The effect of diabetes combined with stroke on disability, self-rated health, and mortality in older Mexican Americans: results from the Hispanic EPESE

Gender disparity in disability among Chinese oldest-old: Age and cohort trends

This study aimed at exploring gender disparity in disability and identifying related disablement process factors among Chinese oldest-old. Data came from eight waves of the Chinese Longitudinal Healthy Longevity Study (CLHLS). A hierarchical logistic Age-Period-Cohort (A-P-C) model was used to estimate the trend of gender disparity, and related disablement process factors were further decomposed by the Oaxaca-Blinder decomposition. Our results found that women had higher disabilities than men. The age-based trend of gender disparity in Instrumental Activities of Daily Living (IADL) continued to decline; that in Functional Limitation (FL) increased at first and then declined. The cohort-based trend of gender disparity in IADL showed a decreasing trend with each subsequent cohort; that in FL showed an increasing trend. Among the disablement process factors, health behaviors and social supports were the most important contributors to gender disparity in disability. The disability was higher for women than men, and the gender differences were attenuated at very old ages. To reduce gender disparities in disability, more attention should be paid to relevant factors of gender disparity in disability.

Self-rated health after stroke: a systematic review of the literature

BACKGROUND

Self-rated health (SRH) allows for comparison and identification of the health status of various populations. The aim of this study was to conduct a systematic review of the literature to expand the understanding of SRH after stroke.

METHODS

This systematic review was registered with PROSPERO (CRD42017056194) and conducted according to PRISMA guidelines. Studies published until December 2018 that evaluated the SRH of adults with stroke were included.

RESULTS

Of the 2132 identified studies, 51 were included. Only four studies had experimental designs (7.8%). In 60.7% of the studies, SRH was assessed by variations on direct questions (i.e., general and comparative SRH). Analog visual scales and quality of life instruments were also used to evaluate SRH, but there is no consensus regarding whether they are appropriate for this purpose. The results of cross-sectional and longitudinal studies revealed significant associations between poor SRH and stroke as well as between SRH, function, and disability. The power of SRH to predict stroke mortality is still uncertain. Two interventions (a home-based psychoeducational program concerning stroke health care and family involvement in functional rehabilitation) effectively improved SRH.

CONCLUSIONS

Direct questions are the most common method of evaluating SRH after stroke. Studies reported significant associations between the SRH of individuals with stroke and several relevant health outcomes. However, few experimental studies have evaluated SRH after stroke. Interventions involving health education and family involvement had a significant impact on SRH.

Diabetes-Multimorbidity Combinations and Disability Among Middle-aged and Older Adults

BACKGROUND

Older adults with diabetes rarely have only one chronic disease. As a result, there is a need to re-conceptualize research and clinical practice to address the growing number of older Americans with diabetes and concurrent chronic diseases (diabetes-multimorbidity).

OBJECTIVE

To identify prevalent multimorbidity combinations and examine their association with poor functional status among a nationally representative sample of middle-aged and older adults with diabetes.

DESIGN

A prospective cohort study of the 2012-2014 Health and Retirement Study (HRS) data. We identified the most prevalent diabetes-multimorbidity combinations and estimated negative binomial models of diabetes-multimorbidity on prospective disability.

PARTICIPANTS

Analytic sample included 3841 HRS participants with diabetes, aged 51 years and older.

MAIN MEASURES

The main outcome measure was the combined activities of daily living (ADL)-instrumental activities of daily living (IADL) index (range 0-11; higher index denotes higher disability). The main independent variables were diabetes-multimorbidity combination groups, defined as the co-occurrence of diabetes and at least one of six somatic chronic diseases (hypertension, cardiovascular disease, lung disease, cancer, arthritis, and stroke) and/or two mental chronic conditions (cognitive impairment and high depressive symptoms (CESD score ≥ 4).

KEY RESULTS

The three most prevalent multimorbidity combinations were, in rank-order diabetes-arthritis-hypertension (n = 694, 18.1%); diabetes-hypertension (n = 481, 12.5%); and diabetes-arthritis-hypertension-heart disease (n = 383, 10%). Diabetes-multimorbidity combinations that included high depressive symptoms or stroke had significantly higher counts of ADL-IADL limitations compared with diabetes-only. In head-to-head comparisons of diabetes-multimorbidity combinations, high depressive symptoms or stroke added to somatic multimorbidity combinations was associated with a higher count of ADL-IADL limitations (diabetes-arthritis-hypertension-high depressive symptoms vs. diabetes-arthritis-hypertension: IRR = 1.95 [1.13, 3.38]; diabetes-arthritis-hypertension-stroke vs. diabetes-arthritis-hypertension: IRR = 2.09 [1.15, 3.82]) even after adjusting for age, gender, education, race/ethnicity, BMI, baseline ADL-IADL, and diabetes duration. Coefficients were robust to further adjustment for diabetes treatment.

CONCLUSIONS

Depressive symptoms or stroke added onto other multimorbidity combinations may pose a substantial functional burden for middle-aged and older adults with diabetes.

Multimorbidity of cardiometabolic diseases: prevalence and risk for mortality from one million Chinese adults in a longitudinal cohort study

OBJECTIVES

The evolution of multimorbidity describes the continuum from a healthy status to the development of a single disease and further progression to multimorbidity with additional diseases. We investigated the evolution of cardiometabolic multimorbidity and risk for mortality in a Chinese population.

DESIGN

Longitudinal cohort study using data from the CHinese Electronic health Records Research in Yinzhou (CHERRY) study, with 5.43 million person-years follow-up (median 5.16 years).

PARTICIPANTS

Data for 1 038 704 adults (total 22 750 deaths) were analysed.

EXPOSURE

Cardiometabolic multimorbidity was defined as ever being diagnosed with two or more of three diseases: hypertension, diabetes and cardiovascular disease (CVD).

PRIMARY AND SECONDARY OUTCOME MEASURES

Age-adjusted and sex-adjusted HRs were calculated for all-cause mortality.

RESULTS

The cardiometabolic disease status of 105 209 (10.1%) individuals changed during the follow-up. The prevalence of cardiometabolic multimorbidity increased from 2.41% (95% CI: 2.38% to 2.44%) to 5.94% (95% CI: 5.90% to 5.99%). Baseline multimorbidity status showed the HR (95% CI) was 1.37 (1.33 to 1.42) in those with one disease, 1.71 (1.64 to 1.79) in those with two diseases and 2.22 (2.00 to 2.46) in those with three diseases. The highest HRs were observed for CVD only (3.31, 95% CI: 3.05 to 3.59) or diabetes and CVD (3.12, 95% CI: 2.37 to 4.11). Those with hypertension only had the lowest HR (1.26, 95% CI: 1.22 to 1.30). Longitudinal data showed the HRs (95% CI) in patients with one, two and three diseases were 1.36 (1.32 to 1.41), 2.03 (1.96 to 2.10) and 2.16 (2.05 to 2.29), respectively.

CONCLUSIONS

The prevalence of cardiometabolic multimorbidity in a general Chinese population increased more than doubled over 5 years, indicating rapid evolution of cardiometabolic multimorbidity. A history of CVD dominates the risk for mortality. A complementary strategy for primary and secondary prevention of cardiometabolic diseases is needed in China.

Application of the short form of quality of life instrument version 2 in a large population of Tehran

Background: Quality of life (QoL) is now considered as a key indicator in health studies. Therefore, this study was conducted to evaluate QoL in the general population of Tehran (capital of Iran) using SF-12v2 questionnaire and determine some factors associated with it.

