Synopsis
Describe basic and instrumental daily function precisely, identify the medical, cognitive, sensory, environmental and social mechanism of loss, and turn observed ability into rehabilitation, equipment and support that works in the person's real setting.
- 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.
Key red flags
New unilateral weakness, speech change or loss of coordination requires an acute stroke pathway, not routine therapy referral.
Pain, deformity or inability to weight bear after a fall requires fracture assessment even when bruising is limited.
New feeding difficulty, coughing, wet voice or recurrent chest infection requires urgent swallow and aspiration assessment.
A sudden inability to toilet with lower abdominal pain, overflow or kidney injury raises retention, constipation or neurological compression.
Repeated medicine errors, unpaid bills, unsafe cooking or getting lost may reveal executive cognitive impairment before basic self-care fails.
A function-based discharge is unsafe if it was tested only with intensive supervision or equipment unavailable at home.
A sudden baseline gap demands medical diagnosis and delirium assessment before long-term placement decisions.
Investigation priorities
Establish usual performance and recent trajectory.
Management branches
A person reports or demonstrates new dependency.
- Treat urgent illness and obtain a dated task-by-task baseline from the person and collateral sources.
- Observe relevant ADLs and IADLs with usual aids and identify physical, cognitive, sensory, emotional and environmental mechanisms.
- Quantify the care gap and agree medical, therapy, equipment and support actions with named owners.