For older adults, concerns about cognitive decline are common, but when cognitive deficits interfere with basic and instrumental activities of daily living (ADLs and IADLs), there may be more serious concerns about dementia. Whether a patient is experiencing challenges with completing basic self care tasks or increased forgetfulness about paying bills, a cognitive and functional assessment can help clinicians determine if a lack of independence in daily activities warrants a dementia diagnosis.
Educating patients about the difference between ADLs and IADLS is helpful when creating a care plan that meets their individual needs. In this post, we will differentiate ADLs and IADLs, explore topics for care planning, and highlight the best assessment tools for providers.
What is the Difference Between an ADL and an IADL?
The term “activities of daily living” was coined by Sidney Katz in 1950, used to describe the basic skills required for patients to independently perform everyday tasks. In 1969, Drs. Lawton and Brody updated this scale to include the “instrumental activities of daily living”, which extended to tasks that require more complex thinking skills (Edemekong et al., 2023).
The Katz Index of Independence in Activities of Daily Living (ADL) (Katz et al., 1963.) and Lawton Instrumental Activities of Daily Living Scale (IADL) (Lawton & Brody, 1969) are two commonly used checklists that measure how patients are performing these skills. These checklists are often an important step in diagnosis of dementia and cognitive care planning, and open up more detailed conversations about a patient’s needs and capabilities.
Here is a detailed breakdown of the difference between ADLs and IADLs, including how they might present in different patients:
Activities of Daily Living (ADLs)
The loss of the ability to perform basic ADLs is a defining characteristic of dementia progression (Desai et al., 2024). Where age-associated memory loss or mild cognitive impairment (MCI) might cause forgetfulness, dementia symptoms severely disrupt a patient’s capacity to safely live independently.
The loss of the ability to perform basic or instrumental ADLs is a defining characteristic of dementia progression (Desai et al., 2024). Mild cognitive impairment (MCI) may be noticeable without interfering with independence, but if a patient has significant cognitive decline that interferes with basic ADLs, the patient may be in a more advanced stage of dementia.
Skills that are considered basic activities of daily living include:
- Personal hygiene includes a patient’s ability to groom and bathe themself. Along with washing and drying their body, this includes choosing and using the right tools for hair, nail, and dental hygiene.
- Ambulating refers to a patient’s capacity to safely move from one place to another, either by walking or independently using mobility devices. This ADL is essential to patient safety, as falls are the most common cause of traumatic brain injuries in seniors (Peterson et al, 2021).
- Dressing includes choosing appropriate clothes and putting them on. The ability to use buttons, zippers, snaps, and velcro is also taken into consideration. If a patient has prosthetics or splints, their capacity to use them will also be measured.
- Feeding and eating includes use of utensils, the ability to safely chew and swallow, and a basic understanding of portion control. Over 80% of patients with behavioural-variant frontotemporal dementia develop feeding abnormalities as the illness progresses, which can lead to malnutrition and dehydration (Piguet et al., 2009; Cipriani et. al, 2016).
- Toileting includes a person’s capacity to get to and from the toilet, use it appropriately, and completely clean themself after use.
- Continence refers to a person’s control of bladder and bowel function.
For dementia patients, each instance of a decrease in ADL or IADL function resulted in nearly five additional hours of monthly caregiving (Alzheimer’s & Dementia, 2024). Taking a patient-centered approach to cognitive assessment and treatment plans helps patients, providers, and family members collaborate on the strategies that can help with everyday tasks.
For example, when it comes to personal hygiene, patients who need help washing their hair have different needs than patients with zero capacity to bathe independently. Understanding the details of a patient’s mental and physical limitations can help determine if a patient might need part-time home health aide versus full time residential care.
Impacts to ADLs are not always tied to dementia. Physical injuries and brain injuries can also cause loss of independence. A dementia diagnosis may be relevant only when significant decline in cognitive abilities is the cause of loss of independence, and that’s why cognitive testing is an essential part of distinguishing different diagnoses.
Instrumental Activities of Daily Living (IADLs)
Where ADLs include the tasks required for basic survival, IADLs include the more complex thinking skills that allow people to manage their daily lives. For example, eating is considered an ADL, whereas the ability to handle shopping and meal preparation is an IADL—emphasizing its importance as a complex skill necessary for living independently. Both of these skills are required for daily functioning, but require different levels of intervention if a patient is struggling.
Because IADLs are more complex, they tend to be disrupted before ADLs in the development of dementia, and a change in the ability to perform IADLs may be a warning sign for dementia in the next few years (Cloutier et al., 2020). Loss of independence in IADLs is also the primary dividing line between MCI and dementia, as defined by the DSM-5.
Instrumental activities of daily living include:
- Basic communication skills, such as the ability to use a mobile phone, landline, email address, and the internet. This helps patients stay in touch with friends, family, and their community.
- Transportation, such as safely driving, using public transportations, or arranging ride services. According to the 2024 Social Threats to Aging Well Survey, 64% of senior respondents said that lack of transportation interfered with their access to medical care.
- Meal preparation includes planning meals, safely cooking them with the right utensils, cleaning up the kitchen, and correctly storing leftovers.
- Shopping for essential items like food, clothing, and home supplies. This includes using complex thinking skills to make appropriate purchasing decisions, as well as knowing how to complete transactions.
- House cleaning and maintenance with chores such as dishwashing, laundry, and vacuuming. Another part of this is knowing how to take care of personal belongings such as appliances and cars, as well as knowing who to call for help with repairs.
- Managing medication includes taking the right amounts at the right time, coordinating refills, and regularly scheduling appointments with healthcare providers. Another part of medication management is also knowing what each medication does and how to take them correctly.
