For older adults with Medicare, ADL assessment can be included in the yearly primary care wellness visit as part of a more extensive health risk assessment and testing for functional status and safety (Tatum et al., 2018). ADL skills assessments can be provided to patients or their caregivers to complete prior to seeing the physician, who can then review the results and discuss any implications and needs for community or rehabilitation assistance.
When working with older patients, particularly those with multiple comorbidities, exploring their desire for ongoing care is important. For many older adults, aging in place—remaining in their home, with or without caregivers—is a major priority. Many agencies are designed to allow older adults to remain at home for as long as possible. However, some strategies may require advanced planning by the patient and their family (National Institute on Aging [NIA], 2019). Exploring options early and planning for possibilities is key to ensuring an older adult can remain at home even when they begin to lose some of their ADL skills.
Cultural Context
ADLs, Multiple Chronic Conditions, and Older Mexican Americans
Individuals of Hispanic heritage now make up the largest minority group in the United States; they include more than 3.1 million individuals aged 65 and over, the majority of whom are Mexican Americans. Older Mexican Americans tend to have more chronic health conditions, such as arthritis, stroke, and cognitive decline, than their non-Hispanic White counterpart; those with three or more health conditions are likely to have severe ADL limitations (Collins et al., 2018). At the same time, they have longer life expectancies than non-Hispanic Whites. While both Hispanic and non-Hispanic populations experience loss of QoL due to limited BADLs and IADLs, older Mexican Americans may experience the limitations longer and with greater severity due to their greater life expectancy and number of chronic health conditions.
Familismo is a cultural practice common to many of Hispanic heritage; it refers to the connections within one’s family, both emotionally and in terms of responsibility. As a result of familismo, older Mexican Americans are less likely to be placed into long-term care situations, such as nursing homes, and less likely to use home health services (Collins et al., 2018). These individuals are more likely to look to families to meet their healthcare needs rather than rely on external resources.
The combination of longer life expectancy and expectation of family responsibility can be a heavy burden on Hispanic families no matter how much they love their older relatives, particularly as the caregivers themselves age. When working with patients of Hispanic or Mexican American heritage, it is important to ensure that ADL and functional limitations are being identified and that their families and caregivers are being offered and given the support they are eligible for in a fashion that is culturally appropriate for them (Collins et al., 2018).
Cognitive Decline
Some minor cognitive decline is considered normal in older adults, and the chances of cognitive impairment increase with age (Tatum et al., 2018). However, a dementia is not a normal part of aging: they are irreversible, progressive disorders of the brain characterized by loss of cognitive and physical functioning. One of the most common causes of dementia is Alzheimer disease, a progressive cognitive disorder of the CNS that destroys the abilities to remember, problem solve, and eventually to manage even simple tasks; the disease may also cause personality and mood changes (NIA, n.d.). An estimated six million Americans have Alzheimer disease, although many have not yet been diagnosed (NIA, n.d.). Assisting these patients to establish early and long-term plans and connecting them with other agencies that can assist them are important parts of their healthcare team’s obligations.
Taking longer to complete BADLs and difficulty managing IADLs are often the first signs that family members, and sometimes the patients themselves, begin to notice. By the time a patient reaches the late stage of Alzheimer disease, they are generally entirely dependent on others for all their ADLs (NIA, n.d.).
Suppose a patient has been diagnosed with early-stage dementia. In that case, they and their family should begin planning for their future. Many will be able to remain in their homes initially, some for years, before needing long-term care. However, they must establish strategies for managing IADLs—such as taking medications, purchasing groceries, and paying bills—as limitations in those activities often appear before limitations in BADLs. The patient should develop strategies to help themselves remember important things they need daily, such as using calendars or notebooks and keeping items together in a prominent place. They should also set up ways to pay bills, such as automatic bill pay, or ask someone they trust to pay their bills instead. Safety measures such as automatic cutoffs on stoves and emergency call buttons should be installed, and smoke detectors should be inspected and upgraded if necessary.
Acute Illness
Particularly among older adults, an acute illness often causes a loss of ADLs. Nurses can improve these outcomes through individualized plans of care. For example, nurses can actively encourage providers to order physical therapy and participate in early mobilization efforts. Additionally, nurses can ensure that call lights are answered promptly to decrease patients’ reliance on adult briefs and discourage the use of urinary catheterization when possible.
Link to Learning
Many agencies offer home health services to individuals to allow them to remain in their homes and live as independently as possible for as long as possible. Adult day care programs are excellent options for many older adults who want to age in place and be as independent as possible but are unable to manage all their ADLs or lack the cognition to be safely alone. Check out this short video about using adult day care to facilitate aging in place.
Delirium
If patients experience episodes of delirium while in the hospital, their chances of losing ADL function increase dramatically. An acute cognitive change called delirium resembles dementia in many ways; it is most often related to medical illnesses, substance use, surgery, chemical imbalances, or withdrawal from medications (Bellelli et al., 2021). However, unlike dementia, delirium is reversible if identified and treated appropriately.
