Independence is a precious commodity we particularly value as we age; but when you’re no longer able to do things like shop for food, prepare meals or handle medications, it can put you at risk for an accident, injury or illness.
If you or an older family member or friend starts to have trouble performing such tasks, it may be time to talk about moving to a senior living or long-term care community. However, there also may be supports and services to keep someone in their home longer to age in place.
Activities of Daily Living Needed to Remain at Home
What are ADLs? Activities of daily living, or ADL, are the life tasks that people need to be able to perform to live safely at home and be independent. How someone can handle any or all of these basic self-care skills helps determine what level of care or support they might need.
ADLs are needed for an individual’s basic functional living, and being able to perform the activities of daily living independently are key for anyone who wants to live on their own.
Activities of daily living examples include:
— Continence (the ability to control bladder and bowel function).
— Walking independently.
— Toileting (the ability to get to and from the bathroom and use the toilet without assistance).
Instrumental Activities of Daily Living
In addition, the instrumental activities of daily living, or IADLs, are equally important for older adults who live on their own.
These IADL skills are:
— Using the Telephone.
— Preparing food.
— Doing laundry.
— Using transportation.
— Handling medications.
— Handling finances.
Using the Telephone
This basically involves being able to place a call and answer the phone. As most everyone has a cell phone, this also means finding a contact and checking messages.
Red flags in this area are when someone seems to have trouble using their phone, fails to answer calls or doesn’t recognize when the phone is ringing, says Dr. Michael Wasserman, past president of the California Association of Long-Term Care Medicine in Thousand Oaks, California.
To stay independent, you need to be able to shop for groceries and other essentials. “Signs of a problem might be that mom goes to the store for milk and comes home with chicken, or dad always ate healthy and has started buying junk food,” Wasserman says. “Other issues to watch for include suddenly or significantly increased shopping and related expenses or an empty refrigerator that suggests mom’s not shopping at all.”
This doesn’t necessarily mean the ability to prepare elaborate meals. It can be as simple as heating microwavable meals or making a sandwich. Red flags include burning food or leaving the stove on, missing meals, weight loss or significant changes in diet or eating habits.
While not everyone has the same standards of cleanliness and order, housekeeping is important to maintain independence. Hoarding, leaving food out, cluttered rooms and letting garbage pile up are the types of signs to watch for.
If someone stops doing laundry or wearing clean clothes, it’s important to find out why. Did they forget how to use the washer? Are they unable to climb up or down stairs to get to the laundry room? Are they depressed and have lost interest in basic hygiene?
The answers can tell you what might be the cause of the issue and how to address it, Wasserman says.
“Transportation means different things to everyone. Some people rely on their car to go everywhere. Others may exclusively use the bus or train, and they walk everywhere,” Wasserman says.
Car accidents, getting lost or getting parking tickets are red flags, he stresses, but it’s also important to assess if someone can navigate using other modes of transportation as well, such as buses or car services. However, people most frequently associate the inability to drive with loss of independence, so those are hard conversations to have.
Joe Jedlowski, CEO of Distinctive Living, LLC, a senior living community headquartered in New Jersey, says, “We always recommend bringing in the physician for these difficult discussions. Having a trusted professional talk about why this decision is the right thing to do and discussing other options can makes the news easier to process and accept.”
According to Bill Deane, senior vice president of operations and commercialization for PharMerica, a national pharmacy provider with a focus on senior care, this doesn’t just mean taking medications correctly, but also getting prescription filled in a timely manner. A problem handling medications, he says, “is among the top reasons someone moves into a senior setting or to a new level of care.”
And it’s a more common issue than you may think. As Deane says, “if you are over 65 and taking more than three medications, you are going to take a medication incorrectly at some point. When this happens — especially if it happens frequently — it contributes to decline.”
This can trigger falls and fall-related injuries, memory and cognitive issues, weight loss or other problems that can result in an emergency room visit or hospitalization, he says.
“Assessing this can be challenging. People often don’t like talking about money,” says Wasserman. However, it’s an essential skill for independent living.
This includes being able to balance a checkbook, make deposits and manage money. In the digital world we live in, it’s also important to understand and avoid scams and cybercrime.
Jedlowski adds that “education and awareness go a long way. We have seminars and provide information about cybersecurity. Once a month, we have a speaker talk about IT communication and how to avoid problems. It’s important to approach conversations about finances and security positively and focus on what they can do and what they’re doing right.”
IADL Declines Don’t Always Mean Nursing Home or Assisted Living
Just because the ability to perform one or more IADL declines, this doesn’t necessarily mean a move to institutional care is imminent. For instance, Wasserman says, “it may be as simple as having a shopping list every time you go to the store. There also are several food delivery services that can bring in groceries or full meals.”
To help with handling medications, Deane suggests that “there are pharmacies that will package medications in compliance packaging that promotes adherence.” Additionally, he notes, there are high-tech devices such as smart pillboxes that not only remind you to take your medications, but also track when you take them and report to a practitioner or family member if you don’t.
Elsewhere, it’s possible to hire help to provide companionship and support. Companies such as Visiting Angels and Comfort Keepers offer a variety of services from helping with meals and light housekeeping to assisting with bathing and grooming. You also can hire organizations or individuals to help with housework, transportation, lawn care and pet sitting or dog walking. Such supports and services can help you or a family member stay safely at home longer.
An independent living community is a viable option that enables ongoing independence but also provides dining and meal services, opportunities for socialization and physical activity and other amenities. Some even have space where residents can work and/or receive some health care services.
Assisted living, memory care and/or skilled nursing facilities may be appropriate when someone’s deficits put themselves or others at risk for illness, accident, injury, further decline or financial problems. A continuing care retirement community, another option, offers access to multiple levels of care on one campus.
Assessing ADL and IADL Skills
“When functional declines start, they can cascade and cause additional problems and worsening health,” cautions Dr. Jawwad Hussain, a geriatrician with Community Physicians in Oak Park, Illinois. “When identified and addressed early, some functional decline can be reversed with physical or occupational therapy or other interventions.”
He also stresses that it’s important to have a good relationship with your geriatrician or other practitioners. “They can look at other possible causes for forgetfulness or other functional decline, such as an adverse drug reaction, malnutrition or a vitamin deficiency. Many of these can be resolved, thereby reversing the deficit.” He adds that it’s also important to have regular vision exams and hearing exams, as well as assessments regarding balance, gait, range of motion and the ability to walk safely.
Sometimes, declines in the ability to perform ADLs and IADLs may require admission to a long-term care facility. However, Hussain stresses that this isn’t necessarily a permanent move. “Just because you go into a facility doesn’t mean you’ll always be there. You can work with your physician and other team members to set goals that may enable you to return home or at least to a more home-like setting.”
“It may sound trite, but it’s the truth: If you act from a place of caring and concern and focus on what you or your loved one can do instead of the deficits, it helps,” Wasserman says. “Avoiding these issues is not a good idea. If the conversation is hard or scary, reach out to your physician or other trusted professional.”
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Update 09/09/22: This story was previously published at an earlier date and has been updated with new information.