Activities of Daily Living: Signs of Decline in Aging Adults

A decline in the ability to complete activities of daily living is a sign that an aging adult may benefit from assistance to support well-being and safety.  Activities of daily living are tasks that most of us complete each day with ease.  For example, eating or taking a shower. As we age, the ability to complete activities of daily living may become more difficult and affect our ability to live independently. Struggling to perform activities of daily living confirms a need for assistance.

The term, activities of daily living, is most often used in the healthcare industry. The term is specific to qualifications for treatment approved provided by Medicare, other types of health insurance, and long-term care insurance. Activities of daily living are discussed when determining if an aging adult is safe to remain living at home.

Activities of daily living are described as bathing, continence, dressing, eating, toileting, and transferring. Beyond these measurements are instrumental activities of daily living that include the ability to manage money, organize and take medications, make phone calls, set appointments and other secondary type activities.

Caregiving Conversations

If you notice declines in activities of daily living, now is the time to have a caregiving conversation with a spouse, aging parent, grandparent, or loved one. Having this conversation may be intimidating and a task you would rather avoid. Have the conversation.

A caregiving conversation is not a shaming conversation. A conversation starter is, “mom I’m noticing that you seem to be having more difficulty with X, what can we do to make this easier for you?”

The goal of the caregiving conversation is not to embarrass but to be supportive to identify solutions. More than often the response will be, “I’m okay. I don’t need any help.” This is what I call the broken record response. None of us wants to admit that it is more difficult to complete tasks we used to complete with ease.  Parents or a spouse do not want anyone thinking less of their abilities.

The caregiving conversation must be held with extreme patience to support dignity and be filled with empathy. Statements like, “I know it must be frustrating that X is happening. It’s going to be the same with me someday. Let’s figure this out together.”

If the caregiving conversation does not go well the first time, agree to have the conversation another day and then follow through. Because there is a concern about well-being and safety this is not a conversation to sweep under the rug until an accident occurs. Your parent our spouse must know that this is serious and that you will continue to re-approach the subject until a willing conversation occurs and solutions are identified.

10 Tips to Noticing Signs of Decline in Activities of Daily Living

1 Bathing and General Hygiene.

Are you noticing a body odor, soiled clothing or dirty hair? A lack of keeping up with regular hygiene confirms that difficulties exist. Are fingernails clean, is skin hydrated and in good condition, are toenails trimmed? Aging adults have difficulty bending over. Many are unable to reach their feet to trim toenails or apply lotion. Many options exist to improve bathroom safety.

2 Urine or Bowel Incontinence.

This is one of the most embarrassing subjects to discuss with an aging parent or a spouse. Signs of urine or bowel incontinence include poor hygiene, an odor, and concerns about going out in public for a lengthy period of time due to the possibility of having an accident. Are you noticing underwear hanging in the bathroom to dry?  Is there a urine smell in the bathroom or in the home?

Frequent falls or mental disorientation may also be a sign of a urinary tract infection. Urinary tract infections are common with persons diagnosed with dementia.

3 Dressing.

The ability to dress, change clothing, and take an interest in how we appear can become more difficult with a physical disability. Interest in maintaining positive self-esteem may also be a sign of depression (see # 10 below).

Lifting a shirt over the head may be difficult due to shoulder pain. Buttoning buttons may become impossible due to arthritis in the hands and fingers. Zippers may be difficult due to poor grip or hand dexterity. Bending over may result in dizziness.  Placing shoes—other than slip-on—closing Velcro tabs or tying shoelaces may be impossible because of a lack of flexibility to bend over.

A related task is ensuring that one has clean clothing and linens. Is your loved one able to remove and replace sheets and pillowcases on the bed and complete laundry? If the laundry room is in the basement, walking up and down stairs safely may be a concern.

Aids exist to help with dressing and placing shoes. Moving the laundry to the main level is a good idea if possible. When these tasks become more challenging, consider hiring in-home caregivers to visit once or twice weekly to provide hands-on support.

4 Poor Nutrition and Weight Loss.

Does, “I’m just not hungry,” sound familiar? As we age the body’s digestive system becomes less efficient. Foods are more difficult to digest. Taking medications stresses the liver that serves to detoxify the body. Poor digestion or frequent indigestion affects the desire to eat.

Because older adults are less active fewer calories are needed to fuel the body. The senses of taste and smell weaken. Weight loss occurs. There may be an inability to lift pots and pans to cook, to use the stove, or a microwave. Options exist for meal delivery to the home or family members bringing pre-made meals or left-overs to reheat.

To maintain well-being the body must be in a mode of thriving versus a mode of “failure to thrive”.  Failure to thrive is a medical term that describes a state of weight loss, decreased appetite, poor nutrition, and inactivity. Conditions associated with failure to thrive are dehydration, depression, and low immune system functioning; meaning a person is more easily susceptible to colds and viruses.

Failure to thrive is a serious concern for which the root causes must be investigated. Depression related to the losses of aging may be playing a part in the bigger picture of poor nutrition and weight loss.

Solutions?  Visit a doctor for a full physical and describe the concerns. Make certain that a family member attends the appointment to relay concerns.

Be willing to take depression medications to resolve symptoms. There are also appetite stimulants that may be provided to re-stimulate the appetite. Probiotic digestive enzymes may be another solution.

