Aging With Long-Term Mobility Impairment: Maintaining Activities of Daily Living via Selection, Optimization, and Compensation

Elena T. Remillard, MS; Cara Bailey Fausset, PhD; Walter Brad Fain, PhD


Gerontologist. 2019;59(3):559-569. 

In This Article

Abstract and Introduction


Background and Objectives: There is a growing number of adults with long-term mobility impairment aging into the older adult population. Little is known about the experiences of these individuals in maintaining activities of daily living (ADLs) and instrumental activities of daily living (IADLs) as they face age-related changes in addition to a pre-existing mobility impairment.

Research Design and Methods: Through in-home interviews with 21 participants (ages 52–86) with long-term mobility impairment, the present study employed a qualitative description design to explore perceptions of how and why select ADL/IADL routines (e.g., bed transfer, toileting) have changed over time. The selection, optimization, and compensation (SOC) model was used as a framework to organize participants' adaptations.

Results: Among the ADL/IADL routine changes mentioned, elective selection strategies, in which a person continues to work at maintaining a task, were more frequently endorsed than loss-based selection strategies, in which a person does a task less or gets help from someone. Findings suggest that this population is actively adapting their routines to preserve their involvement in, and frequency of doing, these ADLs/IADLs. Counter to expectation, perceived age-related changes underlying activity routine changes were subtle and generally did not include sensory and cognitive declines.

Discussion and Implications: Findings provide insights into the difficulties adults with long-term mobility impairment experience as they age, as well as the adaptations they employ to overcome those challenges. Results highlight the need for customizable, mobility supports (e.g., assistive technologies, home modifications) that can adjust to an individual's changing abilities across the life span.


Individuals who have mobility impairment or "serious difficulty walking or climbing stairs" (American Community Survey, U.S. Census Bureau, 2014) are living longer than ever before (Institute of Medicine, 2007). Advances in rehabilitation and technology are supporting a growing population of older adults with long-term, and even lifelong, mobility impairment. A recent U.S. census report revealed that among the population of older adults with one or more disabilities, about two-thirds (66.5%) have mobility difficulty, affecting about 10 million people (U.S. Census Bureau, 2014). Despite the prevalence of mobility impairment among older adults, very little is known about the segment of older adults who acquired their mobility impairment in early or mid-life (Freedman, 2014; Putnam, Molton, Truitt, Smith, & Jensen, 2016). In comparison to the majority of people with mobility impairment who have late-life onsets for relatively short periods of time, people with early or mid-life onset mobility impairment are subject to much longer durations of impairment (Verbrugge & Yang, 2002). This unique group of individuals, said to be "aging with disability," are likely to experience challenges above and beyond normative aging (LePlante, 2014; Verbrugge & Yang, 2002).

Normative age-related changes, such as declines in vision, hearing, strength, and balance, can impact an older adult's ability to carry out a range of everyday activities. Activities of daily living (ADLs) are considered the most basic, self-care tasks such as bathing, toileting, transferring; one's ability to complete these tasks independently is often used to determine need for additional support services (e.g., caregiving, long-term care housing; Katz, Ford, Moskowitz, Jackson & Jaffe, 1963). Instrumental ADL (IADLs) are also important activities for independent living, but are less essential for fundamental functioning. IADLs, such as preparing meals and housekeeping, require more advanced physical and cognitive capabilities (Lawton & Brody, 1969).

As suggested in Lawton's Environmental Press Theory, disability is not an inevitable outcome of having an impairment (Lawton & Nahemow, 1973; Lawton, 1985). Rather, a mismatch between one's competencies (e.g., physical functioning) and the demands of their environment (e.g., the home) creates disability. It can be expected that older adults with long-term mobility impairment are likely to have lower physical functioning resulting in higher environmental demands. Thus, supports to increase an individual's competencies and/or to reduce environmental demand are required. Given the overwhelming preference of older adults to age in place, it is essential for these individuals to achieve and maintain person-environment fit in their homes (Lien, Steggell, & Iwarsson, 2015). There is a need to identify the environmental characteristics of the home that enable individuals with mobility impairment to live as independently as possible across the life span. First, research must explore how individuals in this understudied population change over time.