Methods: This was part of a large population-based cross sectional study conducted in Tehran, Iran, in 2011. Participants were selected from all districts of Tehran using multistage cluster random sampling method. Data were collected using the Iranian version of the SF12v2 questionnaire. Linear regression model was used to assess the independent effect of surveyed variables of the study population on their QoL. P< 0.05 was considered statistically significant.

Results: Overall, 30 809 individuals over the age of 20 from 22 urban districts were included in this study and evaluated by SF-12v2 questionnaire. The mean age of the study population was 44.5±15.9, and most of them were female (19 967 (64.8%)). The total mean score of SF-12v2 was 60.4 and the lowest and highest mean scores were observed in GH (46.9±26.5) and MH subscales (64.1±24.7), respectively. It was also observed that District 3 of Tehran had the highest mean score (65.2±18.7) in the total QoL and District 12 had the lowest mean score (56.6±18.7), respectively. The results of multiple linear regression model showed that sex, age, education, household size, presence of chronic disease in family, having insurance, smoking, and marital status were significantly related to most subscales and two summary components of QoL.

Conclusion: The results of this study showed that the surveyed population of Tehran had a relatively moderate QoL, but it changed from district to district. It was also observed that age and education of the study population were important variables in relation to QoL.

Disability, quality of life and all-cause mortality in older Mexican adults: association with multimorbidity and frailty

BACKGROUND

Multimorbidity and frailty are relevant conditions among older adult population. There is growing evidence about their association with poor health outcomes like disability, worst quality of life, and death. Nonetheless, the independent associations of both conditions have been studied, and few evidence exists about an interaction between them. Our aims were to assess the association of frailty and multimorbidity with the disability, quality of life and all-cause mortality as well as to analyze a potential interaction between these conditions.

METHODS

Analytical samples included 1410 respondents for disability and quality of life, and 1792 for mortality. We performed a longitudinal analysis with older Mexican adults aged 50, using data collected from the WHO's Study on global AGEing and Adult Health Waves 1 and 2. Disability was measured using the World Health Organization Disability Assessment Schedule (WHODAS 2.0), and quality of life using the WHOQOL (WHO Quality of Life) instrument. All-cause mortality was determined by reviewing death certificates. Associations of frailty and multimorbidity with disability, quality of life and mortality were estimated using linear regression and Cox proportional hazards models.

RESULTS

Multimorbidity assessed through three patterns (cardiopulmonary, vascular-metabolic, and mental-musculoskeletal) was associated with the three outcomes in this study. Cardiopulmonary and mental-musculoskeletal patterns increased the WHODAS mean score (β = 5.05; p < 0.01 and β = 5.10; p < 0.01, respectively) and decreased WHOQOL score (β = - 1.81; p < 0.01 and β = - 2.99; p < 0.01, respectively). Vascular-metabolic was associated with mortality (HR = 1.47; p = 0.04), disability (β = 3.27; p < 0.01) and quality of life (β = - 1.30; p = 0.02). Frailty was associated with mortality (pre-frail: HR = 1.48; p = 0.02 and frail: HR = 1.68; p = 0.03), disability (pre-frail: β = 5.02; p < 0.01; frail: β = 13.29; p < 0.01) and quality of life (pre-frail: β = - 2.23; p < 0.01; frail: β = - 4.38; p < 0.01). Interaction terms of frailty and multimorbidity were not statistically significant.

CONCLUSIONS

Multimorbidity and frailty are important predictors of poor health outcomes. These results highlight the importance of carrying out health promotion and prevention actions as well as specific interventions aimed at older adults who suffer from multimorbidity and frailty, in such a way that deleterious effects on health can be avoided.

The Role of Social Context in Racial Disparities in Self-Rated Health

Race disparities in self-rated health in the USA are well-documented, such that African Americans rate their health more poorly than whites. However, after adjusting for health status, socioeconomic status (SES), and health behaviors, residual race differences are observed. This suggests the importance of unmeasured variables. Because African Americans and whites tend to live in differing social contexts, it is possible that accounting for social and environmental conditions may reduce racial disparities in self-rated health. Differences in self-rated health among whites and African Americans were assessed in a low-income, urban integrated community (Exploring Health Disparities in Integrated Communities (EHDIC)) and compared with a national sample (National Health Interview Survey (NHIS)). Controlling for demographics, SES, health insurance, status, and behaviors, African Americans in NHIS had higher odds of reporting fair or poor health (odds ratio [OR] = 1.40, 95% confidence interval [CI] = 1.18-1.66) than whites. In EHDIC, there was no race difference in self-rated health (OR = 0.83, 95% CI = 0.63-1.11). These results demonstrate the importance of social context in understanding race disparities in self-rated health.

Type 2 diabetes, depressive symptoms and disability over a 15-year follow-up period in older Mexican Americans living in the southwestern United States

AIMS

To evaluate how depression and diabetes severity impact disability progression among Mexican Americans over a 15-year period.

METHODS

We used seven waves of the Hispanic Established Population for the Epidemiologic Study of the Elderly (H-EPESE). Primary disability outcomes included the Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) scales. Explanatory variables included time since diagnosis with diabetes (no type 2 diabetes, 1-10, 11-20, 21+), an indicator of disease severity, and depression. Longitudinal generalized estimating equation models were used to estimate the relationship between time since diabetes diagnosis, depressive symptoms and ADL and IADL disability progression over a 15-year time period.

RESULTS

Years since diabetes diagnosis was associated with more rapid ADL and IADL disability progression compared to those without type 2 diabetes. Depression accelerated the disabling process in participants who were diagnosed with diabetes 11years or more years ago.

CONCLUSIONS

Longer duration of diabetes and greater symptoms of depression increase vulnerability for disability among older Mexican American adults.

Aging and Disability Among Hispanics in the United States: Current Knowledge and Future Directions

BACKGROUND AND OBJECTIVES

Hispanics are the most rapidly aging minority population in the United States. Our objective is to provide a summary of current knowledge regarding disability among Hispanics, and to propose an agenda for future research.

RESEARCH DESIGN AND METHODS

A literature review was conducted to identify major areas of research. A life course perspective and the Hispanic Paradox were used as frameworks for the literature review and for identifying future areas of research.

RESULTS

Four research areas were identified: (1) Ethnic disparities in disability; (2) Heterogeneity of the U.S. older Hispanic population; (3) Risk factors for disability; and (4) Disabled life expectancy. Older Hispanics are more likely than non-Hispanic whites to be disabled or to become disabled. Disability varied by country of origin, nativity, age of migration, and duration in the United States. Important risk factors for disability included chronic health conditions, depression, and cognitive impairment. Protective factors included positive affect and physical activity. Older Hispanics have longer life expectancy than non-Hispanic whites but spend a greater proportion of old age disabled. Future research should continue to monitor trends in disability as younger generations of Hispanics reach old age. Attention needs to be given to regional variation within the United States for disability prevalence, early-life risk factors, and factors that may contribute to variation in disabled life expectancy. There is also an urgent need for interventions that can effectively prevent or delay the onset of disability in older Hispanics.

DISCUSSION AND IMPLICATIONS

Considerable research has examined disability among older Hispanics, but continued research is needed. It is important that research findings be used to inform public policies that can address the burden of disability for older Hispanic populations.

