Activities of Daily Living

Definition of “Client”

According to the OTPF-2,³ the term clients refers to persons, organizations, and populations who receive occupational therapy services. Persons include the actual person receiving services, such as Anna, her husband, her family, and her employers and other significant relations. Organizations refer to businesses, industries, or agencies, such as Anna’s church, which may receive general consultation or referral by an occupational therapist on accessibility. Populations refer to larger people groups in communities such as refugees and survivors of particular natural or manmade disasters. Most of the intervention strategies in this chapter will relate to providing such intervention to persons or individuals as clients—such as Anna—though it is acknowledged that occupational therapists also provide services to organizations and populations in the area of ADLs and IADLs.

Client Factors

The analysis of occupational performance in ADLs and IADLs includes observing the client’s performance and noting skills and patterns and the factors that support them.¹ Client factors are specific abilities, characteristics, or beliefs including strength, range of motion (ROM), coordination, sensation, a belief that one has potential to improve, and balance. These client factors are important to consider for Anna’s functioning. Is her ROM and strength intact in her upper body? How is her trunk control and balance?

Client factors can be assessed to determine the potential for remediation and restoration or possible need for adaptive equipment or other modifications. In Anna’s case, it would be important to know whether the spinal cord injury is complete and whether she has potential for muscle return to determine an appropriate approach to treatment. Other client factors include cognitive functions such as memory, attention, and problem solving. These are assessed in relation to ADLs and IADLs. Emotional functioning for coping strategies and behavior management also need to be considered when assessing and treating ADLs and IADLs.¹ The OT questions, “Is Anna requiring cues to perform her weight shifts and skin checks because she has a memory deficit? Or is she having difficulties learning new techniques and strategies because of issues surrounding coping with the disability?”¹ How is her sleep quality? Sleep deficits can severely hamper performance in terms of memory and attention (see Chapter 13). Specific assessments to identify and measure activity demands and client factors contribute information influencing ADL and IADL performance.

Performance Skills

The OTPF describes performance skills as “abilities clients demonstrate in the actions they perform” (p. 639)³ and include motor/praxis skills, sensory/perceptual skills, emotional regulation skills, cognitive skills, communication, and social skills. Whereas client factors reside within a person, performance skills are those that are observable and demonstrable. Examples of a motor/praxis skill for IADLs may be Anna’s ability to reach and bend down to retrieve a pot from a low cupboard or maintain balance while performing the ADL of transferring to a low soft surface. A client with difficulty in sensory/perceptual skills may have difficulty with the ADL of dressing to properly orient his T-shirt. A client with difficulty with the cognitive skill of sequencing the steps of a task may have difficulty taking a shower. Should he turn on the water first or transfer into the shower first? Should he start drying himself off first or rinse the soap off first?

Performance Patterns

Habits, routines, roles, and rituals are all performance patterns according to the OTPF-2.³ All can be helpful or detrimental to occupational performance. As cited in the OTPF-2 (p. 641),³ habits are “specific, automatic behaviors that can be useful, dominating, or impoverished.”^13,32 An example of an ADL habit may be automatically placing a napkin on one’s lap before starting to eat or placing the right leg into pant legs first, then the left leg. Routines are “established sequences of occupations or activities that provide a structure for daily life” (p. 641).³ An example of a routine ADL may be Anna’s routine of waking up at the same time every day and completing the sequence of toileting, showering, dressing, hygiene and grooming, and eating breakfast on a regular basis. Anna’s IADL routine may have been to help her daughter to get ready for the day by completing such activities as changing her diaper, getting her dressed and cleaned, making her breakfast, packing her lunch, and driving her to daycare. Roles are “expected by society, shaped by culture, and may be further conceptualized and defined by the client” (p. 641).³ Examples of roles might include a husband of a wife with severe rheumatoid arthritis or a college student who lives independently in an apartment with a roommate. Important roles for Anna are those of wife, mother, daughter, worker, and Bible study member. Rituals are “symbolic actions with spiritual, cultural, or social meaning that contribute to the client’s identity and reinforce the client’s values and beliefs.”¹⁷ Examples of rituals that are in the realm of ADLs and IADLs include praying or saying grace before every meal or celebrating particular holidays with foods that are only served on that date and have special cultural meanings. Understanding performance patterns including habits, routines, roles, and rituals will allow the OT practitioner to identify performance deficits, set priorities with goal setting, and help the client reestablish continuity in daily living. For example, with her new functional status, Anna may not be able to perform all of the previous morning IADL routines with her daughter. She may have to establish new routines with her daughter and learn to perform those activities differently. Or others, at least in the early stages, may have to assume responsibility for those tasks. Anna may need to redefine her role in the family, an important undertaking for an occupational therapist to help facilitate.

Environment

The environment to which the client will be discharged after treatment is an important consideration. The OTPF-2 describes the environment as the “external physical and social environments that surround the client and in which the client’s daily life occupations occur” (p. 642).³ A physical environment includes the natural and the built environment and the objects in them. A few of the external environments for Anna are her home and the contents in it, her place of work, and her church. The social environment includes relationships by persons, groups, and organizations. Anna’s social environment includes her husband, daughter, parents, coworkers, and friends. Given Anna’s circumstances, questions abound such as who will be her primary caregiver when she goes home, her mother or her husband? How long will Anna’s mother live with her family? Will Anna plan to return to work and community activities? Does Anna’s family own or rent their home? Will Anna be alone at home at times? How important are her friendships to her for social support? The answers to the questions about the physical and social environment will strongly influence the treatment priorities.

