Dement Geriatr Cogn Disord 1998;9(suppl 2):20–26

Ian Hindmarch a
Hartmut Lehfeld b
The Bayer Activities of Daily Living
Perry de Jongh c
Hellmut Erzigkeit b
Scale (B-ADL)
a Human Psychopharmacology Research
Unit, University of Surrey, UK;
b Psychiatric University Hospital Erlangen,
c Bayer AG, Leverkusen, Germany

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Key Words Abstract

B-ADL The Bayer Activities of Daily Living Scale (B-ADL) has been developed on an
Activities of daily living international basis to assess deficits in the performance of everyday activities.
Therapy evaluation The scale’s main target group is community dwelling patients who suffer mild
Dementia screening cognitive impairment or mild-to-moderate dementia. It comprises 25 items
Alzheimer’s disease and takes the form of a questionnaire to be completed by a caregiver or other
Vascular dementia informant sufficiently familiar with the patient. Statistical, clinical and
Mild cognitive impairment domain-related criteria were used to select items from among a large number
of activities of daily living (ADL) questions field tested in pilot studies in the
USA, Germany, UK, Russia and Greece. The items included in the B-ADL
have been chosen for their sensitivity to cognitive impairment, simplicity of
concept, international applicability and their relevance to patients coping with
the demands of everyday life. The scale uses items which reflect a wide range
of domains. On account of its brevity, it is thought especially suitable for
application within a GP and primary care context for both screening a
patient’s ADL capacities as well as for documentation of treatment effects and
the progress of dementia. This paper focuses on a description of the scale and
its application.
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Introduction sess existing ADL impairments can be used as an aid to

Within dementia research over the past 10 years, the
assessment of activities of daily living (ADL) has gained
considerable attention. Functional deficits in everyday
competence have been introduced as a threshold criterion
into standardized diagnostic procedures such as the ICD-
10 or DSM-IV. Since the diagnosis of dementia can only
be made in the presence of manifest difficulties in main-
taining an independent lifestyle, scales developed to as-
the diagnostic process.
Thorough assessment of the ability to cope with the
demands of daily living is expected to contribute to the
early diagnosis of dementia. There is evidence that ADL
deficits are manifest in patients suffering from very mild
cognitive impairment [1] and these may well be noticed
by relatives of patients prior to deficits being revealed by
psychometric test instruments [2]. As effective drug treat-
ment strategies require the diagnosis of the disease at its

