Physical function and perceived health: cohort differences and interrelationships in older people

Network Types and Functional Health in Old Age: It is Not Just the Size of the Network That Matters

OBJECTIVES

Findings on the effect of network size and support on functional health are mixed. We examine whether network types, that simultaneously incorporate multiple network characteristics, are associated with functional health in late life.

METHODS

Data are from the National Social Life, Health, and Aging Project (N = 3005). We estimated the longitudinal effect of membership in five multidimensional network types on disability in six activities of daily living using negative binomial regression, and on mobility (assessed using a timed walk test) using a generalized linear mixed model.

RESULTS

Compared to those in the large without strain network, older adults in the small, restricted, high contact network had fewer disabilities but worse mobility, while those in the large network with strain also had worse mobility.

DISCUSSION

Care plans focusing on function and mobility should consider multiple aspects of older adults' social networks including network size, diversity, and relationship strain.

Determinants of Self-Perceived Health: The Importance of Physical Well-Being but Also of Mental Health and Cognitive Functioning

With life expectancy increasing for the general population, public health promotion activities should be a priority to aim at a reduction of the burden and costs of hospitalization, disability, and lifelong treatment. This study aimed to explore the influence of parameters pertaining to different aspects of well-being, including physical and mental health and cognitive functioning, on self-perceived health, a predictor of chronic disease prevalence and mortality. We used data from the Survey of Health, Aging and Retirement in Europe (SHARE) project gathered between 2013 and 2017, obtaining a sample of 96,902 participants (63.23 ± 6.77 years). We found a strong association between the self-perceived health rating and not only physical health aspects but also mental health and cognitive functioning. In particular, BMI, chronic diseases and medications, muscle strength, and mobility issues had a strong effect on self-perceived health, as also did the quality of life, depression, and verbal fluency, while other aspects, such as individual characteristics, limitations in daily activities, and pain, among others only had a small effect. These results show that public health and prevention interventions should prioritize the targeting of all aspects of well-being and not only of physical health, acknowledging self-perceived health rating as a simple tool that could help provide a complete overview of psycho-physical well-being and functional status.

Predictors of Use of Preventative Health Services for People with Disabilities in Taiwan

People with disabilities display less use of preventive health services, such as health examinations, flu vaccinations, Pap smears and breast screening, but evidence has shown that preventive health services can detect or even prevent serious diseases and medical problems. Therefore, identifying the factors associated with the use of preventive health services is important for people with disabilities. This study examined the use of preventive health services by people with disabilities and identified other associated factors for people with disabilities. The research used social demographics and the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) 12 items to measure activity and participation (AP) and other factors; there were 742 people with disabilities recruited with stratified proportional sampling. The data were collected through face-to-face interviews. The findings revealed that the common types of preventive services accessed by people with disabilities were health examinations and flu vaccinations; most of them had only used one preventive health service in the past year. The factors of having caregivers of spouses (OR = 1.74), perceived good health (OR = 1.26), and less limitation of AP (OR = 0.99) were significantly associated with the use of preventive services (p < 0.01). The study found a significant association between having children as caregivers and the non-use of Pap smears and breast screening services among women, providing valuable evidence for the distribution of the use of preventive health services for people with disabilities. Furthermore, the study highlighted the present status of disparities in the use of preventive services for people with disabilities and should encourage a boost in the adjustment of the medical environment and service resource allocation by the Taiwanese government for people with disabilities.

Age Takes Hold of Us by Surprise: Conceptualizing Vulnerabilities in Aging as the Timing of Adverse Events

OBJECTIVES

Aging in the public eye can be distilled to a limited number of adverse events, such as loss of health, partnership and wealth. While these events are a constitutive part of "normal aging," they do not occur uniformly at the same time point in the life course. This study investigates to what extent bereavement, functional health loss, and onset of poverty are adequate markers of aging, and illustrates inequalities in their timing according to cohort, gender, class, education, and ethnicity.

METHODS

The English Longitudinal Study of Ageing (ELSA), collected over seven waves (2002-2016) (n = 7,890) is examined in an event history framework. Cox proportional hazard models are used with the Andersen Gill extension in case of multiple failures per respondent.

RESULTS

Persistent associations of lower occupational class, lower education, and having a black or minority ethnic background are found with increased hazards of functional health loss and wealth loss. Earlier born cohorts have lower hazards for functional health loss, wealth loss, and bereavement. Women have higher hazards for bereavement, and lower hazards for wealth loss.

DISCUSSION

The timing of adverse events is a crucial gateway through which existing social inequalities are transferred into unequal aging pathways.

The relationship between gender roles and self-rated health: A perspective from an international study

OBJECTIVES

To examine the relationship between gender roles and self-rated health in older men and women from different contexts.

METHODS

2002 community-dwelling older adults from the International Mobility in Aging Study were recruited from 5 research sites. Gender role was measured with the 12-item Bem Sex Role Inventory, which categorized study participants into four gender roles: Masculine, Feminine, Androgynous, and Undifferentiated. Self-rated health was collapsed into a dichotomous variable (Very Good/Good and Fair/Poor/Very Poor). Prevalence risk ratios (PRR) of self-rated health relative to gender roles were estimated with Poisson regression models adjusted for all relevant confounders.

RESULTS

After complete adjustment, feminine (PRR 1.22 (95 % CI 1.01-1.49)) and undifferentiated (PRR 1.25 (95 % CI 1.05-1.50)) gender roles were associated with poorer relative self-rated health.

DISCUSSION

Gender roles confer independent risks and benefits for self-rated health in older adults.

