TY - JOUR T1 - Relationship Between Expectation of Death and Location of Death Varies by Race/Ethnicity. JF - American Journal of Hospital Palliative Care Y1 - 2018 A1 - Rafael D Romo A1 - Irena Cenzer A1 - Brie A Williams A1 - Alexander K Smith KW - End of life decisions KW - Mortality KW - Racial/ethnic differences KW - Subjective Expectations AB -

BACKGROUND: Older black and Latino Americans are more likely than white Americans to die in the hospital. Whether ethnic differences in expectation of death account for this disparity is unknown.

OBJECTIVES: To determine whether surviving family members' expectation of death has a differential association with site of death according to race or ethnicity.

METHODS: We conducted an analysis of decedents from the Health and Retirement Study, a nationally representative study of US older adults. Telephone surveys were conducted with family members for 5979 decedents (decedents were 55% were women, 85% white, 9% black, and 6% Latino). The outcome of interest was death in the hospital; the predictor variable was race/ethnicity, and the intervening variable was expectation of death. Covariates included sociodemographics (gender, age, household net worth, educational attainment level, religion) and health factors (chronic conditions, symptoms, health-care utilization).

RESULTS: Decedents' race/ethnicity was statistically related to the expectation of death and death in the hospital. When death was not expected, whites and Latinos were more likely to die in the hospital than when death was expected (49% vs 29% for whites and 55% vs 37% for Latinos; P < .001). There was no difference in site of death according to family's expectation of death among blacks.

CONCLUSION: Expectation of death did not fully account for site of death and played a greater role among whites and Latinos than among black Americans. Discussing prognosis by itself is unlikely to address ethnic disparities. Other factors appear to play an important role as well.

U1 - http://www.ncbi.nlm.nih.gov/pubmed/29724110?dopt=Abstract ER - TY - JOUR T1 - How safe is your neighborhood? Perceived neighborhood safety and functional decline in older adults. JF - J Gen Intern Med Y1 - 2012 A1 - Vivien K Sun A1 - Irena Cenzer A1 - Helen Kao A1 - Cyrus Ahalt A1 - Brie A Williams KW - Activities of Daily Living KW - Aged KW - Aged, 80 and over KW - Health Status Disparities KW - Humans KW - Longitudinal Studies KW - Male KW - Middle Aged KW - Perception KW - Residence Characteristics KW - Safety KW - Surveys and Questionnaires AB -

BACKGROUND: Neighborhood characteristics are associated with health and the perception of safety is particularly important to exercise and health among older adults. Little is known about the relationship between perception of neighborhood safety and functional decline in older adults.

OBJECTIVE: To determine the relationship between perceived neighborhood safety and functional decline in older adults.

DESIGN/SETTING: Longitudinal, community-based.

PARTICIPANTS: 18,043 persons, 50 years or older, who participated in the 1998 and 2008 Health and Retirement Study.

MAIN MEASURES: The primary outcome was 10-year functional decline (new difficulty or dependence in any Activity of Daily Living, new mobility difficulty, and/or death). The primary predictor was perceived neighborhood safety categorized into three groups: "very safe", "moderately safe", and "unsafe." We evaluated the association between perceived neighborhood safety and 10-year functional decline using a modified Poisson regression to generate unadjusted and adjusted relative risks (ARR).

KEY RESULTS: At baseline 11,742 (68.0%) participants perceived their neighborhood to be very safe, 4,477 (23.3%) moderately safe, and 1,824 (8.7%) unsafe. Over 10 years, 10,338 (53.9%) participants experienced functional decline, including 6,266 (50.2%) who had perceived their neighborhood to be very safe, 2,839 (61.2%) moderately safe, and 1,233 (63.6%) unsafe, P < 0.001. For the 11,496 (63.3%) of participants who were functionally independent at baseline, perceived neighborhood safety was associated with 10-year functional decline (moderately safe ARR 1.15 95% CI 1.09-1.20; unsafe ARR 1.21 95% CI: 1.03-1.31 compared to very safe group). The relationship between perceived neighborhood safety and 10-year functional decline was not statistically significant for participants who had baseline functional impairment.

CONCLUSION: Asking older adults about their perceived neighborhood safety may provide important information about their risk of future functional decline. These findings also suggest that future studies might focus on assessing whether interventions that promote physical activity while addressing safety concerns help reduce functional decline in older adults.

