Activities of Daily Living
Key Points
- ADLs are routine functional tasks used to estimate independence, safety risk, and care needs.
- Basic ADLs (BADLs) focus on personal self-care, while instrumental ADLs (IADLs) reflect community-living complexity.
- IADL decline often appears early in cognitive impairment, while BADL loss signals higher caregiving burden.
- ADL levels are rated per task as independent, supervised, assisted, or dependent.
Pathophysiology
ADL decline usually reflects interaction among physical disease burden, cognitive change, sensory limitations, and environmental barriers rather than one isolated diagnosis. As reserve decreases, routine tasks demand more time and energy, increasing risk for injury, malnutrition, poor hygiene, and avoidable hospitalization.
Pattern and pace matter. Gradual decline can occur with aging and multimorbidity, while rapid decline suggests acute illness, delirium, medication effects, or new injury and requires urgent reassessment.
Classification
- Basic ADLs (BADLs): Transferring, continence/toileting, feeding, dressing, bathing, and grooming.
- Instrumental ADLs (IADLs): Transportation, shopping, finances, meal preparation, housekeeping, laundry, communication, and medication management.
- Task-level performance scale: Independent, supervised, assisted, or dependent for each ADL.
- Care-setting implication: Greater BADL loss correlates with higher long-term-care and staffing needs.
Nursing Assessment
NCLEX Focus
Questions commonly test which change pattern is most concerning, especially rapid ADL decline or new IADL failure in older adults.
- Assess baseline and current BADL/IADL performance separately; avoid global labels without task detail.
- Assess change tempo (gradual vs rapid) and trigger events such as surgery, infection, or hospitalization.
- Assess safety consequences of ADL loss, including fall risk, medication errors, poor intake, and hygiene compromise.
- Assess family/caregiver capacity and strain when multiple BADLs require hands-on assistance.
- Assess client goals around aging-in-place, autonomy, and acceptable support levels.
Nursing Interventions
- Document ADL ability per task and update care plans when performance changes.
- Prioritize early intervention for IADL deficits to delay progression to BADL dependence.
- Coordinate OT/PT, home-health, and community supports to preserve function.
- Implement cueing, setup assistance, and adaptive devices before defaulting to full substitution of care.
- Escalate rapid decline for evaluation of reversible causes such as delirium, infection, or medication effect.
Functional Decline Blind Spot
Treating ADL loss as “normal aging” without assessing reversible causes can lead to preventable morbidity and institutionalization.
Pharmacology
| Drug Class | Examples | Key Nursing Considerations |
|---|---|---|
| sedatives | Benzodiazepines, sedative-hypnotics | Can worsen confusion, balance, and BADL safety; reassess assistance level and fall precautions. |
| anticholinergics | Selected bladder and antihistamine agents | May impair cognition and continence, worsening IADL and toileting performance. |
Clinical Judgment Application
Clinical Scenario
An 83-year-old who previously paid bills and managed medications independently now misses doses and cannot organize finances after a recent hospitalization.
Recognize Cues: New IADL impairment with post-acute transition. Analyze Cues: Pattern suggests possible reversible cognitive or medication-related contributor. Prioritize Hypotheses: Immediate priority is preventing harm from medication and self-management errors. Generate Solutions: Complete functional assessment, simplify regimen, involve caregiver support, and arrange follow-up. Take Action: Implement safety plan and interdisciplinary referral. Evaluate Outcomes: IADL safety improves and progression to BADL dependence is slowed.
Related Concepts
- promoting-independence-during-adls - Preserving participation slows deconditioning and dependence.
- adl-functional-assessment-tools - Standardized tools quantify ADL and IADL performance.
- caring-for-clients-with-dementia - IADL decline often appears before severe BADL loss.
- delirium - Reversible acute cognitive change can rapidly worsen ADL function.
- geriatric-assessment-and-polypharmacy-safety - Functional trends guide discharge and safety planning.
Self-Check
- Why can IADL decline be an early warning sign of cognitive impairment?
- Which findings suggest ADL decline may be acute and reversible?
- How do BADL losses change care-setting and caregiver-burden decisions?