Post-war (1946-2017) population health change in the United Kingdom: A systematic review

We systematically reviewed the evidence on secular trends in main chronic conditions, disability and self-assessed general health among adults in the United Kingdom, as reported in primary/secondary care databases and population-based surveys. Searches were conducted separately for: (1) trends in age-standardised or age-specific prevalence of major non-communicable diseases, disability, and self-reported general health; (2) trends in health expectancy. The databases searched were MEDLINE, EMBASE/EMBASE Classic and Web of Science (all from 1946/7). The evidence was synthesised narratively. There were 39 studies reporting trends in prevalence of health conditions and 15 studies in health expectancy. We did not find evidence for improvement in the age-standardised or age-specific prevalence of any of the studied major chronic conditions over the last few decades, apart from Alzheimer's disease and other dementias. Both increasing or stable prevalence rates with simultaneous rising life expectancy support the expansion of morbidity theory, meaning that people are expected to spend a greater number of years with chronic condition(s). The evidence on disability-expressed as prevalence or health expectancy-was mixed, but also appeared to support the expansion of morbidity among those aged 65 or over. The evidence on trends in disability for younger age is lacking. Across the studied period (1946-2017), the UK population endured more years with chronic morbidity and disability, which may place a serious strain on the health care system, the economy and the society.

Differences between Men and Women in Mortality and the Health Dimensions of the Morbidity Process

BACKGROUND

Do men have worse health than women? This question is addressed by examining sex differences in mortality and the health dimensions of the morbidity process that characterize health change with age. We also discuss health differences across historical time and between countries.

CONTENT

Results from national-level surveys and data systems are used to identify male/female differences in mortality rates, prevalence of diseases, physical functioning, and indicators of physiological status. Male/female differences in health outcomes depend on epidemiological and social circumstances and behaviors, and many are not consistent across historical time and between countries. In all countries, male life expectancy is now lower than female life expectancy, but this was not true in the past. In most countries, women have more problems performing instrumental activities of daily living, and men do better in measured performance of functioning. Men tend to have more cardiovascular diseases; women, more inflammatory-related diseases. Sex differences in major cardiovascular risk factors vary between countries-men tend to have more hypertension; women, more raised lipids. Indicators of physiological dysregulation indicate greater inflammatory activity for women and generally higher cardiovascular risk for men, although women have higher or similar cardiovascular risk in some markers depending on the historical time and country.

SUMMARY

In some aspects of health, men do worse; in others, women do worse. The lack of consistency across historical times and between countries in sex differences in health points to the complexity and the substantial challenges in extrapolating future trends in sex differences.

A qualitative study of older adults' and family caregivers' perspectives regarding their preoperative care transitions

AIMS AND OBJECTIVES

To explore how older patients with multiple chronic conditions and their family caregivers perceive their engagement and overall care experience throughout the preoperative phase of elective orthopaedic hip or knee joint replacement.

BACKGROUND

Patient engagement is a critical component of care necessary for improving patient outcomes. Little is known about how older adults with multiple chronic conditions and their family caregivers engage in preoperative care transitions and the subsequent impact of this experience on postoperative health outcomes.

DESIGN

Prospective qualitative descriptive design was used.

METHODS

Semi-structured telephone interviews with a convenience sample of older adults coping with multiple chronic conditions and their family caregivers. Interviews were conducted prior to surgery and, again 21 days postsurgery, were audio-recorded and transcribed for qualitative content analysis. The Quality Health Outcomes Model was used to categorise study findings.

RESULTS

Eleven patients and five family caregivers participated. Guided by the Quality Health Outcomes Model, four major themes were identified. (i) Older adults perceive that joint replacement is about quality of life. (ii) Standardised interventions often fail to address the unique needs of complex older adults. (iii) Family caregivers perceive they are the primary care coordinators. (iv) Postoperative outcomes and resource utilisation vary widely in complex older adults.

CONCLUSION

Findings suggest that current preoperative care interventions are often not designed to effectively engage complex older patients and their family caregivers. Coordinated patient-centred preoperative care that reflects the needs and goals of complex older patients and their family caregivers may positively influence perioperative care transitions and outcomes beyond this episode of care.

RELEVANCE TO CLINICAL PRACTICE

The current research documents the need for more in-depth knowledge about the relationship between older adults' and their family caregivers' engagement preoperatively and postoperative outcomes and resource utilisation.

Health and income inequalities in Europe: What is the role of circumstances?

Equality of opportunity theories distinguish between inequalities due to individual effort and those due to external circumstances. Recent research has shown that half of the variability in income of World population was determined by country of birth and income distribution. Since health and income are generally strictly related, the aim of this paper is to estimate how much variability in income and health is determined by external circumstances. We use data from the Survey of Health, Ageing and Retirement (SHARE) and the English Longitudinal Survey on Ageing (ELSA), two comparable multidisciplinary surveys that provide micro-level data on health and financial resources among the elderly for a large number of European countries. Our baseline estimation shows that about 20% of the variability in income is explained by current country-specific circumstances, while health outcomes range from 12% using BMI to 19% using self-rated health. By including early-life circumstances, the explained variability increases almost 20 percentage points for income and for self-rated health but less for other health outcomes. Finally, by controlling for endogeneity issues linked with effort, our estimates indicate that circumstances better explain variability in health outcomes. Results are robust to some tests, and the implications of these findings are discussed.

Comparison of a Self-Reported and a Performance-Based Assessment of Mobility in the Hispanic Established Population for Epidemiological Studies of the Elderly

In this study, the authors employ data from the Hispanic Established Population for Epidemiological Studies of the Elderly to examine the concordance between a self-reported measure of the ability to walk across a small room and a performance-based assessment of the respondent’s ability to perform the same task. The data reveal that although these two ways of assessing this particular aspect of functional capacity are roughly concordant, other psychological and social factors affect self-reports independent of actual physical ability. A large proportion of individuals who are unable to complete the performance-based task report that they are mobile. The analysis indicates that performance-based measures are better predictors of mortality than self-assessments, but when viewed in terms of the disablement process, it is clear that performance-based and self-reported measures tap something different. The authors conclude that each type of measure conveys useful information about functioning in complex daily environments.