Research has shown that people aging with long-term mobility impairment are at risk of developing a number of related secondary conditions and experiencing declines that mirror normative age-related changes, more rapidly, a phenomenon known as "accelerated aging" (Groah et al., 2012; Institute of Medicine (U.S.), 2007; McNalley et al., 2015; Stern et al., 2010). For example, among individuals aging with Spinal Cord Injury, high rates of obesity and marked declines in muscle mass and bone density are common and thought to be the result of years, and even decades, with limited to no standing or muscle activity (Groah et al., 2012). Accelerated aging has also been thought to occur among people with multiple sclerosis (MS), which is a progressive, neurological condition with symptoms including but not limited to: weakness, fatigue, pain, and declines in sensory and cognitive capabilities (Stern et al., 2010). Several symptoms of MS are similar to the normative age-related declines of older adults, yet affect individuals at a much younger age.

Many older adults with long-term mobility impairment are experienced in adapting to mobility-related challenges, utilizing supportive solutions such as mobility aids (e.g., wheelchairs, lifts), home modifications (e.g., grabs bars, ramps, widened doorways) and help from others (Cho, MacLachlan, Clarke & Mannan, 2016). However, as these individuals age and face increased biological and social losses, additional environmental and behavioral adaptations may be needed to enable successful performance of ADLs and IADLs and to maintain their independence (Agree, 2014). There is a need to further explore the challenges adults with long-term mobility impairment experience with ADLs/IADLs as they age and their strategies for adapting to them (Harrington, Mitzner, & Rogers, 2015).

The selection, optimization, and compensation (SOC) model provides a framework within which to organize the strategies and behaviors of older adults who must manage age-related changes in conjunction with long-term mobility impairment (Baltes, 1997). The SOC model describes how individuals adapt to developmental challenges across the life span via the processes of selection, optimization, and compensation. The process of selection can be elective such that an individual elects to pursue a goal or behavior and devotes available resources to achieving that goal or behavior (Freund & Baltes, 2002). Alternatively, selection can be loss-based such that an individual discontinues performing a task because he/she can no longer do the task (Freund, 2008). Optimization occurs when an individual continues to work at maintaining a goal or behavior (Baltes); perseverance and practice are examples of optimization. Additionally, optimization includes modifying the approach or altering the current design of the environment without bringing in new elements to maintain a goal or behavior. Lastly, compensation involves using new or additional processes (e.g., mobility aids) aimed at maintaining performance in the face of biological or social losses (Baltes). These processes operate in concert to maximize available resources and minimize losses.

The SOC model has been widely used to understand how older adults adapt to age-related declines (for a review see Freund, 2008). For example, Bourgeois (2001) used the SOC model to understand how older adults managed their daily activities and found that compensation was associated with successful management. In a study that examined how older adults (n = 248) with osteoarthritis managed their daily activities, optimization and compensation were the most frequently reported behavioral adaptations (Gignac, Cott, & Badley, 2002). The relationship between SOC processes and management of home maintenance activities was investigated by providing older adult focus groups with scenarios based on physical and cognitive limitations (Kelly, Fausset, Rogers, & Fisk, 2014). The findings suggested that older adults endorsed compensatory strategies most frequently. In addition to adapting to normative age-related changes, the SOC model can be used as a framework to understand the interaction of these processes within the context of aging with a long-term mobility impairment and to help to identify unmet needs for this growing population.

The goal of this research was to understand how the ADL/IADL routines of older adults with long-term mobility impairment have changed over time. Additionally, we sought to understand their perceptions of why these routines have changed, with regard to underlying age-related changes with self. The SOC framework was used to organize the behavioral adaptations used to overcome challenges in maintaining ADLs/IADLs.