The Instrumental Activity of Daily Living Profile in Aging: A Feasibility Study

Abstract

Background: Dysfunctions in complex activities of daily living (ADLs) are a normal part of the aging process. However, differentiating functional decline associated with healthy aging from the subtle decline experienced by individuals with mild cognitive impairment and early dementia constitutes a challenge. Finding an appropriate tool that can capture these subtle but important functional changes represents a priority.

Objectives: The aims of this study were to evaluate the feasibility of using the Instrumental Activities of Daily Living Profile (IADL Profile) with elderly participants and to describe their level of difficulty encountered in each task.

Methods: The tool was administered to a group of 40 elderly participants living in the community.

Results: The IADL Profile was found to be feasible to use in older individuals; the tool also showed sensitivity to the difficulties experienced by this population in everyday functioning.

Conclusion: The IADL Profile is a promising ecological tool to evaluate independence in aging and may help to identify individuals with MCI. This tool may also contribute to the development of tailored interventions to enhance everyday functioning in the older population.

Keywords

Activities of daily living aging executive functions independence

INTRODUCTION

Decline in functional abilities is part of the normal aging process [1]. While older adults often perform basic everyday tasks independently, they may face challenges when performing complex activities. In fact, a number of studies have shown that the main activities that decline with aging are instrumental activities of daily living (IADL), such as managing finances and medications, preparing meals, and using public transportation [2, 3]. While some individuals will experience the normal decline that accompanies aging, others will suffer from degenerative diseases such as Alzheimer’s disease (AD). In the latter case, the pathological functional decline entails bigger impacts on daily lives [4]. However, the point at which normal functional decline becomes pathological is difficult to determine and no clear criteria have been established. Considering that the distinction between mild cognitive impairment (MCI) and dementia currently rests on the identification of significant impacts on everyday living [4], in combination with other criteria (e.g., neuropsychological performances), it is of utmost importance that functional impairment criteria be clearly defined so that individuals are not misdiagnosed.

Therefore, choosing a measure of everyday functioning that allows to appropriately capture these subtle but important changes in the performance of IADL is crucial. Results in the literature show that performance-based measures can be very sensitive to subtle deficits in IADL performance [5]. In addition, there is growing evidence that the activities which are typically affected in the continuum from normal to pathological cognitive aging depend on the integrity of executive functions (EF) [1 , 6]. EF can be broadly defined as set of processes allowing a person to plan and carry out complex goal-directed behavior [7, 8]. Although IADL performance has been associated with a wide range of cognitive functions, such as processing speed [9] and episodic memory [10, 11], EF emerged as a strong predictor of independence in IADL. More specifically, several EF processes have been found to correlate with IADL performances. In normal aging, measures of mental flexibility [12 –14] and inhibition [15] showed a close correlation with IADL performances. In MCI, problem-solving, self-initiation [16], error detection and self-monitoring [11, 17], as well as executive functions contributing to memory— such as working memory [18], prospective, temporal, and source memories [19]— have been associated with IADL performances. Furthermore, patients with MCI report having difficulties in adapting and coping with situations requiring mental flexibility, self-monitoring, and initiative [20]. Finally, in AD, a meta-analysis confirmed that many EF are associated to performances in IADL, such as working memory, mental control and flexibility [6].

Therefore, tasks used to evaluate the performance of IADL in these populations should comprise characteristics of situations that are known to require the activation of EF. According to the definition of EF presented above, the tasks should have a certain level of complexity (e.g., involve multitasking) or novelty, and the examiner should use an unstructured evaluation approach that permits the observation of the person’s ability to formulate goals, initiate, and plan tasks [21]. More specifically, the idea of an unstructured approach was first introduced by Lezak [22] who argued that, to observe goal formulation and planning abilities, the examiner should not provide the goal or plan to the patient, in contrast with most EF tests. The importance of using an unstructured approach for the evaluation of EF deficits has, since then, been discussed by numerous authors [7 , 23–27]. In fact, certain studies have shown that the evaluation approach should ideally allow for the observation of individuals acting on their own behalf and not simply responding to an examiner’s instructions regarding what to do, how, and when. Shallice & Burgess [24] identified certain limitations in the currently used measures of executive functioning: These assessments generally involve a single task, are strongly initiated by the examiner, take place over a relatively short time interval, and successful trial completion is clearly identified by the examiner. Some studies have shown that more open-ended multiple subgoal situations are more sensitive to the deficits of individuals having sustained a traumatic brain injury, and more representative of real-world functioning, which is inherently unstructured [23, 24]. This type of approach would allow the observation of some of the most important facets of EF. In fact, Lezak [22] proposes that “the more open-ended and unstructured the task, the more likely will impairments in programming become evident (p. 290)”. Considering the importance of EF deficits in the aging process, MCI, and AD, this unstructured approach seems highly relevant to detect very subtle difficulties in theses populations as well.

