Definition of ADLs and IADLs
There are specific daily tasks that persons must be able to do 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 offer variations as to the tasks defined as ADLs and those defined as IADLs, there is considerable overlap. The following definitions are the most common. The ability to independently perform IADLs generally declines for seniors first, followed by ADLs.
Activities of Daily Living
ADLs are basic self-care activities that must be performed on a day-to-day basis for one to live independently. Some sources include seven ADLs, but more commonly, ADLs are limited to the five below.
1) Mobility (also called ambulating or transferring) – The ability to move about both inside and outside of one’s home. This includes walking, going up and down stairs, getting out of bed and into a wheelchair, and standing from a seated position to use a walker.
2) Dressing – Choosing appropriate clothing and putting it on. This includes fastening buttons and zipping 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 (also 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. This means they do not 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, their ability to independently complete their ADLs and IADLs commonly begins to diminish. This may be the result of the natural progression of aging, related to a health condition, or caused by the cognitive and physical decline associated with Alzheimer’s disease and other forms of dementia.
Measuring one’s ability to complete daily living activities (independently or with assistance) via a functional (clinical) assessment serves as an important tool in evaluating a senior’s current health status, current needs, and potential future needs. 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 the specific activities in which 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 (i.e., home, assisted living, nursing home), and type of care assistance (if applicable), is best suited for a particular senior and their needs.
1) Joan has early stage Alzheimer’s disease. She can still function rather independently and can continue to live alone in her home. Via a functional assessment, it is determined she would benefit from in-home assistance with preparing meals, housecleaning, and laundry on a weekly basis.
2) Fred had a stroke and can safely live with a relative. Via a functional assessment, it is found that he requires daytime supervision and assistance with daily activities while the family caregiver works. In this case, adult day care might be a good option.
3) Tonya lives in an assisted living facility. Via a functional assessment, it is determined that nursing home care might be a more appropriate setting for her based on 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. 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 Plan Medicaid program. For seniors, this program 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.
Medicaid is not the only program that considers 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.
There is not a universal functional assessment that is used. Rather, there are many available. This lack of consistency of a universal functional assessment also holds true for long-term care Medicaid eligibility. 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 cover 6 of the more well-known functional assessments used to measure a senior’s functional ability and long-term care needs. Some of the assessments only measure ADLs, others only measure IADLs, and others measure both ADLs and IADLs. These assessments are not generally used for Medicaid eligibility purposes.
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 independently complete their ADLs. 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. This includes 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 activity. For activities for which the senior requires assistance, 0 points are given to indicate dependence. This means 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 IADLs are measured. These include telephone use, shopping, food preparation, housekeeping, laundry, mode of transportation, responsibility of own medications, and handling 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 chosen statement 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. 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.
View Lawton’s Instrumental Scale 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. These include mobility, emergency communication, dressing, elimination, bathing/hygiene, and eating. For each item, a score of 0 (one cannot perform the activity) or a 1 (one can perform the activity or it 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 completes, or could complete, specific ADLs. Each activity is rated on a scale of 0 to 3 points. A 0 indicates the individual is never dependent, 1 is sometimes dependent, 2 is usually dependent, and 3 is always dependent.
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. This includes activities like 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 total dependence.
Barthel Index for Activities of Daily Living
The Barthel Index for Activities of Daily Living takes 10 activities into account. These include 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 between 5 and 15 depending on the activity. 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 Barthel Index is a 100 point scale. A combined score of 100 points indicates that the individual is completely independent. The lower the score, the more assistance the individual requires.
See the Barthel Index for Activities of Daily Living here.