Among nonagenarians, congruence between self-rated and proxy-rated health was low but both predicted mortality

Effectiveness of an individually tailored complex intervention to improve activities and participation in nursing home residents with joint contractures (JointConEval): a multicentre pragmatic cluster-randomised controlled trial

OBJECTIVE

This study aims to examine the effects of the individually tailored complex intervention Participation Enabling Care in Nursing (PECAN) on activities and participation of residents with joint contractures.

DESIGN

Multicentre pragmatic cluster-randomised controlled trial.

SETTING

35 nursing homes in Germany (August 2018-February 2020).

PARTICIPANTS

562 nursing home residents aged ≥65 years with ≥1 major joint contracture (303 intervention group, 259 control group).

INTERVENTIONS

Nursing homes were randomised to PECAN (18 clusters) or optimised standard care (17 clusters) with researcher-concealed cluster allocation by facsimile. The intervention targeted impairments in activities and participation. Implementation included training and support for selected staff. Control group clusters received brief information.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary endpoint PaArticular Scales combined residents' activities and participation at 12 months. The secondary outcome comprised quality of life. Safety measures were falls, fall-related consequences and physical restraints. Residents, staff and researchers were unblinded. Data collection, data entry and statistical analysis were blinded. Primary analyses were intention-to-treat at cluster level and individual level using a generalised mixed-effect regression model and imputation of missing data.

RESULTS

Primary outcome analyses included 301 intervention group residents and 259 control group residents. The mean change on the Activities Scale was -1.47 points (SD 12.2) in the intervention group and 0.196 points (SD 12.5) in the control group and -3.87 points (SD 19.7) vs -3.18 points (SD 20.8) on the Participation Scale. The mean differences of changes between the groups were not statistically significant: Activities Scale: -1.72 (97.5% CI -6.05 to 2.61); Participation Scale: -1.24 (97.5% CI -7.02 to 4.45). We found no significant difference in the secondary outcome and no effects on safety measures.

CONCLUSION

The complex intervention did not improve the activities and participation of nursing home residents on the PaArticular Scales at 12 months. Current nursing conditions in Germany may hamper implementation.

TRIAL REGISTRATION NUMBER

DRKS00015185.

Predictive capacity of self-rated health on all-cause mortality in Spain: differences across sex, age and educational level

BACKGROUND

Published evidence on self-rated health's capacity to predict mortality and its variability across subpopulations lacks consistency. Our objective is to evaluate this predictive association and whether/how it varies by sex, age and educational attainment at the population level in Spain.

METHODS

Data came from a prospective longitudinal study based on 42 645 individuals aged ≥15 years who participated in the 2011-2012 and 2014 Spanish Health Surveys. Median follow-up time for mortality was 5.4 years. Cox proportional hazards models adjusted for sociodemographic, lifestyle and chronic disease variables were used to estimate the predictive capacity of self-rated health on mortality.

RESULTS

Self-rated health was associated with mortality with a dose-response effect (p value for linear trend <0.001). Compared with respondents who rated their health as very good, those rating it as very poor presented an HR of 3.33 (95% CI 2.50 to 4.44). Suboptimal self-rated health was a stronger predictor of mortality among 15-44 year-olds (HR 2.87; 95% CI 1.59 to 5.18), compared with the estimate for 45-64 year-olds (HR 1.86; 95% CI 1.45 to 2.39) (p value for interaction=0.001) and for those 65 and older (HR 1.51; 95% CI 1.36 to 1.68) (p value for interaction <0.001). Regarding educational attainment, the association was stronger for individuals with university studies (HR 2.51; 95% CI 1.67 to 3.76) than for those with only primary or no studies (HR 1.31; 95% CI 1.17 to 1.48) (p value for interaction=0.010). No statistically significant differences were observed between men and women.

CONCLUSIONS

Self-rated health may be considered a good predictor of all-cause mortality in the population of Spain, although the magnitude of this predictive association varies by age and educational level.

Population Aging and Health Trajectories at Older Ages

OBJECTIVE

This study examines relationships between municipal age structure and two types of self-rated health: general (SRH) and comparison with similar-aged peers (C-SRH).

METHODS

Using a national sample of almost 5,000 Japanese older adults over two decades, we employ hierarchical growth curve models to estimate health trajectories. For municipal age structure, we consider both the relative prevalence of elderly adults in the local population and the pace of aging over time.

