The activities of daily living (ADLs) is a term used to collectively describe fundamental skills that are required to independently care for oneself such as eating, bathing, and mobility. The term activities of daily living was first coined by Sidney Katz in 1950.
ADL is used as an indicator of a person’s functional status. The inability to perform ADLs results in the dependence of other individuals and/or mechanical devices. The inability to accomplish essential activities of daily living may lead to unsafe conditions and poor quality of life. Measurement of an individual’s ADL is important as these are predictors of admission to nursing homes, need for alternative living arrangements, hospitalization and use of paid home care. The outcome of a treatment program can also be assessed by reviewing a patient’s ADLs.
Nurses are often the first to note when patients' functionality declines during hospitalization; therefore, routine screening of ADLs is imperative and nursing assessment of ADL's is performed on all hospitalized patients. Hospitalization for an acute or chronic illness may influence a person’s ability to meet personal goals and sustain independent living. Chronic illnesses progress over time, resulting in a physical decline that may lead to a loss of ability to perform ADL's.
Types of ADL
The activities of daily living are classified into basic ADLs and Instrumental Activities of Daily Living (IADLs). The basic ADLs (BADL) or physical ADL are those skills required to manage one’s basic physical needs including personal hygiene or grooming, dressing, toileting, transferring or ambulating, and eating. The Instrumental Activities of Daily Living (IADLs), which include more complex activities that are related to the ability to live independently in the community. This would include activities such as e.g., managing finances and medications, food preparation, housekeeping, laundry.
The basic ADL include the following categories:
Learning how each basic ADL affects an individual to care for themselves can help determine whether a patient would need daily assistance. It can also help the elderly or disabled people to determine their eligibility got state and federal assistance programs.
The instrumental ADLs are those that require more complex thinking skills, including organizational skills.
The IADL differs from ADL as people often begin asking for outside assistance when these tasks become difficult to manage independently. 
Causes for limitations in ADLs
Decline or impairment in physical function arises from many conditions. Aging is a natural process that may present a decline in the functional status of patients and is a common cause of subsequent loss of ADLs.  Musculoskeletal, neurological, circulatory, or sensory conditions can lead to decreased physical function leading to impairment in ADLs. A cognitive or mental decline can also lead to impaired ADL's.  Severe cognitive fluctuations in dementia patients have a significant association with impaired engagement in activities of daily living that negatively affect the quality of life. Social isolation can lead to impairment in instrumental activities of daily living. Other factors such as side effects of medications, social isolation, or the patient's home environment can influence the ability to perform ADLs.
Hospitalization and acute illnesses have also been associated with a decline in ADLs. Sands et al reported that among frail older adults, loss of ADL functioning over 1 year is independently associated with both acute hospital admission for acute illness and cognitive impairment. Similarly, Cinvinsky et al performed a prospective observational study that evaluated the changes in ADL function occurring before and after hospital admission. They found that many hospitalized older people are discharged with ADL function that is worse than their baseline function.
Measurement of ADLs
Defining the extent of loss of ADL and IADL is important to help define and ensure appropriate care support. Several checklists have been developed by various entities. Although there is some consensus among what ADLs should be included, there exists significant variability on how these questionnaires ask about ADL functions. 
The most frequently used checklists are the Katz Index of Independence in Activities of Daily Living and the Lawton Instrumental Activities of Daily Living (IADL) Scale. The Katz scale assesses the basic activities of daily living but does not assess more advanced activities of daily living. The Katz ADL scale is sensitive to changes in declining health status but its limitations include the limited in its ability to measure small elements of change seen in the rehabilitation of older adults. However, it is very useful in creating a common language about patient function for healthcare providers involved in the overall care and discharge planning.
