Almost every older adult hopes to spend later life in a familiar home rather than move into a care home. Whether this is possible often depends less on whether the family can afford a domestic helper or carer, and more on a basic question: can the older adult wash, dress and use the toilet alone? These self-care abilities, repeated every day, are what clinicians call ADL (activities of daily living). They look minor, but they are the real threshold that decides whether an older adult can keep living at home or needs a care home place. This article explains why ADL self-care ability is the key to ageing at home, and how home-visit occupational therapy helps older adults move from being unable to do a task to being able to do it again.
CAPABLE is a programme for low-income older adults in which an occupational therapist, a nurse and a home repair worker visit the home together. Research found that dealing with self-care difficulties at home in this way reduced daily self-care disability (ADL disability) by 30% within 5 months (RR 0.70, 95% CI 0.54–0.93, P=.01; 300 participants) (Szanton SL, et al., 2019). This shows that keeping an older adult safely at home cannot rely on care from others alone, and also needs evidence-based methods to improve their self-care ability.
Population ageing in Hong Kong and the policy of ageing at home
Hong Kong's population is ageing quickly. The policy direction of the Government and the Social Welfare Department is to help older adults live in a familiar community and at home for as long as possible, with institutional care as back-up rather than the first choice. This means that the ability to look after oneself will increasingly decide the quality of later life.
With the older population almost doubling in a little over twenty years, society cannot, and should not, send every older adult who needs care to a care home. Whether an older adult can manage safely at home therefore directly decides whether they can age at home as they wish.
What are activities of daily living (ADL)? BADL and IADL
Activities of daily living (ADL) are the self-care activities needed to maintain a person's basic life. Clinically they fall into two groups: basic activities of daily living (BADL), which are needed for basic survival, and instrumental activities of daily living (IADL), which are needed for independent living at home. Both affect whether an older adult can live independently at home.
Basic activities of daily living (BADL)
- Bathing: cleaning every part of the body safely
- Dressing: choosing suitable clothes, and putting them on and taking them off alone
- Toileting: getting to the toilet and cleaning oneself
- Eating: using utensils to bring food to the mouth
- Transfers: moving safely between bed, chair, wheelchair and toilet
Instrumental activities of daily living (IADL)
- Housework: cleaning, tidying and looking after the home
- Shopping: planning what to buy and buying daily necessities alone
- Medication management: taking medicines on time and correctly, and managing everyday medicines
- Managing money: handling daily spending and paying bills
The six basic items (Katz index)
One of the tools most often used to assess basic self-care objectively is the Katz ADL index. It divides basic self-care into the following six items and assesses whether the patient can do each one independently (Katz S, et al., 1963).
Why dependence in ADL is a warning sign for care home admission, falls and depression
ADL disability is more than an inconvenience. When an older adult can no longer manage basic self-care alone, it often sets off a chain of problems: a higher risk of falls, a greater chance of admission to a care home, and effects on mental health and even life expectancy. A decline in self-care ability is therefore a warning sign that calls for early intervention, and it should not be accepted as a natural part of getting old.
ABLE is a home-visit programme that combines occupational therapy, physiotherapy and home modification to deal with older adults' difficulties in daily self-care. Research found that the programme not only reduced difficulty in daily activities but was also linked to lower mortality: the two-year mortality was 5.6% in older adults who received the service and 13.2% in the control group (P=.020; 319 participants aged 70 and over) (Gitlin LN, et al., 2009). In addition, a long-term follow-up study found that loss of daily self-care ability (ADL and IADL disability) and depressive mood influence each other and make the situation worse, and that the immediate effect of losing self-care ability on depressive mood is especially marked (Ormel J, et al., 2002).
These studies carry an important message. Helping an older adult regain self-care does far more than reduce the carer's workload. It affects whether the older adult can stay safely at home, keep good mental health and even live longer. This is the real value of ADL training.
