Depression among older adults in the United States and England. - Zivin, Kara; David J Llewellyn; Iain A Lang; Sandeep Vijan; Mohammed U Kabeto; Erin M Miller; Kenneth M. Langa (Am J Geriatr Psychiatry, 2010)
CONTEXT: Depression negatively affects health and well being among older adults, but there have been no nationally representative comparisons of depression prevalence among older adults in England and the United States. OBJECTIVE: The authors sought to compare depressive symptoms among older adults in these countries and identify sociodemographic and clinical correlates of depression in these countries. DESIGN AND SETTING: The authors assessed depressive symptoms in non-Hispanic whites aged 65 years and older in 2002 in two nationally representative, population-based studies: the U.S. Health and Retirement Study and English Longitudinal Study of Ageing. PARTICIPANTS: A total of 8,295 Health and Retirement Study respondents and 5,208 English Longitudinal Study of Ageing respondents. MAIN OUTCOME MEASURES: The authors measured depressive symptoms using the eight-item Center for Epidemiologic Studies Depression Scale. The authors determined whether depressive symptom differences between the United States and England were associated with sociodemographic characteristics, chronic health conditions, and health behaviors. RESULTS: Significant depressive symptoms (Center for Epidemiologic Studies Depression Scale score ≥4) were more prevalent in English than U.S. adults (17.6% versus 14.6%, adjusted Wald test F([1, 1593]) = 11.4, p < 0.001). Adjusted rates of depressive symptoms in England were 19% higher compared with the United States (odds ratio: 1.19, 95% confidence interval: 1.01-1.40). U.S. adults had higher levels of education, and net worth, but lower levels of activities of daily living/instrumental activities of daily living impairments, tobacco use, and cognitive impairment, which may have contributed to relatively lower levels of depressive symptoms in the United States. CONCLUSIONS: Older adults in the United States had lower rates of depressive symptoms than their English counterparts despite having more chronic health conditions. Future cross-national studies should identify how depression treatment influences outcomes in these populations.
Keywords: Aged; Aged, 80 and over; depression; England; Female; Health Behavior; Health Status; Health Surveys; Humans; Male; Prevalence; Risk Factors; United States; White People

Depressive symptoms in middle age and the development of later-life functional limitations: the long-term effect of depressive symptoms. - Kenneth E Covinsky; Kristine Yaffe; Lindquist, Karla; Cherkasova, Elena; Yelin, Edward; Dan G. Blazer (J Am Geriatr Soc, 2010)
OBJECTIVES: To determine whether middle-aged persons with depressive symptoms are at higher risk for developing activity of daily living (ADL) and mobility limitations as they advance into older age than those without. DESIGN: Prospective cohort study. SETTING: The Health and Retirement Study (HRS), a nationally representative sample of people aged 50 to 61. PARTICIPANTS: Seven thousand two hundred seven community living participants in the 1992 wave of the HRS. MEASUREMENTS: Depressive symptoms were measured using the 11-item Center for Epidemiologic Studies Depression Scale (CES-D 11), with scores of 9 or more (out of 33) classified as significant depressive symptoms. Difficulty with five ADLs and basic mobility tasks (walking several blocks or up one flight of stairs) was measured every 2 years through 2006. The primary outcome was persistent difficulty with ADLs or mobility, defined as difficulty in two consecutive waves. RESULTS: Eight hundred eighty-seven (12%) subjects scored 9 or higher on the CES-D 11 and were classified as having significant depressive symptoms. Over 12 years of follow-up, subjects with depressive symptoms were more likely to reach the primary outcome measure of persistent difficulty with mobility or difficulty with ADL function (45% vs 23%, Cox hazard ratio (HR)=2.33, 95% confidence interval (CI)=2.06-2.63). After adjusting for age, sex, measures of socioeconomic status, comorbid conditions, high body mass index, smoking, exercise, difficulty jogging 1 mile, and difficulty climbing several flights of stairs, the risk was attenuated but still statistically significant (Cox HR=1.44, 95% CI=1.25-1.66). CONCLUSION: Depressive symptoms independently predict the development of persistent limitations in ADLs and mobility as middle-aged persons advance into later life. Middle-aged persons with depressive symptoms may be at greater risk for losing their functional independence as they age.
Keywords: Activities of Daily Living; depression; Female; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Mobility Limitation; Proportional Hazards Models; Prospective Studies; Risk Factors; United States

Depressive symptoms predict incident stroke independently of memory impairments. - M. Maria Glymour; J Maselko; Gilman, S E; Kristen K Patton; Mauricio Avendano (Neurology, 2010)
BACKGROUND: We evaluated whether depressive symptoms predict the onset of first stroke independently of memory impairment. We conceptualized memory impairment as a marker of preexisting cerebrovascular disease. We hypothesized that if depressive symptoms are causally related to stroke through mechanisms unrelated to cerebrovascular disease, depressive symptoms should predict stroke independently of memory impairment. METHODS: Incidence of first stroke was assessed with self or proxy reports from 19,087 participants in the Health and Retirement Study cohort (1,864 events). Elevated depressive symptoms (3+ on an 8-item Centers for the Epidemiologic Study of Depression scale) and memory impairment (score of ≤6 on a combined immediate and delayed recall of a 10-word list) were used as predictors of incident stroke in Cox survival models with adjustment for sociodemographic and cardiovascular risk factors. RESULTS: After adjustment for sociodemographic and cardiovascular risk factors, elevated depressive symptoms (hazard ratio = 1.25; 95% confidence interval 1.12-1.39) and memory impairment (hazard ratio = 1.26; 95% confidence interval 1.13-1.41) each predicted stroke incidence in separate models. Hazard ratios were nearly unchanged and remained significant (1.23 for elevated depressive symptoms and 1.25 for memory impairment) when models were simultaneously adjusted for both elevated depressive symptoms and memory impairment. Elevated depressive symptoms also predicted stroke when restricting analyses to individuals with median memory score or better. CONCLUSIONS: Memory impairments and depressive symptoms independently predict stroke incidence. Memory impairment may reflect undiagnosed cerebrovascular disease. These results suggest that depressive symptoms might be directly related to stroke rather than merely indicating preexisting cerebrovascular disease.
Glymour, M M Maselko, J Gilman, S E Patton, K K Avendano, M 1R01MH087544/MH/NIMH NIH HHS/United States 1R21 AG34385-01A1/AG/NIA NIH HHS/United States 1R21AG037889-01/AG/NIA NIH HHS/United States 1R21HD066312-01/HD/NICHD NIH HHS/United States 1RC4MH092707-01/MH/NIMH NIH HHS/United States 5R03MH083335/MH/NIMH NIH HHS/United States Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov't United States Neurology Neurology. 2010 Dec 7;75(23):2063-70.
Keywords: Aged; Aged, 80 and over; depression; Female; Health Surveys; Humans; Incidence; Kaplan-Meier Estimate; Longitudinal Studies; Male; Memory Disorders; Middle Aged; Neuropsychological tests; Predictive Value of Tests; Risk Factors; Statistics, Nonparametric; Stroke; United States

Diabetes-related support, regimen adherence, and health decline among older adults. - Emily J Nicklett; Jersey Liang (J Gerontol B Psychol Sci Soc Sci, 2010)
UNLABELLED: OBJECTIVES. Social support is generally conceptualized as health promoting; however, there is little consensus regarding the mechanisms through which support is protective. Illness support has been proposed to promote regimen adherence and subsequent prevention of health decline. We hypothesize that (a) support for regimen adherence is negatively associated with self-reported health decline among older diabetic adults and that (b) regimen adherence is negatively associated with health decline among older diabetic adults. METHODS: We used the Health and Retirement Study data on individuals over the age of 60 years with type 2 diabetes mellitus (n = 1,788), examining change in self-reported health status over a 2-year period using binomial and cumulative ordinal logistic regression models. RESULTS: Diabetic support is not significantly associated with health decline, but it is strongly associated with adherence to health-promoting activities consisting of a diabetic regimen. Therefore, the extent to which one receives illness support for a given regimen component is highly positively associated with adhering to that component, although this adherence does not necessarily translate into protection against perceived decline in health. CONCLUSIONS: Illness-related support appears to be a mechanism through which social support matters in the diabetic population. Although this relationship did not extend to prevention of health status decline among diabetics, the relationship between support and illness management is promising.
Keywords: Activities of Daily Living; Aged; Diabetes Mellitus, Type 2; Disability Evaluation; Female; Health Behavior; Health Status; Humans; Longitudinal Studies; Male; Middle Aged; Patient Compliance; Quality of Life; Social Support; Surveys and Questionnaires; United States

Direct and indirect effects of obesity on U.S. labor market outcomes of older working age adults. - F. Renna; Thakur, Nidhi (Soc Sci Med, 2010)
In this paper, we study the impact of obesity on labor market decisions of older working age adults in USA. Labor market outcomes are defined as any one of three: working; not working due to a disability; or not working due to an early retirement. Based on existing medical literature, we deduce that obesity can largely impact labor market decisions directly through impairment of bodily functions and indirectly by being a risk factor for various diseases like hypertension, arthritis, etc. We use data from the US Health and Retirement Study on older adults who were no more than 64 years of age in 2002. In our modeling effort, we employ two estimation strategies. We first estimate a model in which employment outcome in 2002 is a function of weight status in 1992. In the second strategy, controlling for time-invariant individual heterogeneity, we first consider the impact of obesity on bodily impairments and chronic illnesses; then, we consider the impact of such impairments and illnesses on labor market outcomes. Our results indicate that, for men, obesity class 2 and 3 increases both the probability of taking an early retirement and the incidence of disability by 1.5 percentage points. For women, we find that obesity class 2 and 3 increases the probability of taking an early retirement by 2.5 percentage points and the incidence of disability by 1.7 percentage points.
Using Smart Source Parsing pp. Jul Elsevier Science, Amsterdam The Netherlands
Keywords: Chronic disease; Disabled Persons; Employment; Female; Humans; Male; Middle Aged; Obesity; Retirement; Risk Factors; Sex Factors; United States

Dynamics and heterogeneity in the process of human frailty and aging: evidence from the U.S. older adult population. - Yang, Yang; Lee, Linda C (J Gerontol B Psychol Sci Soc Sci, 2010)
OBJECTIVES: This study investigated the dynamics and heterogeneity of the frailty index (FI) conceived as a systemic indicator of biological aging in the community-dwelling older adult population in the United States. METHODS: We used panel data on multiple birth cohorts from the Health and Retirement Survey 1993-2006 and growth curve models to estimate age trajectories of the FI and their differences by sex, race, and socioeconomic status (SES) within cohorts. RESULTS: The FI for cohorts born before 1942 exhibit quadratic increases with age and accelerated increases in the accumulation of health deficits. More recent cohorts exhibit higher average levels of and rates of increment in the FI than their predecessors do at the same ages. Females, non-Whites, and individuals with low education and income exhibit greater degrees of physiological deregulation than their male, White, and high-SES counterparts at any age. Patterns of sex, race, and SES differentials in rates of aging vary across cohorts. DISCUSSION: Adjusting for social behavioral factors, the analysis provides evidence for physiological differences in the aging process among recent cohorts of older adults, points to the need for biological explanations of female excess in general system damage, and reveals the insufficiency of any single mechanism for depicting the racial and SES differences in the process of physiological deterioration.
Keywords: Aged; Aged, 80 and over; Aging; Cohort Studies; Female; Frail Elderly; Humans; Male; Surveys and Questionnaires; United States

Early-life characteristics, psychiatric history, and cognition trajectories in later life. - Maria T. Brown (Gerontologist, 2010)
PURPOSE OF THE STUDY: Although considerable attention has been paid to the relationship between later-life depression and cognitive function, the relationship between a history of psychiatric problems and cognitive function is not very well documented. Few studies of relationships between childhood health, childhood disadvantage, and cognitive function in later life consider both childhood health and disadvantage, include measures for psychiatric history, or use nationally representative longitudinal data. DESIGN AND METHODS: This study uses growth curve models to analyze the relationships between childhood health and disadvantage, psychiatric history, and cognitive function using 6 waves of the Health and Retirement Study, controlling for demographics, health behavior, and health status. RESULTS: A history of psychiatric problems is associated with lower cognitive function and steeper declines in cognitive function with age. The influence of childhood health is mediated by later-life health status and behaviors. A combined history of childhood disadvantage and psychiatric problems more strongly affects cognitive function, but cognitive declines remain consistent with those associated with psychiatric history. These effects are partially mediated by later-life demographic, socioeconomic, or health characteristics. IMPLICATIONS: These findings demonstrate that cumulative disadvantage and a history of psychiatric problems shape later-life cognition and cognitive decline. This evidence can enhance public understanding of the trajectories of cognitive decline experienced by groups living with disadvantage and can enable policy makers and human services providers to better design and implement preventative interventions and support services for affected populations.
Using Smart Source Parsing pp. Oct Gerontological Society of America, Washington DC
Keywords: Aged; Aged, 80 and over; Aging; Cognition; Cognition Disorders; Cohort Studies; Female; Health Status; Humans; Male; Mental Disorders; Middle Aged; Psychiatric Status Rating Scales; Social Environment; Socioeconomic factors; Time Factors

Education and physical activity mediate the relationship between ethnicity and cognitive function in late middle-aged adults. - Meredith C. Masel; Raji, Mukaila; M. Kristen Peek (Ethn Health, 2010)
OBJECTIVE: Minority status has been implicated as a risk factor for disparate scores on cognitive function tests in older adults. Research on ethnicity and cognitive function has yielded socioeconomic status, particularly education, as a primary reason for the discrepancy. Other factors, such as physical activity may provide insight into the relationship. Despite this knowledge, few studies have thoroughly examined the mediating characteristics of education or physical activity in the relationship between ethnicity and cognitive function in younger aged groups. Most research conducted focuses only on older adults during a time when degeneration of brain tissue may complicate the exploration of the relationships among ethnicity and cognitive function. The current research will expand existing knowledge about education, physical activity, and cognitive function in minority groups. DESIGN: The study presents data from the Health and Retirement Study, a nationally representative sample of late middle-aged White, Black, and Hispanic adults (n=9204, mean age+/-SD = 55.8+/-3.1). Regression and mediation testing determined the mediating effects of education and physical activity in the relationship between ethnicity and cognitive function. RESULTS: Significant association between White ethnicity and higher scores on cognitive tests was evident as early as late middle age. The magnitude of the association significantly diminished on adjusting for education and leisure time physical activity. CONCLUSION: Our data suggest a potential mediating role of education and physical activity on the ethnic differences in cognitive tests in late middle-aged White, Black, and Hispanic adults. Our findings suggest a need for studies to understand if adult education and culturally appropriate physical activity interventions in middle age influence ethnic disparities in prevalence of cognitive impairment in old age.
Using Smart Source Parsing pp. Jun Taylor and Francis, Abingdon UK
Keywords: Black People; Body Mass Index; Brief Psychiatric Rating Scale; Cognition Disorders; Educational Status; Exercise; Female; Health Status; Hispanic or Latino; Humans; Longitudinal Studies; Male; Memory Disorders; Middle Aged; United States; White People

The effects of positive and negative support from children on widowed older adults' psychological adjustment: a longitudinal analysis. - Jung-Hwa Ha (Gerontologist, 2010)
PURPOSE: This article examines the extent to which positive and negative support from children prior to and after spousal loss and changes in support from pre- to post-loss affect widowed older adults' depressive symptoms, anxiety, and anger 18 months following widowhood. DESIGN AND METHODS: Analyses are based on the Changing Lives of Older Couples, a prospective study of 1,532 married individuals aged 65 years and older. The analytic sample includes 148 widowed persons who have at least one living child and participated in the baseline and two follow-up interviews conducted 6 and 18 months following widowhood. RESULTS: The analyses revealed that higher levels of positive support from children 6 months following widowhood were associated with fewer depressive symptoms at the 18-month follow-up, whereas higher levels of negative support 18 months after loss and a decrease in positive support following loss were associated with more depressive symptoms. Greater negative support both prior to and after loss was associated with greater anxiety, whereas greater negative support 6 months after loss and an increase in negative support following loss were related to greater anger. IMPLICATIONS: Given their differential impact on widowed persons' psychological adjustment, both positive and negative aspects of social support as well as its changing nature should be considered in working with bereaved older adults.
Using Smart Source Parsing pp. Aug Gerontological Society of America, Washington DC
Keywords: Adaptation, Psychological; Aged; Aged, 80 and over; Female; Humans; Longitudinal Studies; Male; Middle Aged; Parent-Child Relations; Widowhood

The epidemiology of pain during the last 2 years of life. - Alexander K Smith; Irena Cenzer; Sara J Knight; Kathleen A Puntillo; Eric W Widera; Brie A Williams; W John Boscardin; Kenneth E Covinsky (Ann Intern Med, 2010)
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.
Keywords: Aged; Aged, 80 and over; Arthritis; Chronic disease; Cross-Sectional Studies; Death; Female; Humans; Male; pain; Palliative care; Prevalence; Quality of Life; Socioeconomic factors; Terminally Ill; Time Factors

Ethnicity and changing functional health in middle and late life: a person-centered approach. - Jersey Liang; Xiao Xu; Joan M. Bennett; Wen Ye; Ana R Quiñones (J Gerontol B Psychol Sci Soc Sci, 2010)
OBJECTIVES: Following a person-centered approach, this research aims to depict distinct courses of disability and to ascertain how the probabilities of experiencing these trajectories vary across Black, Hispanic, and White middle-aged and older Americans. METHODS: Data came from the 1995-2006 Health and Retirement Study, which involved a national sample of 18,486 Americans older than 50 years of age. Group-based semiparametric mixture models (Proc Traj) were used for data analysis. RESULTS: Five trajectories were identified: (a) excellent functional health (61%), (b) good functional health with small increasing disability (25%), (c) accelerated increase in disability (7%), (d) high but stable disability (4%), and (e) persistent severe impairment (3%). However, when time-varying covariates (e.g., martial status and health conditions) were controlled, only 3 trajectories emerged: (a) healthy functioning (53%), moderate functional decrement (40%), and (c) large functional decrement (8%). Black and Hispanic Americans had significantly higher probabilities than White Americans in experiencing poor functional health trajectories, with Blacks at greater risks than Hispanics. CONCLUSIONS: Parallel to the concepts of successful aging, usual aging, and pathological aging, there exist distinct courses of changing functional health over time. The mechanisms underlying changes in disability may vary between Black and Hispanic Americans.
Keywords: Age Factors; Aged; Black or African American; Disabled Persons; disease progression; ethnicity; Female; Health Status; Health Status Disparities; Health Surveys; Hispanic or Latino; Humans; Likelihood Functions; Male; Marital Status; Middle Aged; Time Factors; United States; White People

Evolving self-rated health in middle and old age: how does it differ across Black, Hispanic, and White Americans? - Jersey Liang; A. R. Quinones; Joan M. Bennett; Wen Ye; Xiao Xu; Benjamin A Shaw; Mary Beth Ofstedal (J Aging Health, 2010)
OBJECTIVE: This research focuses on ethnic variations in the intraindividual changes in self-rated health. METHOD: Data came from the Health and Retirement Study involving up to 6 repeated observations between 1995 and 2006 of a national sample of 18,486 Americans above 50 years of age. Hierarchical linear models were employed in depicting variations in self-rated health across White, Black, and Hispanic Americans. RESULTS: Subjective health worsened over time albeit moderately. Relative to younger persons, older individuals rated their health poorer with a greater rate of deteriorating health. With reference to ethnic variations in the intercept and slope of perceived health, White Americans rated their health most positively, followed by Black Americans, with Hispanics rating their health least positively. This pattern held even when socioeconomic status, social networks, and prior health were adjusted. DISCUSSION: Significant ethnic differences exist in the evolvement of self-rated health in middle and late life. Further inquiries may include analyzing ethnic heterogeneities from a person-centered perspective, health disparities across subgroups of Hispanics, effects of neighborhood attributes, and implications of left truncation.
Keywords: Age Factors; Aged; Aging; Black or African American; Diagnostic Self Evaluation; Female; Health Status Disparities; Hispanic or Latino; Humans; Linear Models; Male; Middle Aged; United States; White People

An examination of older immigrants' use of dental services in the United States. - Christina N Anderson; Hyungsoo Kim (J Aging Soc Policy, 2010)
The recent influx of immigrants aged 65 and older in the United States triggers an increasing need to understand older immigrants' dental services use. This paper uses data (n = 9,617) from the 2004 and 2006 waves of the Health and Retirement Study to examine the dental services use of older Americans. In particular, this study focuses on differences in dental services use between immigrants and natives and potential contributing factors. Multivariate logistic regression analyses showed, contrary to expectation, that older immigrants were more likely to use dental services than older natives despite numerous barriers (odds ratio = 1.30 in 2004). The results in 2006 confirmed these findings. The results from 2004 and 2006 analyses showed dental insurance coverage, sex, and marital status were associated differently with dental services use for immigrants and natives. Implications for current oral health policies and future research of older Americans are discussed, as well as methods for meeting older immigrants' growing dental services needs.
Keywords: Age Factors; Aged; Dental Care for Aged; Educational Status; Emigrants and Immigrants; Female; Health Services Accessibility; Humans; Insurance, Dental; Logistic Models; Longitudinal Studies; Male; Marital Status; Middle Aged; Multivariate Analysis; Sex Factors; Socioeconomic factors; United States

Factors influencing cost-related nonadherence to medication in older adults: a conceptually based approach. - Zivin, Kara; Scott M Ratliff; Michele M Heisler; Kenneth M. Langa; John D Piette (Value Health, 2010)
OBJECTIVE: Although multiple noncost factors likely influence a patient's propensity to forego treatment in the face of cost pressures, little is known about how patients' sociodemographic characteristics, physical and behavioral health comorbidities, and prescription regimens influence cost-related nonadherence (CRN) to medications. We sought to determine both financial and nonfinancial factors associated with CRN in a nationally representative sample of older adults. METHODS: We used a conceptual model developed by Piette and colleagues that describes financial and nonfinancial factors that could increase someone's risk of CRN, including income, comorbidities, and medication regimen complexity. We used data from the 2004 wave of the Health and Retirement Study and the 2005 HRS Prescription Drug Study to examine the influence of factors within each of these domains on measures of CRN (including not filling, stopping, or skipping doses) in a nationally representative sample of Americans age 65+ in 2005. RESULTS: Of the 3071 respondents who met study criteria, 20% reported some form of CRN in 2005. As in prior studies, indicators of financial stress such as higher out-of-pocket payments for medications and lower net worth were significantly associated with CRN in multivariable analyses. Controlling for these economic pressures, relatively younger respondents (ages 65-74) and depressive symptoms were consistent independent risk factors for CRN. CONCLUSIONS: Noncost factors influenced patients' propensity to forego treatment even in the context of cost concerns. Future research encompassing clinician and health system factors should identify additional determinants of CRN beyond patients' cost pressures.
Keywords: Aged; Aged, 80 and over; Chronic disease; Female; Financing, Personal; Health Status; Humans; Logistic Models; Male; Medication Adherence; Models, Econometric; Multivariate Analysis; Prescription Fees; Risk Factors; Socioeconomic factors; United States

Factors predicting glycemic control in middle-aged and older adults with type 2 diabetes. - Chiu, Ching-Ju; Linda A. Wray (Prev Chronic Dis, 2010)
INTRODUCTION: Few studies have prospectively assessed the explanatory effects of demographics, clinical conditions, treatment modality, and general lifestyle behaviors on glycemic control in large heterogeneous samples of middle-aged and older adults with type 2 diabetes. We hierarchically examined these factors, focused especially on the effects of modifiable factors (ie, general lifestyle behaviors), and compared predictive patterns between middle-aged and older adults. METHODS: We used nationally representative data from the 1998 and 2000 Health and Retirement Study (HRS) and the HRS 2003 Diabetes Study. We analyzed data from 379 middle-aged adults (aged 51-64 y) and 430 older adults (aged >or=65 y) who self-reported having type 2 diabetes at baseline. RESULTS: Among middle-aged adults, demographic factors and clinical conditions were the strongest predictors of hemoglobin A1c (HbA1c) levels. However, among older adults, treatment modality (diet only, oral medication, or insulin only or in combination with other regimens) significantly affected HbA1c levels. Lifestyle (physical activity, smoking, drinking, and body weight control), independent of the effects of demographics, clinical conditions, and treatment modality, significantly affected HbA1c levels. An increase of 1 healthy behavior was associated with a decrease in HbA1c levels of more than 1 percentage point. CONCLUSION: Our findings provide support for current diabetes guidelines that recommend a lifestyle regimen across the entire span of diabetes care and highlight the need to help both sociodemographically and clinically disadvantaged middle-aged adults with type 2 diabetes as well as older adults who exhibit poor adherence to medication recommendations to achieve better glycemic control.
Using Smart Source Parsing Jan, :A08 Index Medicus
Keywords: Age Factors; Aged; Blood Glucose; Diabetes Mellitus, Type 2; Female; Glycated Hemoglobin; Humans; Hypoglycemic Agents; Male; Middle Aged; Retrospective Studies; Socioeconomic factors

Functional declines, social support, and mental health in the elderly: does living in a state supportive of home and community-based services make a difference? - Muramatsu, Naoko; yin, Hongjun; Hedeker, Donald (Soc Sci Med, 2010)
This study examines how acute and chronic stresses associated with functional declines in seniors and their spouses are moderated by their informal and formal support contexts. In the United States, states vary greatly in their support for home and community-based services (HCBS) for seniors with disabilities. This state-to-state variation allowed us to examine mental health effects of living in a society supportive of HCBS for the oldest old, who are at high risk for low or declining functions in daily activities and cognitive abilities. Using a ten-year panel study of a nationally representative sample of the oldest old (>or=70 years old) covering the period 1993-2002, we conducted mixed-effects logistic regression analysis to incorporate time-varying characteristics of persons and states. As expected, low and declining functions in daily living and cognition constituted significant stressors among seniors and their spouse. Results demonstrated the important role of informal support available from non-spouse family/friends in lowering depression. Living in a state supportive of HCBS was associated with lower depression among seniors experiencing consistently low levels of function or recent functional declines, especially among those without informal support. Our findings were consistent with moderating or buffering models of formal support, suggesting that state HCBS support is effective mainly under conditions of high levels of stressors. Political will is needed to prepare US society to collectively support community-based long-term needs, given the difficulty of preparing ourselves fully for common, but often unexpected, functional declines in later life.
Keywords: Activities of Daily Living; Aged; Cognition; Community Health Services; depression; Disabled Persons; Female; Home Care Services; Humans; Logistic Models; Male; Mental Health; Multilevel Analysis; Risk Factors; Social Support; Spouses; State Government; Stress, Psychological; United States

Health outcomes of Experience Corps: a high-commitment volunteer program. - S I Hong; Morrow-Howell, Nancy (Soc Sci Med, 2010)
Experience Corps (EC) is a high-commitment US volunteer program that brings older adults into public elementary schools to improve academic achievement of students. It is viewed as a health promotion program for the older volunteers. We evaluated the effects of the EC program on older adults' health, using a quasi-experimental design. We included volunteers from 17 EC sites across the US. They were pre-tested before beginning their volunteer work and post-tested after two years of service. We compared changes over time between the EC participants (n = 167) and a matched comparison group of people from the US Health and Retirement Study (2004, 2006). We developed the comparison group by using the nearest available Mahalanobis metric matching within calipers combined with the boosted propensity scores of those participating in the EC. We corrected for clustering effects via survey regression analyses with robust standard errors and calculated adjusted post-test means of health outcomes, controlling for all covariates and the boosted propensity score of EC participants. We found that compared to the comparison group, the EC group reported fewer depressive symptoms and functional limitations after two years of participation in the program, and there was a statistical trend toward the EC group reporting less decline in self-rated health. Results of this study add to the evidence supporting high-intensity volunteering as a social model of health promotion for older adults.
Using Smart Source Parsing pp. Jul Elsevier Science, Amsterdam The Netherlands
Keywords: Activities of Daily Living; Aged; Aged, 80 and over; depression; Female; Health Promotion; Health Status; Humans; Male; Middle Aged; Program Evaluation; Regression Analysis; Self Concept; Volunteers

Health trajectories among older movers. - Janet M Wilmoth (J Aging Health, 2010)
OBJECTIVE: To examine health trajectories among older migrants by reason for move. METHOD: Data from the 1992 to 2006 Health and Retirement Study (HRS) are used to model trajectories of self-rated health and activity of daily living (ADL) limitations that occurred prior seven types of moves. RESULTS: There are substantial differences across the reason-for-move groups in initial levels of self-rated health. Declines in self-rated health among nursing home movers are more than two times steeper than the other reason-for-move groups. Employment, comfort, economic security, life crisis, and affiliation movers have low initial levels of ADL limitations and slow increases in ADL limitations. Health and nursing home movers have higher initial ADL limitations and increases in ADL limitations that are three and seven times higher respectively than the other groups. DISCUSSION: The results are consistent with the predictions of Litwak and Longino's (1987) typology of later-life migration and the extant literature on later-life migration. Implications for communities are considered.
Keywords: Activities of Daily Living; Age Factors; Aged; Aged, 80 and over; Aging; Female; Health Status; Humans; Male; Middle Aged; Multivariate Analysis; Regression Analysis; Social Class; Transients and Migrants

Hospitalizations and deaths among adults with cardiovascular disease who underuse medications because of cost: a longitudinal analysis. - Michele M Heisler; Choi, Hwajung; Allison B Rosen; Sandeep Vijan; Mohammed U Kabeto; Kenneth M. Langa; John D Piette (Med Care, 2010)
CONTEXT: It is well-documented that the financial burden of out-of-pocket expenditures for prescription drugs often leads people with medication-sensitive chronic illnesses to restrict their use of these medications. Less is known about the extent to which such cost-related medication underuse is associated with increases in subsequent hospitalizations and deaths. OBJECTIVE: We compared the risk of hospitalizations among 5401 and of death among 6135 middle-aged and elderly adults with one or more cardiovascular diseases (diabetes, coronary artery disease, heart failure, and history of stroke) according to whether participants did or did not report restricting prescription medications because of cost. DESIGN AND SETTING: A retrospective biannual cohort study across 4 cross-sectional waves of the Health and Retirement Study, a nationally representative survey of adults older than age 50. Using multivariate logistic regression to adjust for baseline differences in sociodemographic and health characteristics, we assessed subsequent hospitalizations and deaths between 1998 and 2006 for respondents who reported that they had or had not taken less medicine than prescribed because of cost. RESULTS: Respondents with cardiovascular disease who reported underusing medications due to cost were significantly more likely to be hospitalized in the next 2 years, even after adjusting for other patient characteristics (adjusted predicted probability of 47% compared with 38%, P < 0.001). The more survey waves respondents reported cost-related medication underuse during 1998 to 2004, the higher the probability of being hospitalized in 2006 (adjusted predicted probability of 54% among respondents reporting cost-related medication underuse in all 4 survey waves compared with 42% among respondents reporting no underuse, P < 0.001). There was no independent association of cost-related medication underuse with death. CONCLUSIONS: In this nationally representative cohort, middle-aged and elderly adults with cardiovascular disease who reported cutting back on medication use because of cost were more likely to report being hospitalized over a subsequent 2-year period after they had reported medication underuse. The more extensively respondents reported cost-related underuse over time, the higher their adjusted predicted probability of subsequent hospitalization.
Using Smart Source Parsing Feb Comment In: Med Care. 2010 Feb;48(2):85-6 20057326 Index Medicus
Keywords: Aged; Aged, 80 and over; Cardiovascular Diseases; Female; Financing, Personal; Health Care Costs; Health Services Accessibility; Health Status Disparities; Hospitalization; Humans; Logistic Models; Longitudinal Studies; Male; Medication Adherence; Middle Aged; Multivariate Analysis; Risk Factors; United States

Impact of cognitive impairment on screening mammography use in older US women. - Kala M. Mehta; Kathy Z Fung; Christine E Kistler; Chang, Anna; Louise C Walter (Am J Public Health, 2010)
OBJECTIVES: We evaluated mammography rates for cognitively impaired women in the context of their life expectancies, given that guidelines do not recommend screening mammography in women with limited life expectancies because harms outweigh benefits. METHODS: We evaluated Medicare claims for women aged 70 years or older from the 2002 wave of the Health and Retirement Study to determine which women had screening mammography. We calculated population-based estimates of 2-year screening mammography prevalence and 4-year survival by cognitive status and age. RESULTS: Women with severe cognitive impairment had lower rates of mammography (18%) compared with women with normal cognition (45%). Nationally, an estimated 120,000 screening mammograms were performed among women with severe cognitive impairment despite this group's median survival of 3.3 years (95% confidence interval = 2.8, 3.7). Cognitively impaired women who had high net worth and were married had screening rates approaching 50%. CONCLUSIONS: Although severe cognitive impairment is associated with lower screening mammography rates, certain subgroups with cognitive impairment are often screened despite lack of probable benefit. Given the limited life expectancy of women with severe cognitive impairment, guidelines should explicitly recommend against screening these women.
Keywords: Aged; Aged, 80 and over; Cognition Disorders; Female; Humans; Incidence; Longitudinal Studies; Mammography; Medicare; Patient Acceptance of Health Care; Social Class; United States

Length of stay for older adults residing in nursing homes at the end of life. - Kelly, Anne; Conell-Price, Jessamyn; Kenneth E Covinsky; Irena Cenzer; Chang, Anna; W John Boscardin; Alexander K Smith (J Am Geriatr Soc, 2010)
OBJECTIVES: To describe lengths of stay of nursing home decedents. DESIGN: Retrospective cohort study. SETTING: The Health and Retirement Study (HRS), a nationally representative survey of U.S. adults aged 50 and older. PARTICIPANTS: One thousand eight hundred seventeen nursing home residents who died between 1992 and 2006. MEASUREMENTS: The primary outcome was length of stay, defined as the number of months between nursing home admission and date of death. Covariates were demographic, social, and clinical factors drawn from the HRS interview conducted closest to the date of nursing home admission. RESULTS: The mean age of decedents was 83.3 ± 9.0; 59.1% were female, and 81.5% were white. Median and mean length of stay before death were 5 months (interquartile range 1-20) and 13.7 ± 18.4 months, respectively. Fifty-three percent died within 6 months of placement. Large differences in median length of stay were observed according to sex (men, 3 months vs women, 8 months) and net worth (highest quartile, 3 months vs lowest quartile, 9 months) (all P <.001). These differences persisted after adjustment for age, sex, marital status, net worth, geographic region, and diagnosed chronic conditions (cancer, hypertension, diabetes mellitus, lung disease, heart disease, and stroke). CONCLUSION: Nursing home lengths of stay are brief for the majority of decedents. Lengths of stay varied markedly according to factors related to social support.
Keywords: Advance care planning; Aged; Aged, 80 and over; Female; Follow-Up Studies; Humans; Length of Stay; Male; Middle Aged; Nursing homes; Palliative care; Retrospective Studies; United States

Lifetime marital history and mortality after age 50. - John C Henretta (J Aging Health, 2010)
OBJECTIVES: This article examines the relationship between lifetime marital history and mortality after age 50. METHOD: Data are drawn from the Health and Retirement Study birth cohort of 1931 to 1941. The analysis utilizes three measures of marital history: number of marriages, proportion time married, and age at first marriage. RESULTS: Three or more marriages and a lower proportion of adult life spent married are each associated with a higher hazard of dying after age 50 for both men and women even after controlling for current marital status and socioeconomic status. Smoking behavior accounts for part of the relationship of marital history and status with mortality. DISCUSSION: Research on marital status and health should consider marital history as well as current status. Two topics are particularly important: examining the relationship in different cohorts and disentangling the potentially causal role of health behaviors such as smoking.
Keywords: Age Factors; Aging; Cohort Studies; Female; Health Status; Humans; Interpersonal Relations; Male; Marital Status; Middle Aged; Mortality; Multivariate Analysis; Proportional Hazards Models; Residence Characteristics; Risk Assessment; Risk-Taking; Smoking; Time Factors; United States

Longitudinal changes in disabled husbands' and wives' receipt of care. - Claire Noël-Miller (Gerontologist, 2010)
PURPOSE OF THE STUDY: This study contrasts 2-year adjustments in disabled husbands' and wives' amount of received care following both worsening and recovery in personal (activities of daily living [ADLs]) and routine care (instrumental activities of daily living [IADLs]) disability. DESIGN AND METHODS: Using longitudinal data on 789 husbands and 778 wives from the Health and Retirement Study (2000 and 2002), changes in marital partners' monthly hours of spousal and nonspousal care were jointly modeled using bivariate Tobit models. In addition, asymmetry in the magnitude of responses to worsening and improvement of function was examined. RESULTS: Disabled husbands receive more hours of spousal and nonspousal care following worsening in ADL function than wives. Conversely, disabled wives lose more spousal and nonspousal care hours following improvements in ADL disability than husbands. Moreover, wives recovering in ADL function lose more hours of spousal care than they receive following worsening in personal care disability. There is no evidence of corresponding gender differences in the dynamics of assistance received following changes in IADL function. IMPLICATIONS: Compared with husbands, disabled wives are disadvantaged in the adjustment of their personal care hours. Although disabled married community residents receive more hours of care than their unmarried counterparts, there are important gender differences in the advantages offered by marriage.
Keywords: Activities of Daily Living; Aged; Aged, 80 and over; Caregivers; Disabled Persons; Female; Humans; Long-term Care; Longitudinal Studies; Male; Marriage; Middle Aged; Models, Theoretical; Sex Factors; Social Support; Socioeconomic factors; Spouses; Surveys and Questionnaires; Time Factors

Long-term cognitive impairment and functional disability among survivors of severe sepsis. - Theodore J Iwashyna; E Wesley Ely; Dylan M Smith; Kenneth M. Langa (JAMA, 2010)
CONTEXT: Cognitive impairment and functional disability are major determinants of caregiving needs and societal health care costs. Although the incidence of severe sepsis is high and increasing, the magnitude of patients' long-term cognitive and functional limitations after sepsis is unknown. OBJECTIVE: To determine the change in cognitive impairment and physical functioning among patients who survive severe sepsis, controlling for their presepsis functioning. DESIGN, SETTING, AND PATIENTS: A prospective cohort involving 1194 patients with 1520 hospitalizations for severe sepsis drawn from the Health and Retirement Study, a nationally representative survey of US residents (1998-2006). A total of 9223 respondents had a baseline cognitive and functional assessment and had linked Medicare claims; 516 survived severe sepsis and 4517 survived a nonsepsis hospitalization to at least 1 follow-up survey and are included in the analysis. MAIN OUTCOME MEASURES: Personal interviews were conducted with respondents or proxies using validated surveys to assess the presence of cognitive impairment and to determine the number of activities of daily living (ADLs) and instrumental ADLs (IADLs) for which patients needed assistance. RESULTS: Survivors' mean age at hospitalization was 76.9 years. The prevalence of moderate to severe cognitive impairment increased 10.6 percentage points among patients who survived severe sepsis, an odds ratio (OR) of 3.34 (95% confidence interval [CI], 1.53-7.25) in multivariable regression. Likewise, a high rate of new functional limitations was seen following sepsis: in those with no limits before sepsis, a mean 1.57 new limitations (95% CI, 0.99-2.15); and for those with mild to moderate limitations before sepsis, a mean of 1.50 new limitations (95% CI, 0.87-2.12). In contrast, nonsepsis general hospitalizations were associated with no change in moderate to severe cognitive impairment (OR, 1.15; 95% CI, 0.80-1.67; P for difference vs sepsis = .01) and with the development of fewer new limitations (mean among those with no limits before hospitalization, 0.48; 95% CI, 0.39-0.57; P for difference vs sepsis <.001 and mean among those with mild to moderate limits, 0.43; 95% CI, 0.23-0.63; P for difference = .001). The declines in cognitive and physical function persisted for at least 8 years. CONCLUSIONS: Severe sepsis in this older population was independently associated with substantial and persistent new cognitive impairment and functional disability among survivors. The magnitude of these new deficits was large, likely resulting in a pivotal downturn in patients' ability to live independently.
Keywords: Activities of Daily Living; Aged; Aged, 80 and over; Case-Control Studies; Cognition Disorders; Disabled Persons; Female; Health Status; Hospitalization; Humans; Male; Prospective Studies; Sepsis; Severity of Illness Index; Survivors; United States

