1. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 47 Activities of Daily Living and Instrumental Activities of Daily Living Anne Birge James

2. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Learning Objectives After reading this chapter, you will be able to: 1.Describe the purposes of an occupational therapy ADL and IADL evaluation 2.Given a client case, identify client and contextual factors that would influence the evaluation plan 3.Develop individualized client goals that will drive the intervention process

3. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Learning Objectives (Continued) 4.Describe contextual considerations that influence goal development. 5.Explain the most common approaches to ADL and IADL intervention. 6.Describe the role of client and caregiver education in treatment of ADL and IADL deficits. 7.Grade treatment activities to progress clients toward increased participation in ADLs and IADLs.

4. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Definition of ADL and IADL Activities of daily living (ADL) –Activities that are oriented toward taking care of one’s own body. 1 Instrumental activities of daily living (IADL): –Activities that are oriented toward interacting with home and community environments. They are often complex in nature than ADL. 1 Definitions from the Occupational Therapy Practice Framework, 2 nd ed. (American Occupational Therapy Association, 2008).

5. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Evaluation of ADLs and IADLs Evaluation: The process of gathering and interpreting data to plan intervention. Includes: –developing an evaluation plan; –implementing the data collection; –interpreting the data; and –documenting the evaluation results. Assessment: The specific method used to collect data –One component of the evaluation process. Standardized assessment methods are known as assessment tools or instruments.

6. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Evaluation Planning: Selecting the Appropriate ADL and IADL Assessments Step 1: Identify the purpose of the ADL/IADL evaluation Step 2: Have clients identify their needs, interests, and perceived difficulties with ADLs and/or IADLs Step 3: Further explore clients’ relevant activities so that the activities are operationally defined Consider level of independence, safety, and adequacy parameters (defined by the client or societal standards)

7. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Evaluation Planning: Selecting the Appropriate ADL and IADL Assessments (Continued) Step 4: Estimate the client factors that affect ADLs/IADLs and the assessment process Step 5: Identify contextual features that affect the assessment process itself, including: –physical & social context; –safety; –client’s past experience with a task; –time constraints; –therapists’ training/experience; and –available resources & reimbursement

8. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Evaluation Planning: Selecting the Appropriate ADL and IADL Assessments (Continued) Step 6: Consider features of assessment tools –Tasks included in the assessment –Standardized versus non-standardized –Descriptive versus quantitative data –Reported versus observed performance Step 7: Integrate the information from Steps 1–6 to select the optimal ADL and IADL assessment tools

9. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Implementing the Evaluation: Gathering Data, Critical Observation, and Hypothesis Generation Gathering data and critical observation –Thoughtful selection of assessments is important Hypothesis generation –Clinical reasoning - a kind of internal dialogue - is used to interpret assessment data –Used to identify and focus the therapists’ understanding of the clients’ assets and problems

10. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Establishing Clients’ Goals: The Bridge Between Evaluation and Intervention Establishing client goals – an important step enables transition from evaluation to intervention Synthesizing evaluation results into a meaningful, individualized intervention plan –a complex cognitive task Selecting effective intervention activities is easier when OT has attainable and measurable goals

11. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Identifying Appropriate Goal Behaviors Three performance parameters can be used to establish goals for intervention that target appropriate client behaviors: –value; –level of difficulty; –safety, fatigue and dyspnea

12. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Identifying Appropriate Goal Levels Treatment goals must include a measurable outcome –How well or at what level will the identified behavior will be done? –Sometimes referred to as the degree of performance The performance parameter most commonly focused on in OT is independence in activity performance Safety is also important to consider when setting goals –Safety is a quality of the person–task–environment transaction, so it cannot be observed or treated in isolation from independence

13. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Identifying Appropriate Goal Levels (Continued) Adequacy or quality of the targeted goal behavior can be reflected in the goal. Consider: –pain during or following activity; –fatigue or dyspnea during or following activity; –time needed to complete the task (duration); –societal standards; –client satisfaction with the outcome; and –aberrant task behaviors

14. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Additional Considerations for Setting Realistic Client Goals Additional factors can affect goal achievement and must also be considered: –prognosis for client’s impairments; –client’s past experience with the task; –client’s capacity for learning and openness to alternative methods; –projected follow-through with program outside of treatment; –time available for intervention; and –resources and the expected discharge context

15. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Interventions for ADL and IADL Deficits Planning and Implementing Intervention Selecting an intervention approach –Modify –Establish/Restore –Integrated approaches Education of the client or caregiver –Fit instructional methods to client or caregiver needs

16. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Planning and Implementing Intervention (Continued) Grading the intervention program –Start with easier tasks and progress to harder tasks –Increase the complexity within a task –Vary the performance environment of a task –Therapist-facilitated to client-facilitated problem- solving

17. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Intervention Review Reevaluation of ADL and IADL performance is needed to determine if the: –intervention is resulting in improvement; –intervention should be continued or changed; and –maximal benefit from OT has been achieved