Functional health status as a predictor of mortality in men and women over 65

Prediction of Non-Home Discharge Following Total Hip Arthroplasty in Geriatric Patients

Introduction

The majority of total hip arthroplasty (THA) patients are discharged home postoperatively, however, many still require continued medical care. We aimed to identify important characteristics that predict nonhome discharge in geriatric patients undergoing THA using machine learning. We hypothesize that our analyses will identify variables associated with decreased functional status and overall health to be predictive of non-home discharge.

Materials and Methods

Elective, unilateral, THA patients above 65 years of age were isolated in the NSQIP database from 2018-2020. Demographic, pre-operative, and intraoperative variables were analyzed. After splitting the data into training (75%) and validation (25%) data sets, various machine learning models were used to predict non-home discharge. The model with the best area under the curve (AUC) was further assessed to identify the most important variables.

Results

In total, 19,840 geriatric patients undergoing THA were included in the final analyses, of which 5194 (26.2%) were discharged to a non-home setting. The RF model performed the best and identified age above 78 years (OR: 1.08 [1.07, 1.09], P < .0001), as the most important variable when predicting non-home discharge in geriatric patients with THA, followed by severe American Society of Anesthesiologists grade (OR: 1.94 [1.80, 2.10], P < .0001), operation time (OR: 1.01 [1.00, 1.02], P < .0001), anemia (OR: 2.20 [1.87, 2.58], P < .0001), and general anesthesia (OR: 1.64 [1.52, 1.79], P < .0001). Each of these variables was also significant in MLR analysis. The RF model displayed good discrimination with AUC = .831.

Discussion

The RF model revealed clinically important variables for assessing discharge disposition in geriatric patients undergoing THA, with the five most important factors being older age, severe ASA grade, longer operation time, anemia, and general anesthesia.

Conclusions

With the rising emphasis on patient-centered care, incorporating models such as these may allow for preoperative risk factor mitigation and reductions in healthcare expenditure.

Effect of different patterns of home- and community-based services in Taiwan on the changes in physical function

Our study aimed to explore the impact of different home- and community-based service (HCBS) use patterns on older adults' physical function. The cohort data were drawn from two national datasets, the National Ten-Year Long-Term Care Plan 1.0 database and the National Health Insurance Program claims data. Participants were care recipients ages 65 and over, first evaluated and prescribed HCBS from 2010 through 2013 and evaluated again after 6 months (n = 32,392). Latent class analysis was used to identify subgroups with different HCBS use patterns. Multiple regression was used to examine the impact of different HCBS use patterns on change over time in disability related to activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The analysis was stratified by respondents' levels of disability. Four subgroups of HCBS recipients were identified, with patterns of home-based personal care, home-based personal care and medical care, home-based medical care and community care services. Older adults in the Home-based MpC had significantly more improvement in both ADL (p < 0.05) and IADL (p < 0.001) scores compared with adults in the other three groups, while the community care group regressed the most. In the stratified analysis of the severely disabled, the IADL outcome of the Home-based MC group was better than the home-based PC group (p < 0.001). Study findings shed light on the benefits of promoting the use of integrated HCBS that combines personal and medical care, especially for community care services.

Severe functional impairment increases the risk of major morbidity and mortality in older patients after digestive tract surgery: a retrospective cohort study

PURPOSE

The relationship between the severity of impairment in basic activities of daily living (ADLs) function and postoperative outcomes in older surgical patients remains unclear. This study aimed to clarify the association between the severity of preoperative functional impairment and the composite postoperative outcome of major morbidity and mortality in older patients undergoing digestive tract surgery.

METHODS

This was a retrospective cohort study. We collected perioperative data of older patients (age ≥ 65 years) who underwent digestive tract surgery in our institution. The severity of functional impairment was assessed using the Barthel Index scale before surgery. The major morbidity and mortality were defined as Clavien-Dindo grade III or greater postoperative complications during hospital stay. The association between the severity of functional impairment and the major morbidity and mortality was assessed using a multivariable logistic regression model.

RESULTS

131 of 1076 patients (12.2%) developed major morbidity and mortality. After controlling for confounding factors, high Barthel Index scores were correlated with decreased risk of major morbidity and mortality (OR 0.986, 95% CI 0.976-0.997, P = 0.011); preoperative severe (OR 2.862, 95% CI 1.172-6.989, P = 0.021), but not mild or moderate (OR 1.019, 95% CI 0.602-1.726, P = 0.943) functional impairment was independently associated with an increased risk of major morbidity and mortality, when compared with independent functional status.

CONCLUSIONS

Preoperative severe functional impairment in basic ADLs was independently associated with a higher risk of major postoperative morbidity and mortality in older patients undergoing digestive tract surgery.

The Sickle Cell Disease Functional Assessment (SCD-FA) tool: a feasibility pilot study

Background

The life expectancy for individuals with sickle cell disease (SCD) has greatly increased over the last 50 years. Adults with SCD experience multiple complications such as cardiopulmonary disease, strokes, and avascular necrosis that lead to limitations that geriatric populations often experience. There are no dedicated instruments to measure functional decline and functional age to determine risk of future adverse outcomes in older adults with SCD. The objective of this study was to assess the feasibility of performing the Sickle Cell Disease Functional Assessment (SCD-FA).

