# Activities of Daily Living

Structured assessment of basic and instrumental activities of daily living identifies disability, clarifies its reversible contributors, guides safety planning, and establishes a functional baseline for geriatric, neurologic, cardiovascular, and rehabilitation decisions.

**Clinical question:** How should physicians assess ADL and IADL disability, identify its drivers, and use results to direct care?

Updated: 2026-09-16T01:12:11.759977+00:00

## What matters in practice
- Document basic ADL and IADL separately: basic ADL reflects self-care dependency, whereas IADL detects loss of higher-level community independence and often reveals earlier functional change. [14][15]
- Use a structured instrument rather than an unanchored history; modified Katz is preferred for community-dwelling adults, while Barthel may be useful for personal-care assessment in care-home residents. [18]
- For every newly dependent task, establish the specific limiting mechanism—cognition, vision, hand function, mobility, transportation, or another barrier—because the same IADL deficit can require substantially different interventions. [16]
- Pair functional assessment with fall history, cognition screening, and review of fall-risk-increasing drugs when disability or assistance needs are present. [10][18]
- Self- or proxy-reported ADL/IADL scales can miss subtle impairment and have a ceiling effect; add objective physical-performance assessment when preclinical decline or frailty will affect a major treatment decision. [14][15]

## When ADL and IADL assessment changes management

Assess function when a result will alter diagnosis, safety planning, rehabilitation, prognosis, or treatment selection.

Obtain a structured ADL and IADL baseline in older adults with a fall, recent hospitalization, stroke, suspected cognitive disorder, new caregiver dependence, mobility decline, or before a high-stakes intervention. Functional disability is associated with mortality and long-term-care admission, including among patients with multimorbidity. [14]

Do not label all dependency as frailty. Disability denotes difficulty or dependency in ADL or IADL and may be an outcome of frailty, but it may also result from a discrete event such as injury; this distinction matters when estimating procedural risk or targeting reversible contributors. [15]

In cardiovascular procedural evaluation, document baseline function rather than relying on age alone. For adults considered for transcatheter aortic valve replacement, functional status contributes to risk stratification, and comprehensive geriatric assessment extends the evaluation to sensory deficits, multimorbidity, polypharmacy, nutrition, falls, cognition, mood, and social circumstances. [13]
- Ask the patient and an informed caregiver separately when accounts differ; traditional ADL/IADL measures are self- or caregiver-reported rather than objectively observed. [14]
- Record the premorbid level and the date or tempo of decline, then reassess after an acute illness, rehabilitation episode, or major intervention using the same instrument.
- Treat newly required assistance as a clinical finding requiring task-level explanation, not merely a disposition problem. [16]

*Functional domains to document and the clinical question each domain answers. [14][16][18]*

| Domain | Tasks to assess | What a deficit should trigger |
| --- | --- | --- |
| Basic ADL | Bathing, dressing, transfers, toileting, continence, feeding. [14] | Determine whether the limiting factor is motor, balance, pain, sensory, cognitive, or environmental; establish needed hands-on assistance and home safety supports. |
| IADL | Transportation or telephone use, finances, medications, housekeeping, shopping, meal preparation, and laundry. [14][20] | Identify the exact failed task and mechanism; medication and financial errors should prompt assessment of cognition, vision, dexterity, and availability of a reliable surrogate. [16] |
| Objective function when needed | Physical-performance testing in addition to reported ADL/IADL. [14] | Use when self-report remains independent despite suspected early decline, or when a major cardiovascular or geriatric treatment decision requires better risk discrimination. [14][15] |

## How to perform a structured ADL and IADL assessment

Use a reproducible scale, then convert each impaired task into a specific functional problem list.

For community-dwelling adults, structured assessment with modified Katz ADL is recommended in falls evaluation; the same guideline identifies the Nottingham Extended Activities of Daily Living scale or Barthel Index as options for structured assessment of functional ability, particularly personal care and care-home populations. [18] Document the instrument, respondent, task-level dependence, and whether assistance is due to capacity, environmental access, or an established household role.

Assess IADL even when basic ADL are intact. IADL includes activities required to function outside the home and maintain independent living, such as transportation, telephone use, finances, medication management, housekeeping, shopping, and meal preparation. [14] A normal basic ADL screen should not end the evaluation when there are missed doses, unpaid bills, unsafe cooking, inability to obtain food, or loss of driving or transit independence.