Examination of the Causes and Mechanisms of the Increase in Disability-Free Life Expectancy

From 1981 to 1991, life expectancy at birth in France increased by 2.5 years. Health survey data show that during this 10-year period, disability-free life expectancy increased significantly by 3.0 years in males and 2.6 years in females. Consequently, the proportion of years lived without disability within life expectancy has increased. For example, in males it increased from 86.4% to 87.5% in this time period. These observations show that, contrary to the frequent predictions of "pandemia" of disabilities or expansion of morbidity, the major increase in life expectancy in France over the past 10 years has been accompanied by a compression of morbidity. In the present study, the authors explore the causes and mechanisms of this positive development.

Healthy life expectancy changes in Thailand, 2002-2007

We investigate links between increasing longevity and health status in Thailand. Using data from 2002 and 2007 national surveys of the elderly, healthy life expectancies at older ages were estimated. Change depended on health indicator, gender and age. Self-reported health and self-care disability showed expansion of morbidity. Mobility disability change indicated compression but a wording change means this may be an artefact. We compare these findings with the 1990 and 2010 results of the Global Burden of Disease study. Using HLE based on disease prevalence, the GBD found that Thailand experienced small longevity gains and morbidity compression. Our findings suggest these results should be treated with caution, as, since 2000, Thailand has introduced universal health care.

Effects of social ties on self-rated physical health among African American adults

OBJECTIVES

To examine associations between social ties and self-rated physical health among midlife and older African Americans.

METHODS

Cross-sectional analysis of the 2005-2006 Milwaukee African American oversample of the second Midlife Development in the United States (MIDUS II) study. Multivariate logistic regression examined associations between type of social ties (family or friends), their frequency (number of contacts), and their quality (support and strain) with betterself-rated physical health (SRPH). We defined better SRPH to include self-reports of good, very good, or excellent SRPH: this category was compared with fair or poor SRPH. Control variables included demographic factors; social engagement characteristics such as working, volunteering, and caregiving; and measures of social structure such as types of discrimination experience and ratings of neighborhood quality.

RESULTS

In adjusted results, each additional degree of family support was associated with better self-rated physical health (odds ratio [OR], 1.59; 95% confidence interval (CI], 1.14-2.22). Each additional reported incident of daily discrimination was associated with 9% lower odds of reporting better SRPH (OR, 0.91; CI, 0.83-0.99).

DISCUSSION

Results suggest quality of family support may contribute importantly to the health of African Americans. When working with midlife and older African Americans, providers should engage and support families as a vital resource to improve health.

Generational differences in the reporting of tinnitus

OBJECTIVES

Recent research suggests that hearing impairment is declining among older adults compared with earlier generations of the same age. Tinnitus is often associated with hearing impairment, so one might hypothesize that the prevalence of tinnitus is declining in a similar manner. The purpose of this study was to use multigenerational data with repeated measures to determine whether the prevalence of tinnitus is declining among more recent generations.

DESIGN

Using data from the Epidemiology of Hearing Loss Study (1993-1995, 1998-2000, 2003-2005, and 2009-2010) and the Beaver Dam Offspring Study (2005-2008), the authors examined birth cohort patterns in the report of tinnitus for adults aged 45 years and older (n =12,689 observations from 5764 participants). Participants were classified as having tinnitus if they reported tinnitus in the past year of at least moderate severity or that caused difficulty falling asleep. A low-frequency (500, 1000, and 2000 Hz) and high-frequency (3000, 4000, 6000, and 8000 Hz) pure tone average from the worse ear was used to summarize hearing status. Other potential risk factors for tinnitus were also explored to determine if changes in the prevalence of these factors over time could explain any observed birth cohort differences in the prevalence of tinnitus. These included the following: education, history of head injury, history of doctor-diagnosed ear infections, history of cardiovascular disease (myocardial infarction, stroke, or angina), current noisy job, longest-held job, target shooting in the past year, number of concerts ever attended, alcohol use in the past year, doctor diagnosis of arthritis, current aspirin use, regular exercise, and consulting with a physician in the past year about any hearing/ear problem. Birth cohort effects were modeled with alternating logistic regression models which use generalized estimating equations to adjust for correlation among repeated measurements over time that are nested within families.

RESULTS

The report of tinnitus tended to increase with more recent birth cohorts compared with earlier birth cohorts. For example, at ages 55 to 59 years, 7.6% of participants born between 1935 and 1939 reported tinnitus, compared with 11.0% of those born in 1940 to 1944, 13.6% of those born between 1945 and 1949, and 17.5% of those born between 1950 and 1954. Similarly, at ages 65 to 69 years, 7.9% of participants born between 1925 and 1929 reported tinnitus, compared with 10.0% of those born between 1930 and 1934, 11.9% of those born between 1935 and 1939, and 13.7% of those born between 1940 and 1944. Final alternating logistic regression model results indicated that, on average, after adjusting for age and other factors, participants in a given generation were significantly more likely to report tinnitus than participants from a generation 20 years earlier (odds ratio = 1.78, 95% confidence interval = 1.44, 2.21).

CONCLUSIONS

Increased reports of tinnitus may reflect increased prevalence of symptoms, increased awareness of symptoms, or higher health expectations among more recent generations of adults. Regardless of the reasons, the increasing prevalence of tinnitus suggests that health care providers may see an increased number of patients bothered by this common but little understood symptom.

Changes over time from baseline poor self-rated health: for whom does poor self-rated health not predict mortality?

The aim of this study was to understand for whom and why poor self-rated health (SRH) is a less valid predictor of longevity or future health by examining the predictors of decline in health among people with poor baseline SRH. The sample included 409 participants in the Cross-Sectional and Longitudinal Study of the old-old (75+) in Israel, who were self-respondents and rated their health as poor at baseline and their status was known at follow-up 3.5 years later: deceased/moved to proxy interview/remained in poor SRH/or improved SRH. Baseline measures included self-reported medical status, physical, cognitive, psychological and social functioning. Findings showed that less decline in health was predicted by less difficulty in physical and cognitive functioning at baseline and by a more active physical and social life, after controlling for socio-demographics. Most of the predictors retained a unique contribution in a multivariate model, suggesting that engagement in meaningful activities serves as an indicator of better health and longer survival even within a group of old-old people in poor health. It may reflect greater social support, contribute to fitness and/or provide a sense of mastery, which could explain similar findings regarding gender and race/ethnicity groups for whom SRH is a less potent predictor of mortality.

