Nursing Research: Activities of Daily Living

Ability to care for oneself and meet basic needs is fundamental to maintaining health and independence. The term “activities of daily living” (ADL) is used to refer to the set of skills that constitute these essential abilities. ADL are evaluated for many purposes, such as to assess current capabilities, to determine care requirements, to gauge
progress or response to intervention, and to evaluate outcomes. Thus, ADL are useful to many health disciplines and professions across a wide range of health care settings and populations for addressing both clinical and research goals. ADL are generally viewed hierarchically from the most basic of human skills (e.g., ability to feed oneself) to somewhat higher ones (e.g., ability to bathe and dress oneself). 

Activities of Daily Living

Higher still are those more complex skills necessary to maintain independence in the community, such as using the telephone, doing household chores, and managing one’s finances. This higher-level skill set is usually distinguished from the more basic ones by use of the term “instrumental activities of daily living” or IADL. ADL and IADL are also part of the broader concept of functional assessment, which generally encompasses more domains, such as cognitive and social functioning. Many scales have been developed to measure ADL and IADL. Among the most widely used are the Katz Index of Activities of Daily Living, the Barthel Index, and the Functional Independence Measure, each of which addresses basic ADL. These and similar scales encompassing IADL can be used alone, together, or in combination with other measures of function, depending upon the purpose and breadth of the assessor’s goals. ADL scales vary, not only in the range and complexity of skills they include, but also in the way skills are rated.
Generally, each scale measures along one dimension, such as difficulty in performing a skill (e.g., performs with ease) or type of support (e.g., physical, cognitive) or level of assistance (e.g., single person assist) needed to perform a skill. Dichotomous and ordinal scaling approaches are most common. The scaling model is especially important in determining not only the dimension of ADL to be assessed, but also in determining the scale’s sensitivity to change.
Although ADL and IADL assessments have been used for many years, the prevalence of dichotomous and broad ordinal scaling mod-els has led to only a limited understanding of the pattern of ADL and IADL change overtime for various patient populations.
ADL scales can be used to elicit information from various informants including the individual being assessed, a family member or informal caregiver, a health professional, or research staff. To obtain accurate ADL ratings it is essential to consider the informant’s knowledge of the individual’s abilities and any motivations of the informant that may color responses. Further, it is also important to distinguish between what the informant says the individual can do, what the individual actually can do, and what the individual is expected to do, all of which may or may not actually correspond with one another (Smith & Clark, 1995). Even when obtaining ratings of actual rather than reported performance, accuracy can be a problem. 
An evaluator should take care to note, or control when possible, both environmental factors (e.g., familiarity, glare, and noise), and personal factors (e.g., fatigue or depression), when conducting and interpreting assessments of ADL performance. The application of ADL and IADL measures to particular clinical populations is a new approach that is beginning to gain notice, much as quality of life measures have been specified to various clinical populations.
Such specific ADL measures may be applied best when the most commonly affected ADL and related performance limitations are known for a given population. In these situations, the assessment can be targeted toward the most relevant ADL and scaled more meaningfully to the nature of the difficulty encountered. For example, knowing that a person with dementia is unable to dress themselves independently is useful; but knowing that the person needs help with sequencing the steps involved in selecting and donning appropriate clothing is substantially more useful in supporting a higher level of independence for the individual. This approach to the assessment of ADL may be most beneficial in a clinical context where prescriptions for the kinds and levels of ADL assistance are made.
One disadvantage of specifying ADL assessments to particular populations is that the narrowed view may result in a failure to identify uncommon areas of difficulty. In sum, ADL and IADL are widely used concepts in nursing and health care practice and research because they are valuable in understanding the impact of illness or injury on a person’s everyday life and in determining their needs for assistance in support of continued independence. Particular approaches to assessing ADL and IADL should be selected based on the purpose of the assessment and the quality of information available from informants. 
Careful consideration should begiven to factors that may affect ADL and IADL ratings so that the most accurate assessment can be made. Tailored approaches for specific patient populations are emerging as the next advancement in ADL measurement.