Occupational therapy is far more than helping people bathe, dress, or manage medications. While Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) are essential components of practice—especially across the aging continuum—they represent only one segment of the broader occupational universe.

At its core, occupational therapy is a holistic rehabilitation profession rooted in the therapeutic use of meaningful activities. Treatment is not defined by tasks, but by the integration of a person’s values, habits, roles, environmental contexts, social needs, and medical realities. OT practitioners merge this complex picture into individualized interventions using the most natural medium of human living: occupation.

The American Occupational Therapy Association (AOTA) captures the essence of this beautifully, quoting Wilcock and Townsend:

“Occupation is used to mean all the things people want, need, or have to do… the activist element of human existence whether occupations are contemplative, reflective, meditative, or action based.” (Association, 2014; Townsend & Wilcock, 2004)

This framing makes one thing clear: occupation is massive, far larger than self-care tasks alone.

What Are ADLs and IADLs—And Why Do They Matter?

The OTPF identifies ADLs as the fundamental activities required to care for one’s own body:

• Bathing/showering

• Dressing

• Toileting

• Functional mobility

• Eating/swallowing

• Personal hygiene and grooming

• Sexual activity

• Personal device care

IADLs, by contrast, support independent living in the home and community:

• Meal preparation

• Driving/community mobility

• Health management

• Home management

• Financial management

• Communication management

• Care of others or pets

• Shopping

• Safety/emergency maintenance

• Religious or spiritual participation

These domains matter for one major reason:
Declines in ADLs or IADLs are strongly associated with loss of independence, higher healthcare utilization, increased mortality, and eventual institutionalization.
(Townsend & Wilcock, 2004)

Research shows:

• 69% of adults over 65 will develop disability before death

• 35% will require nursing home placement
  (Kemper et al., 2005/2006)

Early identification of IADL changes—and proactive intervention—can profoundly alter this trajectory.

Why Small Changes Matter: The Clinical Significance of Early Decline

IADLs are often the first to show impairment in early disease processes, including mild cognitive impairment (MCI) and dementia.

For example:

• Confusion with bills or scheduling often appears years before dressing or bathing deficits.

• Executive dysfunction strongly predicts later ADL decline.

• Problems in bathing—often due to apraxia, planning deficits, or sensory changes—carry one of the highest risks for institutionalization.

OTs must understand the “cascade” of decline:

1. IADL impairment → early cognitive shift

2. ADL impairment → moderate to late decline

3. Loss of participation → accelerated functional change, depression, and caregiver strain

Without early intervention, functional decline accelerates due to inactivity, learned helplessness, reduced social engagement, and unaddressed modifiable factors (pain, depression, sleep, chronic disease management).

The OT Process: Evaluation, Monitoring, Intervention

When ADL/IADL changes are reported, an OT evaluation typically includes:

1. Comprehensive Occupational Profile

• Medical history

• Daily routines

• Roles and habits

• Environmental context

• Social supports

• Patient-identified goals

2. Evidence-Based Assessment Selection

Depending on the nature of the concern, OTs may choose:

• Performance-based tests

  • Performance ADL Test (PAT)

  • Erlangen ADL Test (E-ADL)

  • Direct Assessment of Functional Status

• Self-report or informant measures

  • Older Americans Resources and Services (OARS)

  • PSMS and Lawton IADL Scale

  • Barthel Index

  • FIM™ (social cognition included)

Each tool offers a different perspective—physical ability, cognitive sequencing, executive functioning, or real-time performance.

3. Collaborative Clinical Decision-Making

OTs frequently coordinate with:

• Primary care physicians

• Neurology

• Caregivers

• Social workers

• Home health teams

4. Client-Centered Intervention

Interventions may include:

• Motor retraining or graded task practice

• Cognitive rehabilitation strategies

• Environmental modification

• Executive function scaffolding

• Energy conservation and pacing

• Task sequencing and cueing systems

• Behavior management strategies

• Sensory or perceptual retraining

• Pain and fatigue management

• Fall prevention and mobility retraining

• Education on habits, routines, and compensatory strategies

OTs intervene on ability, performance, awareness, and initiation—key distinctions when cognitive decline affects not just the ability to perform a task, but the ability to recognize that the task needs to be done.

Cognitive Changes and ADL Performance: What Practitioners Must Know

The literature highlights important considerations:

• ADLs involve sequencing, conceptual knowledge, and manipulation—making them vulnerable to declines in attention, executive functioning, and memory.

• Apraxia (ideational, ideomotor, limb-kinetic) may disproportionately affect grooming, bathing, and toileting.

• Depression is strongly linked to mobility, transferring, and dressing impairments.

• Social engagement reduces the onset and progression of disability.

• Lifestyle factors (smoking, alcohol use, physical inactivity) accelerate ADL decline, especially in those with cognitive vulnerabilities.

• Trails B performance predicts ADL/IADL performance better than the MMSE.

These findings reinforce the OT role in cognitive–motor integration, functional cognition, and prevention.

Occupation Is Broader Than Self-Care

Many practitioners unintentionally narrow “occupation” to ADLs and IADLs—but OT’s scope is far more expansive.

According to the OTPF, occupations include:

Rest and Sleep

• Rest

• Sleep preparation and routines

• Sleep participation

Education

• Formal education

• Informal learning

• Skill exploration

Work

• Employment pursuits and acquisition

• Job performance

• Volunteer roles

• Retirement preparation

Play and Leisure

• Exploration of interests

• Participation in chosen activities

Social Participation

• Community involvement

• Family roles

• Friend and peer engagement

OT intervention may target ANY of these categories depending on the client’s values, meaningful roles, and functional needs.

This matters deeply, because people do not live solely in the realm of bathing, grooming, and bill paying.

They live in the realm of:

• Joy

• Identity

• Relationships

• Purpose

• Spiritual expression

• Contribution

• Belonging

OT is the profession uniquely skilled to support these domains.

Bringing It Together: A Broader Vision for OT Practice

Re-centering our profession on the full scope of occupation allows practitioners to:

• Provide more comprehensive care

• Identify early functional decline

• Advocate for preventative and ongoing services

• Reduce long-term disability

• Preserve identity and purpose across the lifespan

• Promote aging in place

• Support caregivers more effectively

• Justify skilled intervention with evidence-based precision

Most importantly, it prevents our profession from shrinking into a narrow view of “helping with ADLs” and reclaims the powerful, interdisciplinary, occupation-centered identity OT was founded upon.

Occupational therapy exists because daily life is complex, meaningful, and deeply human. Whether we are addressing bathing, meal preparation, religious participation, volunteer roles, or sleep routines, we are always working toward the same central goal:

Supporting people in living full, meaningful, autonomous lives.

OT is not limited to ADLs and IADLs.
It never has been.
And our future depends on practicing (and teaching) the full breadth of our domain.

References

Association, A. O. T. (2014). Occupational Therapy Framework. American Journal of Occupational Therapy, S3-S53.

Kemper, P., Lomisar, H. L., & Alexcih, L. (2005/206). Long-Term Care Over an Uncertain Future: What Can Current Retirees Expect? Inquiry Journal, 42(Winter), 335-350.

Townsend, E., & Wilcock, A. A. (2004). Occupational justice and client-centered practice: A dialogue in progress. Canadian Journal of Occupational Therapy, 49, 960-972. doi:http:// dx.doi.org/10.1177/000841740407100203