Health-related factors associated with hospitalization for old people: comparisons of elderly aged 85 in a population cohort study

The aim of this population-based study was to (1) describe living conditions and actual health care utilization among 85 year olds; (2) determine factors that affect hospital admissions in this age. The study was conducted on 85-year-old residents in Linköping municipality, Sweden. The data collected included medical records, health care utilization during the preceding 12 months and a postal questionnaire on assistance, assistive technology, functional impairment, feelings of loneliness, worries and health-related quality of life measured by the EQ-5D. Out of 650 eligible individuals, 496 (78% of those alive) participated. Despite the prevalence of multi-morbidity (68%) and mental discomfort, the majority managed self-care (85%), usual activities (74%) and had high (>60/100) self-rated health evaluated by a visual analog scale (VAS). The non-hospitalized group reported a better health status than the hospitalized group in terms of medical aspects, living conditions and subjective estimation. Factors associated with in-patient care were an increased number of general practitioner visits, more assistive technology, community assistance, multimorbidity and/or diagnosed congestive heart failure and arrhythmia.

Later life health optimism, pessimism and realism: psychosocial contributors and health correlates

Prior research has established positive outcomes of health optimism (appraising one's health as good despite poor objective health (OH)) and negative outcomes of health pessimism (appraising health as poor despite good OH), yet little is known about their contributors. We examined the role of psychosocial factors (life event stress, depression, dispositional optimism, perceived social support) in health realism (appraising health in accordance with OH), optimism and pessimism among 489 older men and women. We then accounted for the psychosocial factors when examining multiple health correlates of health realism, optimism and pessimism. Controlling for age, gender and income, regression results indicate that depression and social support were associated with less health optimism, while dispositional optimism was associated with greater health optimism among those in poor OH. Dispositional optimism was associated with less health pessimism and life event stress was associated with greater pessimism among those in good OH. Beyond the effects of the psychosocial factors, structural equation model results indicate that health optimism was positively associated with healthy behaviours and perceived control over one's health; health pessimism was associated with poorer perceived health care management. Health optimism and pessimism have different psychosocial contributors and health correlates, validating the health congruence approach to later life well-being, health and survival.

Mortality and morbidity trends: is there compression of morbidity?

OBJECTIVE

This paper reviews trends in mortality and morbidity to evaluate whether there has been a compression of morbidity.

METHODS

Review of recent research and analysis of recent data for the United States relating mortality change to the length of life without 1 of 4 major diseases or loss of mobility functioning.

RESULTS

Mortality declines have slowed down in the United States in recent years, especially for women. The prevalence of disease has increased. Age-specific prevalence of a number of risk factors representing physiological status has stayed relatively constant; where risks decline, increased usage of effective drugs is responsible. Mobility functioning has deteriorated. Length of life with disease and mobility functioning loss has increased between 1998 and 2008.

DISCUSSION

Empirical findings do not support recent compression of morbidity when morbidity is defined as major disease and mobility functioning loss.

The Unique Role of Sleep Quality in Older Adults’ Psychological Well-Being

Previous research has established a link between sleep quality and psychological well-being in older adults. However, no research to date has investigated this relationship in the context of other factors known to influence both sleep and psychological well-being. Among a sample of 489 independently living older adults (ages 60 to 98), the current study examined the association between sleep quality and psychological well-being (positive emotions, negative emotions, depression) while controlling for individual differences in factors known to affect sleep: physical health, stress, physical activity, functional ability, and demographics. Multiple linear regression models showed that both better current sleep quality and better comparative sleep quality (from middle to older adulthood) predicted better psychological well-being. Implications include interventions to improve sleep quality in older adults.

Locomotor disability: meaning, causes and effects of interventions

This paper provides a synopsis of a long-term programme of MRC-funded work on locomotor disability in older people. Specifically it describes the meaning and experience of disability, examines the risk factors for disability and systematically reviews the evidence from randomized trials of complex interventions for disability. We undertook a national prospective study of a representative sample of 999 people aged 65 years or more plus in-depth interviews with a small subsample and a selected sample obtained from hospital sources. Secondary analysis of several large prospective studies was carried out and a systematic review and meta-analysis of published randomized controlled trials of the effects of complex interventions for disability. Very few participants subscribed to the constructs of longstanding illness, disability or infirmity that surveys often use. A wide range of social and psychological factors, independently of chronic diseases, were strongly associated with disability. People with greater functional reserve capacity and those with greater self-efficacy were generally less likely to suffer from catastrophic decline in ability and had better quality of life in the face of disability. In reviewing 89 trials (over 97,000 participants) of complex interventions for disability, evidence of benefits was found although no relationship with intensity of intervention was apparent. Our findings on the meaning and experience of disability suggest the need for modifications to routinely used survey questions and for different ways of understanding the need for and receipt of care among older people with disabilities. The diverse risk factors for disability suggest that novel approaches across social, psychological as well as more traditional rehabilitation and behavioural risk factor modification would be worth exploring. Complex interventions appeared to help older people to live independently and limit functional decline irrespective of age and health status.

Cohort differences in disease and disability in the young-old: findings from the MRC Cognitive Function and Ageing Study (MRC-CFAS)

Background

Projections of health and social care need are highly sensitive to assumptions about cohort trends in health and disability. We use a repeated population-based cross-sectional study from the Cambridgeshire centre of the UK Medical Research Council Cognitive Function and Ageing Study to investigate trends in the health of the young-old UK population

Methods

Non-overlapping cohorts of men and women aged 65–69 years in 1991/2 (n = 689) and 1996/7 (n = 687) were compared on: self-reported diseases and conditions; self-rated health; mobility limitation; disability by logistic regression and four-year survival by Cox Proportional Hazards Regression models, with adjustments for differences in socio-economic and lifestyle factors.