RESULTS

Living in the oldest municipalities was generally associated with worse health, particularly between the ages of 70 and 80 years. For SRH, the speed of municipal population aging was also independently associated with worse health. For C-SRH, worse health in older areas was partially explained by less favorable economic conditions in those municipalities. Results also suggest that higher levels of employment and social integration among older adults living in the oldest municipalities operate in the opposite direction. That is, these attributes partially "protect" individuals from other factors that contribute to worse health.

DISCUSSION

Relative differences in municipal age structure and the pace of population aging are largely unexplored and potentially important correlates of older adult health. This line of research is increasingly salient in a world with substantial and growing regional variation in population aging.

Structure of self-rated health among the oldest old: Analyses in the total population and those living with dementia

No previous study has explored the structure of self-rated health (SRH), a measure holding strong predictive value for future health events, in the oldest old or in individuals with dementia. The aim was to construct a structural equation model of SRH for oldest old in general and for oldest old with dementia, and to explore direct and indirect associations between health-related factors and SRH. Cross-sectional data from the Vitality 90+, a population-based study in the city of Tampere, Finland, was used. Data were gathered by a mailed questionnaire in 2014. Altogether 1299 nonagenarians, of which 408 had self-reported dementia or cognitive decline, were included. Structural equation models were constructed for all participants and separately for participants with dementia. Diseases (heart disease, stroke, diabetes, arthritis, hip fracture, cancer and dementia for the model for all), dizziness, hearing, vision, mobility, activities of daily living, fatigue, depression and SRH were included in the models. Among all participants, fatigue, depression, problems in mobility, dizziness, deficits in vision and heart disease were directly associated with poor SRH. Among participants with dementia, only fatigue, dizziness and deficits in vision were directly associated with poor SRH. Among all participants, dementia and arthritis were indirectly associated with poor SRH through problems in mobility, depression and fatigue. Among the oldest old, the effects of diseases on SRH were mainly manifested through the consequences of diseases, namely fatigue, dizziness, deficits in vision and problems in mobility. Depression has an important direct and indirect role, and dementia and arthritis an important indirect role in the structure of SRH. Dementia weakens many of the direct and indirect associations for SRH.

•

First study to explore structure of self-rated health in oldest old and persons with dementia.

•

Fatigue, depression, mobility, dizziness, vision and heart disease directly affect health-rating in oldest old.

•

Dementia, depression and arthritis affect health rating indirectly through various routes in oldest old.

•

Dementia weakens many of the associations between objective indicators of health with self-rated health.

Improved participation of older people with joint contractures living in nursing homes: feasibility of study procedures in a cluster-randomised pilot trial

BACKGROUND

Acquired joint contractures have a significant impact on functioning and quality of life in nursing home residents. There is very limited evidence on measures for prevention and treatment of disability due to joint contractures. We have developed the PECAN intervention (Participation Enabling CAre in Nursing) to improve social participation in nursing home residents. A cluster-randomised pilot trial was conducted to assess the feasibility of study procedures in preparation for a main trial according to the UK Medical Research Council (MRC) framework.

METHODS

Nursing homes in two regions of Germany were randomly allocated either to the intervention or optimised standard care (control group). All residents with joint contractures aged > 65 years were eligible for the study. The residents' data were collected through structured face-to-face interviews by blinded assessors at baseline, after 3 and 6 months. The primary outcome was social participation, measured by a subscale of the PaArticular Scales. Secondary outcomes included activities and instrumental activities of daily living, health-related quality of life, falls and fall-related consequences. Data on the trial feasibility were collected via documentation forms.

RESULTS

Seven out of 12 nursing homes agreed to participate and remained in the trial. Of 265 residents who fulfilled the inclusion criteria, 129 were randomised either to the intervention (n = 64) or control group (n = 65) and analysed. A total of 109 (85%) completed the trial after 6 months. The mean age was 85.7 years (SD 7.0), 80% were women. The severity of the residents' disability differed across the clusters. The completion rate was high (> 95%), apart from the Instrumental Activities of Daily Living Scale. Some items of the PaArticular Scales were not easily understood by residents. The frequency of falls did not differ between study groups.

CONCLUSION

Our data confirmed the feasibility of the overall study design. We also revealed the need to improve the procedures for the recruitment of residents and for data collection before implementation into a main trial. The next step will be an adequately powered main trial to assess the effectiveness and cost-effectiveness of the intervention.

TRIAL REGISTRATION

German clinical trials register, ID: DRKS00010037 . Registered on 12 February 2016.