How occupational therapy helps older adults regain self-care
Occupational therapists do not work on muscle strength in the abstract. They work on specific daily tasks. Their core method is to break down activities such as bathing and dressing, which look simple but are made up of dozens of small steps, find the step where the older adult is stuck, and then add a moderate challenge and suitable help so that the person regains the skill step by step. The training generally follows these steps:
- 1Assessment and task analysisThe daily activity is split into small steps to see where the older adult has difficulty, for example whether it is weak hands, poor balance, poor memory or difficulty planning the movement.
- 2A suitable challenge, graded up graduallyThe practice is set at a level the older adult can manage with some effort, and the difficulty is then raised step by step.
- 3Choosing between restoring the ability and compensatingThe therapist assesses whether to train the older adult to regain the original ability, or to use other methods and tools to complete the task.
- 4Adding aids and changing the environmentSuitable aids are added and the places in the home where accidents are likely are modified, so that the older adult can look after themselves with the abilities they have.
- 5Fitting practice into real lifeThe older adult practises repeatedly in their own bathroom and kitchen, so that the skills learned can be used in daily life.
Research found that practising meaningful daily activities directly works much better than simple repetitive exercise. In a randomised controlled trial, the group that practised daily activities improved much more in daily performance and satisfaction than the group that did repetitive exercise only (COPM performance 4.7 vs 2.1, satisfaction 5.3 vs 2.6, P<0.001; 36 participants) (Rostami HR, et al., 2017). In other words, practising real-life tasks directly is itself an effective form of training.
Restoring the original ability and compensatory strategies compared
During training, the therapist keeps weighing whether to help the older adult regain the original ability or to change the method and work around the obstacle. Each approach has its strengths, and in practice they are often combined flexibly.
- Aim: restore the damaged physical or cognitive function through training
- Suits patients with a higher potential for recovery, in the early to middle stage of rehabilitation
- Example: retraining dressing, grip strength and balance after fracture surgery
- Building practice into real tasks works better than abstract drills (Rostami HR, et al., 2017)
- Aim: work around the obstacle with substitute methods, aids or changes to the environment
- Suits situations where function is unlikely to recover fully, or self-care needs to be restored immediately
- Example: one-handed dressing techniques, a long-handled shoe horn, a shower chair
- Older adults who use assistive technology have fewer unmet care needs (Agree EM & Freedman VA, 2003)
Practice techniques for four daily self-care activities
The most important daily routines to put into practice are dressing, bathing, eating and toileting. The following are techniques and safety points that occupational therapists commonly use for these four activities.
Dressing training
Putting on a top
- Choose clothes that open at the front and are loosely cut
- Put the weaker arm into its sleeve first
- Pull the garment over the head, or round the back
- Put the stronger arm into its sleeve last
Putting on lower-body clothing
- Once seated securely, place the weaker leg over the knee of the good leg
- Put the trouser leg over the weaker leg first, then the good leg
- Stand up, or lie on one side, to pull the trousers up
- Velcro can replace ordinary buttons to make dressing easier
The basic rule of dressing is "weaker side in first, stronger side out first". When putting clothes on, the weaker side goes in first. When taking clothes off, the stronger side comes out first. This reduces pulling on the weak arm or leg and makes dressing and undressing safer and smoother.
Bathing training (preventing falls)
The bathroom is a high-risk place for falls in older adults. A wet floor combined with unsteady standing can easily cause a serious accident. Safety measures and assistive equipment therefore need to be used together.
Safety measures
- Install grab rails on the bathroom walls
- Put a non-slip mat or non-slip strips on the floor
- Keep the room well lit
- Clear clutter and obstacles from the floor
Assistive equipment
- Use a shower chair or bath board
- Hand-held shower head
- Long-handled bath brush
- Bath transfer bench
Eating training
Eating training is not only about getting food to the mouth. It also covers adjusting the sitting posture and using adapted utensils, so that older adults who have the use of only one hand, or who have weak hands, can still eat on their own safely and with dignity.
