A Closer Look at Occupations: ADLs—What does that mean?
Mindmap of the 4th edition of the OT Practice Framework from AOTA’s categories of occupation (OTPF4, AOTA, 2020)
Today we’ll start by looking back to the overview of categories of occupation. Over the month of September, we’ll dive even deeper into what occupations are.
Why?
How we spend or occupy our time can greatly influence and be influenced by our health and well being. In the US, many people often think of health as the absence of disease, illness, or injury. And, we all know that wellness and health are much more than the absence of these. We also recognize that there are a variety of factors that influence our health and well being— we’ll talk more about that later on the blog, too.
For now— we’re going to pause to notice and wonder what areas of our lives are flowing well and which areas are calling us to consider an adjustment, or recalibration at this time. If we think of the picture above being the overview of occupation categories, the pictures below zoom in to a closer look at the occupations within those categories.
The Role of Occupational Therapy Practitioners in This
If you’re experiencing difficulties in function in any of these areas, occupational therapy practitioners are among those who can help with these occupations by taking into account what is happening within you or groups of people, the communities of which you are a part, and your environment. It can seem simple— can we do these things well or not?
Often, it is not until we have a change in our function that we realize there is a need to adjust the how, what, why, when, and with whom we complete activities.
The goal for today is to recognize if individuals or groups are experiencing difficulties in these areas, there are more options to help with this than we may realize.
Occupational therapy practitioners are experts in everyday living and may be the partners in helping navigate life you didn’t realize existed or the full extent to which occupational therapy practitioners cover in practice.
4th Edition of the OT Practice Framework’s 8 categories of ADLs. (OTPF-4, AOTA, 2020)
ADLs
There are 8 categories of Activities of Daily Living (ADLs). These are activities we do daily that focus mainly on care of our own bodies and are routinely completed. We’ll start here because it may be the area people are most familiar with and also include areas of focus of which you may not be aware.
They include:
Dressing
Bathing and Showering
Personal Hygiene and Grooming
Toileting and Toileting Hygiene
Feeding
Functional Mobility
Sexual Activity
These categories also, contain several occupations. If you have specific questions or would like the blog to speak to some of these areas in more detail— please let us know.
To understand more about how ADLS might be addressed— let’s consider a common occupational routine and many similar yet different reasons for differences in function.
Bathing, Showering, Dressing, and Personal Hygiene and Grooming with Memory Loss
When people are experiencing memory loss, it is not uncommon for there to be difficulty with bathing, grooming, hygiene and dressing routines. This can be for a variety of reasons and understanding the reasons to each person are key to improving function.
Let’s start with bathing/showering: There could be 4 people who all have memory loss and are not showering or bathing. Why? The reasons can be as unique as each of the people.
I have seen people not shower because:
they fear looking too attractive and don’t want attention
they feel embarrassed that they sometimes forget the steps (sequencing) of how to complete bathing and it used to be automatic
they experience the water as painful as the shower water touches their skin due to changes in the way sensory information is processed and experienced
they have always been independent and never needed help before so being nude and having help is not on their willing to do list
Understanding their why and what matters
Key to figuring out how someone can bathe safely and in a way that suits them is more than just being physically or mentally capable. It requires having a relationship that understands how this occupation meets their needs at this time and considering together what might be adjusted to make that possible. Telling someone they must shower or bathe rarely turns out well, particularly not in the long-term. Figuring out what is needed in the moment for the occupation of bathing to occur and assisting in training caregivers is one of the ways the profession of occupational therapy can help.
In the case of not wanting to look too attractive— this worry also influenced dressing, grooming, and hygiene. None of these activities were wanting to be completed due to this fear. Staying curious about where someone with memory loss is in the continuum of time is very helpful in determining what helps people engage in their day to day activities. On a chronological map of time, it may be 2021— in the person with memory loss’s experience of time— they may feel like they are in a different moment of time— such as 20 years earlier when experiencing the death of a spouse. Meeting the person with memory loss where they are at in time is much more effective than trying to beckon them back to present time.