Cultural, Personal, Temporal, and Virtual Contexts

The terms context and environment have been used interchangeably in the literature but are defined separately in the OTPF-2, though they are considered to be interrelated.³ Context can refer to situations or conditions within and around the client. The OTPF-2 describes context as cultural, personal, temporal, and virtual.

A cultural context includes “customs, beliefs, activity patterns, behavior standards, and expectations accepted by the society” in which one is a member (p. 642).³ Cultures can differ vastly in terms of ADLs/IADLs. For example, one culture may view bathing as a private event, whereas another may consider it a communal event.

Cultural context is also important to consider in understanding differences in how independence is defined and valued. The AOTA Position Paper on the construct of independence supports the view that independence is “defined by the individual’s culture, values, support systems, and ability to direct his or her life.”²³ A thorough evaluation will allow the OT practitioner to understand what activities are critical to each client in order to reestablish the client’s sense of directing his or her own life. An example of differing cultural values frequently occurs when an occupational therapist raised in a more Westernized culture considers it important to foster independence in ADLs and IADLs but a client from a different cultural view may not see independence in ADL tasks as highly valued. The OT practitioner may unfairly label the client as unmotivated. For the individual whose culture does not value ADL or IADL independence, the occupational therapist may focus primarily on teaching the client and family to adapt. The focus would be on family training and identifying the activities of highest value to the client and family.

The ultimate goal of any ADL and IADL training program is for the client and family to learn to adapt to the life changes that necessitated a referral to the occupational therapist. For the individual who values independence, the goal may be to achieve the maximal level of independence. It is important to note that this level is different for each client. For the client with mild muscle weakness in one arm, complete independence in ADLs may be the maximum. In contrast, for the individual with a high-level quadriplegia, self-feeding, oral hygiene, and communication activities with devices and assistance may be the maximal level of independence that can be expected. The potential for independence depends on each client’s unique personal needs, values, capabilities, limitations, and social and environmental resources.

Personal context includes a person’s demographic features, such as age, gender, and educational level, which also need to be considered in ADLs and IADLs. The ADL/IADL tasks and routines may differ based on any one of many demographic factors. For example, a young adult female may consider it important to regain the ability to shave her legs, whereas an elderly female may not. Temporal context includes contexts that refer to time, such as time of year, time of day, or stages of life. An example of how temporal context can be important in ADLs is determining when certain tasks, such as dressing and eating a meal, occur during the day. Virtual context refers to interactions in “simulated, real-time, or near-time situations, absent of physical contact” (p. 646).¹ An example of virtual context for Anna is her ability to contact friends using her computer or cell phone. It would be important for an occupational therapist to recognize the significance of this virtual context in order for Anna to be connected socially and otherwise.

Finances

Financial resources available for potential expenses such as assistant care, special equipment, and home modifications are other important considerations for ADL and IADL performance. For example, consider a client who is a new full-time wheelchair user and can no longer stand to take showers, requiring significant assistance of a caregiver to perform the task. If the client has unlimited financial resources, owns his own home, has an able-bodied committed caregiver, a desire to take showers daily, and an eagerness to fully remodel his home for accessibility, an OT may recommend a fully remodeled bathroom by a licensed contractor. Anna has fewer financial resources but has reliable caregivers and owns her home. She also desires to shower regularly but an occupational therapist may make recommendations for less costly modifications such as removing the sliding glass door from the bathtub/shower and a replacing it with a shower curtain or obtaining a bath bench and other equipment.

Occupational Justice

As cited in the OTPF-2,³ the term occupational justice was coined by Townsend in 2003 to describe the occupational therapy profession’s concerns with the ability of all people to be given the opportunity to engage in occupations, including the ADLs and IADLs that are important to them. Many times occupational therapists are the first to recognize the disparity in abilities to meet occupational needs because of social, economic, and other factors. Occupational therapists can assist in supporting social policies, actions, and laws that allow all persons to engage in occupations that are important to them.³ An example of applying this principle of occupational justice to the most basic of ADLs involves Anna’s roommate in the inpatient rehabilitation unit who does not have the resources to bring in clothes to practice dressing skills. The only clothes Anna’s roommate had were destroyed in the accident that brought her into the hospital. Anna’s roommate has only her hospital-issued gown and pants to practice dressing skills. On a small scale the OT can help to equalize this disparity by working with social services to allow Anna’s roommate access to clothes she can use in order to increase her independence in this important ADL. A common situation for an OT is one where a piece of adaptive equipment such as a transfer bath bench is neither covered by insurance nor within the client’s ability to purchase. Creative, compassionate, and resourceful OTs can help to bridge this disparity to help all clients to perform ADLs and IADLs that are important to them.

ADL and IADL Performance

An occupational performance analysis of ADLs and IADLs may include using a checklist as a guide for questioning and the selection of specific activities to perform as identified during the interview for the occupational profile. For example, in Anna’s case the occupational therapist may select to have Anna perform lower-extremity dressing and transfer to the commode as two key activities. The OT can then determine strategies to promote independence and provide caregiver instruction regarding how to provide Anna with the appropriate level of assistance.