Methods

We enrolled 40 adults with SCD (20 younger adults aged 18–49 years as a comparison group and 20 older adults aged 50 years and older) in a single-center prospective cohort study. Participants were recruited from a comprehensive sickle cell clinic in an academic center in the southeastern United States. We included measures validated in an oncology geriatric assessment enriched with additional physical performance measures: usual gait speed, seated grip strength, Timed Up and Go, six-minute walk test, and 30-second chair stand. We also included an additional cognitive measure, which was the Montreal Cognitive Assessment, and additional patient-reported measures at the intersection of sickle cell disease and geriatrics. The primary outcome was the proportion completing the assessment. Secondary outcomes were the proportion consenting, duration of the assessment, acceptability, and adverse events.

Results

Eighty percent (44/55) of individuals approached consented, 91% (40/44) completed the SCD-FA in its entirety, and the median duration was 89 min (IQR 80–98). There were no identified adverse events. On the acceptability survey, 95% (38/40) reported the length as appropriate, 2.5% (1/40) reported a question as upsetting, and 5% (2/40) reported portions as difficult. Exploratory analyses of physical function showed 63% (25/40) had a slow usual gait speed (< 1.2 m/s).

Conclusion

The SCD-FA is feasible, acceptable, and safe and physical performance tests identified functional impairments in adults with SCD. These findings will inform the next phase of the study where we will assess the validity of the SCD-FA to predict patient-important outcomes in a larger sample of adults with SCD.

Quantifying self-rated age

Chronological age, in conjunction with population life tables, is widely used for estimating future life expectancy. The aims of this study are to estimate a subjective ageing indicator, namely self-rated age, and to evaluate its concurrent validity in comparison with other age indicators: subjective survival probabilities, subjective age, and biological age. We use data from the Wave 6 of the Survey of Health, Ageing and Retirement in Europe, Wave 12 of the Health and Retirement Study in the United States, and life tables from the Human Mortality Database. For the statistical analysis we use multinomial regression models. Our results indicate that health status and frequency of physical activities imply similar patterns of self- rated age, subjective survival probabilities, subjective age, and biological age. However, the impact of cognitive function differs by geographical region. Self-rated age can be interpreted as a subjective adjustment that better reflects the ageing process.

24-h movement behaviors among autistic adults: Differences by sex, age, and level of independence

BACKGROUND

Autistic adults have low levels of physical activity [PA], high levels of sedentary behavior [SB], and insufficient sleep. Not known is the extent to which engagement in these movement behaviors vary by sex, age, and level of independence in activities of daily living (ADLs).

OBJECTIVE

To characterize movement behaviors in a national sample of autistic adults by sex, age, and level of independence in ADLs.

METHODS

A national sample of autistic adults and caregivers of autistic adults self-reported PA, SB and sleep behaviors as well as demographic variables using an electronic survey. Levels of engagement in movement behaviors were described, and compared by sex, age (young-adult versus middle-age), and level of independence in ADLs.

RESULTS

Data were collected on 361 autistic adults (60.3% male, n = 217, mage = 30.82 years, SD = 10.24). Overall, 44% did not meet the PA guideline; PA guideline adherence was lowest among males and those who were dependent on others in ADLs. Overall, the SB guideline was not met by 43% of the sample at weekdays and 48% at weekends. SB guideline adherence was lowest among adults who were middle-aged, and those who were fully independent in ADLs. Overall, 35.2% did not meet the total sleep time (TST) guideline. Middle-aged autistic adults had the lowest adherence to the TST guideline.

CONCLUSIONS

These finding should prompt researchers to consider these demographic differences, and tailor research and programmatic efforts to account for the unique movement behavior profiles of different segments of this heterogenous population.

Socioeconomic Status, Physical Functioning and Mortality: Results From a Cohort Study of Older Adults in Hong Kong

OBJECTIVES

It is inconsistent in the literature on whether inequalities of health in older age widen or narrow over time. We assessed the associations of socioeconomic status (SES), physical functioning, and mortality in an older age cohort in Hong Kong.

DESIGN

Longitudinal cohort study.

SETTING AND PARTICIPANTS

We recruited 2032 older adults aged 70+ in 1991 to 1992 and followed them for 10 years.

METHODS

SES was operationalized as education, baseline individual income, and longest-held occupation in lifetime. Physical functioning was measured by Barthel's Index for activities of daily living (ADL), from which disability was defined as ADL score <20. Mortality data were obtained from the Death Registry. Bayesian joint modeling with 2 sub-models, mixed-effect, and Cox proportional hazard model, were used to respectively model the associations of SES and disability, and SES and mortality, accounting for selection by mortality.

RESULTS

Education and income at baseline were not clearly related to disability, but those with lower education level and income at baseline tended to have their risks increased with time. Older adults who had been mostly economically inactive or unemployed in their lifetime had higher risk of disability [odds ratio 3.24; 95% credible interval (95%CrI) 1.29 to 7.97], and such risk increased over time. For mortality, older adults with no schooling were at higher risk compared with those with secondary education or above (hazard ratio 1.25; 95%CrI 1.00 to 1.57). Income at baseline and longest-held occupation in lifetime were not clearly related to mortality.

CONCLUSIONS AND IMPLICATIONS

We observed inequalities of health of older adults in Hong Kong that widened as they age. Community and medical interventions targeting the older adults with the lowest SES would be important to prevent their more rapid decline in physical functioning.

Self-Management Interventions to Improve Activities of Daily Living and Rest and Sleep for Adults With Chronic Conditions: A Systematic Review

IMPORTANCE

Chronic conditions often cause functional impairments in activities of daily living (ADLs) and rest and sleep, leading to decreased independence and self-efficacy.