Correct eating posture
- Sit with the back upright and both feet flat on the floor
- Keep the table at a suitable height
- Place the food within the older adult's sight and reach
- Reduce distractions so that the older adult can concentrate on eating
Adapted utensils
- Utensils with thicker handles are easier to grip firmly
- Use a curved-handle spoon (angled spoon)
- Use a non-slip mat to hold bowls and plates in place
- Use a plate with a raised edge to stop food being pushed off
Toileting training
Toileting involves several changes of position and removing and replacing clothing, and every step carries a risk of falling. The occupational therapist breaks the whole process into steps, guides the older adult through them one at a time, and adapts the environment for safety.
- 1Safe transferSitting down safely on the toilet from a wheelchair or from standing.
- 2Managing clothingTaking down and putting back on trousers safely.
- 3HygieneCleaning oneself after using the toilet to keep personal hygiene.
- 4Leaving safelyStanding up safely and leaving the toilet.
For the environment, toilet grab rails can be installed and a raised toilet seat can be used, and the pathway should be kept clear. These greatly improve safety and independence in toileting.
Self-care aids at a glance
Suitable aids are an important bridge that helps older adults move from being unable to do a task to being able to do it. Research found that older adults who used assistive technology had fewer unmet care needs than those who relied on personal care from others (Agree EM & Freedman VA, 2003). After hip fracture surgery, about half of older adults also need home aids and changes to the environment for rehabilitation (Hagsten B, et al., 2004). Hip replacement is also hip surgery, but the protection principles are different. After a hip replacement, aids for putting on socks, bathing and adjusting toilet height must be chosen according to the angle limits of the hip joint. The following are common self-care aids:
- Long-handled shoe horn—Allows shoes to be put on without bending over, which reduces the risk of falls.
- Button hook—Allows buttons to be done up with one hand, which helps people with weak hands.
- Sock aid—Allows socks to be put on without bending over or gripping hard.
- Shower chair—Lets the older adult sit while showering, which lowers the chance of slipping in the bathroom.
- Thick-handled utensils—Help the older adult hold utensils more steadily and feed themselves more easily.
- Non-slip mat—Holds bowls and plates in place so that the older adult can eat with one hand.
- Toilet grab rails and raised toilet seat—Help the older adult sit down on and stand up from the toilet safely.
ADL training priorities in different situations
ADL training is not one method for every situation. The priorities and strategies differ for older adults who have had a stroke, who have dementia, who have had fracture surgery, or who are generally frail.
How home-visit occupational therapy supports ageing at home
Ageing at home takes place in the older adult's own home, not in a clinic treatment room. Home-visit occupational therapy works well because the therapist can train and modify things directly in the environment where the older adult lives, so that the results of training carry over into daily life.
Training and modifying in the real home
- Practising directly in the older adult's own bathroom, kitchen and bedroom, so that the skills learned can be used in daily life straight away
- Finding and fixing, on site, places in the home where accidents are likely, such as a wet bathroom floor or a threshold that is too high
- Avoiding the situation where the older adult can do a task in the treatment room but not at home
Research evidence for home-visit occupational therapy
- CAPABLE study: a home-visit intervention reduced daily self-care disability (ADL disability) by 30% within 5 months (Szanton SL, et al., 2019)
- ABLE study: reduced difficulty in daily activities and was linked to lower mortality (Gitlin LN, et al., 2009)
- Graff study: home-visit occupational therapy (home OT) clearly improved the daily performance of older adults with dementia (Graff MJL, et al., 2006)
Frequently asked questions
To help an older adult stay safely at home, ADL training often needs to be combined with other support. Family members may also wish to read about how home modification and assistive devices make the home safer, how cognitive training helps keep an older adult's thinking and planning ability, and how healthcare worker services give suitable care support in daily routines.