Sex differences in functional limitations and the role of socioeconomic factors: a multi-cohort analysis

Impacts of Acculturation on Depressive Symptoms and Activities of Daily Living of U.S. Older Chinese Immigrants

BACKGROUND AND OBJECTIVES

Acculturation is a critical aspect of social experience for immigrants, including Asian immigrants. Existing literature has shown mixed findings on the health impacts of acculturation and largely relied on cross-sectional studies, preventing drawing definitive conclusions. This study aimed to examine the long-term effects of acculturation on depressive symptoms and activities of daily living (ADL) limitations in a large sample of older Chinese immigrants in the United States.

RESEARCH DESIGN AND METHODS

Data were drawn from 2,811 older Chinese immigrants from the Population Study of Chinese Elderly in Chicago. Acculturation was assessed at baseline, and questionnaires on depressive symptoms and ADL limitations were completed at 4 assessments.

RESULTS

Overall, results showed that acculturation was not associated with depressive symptoms at baseline but was associated with a faster decline in depressive symptoms over time. No associations were found between acculturation and ADL limitations. Stratified analyses showed that the significant relationship between acculturation and a faster decline in depressive symptoms was only evident among female participants. Also, acculturation was associated with a lower risk of reporting ADL limitations at baseline in female participants but a higher risk of reporting ADL limitations in male participants.

DISCUSSION AND IMPLICATIONS

This study indicates the long-term benefits of acculturation on mental health among older Chinese immigrants in the United States, particularly among females. Initiatives supporting the acculturation process need to consider sex disparities and individual preferences, aiming to foster sustained benefits for healthy aging in this population.

Gender differences in cost-related unmet healthcare needs: a national study in Turkiye

BACKGROUND

Unmet healthcare needs are a complex and multifaceted issue, influenced by individual, socioeconomic, and healthcare system factors. This study aimed to investigate the determinants influencing cost-related unmet healthcare needs within the Turkish population, emphasizing a comprehensive analysis of gender disparities in accessing healthcare services.

METHODS

This secondary analysis scrutinizes the 2019 Turkiye Health Survey data of 16,976 individuals aged 15 and older. The dependent variables included cost-related unmet medical, dental, and prescribed medication, and mental services. The independent variables were considered under a three-domain approach for the determination of health service utilization, developed by Andersen. Logistic regression models with predisposing, enabling, and need factors were run for any self-perceived cost-related unmet need for each sex and overall population. Another six regression models for both sexes were run for each subgroup of indivuals with unmet healthcare needs.

RESULTS

The study revealed that 15.4% of individuals cannot access healthcare due to financial constraints, with 16.8% for women and 13.5% for men. The highest level of unmet needs is associated with accessing dental care services for both sexes. According to multivariate analyses, the unmet need for both sexes decreases with older age and higher education level, and it is greater for those who have difficulties communicating in Turkish. By adding enabling and needs factors, the odds ratios of education decreased for men, while education became nonsignificant for women. Having chronic disease impacts unmet needs for both sexes. However, the inability to perform daily activities due to health problems was not a significant factor for men. Poorer household income increases overall unmet needs. Education is a determinant of both medical and mental care needs.

CONCLUSIONS

This pioneering study illuminates the multifaceted gender disparities in cost-related unmet healthcare needs across Turkiye, reflecting the intertwined issues of access influenced by a complex interplay of factors. Our findings underscore the significance of adopting an intersectional approach to address health inequalities.

Cardiorespiratory Fitness Benefits of High-Intensity Interval Training After Stroke: A Randomized Controlled Trial

BACKGROUND

Limited evidence supports the effects of short-interval high-intensity interval training (HIIT) for improving cardiorespiratory fitness (V̇O2peak) after stroke. We aimed to compare the effects of 12 weeks of short-interval HIIT versus moderate-intensity continuous training (MICT) on V̇O2peak, cardiovascular risk factors, and mobility outcomes among individuals ≥6 months poststroke.