OBJECTIVE

To aid occupational therapy practitioners in making informed decisions regarding self-management interventions to improve ADLs and rest and sleep for community-dwelling adults with chronic conditions.

DATA SOURCES

We identified literature published from 1995 to 2019 through searches of the Cochrane Database of Systematic Reviews, MEDLINE, PsycINFO, CINAHL, and OTseeker. Study Selection and Data Collection: Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to abstract and assess data quality and validity. The review followed American Occupational Therapy Association Evidence-Based Practice Project methodology. Studies addressing self-management interventions for community-dwelling adults ages 18 and older with chronic cardiovascular disease, Type 2 diabetes, heart disease, hypertension, chronic respiratory problems, or kidney disease were included.

FINDINGS

Fifteen articles met inclusion criteria and were categorized into ADLs and sleep. Strong evidence supports education to improve diabetic foot self-care. Low evidence addresses exercise and education to improve ADLs for people with heart disease and chronic obstructive pulmonary disease. Moderate evidence supports mind-body self-care education to enhance sleep.

CONCLUSIONS AND RELEVANCE

Occupational therapy practitioners working with adults with diabetes are encouraged to routinely offer education that includes discussion of risk factors and daily foot inspections and hygiene. When addressing sleep, education that addresses sleep hygiene, nutrition, relaxation techniques, and physical activity should routinely be provided to adults with chronic conditions. Further research is needed to understand the dosage needed. What This Article Adds: This systematic review supports the role of occupational therapy in providing self-management interventions to address ADLs and sleep for adults with diabetes and other chronic conditions.

Factors associated with the survival of elderly men in almost 15 years

OBJECTIVE

To identify factors associated with a higher probability of survival for men aged 60 and over in the course of almost 15 years.

METHODS

Prospective cohort study, where time zero is the year 2000 and deaths (final event) were measured until November 2014. The independent variables were obtained from personal characteristics, childhood life, educational status, lifestyle, social support, work history, socioeconomic situation, and health condition.

RESULTS

At the end of the period, 25.8% of elderly men remained alive and the factors that stood out associated with a higher probability of survival were: performing 50% or more of the Basic and/or Instrumental Activities of Daily Living (95%CI 0.41 - 0.64), being the head of the family (95%CI 0.42 - 0.82), participating in the community (95%CI 0.52 - 0.88), working on their own (95%CI 0.54 - 0.88), and owning a home and goods (95%CI 0.56 - 0.92).

CONCLUSION

Characteristics related to a greater autonomy of the elderly men, even after almost 15 years, contributed to an increase in the probability of survival.

Developing and validating a multivariable prediction model for in-hospital mortality of pneumonia with advanced chronic kidney disease patients: a retrospective analysis using a nationwide database in Japan

BACKGROUND

The prognosis of pneumonia in patients with advanced stage chronic kidney disease (CKD) remains unimproved for years. We attempt to develop a simple and more useful scoring system for predicting in-hospital mortality for advanced CKD patients with pneumonia.

METHODS

Using the Diagnosis Procedure Combination database, we identified the in-hospital adult patients both with a record of pneumonia and stage 5 or 5D CKD as a comorbidity on admission between April 1, 2012 and March 31, 2016. Predictive variable selection was analyzed by multivariable logistic regression analysis, stepwise method, LASSO method and random forest method, and then develop a new simple scoring system seeking for highest c-statistics combination of variables in one sample data set for model development. Finally, we compared c-statistics of univariate logistic regression about new scoring system with c-statistics about "A-DROP" in the other sample data set.

RESULT

We identified 8402 patients in 707 hospitals, and the total in-hospital mortality was 11.0% (437 patients) in development data set. Seven variables were selected, which includes age (male ≥ 70 years, female ≥ 75 years), respiratory failure, orientation disturbance, low blood pressure, the need of assistance in feeding or bowel control, severe or moderate thinness and CRP 200 mg/L or extent of consolidation on chest X-ray ≥ 2/3 of one lung. The c-statistics of univariate logistic regression was 0.8017 using seven variables, while that was 0.7372 using "A-DROP" CONCLUSION: In advanced CKD patients, if we select appropriate variables for predicting in-hospital mortality, simple scoring system may have better discrimination than "A-DROP".

Ability of Emergency Department Physicians Using a Functional Autonomy-Assessing Version of the Triage Risk Screening Tool to Detect Frail Older Patients Who Require Mobile Geriatric Team Consultation

OBJECTIVES

Frailty in older people associates with poor outcomes. Screening by ED physicians would greatly facilitate detection of frail older patients but our previous attempt to introduce routine ED-physician screening with Short Emergency Geriatric Assessment (SEGA), a 13-item frailty tool that French geriatricians use to identify frail patients, failed due to its length and complexity. A national committee recently generated a new version of the fast and simple 5-item Triage Risk Screening Tool (TRST) in which a subjective item ('nurse concern') was replaced by an item assessing basic activities of daily living. The ability of ED physicians using this French-TRST to accurately detect frail patients who require comprehensive geriatric assessment was assessed.

DESIGN

Prospective cross-sectional study on diagnostic accuracy relative to the gold standard, namely, geriatrician-administered SEGA.

SETTING

Tertiary-care hospital, France.

SUBJECTS AND MEASUREMENTS

The participants were 498 ≥75-year-old patients who visited the ED in 2018-2019 and were administered French-TRSTs by first ED physicians and then geriatricians, followed by SEGA, all within 24 hours. Diagnostic accuracy variables were calculated. Geriatrician-TRST was used to identify TRST items that associated with ED physician misclassification of frail patients.