Diabetes Self-Management Behaviors, Medical Care, Glycemic Control, and Self-Rated Health in U.S. Men by Race/Ethnicity

Men, particularly minorities, have higher rates of diabetes as compared with their counterparts. Ongoing diabetes self-management education and support by specialists are essential components to prevent the risk of complications such as kidney disease, cardiovascular diseases, and neurological impairments. Diabetes self-management behaviors, in particular, as diet and physical activity, have been associated with glycemic control in the literature. Recommended medical care for diabetes may differ by race/ethnicity. This study examined data from the National Health and Nutrition Examination Surveys, 2007 to 2010 for men with diabetes (N = 646) from four racial/ethnic groups: Mexican Americans, other Hispanics, non-Hispanic Blacks, and non-Hispanic Whites. Men with adequate dietary fiber intake had higher odds of glycemic control (odds ratio = 4.31, confidence interval [1.82, 10.20]), independent of race/ethnicity. There were racial/ethnic differences in reporting seeing a diabetes specialist. Non-Hispanic Blacks had the highest odds of reporting ever seeing a diabetes specialist (84.9%) followed by White non-Hispanics (74.7%), whereas Hispanics reported the lowest proportions (55.2% Mexican Americans and 62.1% other Hispanics). Men seeing a diabetes specialist had the lowest odds of glycemic control (odds ratio = 0.54, confidence interval [0.30, 0.96]). The results of this study suggest that diabetes education counseling may be selectively given to patients who are not in glycemic control. These findings indicate the need for examining referral systems and quality of diabetes care. Future studies should assess the effectiveness of patient-centered medical care provided by a diabetes specialist with consideration of sociodemographics, in particular, race/ethnicity and gender.

Stability and Change in Activities of Daily Living Among Older Mexican Americans

BACKGROUND

Longitudinal studies of activities of daily living (ADL) in older adults have identified numerous factors associated with declining ability. Analyses based on population averages may not observe distinct subgroups whose ADL trajectories differ.

METHODS

We used latent class models to identify subgroups of trajectories in a sample from the Hispanic Established Populations for Epidemiologic Study of the Elderly, a population-based study of noninstitutionalized Mexican Americans aged 65 and older from five Southwestern states (n = 2584).

RESULTS

Three distinct trajectories of ADL limitations were identified and characterized as stable, delayed, and rapid ADL increase. Sex (female), diabetes, and arthritis were associated with increased odds of membership in the delayed and rapid groups compared with the stable group. Stroke had a differential magnitude of effect on ADL limitations across the stable (β = 1.11, p < .001), delayed (β = 0.52, p < .001), and rapid groups (β = 0.12, p < .05). Hip fracture was associated with increased limitations in the stable group (β = 1.27, p < .001) but not in the rapid group. Church attendance was associated with fewer limitations in all groups with a larger effect in the stable group (β = -0.87, p < .001) compared with the rapid group (β = -0.10, p < .05).

CONCLUSIONS

Substantial heterogeneity exists in changes in ADL disability over time among older Mexican Americans. Attempts at maintaining function may benefit from targeting reductions in comorbidities and acute health events associated with disability.

Gender differences in life expectancy with and without disability among older adults in Ecuador

BACKGROUND

Knowledge on disability's impact among older women and men in Ecuador is limited. This paper provides gender-specific estimates of disability prevalence, life expectancy with and without disability, and the factors associated with gender differences in disability at older age in Ecuador (2009-2010).

METHODS

Data from the Health, Well-Being, and Aging Survey (SABE) Ecuador 2009 was used. Participants were 4480 men and women aged 60 and over. Life expectancy with and without disability was calculated using the Sullivan method. Logistic regression analyses were used to explore gender differences in disability prevalence. Two disability measures, indicating limitations in activities of daily living (ADL) and instrumental activities of daily living (IADL), were used.

RESULTS

60-year-old women in Ecuador can expect to live 16.3 years without ADL limitations compared to 16.9 years for men. Life expectancy without IADL limitations was 12.5 years for women and 15.5 years for men. At age 60, women's length of life with ADL and IADL disability was higher (7.9 years for women vs. 4.9 years for men with ADL, and 11.7 years for women vs. 6.3 years for men with IADL). After controlling for socioeconomic characteristics, chronic conditions and lifestyle factors, gender differences in ADL disability were not statistically significant. However, older women were 58% more likely (OR=1.58, 95% CI 1.27, 1.95) to report having IADL limitations than men, even after including control variables.

CONCLUSION

Interventions should tackle chronic disease, physical inactivity, and socioeconomic differences to reduce women's vulnerability to disability in older age.

Association of Cardiometabolic Multimorbidity With Mortality

IMPORTANCE

The prevalence of cardiometabolic multimorbidity is increasing.

OBJECTIVE

To estimate reductions in life expectancy associated with cardiometabolic multimorbidity.

DESIGN, SETTING, AND PARTICIPANTS

Age- and sex-adjusted mortality rates and hazard ratios (HRs) were calculated using individual participant data from the Emerging Risk Factors Collaboration (689,300 participants; 91 cohorts; years of baseline surveys: 1960-2007; latest mortality follow-up: April 2013; 128,843 deaths). The HRs from the Emerging Risk Factors Collaboration were compared with those from the UK Biobank (499,808 participants; years of baseline surveys: 2006-2010; latest mortality follow-up: November 2013; 7995 deaths). Cumulative survival was estimated by applying calculated age-specific HRs for mortality to contemporary US age-specific death rates.

EXPOSURES

A history of 2 or more of the following: diabetes mellitus, stroke, myocardial infarction (MI).

MAIN OUTCOMES AND MEASURES

All-cause mortality and estimated reductions in life expectancy.

RESULTS

In participants in the Emerging Risk Factors Collaboration without a history of diabetes, stroke, or MI at baseline (reference group), the all-cause mortality rate adjusted to the age of 60 years was 6.8 per 1000 person-years. Mortality rates per 1000 person-years were 15.6 in participants with a history of diabetes, 16.1 in those with stroke, 16.8 in those with MI, 32.0 in those with both diabetes and MI, 32.5 in those with both diabetes and stroke, 32.8 in those with both stroke and MI, and 59.5 in those with diabetes, stroke, and MI. Compared with the reference group, the HRs for all-cause mortality were 1.9 (95% CI, 1.8-2.0) in participants with a history of diabetes, 2.1 (95% CI, 2.0-2.2) in those with stroke, 2.0 (95% CI, 1.9-2.2) in those with MI, 3.7 (95% CI, 3.3-4.1) in those with both diabetes and MI, 3.8 (95% CI, 3.5-4.2) in those with both diabetes and stroke, 3.5 (95% CI, 3.1-4.0) in those with both stroke and MI, and 6.9 (95% CI, 5.7-8.3) in those with diabetes, stroke, and MI. The HRs from the Emerging Risk Factors Collaboration were similar to those from the more recently recruited UK Biobank. The HRs were little changed after further adjustment for markers of established intermediate pathways (eg, levels of lipids and blood pressure) and lifestyle factors (eg, smoking, diet). At the age of 60 years, a history of any 2 of these conditions was associated with 12 years of reduced life expectancy and a history of all 3 of these conditions was associated with 15 years of reduced life expectancy.

CONCLUSIONS AND RELEVANCE

Mortality associated with a history of diabetes, stroke, or MI was similar for each condition. Because any combination of these conditions was associated with multiplicative mortality risk, life expectancy was substantially lower in people with multimorbidity.

What determines the self-rated health of older individuals with stroke compared to other older individuals? A cross-sectional analysis of the Medical Research Council Cognitive Function and Aging Study

BACKGROUND

Poor self-rated health has been associated with poorer objective health outcomes across a range of conditions including stroke. Identification of factors associated with poor self-rated health in stroke survivors has received little attention compared to that in other older individuals. This study identifies determinants of self-rated health in older individuals with or without a history of stroke participating in the population-representative MRC Cognitive Function and Aging Study (MRC CFAS).