METHODS

This study was a multi-site, 12-week randomized controlled trial (NCT03614585) with an 8-week follow-up. Participants were randomized into 3 d/wk of HIIT (10×1 minute 80%-100% heart rate reserve interspersed with 1 minute 30% heart rate reserve [19 minutes]) or MICT (20-30 minutes 40%-60% heart rate reserve). Secondary outcomes of the trial, including V̇O2peak, cardiovascular risk factors (carotid-femoral pulse wave velocity, blood pressure, and waist-hip ratio), and mobility (6-minute walk test, 10 m gait speed), were reported. Linear mixed model analyses with a group×study time point interaction evaluated between-group differences.

RESULTS

Of the 305 potential participants, 82 consented (mean [SD] age 64.9 [9.3] years, 32 females [39%], 1.8 [1.2] years poststroke) and were randomized to HIIT (n=42, mean [SD] baseline V̇O2peak 17.3 [5.9] mL/kg·min) or MICT (n=40, mean [SD] baseline V̇O2peak 17.2 [6.0] mL/kg·min). Participants attended 82% of visits (n=2417/2952). No adverse events occurred during the study period. A significant group×study time point interaction was found (χ2=8.46; P=0.015) for V̇O2peak at 12 weeks (mean difference, 1.81 [95% CI, 0.58-3.04]; P=0.004) whereby the HIIT group had greater gains in V̇O2peak (∆3.52 mL/kg·min [95% CI, 2.47-4.57]; P<0.001) compared with the MICT group (∆1.71 mL/kg·min [95% CI, 0.55-2.86]; P=0.001). There was no between-group difference in V̇O2peak (mean difference, 1.08 [95% CI, -0.26 to 2.42]; P=0.11) at 8-week follow-up. No group×study time point interactions were found for cardiovascular risk factors or mobility outcomes.

CONCLUSIONS

Short-interval HIIT may be an effective alternative to MICT for improving V̇O2peak at 12 weeks postintervention.

REGISTRATION

URL: https://clinicaltrials.gov; Unique identifier: NCT03614585.

Activity limitations, use of assistive devices, and mortality and clinical events in 25 high-income, middle-income, and low-income countries: an analysis of the PURE study

BACKGROUND

The focus of most epidemiological studies has been mortality or clinical events, with less information on activity limitations related to basic daily functions and their consequences. Standardised data from multiple countries at different economic levels in different regions of the world on activity limitations and their associations with clinical outcomes are sparse. We aimed to quantify the prevalence of activity limitations and use of assistive devices and the association of limitations with adverse outcomes in 25 countries grouped by different economic levels.

METHODS

In this analysis, we obtained data from individuals in 25 high-income, middle-income, and low-income countries from the Prospective Urban Rural Epidemiological (PURE) study (175 660 participants). In the PURE study, individuals aged 35-70 years who intended to continue living in their current home for a further 4 years were invited to complete a questionnaire on activity limitations. Participant follow-up was planned once every 3 years either by telephone or in person. The activity limitation screen consisted of questions on self-reported difficulty with walking, grasping, bending, seeing close, seeing far, speaking, hearing, and use of assistive devices (gait, vision, and hearing aids). We estimated crude prevalence of self-reported activity limitations and use of assistive devices, and prevalence standardised by age and sex. We used logistic regression to additionally adjust prevalence for education and socioeconomic factors and to estimate the probability of activity limitations and assistive devices by age, sex, and country income. We used Cox frailty models to evaluate the association between each activity limitation with mortality and clinical events (cardiovascular disease, heart failure, pneumonia, falls, and cancer). The PURE study is registered with ClinicalTrials.gov, NCT03225586.