The Lawton Instrumental Activities of Daily Living (IADL) Scale is used to evaluate independent living skills (Lawton & Brody, 1969). The instrument is most useful for identifying how a person is functioning at the present time, and to identify improvement or deterioration over time. The scale measures eight domains of function including food preparation, housekeeping, laundering. Individuals are scored according to their highest level of functioning in that category. A summary score ranges from 0 (low function, dependent) to 8 (high function, independent). The scale is easy to administer assessment instrument that provides self-reported information about functional skills necessary to live in the community. Specific deficits identified can assist nurses and other disciplines in planning for safe discharge. The limitations of this scale are that it is a self-administered test rather than the actual demonstration of the functional task. This may lead either to over-estimation or under-estimation of the ability to perform the activity.
Assessment of ADL's is an important aspect of routine patient assessment and assists healthcare providers to assess the patient’s status, plan, and to intervene appropriately. It is important for a provider to address a patient’s general medical condition when determining his/her level of accomplishing functional capabilities that otherwise ensure independent living and personal care.
An ADL assessment helps to determine whether or not a patient may require further rehabilitation or assistance at home or if a skilled nursing or long-term care facility would be a safer environment for the patient. Inability to ambulate may result in an increased risk of falls. It is well-reported that falls are associated with an increased mortality rate. Individuals who have experienced more than one incidence of falling and are 65 years of age and older tend to have a poor prognosis after a fall. Such falls and subsequent hospitalization also place a burden on healthcare utilization and costs.  Other issues to consider before placement in assisted living or nursing home as opposed to independent living at home include a patient’s ability to cook and clean their homes, shop, use of public transportation or drive.
It is important to recognize the impact of a loss of ADL on the patient. Independent living is highly encouraged and advocated in American society, and many aging individuals fear a loss of autonomy.
An ADL assessment is also required to determine benefits for disability insurance and long-term care insurance policies. The cost of home care, skilled care, assisted living, and nursing homes is a concern for many families. Not all supportive care is covered by Medicare or private insurance, thus leading to financial concerns for patients and significant others. The high cost of care may lead to decisions that preclude patients from receiving the care required to support ADL's. 
Access to care can also be an issue. Often lower socioeconomic groups or disadvantaged persons have difficulty accessing quality care for seniors. Access can be difficult due to transportation, distance, and availability.  Though many placements at care facilities are short-term, most patients end up staying longer than a year due to the inability to perform more than two of the six ADLs.
Nurses need to communicate patient ability to perform ADLs and IADLs with providers so that the health care team and their families can discuss if a patient meets the pre-defined criteria to either continue to live in their homes or be placed in assisted living, skilled care, or nursing home facilities. (United States National Library of Medicine, 2017) Depending on the severity of the patient's impairment, most home health nurses complete assessments to make plans for improvements, help with medication administration, and bring resources to assist with independence. Unlicensed assistive personnel help with bathing, light housekeeping, shopping, and activity to support the patient's desire for continued independent living.
All healthcare workers, including providers, nurses, physical therapy, and occupational therapy should collaborate to assess the functionality of patients before discharge. Patients who are unable to perform activities of daily living may require further rehabilitation or assistance at home. The inability to dress or toilet can lead to poor quality of life. Difficulty ambulating or transferring can lead to falls and further decline. Difficulty in eating independently can lead to poor nutrition, dehydration, and further weakness. Appropriate referrals to OT, PT, and dieticians should be considered. Assessment of functionality should become routine practice for all patients as it can affect people of all ages. An interprofessional team communicating and collaborating together will provide the best patient evaluation and discharge with good follow up care. The nursing staff should report to the medical team concerns in regards to patients unable to complete ADLs. The clinical team assists in directing the nursing home health and social work coordinators to make sure patients receive the care they need. The home health nursing staff needs to provide ongoing monitoring and reporting back to the clinical team should increase in deficiency of ADLs occur. [Level V]
The implications and role of a change in ADLs in any particular patient differ among the various stakeholders in the patient’s care team.
The nurse and care manager typically assess and collect information on a person’s ability to perform ADLs. This data enables them to plan ahead for each person’s continuum of care. The physicians use the assessments to formulate and plan of care which is then provided to the home health agency or skilled nursing agency. The agency will then select the appropriate staff needed for each client. The physical and occupational therapists work with the plan of care and document the progress in ADL to ensure the rehabilitation goals are achieved to the extent possible. Insurance providers and government agents use the assessments of ADL to determine the qualifications of the patient and pay for the services rendered.