Finally, real-world assessments, that is, per-formance-based assessments conducted in the person’s home and community environment, are increasingly considered as the optimal approach to document the impact of neuropsychological deficits on daily living [28 –30]. In fact, Goel and collaborators [31] argued that real-world situations are invariably ill-structured problems, a term with a similar definition to the unstructured situations defined by Lezak [22]. One such example is a situation where someone is asked to design a toy airplane without any specification regarding the initial state (e.g., should it be made of wood, steel, cardboard?), the desired state (e.g., size, color, should it fly?), or the transformation process (e.g., how should it be made? By folding paper? Cutting cardboard?). Before an ill-structured problem can be solved, it must first be structured. Their results indicate that individuals with frontal lobe lesions spend a significant amount of time trying to structure the problem, leaving little time to solve the problem. They also present with judgment impairments; for example, it is difficult for them to determine whether their response is correct or not (or to identify a feedback measure) in situations that are not associated with a right or wrong answer, but with better or worse responses or strategies. It has also been observed that individuals with frontal lobe lesions may decide too quickly that they have arrived at a correct solution, even though, in reality, their responses are incorrect [31].

Considering the points presented above, most performance-based tests used in the older population to assess IADL performance, such as the Assessment of Motor and Process Skills - AMPS [32], Timed IADL [33], FUnctional Cognitive Assessment Scale - FUCAS [34], Direct Assessment of Functional Status - DAFS [35, 36] or Naturalistic Action Test [37, 38], present some limitations. Although they can be administered in a short period of time, many include IADL activities with low levels of difficulty. Also, they are based on a very structured approach, as several of the tasks’ essential steps, such as the formulation of goals and planning, are already established before the beginning of the task. Also, these tasks are generally not performed in the person’s home and community environment.

However, there is one tool that shows great promise in addressing these gaps: The Instrumental Activity of Daily Living Profile (IADL Profile) [21 , 39–42]. The IADL Profile is a performance-based measure of independence in complex everyday activities. This tool is administered in the person’s home and community environment and aims to establish whether the subject’s main difficulties in everyday life pertain to EF deficits [21]. Briefly, it involves ill-structured problems and an unstructured approach throughout the administration of the test; the participants are asked to simultaneously plan the full series of embedded tasks necessary to attain a complex goal such as hosting a meal for unexpected guests, without being told when or how to do the tasks. Two other tasks, namely obtaining the daily bus schedule for a long-distance trip between two large urban cities and making an annual budget, are also tested. Tasks are scored on the basis of four cognitive operations related to EF: Ability to formulate the goal, plan the task, execute it, and verify the attainment of the goal. For each operation, the person’s independence level is scored on a five-level ordinal scale ranging from dependent (score of 0) to independent without difficulty (score of 4). In addition to the independence score, this test allows clinicians to understand the types of errors committed by the individual, the type and amount of cues required to perform the task, any self-generated strategies, and the time needed to complete the task.

While this tool has demonstrated excellent psychometric properties and has been extensively used and studied with patients with traumatic brain injury [21 , 39–42], its validity for the geriatric population has yet to be established. Studies are also needed to identify specific parameters related to the normal aging population, upon which to compare the patients’ behaviors. These comparison parameters— for example, the number and types of assistance required, the number and types of errors or strategies put in place by the person to overcome a difficulty— will help to clarify reference points related to the level of independence, i.e., what is expected in IADL functioning from people with normal cognitive aging versus those with impaired cognitive functions.