© 1998 S. Karger AG, Basel Professor Ian Hindmarch

ABC 1420–8008/98/0098–0020$15.00/0 Human Psychopharmacology Research Unit
Fax + 41 61 306 12 34 University of Surrey, Milford Hospital
E-Mail karger@karger.ch This article is also accessible online at: Godalming, Surrey GU7 1UF (UK)
www.karger.com http://BioMedNet.com/karger Tel. +44 1483 306011, Fax. +44 1483 418453
earliest possible stage [3], the evaluation of ADL may be
used for ‘screening’ purposes to detect those changes in a
person’s competencies which might be the first signs of a
dementing disorder [4].
Furthermore, recently drafted guidelines for the evalu-
ation of therapeutic intervention in Alzheimer’s disease
[5, 6] acknowledge the need to measure and document the
effects of treatment on the ADL. These recent protocols
go beyond former recommendations made for clinical
trials in which the evaluation of ADL played only a sec-
ondary role to cognitive assessment using psychometric
tests and global impressions of overall clinical response [7,
8]. However, improvements in everyday capacities – no
matter whether for basic activities, such as feeding, dress-
ing or washing, or more complex tasks, usually classified
as instrumental ADLs (IADLs), e.g. household chores,
shopping, managing finances – are perceived as having a
high clinical relevance [5]. They are, therefore, increasing-
ly considered a primary criterion for measuring the suc-
cess of pharmacotherapeutic intervention.
Impairments in ADL due to dementia are difficult to
assess without additional information on the patient. For
example, changes in ADL cannot be detected without
knowledge of the previous habits, sociopsychological fac-
tors and living conditions which bear on everyday activi-
ties. Furthermore, in the early stages of dementia patients
are able, to varying degrees, to compensate for the decline
if they are subjectively aware of a loss of competence.
Activities of daily living are also moderated by factors not
directly related to dementia, such as existing co-morbidity
or side-effects of a medication. Furthermore, disturbances
of mood, irascibility, lack of motivation and the psycho-
social problems associated with early dementia have an
impact on the patient’s ADL performance. However, the
psychiatric classification systems ICD-10 and DSM-IV
ask for the assessment of ADL impairments which occur
as a consequence of the cognitive problems experienced
by a demented patient. Those additional factors having
effects on ADLs must, therefore, be considered as a source
of variance which interferes with the assessment of the
severity of the impairment of everyday tasks due to the
dementing condition. Moreover, Poon [9] has suggested
the paradox that, in the early stages of dementia, the sensi-
tivity of ADL scales is at its lowest, whereas in order to
detect the subtle deficits and small changes over a given
period of time which characterize early dementia, the
highest possible sensitivity is needed.
In construction of the Bayer Activities of Daily Living
Scale (B-ADL) these various factors were taken into con-
sideration.
Bayer Activities of Daily Living Scale
The Bayer Activities of Daily Living Scale (B-ADL)
Construction of the Scale
The lack of ADL scales that are sufficiently sensitive in
the early stages of dementia prompted the development of
the B-ADL. The outcome of an international ADL project
[10–13], sponsored by Bayer, to construct a scale for use
within clinical trials in mild-to-moderate dementia (intro-
duced in 1997 [14]) encouraged an attempt to identify a
set of items which were particularly suitable for those
patients with early dementia. The resulting B-ADL (ap-
pendix 1) is introduced in this paper. It comprises 25
items and takes the format of a questionnaire completed
by a primary caregiver or relative sufficiently familiar
with the patient. The B-ADL is intended to be a practical
and economic instrument that can be applied by physi-
cians as an aid in the screening process, as well as for eval-
uating changes in ADL related to pharmacotherapeutic
intervention.
In the item selection process, the wealth of information
on ADL impairment in dementia obtained from an em-
pirical field study carried out within the Bayer ADL pro-
ject in the USA, Germany, UK, Russia and Greece [13]
was exploited. Statistical, clinical and domain-related cri-
teria were used to identify the items to be included in the
scale from among the 141 informant- and 63 self-rated
questions that were field tested. The rationale was that
each ADL domain that proved to be affected by early
dementia in the field study was to be represented in the
scale. Items which had been confirmed in other studies
[15, 16] to have a significant gender or cultural bias were
removed. As a result, a 21-item scale was identified from
the results of the field study. Furthermore, evidence of
ADL problems linked to early dementia from studies pub-
lished after initiation of pilot testing was also taken into
account, and a further four newly constructed questions
were added to produce the final B-ADL comprising 25
