Does Self-Rated Health Predict Survival in Older Persons with Cognitive Impairment?

Factors associated with self-rated health in older people living in institutions

BACKGROUND

Although self-rated health has been extensively studied in community older people, its determinants have seldom been investigated in institutional settings. We carried out a cross-sectional study to describe the physical, mental, and social factors associated with self-rated health in nursing homes and other geriatric facilities.

METHODS

A representative sample of 800 subjects 65 years of age and older living in 19 public and 30 private institutions of Madrid was randomly selected through stratified cluster sampling. Residents, caregivers, physicians, and nurses were interviewed by trained geriatricians using standardized instruments to assess self-rated health, chronic illnesses, functional capacity, cognitive status, depressive symptoms, vision and hearing problems, and social support.

RESULTS

Of the 669 interviewed residents (response rate 84%), 55% rated their health as good or very good. There was no association with sex or age. Residents in private facilities and those who completed primary education had significantly better health perception. The adjusted odds ratio (95% confidence interval) for worse health perception was 1.18 (1.07-1.28) for each additional chronic condition, 2.37 (1.38-4.06) when comparing residents with moderate dependency to those functionally independent, and 10.45 (5.84-18.68) when comparing residents with moderate/severe depressive symptoms to those without symptoms. Visual problems were also associated with worse health perception. Similar results were obtained in subgroup analyses, except for inconsistencies in cognitively impaired individuals.

CONCLUSION

Chronic conditions, functional status, depressive symptoms and socioeconomic factors were the main determinants of perceived health among Spanish institutionalized elderly persons. Doubts remain about the proper assessment of subjective health in residents with altered cognition.

Network type and mortality risk in later life

PURPOSE

The purpose of this study was to examine the association of baseline network type and 7-year mortality risk in later life.

DESIGN AND METHODS

We executed secondary analysis of all-cause mortality in Israel using data from a 1997 national survey of adults aged 60 and older (N=5,055) that was linked to records from the National Death Registry up to 2004. We considered six network types--diverse, friend focused, neighbor focused, family focused, community-clan, and restricted--in the analysis, controlling for population group, sociodemographic background, and health factors. We carried out Cox proportional hazards regressions for the entire sample and separately by age group at baseline: 60-69, 70-79, and 80 and older.

RESULTS

Network types were associated with mortality in the 70-79 and 80 and older age groups. Respondents located in diverse and friend-focused network types, and to a lesser degree those located in community-clan network types, had a lower risk of mortality compared to individuals belonging to restricted networks.

IMPLICATIONS

Gerontological practitioners should address older adults' social networks in their assessments of clients. The parameters used to derive network types in this study can serve toward the development of practical network type inventories. Moreover, practitioners should tailor the interventions they implement to the different network types in which their elderly clients are embedded.

Does early retirement lead to longer life?

It has been claimed, but not empirically supported, that early retirement leads to longer life. The present investigation addressed this question using data from a 1997 Israeli national household survey of adults aged 60 or more years linked to mortality records from the national death registry, for 2004. The study examined the association between early retirement and seven-year all-cause mortality among the population of older Jewish Israelis who were employed prior to or at baseline (N=2,374). Both the timing of retirement and the reasons for exit from the labour force were considered in the analysis. The initial hazard regression models, adjusted by gender and reason for retirement including poor health, showed that early retirees indeed had lower mortality risk ratios than respondents who had retired ‘on time’. When additional variables were controlled in the final analytic model, however, the association between early retirement and mortality was not supported. Older age, male gender, and having been diagnosed with one or more of five major illnesses were all associated with greater risk for mortality. Medium level education and being employed at baseline were associated with lesser mortality risk. Nevertheless, the timing of retirement, viz. early versus normative exit from the workforce, was not related to survival. In sum, the respondents who had prematurely exited the labour force did not benefit from disproportionately longer lives when compared with the respondents who retired ‘on time’.

Self-Reported Health and Driving Cessation in Community-Dwelling Older Drivers

BACKGROUND

Stopping driving has significant negative consequences for older adults, but there is no simple, reliable screening tool to predict driving cessation. We sought to determine if self-rated health (SRH) was an independent predictor of driving cessation among older adults.