In addition, our traveling to the moment of time someone is in with their memory loss gives us the chance to meet people where they are and figure out “the thing that is really the thing” affecting their daily habits and routines. As an occupational therapist, I often feel like someone who manages sound with many different areas to fine tune adjustments to consider what is creating the current outcomes we are seeing. It is not just volume up and down, bass, and treble. There are many, many more possibilities if we are trained to notice and consider more nuanced possibilities.
Central to all of this is consistent connection with caregivers, where we meet someone in the moment of time they are in tells the nervous system of an individual with memory loss they are safe. If you’ve ever gotten lost or woke up feeling disoriented to day or time, you recognize how unsettling it can feel to not recognize your surroundings or have a sense of time. Consistent, flexible connection with caregivers was key to resuming bathing, hygiene, grooming, and dressing routines in all four of these circumstances.
Connection and Curiosity as Pathways
Remember when guest, Natalie Lu talked to us about a goal of connection, in Lives Well Occupied: Lessons from Near and Far post— that goal and staying curious are ingredients that really cannot be substituted in figuring out pathways to engaging in the occupations someone wants or needs to do or that give their lives meaning and purpose.
Telling someone “just do it” in any of the circumstances above resulted in more distrust, more frequent unwillingness to engage in these routines, more caregiver frustration and disconnection between care giver and care receiver. It also took more time and didn’t yield the outcomes that protect dignity, skin integrity, and more.
Expanding our Awareness of Why to Reach Desired Occupations
If we look at only someone’s physical capabilities (can they move into the shower, can they sit or stand safely or tolerate standing or sitting), this is just a component of what makes these occupations possible. We add in mental health considerations and we begin to get a clearer look at why someone may or may not engage (fatigue, motivation, attention and focus, oriented to current moment, and more). When we consider the context of the environment we may understand even more— are the lights too bright? Are there vision changes that make it difficult to see and understand where one’s body is in space and so balance feels off? Did they only take baths before and now only showers are available?
Could it be that people aren’t afraid of the shower itself but something else? In the scenario where the shower is experienced as painful, sometimes there are changes in how touch is experienced with certain types of memory loss that make some sensations painful. By staying curious about why someone would run from the shower and understanding some of the changes within that person and their diagnoses, we were able to determine a shower felt like painful pelting drops of water. It wasn’t an issue with being fearful of certain caregivers as originally suspected. Sponge bathing at bedside was received with ease because the sensations changed from pelting, painful drops of water in a bright environment to a warm, wet cloth with predictable pressure experienced as soothing and familiar.
A commitment to figuring out what is happening together and making adjustments that speak louder than our words is one of the most effective ways to partner with someone in adjusting the dials of how activities of daily living are completed. Even with memory loss, people sense our intention and begin to remember us as safe. As you can see— the possible factors for engaging in our daily occupations are endless and as varied as each person. Having a broad perspective of the possibilities, factors, and how they connect allows occupational therapy practitioners to be a valued partner in figuring out what works, what doesn’t, and next steps.
What’s next
Understanding that there is an over 100 year old profession that can help people navigate changes in how they function in their everyday living is something we as OT professionals hope to see increase. As you can see, how this applied varies so much and the clinical reasoning often happens between someone’s two ears instead of a full narration can be helpful (few people want to listen to all the possibilities being considered) and harmful (many people still do not know how occupational therapy can assist people in life navigation).
We’ll continue to talk about the other areas of occupation, and welcome your requests for where you would like to know more. The possibilities are vast and so understanding what matters most to you is most welcome and valuable.
Next week we’ll explore Instrumental Activities of Daily Living (IADLs).
Until then— thanks for sharing the journey
To a life well occupied
Reference
American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), Article 7412410010. https://doi.org/10.5014/ajot.2020.74S2001