FINDINGS

Between Jan 12, 2001, and May 6, 2019, 175 584 individuals completed at least one question on the activity limitation questionnaire (mean age 50·6 years [SD 9·8]; 103 625 [59%] women). Of the individuals who completed all questions, mean follow-up was 10·7 years (SD 4·4). The most common self-reported activity limitations were difficulty with bending (23 921 [13·6%] of 175 515 participants), seeing close (22 532 [13·4%] of 167 801 participants), and walking (22 805 [13·0%] of 175 554 participants); prevalence of limitations was higher with older age and among women. The prevalence of all limitations standardised by age and sex, with the exception of hearing, was highest in low-income countries and middle-income countries, and this remained consistent after adjustment for socioeconomic factors. The use of gait, visual, and hearing aids was lowest in low-income countries and middle-income countries, particularly among women. The prevalence of seeing close limitation was four times higher (6257 [16·5%] of 37 926 participants vs 717 [4·0%] of 18 039 participants) and the prevalence of seeing far limitation was five times higher (4003 [10·6%] of 37 923 participants vs 391 [2·2%] of 18 038 participants) in low-income countries than in high-income countries, but the prevalence of glasses use in low-income countries was half that in high-income countries. Walking limitation was most strongly associated with mortality (adjusted hazard ratio 1·32 [95% CI 1·25-1·39]) and most consistently associated with other clinical events, with other notable associations observed between seeing far limitation and mortality, grasping limitation and cardiovascular disease, bending limitation and falls, and between speaking limitation and stroke.

INTERPRETATION

The global prevalence of activity limitations is substantially higher in women than men and in low-income countries and middle-income countries compared with high-income countries, coupled with a much lower use of gait, visual, and hearing aids. Strategies are needed to prevent and mitigate activity limitations globally, with particular emphasis on low-income countries and women.

FUNDING

Funding sources are listed at the end of the Article.

Limited Physical Functioning in United States Adults with Arthritis: Findings from the 2021 Medical Expenditure Panel Survey

There is little published research on limited physical functioning in United States (US) adults with arthritis. The objective of this cross-sectional 2021 Medical Expenditure Panel Survey (MEPS) database study was to investigate the variables associated with limited physical functioning in US adults with arthritis. Logistic regression tested the associations of predisposing, enabling, and need variables with the dependent variable (limited physical functioning). This study included 5102 US adults with arthritis, reflecting an estimated weighted population of 64,136,870 US adults with arthritis. In the final multivariable logistic regression model, age ≥ 70 and ages 60-69 (vs. 18-49 years), female (vs. male) sex, having quite a bit/extreme or moderate (vs. little) pain, and having 6+ or 4-5 (vs. 0-1) comorbid conditions were all associated with higher odds of the person stating they had limited physical functioning. Whereas high school or less (vs. more than high school), being employed (vs. unemployed), being married (vs. not married), having excellent/very good or good (vs. poor) general health, and exercise (vs. no exercise) were each associated with lower odds of the person reporting they had limited physical functioning. Future work may be considered to explore these variables in greater detail.

Height and Weight, Not Body Mass Index, Are Closely Associated With Activities of Daily Living in Japanese Older Adults

Body mass index (BMI) is routinely used to ascertain health status, including activities of daily living (ADLs); however, the associations of ADLs with height and weight in older adults have not been elucidated. Therefore, we cross-sectionally investigated the correlations between ADLs and height, weight, and BMI in 155 participants aged 82 to 103 years and characterized the naïve Bayesian prediction for ADLs. Activities of daily living showed a significant negative correlation with height and weight and a positive correlation with age. In males, a shorter height was associated with an increased risk of falling and disability in phone calling independently, and losing weight was associated with an increased risk of disability in going out. Combining age, weight, and height improved the area under the receiver operating characteristic curve in the prediction of disability in going out and phone calling independently in males. Therefore, height and weight, not BMI, are potential predictors of ADL decline.

Association of cancer with functional decline at old age: a longitudinal study in Danish twins

INTRODUCTION

There is evidence that older adults with cancer have a higher risk of functional decline than cancer-free older adults. However, few studies are longitudinal, and none are twin studies. Thus, we aimed to investigate the relationship between cancer and functional decline in older adult (aged 70+ years) twins.