RESULTS

Emergency-TRST was significantly less sensitive than Geriatrician-TRST (88% vs. 93%; p=0.04) and tended to have lower negative predictive value (66% vs. 77%; p=0.09). Emergency-TRSTs rated four French-TRST items less well than Geriatrician-TRSTs.

CONCLUSIONS

As a substitute for SEGA in the ED, the French-TRST performed quite well overall but the ED physicians detected frail patients less well than the geriatricians. Modifications of the French-TRST that may improve the diagnostic performance of ED physicians are discussed.

The interaction effect between physical and cultural leisure activities on the subsequent decline of instrumental ADL: the Fujiwara-kyo study

Background

Maintenance of instrumental activities of daily living (IADL) and social role (SR) is crucial to keep independent life because the decline in SR and IADL was a significant predictor of dependence in basic ADL in later. The independent effect of physical and cultural leisure activities and their effect modification on the IADL remains unknown.

Methods

We prospectively observed 3241 elderly with intact IADL at baseline for 5 years. Higher level functional capacity such as IADL and SR was assessed using the Tokyo Metropolitan Institute of Gerontology Index of competence (TMIG index).

Results

The mean age of the participants was 72.3 years (standard deviation 5.1), and 46.9% were male, and 90.9% of them received a follow-up assessment. Of the participants, 10.4% developed an IADL decline. Engagement in leisure physical activity was associated with a significantly lower risk of IADL decline (adjusted risk ratio, 0.73; 95% confidence interval [CI], 0.60 to 0.89), and cultural leisure activity was also associated with lower risk of IADL decline (adjusted risk ratio, 0.77; 95% CI, 0.63 to 0.95) independent of potential confounders. We also found significant and positive interaction between physical and cultural leisure activities at risk for IADL decline (P = 0.024) and SR decline (P = 0.004).

Conclusions

We found an independent association of physical and cultural leisure activities with a lower risk for functional decline in IADL and SR with positive interaction. Combined engagement in physical and cultural activities may effectively prevent from IADL decline and SR decline.

Association of Trajectories of Higher-Level Functional Capacity with Mortality and Medical and Long-Term Care Costs Among Community-Dwelling Older Japanese

Background

Higher-level functional capacity is crucial component for independent living in later life. We used repeated-measures analysis to identify aging trajectories in higher-level functional capacity. We then determined whether these trajectories were associated with all-cause mortality and examined differences in medical and long-term care costs between trajectories among community-dwelling older Japanese.

Methods

2,675 adults aged 65-90 years participated in annual geriatric health assessments and biennial health monitoring surveys during the period from October 2001 through August 2011. The average number of follow-up assessments was 4.0, and the total number of observations was 10,609. Higher-level functional capacity, which correspond to the fourth and fifth sublevels of Lawton's hierarchical model, was assessed with the Tokyo Metropolitan Institute of Gerontology-Index of Competence (TMIG-IC).

Results

We identified four distinct trajectory patterns (high-stable, late-onset decreasing, early-onset decreasing, and low-decreasing) on the TMIG-IC through age 65-90 years. As compared with the high-stable trajectory group, participants in the late-onset decreasing, early-onset decreasing, and low-decreasing TMIG-IC trajectory groups had adjusted hazard ratios for mortality of 1.22 (95% confidence interval: 1.01-1.47), 1.90 (1.53-2.36), and 2.87 (2.14-3.84), respectively. Participants with high-stable and late-onset decreasing higher-level functional capacity trajectories had lower mean monthly medical costs and long-term care costs. In contrast, mean total costs were higher for those with low-decreasing trajectories, after excluding the large increase in such costs at the end of life.

Conclusions

People with a low-decreasing aging trajectory in higher-level functional capacity had higher risks of death and had high monthly total costs.

Adherence to a healthy lifestyle counteracts the negative effects of risk factors on all-cause mortality in the oldest-old

In the study, we examined the extent to which the harmful effects of risk factors on all-cause mortality can be counteracted by healthy lifestyle practices in the oldest-old (80 years of age and older). A total of 17,660 oldest-old from China were followed up for up to 10 years. The data were analyzed using the Cox proportional hazard model with adjustment for potential confounders. We found that having a rural residence, not being married, having lower economic status, physical disability, impaired cognitive function, or comorbidity were all associated with an elevated risk of mortality. Using these factors, we computed a weighted "risk score." Because never smoking, never drinking, doing physical exercise, having an ideal diet, and a normal weight were independently associated with lower mortality, we also combined them to compute a weighted "protection score." Both scores were divided into lowest, middle, and highest groups using their tertiles. In joint effect analyses, participants with the combined highest-risk score and lowest-protection score profile had a nearly threefold higher joint death risk. These analyses show that adherence to a healthy lifestyle counteracts the negative effect of risk factors on all-cause mortality in the oldest-old by more than 20%.

Dependent Functional Status is a Risk Factor for Perioperative and Postoperative Complications After Total Hip Arthroplasty

BACKGROUND

As the population ages, the need for total hip arthroplasty (THA) will increase. However, this will be associated with an increase in comorbidities and a decrease in the ability to independently perform activities of daily living (ADLs). This study was designed to evaluate the impact preoperative functional status has on short-term outcomes after THA.