VL - 27 IS - 5 U1 - http://www.ncbi.nlm.nih.gov/pubmed/22160889?dopt=Abstract U2 - PMC3326109 U4 - neighborhood Characteristics/Safety/Functional decline/Functional decline/Activities Of Daily Living/Mobility/HEALTH ER - TY - JOUR T1 - Subjective social status and functional decline in older adults. JF - J Gen Intern Med Y1 - 2012 A1 - Bonnie Chen A1 - Kenneth E Covinsky A1 - Irena Cenzer A1 - Nancy E Adler A1 - Brie A Williams KW - Activities of Daily Living KW - Aged KW - Aging KW - Female KW - Health Status Disparities KW - Humans KW - Longitudinal Studies KW - Male KW - Middle Aged KW - Mobility Limitation KW - Risk Factors KW - Self Report KW - Social Class AB -

BACKGROUND: It is unknown whether subjective assessment of social status predicts health outcomes in older adults.

OBJECTIVE: To describe the relationship between subjective social status and functional decline in older adults.

DESIGN: Longitudinal cohort study.

SETTING: The Health and Retirement Study, a nationally representative survey of community-dwelling older adults (2004-2008).

PARTICIPANTS: Two thousand five hundred and twenty-three community-dwelling older adults.

MAIN MEASURES: Self-report of social status (SSS), categorized into three groups, reported by participants who marked a 10-rung ladder to represent where they stand in society. Four-year functional decline (new difficulty in any of five activities of daily living, mobility decline and/or death)

KEY RESULTS: Mean age was 64; 46% were male, 85% were white. At baseline, lower SSS was associated with being younger, unmarried, of nonwhite race/ethnicity, higher rates of chronic medical conditions and ADL impairment (P < 0.01). Over 4 years, 50% in the lowest SSS group declined in function, compared to the middle and highest groups (28% and 26%), P-trend <0.001. Those in the lowest rungs of SSS were at increased risk of 4-year functional decline (unadjusted RR = 1.91, CI 1.-9-2.46). The relationship between a subjective belief that one is worse off than others and functional decline persisted after serial adjustment for demographics, objective SES measures, and baseline health and functional status (RR 1.36, CI 1.08-1.73).

CONCLUSIONS: In older adults, the belief that one is in the lowest rungs of social status is a measure of socioeconomic distress and of significant risk for functional decline. These findings suggest that self-report of low subjective social status may give clinicians additional information about which older adults are at high risk for future functional decline.

VL - 27 IS - 6 U1 - http://www.ncbi.nlm.nih.gov/pubmed/22215272?dopt=Abstract U2 - PMC3358399 U4 - health outcomes/socioeconomic Differences/social status/social status/functional decline/functional decline/ADL and IADL Impairments ER - TY - JOUR T1 - The epidemiology of pain during the last 2 years of life. JF - Ann Intern Med Y1 - 2010 A1 - Alexander K Smith A1 - Irena Cenzer A1 - Sara J Knight A1 - Kathleen A Puntillo A1 - Eric W Widera A1 - Brie A Williams A1 - W John Boscardin A1 - Kenneth E Covinsky KW - Aged KW - Aged, 80 and over KW - Arthritis KW - Chronic disease KW - Cross-Sectional Studies KW - Death KW - Female KW - Humans KW - Male KW - pain KW - Palliative care KW - Prevalence KW - Quality of Life KW - Socioeconomic factors KW - Terminally Ill KW - Time Factors AB -

BACKGROUND: The epidemiology of pain during the last years of life has not been well described.

OBJECTIVE: To describe the prevalence and correlates of pain during the last 2 years of life.

DESIGN: Observational study. Data from participants who died while enrolled in the Health and Retirement Study were analyzed. The survey interview closest to death was used. Each participant or proxy was interviewed once in the last 24 months of life and was classified into 1 of 24 cohorts on the basis of the number of months between the interview and death. The relationship between time before death and pain was modeled and was adjusted for age, sex, race or ethnicity, education level, net worth, income, terminal diagnosis category, presence of arthritis, and proxy status.

SETTING: The Health and Retirement Study, a nationally representative survey of community-living older adults (1994 to 2006).

PARTICIPANTS: Older adult decedents.

MEASUREMENTS: Clinically significant pain, as indicated by a report that the participant was "often troubled" by pain of at least moderate severity.