Many types of ADL and IADL checklists and standardized tests are available. They all cover similar categories and performance tasks.⁷ The use of a standardized test will ensure a more objective assessment and provide a standard means of measurement. A standardized assessment tool can be used at a later time for reevaluation, and some assessments allow for comparison to a norm group. Both Asher⁷ and Law²⁶ have developed resources on assessments that can be used as a resource for selecting appropriate tools for evaluation The occupational therapist should review the literature periodically to learn about new assessments developed by occupational therapists and about those that have been developed as interdisciplinary assessments, such as the Assessment of Motor and Process Skills¹⁸ and the Functional Independence Measure (FIM).^26,40

General Procedure

When data have been gathered about the client’s physical, psychosocial, and environmental resources, the feasibility of ADL assessment or ADL training should be determined by the occupational therapist in concert with the client, supervising physician, and other members of the rehabilitation team. In some instances, ADL training should be delayed because of the client’s limitations or in favor of more immediate intervention objectives that require the client’s energy and participation.

The interview may serve as a screening device to help determine the need for further assessment by observation of performance. This need is determined by the therapist based on knowledge of the client, the dysfunction, and previous assessments. A partial or complete performance analysis is invaluable in assessing ADL performance. The interview alone can lead to inaccurate assumptions. The client may recall performance before the onset of the dysfunction, may have some confusion or memory loss, and may overestimate or underestimate his or her abilities because there has been little opportunity to perform routine ADLs since the onset of the physical dysfunction.

Ideally, the occupational therapist assesses the performance of activities in the environment and context where they usually take place.⁵ For example, a dressing assessment could be arranged early in the morning in the treatment facility, when the client is dressed by nursing personnel, or in the client’s home. A self-feeding assessment should occur at regular meal hours. If this timing is not possible, the assessment may be conducted during regular treatment sessions in the OT clinic under simulated conditions. Requiring the client to perform routine self-maintenance tasks at irregular times in an artificial environment may contribute to a lack of carryover, especially for clients who have difficulty generalizing learning.

The therapist should select relatively simple and safe tasks from the ADL and IADL checklist and should progress to more difficult and complex items, including some that involve safety measures. For example, with Anna, transfer training would likely start with transfers from her wheelchair to her bed and then progress to commode transfers, which are more difficult. The ADL assessment should not be completed at one time because this approach would cause fatigue and create an artificial situation. Tasks that would be unsafe or that obviously cannot be performed should be omitted and the appropriate notation made on the assessment form.

During the performance analysis, the therapist should observe the methods the client is using or attempting to use to accomplish the task and try to determine causes of performance problems. Common causes include weakness, spasticity, involuntary motion, perceptual deficits, cognitive deficits, and low endurance. If problems and their causes can be identified, the therapist has a good foundation for establishing training objectives, priorities, methods, and the need for assistive devices.

Other important aspects of this analysis that should not be overlooked are the client’s need for respect and privacy and the ongoing interaction between the client and the therapist. The client’s feelings about having his or her body viewed and touched should be respected. Privacy should be maintained for toileting, grooming, bathing, and dressing tasks. The therapist with whom the client is most familiar and comfortable may be the appropriate person to conduct ADL assessment and training. As the therapist interacts with the client during the performance of daily living tasks, it may be possible to elicit the client’s attitudes and feelings about the particular tasks, priorities in training, dependence and independence, and cultural, family, and personal values and customs regarding performance of ADLs.

Recording Results of ADL Assessment

During the interview and performance analysis, the therapist makes appropriate notations on the checklists. If a standardized assessment is used, the standard terminology identified for that assessment is used to describe or measure performance. Nonstandardized tests may include separate checklists for self-care, home management, mobility, and home environment assessments. When describing levels of independence, occupational therapists often use terms like maximum, moderate, and minimal assistance. These quantitative terms have little meaning to healthcare professionals unless they are defined or unless supporting statements are included in progress summaries to give specific meanings for each. It also should be specified whether the level of independence refers to a single activity, a category of activities such as dressing, or all ADLs. In designating levels of independence, an agreed-upon performance scale should be used to mark the ADL checklist. The following general categories and their definitions are suggested:

These definitions are broad and general. They can be modified to suit the approach of the particular treatment facility.

As stated previously, the AOTA²³ published a position paper on a definition of independence that differs from the relatively narrow definition noted earlier. Hinojosa²³ stated: “Independence is a self-directed state of being characterized by an individual’s ability to participate in necessary and preferred occupations in a satisfying manner, irrespective of the amount or kind of external assistance desired or required” (p. 660). This means that an individual’s independence is not related to whether an individual performs the activity or not or in a modified fashion or with assistance.

Information from the ADL assessment is summarized succinctly for inclusion in the client’s permanent record so that interested professional coworkers can refer it to. A sample case study (Mrs. Hayes) with resulting ADL evaluation summaries of an initial assessment and progress report are included in Figure 10-1, A. Two evaluation forms are being included to show Mrs. Hayes’s progress, a detailed ADL checklist (see Figure 10-1, A), and an abbreviated ADL checklist (Figure 10-1, B). The detailed form with Mrs. Hayes’s information incorporated into it will help the novice OT practitioner appreciate the details of many ADLs and IADLs that may be taken for granted by an able-bodied individual. The abbreviated form is more likely to be used in actual practice. A third form, also included, is a home management checklist (Figure 10-2). When reviewing these, the reader should keep in mind that the assessment and progress summaries relate only to the ADL and IADL portions of the intervention program.

