The relationship between ethnoracial group and functional level in older persons

High rates of undiagnosed vascular cognitive impairment among American Indian veterans

As data on prevalence and etiology of dementia in American Indians are limited, we sought to determine rates and patterns of memory loss among American Indian veterans with vascular risk factors. Sixty consecutive outpatient American Indian veterans with a mean age of 64 years (range 50-86), without prior dementia or mild cognitive impairment (MCI), and with ≥ 2 vascular risk factors were enrolled. The Montreal Cognitive Assessment (MoCA) and the Beck Depression Inventory-II were used to screen for cognitive impairment and depression. Patients with MoCA scores < 26 were referred for additional evaluation, including imaging, serology, and neuropsychological testing. Overall rates, types, and distribution of cognitive impairment were determined. Most prevalent vascular risk factors included hypertension (92%), hyperlipidemia (88%), diabetes (47%), and smoking (78%). Eight patients (13%) with severe depression were excluded, leaving 23/52 with abnormal MoCA scores (44%, 95%CI 30%-59%). Fifteen completed additional evaluation for memory loss, including four with normal MoCA scores who requested evaluation based on symptoms. Results were adjudicated as normal (4), non-amnestic MCI (4), vascular MCI (5), and vascular dementia (2). These results show that rates of undiagnosed cognitive impairment among American Indian veterans with vascular risk factors exceed rates previously published in non-American Indian cohorts. The most common etiology is vascular. Our findings support the need to improve vascular risk reduction in this understudied population.

Spiritual Influences on Ability to Engage in Self-Care Activities among Older African Americans

The influence of spiritual factors on the ability of African-American elders to carry out instrumental activities of daily living (IADL) independent of age, gender, education, and self-rated health is explored using the religion-health explanatory model in a cross-sectional sample of 96 African-American community dwelling adults 62 to 93 years of age. The Reed spiritual perspective (SPS) and self-transcendence (STS) scales are used to study spiritual factors (Reed, 1991). The typical respondent was 75 years of age, female, widowed with 10.4 years of education. Self-rated health and age are strongly related to IADL in models that include the other variables ( R2 = 0.41, p < 0.01). Those who are younger and those who self-report better health have higher IADL scores than those without these characteristics. Spiritual factors are significantly related to IADL in a model that includes an interaction of STS with education ( R2 = 0.50). Among the least educated, STS is associated with higher scores of IADL. Addition of the interaction to the model resulted in a significant positive association of both STS and education with IADL. SPS was unrelated to IADL. Caregivers concerned with functional ability may want to consider interventions based on increasing a sense of self-transcendence, and to consider educational level as a potential moderator of this relationship. Criticism of the religion-health literature has suggested that putative health effects of religion may be exaggerated, because of failure to take confounding variables into account (Sloan, Bagiella, & Powell, 1999). However, this study and a recent survey by Musick, House, and Williams (2004) are evidence that it is just as likely that health benefits of religion would be hidden by confounders as that they would be exaggerated by them.

Factors Contributing to 50-ft Walking Speed and Observed Ethnic Differences in Older Community-Dwelling Mexican Americans and European Americans

BACKGROUND

Mexican Americans comprise the most rapidly growing segment of the older US population and are reported to have poorer functional health than European Americans, but few studies have examined factors contributing to ethnic differences in walking speed between Mexican Americans and European Americans.

OBJECTIVE

The purpose of this study was to examine factors that contribute to walking speed and observed ethnic differences in walking speed in older Mexican Americans and European Americans using the disablement process model (DPM) as a guide.

DESIGN

This was an observational, cross-sectional study.

METHODS

Participants were 703 Mexican American and European American older adults (aged 65 years and older) who completed the baseline examination of the San Antonio Longitudinal Study of Aging (SALSA). Hierarchical regression models were performed to identify the contribution of contextual, lifestyle/anthropometric, disease, and impairment variables to walking speed and to ethnic differences in walking speed.

RESULTS

The ethic difference in unadjusted mean walking speed (Mexican Americans=1.17 m/s, European Americans=1.29 m/s) was fully explained by adjustment for contextual (ie, age, sex, education, income) and lifestyle/anthropometric (ie, body mass index, height, physical activity) variables; adjusted mean walking speed in both ethnic groups was 1.23 m/s. Contextual variables explained 20.3% of the variance in walking speed, and lifestyle/anthropometric variables explained an additional 8.4%. Diseases (ie, diabetes, stroke, chronic obstructive pulmonary disease) explained an additional 1.9% of the variance in walking speed; impairments (ie, FEV1, upper leg pain, and lower extremity strength and range of motion) contributed an additional 5.5%. Thus, both nonmodifiable (ie, contextual, height) and modifiable (ie, impairments, body mass index, physical activity) factors contributed to walking speed in older Mexican Americans and European Americans.