RESULTS: The sample included 4703 decedents. Mean age (SD) of participants was 75.7 years (SD, 10.8); 83.1% were white, 10.7% were black, 4.7% were Hispanic; and 52.3% were men. The adjusted prevalence of pain 24 months before death was 26% (95% CI, 23% to 30%). The prevalence remained flat until 4 months before death (28% [CI, 25% to 32%]), then it increased, reaching 46% (CI, 38% to 55%) in the last month of life. The prevalence of pain in the last month of life was 60% among patients with arthritis versus 26% among patients without arthritis (P < 0.001) and did not differ by terminal diagnosis category (cancer [45%], heart disease [48%], frailty [50%], sudden death [42%], or other causes [47%]; P = 0.195).

LIMITATION: Data are cross-sectional; 19% of responses were from proxies; and information about cause, location, and treatment of pain was not available.

CONCLUSION: Although the prevalence of pain increases in the last 4 months of life, pain is present in more than one quarter of elderly persons during the last 2 years of life. Arthritis is strongly associated with pain at the end of life.

PRIMARY FUNDING SOURCE: National Institute on Aging, National Center for Research Resources, National Institute on Musculoskeletal and Skin Diseases, and National Palliative Care Research Center.

PB - 153 VL - 153 IS - 9 U1 - http://www.ncbi.nlm.nih.gov/pubmed/21041575?dopt=Abstract U2 - PMC3150170 ER - TY - JOUR T1 - "Below average" self-assessed school performance and Alzheimer's disease in the Aging, Demographics, and Memory Study. JF - Alzheimers Dement Y1 - 2009 A1 - Kala M. Mehta A1 - Anita L Stewart A1 - Kenneth M. Langa A1 - Kristine Yaffe A1 - Sandra Y. Moody-Ayers A1 - Brie A Williams A1 - Kenneth E Covinsky KW - Aged KW - Aged, 80 and over KW - Aging KW - Alzheimer disease KW - Apolipoprotein E4 KW - Cognition Disorders KW - Educational Status KW - Female KW - Geriatric Assessment KW - Humans KW - Male KW - Memory KW - Neuropsychological tests KW - Risk Factors AB -

BACKGROUND: A low level of formal education is becoming accepted as a risk factor for Alzheimer's disease (AD). Although increasing attention has been paid to differences in educational quality, no previous studies addressed participants' own characterizations of their overall performance in school. We examined whether self-assessed school performance is associated with AD beyond the effects of educational level alone.

METHODS: Participants were drawn from the population-representative Aging, Demographics, and Memory Study (ADAMS, 2000-2002). The ADAMS participants were asked about their performance in school. Possible response options included "above average," "average," or "below average." The ADAMS participants also underwent a full neuropsychological battery, and received a research diagnosis of possible or probable AD.

RESULTS: The 725 participants (mean age, 81.8 years; 59% female; 16% African-American) varied in self-assessed educational performance: 29% reported "above average," 64% reported "average," and 7% reported "below average" school performance. Participants with a lower self-assessed school performance had higher proportions of AD: 11% of participants with "above average" self-assessed performance had AD, as opposed to 12% of participants with "average" performance and 26% of participants with "below average" performance (P < 0.001). After controlling for subjects' years in school, a literacy test score (Wide-Range Achievement Test), age, sex, race/ethnicity, apolipoprotein E-epsilon4 status, socioeconomic status, and self-reported comorbidities, respondents with "below average" self-assessed school performance were four times more likely to have AD compared with those of "average" performance (odds ratio, 4.0; 95% confidence interval, 1.2-14). "Above average" and "average" self-assessed school performance did not increase or decrease the odds of having AD (odds ratio, 0.9; 95% confidence interval, 0.5-1.7).

CONCLUSIONS: We suggest an association between "below average" self-assessed school performance and AD beyond the known association with formal education. Efforts to increase cognitive reserve through better school performance, in addition to increasing the number of years of formal education in early life, may be important in reducing vulnerability throughout the life course.

PB - 5 VL - 5 UR - http://www.sciencedirect.com/science?_ob=ArticleURLand_udi=B7W6D-4X6VH7W-7and_user=99318and_coverDate=09 2F30 2F2009and_rdoc=1and_fmt=highand_orig=searchand_origin=searchand_sort=dand_docanchor=andview=cand_acct=C000007678and_version=1and_urlVersion=0and_ IS - 5 U1 - http://www.ncbi.nlm.nih.gov/pubmed/19751917?dopt=Abstract U2 - PMC2787515 U4 - alzheimer disease/cognition Disorders/educational Status/Geriatric Assessment/neuropsychological Tests/risk Factors ER - TY - JOUR T1 - Functional limitations, socioeconomic status, and all-cause mortality in moderate alcohol drinkers. JF - J Am Geriatr Soc Y1 - 2009 A1 - Sei J. Lee A1 - Rebecca L. Sudore A1 - Brie A Williams A1 - Lindquist, Karla A1 - Helen L. Chen A1 - Kenneth E Covinsky KW - Activities of Daily Living KW - Aged KW - Alcohol Drinking KW - Comorbidity KW - Education KW - Female KW - Humans KW - Income KW - Male KW - Obesity KW - Risk Factors KW - Sex Factors KW - Smoking KW - Socioeconomic factors AB -