METHODS

The MRC CFAS is a multicentred longitudinal survey of a population representative sample of people in their 65th year and older at baseline. Baseline interview included questions about functional disability, psychiatric history, independent living status, social interactions, and cognitive function. Multiple logistic regression was used to determine associations between demographic, physical, cognitive, psychological and social factors with poor self-rated health among those with and without stroke.

RESULTS

After excluding those with impaired cognitive function, 776 individuals out of 11,957 reported a stroke. Factors associated with self-rated health were similar between those with or without a stroke in older individuals. Poorer self-rated health in those who had suffered a stroke was associated predominantly with the presence of comorbidity with diabetes (OR 3.5; 95% CI 1.5-8.1) and not "getting out and about" (OR 2.6; 95% CI 1.7-4.1) even after adjustment for disability levels and for depression. In those without a stroke the most important determinants were disability (OR 3.9; 95% CI 3.2-4.8) and not "getting out and about" (OR 2.9; 95% CI 2.5-3.3). The presence of disability was less strongly associated with poor self-rated health in those with a history of stroke than those without due to a substantially higher reporting of poor self-rated health in the non-disabled stroke group than the non-disabled stroke-free group, while those with disabilities reported poor self-rated health irrespective of stroke status.

CONCLUSIONS

Self-rated health is determined by a range of psychological and social factors in addition to disability in older patients with stroke. Addressing social integration and mobility out of the home is an important element of rehabilitation for older people with stroke as well as those without.

Association of geriatric conditions and cardiovascular diseases with disability in older adults with diabetes: findings from a nationally representative survey

AIM

To examine how diabetes in combination with cardiovascular diseases (hypertension, heart disease and stroke) and geriatric conditions (cognitive impairment and depressive symptoms) affects the odds of disability in older adults.

METHODS

We analyzed data from a nationally representative sample of people aged 65 years and over (n=2727) participating in the 2005 National Health Interview Survey in Taiwan. A total of 473 participants had a history of self-reported physician diagnosed diabetes. Disability was defined as reporting limitations in one or more tasks of activities of daily living (ADL), instrumental activities of daily living (IADL) or general physical activities (GPA). The Mini-Mental State Examination was used to assess cognitive function. The Center for Epidemiologic Studies Depression Scale was used to assess depressive symptoms.

RESULTS

After adjustment for other factors, cardiovascular diseases and geriatric conditions independently contributed to the excess odds of disability among participants with diabetes. Participants who had diabetes combined with cardiovascular diseases and geriatric conditions had odds ratios for ADL, IADL and GPA disability of 18.02 (95% CI 5.13-63.34), 7.95 (95% CI 4.07-15.50) and 5.89 (95% CI 3.19-10.90), respectively.

CONCLUSION

Our results highlight the high prevalence of co-occurrence of cardiovascular diseases with geriatric conditions in people with diabetes. Furthermore, the combined presence of these diseases and conditions is strongly associated with an excess odds of disability. These findings highlight the critical importance of preventing cardiovascular disease morbidity, and improving depressed mood and cognitive function in order to reduce disability risk in older adults with diabetes.

Correlates of the incidence of disability and mortality among older adult Brazilians with and without diabetes mellitus and stroke

Background

The combined effect of diabetes and stroke on disability and mortality remains largely unexplored in Brazil and Latin America. Previous studies have been based primarily on data from developed countries. This study addresses the empirical gap by evaluating the combined impact of diabetes and stroke on disability and mortality in Brazil.

Methods

The sample was drawn from two waves of the Survey on Health and Well-being of the Elderly, which followed 2,143 older adults in São Paulo, Brazil, from 2000 to 2006. Disability was assessed via measures of activities of daily living (ADL) limitations, severe ADL limitations, and receiving assistance to perform these activities. Logistic and multinomial regression models controlling for sociodemographic and health conditions were used to address the influence of diabetes and stroke on disability and mortality.

Results

By itself, the presence of diabetes did not increase the risk of disability or the need for assistance; however, diabetes was related to increased risks when assessed in combination with stroke. After controlling for demographic, social and health conditions, individuals who had experienced stroke but not diabetes were 3.4 times more likely to have ADL limitations than those with neither condition (95% CI 2.26-5.04). This elevated risk more than doubled for those suffering from a combination of diabetes and stroke (OR 7.34, 95% CI 3.73-14.46). Similar effects from the combination of diabetes and stroke were observed for severe ADL limitations (OR 19.75, 95% CI 9.81- 39.76) and receiving ADL assistance (OR 16.57, 95% CI 8.39-32.73). Over time, older adults who had experienced a stroke were at higher risk of remaining disabled (RRR 4.28, 95% CI 1.53,11.95) and of mortality (RRR 3.42, 95% CI 1.65,7.09). However, risks were even higher for those who had experienced both diabetes and stroke. Diabetes was associated with higher mortality.

Conclusions

Findings indicate that a combined history of stroke and diabetes has a great impact on disability prevalence and mortality among older adults in São Paulo, Brazil.

Self-rated health and ethnicity: focus on indigenous populations

Objectives

Self-rated health (SRH) is a commonly used measure in surveys to assess general health status or health-related quality of life. Differences have been detected in how different ethnic groups and nationalities interpret the SRH measure and assess their health. This review summarizes the research conducted on SRH within and between ethnic groups, with a focus on indigenous groups.

Study design and methods

A search of published academic literature on SRH and ethnicity, including a comprehensive review of all relevant indigenous research, was conducted using PubMed and summarized.

Results

A wide variety of research on SRH within ethnic groups has been undertaken. SRH typically serves as an outcome measure. Minority respondents generally rated their health worse than the dominant population. Numerous culturally-specific determinants of SRH have been identified. Cross-national and cross-ethnicity comparisons of the associations of SRH have been conducted to assess the validity of SRH. While SRH is a valid measure within a variety of ethnicities, differences in how SRH is assessed by ethnicities have been detected. Research in indigenous groups remains generally under-represented in the SRH literature.

Conclusions

These results suggest that different ethnic groups and nationalities vary in SRH evaluations, interpretation of the SRH measure, and referents employed in rating health. To effectively assess and redress health disparities and establish culturally-relevant and effective health interventions, a greater understanding of SRH is required, particularly among indigenous groups, in which little research has been conducted.

Old-age disability and wealth among return Mexican migrants from the United States

OBJECTIVE

To examine the old-age consequences of international migration with a focus on disability and wealth from the perspective of the origin country.

METHOD

Analysis sample includes persons aged 60+ from the Mexican Health and Aging Study, a national survey of older adults in Mexico in 2001. Univariate methods are used to present a comparative profile of return migrants. Multivariate models are estimated for physical disability and wealth.

RESULTS

Gender differences are profound. Return migrant women are more likely to be disabled while men are wealthier than comparable older adults in Mexico.

DISCUSSION

Compared to current older adults, younger cohorts of Mexico-U.S. migrants increasingly include women, and more migrants seem likely to remain in the United States rather than return, thus more research will be needed on the old-age conditions of migrants of both countries.

The excess mortality risk of diabetes associated with functional decline in older adults: results from a 7-year follow-up of a nationwide cohort in Taiwan

BACKGROUND

Diabetes is associated with an increased risk of functional decline in older adults. Few studies have investigated the contribution of functional decline to excess mortality risk in older people with diabetes. The aim of this study was to examine how diabetes in combination with different levels of functional decline affects 7-year mortality in older adults.

METHODS

We analyzed data from a nationally representative sample of people aged 65 years and over, participating in the 2001 National Health Interview Survey in Taiwan. A total of 1873 participants were followed through 2002-2008, of whom 286 (15.3%) had a history of diabetes confirmed by a medical professional. Participants were divided into three functional status groups: (1) high functioning-no limitations involving activities of daily living (ADLs), instrumental activities of daily living (IADLs), or physical functioning; (2) low functioning-limitations in one or more ADLs; (3) middle functioning-all participants in between groups 1 and 2.