Home Management Assessment

Home management tasks are assessed similarly to self-care tasks. First, the client should be interviewed to elicit a description of the home and of former and present home management responsibilities and the significance of the role. Tasks the client needs to perform when returning home, as well as those that he or she would like to perform, should be determined during the interview. If the client has a communication disorder or a cognitive deficit, aid from friends or family members may be enlisted to get the information needed. The client may also be questioned about his or her ability to perform each task on the activities list. The assessment is much more meaningful and accurate if the interview is followed by a performance assessment in the ADL kitchen or apartment of the treatment facility or, if possible, in the client’s home. An example of a standardized assessment to evaluate the executive skills required to perform IADLs is the Executive Function Performance Test.⁸ Examples of specific IADL tasks to evaluate for home management can be found in the home management checklist (see Figure 10-2).

The therapist should select tasks and exercise safety precautions consistent with the client’s capabilities and limitations. The initial tasks should be simple one- or two-step procedures that are not hazardous, such as wiping a dish, sponging a tabletop, and turning the water on and off. As the assessment progresses, tasks graded in complexity and involving safety precautions should be performed, such as making a sandwich and a cup of coffee and vacuuming the carpet. For example, with Anna, initial tasks may include making a sandwich and using the microwave, as using a manual wheelchair in her own home is new for her and requires working from a seated versus a standing position. As Anna performs these simple tasks using her wheelchair, the OT will be able to observe and make suggestions about modification to her kitchen, reorganization, safety techniques, or methods to transport items and simplify tasks.

Home management skills apply to women, men, and sometimes adolescents and children. Individuals may live independently or share home management responsibilities with their partners. In some homes, it is necessary for a role reversal to occur after the onset of a physical disability, and the partner who usually stays at home may seek employment outside the home, whereas the individual with a disability remains at home. In Anna’s case, she has stated she would like to participate in previous home management activities and eventually return to work. Anna’s occupational therapist will collaborate with her on home tasks to be completed by her so that interventions can be prioritized. Until Anna can perform the tasks more independently, Anna’s mother or husband may be available to perform some of these tasks with direction from Anna.

If a client will be home alone, several basic ADL and IADL skills are needed for safety and independence. The most basic IADL skills required to stay at home alone include the ability to³ prepare or retrieve a simple meal,^1a employ safety precautions and exhibit good judgment,³ take medication, get emergency aid⁶ if needed, have a system for managing toileting, and have a method to allow for rest periods. The occupational therapist can assess the potential for remaining at home alone through the activities of home management assessment. An evaluation such as the Executive Function Performance Test can be used to assist in determining whether a person is safe to remain at home or how much assistance is required for some IADL tasks.⁸ A child with a permanent disability also needs to be considered for assessment and training for IADL skills as he or she develops and matures with a growing need for independence.

Home Assessment

To help with the transition from a treatment facility to home, a home evaluation may be performed. A home evaluation can serve several functions, including assessing a home for safety and accessibility, offering a way for an OT to assess client functioning at home, and determining a time when caregiver training can occur. From the initial meeting with a client or caregivers, the occupational therapist must have an idea about the home environment to which the client will return. For example, the OT treating Anna or Mrs. Hayes should know from early on whether they live in second story apartment without an elevator or in a one-story house. When discharge from the treatment facility is imminent, a home assessment may be carried out to facilitate the client’s maximal independence in the living environment.

As will be described here, not all clients who are seen by an occupational therapist in a facility will need or receive a home evaluation. The home assessment will provide the family with a list of modifications and durable medical equipment needed to maximize safety and independence in the home and help the therapists understand the physical, cultural, and social environment the client will be returning to so that realistic treatment methods and goals related to mobility, ADLs, and IADLs are established. Insufficient or incorrect information regarding accessibility can lead to costly mistakes in ordering equipment that may lead to impairing the client’s safety and potential for greater independence.

The home evaluation should be performed when the client’s mobility status is stabilized with status close to where you anticipate it will be at discharge. Collaboration with the physical therapist regarding a client’s ambulatory status and potential is essential to determine the timing and necessity of the evaluation. For example, if the physical therapist reports that a client will be primarily walking at discharge, recommendations for home modifications may be very different than if the primary mode of mobility will be a wheelchair.

Ideally, the occupational and physical therapists could perform the home assessment together. During the home visit, the client and essential caregivers/family members or housemates should be present. However, if it is not feasible to take the client, a wheelchair and other necessary equipment may be taken. Budget, time factors, and reimbursement issues may not allow two professionals to go to the client’s home or may prohibit a home visit altogether.

If a home evaluation is not possible prior to discharge, the rehabilitation team along with the client and family members should identify the most serious concerns and develop a plan to address them. Figure 10-3 shows a home safety checklist that can be completed by the client or client’s family. Family members or housemates could take pictures and measurements of the home or draw floor plans. Figure 10-4 depicts an occupational therapy home evaluation checklist, which is completed by the OT practitioner.

