Open Access Highly Accessed Research article

Long-term declines in ADLs, IADLs, and mobility among older Medicare beneficiaries

Fredric D Wolinsky123*, Suzanne E Bentler1, Jason Hockenberry14, Michael P Jones45, Maksym Obrizan6, Paula AM Weigel1, Brian Kaskie1 and Robert B Wallace27

Author Affiliations

1 Department of Health Management and Policy, College of Public Health, the University of Iowa, Iowa City, Iowa, USA

2 Department of Internal Medicine, Carver College of Medicine, the University of Iowa, Iowa City, Iowa, USA

3 Department of Adult Nursing, College of Nursing, the University of Iowa, Iowa City, Iowa, USA

4 Comprehensive Access and Delivery Evaluation and Research Center (CADRE), Iowa City Veterans Administration Medical Center, Iowa City, Iowa, USA

5 Department of Biostatistics, College of Public Health, the University of Iowa, Iowa City, Iowa, USA

6 Kyiv School of Economics, and Kyiv Economics Institute, Kyiv, UA

7 Department of Epidemiology, College of Public Health, the University of Iowa, Iowa City, Iowa, USA

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BMC Geriatrics 2011, 11:43  doi:10.1186/1471-2318-11-43

Published: 16 August 2011



Most prior studies have focused on short-term (≤ 2 years) functional declines. But those studies cannot address aging effects inasmuch as all participants have aged the same amount. Therefore, the authors studied the extent of long-term functional decline in older Medicare beneficiaries who were followed for varying time lengths, and the authors also identified the risk factors associated with those declines.


The analytic sample included 5,871 self- or proxy-respondents who had complete baseline and follow-up survey data that could be linked to their Medicare claims for 1993-2007. Functional status was assessed using activities of daily living (ADLs), instrumental ADLs (IADLs), and mobility limitations, with declines defined as the development of two of more new difficulties. Multiple logistic regression analysis was used to focus on the associations involving respondent status, health lifestyle, continuity of care, managed care status, health shocks, and terminal drop.


The average amount of time between the first and final interviews was 8.0 years. Declines were observed for 36.6% on ADL abilities, 32.3% on IADL abilities, and 30.9% on mobility abilities. Functional decline was more likely to occur when proxy-reports were used, and the effects of baseline function on decline were reduced when proxy-reports were used. Engaging in vigorous physical activity consistently and substantially protected against functional decline, whereas obesity, cigarette smoking, and alcohol consumption were only associated with mobility declines. Post-baseline hospitalizations were the most robust predictors of functional decline, exhibiting a dose-response effect such that the greater the average annual number of hospital episodes, the greater the likelihood of functional status decline. Participants whose final interview preceded their death by one year or less had substantially greater odds of functional status decline.


Both the additive and interactive (with functional status) effects of respondent status should be taken into consideration whenever proxy-reports are used. Encouraging exercise could broadly reduce the risk of functional decline across all three outcomes, although interventions encouraging weight reduction and smoking cessation would only affect mobility declines. Reducing hospitalization and re-hospitalization rates could also broadly reduce the risk of functional decline across all three outcomes.