Thus, the broader goal of our current line of research is to determine the sensitivity of the IADL Profile in detecting MCI and dementia, according to these parameters. However, as a first step toward this broader goal, the primary aim of the present study was to evaluate the feasibility of using the IADL Profile in a community-dwelling aging population, in order to obtain comparison parameters in terms of participants’ and evaluator’s burden. The secondary aim of this research was to describe the level of difficulty encountered by these participants in each task in order to clarify which difficulties can be considered as “normal” and, ultimately, to establish criteria that help to discriminate between normal agingand MCI.

MATERIALS AND METHODS

Participants

A group of 40 elderly aged 65 years and over and living in the community took part in the study (see Table 1). The inclusion criteria were: 1) score within the normal range on both the Mini-Mental State Examination (MMSE; cut-off of 26/30) [43, 44] and the Dementia Rating Scale (norms established according to the participant’s age and level of education) [45, 46]. Both tests are designed to detect dementia (tests to detect MCI were not used considering that this was a feasibility study); 2) French as first language, 3) No self-reported functional difficulties. The exclusion criteria were: 1) presence of a health condition that affects cognitive functioning, 2) presence of a psychiatric illness, and 3) history of drug or alcohol abuse.

Recruitment

Participants were recruited from a list of subjects who had previously consented to participate in various research projects. This project was authorized by the ethics committee of the Health and Social Services Centre –University Institute of Geriatrics of Sherbrooke (CSSS-IUGS) and the research center of the Institut universitaire de gériatrie de Montréal (CRIUGM). All participants gave their written consent.

Administration

The evaluators were trained for two periods of 3 hours in administering the tool. The evaluators also practiced task analysis and scoring via videotaped administrations of the tool prior to commencing the study. In addition, they received feedback from experienced evaluators (N.B. and C.B.) during their first evaluation. Particular emphasis was given to the analysis and scoring of behaviors according to the tool’s underlying four task-related operations. Guidelines for administering the tool are available in published articles [21 , 39–42].

More specifically, examiners were instructed, overall, to avoid intervening so as to have the opportunity to observe how the participant was able to think on his own throughout the tasks. Also, examiners were informed to give the participant extra time, when needed, to detect and correct errors on his own. They were informed that overly rapid interventions provided by the examiner may lead to overestimation of the person’s actual needs for assistance in everyday activities. Training sessions on the IADL Profile included information on factors (e.g., fatigue, anxiety) that may signal a need for assistance. Examiners were also trained to provide assistance in a graded fashion, i.e., by starting with a series of implicit cues prior to giving more explicit cues.

Data collection

Six evaluators administered the IADL Profile to participants. Evaluations were filmed and later transcribed verbatim. In brief, participants were told that they had to host a meal for unexpected guests and that they were given 20$ to cover the costs. This led to the observation of a series of six interrelated tasks that needed to be performed to reach the overarching goal (dressing to go outdoors, going to the grocery store, shopping for groceries, preparing a hot meal for guests, having the meal with guests, and cleaning up after the meal). In another task, participants were asked to find the complete list of departure times for a long-distance bus trip between two large urban cities (obtaining information task). Finally, in the last task, participants were asked to prepare an annual budget within which they needed to plan the purchase of a car in the coming year (making a budget task). No information was given on how to achieve the tasks and no material was provided, except for the problem sheet in the budgeting task.

For all tasks, when subjects were deemed unable to pursue a task operation, they were given graded assistance. Their performance was scored on the following 5-level ordinal scale of independence: 0 –dependence, 1 –requires verbal and physical assistance, 2 –requires verbal or physical assistance, 3–independence, but with difficulty, 4 –independence, without difficulty.

The information concerning the feasibility of the tool (participants’ and evaluators’ burden) was collected by the six evaluators through semi-structured interviews and from the results obtained in the IADL Profile test. Information on feasibility was categorized according to two criteria [47]: 1) the impact of the administration of the tool on participant’s burden (administration time and participant’s reactions to the tool) and the impact on evaluator’s burden (administration time, simplicity of administration, simplicity of scoring, complexity of training, quality ofinstructions).