Use direct task questions rather than a global question about independence. New difficulty managing money can result from impaired cognition, poor vision, transportation barriers, or hand arthritis; each mechanism directs a different next action. [16] For example, a medication-management deficit warrants reconciliation of actual bottles and administration process, whereas a finance-management deficit warrants assessment for errors, exploitation risk, and the need for a reliable designated helper.
- For each task, record: independent, independent with device or adaptation, needs cueing or supervision, needs physical assistance, or unable.
- Ask whether the patient can perform the task safely, consistently, and without excessive time; task completion alone may obscure unsafe compensation.
- Compare capability with performance. A patient may be capable but unable to shop because transportation is unavailable; this is an actionable access barrier rather than intrinsic inability. [16]

### Avoid misclassification from customary roles

Interpret IADL in the context of prior responsibility. Cultural and household role patterns can make meal preparation or laundry scores appear dependent despite no acquired disability, and sex differences in reported difficulty have been observed for selected IADL tasks. Establish whether the patient previously performed the task and whether a new loss of capacity has occurred. [21]
- When a task was never customary, assess a comparable function that tests the same domain, such as another complex household task, medication organization, or navigation.
- Do not infer cognitive decline solely from one unfamiliar household task; corroborate with a cognitive screen and collateral history. [18]

*Instrument selection based on setting and clinical purpose. [14][18][24]*

| Clinical setting or purpose | Useful structured assessment | Complementary assessment |
| --- | --- | --- |
| Community-dwelling older adult with falls or functional concern | Modified Katz ADL plus structured IADL assessment. [18] | Screen executive function with clock drawing, Montreal Cognitive Assessment, or Trail Making Test Part B when indicated. [18] |
| Care-home resident or personal-care dependency | Barthel Index; it assesses eating, hygiene, dressing, bowel and bladder control, toileting, and mobility. [18][24] | Document falls and mobility limitations; identify whether hands-on assistance is stable or newly increased. [24] |
| Complex cancer or geriatric assessment | Barthel ADL and Nottingham Extended ADL assessment. [24] | Timed Up and Go, fall history, MoCA, medication count, comorbidity, and depression screening can define contributors to functional vulnerability. [24] |

## Evaluate new dependence by the task that failed

A task-level pattern narrows the likely driver and identifies the next assessment.

When IADL decline is disproportionate to basic ADL decline, prioritize cognitive, executive, visual, and access barriers. Screen cognition with a clock-drawing test, Montreal Cognitive Assessment, or Trail Making Test Part B; executive-function testing is specifically relevant because medication management, finances, planning, and community navigation require more than basic self-care capacity. Escalate to formal neuropsychological assessment when screening and collateral history leave clinically consequential uncertainty. [18]

When transfers, toileting, dressing, or bathing are impaired, define whether the proximate limitation is mobility, balance, weakness, coordination, sensory loss, visual-perceptual dysfunction, pain, or cognition. In patients after stroke, occupational therapy assessment should examine motor function, sensation, coordination, visual perception, and cognition in relation to actual daily tasks. [22]

When disability coexists with falls or fear of falling, use the functional assessment as part of a multifactorial falls evaluation. The falls guideline recommends structured ADL/IADL assessment, cognitive screening, and evaluation of fall-risk-increasing drugs; age, prior falls, and need for ADL assistance were common fall-risk factors in a cohort of older inpatients. [10][18]

Distinguish a recent decline after stroke from stable chronic dependence because it changes rehabilitation urgency and goals. Once medically stable, begin coordinated multidisciplinary rehabilitation; occupational therapy directed at personal ADL uses individualized, graded task practice, task adaptation, assistive technology, environmental modification, and patient-caregiver education. [7][22]
- Medication-management failure: determine whether the barrier is executive dysfunction, vision, dexterity, regimen complexity, or inability to obtain refills; observe the organization system rather than accepting a yes-or-no response. [16]
- Finance-management failure: obtain collateral history for missed payments or calculation errors; assess vision, cognition, hand function, and transportation barriers before attributing the deficit to dementia. [16]
- Meal-preparation failure: determine whether the barrier is unsafe appliance use, impaired reach or standing tolerance, hand dysfunction, cognitive sequencing, food access, or a prior noncustomary role. [20][21]
- Mobility-linked ADL failure: document recent falls and assess whether the patient can stand, transfer, and walk safely enough for the required home task; add an objective mobility measure when this will change disposition or rehabilitation planning. [24]