Much of the information can also be gained by interviewing the client and family member(s) following a trial home visit with the client. The family member or caregiver may be instructed to complete the home visit checklist and provide photographs or sketches of the rooms and their arrangements. Problems encountered by the client during a trial home visit should be discussed and the necessary recommendations for their solution made, as described earlier. If a home evaluation is not possible while the client is in the hospital, the home assessment may also be referred to the home health agency that will provide home care services to the client.

The client and a family member should be interviewed prior to the home evaluation to determine the client and family’s expectations and the roles the client will assume in the home and community. A culture’s or family’s values regarding people with disabilities may influence role expectations and whether independence will be encouraged. Willingness and financial ability to make modifications in the home can also be determined. The purposes and procedure of the home assessment should also be clearly explained to the client and caregiver(s) prior to the actual visit.

Understandably, the first time home (which may be at the home evaluation) after an illness or injury can be potentially emotion-filled for everyone concerned, especially for the client. Before performing a home evaluation, especially with the client present, it is important for the occupational therapist to know whether the home being evaluated is new for the client or whether drastic home changes have already had to be made. For example, if Anna lived in a second-story apartment prior to her accident, her family may have had to move to a first-story home. Or if Anna’s mother was going to move into her home to help care for her daughter and granddaughter, rooms may have been switched, furniture moved, belongings displaced. Knowing this ahead of time can help the occupational therapist to be ready to provide emotional support to the client as needed.

If the client is present during the home visit, sufficient time should be scheduled so that the client can demonstrate the required functional mobility skills. The occupational therapist may have the client demonstrate selected self-care and home management tasks in the home environment. During the assessment, the client should use the mobility aid and any assistive devices that he or she is accustomed to using. For example, Anna and Mrs. Hayes would be asked to propel their manual wheelchairs throughout the home to determine what access issues they will encounter. The therapist should bring a sturdy tape measure to measure the width of doorways, the height of stairs, the height of the bed, and other dimensions. A digital camera can be useful to record arrangement of furniture, placement of bathroom fixtures, and other architectural structures/possible barriers for later reference when problem solving solutions.

The therapist can proceed to take the required measurements while surveying the general arrangement of rooms, furniture, and appliances. Figure 10-4 provides a format to document critical measurements. It may be helpful to sketch the size and arrangement of rooms for later reference and attach these sketches to the home assessment checklist (see Figure 10-4). For more information on a variety of checklists, see Letts²⁷ and Anemaet.⁴ Next, the client demonstrates functional mobility skills and essential self-care and home management tasks. The client’s ability to use the entrance to the home and to transfer to and from an automobile, if it is to be used, should be included in the home assessment if time permits.

During the performance assessment, the therapist should observe safety factors, ease of mobility and performance, and limitations imposed by the environment. If the client needs assistance for transfers and other activities, the caregiver should be instructed in the methods that are appropriate. The client may also be instructed in methods to improve maneuverability and simplify the performance of tasks in a small space.

Access into the bathroom and maneuvering with a wheelchair or walker are common problems. Frequently, a bedside commode is recommended until a bathroom can be made accessible or modified to allow independence with toileting (Figure 10-5). Shower seats can be used in the tub if a client can transfer over the edge of the tub and also may be used in a shower. A transfer tub bench (Figure 10-6) is recommended for individuals who cannot safely or independently step over the edge of the tub. Installation of a handheld shower hose increases access to the water and also eliminates risky turns and standing while bathing.

The Americans with Disability Act (ADA) Accessibility Guidelines for Buildings and Facilities are available at its website.¹⁵ Not all modifications recommended will necessarily meet the ADA guidelines, as the home will be modified to suit the individual and to compensate for that specific disability. The ADA is meant to apply to public areas and to meet the needs of people with a variety of disabilities. For example, grab bar placement in ADA guidelines indicates a bar should be placed at the back of the toilet. In the case of Mrs. Hayes, who had a stroke, a grab bar placed on both sides of the toilet may be sufficient. Although this recommendation does not meet ADA guidelines, it does allow for safety and independence at the toilet for Mrs. Hayes. A generalist OT practitioner is not expected to know all of the building codes within a city but should have some familiarity with guidelines when making recommendations. The OT should recommend the family only use licensed contractors who are aware of building code requirements in their area. (See Chapter 15 for ADA Guidelines.)

When the home assessment is completed, the therapist should write a report summarizing the information on the form and describe the client’s performance in the home. The report should conclude with a summary of the environmental barriers and the functional limitations that the client encountered. Recommendations should include additional safety equipment and assistive devices that are needed. Modification recommendations should include specific details about size, building specifications, costs, and sources. Recommendations may also include further functional goals to improve independence in the individual’s home environment. Team members should be notified about the client’s performance in the home and accessibility problems so that they can practice skills or be made aware of issues prior to discharge. For example, the OT may report to the physical therapist that a client such as Mrs. Hayes will eventually need to negotiate a step down into the living room to be more independent. The OT may report to the psychologist that Anna had a difficult time emotionally handling her visit to home in her new functional status.

The therapist should carefully review all recommendations with the client and family. The family should receive a written report with recommendations clearly written. This review should be done with tact and diplomacy in a way that gives the client and family options and the freedom to decline them or consider alternative possibilities. Family finances may limit the implementation of needed changes. The social worker may be involved in working out funding for needed equipment and alterations, and the client should be made aware of this service when cost is discussed.

