US trends in disability and institutionalization among older Blacks and Whites

Racial Disparities in Care Interactions and Clinical Outcomes in Black Versus White Nursing Home Residents With Dementia

BACKGROUND

With the increase in Black nursing home residents, racial and ethnic disparities in quality of care have been raised.

PURPOSE

The purpose of this study was to evaluate racial disparities in care and outcomes over 12 months.

METHODS

This was a secondary data analysis using data from the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia study. A total of 553 residents, 24% Black residents and 76% White residents, from 55 nursing homes were included.

RESULTS

Differences favoring Black resident were noted in agitation, quality of life, inclusion of person-centered care approaches in care plans, and fewer falls and hospitalizations. Differences in quality-of-care interactions favored White residents. There were no differences in depression, resistiveness to care, function, pain, or transfers to the emergency department.

CONCLUSIONS

Disparities in clinical outcomes were small and generally favored Black versus White residents except for quality-of-care interactions.

Trends in inequalities in disability in Europe between 2002 and 2017

BACKGROUND

Monitoring socioeconomic inequalities in population health is important in order to reduce them. We aim to determine if educational inequalities in Global Activity Limitation Indicator (GALI) disability have changed between 2002 and 2017 in Europe (26 countries).

METHODS

We used logistic regression to quantify the annual change in disability prevalence by education, as well as the annual change in prevalence difference and ratio, both for the pooled sample and each country, as reported in the European Union Statistics on Income and Living Conditions (EU-SILC) and the European Social Survey (ESS) for individuals aged 30-79 years.

RESULTS

In EU-SILC, disability prevalence tended to decrease among the high educated. As a result, both the prevalence difference and the prevalence ratio between the low and high educated increased over time. There were no discernible trends in the ESS. However, there was substantial heterogeneity between countries in the magnitude and direction of these changes, but without clear geographical patterns and without consistency between surveys.

CONCLUSIONS

Socioeconomic inequalities in disability appear to have increased over time in Europe between 2002 and 2017 as per EU-SILC, and have persisted as measured by the ESS. Efforts to further harmonise disability instruments in international surveys are important, and so are studies to better understand international differences in disability trends and inequalities.

Black-White Disparities in Moves to Assisted Living and Nursing Homes Among Older Medicare Beneficiaries

OBJECTIVES

Investigate black-white disparities in older adults' moves to assisted living and nursing homes and draw from the Andersen Healthcare Utilization Model to test explanations for any disparities.

METHODS

Data are from a nationally representative sample of older community-dwelling Medicare beneficiaries from the 2015 (N = 5,212) National Health and Aging Trends Study (NHATS). We use stepwise multinomial logistic regression to examine black-white disparities in moves out of community housing to assisted living or a nursing home over 2 years, before and after adjusting for predisposing (age, gender), enabling (income, housing tenure, Medicaid, living arrangement) and need (activities of daily living [ADL] limitation, physical capacity, self-rated health, and dementia) factors.

RESULTS

Black older adults are less likely to move to assisted living and are more likely to move to a nursing home compared to white older adults. Black-white disparities in moves to nursing homes are explained by black-white differences in enabling and need factors, whereas black-white disparities in moves to assisted living remain even after adjusting for enabling and need factors.

DISCUSSION

Unmeasured factors related to systemic racism (e.g., residential racial segregation, racial discrimination) and/or black-white differences in care preferences might further explain black-white disparities in moves to assisted living and warrant further investigation.

Race Differences in ADL Disability Decline 1984-2004: Evidence From the National Long-Term Care Survey

OBJECTIVE

Disability declined in lower levels of impairment during the late 20th century. However, it is unclear whether ADL disability also declined, or whether it did so across race. In this study, we examine cohorts entering later life between 1984 and 1999, by race, to understand changing ADL disability.

METHOD

We used latent class methods to model trajectories of ADL disability and subsequent mortality in the National Long-Term Care Survey among cohorts entering older adulthood (ages 65-69) between 1984 and 1999. We examined patterns by race, focusing on chronic condition profiles.

RESULTS

White cohorts experienced consistent declines in ADL disability but Blacks saw little improvement with some evidence for increased disability. Stroke, diabetes, and heart attack were predominant in predicting disability among Blacks.

DISCUSSION

Declining disability trends were only observed consistently among Whites, suggesting previous and future disability trends and their underlying causes should be examined by race.

Synergistic effects of cognitive impairment on physical disability in all-cause mortality among men aged 80 years and over: Results from longitudinal older veterans study

Objective

We evaluated effects of the interrelationship between physical disability and cognitive impairment on long-term mortality of men aged 80 years and older living in a retirement community in Taiwan.

Methods

This prospective cohort study enrolled older men aged 80 and older living in a Veterans Care Home. Those with confirmed diagnosis of dementia were excluded. All participants received comprehensive geriatric assessment, including sociodemographic data, Charlson’s Comorbidity Index (CCI), geriatric syndromes, activities of daily living (ADL) using the Barthel index and cognitive function using the Mini-Mental State Examination (MMSE). Subjects were categorized into normal cognitive function, mild cognitive deterioration, and moderate-to-severe cognitive impairment and were further stratified by physical disability status. Kaplan-Meier log-rank test was used for survival analysis. After adjusting for sociodemographic characteristics and geriatric syndromes, Cox proportional hazards model was constructed to examine associations between cognitive function, disability and increased mortality risk.