### When self-report is not enough

Basic ADL and IADL questionnaires can identify the most disabled patients but have a ceiling effect and may not capture subtler, preclinical impairment. Add objective physical-performance measures when reported independence conflicts with observed slowing, recurrent falls, caregiver concern, or anticipated stress from a procedure. Higher-level disability measures can be more sensitive than basic ADL scales in cardiovascular surgical populations. [14][15]
- The Timed Up and Go assesses standing from a chair, walking 3 meters, turning, returning, and sitting; use it as an objective mobility measure within a broader geriatric assessment rather than as a substitute for task-level ADL history. [24]
- Do not equate preserved test performance with safe independent living; medication, financial, and environmental tasks require direct history and collateral information. [16]

*Task-pattern approach to new dependence. [16][18][22][24]*

| Observed pattern | Focused assessment | Result that changes the next action |
| --- | --- | --- |
| IADL loss with preserved personal care | Clock drawing, MoCA, or Trail Making Test Part B; collateral history. [18] | Executive or cognitive concern supports further cognitive assessment and immediate supervision of high-risk tasks such as medications and finances. |
| Bathing, dressing, transfer, or toileting dependence after stroke | Occupational therapy assessment of motor, sensory, coordination, visual-perceptual, and cognitive contributors. [22] | Identified task impairment directs graded ADL practice, adaptive techniques, assistive technology, and environmental modifications. [7][22] |
| ADL assistance need with falls | Structured ADL/IADL assessment, fall history, cognition assessment, and fall-risk-increasing medication review. [10][18] | Multifactorial fall-risk findings should be incorporated into a tailored prevention care plan. [10][18] |
| Reported independence but suspected early functional decline | Objective physical-performance assessment; Timed Up and Go can be included in geriatric assessment. [14][24] | Objective impairment identifies vulnerability missed by self-report and may refine rehabilitation or procedural planning. [14][15] |

## Translate ADL findings into a functional care plan

Intervene at the failed task, its limiting impairment, and the environment in which the task is performed.

A positive ADL or IADL screen should generate explicit orders and ownership, not only a notation of “needs assistance.” For post-stroke disability, occupational therapy interventions include assessment, treatment, adaptive techniques, assistive technology, and environmental modification; therapy focused on personal ADL has been associated with greater independence than no occupational therapy. [7][22]

Set goals in observable task terms: transfer safely to the toilet, organize and take medications with a defined support system, prepare a simple meal using adaptive methods, or complete a bathing routine with specified equipment and supervision. Occupational therapy after stroke uses individualized, graded tasks to retrain motor, sensory, visual, perceptual, and cognitive skills in the context of functional activity while educating caregivers. [22]

Include caregivers in the plan when a patient needs cueing, supervision, or physical help. Functional assessment should distinguish the patient’s own capacity from the help currently provided, because unnecessary assistance can overestimate dependency and may obscure potentially remediable ability. [21] Reassess task-level status after the planned rehabilitation interval, transition of care, or change in health status with the same scale and collateral informant when possible.

Use function as a longitudinal outcome, not only a baseline descriptor. In older adults undergoing TAVR, baseline and 1-year trajectories have been characterized using a composite of unassisted ADL, IADL, and higher-function tasks; therefore, preprocedure counseling should address expected functional recovery as well as survival and technical procedural risk. [13]
- After stroke, initiate rehabilitation as soon as medical stability permits. [22]
- For an ADL limitation linked to fall risk, document the fall-prevention actions that correspond to the identified risks rather than relying on generic fall precautions. [10][18]
- For a medication-management deficit, assign a reliable process—supervised administration, caregiver setup, or another verified method—and reassess actual execution rather than relying on patient report. [16]
- For finance-management deficits, determine whether the patient can safely manage bills and whether a trusted support arrangement is required; the deficit may reflect cognition, vision, transportation, or hand function. [16]