METHODS

Primary THAs performed from 2012 to 2016 were identified in the National Surgical Quality Improvement Program database. Final analysis included 115,590 cases. Patients who could perform all ADLs were classified as independent functional status (n = 113,436), and patients requiring assistance with ADLs were classified as dependent functional status (n = 2154). Univariate analysis was used to compare perioperative outcomes and 30-day complication rates. Multivariate regression was then applied to determine if preoperative dependent functional status was an independent risk factor for adverse outcomes.

RESULTS

Functionally dependent patients were more likely to experience operative times >120 minutes (odds ratio [OR] = 1.39; P < .001), hospital stays >10 days (OR = 2.96; P < .001), and nonhome discharge (OR = 2.53; P < .001). Dependent functional status was also an independent risk factor for mortality (OR = 3.00; P = .001), reoperation (OR = 1.39; P = .015), readmission (OR = 1.75; P < .001), superficial surgical site infection (OR = 1.96; P = .002), wound dehiscence (OR = 2.72; P = .034), pneumonia (OR = 2.16; P = .001), reintubation (OR = 2.31; P = .007), prolonged ventilator use (OR = 3.01; P = .009), renal failure necessitating dialysis (OR = 3.94; P = .002), urinary tract infection (OR = 1.78; P = .001), blood transfusion (OR = 1.75; P < .001), and sepsis (OR = 2.38; P = .001).

CONCLUSIONS

Functionally dependent patients undergoing THA are at higher risk of mortality, adverse perioperative outcomes, and complications. These data may aid for patient counseling and risk stratification.

A multi-dimensional measure of population ageing accounting for Quantum and Quality in life years: An application of selected countries in Europe and Asia

Population ageing measured through a fixed old-age threshold like 60+ or 65+ ignores the other important dimensions of ageing. There has been changes among the older persons in multiple dimensions that corresponds to quantity of life years lived as well as the quality of life. The existing multi-dimensional measures also consider the characteristics within a fixed old-age threshold framework which does not account for significant improvements in life expectancy over the years. We propose a new Multidimensional Old Age Threshold (MOAT) measure that accommodates different dimensions of quantity and quality of older persons. We achieve this through a modified framework of the Characteristic Approach. Our measure incorporates a forward-looking approach to measure ageing and specifies an old-age threshold for different countries after accounting for different dimensions of life expectancy, health and human capital. This method is more suitable for comparison across countries with distinct demographic and health achievements. The empirical application of our method using selected countries from Europe and Asia shows that the relative performance of countries differs in terms of MOAT in comparison to estimates based on existing measures, primarily due to the inclusion of the quality dimensions. Countries that have better performance in life expectancy, health and human capital have higher values of MOAT and a lower 'burden' of older persons in a cross-country perspective in comparison to the existing measures.

Barthel Index at hospital admission is associated with mortality in geriatric patients: a Danish nationwide population-based cohort study

Purpose

The Barthel Index (BI)-100 is used to measure geriatric patients’ activities of daily living (ADL). The aim of this study was to explore whether BI at hospital admission is associated with mortality.

Patients and methods

In a nationwide population-based cohort study, patients aged ≥65 years admitted during 2005–2014 to Danish geriatric departments were assessed with BI at admission. Data were entered into the Danish National Database of Geriatrics and linked at the individual level to the Danish health registers (Civil Registration System, National Patient Register, and National Database of Reimbursed Prescriptions). The BI was categorized into four predefined standard subcategories according to the national Danish version of the statistical classification of diseases (BI =80–100 [independent ADL], BI =50–79 [moderate reduced ADL], BI =25–49 [low ADL], and BI =0–24 [very low ADL]). Patients were followed until death, emigration, or end of the study (December 31, 2015). Associations with mortality adjusted for age, admission year, marital status, body mass index, Charlson comorbidity index, polypharmacy, and hospitalizations during the preceding year were analyzed by multivariable Cox regression analysis.

Results

Totally, 74,603 patients were included. Women (63%) were older than men (mean [SD] age; 83 [7] vs 81 [7] years) and had higher BI (median [IQR]; 55 [30–77] vs 52 [26–77]). Median survival (years [95% CI]) was lowest in the subcategory “BI =0–24” in both women (1.3 [1.2–1.4]) and men (0.9 [0.8–0.9]). Adjusted mortalities (HR [95% CI]; reference BI =80–100) in women were 2.41 (2.31–2.51) for BI =0–24, 1.66 (1.60–1.73) for BI =25–49, and 1.34 (1.29–1.39) for BI =50–79 and in men were 2.07 (1.97–2.18) for BI =0–24, 1.58 (1.51–1.66) for BI =25–49, and 1.29 (1.23–1.35) for BI =50–79.

Conclusion

BI at admission is strongly and independently associated with mortality in geriatric patients. BI has the potential to provide useful supplementary information for the planning of treatment and future care of older patients.

Prevalence of functional dependence in Chinese centenarians and its relationship with serum vitamin D status

Background

Functional dependence (FD) and vitamin D deficiency are common conditions in older adults. However, little is known about the relationship between FD and serum vitamin D status in centenarians. The current study was designed to evaluate the prevalence of FD and examine its relationship with serum vitamin D status among centenarians in China.

Subjects and methods

A cross-sectional study of a large sample of Chinese centenarians including 180 men and 822 women was conducted from June 2014 to December 2016. Home interviews, physical examinations, and blood analyses were performed in 958 centenarians following standard procedures. FD was evaluated using the Barthel index of activities of daily living (ADL). Serum 25-hydroxyvitamin D (25OHD) concentrations were measured as a marker of vitamin D status.