Results

Survival was similar between cohorts (HR: 0.91, 95% CI: 0.62 to 1.32). There was a significant increase in the number of conditions reported between cohorts, with more participants reporting 3 or more conditions in the new cohort (14.2% vs. 10.1%). When individual conditions were considered, there was a 10% increase in the reporting of arthritis and a significant increase in the reporting of chronic airways obstruction (OR: 1.36, 95% CI: 1.04 to 1.78).

Conclusion

This study provides evidence of rising levels of ill-health, as measured by the prevalence of self-reported chronic conditions, in the newer cohorts of the young-old. Though changes in diagnosis or reporting of disease cannot, as yet, be excluded, to better understand whether our findings reflect real increases in ill-health, investment should be made into improved population-based databases, linking self-report and objective measures of health and function, and including those in long-term care.

The burden of diseases on disability-free life expectancy in later life

BACKGROUND

The consequences of diseases in later life have been judged predominantly through mortality, resulting in an emphasis on the fatal rather than the nonfatal disabling conditions. We use a longitudinal study with follow-up at 2, 6, and 10 years to assess the impact of different diseases on both total life expectancy (TLE) and disability-free life expectancy (DFLE).

METHODS

The Medical Research Council Cognitive Function and Ageing Study investigators interviewed 13,004 people aged 65 years and older from five U.K. centers starting in 1991. Persons aged 75 years and older were oversampled. Disability (mild, moderate, and severe) was assessed through basic Activities of Daily Living (ADL) and Instrumental ADL (IADL) scales at baseline and at follow-ups at 2, 6, and 10 years. TLE and DFLE were compared for persons with and without each of nine conditions.

RESULTS

At age 65, men had a TLE of 15.3 years of which 12.1 (79%) were free of any disability, whereas women of the same age had an average TLE of 19.4 years, 11.0 years (57%) disability-free. Men (women) aged 65 years without stroke had 4.8 (4.6) more years of TLE and 6.5 (5.8) more years DFLE. Without diabetes, men (women) lived 4.4 (5.6) years longer and had 4.1 (5.1) years disability-free.

CONCLUSIONS

More disability-free years were gained than total life years in persons free of stroke, cognitive impairment, arthritis, and/or visual impairment at baseline. This finding suggests that elimination of these conditions would result in a compression of disability.

Health Trends in the Elderly Population: Getting Better and Getting Worse

Health trends in the fastest growing sector of the population, the oldest old, have received much attention during the past decade because of the rising costs of medical and long-term care. Many studies have suggested a compression of morbidity in this sector, implying that the future care needs of elderly people will not follow the demographic prognoses. Most of these studies have used health indicators based on disability, a concept that is contextually embedded. We have taken a closer look at health-trend surveys with a focus on the health indicator used. Our findings reveal that although disability measures often show improvement, there is a simultaneous increase in chronic disease and functional impairments-health components that require care resources. That is, an expansion of other health problems may accompany a compression of disability. Therefore, a concept of general morbidity is not sufficient when discussing health trends and the need for care services in the elderly population. Because different indicators do not show the same trends over time, we suggest a more refined discussion that distinguishes between different health components. In addition, different components have different implications for the amount and kind of care resources needed. If the current positive trends in disability continue, future need for social services and long-term care may not parallel demographic projections. Trends in disease and functional limitations seem to have taken a different direction, suggesting a parallel or increased need for resources in medical care, rehabilitation, and compensatory interventions such as assistive technology.

Self-rated health status as a predictor of death, functional and cognitive impairment: a longitudinal cohort study

Understanding the prognostic capacity of a simple measure of self-rated health (SRH) by older people becomes increasingly important as the population ages. SRH has been shown to predict survival, functional status and service use. The relationship with cognitive impairment has not been widely investigated. This paper investigates SRH as a predictor of death, functional impairment (inability to perform activities of daily living) and cognitive impairment (MMSE < 18) over a 10-year follow-up of participants in the MRC Cognitive Function and Ageing Study. A stratified random sample of 13,004 people aged 65 or over resident in five areas in England and Wales were interviewed. Analysis used data from interviews at baseline, 2, 6 and 10 year follow-up. Hazard ratios for risk of death, functional and cognitive impairment were estimated, unadjusted and adjusted for potential confounding baseline factors. Of the 13,004 participants recruited, 6,882 had died by 10 years and 1,252 and 481 new cases of functional and cognitive impairment respectively were recorded. SRH was associated with a higher risk of death, functional and cognitive impairment. The associations remained after adjustment for age, gender, functional ability and MMSE at baseline: comparing those who rated their health as excellent and good, hazard ratios for risk of death, functional and cognitive impairment were 0.8 (95% CI 0.8-0.9), 0.6 (95% CI 0.5-0.7) and 0.7(95% CI 0.5-0.9), respectively. In-depth qualitative study designs are needed to investigate why the meaning older people give to their health status predicts long-term outcomes.

When mental health becomes health: age and the shifting meaning of self-evaluations of general health

Do self-evaluations of general health change as individuals age? Although several perspectives point to age-related shifts, few researchers have compared them. For this article, several competing hypotheses were tested using a large, nationally representative, and longitudinal data set. The results suggest two trends. First, the correspondence between functional limitations and self-rated health declines, especially after age 50. Similarly, the correspondence between various chronic conditions and self-rated health declines with age. These findings are consistent with social comparison theory. Yet, the results also suggest that the correspondence between depressive symptoms and self-rated health increases. Indeed, after age 74, the correspondence between self-rated health and some common symptoms of depression becomes stronger than that between self-rated health and several chronic, and often fatal, somatic conditions. This crossover has important implications for the detection and treatment of depressive symptoms in later life.

From a postal questionnaire of older men, healthy lifestyle factors reduced the onset of and may have increased recovery from mobility limitation

BACKGROUND AND OBJECTIVE

We have examined predictors of the onset of and recovery from mobility limitation and the association between lifestyle changes in later life and mobility status.

STUDY DESIGN AND SETTING

From a cohort of 7,735 men recruited at ages 40-59 years (1978-1980), 5,075 men completed follow-up postal questionnaires in 1992 (Q92), then aged 52-73 years, and again in 1996 (Q96). Mobility limitation was defined as reported difficulty in any one or more of the following: getting outdoors, walking 400 yards, or climbing stairs.

