Activities of daily living

Activities of daily living (ADLs or ADL) is a term used in healthcare to refer to people's daily self-care activities. Health professionals often use a person's ability or inability to perform ADLs as a measurement of their functional status. The concept of ADLs was originally proposed in the 1950s by Sidney Katz and his team at the Benjamin Rose Hospital in Cleveland, Ohio. The concept of ADLs has been added to and refined by a variety of researchers since that time. For example, many indexes that assess ADLs now include some measure of mobility. Additionally, to be more inclusive of the range of activities that support independent living, in 1969, Lawton and Brody developed the instrumental activities of daily living (IADLs). ADLs are often used in the care of people with disabilities, people with injuries, and elderly people. Younger children often require help from adults to perform ADLs, as they have not yet developed the skills necessary to perform them independently. Regardless of age, aging and disabilities cause substantial changes to a patient's everyday life that must be accounted for and overcome.
Common ADLs include feeding oneself, bathing, dressing, grooming, work, homemaking, cleaning oneself after urinating and defecating, and leisure. A number of national surveys have collected data on the ADL status of the U.S. population. While basic definitions of ADLs have been suggested, what specifically constitutes a particular ADL for each individual may vary. Some factors that influence peoples' perception of their function level include culture and education.
ADLs are categorized into basic, self-care tasks acquired starting from infancy, and instrumental, tasks learned throughout adolescence. A person who cannot perform essential ADLs may have poorer quality of life or be unsafe in their current living conditions; therefore, they may require the help of other individuals and/or mechanical devices. Examples of mechanical devices to aid in ADLs include electric lifting seats, bathtub transfer benches, and ramps to replace stairs.
Basic
Basic ADLs consist of self-care tasks that include:
Bathing and showering
Personal hygiene and grooming (including brushing/combing/styling hair)
Dressing
Toilet hygiene (getting to the toilet, cleaning oneself, and getting back up)
Functional mobility, often referred to as "transferring", as measured by the ability to walk, get in and out of bed, and get into and out of a chair; the broader definition (moving from one place to another while performing activities) is useful for people with different physical abilities who are still able to get around independently
Self-feeding (not including cooking or chewing and swallowing), as opposed to assisted feeding
The functional independence measure (FIM) is a tool developed in 1983 that uses a 0-7 scale to rank different ADLs based on the level of assistance they require. A 7 on the scale means the patient is independent, whereas a 0 on the scale means the patient cannot complete the activity without assistance. The specific breakdown of the scale is shown below:
7 - Independent
6 - Modified Independent
5 - Supervision/Set-up
4 - Minimal Assist
3 - Moderate Assist
2 - Maximal Assist
1 - Total Assist
0 - Activity Does Not Occur
Although not in wide general use, a mnemonic that some find useful for identifying different ADLs is DEATH: dressing/bathing, eating, ambulating (walking), toileting, hygiene.
Instrumental
Instrumental activities of daily living (IADLs) are not necessary for fundamental functioning, but they let an individual live independently in a community:
Cleaning and maintaining the house
Managing money
Moving within the community
Preparing meals
Shopping for groceries and necessities
Taking prescribed medications
Using the telephone or other form of communication
Occupational therapists often evaluate IADLs when completing patient assessments. The American Occupational Therapy Association identifies 12 types of IADLs that may be performed as a co-occupation with others:
Care of others (including selecting and supervising caregivers)
Care of pets
Child rearing
Communication management
Community mobility
Financial management
Health management and maintenance
Home establishment and maintenance
Meal preparation and cleanup
Religious observances
Safety procedures and emergency responses
Shopping
Therapy
Occupational therapists evaluate and use therapeutic interventions to rebuild the skills required to maintain, regain or increase a person's independence in all Activities of Daily Living that have declined because of health conditions (physical or mental), injury or age-related debility.
Physical therapists use exercises to assist patients in maintaining and gaining independence in ADLs. The exercise program is based on what components patients are lacking such as walking speed, strength, balance, and coordination. Slow walking speed is associated with increased risk of falls. Exercise enhances walking speed, allowing for safer and more functional ambulation capabilities. After initiating an exercise program, it is important to maintain the routine. Otherwise, the benefits will be lost. Exercise for patients who are frail is essential for preserving functional independence and avoiding the necessity for care from others or placement in a long-term-care facility.
Assistance
Assisting in ADL are skills required in nursing and other professions such as nursing assistants in hospitals, homes for the aged, assisted living and other Long-term patient care facilities. This includes assisting in patient mobility, such as moving an activity-intolerant patient within bed. For hygiene, this often involves bed baths and assisting with urinary and bowel elimination. Personal care assistants are required to upholding certain standards of care. Personal assistance is defined as wagered support of 20 or more hours a week for people with impairments. A 2008 review reported that personal assistance is possibly beneficial to some older people and their informal caretakers. Further research is needed to assess which models of personal assistant are more efficient, as well as their relative total costs.
Caretaker requirements
Personal assistants, as well as doctors and nurses in community residential care settings need to remember that illness often changes the patient's psyche, including: reactions to change, developed tendencies of fussiness, capriciousness, etc. It takes patience, tact, concentration, discipline, and care to reach out to the patient, to gain their trust, and to maintain their confidence in recovery and success of the treatment.
In addition to morale, it is necessary to look after how one looks. Clothes should be clean, ironed, neat, hair tidied, hands clean, nails trimmed, with moderate use of cosmetics, perfume, and jewellery. In many health care facilities, special uniforms have been introduced. Due to the fact that nursing care requires a lot of attention and energy, nursing staff usually take additional courses based on practical data, such as NCLEX. Nursing care is usually divided into general and special care. Particular difficulties arise when caring for the severely ill.