The therapist should include recommendations regarding the feasibility of the client’s discharge to the home environment or remaining in or managing the home alone, if applicable. If there is a question regarding the client’s ability to return home safely and independently, the home assessment summary should include the functional skills the client needs to return home.

See Box 10-2 for the most common modifications recommended and Box 10-3 for a list of supplies to take on a home evaluation.

Financial Management

If the client is to resume management of money and financial matters independently, a cognitive and perceptual assessment that accurately tests these skills should be implemented. Because some persons with physical disabilities also have concurrent involvement of cognition and perception, the level of impairment should be determined. The OT evaluates the methods and routines the client typically implements for financial management. For example, one client may pay each bill as it arrives by writing a check, whereas another client may pay bills once a month online. The skills needed for each are different and require different levels of organization. Like any other performance area, the OT will break down the activity into small tasks and focus treatment on building skills for each component of the task. Caregivers may require training if the role of financial manager is new and must be assumed. In the case of Mrs. Hayes, she is having slight cognitive deficits and handwriting difficulties. She may need to teach her husband how to manage bill paying or they may choose to work together. The client may be capable of handling only small amounts of money or may need retraining in activities that require money management, such as shopping, balancing a checkbook, or making a budget. If a physical limitation is involved, the therapist may introduce adaptive writing devices to allow the client to handle the paperwork aspects of money management.

Community Mobility

The occupational therapist also evaluates the client’s potential to participate in the community where some type of community mobility is required. Zahoransky⁴⁵ identified community mobility in the following categories:

The occupational therapist must assess the client’s physical, perceptual, cognitive, functional, and social capabilities to be independent and safe with community mobility. The OT should also be familiar with the environment where the client lives and accesses the community. It is not always possible to know about the client’s community or neighborhood from an inpatient or outpatient setting. In this case, the OT has the opportunity to teach the client and caregiver about how to evaluate access and environmental obstacles to help prepare for return to community participation. The OT may also inform the family of needed resources that will help the client resume or learn community access skills.

Physical capabilities to be considered are (1) whether the client has the endurance to be mobile in the community without fatigue and (2) whether the client is sufficiently independent with the walker, cane, crutch, or wheelchair skills and transfers needed to go beyond the home environment. These skills include managing uneven pavement, curbs, and inclines and crossing the street. Other functional skills to be evaluated before considering community mobility are how to (1) handle money, (2) carry objects in a wheelchair or with a walker, and (3) manage toileting in a public restroom.

Cognitive skills include the ability to be geographically and topographically oriented; if taking a bus, to know how to read a schedule and map or know how to get directions; and to have good problem-solving skills if a problem should occur in the community.

If the disability is new, the client may need to develop new social skills or relearn them. At first, these skills will be stretched to the limit once the client is out in the community—for example, learning how to be assertive to get an accessible table at a restaurant, obtaining assistance with unreachable items in the grocery store, and becoming comfortable with a new body image within the able-bodied community.

Visual spatial skills are critical to safety in judging distance stepping down from a curb, driving a car, maneuvering a wheelchair on a narrow sidewalk. The visual spatial skills are identified during an evaluation, considered in relationship to the cognitive, physical, and functional deficits the client exhibits. Some individuals have awareness of their deficits and compensate well. Others are not aware of the deficits or have difficulty with compensatory strategies and therefore will require greater supervision with community mobility than others.

The therapist should also assess the client’s community environment. For example, is the neighborhood safe enough for an individual who might be vulnerable because of physical limitations? What is the terrain like? Are there curb cutouts? Are the sidewalks smooth and even? How far away are the closest store and bus stop? Are the traffic lights long enough for the client to negotiate safely given mobility limitations?

Accessibility of community transportation should also be considered. Some communities have door-to-door cab and van service, which have certain restrictions. Some of these restrictions include the need to arrange transportation a week in advance, the ability to get out the front door and to the curb independently, and the ability to transfer independently into the vehicle. If the client is to use a public bus, he or she must learn how to use the electric lifts and how to lock a wheelchair into place. Because not all bus stops are wheelchair accessible, the neighboring bus stops should be surveyed.

Community mobility requires preplanning by the occupational therapist and the client; accurate assessment of the client’s abilities; and knowledge of potential physical, cognitive, visual perceptual, and social barriers that the client may encounter. Armstrong and Lauzen’s Community Integration Program⁶ is a valuable resource for providing practical treatment protocols to establish a community-living skills program. Attaining independence in community mobility allows the client to expand life tasks beyond those in the home and allows participation in the community.

Health Management and Maintenance

Health management and maintenance include the client’s ability to understand the medical condition and make decisions to maintain good health and avoid behaviors that compromise health.³ The client’s ability to handle medications, know when to call a physician, and know how to make a medical appointment are practical aspects of health management. The evaluation of the client’s ability to perform these activities may be completed solely by the occupational therapist but will probably include other team members such as the nurse and the physician. The information provided by the occupational therapist’s skilled evaluation of the client’s cognition, visual perception, and physical abilities can greatly enhance the skilled nurse’s ability to use appropriate interventions and teaching strategies when teaching medication management to the client.

