Daily living can be the most challenging cognitive task of all—an activity like cooking a meal may seem basic, but it involves a wide range of intellectual and physical skills.
The Instrumental Activities of Daily Living (IADL) assessment measures a patient’s ability to complete everyday tasks, such as managing finances, meal preparation, remembering directions, and more. Loss of functionality when completing these tasks independently can be a key marker of decline in aging patients, and as a result, many physicians gain great value from quantifying independence when making decisions about treatment, living arrangements, or other next steps.
Approximately 18% of people over age 75 require assistance with at least one instrumental activity of daily living. Individuals unable to perform certain IADLs may need outside help to make sure they stay healthy. When there is an acute reason for the loss of function, such as a stroke, treatments and compensatory strategies may be needed to regain functionality.
The Brody and Lawton IADL scale (created by M. Powell Lawton and Elaine M. Brody in 1969) is now available within the Creyos Health assessment platform to help clinicians measure independence in daily living. It can be included alongside objective cognitive assessments and other health questionnaires to easily gain important information about a patient’s health.
The instrumental activities of daily living (IADL) scale is used to make a functional assessment of a patient’s independent living skills and measure improvements or declines over time. The questionnaire asks patients or caregivers to indicate functionality in eight realms of complex everyday activities, such as using a telephone, paying bills, shopping, and meal preparation.
This evaluation is commonly used by occupational therapists, physical therapists, neurologists, primary care physicians, elder care specialists, and researchers working with aging patients to help determine the need for assistance. It can be used in any group where impairment may be standing in the way of everyday activities, such as rehabilitation after an injury or stroke. It is not recommended for individuals who are already living in assisted living facilities, however.
Each of the assessed domains rely on both cognitive and physical function to varying degrees. These skills are considered more complex than basic activities of daily living (ADLs), which include activities essential for survival, such as eating and hygiene. IADLs build on ADLs—for example, independently eating is required before considering meal preparation. Therapy and decision-making often consider goals related to both ADLs and IADLs. Because IADLs are more complex, they are often more clearly linked with cognitive impairment.
In Creyos Health, activities are presented one at a time, and the patient is asked to indicate their degree of independence. The summary score is presented on an activities of daily living scale.
A unique—and somewhat controversial—aspect of the IADL is that different items are scored for people who identify as men compared to people who identify as women. Specifically, food preparation, home maintenance, and laundry are left out of scoring for male patients. Although attitudes toward gender stereotypes are changing, the older people that the IADL questionnaire is generally administered to may have genuine difference in the degree to which they have participated in various household activities.
In Creyos Health, the full version of the IADL is administered to all patients, but males are only scored on 5 items. The patient’s gender setting can be changed or omitted (by choosing “other”) at any time to have all 8 items scored.
The results are scored automatically by counting the number of activities the patient completes independently. If the patient has completed the IADL more than once, then scores are tracked over time, and a graph is generated to easily view progress on the activities of daily living scale.
If the patient is completely dependent on others for any activity, the results will be highlighted red. Typically, cognitively healthy individuals do not report dependence for any activities, while those with mild cognitive impairment or dementia report dependence for one or more activities.
Note: The IADL should not be used as a standalone diagnostic tool, and many clinicians choose their own cutoff points based on experience in their particular field and patient population.
Studies have generally found that this version of the IADL is reliable over time and across raters (e.g., Edwards, 1990), and is valid for discriminating between people with and without dementia when using a cutoff score of one or more deficits to indicate possible dementia (e.g., Mao et al., 2018).
The IADL is a natural complement to the more specific but abstract areas of cognition measured by the Creyos cognitive tasks.
Reviews of studies using the IADL have found that deficits revealed by the questionnaire are associated with mild cognitive impairment (MCI), and that patients with MCI who exhibit IADL deficits are at a higher risk of converting to dementia (Jekel et al., 2015).
Traditional performance-based tasks designed to assess cognitive decline, such as the MoCA, are related with deficits in IADLs (Lahav & Katz, 2020). More detailed cognitive measures also predict deficits in activities of daily life (Cahn-Weiner, Boyle, & Malloy, 2010), and specific tests, such as those measuring response inhibition (measured by the Double Trouble task in CBS Health), may be particularly predictive of IADL deficits (Jefferson et al., 2006).
Assessing IADLs is not without limitations. Whether rated by self-report or by proxy via a caregiver, biases can creep in that over- or under-estimate the patient’s abilities. Therefore, objective, performance-based measures of cognition are also needed to complement the IADL, identify specific strengths and weaknesses in various domains of cognitive function, and possibly spot cognitive deficits that have not yet translated into an inability to complete complex activities independently.
Creyos Health’s neuropsychological tasks are validated measures of cognitive function that contribute information over and above results from an IADL questionnaire. Objective computerized testing helps assess the nature and severity of cognitive deficits, distinguish between cognitive and physical impairments, track recovery, or monitor for signs of decline over time.
The IADL can be administered during routine brain health checks, or when patients raise concerns about cognition. For aging patients, it can be used as part of an Annual Wellness visit or to evaluate concerns about their ability to continue to live independently.
The IADL assessment helps healthcare providers determine if the patient:
Can independently continue medication management
Requires in-home care, or
Requires arrangements for assisted living facilities or nursing homes
Requires support of social workers, community programs, or other social services
And more
For older patients, if severe changes to senior living occur, clinicians may also choose to conduct further cognitive assessment and cognitive care planning.
Administering the IADL in Creyos Health is easy. It can be given to a patient on its own or included as part of any protocol that mixes questionnaires and cognitive assessments. When creating a protocol within Creyos Health, click the Questionnaires section, then check off the IADL. You can select and rearrange other assessments for an integrated flow.
For detailed instructions on administering questionnaires within Creyos Health, please see our previous blog post on administering a computerized PHQ-9.
The Creyos Health version of the IADL is digital and web-based, so the test can be administered to a patient in-clinic or at home, and requires no special training. This version of the questionnaire can be completed as a self-report measure or by a third-party rater familiar with the patient’s status. The IADL can also be added to a Creyos Health schedule, allowing you to automatically send it via email on a regular cadence. The results are scored instantly, and if a patient completes the questionnaire more than once, results are added to the patient’s report to track changes and monitor for improvement or decline over time. Registration and login are not required, and the IADL takes as little as 2 minutes to complete. With minimal effort, healthcare providers, patients, and caregivers can all benefit from the valuable information provided by a standardized measure of functional difficulties.
If there are additional questionnaires you would like integrated in Creyos Health, such as instruments you currently administer in pen-and-paper form, please do not hesitate to let us know by commenting on this blog post or contacting us directly by email at help@creyos.com. We are always happy to hear your feedback.