Migration and psychological well-being among older adults: a growth curve analysis based on panel data from the Health and Retirement Study, 1996-2006. - Don E Bradley; Van Willigen, Marieke (J Aging Health, 2010)
PURPOSE: A vibrant body of research examines migration among older adults. Existing research, however, grants scarce attention to the implications of later-life migration for the migrants themselves. Our research focuses on the impacts of migration on depressive symptomatology among older U.S. adults. METHODS: Our analysis employs six waves of panel data from the Health and Retirement Study, 1996-2006. Growth curve modeling techniques are employed. RESULTS: Net of other stressful life events, migration effects appear to vary significantly across persons. Findings highlight the particularly depressive impact of moves motivated by negative life events or circumstances. Results further suggest that later life moves may be especially stressful for women and as individuals age. DISCUSSION: The stress of moving late in life may depend on social integration at destination. Further research should pursue this issue. Study limitations and additional directions for further research are delineated.
Keywords: Adaptation, Psychological; Age Factors; Aging; depression; Female; Happiness; Health Status; Humans; Life Change Events; Male; Mental Health; Middle Aged; Models, Psychological; Models, Theoretical; Multivariate Analysis; Psychometrics; Retirement; Stress, Psychological; Transients and Migrants

Modifiable risk factors for incidence of pain in older adults. - Yu Shi; Hooten, W Michael; Rosebud O. Roberts; David O. Warner (Pain, 2010)
Pain symptoms in aging populations have significant public health impact. The aim of this study was to determine risk factors for the incidence of pain in older adults, focusing on those factors that can be modified. Secondary analyses were performed of survey data from the nationally representative Health and Retirement Study of US adults older than 50 years. Generalized estimating equations logistic regressions were used to evaluate the effect of selected variables on the incidence of pain using biennial (1992 through 2006) data, determining the relationship between the incidence of pain and the potential risk factors. Of the 18,439 survey respondents in 2006, 34.1% (95% CI: 33.2%, 35.0%) reported that they were often troubled by pain; 24.3% reported having moderate to severe pain; and 22.3% reported that their daily life was affected by pain. Between 1992 and 2006, 7967 individuals reported new onset of pain in 169,762 person-years of follow-up, an incidence of 4.69 (4.59, 4.80) per 100 person-years. Depression and being overweight were independent predictors associated with an increased likelihood of incident pain. Current smoking increased the likelihood of incident pain only in those subjects who also reported depression. In conclusion, pain is a common symptom in older adults. Depression, smoking, and overweight are potentially modifiable risk factors and could be considered in the prevention and management of pain in older adults.
Keywords: Age Factors; Aged; Aged, 80 and over; Cross-Sectional Studies; Demography; depression; Female; Humans; Incidence; Longitudinal Studies; Male; Middle Aged; Overweight; pain; Prevalence; Retrospective Studies; Risk Assessment; Risk Factors; Smoking; United States

Neighborhood disadvantage and self-assessed health, disability, and depressive symptoms: longitudinal results from the health and retirement study. - M. Maria Glymour; Mujahid, Mahasin; Wu, Qiong; White, Kellee; Tchetgen Tchetgen, Eric J (Ann Epidemiol, 2010)
PURPOSE: By using a longitudinal cohort, we assessed the association between neighborhood disadvantage and incidence of poor health and function in three domains. METHODS: More than 4,000 enrollees aged 55 to 65 years in the national Health and Retirement Study were assessed biennially from 1998 through 2006 for incidence of fair/poor self-rated health, elevated depressive symptoms, and limitations in six basic activities of daily living (disability). Each analysis was restricted to subjects without that condition in 1994 or 1996. Neighborhoods (census tracts, time-updated for moves), were considered disadvantaged if they fell below the 25th percentile in an index comprising six socioeconomic status indicators. Repeated measures logistic regressions, inverse probability weighted to account for individual confounders, selective survival, and loss to follow-up were used to estimate odds ratios (ORs) for incidence of each outcome in the wave after exposure to disadvantaged neighborhood. RESULTS: After covariate adjustment, neighborhood disadvantage predicted onset of fair/poor SRH (OR, 1.36; 95% confidence interval, 1.15-1.59) but not disability (OR, 0.97; 0.81-1.16) or elevated depressive symptoms (OR, 0.97; 0.81-1.16). CONCLUSIONS: Results confirmed previous findings that neighborhood disadvantage predicts self-rated health in a longitudinal context but did not support an association between neighborhood disadvantage and onset of disability or elevated depressive symptoms.
Keywords: Activities of Daily Living; Age Factors; Aged; Confidence Intervals; depression; Disabled Persons; Female; Health Status Disparities; Humans; Incidence; Logistic Models; Longitudinal Studies; Male; Middle Aged; Odds Ratio; Poverty; Residence Characteristics; Risk; Self-Assessment; Socioeconomic factors; Time Factors

Obesity and excess mortality among the elderly in the United States and Mexico. - Monteverde, Malena; Noronha, Kenya; Alberto Palloni; Beatriz Novak (Demography, 2010)
Increasing levels of obesity could compromise future gains in life expectancy in low- and high-income countries. Although excess mortality associated with obesity and, more generally, higher levels of body mass index (BAI) have been investigated in the United States, there is little research about the impact of obesity on mortality in Latin American countries, where very the rapid rate of growth of prevalence of obesity and overweight occur jointly with poor socioeconomic conditions. The aim of this article is to assess the magnitude of excess mortality due to obesity and overweight in Mexico and the United States. For this purpose, we take advantage of two comparable data sets: the Health and Retirement Study 2000 and 2004 for the United States, and the Mexican Health and Aging Study 2001 and 2003 for Mexico. We find higher excess mortality risks among obese and overweight individuals aged 60 and older in Mexico than in the United States. Yet, when analyzing excess mortality among different socioeconomic strata, we observe greater gaps by education in the United States than in Mexico. We also find that although the probability of experiencing obesity-related chronic diseases among individuals with high BMI is larger for the U.S. elderly, the relative risk of dying conditional on experiencing these diseases is higher in Mexico.
Keywords: Aged; Aged, 80 and over; Body Mass Index; Chronic disease; Female; Humans; Logistic Models; Male; Mexico; Middle Aged; Mortality; Multivariate Analysis; Obesity; Risk Factors; Socioeconomic factors; United States

Obesity, physical activity, and depressive symptoms in a cohort of adults aged 51 to 61. - Dianna D Carroll; Heidi M Blanck; Mary K. Serdula; David R Brown (J Aging Health, 2010)
OBJECTIVE: To determine associations between changes in obesity and vigorous physical activity (PA) status and depressive symptoms in a cohort aged 51 to 61 years at baseline. METHOD: Two waves (1992, 1998) of Health and Retirement Study data were used to divide participants into four obesity and four vigorous PA status categories based on change in or maintenance of their 1992 status in 1998. Depressive symptoms were defined as the upper quintile score (women >/= 4, men >/= 3) on the eight-item Center for Epidemiologic Studies-Depression Scale. Logistic regression determined adjusted odds ratios for depressive symptoms associated with obesity and vigorous PA status. RESULTS: Among men, no significant associations were found. Among women, decreasing from high vigorous PA status and maintenance of obese status were independently associated with increased odds for depressive symptoms in 1998. DISCUSSION: The findings illustrate the importance of examining gender differences in studies of risk factors for depression.
Keywords: Activities of Daily Living; Age Factors; Aging; Chi-Square Distribution; Cohort Studies; Confidence Intervals; depression; Female; Health Status; Humans; Logistic Models; Male; Middle Aged; Motor Activity; Multivariate Analysis; Obesity; Odds Ratio; Psychometrics; Self Report; Sex Factors; United States

Older adults' expectations to move: do they predict actual community-based or nursing facility moves within 2 years? - Julie F. Sergeant; David J Ekerdt; Chapin, Rosemary K (J Aging Health, 2010)
OBJECTIVE: This study examined the relationship between older adults' expectations to move and actual residential relocation in the community or to a nursing facility within 2 years. METHOD: Two waves of data (2000, 2002) from the Health and Retirement Study were used to compare expectations with subsequent moves. Logistic regression techniques were used to analyze the association between decision outcomes and expectations to move, health and functioning, physical environment, informal supports, and formal services. RESULTS: Findings indicated that expectations to move did predict community-based moves but did not predict moves to nursing facilities. Additional factors had significant effects but did not diminish relationships between expectations and actual moves. DISCUSSION: Results support the residential decision process as a dynamic one based on the cumulative effect of factors from an ecological model. Findings will inform policy makers and practitioners as they work to support older adults' preferences to remain living in their homes.
Keywords: Age Factors; Aged; Aged, 80 and over; Aging; Community Health Services; Decision making; Female; Humans; Logistic Models; Male; Odds Ratio; Residence Characteristics; Skilled Nursing Facilities; Social Support; Statistics as Topic; Time Factors; Transients and Migrants

Out-of-pocket burden of health care spending and the adequacy of the Medicare Part D low-income subsidy. - Becky A. Briesacher; Ross-Degnan, Dennis; Anita K Wagner; Hassan Fouayzi; Fang Zhang; Jerry Gurwitz; Soumerai, Stephen B (Med Care, 2010)
BACKGROUND: Evaluating the adequacy of Medicare prescription drug program (Part D) and its low-income subsidy (LIS) requires a comprehensive understanding of drug spending in relation to household resources. OBJECTIVE: : To estimate out-of-pocket health care costs in the year before Part D, in context of total household spending, health status, and LIS eligibility. RESEARCH DESIGN: Nationally representative cross-sectional study. SUBJECTS: Two thousand two hundred thirty-one Medicare families in the 2005/2006 Health and Retirement Study. METHODS: We assessed health care costs as a share of household resources remaining after spending on essential housing, food, personal care, and transportation. Burdensome health care costs were defined as exceeding 40% of nonessential resources. We used logistic regressions to assess the probability of incurring burdensome health expenditures, controlling for LIS eligibility. RESULTS: In the year before Part D, more than half of Medicare families [56.0%; 95% confidence interval (CI): 55.3-59.9] experienced burdensome health care costs. Families in poor health allocated a median of 68.1% [interquartile range (IQR): 35.1-82.9] of nonessential resources to health care (compared with 34.0% median; IQR 11.9-52.2 among families in excellent health, P < 0.011). Most (64%) out-of-pocket health care spending was allocated to health insurance premiums and medications. As many as 26% of Medicare families had burdensome health care costs but were not eligible for LIS assistance. CONCLUSIONS: Before Part D, burdensome health care expenditures were common in Medicare families. Our estimates of Part D and LIS benefits indicate a limited scope of relief.
Keywords: Adult; Aged; Confidence Intervals; Cost of Illness; Deductibles and Coinsurance; Drug Prescriptions; Female; Financing, Personal; Health Expenditures; Humans; Income; Male; Medicare Part D; Middle Aged; Odds Ratio; Poverty; Socioeconomic factors; United States

Physical health and depression: a dyadic study of chronic health conditions and depressive symptomatology in older adult couples. - Brian J Ayotte; Frances Margaret Yang; Richard N Jones (J Gerontol B Psychol Sci Soc Sci, 2010)
This study examined the associations among chronic health conditions, sociodemographic factors, and depressive symptomatology in older married couples. Data from the 2004 wave of the Health and Retirement Study (n = 2,184 couples) were analyzed. Results indicated a reciprocal relationship in depressive symptoms between spouses. Additionally, post hoc analyses indicated that husbands' stroke and high blood pressure were related to increased depressive symptomatology among wives. Beyond the reciprocal relationship, husbands were unaffected by wives' health. These results suggest sex differences underlying psychological distress in the context of physical health among older adults and that older women with husbands who have high levels of depressive symptomatology, high blood pressure, or a history of stroke may be at particular risk of experiencing depressive symptoms.
Keywords: Age Factors; Aged; Chi-Square Distribution; Chronic disease; Cohort Studies; depression; Female; Health Status; Humans; Hypertension; Least-Squares Analysis; Male; Marriage; Middle Aged; Psychiatric Status Rating Scales; Risk Factors; Sex Factors; Socioeconomic factors; Spouses; Stroke

Predicting positive well-being in older men and women. - Erin L. Waddell; Joy M Jacobs-Lawson (Int J Aging Hum Dev, 2010)
The purpose of this study was to examine the effects of background, psychological, and social variables on older adults' well-being, and how this may differ for men and women. Participants included 800 adults from the 2002 Health and Retirement Study (HRS), aged 60 to 101 years old (M = 71.22, SD = 8.46), who completed the optional positive well-being module. Gender-based regression models revealed that for men, marital status, self-rated health, and depression were significant predictors and accounted for 32% of the variability in positive well-being. Similar to men, self-rated health and depression were significant predictors of well-being for women. Additional significant predictors for women included age, the importance of religion, and volunteer work. Combined, these variables explained 35% of the variance in women's positive well-being. These results can help us understand which variables are important to target when developing interventions to improve the well-being of older men and women.
Keywords: Aged; Aged, 80 and over; Aging; depression; Female; Health Status; Humans; Male; Marriage; Middle Aged; Personal Satisfaction; Predictive Value of Tests; Quality of Life; Regression Analysis; Religion and Psychology; Self Concept; Sex Distribution; Social Behavior; Surveys and Questionnaires; Volunteers

Prevalence and predictors of fatigue in middle-aged and older adults: evidence from the health and retirement study. - Meng, Hongdao; Hale, Lauren; Friedberg, Fred (J Am Geriatr Soc, 2010)
Keywords: Aged; Aged, 80 and over; Fatigue; Female; Health Surveys; Humans; Male; Middle Aged; Prevalence; Retirement; Retrospective Studies; Survival Rate; United States

Prevalence of neuropsychiatric symptoms and their association with functional limitations in older adults in the United States: the aging, demographics, and memory study. - Okura, Toru; Brenda L Plassman; David C Steffens; David J Llewellyn; Guy G Potter; Kenneth M. Langa (J Am Geriatr Soc, 2010)
OBJECTIVES: To estimate the prevalence of neuropsychiatric symptoms and examine their association with functional limitations. DESIGN: Cross-sectional analysis. SETTING: The Aging, Demographics, and Memory Study (ADAMS). PARTICIPANTS: A sample of adults aged 71 and older (N=856) drawn from Health and Retirement Study (HRS), a nationally representative cohort of U.S. adults aged 51 and older. MEASUREMENTS: The presence of neuropsychiatric symptoms (delusions, hallucinations, agitation, depression, apathy, elation, anxiety, disinhibition, irritation, and aberrant motor behaviors) was identified using the Neuropsychiatric Inventory. A consensus panel in the ADAMS assigned a cognitive category (normal cognition; cognitive impairment, no dementia (CIND); mild, moderate, or severe dementia). Functional limitations, chronic medical conditions, and sociodemographic information were obtained from the HRS and ADAMS. RESULTS: Forty-three percent of individuals with CIND and 58% of those with dementia exhibited at least one neuropsychiatric symptom. Depression was the most common individual symptom in those with normal cognition (12%), CIND (30%), and mild dementia (25%), whereas apathy (42%) and agitation (41%) were most common in those with severe dementia. Individuals with three or more symptoms and one or more clinically significant symptoms had significantly higher odds of having functional limitations. Those with clinically significant depression had higher odds of activity of daily living limitations, and those with clinically significant depression, anxiety, or aberrant motor behaviors had significantly higher odds of instrumental activity of daily living limitations. CONCLUSION: Neuropsychiatric symptoms are highly prevalent in older adults with CIND and dementia. Of those with cognitive impairment, a greater number of total neuropsychiatric symptoms and some specific individual symptoms are strongly associated with functional limitations.
Keywords: Activities of Daily Living; Aged; Aged, 80 and over; Behavioral Symptoms; Cognition Disorders; Cross-Sectional Studies; Dementia; Female; Humans; Male; Mental Disorders; Prevalence; United States

Prior hospitalization and the risk of heart attack in older adults: a 12-year prospective study of Medicare beneficiaries. - Frederic D Wolinsky; Suzanne E Bentler; Li Liu; Michael P Jones; Kaskie, Brian; Jason Hockenberry; Elizabeth A Chrischilles; Kara B Wright; John F Geweke; Maksym Obrizan; Robert L. Ohsfeldt; Gary E Rosenthal; et al. (J Gerontol A Biol Sci Med Sci, 2010)
BACKGROUND: We investigated whether prior hospitalization was a risk factor for heart attacks among older adults in the survey on Assets and Health Dynamics among the Oldest Old. METHODS: Baseline (1993-1994) interview data were linked to 1993-2005 Medicare claims for 5,511 self-respondents aged 70 years and older and not enrolled in managed Medicare. Primary hospital International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) 410.xx discharge codes identified postbaseline hospitalizations for acute myocardial infarctions (AMIs). Participants were censored at death or postbaseline managed Medicare enrollment. Traditional risk factors and other covariates were included. Recent postbaseline non-AMI hospitalizations (ie, prior hospitalizations) were indicated by a time-dependent marker, and sensitivity analyses identified their peak effect. RESULTS: The total number of person-years of surveillance was 44,740 with a mean of 8.1 (median = 9.1) per person. Overall, 483 participants (8.8%) suffered postbaseline heart attacks, with 423 participants (7.7%) having their first-ever AMI. As expected, significant traditional risk factors were sex (men); race (whites); marital status (never being married); education (noncollege); geography (living in the South); and reporting a baseline history of angina, arthritis, diabetes, and heart disease. Risk factors were similar for both any postbaseline and first-ever postbaseline AMI analyses. The time-dependent recent non-AMI hospitalization marker did not alter the effects of the traditional risk factors but increased AMI risk by 366% (adjusted hazards ratio = 4.66, p < .0001). Discussion. Our results suggest that some small percentage (<3%) of heart attacks among older adults might be prevented if effective short-term postdischarge planning and monitoring interventions were developed and implemented.
Keywords: Aged; Educational Status; Female; Hospitalization; Humans; Male; Marital Status; Medicare; Myocardial Infarction; Patient Discharge; Proportional Hazards Models; Prospective Studies; Risk Factors; Sex Factors; United States

The Process of Retirement Planning Scale (PRePS): development and validation. - Jack H Noone; Christine Stephens; Fiona M. Alpass (Psychol Assess, 2010)
Although a substantial proportion of the western population is approaching retirement age, little is known about how they are preparing for the future. Much attention has been paid to the consumption of educational material and retirement wealth in the present literature, but the process of retirement planning has been ignored. S. L. Friedman and E. K. Scholnick's (1997) theoretical model provided the basis for a comprehensive measure of retirement planning. According to their process theory, individuals develop an understanding of the problem, set goals, make a decision to start preparing, and finally undertake the behaviors needed to fulfill their goals. Fifty-two items were developed to assess each stage of the planning process for financial, health, lifestyle, and psychosocial retirement planning. These were tested on a population sample of 1,449 New Zealanders aged 49-60. Confirmatory factor analysis, bivariate correlations, and hierarchical regression provided support for the valid use of the measure. Necessary antecedents, such as the tendency to look to the future, and locus of control were significantly related to the Process of Retirement Planning Scale (PRePS). The PRePS also outperformed retirement planning measures used in the Health and Retirement Study (F. T. Juster & R. Suzman, 1995) after controlling for socioeconomic and psychological variables. This measure will enable social policy makers to determine which stages of retirement planning require support and intervention. The PRePS will also help to determine which domains of retirement planning predict well-being in later life and the factors which differentiate those who are planning from those who are not.
Keywords: Age Factors; Aged; Educational Status; Factor Analysis, Statistical; Female; Financing, Personal; Goals; Health Status; Humans; Internal-External Control; Male; Middle Aged; Pilot Projects; Planning Techniques; Psychological Tests; Psychology; Reproducibility of Results; Retirement; Surveys and Questionnaires

The prospective relationship between binge drinking and physician visits among older adults. - Kristi Rahrig Jenkins; Robert A. Zucker (J Aging Health, 2010)
OBJECTIVES: The objectives are to (a) determine if binge drinking is related to physician visits and (b) estimate the degree to which the relationship between binge drinking and physician visits can be explained by other health characteristics. METHOD: Data on a sample of 4,960 older adults (70+ years of age in 2002) from the Health and Retirement Study (HRS) were used. Three linear regression models estimated the impact of binge drinking on physician visits. RESULTS: In the fully adjusted models, binge drinking did have an effect on the number of physician visits by older adults, with more frequent binge drinkers having fewer physician visits. This negative relationship exists even when demographic as well as other current health characteristics are controlled. DISCUSSION: The implications of these results are discussed in terms of more broadly communicating the risks associated with binge drinking and more effectively targeting interventions to older binge drinkers.
Keywords: Age Factors; Aged; Aged, 80 and over; Aging; Alcoholic Intoxication; Female; Health Resources; Health Services Accessibility; Health Services Needs and Demand; Health Status Indicators; Humans; Linear Models; Male; Michigan; Multivariate Analysis; Patient Satisfaction; Physicians; Prospective Studies; Psychometrics; Risk Assessment; Risk Factors; Self Report

The role of health behaviors in mediating the relationship between depressive symptoms and glycemic control in type 2 diabetes: a structural equation modeling approach. - Chiu, Ching-Ju; Linda A. Wray; Elizabeth A Beverly; Oralia G Dominic (Soc Psychiatry Psychiatr Epidemiol, 2010)
OBJECTIVES: We investigated the longitudinal association between depressive symptoms and glycemic control (HbA1c) in adults with type 2 diabetes, and the extent to which that association was explained by health behaviors. METHODS: This study assessed data on 998 adults (aged 51 and above) with type 2 diabetes in the US nationally representative Health and Retirement Study and its diabetes-specific mail survey. Participants' depressive symptoms and baseline health behaviors (exercise, body weight control, and smoking status) were collected in 1998. Follow-up health behaviors and the glycemic control outcome were measured at a 2- and 5-year intervals, respectively. RESULTS: Nearly one in four of participants (23%) reported moderate or high levels of depressive symptoms at baseline (CES-D score >or=3). Adults with higher levels of depressive symptoms at baseline showed lower scores on baseline and follow-up health behaviors as well as higher HbA1c levels at a 5-year follow-up. Structural equation models (SEM) reveal that health behaviors accounted for 13% of the link between depressive symptoms and glycemic control. CONCLUSIONS: The long-term relationship between depressive symptoms and glycemic control was supported in the present study. Health behaviors, including exercise, body weight control, and smoking status, explained a sizable amount of the association between depressive symptoms and glycemic control. More comprehensive diabetes self-care behaviors should be examined with available data. Other competing explicators for the link, such as endocrinological process and antidepressant effects, also warrant further examination.
Keywords: Adult; Aged; Blood Glucose; Body Weight; Comorbidity; depression; Diabetes Mellitus, Type 2; Female; Follow-Up Studies; Glycated Hemoglobin; Glycemic Index; Health Behavior; Health Surveys; Humans; Life Style; Longitudinal Studies; Male; Middle Aged; Models, Statistical; Self Care; Smoking; United States

Self-reported versus measured height and weight in the health and retirement study. - Meng, Hongdao; Xiaoxing He; Dixon, Denise (J Am Geriatr Soc, 2010)
Keywords: Aged; Body Height; Body Weight; Female; Humans; Male; Middle Aged; Obesity; Population Surveillance; Prevalence; Reproducibility of Results; Sensitivity and Specificity; United States

Situational versus chronic loneliness as risk factors for all-cause mortality. - Sharon Shiovitz-Ezra; Liat Ayalon (Int Psychogeriatr, 2010)
BACKGROUND: Several international studies have substantiated the role of loneliness as a risk factor for mortality. Although both theoretical and empirical research has supported the classification of loneliness as either situational or chronic, research to date has not evaluated whether this classification has a differential impact upon mortality. METHODS: To establish the definition of situational vs. chronic loneliness, we used three waves of the Health and Retirement Study (HRS), a nationally representative sample of Americans over the age of 50 years. Baseline data for the present study were collected in the years 1996, 1998, and 2000. The present study concerns the 7,638 individuals who completed all three waves; their loneliness was classified as either not lonely, situational loneliness or chronic loneliness. Mortality data were available through to the year 2004. RESULTS: Those identified as "situationally lonely" (HR = 1.56; 95% CI: 1.52-1.62) as well as those identified as "chronically lonely" (HR = 1.83; 95% CI: 1.71-1.87) had a greater risk for all cause mortality net of the effect of possible demographic and health confounders. Nonetheless, relative to those classified as "situationally lonely," individuals classified as "chronically lonely" had a slightly greater mortality risk. CONCLUSIONS: The current study emphasizes the important role loneliness plays in older adults' health. The study further supports current division into situational vs. chronic loneliness, yet suggests that both types serve as substantial mortality risks.
Keywords: Age Factors; Aged; Aged, 80 and over; Aging; Cause of Death; Female; Geriatric Assessment; Health Surveys; Humans; Israel; Life Change Events; Loneliness; Male; Middle Aged; Risk Factors; social isolation; Surveys and Questionnaires; Time Factors

Sociodemographic and health-related risks for loneliness and outcome differences by loneliness status in a sample of U.S. older adults. - Laurie A. Theeke (Res Gerontol Nurs, 2010)
This study assesses sociodemographic and health-related factors associated with loneliness and outcome differences between loneliness groups using a sample of 13,812 older adults from the U.S Health and Retirement Study. Descriptive and bivariate analyses were followed by logistic regression to evaluate risks and analysis of covariance testing to determine outcome differences. Overall, prevalence of loneliness was 16.9%. Nonmarried status, poorer self-report of health, lower educational level, functional impairment, increasing number of chronic illnesses, younger age, lower income, and less people living in the household were all associated with loneliness. The chronically lonely group reported less exercise, more tobacco use, less alcohol use, a greater number of chronic illnesses, higher depression scores, and greater average number of nursing home stays. Future research evaluating the effectiveness of both prevention and treatment interventions for loneliness in older adults would provide empirical data to further guide gerontological nursing practice.
Keywords: Aged; Aged, 80 and over; Female; Health Status; Humans; Logistic Models; Loneliness; Male; Middle Aged; Multivariate Analysis; Risk Factors; Socioeconomic factors; United States

Spousal loss, children, and the risk of nursing home admission. - Claire Noël-Miller (J Gerontol B Psychol Sci Soc Sci, 2010)
UNLABELLED: OBJECTIVES. Informed by a life course perspective, this study investigates the effects of spousal loss and availability of adult children on elderly husbands' and wives' risk of nursing home entry. METHODS: Based on longitudinal data from the Health and Retirement Study, we studied 2,116 couples who were community residents in 1998. We estimate proportional hazards models for husbands' and wives' duration to first nursing home admission during 8 years of follow-up. RESULTS: Overall, 438 (20.7%) husbands and 382 (18.1%) wives were institutionalized, and 362 (17.1%) husbands and 701 (33.1%) wives lost their spouse. Accounting for measured covariates, the risk of nursing home entry doubled for men following spousal death, but was unchanged for women. Results indicate that adult children reduced wives' risk of nursing home admission regardless of husbands' vital status, but buffered husbands' risk only after the death of their wives. We uncover suggestive evidence of parent-child gender concordance in children's buffering effect of widowed parents' risk of institutionalization. Discussion. Our findings are consistent with gender variations in spousal caregiving and in husbands' and wives' relative reliance on care from a partner and children. This study provides new evidence on the relationship between institutionalization and family structure among married elderly persons.
Keywords: Activities of Daily Living; Adult children; Aged; Aged, 80 and over; Aging; Bereavement; Caregivers; Family Characteristics; Female; Gender Identity; Homes for the Aged; Humans; Long-term Care; Male; Nursing homes; Parent-Child Relations; Patient Admission; Proportional Hazards Models; Social Support; Spouses; Utilization Review

Stability and changes in living arrangements: relationship to nursing home admission and timing of placement. - Judith D Kasper; Liliana E Pezzin; Rice, J Bradford (J Gerontol B Psychol Sci Soc Sci, 2010)
OBJECTIVES: To examine whether stability of living arrangements and changes in household composition-both types and frequency-influence nursing home placement or timing to entry among older people. METHODS: Data from the first 5 waves of the Assets and Health Dynamics of the Elderly (1993-2002) on 8,093 persons aged 70 years or older at baseline are used in probit and hazard models to predict nursing home entry and time to entry. RESULTS: Stable living arrangements carry different risks of institutionalization. Those living continuously alone or with others were at highest risk; at lowest risk were those living continuously with a spouse or the same child (lowest overall). Changes in household composition were protective against nursing home entry and slowed time to entry; types of change were not influential when number of changes was taken into account. DISCUSSION: Results suggest that stability of living arrangements in and of itself is not protective against institutionalization. Having options that allow one to change living arrangements over time in response to changing needs for assistance is of importance if the goal is to avoid institutional care or extend community residence prior to entry.
Keywords: Aged; Aged, 80 and over; Family Characteristics; Female; Health Status; Homes for the Aged; Humans; Institutionalization; Male; Marital Status; Multivariate Analysis; Nursing homes; Risk Factors; Single Person; Socioeconomic factors; Time Factors; United States

Successful aging in the United States: prevalence estimates from a national sample of older adults. - Sara J McLaughlin; Cathleen M. Connell; Steven G Heeringa; Lydia W Li; J Scott Roberts (J Gerontol B Psychol Sci Soc Sci, 2010)
OBJECTIVES: To estimate the prevalence of successful aging in the United States, with the broad aim of contributing to the dialogue on Rowe and Kahn's concept of successful aging. METHODS: Using data from the Health and Retirement Study, the prevalence of successful aging was calculated for adults aged 65 years and older at four time points: 1998, 2000, 2002, and 2004. Successful aging was operationalized in accordance with Rowe and Kahn's definition, which encompasses disease and disability, cognitive and physical functioning, social connections, and productive activities. RESULTS: No greater than 11.9% of older adults were aging "successfully" in any year. The adjusted odds of successful aging were generally lower for those of advanced age, male gender, and lower socioeconomic status. Between 1998 and 2004, the odds of successful aging declined by 25%, after accounting for demographic changes in the older population. DISCUSSION: Few older adults meet the criteria put forth in Rowe and Kahn's definition of successful aging, suggesting the need for modification if the concept is to be used for broad public health purposes. Disparities in successful aging were evident for socially defined subgroups, highlighting the importance of structural factors in enabling successful aging.
Keywords: Affect; Aged; Aging; Female; Health Status; Humans; Male; Middle Aged; Prevalence; United States

Surgery as a teachable moment for smoking cessation. - Yu Shi; David O. Warner (Anesthesiology, 2010)
BACKGROUND: A "teachable moment" is an event that motivates spontaneous behavior change. Some evidence suggests that major surgery for a smoking-related illness can serve as a teachable moment for smoking cessation. This study tested the hypotheses that surgery increases the likelihood of smoking cessation and that cessation is more likely after major surgical procedures compared with outpatient surgery. METHODS: Secondary analyses were performed of longitudinal biennial survey data (1992-2004) from the nationally representative Health and Retirement Study of U.S. adults older than 50 yr, determining the relationship between the incidence of smoking cessation and the occurrence of surgery. RESULTS: Five thousand four hundred ninety-eight individuals reported current smoking at enrollment, and 2,444 of them (44.5%) quit smoking during the period of examination. The incidence of quitting in smokers undergoing major surgery was 20.6/100 person-years of follow-up and 10.2/100 person-years in those undergoing outpatient surgery. In a multivariate negative binomial regression model, the incidence rate ratio of quitting associated with major surgery was 2.02 (95% CI: 1.67-2.44) and that of those associated with outpatient surgery was 1.28 (95% CI: 1.09-1.50). Estimates derived from national surgical utilization data show that approximately 8% of all quit events in the United States annually can be attributed to the surgical procedures analyzed. CONCLUSIONS: Undergoing surgery is associated with an increased likelihood of smoking cessation in the older U.S. population. Cessation is more likely in association with major procedures compared with outpatient surgery. These data support the concept that surgery is a teachable moment for smoking cessation.
Keywords: Aged; Aged, 80 and over; Ambulatory Surgical Procedures; Analysis of Variance; Cohort Studies; Female; Follow-Up Studies; General Surgery; Humans; Longitudinal Studies; Male; Middle Aged; Patient Education as Topic; Regression Analysis; Smoking cessation; Treatment Outcome; United States

Trading years for perfect health: results from the health and retirement study. - Liat Ayalon; King-Kallimanis, Bellinda L (J Aging Health, 2010)
OBJECTIVE: To evaluate the preferences of an ethnically diverse national sample of older Americans regarding length of life versus health quality. METHOD: A time trade-off task administered as part of the 2002 wave of the Health and Retirement Study. RESULTS: Respondents equated 6.86 (SD = 3.46) years of perfect health with 10 years of life in imperfect health. Women and those who ranked their health less favorably were more likely to give up years of life for perfect health. Relative to Whites, Blacks were more willing to live longer in imperfect health. Those of lower levels of education were more likely to prefer 10 years of life in imperfect health. DISCUSSION: There is wide variability in responses to the time trade-off task that is partially associated with self-rated health, gender, ethnicity, and education.
Keywords: Activities of Daily Living; Age Factors; Aged; Aged, 80 and over; Aging; Community Participation; Confidence Intervals; Culture; Epidemiologic Methods; ethnicity; Female; Health Surveys; Humans; Longevity; Male; Multivariate Analysis; Psychometrics; Retirement; Self Report; Surveys and Questionnaires; Time Factors

Untreated poor vision: a contributing factor to late-life dementia. - Mary A M Rogers; Kenneth M. Langa (Am J Epidemiol, 2010)
Ophthalmologic abnormalities have been described in patients with dementia, but the extent to which poor vision and treatment for visual disorders affect cognitive decline is not well defined. Linked data from the Health and Retirement Study and Medicare files (1992-2005) were used to follow the experiences of 625 elderly US study participants with normal cognition at baseline. The outcome was a diagnosis of dementia, cognitively impaired but no dementia, or normal cognition. Poor vision was associated with development of dementia (P = 0.0048); individuals with very good or excellent vision at baseline had a 63% reduced risk of dementia (95% confidence interval (CI): 20, 82) over a mean follow-up period of 8.5 years. Participants with poorer vision who did not visit an ophthalmologist had a 9.5-fold increased risk of Alzheimer disease (95% CI: 2.3, 39.5) and a 5-fold increased risk of cognitively impaired but no dementia (95% CI: 1.6, 15.9). Poorer vision without a previous eye procedure increased the risk of Alzheimer disease 5-fold (95% CI: 1.5, 18.8). For Americans aged 90 years or older, 77.9% who maintained normal cognition had received at least one previous eye procedure compared with 51.7% of those with Alzheimer disease. Untreated poor vision is associated with cognitive decline, particularly Alzheimer disease.
Keywords: Aged, 80 and over; Cognition Disorders; Dementia; Female; Humans; Logistic Models; Male; Medicare; Ophthalmology; Patient Acceptance of Health Care; Risk Factors; United States; Vision Disorders

Urban neighborhood context and mortality in late life. - Richard G Wight; Janet R. Cummings; Arun S Karlamangla; Carol S Aneshensel (J Aging Health, 2010)
OBJECTIVE: To examine the contextual effects of urban neighborhood characteristics on mortality among older adults. METHOD: Data are from the Study of Assets and Health Dynamics Among the Oldest Old (AHEAD). Death is assessed between the baseline assessment (1993) and the first follow-up interview (1995). Neighborhood data are from the 1990 Census. RESULTS: The log odds of dying between the two time points are higher in high proportion Hispanic neighborhoods, net of individual-level sociodemographic variables, but this effect is partly mediated by individual-level health. The log odds of dying are significantly (p < .05) lower in affluent neighborhoods, controlling for all individual-level variables and neighborhood proportion Hispanic. DISCUSSION: There are survival-related benefits of living in an affluent urban neighborhood, which we posit may be manifested through the diffusion of innovations in health care and health-promotion activities.
Keywords: Age Factors; Aged; Aging; Cognition; Confidence Intervals; depression; Female; Health Status; Humans; Los Angeles; Male; Middle Aged; Mortality; Odds Ratio; Poverty; Psychometrics; Residence Characteristics; Self Report; Socioeconomic factors; Statistics as Topic; Urban Population

A 12-year prospective study of stroke risk in older Medicare beneficiaries. - Frederic D Wolinsky; Suzanne E Bentler; Elizabeth A Cook; Elizabeth A Chrischilles; Li Liu; Kara B Wright; John F Geweke; Maksym Obrizan; Claire E Pavlik; Robert L. Ohsfeldt; Michael P Jones; Robert B Wallace; et al. (BMC Geriatr, 2009)
BACKGROUND: 5.8 M living Americans have experienced a stroke at some time in their lives, 780K had either their first or a recurrent stroke this year, and 150K died from strokes this year. Stroke costs about $66B annually in the US, and also results in serious, long-term disability. Therefore, it is prudent to identify all possible risk factors and their effects so that appropriate intervention points may be targeted. METHODS: Baseline (1993-1994) interview data from the nationally representative Survey on Assets and Health Dynamics among the Oldest Old (AHEAD) were linked to 1993-2005 Medicare claims. Participants were 5,511 self-respondents >or= 70 years old. Two ICD9-CM case-identification approaches were used. Two approaches to stroke case-identification based on ICD9-CM codes were used, one emphasized sensitivity and the other emphasized specificity. Participants were censored at death or enrollment into managed Medicare. Baseline risk factors included sociodemographic, socioeconomic, place of residence, health behavior, disease history, and functional and cognitive status measures. A time-dependent marker reflecting post-baseline non-stroke hospitalizations was included to reflect health shocks, and sensitivity analyses were conducted to identify its peak effect. Competing risk, proportional hazards regression was used. RESULTS: Post-baseline strokes occurred for 545 (9.9%; high sensitivity approach) and 374 (6.8%; high specificity approach) participants. The greatest static risks involved increased age, being widowed or never married, living in multi-story buildings, reporting a baseline history of diabetes, hypertension, or stroke, and reporting difficulty picking up a dime, refusing to answer the delayed word recall test, or having poor cognition. Risks were similar for both case-identification approaches and for recurrent and first-ever vs. only first-ever strokes. The time-dependent health shock (recent hospitalization) marker did not alter the static model effect estimates, but increased stroke risk by 200% or more. CONCLUSION: The effect of our health shock marker (a time-dependent recent hospitalization indicator) was large and did not mediate the effects of the traditional risk factors. This suggests an especially vulnerable post-hospital transition period from adverse effects associated with both their underlying health shock (the reasons for the recent hospital admission) and the consequences of their treatments.
Keywords: Aged; Aged, 80 and over; Female; Humans; Insurance Benefits; Male; Medicare; Prospective Studies; Risk Factors; Socioeconomic factors; Stroke; United States