Trajectories of Nonagenarian Health: Sex, Age, and Period Effects

The US population aged 90 years or more is growing rapidly, and there are limited data on their health. The Cardiovascular Health Study is a prospective study of black and white adults aged ≥65 years recruited in 2 waves (1989-1990 and 1992-1993) from Medicare eligibility lists in Forsyth County, North Carolina; Sacramento County, California; Washington County, Maryland; and Pittsburgh, Pennsylvania. We created a synthetic cohort of the 1,889 participants who had reached age 90 years at baseline or during follow-up through July 16, 2015. Participants entered the cohort at 90 years of age, and we evaluated their changes in health after age 90 years (median duration of follow-up, 3 years (interquartile range, 1.3-5)). Measures of health included cardiovascular events, cognitive function, depressive symptoms, prescription medications, self-rated health, and functional status. The mortality rate was high: 19.0 per 100 person-years (95% confidence interval : 17.8, 20.3) in women and 20.9 per 100 person-years (95% confidence interval: 19.2, 22.8) in men. Cognitive function and all measures of functional status declined with age; these changes were similar by sex. When we isolated period effects, we found that medication use increased over time. These estimates can help inform future research and can help health-care systems meet the needs of this growing population.

Sex differences in healthy life expectancy among nonagenarians: A multistate survival model using data from the Vitality 90+ study

OBJECTIVES

Little is known about sex differences in healthy life expectancy among the oldest old, the fastest growing segment of the older population. This study examines sex differences in total, healthy and unhealthy life expectancy among nonagenarians.

METHODS

Longitudinal data of 884 older adults aged 90 and over participating in the Vitality 90+ study (Tampere, Finland) were used, including 2501 observations (health or death states) from 5 measurement waves between 2001 and 2014. Using the MSM and ELECT packages in R, multistate survival models were performed to estimate the transition probabilities of older adults through the different health states and to calculate life expectancies. The analyses were done separately for two health indicators (disability and multimorbidity) to see whether patterns were consistent.

RESULTS

Women had higher total life expectancies than men (about 8 months), but also higher unhealthy life expectancies. Men had a higher disability-free life expectancy between the age of 90 and 95 compared to women. For multimorbidity, no sex differences in healthy life expectancy were found.

CONCLUSIONS

This study showed that the male-female health-survival paradox remains at very old age. Women aged 90+ live longer than men, and spend more time in poor health.

Predictors of long-term care among nonagenarians: the Vitality 90 + Study with linked data of the care registers

BACKGROUND

The need for long-term care services increases with age. However, little is known about the predictors of long-term care (LTC) entry among the oldest old.

AIMS

Aim of this study was to assess predictors of LTC entry in a sample of men and women aged 90 years and older.

METHODS

This study was based on the Vitality 90 + Study, a population-based study of nonagenarians in the city of Tampere, Finland. Baseline information about health, functioning and living conditions were collected by mailed questionnaires. Information about LTC was drawn from care registers during the follow-up period extending up to 11 years. Cox regression models were used for the analyses, taking into account the competing risk of mortality.

RESULTS

During the mean follow-up period of 2.3 years, 844 (43%) subjects entered first time into LTC. Female gender (HR 1.39, 95% CI 1.14-1.69), having at least two chronic conditions (HR 1.24, 95% CI 1.07-1.44), living alone (HR 1.37, 95% CI 1.15-1.63) and help received sometimes (HR 1.23, 95% CI 1.02-1.49) or daily (HR 1.68, 95% CI 1.38-2.04) were independent predictors of LTC entry.

CONCLUSION

Risk of entering into LTC was increased among women, subjects with at least two chronic conditions, those living alone and with higher level of received help. Since number of nonagenarians will increase and the need of care thereby, it is essential to understand predictors of LTC entry to offer appropriate care for the oldest old in future.

Self-Rated Health, Interviewer-Rated Health, and Their Predictive Powers on Mortality in Old Age

OBJECTIVES

This study examines the potential use of interviewer-rated health (IRH) as a complementary measure of self-rated health (SRH) through a systematic comparison of their components and mortality-predictive powers in the Chinese elderly population.

METHODS

This study used a nationwide dataset with more than 12,000 adults aged 65 or older drawn from the 2005 and 2008 waves of the Chinese Longitudinal Health Longevity Survey (CLHLS).

RESULTS

Disability, cognitive function, chronic disease conditions, psychological well-being, and health behaviors influenced both the SRH and IRH of Chinese older adults; these factors, especially disabilities, explained a large portion of the association between SRH and mortality. However, the impact of these factors on the association between IRH and mortality was limited. Furthermore, when both SRH and IRH were included in the analytical models, the association between SRH and mortality disappeared, while the association between IRH and mortality still persisted.

DISCUSSION

Although there is some difference between IRH and SRH, IRH captures similar health information as SRH and is strongly predictive of mortality independent of SRH; thus, IRH could be a good supplementary measurement for well-adopted SRH.

