Article: Advance Living Directive™ Part III

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

Member of the national ElderCare Matters Alliance, California chapter

In this article, we will discuss what are called Instrumental Activities of Daily Living (IADLs).  We consider these as important as ADLs, in terms of establishing the need for home care or alternative living arrangements.  We wish that providers of Long Term Care Insurance took them more seriously, as well.

The distinction from “basic” Activities of Daily Living is subtle, in our view, and there is a tendency in the insurance and medical communities to underestimate their importance, frankly.  When Long-Term Care Insurance companies perform an assessment as to whether their clients are eligible for benefits to begin, the insurance companies require that assistance is needed for at least two of the basic ADLs that we discussed in Part II:

• 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

Instrumental ADLs (IADLs) are seen as supporting that basic set.  In many ways, IADLs are more nuanced than the basic ADLs.  We are able to more clearly articulate the levels of ability to perform them than with basic ADLs.  In some ways, that actually makes them easier to use as a benchmark or planning tool set than the basic ADLs.  We will talk about the levels of ability to perform IADLs in Part IV of this series.

The IADL set includes:

• Ability to use a telephone
• Shopping for food and other necessities
• Food preparation
• Housekeeping and organization
• Doing laundry
• Meeting needs for transportation
• Managing medication
• Handling finances

For the first IADL, ability to use a telephone, there are four levels of ability:

• Operates telephone on own initiative; looks up and dials numbers, etc. (4 Points)
• Dials a few well-known numbers (3 Points)
• Answers telephone but does not dial (2 Points)
• Does not use telephone at all (1 Point)

For each of the IADLs there is a score, which becomes part of the total score for IADLs.  However, for each IADL, we believe there is a threshold below which we feel home care is appropriate or that other living arrangements might be worth exploring.  For this IADL, even at the two point level, communication by phone is still available and emergency communication, via a pendant or bracelet alarm system is still possible.  Discussion of options is appropriate, but technology in this area can help someone live alone at home if this is the only issue.

The next IADL, shopping for food and other necessities, also has four levels.

• Takes care of all shopping needs independently (4 Points)
• Shops independently for small purchases (3 Points)
• Needs to be accompanied on any shopping trip (2 Points)
• Completely unable to shop (1 Point)

For shopping, we believe that the two point level requires home care or other assistance.  The need to be accompanied may be from physical limitations or dementia.  As is the case with several other IADLs, the need involved in performing the IADL is critical to an underlying ADL.  For example, I may be able to satisfy the Eating ADL — I can feed myself.  However, if I cannot shop or take care of the next IADL, food preparation, I still definitely need help.

For food preparation, there are, again, four levels:

•  Plans, prepares and serves adequate meals independently (4 Points)
• Prepares adequate meals if supplied with ingredients (3 Points)
• Heats, serves and prepares meals or prepares meals but does not maintain adequate diet (2 Points)
• Needs to have meals prepared and served (1 Point)

As for the prior IADL, we believe that being at the two point level for food preparation does mean home care is needed.  There are wonderful programs such as Meals On Wheels that help with food preparation.  However, they do not substitute for a balanced, adequate diet. 

Housekeeping has five levels of ability associated with it:

• Maintains house alone or with occasional assistance (5 Points)
• Performs light daily tasks such as dishwashing, bed making (4 Points)
• Performs light daily tasks but cannot maintain acceptable level of cleanliness (3 Points)
• Needs help with all home maintenance tasks (2 Points)
• Does not participate in any housekeeping tasks (1 Point)

At the three level point, there is still the opportunity to use maid services rather than true caregivers.  It may be marginal, however and, combined with other lower scores for IADLs, even a three on Housekeeping may point very clearly to the need for home care.

In the last article in this series, we will conclude the discussion of IADLs and the use of the Excel spreadsheet that supports using the Advance Living Directive™.