Results

The prevalence of centenarians with FD was 71.2%. Vitamin D deficiency, lack of tea consumption, lack of outdoor activities, visual impairment, and fracture were predictors of FD. Centenarians in the lowest quartile of serum 25OHD concentration had an approximately threefold greater likelihood of FD than those in the highest quartile in multiple logistic regression models (OR =2.88; 95% CI 1.75–4.73; P<0.001). The multivariable OR with a 1 ng/mL decrease in serum 25OHD concentration was 1.06 (95% CI 1.04–1.08; P<0.001) for FD.

Conclusion

Serum 25OHD levels have important associations with FD in Chinese centenarians. Future research could focus on the value of intervening in the case of low serum 25OHD levels through vitamin D supplementation and improving ADL in the older population.

Screening mammography use in older women according to health status: a systematic review and meta-analysis

Background

The extent to which screening mammography (SM) recommendations in older women incorporate life expectancy factors is not well established.

Objective

The objective of this review was to evaluate evidence on SM utilization in older women by life expectancy factors.

Data sources

We searched Medline, Embase and Web of Science from January 1991 to March 2016.

Study selection

We included studies examining SM utilization in women ages ≥65 years that measured life expectancy using comorbidity, functional limitations or health or prognostic status.

Data extraction and synthesis

ORs and 95% CIs were extracted and grouped by life expectancy category. Findings were aggregated into pooled ORs and 95% CIs and meta-analyzed by life expectancy category.

Main outcomes and measures

The primary outcome was SM utilization within the last 5 years. Life expectancy factors included number of comorbidities, Charlson Comorbidity Index (CCI), activities of daily living, instrumental activities of daily living, self-reported health status and 5-year prognostic indices.

Results

Of 2,606 potential titles, we identified 25 meeting the inclusion criteria (comorbidity: eight studies, functional status: 11 studies and health/prognostic status: 13 studies). Women with higher CCI scores had decreased SM utilization (pooled OR: 0.75, 95% CI: 0.67–0.85), but increased absolute number of comorbidities were weakly associated with increased SM utilization (pooled OR: 1.17, 95% CI: 1.00–1.36). Women with more functional limitations had lower SM use odds than women with no limitations (pooled OR: 0.72, 95% CI: 0.62–0.83). Screening utilization odds were lower among women with poor vs excellent health (pooled OR: 0.85, 95% CI: 0.74–0.96).

Conclusion

Greater CCI score, functional limitations and lower perceived health were associated with decreased SM use, whereas higher absolute number of comorbidities was associated with increased SM use. SM guidelines should consider these factors to improve assessments of potential benefits and harms in older women.

Do incident musculoskeletal complaints influence mortality? The Nord-Trøndelag Health study

Background

Musculoskeletal complaints (MSC) are common in the general population, causing a major disease burden to the individual and society. The association between MSC and mortality is still unclear. To our knowledge, no study has hitherto evaluated the association between MSC onset within the last month (incident MSC) on the one hand, and all-cause and cause-specific mortality on the other.

Methods

This prospective population-based cohort study was done using data from the second Nord-Trøndelag Health Study (HUNT2) linked with data from a comprehensive national registry of cause of death. A total of 25,931 participants at risk for incident MSC were included. Hazard ratios (HR) of mortality were estimated for participants with incident MSC using Cox regression based on a mean of 14.1 years of follow-up.

Results

Participants who reported incident MSC did not have an excess mortality compared to those with no MSC in the analyses of all-cause mortality (HR 0.99, 95% CI 0.89–1.10) and cause specific mortality. This was true also after adjustment for several potential confounding factors. No clear association between the number of MSC body sites and mortality was found.

Conclusion

Incident MSC were not associated with an increased mortality, neither for all-cause mortality, nor cause-specific mortality.

Association of socioeconomic status and health-related behavior with elderly health in China

Previous health studies have focused on the correlation between socioeconomic status (SES) and health. We pooled data from the Chinese Longitudinal Healthy Longevity Survey (N = 9765) conducted in 2011, and examined the association of SES and health-related behavior with elderly health in China. The cumulative health disadvantage of the elderly caused by SES can be relieved by lifelong health-related behavior. In the same SES, the odds of self-rated health (SRH) as “good,” mini-mental state examination (MMSE) as “not impaired,” and activities of daily living (ADLs) as “not impaired” among the elderly who exercised regularly, were 46.9%, 28.6%, and 62.3% lower for the elderly who rarely exercised. The elderly who started doing regular exercise from 30 years old, achieved higher SRH, ADL, and MMSE scores to some extent. The health improvement advantage for the elderly who started doing regular exercises after 60 years old, was reduced. However, the odds of SRH as “good,” MMSE as “not impaired,” and ADLs as “not impaired” were still 3.4%, 12.5%, and 17.8%, respectively, higher than the respondents who never exercised. The health-related behaviors not only promote elderly health improvement, but its duration has also been found to be associated with the extent of health improvement.

The Change of Self-Rated Health According to Working Hours for Two Years by Gender

OBJECTIVE

The aim of this study was to confirm the association between working hours and self-rated health, and to find the degree of changes in health level by working hours according to gender.

METHODS

This study was based on the 929 workers (571 men and 358 women) from the Korean Labor and Income Panel Study during 2004⁻2006. To minimize the healthy worker effects, the study subjects included only those who did not have any chronic diseases, and who answered their health status as "moderate" or above in the baseline. Logistic regression analysis was used to confirm the associations between working hours and self-rated health.