MATERIALS AND METHODS

Cancer cases in the Longitudinal Study of Aging Danish Twins were identified through the Danish Cancer Registry. Functional status was assessed using hand grip strength (6 years follow-up), and self-reported questions on mobility (10 years follow-up), and cut-offs were defined to assess functional decline. Cox regression models were performed for all the individual twins. In addition, we extended the analysis to discordant twin pairs (twin pairs with one having cancer and the other being cancer-free), to control to a certain extent for (unmeasured) shared confounders (genetic and environmental factors).

RESULTS

The analysis based on individual twins showed that individual twins with cancer are at increased hazard of worsening hand grip strength (hazard ratio (HR) 1.37, 95% confidence interval (CI) 1.04, 1.80) than cancer-free twins. Among the discordant twin pairs, twins with cancer had a higher hazard of worsening hand grip strength (HR 3.50, 95% CI 1.15, 10.63) than cancer-free cotwins. In contrast, there was no evidence of a difference between the hazard of experiencing mobility decline for twins with cancer compared with cancer-free twins, in both individual twins and discordant twin pairs analyses.

DISCUSSION

Cancer was associated with hand grip strength functional decline in old individual twins and discordant pairs. Our results strengthen the importance of comprehensive geriatric assessment in older adults with cancer, as well as the importance of routine assessment of functional status. Promoting physical activity through exercise training programmes could enable the prevention of functional decline in older adults with cancer.

Effect of Autonomy and Physical Activity on Self-Rated Health of Older Adults in India: Gendered Analysis Using Structural Equation Models

The gendered expectations and responsibilities placed upon women can impede their ability to participate in social activities and engage in physical leisure pursuits, ultimately having a negative impact on their health. Our study investigates the mechanisms through which gender influences individuals' engagement with physical activity during free time and how this relates to self-rated health outcomes among adults aged 45 years or older living in India. Using cross-sectional analysis and Structural Equation Modelling, we analyzed data stratified by gender and age from the Longitudinal Ageing Study of India to examine these conceptual pathways. We found that compared to men, women face greater limitations related to decision-making autonomy, experience more functional impairments, have weaker social networks that provide less support for engaging in leisure-time physical activity, leading them to report lower levels of overall wellbeing than men. Further analyses demonstrated distinct pathways through which each gender's level of social network connectivity shapes behavior - strong connections increase opportunities for women specifically to engage positively with both peers and physically active pursuits supporting overall wellness goals.

Self-Reported Visual Difficulty and Daily Activity Limitations: The Moderating Role of Neighborhood Characteristics

BACKGROUND AND OBJECTIVES

Understanding how neighborhood-level factors moderate the relationship between visual health and activity limitations could inform strategies for successful aging in place among older adults with sensory impairments. Guided by a vision loss impact framework, this study aims to examine whether neighborhood social cohesion and physical disorder moderate the association between visual difficulty and activity limitation.

RESEARCH DESIGN AND METHODS

Secondary analyses were conducted using data from Round 5 of the National Health and Aging Trend Study. A 4-level indicator was used to indicate the visual difficulty. Neighborhood social cohesion and physical disorder were each measured using a 3-item scale. Summary scores were created for daily activity limitations. Ordinary least squares regressions were performed to test the study hypotheses. The complex survey design factors were applied. Missing data were handled using multiple imputations.

RESULTS

Older adults reporting any type of visual difficulty experienced more limitations in self-care tasks, household activities, and mobility than those without visual difficulty. Neighborhood physical disorder moderated visual difficulty and activity limitations. Specifically, visual difficulty was associated with higher risk of activity limitations among participants perceiving physical disorder in the neighborhood compared to those perceiving no physical disorder.

DISCUSSION AND IMPLICATIONS

The study findings suggest that the vision loss impact framework provides an integrative approach to identify the health needs of older adults with visual difficulty. Future research is needed to further understand the role of neighborhood in independent living among older adults with visual difficulty and to inform community-level interventions.

To what extent do disparities in economic development and healthcare availability explain between-province health inequalities among older people in China?

