2.3 Functional (ADL/IADL) & Pain Assessment

Function and pain sit at the center of gerontological assessment because they determine independence, caregiving intensity, rehabilitation potential, and quality of life. GERO-BC Domain I expects you to use structured functional tools and to adapt pain assessment when cognition or communication is impaired.

Functional Assessment: ADLs and IADLs

Katz Index of Independence in ADL

The Katz ADL index evaluates six basic self-care domains:

1. Bathing
2. Dressing
3. Toileting
4. Transferring
5. Continence
6. Feeding

Each activity is typically scored as independent versus dependent (tool versions vary in granularity). Higher independence predicts lower hands-on care needs; dependence in multiple ADLs signals need for substantial caregiver support or facility-level assistance.

Clinical meaning: ADL loss often follows a hierarchical pattern (bathing/dressing commonly decline before feeding), though acute illness can disrupt any domain suddenly. New ADL decline after hospitalization is a red flag for deconditioning, delirium aftermath, uncontrolled pain, or inadequate home support.

Lawton Instrumental ADL (IADL) Scale

The Lawton IADL scale assesses more complex community-living skills, commonly including:

IADLs usually decline before basic ADLs in neurodegenerative disease. An older adult may still dress and feed independently while already failing medications and finances—exactly the profile that needs care coordination, medication management supports, and possible driving/financial safety evaluation.

Implications for Discharge and Safety

Translate scores into concrete plans:

• Independent ADLs + impaired IADLs → consider home health, medication prefill/pharmacy sync, meal services, bill-pay supports, caregiver education, and cognitive evaluation if new.
• Multiple ADL dependencies → assess 24-hour supervision needs, rehab potential, durable medical equipment, and whether home is safe even with caregivers.
• Mismatch between patient report and performance → verify with observation and informants; anosognosia and pride commonly inflate self-report.
• Sudden change from prior baseline → investigate acute medical causes (infection, heart failure, stroke, pain, medication effect) rather than assuming irreversible decline.

Document prior baseline function whenever possible (“two weeks ago shopped and cooked; now needs setup for dressing”). Baseline-to-current comparison drives realistic goals and prevents both under- and over-placement.

Limits of ADL/IADL Tools

Scores summarize capacity or performance but may not capture intermittent risks (night wandering, episodic hypoglycemia). Cultural roles can skew Lawton items historically gendered in older versions—interpret with person-centered context. Functional tools do not replace home safety evaluation, cognitive testing, or caregiver burden assessment.

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Pain Assessment in Older Adults

Pain is common in osteoarthritis, neuropathy, cancer, vertebral compression, and post-acute recovery—yet it is still undertreated, especially in long-term care and in people living with dementia.

Self-Report Approaches (When Communication Allows)

Numeric Rating Scale (NRS): commonly 0–10, with 0 = no pain and 10 = worst imaginable. Simple and useful for trending response to analgesics and nonpharmacologic measures.

Faces Pain Scale–Revised (FPS-R) and similar faces tools: helpful when literacy is limited or when a visual prompt improves understanding. Confirm the person understands that faces represent pain intensity, not mood alone.

Clinical tips for valid self-report:

• Allow extra time; use hearing amplifiers and glasses
• Ask about pain now, with movement, and at its worst/best
• Use the older adult’s preferred words (“aching,” “soreness,” “hurt”)
• Reassess after interventions using the same scale
• Do not assume stoicism or “normal aging” means absence of pain

Self-report remains the gold standard whenever the person can provide it, including many with mild-to-moderate dementia during lucid periods.

Observational Tools for Advanced Dementia

When self-report is unreliable or impossible, use structured observational scales and caregiver input.

PAINAD (Pain Assessment in Advanced Dementia)

PAINAD rates five items, typically 0–2 each (total 0–10):

• Breathing (independent of vocalization)
• Negative vocalization
• Facial expression
• Body language
• Consolability

Higher totals suggest greater pain intensity. PAINAD is designed for advanced dementia and should be paired with a search for likely sources (positioning, infection, fracture, oral pain, constipation, urinary retention, wound care).

Abbey Pain Scale

The Abbey Pain Scale is another observational tool used in advanced dementia/residential care. It scores domains such as vocalization, facial expression, change in body language, behavioral change, physiologic change, and physical changes. Elevated scores cue analgesic trials and nonpharmacologic comfort measures, with reassessment to confirm response.

Under-Recognition of Pain in Cognitively Impaired Older Adults

Pain is systematically under-recognized when clinicians rely only on verbal complaint. Patterns that should raise suspicion include:

1. New or worsened agitation, aggression, or resisting care
2. Facial grimacing, guarding, or braced posture during transfers
3. Decreased appetite, sleep disruption, or withdrawal
4. Sudden ADL decline without clear alternative explanation
5. Calling out, moaning, or restless rocking
6. Tachycardia or hypertension during personal care (nonspecific but supportive)

Hypoactive presentations matter too: quiet immobility is not comfort. Staff may mislabel pain behaviors as “behavioral and psychological symptoms of dementia” and escalate antipsychotics instead of treating pain—an unsafe pattern GERO-BC clinicians should actively prevent.

A Practical Assessment Sequence

1. Ask for self-report using an appropriate scale if any meaningful communication exists.
2. Observe during rest and movement/care.
3. Use PAINAD/Abbey when advanced dementia limits report.
4. Identify likely nociceptive sources with focused exam.
5. Trial comfort measures and appropriate analgesia; reassess with the same tool.
6. Document baseline behaviors so improvements are visible to the whole team.

Pharmacologic choices in older adults require caution (Beers Criteria considerations appear elsewhere in this guide), but assessment comes first: untreated pain worsens delirium risk, immobility, pressure injury risk, and depression.

Integrating Function and Pain

Pain often masquerades as functional loss. Before concluding that an older adult “needs long-term placement,” treat pain, optimize mobility aids, address fear of falling, and reassess Katz/Lawton performance. Likewise, new dependence in dressing or transferring should trigger both functional analysis and a pain/behavior review—especially in dementia.

Exam Focus

Match Katz to basic self-care and Lawton to community/safety skills; use IADL decline as an early signal for supports and cognitive workup. Prefer self-report pain tools when possible; switch to PAINAD/Abbey in advanced dementia; interpret behavior change as possible pain rather than purely “difficult dementia.”