Results

Among 305 male subjects aged 85.1 ± 4.1 years, 89 subjects died during follow-up (mean follow-up: 1.87 ± 0.90 years). Kaplan-Meier unadjusted analysis showed reduced survival probability associated with moderate-to-severe cognitive status and physical disability. Mortality risk increased significantly only for physically disabled subjects with simultaneous mild cognitive deterioration (adjusted HR 1.951, 95% CI 1.036–3.673, p = 0.038) or moderate-to-severe cognitive impairment (aHR 2.722, 95% CI 1.430–5.181, p = 0.002) after adjusting for age, BMI, education levels, smoking status, polypharmacy, visual and hearing impairment, urinary incontinence, fall history, depressive symptoms and CCI. Mortality risk was not increased among physically independent subjects with or without cognitive impairment, and physically disabled subjects with intact cognition.

Conclusions

Physical disability is a major risk factor for all-cause mortality among men aged 80 years and older, and risk increased synergistically when cognitive impairment was present. Cognitive impairment alone without physical disability did not increase mortality risk in this population.

Differences in Functional Disability of Rural American Indian and White Older Adults With Comorbid Diabetes

This study examines racial/ethnic differences in functional disability among a sample of rural older adults with comorbid diabetes. In 2002, interviews were conducted with 62 rural American Indian and 64 White community-dwelling persons aged 65 years or older. Examination of disability levels by group suggested that functional disability for Whites was concentrated in the lower levels (1-2 limitations), whereas disability for American Indians was concentrated in the higher levels (3 or more limitations). Adjusted prevalence rates indicated that American Indian older adults were significantly more likely than Whites to require assistance with dressing, walking, bathing, and shopping. Conversely, for reaching the toilet in time, Whites were significantly more likely than American Indians to report a limitation. Results of this study, coupled with previous literature, suggest that American Indians are more functionally disabled than other racial/ethnic groups and have a marked need for future long-term care.

Past, Present, and Future of Healthy Life Expectancy

The success of the current biomedical paradigm based on a "disease model" may be limited in the future because of large number of comorbidities inflicting older people. In recent years, there has been growing empirical evidence, based on animal models, suggesting that the aging process could be delayed and that this process may lead to increases in life expectancy accompanied by improvements in health at older ages. In this review, we explore past, present, and future prospects of healthy life expectancy and examine whether increases in average length of life associated with delayed aging link with additional years lived disability-free at older ages. Trends in healthy life expectancy suggest improvements among older people in the United States, although younger cohorts appear to be reaching old age with increasing levels of frailty and disability. Trends in health risk factors, such as obesity and smoking, show worrisome signs of negative impacts on adult health and mortality in the near future. However, results based on a simulation model of delayed aging in humans indicate that it has the potential to increase not only the length of life but also the fraction and number of years spent disability-free at older ages. Delayed aging would likely come with additional aggregate costs. These costs could be offset if delayed aging is widely applied and people are willing to convert their greater healthiness into more years of work.

Medicare Part D coverage gap: race, gender, and cost-related medication nonadherence

This study examined whether the Medicare Part D coverage gap directly and indirectly affects the relationship between race, gender, and cost-related nonadherence (CRN). Using a nationally representative sample (N = 1,157), this study found that racial disparities in CRN existed under Medicare Part D. However, reaching the coverage gap mediated differences in CRN between older Blacks and Whites. The coverage gap was associated with CRN and poorer health and lower income were associated with CRN after accounting for coverage gap status. Findings highlight the need to help vulnerable populations avoid CRN and for greater consideration of racial inequities in future policy decisions.

Functional disability in late-middle-aged and older adults admitted to a safety-net hospital

OBJECTIVES

To determine the prevalence of preadmission functional disability in late-middle-aged and older safety-net inpatients and to identify characteristics associated with functional disability by age.

DESIGN

Cross-sectional analysis.

SETTING

Safety-net hospital in San Francisco, California.

PARTICIPANTS

English-, Spanish-, and Chinese-speaking community-dwelling individuals aged 55 and older admitted to a safety-net hospital with anticipated return to the community (N = 699).

MEASUREMENTS

At hospital admission, participants reported their need for help performing five activities of daily living (ADLs) and seven instrumental activities of daily living (IADLs) 2 weeks before admission. ADL disability was defined as needing help performing one or more ADLs and IADL disability as needing help performing two or more IADLs. Participant characteristics were assessed, including sociodemographic characteristics, health status, health-related behaviors, and health-seeking behaviors.