questions.
Contents of the Scale
The two introductory items of the B-ADL (see appen-
dix 1) evaluate the individual’s ability to manage every-
day activities and to take care of him or herself. Both are
intended as ‘warming-up’ questions as well as a means of
gaining an impression of the patient’s general ADL com-
petencies. These assessments, as with all other items,
should take into account problems with the initiation,
execution and completion of an activity. In addition, with
all 25 items of the scale the difficulties reported must not
be the result of physical handicaps such as impaired
Dement Geriatr Cogn Disord 21
1998;9(suppl 2):20–26
vision, arthritis or a broken wrist, but the consequence of
cognitive decline.
Items numbered 3 to 20 directly assess the problems a
patient might face with specific tasks of everyday life.
These questions pertain to the following domains: medi-
cation (item 3), hygiene (item 4), reading (item 6), conver-
sation (item 8), telephoning (item 9), shopping (item 12),
food preparation (item 13), handling money and financial
affairs (items 14, 15), household appliances (item 17),
transportation (item 19) and leisure activities (item 20).
Three questions assess everyday tasks which require un-
impaired short- or long-term memory (items 5, 7, 19) and
three assess ‘orientation’ in both familiar and unfamiliar
surroundings (items 11, 16, 18).
The five items at the end of the B-ADL do not refer to
concrete activities. They relate to cognitive functions
important for the management of everyday life. Item 21
assesses competence in remembering where to continue
with an ongoing task after an interruption (e.g. telephone,
doorbell). Item 22 enquires, in a general way, about diffi-
culties which are linked to ‘divided attention’ and may be
observed when the patient has to do two things at the
same time, e.g. playing a game and conducting a conversa-
tion. It is often observed that patients with cognitive
impairment complain about performing two activities at
the same time, saying they prefer to complete one task
before starting another [17]. Item 23 addresses coping
with unfamiliar or new situations which require the pro-
cessing of new information. It is known from clinical
experience that demented patients have problems ap-
praising situational demands and allocating appropriate
personal resources, selecting adequate coping strategies,
translating them into action and re-evaluating the particu-
lar situation when routine behaviour cannot be per-
formed. In accordance with findings from a clinical study
evaluating the efficacy of the calcium antagonist nimodi-
pine [18] which has revealed a propensity to minor acci-
dents in patients suffering from mild dementia, item 24
relates to the safety aspects of ADLs. The final item of the
B-ADL addresses whether the patient has difficulties per-
forming a task when under pressure. Stress is known to
adversely affect cognitive functioning to a greater extent
in demented as opposed to healthy persons. Item 25 con-
cerns confusion, no longer knowing which steps to take
and in what sequence it is necessary to perform them in
order to successfully complete a task. Difficulties also
include frustration, highly emotional responses and simp-
ly giving up trying to complete the task.
22 Dement Geriatr Cogn Disord
1998;9(suppl 2):20–26
Format of the Scale
The principal aim with the construction of the B-ADL
was its use in a primary care setting [19]. Thus, the deci-
sion was made to adapt the mode of administration from
the ADL interview carried out in the pilot study to a ques-
tionnaire completed by a relative. This format was chosen
to allow for an economic use of the B-ADL in order to
obtain a quick survey of the patient’s ADL capacities.
However, as a consequence, the wording of the items used
in the pilot study required considerable simplification.
With this in mind, a standardized item format was intro-
duced to improve understanding and to facilitate admin-
istration of the scale. In its present form, every item con-
tained in the B-ADL begins with the same phrase asking
whether the person to be assessed has difficulties doing
the activity in question.
Another change in comparison with the empirical pilot
testing of the items concerns the scaling procedure. The
scale originally used was a relatively coarse 5-point Likert
scale. The answer categories employed to assess the fre-
quency of ADL impairments were verbalized as ‘never’,
‘sometimes’, ‘often’, ‘always’, and ‘activity has been given
up’. This scale was replaced by a 10-point scale to allow
for the documentation of more subtle deficits and
changes. Furthermore, as is the case with visual analogue
scales, verbalizations of answer categories were only
maintained for the two extremes of the 10-point scale
which are labeled ‘never’ and ‘always’. This alteration was
deemed necessary to facilitate the international use of the
scale. Brislin [20], for example, warns against the use of
indefinite adverbs telling place or time with items in-