*Functional care-plan elements linked to common ADL and IADL findings. [7][16][22]*

| Finding | Immediate action | Monitoring endpoint |
| --- | --- | --- |
| Personal ADL dependence after stroke | Refer for occupational therapy once medically stable; use task-specific retraining, adaptation, assistive technology, and environmental intervention. [7][22] | Ability to perform the target activity with the planned level of assistance. |
| Medication-management dependence | Identify whether cognition, vision, dexterity, refill access, or transportation is responsible; implement a verified administration support process. [16] | Observed or collateral-confirmed correct medication organization and administration. |
| Falls plus assistance with ADL | Complete structured ADL/IADL assessment, cognitive screening when indicated, and review of fall-risk-increasing drugs. [10][18] | Falls, near-falls, level of assistance, and safety of transfers or mobility-related tasks. |
| IADL decline with intact basic ADL | Assess executive function and obtain collateral history; address the specific unsafe task rather than assuming global incapacity. [16][18] | Safety and reliability of the affected task, especially medications, finances, meals, and transportation. |

## Use disability findings appropriately in prognosis and referral

Functional impairment is prognostically important but should not be mistaken for a diagnosis or a stand-alone reason to deny treatment.

Disability is associated with increased mortality and long-term-care admission, and functional status is a central element of comprehensive geriatric assessment. [14] In cardiovascular care, frailty has demonstrated prognostic value with risk ratios often exceeding 2, but disability and frailty are overlapping yet distinct constructs; document both rather than substituting an ADL score for frailty assessment. [15]

Escalate to a comprehensive geriatric assessment when multiple domains are abnormal, when the trajectory is unclear, or when a major intervention may have limited functional benefit. A multidomain evaluation includes physical health, vision, hearing, multimorbidity, polypharmacy, nutrition, balance and falls; functional status; cognition and mood; and social context. [13]

For a patient being considered for TAVR, severe comorbidity, physical disability, slow gait, advanced dementia, poor rehabilitation candidacy, limited life expectancy, and high surgical risk may influence discussions of expected benefit; cited futility considerations are based on expert opinion rather than primary outcomes research. [13] Use this information for shared decision-making and goal-concordant planning, not as an automatic exclusion rule.
- Refer for occupational therapy when an identifiable task limitation could respond to retraining, adaptation, assistive technology, or environmental modification. [7][22]
- Add objective performance testing when self-reported ADL/IADL independence conflicts with caregiver concern or a high-stakes treatment decision. [14][15]
- Obtain collateral information and cognitive evaluation when IADL loss affects medication safety, finances, cooking, or transportation. [16][18]

*Escalation decisions based on functional assessment. [13][14][15][18]*

| Clinical situation | Escalate to | Reason |
| --- | --- | --- |
| New IADL failure affecting medications, finances, cooking, or travel | Cognitive screening and, when indicated, formal neuropsychological assessment. [18] | Executive and cognitive deficits may underlie high-risk community tasks. |
| Multiple functional, sensory, cognitive, medication, nutrition, or fall concerns | Comprehensive geriatric assessment. [13] | A multidomain assessment identifies interacting contributors to loss of independence. |
| Stroke-related task dependence | Coordinated multidisciplinary rehabilitation with occupational therapy. [22] | Task-specific intervention can improve participation and independence in personal ADL. [22] |
| Major cardiovascular procedure with disability or suspected frailty | Geriatric-informed procedural assessment. [13][15] | Baseline function, frailty, rehabilitation potential, and expected trajectory inform benefit-risk counseling. |

