01Purpose and principlesWhat the assessment is for and the core concepts behind it.
Ask the person to describe an ordinary day before illness and what became different. For every task record whether it was done safely, reliably and in reasonable time, with which aid, cue or person. Collateral from family, carers, pharmacy, community notes and care records is essential when delirium or memory impairment obscures change. Consent and capacity principles still apply.
Basic ADLs sustain bodily self-care: bathing, dressing, toileting, transferring, continence and feeding. Instrumental ADLs require more complex physical and executive work: using telephone or digital communication, shopping, meal preparation, housework, laundry, transport, medicines and finances. Cultural roles matter; never classify inability from a task the person has never chosen to perform.
Separate capacity from performance. A patient may have the strength to dress but not initiate or sequence it, or may manage in a familiar home but fail in a noisy unfamiliar ward. Conversely, institutional routines can provide more help than needed. Record opportunity, usual habit, safety and cueing before concluding dependence.
Observe transfers, walking, dressing components, toilet access and a relevant IADL simulation when safe. Check strength, joints, pain, feet, balance, postural pressure, cardiopulmonary tolerance, vision, hearing, neglect, apraxia and executive function. Link each limitation to a working mechanism; functional decline must not replace medical diagnosis.
Use a validated scale to communicate and monitor, not to automate placement. Barthel captures common basic tasks and mobility; Katz describes six ADLs; Lawton considers IADLs. Ceiling effects, sex-role history and scoring differences limit comparison between tools. Record the named version, date, setting and help actually supplied.
Intervention combines treatment of disease and pain with graded practice, strength and balance work, pacing, task simplification, aids and environmental modification. OT may assess bathroom, kitchen, stairs, cognition and equipment; physiotherapy plans transfer and gait progression. Speech and language therapy, dietetics, continence and sensory services address specific barriers.
Before discharge, test the proposed plan against the real home: door and chair heights, steps, toilet distance, food preparation, medicine packaging, emergency access and overnight needs. Ask carers what help they are willing and able to provide and arrange formal care, rehabilitation or temporary placement when the gap cannot be safely bridged.
Monitor task achievement meaningful to the person rather than only a total score. Failure to recover may reflect missed infection, fracture, depression, fear of falling, sedative burden, malnutrition or inadequate therapy exposure. Revise diagnosis and goals, and communicate new baseline and review triggers across settings.
Continence and feeding require mechanism-level description. Reaching the toilet, recognising need, removing clothing, transferring and cleaning are separate abilities; a continence label hides which step fails. Eating independently does not prove safe swallowing, adequate intake or ability to obtain food. Record aspiration features, dentition, utensil handling, meal preparation, cueing and fatigue so continence, speech and language, dietetic and care interventions solve the correct task.
Key points
- Function is both an outcome and a diagnostic sign. Record what changed, when, why and what assistance makes the activity possible.
- Basic ADLs include washing, dressing, toileting, transfers, continence and feeding; IADLs include shopping, cooking, housework, transport, communication, finances and medicines.
- First-line assessment uses direct history plus collateral and observed performance. A score alone cannot distinguish strength, pain, cognition, vision, environment or motivation.
- Anchor baseline to the period before acute illness and separate capacity, usual performance and current ward performance.
- Specify independent, set-up, verbal cueing, supervision, one-person or two-person hands-on help, equipment and time rather than writing needs assistance.
- Katz and Barthel tools summarise basic function; Lawton IADL explores complex tasks. Use the same validated version serially and retain narrative context.
- Occupational therapy analyses meaningful tasks and environment; physiotherapy assesses transfer, gait, balance, strength and rehabilitation potential.
- Discharge planning must reproduce meals, medicines, toileting, stairs and night needs in the destination, with the person and carer agreeing the plan.
- Loss of IADLs often precedes basic ADL dependency and can expose cognition, sensory loss or social barriers rather than physical frailty alone.
- Reassess after treatment: persistent loss prompts renewed diagnosis, mood and sensory review, more rehabilitation or an adapted long-term support plan.
02Indications, selection and cautionsWhen it is useful, when urgency changes and important limitations.
New help with feeding, transfers, toileting, washing or dressing indicates substantial illness impact and personal-care need.
Medicine, money, transport, shopping and cooking errors may reveal executive or sensory difficulty before self-care dependency.
The person can perform a task under ideal prompting but cannot initiate, sequence or sustain it safely in ordinary life.
A task possible on a level ward may fail at home because of stairs, low furniture, poor lighting or absent rails.