RESULTS

Lifestyle factors (smoking, obesity, physical inactivity, and heavy drinking) and manual worker social class were significantly and independently associated with onset of mobility limitation and with the exception of physical activity remained significant after further adjustment for chronic diseases. Smoking cessation and taking up physical activity in later life are associated with reduced onset of mobility limitation. Among men with mobility limitation at Q92 (n=645), light or moderate levels of physical activity were associated with significantly increased odds of recovery at Q96 (light activity, OR=2.43, 95% CI 1.48, 4.00; moderate activity, OR=2.57, 95% CI 1.31, 5.02).

CONCLUSION

Maintaining and adopting a healthy lifestyle in later life reduces the onset of mobility limitation in old age. Maintaining physical activity may improve recovery.

Looking Forward to a General Theory on Population Aging

The main theories on population aging based on recent data on human longevity, life expectancy, morbidity changes, disability trends, and mortality decrease are presented and discussed within their own geographic, cultural, socioeconomic, and medical contexts. The complex interactions between all these components do not facilitate trend forecasting of aging population (healthy aging versus disability pandemic). In the context of population aging, four elements were introduced with their implications: 1) an increase in the survival rates of sick persons, which would explain the expansion of morbidity, 2) a control of the progression of chronic diseases, which would explain a subtle equilibrium between the decrease in mortality and the increase in disability, 3) an improvement of the health status and health behaviors of new cohorts of elderly people, which would explain the compression of morbidity, and eventually 4) an emergence of very old and frail populations, which would explain a new expansion of morbidity. Obviously, all these elements coexist today, and future trend scenarios-expansion or compression of disability-depend on their respective weights leading to the need of elaborating "a general theory on population aging." This theory has to be based on a world harmonization of functional decline measurements and a periodic "International Aging Survey" to monitor global aging through a sample of carefully selected countries.

Functional ability in the elderly Finnish population: time period differences and associations, 1985-99

AIMS

The aim of this study was to determine whether functional ability among 65- to 79-year-old Finnish men and women changed at population level from the 1980s to 1990s and how gender, age, previous occupation, and marital status are associated with functional ability and whether these associations have changed over time.

METHODS

Biennial surveys on health behaviour among Finnish elderly people were used to study 10,309 men and women from 1985 to 1999. Age, gender, previous occupation, and marital status were the demographic variables. Logistic regression was used to determine differences.

RESULTS

Functional ability deteriorated clearly with age, but was slightly better in the 1990s than 1980s. Gender differences of functional ability were small. Retired office employees had the best functional ability. Moreover, time changes of functional ability between occupational groups were a little more positive among men than among women. Functional ability of divorced and widowed elderly emerged as slightly worse than among married persons.

CONCLUSIONS

Young age and non-manual occupation prior to retirement were associated with better functional ability. The overall improvement of self-reported functional ability among elderly people suggests that the onset of disabilities could be postponed, especially if health-related circumstances were more evenly distributed at the start of or even before retirement age.

Recent perspectives on active life expectancy for older women

This article provides a critical review of recent active life expectancy literature, describing trends of special interest to women. We review findings from leading perspectives used to study life expectancy and active life expectancy, including gender, racial and socioeconomic differences, disease-specific effects, and biodemography. We examine three competing theories of population health that frame active life expectancy research-compression of morbidity, expansion of morbidity, and dynamic equilibrium-concluding there is support for both the compression of morbidity and dynamic equilibrium theories. Policy implications for women include a greater understanding of the role of education and racial and ethnic diversity in active life trends, and an increased public policy emphasis on prevention and treatment of chronic disease, together with adoption of more healthy lifestyles.

Improved functional status in 16 years of follow up of middle aged and elderly men and women in north eastern Finland

STUDY OBJECTIVE

To investigate age, period, and cohort effects on functional status.

DESIGN

A prospective cohort study with measurements in 1981, 1990, and 1996.

SETTING

Three municipalities in north east Finland.

PARTICIPANTS

A regionally representative sample of 19 to 63 year old men and women was drawn from the census data in 1979, of which 758 men and 1033 women initially aged 39-63 years entered the study in 1980 and completed the follow up in 1996 (90.9% of the alive cohort).

MEASUREMENTS AND MAIN RESULTS

Functional status was determined based on self estimated disabilities (difficulties or not able) to walk 2 km, climb several flights of stairs, and run 100 m. The age adjusted odds of disability in stair climbing and running were lower among the men and the women in 1990 and 1996 than among the men and the women in 1981. There was a declining trend in the odds of disability with succeeding birth cohorts among both the men (odds ratios (OR) 0.79 and 95% confidence intervals (CI) 0.70 to 0.88 for stair climbing and OR 0.88 and 95% CI 0.78 to 0.98 for running) and the women (OR 0.85 and 95% CI 0.77 to 0.93 for stair climbing and OR 0.85 and 95% CI 0.76 to 0.94 for running). No statistically significant differences in walking disability were found between the study periods or the study cohorts.

CONCLUSIONS

The findings depict an improved time trend in functional status in the study population, with implications for future health and social care planning.

Improved health among 70-year olds: comparison of health indicators in three different birth cohorts

BACKGROUND AND AIMS

Whether or not there has been a "compression of morbidity" in older ages has been vividly debated during the last decades. Previous studies have found indications of both improved and deteriorated health among elderly persons. Few studies have analyzed how changes in health indicators are influenced by social background factors. The aim of this study was to analyze the differences in morbidity--measured as self-assessed health, number of symptoms, number of diseases and physical function--in three different cohorts of 70-year olds, with special regard to the impact of social factors.

METHODS

We used data from random samples of 70-year-old people born in 1901/02 (cohort 1), 1906/07 (cohort 2), and 1911/12 (cohort 3). In the three cohorts there were 973, 1036 and 619 participants, respectively. They had a medical examination and were interviewed regarding social background, social network, self-assessed health, need of care, and number of diseases.