The IADL Profile has shown good psychometric properties in populations with head injuries. More specifically, some essential psychometric properties of this tool have been established in a study involving 100 individuals with moderate or severe traumatic brain injury (TBI): Content validity, reliability, factorial validity and criterion-related validity with indices of injury severity, sociodemographic characteristics, and measures of EF. In particular, its high reliability was evidenced by the excellent generalizability coefficients obtained for all factor scores [41]. Exploratory and confirmatory factor analyses (n = 100) showed that six correlated factors underlied the structure of the tool (going to the grocery store/shopping for groceries, having a meal/cleaning up, putting on outdoor clothing, obtaining information, making a budget, and preparing a hot meal for unexpected guests) [42]. Results of the multiple stepwise regressions provided new insights into the variables that best accounted for the cross-sectional variance in independence in IADLs. Altogether, 28% of the variance in IADL independence, as measured by the IADL Profile total score, could be accounted for by scores on post-traumatic amnesia and working memory. The size and direction of the relationships suggested that individuals with a lesser IADL independence had a more severe TBI, as indicated by longer post-traumatic amnesia and poorer working memory.

Data analysis

First, data regarding the feasibility were extracted from the transcribed verbatims of each participant’s evaluation and from semi-structured interviews with the evaluators. Second, to evaluate the level of difficulty encountered by participants in the performance of each task, Friedman’s ANOVA for repeated measures, Wilcoxon sign rank tests, Spearman’s correlations, and Mann-Whitney U tests were used. Qualitative descriptions of the principal task-related difficulties incurred by participants during task performance were also noted. These difficulties were identified based on the core elements involved in each operation of the tool [42]: (1) formulating goal: Participant expresses a solution to satisfy a need or solve a problematic situation; (2) planning: Participant thinks about the initial conditions before acting, i.e., identifies alternatives, chooses the most adequate alternatives, elaborates a general strategic and tacticalaction plan (sequence of actions or steps); (3) carrying out: Participant initiates his action plan; carries out the plan of action while adapting to errors or novel situations; perceives errors in planning (time and space estimation errors) and execution (manipulation errors, tool selection errors); adjusts actions in relation to perceived errors and new or unforeseen situations; and (4) verifying attainment of the goal: Participant completes the tasks having considered all initial conditions; verifies that the task initially planned was carried out; compares the final result to the initial goal; accepts or rejects the result; ends the task or starts the process again when the result is not attained.

RESULTS

Primary aim: Feasibility criteria

Participants’ burden

The total time required to administer the tool was approximately 3 hours (mean time: 3 hours and 4 minutes±31 minutes; range 1 h 52 min–3 h 59 min). The duration of the evaluation depended on the speed at which tasks were performed, on the degree of complexity of the meal that the participant decided to prepare, and on the discussions held between the participant and the evaluator. No participants reported fatigue, but some showed signs of irritations during the obtaining information task when they had difficulty in completing it. None of the participants reported being bothered by the fact that they were evaluated in their home and community environments. Many even mentioned having appreciated being evaluated at home and found it reassuring considering the stress associated with usual evaluation procedures.

Evaluators’ burden

Simplicity of administration

The most challenging aspect of the administration of the tool was related to the offer of assistance. More specifically, the evaluators had difficulty deciding whether the errors made by participants were significant enough to warrant a correction or an offer of assistance. This was particularly true for the budget and obtaining information tasks, in which greater verbal assistance could have been provided based on the type and number of errors observed in thesetasks.

Simplicity of scoring

The evaluators required support when evaluating their first participants in order to ensure that the scoring system and graded offer of assistance had been well understood and that they would be properly applied.

Quality of instructions

When offered a 20$ compensation to prepare a meal, a number of participants failed to understand that the implicit request was to shop for groceries. A number of participants also failed to understand that the complete list of bus departures was requested in the obtaining information task.

Secondary aim: Level of difficulty

Quantitative data on performance assessment

The median scores obtained for all tasks indicate that participants were generally “independent, but with difficulty” (score 3/4). The type of tasks had a significant effect on participants’ level of independence (χ² = 154.95, p < 0.001). More difficulties were observed for going to the grocery store, shopping for groceries, in the budgeting task, and in the obtaining information task (Wilcoxon sang rank tests, all p values < 0.001). Lower scores, representing increased task difficulty, were obtained for the budgeting and the obtaining information tasks. For all tasks, there were no differences between men’s and women’s performances (all p values > 0.28).