RESULTS

The crude mortality rate was 52.7 per 1,000 person-years in those with diabetes and 34.1 per 1,000 person-years in those without diabetes. After adjustment for other factors, diabetes alone was not associated with an increased mortality risk in those with high functioning. However, diabetes alone had a hazard ratio (HR) for mortality of 1.90 (95%CI = [1.02-3.53]) in those with middle functioning and 3.67 (95%CI = [1.55-8.69]) in those with low functioning. The presence of diabetes and one or more other chronic conditions was associated with a HR for mortality of 2.46 (95%CI = [1.61-3.77]) in those with middle functioning and 4.03 (95%CI = [2.31-7.03]) in those with low functioning.

CONCLUSIONS

Our results indicate that diabetes is not associated with increased mortality in those with high functioning. There was a gradient effect of functional decline on mortality in individuals with diabetes. Additionally, among participants with other chronic conditions, functional decline was associated with a greater burden of mortality in older adults with diabetes. These findings highlight the critical importance of the prevention of cardiovascular disease morbidity and the maintenance of functional abilities in order to reduce mortality risk in older adults with diabetes.

Somatic multimorbidity and self-rated health in the older population

OBJECTIVES

Chronic diseases are important predictors of self-rated health (SRH). This study investigated whether multimorbidity has a synergistic or cumulative impact on SRH. Moderation by gender and age was examined.

METHODS

Data originated from the Longitudinal Aging Study Amsterdam (N=2046, aged 57-98 years). We assessed the presence of lung disease, cardiac disease, peripheral atherosclerosis, stroke, diabetes mellitus, arthritis, and cancer. SRH was measured with the question "How is your health in general?" including 5 response categories. Generalized ordered probit models were applied; possible synergism was examined by testing for nonlinearity of the association.

RESULTS

The association between multimorbidity and SRH was nonlinear in that the effect of having a single disease was larger than the added effects of co-occurring diseases. However, from the second disease onward, each additional co-occurring disease caused cumulative declines in SRH. Only in the oldest old (85+), the impact of a single disease was similar to that of co-occurring diseases. Results were similar for men and women.

DISCUSSION

Our findings help to improve understanding of the impact multimorbidity has on SRH: Having a single disease increases the chance of poor health more than each co-occurring disease, indicating some overlap between diseases or adaptation to declining health.

Population attributable risk for functional disability associated with chronic conditions in Canadian older adults

OBJECTIVES

to investigate the population impact on functional disability of chronic conditions individually and in combination.

METHODS

data from 9,008 community-dwelling individuals aged 65 and older from the Canadian Study of Health and Aging (CSHA) were used to estimate the population attributable risk (PAR) for chronic conditions after adjusting for confounding variables. Functional disability was measured using activity of daily living (ADL) and instrumental activity of daily living (IADL).

RESULTS

five chronic conditions (foot problems, arthritis, cognitive impairment, heart problems and vision) made the largest contribution to ADL- and IADL-related functional disabilities. There was variation in magnitude and ranking of population attributable risk (PAR) by age, sex and definition of disability. All chronic conditions taken simultaneously accounted for about 66% of the ADL-related disability and almost 50% of the IADL-related disability.

CONCLUSIONS

in community-dwelling older adults, foot problems, arthritis, cognitive impairment, heart problems and vision were the major determinants of disability. Attempts to reduce disability burden in older Canadians should target these chronic conditions; however, preventive interventions will be most efficient if they recognize the differences in the drivers of PAR by sex, age group and type of functional disability being targeted.

Measuring the impact of diabetes on life expectancy and disability-free life expectancy among older adults in Mexico

OBJECTIVES. The aim of the present study is to investigate differences in total life expectancy (TLE), disability-free life expectancy (DFLE), disabled life expectancy (DLE), and personal care assistance between individuals with and without diabetes in Mexico.

METHODS

The sample was drawn from the nationally representative Mexican Health and Aging Study. Disability was assessed through a basic Activities of Daily Living (ADL) measure, the Instrumental Activities of Daily Living (IADL) scale, and the Nagi physical performance measure. The Interpolation of Markov Chains method was used to estimate the impact of diabetes on TLE and DFLE.

RESULTS

Results indicate that diabetes reduces TLE at ages 50 and 80 by about 10 and 4 years, respectively. Diabetes is also associated with fewer years in good health. DFLE (based on ADL measures) at age 50 is 20.8 years (95% confidence interval [CI]: 19.2-22.3) for those with diabetes, compared with 29.9 years (95% CI: 28.8-30.9) for those without diabetes. Regardless of diabetes status, Mexican women live longer but face a higher disability burden than men.

CONCLUSION

Among older adults in Mexico, diabetes is associated with shorter TLE and DFLE. The negative effect of diabetes on the number of years lived, particularly in good health, creates significant economic, social, and individual costs for elderly Mexicans.

[Socioeconomic inequity in self-rated health status and contribution of health behavioral factors in Korea]

OBJECTIVES

The study is investigated socioeconomic variations in self-rated health status and contribution of health behavioral factors in Korea.

METHODS

A nationally representative sample (2,800 men and 3,230 women aged 20-64 years) from the 2005 Korea National Health and Nutrition Surveys was analyzed using logistic regression.

RESULTS

Self-rated health was lower among lower socioeconomic groups compared with higher socioeconomic groups, with gender being irrelevant. This association was attenuated when health behavioral and socio-demographic factors were adjusted. When each health behavioral factor was considered separately, mediators such as smoking in men, and stress or exercise in women explained a large part of the decreased socioeconomic health inequalities.

CONCLUSIONS

In Korea, subjective health inequalities arise from different socioeconomic status, but this difference is decreased by health behavioral factors. Therefore, socioeconomic inequity in self-rated health status can be corrected more effectively by promotional health behaviors.

The economic consequences of diabetes and cardiovascular disease in the United States

Diabetes-related care and complications constitute a significant proportion of the United States' (US) health care expenditure. Of these complications, cardiovascular disease (CVD) is a major component. Higher morbidity and mortality rates translate to higher costs of care in patients with diabetes compared to those who do not have the disease. Minorities bear a disproportionate burden of diabetes and CVD. We review this disparity and examine potential etiologies for it in Hispanics and African-Americans, the two largest minority groups in the US. We examine strategies in these populations that may improve outcomes in diabetes and CVD, potentially decreasing health care costs.

Relationship between diabetes codes that affect Medicare reimbursement (tier comorbidities) and outcomes in stroke rehabilitation

OBJECTIVES

To examine the extent to which diabetes codes that increase reimbursement (tier comorbidities) under the prospective payment system are related to length of stay and functional outcomes in stroke rehabilitation.

DESIGN

Secondary data analysis.

SETTING

Inpatient rehabilitation facilities (N=864) across the United States.

PARTICIPANTS

Patients (N=135,097) who received medical rehabilitation for stroke in 2002-2003.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Length of stay, FIM instrument, and discharge setting. Diabetes status was assigned to 1 of 3 categories: tier (increases reimbursement), nontier (no reimbursement effect), and no diabetes.

RESULTS

Mean +/- standard deviation age of the sample was 70.4+/-13.4 years, and 31% had diabetes (6% tier, 25% nontier). Diabetes status by age demonstrated significant (P<.05) interaction effects, which lead to the following age-specific findings. In younger stroke patients (60y), tier diabetes was associated with shorter lengths of stay compared with both groups, lower FIM discharge scores compared with both groups, and lower odds of discharge home relative to the no-diabetes group. In older stroke patients (80y), tier diabetes was associated with longer lengths of stay compared with both groups and with higher FIM discharge scores compared with the nontier group.