RESULTS

There were fewer 70-year olds not feeling healthy in the two younger cohorts (OR = 0.68; CI = 0.56-0.83, and OR = 0.67; CI = 0.53-0.84 respectively) and fewer with many symptoms. There were also indications of better physical functioning in the younger cohorts. Women seemed to have gained more than men, while the institutionalized persons had a deterioration.

CONCLUSIONS

There are indications of good years being added, but not for the institutionalized persons.

Subjective well-being among the old-old: the role of health, personality and social support

The purpose of this study was to devise and test a path model that explains how background variables, physical capacity, and psychosocial resources (locus of control and social network supportiveness) affect three well-being outcome measures--self-rated health, mental health, and life satisfaction--among the old-old in Israel. A sample of European-born persons aged seventy-five and over, drawn randomly from the population registry in the greater Tel Aviv area, was administered a structured questionnaire in personal interviews (N=194). The findings confirm that the relationship between background variables, physical capacity and well-being is differentially mediated by the psychosocial resources, with different variable combinations predicting each of the respective facets of well-being. Moreover, the relative strength of the relationships between locus of control and social network supportiveness and well-being indicate that among the old-old, personality factors may be more consequential than social resources for one's well-being.

Trends in informal care in Great Britain during the 1990s

The population of adult carers in Great Britain declined during the 1990s while the proportion of those heavily involved in providing informal care increased. The intensification of care-giving was associated with an increasing number of caring relationships that typically make heavy demands on the carer: spouse care and caring for a child or parent. The provision of informal care by friends and neighbours diminished resulting in an overall decline in care-giving between households. However, parents were increasingly looked after in their own homes by non-resident daughters. More women than men withdrew from the less intensive care-giving between households while more men than women took on the role of a spouse carer. By the end of the decade, as many men as women provided informal care for a spouse or partner. If the trends identified here continue beyond the study period, increasing resources will be required to identify heavily involved carers, assess their needs, and support them in their caring activities. The findings are based on secondary analysis of the British Household Panel Survey covering the years 1991-1998. As well as charting trends in the prevalence of informal care, changes in the locus of care, the number of care recipients, their relationship to their carer and the amount of time devoted to caring activities are described and interpreted.

Correlates of subjective health in older adults: a meta-analysis

Age-associated changes of subjective health and associations of subjective health with physical health, functional health, and mental health were meta-analyzed in older adults (M age > 60 years). An age-associated decline of subjective health, which was stronger in old-old samples than in young-old samples, was found. Subjective health was correlated with the indicators of objective health, but the association with physical health was stronger than with functional health. Correlations of subjective health with physical health and functional health were lower in the old-old than in the young-old samples, whereas associations of subjective health with mental health were stronger in older samples. Furthermore, the size of the association between subjective and objective health varied by the method of assessment of objective health, showing highest associations with symptom checklists and results of medical examinations due to strict protocols.

Secular trends in self-reported functioning, need for assistance and attitudes towards life: 10-year differences of three older cohorts

OBJECTIVES

To compare the self-reported functional status of cohorts, born 10 years apart, when they were at equivalent ages: 75, 80, or 85.

DESIGN

Cross-sectional mailed survey of three birth cohorts in 1989 and 1999.

PARTICIPANTS

Random samples of older home-dwelling residents from birth cohorts 1904, 1909, and 1914 in 1989 ( N = 685) and the birth cohorts 1914, 1919, and 1924 in 1999 ( N = 2,047) were asked the same questions.

MEASUREMENTS

Self-reported physical functioning, need for assistance in daily living, and attitudes toward life.

RESULTS

Among 85-year-olds born in 1914 there was a significantly larger proportion able to go outdoors compared with 85-year-olds born in 1904 (72.9% vs 60.6% in women (P <.01) and 84.6% vs 63.6 % in men (P <.01), respectively). Similar trends were observed between the oldest cohorts concerning the need for assistance. The amount of publicly funded domestic help had reduced in the two oldest cohorts in 1999 compared with 1989 (20.3% vs 29.8% in 85-year-old women born in 1914 vs 1904 (P <.05); and 10.2 % vs 25.0% in 85-year-old men born 1914 vs 1904 (P <.05), but at the same time 75-year-old women born in 1924 had increased the use of private domestic help compared with 75-year-old women born in 1914. Significantly larger proportions of both men and women had plans for the future in all the cohorts in 1999 than in 1989.

CONCLUSIONS

Consistent yet small differences between the corresponding cohorts suggest that physical functioning and more-optimistic attitude toward life have increased and need for assistance has decreased over 10 years in the older population up to the age of 85.

Evolution of self-rated health status in the elderly: cross-sectional vs. longitudinal estimates

We assessed the perceived health status evolution among elderly subjects and examined the age-related differences in perceived health when comparing estimates obtained from cross-sectional and longitudinal approaches. Data come from a cohort of non-institutionalized individuals aged 65 years or older, living in Barcelona, Spain. One thousand three hundred fifteen (1315) elderly were successfully interviewed at baseline in 1986 and 754 (84.6% of the eligible) at the re-assessment (1993-1994). Estimates of change in perceived health status were calculated based on cross-sectional and longitudinal approaches. Cross-sectionally, no significant differences in the proportion of individuals with poor self-rated health were found (40.5 vs. 42.5%, P = 0.90). Among survivors, the proportion of individuals with poor health increased from 37.8% to 55.1% (P < 0.01), an 8.7-fold decline of perceived health when compared with the cross-sectional estimates. Comorbidity (aOR 2.1; 95%CI: 1.4-3.3) and no education (aOR 1.9; 95%CI: 1.1-3.2) were associated with a decline in health status after adjusting by baseline health status. We recommend the use of longitudinal studies to understand the evolution of perceived health in the elderly.

