Definition of ADLs and IADLs
There are specific daily tasks that persons must be able to do in order to maintain their full independence. These daily living activities are broken into two groups: Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). While different sources have slight variations as to what tasks are labeled as ADLs and what tasks are labeled as IADLs, there is considerable overlap. The definitions included below are the most common. The capability for seniors to perform IADLs independently generally declines prior to their ability to perform ADLs independently.
Activities of Daily Living
ADLs are basic self-care activities that persons must perform on a day-to-day basis in order to live independently. Some scales consider seven ADLs but it is more common to measure the five ADLs below.
1. Mobility (may also be referred to as ambulating or transferring) – moving about inside and outside of one’s home. Examples include the ability to walk, go up and down stairs, get out of bed and into a wheelchair, or stand from a seated position to use a walker.
2. Dressing – choosing appropriate clothing and putting them on (i.e., fasten buttons and zip zippers).
3. Eating – utilizing a fork and other utensils to get food to the mouth and the physical act of eating.
4. Personal Hygiene –safely getting in and out of the bathtub or shower and cleaning oneself. Also includes other grooming activities, such as shaving, nail care, and brushing teeth.
5. Toileting (may also be called continence) – making it to the toilet in time by controlling one’s bladder and/or bowel, getting on and off the toilet, and cleaning oneself after use.
Instrumental Activities of Daily Living
IADLs are necessary for independent living but are not as crucial to daily functioning as ADLs. Stated differently, IADLs are tasks that do not necessarily have to be done every single day.
1. Shopping – buying essentials, such as groceries, prescription medications, and clothes.
2. Meal Preparation – planning meals, getting the necessary ingredients, and cooking.
3. Housework – maintaining the home, keeping it clean and free of trash, doing laundry, etc.
4. Money Management – paying bills, managing bank accounts, etc.
5. Transportation – driving oneself or obtaining and accessing other modes of transportation, such as public transportation, taxis, and arranging rides with loved ones.
6. Medication Management – ensuring prescriptions are filled and taking as prescribed.
7. Communication – looking up phone numbers and using the telephone, or communicating via a computer
Why Measure One’s Ability to Complete ADLs / IADLs?
As persons age, it is common that their ability to independently complete their ADLs and IADLs begins to diminish. This may be the result of the natural progression of aging, be related to a health condition, or be caused by the cognitive and physical decline associated with Alzheimer’s disease and other forms of dementia.
Measuring one’s ability to complete their activities of daily living (independently or with assistance) via a functional (clinical) assessment serves as an important tool in evaluating a senior’s current health status. Via a functional assessment of ADLs and IADLS, it can be determined if, and how much, care assistance an elderly individual requires. In addition to determining for which (if any) activities of daily living a senior requires assistance, potential safety hazards, such as the risk of slipping on the stairs or falling while trying to transition from a chair to standing, are identified. This knowledge can help to determine which living environment, and type of care assistance (if applicable), is best suited for a particular senior and his / her needs. In other words, functional assessments can help to identify current and future care needs as well the type of living arrangements (such as assisted living or a nursing home).
For example, an elderly individual in the very early stage of Alzheimer’s disease can likely still function rather independently and can continue to live alone in his / her home. However, via a functional assessment, it might be determined that the individual would benefit from in-home assistance with preparing meals, housecleaning, and laundry on a weekly basis. As a different example, a senior who has had a stroke might be able to safely live with a relative, but via a functional assessment it is found that the senior requires daytime supervision and assistance with daily activities while the family caregiver works. In this case, adult day care might be a good option. And lastly, a functional assessment of a senior residing in assisted living might reveal that nursing home care might be a more appropriate setting for the individual based on his / her evolving needs.
Importance of ADLs / IADLs for Medicaid Eligibility
The ability / inability to independently complete daily living activities (both ADLs and IADLs) is often used as a measure to gauge one’s eligibility for long-term care Medicaid. Stated differently, in order for seniors to be eligible for long-term care Medicaid, they must demonstrate a functional need, sometimes called a medical need, for the Medicaid program for which they are applying.
For HCBS Medicaid waivers and nursing home Medicaid eligibility, often a nursing home level of care, also called a nursing facility level of care (NFLOC), is required. (HCBS Medicaid waivers provide long-term care in a variety of settings, such as one’s home, adult day care, assisted living, memory care, and adult foster care homes). When determining if the functional need for NFLOC is met, ADLs and IADLs are often considered. For instance, the need for assistance with a specified number of daily living activities might be required.
Long-term care services, such as personal care assistance and homemaker services, may also be accessed through one’s regular state Medicaid program. (Regular state Medicaid for seniors is commonly called Aged, Blind and Disabled Medicaid and is abbreviated as ABD). While a medical need must still be demonstrated, the level of care needed is generally less than a NFLOC. However, it is the inability to complete daily living activities that is generally still used as a factor in determining functional eligibility.