tended for international application because their direct
equivalents in other languages might have a different
meaning and, therefore, be inappropriate. Sartorius and
Kuyken [21] comment similarly on response scales de-
signed for cross-cultural usage: ‘Although endpoints such
as ‘never’ or ‘always’ are relatively universal, shades of
meaning between endpoints (e.g. ‘sometimes’) are more
ambiguous, difficult to translate, and subject to cultural
variation in their interpretation’.
In the same way, with respect to its cross-cultural
usage, the wording of some of the items was modified to
enlarge their scope for international application. For ex-
ample, item 19 which originally asked about the capacity
to drive a car was altered to evaluate the ability to use
transportation. This proposed change was suggested by a
number of countries, including Malaysia, in which a field
study was carried out using a pilot version of the scale
(Fadzillah and Krishnaswamy, unpubl. data) and which
clearly suggested this change. It has to be noted however,
Hindmarch/Lehfeld/de Jongh/Erzigkeit
that this modification does not exclude the assessment of format. The B-ADL covers a wide range of ADL with the
problems with active driving in some industrialized coun- majority of items relating to specific tasks. Furthermore,
tries where a proportion of the elderly population regular- the B-ADL contains two items reflecting a general impres-
ly use a car. sion of the patient’s ADL capacity and five questions
addressing unspecified demands of everyday life. Al-
Application and Scoring of the Scale though originally written in English, high quality transla-
The relative or caregiver assessing the patient’s diffi- tions of the B-ADL into German, French and Spanish
culties with ADLs using the B-ADL is instructed to indi- now are under way.
cate how often difficulties occur with the activity in ques- The B-ADL is expected to provide a useful tool for the
tion by drawing a line through one of the circles numbered documentation of the efficacy of therapeutic intervention,
‘1’ to ‘10’. Additionally, a ‘not applicable’ category is pro- as well as having primary utility as a valid, sensitive and
vided for instances where a question is not appropriate or reliable instrument for aiding the assessment of early
relevant to a given patient. Only when a choice cannot be dementia. Understandably, the proof of scales such as the
reasonably made is the informant asked to tick the box B-ADL lies in their formal validation. The results from
‘unknown’. ongoing research, available at the end of the year are
To compute a global scale score, first the individual expected to confirm the utility of the B-ADL as part of the
item scores are summed up. Items rated ‘not applicable’ armamentarium of testing procedures for the early recog-
and ‘unknown’ are not used for the computation of this nition of dementia.
sum score. The total is then divided by the number of
items rated between ‘1’ and ‘10’. Thus, the scale’s sum
score is corrected for the number of irrelevant items and Acknowledgments
missing scores. The resulting figure is rounded to two
The authors wish to express their gratitude to Eileen Lintz, Karin
decimal places, ensuring that total scores of the B-ADL
Morgenroth and Lilli Bart for their co-operation in drawing up the
range between values 1.00 and 10.00. scale, editing the manuscript and evaluating all the statistical print
outs.
Main Features of the Scale
The B-ADL was constructed as a ‘pure’ measure for
ADL deficits. It therefore contains only items asking for
difficulties with ADL focusing on the more complex,
instrumental activities (IADLs). It does not include items
assessing other aspects of the dementia syndrome, for
example, disturbances of mood, behavioural abnormali-
ties, psychotic symptoms, personality changes, motor dis-
orders or somatic problems.
Moreover, as its focus of application is in general
practitioners’ and primary care physicians’ offices, the
B-ADL does not cover the whole spectrum of dementia
symptomatology. Instead, it focuses on problems relevant
to community residing patients suffering from very mild-
to-moderate cognitive decline or from mild-to-moderate
dementia. These severity stages correspond to those of the
study populations investigated in the field trial where
Global Deterioration Scale (GDS) [22] stage 5 was the
maximum allowed degree of impairment for inclusion.
The B-ADL was constructed using the results of an
international field study as a starting point. On the basis
of statistical, clinical and domain-related criteria, items
which had indicated their usefulness for assessing patients
suffering from mild cognitive impairment or early de-
mentia were selected and simplified for the questionnaire

Bayer Activities of Daily Living Scale Dement Geriatr Cogn Disord 23

1998;9(suppl 2):20–26
24 Dement Geriatr Cogn Disord Hindmarch/Lehfeld/de Jongh/Erzigkeit
1998;9(suppl 2):20–26
Bayer Activities of Daily Living Scale Dement Geriatr Cogn Disord 25
1998;9(suppl 2):20–26
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