Nurses assess ADLs and IADLs daily in all hospitalized patients. Appropriately assessing, planning, intervening, and evaluating ADLs and IADLs can mean the difference between independent aging and needing daily assistance.
There are many tools included in daily shift assessments, but all nurses should be aware of each patient's needs for assistance in managing ADL's. When a patient is at risk for a change in ADLs or IADLs, the nurse should assist patients and report to the interprofessional team members so that a new plan of care can be established.
Possible NANDA nursing diagnoses include altered health maintenance, defined as a "State in which an individual has no physiological or psychological energy enough to resist or complete required or desired daily activities". Other possible nursing diagnoses include: risk of injury, activity intolerance, social isolation, or ineffective family coping.
|||Katz S, Assessing self-maintenance: activities of daily living, mobility, and instrumental activities of daily living. Journal of the American Geriatrics Society. 1983 Dec; [PubMed PMID: 6418786]|
|||Bieńkiewicz MM,Brandi ML,Goldenberg G,Hughes CM,Hermsdörfer J, The tool in the brain: apraxia in ADL. Behavioral and neurological correlates of apraxia in daily living. Frontiers in psychology. 2014; [PubMed PMID: 24795685]|
|||Guidet B,de Lange DW,Boumendil A,Leaver S,Watson X,Boulanger C,Szczeklik W,Artigas A,Morandi A,Andersen F,Zafeiridis T,Jung C,Moreno R,Walther S,Oeyen S,Schefold JC,Cecconi M,Marsh B,Joannidis M,Nalapko Y,Elhadi M,Fjølner J,Flaatten H, The contribution of frailty, cognition, activity of daily life and comorbidities on outcome in acutely admitted patients over 80 years in European ICUs: the VIP2 study. Intensive care medicine. 2019 Nov 29; [PubMed PMID: 31784798]|
|||Costenoble A,Knoop V,Vermeiren S,Vella RA,Debain A,Rossi G,Bautmans I,Verté D,Gorus E,De Vriendt P, A Comprehensive Overview of Activities of Daily Living in Existing Frailty Instruments: A Systematic Literature Search. The Gerontologist. 2019 Dec 17; [PubMed PMID: 31872238]|
|||Cagle JG,Lee J,Ornstein KA,Guralnik JM, Hospice Utilization in the United States: A Prospective Cohort Study Comparing Cancer and Noncancer Deaths. Journal of the American Geriatrics Society. 2019 Dec 27; [PubMed PMID: 31880312]|
|||Rosenberg T,Montgomery P,Hay V,Lattimer R, Using frailty and quality of life measures in clinical care of the elderly in Canada to predict death, nursing home transfer and hospitalisation - the frailty and ageing cohort study. BMJ open. 2019 Nov 12; [PubMed PMID: 31722953]|
|||Wolff JL,Feder J,Schulz R, Supporting Family Caregivers of Older Americans. The New England journal of medicine. 2016 Dec 29; [PubMed PMID: 28029922]|
|||Adams PF,Kirzinger WK,Martinez ME, Summary health statistics for the u.s. Population: national health interview survey, 2011. Vital and health statistics. Series 10, Data from the National Health Survey. 2012 Dec; [PubMed PMID: 25116371]|
|||Cahn-Weiner DA,Boyle PA,Malloy PF, Tests of executive function predict instrumental activities of daily living in community-dwelling older individuals. Applied neuropsychology. 2002; [PubMed PMID: 12584085]|
|||Delirium is prevalent in older hospital inpatients and associated with adverse outcomes: results of a prospective multi-centre study on World Delirium Awareness Day. BMC medicine. 2019 Dec 14; [PubMed PMID: 31837711]|
|||Farias ST,Park LQ,Harvey DJ,Simon C,Reed BR,Carmichael O,Mungas D, Everyday cognition in older adults: associations with neuropsychological performance and structural brain imaging. Journal of the International Neuropsychological Society : JINS. 2013 Apr; [PubMed PMID: 23369894]|