5 Mobility, Standing, Toileting, and Transferring.

Challenges with mobility as the result of physical weakness and disability are the beginning of a slippery slope to further decline. The ability to walk and balance are extremely important skills to maintain independence.

When walking up and down stairs takes effort, walking distances us exhausting, holding onto furniture supports balance, multiple attempts occur to stand from a seated position, and uneven walking occurs, these events indicate significant risk for a fall. Falls sometimes result in nursing home placements. 

Make a doctor appointment with mention of these concerns to request a physical therapy evaluation. A physical therapist will provide exercises to support strength, balance, and walking. An occupational evaluation may also be included to provide support with dressing and bathing tips. Both physical and occupational therapist are able to recommend safety devices for the home like sock grippers, raised toilet seats, hand-held shower heads, and others.

Encouraging a loved one to be as active as possible is good. If caregivers have time, a daily walk is an ideal way to spend time with a loved one to support physical strength and balance. The exercise is also beneficial for the caregiver. 

6 Chronic Medical Conditions.

As we age, we are more likely to have one or more chronic health conditions like high blood pressure, cardiac concerns, arthritis, diabetes, or breathing difficulties. The greater the number of conditions the more difficult it is to manage medical care. Multiple medications may also be prescribed that require management.

Scheduling and attending medical appointments can become challenging especially if driving skills are less than ideal. Being attentive at medical appointments, receiving, and following through on recommendations may be a challenge. It may be time, for family caregivers to begin attending medical appointments with a loved one.

7 Difficulty Managing Medications.

Common observations that should cause concern are prescriptions not filled on time and taken as scheduled.  Pick up a medication bottle and look at the date.  Was the medication filled in the last 30 days? Open the lid. How many pills are inside? Is there a daily system for setting out and taking medications?

Not filling, forgetting to take medications, taking medications incorrectly, or sharing medications with others for whom the medication is not prescribed are serious and common concerns for aging adults. Taking medications not according to the directions, or not at all are in the top 10 reasons aging adults are sent to the emergency room.

If you notice problems, develop a system to ensure that medications are picked up and organized. Then ensure medications are taken according to directions. Questions about the best time of day to take medications? Consult with the pharmacist.

8 Difficulty Paying Bills and General Disorganization.

When you visit, what do you see? Unopened mail? Stacks of paperwork everywhere? Past due bill payment notices? Sticky notes and reminders? Difficulty paying bills, managing finances, and maintaining an organized home (unless this was a lifelong habit) are early signs of dementia.

All of the above tasks may result in difficulty as a result of memory loss. Seek an evaluation from a medical professional for memory loss and attend the appointment. 50% of older adults with dementia are undiagnosed. Physicians strongly rely on reports from family members to diagnose as the aging adult may be an unreliable reporter.

9 Forgetfulness That Becomes a Pattern.

We all forget information and lose keys every now and then. Forgetfulness that becomes a pattern is more serious. Are telephone calls and conversations forgotten? Does your loved one call multiple times in the same day asking the same question? Are stories repeated? Is regularly used information like a name or phone number forgotten?

Schedule an appointment with a physician for a memory evaluation. Have a family member attend to provide additional background. If a primary care physician is not skilled in diagnosing dementia request a referral to a neurologist and a neuropsychologist for the best results.

Ongoing testing should occur every 6-12 months to determine the level of decline. Medications to slow memory loss exists and should be considered as some offer benefits to support physical coordination which is a function of brain activity.

10 Depression.

Changes associated with aging require above average coping skills. Placing changes into context and into perspective may become difficult when it seems like life may be crashing down. Losing friends, experiencing changing routines, and missing the good old days become more common.

While having an occasional bad day happens to all of us, a regular pattern of feeling down may be more serious. Depression results in poor sleep, a decreased appetite, weight loss, talk about not wanting to be around anymore and about the worth of life.

An evaluation to evaluate depression is a good idea. The caveat is that most aging adults view depression as an embarrassment. More than likely denial will occur about daily activities and feelings. Again, in this situation, it is important for a family member to attend to provide a realistic picture of daily activities and feelings.

Worst case if a depression medication is tried and no improvement results, either the wrong medication was chosen and needs to be adjusted or improvement occurs. Try medication and see what happens.

Be Open to Change

Being open to change is the solution to managing the declines that occur as the result of challenges in completing activities of daily living. Change may be viewed as a negative. Too much effort. “I’m fine the way I am.” “Why should I change?” Encourage your loved one about the importance of change to avoid the present situation worsening.

Discuss the consequences of not being able to remain at home unless one is able to manage. Consider in-home caregivers to help and provide encouragement for activities. Discuss moving to a retirement community.  Talk about the end of life. Have the caregiving conversation about ways to prevent a move from the home. Talk now to avoid crises later.

2018 Pamela D. Wilson, All Rights Reserved.

Pamela D. Wilson, MS, BS/BA, CG, CSA, is a national caregiving thought leader, caregiving expert, advocate, and speaker offering online support and programs for caregivers seeking support and advice for the care of aging parents, spouses, and other family members. Pamela supports adults, age 50+, with positive aging advice and online programs to advance health literacy and self-advocacy. Collaboration with professionals in the specialty areas of estate planning, elder law, and probate, financial planning, and healthcare raises awareness of and sensitivity to stressful family caregiving and healthcare issues.