Background

Uneven economic development has led to substantial health inequalities between Chinese provinces. The extent of, and factors underlying, between-province health inequalities have received little attention.

Methods

Data from 15,278 respondents in Wave 2 (2013) of the China Health and Retirement Longitudinal Study (CHARLS) were used to investigate inequalities among people aged ≥50 years in five health outcomes between 27 Chinese province-level administrative units. After characterizing the between-province differences and the relevance of province effects, proportional change in variance between unadjusted and adjusted models was calculated to determine the percentage of between-province variance in health outcomes explained by province-level variables including measures of economic development and healthcare availability.

Results

Although province effects explained <10% of overall variance in health outcomes, they underpinned large between-province inequalities among people aged ≥50 years. Gross Regional Product per capita was more important than doctor density in explaining between-province variance in health outcomes, particularly depression symptoms and instrumental activities of daily living impairment.

Conclusion

Policy efforts, including more equal distribution of healthcare personnel, may be warranted to reduce between-province health inequalities.

Assistive technology access in longitudinal datasets: a global review

Functional limitations become more prevalent as populations age, emphasising an increasingly urgent need for assistive technology (AT). Critical to meeting this need trajectory is understanding AT access in older ages. Yet few publications examine this from a longitudinal perspective. This review aims to identify and collate what data exist globally, seeking all population-based cohorts and repeated cross-sectional surveys through the Maelstrom Research Catalogue (searched May 10, 2022) and the Disability Data Report (published 2022), respectively. Datasets incorporating functional limitations modules and question(s) dedicated to AT, with a wave of data collection since 2009, were included. Of 81 cohorts and 202 surveys identified, 47 and 62 meet inclusion criteria, respectively. Over 40% of cohorts were drawn from high-income countries which have already experienced significant population ageing. Cohorts often exclude participants based on pre-existing support needs. For surveys, Africa is the most represented region (40%). Globally, 73% of waves were conducted since 2016. 'Use' is the most collected AT access indicator (69% of cohorts and 85% of surveys). Glasses (78%) and hearing aids (77%) are the most represented AT. While gaps in data coverage and representation are significant, collating existing datasets highlights current opportunities for analyses and methods for improving data collection across the sector.

Biomarkers associated with lower limb muscle function in individuals with sarcopenia: a systematic review

Lower limb muscle dysfunction is a key driver for impaired physical capacity and frailty status, both characteristics of sarcopenia. Sarcopenia is the key pathway between frailty and disability. Identifying biological markers for early diagnosis, treatment, and prevention may be key to early intervention and prevention of disability particularly mobility issues. To identify biological markers associated with lower limb muscle (dys)function in adults with sarcopenia, a systematic literature search was conducted in AMED, CINAHL, Cochrane Library, EMBASE, Medline, PubMed, Scopus, SPORTDiscus, and Web of Science databases from inception to 17 November 2021. Title, abstract, and full-text screening, data extraction, and methodological quality assessment were performed by two reviewers independently and verified by a third reviewer. Depending on available data, associations are reported as either Pearson's correlations, regression R² or partial R² , P value, and sample size (n). Twenty eligible studies including 3306 participants were included (females: 79%, males: 15%, unreported: 6%; mean age ranged from 53 to 92 years) with 36% in a distinct sarcopenic subgroup (females: 73%, males: 19%, unreported: 8%; mean age range 55-92 years). A total of 119 biomarkers were reported, categorized into: genetic and microRNAs (n = 64), oxidative stress (n = 10), energy metabolism (n = 18), inflammation (n = 7), enzyme (n = 4), hormone (n = 7), bone (n = 3), vitamin (n = 2), and cytokine (n = 4) markers) and seven lower limb muscle measures predominately focused on strength. Seven studies reported associations between lower limb muscle measures including (e.g. power, force, and torque) and biomarkers. In individuals with sarcopenia, muscle strength was positively associated with free testosterone (r = 0.40, P = 0.01; n = 46). In analysis with combined sarcopenic and non-sarcopenic individuals, muscle strength was positively associated with combined genetic and methylation score (partial R²  = 0.122, P = 0.03; n = 48) and negatively associated with sarcopenia-driven methylation score (partial R²  = 0.401, P < 0.01; n = 48). Biomarkers related to genetics (R²  = 0.001-0.014, partial R²  = 0.013-0.122, P > 0.05; n = 48), oxidative stress (r = 0.061, P > 0.05; n ≥ 77), hormone (r = 0.01, ρ = 0.052 p > 0.05, n ≥ 46) and combined protein, oxidative stress, muscle performance, and hormones (R²  = 22.0, P > 0.05; n ≥ 82) did not report significant associations with lower limb muscle strength. Several biomarkers demonstrated associations with lower limb muscle dysfunction. The current literature remains difficult to draw clear conclusions on the relationship between biomarkers and lower limb muscle dysfunction in adults with sarcopenia. Heterogeneity of biomarkers and lower limb muscle function precluded direct comparison. Use of international classification of sarcopenia and a set of core standardized outcome measures should be adopted to aid future investigation and recommendations to be made.

