WHY: The assessment of functional status is critical when caring for older adults. Normal changes due to aging, acute illness, worsening chronic  illness, and hospitalization can contribute to a decline in the ability to perform tasks necessary to live independently in the community. The  information from a functional assessment can provide objective data to assist with targeting individualized rehabilitation needs or to plan for specific in home services such as meal preparation, nursing and personal care, home-maker services, financial and medication management, and/or  continuous supervision. A functional assessment can also guide the clinician to focus on the person’s baseline capabilities, facilitating early recognition of changes that may signify a need either for additional resources or for a medical work-up (Greenberg & McCabe, 2018).

BEST TOOL: The Lawton Instrumental Activities of Daily Living Scale (IADL) is an appropriate instrument to assess independent living skills (Lawton & Brody, 1969). These skills are considered more complex than the basic activities of daily living as measured by the Katz Index of ADLs (See Try This:® Katz Index of ADLs).  The instrument is most useful for identifying how a person is functioning at the present time and for  identifying improvement or deterioration over time. There are 8 domains of function measured with the Lawton IADL scale. Historically, women were scored on all 8 areas of function; men were not scored in the domains of food preparation, housekeeping, laundering. However, current  recommendations are to assess all domains for both genders (Lawton, Moss, Fulcomer, & Kleban, 2003). Persons are scored according to their  highest level of functioning in that category. A summary score ranges from 0 (low function, dependent) to 8 (high function, independent).

TARGET POPULATION: This instrument is intended to be used among older adults, and may be used in community, clinic, or hospital settings. The instrument is not useful for institutionalized older adults. It may be used as a baseline assessment tool and to compare baseline function to  periodic assessments.

VALIDITY AND RELIABILITY: Few studies have been performed to test the Lawton IADL scale psychometric properties. The Lawton IADL Scale was originally tested concurrently with the Physical Self-Maintenance Scale (PSMS). Reliability was established with twelve subjects interviewed by one interviewer with the second rater present but not participating in the interview process. Inter-rater reliability was established at 0.85. The validity of the Lawton IADL was tested by determining the correlation of the Lawton IADL with four scales that measured domains of functional status, the Physical Classification (6-point rating of physical health), Mental Status Questionnaire (10-point test of orientation and memory), Behavior and Adjustment rating scales (4-6-point measure of intellectual, person, behavioral and social adjustment), and the PSMS (6-item ADLs). A total of 180 research subjects participated in the study, however, few received all five evaluations. All correlations were significant at the 0.01 or 0.05 level. To avoid potential gender bias at the time the instrument was developed, specific items were omitted for men. This assessment instrument is widely used both in research and clinical practice.

STRENGTHS AND LIMITATIONS: The Lawton IADL is an easy to administer assessment instrument that provides self-reported information about functional skills necessary to live in the community. Administration time is 10-15 minutes. Specific deficits identified can assist nurses and other disciplines in planning for safe hospital discharge.  

A limitation of the instrument includes the self-report or surrogate report method of administration rather than a demonstration of the functional task. This may lead either to over-estimation or under-estimation of ability. In addition, the instrument may not be sensitive to small, incremental changes in function.

FOLLOW-UP: The identification of new disabilities in these functional domains warrants intervention and further assessment to prevent ongoing decline and to promote safe living conditions for older adults. If using the Lawton IADL tool with an acute hospitalization, nurses should  communicate any deficits to the physicians and social workers/case managers for appropriate discharge planning.

MORE ON THE TOPIC:

Graf, C. (2006). Functional decline in hospitalized older adults. AJN, 106(1), 58-67.

Graf, C. (2008). The Lawton Instrumental Activities of Daily Living Scale. AJN, 108(4), 52-62.

Greenberg, S. A., & McCabe, D. (2018). Functional assessment of older adults.  In T. Fulmer, & B. Chernof (Eds.), Handbook of Geriatric Assessment (5th ed., pp. 231-240). MA: Jones and Bartlett Learning.

Lawton, M.P., & Brody, E.M.  (1969). Assessment of older people: Self-maintaining and instrumental activities of daily living. The Gerontologist, 9(3), 179-186.

Lawton, M.P., Moss, M., Fulcomer, M., & Kleban, M. H. (2003). Multi-level assessment instrument manual for full-length MAI. North Wales PA: Polisher Research Institute, Madlyn and Leonard Abramson Center for Jewish Life.

Pearson, V. (2000). Assessment of function. In R. Kane, & R. Kane (Eds.), Assessing Older Persons. Measures, Meaning and Practical Applications (pp. 17-48). New York: Oxford University Press.