A sudden baseline gap demands medical diagnosis and delirium assessment before long-term placement decisions.
Apparent independence may rely on extensive invisible preparation, cueing and supervision that must be measured.
03Method and interpretationA systematic approach to the test and its findings.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Dated functional historyFirst step - Why
- Establish usual performance and recent trajectory.
- Interpretation and limitations
- Describe basic and instrumental tasks, assistance, aids, safety and time before illness, supported by collateral when needed.
- 02
Observed task assessment - Why
- Test ability rather than relying only on report.
- Interpretation and limitations
- Observe transfers, gait and relevant self-care or simulated home tasks with usual aids and record cueing, fatigue, pain and safety.
- 03
Katz or Barthel assessment - Why
- Summarise basic ADL dependency serially.
- Interpretation and limitations
- Use a named validated version consistently; interpret change with illness, setting and assistance because totals do not explain mechanism.
- 04
Lawton IADL assessment - Why
- Explore the person's complex community independence.
- Interpretation and limitations
- Consider prior roles and opportunity; failure in finances, medicines or transport can be cognitive, sensory, physical or social.
- 05
Mobility and falls assessment - Why
- Define physical contributors and rehabilitation targets.
- Interpretation and limitations
- Check gait, balance, strength, feet, aids, postural pressure and fear of falling and investigate focal pain or neurology.
- 06
Cognition, mood and sensory review - Why
- Find non-motor reasons for task failure.
- Interpretation and limitations
- Assess delirium first, then executive cognition, depression, hearing and vision after communication is optimised.
04Clinical next stepsHow the result changes management or prompts escalation.
01First-line assessmentCompare baseline, capacity and current performanceFirst stepFirst lineA person reports or demonstrates new dependency.+
- 1Treat urgent illness and obtain a dated task-by-task baseline from the person and collateral sources.
- 2Observe relevant ADLs and IADLs with usual aids and identify physical, cognitive, sensory, emotional and environmental mechanisms.
- 3Quantify the care gap and agree medical, therapy, equipment and support actions with named owners.
02Rehabilitation planPractise meaningful tasks in contextPotentially reversible limitation remains after initial treatment.+
- 1Set goals defined by observable activities that matter to the person and control pain, breathlessness and fatigue.
- 2Provide graded strength, balance, transfer and task-specific practice with appropriate aids and cueing.
- 3Review progress and barriers frequently, increasing intensity or revisiting diagnosis when expected gains do not occur.
03Safe transitionTest destination against real needsHospital treatment is complete but function differs from baseline.+
- 1Simulate stairs, toileting, meals and medicines using the equipment and supervision actually available after discharge.
- 2Confirm carer willingness, formal-care timing, contingency access and who will arrange outstanding adaptations.
- 3Communicate new baseline, assistance level, equipment, goals and deterioration triggers to community teams.
05Risks, monitoring and follow-upComplications, safety checks and further assessment.
- Repeat the same observed tasks and tool version after acute treatment and rehabilitation, retaining narrative information about assistance and safety.
- Track pain, postural symptoms, fatigue, delirium, mood, nutrition and medicine adverse effects that may limit participation.
- Verify that recommended aids fit, are delivered and are used safely in the intended environment.
- Review carer workload and formal support when function changes; one additional transfer dependency can transform day and night feasibility.
- Treat failure to regain an expected task as a prompt to reopen diagnosis and rehabilitation delivery, not automatic irreversible decline.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
IADLs reveal executive function
Complex tasks often fail before feeding or dressing and may expose cognition, vision or planning problems.
Performance depends on setting
Familiar cues and adapted furniture can make home ability better than a ward test, while home stairs can expose hidden risk.
Assistance has levels
Set-up, cueing, standby and hands-on help create very different staffing and carer requirements.
Scores do not explain why
Identical Barthel totals can arise from stroke, pain, delirium or environment and need different treatment.
Function is a vital sign
Abrupt dependency can be the clearest evidence of serious acute illness when classic symptoms are absent.
07Common pitfallsFrequent interpretation and management errors.
- 01
Writing independent when a relative prepares every meal, fills medicines and supervises bathing.
- 02
Scoring current septic or delirious performance as the stable long-term baseline.
- 03
Assuming a low total identifies the cause or determines residential placement.
- 04
Testing mobility with two staff and ward equipment then planning home with neither.
- 05
Calling inability to perform an unfamiliar culturally assigned task functional loss.
- 06
Failing to investigate new IADL errors for delirium, cognitive disorder, depression and sensory impairment.