Can Sex Differences in Old Age Disabilities be Attributed to Socioeconomic Conditions? Evidence from a Mapping Review of the Literature

Old age disabilities are more common among women than men, and adverse socioeconomic conditions are associated with a higher prevalence of disabilities among older adults. The goal of this study was to complete a mapping review of the available evidence assessing the extent to which the observed sex differences in older adults’ disabilities can be attributed to sex differences in socioeconomic status. We searched three databases for articles published between 2009 and 2019, and after screening and looking at eligibility criteria, 6 articles were included in the review. For those studies that did not directly analyse the contribution of socioeconomic conditions, we used the ‘difference method’ to estimate the proportion of the sex gap in disabilities among older adults that could be attributed to socioeconomic conditions. Our review demonstrated that women generally have a higher prevalence of disabilities than men. In several studies, these differences could be partly attributed to sex differences in the distribution of socioeconomic conditions. We also find great elasticity in the magnitude of both the sex gap in disabilities and in the proportion that could be attributed to differences in socioeconomic conditions.

Validating intrinsic capacity to measure healthy aging in an upper middle-income country: Findings from the ELSI-Brazil

Background

While efforts have been made to validate intrinsic capacity (IC) as a multidimensional indicator of healthy aging in high-income countries, we still need evidence from lower-income countries. We examined associations of IC with wide ranges of activities of daily living in a nationally representative sample of Brazilians aged≥50 years.

Methods

This cross-sectional analysis included 7175 participants from the Brazilian Longitudinal Study of Aging. IC domains (cognitive, psychological, sensory, locomotor, and vitality) were determined using self-reported and physical performance measures. IC was operationalized through factorial analysis. We investigated associations of IC and its domains with functional ability in basic, instrumental, and advanced activities of daily living (ADL, IADL, and AADL) using logistic regressions adjusted for sociodemographic, clinical, and modifiable risk factors.

Findings

The IC bi-factorial model revealed satisfactory goodness-of-fit. Preserved ability in ADL and IADL, respectively, ranged from 69% and 29% to 89% and 74% across IC quartiles. In adjusted analyses, every standard deviation increment in IC composite score was associated with almost twice the odds of preserved ADL (OR=1·72; 95%CI=1·54-1·93), preserved IADL (OR=1·95; 95%CI=1·77-2·16), and high performance in AADL (OR=1·79; 95%CI=1·59-2·00). Similar results were reported using the IC domains as predictors. Although age, race/ethnicity, and education did not modify associations of IC with functional ability, we found sex differences with stronger relationships of IC with preserved ADL or IADL in females.

Interpretation

Our results support IC validity and reliability to measure healthy aging in diverse socioeconomic and cultural settings. Incorporating IC in routine practices can promote holistic and person-centered care approaches in aging societies.

Funding

The Brazilian Ministry of Health and Ministry of Science, Technology, Innovation, and Communication.