RESULTS

Overall, 28.3% of participants reported that they had an ADL disability 2 weeks before admission, and 40.4% reported an IADL disability. The prevalence of preadmission ADL disability was 28.9% of those aged 55 to 59, 20.7% of those aged 60 to 69, and 41.2% of those aged 70 and older (P < .001). The prevalence of IADL disability had a similar distribution. The characteristics associated with functional disability differed according to age; in participants aged 55 to 59, African Americans had a higher odds of ADL and IADL disability, whereas in participants aged 60 to 69 and aged 70 and older, inadequate health literacy was associated with functional disability.

CONCLUSION

Preadmission functional disability is common in individuals aged 55 and older admitted to a safety-net hospital. Late-middle-aged individuals admitted to safety-net hospitals may benefit from models of acute care currently used for older adults that prevent adverse outcomes associated with functional disability.

Physical function assessment in a community-dwelling population of U.S. Chinese older adults

BACKGROUND

This report describes the levels of physical function in U.S. Chinese older adults utilizing self-reported and performance-based measures, and examines the association between sociodemographic characteristics and physical function.

METHODS

The Population Study of Chinese Elderly in Chicago enrolled an epidemiological cohort of 3,159 community-dwelling Chinese older adults aged 60 and older. We collected self-reported physical function using Katz activities of daily living and Lawton instrumental activities of daily living items, the Index of Mobility scale, and the Index of Basic Physical Activities scale. Participants were also asked to perform tasks in chair stand, tandem stand, and timed walk. We computed Pearson and Spearman correlation coefficients to examine the correlation between sociodemographic and physical function variables.

RESULTS

A total of 7.8% of study participants experienced activities of daily living impairment, and 50.2% experienced instrumental activities of daily living impairment. With respect to physical performance testing, 11.4% of the participants were not able to complete chair stand for five times, 8.5% of the participants were unable to do chair stands at all. Older age, female gender, lower education level, being unmarried, living with fewer people in the same household, having fewer children, living fewer years in the United States, living fewer years in the community, and worsening health status were significantly correlated with lower levels of physical function.

CONCLUSIONS

Utilizing self-reported and performance-based measures of physical function in a large population-based study of U.S. Chinese older adults, our findings expand current understanding of minority older adults' functional status.

Black-white disparity in disability among U.S. older adults: age, period, and cohort trends

OBJECTIVES

This study delineates activities of daily living (ADL) and instrumental activities of daily living (IADL) black-white disparity trends by age, period, and cohort (APC) and explores sociodemographic contributors of cohort-based disparity trends.

METHOD

We utilized multiple cross-sectional waves of National Health Interview Survey data (1982-2009) to describe APC trends of ADL and IADL disparities using a cross-classified random effect model. Further, we decomposed the cohort-based disparity trends using Fairlie's decomposition method for nonlinear outcomes.

RESULTS

The crossover ADL and IADL disparities (whites > blacks) occurring at age 75 increased with age and reached a plateau at age of 80, whereas period-based ADL and IADL disparities remained constant for the past 3 decades. The cohort disparity trends for both disabilities showed a decline with each successive cohort except for ADL disparity among women.

DISCUSSION

We examined the role of aging on racial disparity in disability and found support for the racial crossover effect. Further, the racial disparity in disability will disappear should the observed pattern of declining cohort-based ADL and IADL disparities persist. Although education, income, and marital status are important sociodemographic contributors to cohort disparity trends, future studies should investigate individual behavioral health determinants and cohort-specific characteristics that explain the cohort-based racial difference in ADL and IADL disabilities.

Black-white differences in self-reported disability outcomes in the U.S.: early childhood to older adulthood

OBJECTIVE

We examined black-white differences in activities of daily living (ADLs), functional limitations (FLs), vision/hearing/sensory impairment, and memory/learning problems in a large, nationally representative sample of community-dwelling and institutionalized people across the lifespan.

METHODS

Data are from the 2006 American Community Survey (n=2,288,800). We included data on non-Hispanic black respondents (125,985 males and 145,780 females) and non-Hispanic white respondents (977,792 males and 1,039,243 females) ≥5 years of age. We used logistic regression to examine the black-white odds for each disability outcome. The overall response rate was 97.5%.

RESULTS

For FLs, ADL limitations, and memory/learning problems, black people experienced higher odds of disability across the adult lifespan compared with white people. Black-white differences narrowed in older age. For vision/hearing problems, a black-white crossover was found in older age (≥85 years), where odds of vision/hearing problems were lower among black people than among white people. For all disability outcomes, black-white differences peaked in midlife (50-69 years of age), with black people having approximately 1.5 to two times the odds of disabilities as their white peers.

CONCLUSIONS

The study findings suggest the need to address black-white disparities across a range of disability outcomes throughout the lifespan. Future work identifying the factors accounting for this pattern of disparities will help inform the development of appropriate prevention strategies.

Socioeconomic and ethnic differences in disease burden and disparities in physical function in older adults

OBJECTIVES

We investigated whether a greater burden of disease among poorer individuals and ethnic minorities accounted for socioeconomic and racial disparities in self-reported physical functioning among older adults.

METHODS

We used data from adults aged 60 years or older (n = 5556) in the Third National Health and Nutrition Examination Survey, 1988-1994 to test associations between education level, poverty index, and race/ethnicity and limitations in 11 functions. We adjusted for demographic features and measures of disease burden (comorbid conditions, smoking, hemoglobin level, serum albumin level, knee pain, body mass index, and skeletal muscle index).