METHODS

Data on SRH (poor, fair, good, very good, or excellent), medical diagnoses, physical performance, visual acuity, driving status, and other relevant covariates were collected from 649 community-dwelling older Alabama drivers during in-home interviews. Using multivariable logistic regression analyses, we estimated the association of SRH with driving cessation 2 years later.

RESULTS

Participants had a mean age of 74 years; 43% were women, 41% African American, and 48% rural. Overall, 36% reported poor to fair SRH at baseline, and 11% had stopped driving after 2 years. Compared to 8% of drivers with good to excellent SRH, 17% with poor to fair health stopped driving (adjusted odds ratio [OR], 1.93; 95% confidence interval [CI], 1.09-3.41; p=.025). Lower Short Physical Performance Battery (SPPB) scores (adjusted OR, 0.86; 95% CI, 0.78-0.95; p=.001) and older age (adjusted OR, 1.06 per year; 95% CI, 1.01-1.11; p=.010) were also associated with driving cessation. Receiver operating characteristics curves documented similar predictive discrimination (c statistics) for SRH (0.72), the SPPB (0.70), and a count of comorbidities based on the Charlson Comorbidity Index (0.73).

CONCLUSIONS

Poor to fair SRH predicted incident driving cessation after 2 years in a cohort of older adults. SRH can be easily obtained during clinic visits to identify at-risk drivers.

Self-rated health in the unwell elderly presenting to the emergency department

OBJECTIVE

Self-rated health (SRH) has been shown to be a reliable predictor of functional decline and mortality. These studies, however, have largely focused on well community-dwelling elderly. We assessed whether the predictive value of SRH would still be valid for the acutely unwell older person presenting to the ED.

METHODS

The present study was a secondary analysis of data obtained from the Discharge of Elderly from Emergency Department (DEED II) study. The sample consisted of 741 older people sent home from an ED. On enrollment, patients were asked the SRH question, 'In general, would you say your health is excellent, very good, good, fair or poor?' Phone interviews were conducted at 3, 6, 12 and 18 months. Functional status was assessed using the Barthel index of activities of daily living (ADL), modified instrumental activities of daily living (IADL) and the Short Portable Mental Status Questionnaire (MSQ).

RESULTS

An SRH of fair/poor produced a hazard ratio of 3.1 (95% confidence interval 1.3-7.2, P = 0.010) for predicting mortality after controlling for confounders. The rate of decline in ADL and IADL (but not MSQ) over time was also more pronounced for those with an SRH of fair/poor (P < 0.001 for both ADL and IADL). An SRH of fair/poor had a relative risk of 3.4 for predicting decline in ADL at 18 months (95% confidence interval 1.7-7.1, P = 0.001). The effects of SRH on IADL and MSQ were not statistically significant.

CONCLUSIONS

The ability of SRH to predict functional decline and mortality persists for the acutely unwell elderly presenting to the ED. SRH is a simple and valuable tool to assess the elderly in the ED and to identify high-risk patients who would benefit from comprehensive geriatric assessment aimed at delaying such outcomes.

Inflammatory cytokines, behaviour and age as determinants of self-rated health in women

Self-rated health is a powerful and independent predictor of long-term health, but its biological basis is unknown. We have shown previously that self-rated health is associated with increased levels of circulating cytokines in women. The main aim of the present study was to increase the understanding of the association between markers of wellbeing, such as self-rated health, and cytokines and to investigate the impact of age on these associations. In 174 female consecutive primary health care patients divided into three age groups, we examined subjective ratings of health and aspects of wellbeing and circulating levels of IL (interleukin)-1beta, IL-1ra (IL-1 receptor antagonist), IL-6 and TNF-alpha (tumour necrosis factor-alpha). Poor self-rated health was significantly associated with higher levels of TNF-alpha in all of the age groups. For IL-1beta and IL-1ra, the correlations with self-rated health were significant only in the oldest age group. Lower ratings of other measurements of health and wellbeing were related to higher levels of cytokines, most pronounced for TNF-alpha and IL-1beta, and in the middle and olderst age groups. More symptoms resembling a sickness response induced by inflammation were implicated to be associated with lower self-rated health. The strength of the association between inflammatory cytokines and poor health perception increased with advanced age, indicating an increased vulnerability for inflammatory activity during aging. It is suggested that higher levels of TNF-alpha are connected to a sickness response that, in turn, is connected to self-rated health. The results provide a possible psychobiological basis to understand better diffuse subjective symptoms and poor subjective health in women.