OBJECTIVES: To determine whether the survival benefit associated with moderate alcohol use remains after accounting for nontraditional risk factors such as socioeconomic status (SES) and functional limitations.

DESIGN: Prospective cohort.

SETTING: The Health and Retirement Study (HRS), a nationally representative study of U.S. adults aged 55 and older.

PARTICIPANTS: Twelve thousand five hundred nineteen participants were enrolled in the 2002 wave of the HRS.

MEASUREMENTS: Participants were asked about their alcohol use, functional limitations (activities of daily living, instrumental activities of daily living, and mobility), SES (education, income, and wealth), psychosocial factors (depressive symptoms, social support, and the importance of religion), age, sex, race and ethnicity, smoking, obesity, and comorbidities. Death by December 31, 2006, was the outcome measure.

RESULTS: Moderate drinkers (1 drink/d) had a markedly more-favorable risk factor profile, with higher SES and fewer functional limitations. After adjusting for demographic factors, moderate drinking (vs no drinking) was strongly associated with less mortality (odds ratio (OR)=0.50, 95% confidence interval (CI)=0.40-0.62). When traditional risk factors (smoking, obesity, and comorbidities) were also adjusted for, the protective effect was slightly attenuated (OR=0.57, 95% CI=0.46-0.72). When all risk factors including functional status and SES were adjusted for, the protective effect was markedly attenuated but still statistically significant (OR=0.72, 95% CI=0.57-0.91).

CONCLUSION: Moderate drinkers have better risk factor profiles than nondrinkers, including higher SES and fewer functional limitations. Although these factors explain much of the survival advantage associated with moderate alcohol use, moderate drinkers maintain their survival advantage even after adjustment for these factors.

PB - 57 VL - 57 IS - 6 U1 - http://www.ncbi.nlm.nih.gov/pubmed/19473456?dopt=Abstract U2 - PMC2847409 U4 - Alcohol Drinking/socioeconomic status/ADL and IADL Impairments/Mobility/Survival Analysis ER - TY - JOUR T1 - Screening mammography in older women. Effect of wealth and prognosis. JF - Arch Intern Med Y1 - 2008 A1 - Brie A Williams A1 - Lindquist, Karla A1 - Rebecca L. Sudore A1 - Kenneth E Covinsky A1 - Louise C Walter KW - Aged KW - Breast Neoplasms KW - Chi-Square Distribution KW - Female KW - Humans KW - Longitudinal Studies KW - Mammography KW - Mass Screening KW - Prognosis KW - Risk Factors KW - Social Class AB -

BACKGROUND: Wealthy women have higher rates of screening mammography than poor women do. Screening mammography is beneficial for women with substantial life expectancies, but women with limited life expectancies are unlikely to benefit. It is unknown whether higher screening rates in wealthy women are due to increased screening in women with substantial life expectancies, limited life expectancies, or both. This study examines the relationship between wealth and screening mammography use in older women according to life expectancy.

METHODS: A cohort study was performed of 4222 women 65 years or older with Medicare participating in the 2002 and 2004 Health and Retirement Survey. Women were categorized according to wealth and life expectancy (based on 5-year prognosis from a validated prognostic index). The outcome was self-reported receipt of screening mammography within 2 years.

RESULTS: Overall, within 2 years, 68% of women (2871 of 4222) received a screening mammogram. Screening was associated with wealth (net worth, > $100 000) and good prognosis (< or = 10% probability of dying in 5 years). Screening mammography was more common among wealthy women than among poor women (net worth, < $10 000) both for women with good prognosis (82% vs 68%; P < .001) and for women with limited prognoses (> or = 50% probability of dying in 5 years) (48% vs 32%; P = .02). These associations remained after multivariate analysis accounting for age, race, education, proxy report, and rural residence.