CONCLUSIONS

The diabetes-related conditions identified as tier comorbidities under the prospective payment system are significant predictors of stroke rehabilitation outcomes, but these relationships are moderated by patient age.

Self-rated Health, Associated Factors and Diseases: A Community-based Cross-sectional Study of Singaporean Adults Aged 40 Years and Above

Introduction: Subjective indicators of health like self-rated health (SRH) have been shown to be a predictor of mortality and morbidity. We determined the prevalence of poor SRH in Singapore and its association with various lifestyle and socioeconomic factors and disease states. Materials and Methods: Cross-sectional survey by interviewer-administered questionnaire of participants aged 40 years and above. SRH was assessed from a standard question and categorised into poor, fair, good or excellent. Lifestyle factors, socioeconomic factors and presence of disease states were also assessed. Results: Out of 409 participants, 27.6% rated their health as poor or fair, 53.1% as good and 19.3% as excellent. Smaller housing-type (PRR: 1.64, 95% CI: 1.10-2.44) and lack of exercise (PRR: 1.54, 95% CI: 1.06-2.22) were found to be associated with poor SRH. Presence of chronic diseases such as coronary artery disease (PRR: 1.89, 95% CI: 1.13-3.17), diabetes mellitus (PRR: 1.85, 95% CI: 1.18-2.91), history of cancer (PRR: 2.15, 95% CI: 1.05-4.41) and depression (PRR: 1.73, 95% CI: 1.13-2.65) were associated with poor SRH. Conclusion: Prevalence and factors associated with poor SRH in Singapore was comparable to other developed countries. SRH is an important subjective outcome of health and has the potential for wider use in clinical practice in Singapore. Key words: Chronic diseases, Socioeconomic factors, Subjective health indicators

Functional outcome of ischemic stroke: A comparative study of diabetic and non-diabetic patients

BACKGROUND AND PURPOSE

Diabetes is associated with more ischemic strokes and diabetic patients have up to a three-fold increased risk for suffering a stroke, compared with non-diabetics. The aim of this study is to evaluate whether diabetes mellitus may also affect the functional outcome of patients with acute ischemic stroke, undergoing post-acute care rehabilitation.

METHODS

A retrospective charts analysis of consecutive older patients with acute ischemic stroke admitted for rehabilitation at a tertiary hospital with post-acute care geriatric rehabilitation wards. Functional outcome of diabetics and non-diabetics was assessed by the Functional Independence Measurement scale (FIM) at admission and discharge. Data were analysed by t-tests, Pearson correlation, and Chi-square test, as well as by linear regression analysis.

RESULTS

A total number of 527 patients were admitted, of whom 39% were diabetics. Compared with non-diabetics, diabetic stroke patients were slightly younger (p = 0.0001) but had similar admission FIM scores. FIM gain parameters (total FIM gain, motor FIM gain, daily total and motor FIM gains) upon discharge were similar in both groups. A linear regression analysis showed that higher MMSE scores (beta = 0.08; p = 0.01) and higher admission total FIM scores (beta = 0.87; p < 0.001) predicted higher total FIM scores upon discharge. Diabetes mellitus was not interrelated, whatsoever, with better total FIM scores upon discharge (beta = -0.03; p = 0.27).

CONCLUSIONS

The findings suggest that there is no difference in the functional outcome of diabetic and non-diabetic patients, presenting for rehabilitation after acute ischemic stroke. Diabetes should not be considered as adversely affecting rehabilitation of such patients.

Health-related quality of life and help seeking among American Indians with diabetes and hypertension

OBJECTIVE

To evaluate the Health-Related Quality of Life (HRQoL) of American Indians with diabetes, hypertension, or both conditions using the SF36; and to explore how the HRQoL is associated with help seeking among American Indians with and without these chronic conditions.

METHODS

We analyzed data obtained from respondents with diabetes and/or hypertension who participated in a large epidemiological study of two culturally distinct American Indian tribes. Comparison data were provided by an age, gender, and tribe matched sample from the same study who did not report either condition.

RESULTS

The respondents with both diabetes and hypertension had the lowest HRQoL on all eight subscales of SF36. Confirmatory factor analysis (CFA) showed that the assumption of equivalent factor loadings for participants with and without diabetes and/or hypertension was not satisfied. Biomedical service use was significantly associated with the SF36 physical health factor in those with hypertension only. Help seeking from traditional healers was significantly negatively related to physical factor scores for all the respondents except those with diabetes only.

CONCLUSIONS

Participants with comorbid diabetes and hypertension had worse HRQoL. The relationships between HRQoL and different types of help seeking varied depending on the comorbidity status of the respondents.

Disability and its correlates with chronic morbidities among U.S. adults aged 50-<65 years

OBJECTIVE

To examine the prevalence of disability and its associations with multiple chronic morbidities in U.S. adults aged 50-<65 years.

METHODS

Self-reported data on disability and chronic morbidities were collected from 95,103 participants (aged 50-<65 years) of the 2005 Behavioral Risk Factor Surveillance System. Prevalence estimates for disability and chronic morbidities were age-standardized to the 2000 U.S. population. Adjusted odds ratios for disability among people with chronic morbidities (versus those without) were estimated using logistic regression analyses.

RESULTS

The age-adjusted prevalence of the six chronic morbidities ranged from 3.1% (for stroke) to 40.3% (for arthritis). Overall, the prevalence of disability was 26.3%; it was significantly higher in adults with chronic morbidities than in those without and increased linearly with the number of the chronic morbidities. Adults with any of the chronic morbidities were 1.9 to 4.5 times as likely, and adults with 1 to 5-6 of the chronic morbidities were 2.7 to 42.9 times as likely, to have disability as those without after adjustment for demographics, smoking and leisure-time exercise.

CONCLUSIONS

Chronic morbidities remain major factors associated with disability in adults aged 50-<65 years. Effective interventions to prevent and manage chronic diseases from an earlier age may help reduce the risk of disability.

Racial and ethnic differences in activities of daily living disability among the elderly: the case of Spanish speakers

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.

Health of community-dwelling adults with mobility limitations in the United States: prevalent health conditions. Part I

OBJECTIVE

To characterize the extent and types of prevalent health conditions among nationally representative groups of adults with mobility, nonmobility, and no limitations.

DESIGN

Data were collected during 5 rounds of household interviews from a probability subsample of households that represent the civilian, noninstitutionalized U.S. population. With some exceptions, round 1 variables were used for this analysis.

SETTING

Community.

PARTICIPANTS

Data were analyzed on the same respondents from the 1996 to 1997 Medical Expenditure Panel Survey (MEPS) and the 1995 National Health Interview Survey Disability Supplement. Respondents were categorized into 3 groups for analysis: those with mobility limitations, nonmobility limitations; and no limitations. The analytic sample included 13,897 MEPS adults (> or =18y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Number, types, and prevalence of self-reported health conditions compared across groups.

RESULTS

On average, adults with mobility limitations had significantly more prevalent conditions (3.6) than those with nonmobility limitations (2.4), or no limitations (1.3). Greater comorbidity existed in the context of fewer personal resources and more than half of adults with mobility limitations were working age.

CONCLUSIONS

Determining factors that influence the health of adults with mobility limitations is a critical public health issue.