The accuracy of Medicare claims as an epidemiological tool: the case of dementia revisited. - Donald H. Taylor Jr.; Østbye, Truls; Kenneth M. Langa; David R Weir; Brenda L Plassman (J Alzheimers Dis, 2009)
Our study estimates the sensitivity and specificity of Medicare claims to identify clinically-diagnosed dementia, and documents how errors in dementia assessment affect dementia cost estimates. We compared Medicare claims from 1993-2005 to clinical dementia assessments carried out in 2001-2003 for the Aging Demographics and Memory Study (ADAMS) cohort (n = 758) of the Health and Retirement Study. The sensitivity and specificity of Medicare claims was 0.85 and 0.89 for dementia (0.64 and 0.95 for AD). Persons with dementia cost the Medicare program (in 2003) $7,135 more than controls (P < 0.001) when using claims to identify dementia, compared to $5,684 more when using ADAMS (P < 0.001). Using Medicare claims to identify dementia results in a 110% increase in costs for those with dementia as compared to a 68% increase when using ADAMS to identify disease, net of other variables. Persons with false positive Medicare claims notations of dementia were the most expensive group of subjects ($11,294 versus $4,065, for true negatives P < 0.001). Medicare claims overcount the true prevalence of dementia, but there are both false positive and negative assessments of disease. The use of Medicare claims to identify dementia results in an overstatement of the increase in Medicare costs that are due to dementia.
Keywords: Aged; Aged, 80 and over; Alzheimer disease; Cohort Studies; Dementia; Female; Health Care Costs; Humans; Insurance Claim Reporting; Male; Medicare; Prevalence; Sensitivity and Specificity; United States

The aftermath of hip fracture: discharge placement, functional status change, and mortality. - Suzanne E Bentler; Li Liu; Maksym Obrizan; Elizabeth A Cook; Kara B Wright; John F Geweke; Elizabeth A Chrischilles; Claire E Pavlik; Robert B Wallace; Robert L. Ohsfeldt; Michael P Jones; Gary E Rosenthal; et al. (Am J Epidemiol, 2009)
The authors prospectively explored the consequences of hip fracture with regard to discharge placement, functional status, and mortality using the Survey on Assets and Health Dynamics Among the Oldest Old (AHEAD). Data from baseline (1993) AHEAD interviews and biennial follow-up interviews were linked to Medicare claims data from 1993-2005. There were 495 postbaseline hip fractures among 5,511 respondents aged >or=69 years. Mean age at hip fracture was 85 years; 73% of fracture patients were white women, 45% had pertrochanteric fractures, and 55% underwent surgical pinning. Most patients (58%) were discharged to a nursing facility, with 14% being discharged to their homes. In-hospital, 6-month, and 1-year mortality were 2.7%, 19%, and 26%, respectively. Declines in functional-status-scale scores ranged from 29% on the fine motor skills scale to 56% on the mobility index. Mean scale score declines were 1.9 for activities of daily living, 1.7 for instrumental activities of daily living, and 2.2 for depressive symptoms; scores on mobility, large muscle, gross motor, and cognitive status scales worsened by 2.3, 1.6, 2.2, and 2.5 points, respectively. Hip fracture characteristics, socioeconomic status, and year of fracture were significantly associated with discharge placement. Sex, age, dementia, and frailty were significantly associated with mortality. This is one of the few studies to prospectively capture these declines in functional status after hip fracture.
Keywords: Activities of Daily Living; Aged; Aged, 80 and over; depression; Female; Health Status; Health Status Indicators; Hip Fractures; Humans; Interviews as Topic; Iowa; Length of Stay; Logistic Models; Medicare; Patient Discharge; Prospective Studies; Psychometrics; Socioeconomic factors; Time Factors; Treatment Outcome; United States

Are mature smokers misinformed? - Ahmed Khwaja; Daniel S. Silverman; Frank A Sloan; Wang, Yang (J Health Econ, 2009)
While there are many reasons to continue to smoke in spite of its consequences for health, the concern that many smoke because they misperceive the risks of smoking remains a focus of public discussion and motivates tobacco control policies and litigation. In this paper we investigate the relative accuracy of mature smokers' risk perceptions about future survival, and a range of morbidities and disabilities. Using data from the survey on smoking (SOS) conducted for this research, we compare subjective beliefs elicited from the SOS with corresponding individual-specific objective probabilities estimated from the health and retirement study. Overall, consumers in the age group studied, 50-70, are not overly optimistic in their perceptions of health risk. If anything, smokers tend to be relatively pessimistic about these risks. The finding that smokers are either well informed or pessimistic regarding a broad range of health risks suggests that these beliefs are not pivotal in the decision to continue smoking. Although statements by the tobacco companies may have been misleading and thus encouraged some to start smoking, we find no evidence that systematic misinformation about the health consequences of smoking inhibits quitting.
Keywords: Aged; Deception; Female; Health Knowledge, Attitudes, Practice; Health Surveys; Humans; Male; Middle Aged; Risk Assessment; Smoking; United States

Association between cognitive function and social support with glycemic control in adults with diabetes mellitus. - Okura, Toru; Michele M Heisler; Kenneth M. Langa (J Am Geriatr Soc, 2009)
OBJECTIVES: To examine whether cognitive impairment in adults with diabetes mellitus is associated with worse glycemic control and to assess whether level of social support for diabetes mellitus care modifies this relationship. DESIGN: Cross-sectional analysis. SETTING: The 2003 Health and Retirement Study (HRS) Mail Survey on Diabetes and the 2004 wave of the HRS. PARTICIPANTS: Adults aged 50 and older with diabetes mellitus in the United States (N=1,097, mean age 69.2). MEASUREMENTS: Glycosylated hemoglobin (HbA1c) level; cognitive function, measured with the 35-point HRS cognitive scale (HRS-cog); sociodemographic variables; duration of diabetes mellitus; depressed mood; social support for diabetes mellitus care; self-reported knowledge of diabetes mellitus; treatments for diabetes mellitus; components of the Total Illness Burden Index related to diabetes mellitus; and functional limitations. RESULTS: In an ordered logistic regression model for the three ordinal levels of HbA1c (<7.0, 7.0-7.9, >or=8.0 mg/dL), respondents with HRS-cog scores in the lowest quartile had significantly higher HbA1c levels than those in the highest cognitive quartile (adjusted odds ratio=1.80, 95% confidence interval=1.11-2.92). A high level of social support for diabetes mellitus care modified this association; for respondents in the lowest cognitive quartile, those with high levels of support had significantly lower odds of having higher HbA1c than those with low levels of support (1.11 vs 2.87, P=.02). CONCLUSION: Although cognitive impairment was associated with worse glycemic control, higher levels of social support for diabetes mellitus care ameliorated this negative relationship. Identifying the level of social support available to cognitively impaired adults with diabetes mellitus may help to target interventions for better glycemic control.
Keywords: Aged; Blood Glucose; Cognition; Cross-Sectional Studies; Diabetes Mellitus; Female; Humans; Male; Middle Aged; Social Support

"Below average" self-assessed school performance and Alzheimer's disease in the Aging, Demographics, and Memory Study. - Kala M. Mehta; Anita L Stewart; Kenneth M. Langa; Kristine Yaffe; Sandra Y. Moody-Ayers; Brie A Williams; Kenneth E Covinsky (Alzheimers Dement, 2009)
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.
Keywords: Aged; Aged, 80 and over; Aging; Alzheimer disease; Apolipoprotein E4; Cognition Disorders; Educational Status; Female; Geriatric Assessment; Humans; Male; Memory; Neuropsychological tests; Risk Factors

Bridge employment and retirees' health: a longitudinal investigation. - Zhan, Yujie; Wang, Mo; Liu, Songqi; Kenneth S. Shultz (J Occup Health Psychol, 2009)
The present study examined the relationship between bridge employment and retirees' health outcomes (i.e., major diseases, functional limitations, and mental health). We used a nationally representative sample of 12,189 retirees from the first 4 waves of the Health and Retirement Study. Hierarchical regression analyses showed that compared with full retirement, engaging in bridge employment either in a career field or in a different field was associated with fewer major diseases and functional limitations, whereas engaging in career bridge employment was associated with better mental health. The findings highlight the health benefits of engaging in bridge employment for retirees. The practical implications of this study are discussed at both the individual and policy levels. Limitations of the current findings are also noted in conjunction with future research directions.
PMID: 19839658
Keywords: Employment; Female; Health Status; Humans; Interviews as Topic; Longitudinal Studies; Male; Middle Aged; Retirement; United States

Can self-reported strokes be used to study stroke incidence and risk factors?: evidence from the health and retirement study. - M. Maria Glymour; Mauricio Avendano (Stroke, 2009)
BACKGROUND AND PURPOSE: Most stroke incidence studies use geographically localized (community) samples with few national data sources available. Such samples preclude research on contextual risk factors, but national samples frequently collect only self-reported stroke. We examine whether incidence estimates from clinically verified studies are consistent with estimates from a nationally representative US sample assessing self-reported stroke. METHODS: Health and Retirement Study (HRS) participants (n=17 056) age 50+ years were followed for self- or proxy-reported first stroke (1293 events) from 1998 to 2006 (average, 6.8 years). We compared incidence rates by race, sex, and age strata with those previously documented in leading geographically localized studies with medically verified stroke. We also examined whether cardiovascular risk factor effect estimates in HRS are comparable to those reported in studies with clinically verified strokes. RESULTS: The weighted first-stroke incidence rate was 10.0 events/1000 person-years. Total age-stratified incidence rates in whites were mostly comparable with those reported elsewhere and were not systematically higher or lower. However, among blacks in HRS, incidence rates generally appeared higher than those previously reported. HRS estimates were most comparable with those reported in the Cardiovascular Health Study. Incidence rates approximately doubled per decade of age and were higher in men and blacks. After demographic adjustment, all risk factors predicted stroke incidence in whites. Smoking, hypertension, diabetes, and heart disease predicted incident stroke in blacks. CONCLUSIONS: Associations between known risk factors and stroke incidence were verified in HRS, suggesting that misreporting is nonsystematic. HRS may provide valuable data for stroke surveillance and examination of classical and contextual risk factors.
Keywords: Age Factors; Aged; Aged, 80 and over; Algorithms; Epidemiologic Methods; ethnicity; Female; Humans; Longitudinal Studies; Male; Middle Aged; Retirement; Risk Factors; Sex Factors; Stroke; Treatment Outcome; United States

Cancer survivorship, health insurance, and employment transitions among older workers. - Tunceli, Kaan; Pamela F. Short; John R. Moran; Tunceli, Ozgur (Inquiry, 2009)
This study examined the effect of job-related health insurance on employment transitions (labor force exits, reductions in hours, and job changes) of older working cancer survivors. Using multivariate models, we compared longitudinal data for the period 1997-2002 from the Penn State Cancer Survivor Study to similar data for workers with no cancer history in the Health and Retirement Study, who were also ages 55 to 64 at follow-up. The interaction of cancer survivorship with health insurance at diagnosis was negative and significant in predicting labor force exits, job changes, and transitions to part-time employment for both genders. The differential effect of job-related health insurance on the labor market dynamics of cancer survivors represents an additional component of the economic and psychosocial burden of cancer on survivors.
PMID: 19489481
Keywords: Career Mobility; Cohort Studies; Female; Health Benefit Plans, Employee; Health Insurance Portability and Accountability Act; Humans; Longitudinal Studies; Male; Middle Aged; Models, Statistical; Neoplasms; Retirement; Survivors; United States

Childhood socioeconomic status and racial differences in disability: evidence from the Health and Retirement Study (1998-2006). - Mary E Bowen (Soc Sci Med, 2009)
This study used a life course approach to examine the ways in which childhood socioeconomic status (SES) may account for some of the racial differences in disability in later life. Eight years (5 waves) of longitudinal data from the US Health and Retirement Study (HRS; 1998-2006), a nationally representative sample of community-dwelling Black and White Americans over age 50 (N=14,588), were used in nonlinear multilevel models. Parental education and father's occupation were used to predict racial differences in activities of daily living (ADL) and instrumental activities of daily living (IADL). The role of adult SES (education, income, and wealth) and health behaviors (smoking, drinking alcohol, exercising, and being obese) were also examined and models were adjusted for health conditions (heart problems, diabetes, stroke, hypertension, cancer, lung disease, and arthritis). With the inclusion of childhood SES indicators, racial differences in ADL and IADL disability were reduced. Adult SES and health behaviors mediated some of the relationship between low childhood SES and disability, though low childhood SES continued to be associated with disability net of these. In support of a life course approach, these findings suggest that socioeconomic conditions in early life may have implications for racial differences in disability between older Black and older White adults.
PMID: 19541400
Keywords: Activities of Daily Living; Aged; Aged, 80 and over; Black or African American; Disabled Persons; Female; Health Behavior; Humans; Male; Middle Aged; Models, Statistical; Prejudice; Prospective Studies; Racial Groups; Social Justice; Socioeconomic factors; Statistics as Topic; United States; White People

Cognitive decline among patients with chronic obstructive pulmonary disease. - William W. Hung; Juan P. Wisnivesky; Albert L Siu; Joseph S. Ross (Am J Respir Crit Care Med, 2009)
RATIONALE: Prior research has suggested an association between chronic obstructive pulmonary disease (COPD) and the development of cognitive decline; however, these studies have been cross-sectional or small case series. OBJECTIVES: To determine whether COPD increases the risk of cognitive decline among older adults surveyed in a large, population-based longitudinal cohort. METHODS: We included data from the 1996 to 2002 waves of the Health and Retirement Study, a biennial nationally representative survey. We studied respondents who completed cognitive testing in 1996 and at least one subsequent survey, and excluded those with unknown history of COPD. Clinical history of COPD was based on self-report; severity was categorized based on use of oxygen or disease-related activity limitations. Our primary outcome was cognitive performance, measured using a validated 35-point scale. We examined the effect of COPD on cognition using multivariable mixed linear models accounting for repeated measurements, adjusted for sociodemographic and clinical characteristics. MEASUREMENTS AND MAIN RESULTS: A total of 4,150 adults were included in our study. Among them, 12% reported a history of COPD (29% severe, 71% nonsevere disease). On repeated measurement, mean cognition scores of older adults with both severe and nonsevere COPD were significantly lower when compared with adults without COPD (2.6 points [P < 0.001] and 0.9 points [P < 0.001], respectively). After multivariable adjustment, mean scores of adults with severe COPD remained lower (0.9 point [P < 0.001]), whereas mean score of adults with nonsevere COPD was no longer different (P = 0.39) when compared with adults without COPD. CONCLUSIONS: Severe COPD was associated with lower cognitive performance on standardized measurement over time.
PMID: 19423714
Keywords: Aged; Case-Control Studies; Cognition Disorders; Female; Health Surveys; Humans; Longitudinal Studies; Male; Middle Aged; Pulmonary Disease, Chronic Obstructive; Pulmonary Ventilation; Risk Factors; Severity of Illness Index; Socioeconomic factors; United States

Cognitive health among older adults in the United States and in England. - Kenneth M. Langa; David J Llewellyn; Iain A Lang; David R Weir; Robert B Wallace; Mohammed U Kabeto; Felicia A Huppert (BMC Geriatr, 2009)
BACKGROUND: Cognitive function is a key determinant of independence and quality of life among older adults. Compared to adults in England, US adults have a greater prevalence of cardiovascular risk factors and disease that may lead to poorer cognitive function. We compared cognitive performance of older adults in the US and England, and sought to identify sociodemographic and medical factors associated with differences in cognitive function between the two countries. METHODS: Data were from the 2002 waves of the US Health and Retirement Study (HRS) (n = 8,299) and the English Longitudinal Study of Ageing (ELSA) (n = 5,276), nationally representative population-based studies designed to facilitate direct comparisons of health, wealth, and well-being. There were differences in the administration of the HRS and ELSA surveys, including use of both telephone and in-person administration of the HRS compared to only in-person administration of the ELSA, and a significantly higher response rate for the HRS (87% for the HRS vs. 67% for the ELSA). In each country, we assessed cognitive performance in non-hispanic whites aged 65 and over using the same tests of memory and orientation (0 to 24 point scale). RESULTS: US adults scored significantly better than English adults on the 24-point cognitive scale (unadjusted mean: 12.8 vs. 11.4, P < .001; age- and sex-adjusted: 13.2 vs. 11.7, P < .001). The US cognitive advantage was apparent even though US adults had a significantly higher prevalence of cardiovascular risk factors and disease. In a series of OLS regression analyses that controlled for a range of sociodemographic and medical factors, higher levels of education and wealth, and lower levels of depressive symptoms, accounted for some of the US cognitive advantage. US adults were also more likely to be taking medications for hypertension, and hypertension treatment was associated with significantly better cognitive function in the US, but not in England (P = .014 for treatment x country interaction). CONCLUSION: Despite methodological differences in the administration of the surveys in the two countries, US adults aged >/= 65 appeared to be cognitively healthier than English adults, even though they had a higher burden of cardiovascular risk factors and disease. Given the growing number of older adults worldwide, future cross-national studies aimed at identifying the medical and social factors that might prevent or delay cognitive decline in older adults would make important and valuable contributions to public health.
PMID: 19555494
Keywords: Aged; Aged, 80 and over; Aging; Cognition; Cognition Disorders; Cohort Studies; Cross-Sectional Studies; England; Female; Health Status; Humans; Longitudinal Studies; Male; Neuropsychological tests; United States

Cognitive performance and informant reports in the diagnosis of cognitive impairment and dementia in African Americans and whites. - Guy G Potter; Brenda L Plassman; James R Burke; Mohammed U Kabeto; Kenneth M. Langa; David J Llewellyn; Mary A M Rogers; David C Steffens (Alzheimers Dement, 2009)
BACKGROUND: The diagnosis of cognitive impairment and dementia must reflect an increasingly diverse and aging United States population. This study compared direct testing and informant reports of cognition with clinical diagnoses of cognitive impairment and dementia between African Americans and whites. METHODS: Participants in the Aging, Demographics, and Memory Study completed in-person dementia evaluations, and were assigned clinical diagnoses (by a consensus panel of dementia experts) of normal; cognitive impairment, not demented (CIND); and dementia. The Consortium to Establish a Registry for Alzheimer's Disease (CERAD) total score and the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) were used to assess cognitive performance and reported cognitive decline. RESULTS: A higher CERAD total score was associated with lower odds of CIND and dementia, at comparable ratios between African Americans and whites. Higher IQCODE scores were associated with increased odds of dementia in both African Americans and whites. Higher IQCODE scores were associated with increased odds of CIND among whites, but not among African Americans. CONCLUSIONS: Cultural differences may influence informant reports of prevalent CIND and dementia. Our findings also highlight the need for more comparative research to establish the cultural validity of measures used to diagnose these conditions.
Keywords: Activities of Daily Living; Age of Onset; Aged; Aged, 80 and over; Black or African American; Caregivers; Cognition Disorders; Cohort Studies; Culture; Dementia; Disability Evaluation; Female; Geriatric Assessment; Health Surveys; Humans; Male; Neuropsychological tests; Observer Variation; Population Surveillance; Predictive Value of Tests; Prevalence; Psychiatric Status Rating Scales; Psychometrics; Registries; Sensitivity and Specificity; Surveys and Questionnaires; White People

Compensatory conscientiousness and health in older couples. - Brent W Roberts; Jacqui Smith; Joshua J Jackson; Edmonds, Grant (Psychol Sci, 2009)
The present study tested the effect of conscientiousness and neuroticism on health and physical limitations in a representative sample of older couples (N= 2,203) drawn from the Health and Retirement Study. As in past research, conscientiousness predicted better health and physical functioning, whereas neuroticism predicted worse health and physical functioning. Unique to this study was the finding that conscientiousness demonstrated a compensatory effect, such that husbands' conscientiousness predicted wives' health outcomes above and beyond wives' own personality. The same pattern held true for wives' conscientiousness as a predictor of husbands' health outcomes. Furthermore, conscientiousness and neuroticism acted synergistically, such that people who scored high for both traits were healthier than others. Finally, we found that the combination of high conscientiousness and high neuroticism was also compensatory, such that the wives of men with this combination of personality traits reported better health than other women.
Keywords: Activities of Daily Living; Adult; Aged; Aged, 80 and over; Aging; Conscience; Female; Health Status; Humans; Longevity; Longitudinal Studies; Male; Middle Aged; Neurotic Disorders; Personality Inventory; Social Conformity; Spouses

The co-occurrence of chronic diseases and geriatric syndromes: the health and retirement study. - Pearl G. Lee; Christine T Cigolle; Caroline S Blaum (J Am Geriatr Soc, 2009)
OBJECTIVES: To analyze the co-occurrence, in adults aged 65 and older, of five conditions that are highly prevalent, lead to substantial morbidity, and have evidence-based guidelines for management and well-developed measures of medical care quality. DESIGN: Secondary data analysis of the 2004 wave of the Health and Retirement Study (HRS). SETTING: Nationally representative health interview survey. PARTICIPANTS: Respondents in the 2004 wave of the HRS aged 65 and older. MEASUREMENTS: Self-reported presence of five index conditions (three chronic diseases (coronary artery disease, congestive heart failure, and diabetes mellitus) and two geriatric syndromes (urinary incontinence and injurious falls)) and demographic information (age, sex, race, living situation, net worth, and education). RESULTS: Eleven thousand one hundred thirteen adults, representing 37.1 million Americans aged 65 and older, were interviewed. Forty-five percent were aged 76 and older, 58% were female, 8% were African American, and 4% resided in a nursing home. Respondents with more conditions were older and more likely to be female, single, and residing in a nursing home (all P<.001). Fifty-six percent had at least one of the five index conditions, and 23% had two or more. Of respondents with one condition, 20% to 55% (depending on the index condition) had two or more additional conditions. CONCLUSION: Five common conditions (3 chronic diseases, 2 geriatric syndromes) often co-occur in older adults, suggesting that coordinated management of comorbid conditions, both diseases and geriatric syndromes, is important. Care guidelines and quality indicators, rather than considering one condition at a time, should be developed to address comprehensive and coordinated management of co-occurring diseases and geriatric syndromes.
Keywords: Accidental Falls; Activities of Daily Living; Aged; Aged, 80 and over; Angina Pectoris; Comorbidity; Cross-Sectional Studies; Diabetes Mellitus, Type 2; Female; Geriatric Assessment; Health Surveys; Heart Failure; Humans; Male; Myocardial Infarction; Sick Role; Syndrome; United States; Urinary incontinence

Correlates of improvement in walking ability in older persons in the United States. - Joseph Feinglass; Song, Jing; Larry M Manheim; Semanik, Pamela; Rowland W Chang; Dorothy D Dunlop (Am J Public Health, 2009)
OBJECTIVES: We analyzed factors associated with improvement in walking ability among respondents to the nationally representative Health and Retirement Study. METHODS: We analyzed data from 6574 respondents aged 53 years or older who reported difficulty walking several blocks, 1 block, or across the room in 2000 or 2002. We examined associations between improvement (versus no change, deterioration, or death) and baseline health status, chronic conditions, baseline walking difficulty, demographic characteristics, socioeconomic status, and behavioral risk factors. RESULTS: Among the 25% of the study population with baseline walking limitations, 29% experienced improved walking ability, 40% experienced no change in walking ability, and 31% experienced deteriorated walking ability or died. In a multivariate analysis, we found positive associations between walking improvement and more recent onset and more severe walking difficulty, being overweight, and engaging in vigorous physical activity. A history of diabetes, having any difficulty with activities of daily living, and being a current smoker were all negatively associated with improvement in walking ability. After we controlled for baseline health, improvement in walking ability was equally likely among racial and ethnic minorities and those with lower socioeconomic status. CONCLUSIONS: Interventions to reduce smoking and to increase physical activity may help improve walking ability in older Americans.
Keywords: Age Factors; Aged; Aged, 80 and over; Confidence Intervals; Female; Health Promotion; Humans; Male; Middle Aged; Motor Activity; Multivariate Analysis; Odds Ratio; Overweight; Smoking Prevention; Social Marketing; Socioeconomic factors; United States; Walking

Dental care coverage transitions. - Richard J. Manski; John F Moeller; Haiyan Chen; Patricia A St Clair; Jody Schimmel; Larry S. Magder; John V Pepper (Am J Manag Care, 2009)
OBJECTIVE: To examine dental insurance transition dynamics in the context of changing employment and retirement status. STUDY DESIGN: Data from the Health and Retirement Study (HRS) were analyzed for individuals 51 years and older between the 2004 and 2006 waves of the HRS. METHODS: The primary focus of the analysis is the relationship between retirement and transitions in dental care coverage. We calculate and present bivariate relationships between dental coverage and retirement status transitions over time and estimate a multivariable model of dental coverage controlling for retirement and other potentially confounding covariates. RESULTS: Older adults are likely to lose their dental coverage on entering retirement compared with those who remain in the labor force between waves of the HRS. While more than half of those persons in the youngest group (51-64 years) were covered over this entire period, two-thirds of those in the oldest group (>or=75 years) were without coverage over the same period. We observe a high percentage of older persons flowing into and out of dental coverage over the period of our study, similar to flows into and out of poverty. CONCLUSIONS: Dental insurance is an important factor in the decision to seek dental care. Yet, no dental coverage is provided by Medicare, which provides medical insurance for almost all Americans 65 years and older. This loss of coverage could lead to distortions in the timing of when to seek care, ultimately leading to worse oral and overall health.
Keywords: Aged; Career Mobility; Female; Health Benefit Plans, Employee; Humans; Insurance Coverage; Insurance, Dental; Interviews as Topic; Male; Middle Aged; United States

Does job loss cause ill health? - Salm, Martin (Health Econ, 2009)
This study estimates the effect of job loss on health for near elderly employees based on longitudinal data from the Health and Retirement Study. Previous studies find a strong negative correlation between unemployment and health. To control for possible reverse causality, this study focuses on people who were laid off for an exogenous reason - the closure of their previous employers' business. I find no causal effect of exogenous job loss on various measures of physical and mental health. This suggests that the inferior health of the unemployed compared to the employed could be explained by reverse causality.
Keywords: Activities of Daily Living; Age Factors; Cohort Studies; Cross-Sectional Studies; Employment; Female; Health Status; Humans; Male; Mental Health; Middle Aged; Sex Factors; Smoking; Socioeconomic factors

The effect of depression and cognitive impairment on enrollment in Medicare Part D. - Zivin, Kara; Mohammed U Kabeto; Helen C Kales; Kenneth M. Langa (J Am Geriatr Soc, 2009)
OBJECTIVES: To examine concerns that vulnerable populations, such as depressed or cognitively impaired beneficiaries would have challenges accessing Part D coverage. DESIGN: Logistic regression analysis was used to assess whether elderly Medicare beneficiaries with depression or cognitive impairment differentially planned to and actually signed up for Part D. SETTING: 2004 and 2006 data from the Health and Retirement Study (HRS) were used, including a subsample that completed the Prescription Drug Study (PDS) in 2005. PARTICIPANTS: Nine thousand five hundred ninety-three HRS respondents and 3,567 PDS respondents. MEASUREMENTS: The outcome variables of interest were planned and actual enrollment in Part D. The independent variables were depression and cognitive impairment status. The analyses were adjusted using clinical and demographic predictors including age, sex, race or ethnicity, educational attainment, net worth, marital status, health status, number of health conditions being treated with prescription medications, and presence of a caregiver. RESULTS: Although having depression or cognitive impairment was associated with a higher likelihood of planning to and actually signing up for Part D in unadjusted analyses, in adjusted analyses, having depression or cognitive impairment was not significantly associated with whether Medicare beneficiaries planned to enroll in or actually enrolled in Part D. CONCLUSION: Vulnerable Medicare beneficiaries with depression or cognitive impairment were able to access Part D benefits to the same extent as nonvulnerable beneficiaries. More research is needed to determine how well Part D meets the needs of these populations.
Keywords: Aged; Aged, 80 and over; Chi-Square Distribution; Cognition Disorders; depression; Female; Humans; Logistic Models; Longitudinal Studies; Male; Medicare Part D; Middle Aged; Patient Participation; Risk Factors; United States

Effect of Medicare home health care payment on informal care. - Ezra Golberstein; David C Grabowski; Kenneth M. Langa; M.E. Chernew (Inquiry, 2009)
This paper assesses the effect of payment caps for Medicare home health care on the use of informal care by older adults with functional limitations. We find that individuals exposed to more restrictive payment caps offset reductions in Medicare home health care with increased informal care, although we only observe this effect for lower-income individuals. This suggests that home care payment restrictions may have increased the caregiving burden on some low-income families, but that many higher-income families were able to either forgo the care or finance it privately. Home care payment policies should recognize these effects, balancing costs of the program with the desire to protect families from the burdens associated with providing informal home care.
Keywords: Caregivers; Confidence Intervals; Female; Health Care Surveys; Home Care Services; Humans; Male; Medicare; Organizational Policy; Reimbursement Mechanisms; United States

Is the effect of reported physical activity on disability mediated by cognitive performance in white and african american older adults? - Mihaela A. Popa; Sandra L Reynolds; Brent J. Small (J Gerontol B Psychol Sci Soc Sci, 2009)
This study examined if reported physical activity has beneficial outcomes on disability through cognitive performance-mediated effects and if these mediation effects are comparable for White and African American elders. Longitudinal data from the Assets and Health Dynamics among the Oldest Old study (N = 4,472) are used to test mediation in multilevel models. During the 7-year follow-up, cognitive performance mediated the effects of reported physical activity on disability in the entire sample and in Whites but not in African Americans. Our results indicate that reported physical activity may delay the disability development through improvement in cognitive performance. Unmeasured education and comorbidity influences may have obscured the mediation effects in African Americans. Reported physical activity plays a key role in the independence of older adults and should be particularly promoted in African Americans and during the entire life course.
Keywords: Activities of Daily Living; Aged; Aged, 80 and over; Black or African American; Cognition Disorders; Cohort Studies; Disability Evaluation; Exercise; Female; Follow-Up Studies; Health Status Disparities; Humans; Male; Motor Activity; Neuropsychological tests; Socioeconomic factors; United States; White People

The effect of retirement on weight. - Chung, Sukyung; Marisa E Domino; Sally C. Stearns (J Gerontol B Psychol Sci Soc Sci, 2009)
OBJECTIVES: People who are close to retirement age show the highest rates of weight gain and obesity. We investigate the effect of retirement on the change in body mass index (BMI) in diverse groups varying by wealth status and occupation type. METHODS: Six panels of the Health and Retirement Study (1992-2002) on individuals aged 50-71 were used (N = 37,807). We used fixed-effects regression models with instrumental variables method to estimate the causal effect of retirement on change in the BMI. RESULTS: Retirement leads to modest weight gain, 0.24 BMI on average. Weight gain with retirement was found among people who were already overweight and those with lower wealth retiring from physically demanding occupations. The cumulative effect of aging among people in their 50s, however, outweighs the effect of retirement; the average BMI gain between ages 50 and 60 is 1.30, 5 times the effect of retirement. CONCLUSIONS: Given the increasing number of people approaching retirement age, the population level impact of the weight gain ascribed to retirement on health outcomes and health care system might be significant. Future research should evaluate programs targeted to older adults who are most likely to gain weight with retirement.
Keywords: Aged; Aging; Body Mass Index; Cohort Studies; Cross-Sectional Studies; Female; Geriatric Assessment; Health Status; Humans; Longitudinal Studies; Male; Middle Aged; Models, Statistical; Motor Activity; Obesity; Overweight; Pensions; Retirement; Social Security; Socioeconomic factors; United States; Weight Gain

The effects of developing a dual sensory loss on depression in older adults: a longitudinal study. - Michele Capella McDonnall (J Aging Health, 2009)
OBJECTIVE: To determine the effect of developing a dual sensory loss (DSL) on depression over time and evaluate the impact of preexisting single sensory loss on this effect. METHOD: Multilevel modeling was used to analyze data (N = 2,689) from the Health and Retirement Study. RESULTS: A significant increase in depression at the first report of DSL occurred, and depression increased at a significantly faster rate following DSL, in a curvilinear pattern. In addition, persons who eventually developed DSL began the study with a depression score significantly higher than persons who did not experience sensory loss. A preexisting single sensory loss did not alter the effect of DSL on depression. DISCUSSION: Two sources of disparity in depression between persons with and without DSL were identified: preexisting differences and differences that occurred due to the DSL. The relationship exhibited between depression and developing a DSL indicated an adjustment process.
Keywords: Adaptation, Psychological; Adult; Aged; Aged, 80 and over; Black or African American; depression; Depressive Disorder; Female; Health Surveys; Hearing loss; Hispanic or Latino; Humans; Longitudinal Studies; Male; Middle Aged; Models, Statistical; Multivariate Analysis; Rehabilitation; Retirement; Risk Factors; Sensation Disorders; United States; Vision Disorders; White People

Estimating the quantity and economic value of family caregiving for community-dwelling older persons in the last year of life. - Rhee, YongJoo; Howard B Degenholtz; Anthony T. Lo Sasso; Linda L Emanuel (J Am Geriatr Soc, 2009)
OBJECTIVES: To estimate the quantity and economic value of informal care provided to older persons during their final year of life in the community. DESIGN: Retrospective analysis of publicly available nationally representative survey data. SETTING: This retrospective study used data from the Health and Retirement Study, a nationally representative, longitudinal study of community-dwelling older people. PARTICIPANTS: Older people who died between 2000 and 2002. MEASUREMENTS: Data were extracted from the 2002 "exit survey" and linked with characteristics of caregivers from the helper file. Ordinary least squares regression was used to estimate hours of informal caregiving for community-dwelling older people (N=990). Adjusted hours were multiplied by the 2002 national average home aide wage (9.16 USD per hour). Sensitivity tests were performed using the 10th percentile wage rate (6.56 USD) and 90th percentile wage rate (12.34 USD). RESULTS: Older people who died in the community received on average 65.8 hours per week of informal care in the last year of life. The estimated economic value ranges from 22,514 USD to 42,351 USD, which is equivalent to the annual direct replacement cost with a home aide in 2002. CONCLUSION: Family members provide substantial assistance during the last year of life for older people who die in the community. If the informal care provided in the last year of life is replaced with a home aide, the total economic value for the United States would be approximately 1.4 billion USD (in 2002).
Keywords: Activities of Daily Living; Adult; Aged; Aged, 80 and over; Caregivers; Costs and Cost Analysis; Disability Evaluation; Female; Health Surveys; Home Health Aides; Home Nursing; Humans; Independent Living; Male; Middle Aged; Retrospective Studies; Terminal Care; United States

Ethnic differences in cognitive function over time. - Meredith C. Masel; M. Kristen Peek (Ann Epidemiol, 2009)
PURPOSE: Minority group membership in old age has been implicated as a risk factor for lower scores on cognitive function tests, independent of education level. In addition, differential rates of cognitive decline by ethnic group have been identified in several epidemiologic studies. However, others have not been able to detect differences. METHODS: In order to determine if health disparities in cognitive function scores extend to rates of decline, the current research examined rates of change in memory and mental status over the course of 9 years (1996-2004) in a nationally representative sample of late middle-aged and older white, black, and Hispanic adults who were part of the nationally representative Health and Retirement Study. Change in cognitive function was measured by separate indices of memory and mental status items and analyzed with multivariable mixed modeling. RESULTS: Results indicated that, after controlling for demographic, social, and health-related variables, ethnicity was associated with cognitive function scores across waves (P<0.01), but did not greatly impact rates of decline. Furthermore, although education was associated with cognitive function scores across waves (P<0.01), education level did not impact decline rates. CONCLUSIONS: Some health disparities in cognitive function exist even in late middle age, but ethnic differences in rates of decline are mixed.
Keywords: Black or African American; Brief Psychiatric Rating Scale; Cognition Disorders; Educational Status; Female; Hispanic or Latino; Humans; Logistic Models; Longitudinal Studies; Male; Memory Disorders; Middle Aged; Odds Ratio; White People

Factors associated with long-stay nursing home admissions among the U.S. elderly population: comparison of logistic regression and the Cox proportional hazards model with policy implications for social work. - Cai, Qian; J. Warren Salmon; Mark E. Rodgers (Soc Work Health Care, 2009)
Two statistical methods were compared to identify key factors associated with long-stay nursing home (LSNH) admission among the U.S. elderly population. Social Work's interest in services to the elderly makes this research critical to the profession. Effectively transitioning the "baby boomer" population into appropriate long-term care will be a great societal challenge. It remains a challenge paramount to the practice of social work. Secondary data analyses using four waves (1995, 1998, 2000, and 2002) of the Health Retirement Study (HRS) coupled with the Assets and Health Dynamics among the Oldest Old (AHEAD) surveys were conducted. Multivariable logistic regression and Cox proportional hazards model were performed and compared. Older age, lower self-perceived health, worse instrumental activities of daily living (IADL), psychiatric problems, and living alone were found significantly associated with increased risk of LSNH admission. In contrast, being female, African American, or Hispanic; owning a home; and having lower level of cognitive impairment reduced the admission risk. Home ownership showed a significant effect in logistic regression, but a marginal effect in the Cox model. The Cox model generally provided more precise parameter estimates than logistic regression. Logistic regression, used frequently in analyses, can provide a good approximation to the Cox model in identifying factors of LSNH admission. However, the Cox model gives more information on how soon the LSNH admission may happen. Our analyses, based on two models, dually identified the factors associated with LSNH admission; therefore, results discussed confidently provide implications for both public and private long-term care policies, as well as improving the assessment capabilities of social work practitioners for development of screening programs among at-risk elderly. Given the predicted surge in this population, significant factors found from this study can be utilized in a strengths-based empowerment approach by social workers to aid in avoiding LSNH utilization.
Keywords: Activities of Daily Living; Age Factors; Aged; Aged, 80 and over; Female; Geriatric Assessment; Health Status; Homes for the Aged; Humans; Logistic Models; Male; Mental Health; Nursing homes; Proportional Hazards Models; Risk Factors; Sex Factors; Social work; Socioeconomic factors; United States

Fall risk in older adults: roles of self-rated vision, home modifications, and limb function. - Bernard A Steinman; Pynoos, Jon; Anna Q D Nguyen (J Aging Health, 2009)
Objective. To assess direct effects of self-rated vision, home modifications, and limb functioning, and moderating effects of self-rated vision on change in functioning of upper and lower limbs on fall risk in older adults. Method. Logistic regression was used to analyze 2004 and 2006 waves of the Health and Retirement Study. Results. Effects of self-rated vision and home modifications in predicting falls decreased after controlling functioning in upper and lower extremities. Declines/gains in functioning across short periods of time superseded self-rated vision in predicting falls. No evidence was found for a moderating effect of vision status on limb functioning. Discussion. Poor self-rated vision may not be a good indicator of fall risk in older adults. Thus, for older adults with visual impairments, preserving residual limb functioning through exercise and activity has the important potential to reduce fall risk in addition to improving muscle and bone strength as well as improving balance and gait.
Keywords: Accidental Falls; Activities of Daily Living; Aged; Aged, 80 and over; Black or African American; Disabled Persons; Educational Status; Female; Health Status; Health Surveys; Humans; Logistic Models; Longitudinal Studies; Male; Musculoskeletal Physiological Phenomena; Risk; Risk Factors; Self-Assessment; Self-Help Devices; Surveys and Questionnaires; Vision, Low; Visual Acuity; White People