Special care needs
Mobility
Inactive patients must be turned every two hours, the minimum time that a bed sore can develop. Some other benefits of moving hospitalized patients include reduced incidence of deep vein thrombosis, a decrease in pressure ulcers, and limited functional decline. A pillow is often placed at the head of the bed to protect the head from any injury when moving a bedridden patient up in bed. The patient is pulled up either by the friction reducing sheet or a draw sheet.
Hygiene
Bathing
For a bed bath, a bath blanket is put over the patient and only the area washed is exposed at a time for privacy and warmth. The eyes are cleaned, usually first, without soap to avoid irritation. The eye is cleaned from the inner side near the nose to the outer edge to avoid carrying debris to the tear duct. The cloth is rinsed or turned before going to the other eye to prevent spreading any organisms. Each area is dried at a time before washing the next area. For perineal care, the perineum is washed from least contaminated to most contaminated to reduce the spread of microorganisms. For females, the labia are spread and washed from the pubic area toward the anal area and not the other way around. For males, the tip of the penis is cleaned first and cleaned away from the meatus. In an uncircumcised penis, the foreskin is retracted and immediately put back in place to avoid compromising circulation and the foreskin is not retracted for children in order to prevent injury.
Toileting
A bedpan is used for bed-bound patients for bowel elimination as well urinary elimination for females. The head of the bed is raised to assist in voiding or defecating.
Dressing
For those with a weaker side (such as from strokes), the arm on the stronger side is used to dress the weaker side first. When undressing, the arm or leg on the stronger side is pulled out first.
When making an occupied bed, such as for patients who are unable or have difficulty getting out of bed, one side of the bed is made at a time. For those for whom it is contraindicated to roll to the side, such as those recovering from hip replacement surgery, then the patient sits up in bed while the top half of the bed is made and afterward the bottom half of the bed is made.
Feeding
To maintain self-esteem, the patient is involved as much as possible. His or her preferences are asked regarding the order of items eaten. Condiments are added and food cut according to patient preferences. Sufficient liquid with the meal is also provided. Dentures, hearing aids, or glasses are put in place before mealtime. Oral hygiene is important after eating: brushing the teeth, cleaning the dentures, and using mouth wash. For those with dysphagia, the patient has placed on aspiration (choking) precautions. The rate of feeding and size of bites are adjusted to the patient's tolerance. The diet is modified according to the nutrition consult. Modifications may include the chopping, mincing, pureeing, or adding thickening liquids to the meal because they are easier to swallow than thin liquids. For visually impaired patients, using a clock face analogy to relate the position of items is common. For beverages, straws are used when possible, if not contradicted by dysphagia, in order to prevent spilling.
Suicide precautions
For those on suicide precautions, food is served in plastic or paper containers with plastic utensils (no knives) and sharp items are only used with continual staff supervision.
Bed making
A fitted sheet goes over the mattress of a hospital bed. Often a draw sheet (also called lift sheet), is placed over the fitted sheet and in the centre where it will be under the patient's midsection. The draw sheet is frequently used to help with lifting or moving the patient. sheets that go under the patient are firmly tucked-in to prevent wrinkles that can promote skin breakdown. A top sheet and blanket are placed over the bed and the corners are mitred.
Wound care
The types of wound dressings are hydrocolloid dressings, hydrogel, alginate, collagen, foam, transparent and cloth.
Evaluation
There are several evaluation tools, such as the Katz ADL scale, the Older Americans Resources and Services (OARS) ADL/IADL scale, the Lawton IADL scale and the Bristol Activities of Daily Living Scale.
In the domain of disability, measures have been developed to capture functional recovery in performing basic activities of daily living. Among them, some measures like the Functional Independence Measure are designed for assessment across a wide range of disabilities. Others like the Spinal Cord Independence Measure are designed to evaluate participants in a specific type of disability.
Most models of health care service use ADL evaluations in their practice, including the medical (or institutional) models, such as the Roper–Logan–Tierney model of nursing, and the resident-centered models, such as the Program of All-Inclusive Care for the Elderly (PACE).
The Pervasive computing technology was considered to determine the wellness of the elderly living independently in their homes. The framework of the intelligent system consists of monitoring important daily activities through the observation of everyday object usage. The improved wellness indices helped in reducing false warnings related to the daily activities of elderly living.
Research
ADL evaluations are used increasingly in epidemiological studies as an assessment of health in later-life that does not necessarily involve specific ailments. Studies using ADL differ from those investigating specific disease outcomes, as they are sensitive to a broader spectrum of health effects, at lower-levels of impact. ADL is measured on a continuous scale, making the process of investigation fairly straightforward.
Sidney Katz initially studied 64 hip fracture patients over an 18-month period. Comprehensive data on treatments, patient progression, and outcomes were collected during this study. After analyzing the study data, the researchers discovered that the patients they viewed as being most independent could perform a set of basic activities – ranging from the most complex bathing activity, to the least complex feeding activity. From these data, Katz developed a scale to assess patients' ability to live independently. This was first published in the 1963 in the Journal of the American Medical Association; the paper has since been cited over 1,000 times.
Although the scale offers a standardized measure for psychological and biological function, the process of arriving at this assumption has been criticised. Specifically, Porter has argued for a phenomenological approach noting that:
Porter emphasizes the possible disease-specific nature of ADLs (being derived from hip-fracture patients), the need for objective definition of ADLs, and the possible value of adding additional functional measures.
A systematic review examined the effectiveness of imparting activities of daily life skills programmes, specifically for people with schizophrenia:
See also
Schwab and England ADL scale
Global Assessment of Functioning
Long term care insurance
References
Occupational therapy
Nursing
Caregiving
Self-care