Co-morbidity, functionality and time since diagnosis as predictors of physical activity in individuals with type 1 or type 2 diabetes

Physical activity plays a key role in diabetes management, and in reducing the risk factors related to the development of co-morbid conditions. This study examined predictors of physical activity (Static Model) and activity change (Change Model) for individuals with type 1 (T1D) or type 2 diabetes (T2D) in a population sample of 1662 adults (510 type 1; 1152 type 2) using self-reported measures of co-morbidities, perceived difficulties in performing tasks of daily living (TDL), time since diagnosis, and selected demographic factors. Since the motivation for physical activity could be influenced by the initial diagnosis of diabetes, analyses were conducted separately for newly diagnosed individuals (diagnosed with diabetes < or =1 year), and those that have been diagnosed for sometime (diagnosed with diabetes >1 year). In the Static Model, a younger age (beta=-.11, p<.05) and having less perceived difficulties in performing TDL (beta=-.12, p<.05) were associated with a higher physical activity in individuals with type 1 diabetes. The presence of difficulties in TDL (beta=-.08, p<.05) and co-morbidities (beta=-.08, p<.05) were associated with physical activity participation in type 2 individuals diagnosed for >1 year, but not in newly diagnosed individuals. A shorter duration of disease (beta=-.07, p<.05), a higher body mass index (BMI) (beta=.09, p<.05) and female gender (beta=.07, p<.05) was associated with physical activity increase in individuals with type 2 diabetes. A higher BMI predicted physical activity change in both newly diagnosed individuals and those diagnosed for sometime. However, both genders were equally likely to increase their physical activity among newly diagnosed individuals. Although the magnitude of the study results are relatively modest, they could potentially guide and encourage future investigations in this area that could lead to useful insights in designing PA intervention programs for these specific populations.

Racial/ethnic differences in activities of daily living disability in older adults with arthritis: a longitudinal study

OBJECTIVE

To investigate racial/ethnic differences in disability onset among older Americans with arthritis. Factors amenable to clinical and public health intervention that may explain racial/ethnic differences in incident disability were examined.

METHODS

We analyzed longitudinal data (1998-2004) from a national representative sample of 5,818 non-Hispanic whites, 1,001 African Americans, 228 Hispanics interviewed in Spanish (Hispanic/Spanish), and 210 Hispanics interviewed in English (Hispanic/English), with arthritis and age >or=51 years who did not have baseline disability. Disability in activities of daily living (ADL) was identified from report of inability, avoidance, or needing assistance to perform >or=1 ADL task.

RESULTS

Over the period of 6 years, 28.0% of African Americans, 28.5% of Hispanic/Spanish, 19.1% of Hispanic/English, and 16.2% of whites developed disability. The demographic-adjusted disability hazard ratios (AHR) were significantly greater among African Americans (AHR 1.94, 95% confidence interval [95% CI] 1.51-2.38) and Hispanic/Spanish (AHR 2.03, 95% CI 1.35-2.71), but not significantly increased for Hispanic/English (AHR 1.41, 95% CI 0.82-2.00) compared with whites. Differences in health factors (comorbid conditions, functional limitations, and behaviors) explained over half the excess risk among African Americans and Hispanic/Spanish. Medical access factors (education, income, wealth, and health insurance) were substantial mediators of racial/ethnic differences in all minority groups.

CONCLUSION

Racial/ethnic differences in the development of disability among older adults with arthritis were largely attenuated by health and medical access factors. Lack of health insurance was particularly problematic. At the clinical level, treatment of comorbid conditions, functional limitations, and promotion of physical activity and weight maintenance should be a priority to prevent the development of disability, especially in minority populations.

Is the impact of depressive complaints on the use of general health care services dependent on severity of somatic morbidity?

OBJECTIVE

The aim of this study was to examine the effects of depressive complaints and chronic medical illnesses on prospective somatic health care utilization and the possible heterogeneity of the effect of depressive complaints across levels of medical illness severity.

METHODS

Data from a community-based sample of adults (n=9428) were used, of whom a health survey and claims data, indicating health care use, were available. Assessments of depressive complaints and somatic illnesses were based on self-report. Binomial regression analyses were used to study the expected relations.

RESULTS

Depressive complaints and somatic morbidity were both positively related to general health care utilization. Somatic morbidity has an attenuating effect on the impact of depressive complaints: If it becomes more severe, the impact of depressive complaints on utilization is reduced. Depressive complaints are especially related to the use of paramedic services, use of prescription drugs, and consultations of medical specialists.

CONCLUSION

Depressive complaints predict somatic health care utilization, but somatic morbidity attenuates this relation. Future research on this subject should include interaction effects of depressive complaints and somatic morbidity. Interventions aiming to reduce excess use related to mental distress should be primarily targeted on subjects with mental distress who have no comorbid somatic morbidity.

Diabetes mellitus and incidence of lower body disability among older Mexican Americans

BACKGROUND

Little is known about the effect of diabetes mellitus on subsequent lower body disability in older Mexican Americans, one of the fastest growing ethnic groups in the United States. The aim of this study is to examine the relationship between diabetes mellitus and incident lower body disability over a 7-year follow-up period.

METHODS

Ours was a 7-year prospective cohort study of 1835 Mexican-American individuals > or = 65 years old, nondisabled at baseline, and residing in five Southwestern states. Measures included self-reported physician diagnosis of diabetes, stroke, heart attack, hip fracture, arthritis, or cancer. Disability measures included activities of daily living (ADLs), mobility tasks, and an 8-foot walk test. Body mass index, depressive symptoms, and vision function were also measured.

RESULTS

At 7-year follow-up, 48.7% of diabetic participants nondisabled at baseline developed limitations in one or more measures of lower body function. Cox proportional regression analyses showed that diabetic participants were more likely to report any limitation in lower body ADL function (hazard ratio [HR] = 2.05, 95% confidence interval [CI], 1.58-2.67), mobility tasks (HR = 1.69, 95% CI, 1.39-2.04), and 8-foot walk (HR = 1.46, 95% CI, 1.15-1.85) compared with nondiabetic participants, after controlling for relevant factors. Older age and having one or more diabetic complications were significantly associated with increased risk of limitations in any lower body ADL and mobility task at follow-up.

CONCLUSION

Older Mexican Americans with diabetes mellitus are at high risk for development of lower body disability over time. Awareness of disability as a potentially modifiable complication and use of interventions to reduce disability should become health priorities for older Mexican Americans with diabetes.

The brain of the elderly diabetic patient

All available estimations agree that the French population is aging and that the proportion of diabetics in the elderly population is increasing. The prevalence of diabetes could be about 10% in the over 65 y population. The fact that diabetes has an effect on brain function is widely accepted, but there are very few studies providing pertinent details. Diabetes is known to affect brain function, potential consequences including cognitive decline, dementia, depression, and stroke. These complications are frequently associated, leading to poor quality-of-life with considerable social and economic impact. While the results of different studies can be contradictory, there is an overall trend towards the conclusion that diabetes, often associated with high blood pressure, contributes to cognitive decline in elderly diabetics as well as to an increased frequency and severity of cerebral vascular events. These considerations point out the importance of proper management of diabetes in the elderly population and the need for cooperative studies to determine the role of diabetes and different cardiovascular risk factors in the development of dementia, stroke, and depressive syndromes whose consequences are probably underestimated.

Geriatric Assessment with Focus on Instrument Selectivity for Outcomes

More than one half of all cancers in developed countries occur in patients aged 70 years and older. Therefore, in recent years, there has been a growing interest in integrating a comprehensive geriatric assessment into the management of these patients with cancer. This review article emphasizes the data gathered so far on the correlation between such an assessment and outcome in patients with cancer. The most developed data relate to functional status and comorbidity. Geriatric instruments appear more sensitive than classic oncological instruments in measuring functional status. There is also good evidence that as a patient's age advances, comorbidity affects in an increasing fashion their survival and cancer management. Some evidence is beginning to appear as to the impact a comprehensive geriatric assessment could have on the oncologic management of older patients with cancer.