Financial hardship and mortality among older adults using the 1996-2004 Health and Retirement Study. - Reginald D. Tucker-Seeley; Li, Yi; Subramanian, S V; Sorensen, Glorian (Ann Epidemiol, 2009)
PURPOSE: We investigated the effect of financial hardship on mortality risk in a community-dwelling sample of adults 50 years of age and olderin the United States. METHOD: The 1996 Health and Retirement Study cohorts were followed prospectively to 2004 (N = 8,377). Gender-stratified grouped Cox models were used to estimate the difference in the relative risk (RR) of mortality between a specific number of financial hardships (one, two, or three or more) and no hardships; and the predictive utility of each individual financial hardship for mortality during the follow-up period. RESULTS: Gender-stratified models adjusted for demographics, socioeconomic characteristics, and functional limitations in 1996 showed that women reporting one (hazard ratio [HR] = 1.42; 95% confidence interval [CI]: 1.05-1.92) or three or more (HR = 1.60; 95% CI: 1.05-2.46) and men reporting two (HR = 1.80; 95% CI: 1.21-2.69) financial hardships had a substantially higher probability of mortality compared to those reporting no financial hardships. Individual financial hardships that predicted mortality in fully adjusted models for women included receiving Medicaid (HR = 2.23; 95% CI: 1.68-2.98) and for men receiving Medicaid (HR = 2.11; 95% CI: 1.57-2.84) and receiving food stamps (HR = 1.59; 95% CI: 1.09-2.33). CONCLUSIONS: These findings suggest that over and above the influence of traditional measures of socioeconomic status, financial hardship exerts an influence on the risk of mortality among older adults and that the number and type of hardships important in predicting mortality may differ for men and women.
Keywords: Aged; Female; Geriatric Assessment; Health Surveys; Humans; Male; Medicaid; Middle Aged; Mortality; Poverty; Proportional Hazards Models; Prospective Studies; Retirement; Risk; Sex Factors; United States

Financial status, employment, and insurance among older cancer survivors. - Norredam, Marie; Meara, Ellen; Landrum, Mary Beth; Haiden A. Huskamp; Nancy L. Keating (J Gen Intern Med, 2009)
BACKGROUND: Few data are available about the socioeconomic impact of cancer for long-term cancer survivors. OBJECTIVES: To investigate socioeconomic outcomes among older cancer survivors compared to non-cancer patients. DATA SOURCE: 2002 Health and Retirement Study. STUDY DESIGN: We studied 964 cancer survivors of > 4 years and 14,333 control patients who had never had cancer from a population-based sample of Americans ages >or= 55 years responding to the 2002 Health and Retirement Study. MEASURES: We compared household income, housing assets, net worth, insurance, employment, and future work expectations. ANALYSES: Propensity score methods were used to control for baseline differences between cancer survivors and controls. RESULTS: Female cancer survivors did not differ from non-cancer patients in terms of income, housing assets, net worth, or likelihood of current employment (all P > 0.20); but more were self-employed (25.0% vs. 17.7%; P = 0.03), and fewer were confident that if they lost their job they would find an equally good job in the next few months (38.4% vs. 45.9%; P = 0.03). Among men, cancer survivors and noncancer patients had similar income and housing assets (both P >or= 0.10) but differed somewhat in net worth (P = 0.04). Male cancer survivors were less likely than other men to be currently employed (25.2% vs. 29.7%) and more likely to be retired (66.9% vs. 62.2%), although the P value did not reach statistical significance (P = 0.06). Men were also less optimistic about finding an equally good job in the next few months if they lost their current job (33.5% vs. 46.9%), although this result was not significant (P = 0.11). CONCLUSIONS: Despite generally similar socioeconomic outcomes for cancer survivors and noncancer patients ages >or=55 years, a better understanding of employment experience and pessimism regarding work prospects may help to shape policies to benefit cancer survivors.
Keywords: Aged; Aged, 80 and over; Cohort Studies; Data collection; Employment; Female; Financing, Personal; Humans; Income; Insurance Coverage; Insurance, Health; Longitudinal Studies; Male; Middle Aged; Neoplasms; Socioeconomic factors; Survivors

Functional limitations, socioeconomic status, and all-cause mortality in moderate alcohol drinkers. - Sei J. Lee; Rebecca L. Sudore; Brie A Williams; Lindquist, Karla; Helen L. Chen; Kenneth E Covinsky (J Am Geriatr Soc, 2009)
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.
Keywords: Activities of Daily Living; Aged; Alcohol Drinking; Comorbidity; Education; Female; Humans; Income; Male; Obesity; Risk Factors; Sex Factors; Smoking; Socioeconomic factors

Health and well-being in older married female cancer survivors. - Aloen L. Townsend; Karen J Ishler; Karen F Bowman; Rose, Julia Hannum; Peak, Nicole Juszczak (J Am Geriatr Soc, 2009)
OBJECTIVES: To investigate differences between older married female cancer survivors and a matched comparison sample on physical health and on effects of health on depressive symptomatology. DESIGN AND SETTING: National survey data from the 1992 Health and Retirement Study. PARTICIPANTS: Married women who reported having been diagnosed with cancer (N=245) and married women who did not report a cancer diagnosis but who matched the survivors on age, race, and ethnicity (N=245). MEASUREMENTS: Outcome measure was depressive symptomatology (modified CES-D). Predictors were multiple indicators of health and demographic characteristics. RESULTS: Cancer survivors reported significantly worse health on all indicators but not higher depressive symptomatology after health and demographics were controlled. Predictors of higher depression were fatigue, pain, and lower education. These effects did not differ between groups. CONCLUSION: Health impairment in cancer survivors highlights the need for ongoing follow-up care. Survivorship was associated indirectly with higher depressive symptomatology through its relationship with health impairment.
Keywords: Age Factors; Case-Control Studies; Depressive Disorder; Female; Health Status; Health Status Indicators; Health Surveys; Humans; Marriage; Middle Aged; Neoplasms; Predictive Value of Tests; Risk Factors; Survivors; United States

Health disadvantage in US adults aged 50 to 74 years: a comparison of the health of rich and poor Americans with that of Europeans. - Mauricio Avendano; M. Maria Glymour; James Banks; Johan P Mackenbach (Am J Public Health, 2009)
OBJECTIVES: We compared the health of older US, English, and other European adults, stratified by wealth. METHODS: Representative samples of adults aged 50 to 74 years were interviewed in 2004 in 10 European countries (n = 17,481), England (n = 6527), and the United States (n = 9940). We calculated prevalence rates of 6 chronic diseases and functional limitations. RESULTS: American adults reported worse health than did English or European adults. Eighteen percent of Americans reported heart disease, compared with 12% of English and 11% of Europeans. At all wealth levels, Americans were less healthy than were Europeans, but differences were more marked among the poor. Health disparities by wealth were significantly smaller in Europe than in the United States and England. Odds ratios of heart disease in a comparison of the top and bottom wealth tertiles were 1.94 (95% confidence interval [CI] = 1.69, 2.24) in the United States, 2.13 (95% CI = 1.73, 2.62) in England, and 1.38 (95% CI = 1.23, 1.56) in Europe. Smoking, obesity, physical activity levels, and alcohol consumption explained a fraction of health variations. CONCLUSIONS: American adults are less healthy than Europeans at all wealth levels. The poorest Americans experience the greatest disadvantage relative to Europeans.
Keywords: Age Factors; Aged; Chronic disease; Confidence Intervals; Disabled Persons; Europe; Female; Health Status Disparities; Heart Diseases; Humans; Male; Middle Aged; Odds Ratio; Poverty; Prevalence; Risk Factors; Socioeconomic factors; United States

The health effects of Medicare for the near-elderly uninsured. - Daniel Polsky; Jalpa A Doshi; José J Escarce; Manning, Willard; Susan M Paddock; Cen, Liyi; Jeannette Rogowski (Health Serv Res, 2009)
OBJECTIVE: To determine whether Medicare enrollment at age 65 has an effect on the health trajectory of the near-elderly uninsured. DATA SOURCES: Eight biennial waves (1992-2006) of the Health and Retirement Study, a nationally representative panel survey of noninstitutionalized 51-61 year olds and their spouses. STUDY DESIGN: We use a quasi-experimental approach to compare the health effects of insurance for the near-elderly uninsured with previously insured contemporaneous controls. The primary outcome measure is overall self-reported health status combined with mortality (i.e., excellent to very good, good, fair to poor, dead). RESULTS: The change in the trajectory of overall health status for the previously uninsured that can be attributed to Medicare is small and not statistically significant. For every 100 persons in the previously uninsured group, joining Medicare is associated with 0.6 fewer in excellent or very good health (95 percent CI: -4.8, 3.3), 0.3 more in good health (95 percent CI: -3.8, 4.1), 2.5 fewer in fair or poor health (95 percent CI: -7.4, 2.3), and 2.8 more dead (-4.0, 10.0) by age 73. The health trajectory patterns from physician objective health measures are similarly small and not statistically significant. CONCLUSIONS: Medicare coverage at age 65 for the previously uninsured is not linked to improvements in overall health status.
Keywords: Aged; Attitude to Health; Female; Follow-Up Studies; Health Services Accessibility; Health Services Research; Health Status; Health Surveys; Humans; Insurance Coverage; Logistic Models; Male; Medically Uninsured; Medicare; Mortality; Multivariate Analysis; Program Evaluation; Retirement; Socioeconomic factors; Statistics, Nonparametric; United States

The health impact of remarriage behavior on chronic obstructive pulmonary disease: findings from the US longitudinal survey. - Noda, Tatsuya; Ojima, Toshiyuki; Hayasaka, Shinya; Hagihara, Okihito; Takayanagi, Ryoichi; Nobutomo, Koichi (BMC Public Health, 2009)
BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a major disease among adults, and its deterioration was reported to be associated with psychological imbalance. Meanwhile, bereavement and divorce have proven harmful to the health status of a surviving spouse. But few studies have been conducted to evaluate the remedial effect on survivors' health outcome by remarriage after bereavement. The present study thus examined the associations between remarriage and the onset of COPD. METHODS: Our cohort was drawn from Health and Retirement Study participants in the United States, and consisted of 2676 subjects who were divorced or bereaved from 1992 to 2002. We then followed them for up to 11 years and assessed the incidence rate of COPD using a Cox proportional hazard model after adjusting for marital status, age, gender, education and the number of cigarettes smoked. RESULTS: Among all subjects, 224 who remarried after bereavement or divorce tended to be younger and more male dominated. Remarriage after bereavement/divorce was associated with significantly decreased risk of COPD onset for overall subjects [hazard ratio (HR): 0.51, 95% confidence interval (95% CI): 0.28-0.94], female subjects [HR: 0.36, 95% CI: 0.13-0.98], and for those under 70 years old [HR: 0.36, 95% CI: 0.17-0.79]. CONCLUSION: This study investigates the impact of remarriage on health outcome based on a large-scale population survey and indicates that remarriage significantly correlates with reduced risk of COPD incidence, even after adjusting smoking habit.
Keywords: Aged; Bereavement; Educational Status; Female; Follow-Up Studies; Health Status; Health Surveys; Humans; Lung Diseases, Obstructive; Male; Marriage; Middle Aged; Outcome Assessment, Health Care; Proportional Hazards Models; Smoking; United States

The impact of occupation on self-rated health: cross-sectional and longitudinal evidence from the health and retirement survey. - Ralitza Gueorguieva; Jody L Sindelar; Tracy Falba; Jason M. Fletcher; Patricia S Keenan; Wu, Ran; William T Gallo (J Gerontol B Psychol Sci Soc Sci, 2009)
BACKGROUND: The objective of this study is to estimate occupational differences in self-rated health, both in cross-section and over time, among older individuals. METHODS: We use hierarchical linear models to estimate self-reported health as a function of 8 occupational categories and key covariates. We examine self-reported health status over 7 waves (12 years) of the Health and Retirement Study. Our study sample includes 9,586 individuals with 55,389 observations. Longest occupation is used to measure the cumulative impact of occupation, address the potential for reverse causality, and allow the inclusion of all older individuals, including those no longer working. RESULTS: Significant baseline differences in self-reported health by occupation are found even after accounting for demographics, health habits, economic attributes, and employment characteristics. But contrary to our hypothesis, there is no support for significant differences in slopes of health trajectories even after accounting for dropout. CONCLUSIONS: Our findings suggest that occupation-related differences found at baseline are durable and persist as individuals age.
PMID 19196689
Keywords: Aged; Attitude to Health; Cohort Studies; Cross-Sectional Studies; Educational Status; Female; Health Status Indicators; Health Surveys; Humans; Linear Models; Longitudinal Studies; Male; Middle Aged; Mortality; Occupations; Odds Ratio; Retirement; Social Class; Socioeconomic factors; United States

Incidence and remission of urinary incontinence in a community-based population of women ≥ 50 years. - Yuko M Komesu; Rebecca G Rogers; Ronald M Schrader; Cynthia M. Lewis (Int Urogynecol J Pelvic Floor Dysfunct, 2009)
INTRODUCTION AND HYPOTHESIS: The objective of the study was to determine incidence, remission, and predictors of change in urinary incontinence in women ≥ 50 in a racially diverse population. METHODS: Subjects were women ≥ 50 with 4-year follow-up incontinence information in the Health and Retirement Study. Women with Any UI (AUI) and Severe UI (SVUI) were evaluated. Repeated measures logistic regression determined predictors of progression to and improvement of SVUI. RESULTS: Women (11,591) were evaluated. AUI 4-year cumulative incidence was 12.7-33.8% (fifth vs. ninth decades). SVUI incidence was lower but also increased with age. Among the predictors of improvement in SVUI were age (ninth vs. fifth decade odds ratios (OR) = 6.06) and ethnicity (Black vs. White OR = 0.57). Improvement of SVUI (45.8% overall) decreased with age (ninth vs. fifth decade OR = 0.12). CONCLUSIONS: SVUI incidence increased and remission decreased with age. Ethnicity and age predicted SVUI progression while age predicted improvement. Rates of the latter were high, particularly in younger patients.
Keywords: Age Factors; Black People; disease progression; Female; Hispanic or Latino; Humans; Incidence; Logistic Models; Longitudinal Studies; Middle Aged; Odds Ratio; Prevalence; Remission, Spontaneous; Severity of Illness Index; United States; Urinary incontinence; White People

Individual well-being in middle and older adulthood: do spousal beliefs matter? - Tim D Windsor; Lindsay H Ryan; Jacqui Smith (J Gerontol B Psychol Sci Soc Sci, 2009)
Associations between health, control beliefs, and well-being in later life are frequently conceptualized in terms of the characteristics of individuals. However, spousal interdependencies in psychosocial characteristics are also likely to be relevant for well-being. The present study investigated associations of self-rated health, control, and relationship closeness with life satisfaction and positive and negative affect in a sample of 2,235 spousal dyads. A significant proportion of variance in health, control, closeness, and well-being occurred between dyads. Individuals' self-rated health, control, and relationship closeness were associated with higher well-being. Spouses' self-rated health and control beliefs were consistently and positively associated with individuals' well-being; however, effect sizes were small. Some evidence for individual's control beliefs buffering the association between health and well-being emerged, whereas spouses' perceived control was not a significant moderator of the health-well-being association. Results highlight the importance of couple interdependencies for contextualizing health and well-being in older adulthood.
Keywords: Adult; Affect; Aged; Aged, 80 and over; Aging; Attitude to Health; Culture; Female; Humans; Individuality; Internal-External Control; Male; Marriage; Middle Aged; Quality of Life; Spouses

The influence of long-term care insurance on the likelihood of nursing home admission. - Tanya R Gure; Mohammed U Kabeto; Kenneth M. Langa (J Am Geriatr Soc, 2009)
OBJECTIVES: To determine the effect of long-term care (LTC) insurance on nursing home use. DESIGN: Longitudinal analysis, 1998 to 2006 waves of the Health Retirement Study. SETTING: Community-dwelling nationally representative sample. PARTICIPANTS: Nineteen thousand one hundred seventy adults aged 50 and older, 1998 wave. METHODS: Two groups of respondents were created at baseline: those with and without an LTC insurance policy. Respondents admitted to the nursing home from 1998 to 2006 were identified. Propensity scores were used to control for known predictors of LTC insurance possession. A Cox proportional hazards model was used to compare the probability of nursing home admission over 8 years of follow-up for respondents possessing LTC insurance and those without a policy. RESULTS: Of the 19,170 respondents aged 50 and older in 1998, 1,767 (9.2%) possessed LTC insurance. A total of 1,778 (8.5%) were admitted to a nursing home during the 8-year period: 149 (8.7%) of those with LTC insurance and 1,629 (8.4%) of those without LTC insurance. The hazard ratio, adjusted for propensity score, for those with LTC insurance entering a nursing home compared with those without was 1.07 (95% confidence interval=0.83-1.38). Likelihood of nursing home admission was relatively low because the low-risk population included in the study, limiting the power to detect small differences in risk of nursing home utilization between groups. CONCLUSION: There was no difference in nursing home utilization between low-risk older adults who did and did not possess an LTC insurance policy.
Keywords: Aged; Aged, 80 and over; Female; Humans; Insurance, Long-Term Care; Longitudinal Studies; Male; Middle Aged; Nursing homes

The intersection of sex, marital status, and cardiovascular risk factors in shaping stroke incidence: results from the health and retirement study. - J Maselko; Lisa M. Bates; Mauricio Avendano; M. Maria Glymour (J Am Geriatr Soc, 2009)
OBJECTIVES: To examine the role of sex and marital status in the distribution and consequences of cardiovascular risk factors for stroke. DESIGN: Longitudinal cohort. SETTING: U.S. national sample, community based. PARTICIPANTS: U.S. adults aged 50 and older and their spouses. MEASUREMENTS: Health and Retirement Study (HRS) participants born between 1900 and 1947 (N=22,818), aged 50 and older, and stroke-free at baseline were followed an average of 9.4 years for self- or proxy-reported stroke (2,372 events). Financial resources, behavioral risk factors, and cardiovascular conditions were used to predict incident stroke in Cox proportional hazard models stratified according to sex and marital status (married, widowed, divorced or separated, or never married). RESULTS: Women were less likely to be married than men. The distribution of risk factors differed according to sex and marital status. Men had higher incident stroke rates than women, even after full risk factor adjustment (hazard ratio (HR)=1.22, 95% confidence interval (CI)=1.11-1.34). For both sexes, being never married or widowed predicted greater risk, associations that were attenuated after adjustment for financial resources. Widowed men had the highest risk (HR=1.40, 95% CI=1.12-1.74 vs married women). Lower income and wealth were associated with similarly high risk across subgroups, although this risk factor especially affected unmarried women, with this group reporting the lowest income and wealth levels. Most other risk factors had similar HRs across subgroups, although moderate alcohol use did not predict lower stroke risk in unmarried women. CONCLUSION: Stroke incidence and risk factors vary substantially according to sex and marital status. It is likely that gendered social experiences, such as marriage and socioeconomic disadvantage, mediate pathways linking sex and stroke.
Keywords: Aged; Cardiovascular Diseases; Female; Health Surveys; Humans; Incidence; Longitudinal Studies; Male; Marital Status; Middle Aged; Risk Factors; Sexuality; Stroke

Level and change in cognitive test scores predict risk of first stroke. - Triveni DeFries; Mauricio Avendano; M. Maria Glymour (J Am Geriatr Soc, 2009)
OBJECTIVES: To determine whether cognitive test scores and cognitive decline predict incidence of first diagnosed stroke. DESIGN: Stroke-free Health and Retirement Study participants were followed on average 7.6 years for self- or proxy-reported first stroke (1,483 events). Predictors included baseline performance on a modified Telephone Interview for Cognitive Status (Mental Status) and Word Recall test and decline between baseline and second assessment in either measure. Hazard ratios (HRs) were estimated using Cox proportional hazards models for the whole sample and stratified according to five major cardiovascular risk factors. SETTING: National cohort study of noninstitutionalized adults with a mean baseline age of 64+/-9.9. PARTICIPANTS: Health and Retirement Study participants (n=19,699) aged 50 and older. RESULTS: Word Recall (HR for 1 standard deviation difference=0.92, 95% confidence interval (CI)=0.86-0.97)) and Mental Status (HR=0.89, 95% CI=0.84-0.95) predicted incident stroke. Mental Status predicted stroke risk in those with (HR=0.93, 95%=0.87-0.99) and without (HR=0.81, 95% CI=0.72-.91) one or more vascular risk factors. Word Recall declines predicted a 16% elevation in subsequent stroke risk (95% CI=1.01-1.34). Declines in Mental Status predicted a 37% elevation in stroke risk (95% CI=1.11-1.70). CONCLUSION: Cognitive test scores predict future stroke risk, independent of other major vascular risk factors.
Keywords: Aged; Aged, 80 and over; Cognition Disorders; Cohort Studies; Dementia, Vascular; Female; Follow-Up Studies; Humans; Interviews as Topic; Kaplan-Meier Estimate; Male; Mental Status Schedule; Middle Aged; Predictive Value of Tests; Psychometrics; Risk; Stroke; United States

Major depression and urinary incontinence in women: temporal associations in an epidemiologic sample. - Jennifer L Melville; Fan, Ming-Yu; Rau, Holly; Ingrid E Nygaard; Wayne J Katon (Am J Obstet Gynecol, 2009)
OBJECTIVE: To determine whether: (1) major depression is associated with increased risk for onset of urinary incontinence, and (2) urinary incontinence is associated with increased risk for onset of depression. STUDY DESIGN: Longitudinal cohort study of female Health and Retirement Study participants completing baseline interviews at Wave 3 (1996-1997) and follow-up interviews at Waves 4-6 (1998-2003). RESULTS: In a cohort of 5820 women with a mean age 59.3 (+/- 0.5) years, 6-year cumulative incidences of depression and incontinence were 11% and 21%, respectively. Major depression was associated with increased odds of incident incontinence (adjusted odds ratio, 1.46; 95% confidence interval, 1.08-1.97) during follow-up compared with those without major depression at baseline. Conversely, incontinence was not associated with increased odds of incident depression (adjusted odds ratio, 1.03; 95% confidence interval, 0.75-1.42) compared with those without incontinence at baseline. CONCLUSION: Major depression predicted onset of urinary incontinence in a population-based sample of at-risk, community-dwelling women. Incontinence did not predict onset of depression.
Keywords: Depressive Disorder, Major; Female; Humans; Longitudinal Studies; Middle Aged; Risk Factors; Time Factors; Urinary incontinence

Marital biography and health at mid-life. - Mary Elizabeth Hughes; Linda J. Waite (J Health Soc Behav, 2009)
This article develops a series of hypotheses about the long-term effects of one's history of marriage, divorce, and widowhood on health, and it tests those hypotheses using data from the Health and Retirement Study. We examine four dimensions of health at mid-life: chronic conditions, mobility limitations, self-rated health, and depressive symptoms. We find that the experience of marital disruption damages health, with the effects still evident years later; among the currently married, those who have ever been divorced show worse health on all dimensions. Both the divorced and widowed who do not remarry show worse health than the currently married on all dimensions. Dimensions of health that seem to develop slowly, such as chronic conditions and mobility limitations, show strong effects of past marital disruption, whereas others, such as depressive symptoms, seem more sensitive to current marital status. Those who spent more years divorced or widowed show more chronic conditions and mobility limitations.
Keywords: Female; Health Status; Humans; Interviews as Topic; Longitudinal Studies; Male; Marital Status; Middle Aged; United States

Marital trajectories and mortality among US adults. - Matthew E Dupre; Audrey N Beck; Sarah O. Meadows (Am J Epidemiol, 2009)
More than a century of empirical evidence links marital status to mortality. However, the hazards of dying associated with long-term marital trajectories and contributing risk factors are largely unknown. The authors used 1992-2006 prospective data from a cohort of US adults to investigate the impact of current marital status, marriage timing, divorce and widow transitions, and marital durations on mortality. Multivariate hazard ratios were significantly higher for adults currently divorced and widowed, married at young ages (< or =18 years), who accumulated divorce and widow transitions (among women), and who were divorced for 1-4 years. Results also showed significantly lower risks of mortality for men married after age 25 years compared with on time (ages 19-25 years) and among women experiencing > or =10 years of divorce and > or =5 years of widowhood relative to those without exposure to these statuses. For both sexes, accumulation of marriage duration was the most robust predictor of survival. Results from risk-adjusted models indicated that socioeconomic resources, health behaviors, and health status attenuated the associations in different ways for men and women. The study demonstrates that traditional measures oversimplify the relation between marital status and mortality and that sex differences are related to a nexus of marital experiences and associated health risks.
Keywords: Age Factors; Cohort Studies; Female; Health Behavior; Humans; Male; Marital Status; Middle Aged; Mortality; Retirement; Retrospective Studies; Risk Factors; Sex Factors; Time Factors; United States

Material resources and population health: disadvantages in health care, housing, and food among adults over 50 years of age. - Dawn E Alley; Beth J Soldo; José A Pagán; John McCabe; deBlois, Madeleine; Samuel H Field; David A Asch; Carolyn Cannuscio (Am J Public Health, 2009)
OBJECTIVES: We examined associations between material resources and late-life declines in health. METHODS: We used logistic regression to estimate the odds of declines in self-rated health and incident walking limitations associated with material disadvantages in a prospective panel representative of US adults aged 51 years and older (N = 15,441). RESULTS: Disadvantages in health care (odds ratio [OR] = 1.39; 95% confidence interval [CI] = 1.23, 1.58), food (OR = 1.69; 95% CI = 1.29, 2.22), and housing (OR = 1.20; 95% CI = 1.07, 1.35) were independently associated with declines in self-rated health, whereas only health care (OR = 1.43; 95% CI = 1.29, 1.58) and food (OR = 1.64; 95% CI = 1.31, 2.05) disadvantage predicted incident walking limitations. Participants experiencing multiple material disadvantages were particularly susceptible to worsening health and functional decline. These effects were sustained after we controlled for numerous covariates, including baseline health status and comorbidities. The relations between health declines and non-Hispanic Black race/ethnicity, poverty, marital status, and education were attenuated or eliminated after we controlled for material disadvantage. CONCLUSIONS: Material disadvantages, which are highly policy relevant, appear related to health in ways not captured by education and poverty. Policies to improve health should address a range of basic human needs, rather than health care alone.
Keywords: Aged; Female; Food Supply; Health Status Disparities; Health Surveys; Healthcare Disparities; Housing; Humans; Logistic Models; Male; Middle Aged; Poverty; United States

Measuring socioeconomic differences in use of health care services by wealth versus by income. - Allin, Sara; Masseria, Cristina; Elias Mossialos (Am J Public Health, 2009)
OBJECTIVES: We compared the extent of socioeconomic differences in use of health care services based on wealth (i.e., accumulated assets) as the socioeconomic ranking variable with the extent of differences based on income to explore the sensitivity of the estimates of equity to the choice of the socioeconomic indicator. METHODS: We used data from the Health and Retirement Study in the United States and the Survey of Health, Ageing, and Retirement in Europe to estimate levels of income- and wealth-related disparity in use of physician and dental services among adults 50 or older in 12 countries. RESULTS: We found socioeconomic differences in use of physician services after standardizing for need in about half of the countries studied. No consistent pattern in levels of disparity measured by wealth versus those measured by income was found. However, the rich were significantly more likely to use dental services in all countries. Wealth-related differences in dental service use were consistently higher than were income-related differences. CONCLUSIONS: We found some support for wealth as a more sensitive indicator of socioeconomic status among older adults than was income. Wealth may thus allow more accurate measurements of socioeconomic differences in use of health care services for this population.
Keywords: Aged; Aged, 80 and over; Aging; Data collection; Europe; Female; Health Services; Health Services Accessibility; Health Status Disparities; Humans; Income; Male; Middle Aged; Odds Ratio; Pensions; Retirement; Socioeconomic factors; Statistics as Topic; United Kingdom

Medicare savings programs: analyzing options for expanding eligibility. - Zuckerman, Stephen; Shang, Baoping; Timothy A Waidmann (Inquiry, 2009)
The Medicare Savings Programs (MSPs) are designed to provide financial assistance to Medicare beneficiaries who do not qualify for full Medicaid coverage. This paper considers changes in eligibility that would better align MSP program rules with those related to receiving low-income subsidies for the Medicare Part D drug benefit. These changes would make more people eligible for the MSPs and could encourage greater participation; similar changes were incorporated in recently passed legislation. Our analysis, based on 2006 data from the Health and Retirement Study, shows there is a trade-off between making larger numbers of beneficiaries eligible by eliminating resource requirements and better targeting of individuals with greater health care needs by expanding income standards.
Journal Article
Keywords: Aged; Demography; Disabled Persons; Eligibility Determination; Female; Health Status; Humans; Income; Male; Medical Assistance; Medicare; Medicare Part D; Public Policy; United States

Memory and depressive symptoms are dynamically linked among married couples: longitudinal evidence from the AHEAD study. - Denis Gerstorf; Christiane A Hoppmann; Kelly M Kadlec; John J McArdle (Dev Psychol, 2009)
This study examined dyadic interrelations between episodic memory and depressive symptom trajectories of change in old and advanced old age. The authors applied dynamic models to 10-year incomplete longitudinal data of initially 1,599 married couples from the study of Asset and Health Dynamics Among the Oldest Old (M(age) = 75 years at Time 1). The authors found domain-specific lead-lag associations (time lags of 2 years) among wives and husbands as well as between spouses. For memory, better performance among husbands protected against subsequent memory decline among wives, with no evidence of a directed effect in the other direction. For depressive symptoms, wives' scores predicted subsequent depression increase and memory decline among husbands. Possible individual covariates (age, education, functional limitations) and spousal covariates (length of marriage, number of children, and whether the couple remained intact over the study period) did not account for differential lead-lag associations. The findings of antecedent-consequent relations between wives and husbands are consistent with life-span notions that individual development both influences and is influenced by contextual factors such as close social relationships.
PMID: 19899917
Keywords: Adaptation, Psychological; Aged; Aged, 80 and over; Aging; Cognition; depression; Female; Health Status; Humans; Interpersonal Relations; Longitudinal Studies; Male; Marriage; Mental Recall; Models, Psychological; Quality of Life; Spouses

Mortality attributable to obesity among middle-aged adults in the United States. - Neil K Mehta; Virginia W Chang (Demography, 2009)
Obesity is considered a major cause of premature mortality and a potential threat to the longstanding secular decline in mortality in the United States. We measure relative and attributable risks associated with obesity among middle-aged adults using data from the Health and Retirement Study (1992-2004). Although class II/III obesity (BMI > or = or = 35.0 kg/m2) increases mortality by 40% in females and 62% in males compared with normal BMI (BMI = 18.5-24.9), class I obesity (BMI = 30.0-34.9) and being overweight (BMI = 25.0-29.9) are not associated with excess mortality. With respect to attributable mortality, class II/III obesity (BMI > or = 35.0) is responsible for approximately 4% of deaths among females and 3% of deaths among males. Obesity is often compared with cigarette smoking as a major source of avoidable mortality. Smoking-attributable mortality is much larger in this cohort: about 36% in females and 50% in males. Results are robust to confounding by preexisting diseases, multiple dimensions of socioeconomic status (SES), smoking, and other correlates. These findings challenge the viewpoint that obesity will stem the long-term secular decline in U.S. mortality.
Keywords: Body Mass Index; Confidence Intervals; Confounding Factors, Epidemiologic; Female; Humans; Male; Middle Aged; Multivariate Analysis; Obesity; Proportional Hazards Models; Risk; Socioeconomic factors; United States

Neighborhood safety, socioeconomic status, and physical activity in older adults. - Reginald D. Tucker-Seeley; Subramanian, S V; Li, Yi; Sorensen, Glorian (Am J Prev Med, 2009)
BACKGROUND: Neighborhood environment can have a substantial influence on the level of physical activity among older adults. Yet, the moderating influence of various measures of SES on the association between perceived neighborhood safety and leisure-time physical activity (LTPA) among older adults remains unknown. PURPOSE: The study was designed to investigate the association between perceived neighborhood safety and LTPA in a nationally representative sample of older adults, and to evaluate SES characteristics as potential effect modifiers in the association between perceived neighborhood safety and LTPA. METHODS: Cross-sectional data from the 2004 Health and Retirement Study of older adults aged >or=50 years were used to examine the association between perceived neighborhood safety and LTPA. Differences in LTPA were evaluated across three measures of SES: education, household income, and household wealth. SES was also evaluated as a potential effect modifier in the association between perceived neighborhood safety and LTPA. The analysis was conducted in 2008. RESULTS: An SES gradient in LTPA was noted across measures of SES used in this study. After controlling for SES and demographic characteristics and functional limitations, older adults who perceived their neighborhood as safe had an 8% higher mean rate of LTPA compared to older adults who perceived their neighborhood as unsafe. The association was no longer significant when self-rated health was added. Additionally, SES was not a significant effect modifier in the association between perceived neighborhood safety and LTPA. CONCLUSIONS: SES, demographic characteristics, and functional limitations substantially attenuated the positive association between perceived neighborhood safety and LTPA; however, with the inclusion of self-rated health, the association was no longer present. This finding suggests that self-rated health may mediate this association. The lack of significance in the interaction between perceived neighborhood safety and SES suggests that prevention efforts to increase physical activity among older adults should consider perceptions of neighborhood safety as a potential barrier regardless of SES.
Keywords: Aged; Aged, 80 and over; Cross-Sectional Studies; Female; Florida; Health Status; Humans; Leisure activities; Male; Middle Aged; Motor Activity; Recreation; Residence Characteristics; Safety; Sex Distribution; Social Support; Socioeconomic factors; Surveys and Questionnaires

A new measure of medication affordability. - Becky A. Briesacher; Ross-Degnan, Dennis; Adams, Alyce; Anita K Wagner; Jerry Gurwitz; Soumerai, Stephan (Soc Work Public Health, 2009)
This study developed a new measure of medication affordability that examines out-of-pocket drug expenses relative to available household resources. The authors assessed the spending patterns of approximately 2.1 million poor households (< or =100% federal poverty level) of adults aged 51 and older by Medicaid status. The data were drawn from the 2000-2001 Health and Retirement Study. Household spending was categorized into three broad types: basic living, health care, and discretionary. Older (aged 51 or older) poor households without Medicaid allocated about 72% of their total resources ($17,421, SE $783) to basic living needs. In comparison, those with Medicaid had scarcer total resources ($12,498, SE $423) and allocated 85% to basic living needs. Medication costs consumed the largest proportion of health care expenses for both types of poor households (Medicaid: $463, SE $67; non-Medicaid: $970, SE $102). After paying for basic living needs and health care costs, these families had, on average, only $16 left each week. Poor families have very few resources available for anything beyond basic living needs, even when they have Medicaid coverage. There is no great reservoir of discretionary funds to pay for increases in cost-sharing under Medicaid and Medicare Part D.
Keywords: Aged; Data collection; Female; Financing, Personal; Humans; Male; Medicaid; Middle Aged; Poverty; Prescription Fees; United States

Pain, functional limitations, and aging. - Kenneth E Covinsky; Lindquist, Karla; Dorothy D Dunlop; Yelin, Edward (J Am Geriatr Soc, 2009)
OBJECTIVES: To examine the relationship between functional limitations and pain across a spectrum of age, ranging from mid life to advanced old age. DESIGN: Cross-sectional study. SETTING: The 2004 Health and Retirement Study (HRS), a nationally representative study of community-living persons aged 50 and older. PARTICIPANTS: Eighteen thousand five hundred thirty-one participants in the 2004 HRS. MEASUREMENTS: Participants who reported that they were often troubled by pain that was moderate or severe most of the time were defined as having significant pain. For each of four functional domains, subjects were classified according to their degree of functional limitation: mobility (able to jog 1 mile, able to walk several blocks, able to walk one block, unable to walk one block), stair climbing (able to climb several flights, able to climb one flight, not able to climb a flight), upper extremity tasks (able to do 3, 2, 1, or 0), and activity of daily living (ADL) function (able to do without difficulty, had difficulty but able to do without help, need help). RESULTS: Twenty-four percent of participants had significant pain. Across all four domains, participants with pain had much higher rates of functional limitations than subjects without pain. Participants with pain were similar in terms of their degree of functional limitation to participants 2 to 3 decades older. For example, for mobility, of subjects aged 50 to 59 without pain, 37% were able to jog 1 mile, 91% were able to walk several blocks, and 96% were able to walk one block without difficulty. In contrast, of subjects aged 50 to 59 with pain, 9% were able to jog 1 mile, 50% were able to walk several blocks, and 69% were able to walk one block without difficulty. Subjects aged 50 to 59 with pain were similar in terms of mobility limitations to subjects aged 80 to 89 without pain, of whom 4% were able to jog 1 mile, 55% were able to walk several blocks, and 72% were able to walk one block without difficulty. After adjustment for demographic characteristics, socioeconomic status, comorbid conditions, depression, obesity, and health habits, across all four measures, participants with significant pain were at much higher risk for having functional limitations (adjusted odds ratio (AOR)=2.85, 95% confidence interval (CI)=2.20-3.69, for mobility; AOR=2.84, 95% CI=2.48-3.26, for stair climbing; AOR=3.96, 95% CI=3.43-4.58, for upper extremity tasks; and AOR=4.33; 95% CI=3.71-5.06, for ADL function). CONCLUSION: Subjects with pain develop the functional limitations classically associated with aging at much earlier ages.
Keywords: Activities of Daily Living; Aged; Aged, 80 and over; Aging; Comorbidity; Cross-Sectional Studies; Disability Evaluation; Female; Geriatric Assessment; Health Behavior; Health Surveys; Humans; Life Style; Male; Middle Aged; Mobility Limitation; pain; Pain Measurement; Quality of Life; Risk Factors

Parental education and late-life dementia in the United States. - Mary A M Rogers; Brenda L Plassman; Mohammed U Kabeto; Gwenith G Fisher; John J McArdle; David J Llewellyn; Guy G Potter; Kenneth M. Langa (J Geriatr Psychiatry Neurol, 2009)
We investigated the relation between parental education and dementia in the United States. Participants in the Aging, Demographics, and Memory Study were included, with information regarding parental education obtained from the Health and Retirement Study. The odds of dementia in elderly Americans whose mothers had less then 8 years of schooling were twice (95% CI, 1.1-3.8) that of individuals with higher maternal education, when adjusted for paternal education. Of elderly Americans with less educated mothers, 45.4% (95% CI, 37.4-53.4%) were diagnosed with dementia or ;;cognitive impairment, no dementia'' compared to 31.2% (95% CI, 25.0-37.4%) of elderly Americans whose mothers had at least an 8th grade education. The population attributable risk of dementia due to low maternal education was 18.8% (95% CI, 9.4-28.2%). The education of girls in a population may be protective of dementia in the next generation.
Keywords: Age Distribution; Aged; Aged, 80 and over; Apolipoproteins E; Biomarkers; Cognition Disorders; Dementia; Educational Status; Fathers; Female; Genetic Predisposition to Disease; Humans; Longitudinal Studies; Male; Mothers; Odds Ratio; Parents; Prevalence; Prospective Studies; Racial Groups; Risk Factors; Sex Distribution; United States