RESULTS

Associations between education and functional limitations were attenuated after adjustment, but those with 0-8 years of education were more likely than those with 13 or more years of education to have limitations in 3 functions. Poverty was associated with a higher likelihood of limitations despite adjustment. The likelihood of limitations among non-Hispanic Blacks and Mexican Americans was similar to that of non-Hispanic Whites after adjustment.

CONCLUSIONS

Socioeconomic disparities in functional limitations among older Americans exist independent of disease burden, whereas socioeconomic differences and disease burden account for racial disparities.

Obesity, intentional weight loss and physical disability in older adults

We examine obesity, intentional weight loss and physical disability in older adults. Based on prospective epidemiological studies, body mass index exhibits a curvilinear relationship with physical disability; there appears to be some protective effect associated with older adults being overweight. Whereas the greatest risk for physical disability occurs in older adults who are ≥class II obesity, the effects of obesity on physical disability appears to be moderated by both sex and race. Obesity at age 30 years constitutes a greater risk for disability later in life than when obesity develops at age 50 years or later; however, physical activity may buffer the adverse effects obesity has on late life physical disability. Data from a limited number of randomized clinical trials reinforce the important role that physical activity plays in weight loss programmes for older adults. Furthermore, short-term studies have found that resistance training may be particularly beneficial in these programmes as this mode of exercise attenuates the loss of fat-free mass during caloric restriction. Multi-year randomized clinical trials are needed to examine whether weight loss can alter the course of physical disablement in aging and to determine the long-term feasibility and effects of combining resistance exercise with weight loss in older adults.

Disparities in long-term care: building equity into market-based reforms

A growing body of evidence documents pervasive racial, ethnic, and class disparities in long-term care in the United States. At the same time, major quality improvement initiatives are being implemented that rely on market-based incentives, many of which may have the unintended consequence of exacerbating disparities. We review existing evidence on disparities in the use and quality of long-term care services, analyze current market-based policy initiatives in terms of their potential to ameliorate or exacerbate these disparities, and suggest policies and policy modifications that may help decrease disparities. We find that racial disparities in the use of formal long-term care have decreased over time. Disparities in quality of care are more consistently documented and appear to be related to racial and socioeconomic segregation of long-term care facilities as opposed to within-provider discrimination. Market-based incentives policies should explicitly incorporate the goal of mitigating the potential unintended consequence of increased disparities.

Medicaid nursing facility rates, capacity, and utilization: a structural analysis

This analysis extends earlier work using national data to examine Medicaid nursing facility (NF) utilization (participants per aged population) and its interrelationships with Medicaid per diem NF reimbursement rates and NF bed capacity, using state-level data over 19 years to estimate two-stage structural equations. Findings demonstrate complex relationships among these factors. Reimbursement rates showed no demonstrable impact on utilization but positive effects on beds. Beds, in turn, positively predict utilization and negatively predict rates. Findings suggest that policy makers might focus on constraining Medicaid NF costs through controlling bed stock rather than by keeping rates lower, which can have untoward effects on quality and equity.

Transitions among disability levels or death in African American and white older women

BACKGROUND

This study examined the racial differences in probabilities of transitioning across three disability levels of walking (1/2) mile in a community-dwelling population of older women.

METHODS

The sample comprised 436 community-dwelling older women who were among the two-third least disabled women in Baltimore, Maryland. The levels of disability status of walking (1/2) mile included high functioning defined as reporting no difficulty, preclinical disability defined as reports of task modification but no reported difficulty, and disability defined as reported difficulty. First-order Markov transition models were specified to determine whether race influences the types of individual-level transitions between difficulty levels of walking (1/2) mile.

RESULTS

Among high-functioning women, African Americans were more likely to be disabled at the next round than their White counterparts. African American women who began with preclinical disability were more likely to die before the next round. After adjusting for age, education, and perceived income inadequacy, African American women tended to have an increased risk of becoming disabled if preclinically disabled than White women.

CONCLUSIONS

Prevention through identification of individuals at an early phase of decline appears to be key to addressing racial disparities in physical disability even in later life.

Intercohort trends in the relationship between education and health: examining physical impairment and depressive symptomatology

OBJECTIVE

This study examines whether educational differentials in functional and mental health are greater in more recent cohorts in the United States.

METHOD

This study utilizes latent growth-curve modeling to examine intercohort trends in physical impairment and depressive symptomatology for three educational subgroups, using panel data (1986-1994) based on a national probability sample of 3,617 U.S. adults.

RESULTS

Among those with less than a high school diploma, the 8-year newer cohort demonstrated higher physical impairment at the same age, implying an unfavorable trend. College graduates and high school graduates enjoyed favorable trends in mental health, and the trends were different across age groups within certain educational groups.

DISCUSSION

This study provides evidence that the education-based disparity in health is increasing, but there are variations in the trend depending on health outcomes. These results argue for the necessity of examining trends in education and health using diverse health outcomes.

