Due to the physiological limitations, the proportion of centenarians within the population remains very low, and research on this unique group is relatively scarce. While most people aspire to live as long as possible, advancements in material resources and medical science have increased this possibility (Li et al., 2024). However, with the extension of life span, physical, cognitive, and multi-morbidity challenges inevitably accumulate (Robert and Fulop, 2014). Data from the Chinese Longitudinal Healthy Longevity Study (CLHLS) showed that activities of daily living (ADL) decreased by 0.8%–2.8% annually in individuals aged 80 years and older (Zeng et al., 2017). Compared with the general elderly population, centenarians exhibit a higher dependency on medical resources, social care, as well as associated care costs (Chen and Park, 2023). Understanding the influencing factors contributing to disability and mortality in this population is crucial, as targeted interventions can help reduce costs and improve the efficiency of limited social resources (Cruces-Salguero et al., 2022; Zhao et al., 2020).

Among the various challenges faced by centenarians, the decline in physical function is pronounced (Lepers et al., 2016). A modeling study (Zimmer et al., 2012) of individuals aged 80 and older revealed an increase in the number of people with impaired ADL as age progresses. This decline in physical function often places centenarians at greater risk of health deterioration and mortality (Mosfeldt et al., 2019). An analysis of 13666 individuals aged 65 and older from the CLHLS (2002–2014) showed that the hazard ratio (HR) for death among individuals with disabilities was 1.44 (95%CI: 1.48–1.90) compared with those without disabilities (Yang et al., 2021). The deteriorated physical function of centenarians also have a detrimental effect on their mental health. Therefore, this study proposes the following hypothese:

H1

Physical disability negatively influence the survival of centenarians.

Widowhood, which occurs at various stages of adulthood, significantly impacts both the physical and psychological wellbeing of those affected (Wang et al., 2024). The consequences can be both short-term and long-term. In the early stages of losing a partner, survivors may experience severe psychological and emotional distress (Sheftel et al., 2024). Over time, long-term widows often experience feelings of loneliness and lack of dependence (Yang, 2021; Yang and Gu, 2021). Previous studies have confirmed the relationship between widowhood and increased mortality (Barrenetxea et al., 2023; Blanner et al., 2020). A cross-sectional survey (Hsiao et al., 2021) in Taiwan showed that widowed individuals had a higher risk of death compared with the non-widowed individuals. Similarly, a study (Barrenetxea et al., 2023) based on 15,858 Singaporean Chinese aged 61–96 found that widowed adults had a higher mortality risk (HR = 1.18, 95% CI: 1.01–1.38). However, there is limited research on the impact of widowhood on the survival of centenarians, suggesting the need for greater attention to the health status and marital circumstances of centenarians. Therefore, this study proposes the following hypotheses:

H2

Widowhood negatively influence the survival of centenarians.

Previous studies (Ho and Hung, 2013) have highlighted the importance of ADL and widowhood separately as predictors of mortality risk among ordinary population. Physically disabled centenarians lack the ability to complete daily life. Spouses are the closest partners of centenarians and can provide the most ideal external assistance for disabled centenarians. The loss of external help given by partners may cause physically disabled centenarians fail to complete basic daily activities, which may increase the risk of death.Therefore, this study proposes the following hypothese:

H3

Widowhood modify the associations between ADL and mortality.

Gaining insights into this relationship will help inform corresponding policies and strategies to support the health of centenarians. Therefore, this study, based on the China Hainan Centenarian Cohort Study (CHCCS) (He et al., 2018), aims to investigate the impact of physical disability and widowhood on the survival of centenarians.

Physiologically, as individuals age, they experience a range of challenges, including physical decline, the development of chronic diseases and social changes, such as children leaving home and the death of a spouse, along with reduced social engagement (Sheftel et al., 2024; Beard et al., 2016; Christensen et al., 2009). These issues significantly diminish the quality of life, leading to an increase in nursing and medical costs, especially for centenarians (Rozzini, 2016). These factors ultimately influence the expected survival time of the elderly (Cheng et al., 2020). Even more concerning is the cumulative effect of these adverse factors, which can accumulate either individually or in combination over time (Zhao et al., 2020; Xu and Yang, 2022).

The physiological capacity of the elderly declines progressively with age, or more rapidly due to diseases, accidents or other factors, resulting in disability or semi-disability of the elderly (Strax et al., 2010). The disability rate increases monotonously with age, meaning that as individuals grow older, the risk of becoming disabled rises (Lamarca et al., 2003; Chen et al., 2018). However, the age-related decline in ADL scores is well-documented (Chaoping et al., 2023). For example, the prevalence of disability has been reported to be 19% (95% CI: 17.8%–20.2%) in individuals over 60 years of age, and 36.85% of Europeans aged 71–80 years exhibit ADL impairment (Jitapunkul et al., 2003; Ćwirlej-Sozańska et al., 2018). According to the European Health Survey (Carmona-Torres et al., 2019), the prevalence of ADL impairment in those aged 85 years and older was 34%. In this study, the rate of disabled and semi-disabled centenarians was found to be 52.22%, significantly higher than in younger populations. These findings were consistent with those from the Danish 1895-West and 1915-West Birth Cohort Studies (1895-West vs. 1905-West: 53% vs. 50%) (Rasmussen et al., 2018). For centenarians, the compression of disability and morbidity toward the end of life is characteristic of their longevity (Terry et al., 2008).