Physician outpatient contacts and hospitalizations among cognitively impaired elderly. - Caspi, Eilon; Nina M Silverstein; Frank Porell; Kwan, Ngai (Alzheimers Dement, 2009)
BACKGROUND: This study examined how physician contacts and hospitalizations vary in relation to cognitive function level among community-residing older adults. METHODS: Analysis of the 1998 wave of the Health and Retirement Survey (HRS) was conducted to create three levels of cognitive function among 6,991 older adults by using direct measures for self-respondents and proxy evaluations. Ordinary least square regression analyses were used to estimate the probability of physician outpatient contacts, number of hospitalizations, and nights hospitalized during the last 2 years. RESULTS: Lower cognitive function level was found to be associated with decreasing levels of physician contacts and increasing levels of hospitalizations as well as nights hospitalized. In addition, lower cognitive function levels were consistently related to a variety of comorbidities. Moreover, many older adults with low cognitive function levels reported or were reported by their proxies as not having a diagnosis of a memory-related disease (MRD). Finally, having a diagnosis of an MRD was found to be associated with more physician contacts but fewer hospital nights compared with those who had never received such a diagnosis. CONCLUSIONS: The findings suggest the need for increased outreach targeted at identification of community-dwelling older adults with decline in cognitive function who are in need of care but are underdiagnosed, underutilize physician care, and are overhospitalized.
Keywords: Aged; Aged, 80 and over; Alzheimer disease; Ambulatory Care; Cognition Disorders; Community-Institutional Relations; Comorbidity; Female; Hospitalization; Housing for the Elderly; Humans; Male; Memory Disorders; Physicians; Prevalence; Severity of Illness Index

Predictors of loneliness in U.S. adults over age sixty-five. - Laurie A. Theeke (Arch Psychiatr Nurs, 2009)
The purpose of this study was to examine sociodemographic and health-related risks for loneliness among older adults using Health and Retirement Study Data. Overall prevalence of loneliness was 19.3%. Marital status, self-report of health, number of chronic illnesses, gross motor impairment, fine motor impairment, and living alone were predictors of loneliness. Age, female gender, use of home care, and frequency of healthcare visits were not predictive. Loneliness is a prevalent problem for older adults in the United States with its own health-related risks. Future research of interventions targeting identified risks would enhance the evidence base for nursing and the problem of loneliness.
Keywords: Aged; Aged, 80 and over; Female; Health Status; Humans; Likelihood Functions; Logistic Models; Loneliness; Male; Prevalence; Risk Factors; Single Person; Socioeconomic factors; United States

Preferences, beliefs, and self-management of diabetes. - Frank A Sloan; Padrón, Norma A; Alyssa C Platt (Health Serv Res, 2009)
OBJECTIVE: To assess relationships between self-assessed control over life events, subjective beliefs about longevity, time and risk preference, and other factors on use of recommended care for diabetes mellitus (DM), self-assessed control of diabetes, general health, and laboratory measures of HbA1c levels. DATA SOURCES: Health and Retirement Study (HRS) and 2003 HRS Diabetes Study (HRS-DS). STUDY DESIGN: We used logit and ordered logit analyses to assess use of recommended care, and subjective and objective measures of health outcomes. DATA COLLECTION: Secondary analysis of HRS and HRS-DS data. PRINCIPAL FINDINGS: Individuals with higher self-assessed control over life events and higher subjective probabilities of living 10 years engaged in more recommended DM care practices and had better self-assessed DM control and general health. However, these beliefs did not influence HbA1c levels. More highly educated and cognitively able persons were more likely to follow care recommendations. There were differences by race/ethnicity in health outcomes, but not in health investment among Hispanics. CONCLUSIONS: Individuals' beliefs about control over life events and longevity influenced health investment and subjective health outcomes, although these beliefs did not translate into differences in HbA1c levels. Hispanics may realize lower returns on health investments, at least for diabetes care.
PMID: 19674433
Keywords: Black or African American; Choice Behavior; Cross-Sectional Studies; Diabetes Mellitus; Female; Glycated Hemoglobin; Health Knowledge, Attitudes, Practice; Health Status; Hispanic or Latino; Humans; Internal-External Control; Logistic Models; Longevity; Longitudinal Studies; Male; Patient Compliance; Risk Assessment; Self Care; Self-Assessment; Socioeconomic factors; Surveys and Questionnaires

Prevalence of depression among older Americans: the Aging, Demographics and Memory Study. - David C Steffens; Gwenith G Fisher; Kenneth M. Langa; Guy G Potter; Brenda L Plassman (Int Psychogeriatr, 2009)
BACKGROUND: Previous studies have attempted to provide estimates of depression prevalence in older adults. The Aging, Demographics and Memory Study (ADAMS) is a population-representative study that included a depression assessment, providing an opportunity to estimate the prevalence of depression in late life in the U.S.A. METHODS: The ADAMS sample was drawn from the larger Health and Retirement Study. A total of 851 of 856 ADAMS participants aged 71 and older had available depression data. Depression was measured using the Composite International Diagnostic Interview - Short Form (CIDI-SF) and the informant depression section of the Neuropsychiatric Inventory (NPI). We estimated the national prevalence of depression, stratified by age, race, sex, and cognitive status. Logistic regression analyses were performed to examine the association of depression and previously reported risk factors for the condition. RESULTS: When combining symptoms of major or minor depression with reported treatment for depression, we found an overall depression prevalence of 11.19%. Prevalence was similar for men (10.19%) and women (11.44%). Whites and Hispanics had nearly three times the prevalence of depression found in African-Americans. Dementia diagnosis and pain severity were associated with increased depression prevalence, while black race was associated with lower rates of depression. CONCLUSIONS: The finding of similar prevalence estimates for depression in men and women was not consistent with prior research that has shown a female predominance. Given the population-representativeness of our sample, similar depression rates between the sexes in ADAMS may result from racial, ethnic and socioeconomic diversity.
PMID: 19519984
Keywords: Aged; Aged, 80 and over; Alzheimer disease; Black People; Cohort Studies; Comorbidity; Cross-Sectional Studies; Depressive Disorder; Female; Health Status; Hispanic or Latino; Humans; Male; Neuropsychological tests; Personality Assessment; Sex Factors; Socioeconomic factors; United States; White People

Proximity to death and participation in the long-term care market. - Weaver, France; Sally C. Stearns; Edward C Norton; Spector, William (Health Econ, 2009)
The extent to which increasing longevity increases per capita demand for long-term care depends on the degree to which utilization is concentrated at the end of life. We estimate the marginal effect of proximity to death, measured by being within 2 years of death, on the probabilities of nursing home and formal home care use, and we determine whether this effect differs by availability of informal care--i.e. marital status and co-residence with an adult child. The analysis uses a sample of elderly aged 70+ from the 1993-2002 Health and Retirement Study. Simultaneous probit models address the joint decisions to use long-term care and co-reside with an adult child. Overall, proximity to death significantly increases the probability of nursing home use by 50.0% and of formal home care use by 12.4%. Availability of informal support significantly reduces the effect of proximity to death. Among married elderly, proximity to death has no effect on institutionalization. In conclusion, proximity to death is one of the main drivers of long-term care use, but changes in sources of informal support, such as an increase in the proportion of married elderly, may lessen its importance in shaping the demand for long-term care.
PMID: 18770873
Keywords: Aged; Aged, 80 and over; Caregivers; Female; Health Services Needs and Demand; Home Care Services; Humans; Interviews as Topic; Longevity; Male; Models, Statistical; Nursing homes; Terminal Care; United States

Recent hospitalization and the risk of hip fracture among older Americans. - Frederic D Wolinsky; Suzanne E Bentler; Li Liu; Maksym Obrizan; Elizabeth A Cook; Kara B Wright; John F Geweke; Elizabeth A Chrischilles; Claire E Pavlik; Robert L. Ohsfeldt; Michael P Jones; Kelly K Richardson; et al. (J Gerontol A Biol Sci Med Sci, 2009)
BACKGROUND: We identified hip fracture risks in a prospective national study. METHODS: Baseline (1993-1994) interview data were linked to Medicare claims for 1993-2005. Participants were 5,511 self-respondents aged 70 years and older and not in managed Medicare. ICD9-CM 820.xx (International Classification of Diseases, 9th Edition, Clinical Modification) codes identified hip fracture. Participants were censored at death or enrollment into managed Medicare. Static risk factors included sociodemographic, socioeconomic, place of residence, health behavior, disease history, and functional and cognitive status measures. A time-dependent marker reflecting postbaseline hospitalizations was included. RESULTS: A total of 495 (8.9%) participants suffered a postbaseline hip fracture. In the static proportional hazards model, the greatest risks involved age (adjusted hazard ratios [AHRs] of 2.01, 2.82, and 4.91 for 75-79, 80-84, and > or =85 year age groups vs those aged 70-74 years; p values <.001), sex (AHR = 0.45 for men vs women; p < .001), race (AHRs of 0.37 and 0.46 for African Americans and Hispanics vs whites; p values <.001 and <.01), body mass (AHRs of 0.40, 0.77, and 1.73 for obese, overweight, and underweight vs normal weight; p values <.001, <.05, and <.01), smoking status (AHRs = 1.49 and 1.52 for current and former smokers vs nonsmokers; p values <.05 and <.001), and diabetes (AHR = 1.99; p < .001). The time-dependent recent hospitalization marker did not alter the static model effect estimates, but it did substantially increase the risk of hip fracture (AHR = 2.51; p < .001). CONCLUSIONS: Enhanced discharge planning and home care for non-hip fracture hospitalizations could reduce subsequent hip fracture rates.
Keywords: Accidental Falls; Age Distribution; Aged; Aged, 80 and over; Aging; Cohort Studies; Female; Follow-Up Studies; Geriatric Assessment; Hip Fractures; Hospitalization; Humans; Logistic Models; Male; Multivariate Analysis; Probability; Proportional Hazards Models; Prospective Studies; Risk Factors; Sex Distribution; Survival Analysis; United States

Retirement and physical activity: analyses by occupation and wealth. - Chung, Sukyung; Marisa E Domino; Sally C. Stearns; Barry M Popkin (Am J Prev Med, 2009)
BACKGROUND: Older adults close to retirement age show the lowest level of physical activity. Changes in lifestyle with retirement may alter physical activity levels. This study investigated whether retirement changes physical activity and how the effect differs by occupation type and wealth level. METHODS: This longitudinal study used the Health and Retirement Study (1996-2002), U.S. population-based data. Analyses were conducted in 2007 and 2008. Physical activity was measured by a composite indicator of participation in either work-related or leisure-time physical activity. Fixed-effects regression models were used to account for confounders and unobserved heterogeneity. The dependent variable was a composite indicator of participation in regular physical activity either at work or during nonworking hours. RESULTS: Physical activity decreased with retirement from a physically demanding job but increased with retirement from a sedentary job. Occupation type interacted with wealth level, with the negative impact on physical activity of retirement exacerbated by lack of wealth and the positive effect of retirement on physical activity enhanced by wealth. CONCLUSIONS: Substantial differences in the effect of retirement on physical activity occurred across subgroups. As the number of people approaching retirement age rapidly increases, findings suggest that a growing segment of the nation's population may not sustain an adequate level of physical activity.
Keywords: Cohort Studies; Female; Humans; Income; Life Style; Longitudinal Studies; Male; Middle Aged; Motor Activity; Occupations; Retirement; United States

Risk factors associated with injury attributable to falling among elderly population with history of stroke. - Afshin A Divani; Vazquez, Gabriela; Anna M Barrett; Asadollahi, Marjan; Andreas R Luft (Stroke, 2009)
BACKGROUND AND PURPOSE: Stroke survivors are at high risk for falling. Identifying physical, clinical, and social factors that predispose stroke patients to falls may reduce further disability and life-threatening complications, and improve overall quality of life. METHODS: We used 5 biennial waves (1998-2006) from the Health and Retirement Study to assess risk factors associated with falling accidents and fall-related injuries among stroke survivors. We abstracted demographic data, living status, self-evaluated general health, and comorbid conditions. We analyzed the rate ratio (RR) of falling and the OR of injury within 2 follow-up years using a multivariate random effects model. RESULTS: We identified 1174 stroke survivors (mean age+/-SD, 74.4+/-7.2 years; 53% female). The 2-year risks of falling, subsequent injury, and broken hip attributable to fall were 46%, 15%, and 2.1% among the subjects, respectively. Factors associated with an increased frequency of falling were living with spouse as compared to living alone (RR, 1.4), poor general health (RR, 1.1), time from first stroke (RR, 1.2), psychiatric problems (RR, 1.7), urinary incontinence (RR, 1.4), pain (RR, 1.4), motor impairment (RR, 1.2), and past frequency of > or = 3 falls (RR, 1.3). Risk factors associated with fall-related injury were female gender (OR, 1.5), poor general health (OR, 1.2), past injury from fall (OR, 3.2), past frequency of > or = 3 falls (OR, 3.1), psychiatric problems (OR, 1.4), urinary incontinence (OR, 1.4), impaired hearing (OR, 1.6), pain (OR, 1.8), motor impairment (OR, 1.3), and presence of multiple strokes (OR, 3.2). CONCLUSIONS: This study demonstrates the high prevalence of falls and fall-related injuries in stroke survivors, and identifies factors that increase the risk. Modifying these factors may prevent falls, which could lead to improved quality of life and less caregiver burden and cost in this population.
Keywords: Accidental Falls; Aged; Aged, 80 and over; Aging; Causality; Cohort Studies; Comorbidity; disease progression; Female; Health Status; Humans; Male; Marital Status; Mental Disorders; Movement Disorders; Prevalence; Risk Factors; Risk Reduction Behavior; Sex Distribution; Stroke; Urinary incontinence; Wounds and Injuries

Risk perception and preference for prevention of Alzheimer's disease. - Chung, Sukyung; Kala M. Mehta; Shumway, Martha; Alvidrez, Jennifer; Eliseo J Perez-Stable (Value Health, 2009)
OBJECTIVES: To understand how older adults perceive their risk of Alzheimer's Disease (AD) and how this may shape their medical care decisions, we examined whether presence of established risk factors of AD is associated with individuals' perceived risk of AD, and with preference for preventing AD. PARTICIPANTS: Data came from the US Health and Retirement Study participants who were asked questions on AD risk perception (N = 778). MEASUREMENTS: Perceived risk of AD was measured by respondents' estimate of their percent chance (0-100) developing AD in the next 10 years. Preference for AD prevention was measured with questions eliciting willingness to pay for a drug to prevent AD. ANALYSIS: Multivariate linear regressions were used to estimate correlates of perceived risk and preference for prevention. RESULTS: Better cognitive functioning and physical activity are associated with decreased perceived risk. Neither age nor cardiovascular disease is associated with perceived risk. African Americans have lower perceived risk than non-Latino whites; the difference is wider among people age 65 and above. Only 4% to 7% of the variation in perceived risk was explained by the model. Preference for prevention is stronger with increased perceived risk, but not with the presence of risk factors. Persons with better cognitive functioning, physical functioning, or wealth status have a stronger preference for prevention. CONCLUSION: Some known risk factors appear to inform, but only modestly, individuals' perceived risk of AD. Furthermore, decisions about AD prevention may not be determined by objective needs alone, suggesting a potential discrepancy between need and demand for AD preventive care.
Keywords: Age Factors; Aged; Aged, 80 and over; Alzheimer disease; Cognition; Female; Health education; Health Knowledge, Attitudes, Practice; Health Surveys; Humans; Linear Models; Male; Multivariate Analysis; Psychometrics; Risk Assessment; Risk Factors; Social Perception; Statistics as Topic; United States

Smoking kills, obesity disables: a multistate approach of the US Health and Retirement Survey. - Mieke Reuser; Luc G Bonneux; Frans J Willekens (Obesity (Silver Spring), 2009)
Increasing BMI causes concerns about the consequences for health care. Decreasing cardiovascular mortality has lowered obesity-related mortality, extending duration of disability. We hypothesized increased duration of disability among overweight and obese individuals. We estimated age-, risk-, and state-dependent probabilities of activities of daily living (ADL) disability and death and calculated multistate life tables, resulting in the comprehensive measure of life years with and without ADL disability. We used prospective data of 16,176 white adults of the Health and Retirement Survey (HRS). Exposures were self-reported BMI and for comparison smoking status and levels of education. Outcomes were years to live with and without ADL disability at age 55. The reference categories were high normal weight (BMI: 23-24.9), nonsmoking and high education. Mild obesity (BMI: 30-34.9) did not change total life expectancy (LE) but exchanged disabled for disability-free years. Mild obesity decreased disability-free LE with 2.7 (95% confidence limits 1.2; 3.2) year but increased LE with disability with 2.0 (0.6; 3.4) years among men. Among women, BMI of 30 to 34.9 decreased disability-free LE with 3.6 (2.1; 5.1) year but increased LE with disability with 3.2 (1.6;4.8) years. Overweight (BMI: 25-29.9) increases LE with disability for women only, by 2.1 (0.8; 3.3) years). Smoking compressed disability by high mortality. Smoking decreased LE with 7.2 years, and LE with disability with 1.3 (0.5; 2.5) years (men) and 1.4 (0.3; 2.6) years (women). A lower education decreased disability-free life, but not duration of ADL disability. In the aging baby boom, higher BMI will further increase care dependence.
Keywords: Activities of Daily Living; Aged; Aged, 80 and over; Body Mass Index; Disability Evaluation; Educational Status; Female; Health Surveys; Humans; Life Expectancy; Life Tables; Male; Middle Aged; Obesity; Proportional Hazards Models; Prospective Studies; Smoking; United States; White People

Socioeconomic differentials in immune response. - Jennifer B Dowd; Allison E Aiello (Epidemiology, 2009)
BACKGROUND: Lower socioeconomic status (SES) is strongly linked to health outcomes, though the mechanisms are poorly understood. Little is known about the role of the immune system in creating and sustaining health disparities. Here we test whether SES is related to cell-mediated immunity, as measured by the host's ability to keep persistent cytomegalovirus (CMV) antibody levels in a quiescent state. METHODS: Censored regression models were used to test the cross-sectional relationship of education, income, and race/ethnicity with antibody response to CMV, using a nationally representative sample of 9721 respondents aged 25 years and older in the Third National Health and Nutrition Examination Survey (NHANES III, 1988-1994). RESULTS: Among CMV-seropositive respondents, those with less education, lower income, and nonwhite race/ethnicity had higher levels of CMV antibodies at all ages. On average, each additional year of age was associated with CMV antibody levels that were 0.03 units higher (95% confidence interval = 0.03 to 0.04), whereas each additional year of education was associated with antibody levels that were 0.05 units lower (0.02 to 0.09). A doubling of family income was associated with antibody levels that were 0.25 units lower (0.11 to 0.39), the equivalent of 8 fewer years of age-related CMV antibody response. These relationships remained strong after controlling for baseline health conditions, smoking status, and BMI. CONCLUSIONS: SES is associated with an indirect marker of cell-mediated immunity in a nationally representative sample. SES differences in immune control over CMV may have fundamental implications for health disparities over the life course.
Keywords: Adult; Aged; Cytomegalovirus; Cytomegalovirus Infections; Female; Health Status Disparities; Humans; Male; Middle Aged; Nutrition Surveys; Regression Analysis; Social Class; United States

Spouse-rated vs self-rated health as predictors of mortality. - Liat Ayalon; Kenneth E Covinsky (Arch Intern Med, 2009)
BACKGROUND: The Health and Retirement Study is a national sample of Americans older than 50 years and their spouses. The present study evaluated cross-sectional and longitudinal data from January 2000 through December 2006. The objective of the study was to evaluate the roles of spouse-rated vs self-rated health as predictors of all-cause mortality among adults older than 50 years. METHODS: A total of 673 dyads of married couples were randomly selected to participate in a Health and Retirement Study module examining spouse-rated health. For each couple, one member was asked to rate his or her overall health status, and his or her spouse was asked to report the partner's overall health status. Mortality data were available through 2006. RESULTS: Our findings demonstrate that spouse-rated health (area under the curve, 0.75) is as strong a predictor of mortality as self-rated health (area under the curve, 0.73) (chi(2)(1) = 0.36, P = .54). Combining spouse-rated and self-rated health predicts mortality better than using self-rated health alone (area under the curve, 0.77) (chi(2)(1) = 6.72, P = .009). CONCLUSIONS: Spouse ratings of health are at least as strongly predictive of mortality as self-rated health. This suggests that, when self-rated health is elicited as a prognostic indicator, spouse ratings can be used when self-ratings are unavailable. Both measures together may be more informative than either measure alone.
Keywords: Aged; Cross-Sectional Studies; Female; Health Status; Humans; Longitudinal Studies; Male; Middle Aged; Self-Assessment; Spouses

Statistical design and estimation for the national social life, health, and aging project. - O'Muircheartaigh, Colm; Eckman, Stephanie; Smith, Stephen (J Gerontol B Psychol Sci Soc Sci, 2009)
OBJECTIVES: The paper discusses the sample design of the National Social Life, Health, and Aging Project (NSHAP) and how the design affects how estimates should be calculated from the survey data. The NSHAP study allows researchers to study the links between sexuality and health in older adults. The goal of the design was to represent adults aged 57-85 years in six demographic domains. METHODS: The sample design begins with a national area probability sample of households, carried out jointly with the 2004 round of the Health and Retirement Study. Selection of respondents for NSHAP balanced age and gender subgroups and oversampled African Americans and Latinos. Data collection was carried out from July 2005 to March 2006. RESULTS: The survey obtained an overall response rate of 75.5%. DISCUSSION: The complex sample design requires that the selection probabilities and the field implementation be accounted for in estimating population parameters. The data set contains weights to compensate for differential probabilities of selection and response rates among demographic groups. Analysts should use weights in constructing estimates from the survey and account for the complex sample design in estimating standard errors for survey estimates.
Keywords: Aged; Aged, 80 and over; Aging; Bias; Data collection; Data Interpretation, Statistical; Female; Health Status; Health Surveys; Humans; Longitudinal Studies; Male; Mass Screening; Middle Aged; Research Design; Sampling Studies; Sexual Behavior; Social Behavior; United States

Surrogate consent for dementia research: a national survey of older Americans. - Scott Y H Kim; H.M. Kim; Kenneth M. Langa; Jason H. Karlawish; David S Knopman; Appelbaum, P S (Neurology, 2009)
BACKGROUND: Research in novel therapies for Alzheimer disease (AD) relies on persons with AD as research subjects. Because AD impairs decisional capacity, informed consent often must come from surrogates, usually close family members. But policies for surrogate consent for research remain unsettled after decades of debate. METHODS: We designed a survey module for a random subsample (n = 1,515) of the 2006 wave of the Health and Retirement Study, a biennial survey of a nationally representative sample of Americans aged 51 and older. The participants answered questions regarding one of four randomly assigned surrogate-based research (SBR) scenarios: lumbar puncture study, drug randomized control study, vaccine study, and gene transfer study. Each participant answered three questions: whether our society should allow family surrogate consent, whether one would want to participate in the research, and whether one would allow one's surrogate some or complete leeway to override stated personal preferences. RESULTS: Most respondents stated that our society should allow family surrogate consent for SBR (67.5% to 82.5%, depending on the scenario) and would themselves want to participate in SBR (57.4% to 79.7%). Most would also grant some or complete leeway to their surrogates (54.8% to 66.8%), but this was true mainly of those willing to participate. There was a trend toward lower willingness to participate in SBR among those from ethnic or racial minority groups. CONCLUSIONS: Family surrogate consent-based dementia research is broadly supported by older Americans. Willingness to allow leeway to future surrogates needs to be studied further for its ethical significance for surrogate-based research policy.
PMID 19139366
Keywords: Advance directives; Age Factors; Aged; Aged, 80 and over; Alzheimer disease; Biomedical Research; Caregivers; Clinical Trials as Topic; Data collection; ethnicity; Female; Humans; Informed Consent; Legal Guardians; Male; Mental Competency; Middle Aged; Patient Participation; Proxy; Research Subjects; Surveys and Questionnaires; Therapeutic Human Experimentation; Third-Party Consent

Telephone interview for cognitive status: Creating a crosswalk with the Mini-Mental State Examination. - Tamara G Fong; Michael A Fearing; Richard N Jones; Peilin Shi; Edward R Marcantonio; James L Rudolph; Frances Margaret Yang; Dan K Kiely; Sharon K Inouye (Alzheimers Dement, 2009)
BACKGROUND: Brief cognitive screening measures are valuable tools for both research and clinical applications. The most widely used instrument, the Mini-Mental State Examination (MMSE), is limited in that it must be administered face-to-face, cannot be used in participants with visual or motor impairments, and is protected by copyright. Screening instruments such as the Telephone Interview for Cognitive Status (TICS) were developed to provide a valid alternative, with comparable cut-point scores to rate global cognitive function. METHODS: The MMSE, TICS-30, and TICS-40 scores from 746 community-dwelling elders who participated in the Aging, Demographics, and Memory Study (ADAMS) were analyzed with equipercentile equating, a statistical process of determining comparable scores based on percentile equivalents for different forms of an examination. RESULTS: Scores from the MMSE and TICS-30 and TICS-40 corresponded well, and clinically relevant cut-point scores were determined. For example, an MMSE score of 23 is equivalent to 17 and 20 on the TICS-30 and TICS-40, respectively. CONCLUSIONS: These findings indicate that TICS and MMSE scores can be linked directly. Clinically relevant and important MMSE cut points and the respective ADAMS TICS-30 and TICS-40 cut-point scores are included, to identify the degree of cognitive impairment among respondents with any type of cognitive disorder. These results will help in the widespread application of TICS in both research and clinical practice.
Keywords: Aged; Aged, 80 and over; Alzheimer disease; Cognition Disorders; Disability Evaluation; Female; Geriatric Assessment; Health Status; Humans; Interviews as Topic; Male; Mass Screening; Models, Statistical; Neuropsychological tests; Predictive Value of Tests; Psychiatric Status Rating Scales; Remote Consultation; Reproducibility of Results; Sensitivity and Specificity

Trajectories of cognitive function in late life in the United States: demographic and socioeconomic predictors. - Arun S Karlamangla; Miller-Martinez, Dana; Carol S Aneshensel; Teresa Seeman; Richard G Wight; Joshua Chodosh (Am J Epidemiol, 2009)
This study used mixed-effects modeling of data from a national sample of 6,476 US adults born before 1924, who were tested 5 times between 1993 and 2002 on word recall, serial 7's, and other mental status items to determine demographic and socioeconomic predictors of trajectories of cognitive function in older Americans. Mean decline with aging in total cognition score (range, 0-35; standard deviation, 6.00) was 4.1 (0.68 standard deviations) per decade (95% confidence interval: 3.8, 4.4) and in recall score (range, 0-20; standard deviation, 3.84) was 2.3 (0.60 standard deviations) per decade (95% confidence interval: 2.1, 2.5). Older cohorts (compared with younger cohorts), women (compared with men), widows/widowers, and those never married (both compared with married individuals) declined faster, and non-Hispanic blacks (compared with non-Hispanic whites) and those in the bottom income quintile (compared with the top quintile) declined slower. Race and income differences in rates of decline were not sufficient to offset larger differences in baseline cognition scores. Educational level was not associated with rate of decline in cognition scores. The authors concluded that ethnic and socioeconomic disparities in cognitive function in older Americans arise primarily from differences in peak cognitive performance achieved earlier in the life course and less from declines in later life.
Keywords: Aged; Aged, 80 and over; Aging; Black or African American; Cognition; Confidence Intervals; Education; Female; Geriatric Assessment; Hispanic or Latino; Humans; Income; Male; Marital Status; Mexican Americans; Poverty; Sampling Studies; Socioeconomic factors; Surveys and Questionnaires; United States; White People

Urban neighborhood context and change in depressive symptoms in late life. - Richard G Wight; Janet R. Cummings; Arun S Karlamangla; Carol S Aneshensel (J Gerontol B Psychol Sci Soc Sci, 2009)
OBJECTIVES: This study examines associations between urban neighborhood sociodemographic characteristics and change over time in late-life depressive symptoms. METHODS: Survey data are from three waves (1993, 1995, and 1998) of the Study of Assets and Health Dynamics Among the Oldest Old, a U.S. national probability sample of noninstitutionalized persons aged 70 years or older in 1993. Neighborhoods are 1990 U.S. Census tracts. Hierarchical linear regression is used to estimate multilevel models. RESULTS: The average change over time in depressive symptoms varies significantly across urban neighborhoods. Change in depressive symptoms is significantly associated with neighborhood-level socioeconomic disadvantage and ethnic composition in unadjusted models but not in models that control for individual-level characteristics. CONCLUSIONS: Findings indicate that apparent neighborhood-level effects on change in depressive symptoms over time among urban-dwelling older adults reflect, for the most part, differences in characteristics of the neighborhood residents.
Keywords: Aged; Aged, 80 and over; Aging; Cultural Diversity; depression; Disability Evaluation; Educational Status; Female; Humans; Longitudinal Studies; Los Angeles; Male; Personality Inventory; Poverty; Psychosocial Deprivation; Residence Characteristics; Risk Factors; Urban Population

Volunteer dynamics of older Americans. - Barbara A Butrica; Richard W. Johnson; Sheila R Zedlewski (J Gerontol B Psychol Sci Soc Sci, 2009)
OBJECTIVES: The impending retirement of boomers has spurred interest in tapping their productive energies to benefit society. This study examined volunteer transitions among older adults to understand the factors that affect volunteer dynamics. METHODS: Using data from the Health and Retirement Study, the analysis examined entries into and exits from formal volunteer activities between 1996 and 2004 by adults aged 55-65 at study baseline. The study showed the duration of volunteer activities, the probability that older adults start and stop volunteering, and the factors that significantly predict volunteer transitions. RESULTS: The findings reveal considerable stability among both volunteers and nonvolunteers; however, older adults are more likely to stop volunteering than to start. Volunteers who contribute intensely and for many years and who are married to volunteers are the least likely to quit. And nonvolunteers are more likely to start volunteering if they have been uninvolved for few years and their spouses volunteer. CONCLUSIONS: The results point to the need to focus efforts on retaining older volunteers to maximize volunteer engagement during later years. Recruiting older adults in volunteer activities early on, ideally before they retire, could also help meet volunteer needs.
Keywords: Aged; Aging; Cross-Sectional Studies; Female; Humans; Life Change Events; Male; Middle Aged; Probability; Retirement; United States; Volunteers

Willingness to participate in Alzheimer disease research and attitudes towards proxy-informed consent: results from the Health and Retirement Study. - Liat Ayalon (Am J Geriatr Psychiatry, 2009)
OBJECTIVES: To evaluate public opinion about participation in Alzheimer disease (AD) research and willingness to have a proxy-informed consent. DESIGN: Cross-sectional. SETTING: A national survey of community-dwelling adults over the age of 50 and their spouse of any age. PARTICIPANTS: The 2006 wave of the Health and Retirement Study (N = 1,517). MEASUREMENTS: Willingness to participate in one of four possible research scenarios and to have a proxy-informed consent for AD research. RESULTS: Overall, 65.8% agreed to participate in AD research and 70.7% agreed to proxy-informed consent. Relative to a minimal benefit and moderate risk scenario, participants were more likely to favor participation in a moderate benefit and minimal risk scenario and less likely to endorse a minimal benefit and severe risk scenario. Those agreeing to participate in the study were more likely to agree to proxy consent and to give leeway to a research proxy to go against their will. CONCLUSIONS: Most participants view AD research favorably and are agreeable toward participating in such research as well as toward having a research proxy. Participants are able to distinguish between studies of different levels of benefit and risk. Nevertheless, over 50% agreed to a study of minimal benefit and severe risk. Researchers and clinicians should be aware that those less agreeable toward AD research are less interested in having a research proxy.
Keywords: Alzheimer disease; Attitude; Community Participation; Cross-Sectional Studies; Female; Human Experimentation; Humans; Informed Consent; Male; Middle Aged; Public Opinion; Risk Assessment; Third-Party Consent

Work expectations, realizations, and depression in older workers. - Tracy Falba; Jody L Sindelar; William T Gallo (J Ment Health Policy Econ, 2009)
AIMS OF THE STUDY: In this study, we explore whether ex ante work expectations, conditional on work force status at age 62, affect self-reported depressive symptoms at age 62. METHODS: Our sample includes 4,387 participants of the Health and Retirement Study, a national longitudinal survey of individuals born between 1931 and 1941, and their spouses. The sample is composed of workers who were less than 62 years of age at the study baseline (1992), and who had reached age 62 by the current study endpoint (2004). This sample enables comparison of realized work status with prior expectations. We estimate the impact of expected work status on self-reported depressive symptoms using negative binomial and logistic regression methods. Sex-stratified regressions are estimated according to full-time work status at age 62. The primary outcome is a summary measure of self-reported depressive symptoms based on a short form of the Center for Epidemiologic Studies-Depression (CES-D) scale. The explanatory variable of interest is the subjective probability of working full-time at the age of 62, reported by participants at the 1992 HRS baseline. We control for baseline socioeconomic and demographic variables as well as life events and changes in macroeconomic conditions that occur within the study timeframe. RESULTS: Among participants who were not working full time at age 62, we find that men who provided a higher ex ante likelihood of full-time employment at 62 had significantly worse self-reported depressive symptoms than men who provided a lower ex ante likelihood. A similar effect was not found for women. Among participants who were working full time at age 62, we do not find a statistical relationship between ex ante expectations and age-62 self-reported depressive symptoms, for either men or women. DISCUSSION: The results suggest that an earlier-than-anticipated work exit is detrimental to mental health for men nearing normal retirement age. Previous research has demonstrated that stress is a causal factor in depression, and a premature labor force departure, which is inconsistent with an individual's cognitive judgment of a suitably timed exit from work, is a psychologically stressful transition that could realistically induce depression. This may be especially true of men, who in this cohort, have stronger labor force attachment than women and tend to define their roles by their occupation. The advantages of the study include nationally representative data, a baseline depression control that circumscribes the effect of endogeneity, and a reasonably long follow-up. Despite our efforts to infer causality, unmeasured factors may account for part of the observed relationship. IMPLICATIONS FOR HEALTH POLICY AND RESEARCH: Depression is a disease that, if untreated, may have serious consequences for behavioral, medical, and social well-being. Our results suggest that further research should aim to estimate the magnitude of clinically severe and mild depression in populations of those who retire earlier than expected, especially for men. Such information could help health care planners and policy makers to direct resources to the mental health needs of men who retire prematurely.
Journal Article
Keywords: Age Factors; depression; Employment; Female; Health Behavior; Humans; Longitudinal Studies; Male; Middle Aged; Psychometrics; Retirement; Sex Factors; Stress, Psychological

Age and racial/ethnic disparities in arthritis-related hip and knee surgeries. - Dorothy D Dunlop; Larry M Manheim; Song, Jing; Sohn, Min-Woong; Joseph Feinglass; Huan J. Chang; Rowland W Chang (Med Care, 2008)
BACKGROUND: Nearly 18 million Americans experience limitations due to their arthritis. Documented disparities according to racial/ethnic groups in the use of surgical interventions such as knee and hip arthroplasty are largely based on data from Medicare beneficiaries age 65 or older. Whether there are disparities among younger adults has not been previously addressed. OBJECTIVE: This study assesses age-specific racial/ethnic differences in arthritis-related knee and hip surgeries. DESIGN: Longitudinal (1998-2004) Health and Retirement Study. SETTING: National probability sample of US community-dwelling adults. SAMPLE: A total of 2262 black, 1292 Hispanic, and 13,159 white adults age 51 and older. MEASUREMENTS: The outcome is self-reported 2-year use of arthritis-related hip or knee surgery. Independent variables are demographic (race/ethnicity, age, gender), health needs (arthritis, chronic diseases, obesity, physical activity, and functional limitations), and medical access (income, wealth, education, and health insurance). Longitudinal data methods using discrete survival analysis are used to validly account for repeated (biennial) observations over time. Analyses use person-weights, stratum, and sampling error codes to provide valid inferences to the US population. RESULTS: Black adults under the age of 65 years report similar age/gender adjusted rates of hip/knee arthritis surgeries [hazard ratio (HR) = 1.43, 95% confidence interval (CI) = 0.87-2.38] whereas older blacks (age 65+) have significantly lower rates (HR = 0.38, CI = 0.16-0.55) compared with whites. These relationships hold controlling for health and economic differences. Both under age 65 years (HR = 0.64, CI = 0.12-1.44) and older (age 65+) Hispanic adults (HR = 0.60, CI = 0.32-1.10) report lower utilization rates, although not statistically different than whites. A large portion of the Hispanic disparity is explained by economic differences. CONCLUSIONS: These national data document lower rates of arthritis-related hip/knee surgeries for older black versus white adults age 65 or above, consistent with other national studies. However, utilization rates for black versus white under age 65 do not differ. Lower utilization among Hispanics versus whites in both age groups is largely explained by medical access factors. National utilization patterns may vary by age and merit further investigation.
Keywords: Age Distribution; Aged; Arthritis; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Black or African American; Female; Health Services Accessibility; Healthcare Disparities; Hispanic or Latino; Humans; Longitudinal Studies; Male; Middle Aged; Proportional Hazards Models; United States; Utilization Review; White People

Antecedents of bridge employment: a longitudinal investigation. - Wang, Mo; Zhan, Yujie; Liu, Songqi; Kenneth S. Shultz (J Appl Psychol, 2008)
Bridge employment is the labor force participation pattern increasingly observed in older workers between their career jobs and their complete labor force withdrawal. It serves as a transition process from career employment to full retirement. Typical bridge employment decisions include full retirement, career bridge employment, and bridge employment in a different field. In the current study, 3 dominant theories (i.e., role theory, continuity theory, and life course perspective) on retirement processes were reviewed. On the basis of these theories, the authors proposed 4 categories of antecedents (i.e., individual attributes, job-related psychological variables, family-related variables, and a retirement-planning-related variable) of different types of bridge employment decisions. The authors used longitudinal data of a large, nationally representative sample from the Health and Retirement Study (F. Juster & R. Suzman, 1995) to test the current hypotheses. These data were analyzed with multinomial logistic regression, and most of the hypotheses were supported by the results. The implications of this study are discussed at both theoretical and practical levels.
Keywords: Aged; Career Mobility; Employment; Female; Follow-Up Studies; Humans; Job Satisfaction; Male; Middle Aged; Psychological Theory; Retirement; Surveys and Questionnaires

The burden of mortality of obesity at middle and old age is small. A life table analysis of the US Health and Retirement Survey. - Mieke Reuser; Luc G Bonneux; Frans J Willekens (Eur J Epidemiol, 2008)
The evidence of effect of overweight and obesity on mortality at middle and old age is conflicting. The increased relative risk of cardiovascular disease and diabetes for overweight and obese individuals compared to normal weight is well documented, but the absolute risk of cardiovascular death has decreased spectacularly since the 1980s. We estimate the burden of mortality of obesity among middle and old aged adults in the Health and Retirement Survey (HRS), a US prospective longitudinal study. We calculate univariate and multivariate age-specific probabilities and proportional hazard ratios of death in relation to self-reported body mass index (BMI), smoking and education. The life table translates age specific adjusted event rates in survival times, dependent on risk factor distributions (smoking, levels of education and self reported BMI). 95% confidence intervals are calculated by bootstrapping. The highest life expectancy at age 55 was found in overweight (BMI 25-29.9), highly educated non smokers: 30.7 (29.5-31.9) years (men) and 33.2 (32.1-34.3) (women), slightly higher than a BMI 23-24.9 in both sexes. Smoking decreased the population life expectancy with 3.5 (2.7-4.4) years (men) and 1.8 (1.0-2.5) years (women). Less than optimal education cost men and women respectively 2.8 (2.1-3.6) and 2.6 (1.6-3.6) years. Obesity and low normal weight decreased population life expectancy respectively by 0.8 (0.2-1.3) and 0.8 (0.0-1.5) years for men and women in a contemporary, US population. The burden of mortality of obesity is limited, compared to smoking and low education.
PMID: 18584293
Keywords: Aged; Aged, 80 and over; Body Mass Index; Educational Status; Female; Health Surveys; Humans; Life Expectancy; Life Tables; Male; Middle Aged; Multivariate Analysis; Obesity; Proportional Hazards Models; Smoking; United States; Weight Gain; Weight Loss