Timing, Accumulation, and the Black/White Disability Gap in Later Life

Examining the Black/White disability gap among older adults, this study focuses on the role of timing in racial inequality over time. Using the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE), the author reexamines Black and White disability trajectories with attention to timing of onset. In addition, known mediators are examined for their relative impact on onset and accumulation of disability. The author finds that diverging trajectories of Black and White disability, evidence of a cumulative disadvantage argument, are fueled solely by differences in onset. A more nuanced picture of racial disparities arises when controls are included, lending support to a weathering hypothesis. Access to health care is primary in explaining the Black/White disparity. The author concludes that timing is integral to the study of health trajectories and that research using cumulative disadvantage benefits from supplemental theories with specific assertions as to timing, including weathering.

Minority disparities in disability between Medicare beneficiaries

OBJECTIVES

To examine racial and ethnic disparities in mobility limitation, activities of daily living (ADLs), and instrumental activities of daily living (IADLs) in older adults enrolled in Medicare.

DESIGN

Longitudinal national survey.

PARTICIPANTS

Community-dwelling respondents in the Medicare Current Beneficiaries Survey from 1992 to 2004 (10,180-16,788 respondents per year).

MEASUREMENTS

Disability-related outcomes included mobility limitation, difficulty in six ADLs and six IADLs. Explanatory variables included age, sex, racial or ethnic group, living situation, and income level.

RESULTS

From 1992 to 2004, proportions of Medicare beneficiaries with mobility limitations were stable across racial and ethnic groups, improving slightly for ADLs and IADLs. Blacks reported more limitations in all three disability-related measures. In a longitudinal analysis, the probability of developing mobility limitation was consistently higher for blacks, followed by white Hispanics, white non-Hispanics, and Asians, after adjusting for age, sex, socioeconomic status, and living situation. For ADL and IADL difficulties, the number of reported difficulties increased with age for all ethnic and racial groups. At approximately age 75, Asians and white Hispanics reported difficulties with much higher numbers of ADLs and IADLs than the other groups.

CONCLUSION

Across all ethnic and racial groups, self-reported disability has declined in the past decade, but even after adjusting for age, sex, socioeconomic status, and living situation, racial and ethnic disparities in disability outcomes persist. Race and ethnicity may influence the reporting of disability, potentially affecting measures of prevalence. Further research is needed to understand whether these differences are a result of perceptions related to disablement or true differences in disability between racial and ethnic groups.

Relationship of race and poverty to lower extremity function and decline: findings from the Women's Health and Aging Study

Race- and poverty-related disparities in physical function are well documented, though little is known about effects of race and poverty on functional decline and the progression of disability. We examined cross-sectional and longitudinal relationships between race, poverty and lower extremity function using data from moderately to severely disabled women in the U.S. Women's Health and Aging Study. Severity of lower extremity functional limitation was determined from scaled responses of reported difficulty walking (1/4) mile, walking across a room, climbing stairs, and stooping, crouching or kneeling. Usual walking speed assessed over 4m was our objective measure of function. Of the 996 women who described themselves as black or white, 284 (29%) were black and 367 (37%) were living at or below 100% of the federal poverty level. Independent of demographic and health-related factors, among white women, the poor exhibited consistently worse lower extremity function than the non-poor; this association, however, was not observed in black women. Among the non-poor, black women had slower walking speeds, and reported more limitation in lower extremity function than their non-poor white counterparts, even after adjusting for demographic variables and health-related characteristics. After 3 years, accounting for baseline function, demographic and health-related factors, race and poverty status were unrelated to functional decline. Thus, while race and poverty status were associated with functional deficits in old age, they do not appear to impact the rate of functional decline or progression of disability over 3 years.

Assessing racial health inequality in older adulthood: comparisons from mixed-mode panel interviews

OBJECTIVES

Estimates of the extent of health disparities among Black and White older adults are not consistent across studies. The purpose of this study was to systematically compare responses from Black and White older adults in telephone and face-to-face interviews in order to determine whether estimates of racial health inequality vary by survey interview mode.

METHODS

By using data from a mixed-mode panel study, I compared estimates of changing health inequality for Black and White older adults collected from face-to-face and telephone interviews. I calculated trajectories of physical disability by using latent growth models across seven waves of data.

RESULTS

Face-to-face interviews yielded consistently higher reports of disability relative to telephone interviews of the same persons. Black adults had significantly greater and increasing disability than did White adults for both interview modes. After adjusting for covariates, I found that Black and White older adults had parallel disability trajectories in face-to-face interviews but a widening gap in disability over time in telephone interviews.

DISCUSSION

Researchers should judiciously consider whether estimates of racial health inequality-and change in disability more broadly-may be misleading because of interview-mode effects.