Racial Differences in Activities of Daily Living Limitation Onset in Older Adults With Arthritis: A National Cohort Study

OBJECTIVE

To investigate factors that predict the onset of limitations in activities of daily living (ADLs) in adults 65 years old or older who have arthritis, in order to develop public health programs for minorities (African and Hispanic Americans) and white Americans.

DESIGN

Longitudinal cohort study.

SETTING

National probability sample.

PARTICIPANTS

Older adults with arthritis (N=3541) who participated in the 1998 and 2000 Health and Retirement Study interviews and who had no baseline ADL limitations.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Onset of ADL limitations was identified from reports of 1 or more ADL task limitations at 2-year follow-up.

RESULTS

Onset is most frequent among African Americans (24.4%), followed by Hispanics (22.2%), and whites (16.9%). Race specific multivariate analysis showed that the strongest risk factor predicting onset of limitations across all racial and ethnic groups is physical limitations. Low household income was significant for older minorities but not for whites. Comorbid cardiovascular disease was a unique multivariate risk factor among African Americans.

CONCLUSIONS

Physical limitation is a strong risk factor for ADL limitation onset that is shared by all racial and ethnic groups. Early identification and treatment of physical limitations may prevent the onset of ADL limitations and thus improve quality of life. Race specific public health interventions should be considered to reduce the development of ADL limitations among older adults with arthritis.

The impact of type 2 diabetes and peripheral arterial disease on quality of life

Peripheral arterial disease (PAD) is associated with impaired walking distance as the result of claudication and reduced quality of life (QOL). Diabetes mellitus (DM) is commonly associated with PAD. The combined effect of DM and PAD versus PAD alone on walking distance and QOL is not well understood. This prospective, descriptive study examined walking distance and QOL associated with DM and PAD compared with PAD alone. Walking distance was assessed by an exercise treadmill test to determine initial claudication distance and absolute claudication distance and by self-report using the Walking Impairment Questionnaire. QOL was measured using the Short Form-36. The overall sample consisted of 92 men and women with PAD and DM or PAD alone. Of the total sample, 74 participants had PAD with ABI less than 0.9 mm Hg and 18 subjects had PAD and uncontrolled DM with hemoglobin A1c 7.0 mg/dL or greater. The mean age was 72 years (standard deviation [SD] = 7) for the PAD only group and 75 years (SD = 8) (not significant) for the PAD and DM groups. Initial claudication distance was greater in subjects with PAD only (186.9 m, SD = 136.4) than in diabetic subjects with PAD (127.3 m, SD = 70.0, P = .01). Absolute claudication distance was higher in patients with PAD only (461.3 m, SD 308) than in diabetic subjects with PAD (279.1 m, SD = 100, P = .01). Self-reported walking speed was reduced in patients with DM and PAD compared with patients with PAD only (P = .05). Diabetic patients with PAD reported impaired role function (P = .007), general health (P = .03), and social function (P = .04) compared with patients with PAD only. We conclude that DM has a significant detrimental impact on walking distance and QOL in patients with PAD. These findings suggest that diabetic patients with PAD are at greater risk for experiencing social isolation, impaired role function, reduced overall perceptions of general health, and impaired functional capacity. Future studies with larger sample sizes are needed to identify factors that contribute to these perceptions in diabetic patients with PAD.

Awareness of hypertension and diabetes in the Hispanic community

Major barriers to awareness and control of hypertension and diabetes in Hispanic Americans include poor language comprehension, poor physician-patient communication, cultural differences, low educational level, and lack of health insurance. To better communicate the concerns about the risk factors for cardiovascular disease, physicians could use patient-education materials that include illustrations, familiarize themselves with their Hispanic patients and their preferences regarding communication (e.g., formality, close proximity, appropriately used touch), and advocate government action to make health insurance more affordable. An increase in Spanish-speaking physicians would help alleviate some of the confusion that Hispanic patients experience in their interactions with health care providers.

Disability and its effects on quality of life among older people living in Antalya city center, Turkey

The problems of older people become more prevalent with aging of the population. Occurrence of disability and its effects on living conditions are two of the major factors that determine the quality of life of elderly people. The aim of this study is to find out the frequency and severity level of disability for people aged 65 and older living in Antalya city center. We also aim to determine the effects of disability over living conditions and to detect the variables associated with disability. World Health Organization-Disability Assessment Schedule (WHO-DAS-II) was implemented to 840 people who were selected from the research population with cluster sampling method. Disability status of these 840 people was measured for six different fields of life (domains). The domains that disability was the most frequent were; "participation in society (86.7%)", "getting around (70.2%)" and "life activities (68.8%)". The fields that were found to contain the most severe disabilities were "life activities" (50.5 +/- 32.5 points), "getting around" (40.6 +/- 27.0 points) and "self care" (34.2 +/- 23.4 points). It was found that disability frequency was positively associated with age, number of chronic diseases and number of acute complaints (odds ratios are 1.05, 1.31 and 1.43, respectively). Disability was also found to be 1.71 times more frequent for women, 2.54 times more frequent for people who live in separate houses and 4.50 times more frequent for illiterates. Disability affects the fields of lives of elderly people with rates of 90.4% for "self care", 88.6% for "getting around" and 85.2% for "life activities". For the elderly population participating in our study, disability is most frequently seen in "participation in society", the most severe disability is seen in "life activities" and the most effected field is found to be "self care". These findings must to be incorporated into planning procedures as expenditure is allocated in order to decrease disability.

The impact of diabetes mellitus and other chronic medical conditions on health-related Quality of Life: is the whole greater than the sum of its parts?

BACKGROUND

Diabetes mellitus (DM) is an important public health concern, the impact of which is increased by the high prevalence of co-existing chronic medical conditions among subjects with DM. The aims of this study were therefore to (1) evaluate the impact of DM and co-existing chronic medical conditions on health-related quality of life (HRQoL) (which could be additive, synergistic or subtractive); (2) to determine the extent to which the SF-6D (a single-index preference measure) captures the multidimensional information provided by the SF-36 (a profile measure).

METHODS

Using data from a cross-sectional, population-based survey of Chinese, Malay and Indians in Singapore, we developed 9 separate multiple linear regression models, with each SF-36 scale or SF-6D index score being the dependent variable for one model. The influence of DM and a second chronic medical condition (hypertension (HTN), heart disease (HD), musculoskeletal illnesses (MS)) and their interactions were studied after adjusting for the influence of potential confounding variables.

RESULTS

Among 5,224 subjects, the prevalence of DM, HTN, HD and MS were 5.9%, 10.7%, 2.4% and 26.6% respectively. DM lowered SF-36 scores by more than 2 points on 3 SF-36 scales and lowered SF-6D scores by 0.03 points. Subjects with DM and HTN, DM and HD or DM and MS experienced further lowering of SF-36 scores exceeding 2 points on at least 6 scales and further lowering of SF-6D scores by 0.05, 0.08 and 0.10 points respectively. Generally, DM and co-existing medical conditions exerted additive effects on HRQoL, with the exception of DM and heart disease, where a subtractive effect was noted. SF-6D index scores generally reflected the patterns of influence of DM and chronic medical conditions on SF-36 scores.

CONCLUSION

DM and chronic medical conditions generally reduced HRQoL in this multiethnic general population in an additive, rather than synergistic or subtractive fashion. In this study, the SF-6D was a reasonably good summary measure for the SF-36.