- Managing finances includes operating within a budget, as well as knowing how to pay bills in person or online, write cheques, and avoid scams. In 2023 alone, adults 60 and over lost a combined 3.4 billion dollars to fraud worldwide (National Council on Aging).
There are nuances involved in understanding the results of an IADL screener, including that requiring help with some aspects of IADLs does not always mean a patient has failed the screen.
It may also be worthwhile for healthcare providers to understand some biases that have previously been associated with IADL screeners; the original IADL by Lawton & Brody excluded housekeeping, laundry, and food preparation when evaluating men. These gender biases could lead to inequitable healthcare practices and missed symptoms related to independent living, and generally should be avoided.
Conducting behavioral health assessments is one way to determine how a patient’s capacity to socialize might also be connected to their IADLs. For example, 48% of depressed adults experience appetite decrease (Simmons et. al, 2017). If a patient is struggling to feed themself, a combination of cognitive and behavioral health screens might help hone in on the cause of struggles with meal preparation.
Tools for Assessing Both ADLs and IADLs
The Katz ADL Scale (Katz et al., 1963.) and Lawton IADL Scale (Lawton & Brody, 1969) are basic checklists for assessing ADLs and IADLs, and provide a good understanding of a patient’s capacity to perform everyday tasks. However, they are most effective when used in combination with cognitive assessments, which screen for potential origins of a patient’s challenges with daily living.
Routine cognitive testing can be billed under Medicare in the annual wellness visit for patients over 65. By performing these screens early, patients can get early intervention.
Cognitive testing for dementia may include pen-and-paper screeners (such as the MoCA) and full neuropsychological evaluations. However, these assessments either lack detail or require a long process when time is critical. Examples include:
- The Montreal Cognitive Assessment (MoCA): Tests spatial awareness, naming, language, short term memory, attention, and executive function for patients in later-stage dementia.
- The Mental State Examination (MMSE): A pen-and-paper test that advances more advanced struggles with cognitive function.
- The Saint Louis University Mental Status (SLUMS) exam: Measures logical memory, delayed and immediate recall, executive function, calculation, and visuospatial recall. It’s typically most effective for patients with mild cognitive impairment (MCI).
- Neuropsychological testing: An in-depth assessment that generally requires a referral and can take 4-8 hours to complete.
The Creyos Dementia Protocol is a scientifically-backed assessment tool that can be completed either online or in person, and includes:
- A 5-minute screener that is sensitive to detect early signs of age-related cognitive impairment
- A DSM-5 aligned assessment protocol with up to six cognitive tests, the Lawton and Brody IADL functional questionnaire, and mental health assessments
- A comprehensive care planning toolkit
- Automated reporting tools that upload to a patient’s EHRs
- Tracking of patient performance across follow-up tests
Creating a Care Plan for Everyday Tasks
When patients are struggling to perform ADLs or IADLs, creating a care plan ensures they receive appropriate support to maintain dignity, independence, and overall quality of life. A family member often plays a crucial role in recognizing the need for assistance and navigating various care options. The type and level of care will depend on the wants and needs of the patient, as well as what is within the family caregivers’ needs and capacities.
In a 2021 survey from the AARP, 77% of adults over 50 stated they would prefer to age in place rather than in a nursing home (Ratnayake et. al, 2022). For seniors who are just beginning to struggle with ADLs and IADLS, there are different types of support that can allow them to remain as independent as possible in their home, emphasizing the importance of maintaining independence.
For patients who are struggling with basic activities of daily living, some at-home care options might include:
- Part- or full-time home health care for showering, toileting, and dressing
- Purchasing adaptive utensils for meals
- Installing shower bars to prevent falls
At-home support for patients who need help with IADLs could look like:
- Automated medication reminders or visits from nurses
- Grocery or meal delivery services
- Transportation arrangement
- Hiring a weekly house cleaner
For patients with cognitive impairment, family members often take on caregiving roles. However, the rise of caregiver burnout can lead to negative health outcomes for both patients and the caregivers themselves. 58% of caregivers for patients with Alzheimer’s disease report extreme stress, and 47% have developed sleep disorders since becoming caregivers (Vu et. al, 2022).
Full-time caregiving can also have financial consequences, with 57% of caregivers going to work late, leaving early, or needing time off (Vu et. al, 2022). When caregivers’ quality of life begins to deteriorate, long term care homes can be a valuable option, especially when a patient has complex medical needs.
Skilled nursing facilities provide 24-hour support for basic daily activities, as well as continuous medical care, such as physical therapy, medication administration, and management of chronic health conditions.
Advance care planning is one way to give patients autonomy over their healthcare before they begin to significantly struggle with everyday tasks. Openly discussing medical treatment preferences, future care needs, and end-of-life decisions makes sure that individual wishes are honored when the patient no longer has the capacity to communicate them.
Creyos offers a pre-made care planning toolkit that enables healthcare providers to efficiently administer questionnaires for the patient and caregiver to evaluate IADLs. Speak to our product specialists to learn more.
Supporting Patients in Their Daily Activities
Understanding the distinction between IADLs and ADLs is key to understanding the nature of a patient’s loss of independence, then creating effective and personalized care plans for older adults, as both types of activities are essential for maintaining independence in daily life. Early cognitive screening gives providers a head start on identifying a potential source of functional difficulties, pointing toward a dementia diagnosis that can get patients on a path toward prevention and management.
Reviewed by Sydni Paleczny, Staff Scientist
Sydni earned her MSc in Neurosciences at Western University under Dr. Adrian Owen. Her research explores neuropsychological outcomes after cardiac surgery, with interests in cognitive neuroscience, critical care, and brain health. At Creyos, she supports scientific validity, health technology, and ongoing research.