Changes in weight among U.S. adults aged 70 and over, 1993 to 2002. - Xiaoxing He; Meng, Hongdao (Prev Med, 2008)
OBJECTIVE: To describe the patterns and predictors of weight change among U.S. adults aged 70 and over. METHOD: The study is a retrospective cohort study of 7441 community-dwelling U.S. adults aged 70 years and over during 1993-2002. We examined changes in weight for men and women, and by race/ethnicity groups. We used multivariate linear regression analysis to determine predictors of weight change while controlling for key covariates at baseline. RESULTS: The mean body weight decreased in both genders and all ethnic groups. Unadjusted average weight loss was 3.41 kg for men and 3.29 kg for women over nine years. Black women had higher mean body weight at baseline and were more likely to report weight gains of 5 kg or more. Multivariate analysis showed that age and baseline weight were major predictors of weight loss. Physical activity was associated with less weight loss among men. CONCLUSION: The trends of weight change among U.S. adults aged 70 and over were more prone to weight loss than weight gain, with substantial variations. Public health messages regarding weight control should take into account the heterogeneity of this population and target weight loss as well as weight gain to meet diverse needs of the population.
Keywords: Aged; Aged, 80 and over; Aging; Female; Humans; Interviews as Topic; Linear Models; Male; Multivariate Analysis; Population Growth; Retrospective Studies; United States; Weight Gain; Weight Loss

Chronic conditions and mortality among the oldest old. - Sei J. Lee; Alan S Go; Lindquist, Karla; Bertenthal, Daniel; Kenneth E Covinsky (Am J Public Health, 2008)
OBJECTIVES: We sought to determine whether chronic conditions and functional limitations are equally predictive of mortality among older adults. METHODS: Participants in the 1998 wave of the Health and Retirement Study (N=19430) were divided into groups by decades of age, and their vital status in 2004 was determined. We used multivariate Cox regression to determine the ability of chronic conditions and functional limitations to predict mortality. RESULTS: As age increased, the ability of chronic conditions to predict mortality declined rapidly, whereas the ability of functional limitations to predict mortality declined more slowly. In younger participants (aged 50-59 years), chronic conditions were stronger predictors of death than were functional limitations (Harrell C statistic 0.78 vs. 0.73; P=.001). In older participants (aged 90-99 years), functional limitations were stronger predictors of death than were chronic conditions (Harrell C statistic 0.67 vs. 0.61; P=.004). CONCLUSIONS: The importance of chronic conditions as a predictor of death declined rapidly with increasing age. Therefore, risk-adjustment models that only consider comorbidities when comparing mortality rates across providers may be inadequate for adults older than 80 years.
PMID 18511714
Keywords: Activities of Daily Living; Aged; Aged, 80 and over; Chronic disease; Female; Health Behavior; Health Status; Humans; Male; Middle Aged; Models, Statistical; Predictive Value of Tests; Proportional Hazards Models; Reproducibility of Results; Risk Adjustment; Severity of Illness Index; Socioeconomic factors; Survival Analysis; United States

Cohort differences in wealth and pension participation of near-retirees. - Irena Dushi; Howard M Iams (Soc Secur Bull, 2008)
The approaching retirement of the baby-boom generation has attracted both research and public policy attention. Many social and economic changes occurred during the second half of the twentieth century, changes that are likely to affect the retirement economic security of recent cohorts in many ways. In this article, using data from the Health and Retirement Study (HRS), a longitudinal, nationally representative survey of older Americans, we compare potential retirement economic resources-pension participation and nonpension net worth-of two cohorts of near-retirees. Particularly we look at individuals born from 1933 through 1939, often referred to as depression babies, who were ages 55-61 in 1994 and the more recent cohort consisting of individuals of the same ages (55-61) in 2004, who were born from 1943 through 1949. Our findings indicate that the more recent cohort of near-retirees has a significantly higher pension participation rate over their working life, and therefore greater opportunity to establish pension income through their working life, compared with the earlier cohort (82 percent versus 64 percent). The increase in pension participation was more pronounced among the recent cohort of women, an expected outcome given the increase in labor force participation of women over the past half century. As a result, although differences by sex in pension participation remained significant, the gap has narrowed for the recent cohort of near-retirees. In addition, we find that the gap in participation rate between those in the highest and the lowest wealth quintiles has widened over time (from 22 percent in 1994 to 26 percent in 2004). For both cohorts of near-retirees, the evidence indicates that those without a pension have much lower levels of net total worth than those who report having a pension. The pattern that emerges for both cohorts is that about one-fifth of individuals aged 55-61 hold little or no wealth at all, whereas about two-fifths hold a substantial amount of wealth. In addition, housing equity, which rarely is used to finance consumption in retirement, comprises more than one-half of total nonpension net worth for about 60 percent of all households, leaving--on average less than $45,000 jointly in nonhousing wealth and IRA/Keogh assets--a much smaller amount of wealth that is readily accessible if the need arises. The fact that many near-retirees (about 40 percent) in the lowest-two wealth quintiles have no pension to potentially draw income from, coupled with the very low level of total nonpension wealth raises concern about their income security in retirement; they may be likely to rely heavily on Social Security, rely on welfare programs, or continue work in retirement.
Keywords: Female; Humans; Income; Longitudinal Studies; Male; Middle Aged; Pensions; Population Growth; Retirement; United States

Declines in late-life disability: the role of early- and mid-life factors. - Vicki A Freedman; Linda G Martin; Robert F. Schoeni; Jennifer C. Cornman (Soc Sci Med, 2008)
Investigations into the reasons for declines in late-life disability have largely focused on the role of contemporaneous factors. Adopting a life-course perspective as a backdrop, in this paper we ask whether there also has been a role for selected early- and mid-life factors in the decline, and if so whether these factors have been operating through changes in the risks of disability onset or recovery. Drawing on five waves from 1995 to 2004 of the U.S. Health and Retirement Study, we found for the 75 years and older population in the United States that the prevalence of difficulty with activities of daily living (ADL) declined from 30.2% in 1995 to 26.0% in 2004, whereas the trend in difficulty with instrumental activities of daily living (IADL) was flat. Onset of ADL limitations also was reduced during this period while recovery increased. Changes in the educational composition of the older population were linked to declines in the prevalence of ADL limitations, but there were also modest contributions of changes in mother's education, self-rated childhood health, and lifetime occupation. Declines in late-life vision impairments and increases in wealth also contributed substantially to the downward trend, and had chronic conditions not increased, it would have been even larger. Reductions in the onset of ADL limitations were partly driven by changes in educational attainment of respondents and their mothers and, in late-life, better vision and wealth. In contrast, the recovery trend was not accounted for by changes in early- or mid-life factors. We conclude that early- and mid-life factors have contributed along with late-life factors to U.S. late-life disability trends mainly through their influence on the onset of, rather than recovery from, limitations.
Keywords: Activities of Daily Living; Aged; Aged, 80 and over; Aging; Chronic disease; Cross-Sectional Studies; Disabled Persons; Female; Frail Elderly; Health Behavior; Health Status; Health Surveys; Humans; Life Style; Logistic Models; Male; Morbidity; Population Surveillance; Socioeconomic factors; United States

Degree of disability and patterns of caregiving among older Americans with congestive heart failure. - Tanya R Gure; Mohammed U Kabeto; Caroline S Blaum; Kenneth M. Langa (J Gen Intern Med, 2008)
OBJECTIVES: Although congestive heart failure (CHF) is a common condition, the extent of disability and caregiving needs for those with CHF are unclear. We sought to determine: (1) prevalence of physical disability and geriatric conditions, (2) whether CHF is independently associated with disability, (3) rates of nursing home admission, and (4) formal and informal in-home care received in the older CHF population. METHODS: We used cross-sectional data from the 2000 wave of the Health and Retirement Study. We compared outcomes among three categories of older adults: (1) no coronary heart disease (CHD), (2) CHD, without CHF, and (3) CHF. Compared to those without CHF, respondents reporting CHF were more likely to be disabled (P < 0.001) and to have geriatric conditions (P < 0.001). Respondents reporting CHF were more likely to have been admitted to a nursing home (P < 0.05). CHF respondents were more functionally impaired than respondents without CHF. RESULTS: The adjusted average weekly informal care hours for respondents reporting CHF was higher than for those reporting CHD but without CHF and those reporting no CHD (6.7 vs 4.1 vs 5.1, respectively; P < 0.05). Average weekly formal caregiving hours also differed among the three groups (1.3 CHF vs 0.9 CHD without CHF vs 0.7 no CHD; P > 0.05). CONCLUSIONS: CHF imposes a significant burden on patients, families, and the long-term care system. Older adults with CHF have higher rates of disability, geriatric conditions, and nursing home admission.
Keywords: Activities of Daily Living; Aged; Aged, 80 and over; Caregivers; Coronary Disease; Cross-Sectional Studies; Disabled Persons; Female; Health Surveys; Heart Failure; Hospitalization; Humans; Male; Nursing homes; United States

Depression and retirement in late middle-aged U.S. workers. - Jalpa A Doshi; Cen, Liyi; Daniel Polsky (Health Serv Res, 2008)
OBJECTIVE: To determine whether late middle-aged U.S. workers with depression are at an increased risk for retirement. DATA SOURCE: Six biennial waves (1992-2002) of the Health and Retirement Study, a nationally representative panel survey of noninstitutionalized 51-61-year-olds and their spouses started in 1992. STUDY DESIGN: Workers aged 53-58 years in 1994 were followed every 2 years thereafter, through 2002. Depression was coded as lagged time-dependent variables measuring active depression and severity of depression. The main outcome variable was a transition to retirement which was measured using two distinct definitions to capture different stages in the retirement process: (1) Retirement was defined as a transition out of the labor force in the sample of all labor force participants (N=2,853); (2) In addition a transition out of full time work was used as the retirement definition in the subset of labor force participants who were full time workers (N=2,288). PRINCIPAL FINDINGS: In the sample of all labor force participants, the presence of active depression significantly increased the hazard of retirement in both late middle-aged men (adjusted OR: 1.37 [95 percent CI 1.05, 1.80]) and women (adjusted OR: 1.40 [95 percent CI 1.10, 1.78]). For women, subthreshold depression was also a significant predictor of retirement. In the sample of full time workers, the relationship between depression and retirement was considerably weaker for women yet remained strong for men. CONCLUSIONS: Depression and depressive symptoms were significantly associated with retirement in late middle-aged U.S. workers. Policymakers must consider the potentially adverse impact of these labor market outcomes when estimating the cost of untreated depression and evaluating the value of interventions to improve the diagnosis and treatment of depression.
Keywords: Activities of Daily Living; Comorbidity; depression; Employment; Female; Humans; Male; Middle Aged; Retirement; Severity of Illness Index; Sex Factors; Socioeconomic factors; United States

Does childhood schooling affect old age memory or mental status? Using state schooling laws as natural experiments. - M. Maria Glymour; Ichiro Kawachi; Jencks, Christopher; Lisa F Berkman (J Epidemiol Community Health, 2008)
BACKGROUND: The association between schooling and old age cognitive outcomes such as memory disorders is well documented but, because of the threat of reverse causation, controversy persists over whether education affects old age cognition. Changes in state compulsory schooling laws (CSL) are treated as natural experiments (instruments) for estimating the effect of education on memory and mental status among the elderly. Changes in CSL predict changes in average years of schooling completed by children who are affected by the new laws. These educational differences are presumably independent of innate individual characteristics such as IQ. METHODS: CSL-induced changes in education were used to obtain instrumental variable (IV) estimates of education's effect on memory (n = 10,694) and mental status (n = 9751) for white, non-Hispanic US-born Health and Retirement Survey participants born between 1900 and 1947 who did not attend college. RESULTS: After adjustment for sex, birth year, state of birth and state characteristics, IV estimates of education's effect on memory were large and statistically significant. IV estimates for mental status had very wide confidence intervals, so it was not possible to draw meaningful conclusions about the effect of education on this outcome. CONCLUSIONS: Increases in mandatory schooling lead to improvements in performance on memory tests many decades after school completion. These analyses condition on individual states, so differences in memory outcomes associated with CSL changes cannot be attributed to differences between states. Although unmeasured state characteristics that changed contemporaneously with CSL might account for these results, unobserved genetic variation is unlikely to do so.
Keywords: Aged; Aging; Censuses; Child; Cognition; Education; Educational Status; Female; Health Status; Humans; Least-Squares Analysis; Male; Massachusetts; Memory; Schools; Socioeconomic factors

Dynamics of work disability and pain. - Arie Kapteyn; James P Smith; Arthur H.O. vanSoest (J Health Econ, 2008)
This paper investigates the role of pain dynamics in subsequently affecting dynamics in self-reported work disability and the dynamics of employment patterns of older workers in the US. Not only is pain prevalence quite high, there also are many transitions in and out of pain at these ages. We investigate pain and its relationship to health (work disability) and work in a dynamic panel data model, using six biennial waves from the Health and Retirement Study. We find that the dynamics of the presence of pain are central to understanding the dynamics of self-reported work disability and through this pathway, pain dynamics are also a significant factor in the dynamic patterns of employment.
Keywords: Aged; Disabled Persons; Employment; Female; Humans; Male; Middle Aged; Models, Statistical; pain; United States

Early motherhood and mental health in midlife: a study of British and American cohorts. - John C Henretta; Emily M D Grundy; Lucy C Okell; Michael E J Wadsworth (Aging Ment Health, 2008)
OBJECTIVES: Examine the relationship between early age at first birth and mental health among women in their fifties. METHODS: Analysis of data on women from a British 1946 birth cohort study and the U.S. Health and Retirement Study birth cohort of 1931-1941. RESULTS: In both samples a first birth before 21 years, compared to a later first birth, is associated with poorer mental health. The association between early first birth and poorer mental health persists in the British study even after controlling for early socioeconomic status, midlife socioeconomic status and midlife health. In the U.S. sample, the association becomes non-significant after controlling for educational attainment. CONCLUSIONS: Early age at first birth is associated with poorer mental health among women in their fifties in both studies, though the pattern of associations differs.
PMID: 18855176
Keywords: Adolescent; Birth Order; Cohort Studies; England; Female; Humans; Interviews as Topic; Maternal Age; Mental Health; Middle Aged; Mothers; Pregnancy; Pregnancy in Adolescence; United States

Educational differentials in life expectancy with cognitive impairment among the elderly in the United States. - Agnès Lièvre; Dawn E Alley; Eileen M. Crimmins (J Aging Health, 2008)
OBJECTIVE: This article provides estimates of education differentials in life expectancy with and without cognitive impairment for the noninstitutionalized population aged 70 years and older in the United States. METHOD: Life expectancy with cognitive impairment was calculated using multistate models, allowing transitions between cognitively intact and cognitively impaired states and from each of these states to death and allowing transition rates to vary across age and education. Four waves of the Assets and Health Dynamics of the Oldest Old survey were used. RESULTS: Those with low levels of education are more likely to become cognitively impaired and do so at an earlier age. After age 70, persons with low educational levels can expect to live 11.6 years, and persons with high education 14.1 years, without cognitive impairment. Length of life with cognitive impairment differs by education (1.6 years and 1.0 years at age 70, respectively) but differs little by age. DISCUSSION: Although those with higher education have lower rates of both cognitive impairment and mortality, those who do become cognitively impaired appear to be in poorer health, leading to a reduced probability of improved cognition and increased probability of mortality relative to those with lower educational levels.
Keywords: Aged; Aged, 80 and over; Cognition Disorders; Educational Status; Female; Humans; Life Expectancy; Male; United States

Effect of arthritis in middle age on older-age functioning. - Kenneth E Covinsky; Lindquist, Karla; Dorothy D Dunlop; Thomas M Gill; Yelin, Edward (J Am Geriatr Soc, 2008)
OBJECTIVES: To examine whether symptomatic arthritis in middle age predicts the earlier onset of functional difficulties (difficulty with activities of daily living (ADLs) and walking) that are associated with loss of independence in older persons. DESIGN: Prospective longitudinal study. SETTING: The Health and Retirement Study, a nationally representative sample of persons aged 50 to 62 at baseline who were followed for 10 years. PARTICIPANTS: Seven thousand five hundred forty-three subjects with no difficulty in mobility or ADL function at baseline. MEASUREMENTS: Arthritis was measured at baseline according to self-report. The primary outcome was time to persistent difficulty in one of five ADLs or mobility (walking several blocks or up a flight of stairs). Difficulty with ADLs or mobility was assessed according to subject interview every 2 years. Analyses were adjusted for other comorbid conditions, body mass index, exercise, and demographic characteristics. RESULTS: Twenty-nine percent of subjects reported arthritis at baseline. Subjects with arthritis were more likely to develop persistent difficulty in mobility or ADL function over 10 years of follow-up (34% vs 18%, adjusted hazard ratio (HR)=1.63, 95% confidence interval (CI)=1.43-1.86). When each component of the primary outcome was assessed separately, arthritis was also associated with persistent difficulty in mobility (30% vs 16%, adjusted HR=1.55, 95% CI=1.41-1.71) and persistent difficulty in ADL function (13% vs 5%, adjusted HR=1.85, 95% CI=1.58-2.16). CONCLUSION: Middle-aged persons who report a history of arthritis are more likely to develop mobility and ADL difficulties as they enter old age. This finding highlights the need to develop interventions and treatments that take a life-course approach to preventing the disabling effect of arthritis.
Keywords: Activities of Daily Living; Arthritis; Chronic disease; Confidence Intervals; Female; Follow-Up Studies; Humans; Male; Middle Aged; Mobility Limitation; Prognosis; Prospective Studies; Risk Factors; Severity of Illness Index; Surveys and Questionnaires; Time Factors; Walking

Effects of social integration on preserving memory function in a nationally representative US elderly population. - Karen A Ertel; M. Maria Glymour; Lisa F Berkman (Am J Public Health, 2008)
OBJECTIVES: We tested whether social integration protects against memory loss and other cognitive disorders in late life in a nationally representative US sample of elderly adults, whether effects were stronger among disadvantaged individuals, and whether earlier cognitive losses explained the association (reverse causation). METHODS: Using data from the Health and Retirement Study (N = 16,638), we examined whether social integration predicted memory change over 6 years. Memory was measured by immediate and delayed recall of a 10-word list. Social integration was assessed by marital status, volunteer activity, and frequency of contact with children, parents, and neighbors. We examined growth-curve models for the whole sample and within subgroups. RESULTS: The mean memory score declined from 11.0 in 1998 to 10.0 in 2004. Higher baseline social integration predicted slower memory decline in fully adjusted models (P<.01). Memory among the least integrated declined at twice the rate as among the most integrated. This association was largest for respondents with fewer than 12 years of education. There was no evidence of reverse causation. CONCLUSIONS: Our study provides evidence that social integration delays memory loss among elderly Americans. Future research should focus on identifying the specific aspects of social integration most important for preserving memory.
Keywords: Aged; Aged, 80 and over; Cognition Disorders; Female; Health Behavior; Health Status; Humans; Interpersonal Relations; Male; Mental Health; Mental Recall; Predictive Value of Tests; Reproducibility of Results; Severity of Illness Index; social isolation; Social Support; Socioeconomic factors; United States

Emergency department utilization patterns among older adults. - Frederic D Wolinsky; Li Liu; Thomas R Miller; An, Hyonggin; John F Geweke; Kaskie, Brian; Kara B Wright; Elizabeth A Chrischilles; Claire E Pavlik; Elizabeth A Cook; Robert L. Ohsfeldt; Kelly K Richardson; et al. (J Gerontol A Biol Sci Med Sci, 2008)
BACKGROUND: We identified 4-year (2 years before and 2 years after the index [baseline] interview) ED use patterns in older adults and the factors associated with them. METHODS: A secondary analysis of baseline interview data from the nationally representative Survey on Assets and Health Dynamics Among the Oldest Old linked to Medicare claims data. Participants were 4310 self-respondents 70 years old or older. Current Procedural Terminology (CPT) codes 99281 and 99282 identified low-intensity use, and CPT codes 99283-99285 identified high-intensity use. Exploratory factor analysis and multivariable multinomial logistic regression were used. RESULTS: The majority (56.6%) of participants had no ED visits during the 4-year period. Just 5.7% had only low-intensity ED use patterns, whereas 28.9% used the ED only for high-intensity visits, and 8.7% had a mixture of low-intensity and high-intensity use. Participants with lower immediate word recall scores and those who did not live in major metropolitan areas were more likely to be low-intensity-only ED users. Older individuals, those who did not live in rural counties, had greater morbidity and functional status burdens, and lower immediate word recall scores were more likely to be high-intensity-only ED users. Participants who were older, did not live in major cities, had lower education levels, had greater morbidity and functional status burdens, and lower immediate word recall scores were more likely to have mixed ED use patterns. CONCLUSIONS: Nearly half of these older adults used the ED at least once over a 4-year period, with a mean annual ED use percentage of 18.4. Few, however, used the ED only for visits that may have been avoidable. This finding suggests that triaging Medicare patients would not decrease ED overcrowding, although continued surveillance is necessary to detect potential changes in ED use patterns among older adults.
Keywords: Aged; Emergency Service, Hospital; Factor Analysis, Statistical; Female; Humans; Logistic Models; Male; Medicare; Risk Factors; United States

End-of-life medical treatment choices: do survival chances and out-of-pocket costs matter? - Chao, Li-Wei; José A Pagán; Beth J Soldo (Med Decis Making, 2008)
BACKGROUND: Out-of-pocket medical expenditures incurred prior to the death of a spouse could deplete savings and impoverish the surviving spouse. Little is known about the public's opinion as to whether spouses should forego such end-of-life (EOL) medical care to prevent asset depletion. OBJECTIVES: To analyze how elderly and near elderly adults assess hypothetical EOL medical treatment choices under different survival probabilities and out-of-pocket treatment costs. METHODS: Survey data on a total of 1143 adults, with 589 from the Asset and Health Dynamics Among the Oldest Old (AHEAD) and 554 from the Health and Retirement Study (HRS), were used to study EOL cancer treatment recommendations for a hypothetical anonymous married woman in her 80s. RESULTS: Respondents were more likely to recommend treatment when it was financed by Medicare than by the patient's own savings and when it had 60% rather than 20% survival probability. Black and male respondents were more likely to recommend treatment regardless of survival probability or payment source. Treatment uptake was related to the order of presentation of treatment options, consistent with starting point bias and framing effects. CONCLUSIONS: Elderly and near elderly adults would recommend that the hypothetical married woman should forego costly EOL treatment when the costs of the treatment would deplete savings. When treatment costs are covered by Medicare, respondents would make the recommendation to opt for care even if the probability of survival is low, which is consistent with moral hazard. The sequence of presentation of treatment options seems to affect patient treatment choice.
Keywords: Aged; Choice Behavior; Female; Financing, Personal; Health Care Costs; Humans; Life Expectancy; Male; Medicare; Neoplasms; Socioeconomic factors; Terminal Care; United States

Exploring the determinants of racial and ethnic disparities in total knee arthroplasty: health insurance, income, and assets. - Amresh D Hanchate; Zhang, Yuqing; David T Felson; Arlene S Ash (Med Care, 2008)
OBJECTIVE: To estimate national total knee arthroplasty (TKA) rates by economic factors, and the extent to which differences in insurance coverage, income, and assets contribute to racial and ethnic disparities in TKA use. DATA SOURCE: US longitudinal Health and Retirement Study survey data for the elderly and near-elderly (biennial rounds 1994-2004) from the Institute of Social Research, University of Michigan. STUDY DESIGN: The outcome is dichotomous, whether the respondent received first TKA in the previous 2 years. Longitudinal, random-effects logistic regression models are used to assess associations with lagged economic indicators. SAMPLE: Sample was 55,469 person-year observations from 18,439 persons; 663, with first TKA. RESULTS: Racial/ethnic disparities in TKA were more prominent among men than women. For example, relative to white women, odds ratios (ORs) were 0.94, 0.46, and 0.79, for white, black, and Hispanic men, respectively (P < 0.05 for black men). After adjusting for economic factors, racial/ethnic differences in TKA rates for women essentially disappeared, while the deficit for black men remained large. Among Medicare-enrolled elderly, those with supplemental insurance may be more likely to have first TKA compared with those without it, whether the supplemental coverage was private [OR: 1.27; 95% confidence interval (CI): 0.82-1.96] or Medicaid (OR: 1.18; 95% CI: 0.93-1.49). Among the near-elderly (age 47-64), compared with the privately insured, the uninsured were less likely (OR: 0.61; 95% CI: 0.40-0.92) and those with Medicaid more likely (OR: 1.53; 95% CI: 1.03-2.26) to have first TKA. CONCLUSIONS: Limited insurance coverage and financial constraints explain some of the racial/ethnic disparities in TKA rates.
Keywords: Aged; Aged, 80 and over; Arthroplasty, Replacement, Knee; Comorbidity; ethnicity; Female; Healthcare Disparities; Humans; Income; Insurance, Health; Logistic Models; Longitudinal Studies; Male; Middle Aged; Sex Distribution; Socioeconomic factors; United States

Gender differences in functional status in middle and older age: are there any age variations? - Jersey Liang; Joan M. Bennett; Benjamin A Shaw; Ana R Quiñones; Wen Ye; Xiao Xu; Mary Beth Ofstedal (J Gerontol B Psychol Sci Soc Sci, 2008)
OBJECTIVES: The present study examines gender differences in changes in functional status after age 50 and how such differences vary across different age groups. METHODS: Data came from the Health and Retirement Study, involving up to six repeated observations of a national sample of Americans older than 50 years of age between 1995 and 2006. We employed hierarchical linear models with time-varying covariates in depicting temporal variations in functional status between men and women. RESULTS: As a quadratic function, the worsening of functional status was more accelerated in terms of the intercept and rate of change among women and those in older age groups. In addition, gender differences in the level of functional impairment were more substantial in older persons than in younger individuals, although differences in the rate of change between men and women remained constant across age groups. DISCUSSION: A life course perspective can lead to new insights regarding gender variations in health within the context of intrapersonal and interpersonal differences. Smaller gender differences in the level of functional impairment in the younger groups may reflect improvement of women's socioeconomic status, greater rate of increase in chronic diseases among men, and less debilitating effects of diseases.
Keywords: Activities of Daily Living; Age Factors; Aged; Aged, 80 and over; Disabled Persons; Female; Health Status; Humans; Linear Models; Longitudinal Studies; Male; Middle Aged; Sex Factors; United States

Health and wealth of elderly couples: causality tests using dynamic panel data models. - Pierre-Carl Michaud; Arthur H.O. vanSoest (J Health Econ, 2008)
A positive relationship between socio-economic status (SES) and health, the "health-wealth gradient", is repeatedly found in many industrialized countries. This study analyzes competing explanations for this gradient: causal effects from health to wealth (health causation) and causal effects from wealth to health (wealth or social causation). Using six biennial waves of couples aged 51-61 in 1992 from the US Health and Retirement Study, we test for causality in panel data models incorporating unobserved heterogeneity and a lag structure supported by specification tests. In contrast to tests relying on models with only first order lags or without unobserved heterogeneity, these tests provide no evidence of causal wealth health effects. On the other hand, we find strong evidence of causal effects from both spouses' health on household wealth. We also find an effect of the husband's health on the wife's mental health, but no other effects from one spouse's health to health of the other spouse.
Keywords: Aged; Causality; Family Characteristics; Female; Health Status Indicators; Humans; Income; Longitudinal Studies; Male; Middle Aged; Models, Econometric; Retirement; Social Class; Spouses; United States

Health insurance coverage as people approach and pass age-eligibility for Medicare. - Caffrey, Christine; Christine L Himes (J Aging Soc Policy, 2008)
This study uses six waves of the Health and Retirement Study (HRS) to measure dynamics of health insurance coverage as people approach and pass age-eligibility for Medicare. Thirteen percent of 59- to 64-year-olds were uninsured and 13% of 65- to 70-year-olds relied solely on Medicare. Those unmarried, in good health, and in poor health had an increased likelihood of being uninsured before age-eligibility for Medicare, while non-whites and those in good health had an increased likelihood of having Medicare-only coverage after age-eligibility for Medicare. Although only a small percentage was continually without coverage or with Medicare-only coverage, a substantial percentage had these coverage types at some point. Limitations and policy implications are included.
Keywords: Aged; Eligibility Determination; Female; Humans; Insurance Coverage; Insurance, Health; Male; Medicare; Middle Aged; United States

Health status and health dynamics in an empirical model of expected longevity. - Hugo Benítez-Silva; Ni, Huan (J Health Econ, 2008)
Expected longevity is an important factor influencing older individuals' decisions such as consumption, savings, purchase of life insurance and annuities, claiming of Social Security benefits, and labor supply. It has also been shown to be a good predictor of actual longevity, which in turn is highly correlated with health status. A relatively new literature on health investments under uncertainty, which builds upon the seminal work by Grossman [Grossman, M., 1972. On the concept of health capital and demand for health. Journal of Political Economy 80, 223-255] has directly linked longevity with characteristics, behaviors, and decisions by utility maximizing agents. Our empirical model can be understood within that theoretical framework as estimating a production function of longevity. Using longitudinal data from the Health and Retirement Study, we directly incorporate health dynamics in explaining the variation in expected longevities, and compare two alternative measures of health dynamics: the self-reported health change, and the computed health change based on self-reports of health status. In 38% of the reports in our sample, computed health changes are inconsistent with the direct report on health changes over time. And another 15% of the sample can suffer from information losses if computed changes are used to assess changes in actual health. These potentially serious problems raise doubts regarding the use and interpretation of the computed health changes and even the lagged measures of self-reported health as controls for health dynamics in a variety of empirical settings. Our empirical results, controlling for both subjective and objective measures of health status and unobserved heterogeneity in reporting, suggest that self-reported health changes are a preferred measure of health dynamics.
Keywords: Chronic disease; Delivery of Health Care; Empirical Research; Female; Health Expenditures; Health Status; Humans; Life Expectancy; Longevity; Male; Models, Econometric

Identification of dementia: agreement among national survey data, medicare claims, and death certificates. - Truls Ostbye; Donald H. Taylor Jr.; Elizabeth C. Clipp; Lynn Van Scoyoc; Brenda L Plassman (Health Serv Res, 2008)
OBJECTIVE: To estimate the proportion of seniors with dementia from three independent data sources and their agreement. DATA SOURCES: The longitudinal Asset and Health Dynamics among the Oldest Old (AHEAD) study (n=7,974), Medicare claims, and death certificate data. STUDY DESIGN: Estimates of the proportion of individuals with dementia from: (1) self- or proxy-reported cognitive status measures from surveys, (2) Medicare claims, and (3) death certificates. Agreement using Cohen's kappa; multivariate logistic regression. PRINCIPAL FINDINGS: The proportion varied substantially among the data sources. Agreement was poor (kappa: 0.14-0.46 depending upon comparison assessed); the individuals identified had relatively modest overlap. CONCLUSIONS: Estimates of dementia occurrence based on cognitive status measures from three independent data sources were not interchangeable. Further validation of these sources is needed. Caution should be used if policy is based on only one data source.
Keywords: Aged; Consensus; Data Interpretation, Statistical; Death Certificates; Dementia; Female; Health Surveys; Humans; Incidence; Insurance Claim Review; Male; Mass Screening; Medicare; Research Design; United States

Impact of functional limitations and medical comorbidity on subsequent weight changes and increased depressive symptoms in older adults. - Valerie L Forman-Hoffman; Kelly K Richardson; Jon W. Yankey; Stephen L Hillis; Robert B Wallace; Frederic D Wolinsky (J Aging Health, 2008)
OBJECTIVE: The primary goal of this study was to determine the effect of the onset of major medical comorbidity and functional decline on subsequent weight change and increased depressive symptoms. METHODS: The sample included a prospective cohort of 53 to 63 year olds (n = 10,150) enrolled in the Health and Retirement Study. Separate lagged covariate models for men and women were used to study the impact of functional decline and medical comorbidity on subsequent increases in depressive symptoms and weight change 2 years later. RESULTS: Functional decline and medical comorbidity were individual predictors of subsequent weight changes but not increased depressive symptoms. Most specific incident medical comorbidities or subtypes of functional decline predicted weight changes in both directions. DISCUSSION: The elevated risk of weight gain subsequent to functional decline or onset of medical comorbidities may require the receipt of preventive measures to reduce further weight-related complications.
Keywords: Activities of Daily Living; Age Factors; Arthritis; Comorbidity; depression; Depressive Disorder; Diabetes Complications; Diabetes Mellitus; Disabled Persons; Female; Health Surveys; Heart Diseases; Humans; Hypertension; Lung Diseases; Male; Mental Disorders; Middle Aged; Neoplasms; Obesity; Risk Factors; Sex Factors; Stroke; United States; Weight Gain

Job loss, retirement and the mental health of older Americans. - Mandal, Bidisha; Roe, Brian (J Ment Health Policy Econ, 2008)
BACKGROUND: Millions of older individuals cope with physical limitations, cognitive changes, and various losses such as bereavement that are commonly associated with aging. Given increased vulnerability to various health problems during aging, work displacement might exacerbate these due to additional distress and to possible changes in medical coverage. Older Americans are of increasing interest to researchers and policymakers due to the sheer size of the Baby Boom cohort, which is approaching retirement age, and due to the general decline in job security in the U.S. labor market. AIMS OF THE STUDY: This research compares and contrasts the effect of involuntary job loss and retirement on the mental health of older Americans. Furthermore, it examines the impact of re-employment on the depressive symptoms. METHODS: There are two fundamental empirical challenges in isolating the effect of employment status on mental health. The first is to control for unobserved heterogeneity--all latent factors that could impact mental health so as to establish the correct magnitude of the effect of employment status. The second challenge is to verify the direction of causality. First difference models are used to control for latent effects and a two-stage least squares regression is used to account for reverse causality. RESULTS: We find that involuntary job loss worsens mental health, and re-employment recaptures the past mental health status. Retirement is found to improve mental health of older Americans. DISCUSSION: With the use of longitudinal data from the Health and Retirement Study surveys and the adoption of proper measures to control for the possibility of reverse causality, this study provides strong evidence of elevating depressive symptoms with involuntary job displacement even after controlling for other late-life events. Women suffer from greater distress levels than men after job loss due to business closure or lay-off. However, women also exhibit better psychological well-being than men following retirement. The present study is the first to report that the re-employment of involuntary job-loss sufferers leads to a recapturing of past mental health status. Additionally, we find that re-entering the labor force is psychologically beneficial to retirees as well. IMPLICATIONS FOR HEALTH CARE PROVISION: It is well established that out-of-pocket expenditures on all forms of health care for seniors with self-diagnosed depression significantly exceeds expenditures for seniors with other common ailments such as hypertension and arthritis in the U.S. Thus, our research suggests that re-employment of older Americans displaced from the labor force will be cost-effective with regard to personal mental health outcomes. IMPLICATIONS FOR HEALTH POLICIES: That re-employment of involuntary job loss sufferers leads to a recapturing of past mental health status illuminates one potential policy trade off - increased resources dedicated to job training and placement for older U.S. workers could reap benefits with regard to reduced private and public mental health expenditures. IMPLICATIONS FOR FURTHER RESEARCH: Further research could more clearly assess the degree to which the mental health benefits of employment among older Americans would warrant the expansion of job training and employment programs aimed at this group.
Keywords: depression; Female; Health Status; Humans; Insurance Coverage; Insurance, Health; Life Change Events; Longitudinal Studies; Male; Mental Health; Middle Aged; Retirement; Socioeconomic factors; Stress, Psychological; Unemployment; United States

Life with and without heart disease among women and men over 50. - Eileen M. Crimmins; Mark D Hayward; Ueda, Hiroshi; Saito, Yasuhiko; Jung K Kim (J Women Aging, 2008)
This article uses a demographic approach and data from the Health and Retirement Survey, a nationally representative sample of the U.S. population, to investigate sex differences in the length of life lived with heart disease and after a heart attack for persons in the United States age 50 and older. On average, women live longer than men with heart disease. At age 50 women can expect to live 7.9 years and men 6.7 years with heart disease. The average woman experiences heart disease onset three years older and heart attacks 4.4 years older than men.
Keywords: Activities of Daily Living; Aged; Female; Health Status; Heart Diseases; Humans; Life Expectancy; Male; Middle Aged; Myocardial Infarction; Patient Education as Topic; Prejudice; Risk Factors; United States; Women's Health; Women's Health Services

Lifecourse social conditions and racial disparities in incidence of first stroke. - M. Maria Glymour; Mauricio Avendano; Steven A Haas; Lisa F Berkman (Ann Epidemiol, 2008)
PURPOSE: Some previous studies found excess stroke rates among black subjects persisted after adjustment for socioeconomic status (SES), fueling speculation regarding racially patterned genetic predispositions to stroke. Previous research was hampered by incomplete SES assessments, without measures of childhood conditions or adult wealth. We assess the role of lifecourse SES in explaining stroke risk and stroke disparities. METHODS: Health and Retirement Study participants age 50+ (n = 20,661) were followed on average 9.9 years for self- or proxy-reported first stroke (2175 events). Childhood social conditions (southern state of birth, parental SES, self-reported fair/poor childhood health, and attained height), adult SES (education, income, wealth, and occupational status) and traditional cardiovascular risk factors were used to predict first stroke onset using Cox proportional hazards models. RESULTS: Black subjects had a 48% greater risk of first stroke incidence than whites (95% confidence interval, 1.33-1.65). Childhood conditions predicted stroke risk in both blacks and whites, independently of adult SES. Adjustment for both childhood social conditions and adult SES measures attenuated racial differences to marginal significance (hazard ratio, 1.13; 95% CI, 1.00-1.28). CONCLUSIONS: Childhood social conditions predict stroke risk in black and White American adults. Additional adjustment for adult SES, in particular wealth, nearly eliminated the disparity in stroke risk between black and white subjects.
Keywords: Aged; Aged, 80 and over; Black or African American; Cardiovascular Diseases; ethnicity; Female; Health Status Disparities; Humans; Incidence; Interviews as Topic; Life Style; Longitudinal Studies; Male; Middle Aged; Models, Statistical; Risk Factors; Social Environment; Socioeconomic factors; Stroke; United States; White People

Long-term effects of cancer survivorship on the employment of older workers. - Pamela F. Short; Joseph J. Vasey; John R. Moran (Health Serv Res, 2008)
OBJECTIVE: To estimate the long-term effects of cancer survivorship on the employment of older workers. DATA SOURCES: Primary data for 504 subjects who were 55-65 in 2002 and were working when diagnosed with cancer in 1997-1999, and secondary data for a comparison group of 3,903 similarly aged workers in the Health and Retirement Study (HRS) in 2002. STUDY DESIGN: Three employment outcomes (working, working full time, usual hours per week) were compared between the two groups. Both Probit/Tobit regressions and propensity score matching were used to adjust for potentially confounding differences between groups. Sociodemographic characteristics, baseline employment characteristics, and the presence of other health conditions were included as covariates. DATA COLLECTION METHODS: Four telephone interviews were conducted annually with cancer survivors identified from tumor registries at four large hospitals in Pennsylvania and Maryland. Many of the questions were taken from the HRS to facilitate comparisons. PRINCIPAL FINDINGS: Cancer survivors of both genders worked an average of 3-5 hours less per week than HRS controls. For females, we found significant effects of survivorship on the probability of working, the probability of working full-time, and hours. For males, survivorship affected the probability of full-time employment and hours without significantly reducing the probability of working. For both genders, these effects were primarily attributable to new cancers. There were no significant effects on the employment of cancer-free survivors. CONCLUSIONS: Survivors with recurrences or second primary tumors may particularly benefit from employment support services and workplace accommodation. Reassuringly, any long-term effects on the employment of cancer-free survivors are fairly small.
Keywords: Age Factors; Aged; Data collection; Demography; Disease-Free Survival; Employment; Female; Health Status; Humans; Male; Maryland; Middle Aged; Neoplasms; Pennsylvania; Probability; Prospective Studies; Registries; Retrospective Studies; Sickness Impact Profile; Survivors; Time Factors