Disparities in Disability Life Expectancy in US Birth Cohorts: The Influence of Sex and Race

Racial and sex disparities in chronic diseases and mortality are sources of health inequality and have been observed from infancy to adulthood. Disparities in health and mortality contribute to corresponding disparities in healthy life. I address two previously unanswered questions in the aging literature. First, does the racial and sex gap in healthy life narrow, persist, or expand over age and time, particularly considering severity of ill health, among the oldest old? Second, do some race-sex groups of birth cohorts live not just longer lives, but longer healthier lives, while others spend additional years in illness? To estimate the quantities, I employ a refined definition of physical disability and apply a new extension of Sullivan's method to true birth cohorts. The results suggest among the oldest old, few racial or sex disparities exist over age and time in mild disability. Yet, racial and sex disparities persist over age and time in severe disability.

Persistent and growing socioeconomic disparities in disability among the elderly: 1982-2002

OBJECTIVE

We sought to determine whether socioeconomic and racial/ethnic disparities in prevalence of disability over age 70 have widened or narrowed during the past 2 decades.

METHODS

We used data from the 1982-2002 National Health Interview Surveys, which are nationally representative cross-sectional surveys of the noninstitutionalized population of the United States. Participants included 172227 people aged 70 years and older. The primary outcome measure was the average annual percentage change in the prevalence of 2 self-reported disability measures: the need for help with activities of daily living ("ADL disability") and need for help with either ADL or instrumental activities of daily living ("any disability").

RESULTS

All groups experienced declines in the age- and gender-adjusted prevalence of any disability during the 1982 to 2002 period. However, the average annual percent declines were smaller for the least advantaged socioeconomic groups. Differences in trends across racial/ethnic groups were not statistically significant. ADL disability prevalence decreased for the more advantaged groups but increased among the lowest income and education groups. Non-Hispanic Whites and minorities experienced similar average annual percent declines in ADL disability.

CONCLUSIONS

Racial/ethnic disparities in old-age disability have persisted over the last 20 years, whereas socioeconomic disparities have increased.

Racial disparities in disability: recent evidence from self-reported and performance-based disability measures in a population-based study of older adults

OBJECTIVE

Although disability levels have been declining in older adults, there is little current information on racial differences in disability.

METHODS

Our data came from a longitudinal, population-based study of 6,158 Black and White adults aged 65 and older from the south side of Chicago. Data were collected during three face-to-face interviews between 1993 and 2002. We ascertained disability using three self-report measures and a performance-based measure of physical function. Using longitudinal data analysis, we examined overall racial differences in disability and the degree to which they varied by age and gender.

RESULTS

After an average of 6 years of follow-up, Blacks reported significantly higher disability levels than Whites after adjustment for age and sex. There was a significant increase in disability during follow-up on all four measures. Racial differences in disability did not vary consistently by age at baseline or over time but were greater among women. Findings were largely similar for self-reported and performance-based measures of disability. Adjustment for socioeconomic status substantially reduced racial differences in disability, although some of the differences remained significant, especially among women.

CONCLUSION

Racial disparities in disability have not been eliminated, are greater among women, and have their origins earlier in adulthood.

Changes in health behaviors among older Americans, 1990 to 2000

OBJECTIVES

The authors used a large population-based survey to examine changes from 1990 to 2000 in age distribution by sex and race or ethnicity, to estimate both state-specific and national trends in the proportion of older Americans, and to examine changes in risk factors and quality-of-life indicators among those Americans.

METHODS

The Behavioral Risk Factor Surveillance System (BRFSS), a cross-sectional telephone survey of adults aged > or =18 years. BRFSS data were analyzed for the District of Columbia and all states that participated from 1990 to 2000. SAS and SUDAAN were used in the analyses to account for the complex sampling design.

RESULTS

The percentage of Americans aged > or =75 years increased 23.0% from 1990 to 2000, with the magnitude of the increase varying by state. In 2000, Florida had the highest percentage of persons aged > or =75 (10.27%) and Alaska the lowest (3.49%). Compared with 1990, older Americans in 2000 were more likely to be obese (16.3% vs. 13.5%) or diabetic (14.3% vs. 11.0%). Older Americans in 2000 were also more likely to exercise, consume more fruits and vegetables daily, and to have recently obtained a routine medical checkup. In addition, they were less likely to smoke tobacco or drink any alcohol.

CONCLUSIONS

Increases in the population of older people will have a tremendous impact on health care in the states and will affect their future plans for serving the elderly. Although older Americans are living more healthfully than previously, there is an enormous need for targeted health promotion programs to prevent chronic diseases in this age group.

Peripheral Arterial Disease in African Americans: Clinical Characteristics, Leg Symptoms, and Lower Extremity Functioning

OBJECTIVES

The describe peripheral arterial disease (PAD) in African Americans, and compare findings in African Americans and whites with PAD.

DESIGN

Cross-sectional.

SETTING

Three academic medical centers.

PARTICIPANTS

Three hundred sixty-six whites and 76 African Americans with PAD (as defined by an ankle brachial index (ABI) <0.90) aged 55 and older identified from lower extremity arterial studies performed between 1996 and the fall of 1999.

MEASUREMENTS

Comprehensive medical interview, body mass index, and neuropathy score. Functional measurements included the 6-minute walk distance, 4-m walking velocity, and the summary performance score.

