Article: Advance Living Directive™ Part II

Bert Cave
President of Support For Home
Sacramento, California  95825
916-482-8484

Member of the national ElderCare Matters Alliance, California chapter

We introduced the Advance Living Directive™ Support For Home developed in our last article.  It is neither a commercial product nor a sole creation of our agency.  Like most good things, it is collaborative, adapted from an article by M.P. Lawton and E.M. Brody.  This tool allows individuals and families to look at all of the Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) that we perform virtually every day.

We really do encourage families to participate in this exercise together, applying it not just to Mom and Dad, but to themselves, as well.  Using the tool together and discussing the results as a family goes through the exercise will generate some excellent discussion and make the outcome more meaningful for all.

By examining our current and projecting our future ability to perform those activities, we can set a baseline for helping us determine whether we need home care or if we need even more support, in a skilled nursing or memory care facility, for example.

The goal is to begin using the tool before there is any question about our ability to perform those ADLs and IADLs.  That way, there is less emotional stress and no temptation to “fudge” just a bit as we rate our abilities.  As well, there is less of a tendency for families to get into confrontations about Mom’s or Dad’s functional level or need for support.

In the next part of our series we will explore the concepts and the tool in greater depth, focusing on the individual basic ADLs (Activities of Daily Living).  What are they and why are they singled out?  In a subsequent article, we will cover the Instrumental Activities of Daily Living (IADLs), that we consider to be as important as the “regular” ADLs.  Then we will talk about the “scoring” levels for each of the ADLs and IADLs and what they mean – and what decisions should be made based upon the individual and cumulative scores.

There are many daily living assessment tools, but most of them are too technical and cumbersome for a family to make much use of, frankly.  That is why we developed a Microsoft Excel tool for our clients and families – and ourselves.  You can find that tool, and a PDF version, on the Web.

Most scales list either six or seven ADLs.  Our scale uses seven.  Our Advance Living Directive tool uses four status points, relative to our ability to perform this and all ADLs.  Ratings for Instrumental ADLs are a bit different, and we will talk about that in the next article.

Activities of Daily Living (ADLs)

• Personal Hygiene: involves bathing, including sponge / bed bath, tub bath or shower
• Dressing and Undressing: gets and replaces clothing and applies / removes them, with the possible exception of tying shoes
• Eating: involves feeding oneself, with the possible exception of activities such as cutting meat or buttering bread
• Transferring: moves from bed to chair or to standing; may use a cane or walker or grab bar or pole
• Continence: control of urine and bowel function
• Toileting: ability to use restroom, separate from continence
• Ambulation / Mobility: separate from transferring; ability to walk, including with use of a cane or walker

The use of our ability to perform Activities of Daily Living to determine the need for home care is very common.  In fact, almost every Long-Term Care Insurance (LTCI) company uses this to determine whether benefits will be paid to their clients.  Within the scope of ADLs, the four points on the scale indicate that the individual is,

• Independent – requires no assistance from a caregiver
• Needs Help – needs some assistance but can participate in the activity with a caregiver
• Dependent – cannot participate in the ADL; must rely completely on a caregiver
• Does Not Do / Perform – even with a caregiver’s assistance, the activity cannot be performed

As you can see, each of these ADLs is critical to our ability to live independently.  The more our ability is compromised in one or multiple activities, the more likely we are to need (a) a professional Home Care Aide in order to successfully age in place at home or (b) Assisted Living or (c) a Skilled Nursing Facility.

In Part III of this series, we will introduce the Instrumental Activities of Daily Living (IADLs), another critical part of the planning tool.