U.S. Department of Health and Human ServicesU.S. Department of Health and Human Services
This report was prepared under contract between the U.S. Department of Health and Human Services (HHS), Office of Social Services Policy (now the Office of Disability, Aging and Long-Term Care Policy (DALTCP)) and the Brookings Institution. For additional information about the study, you may visit the DALTCP home page at http://aspe.hhs.gov/daltcp/home.htm or contact the office at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. The e-mail address is: webmaster.DALTCP@hhs.gov. The DALTCP Project Officer was Robert Clark.
This article appeared in the Journal of Gerontology: SOCIAL SCIENCES (November 1990, Volume 45, Number 6, pp.S229-237).
The "activities of daily living," or ADLs, are the basic tasks of everyday life, such as eating, bathing, dressing, toileting, and transferring. Reported estimates of the size of the elderly population with ADL disabilities differ substantially across national surveys. Differences in which ADL items are being measured and in what constitutes a disability account for much of the variation. Other likely explanations are differences in sample design, sample size, survey methodology, and age structure of the population to which the sample refers. When essentially equivalent ADL measures are compared, estimates for the community-based population vary by up to 3.1 percentage points; and for the institutionalized population, with the exception of toileting, by no more than 3.2 percentage points. As small as these differences are in absolute terms, they can be large in percent differences across surveys. For example, the National Medical Expenditure Survey estimates that there are 60 percent more elderly people with ADL problems than does the Supplement on Aging.
The term "activities of daily living," or ADLs, refers to the basic tasks of everyday life, such as eating, bathing, dressing, toileting, and transferring. When people are unable to perform these activities, they need help in order to cope, either from other human beings or mechanical devices or both. Although persons of all ages may have problems performing the ADLs, prevalence rates are much higher for the elderly than for the nonelderly. Within the elderly population, ADL prevalence rates rise steeply with advancing age and are especially high for persons aged 85 and over (Rivlin and Wiener, 1988).
Measurement of the activities of daily living is critical because they have been found to be significant predictors of admission to a nursing home (Branch and Jette, 1982); use of paid home care (Garber, 1989; Soldo and Manton, 1985); use of hospital services (Branch, Jette, and Evashwick, 1981; Wan and Odell, 1981); living arrangements (Bishop, 1986); use of physician services (Wan and Odell, 1981); insurance coverage (Dunlop, Wells, and Wilensky, 1989); and mortality (Manton, 1988). For research on the elderly, the ability to perform the ADLs has become a standard variable to include in analyses, just like age, sex, marital status, and income.
Estimates of the number and characteristics of people with problems performing ADLs are also important because of the increasing number of private long-term care insurance policies and proposed public long-term care insurance programs that rely on ADL measures to determine whether an individual qualifies for benefits. For example, private insurance policies sold by John Hancock, Aetna, Travelers, Metropolitan Life, and CNA rely on ADL measures as a trigger for benefits (Van Gelder and Johnson, 1989). All of the proposed public insurance plans, including those introduced by Senators George Mitchell and Edward Kennedy and by Representatives Henry Waxman, Fortney "Pete" Stark, and Claude Pepper, do the same. Obviously, the amount of long-term care benefits paid out by such private and public plans will largely depend on the number of persons who meet the various ADL eligibility criteria.
A number of national surveys which measure the ability of elderly people to perform the ADLs have been conducted. A legitimate question is whether these diverse surveys produce consistent estimates. A cursory glance at some recent studies suggests that this is not the case. For example, one analysis using the 1984 National Long-Term Care Survey reported that there were 3.0 million elderly with impairments in one or more ADLs (Manton, 1988); while another study using the Supplement on Aging found 6.0 million impaired elderly (Kasper, 1988). Yet another study using the 1984 Survey of Income and Program Participation identified only 1.5 million elderly with "personal care needs," a concept roughly comparable to requiring help with the ADLs (U.S. Bureau of the Census, 1986). The very wide differences in the cost estimates for Rep. Claude Pepper's long-term home care bill, H.R.3436, between the U.S. Congressional Budget Office and the U.S. Department of Health and Human Services, served to focus attention on the inconsistency of the ADL estimates across surveys.
In May 1988, the federal Interagency Forum on Aging-Related Statistics decided to systematically examine the surveys measuring ADLs and to try to discover the reasons for the varying estimates. A Committee on Estimates of Activities of Daily Living in National Surveys, including government and nongovernment experts familiar with the different surveys, was formed to study the issue. This article is based on the report of that committee.
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