What does self rated health measure? Results from the British Whitehall II and French Gazel cohort studies

OBJECTIVES

To investigate the determinants of self rated health (SRH) in men and women in the British Whitehall II study and the French Gazel cohort study.

METHODS

The cross sectional analyses reported in this paper use data from wave 1 of the Whitehall II study (1985-88) and wave 2 of the Gazel study (1990). Determinants were either self reported or obtained through medical screening and employer's records. The Whitehall II study is based on 20 civil service departments located in London. The Gazel study is based on employees of France's national gas and electricity company (EDF-GDF). SRH data were available on 6889 men and 3403 women in Whitehall II and 13 008 men and 4688 women in Gazel.

RESULTS

Correlation analysis was used to identify determinants of SRH from 35 measures in Whitehall II and 33 in Gazel. Stepwise multiple regressions identified five determinants (symptom score, sickness absence, longstanding illness, minor psychiatric morbidity, number of recurring health problems) in Whitehall II, explaining 34.7% of the variance in SRH. In Gazel, four measures (physical tiredness, number of health problems in the past year, physical mobility, number of prescription drugs used) explained 41.4% of the variance in SRH.

CONCLUSION

Measures of mental and physical health status contribute most to the SRH construct. The part played by age, early life factors, family history, sociodemographic variables, psychosocial factors, and health behaviours in these two occupational cohorts is modest.

Physical and Cognitive Domains of the Instrumental Activities of Daily Living: Validation in a Multiethnic Population of Asian Older Adults

BACKGROUND

We sought to assess the validity of the physical and cognitive domains of Lawton and Brody's Instrumental Activities of Daily Living (IADL) scale and its cross-cultural applicability across ethnic groups in an Asian population of community-living older adults.

METHODS

Using data from a random population sample of noninstitutionalized Chinese, Malay, and Indian older adults 60 years old and older in Singapore (N = 1072), we modeled the dimensional structure of the 8-item IADL Scale using exploratory and confirmatory factor analyses, and assessed its convergent and divergent validity using known group differences and strengths of association.

RESULTS

Factor analyses yielded two strong and reliable factors representing underlying physical and cognitive dimensions of IADL. The validity of the model was supported by the pattern of associations of the IADL with age, gender, education, self-reported health status, hospitalization, physical comorbidities, dementia and depression, and Mini-Mental State Examination (MMSE) scores. Notably, cognitive IADL showed a greater total effect on MMSE cognitive performance score than did physical IADL, with the effect of physical IADL on MMSE score mostly explained by cognitive IADL. Reasonably good cross-cultural validity was demonstrated among Chinese, Malays, and Indians, with strongest validity for Indians.

CONCLUSION

The eight-item IADL Scale has physical and cognitive domains and is cross-culturally applicable. The cognitive IADL domain taps a set of activities directly related to cognitive functioning.

Self-rated health and mortality: Could clinical and performance-based measures of health and functioning explain the association?

It is well established that self-rated health (SRH) predicts mortality even when other indicators of health status are taken into account. It has been suggested that SRH measures a wide array of mortality-related physiological and pathological characteristics not captured by the covariates included in the analyses. Our aim was to test this hypothesis by examining the predictive value of SRH on mortality controlling for different measurements of body structure, performance-based functioning and diagnosed diseases with a population-based, prospective study over an 18-year follow-up. Subjects consisted of 257 male residents of the city of Jyväskylä, central Finland, aged 51-55 and 71-75 years. Among the 71-75-year-olds the association between SRH and mortality was weaker over the longer compared to shorter follow-up period. In the multivariate Cox regression models with an 18-year follow-up time for middle-aged and a10-year follow-up time for older men, SRH predicted mortality even when the anthropometrics, clinical chemistry and performance-based measures of functioning were controlled for, but not when the number of chronic diseases was included. Although our results confirm the hypothesis that the predictive value of SRH can be explained by diagnosed diseases, its predictive power remained, when the clinical and performance-based measures of health and functioning were controlled.