Evaluating activities of daily living: directions for the future (Law, 1993)

Law, M. (1993). Evaluating activities of daily living: directions for the future. American Journal of Occupational Therapy, 47(3), 233-237.

School of Occupational Therapy and Physiotherapy, McMaster University, Hamilton, Ontario, Canada.

Abstract: Current assessments of simple activities of daily living (ADL) and more complex, instrumental activities of daily living (IADL) could be improved. These assessments are criticized because there are so many different tests for various diagnostic populations, because they rely on self-report rather than observation, because they are based on such varied conceptual frameworks, because they are often cumbersome and lengthy to administer, and because they often rely on outdated or specific cultural perspectives. Improvement of ADL and IADL assessment lies in making them more contextual and client specific, (i.e., by addressing clients' needs in real-life contexts that consider roles, culture, varying environments, and developmental stage.

http://www.ncbi.nlm.nih.gov/pubmed/8456923

My Notes

Interesting historical facts (really cool to know...):

• The actual term activities of daily living or ADL has not always been used in occupational therapy. The first reference to an "assessment of every day activities" was reported by Sheldon in the journal of health and physical education in 1935 (Feinstein, Josephy, & Wells, 1986)
• Edith Buchwalk (1949), a physiotherapist, was the first to publish the term activities of daily living; she used it to refer to an assessment checklist.
  

Currently ADL & IADL evaluation issues

• Predictive ADL and IADL tools attempt to predict an event or functional status in another situation on the basis of the client's current level of functional performance.
• Evaluative ADL and IADL scales are used to evaluate client functional performance over time, thereby allowing the evaluation of process and the effectiveness of the occupational therapy intervention—norm-reference tool.
• Many ADL assessments have been developed but not those for IADL.

Analysis of current evaluation practices

• There are too many ADL assessments developed and validated for different populations. Feinstein et al. (1986) did a review and found at least 43 different instruments developed in a period of over 40 years.
• There is a significant trend for developing self-report instruments. However, there are significant differences in the observations made through self-report and reports by professionals.
• ADL and IADL instruments are often developed with different conceptual framework, including the inclusions of different impairment-related items and scaling methods. For instance, most instruments use ordinal scaling which results in the issue of incompatibility between the scores because the distance between scores are not equal (Merbits, Morris, & Grip, 1989).
• Another issue concern the administration of ADL and IADL because the instruments are either too long or too short.
• A fifth issue related to the instruments concerning the philosophical and ethical basis. For instance, following the philosophy of the medical model, improvements are made through changes in the clients. By reframing the problem as a function of the interaction between the individual and the environment, the resolution would involve the change in the environment.
• Finally, the biggest limitation of the current instruments lies in their nature of decontextualization. With most evaluations, factors such as the patient's cultural background, roles and developmental stage were not taken into consideration.

Essentially, there is a consensus among the experts that there should be better methods of development and validation for ADL and IADL instruments (Feinstein et al., 1986; Fisher, 1990; Law & Letts, 1989)

What should be evaluated?

• From the occupational perspective, assessments and their process should focus on the daily activities endorsed by the clients. Feinstein et al (1986) identified three advantages of client-centered assessment: clear goals, interventions are valued by the clients and intervention outcomes are enhanced.
• Other than focusing solely on the changes in the clients, there is also a need to modify contextual factors such as physical, cultural, social, economic or institutional environment.
• In addition, the intervention outcome should be the contextualized occupational performance of the ADLs rather than the decontextualized performance of the components.

Methodological issues concerning the development of the instruments:

• Testing the reliability and validity of the instruments (Classical Testing Theory CTT)
• Investigating the use of new methodologies such as Rasch Model (IRT)
• Investigating the use of alternative scaling models.