LIMITATIONS

The study was conducted in a single geographic area and included only Mexican American Hispanic individuals.

CONCLUSIONS

Walking speed in older Mexican Americans and European Americans is influenced by modifiable and nonmodifiable factors, underscoring the importance of the DPM framework, which incorporates both factors into the physical therapist patient/client management process.

Social support, stressors, and frailty among older Mexican American adults

BACKGROUND

There is little research on the effects of stressors and social support on frailty. Older Mexican Americans, in particular, are at higher risk of medical conditions, such as diabetes, that could contribute to frailty. Given that the Mexican American population is rapidly growing in the United States, it is important to determine whether there are modifiable social factors related to frailty in this older group.

METHOD

To address the influence of social support and stressors on frailty among older Mexican Americans, we utilized five waves of the Hispanic Established Populations for the Epidemiologic Study of the Elderly (Hispanic EPESE) to examine the impact of stressors and social support on frailty over a 12-year period. Using a modified version of the Fried and Walston Frailty Index, we estimated the effects of social support and stressors on frailty over time using trajectory modeling (SAS 9.2, PROC TRAJ).

RESULTS

We first grouped respondents according to one of three trajectories: low, progressive moderate, and progressive high frailty. Second, we found that the effects of stressors and social support on frailty varied by trajectory and by type of stressor. Health-related stressors and financial strain were related to increases in frailty over time, whereas social support was related to less-steep increases in frailty.

CONCLUSION

Frailty has been hypothesized to reflect age-related physiological vulnerability to stressors, and the analyses presented indicate partial support for this hypothesis in an older sample of Mexican Americans. Future research needs to incorporate measures of stressors and social support in examining those who become frail, especially in minority populations.

The protective effect of neighborhood composition on increasing frailty among older Mexican Americans: a barrio advantage?

OBJECTIVE

Little is known about the nature of the frailty syndrome in older Hispanics who are projected to be the largest minority older population by 2050. The authors examine prospectively the relationship between medical, psychosocial, and neighborhood factors and increasing frailty in a community-dwelling sample of Mexican Americans older than 75 years.

METHOD

Based on a modified version of the Cardiovascular Health Study Frailty Index, the authors examine 2-year follow-up data from the Hispanic Established Populations for Epidemiologic Studies of the Elderly (H-EPESE) to ascertain the rates and determinants of increasing frailty among 2,069 Mexican American adults 75+ years of age at baseline.

RESULTS

Respondents at risk of increasing frailty live in a less ethnically dense Mexican-American neighborhood, are older, do not have private insurance or Medicare, have higher levels of medical conditions, have lower levels of cognitive functioning, and report less positive affect.

DISCUSSION

Personal as well as neighborhood characteristics confer protective effects on individual health in this representative, well-characterized sample of older Mexican Americans. Potential mechanisms that may be implicated in the protective effect of ethnically homogenous communities are discussed.

Chronic illness self-care and the family lives of older adults: a synthetic review across four ethnic groups

The purpose of this paper is to integrate the literature on family and social ties among older ethnic minority men and women with the literature on chronic illness self-care among elders in these groups, in order to increase understanding of social influences on self-care behavior, raise questions for future research, and inform culturally appropriate interventions to maximize the health-promoting potential of social relationships. The paper presents demographic and chronic illness prevalence information, and then summarizes literature about patterns of chronic illness self-care behaviors for older African-Americans, Latinos, Asian-Americans, and American Indians in the U.S. For each group, the sociological literature about residential, cultural, and socioeconomic patterns, family lives, and other social ties is then reviewed, and the self-care literature that has accounted for these patterns is discussed. Finally, six themes are outlined and related questions are identified to further illuminate the social context of older adults' chronic illness self-care.

Frailty and 10-year mortality in community-living Mexican American older adults

BACKGROUND

The older Hispanic population of the United States is growing rapidly. Hispanic older adults have relatively high-risk profiles for increased morbidity and disability, yet little is known about how the construct of frailty is related to health trajectories in this population.

OBJECTIVE

The purpose of this study was to examine the relationship between frailty and 10-year mortality in older community-dwelling Mexican Americans.

METHODS

Data were from the Hispanic Established Populations for Epidemiologic Studies of the Elderly and included 1,996 Mexican Americans, aged 65 and older, living in the southwestern US. Primary measures included mortality and a 5-item frailty index comprised of weight loss, exhaustion, walking speed, grip strength, and physical activity.

RESULTS

Mean baseline age was 74.5 years (SD 6.1) and 58.5% were women. Baseline frailty assessments yielded the following distribution: 44.9% non-frail, 47.3% pre-frail, and 7.8% frail. Overall, 892 (44.7%) participants died during the 10-year study period. Hazard ratios (HR), adjusted for sociodemographic, health, and medical factors, demonstrated increased odds for mortality in the pre-frail (HR = 1.25, 95% confidence interval, CI(95%), 1.07-1.46) and frail (HR = 1.81, CI(95%) 1.41-2.31) groups compared to the non-frail cohort.