|||Farias ST,Harrell E,Neumann C,Houtz A, The relationship between neuropsychological performance and daily functioning in individuals with Alzheimer's disease: ecological validity of neuropsychological tests. Archives of clinical neuropsychology : the official journal of the National Academy of Neuropsychologists. 2003 Aug; [PubMed PMID: 14591439]|
|||Chu NM,Sison S,Muzaale AD,Haugen CE,Garonzik-Wang JM,Brennan DC,Norman SP,Segev DL,McAdams-DeMarco M, Functional independence, access to kidney transplantation and waitlist mortality. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association. 2019 Dec 20; [PubMed PMID: 31860087]|
|||Desai AK,Grossberg GT,Sheth DN, Activities of daily living in patients with dementia: clinical relevance, methods of assessment and effects of treatment. CNS drugs. 2004; [PubMed PMID: 15521790]|
|||Fields JA,Machulda M,Aakre J,Ivnik RJ,Boeve BF,Knopman DS,Petersen RC,Smith GE, Utility of the DRS for predicting problems in day-to-day functioning. The Clinical neuropsychologist. 2010 Oct; [PubMed PMID: 20924981]|
|||Katz S,Downs TD,Cash HR,Grotz RC, Progress in development of the index of ADL. The Gerontologist. 1970 Spring; [PubMed PMID: 5420677]|
|||Graf C, The Lawton Instrumental Activities of Daily Living (IADL) Scale. Medsurg nursing : official journal of the Academy of Medical-Surgical Nurses. 2009 Sep-Oct; [PubMed PMID: 19927971]|
|||Lawton MP,Brody EM, Assessment of older people: self-maintaining and instrumental activities of daily living. The Gerontologist. 1969 Autumn; [PubMed PMID: 5349366]|
|||Wong MM,Pang PF, Factors Associated with Falls in Psychogeriatric Inpatients and Comparison of Two Fall Risk Assessment Tools. East Asian archives of psychiatry : official journal of the Hong Kong College of Psychiatrists = Dong Ya jing shen ke xue zhi : Xianggang jing shen ke yi xue yuan qi kan. 2019 Mar [PubMed PMID: 31237251]|
|||Vaughan L,Leng X,La Monte MJ,Tindle HA,Cochrane BB,Shumaker SA, Functional Independence in Late-Life: Maintaining Physical Functioning in Older Adulthood Predicts Daily Life Function after Age 80. The journals of gerontology. Series A, Biological sciences and medical sciences. 2016 Mar; [PubMed PMID: 26858328]|
|||Warmoth K,Tarrant M,Abraham C,Lang IA, Relationship between perceptions of ageing and frailty in English older adults. Psychology, health [PubMed PMID: 28675053]|
|||Damukaitis C,Schirm V, Program planning for long-term care: meeting the demand for nursing services. Nursing homes and senior citizen care. 1989 Nov [PubMed PMID: 10296792]|
|||Gorges RJ,Sanghavi P,Konetzka RT, A National Examination Of Long-Term Care Setting, Outcomes, And Disparities Among Elderly Dual Eligibles. Health affairs (Project Hope). 2019 Jul [PubMed PMID: 31260370]|
|||Abrahamson K,Hass Z,Arling G, Shall I Stay or Shall I Go? The Choice to Remain in the Nursing Home Among Residents With High Potential for Discharge. Journal of applied gerontology : the official journal of the Southern Gerontological Society. 2018 Oct 26; [PubMed PMID: 30366510]|
|||Wang J,Caprio TV,Simning A,Shang J,Conwell Y,Yu F,Li Y, Association Between Home Health Services and Facility Admission in Older Adults With and Without Alzheimer's Disease. Journal of the American Medical Directors Association. 2019 Dec 23; [PubMed PMID: 31879184]|
|||Fong JH,Mitchell OS,Koh BS, Disaggregating activities of daily living limitations for predicting nursing home admission. Health services research. 2015 Apr; [PubMed PMID: 25256014]|