## References
1. Association of intrinsic capacity with functional decline and mortality ... — www.thelancet.com — https://www.thelancet.com/pdfs/journals/lanhl/PIIS2666-7568(24)00092-8.pdf
2. A global gap in autonomy assessment among older adults — www.thelancet.com — https://www.thelancet.com/pdfs/journals/lanhl/PIIS2666-7568(25)00133-3.pdf
3. Supplementary appendix 2 — www.thelancet.com — https://www.thelancet.com/cms/10.1016/S2666-7568(23)00057-0/attachment/a6f06938-a769-446e-9735-2828fa23d6cf/mmc2.pdf
4. Validating intrinsic capacity to measure healthy aging in an upper ... — www.thelancet.com — https://www.thelancet.com/journals/lanam/article/PIIS2667-193X(22)00101-6/fulltext
5. A Randomized Trial of In-Home Visits for Disability Prevention in ... — jamanetwork.com — https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/485278
6. Comparison of 2 Frailty Indexes for Prediction of Falls, Disability ... — jamanetwork.com — https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/414008
7. Occupational Therapy for Adults With Problems in Activities of Daily ... — www.ahajournals.org — https://www.ahajournals.org/doi/10.1161/strokeaha.117.018923
8. 2026 Guideline for Adult Stroke Rehabilitation and Recovery — www.ahajournals.org — https://www.ahajournals.org/doi/10.1161/STR.0000000000000536?intcmp=Area_C_AMP_nd_100725_corriere_ss_COR_AMP
9. Comprehensive Overview of Nursing and Interdisciplinary ... — www.ahajournals.org — https://www.ahajournals.org/doi/10.1161/str.0b013e3181e7512b
10. Psychotropic medication and in-hospital falls in older adults: a cohort-based secondary analysis with exploratory stratification among users | Scientific Reports — www.nature.com — https://www.nature.com/articles/s41598-025-31320-7
11. Exploration and practice of home care mode for elderly with stroke ... — www.nature.com — https://www.nature.com/articles/s41598-026-57414-4
12. High-Dose, High-Intensity Stroke Rehabilitation: Why Aren't We ... — www.ahajournals.org — https://www.ahajournals.org/doi/10.1161/STROKEAHA.124.043650?doi=10.1161%2FSTROKEAHA.124.043650
13. TAVR in Older Adults: Moving Toward a Comprehensive Geriatric Assessment and Away From Chronological Age: JACC Family Series — www.jacc.org — https://www.jacc.org/doi/10.1016/j.jacadv.2024.100877
14. Comprehensive Geriatric Assessment to Optimize the Management of Older Patients With Transthyretin Cardiac Amyloidosis — www.jacc.org — https://www.jacc.org/doi/10.1016/j.jacadv.2024.101123
15. Frailty Assessment in the Cardiovascular Care of Older Adults — www.jacc.org — https://www.jacc.org/doi/10.1016/j.jacc.2013.09.070
16. Lawton Instrumental Activities of Daily Living Scale - an overview | ScienceDirect Topics — www.sciencedirect.com — https://www.sciencedirect.com/topics/medicine-and-dentistry/lawton-instrumental-activities-of-daily-living-scale
17. The perception of the clinical relevance of the ... - Oxford Academic — academic.oup.com — https://academic.oup.com/fampra/article-pdf/27/6/638/1337217/cmq055.pdf
18. World guidelines for falls prevention and management for older adults — academic.oup.com — https://academic.oup.com/ageing/article/51/9/afac205/6730755
19. The Nursing Home Physical Performance Test: A Secondary Data ... — academic.oup.com — https://academic.oup.com/gerontologist/article-pdf/58/4/e197/25138942/gnx033.pdf
20. GREFON recommendations for assessment of instrumental activities of daily living in memory clinics - ScienceDirect — www.sciencedirect.com — https://www.sciencedirect.com/science/article/abs/pii/S0035378716301941
21. Overestimated functional dependency in older patients: Can we blame gender difference, unneeded assistance or assessment tools? - ScienceDirect — www.sciencedirect.com — https://www.sciencedirect.com/science/article/abs/pii/S0167494320300121
22. Role of occupational therapy after stroke : Annals of Indian Academy of Neurology — journals.lww.com — https://journals.lww.com/annalsofian/fulltext/2008/11001/role_of_occupational_therapy_after_stroke.12.aspx
23. Canadian Stroke Best Practice Recommendations... : American Journal of Physical Medicine & Rehabilitation — journals.lww.com — https://journals.lww.com/ajpmr/fulltext/2026/02000/canadian_stroke_best_practice_recommendations.8.aspx
24. [PDF] Improving outcomes for older cancer patients ... - ClinicalTrials.gov — cdn.clinicaltrials.gov — https://cdn.clinicaltrials.gov/large-docs/40/NCT03071640/Prot_SAP_000.pdf

## Editorial note

Prepared from cited clinical literature using Astra's research workflow. Verify recommendations against current guidance and patient-specific factors.