For the 6 tasks related to hosting a meal, the most difficult operations were formulating the goal (all p values < 0.001) and planning (all p values < 0.003) (see Fig. 1). For the budgeting and obtaining information tasks, there were no differences between the operations (all p values > 0.21) (see Fig. 2), which seemed to present the same level of complexity.

Correlations between performance in the most difficult tasks and socio-demographic data (age, education, DRS) were assessed using Spearman’s correlations (Table 2). There were no significant correlations between sociodemographic factors and performance in the grocery shopping task. Participants with higher levels of education, however, performed better at obtaining information, making a budget, and going to the grocery store. The performance in budget preparation was also significantly correlated with age (younger participants performed better) and global cognitive functioning.

Difficulties and errors

Preparing a meal for guests

The main difficulty observed during the six interrelated tasks needed for the preparation of a meal for unexpected guests was to formulate the goal of going to the grocery store, as 24 participants required verbal assistance for this operation. Of these, 14 initially insisted on using food in their pantry and four had difficulty adapting to the idea of going shopping on a day that was not their usual shopping day.

Obtaining information

In this task, several persons failed to understand that all daily bus departures were required to attain the task goal; eight participants only gave a single departure time and five suggested only a few of them, without giving the complete list. Also, nine of the 13 participants who decided to look for the information on the Internet (rather than using directory assistance) had difficulty finding their way on the web.

Making an annual budget

Concerning the budgeting task, the majority of participants (34 of 40 participants) forgot necessary expenses during their planning and made calculation errors or errors in cost estimates (21 participants).

DISCUSSION

The aim of this study was to explore the feasibility of using the IADL Profile [21] in a healthy aging population; in particular, the participant’s and evaluator’s burdens were evaluated (objective 1), as well as the level of difficulty encountered by participants in each task included in the tool (objective 2). Globally, the results showed that elderly persons adapt well to the tool’s unstructured approach and that theadministration of the tool in their home and community (which forms part of participant’s burden) is possible. As for the examiner’s burden, the offer of graded assistance proved to be the greatest challenges. Community-dwelling elderly persons generally performed well in tasks related to hosting a meal for unexpected guests but showed some difficulties when obtaining information and making a budget. Difficulties were documented in all cognitive operations related to EF; for example, some participants were unable to adapt to the idea of going shopping on a day that was not their usual shopping day (formulating goal); in the budget task, they sometimes forgot to plan (planning) necessary expenses or made calculation errors (carrying out); in the obtaining information task (daily bus schedule), some participants did not verify if they were giving all departure times to the examiner (verifying attainment of the goal).

When considering the participants’ burden (objective 1), the IADL Profile is longer to administer than several other assessments currently being used with an elderly clientele. However, the three-hour duration of the test allows the examiner to document, in addition to previously reported components, frequently unnoticed difficulties related to the effect of fatigue on a person’s functioning throughout a typical day [28]. Apart from reflecting a typical day in a person’s life, the duration of the test also allows to obtain information on all types of cues that may facilitate performance and that can be taught to the family [48]. Because it allows for the observation of the person’s performances in many different situations, spontaneously generated strategies can also be identified [49]; moreover, the influence of various environmental variables can be observed. Finally, considering that the usage of the tool with the geriatric clientele is still in its infancy, it seems important to first identify all important parameters related to the aging population. Therefore, using only some of the tasks to shorten the tool (e.g., only the budget task), could limit the possibility to identify subtle difficulties that may arise in some tasks but not in others. Also, using many tasks avoids a possible floor or ceiling effect and gives a more complete profile of the individual being evaluated.

The implicit request to shop for groceries at a time that is potentially outside of a person’s normal routine may be considered as a novel situation for elderly participants and can reveal task-related EF deficits. In comparison, other observation-based tools tend to encourage a degree of familiarity with the task before the evaluation, or they evaluate a single task at a time [32 , 51]; yet, these testing strategies do not allow for the creation of contexts that require participants to use EF. Finally, although the evaluation may seem lengthy at first, it is worth nothing that the functional profile is considered an essential part of the dementia diagnosis; in this case, a complete and rigorous evaluation— rather than a rapid performance-based screening— should be conducted to highlight difficulties experienced in everyday activities. It should also be noted that screening may lack sensitivity in detecting subtle difficulties in everyday functioning that may differentiate subgroups within the dementia continuum [5].