CONCLUSION

The 5-item frailty index differentiated odds of 10-year mortality in older community-dwelling Mexican Americans. This clinical index has the potential to identify older minorities at risk for poor health outcomes and mortality.

Chronic disease self-management program for low back pain in the elderly

OBJECTIVE

To evaluate the effectiveness of Stanford's Chronic Disease Self-Management Program (CDSMP) for chronic low back pain (LBP) in older Americans.

DESIGN

Randomized controlled trial.

SETTING

Community-based program offered at 12 locations.

SUBJECTS

Community-dwelling seniors (n = 109) aged 60 and older with chronic LBP of mechanical origin.

METHODS

Patients were randomly allocated to the CDSMP or to a 6-month, wait-list control group. The program included one 2.5-hour session per week for 6 weeks. Outcomes evaluated at 6 months included 100-point modified Von Korff pain and disability scales; days with pain and disability; SF-36 general health, energy-fatigue, and emotional well-being scales; 2 scales from the Arthritis Self-Efficacy Scale, self-care attitudes/behaviors, and health services utilization.

RESULTS

For pain at 6 months, the primary outcome, the adjusted mean difference between the program and control, was -1.0 (P = .835). There was a sizable advantage for the program in disability averaged over the course of the entire 6-month study (-9.2, P = .027), but not at the 6-month follow-up (-5.8, P = .278). There was an interaction between intervention and baseline disability days favoring the program for higher baseline values (P = .007). The CDSMP affected emotional well-being (7.6, P = .037) and energy-fatigue (5.1, P = .274). There were no differences for self-efficacy, pain days, and general health.

CONCLUSION

There was no advantage for the CDSMP over a wait-list control for improving pain, general health, self-efficacy, and self-care attitudes in older Americans with chronic LBP. A benefit was suggested for emotional well-being, fatigue, functional disability, and days with disability.

Inner city, middle-aged African Americans have excess frank and subclinical disability

BACKGROUND

Healthy People 2010 seeks to decrease or eliminate the health disparities experienced by disadvantaged minority groups.

METHODS

African American Health (AAH) is a population-based panel study of community-dwelling African Americans born between 1936 and 1950 from two strata. The first encompasses a poor, inner city area, and the second involves a suburban population with higher socioeconomic status. The authors recruited 998 participants (76% recruitment). Frank disability was assessed for 25 tasks and defined as inability or difficulty performing that task. Subclinical disability was assessed for 12 tasks and defined as no difficulty but a change in either manner or frequency of task performance. Frank disability prevalences were compared with national data for community-dwelling non-Hispanic white persons (NHW) and African American persons in the same age range.

RESULTS

Compared with the suburban sample, the inner city group had a higher prevalence of frank disability for all 25 tasks (p<.05 for 16) and subclinical disability for 11 of the 12 tasks (p<.05 for 5). Both strata had more frank disability compared with the national NHW population. The inner city area had higher frank disability proportions than did the national African American sample, whereas the suburban group had similar disability levels.

CONCLUSIONS

The AAH inner city group experiences more frank disability than other populations of African Americans and NHWs. The increased prevalence of subclinical disability in the inner city group compared with the suburban group suggests that the disparity in frank disability will continue. These findings indicate that African Americans living in poor inner city areas in particular need intensive and targeted clinical and public health efforts.

Hispanic healthcare disparities: challenging the myth of a monolithic Hispanic population

BACKGROUND

Hispanic Americans are often treated as a monolithic ethnic group with a single pattern of healthcare utilization. However, there could be considerable differences within this population. We examine the association between use of healthcare services and Hispanic Americans'country of ancestry or origin, language of interview, and length of time lived in the United States.

METHODS

Our data come from the Medical Expenditure Panel Survey, a nationally representative survey of healthcare use and expenditures. Descriptive statistics and logistic regression results are presented.

RESULTS

Multivariate models show that Mexicans and Cubans are less likely, and Puerto Ricans more likely, to have any emergency department visits than non-Hispanic whites. Mexicans, Central American/Caribbeans, and South Americans are less likely to have any prescription medications. All Hispanics are less likely to have any ambulatory visits and prescription medications, whereas only those with a Spanish-language interview are less likely to have emergency department visits and inpatient admissions. More recent immigrants are less likely to have any ambulatory care or emergency department visits, whereas all Hispanics born outside the United States are less likely to have any prescription medications.

CONCLUSIONS

The Hispanic population is composed of many different groups with diverse health needs and different barriers to accessing care. Misconceptions of Hispanics as a monolithic population lacking within-group diversity could function as a barrier to efforts aimed at providing appropriate care to Hispanic persons and could be 1 factor contributing to inequalities in the availability, use, and quality of healthcare services in this population.