Delirium is more common in older adults. For patients, the risk of delirium increases with the length of hospitalization, severity of illness, frailty of the patient, and number of medications and treatments provided. Additional risks include sensory deprivation, urinary catheterization, and preexisting dementia (Bellelli et al., 2021). Patients experiencing delirium are often too confused to provide self-care and lose their ADL abilities. Those losses can be permanent if not identified early and treated promptly (Weng et al., 2019).
Measurements for Performance of ADLs
Measuring ADL performance is an important part of evaluating an individual’s health status and needs. Measurement can assist in identifying safety risks and the kinds of living environments or assistance strategies that are appropriate for a patient. Medicaid, the U.S. Department of Veterans Affairs (VA), and other insurers consider a patient’s functional ability—the ability to independently perform expected tasks, including ADLs—when determining whether they are eligible for benefits such as home health aides or long-term care (American Council on Aging [ACA], 2023).
A measurement of ADL performance is called a functional assessment. They aid in determining an individual’s capacity to perform BADLs and IADLs. They are used in a variety of settings. Primary care and acute hospital providers may use them to decide the types of care a patient requires upon discharge or the onset of acute functional changes. Short-term rehabilitation specialists may use them to assist in developing care plans and establishing a baseline between where a patient was prior to an illness or surgery, where they are currently, and where they would like to be. Long-term care facilities may use them to validate the need for a patient’s continued admission. Third-party payers, such as Medicaid and the VA, use them to confirm a patient’s need for services.
There are a variety of common functional assessments that may be used independently or in conjunction with each other, depending on the purpose of the assessment. They include the Katz Index of Independence in Activities of Daily Living (Katz ADL Index), the Lawton-Brody Instrumental Activities of Daily Living Scale (Lawton Scale for IADL), the Klein-Bell Scale (the most complex), the Cleveland Scale (for individuals who have Alzheimer disease), the Bristol Scale (for individuals with dementia), and the Barthel Index. The most common are the Katz ADL Index, the Lawton Scale for IADL, and the Barthel Index (ACA, 2023).
Katz Index of Independence in Activities of Daily Living (Katz ADL Index)
The Katz ADL Index measures the ability of an individual to perform six BADLs. It can be given periodically to identify whether changes to the individual’s functioning have occurred. It is one of the most used indexes, particularly for patients transferring from hospital to home (Liebzeit et al., 2018). It is effective in identifying large declines but not incremental declines or improvements (Witt & Hoyt, 2023).
Link to Learning
The Hartford Institute offers an example of a Katz ADL Index worksheet. Check it out to see how it works in practice.
The Katz ADL Index contains six items: the BADLs of dressing, toileting, bathing, transferring, continence, and feeding (Liebzeit et al., 2018). It is a yes-or-no instrument; either the patient can perform a task independently or they require assistance. If the patient can perform the task independently, they score a 1 for that item and if they cannot perform the task independently, they score a 0 for that item. Assessment is usually done either through self-report by the patient or by their caregivers. A score of 6 indicates the patient is independent, 4 indicates the patient has moderate impairment, and 0 indicates the patient is very dependent.
Patient Conversations
How to Perform a Katz ADL Index Assessment
Scenario: Mr. Solomon is a 69-year-old Black male who has recently moved and is having an initial appointment with a new primary care provider. During his intake, the nurse collects much of his history and pertinent data and uses the Katz ADL Index assessment to evaluate Mr. Solomon’s ADLs.
Nurse: Okay, Mr. Solomon, I’m going to move on to some other types of questions about your daily life and activities. Are you able to bathe yourself?
Patient: Yes.
Nurse: Do you dress yourself?
Patient: Depends on who you ask. My granddaughter says I have no fashion sense.
Nurse: My daughter says the same about me. How about toileting? Do you ever need help with that?
Patient: Only for a few weeks after I broke my leg. That was so embarrassing to have to get my wife to wipe me after I stooled. Now I’m fine again.
Nurse: Do you ever have problems getting to the toilet? Or do you have issues controlling your bladder?
Patient: Since my prostate surgery, I sometimes have problems getting to the toilet quickly enough and pee myself. I wear pads for that.
Nurse: That is more common than you may realize. I see that you walk with a cane. Do you ever have problems getting from one place to another?
Patient: Only if I do not have my cane. I can get off balance easily, you see. But if I have my cane, I can get wherever I need to go.
Nurse: Finally, are you able to feed yourself?
Patient: Yes.
Scenario follow-up: The nurse has quickly completed the Katz ADL Index scale with Mr. Solomon; being unable to reliably control his bladder, he scored 5 out of 6 possible points. Also, he has a strategy to manage the one issue for which he is not fully independent without assistance: pads for when he can’t get to the toilet in time. This information provides the new provider with a baseline for Mr. Solomon’s physical functioning. The nurse performed the same type of questions with Mr. Solomon about his IADLs and discovered he has no difficulties there.