RESULTS

Age- and sex-adjusted results showed that African Americans had a lower mean ABI than whites (0.60 vs 0.66, P=.001), were less likely to be college graduates (13.7% vs 44.4%, P<.001), and had nearly twice the prevalence of diabetes mellitus (46.8% vs 28.0%, P=.001). After adjusting for age, sex, education level, and ABI, African Americans had a higher prevalence of no exertional leg pain (28.0% vs 18.2%, P=.044) and leg pain with exertion and rest (30.0% vs 17.3%, P=.023). African Americans had a shorter 6-minute walk distance (989 vs 1,156 ft, P<.001), a slower normal-pace 4-m walking velocity (0.79 vs 0.89 m/s, P<.001), a slower fast-pace 4-m walking velocity (1.12 vs 1.20 m/s, P=.012), and a lower summary performance score (8.8 vs 9.6, P=.018) than whites. These differences in functioning were attenuated after adjusting for age, sex, ABI, education, and leg symptoms.

CONCLUSION

Poorer lower extremity functioning in African Americans was largely explained by differences in leg symptoms and, to a somewhat lesser degree, lower ABI levels and poorer education in African Americans than in whites. Further study is needed to determine whether these findings affect racial treatment disparities and poorer outcomes previously reported in African Americans than in whites with PAD.

The black/white disability gap: persistent inequality in later life?

OBJECTIVES

Previous research on differences between Black and White older adults has produced inconsistent results on whether a gap in disability exists and whether it persists over time. The present research identifies several reasons for the inconsistent results to date and examines Black/White differences in disability trajectories over 6 years.

METHODS

Data from the North Carolina Established Populations for the Epidemiologic Studies of the Elderly (1986-1992) are used to estimate the disability gap and trajectory over time for both Black and White older adults.

RESULTS

Results indicate that a disability gap between Black and White adults exists, but after socioeconomic resources, social integration, and other health indicators are adjusted for, the trajectories of disability by race are not significantly different. Controlling for incident morbidity over time accounts for the significant difference in level of disability between the two groups.

DISCUSSION

This research supports the "persistent inequality" interpretation, indicating that Black adults have higher morbidity and disability earlier in life compared with White adults, and that the gap neither converges nor diverges over time.

Differences in mortality of black and white patients enrolled in the program of all-inclusive care for the elderly

OBJECTIVES

To examine the relationship between race and mortality in frail community-dwelling older people with access to a program providing comprehensive access and coordination of services.

DESIGN

A longitudinal cohort study.

SETTING

Twelve nationwide demonstration sites of the Program of All-Inclusive Care for the Elderly (PACE) from 1990 to 1996. PACE provides comprehensive medical and long-term care services for nursing home-eligible older people who live in the community.

PARTICIPANTS

Two thousand two white patients and 859 black patients.

MEASUREMENTS

Patients were followed after enrollment until death or the end of the follow-up period. Time from enrollment to death was measured with adjustment of the Cox proportional hazards model for comorbid conditions, functional status, site, and other demographic characteristics.

RESULTS

Black patients were younger than white patients (mean age 77 vs 80, P <.001) but had worse functional status (mean activity of daily living (ADL) score 6.5 vs 7.2, P <.001) on enrollment. Survival for black and white patients was 88% and 86% at 1 year, 67% and 61% at 3 years, and 51% and 42% at 5 years, respectively (unadjusted hazard ratio (HR) for black patients = 0.77; 95% confidence interval (CI) = 0.67-0.89). After adjustment for baseline comorbid conditions, functional status, site, and demographic characteristics, black patients still had a lower mortality rate (HR = 0.77; 95% CI =.65-0.93). The survival advantage for black patients did not emerge until about 1 year after PACE enrollment (HR for first year after enrollment = 0.97; 95% CI = 0.72-1.31; HR after first year = 0.67; 95% CI = 0.54-0.85, P-value for time interaction <.001). During the first year of enrollment, black patients were more likely to improve and less likely to decline in ADL function than white patients (P <.001).

CONCLUSION

In PACE, a system providing access to and coordination of comprehensive medical and long-term care services for frail older people, black patients have a lower mortality rate than white patients. This survival advantage, which emerges approximately 1 year after PACE enrollment, may be related to the comprehensive access and coordination of services provided by the PACE program.

Expanding the Andersen model: the role of psychosocial factors in long-term care use

OBJECTIVE

To examine a prevailing conceptual model of health services use (Andersen 1995) and to suggest modifications that may enhance its explanatory power when applied to empirical studies of race/ethnicity and long-term care.

STUDY SETTING

Twelve focus groups of African-American (five groups) and white (seven groups) individuals, aged 65 and older, residing in Connecticut during 2000.

STUDY DESIGN

Using qualitative analysis, data were coded and analyzed in NUD-IST 4 software to facilitate the reporting of recurrent themes, supporting quotations, and links among the themes for developing the conceptual framework. Specific analysis was conducted to assess distinctions in common themes between African-American and white focus groups.

DATA COLLECTION

Data were collected using a standardized discussion guide, augmented by prompts for clarification. Audio taped sessions were transcribed and independently coded by investigators and crosschecked to enhance coding validity. An audit trail was maintained to document analytic decisions during data analysis and interpretation.