Results of this study also showed that it was feasible to evaluate the elderly clientele in their daily environment and within their community. Evaluation in people’s home has previously been shown to be desirable with elderly clients and studies suggest that independence in IADL is best understood in real-world contexts [28], even more so when older adults present with EF deficits [30]. Furthermore, older persons tend to inaccurately report their ability to perform IADL [52] and this is exacerbated by EF deficits [53]. Therefore, a real-word assessment, instead of a self-reported questionnaire, may be more representative of the impacts of cognitive deficits in everyday activities [5]. Finally, despite the fact that the majority of tasks evaluated by the IADL Profile are connected to meal preparation, the results of our study showed that there was no difference between genders. Similar results were obtained in persons with TBI [39], suggesting that this test is appropriate for both men and women and that women are not advantaged by the proposed evaluation context. As for correlations with other socio-demographic characteristics, the task “making a budget” was the one that showed more correlations. In fact, younger participants with better general cognitive functioning and more education performed better in this task. Our results are in line with those observed in the TBI population [39], suggesting that socio-demographic characteristics influence independence levels measured with tools like the IADL Profile.

Regarding the evaluator’s burden (objective 1) and the observed difficulties related to the graded offer of verbal assistance, it will be important, in future studies, to further our understanding of ADL errors; the errors that clinicians consider as being “normal” and those considered as atypical and requiring the examiner’s intervention need to be clarified. Initial studies have shown that clinicians accurately discriminate only about 55% of EF-type errors in everyday activities made by individuals with neurological impairments [54, 55]. These results suggest that there is a need for investigation to help clinicians be able to better identify situations where verbal assistance should in fact be provided, more importantly in the dementia continuum.

Finally, elderly persons living in the community showed difficulties while performing the test (objective 2). This suggests, in accordance with other studies [37], that errors in IADL are part of the aging process. More specifically, results suggest that almost all participants showed minor difficulties that can be related to EF task-related components. These difficulties may only be revealed, at present, in more complex tasks like shopping, making a budget, and obtaining information, and more specifically while formulating the goal and planning the different steps. These results are in line with the existing literature which emphasizes that these tasks are among the most difficult for the normal elderly [2] and among the first affected in persons with AD [56]. It is worth noting that few ADL tests include the combination of a context that breaks the usual routine and components such as goal formulation and planning of a set of complex or interrelated tasks like those proposed in the IADL Profile. Elderly participants were very sensitive to these aspects of the test; the difficulties that they encountered could go unnoticed if another evaluation— simpler and more structured (e.g., an evaluation limited to the evaluation of the execution of a task)— had been used, as it is often the case during an evaluation based on short observations [55]. Nonetheless, additional studies, involving a large sample of normal participants, as well as participants with cognitive deficits (subjective cognitive impairments, MCI, and dementia), need to be conducted in order to confirm that there are no ceiling or floor effects with the test and, consequently, that different levels of difficulties can be identified for each subgroup.

It is important to note that this feasibility study is a first step toward the validation of this tool in cognitive aging and that other studies are required to complete the validation process. Further studies should focus on recruiting different subgroups of participants to assess the sensitivity and specificity of the tool; more complete neuropsychological evaluations would also be required to specifically screen for MCI or dementia. Finally, future studies could identify the leverages and obstacles to the implementation of this tool in clinical practice.

In conclusion, the IADL Profile is a promising tool to evaluate the impact of cognitive deficits in aging, as this tool considers crucial elements related to independence and offers an unstructured approach that has the unique potential to better evaluate the impacts of cognitive deficits on everyday living.

Footnotes

ACKNOWLEDGMENTS

NB is supported by the Fonds de la recherche du Québec –Santé (Canada). EM is funded by the Alzheimer’s Association (USA) and the Alzheimer’s Society (UK).

Authors’ disclosures available online ().

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