RESULTS

In men, working hours per week of 47⁻52 h, 53⁻68 h, and >68 h were associated with 1.2, 1.3, and 1.1 times increases, respectively, in the odds ratio on worsened self-rated health, compared with the reference group (40⁻46 h). On the other hand, the risks were 1.0, 2.2, and 2.6 times increases in women. However, the results were different according to gender in the group with less than 40 h. The men with less than 40 h had a 0.9 times odds ratio on worsened self-rated health. For the women with less than 40 h, the odds ratio on self-rated health was 5.4 times higher than the reference group.

CONCLUSIONS

Working more than 52 h per week had a negative effect on health, regardless of gender. However, in the group with less than 40 h, the negative association between working hours and self-rated health were shown only in women. Health outcomes due to working hours may differ by gender. Therefore, further studies are needed to explore the causes of these results.

Impact of the disability trajectory on the mortality risk of older adults in China

Using data from the Chinese Longitudinal Health Longevity Survey of 2005, 2008 and 2011, the authors compared the difference in the disability trajectory (DT) of survivor, decedent and dropped-out survey respondents and examined gender differences in DT using a group-based trajectory model, gender differences in the impact of DT on mortality risk (MR) among older adults, and mediating effects of resources and health status during late life through survival analysis. This analysis shows that the DTs of the survivors, decedents and dropped-out respondents differ remarkably. The trajectories of the decedents generally begin higher and increase more rapidly. Three types of DT exist for both genders: Type 1, the "independent type"; Type 2, the "low start, rapidly increasing in late life type"; and Type 3, the "high start, rapid development type". Women are more likely to experience a DT of functional impairment. Men who experience the Type 3 trajectory suffer the highest MR, followed by those of the Type 1 and Type 2 trajectories. Women who experience the Type 3 trajectory suffer the highest MR, followed by those of the Type 2 and Type 1 trajectories. In addition, economic status, medical treatment, daily care by the family and chronic diseases mediate the impact of DT on MR for both genders, while the mediating effect of emotional support from children was only observed for women.

The role of gender in the association between self-rated health and mortality among older adults in Santiago, Chile: A cohort study

Background

Previous studies on the role of gender in the association between self-rated health and mortality have shown contrasting results. This study was aimed to determine the importance of gender in the association between self-rated health and mortality among older people in Santiago, Chile.

Methods

A 10 year follow-up of 1066 people aged 60 or more, from the Chilean cohort of the Study of Health, Ageing and Well-Being. Self-rated health was assessed in face to face interviews through a single general question, along with socio-demographic and health status information. Cox proportional hazards and flexible parametric models for survival analyses were employed.

Results

By the end of follow-up, 30.7% of women and 39.4% of men died. Adjusted hazard ratio of poor self-rated health, compared to good self-rated health, was 1.92(95% CI 1.29–2.86). In models stratified by gender, an increased risk of mortality was observed among women who rated their health as poor (HR = 2.21, 95% CI 1.43–3.40), but not among men (HR = 1.04, 95% CI 0.58–1.86). Age was associated with mortality in both groups; for men, functional limitation and underweight were also risk factors and obesity was a protective factor.

Conclusions

Compared to older women who rated their health as good, older women who rated their health as poor had a 2 fold increased risk of mortality over the subsequent 10 years. These findings stress the importance of considering a gender perspective into health programmes, including those focused on older people, in order to address the different elements that increase, on the long run, the risk of dying among older women and men.

Projections of the number of Australians with disability aged 65 and over eligible for the National Disability Insurance Scheme: 2017-2026

OBJECTIVE

To develop projections of the size of the Australian population aged 65 years and over eligible for disability support through the National Disability Insurance Scheme (NDIS) for the decade following its introduction, to support planning and costing of the scheme.

METHODS

We estimate disability and mortality transition probabilities and develop projections of the NDIS-eligible, ageing population from 2017 to 2026.

RESULTS

An estimated 8000 men and 10 200 women aged 65 years and over will be eligible for support through the NDIS in 2017 (the scheme's first full year), increasing to 48 800 men and 56 900 women in 2026.

CONCLUSIONS

Growth in the NDIS-eligible, ageing population has implications for relative budget allocations between the NDIS and the aged-care system, and projections of the size of this population are useful for calculating the overall cost of the NDIS.

Associations between body mass index, mid-arm circumference, calf circumference, and functional ability over time in an elderly Taiwanese population

Background

Anthropometric measurements such as body mass index (BMI), mid-arm circumference (MAC), and calf-circumference (CC) are assessed with ease during regular health visits, but the associations between these anthropometric parameters and functional ability in elderly population over time has not been studied in detail. This study aimed to examine the associations between functional ability and the anthropometric parameters BMI, MAC, and CC in Taiwanese adults ≥ 65 years old.

Methods

Data were obtained from the Taiwan Longitudinal Study of Aging and analyzed retrospectively.

Results

Functional decline over a 4- and 8-year period was noted in approximately 14% and 21% of study participants, respectively. BMI was negatively associated with participants’ current Activities of Daily Living (ADL) scores, and was positively associated with 4-year ADL scores in adults ≥ 65 years old (β = -1.19 and 1.14, P = 0.0010 and 0.0420, respectively). MAC and CC were negatively associated with current ADL scores (β = -1.46, P < 0.0001 and β = -4.68, P < 0.0001, respectively). The association between CC and current ADL score was stronger than the association between current ADL score and either BMI or MAC. For adults ≥ 65 years old, a high BMI increased the risk of ADL decline over 4 and 8 years by 4-fold and 3-fold (adjusted odds ratio = 4.23 and 2.64, 95% confidential interval = 1.95–9.19 and 1.22–5.71, P = 0.0003 and 0.0141, respectively).