Performance skills and patterns must be assessed in light of the skills required for each task. The OT assessment can be helpful in determining which aspects of the task need to be modified for the client to be independent. For example, the occupational therapist can work jointly with a nurse to ensure that a client with hemiplegia and diabetes can manage insulin shots. The OT evaluation considers the client’s cognitive and perceptual abilities to make judgments about drawing the insulin out of the bottle, measuring the insulin, and injecting the insulin. Physical concerns include how to stabilize the insulin bottle, accurately see the measurement, and handle the syringe with one hand. Other medication management may involve how the client is able to open the medication and measure it, if the medication is a liquid. The occupational therapist may also evaluate and train the client in other skills that affect health management. Examples include using the phone, finding the appropriate phone numbers, and providing the needed information to make a medical appointment.

Because she has paraplegia, Anna’s new health management and maintenance routine may be to perform regular skin checks and weight shifts to prevent decubiti (pressure sores) from developing. An occupational therapist can help Anna to obtain necessary adaptive aids and strategies to ensure good skin health.

Health maintenance is an issue for the client and entire healthcare team. The occupational therapist plays an important role because of the scope of the ADL and IADL assessments, which may identify and help resolve problems related to health maintenance.

Methods of Teaching ADLs

The therapist must tailor methods of teaching the client to perform daily living tasks to suit each client’s learning style and ability. The client who is alert and grasps instructions quickly may be able to perform an entire process after a brief demonstration and oral instruction. Clients who have perceptual problems, poor memory, and difficulty following instructions of any kind need a more concrete, step-by-step approach, reducing the amount of assistance gradually as success is achieved. For these clients it is important to break down the activity into small steps and progress through them slowly, one at a time. A slow demonstration of the task or step by the therapist in the same plane and in the same manner in which the client is expected to perform is helpful. Oral instructions to accompany the demonstration may or may not be helpful, depending on the client’s receptive language skills and ability to process and integrate two modes of sensory information simultaneously. See Chapter 7 for further discussion of teaching activities in occupational therapy.

Touching body parts to be moved, dressed, bathed, or positioned; passive movement of the part through the desired pattern to achieve a step or a task; and gentle manual guidance through the task are helpful tactile and kinesthetic modes of instruction (see Chapter 7). These techniques can augment or replace demonstration and oral instruction, depending on the client’s best avenues of learning. It is necessary to perform a step or complete a task repeatedly to achieve skill, speed, and have a task that is currently declarative learning (consciously knowing what to do) become automatic/procedural learning (unconsciously knowing how to do it). Tasks may be repeated several times during the same training session if time and the client’s physical and emotional tolerance allow, or they may be repeated daily until the desired retention or level of skill is achieved.

The process of backward chaining can be used in teaching ADL skills. In this method, the therapist assists the client until the last step of the process is reached. The client then performs this step independently, which affords a sense of success and completion. When the last step is mastered, the therapist assists until the last two steps are reached and the client then completes these two steps. The process continues, with the therapist offering less and less assistance and the client performing successive steps of the task, from last to first, independently.

Before beginning training in any ADL, the occupational therapist must prepare by providing adequate space and arranging equipment, materials, and furniture for maximal convenience and safety. The occupational therapy practitioner should be thoroughly familiar with the task to be performed and any special methods or assistive devices that will be used in its performance. The occupational therapist should be able to perform (or know how to perform) the task as skillfully as he or she expects the client to perform it. After preparation, the activity is presented to the client, usually in one or more of the modes of guidance, demonstration, and oral instruction described earlier. The OT ensures appropriate environmental set up for success and safety. For example, a chair with arms or safely locked wheelchair may be provided to start. The client’s feet are placed flat on the floor or, at times if a using a wheelchair, on the footplates. Personal care items are located within safe reaching distance when initially learning an activity. The client then performs the activity either along with the occupational therapist or immediately after being shown, with the required amount of supervision and assistance. Performance is modified and corrected as needed and the process is repeated to ensure learning.

Because other staff or family members are frequently reinforcing the newly learned skills, staff and family training is critical to reinforce learning and ensure that the client carries over the skills from previous treatment sessions. In the final phase of instruction, when the client has mastered one or more tasks, he or she is asked to perform them independently. The therapist should check performance in progress and later arrange to check on the adequacy of performance and carryover of learning with the client, the nursing personnel, the caregiver, or the supervising family members.

Recording Progress in ADL Performance

The ADL checklists used to record performance on the initial assessment usually have one or more spaces for recording changes in abilities and the results of reassessment during the training process. The sample checklist given earlier in this chapter is so designed and completed for illustration purposes using Mrs. Hayes’s information (see Figure 10-1). If a standardized assessment is used during the initial evaluation, it should be used in the reevaluation process to objectively measure the level of progress the client has made.

Progress is usually summarized for inclusion in the medical record. The progress record should summarize changes in the client’s abilities and current level of independence and should also estimate the client’s potential for further independence, attitude, motivation for ADL training, and future goals for the ADL program. The information about the client’s level of assistance needed for ADLs and IADLs will help with the discharge planning. For example, if a client continues to require moderate assistance with self-care, he or she may need to hire an attendant, or the occupational therapist may justify ongoing treatment when the client has potential for further independence.

