Instruments For The Assessment Of The Activities Of Daily Living [ADLs]

CMS Disease Specific Criteria for determining hospice eligibility (6 months prognosis or less) requires the patient be assessed for the Activities of Daily Living (ADLs).

The disease specific criteria require the patient meet:

A patient is eligible for hospice services if he
meets these three criteria:
1) has a Palliative Performance Scale of
less than 70%
2) is dependent on at least two Activities
of Daily Living, and
3) meets the Disease Specific Guidelines

In this post there are links in Resources below to an excellent background article on assessment of ADLs (1), and links to The Functional Independence Measure (2), Katz Index of Independence In Activities of Daily Living (ADL) and The Lawton Instrumental Activities of Daily Living  (IADL) (3), and the Barthel Index of Activities of Daily Living (4).

The following are excerpts from Resource (1) below that discuss some of the ADL assessment instruments:

Activities of daily living (ADLs), often termed physical ADLs or basic ADLs, include the fundamental skills typically
needed to manage basic physical needs, comprised the following areas: grooming/personal hygiene, dressing, toileting/continence, transferring/ambulating, and eating. These functional skills are mastered early in life and are relatively more preserved in light of declined cognitive functioning when compared to higher level tasks. Basic ADLs are generally categorized separately from Instrumental Activities of Daily Living (IADLs), which include more complex activities related to independent living in the community (e.g., managing finances and medications). IADL performance is sensitive to early cognitive decline, whereas physical functioning is often a significant driver of basic ADL ability (Boyle, Cohen, Paul, Moser, & Gordon, 2002; Cahn-Weiner et al., 2007). IADL impairment can often present in mild cognitive impairment and early dementia (Farias et al., 2013), whereas basic ADL declines are often not present until later dementia stages (Cahn-Weiner et al., 2007; West, McCue, & Golden, 2012).

Several types of approaches have been used to quantify level of independence in ADLs. ADLs may be measured by selfreport,
proxy/caregiver/informant report, and/or direct observation.  . .  .  Self-report measures are convenient to administer
and are frequently used when direct observation is not possible or when individuals are relatively cognitively intact.

Informant-based ratings are commonly completed by caregivers who know the patient well, but how also may be biased by their own burden in caring for the individual or by over or underestimating the patient’s true functioning.

The Katz Index of independence in ADLs (Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963) [Resource (3) below] is one of the most commonly used tools to asses basic ADLs (bathing, dressing, toileting transferring, continence, and feeding). Clinicians rate individuals as either fully independent (no supervision, direction, or personal assistance needed) or dependent (needing supervision, direction, personal assistance, or total care) across the six skills, with a maximum score of six points indicating fully independent, four points moderately impaired, and two points severely impaired. This measure was originally created to assess the physical functioning among those who were in rehabilitation.

In contrast to the Katz, which is a good fit in long-term care where patients’ disability is typically more severe and stable,
the Barthel ADL Index (Mahoney & Barthel, 1965) [Resource (4) below] may be better suited to more acute settings (Hartigan, 2007). The Barthel covers eight domains: feeding, bathing, grooming, dressing, bowel, bladder, toilet, transfers, mobility and stairs. Clinicians rate patients on the ability to perform these ADLs in a real-world setting over the prior 24–48 hr, based on self-report, collateralinformation, and direct observation. Performance on these domains is rated by level of assistance needed, with each task yielding a maximum score of 100 points, with independence in transferring and stairs weighted more heavily than other
ADLs. One of its strengths compared with the Katz is that it may offer a more nuanced picture of disability and is able to detect more subtle changes in functioning (Hartigan, 2007; Roedl, Wilson, & Fine, 2015). The FIM [Functional Independence Measure, Resource (2) below] (Keith, Granger,
Hamilton, & Sherwin, 1987) is more comprehensive than the Katz or the Barthel, as in addition to basic ADLS, it includes domains of social cognition and communication that are not present in those measures. It is typically used by a clinician but
has found to be valid as a self-report instrument with some populations (Grey & Kennedy, 1993).

Compared with self or informant-report, performance-based measures such as Performance ADL Test (PAT (WeeningDijksterhuis, Kamsma, & Van Heuvelen, 2011) and the Erlangen Test of Activities of Daily Living (E-ADL-Test, Graessel et al., 2009) provide a more objective evaluation of the person’s true abilities measured in a way that is quantifiable and repeatable. For example, the PAT includes measures of fine and gross motor control, and assesses both basic and instrumental ADL tasks, so may be able to detect change over time in a way that self-report cannot. The E-ADL-Test consists of five simple activities related to eating and self-care, each scored on a 6-point scale of accuracy.


(1) Assessment of Activities of Daily Living, Self-Care, and Independence [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Arch Clin Neuropsychol. 2016 Sep;31(6):506-16. doi: 10.1093/arclin/acw049. Epub 2016 Jul 29.

(2) Functional Independence Measure (FIM) from Physiopedia – Improving global health through universal access to physiotherapy knowledge

(3) Katz Index of Independence in Activities of Daily Living (ADL) and The Lawton Instrumental Activities of Daily Living (IADL) Scale [PDF]

(4) Barthel Index of Activities of Daily Living [PDF] from Canadian Association of MAID Assessors and Providers

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