Measurement differences in depression: chronic health-related and sociodemographic effects in older Americans. - Frances Margaret Yang; Richard N Jones (Psychosom Med, 2008)
OBJECTIVE: To evaluate the influence of five chronic health conditions (high blood pressure, heart conditions, stroke, diabetes, and lung diseases) and four sociodemographic characteristics (age, gender, education, and race/ethnicity) on the endorsement patterns of depressive symptoms in a sample of community-dwelling older adults. METHOD: Participants were adults aged >or=65 years from the 2004 Health and Retirement Study (n = 9448). Depressive symptoms were measured with a nine-item Center for Epidemiologic Studies-Depression scale. Measurement differences attributable to health and sociodemographic factors were assessed with a multidimensional model based on item response theory. RESULTS: Evidence for unidimensionality was equivocal. We used a bifactor model to express symptom endorsement patterns as resulting from a general factor and three specific factors ("dysphoria," "psychosomatic," and "lack of positive affect"). Even after controlling for the effects of health on the psychosomatic factor, heart conditions, stroke, diabetes, and lung diseases had significant positive effects on the general factor. Significant effects due to gender and educational levels were observed on the "lack of positive affect" factor. Older adults self-identifying as Latinos had higher levels of general depression. On the symptom level, meaningful measurement noninvariance due to race/ethnic differences were found in the following five items: depressed, effort, energy, happy, and enjoy life. CONCLUSIONS: The increased tendency to endorse depressive symptoms among persons with specific health conditions is, in part, explained by specific associations among symptoms belonging to the psychosomatic domain. Differences attributable to the effects of health conditions may reflect distinct phenomenological features of depression. The bifactor model serves as a vehicle for testing such hypotheses.
Keywords: Aged; Aged, 80 and over; Chronic disease; Cohort Studies; Comorbidity; Confounding Factors, Epidemiologic; Culture; depression; Diabetes Mellitus; Educational Status; ethnicity; Factor Analysis, Statistical; Female; Heart Diseases; Humans; Hypertension; Interviews as Topic; Lung Diseases; Male; Self-Assessment; Sex Factors; Stroke; United States

Memory decline and depressive symptoms in a nationally representative sample of older adults: the Health and Retirement Study (1998-2004). - Hector M González; Mary E Bowen; Gwenith G Fisher (Dement Geriatr Cogn Disord, 2008)
BACKGROUND/AIMS: Inconsistencies in the relationship between depression and cognitive decline may exist because the expected cognitive domains at risk have not been specified in previous study designs. We aimed to examine the relationship between depressive symptoms and verbal episodic memory functioning over time. METHODS: Data from a prospective cohort study (Health and Retirement Study; 1998-2004; n = 18,465), a multistage national probability sample of older adults in the United States, were analyzed. Verbal learning and memory of a 10-word list learning task were the main outcomes. Depressive symptoms (Center for Epidemiologic Studies - Depression Scale) constituted the main predictor. RESULTS: Depressive symptoms were associated with significantly lower immediate (-0.05; p < 0.001) and delayed (-0.06; p < 0.001) word list recall scores after controlling for demographics and baseline and time-varying cardiovascular disease risks and diseases. CONCLUSIONS: In this US national study of older adults, elevated depressive symptoms were associated with declines in episodic learning and memory over time. These associations were little affected by the demographic or medical conditions considered in this study. The results suggest that learning and memory decline may be a long-term feature associated with depressive symptoms among the nation's older adult population.
Keywords: Aged; Aged, 80 and over; depression; Female; Health Status; Humans; Incidence; Male; Memory Disorders; Neuropsychological tests; Prevalence; Retirement; United States

A multilevel analysis of urban neighborhood socioeconomic disadvantage and health in late life. - Richard G Wight; Janet R. Cummings; Miller-Martinez, Dana; Arun S Karlamangla; Teresa Seeman; Carol S Aneshensel (Soc Sci Med, 2008)
The associations between neighborhood context and various indicators of health are receiving growing empirical attention, but much of this research is regionally circumscribed or assumes similar effects across the life course. This study utilizes a U.S. national sample to investigate the association between urban neighborhood socioeconomic disadvantage and health specifically among older adults. Data are from 3442 participants aged 70 years and older in the 1993 Asset and Health Dynamics Among the Oldest Old (AHEAD) Study, and the 1990 U.S. Census. Our approach underscores the importance of multiple dimensions of health (self-reported physician-diagnosed cardiovascular disease [CVD], functional status, and self-rated health) as well as multiple dimensions of neighborhood disadvantage, which are conceptualized as environmental hazards that may lead to a physiologically consequential stress response. We find that individual-level factors attenuate the association between neighborhood disadvantage and both CVD and functional status, but not self-rated health. Net of covariates, high neighborhood socioeconomic disadvantage is significantly associated with reporting poor health. In late life, neighborhood socioeconomic disadvantage is more consequential to subjective appraisals of health than diagnosed CVD or functional limitations.
Keywords: Aged; Female; Health Behavior; Health Status Disparities; Humans; Male; Poverty; Small-Area Analysis; Socioeconomic factors; United States; Urban Population

Neighborhoods and disability in later life. - Vicki A Freedman; Irina B Grafova; Robert F. Schoeni; Jeannette Rogowski (Soc Sci Med, 2008)
This paper uses the US Health and Retirement Study to explore linkages between neighborhood conditions and stages of the disablement process among adults aged 55 years and older in the United States. We consider multiple dimensions of the neighborhood including the built environment as well as social and economic conditions. In doing so, we use factor analysis to reduce indicators into eight neighborhood scales, which we incorporate into two-level logistic regression models along with controls for individual-level factors. We find evidence that economic conditions and the built environment, but not social conditions, matter. Neighborhood economic advantage is associated with a reduced risk of lower body limitations for both men and women. We also find for men that neighborhood economic disadvantage is linked to increased chances of reporting personal care limitations, particularly for those aged 55-64 years, and that high connectivity of the built environment is associated with reduced risk of limitations in instrumental activities. Our findings highlight the distinctive benefits of neighborhood economic advantage early in the disablement process. In addition, findings underscore the need for attention in the design and evaluation of disability-prevention efforts to the benefits that accrue from more physically connected communities and to the potential harm that may arise in later life from living in economically disadvantaged areas.
Keywords: Aging; Disabled Persons; Factor Analysis, Statistical; Female; Health Status Disparities; Humans; Male; Middle Aged; Residence Characteristics; Social Conditions; Socioeconomic factors; United States

Neighborhoods and obesity in later life. - Irina B Grafova; Vicki A Freedman; Kumar, Rizie; Jeannette Rogowski (Am J Public Health, 2008)
OBJECTIVES: We examined the influence of neighborhood environment on the weight status of adults 55 years and older. METHODS: We conducted a 2-level logistic regression analysis of data from the 2002 wave of the Health and Retirement Study. We included 8 neighborhood scales: economic advantage, economic disadvantage, air pollution, crime and segregation, street connectivity, density, immigrant concentration, and residential stability. RESULTS: When we controlled for individual- and family-level confounders, living in a neighborhood with a high level of economic advantage was associated with a lower likelihood of being obese for both men (odds ratio [OR] = 0.86; 95% confidence interval [CI] = 0.80, 0.94) and women (OR = 0.83; 95% CI = 0.77, 0.89). Men living in areas with a high concentration of immigrants and women living in areas of high residential stability were more likely to be obese. Women living in areas of high street connectivity were less likely to be overweight or obese. CONCLUSIONS: The mechanisms by which neighborhood environment and weight status are linked in later life differ by gender, with economic and social environment aspects being important for men and built environment aspects being salient for women.
Keywords: Aged; Air Pollution; Crime; Emigrants and Immigrants; Environment Design; Female; Health Status Indicators; Humans; Income; Logistic Models; Male; Middle Aged; Obesity; Odds Ratio; Overweight; Population Density; Residence Characteristics; Retirement; Social Class; Social Conditions; Social Environment; Socioeconomic factors; United States

Parental marital disruption, family type, and transfers to disabled elderly parents. - Liliana E Pezzin; Robert A. Pollak; Barbara Steinberg Schone (J Gerontol B Psychol Sci Soc Sci, 2008)
OBJECTIVE: The objective of this study was to investigate the effect of parental marital status, marital history, and family type on intergenerational living arrangements and adult children's time and cash transfers to their unpartnered disabled elderly parents. METHODS: We used data from the Asset and Health Dynamics Among the Oldest Old survey to estimate the joint probabilities that an adult child provides time and/or cash transfers to a parent and to analyze a five-level categorical variable capturing parent-child living arrangements. RESULT: The estimates suggest significant detrimental effects of parental divorce and step relationship on time transfers and on the probability of coresidence with the index child. Family type, as captured by the composition of the index child's sibling network according to kin relationship to the parent, also affected transfers and living arrangement choices of adult children. DISCUSSION: The findings that transfers from adult children to their unpartnered disabled elderly parents depend on parental marital status and kin relationship suggest that changing family patterns are altering the traditional role of the family as a support network. These findings raise concerns about the care likely to be available to future cohorts of elderly persons who will have experienced substantially higher rates of divorce, remarriage, and step parenthood than the cohort considered in this study.
Keywords: Adult; Aged; Altruism; Divorce; Family Characteristics; Female; Frail Elderly; Gift Giving; Humans; Likelihood Functions; Longitudinal Studies; Male; Multivariate Analysis; Parent-Child Relations; Residence Characteristics; Siblings; United States

Predictors of non-local moves among older adults: a prospective study. - Charles F Longino; Don E Bradley; Eleanor P. Stoller; William H Haas (J Gerontol B Psychol Sci Soc Sci, 2008)
OBJECTIVES: The goal of this article was to test a series of established predictors of the hazard of moving for persons primarily in their 50s and 60s. We tested demographic covariates, resources, travel experience, and community and person ties using a prospective design. METHODS: We employed data from the Health and Retirement Study, 1994 to 2002, based on a representative sample of households containing at least one member aged 51 to 61 in 1992. We employed measures available in the Health and Retirement Study to construct a series of Cox proportional hazards models that examined the causes of non-local moves. RESULTS: Community and person ties emerged as important predictors of non-local moves. DISCUSSION: Travel experience, when measured by regular vacationing and second homes, may increase community ties to a destination. The life-course model must be modified in its explanation of the importance of community and person ties, and of life transitions, as motivators of migration.
Keywords: Aged; Emigration and Immigration; Female; Humans; Interpersonal Relations; Life Change Events; Male; Prospective Studies; Socioeconomic factors; Surveys and Questionnaires; Travel

Preventive health behaviors among grandmothers raising grandchildren. - Lindsey A Baker; Merril Silverstein (J Gerontol B Psychol Sci Soc Sci, 2008)
OBJECTIVES: We examined differential preventive health behavior among grandmothers who recently began raising a grandchild, grandmothers raising a grandchild for at least 2 years, and grandmothers not raising a grandchild. METHODS: Data came from the 2000, 2002, and 2004 waves of the Health and Retirement Study. We ran multivariate logistic regression models to assess receipt of influenza vaccination, cholesterol screening, monthly breast self-exam, mammography, and Papanicolaou (Pap) tests among grandmothers aged 50 to 75. RESULTS: Grandmothers who recently began raising a grandchild were significantly less likely to report influenza vaccination and cholesterol screening than grandmothers not raising grandchildren, even after we controlled for increased emotional and financial strains within the household. We also observed this association for Pap tests, although this finding was only marginally significant. Grandmothers who had been raising a grandchild for at least 2 years were significantly more likely to report influenza vaccination and monthly breast self-exam than grandmothers not raising grandchildren. DISCUSSION: The enhancement of preventive behavior seen among long-term grandparent caregivers does not fully offset the suppression of preventive behavior during the transition into care; support groups should target a range of interventions toward the promotion of healthy behavior among new grandparent caregivers.
ProCite field 6 : The Journals of Gerontology, Series B: Psychological Sciences and Social Sciences
Keywords: Aged; Breast Self-Examination; Caregivers; Female; Health Behavior; Humans; Hypercholesterolemia; Influenza, Human; Intergenerational Relations; Logistic Models; Mass Screening; Middle Aged; Papanicolaou Test; Preventive Health Services; United States; Vaccination; Vaginal Smears

Productive activities and psychological well-being among older adults. - Hao, Yanni (J Gerontol B Psychol Sci Soc Sci, 2008)
OBJECTIVES: The purpose of this study was to test whether paid work and formal volunteering reduce the rate of mental health decline in later life. METHODS: Using four waves of Health and Retirement Study data collected from a sample of 7,830 individuals aged 55 to 66, I estimated growth curve models to assess the effects of productive activities on mental health trajectories. The analytical strategy took into account selection processes when examining the beneficial effects of activities. The analyses also formally attended to the sample attrition problem inherent in longitudinal studies. RESULTS: The results indicated that activity participants generally had better mental health at the beginning of the study. Full-time employment and low-level volunteering had independent protective effects against decline in psychological well-being. Joint participants of both productive activities enjoyed a slower rate of mental health decline than single-activity participants. DISCUSSION: The results are consistent with activity theory and further confirm the role accumulation perspective. The finding that full-time work combined with low-level volunteering is protective of mental health reveals the complementary effect of volunteering to formal employment. Methodological and theoretical implications are discussed.
Keywords: Activities of Daily Living; Aged; Cohort Studies; depression; Employment; Female; Health Status; Humans; Male; Mental Health; Middle Aged; Models, Psychological; Psychological Theory; Psychomotor Performance; Quality of Life; Social Environment; Volunteers

Racial and ethnic differences in activities of daily living disability among the elderly: the case of Spanish speakers. - Manasi A. Tirodkar; Song, Jing; Rowland W Chang; Dorothy D Dunlop; Huan J. Chang (Arch Phys Med Rehabil, 2008)
OBJECTIVE: To compare incident disability patterns across racial and ethnic groups. DESIGN: Prospective cohort study with 6-year follow-up (1998-2004). SETTING: National probability sample. PARTICIPANTS: A 1998 Health and Retirement Study sample of 12,288 non-Hispanic whites, 1952 African Americans, 575 Hispanics interviewed in Spanish (Hispanic-Spanish), and 518 Hispanics interviewed in English (Hispanic-English), older than 51 years, and free of disability at baseline. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Disability in activities of daily living (ADL) tasks (walking, dressing, transferring, bathing, toileting, feeding). RESULTS: Hispanic-Spanish reported disproportionately lower rates of walking disability (standardized rates, 4.31% vs Hispanic-English [8.57%], black [7.54%], white [7.20%]) despite higher reported Hispanic-Spanish frequencies of lower-extremity dysfunction than other racial and ethnic groups. Across the 6 ADL tasks, the development of walking disability was most frequent among Hispanic-English subjects, African Americans, and whites. In contrast, Hispanic-Spanish subjects reported dressing as the most frequent ADL task disability, whereas walking ranked fourth. CONCLUSIONS: Aggregating all Hispanics, regardless of interview language, may be inappropriate. Future research on linguistic group differences in self-reported health outcomes is necessary to ensure that health status measures will be appropriate for use in diverse racial and ethnic groups.
Keywords: Acculturation; Activities of Daily Living; Aged; Aged, 80 and over; Disability Evaluation; Disabled Persons; Female; Geriatric Assessment; Health Status Indicators; Hispanic or Latino; Humans; Male; Middle Aged

Racial and ethnic disparities in mobility device use in late life. - Jennifer C. Cornman; Vicki A Freedman (J Gerontol B Psychol Sci Soc Sci, 2008)
OBJECTIVE: Although racial and ethnic disparities in disability are well established and technology is increasingly used to bridge gaps between functional deficits and environmental demands, little research has focused on racial and ethnic disparities in device use. This study investigated whether use of mobility devices differs by race and ethnicity and explored several reasons for this difference. METHODS: The sample included community-dwelling adults aged 65 and older from the 2002 and 2004 waves of the Health and Retirement Study. We used predisposing, need, and enabling factors to predict mobility device use alone and combined with personal care. RESULT: Blacks had the highest rates of using mobility devices, followed by Hispanics and then Whites. Need and enabling factors explained differences between Blacks and Whites in wheelchair use but not cane use or use of devices without personal care. Other predisposing factors explained most differences between Hispanics and Whites. DISCUSSION: Because minorities appear to be using mobility devices in proportion to underlying need, increasing device use by minorities may not reduce disparities in mobility disability. Efforts to address racial/ethnic disparities in mobility disability in late life, therefore, may need to focus on differences in underlying functional decline rather than the accommodation of it.
Keywords: Aged; Cross-Sectional Studies; Demography; ethnicity; Female; Health Services Needs and Demand; Humans; Insurance, Health; Male; Self-Help Devices; Socioeconomic factors

Racial disparities in receipt of hip and knee joint replacements are not explained by need: the Health and Retirement Study 1998-2004. - Steel, Nicholas; Clark, Allan; Iain A Lang; Robert B Wallace; David Melzer (J Gerontol A Biol Sci Med Sci, 2008)
BACKGROUND: Hip and knee joint replacement rates vary by demographic group. This article describes the epidemiology of need for joint replacement, and of subsequent receipt of a joint replacement by those in need. METHODS: Data from the Health and Retirement Study were used to assess need for hip or knee joint replacement in a total of 14,807 adults aged 60 years or older in 1998, 2000, and 2002 and receipt of needed surgery 2 years later. "Need" classification was based on difficulty walking, joint pain, stiffness, or swelling and receipt of treatment for arthritis, without contraindications to surgery. RESULTS: Need in 2002 was greater in participants who were older than 74 years (vs 60-64: adjusted odds ratio 2.06; 95% confidence interval, 1.68-2.53), women (vs men: 1.81; 1.53-2.14), less educated (vs college educated: 1.27; 1.06-1.52), in the poorest third (vs richest: 2.20; 1.78-2.72), or obese (vs nonobese: 2.39; 2.02-2.81). One hundred sixty-eight participants in need received a joint replacement, with lower receipt in black or African American participants (vs white: 0.47; 0.26-0.83) or less educated (vs college educated: 0.65; 0.44-0.96). These differences were not explained by current employment, access to medical care, family responsibilities, disability, living alone, comorbidity, or exclusion of those younger than Medicare eligibility age. CONCLUSIONS: After taking variations in need into consideration, being black or African American or lacking a college education appears to be a barrier to receiving surgery, whereas age, sex, relative poverty, and obesity do not. These disparities maintain disproportionately high levels of pain and disability in disadvantaged groups.
Keywords: Aged; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Black or African American; Educational Status; Female; Health Services Needs and Demand; Humans; Male; Middle Aged; United States

Racial/ethnic differences in the relationship between the use of health care services and functional disability: the health and retirement study (1992-2004). - Mary E Bowen; Hector M González (Gerontologist, 2008)
PURPOSE: The purpose of this study was to examine racial/ethnic differences in the relationship between functional disability and the use of health care services in a nationally representative sample of older adults by using the Andersen behavioral model of health services utilization. DESIGN AND METHODS: The study used 12 years of longitudinal data from the Health and Retirement Study (1992-2004), a nationally representative sample of community-dwelling adults older than 50 in 1992 (N = 8,947). Nonlinear multilevel models used self-reported health care service utilization (physician visits and hospital admissions) to predict racial/ethnic differences in disability (activities of daily living and mobility limitations). The models also evaluated the roles of other predisposing (age and gender), health need (medical conditions and self-rated health), and enabling factors (health insurance, education, income, and wealth). RESULTS: Blacks and Latinos utilizing physician visits and hospital admissions were associated with significantly more activity of daily living disability than Whites (p <.001). Blacks utilizing physician visits (p <.001) and hospital admissions (p <.05) and Latinos utilizing hospital admissions (p <.05) were associated with more mobility disability than Whites. Other predisposing, health need, and enabling factors did not account for these racial/ethnic differences. IMPLICATIONS: Nationally, health care use for Blacks and Latinos was associated with more disabilities than for Whites after we accounted for predisposing, health need, and enabling factors. The findings suggest that improving health care quality for all Americans may supersede equal access to health care for reducing ethnic and racial disparities in functional health.
Keywords: Activities of Daily Living; Disabled Persons; ethnicity; Female; Health Services; Health Status Disparities; Healthcare Disparities; Humans; Longitudinal Studies; Male; Middle Aged; Mobility Limitation; Racial Groups; Retirement

Retirement and weight changes among men and women in the health and retirement study. - Valerie L Forman-Hoffman; Kelly K Richardson; Jon W. Yankey; Stephen L Hillis; Robert B Wallace; Frederic D Wolinsky (J Gerontol B Psychol Sci Soc Sci, 2008)
OBJECTIVES: Older adults may experience weight changes upon retirement for a number of reasons, such as being less physically active; having less structured meal times; and consuming food in response to losing personal identity, the potential for social interactions, or the sense of accomplishment derived from working. The purpose of this study was to determine whether retirement was associated with either weight gain or weight loss. METHODS: We used the 1994-2002 Health and Retirement Study to determine whether retirement between biennial interviews was associated with weight change, separately for men (n = 1,966) and women (n = 1,759). We defined weight change as a 5% increase or decrease in body mass index between interviews. RESULT: . We did not find a significant association between retirement and weight change among men. Women who retired were more likely to gain weight than women who continued to work at least 20 hr per week (odds ratio [OR] = 1.24, 95% confidence interval [CI] = 1.04-1.48). We found a significant relationship between retirement and weight gain only for women who were normal weight upon retiring (OR = 1.30, 95% CI = 1.01-1.69) and who retired from blue-collar jobs (OR = 1.58, 95% CI = 1.13-2.21). DISCUSSION: Public health interventions may be indicated for women, particularly those working in blue-collar occupations, in order to prevent weight gain upon retirement.
Keywords: Aged; Aging; Body Mass Index; Body Weight; Demography; depression; Female; Health Behavior; Health Status; Humans; Interviews as Topic; Male; Middle Aged; Obesity; Retirement

Robustness in health research: do differences in health measures, techniques, and time frame matter? - Frijters, Paul; Ulker, Aydogan (J Health Econ, 2008)
Survey-based health research is in a boom phase following an increased amount of health spending in OECD countries and the interest in ageing. A general characteristic of survey-based health research is its diversity. Different studies are based on different health questions in different datasets; they use different statistical techniques; they differ in whether they approach health from an ordinal or cardinal perspective; and they differ in whether they measure short-term or long-term effects. The question in this paper is simple: do these differences matter for the findings? We investigate the effects of life-style choices (drinking, smoking, exercise) and income on six measures of health in the US Health and Retirement Study (HRS) between 1992 and 2002: (1) self-assessed general health status, (2) problems with undertaking daily tasks and chores, (3) mental health indicators, (4) BMI, (5) the presence of serious long-term health conditions, and (6) mortality. We compare ordinal models with cardinal models; we compare models with fixed effects to models without fixed-effects; and we compare short-term effects to long-term effects. We find considerable variation in the impact of different determinants on our chosen health outcome measures; we find that it matters whether ordinality or cardinality is assumed; we find substantial differences between estimates that account for fixed effects versus those that do not; and we find that short-run and long-run effects differ greatly. All this implies that health is an even more complicated notion than hitherto thought, defying generalizations from one measure to the others or one methodology to another.
Keywords: Aged; Algorithms; Australia; Data Interpretation, Statistical; Female; Health Behavior; Health Services Research; Health Status Indicators; Humans; Male; Middle Aged; Morbidity; Mortality; Social Class

Screening mammography in older women. Effect of wealth and prognosis. - Brie A Williams; Lindquist, Karla; Rebecca L. Sudore; Kenneth E Covinsky; Louise C Walter (Arch Intern Med, 2008)
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.
Keywords: Aged; Breast Neoplasms; Chi-Square Distribution; Female; Humans; Longitudinal Studies; Mammography; Mass Screening; Prognosis; Risk Factors; Social Class

Spousal caregiving in late midlife versus older ages: implications of work and family obligations. - Julie C Lima; Susan M Allen; Goldscheider, Frances; Intrator, Orna (J Gerontol B Psychol Sci Soc Sci, 2008)
OBJECTIVES: This study examined life-stage differences in the provision of care to spouses with functional impairment. METHODS: We examined 1,218 married adults aged 52 and older from the 2000 wave of the Health and Retirement Study who received impairment-related help with at least one activity of daily living. We examined the differential likelihood that spouses served as primary caregiver and the hours of care provided by spousal primary caregivers by life stage. RESULTS: We found that late middle-aged care recipients were more likely than their older counterparts to receive the majority of their care from their spouse but received fewer hours of spousal care, mostly when spouses worked full time. Competing demands of caring for children or parents did not affect the amount of care provided by a spouse. DISCUSSION: Late middle-aged adults with functional limitations are more likely than older groups to be married and cared for primarily by spouses; however, they may be particularly vulnerable to unmet need for care. As the baby boom generation ages, retirement ages increase, and federal safety nets weaken, people with health problems at older ages may soon find themselves in the same caregiving predicament as those in late middle age.
Keywords: Activities of Daily Living; Age Factors; Aged; Aged, 80 and over; Caregivers; Employment; Family Relations; Female; Gender Identity; Health Surveys; Humans; Longitudinal Studies; Male; Middle Aged; Mobility Limitation; Spouses; Time Factors; United States

Spousal concordance in health behavior change. - Tracy Falba; Jody L Sindelar (Health Serv Res, 2008)
OBJECTIVE: This study examines the degree to which a married individual's health habits and use of preventive medical care are influenced by his or her spouse's behaviors. STUDY DESIGN: Using longitudinal data on individuals and their spouses, we examine changes over time in the health habits of each person as a function of changes in his or her spouse's health habits. Specifically, we analyze changes in smoking, drinking, exercising, cholesterol screening, and obtaining a flu shot. DATA SOURCE: This study uses data from the Health and Retirement Study (HRS), a nationally representative sample of individuals born between 1931 and 1941 and their spouses. Beginning in 1992, 12,652 persons (age-eligible individuals as well as their spouses) from 7,702 households were surveyed about many aspects of their life, including health behaviors, use of preventive services, and disease diagnosis. SAMPLE: The analytic sample includes 6,072 individuals who are married at the time of the initial HRS survey and who remain married and in the sample at the time of the 1996 and 2000 waves. PRINCIPAL FINDINGS: We consistently find that when one spouse improves his or her behavior, the other spouse is likely to do so as well. This is found across all the behaviors analyzed, and persists despite controlling for many other factors. CONCLUSIONS: Simultaneous changes occur in a number of health behaviors. This conclusion has prescriptive implications for developing interventions, treatments, and policies to improve health habits and for evaluating the impact of such measures.
Keywords: Attitude to Health; Cross-Sectional Studies; Exercise; Family Characteristics; Female; Health Behavior; Health Care Surveys; Health Promotion; Health Status; Humans; Interpersonal Relations; Life Style; Male; Marriage; Middle Aged; Preventive Health Services; Prospective Studies; Risk-Taking; Smoking; Spouses; United States

Spousal smoking and incidence of first stroke: the Health and Retirement Study. - M. Maria Glymour; Triveni DeFries; Ichiro Kawachi; Mauricio Avendano (Am J Prev Med, 2008)
BACKGROUND: Few prospective studies have investigated the relationship between spousal cigarette smoking and the risk of incident stroke. METHODS: Stroke-free participants in the U.S.-based Health and Retirement Study (HRS) aged >or=50 years and married at baseline (n=16,225) were followed, on average, 9.1 years between 1992 and 2006) for proxy or self-report of first stroke (1,130 events). Participants were stratified by gender and own smoking status (never-smokers, former smokers, or current smokers), and the relationship assessed between the spouse's smoking status and the risk of incident stroke. Analyses were conducted in 2007 with Cox proportional hazards models. All models were adjusted for age; race; Hispanic ethnicity; Southern birthstate; parental education; paternal occupation class; years of education; baseline income; baseline wealth; obesity; overweight; alcohol use; and diagnosed hypertension, diabetes, or heart disease. RESULTS: Having a spouse who currently smoked was associated with an increased risk of first stroke among never-smokers (hazard ratio=1.42, 95% CI=1.05, 1.93) and former smokers (hazard ratio=1.72, 95% CI=1.33, 2.22). Former smokers married to current smokers had a stroke risk similar to respondents who themselves smoked. CONCLUSIONS: Spousal smoking poses important stroke risks for never-smokers and former smokers. The health benefits of quitting smoking likely extend to both the individual smoker and his or her spouse.
Keywords: Age Factors; Confidence Intervals; Female; Humans; Incidence; Male; Middle Aged; Prospective Studies; Risk Factors; Smoking; Spouses; Stroke; Time Factors; Tobacco Smoke Pollution; United States

Stroke disparities in older Americans: is wealth a more powerful indicator of risk than income and education? - Mauricio Avendano; M. Maria Glymour (Stroke, 2008)
BACKGROUND AND PURPOSE: This study examines the independent effect of wealth, income, and education on stroke and how these disparities evolve throughout middle and old age in a representative cohort of older Americans. METHODS: Stroke-free participants in the Health and Retirement Study (n=19,565) were followed for an average of 8.5 years. Total wealth, income, and education assessed at baseline were used in Cox proportional hazards models to predict time to stroke. Separate models were estimated for 3 age-strata (50 to 64, 65 to 74, and >or=75), and incorporating risk factor measures (smoking, physical activity, body mass index, hypertension, diabetes, and heart disease). RESULTS: 1542 subjects developed incident stroke. Higher education predicted reduced stroke risk at ages 50 to 64, but not after adjustment for wealth and income. Wealth and income were independent risk factors for stroke at ages 50 to 64. Adjusted hazard ratios comparing the lowest decile with the 75th-90th percentiles were 2.3 (95% CI 1.6, 3.4) for wealth and 1.8 (95% CI 1.3, 2.6) for income. Risk factor adjustment attenuated these effects by 30% to 50%, but coefficients for both wealth (HR=1.7, 95% CI 1.2, 2.5) and income (HR=1.6, 95% CI 1.2, 2.3) remained significant. Wealth, income, and education did not consistently predict stroke beyond age 65. CONCLUSIONS: Wealth and income are independent predictors of stroke at ages 50 to 64 but do not predict stroke among the elderly. This age patterning might reflect buffering of the negative effect of low socioeconomic status by improved access to social and health care programs at old ages, but may also be an artifact of selective survival.
Keywords: Age Distribution; Age Factors; Aged; Cohort Studies; Educational Status; Female; Humans; Incidence; Income; Life Style; Longitudinal Studies; Male; Middle Aged; Proportional Hazards Models; Risk Factors; Socioeconomic factors; Stroke; United States

Trajectories of functional health: the 'long arm' of childhood health and socioeconomic factors. - Steven A Haas (Soc Sci Med, 2008)
Few studies have specifically examined trajectories of functional health status or estimated the extent to which they are influenced by childhood health and socioeconomic conditions. This study examines how circumstances associated with early life may shape the level and progression of functional limitations among adults at or near retirement. Employing data from the US Health and Retirement Study (HRS), it estimates latent growth curve models (LGM) of functional limitation. The results demonstrate that functional health trajectories in old age continue to be shaped by childhood health and socioeconomic circumstances. Poor childhood health and disadvantaged social origins are associated with both more functional limitations at baseline and higher rates of increase over time. This association is net of baseline adult chronic disease and socioeconomic status. While both childhood and adult factors influence the baseline level of functional limitation, only childhood health and socioeconomic status are associated with the rate of change in limitations over time.
Keywords: Aged; Child; Female; Health Behavior; Health Status Disparities; Humans; Male; Middle Aged; Social Class; Socioeconomic factors

Trends in the prevalence and mortality of cognitive impairment in the United States: is there evidence of a compression of cognitive morbidity? - Kenneth M. Langa; Eric B Larson; Jason H. Karlawish; David M Cutler; Mohammed U Kabeto; Scott Y H Kim; Allison B Rosen (Alzheimers Dement, 2008)
BACKGROUND: Recent medical, demographic, and social trends might have had an important impact on the cognitive health of older adults. To assess the impact of these multiple trends, we compared the prevalence and 2-year mortality of cognitive impairment (CI) consistent with dementia in the United States in 1993 to 1995 and 2002 to 2004. METHODS: We used data from the Health and Retirement Study (HRS), a nationally representative population-based longitudinal survey of U.S. adults. Individuals aged 70 years or older from the 1993 (N = 7,406) and 2002 (N = 7,104) waves of the HRS were included. CI was determined by using a 35-point cognitive scale for self-respondents and assessments of memory and judgment for respondents represented by a proxy. Mortality was ascertained with HRS data verified by the National Death Index. RESULTS: In 1993, 12.2% of those aged 70 or older had CI compared with 8.7% in 2002 (P < .001). CI was associated with a significantly higher risk of 2-year mortality in both years. The risk of death for those with moderate/severe CI was greater in 2002 compared with 1993 (unadjusted hazard ratio, 4.12 in 2002 vs 3.36 in 1993; P = .08; age- and sex-adjusted hazard ratio, 3.11 in 2002 vs 2.53 in 1993; P = .09). Education was protective against CI, but among those with CI, more education was associated with higher 2-year mortality. CONCLUSIONS: These findings support the hypothesis of a compression of cognitive morbidity between 1993 and 2004, with fewer older Americans reaching a threshold of significant CI and a more rapid decline to death among those who did. Societal investment in building and maintaining cognitive reserve through formal education in childhood and continued cognitive stimulation during work and leisure in adulthood might help limit the burden of dementia among the growing number of older adults worldwide.
Keywords: Aged; Aged, 80 and over; Cognition Disorders; Female; Humans; Male; Neurology; Prevalence; Quality of Life; Socioeconomic factors; United States

Using subjective expectations to forecast longevity: do survey respondents know something we don't know? - Maria Perozek (Demography, 2008)
Old-age mortality is notoriously difficult to predict because it requires not only an understanding of the process of senescence-which is influenced by genetic, environmental, and behavioral factors-but also a prediction of how these factors will evolve. In this paper I argue that individuals are uniquely qualified to predict their own mortality based on their own genetic background, as well as environmental and behavioral risk factors that are often known only to the individual. Given this private information, individuals form expectations about survival probabilities that may provide additional information to demographers and policymakers in their challenge to predict mortality. From expectations data from the 1992 Health and Retirement Study (HRS), I construct subjective, cohort life tables that are shown to predict the unusual direction of revisions to U.S. life expectancy by gender between 1992 and 2004: that is, for these cohorts, the Social Security Actuary (SSA) raised male life expectancy in 2004 and at the same lowered female life expectancy, narrowing the gender gap in longevity by 25% over this period. Further, although the subjective life expectancies for men appear to be roughly in line with the 2004 life tables, the subjective expectations of women suggest that female life expectancies estimated by the SSA might still be on the high side.
Keywords: Aged; Aged, 80 and over; Aging; Data collection; Demography; Female; health policy; Humans; Life Expectancy; Life Tables; Longevity; Male; Middle Aged; Mortality; Risk Factors; Sex Factors; United States

Within-group differences in depression among older Hispanics living in the United States. - Frances Margaret Yang; Cazorla-Lancaster, Yamileth; Richard N Jones (J Gerontol B Psychol Sci Soc Sci, 2008)
Using the Health and Retirement Study, we examine the prevalence of depression in different groups of Hispanic older adults. Respondents (n = 759) were aged 59 and older and identified themselves as Mexican American (56%), Cuban American (13%), Puerto Rican (8%), other (8%), or not specified (15%). We used a modified version of the Center for Epidemiologic Studies-Depression scale and the Composite International Diagnostic Interview to assess depressive symptoms and the presence of major depression. Relative to Puerto Ricans, each Hispanic group had significantly lower levels of depressive symptoms, except for Cuban Americans; and each Hispanic group had lower prevalence rates for major depression, except for other Hispanics, even after we adjusted for sociodemographic, cultural factors, socioeconomic, functional limitations, and chronic health conditions.
Keywords: Aged; Culture; Depressive Disorder, Major; Female; Hispanic or Latino; Humans; Insurance, Health; Male; Middle Aged; Prevalence; Severity of Illness Index; Socioeconomic factors; United States

Work disability associated with cancer survivorship and other chronic conditions. - Pamela F. Short; Joseph J. Vasey; BeLue, Rhonda (Psychooncology, 2008)
The long-term effects of cancer and its treatment on employment and productivity are a major concern for the 40% of cancer survivors in the U.S. who are working age. This study's objectives were (1) to quantify the increase in work disability attributable to cancer in a cohort of adult survivors who were an average of 46 months post-diagnosis and (2) to compare disability rates in cancer survivors to individuals with other chronic conditions. Data from the Penn State Cancer Survivor Study (PSCSS) and the Health and Retirement Study (HRS) were compared. The PSCSS sample included 647 survivors age 55-65, diagnosed at four medical centers in Pennsylvania and Maryland. There were 5988 similarly aged subjects without cancer in the HRS. Adjusted odds ratios for work disability were estimated for cancer survivorship, heart disease, stroke, diabetes, lung disease, and arthritis/rheumatism with multivariate logistic regression. Even for cancer-free survivors, the adjusted disability rate was significantly higher in comparison to adults with no chronic conditions (female OR = 1.94; male OR = 1.89). There were few significant differences between disability rates for cancer and other conditions. The elevated disability rate is another argument for viewing cancer survivorship as a chronic condition potentially requiring a broad range of psychosocial services.
Keywords: Adult; Aged; Chronic disease; Disability Evaluation; Employment; Female; Humans; Male; Maryland; Middle Aged; Neoplasms; Pennsylvania; Survivors

Age group differences in depressive symptoms among older adults with functional impairments. - Namkee G Choi; Kim, Johnny S. (Health Soc Work, 2007)
This study used data from the 2000 interview wave of the Health and Retirement Study to examine age group differences in the likelihood of self-reported depressive symptomatology among a nationally representative sample of 3,035 adults age 55 years or older who had at least one activities of daily living (ADL) or instrumental activities of daily living (IADL) limitation. Depression was defined as scoring three points or higher on the eight-point Center for Epidemiological Studies Depression Scale. The results show that respondents age 75 years or older with one ADL/IADL impairment or more were significantly less likely to be depressed than were those between ages 55 and 64 with the same degree of functional impairment. It is recommended that doctors, social workers, and other health care and social services providers pay special attention to younger old adults with health problems and functional limitations because they have a greater risk of being depressed.
Keywords: Activities of Daily Living; Age Factors; Aged; Aged, 80 and over; Demography; depression; Disabled Persons; Female; Health Status; Humans; Interviews as Topic; Logistic Models; Male; Middle Aged; United States