Long-range antecedents of functional capability in later life

A number of demographic, social, psychological, lifestyle, and health characteristics have been advanced as precursors of functional limitation among those who survive to old age. This study uses data from a 16-year longitudinal study to examine long-range antecedents of the respondents' level of physical functional capability in 1991. The model predicting functional capability from longitudinal data is more complex and more effective for women than for men. Older age, lower self-rated health, lower functional capability, and lower physical activity level in 1975 predict 35% of the variation in functional capability among women in 1991. Only older age and lower self-rated health are predictive for men and account for just 11% of the variation. These findings suggest a need for gender-specific models of antecedents of physical functional limitations in later life.

Social network type and health status in a national sample of elderly Israelis

A typology of social support networks was examined in relation to five health measures in a national probability sample of Israelis aged 60 and over, using multiple classification analysis (N = 4214). The procedure revealed that the more resourceful diversified and friend and neighbor network types were consistently associated with better scores on measures of basic and instrumental activities of daily living, incontinence, vision and self-rated health, even when controlling for respondents' age, sex and education. The religious family network type, also endowed with considerable support potential, tended to correlate with lower health scores. The narrow family focused network had average health ratings or less, and a moderate support capability. The least resourceful network type, the attenuated network, was most frequently associated with poor health.

Self-rated health and self-assessed change in health in elderly men and women--a five-year longitudinal study

The purpose of the present investigation was two fold: (1) to examine how men and women self-rate their health as they age from 75 to 80 yr and how they assess the change in their health over the five year period; and (2) to ascertain how self-assessed change in health over the follow-up period corresponded to the difference in self-ratings of health between the assessments performed at baseline and at follow-up. The study was part of the Evergreen-project with the study group comprising all inhabitants born in 1914 (N = 388) living in Jyväskylä, central Finland. At baseline, 93.4%, and at follow-up, 93.3%, of those who were eligible participated in the interview. Self-rated health, when asked using the same questions, did not change at follow-up compared to baseline. However, nearly half of the follow-up group reported that their health had become worse over the five year period. Gender differences in self-rated health were not found, although women reported more often than men that their health had become worse and some of the men said their health had become better. It is concluded that self-rated health seems to be age-adjusted; elderly people who say their health has become worse as they age actually self-rate their health as the same or better than before.

Health expectancy and the problem of substitute morbidity

During the past century, the developed world has not only witnessed a dramatic increase in life expectancy (ageing), but also a concomitant rise in chronic disease and disability. Consequently, the tension between 'living longer' on the one hand and health-related 'quality of life' on the other has become an increasingly important health policy problem. The paper deals with two consequences of this so-called epidemiological transition in population health. The first one concerns the question of how--given the impressive changes--population health can be measured in an adequate and policy relevant present-day fashion. The second one is the so-called phenomenon of 'substitute morbidity and mortality': more and more acute fatal diseases are replaced by non-fatal delayed degenerative diseases like dementia and arthritis. How the phenomenon of substitute morbidity and mortality affects the development of population health is illustrated with the epidemiological transitions, worldwide shifts in the main causes of death, assumptions used in models, adverse consequences of medical technologies and some results from intervention trials. Substitute morbidity and mortality may thwart our disease-specific expectations of interventions and asks for a shift to a 'total population health' perspective when judging potential health gains of interventions. Better understanding of the dynamics that underly the changes in population health is necessary. Implications for data collections are more emphasis on morbidity data and their relation with mortality, more longitudinal studies, stricter requirements for intervention trials and more use of modelling as a tool. A final recommendation is the promotion of integrative measures of population health. For the latter several results are presented suggesting that, although the amount of morbidity and disability is growing with an increasing life expectancy, this is mild unhealthiness in particular. This finding supports the 'dynamic equilibrium' theory. In absolute numbers, however, the burden of disease will continue to increase with further ageing of the population.

Ageing and the relationship between functional status and self-rated health in elderly men

Functional status (measured as functional limitations or disabilities) is an important determinant of self-rated health in the elderly. Several issues which are not yet clear in this association are addressed in this study: (i) the modifying effect of age on the association; (ii) the effect of recent changes in disability level on the current level of self-rated health, and (iii) the effect of functional limitations on self-rated health, independent of disabilities. Data were derived from the 1990, 1993 and 1995 surveys of the Zutphen Elderly Study, a longitudinal health study in men born between 1900 and 1920. Analyses of repeated measurements were performed with self-rated health as dependent variable and disabilities, functional limitations, age, survey year, and interaction terms as independent variables. Odds ratios were calculated from these models. Men with disabilities in instrumental activities of daily living had no different health ratings than men without disabilities. Those with disabilities in mobility and basic activities of daily living, however, had an odds ratio on poor self-rated health of 4.7 (95% confidence interval: 2.7-7.9) and 8.9 (4.6-17.1) respectively. This association became weaker with increasing age, leading to an absence of a significant association in the oldest group. The current level of self-rated health was only associated with the current level of disabilities. Information on previous levels of disabilities did not contribute to current self-rated health. Functional limitations had a small, but significant, effect on self-rated health when disabilities were taken into account. This study helps in enhancing insight in the complex relationship between functional status and self-rated health in the elderly.

Age, time, and cohort effects on functional status and self-rated health in elderly men

OBJECTIVES

This study investigated age-related changes in functional status and self-rated health in elderly men, taking into account changes over time and differences between birth cohorts.

METHODS

The Zutphen Elderly Study is a longitudinal study of men born in the Netherlands between 1900 and 1920. Functional status and self-rated health were measured in 513 men in 1990, in 381 men in 1993, and in 340 men in 1995. Age, time, and cohort effects were analyzed in a mixed longitudinal model.

RESULTS

Longitudinal analyses showed that during 5 years of follow-up, the proportion of men without disabilities decreased from 53% to 39%, whereas the percentage who rated themselves as healthy decreased from 50% to 35%. Cross-sectional analyses confirmed changes in functional status, suggesting an age effect. Time-series analyses confirmed changes in self-rated health, suggesting a time effect. No birth-cohort effects were found.

CONCLUSIONS

Functional status deteriorates with age, whereas self-rated health is not related to age in men aged 70 years and older. The observed 5-year decline in self-rated health seemed to be due to a secular trend.