Do successful agers live longer? The Vitality 90+ study

OBJECTIVE

To discover whether successful aging, understood as a multidimensional concept, predicts further survival in very old people.

METHOD

The population sample consisted of 1,370 persons aged 90 or over in the Vitality 90+ study. Four alternative models of successful aging were constructed, each of them consisting of physical, psychological, and social dimensions. Mortality was followed up after 4 and 7 years.

RESULTS

Three out of four models significantly predicted survival at both follow-ups for the whole group. Separately, "success" in the physical, psychological, and social components was also associated with higher survival. The associations were stronger in women than in men.

DISCUSSION

Successful aging, measured using physical, psychological, and social dimensions, predicts the length of future life in nonagenarians.

Self-rated health changes and oldest-old mortality

OBJECTIVES

This study explores how 2 measures of self-rated health (SRH) change are related to mortality among oldest-old adults. In doing so, it also considers how associations between SRH and mortality may depend on prior SRH.

METHOD

Data come from the Asset and Health Dynamics survey--the oldest-old portion of the Health and Retirement Study-and follow 6,233 individuals across 13 years. I use parametric hazard models to examine relationships between death and 2 measures of short-term SRH change--a computed measure comparing SRH at time t-1 and t, and a respondent-provided retrospectively reported change.

RESULTS

Respondents who demonstrate or report any SRH change between survey waves died at a greater rate than those with consistent SRH. After controlling for morbidity, individual characteristics, and SRH, those who changed SRH categories between survey waves and those who retrospectively reported an improvement in health continue to have a greater risk of death, when compared with those with no change.

DISCUSSION

These findings suggest that the well-established associations between SRH status and mortality may understate the risk of death for oldest-old individuals with recent subjective health improvements.

Is self-rated health still sensitive for changes in disease and functioning among nonagenarians?

OBJECTIVES

With age, there is an increasing gap between relatively stable levels of self-rated health (SRH) and actual health status. This study investigates longitudinal changes in SRH and examines its sensitivity to changes in chronic conditions and functioning among people aged 90 and older.

METHODS

In the Vitality 90+ Study, questionnaires were sent to all people aged 90 years and older living in Tampere, Finland. Included were respondents who provided data on the 2001 measurement and at least one follow-up measurement in 2003, 2007, or 2010 (N = 334). Generalized Estimating Equations analyses examined longitudinal change in SRH and the predictive value of number of chronic conditions and a functioning score based on 5 activities.

RESULTS

Within 2 years, most people (56.3%) had unchanged SRH, but declined SRH (22.3%) was associated with worse baseline functioning and declined functioning. Clear declines in SRH after 6 and 9 years were associated with increased chronic conditions (odds ratio [OR] = 1.23) and decreased functioning (OR = 1.28). The impact of chronic conditions and functioning was smaller among institutionalized people (chronic conditions OR = 0.90; functioning OR = 1.18) than among people living independently (chronic conditions OR = 1.30; functioning OR = 1.44).

DISCUSSION

SRH among nonagenarians was sensitive to changes in the number of chronic conditions and functioning although more pronounced on the longer than on the shorter term.

Predictors of mortality in men and women aged 90 and older: a nine-year follow-up study in the Vitality 90+ study

BACKGROUND

information about the predictors of mortality among the oldest-old is limited. Also possible gender differences are poorly known.

OBJECTIVE

to examine the predictors of mortality among individuals aged 90 and older, focusing on differences between men and women. We also analysed gender differences in survival at different levels of mobility and activities in daily living (ADL).

DESIGN

this 9-year follow-up study is part of the Vitality 90+ study, a population-based study of people aged 90 and older.

SUBJECTS

all inhabitants aged 90 and older in the area of Tampere, Finland were contacted, irrespective of health or dwelling place. The study population consisted of 171 men and 717 women.

METHODS

data were collected with a mailed questionnaire asking questions concerning ADL and mobility, self-rated health, chronic conditions and socio-economic factors. The participation rate was 79%. Cox regression enter models were used for the analysis.

RESULTS

older age, male gender, disability in ADL and mobility, poor self-rated health and institutionalisation increased the risk of mortality in the total study group. In age-adjusted Cox regression models, ADL and mobility were stronger predictors in men than in women (gender interactions, P < 0.001). Among those who were partly but not totally dependent in ADL or mobility women survived longer than men.

CONCLUSION

the same health indicators that are important at younger old age also predict mortality in the oldest-old. Disability increases the likelihood of death more in men than women. At a very old age, women survive longer with moderate disability than do men.