All in the family: the impact of caring for grandchildren on grandparents' health. - Mary Elizabeth Hughes; Linda J. Waite; Tracey A. LaPierre; Ye Luo (J Gerontol B Psychol Sci Soc Sci, 2007)
OBJECTIVES: The purpose of this study was to examine the effects of caring for grandchildren on health behaviors and mental and physical health among older adults. METHODS: Using a sample of 12,872 grandparents aged 50 through 80 from the Health and Retirement Study, we examined the relationship between stability and change in various types of grandchild care and subsequent health, controlling for covariates and earlier health. RESULTS: We found no evidence to suggest that caring for grandchildren has dramatic and widespread negative effects on grandparents' health and health behavior. We found limited evidence that grandmothers caring for grandchildren in skipped-generation households are more likely to experience negative changes in health behavior, depression, and self-rated health. We also found some evidence of benefits to grandmothers who babysit. DISCUSSION: Our findings suggest that the health disadvantages found previously among grandparent caregivers arise from grandparents' prior characteristics, not as a consequence of providing care. Health declines as a consequence of grandchild care appear to be the exception rather than the rule. These findings are important given continuing reliance on grandparents for day care and increasing reliance on grandparents for custodial care. However, the findings should be tempered by the recognition that for a minority of grandparents, coresidential grandchild care may compromise health.
Keywords: Adaptation, Psychological; Aged; Aged, 80 and over; Aging; Caregivers; Child Care; Child, Preschool; Family Relations; Female; Health Status; Humans; Intergenerational Relations; Male; Middle Aged; Parenting; Risk Assessment; Stress, Psychological

Beyond comorbidity counts: how do comorbidity type and severity influence diabetes patients' treatment priorities and self-management? - Eve A Kerr; Michele M Heisler; Sarah L. Krein; Mohammed U Kabeto; Kenneth M. Langa; David R Weir; John D Piette (J Gen Intern Med, 2007)
BACKGROUND: The majority of older adults have 2 or more chronic conditions and among patients with diabetes, 40% have at least three. OBJECTIVE: We sought to understand how the number, type, and severity of comorbidities influence diabetes patients' self-management and treatment priorities. DESIGN: Cross-sectional observation study. PATIENTS: A total of 1,901 diabetes patients who responded to the 2003 Health and Retirement Study (HRS) diabetes survey. MEASUREMENTS: We constructed multivariate models to assess the association between presence of comorbidities and each of 2 self-reported outcomes, diabetes prioritization and self-management ability, controlling for patient demographics. Comorbidity was characterized first by a count of all comorbid conditions, then by the presence of specific comorbidity subtypes (microvascular, macrovascular, and non-diabetes related), and finally by severity of 1 serious comorbidity: heart failure (HF). RESULTS: 40% of respondents had at least 1 microvascular comorbidity, 79% at least 1 macrovascular comorbidity, and 61% at least 1 non-diabetes-related comorbidity. Patients with a greater overall number of comorbidities placed lower priority on diabetes and had worse diabetes self-management ability scores. However, only macrovascular and non-diabetes-related comorbidities, but not microvascular comorbidities, were associated with lower diabetes prioritization, whereas higher numbers of microvascular, macrovascular, and non-diabetes-related conditions were all associated with lower diabetes self-management ability scores. Severe, but not mild, HF was associated with lower diabetes prioritization and self-management scores. CONCLUSIONS: The type and severity of comorbid conditions, and not just the comorbidity count, influence diabetes patients' self-management. Patients with severely symptomatic comorbidities and those with conditions they consider to be unrelated to diabetes may need additional support in making decisions about care priorities and self-management activities.
Keywords: Aged; Attitude to Health; Cohort Studies; Comorbidity; Cross-Sectional Studies; Diabetes Mellitus; Female; Health Priorities; Heart Failure; Humans; Male; Middle Aged; Self Care; Severity of Illness Index; United States

Burden of common multiple-morbidity constellations on out-of-pocket medical expenditures among older adults. - Schoenberg, Nancy E.; Hyungsoo Kim; Edwards, William; Fleming, Steven T. (Gerontologist, 2007)
PURPOSE: On average, adults aged 60 years or older have 2.2 chronic diseases, contributing to the over 60 million Americans with multiple morbidities. We aimed to understand the financial implications of the most frequent multiple morbidities among older adults. DESIGN AND METHODS: We analyzed Health and Retirement Study data, determining out-of-pocket medical expenses from 1998 and 2002 separately and examining differences in the impact of multiple-morbidity constellations on these expenses. We paid particular attention to the most common disease constellations - hypertension, arthritis, and heart disease. RESULTS: An increasing prevalence of multiple morbidity (58% compared with 70% of adults had two or more chronic conditions in 1998 and 2002, respectively) was accompanied by escalating out-of-pocket expenditures (2,164 dollars in 1998, increasing by 104% to 3,748 dollars in 2002). Individuals with two, three, and four chronic conditions had health care expenditure increases of 41%, 85%, and 100%, respectively, over 4 years. Such patterns were particularly noticeable among the oldest old, those with higher educational attainment, and women, although having supplementary health insurance or Medicaid mitigated these expenses. Finally, there were significant differences in out-of-pocket expenditure levels among the multiple-morbidity combinations. IMPLICATIONS: Increasing rates of multiple morbidities in conjunction with escalating health care costs and stable or declining incomes among elders warrant creative attention from providers, researchers, and policy makers. Further understanding how specific multiple-morbidity constellations impact out-of-pocket spending moves us closer to effective interventions to support vulnerable elders.
Keywords: Aged; Arthritis; Chronic disease; Comorbidity; Cost of Illness; Female; Financing, Personal; Health Expenditures; Health Surveys; Heart Diseases; Humans; Hypertension; Interviews as Topic; Male; Middle Aged; United States

Change in depression of spousal caregivers of dementia patients following patient's death. - Tweedy, Maureen P.; Charles A Guarnaccia (Omega (Westport), 2007)
Caring for an elderly spouse with dementia places a heavy burden on spousal caregivers and often results in chronic depression. Little has been written about change in depression caregivers experience from before to after the death of the spouse with dementia. This longitudinal study examines change in depression of spousal caregivers that occurs following death of the dementia patient. Two theoretical models, the Relief and Stress Models, are discussed in terms of caregiver depression after the death of the dementia-patient care-recipient spouse. These two theoretical models were tested using longitudinal data from the National Institute on Aging sponsored Health and Retirement Study. Both male and female spousal caregivers report an increase in depression after the death of the dementia-patient care-recipient spouse. As time passed following the spouse's death, the conjugally bereaved husbands showed a decrease in depression while the conjugally bereaved wives continued to report increased depression.
Keywords: Adaptation, Psychological; Aged; Aged, 80 and over; Bereavement; Caregivers; Dementia; depression; Female; Humans; Life Change Events; Long-term Care; Longitudinal Studies; Male; Sex Factors; Spouses; Surveys and Questionnaires; United States

Changes in adult child caregiver networks. - Maximiliane E Szinovacz; Adam Davey (Gerontologist, 2007)
PURPOSE: Caregiving research has typically relied on cross-sectional data that focus on the primary caregiver. This approach neglects the dynamic and systemic character of caregiver networks. Our analyses addressed changes in adult child care networks over a 2-year period. DESIGN AND METHODS: The study relied on pooled data from Waves 1 through 5 of the Health and Retirement Study. Based on a matrix of specific adult child caregivers across two consecutive time points, we assessed changes in any adult child caregiver as well as in the primary adult child caregiver. RESULTS: More than half of all adult-child care networks, including more than one fourth of primary adult child caregivers, changed between waves. Gender composition of the caregiver network and availability of other adult child caregivers were particularly important for network change, but socioeconomic context, caregiver abilities and resources, and caregiver burden played a role as well. IMPLICATIONS: The results underline the need to shift caregiving research toward a dynamic life course and family systems perspective. They also raise concerns about the viability of informal care networks for future smaller birth cohorts and suggest that health care providers need to recognize and address coordination and potential conflicts among care network members.
Keywords: Adult; Caregivers; Child; Child Care; Community Networks; Female; Humans; Male; Middle Aged; Socioeconomic factors

Childhood social and economic well-being and health in older age. - Sandra Y. Moody-Ayers; Lindquist, Karla; Sen, Saunak; Kenneth E Covinsky (Am J Epidemiol, 2007)
Childhood socioeconomic status (SES) acts over a lifetime to influence adult health outcomes. Whether the impact of childhood SES differs by age or race/ethnicity is unclear. The authors studied 20,566 community-living US adults aged > or =50 years. Parental education was the main predictor. Outcomes evaluated (1998-2002) included self-reported health and functional limitation. The influence of childhood SES on later-life health was also examined in groups stratified by age and race/ethnicity, with adjustment for demographic factors and current SES. Participants' mean age was 67 years; 57% were women. By race/ethnicity, 76% were White, 14% were Black, and 8% were Latino. The relation between low parental education and fair/poor self-rated health declined with advancing age (age 50-64 years: adjusted odds ratio (AOR) = 1.42, 95% confidence interval (CI): 1.24, 1.63; age > or =80 years: AOR = 1.14, 95% CI: 0.96, 1.36). The relation between low parental education and fair/poor self-rated health differed across racial/ethnic groups and was significant in White (AOR = 1.33, 95% CI: 1.21, 1.47) and Black (AOR = 1.37, 95% CI: 1.14, 1.64) participants but not Latinos. These findings suggest that childhood SES affects health status through midlife but the effects may abate in late life; its effects also may be weaker in Latinos than in Whites or Blacks.
Keywords: Aged; Aged, 80 and over; Black or African American; Child; Confidence Intervals; Educational Status; Female; Frail Elderly; Health Status; Health Status Indicators; Hispanic or Latino; Humans; Male; Middle Aged; Mobility Limitation; Odds Ratio; Poverty; Retrospective Studies; Sampling Studies; San Francisco; Socioeconomic factors; Surveys and Questionnaires; White People

Do panel surveys really make people sick? A commentary on Wilson and Howell (60:11, 2005, 2623-2627). - David R Weir; James P Smith (Soc Sci Med, 2007)
In a recent article in this journal, Wilson and Howell [2005. Do panel surveys make people sick? US arthritis trends in the Health and Retirement Survey. Social Science & Medicine, 60(11), 2623-2627.] argue that the sharp trend of rising age-specific arthritis prevalence from 1992 to 2000 in the USA among those in their 50s based on the original Health and Retirement Study (HRS) cohort of respondents is "almost surely spurious." Their reasons are that no such trend is found in the National Health Interview Study (NHIS) over this same time period, and that an introduction of a new birth cohort into HRS in 1998 also indicates no trend. They also claim that there may be an inherent bias in panel surveys leading respondents to report greater levels of disease as the duration of their participation in the panel increases. This bias, which they call "panel conditioning," suggests a tendency for participants in a longitudinal survey to seek out medical care and diagnosis of symptoms asked about in previous waves. In this paper, we show that the evidence presented and the conclusions reached by Wilson and Howell are incorrect. Properly analyzed, three national health surveys--the NHIS, National Health and Nutrition Examination Survey (NHANES), and HRS--all show increases in age-specific arthritis prevalence during the 1990s. Since the new HRS sample cohort introduced in 1998 represents only a part of that birth cohort, we also demonstrate that Wilson and Howell's evidence in favor of panel conditioning was flawed. We find little indication of panel conditioning among existing participants in a panel survey.
Keywords: Arthritis; Female; Health Surveys; Humans; Male; Middle Aged; Prevalence; United States

Does physician communication influence older patients' diabetes self-management and glycemic control? Results from the Health and Retirement Study (HRS). - Michele M Heisler; Cole, Ian; David R Weir; Eve A Kerr; Rodney A. Hayward (J Gerontol A Biol Sci Med Sci, 2007)
BACKGROUND: Effective chronic disease self-management among older adults is crucial for improved clinical outcomes. We assessed the relative importance of two dimensions of physician communication-provision of information (PCOM) and participatory decision-making (PDM)-for older patients' diabetes self-management and glycemic control. METHODS: We conducted a national cross-sectional survey among 1588 older community-dwelling adults with diabetes (response rate: 81%). Independent associations were examined between patients' ratings of their physician's PCOM and PDM with patients' reported diabetes self-management (medication adherence, diet, exercise, blood glucose monitoring, and foot care), adjusting for patient sociodemographics, illness severity, and comorbidities. Among respondents for whom hemoglobin A1c (HbA1c) values were available (n=1233), the relationship was assessed between patient self-management and HbA1c values. RESULTS: In separate multivariate regressions, PCOM and PDM were each associated with overall diabetes self-management (p<.001) and with all self-management domains (p<.001 in all models), with the exception of PDM not being associated with medication adherence. In models with both PCOM and PDM, PCOM alone predicted medication adherence (p=.001) and foot care (p=.002). PDM alone was associated with exercise and blood glucose monitoring (both p<.001) and was a stronger independent predictor than PCOM of diet. Better patient ratings of their diabetes self-management were associated with lower HbA1c values (B= -.10, p=.005). CONCLUSION: Among these older adults, both their diabetes providers' provision of information and efforts to actively involve them in treatment decision-making were associated with better overall diabetes self-management. Involving older patients in setting chronic disease goals and decision-making, however, appears to be especially important for self-care areas that demand more behaviorally complex lifestyle adjustments such as exercise, diet, and blood glucose monitoring.
Keywords: Aged; Blood Glucose; Communication; Cross-Sectional Studies; Diabetes Mellitus; Female; Glycated Hemoglobin; Humans; Male; Multivariate Analysis; Physician-Patient Relations; Self Care

Early childbearing, marital status, and women's health and mortality after age 50. - John C Henretta (J Health Soc Behav, 2007)
This article examines the relationship between a woman's childbearing history and her later health and mortality, with primary focus on whether the association between them is due to early and later socioeconomic status. Data are drawn from the Health and Retirement Study birth cohort of 1931-1941. Results indicate that, conditional on reaching midlife and controlling for early and later socioeconomic status, a first birth before age 20 is associated with a higher hazard of dying. In addition, having an early birth is associated with a higher prevalence of reported heart disease, lung disease, and cancer in 1994. Being unmarried at the time of the first birth is associated with earlier mortality, but this association disappears when midlife socioeconomic status is controlled. The number of children ever born does not significantly affect mortality but is associated with prevalence of diabetes.
Keywords: Adolescent; Cohort Studies; Female; Humans; Marital Status; Maternal Age; Middle Aged; Mortality; Parity; Pregnancy; Pregnancy in Adolescence; Prevalence; Proportional Hazards Models; Social Class; United States; Women's Health

The economic consequences of widowhood for older minority women. - Jacqueline L. Angel; Maren A. Jimenez; Ronald J. Angel (Gerontologist, 2007)
PURPOSE: We compare the economic consequences of widowhood for pre-retirement age and early-retirement age Black, Hispanic, and non-Hispanic White women. METHODS: We use the 1992 and 2000 waves of the Health and Retirement Study to assess the effects of widowhood on the household incomes and assets of non-Hispanic White, Black, and Hispanic women who were 51 years of age or older at baseline (N = 4,544). RESULTS: For women of all racial and ethnic groups, marital disruption, including widowhood, results in a substantial decline in household income and assets. Net of demographic controls, the relative loss is far greater for Black and Hispanic widows than for non-Hispanic White widows. IMPLICATIONS: The data reveal a substantial widowhood penalty for total household income and net worth for women in each racial and ethnic group. However, the findings suggest that minority widows are at a particularly high risk of poverty in late life, given that they have lower incomes and fewer assets to begin with. Implications of the results for the financial security of women approaching retirement are discussed.
Keywords: Aged; Black or African American; Female; Hispanic or Latino; Humans; Longitudinal Studies; Middle Aged; United States; White People; Widowhood

Educational disparities in the prevalence and consequence of physical vulnerability. - Daniel O. Clark; Timothy E. Stump; Douglas K Miller; Long, J. Scott (J Gerontol B Psychol Sci Soc Sci, 2007)
OBJECTIVES: The purpose of this study was to estimate educational differences in the prevalence and mortality consequence of physical vulnerability among older adults in the United States. METHODS: Data came from the 1998 and 2000 waves of the Health and Retirement Study, a nationally representative cross-sectional and prospective cohort study of community-based adults aged 65 and older. We created a physical vulnerability score from age, gender, and self-reported disability measures and measured socioeconomic status via educational attainment. Mortality data came from the National Death Index. RESULTS: In the 1998 cohort, high physical vulnerability was more than 3 times more prevalent in individuals with less than 12 years of education compared to those with 16 or more years of education. Although less educated older adults had a higher probability of death overall, evidence of educational differences in the mortality consequence of high physical vulnerability was limited. In 2000, 2.16 million older adults had high physical vulnerability, and more than one half (53%) of these adults had less than 12 years of education. DISCUSSION: In persons 65 years of age or older, educational differences are more apparent in the prevalence of physical vulnerability than in the mortality consequence of that vulnerability.
Keywords: Activities of Daily Living; Aged; Aged, 80 and over; Chronic disease; Cohort Studies; Cross-Sectional Studies; Educational Status; Female; Geriatric Assessment; Health Surveys; Humans; Male; Mobility Limitation; Risk Factors; Socioeconomic factors; Survival Analysis; United States

Evidence on early-life income and late-life health from America's Dust Bowl era. - David M Cutler; Grant Miller; Douglas M Norton (Proceedings of the National Academy of Sciences, 2007)
In recent decades, elderly Americans have enjoyed enormous gains in longevity and reductions in disability. The causes of this progress remain unclear, however. This paper investigates the role of fetal programming, exploring how economic progress early in the 20th century might be related to declining disability today. Specifically, we match sudden unexpected economic changes experienced in utero in America's Dust Bowl during the Great Depression to unusually detailed individual-level information about old-age disability and chronic disease. We are unable to detect any meaningful relationship between early life factors and outcomes in later life. We conclude that, if such a relationship exists in the United States, it is most likely not a quantitatively important explanation for declining disability today.
Keywords: Aged; Data collection; Female; Health Status; History, 20th Century; Humans; Income; Male; Middle Aged; Retirement; Socioeconomic factors; United States

Geriatric conditions and disability: the Health and Retirement Study. - Christine T Cigolle; Kenneth M. Langa; Mohammed U Kabeto; Zhiyi Tian; Caroline S Blaum (Ann Intern Med, 2007)
BACKGROUND: Geriatric conditions, such as incontinence and falling, are not part of the traditional disease model of medicine and may be overlooked in the care of older adults. The prevalence of geriatric conditions and their effect on health and disability in older adults has not been investigated in population-based samples. OBJECTIVE: To investigate the prevalence of geriatric conditions and their association with dependency in activities of daily living by using nationally representative data. DESIGN: Cross-sectional analysis. SETTING: Health and Retirement Study survey administered in 2000. PARTICIPANTS: Adults age 65 years or older (n = 11 093, representing 34.5 million older Americans) living in the community and in nursing homes. MEASUREMENTS: Geriatric conditions (cognitive impairment, falls, incontinence, low body mass index, dizziness, vision impairment, hearing impairment) and dependency in activities of daily living (bathing, dressing, eating, transferring, toileting). RESULTS: Of adults age 65 years or older, 49.9% had 1 or more geriatric conditions. Some conditions were as prevalent as common chronic diseases, such as heart disease and diabetes. The association between geriatric conditions and dependency in activities of daily living was strong and significant, even after adjustment for demographic characteristics and chronic diseases (adjusted risk ratio, 2.1 [95% CI, 1.9 to 2.4] for 1 geriatric condition, 3.6 [CI, 3.1 to 4.1] for 2 conditions, and 6.6 [CI, 5.6 to 7.6] for > or =3 conditions). LIMITATIONS: The study was cross-sectional and based on self-reported data. Because measures were limited by the survey questions, important conditions, such as delirium and frailty, were not assessed. Survival biases may influence the estimates. CONCLUSIONS: Geriatric conditions are similar in prevalence to chronic diseases in older adults and in some cases are as strongly associated with disability. The findings suggest that geriatric conditions, although not a target of current models of health care, are important to the health and function of older adults and should be addressed in their care.
Keywords: Accidental Falls; Activities of Daily Living; Age Factors; Aged; Aged, 80 and over; Body Mass Index; Chronic disease; Cognition Disorders; Comorbidity; Cross-Sectional Studies; Disability Evaluation; Dizziness; Female; Geriatric Assessment; Geriatrics; Hearing Disorders; Humans; Male; Prevalence; Retirement; Urinary incontinence; Vision Disorders

Health of previously uninsured adults after acquiring Medicare coverage. - J. Michael McWilliams; Meara, Ellen; Alan M. Zaslavsky; John Z. Ayanian (JAMA, 2007)
CONTEXT: Uninsured near-elderly adults, particularly those with cardiovascular disease or diabetes, experience worse health outcomes than insured adults. However, the health benefits of providing insurance coverage for uninsured adults have not been clearly demonstrated. OBJECTIVE: To assess the effect of acquiring Medicare coverage on the health of previously uninsured adults. DESIGN AND SETTING: We conducted quasi-experimental analyses of longitudinal survey data from 1992 through 2004 from the nationally representative Health and Retirement Study. We compared changes in health trends reported by previously uninsured and insured adults after they acquired Medicare coverage at age 65 years. PARTICIPANTS: Five thousand six adults who were continuously insured and 2227 adults who were persistently or intermittently uninsured from ages 55 to 64 years. MAIN OUTCOME MEASURES: Differential changes in self-reported trends after age 65 years in general health, change in general health, mobility, agility, pain, depressive symptoms, and a summary measure of these 6 domains; and adverse cardiovascular outcomes (all trend changes reported in health scores per year). RESULTS: Compared with previously insured adults, previously uninsured adults reported significantly improved health trends after age 65 years for the summary measure (differential change in annual trend, +0.20; P = .002) and several component measures. Relative to previously insured adults with cardiovascular disease or diabetes, previously uninsured adults with these conditions reported significantly improved trends in summary health (differential change in annual trend, +0.26; P = .006), change in general health (+0.02; P = .03), mobility (+0.04; P = .05), agility (+0.08; P = .003), and adverse cardiovascular outcomes (-0.015; P = .02) but not in depressive symptoms (+0.04; P = .32). Previously uninsured adults without these conditions reported differential improvement in depressive symptoms (+0.08; P = .002) but not in summary health (+0.10; P = .17) or any other measure. By age 70 years, the expected difference in summary health between previously uninsured and insured adults with cardiovascular disease or diabetes was reduced by 50%. CONCLUSION: In this study, acquisition of Medicare coverage was associated with improved trends in self-reported health for previously uninsured adults, particularly those with cardiovascular disease or diabetes.
Keywords: Aged; Cardiovascular Diseases; depression; Diabetes Mellitus; Female; Health Status; Health Surveys; Humans; Longitudinal Studies; Male; Medically Uninsured; Medicare; Middle Aged; Outcome Assessment, Health Care; United States

Hospital episodes and physician visits: the concordance between self-reports and medicare claims. - Frederic D Wolinsky; Thomas R Miller; An, Hyonggin; John F Geweke; Robert B Wallace; Kara B Wright; Elizabeth A Chrischilles; Li Liu; Claire E Pavlik; Elizabeth A Cook; Robert L. Ohsfeldt; Kelly K Richardson; et al. (Med Care, 2007)
BACKGROUND: Health services use typically is examined using either self-reports or administrative data, but the concordance between the 2 is not well established. OBJECTIVE: We evaluated the concordance of hospital and physician utilization data from self-reports and claims data, and identified factors associated with disagreement. METHODS: We performed a secondary analysis on linked observational and administrative data. A national sample of 4310 respondents who were 70 years old or older at their baseline interviews was used. Self-reported and Medicare claims-based hospital episodes and physician visits for 12 months before baseline were examined. Kappa statistics were used to evaluate concordance, and multivariable multinomial logistic regression was used to identify factors associated with overreporting (self-reports > claims), underreporting (self-reports < claims), and concordant-reporting (self-reports approximately claims). RESULTS: The concordance of hospital episodes was high (kappa = 0.767 for the 2 x 2 comparison of none vs. some and kappa = 0.671 for the 6 x 6 comparison of none, 1, ..., 4, or 5 or more), but concordance for physician visits was low (kappa = 0.255 for the 2 x 2 comparison of none versus some and kappa = 0.351 for the 14 x 14 comparison of none, 1, ..., 12, and 13 or more). Multivariable multinomial logistic regression indicated that over-, under-, and concordant-reporting of hospital episodes was significantly associated with gender, alcohol consumption, arthritis, cancer, heart disease, psychologic problems, lower body functional limitations, self-rated health, and depressive symptoms. Over-, under-, and concordant-reporting of physician visits were significantly associated with age, gender, race, living alone, veteran status, private health insurance, arthritis, cancer, diabetes, hypertension, heart disease, lower body functional limitations, and poor memory. CONCLUSIONS: Concordance between self-reported and claims-based hospital episodes was high, but concordance for physician visits was low. Factors significantly associated with bidirectional (over- and underreporting) and unidirectional (over- or underreporting) error patterns were detected. Therefore, caution is advised when drawing conclusions based on just one physician visit data source.
Keywords: Aged; Centers for Medicare and Medicaid Services, U.S.; Episode of Care; Female; Hospitalization; Humans; Insurance Claim Review; Interviews as Topic; Male; Physicians; Quality Assurance, Health Care; Self Disclosure; United States

Informal caregiving and Body Mass Index among older adults. - Kristi Rahrig Jenkins; Mohammed U Kabeto; Fultz, Nancy H.; Kenneth M. Langa (J Gerontol Nurs, 2007)
The authors sought to obtain nationally representative estimates of the time of informal caregiving provided to older adults classified into the four standard Body Mass Index (BMI) classifications. They estimated multivariate regression models using data from the 2000 Health and Retirement Study to determine the weekly hours of informal caregiving for older adults classified into the four standard BMI classifications. In the fully adjusted models, being underweight was associated with receiving significantly more informal care, however, obesity was not associated with more informal care. The implications of these findings are discussed in terms of nursing practice and research to prevent weight loss and frailty.
Keywords: Activities of Daily Living; Aged; Aged, 80 and over; Body Mass Index; Body Weight; Caregivers; Female; Geriatric Assessment; Humans; Male; Social Class

An interpersonal continuity of care measure for Medicare Part B claims analyses. - Frederic D Wolinsky; Thomas R Miller; John F Geweke; Elizabeth A Chrischilles; An, Hyonggin; Robert B Wallace; Claire E Pavlik; Kara B Wright; Robert L. Ohsfeldt; Gary E Rosenthal (J Gerontol B Psychol Sci Soc Sci, 2007)
OBJECTIVES: This article presents an interpersonal continuity of care measure. METHODS: We operationalized continuity of care as no more than an 8-month interval between any two visits during a 2-year period to either (a) the same primary care physician or (b) the same physician regardless of specialty. Sensitivity analyses evaluated two interval censoring algorithms and two alternative intervals. We linked Medicare Part A and B claims to baseline survey data for 4,596 respondents to the Survey on Asset and Health Dynamics Among the Oldest Old. We addressed the potential for selection bias by using propensity score methods, and we explored construct validity. RESULTS: Interpersonal continuity with a primary care physician was 17.3%, and interpersonal continuity of care with any physician was 26.1%. Older participants; men; individuals who lived alone; people who had difficulty walking; and respondents with medical histories of arthritis, cancer, diabetes, heart conditions, hypertension, and stroke were most likely to have continuity. Individuals who had never married, were widowed, were working, or had low subjective life expectancy were least likely to have continuity. DISCUSSION: Researchers can measure interpersonal continuity of care using Medicare Part B claims. Replication of these findings and further construct validation, however, are needed prior to widespread adoption of this method.
Keywords: Aged; Aged, 80 and over; Continuity of Patient Care; Disability Evaluation; Female; Health Services Accessibility; Health Surveys; Humans; Insurance Claim Review; Male; Medicare Part B; Mobility Limitation; Physician-Patient Relations; Primary Health Care; United States

Latent variable analyses of age trends of cognition in the Health and Retirement Study, 1992-2004. - John J McArdle; Gwenith G Fisher; Kelly M Kadlec (Psychol Aging, 2007)
The present study was conducted to better describe age trends in cognition among older adults in the longitudinal Health and Retirement Study (HRS) from 1992 to 2004 (N = 17,000). The authors used contemporary latent variable models to organize this information in terms of both cross-sectional and longitudinal inferences about age and cognition. Common factor analysis results yielded evidence for at least 2 common factors, labeled Episodic Memory and Mental Status, largely separable from vocabulary. Latent path models with these common factors were based on demographic characteristics. Multilevel models of factorial invariance over age indicated that at least 2 common factors were needed. Latent curve models of episodic memory were based on age at testing and showed substantial age differences and age changes, including impacts due to retesting as well as several time-invariant and time-varying predictors.
Keywords: Aged; Aged, 80 and over; Aging; Cognition; Female; Health Surveys; Humans; Individuality; Longitudinal Studies; Male; Mental Recall; Mental Status Schedule; Middle Aged; Models, Statistical; Neuropsychological tests; Psychometrics; Retention, Psychology; Sex Factors; United States

Longitudinal variable selection by cross-validation in the case of many covariates. - Cantoni, E.; Field, C.; Mills Fleming, J.; Ronchetti, E. (Stat Med, 2007)
Longitudinal models are commonly used for studying data collected on individuals repeatedly through time. While there are now a variety of such models available (marginal models, mixed effects models, etc.), far fewer options exist for the closely related issue of variable selection. In addition, longitudinal data typically derive from medical or other large-scale studies where often large numbers of potential explanatory variables and hence even larger numbers of candidate models must be considered. Cross-validation is a popular method for variable selection based on the predictive ability of the model. Here, we propose a cross-validation Markov chain Monte Carlo procedure as a general variable selection tool which avoids the need to visit all candidate models. Inclusion of a 'one-standard error' rule provides users with a collection of good models as is often desired. We demonstrate the effectiveness of our procedure both in a simulation setting and in a real application.
Keywords: Cohort Studies; Computer Simulation; Female; Humans; Linear Models; Longitudinal Studies; Male; Markov chains; Monte Carlo Method; Smoking; Socioeconomic factors

The long-term effects of poor childhood health: an assessment and application of retrospective reports. - Steven A Haas (Demography, 2007)
This study assesses retrospective childhood health reports and examines childhood health as a predictor of adult health. The results suggest that such reports are of reasonable reliability as to warrant their judicious use in population research. They also demonstrate a large positive relationship between childhood and adult health. Compared with excellent, very good, or good childhood health, poor childhood health is associated with more than three times greater odds of having poor adult self-rated health and twice the risk of a work-limiting disability or a chronic health condition. These associations are independent of childhood and current socioeconomic position and health-related risk behaviors.
Keywords: Adolescent; Adult; Age Factors; Aged; Child; Child Welfare; Child, Preschool; Chronic disease; Disabled Persons; Female; Health Status; Humans; Infant; Infant, Newborn; Male; Middle Aged; Reproducibility of Results; Retrospective Studies; Risk Assessment; Risk Factors; Socioeconomic factors; Time; United States

Mechanisms for racial and ethnic disparities in glycemic control in middle-aged and older Americans in the health and retirement study. - Michele M Heisler; Jessica Faul; Rodney A. Hayward; Kenneth M. Langa; Caroline S Blaum; David R Weir (Arch Intern Med, 2007)
BACKGROUND: Mechanisms for racial/ethnic disparities in glycemic control are poorly understood. METHODS: A nationally representative sample of 1901 respondents 55 years or older with diabetes mellitus completed a mailed survey in 2003; 1233 respondents completed valid at-home hemoglobin A(1c) (HbA(1c)) kits. We constructed multivariate regression models with survey weights to examine racial/ethnic differences in HbA(1c) control and to explore the association of HbA(1c) level with sociodemographic and clinical factors, access to and quality of diabetes health care, and self-management behaviors and attitudes. RESULTS: There were no significant racial/ethnic differences in HbA(1c) levels in respondents not taking antihyperglycemic medications. In 1034 respondents taking medications, the mean HbA(1c) value (expressed as percentage of total hemoglobin) was 8.07% in black respondents and 8.14% in Latino respondents compared with 7.22% in white respondents (P < .001). Black respondents had worse medication adherence than white respondents, and Latino respondents had more diabetes-specific emotional distress (P < .001). Adjusting for hypothesized mechanisms accounted for 14.0% of the higher HbA(1c) levels in black respondents and 19.0% in Latinos, with the full model explaining 22.0% of the variance. Besides black and Latino ethnicity, only insulin use (P < .001), age younger than 65 years (P = .007), longer diabetes duration (P = .004), and lower self-reported medication adherence (P = .04) were independently associated with higher HbA(1c) levels. CONCLUSIONS: Latino and African American respondents had worse glycemic control than white respondents. Socioeconomic, clinical, health care, and self-management measures explained approximately a fifth of the HbA(1c) differences. One potentially modifiable factor for which there were racial disparities--medication adherence--was among the most significant independent predictors of glycemic control.
Keywords: Aged; Aged, 80 and over; Black People; Diabetes Mellitus; Female; Glycated Hemoglobin; Health Services Accessibility; Hispanic or Latino; Humans; Longitudinal Studies; Male; Middle Aged; Patient Compliance; Socioeconomic factors; Treatment Refusal; United States; White People

New evidence of racial differences in access and their effects on the use of nursing homes among older adults. - Adaeze B Akamigbo; Frederic D Wolinsky (Med Care, 2007)
BACKGROUND: Historical disparities in rates of nursing home placement between blacks and whites have been well documented, and are thought to result from more extensive and supportive social networks, cultural aversion, and poorer geographic access among African Americans. A few recent studies, however, suggest that these racial disparities may no longer exist. We used comprehensive data to assess whether racial differences in nursing home placement remain, and if so, to identify the reasons for them. METHODS: Data on 6242 black and white self-respondents to the Survey of Assets and Health Dynamics Among the Oldest Old cohort who were 70 years old or older at baseline (1993) were used. Placement status was ascertained at each biennial follow-up through 2004, and discrete-time hazards models were estimated. RESULTS: After adjusting for baseline covariates, it was found that blacks were 26% (lambda = 0.74, P < 0.001) less likely to use a nursing home over an 11-year period than whites. Moreover, the supply of skilled nursing beds was more salient for nursing home placement for blacks than whites, as was the increasing supply of assisted living beds. CONCLUSIONS: The racial gap in nursing home placement remains, despite the increased supply of nursing home beds and the emergence of assisted living facilities as the preferred alternative. As the supply of skilled nursing beds increases, in part due to whites choosing assisted living facilities, the racial gap in the risks of nursing home placement may be lessening. Blacks, however, remain less likely to be placed in a nursing home than whites.
Keywords: Aged; Assisted Living Facilities; Attitude to Health; Black or African American; Female; Health Services Accessibility; Health Status; Homes for the Aged; Humans; Male; Nursing homes; Socioeconomic factors; Time Factors; White People

Pain in aging community-dwelling adults in the United States: non-Hispanic whites, non-Hispanic blacks, and Hispanics. - Reyes-Gibby, Cielito C.; Aday, Lu Ann; Todd, Knox H.; Cleeland, Charles S.; Anderson, Karen O. (J Pain, 2007)
UNLABELLED: Racial and ethnic disparities in healthcare persist in the U.S. Although pain is one of the most prevalent and disabling symptoms of disease, only a few studies have assessed disparities in pain in large racially and ethnically diverse, middle- to late aged community samples, thus limiting the generalizability of study findings in broader populations. With data from the 2000 Health and Retirement Study, we assessed the prevalence and impact of pain in a community sample of aging (> or =51 years old) non-Hispanic whites (n = 11,021), non-Hispanic blacks (n = 1,804), and Hispanics (n = 952) in the U.S. Pain, pain severity, activity limitation as a result of pain, comorbid conditions, and sociodemographic variables were assessed. Results showed that pain prevalence was 28%, and 17% of the sample reported activity limitation as a result of pain. Non-Hispanic blacks (odds ratio [OR], 1.78; 99% confidence interval [CI], 1.33-2.37) and Hispanics (OR, 1.80; 99% CI, 1.26-2.56) had higher risk for severe pain compared with non-Hispanic whites. Analyses of respondents with pain (n = 3,811) showed that having chronic diseases (2 comorbid conditions, OR, 1.5; 99% CI, 1.09-2.17), psychological distress (OR, 1.99; 99% CI, 1.54-2.43), being a Medicaid recipient (OR, 1.63; 99% CI, 1.17-2.25), and lower educational level (OR, 1.45; 99% CI, 1.14-1.85) were significant predictors for severe pain and helped to explain racial/ethnic differences in pain severity. PERSPECTIVE: This study, which used a large racially and ethnically diverse community sample, provided empirical evidence that racial/ethnic difference in pain severity in aging community adults in the U.S. can be accounted for by differential vulnerability in terms of chronic disease, socioeconomic conditions, and access to care.
Keywords: Activities of Daily Living; Age Factors; Aged; Aged, 80 and over; Aging; Black People; Chronic disease; Data collection; ethnicity; Female; Hispanic or Latino; Humans; Insurance, Health; Logistic Models; Male; Middle Aged; pain; Pain Measurement; Population; Socioeconomic factors; United States; White People

Participation in food assistance programs modifies the relation of food insecurity with weight and depression in elders. - Kim, Kirang; Edward A Frongillo (J Nutr, 2007)
The relation of food insecurity in elders with outcomes such as overweight and depression, and the influence of participation in food assistance programs on these relations, has not been established. The aim of this study was to examine the relation between food insecurity and weight and depression in elders, and determine whether participation in food assistance programs modifies the effect of food insecurity on weight and depression. Two longitudinal data sets were used: the Health and Retirement Study (1996-2002) and the Asset and Health Dynamics Among the Oldest Old (1995-2002). The relation of food insecurity and participation in food assistance programs was assessed by multilevel linear regression analysis. Food insecurity was positively related to weight and depression among elders. Some analyses supported that food-insecure elders who participated in food assistance programs were less likely to be overweight and depressed than those who did not participate in food assistance programs. This finding implies that food assistance programs can have both nutritional and non-nutritional impacts. The positive impact of participation in food assistance programs of reducing or preventing poor outcomes resulting from food insecurity will improve elders' quality of life, save on their healthcare expenses, and help to meet their nutritional needs.
Keywords: Aged; depression; Female; Food Services; Food Supply; Health Surveys; Humans; Linear Models; Longitudinal Studies; Male; Middle Aged; Models, Theoretical; Overweight; Public Assistance; United States

Predicting the changes in depressive symptomatology in later life: how much do changes in health status, marital and caregiving status, work and volunteering, and health-related behaviors contribute? - Namkee G Choi; Bohman, Thomas M. (J Aging Health, 2007)
This study examined the unique effects of four variable groups on changes in older adults' depressive symptoms for a 2-year period: (1) baseline health and disability status, (2) changes in health and disability since baseline, (3) stability and changes in marital and caregiving status and in work and volunteering, and (4) stability and changes in health-related behaviors. With data from the 1998 and 2000 interview waves of the Health and Retirement Study, the authors used gender-separate multistep (hierarchical) residualized regression analyses in which the Center for Epidemiological Studies Depression scale (CES-D) score at follow-up is modeled as a function of the effect of each group of independent variables. As hypothesized, changes in health, disability, marital, and caregiving status explained a larger amount of variance than the existing and stable conditions, although each group of variables explained a relatively small amount (0.3-3.4%) of variance in the follow-up CES-D score.
Keywords: Aged; Caregivers; depression; Employment; Female; Forecasting; Health Behavior; Health Status; Humans; Male; Marital Status; Middle Aged; Netherlands; Regression Analysis; Sweden; United States; Volunteers