PRINCIPAL FINDINGS

Psychosocial factors (e.g., attitudes and knowledge, social norms, and perceived control) are identified as determinants of service use, thereby expanding the Andersen model (1995). African-American and white focus group members differed in their reported accessibility of information about long-term care, social norms concerning caregiving expectations and burden, and concerns of privacy and self-determination.

CONCLUSIONS

More comprehensive identification of psychosocial factors may enhance our understanding of the complex role of race/ethnicity in long-term care use as well as the effectiveness of policies and programs designed to address disparities in long-term care service use among minority and nonminority groups.

Changes in the prevalence of chronic disability in the United States black and nonblack population above age 65 from 1982 to 1999

Survey evidence through the early 1990s generally suggests a reduction in disability in the elderly population of the United States. Because the evidence is not fully consistent, several authors have speculated about whether disability declines will continue. This paper reports results from the 1999 National Long-Term Care Survey on disability trends from 1982 through 1999. It is found that disability continued to decline in the 1994 to 1999 period, and that the decline was greater in the 1990s than in the 1980s. The disability decline from 1982 to 1989 was 0.26% per year, from 1989 to 1994 it was 0.38% per year, and from 1994 to 1999 it was 0.56% per year. In addition, disability declined by a greater percentage for blacks than for nonblacks over the 1989 to 1999 period.

Environmental press and adaptation to disability in hospitalized live-alone older adults

PURPOSE

This study examined the ability of personal competency variables at the time of hospital discharge to predict primary instrumental activities of daily living (IADLs) and secondary outcomes (living arrangements) in a sample of 194 urban, live-alone, older adults who had a new onset disability.

DESIGN AND METHODS

Consecutively admitted medical rehabilitation patients, 72% women and 85% African American, participated in the study. Using path analysis, three of the four competency variables collected at the time of hospitalization (cognition, medical burden, activities of daily living) predicted IADLs at 3 and 6 months after hospitalization (e.g., cooking, telephone use, money management). IADLs, in turn, predicted living arrangements at 3 and at 6 months after hospitalization.

RESULTS

The findings provided strong support for the importance of assessing a broad range of competency variables when investigating adaptation to disability.

IMPLICATIONS

The increased understanding of adaptation in live-alone older adults with a new-onset disability is particularly timely given the increase in live-alone older adults and the dire consequences associated with change in living arrangement (i.e., mortality and morbidity) in this group.

Differences in functional status of Hispanic versus non-Hispanic White elders: data from the Medical Expenditure Panel Survey

OBJECTIVES

Few national studies have focused specifically on the functional status of Hispanic elders. We examined the prevalence of functional limitations and disabilities among Hispanic and Black elders compared to non-Hispanic Whites.

METHODS

We analyzed seven measures of functional limitations, disabilities, and dependencies. Logistic regression was used to examine racial and ethnic group differences adjusting for age, gender, and education.

RESULTS

Compared to non-Hispanic Whites, Hispanics tended to report greater instrumental activities of daily living (IADL) dependencies and cognitive disabilities. Blacks were more likely to have activities of daily living (ADL) and IADL dependencies and require use of assistive devices compared to non-Hispanic Whites. Further adjustment for respondent status reduced differences between groups, but these models may overadjust for functional status differences.

DISCUSSION

Given the projected growth of minority elders, policymakers and planners will need to consider race and ethnic differentials in functional status in determining future medical and social service needs.

The role of education in explaining and forecasting trends in functional limitations among older Americans*

Using the Survey of Income and Program Participation, we document the importance of education in accounting for declines in functional limitations among older Americans from 1984 to 1993. Of the eight demographic and socioeconomic variables considered, education is most important in accounting for recent trends. The relationship between educational attainment and functioning has not changed measurably, but educational attainment has increased greatly during this period. Our analysis suggests, all else being equal, that future changes in education will continue to contribute to improvements in functioning, although at a reduced rate.

The role of education in explaining and forecasting trends in functional limitations among older Americans

Using the Survey of Income and Program Participation, we document the importance of education in accounting for declines in functional limitations among older Americans from 1984 to 1993. Of the eight demographic and socioeconomic variables considered, education is most important in accounting for recent trends. The relationship between educational attainment and functioning has not changed measurably, but educational attainment has increased greatly during this period. Our analysis suggests, all else being equal, that future changes in education will continue to contribute to improvements in functioning, although at a reduced rate.

Activities of daily living. Old-fashioned or still useful?

1 The Index of Activities of Daily Living (ADL) is used by many nurses to assess function in older adults, but there is debate regarding the scoring, wording of questions, and validity in diverse populations. 2 Older adults may give inaccurate answers to ADL questions because they misunderstand the questions, have personal reasons for underreporting or overreporting difficulty in ADL, or fail to recognize difficulty because they have adapted to changes in function. 3 Physical performance tests, especially of the lower extremities, may be an alternative method of assessing function, especially in high-functioning older adults who report no difficulty in ADL.