When are activities of daily living NOT activities of DAILY living?

Professor Terry Quinn is the David Cargill Professor of Geriatric Medicine, University of Glasgow, and has a research interest in how to measure concepts like memory, functional ability… and ADLs. He posts on X @DrTerryQuinn.

Clinicians and researchers love a TLA (three letter abbreviation), and ADL (activity of daily living) must rank as one of the most commonly used abbreviations in the older adult space.

If we consider older adult care pathways, we start to realise just how often we use ADL assessments in practice. Performance on ADLs can determine whether someone is ready to return home after a hospital admission, measuring ADLs is often used to judge the success of rehabilitation, and the inability to complete ADLs is an important part of diagnoses like dementia. Perhaps ADL assessment is itself an activity of daily living for modern clinical teams. However, when ADL assessment is so ubiquitous, there is a danger that we lose sight of what the term implies.

When considering ADLs, we often use two categories. ‘Basic’ or ‘fundamental’ ADLs are relatively straightforward; these are activities we need to perform in order to survive. Basic ADLs would include eating, drinking, toileting, etc. The other category of ‘extended’ or ‘instrumental’ ADLs is more complex - complex both in terms of the activities that fall under this rubric, but also complex in terms of a consensus definition. In general, extended ADLs are those higher order activities that we need to perform in order to function in society. As a theoretical concept this is fine, but what ARE the common extended ADLs, and are my extended ADLs the same as yours?

A common approach to assessing extended ADLs is to document performance against a series of pre-defined tasks. There are many tools available to help with this - you may have heard of the Lawton Scale, the Nottingham, the Bristol – but can you list the activities these tools focus on? Many of the most popular extended ADL questionnaires were devised decades ago. Having an assessment that teams have used for years, and that everyone is familiar with, has many advantages. However, we were interested in whether the tasks included in these ADL questionnaires were still relevant to older adults in the year 2024.

To answer this question, we surveyed older adults from across the UK. We asked them to look at the tasks included in popular extended ADL questionnaires and tell us how often, if at all, they performed those tasks. We also asked then to list tasks that they performed every day and that did not feature in the long lists of ADLs from those assessments.

We received responses from over 2000 participants and the results were striking. Many of the tasks that feature in activities of daily living assessments were not performed daily; in fact, many were not performed at all. This finding is perhaps less surprising if we consider that tasks commonly included in extended ADL questionnaires include using a telephone directory, writing a cheque, and sending a letter. With the Yellow Pages and Blankety Blank chequebook and pen now historical curios, it is no wonder that the associated tasks do not feature in older adults’ daily ‘to-do’ lists. Just as there were many so-called ‘daily’ tasks that were not performed, so there were consistent responses that described tasks that are performed frequently but that don’t feature in any of the common ADL lists. Examples included online shopping, using email, and social media.

We think our results provide reasonably compelling evidence that many of the extended ADL measures we use are no longer fit for purpose. So, what is the solution? Assessing how people perform in the activities that are important to them is still a core component of older adult clinical practice. We can’t abandon ADLs, so perhaps we need to update how we assess them. This is not a call for clinical teams to start creating their own ADL measures; the process of developing an assessment that is suitable for clinical practice takes time and effort, and the ideal would be to have a tool that is consistently used across the NHS and that will not become obsolete. In terms of how to do this, the respondents to our survey offer us a strong steer. Our results suggest that digital technology is increasingly a major part of older adults’ daily life. So, perhaps we can harness developments in technology to allow for digital based individual ADL assessments that are comprehensive, continually updated, and relevant to the end user. Hopefully people agree that this is a plausible direction of travel, as it is the basis for the next research project from our team. Whether it will work – watch this space.