Disability is well-known predictor of death, and disability in the elderly is often irreversible (Rupp and Dushi, 2017; Kuper et al., 2024). Not only does disability caused by diseases accelerate the death process, but the physiological disability also negatively impacts life expectancy and survival rates (Thomas and Barnes, 2010). A study (Wu et al., 2016) based on the National Health and Nutrition Examination Survey (NHANES) showed that disability increases all-cause mortality in older adults 60–84 years of age. Furthermore, physical activity was identified as a risk predictor of death for community-dwelling residents aged 75–83 years old (Male: HR = 1.65, 95% CI: 1.27–2.14; Female: HR = 1.77, 95% CI: 1.42–2.19) (Schultz-Larsen et al., 2012). A survey of older adults aged over 65 years in Taiwan revealed that 93% of older adults showed no ADL impairment 10 years before death (Chiu et al., 2021). However, as death approached, the prevalence of ADL impairments increased, with an average of 10% participants showing more than three ADL abnormalities 6 years before death, and moderate to severe disability affecting 38% of individuals in the year before death. The loss of physical activity, as demonstrated in this study, was associated with the mortality in centenarians. Additionally, a linear relationship was observed between physical function loss and mortality in centenarians.

The proportion of elderly individuals who are widowed increases with age. Among individuals aged 65 and older, 13% of men and 40% of women are widowed. This rate rises to 57% for those over 75 years old (Sundström et al., 2014). In this study, the proportion of centenarians without a partner reached 88.82%. Health deficits associated with bereavement may manifest earlier during the marital transition than previously anticipated, highlighting the need for attention to the health of older adults whose spouses are suffering chronic or life-limiting illness (Williams et al., 2008). The Longitudinal Study of Aging (1984–1990) revealed that marital status was associated with the health and survival of the elderly, with widowed men at higher risk of disability compared to non-widowed individuals (Goldman et al., 1982). Additionally, a health survey (Barrenetxea et al., 2023) conducted with 15,858 Singaporean Chinese aged 61–96 showed that widowed adults had a higher risk of death, a phenomenon often referred to as the Widowhood Effect (Zhu et al., 2022; Ennis and Majid, 2021). However, the preliminary analysis of this study found that marital status alone did not affect the mortality of centenarians.

Further stratified analysis found that the loss of physical capacity was not associated with mortality among non-widowed centenarians, which may be due to the limited simple size. On the other hand, physical disability was associated with high mortility among widowed centenarians. The reasons behind this phenomenon are multifactorial, encompassing changes in biological, social, and psychological factors (Robards et al., 2012; Cornwell and Qu, 2024). For the elderly, widowhood often results in living alone, which is a known risk factor for mental health issues and can increase the likelihood of death (Yang and Gu, 2021; Chen et al., 2022; Srivastava et al., 2021). Emotional support during the first 6 months after the loss of a spouse has been shown to improve survival rates (Penninx et al., 1997). Results from the Midlife in the United States cross-sectional survey (Yuan et al., 2024) showed that the greatest improvement in physical function occurred during the transition from widowhood to non-widowhood. This underscores the vital role that marriage, as a fundamental form of social support, plays in the health of the elderly (Rodin et al., 2024). After eliminated the influence of confounding factors such as living arrangements (living with or without family members), the possiblility of external help (number of children), and the possiblility of cognitive impairment (MMSE) on survival analysis, the above results were still valid. For some centenarians with poor economic conditions, the loss of spouse means that they will not be able to handle basic daily activities. Despite external supports given by their children, guardians or caregivers, some centenarians tend to be more adaptive to the care and companionship mode of their partners (Lau et al., 2024).

This study has several limitations. Firstly, the CHCCS cohort is based exclusively on centenarians from Hainan Island, China, which is geographically isolated from other regions. As a result, the findings may not fully represent the real situation in other regions. Secondly, due to the extended duration of one-by-one surveys, some centenarians had passed away before the survey was completed. It is possible that these deceased centenarians had poor ADL scores, which could affect the accuracy of the ADL, mortality, and survival data. Thirdly, excluded participants with missing baseline data may limit generalizability, and introduce bias to the analysis. Lastly, centenarians prone to make female survival, so potential gender differences in centenarians may bias or dilute the estimated associations. Future research should focus on the influence of gender differences on survival.

This study suggested that physically disabiled centenarians exhibited the highest mortility, while physically healthy centenarians demonstrated the highest survival rate. Further survival analysis revealed that physical disability and widowhood were both predictive factors influencing the survival of centenarians. Our findings suggest that, when a centenarian was physically disabled, or lost a spouse, caregivers and social workers should prioritize the needs of the vulnerable centenarians, implementing targeted interventions to improve their quality of life.