Lawton-Brody Instrumental Activities of Daily Living Scale (Lawton Scale for IADL)
The Lawton Scale for IADL was developed to measure more complicated ADLs. Interestingly, the original scale, developed in 1969, reflected the expected gender roles of the time (Liebzeit et al., 2018). It had 8 points for women: the abilities to use a telephone, prepare food, do laundry, shop, and manage transportation, medications, housekeeping, and finances. It had only 5 points for men: the abilities to use a telephone, shop, and manage transportation, medications, and finances. Today’s version includes 8 points for all genders—those on the original scale for women (Liebzeit et al., 2018). It is a self-reported questionnaire that can either be filled out by a patient or family member or given orally by a nurse.
The Barthel Index
The Barthel Index (BI) is another common instrument frequently used in rehabilitation centers to gauge patient progression. It allows for a more nuanced and expanded examination of the BADLs (Liebzeit et al., 2018). It expands and separates some categories. For example, controlling one’s bowel and bladder are separate activities, as are bathing and grooming (e.g., caring for one’s face, hair, and teeth) and mobility on flat surfaces and on stairs. It also allows for more nuanced reporting of abilities: users may be rated as independent, in need of assistance, or dependent (Liebzeit et al., 2018). BI is scored from 0 to 100, with 0 being totally dependent and 100 being totally independent.
Levels of ADL Performance
It is possible—indeed, probable—that a given individual will perform different ADLs at different levels. The various activities are relatively distinct from each other. For example, the same patient who cannot transfer themselves from their bed to their wheelchair may be able to button the buttons on their shirt, brush their teeth, and feed themselves. Thus, for each ADL, providers may gauge a patient to be fully independent, in need of supervision or assistance, or fully dependent.
Independent
An independent ADL requires no assistance; the patient can perform them with no help or coaching. Individuals who perform a given ADL independently may use an assistive device, such as a wheelchair or scooter for mobility or a Provale cup to prevent aspiration when drinking. They still perform the activity without the assistance of other individuals. For example, Susan is a 45-year-old female who uses a wheelchair because of a traumatic lower leg amputation in a car wreck three years ago.
- Susan easily transfers between surfaces such as her bed and wheelchair, and she can move around her home independently.
- Susan cannot drive yet because she has no car adapted to her prosthesis. However, she is adept at arranging transportation via ride-sharing apps and has also used local buses. Therefore, she can manage her transportation needs independently.
Supervised
A supervised ADL describes an activity that an individual can safely perform with supervision or with coaching or reminders of what to do. Individuals who require supervision may technically be able to perform all the skills needed for the action; however, they may lack either the physical ability to do it consistently without harming themselves or the cognitive ability to remember how to do it. For example, Eduardo is a 65-year-old male with the early stages of Alzheimer disease who also has some mobility issues.
- Eduardo gets bored easily and loves to walk but has an unsteady gait and needs a cane. However, he forgets to use his cane, and he falls often. He requires coaching and reminders to use his cane to walk without falling.
- Eduardo is from Puerto Rico but now lives in the Northeast. He prefers to wear shorts and lightweight button-up shirts, which he always chooses, even when the temperature is quite cold. He requires coaching and someone to restrict his clothing options to seasonally appropriate ones.
Assisted
An assisted ADL describes an activity that an individual cannot perform independently or with supervision but can participate in and do some of the work. Individuals who require some assistance with ADLs are frequently able to perform all the movements required for the skill but lack the strength to do it independently. They may also be unable to perform all the movements required or be confused and require direct coaching and hands-on help to perform ADLs. For example, Frederica is a 51-year-old female who recently broke her ankle and upper arm on the right side, her dominant side. She cannot put any weight on her broken ankle or use her right arm. She can maneuver herself from a chair into her wheelchair to get to the bathroom and use her left leg and arm to move the wheelchair around.
- Frederica can stand on one leg and pivot to the toilet without help. However, she cannot stand on one leg, support herself with one arm, and clean herself after toileting. She requires assistance with toileting.
- Frederica can get her wheelchair up to the sink with assistance and perform a partial sponge bath on her upper body with her left hand. However, she cannot bathe the left side of her upper body with her right hand or effectively clean her lower legs, back, and bottom. She requires assistance with bathing.
Dependent
A dependent ADL must be done entirely for an individual because they cannot or will not do them for themselves. These individuals may be sedated and not know that care is being provided, or unaware or uncaring that the care is necessary; they may be passive participants who follow instructions but provide no active assistance; or they may actively discourage ADL care. For example, John is 75 years old and lives in a nursing home. He has advanced Alzheimer disease.
- John no longer feeds himself. He will open his mouth when asked and chew and swallow food when placed in his mouth. However, someone else must feed him. He is dependent for feeding.
- John also no longer dresses himself. He does not fight when someone is dressing him; however, he does not offer any assistance by bending his arms or legs. He must be fully dressed by someone else. He is dependent for dressing.
Unfolding Case Study
Unfolding Case Study #4: Part 4
Refer back to Unfolding Case Study #4: Part 3 for a review on the patient data.
| Nursing Notes | Time: 1315 Patient reports experiencing persistent joint pain, particularly in the shoulders and wrists, rated at 6/10 on the numerical pain scale. Patient states that pain interferes with daily activities, such as getting dressed and cooking. Patient also reports stiffness in affected joints, especially in the morning or after prolonged periods of rest, which improves with movement throughout the day. |
| Provider’s Orders | Time: 1400
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