CONCLUSIONS: Poorer older women with favorable prognoses are at risk of not receiving screening mammography when they are likely to benefit. Wealthier older women with limited prognoses are often screened when they are unlikely to benefit.

PB - 168 VL - 168 IS - 5 U1 - http://www.ncbi.nlm.nih.gov/pubmed/18332298?dopt=Abstract U3 - 18332298 U4 - Mammography/WOMEN/life Expectancy/Wealth/methodology/risk factors ER - TY - JOUR T1 - Should health studies measure wealth? A systematic review. JF - Am J Prev Med Y1 - 2007 A1 - Craig E Pollack A1 - Chideya, Sekai A1 - Cubbin, Catherine A1 - Brie A Williams A1 - Dekker, Mercedes A1 - Paula Braveman KW - Bias KW - Biomedical Research KW - Female KW - Financing, Personal KW - Health Services Research KW - Health Status Indicators KW - Humans KW - Male KW - Research Design KW - Socioeconomic factors AB -

BACKGROUND: Health researchers rarely measure accumulated wealth to reflect socioeconomic status/position (SES). In order to determine whether health research should more frequently include measures of wealth, this study assessed the relationship between wealth and health.

METHODS: Studies published between 1990 to 2006 were systematically reviewed. Included studies used wealth and at least one other SES measure as independent variables, and a health-related dependent variable.

RESULTS: Twenty-nine studies met inclusion criteria. Measures of wealth varied greatly. In most studies, greater wealth was associated with better health, even after adjusting for other SES measures. The findings appeared most consistent when using detailed wealth measures on specific assets and debts, rather than a single question. Adjusting for wealth generally decreased observed racial/ethnic disparities in health.

CONCLUSIONS: Health studies should include wealth as an important SES indicator. Failure to measure wealth may result in under-estimating the contribution of SES to health, such as when studying the etiology of racial/ethnic disparities. Validation is needed for simpler approaches to measuring wealth that would be feasible in health studies.

PB - 33 VL - 33 IS - 3 U1 - http://www.ncbi.nlm.nih.gov/pubmed/17826585?dopt=Abstract U4 - Health Care Surveys/HEALTH/Wealth/socioeconomic status ER - TY - JOUR T1 - Functional impairment, race, and family expectations of death. JF - J Am Geriatr Soc Y1 - 2006 A1 - Brie A Williams A1 - Lindquist, Karla A1 - Sandra Y. Moody-Ayers A1 - Louise C Walter A1 - Kenneth E Covinsky KW - Activities of Daily Living KW - Aged KW - Attitude to Death KW - Black or African American KW - Cross-Sectional Studies KW - Disabled Persons KW - Family KW - Female KW - Hispanic or Latino KW - Humans KW - Male KW - White People AB -

OBJECTIVES: To assess the effect of functional impairment on family expectations of death and to examine how this association varies by race.

DESIGN: Cross-sectional.

SETTING: Community based.

PARTICIPANTS: Two thousand two hundred thirty-seven family members of decedents from the Health and Retirement Survey (HRS), a national study of persons aged 50 and older.

MEASUREMENTS: Families were interviewed within 2 years of the HRS participant's death. The primary outcome was whether death was expected. The primary predictors were the decedent's functional status (impairment in any activity of daily living (ADL; eating, dressing, transferring, toileting, or bathing) during the last 3 months of life and the decedent's race.

RESULTS: Overall, 58% of families reported that their family member's death was expected. Expecting death was strongly associated with functional impairment; 71% of families of decedents with ADL disability expected death, compared with 24% of those without ADL disability (P < .01). Death was expected more often in families of white decedents (60%) than African Americans (49%) (P < .01), although the effect of ADL disability was similar in both groups. After adjustment for potentially confounding factors, there were still significant associations between expecting death and functional impairment (odds ratio (OR) = 3.58, 95% confidence interval (CI) 2.73-4.70), and families of African Americans expected death less often than families of white decedents (OR = 0.63, 95% CI = 0.46-0.86).

CONCLUSION: Family members of older adults expected death only 58% of the time. Families of functionally impaired older people were more likely to expect death when it occurred than were families of older people who were not functionally impaired, and the expectation of death was lower for families of African Americans than for whites.

PB - 54 VL - 54 IS - 11 U1 - http://www.ncbi.nlm.nih.gov/pubmed/17087694?dopt=Abstract U4 - Activities of Daily Living/Minorities/Hispanic/African Americans/functional impairment/expectations/death ER -