In addition to Medicaid considering one’s inability to independently complete ADLs and IADLs as functional eligibility criteria, the VA also takes this into account for the eligibility of some benefits, such as the Aid & Attendance pension.
Types of ADL and IADL Assessments
Functional assessments are used as a tool to measure an individual’s capability / incapability to complete their ADLs and IADLs, whether it be independently or with assistance. They are used by healthcare professionals to put together a care plan, informal caregivers to assess the current needs of their loved one, and by long-term care Medicaid agencies to ensure an applicant meets the programs functional need requirement, functional assessments play a vital role.
That said, there is not one universal functional assessment that is used; rather there are many available. To be clear, the lack of consistency of a universal functional assessment also holds true for long-term care Medicaid eligibility. In fact, even within the same state, functional ability may be measured by different functional assessment tools based on the specific Medicaid program for which one is applying.
Below we will cover 6 of the more well-known functional assessments that are traditionally used to measure a senior’s functional ability and long-term care needs (though generally not for Medicaid eligibility purposes). Some of them only consider ADLs, others only IADLs, and still others take both ADLs and IADLs into account.
Katz Index of Independence in Activities of Daily Living (Katz ADL)
The Katz Index of Independence in Activities of Daily Living is one of the most commonly used tools to measure a senior’s ability to complete their ADLs independently. This simple checklist, which is ideal for seniors who live at home or in a residential setting, measures one’s dependence / independence of six ADLs: Bathing, dressing, toileting, transferring, continence, and feeding.
For activities for which the senior requires no assistance, 1 point is given for independence (this indicates the senior does not need to be supervised, directed, or receive personal assistance with the particular ADL). For activities for which the senior requires assistance, 0 points are given to indicate dependence (the indicates the senior needs supervision, direction, personal assistance, or total care). Persons who receive a score of 6 are considered very independent, while a score of 0 is considered highly dependent.
An online version of the Katz ADL assessment is available here.
Lawton-Brody Instrumental Activities of Daily Living (IADL)
The Lawton-Brody Instrumental Activities of Daily Living scale is one of the most commonly used checklists to determine one’s ability to complete IADLs. Appropriate for persons living at home and in other community settings, 8 instrumental activities of daily living are measured: The ability to use the telephone, shopping, food preparation, housekeeping, laundry, mode of transportation, responsibility of own medications, and the ability to handle finances.
Under each of the 8 categories are several statements and the one that is most relevant for the senior in question is indicated. The statement that is chosen should be the one that is the closest to the individual’s level of functioning. The correlating score for each category is either a 0 or a 1, with a total possible score of 8 for Lawton’s instrumental scale. A score of 0 indicates that the person is low functioning, while a score of 8 means the individual is high functioning. Please note that men are not always scored on all 8 categories. For instance, if a man has no history of preparing food, housekeeping, or doing laundry, he will not be scored on these tasks.
To view Lawton’s instrumental scale, click here.
Klein-Bell Activities of Daily Living Scale (K-B Scale)
The Klein-Bell ADL Scale is a 170-item list measuring 6 categories of ADLs: Mobility, emergency communication, dressing, elimination, bathing/hygiene, and eating. For each item, a score of 0 (indicating that one cannot perform the activity) or a 1 (indicating that one can perform the activity or is non-applicable) is given. The greater the total score, the greater one’s level of independence.
Cleveland Scale for Activities of Daily Living (CSADL)
The Cleveland Scale for Activities of Daily Living consists of a list of 47 items and is intended for persons with Alzheimer’s disease and related dementias. With this checklist, it is determined if the individual with dementia completes, or could complete, specific activities of daily living. Each activity is rated on a scale of 4 points.
Bristol Scale (BADLS)
The Bristol Scale is a 20 item questionnaire intended for persons with dementia and consists of a combination of ADLs and IADLs, such as preparing food, drinking, dressing, toilet/commode, mobility, orientation to time and space, and finances.
Each item is rated from total dependence to total independence and is calculated on a 4-point scale, with a 60-point total score available. (There is also an option for non-applicability). A score of 0 indicates complete independence, while a score of 60 indicates complete independence.
See the Bristol Scale here.
Barthel Index for Activities of Daily Living
The Barthel Index for Activities of Daily Living takes 10 activities into account: Feeding, bathing, grooming, dressing, bowel control, bladder control, toilet use, transfers (bed to chair and back), mobility on level surfaces, and stairs. This functional assessment tool is often used for persons who have had a stroke.
For each activity, an individual receives a score. For instance, a score of 0 points indicates that the individual is unable to do an activity, a score of 5 or 10 points frequently indicates that some assistance is required (physical or verbal), and a score of 10 or 15 points generally indicates that the individual can perform the activity independently. (The number of total possible points per activity is between 5 and 15 depending on the activity).
The Barthel Index is a 100 point scale, and a combined score of 100 points indicates that the individual is completely independent. Put differently, the lower the score, the more assistance the individual requires.
To see the Barthel Index for Activities of Daily Living, click here.