Assistive Technology and Adaptive Equipment

Assistive technology is defined as any item, piece of equipment, or product system, whether acquired commercially, off the shelf, modified, or customized, that is used to increase or improve functional capabilities of individuals with disabilities. This is a definition provided in Public Law (PL) 100-47, the Technical Assistance to the States Act.³⁰ The terms assistive technology, adaptive equipment, and assistive devices are generally used interchangeably throughout the profession. Adaptive equipment is used to compensate for a physical limitation, to promote safety, and to prevent joint injury. Electronic aids to daily living (EADLs) provide a bridge between an individual with limited function and an electrical device such as a telephone or door operator.³⁰ Physical limitations may include a loss of muscle strength, loss of range of motion (ROM), incoordination, or sensory loss. An example of using adaptive equipment to improve safety is the use of a bed or door alarm to alert a caregiver that a patient with impaired cognition and poor balance is wandering. The use of adaptive equipment to prevent joint injury is indicated for the person with rheumatoid arthritis, such as a built-up handled eating utensil.

Before recommending a piece of adaptive equipment, the OT practitioner must complete a thorough assessment to determine the client’s functional problems and causes of the problems. The OT practitioner may also consider practical solutions first, before settling on adaptive equipment as the solution. Some practical solutions would be to avoid the cause of the problem, use a compensatory technique or alternative method, get assistance from another person, or modify the environment. Typical of these considerations is the case example of Ms. Robins (who will be discussed in the case that follows) where the environment was adapted, wheelchair positioning/setup adapted, and a compensatory strategy of propping her elbows on the table was used instead of adaptive equipment.

Other factors to consider when selecting adaptive equipment are whether the disability is short or long term, the client’s tolerance for gadgets, the client’s feelings about the device, and the cost and upkeep of the equipment.

• Limited ROM or strength

• Incoordination

• Hemiplegia or use of only one upper extremity

• Paraplegia

• Quadriplegia

• Low vision

• Exceptionally large size body (bariatric population)

• Dressing activities

• Feeding activities (eating and swallowing are addressed in Chapter 27)

• Personal hygiene and grooming activities

• Communication management and environmental adaptations

• Functional mobility (transfers and wheelchair mobility are addressed in Chapter 11)

• Home management, meal preparation, and cleanup activities

ADLs for the Person with Limited ROM or Strength

The major problem for persons with limited joint ROM is compensating for the lack of reach and joint excursion through such means as environmental adaptation and assistive devices. Individuals who lack muscle strength may require some of the same devices or techniques to compensate and to conserve energy. Some adaptations and devices are outlined here.^22,36

Functional Mobility

The individual who has limited ROM without significant muscle weakness may benefit from the following assistive devices:

ADLs for the Person with Incoordination

Incoordination in the form of tremors, ataxia, athetoid, or choreiform movements can be caused by a variety of central nervous system (CNS) disorders, such as Parkinson’s disease, multiple sclerosis, cerebral palsy, Freidrich’s ataxia, and head injuries. The major problems encountered in ADL performance are safety and adequate stability of gait, body parts, and objects to complete the tasks.^22,31

Fatigue, stress, emotional factors, and fear may influence the severity of incoordinated movement.²² The client must be taught appropriate energy conservation and work simplification techniques along with appropriate work pacing and safety methods to prevent the fatigue and apprehension that could increase incoordination and affect performance.

Stabilizing the arm reduces some of the incoordination and may allow the individual to accomplish gross and fine motor movements without assistive devices. A technique that can be used throughout all ADL tasks is the stabilization of the involved upper extremity. This technique is accomplished by propping the elbow on a counter or tabletop, pivoting from the elbow, and only moving the forearm, wrist, and hand in the activity. When muscle weakness is not a major deficit for the individual with incoordination, the use of weighted devices can help with stabilization of objects. A Velcro-fastened weight can be attached to the client’s arm or to the back of the client’s hand to decrease ataxia, or the device being used (e.g., eating utensils, pens, and cups) can be weighted.³¹

ADLs for the Person with Hemiplegia or Use of Only One Upper Extremity

Suggestions for performing daily living skills apply to persons with hemiplegia, unilateral upper-extremity amputations, and temporary disorders such as fractures, burns, and peripheral neuropathic conditions that can result in the dysfunction of one upper extremity.

The client with hemiplegia needs specialized methods of teaching, and many such clients have greater difficulty learning and performing one-handed skills than do those with orthopedic or lower motor neuron dysfunction. Because the trunk and leg are involved, as well as the arm, ambulation and balance difficulties may exist. Sensory, perceptual, cognitive, and speech disorders may be present in a mild to severe degree. These disorders affect the ability to learn and retain learning and performance. Finally, the presence of apraxia (or difficulty with motor planning) sometimes seen in this group of clients can have a profound effect on the potential for learning new motor skills and remembering old ones. Therefore, the client with normal perception and cognition and the use of only one upper extremity may learn the techniques quickly and easily. The client with hemiplegia needs to be assessed for sensory, perceptual, and cognitive deficits to determine the potential for ADL performance and to establish appropriate teaching methods to facilitate learning. The following are primarily adaptive techniques versus restorative techniques. However, it is important to incorporate the upper extremity with hemiplegia to assist in returning functional to the extremity.

The major problems for the one-handed worker are reduction of work speed and dexterity and stabilization to substitute for the role normally assumed by the nondominant arm.²² The major problems for the individual with hemiplegia are balance and precautions relative to sensory, perceptual, and cognitive losses.