Conclusions

BMI is a significant predictor of decline of functional ability in Taiwanese adults ≥ 65 years old. CC is an important anthropometric indicator of current functional ability among older adults.

Mobility as a predictor of all-cause mortality in older men and women: 11.8 year follow-up in the Tromsø study

BACKGROUND

Disability in older adults is associated with loss of independence, institutionalization, and death. The aim of this study was to study the association between the Timed Up and Go (TUG) test and all-cause mortality in a population-based sample of older men and women.

METHODS

Our study population was home dwellers aged 65 and above, who participated in the fifth wave of the Tromsø study. This study included the TUG test and a range of lifestyle and mortality predictors. Participants were linked to the Cause of Death Registry and followed up for mortality for a maximum of 11.8 years. Cox regression was used to investigate the association between TUG and total mortality.

RESULTS

Mean TUG score was 12.6 s, and men performed better than women. The oldest participants had poorer TUG score compared to younger participants, increasing 0.25 s per year. There was a significant association between TUG and all-cause mortality, and the association was equally strong in men and women. Across the TUG-score categories, from quickest fifth to slowest fifth, the mortality increased in a step-wise fashion. Compared to the quickest fifth, the slowest fifth had hazard ratio (HR) of 1.79 (95% confidence interval (CI) 1.33, 2.42) in a model adjusted for age and gender. For each standard deviation TUG-score the increase in HR was 1.23 (95% CI 1.14, 1.33). The association between the TUG score and mortality remained significant after adjusting for self-reported health, body mass index, smoking and education.

CONCLUSIONS

A significant association between the TUG score and mortality was observed in both men and women. Identifying older people with poor TUG may aid in identifying those at risk and thus targeted interventions may be applied.

Gender differences in the predictive role of self-rated health on short-term risk of mortality among older adults

OBJECTIVES

Despite the well-established association between self-rated health and mortality, research findings have been inconsistent regarding how men and women differ on this link. Using a national sample in the United States, this study compared American male and female older adults for the predictive role of baseline self-rated health on the short-term risk of mortality.

METHODS

This longitudinal study followed 1500 older adults (573 men (38.2%) and 927 women (61.8%)) aged 66 years or older for 3 years from 2001 to 2004. The main predictor of interest was self-rated health, which was measured using a single item in 2001. The outcome was the risk of all-cause mortality during the 3-year follow-up period. Demographic factors (race and age), socio-economic factors (education and marital status), and health behaviors (smoking and drinking) were covariates. Gender was the focal moderator. We ran logistic regression models in the pooled sample and also stratified by gender, with self-rated health treated as either nominal variables, poor compared to other levels (i.e. fair, good, or excellent) or excellent compared to other levels (i.e. good, fair, or poor), or an ordinal variable.

RESULTS

In the pooled sample, baseline self-rated health predicted mortality risk, regardless of how the variable was treated. We found a significant interaction between gender and poor self-rated health, indicating a stronger effect of poor self-rated health on mortality risk for men compared to women. Gender did not interact with excellent self-rated health on mortality.

CONCLUSION

Perceived poor self-rated health better reflects risk of mortality over a short period of time for older men compared to older women. Clinicians may need to take poor self-rated health of older men very seriously. Future research should test whether the differential predictive validity of self-rated health based on gender is due to a different meaning of poor self-rated health for older men and women and whether poor self-rated health reflects different health statuses based on gender.

Predictors of Discrepancy Between Care Recipients With Mild-to-Moderate Dementia and Their Caregivers on Perceptions of the Care Recipients' Quality of Life

PURPOSE

The goal of this study was to explore predictors of discrepancy between reports of caregivers (CGs) and care recipients (CRs) with mild-to-moderate dementia about CRs' quality of life (QOL).

DESIGN AND METHODS

This study was a secondary analysis of cross-sectional data drawn from a study of 200 care dyads of CRs with mild-to-moderate dementia and their primary family CGs. Paired t test, ordinary least squares multiple regression, and binary logistic regression were used for the analyses.

RESULTS

Caregivers rated CRs' QOL significantly lower (worse) than CRs did. Ordinary least square regression results showed that greater incongruence in perceptions of CRs' decision-making involvement (DMI) and higher level of CR impairment in activities of daily living were significantly related to higher absolute discrepancy between CG and CR about CRs' QOL. In the logistic models, when the dyad had more DMI incongruence, or CG reported higher relationship strain, the CG was more likely to report a lower CR QOL than CR reported.

IMPLICATIONS

Practitioners should consider incorporating CRs' perspective when planning care instead of solely depending on CGs' perspective. Also, practitioners should pay attention to any gap between perceptions of CGs and CRs, particularly with regard to CRs' QOL.

Gender Differentials of the Oldest Old in China

Based on unique data from a sample of nearly 9,000 people ages 80 to 105 interviewed in 22 provinces in 1998, we found that gender differentials in educational attainment among the Chinese oldest old are enormous: Many more women are illiterate. Oldest old women are more likely to be widowed and economically dependent, much less likely to have pensions, and thus more likely to live with their children and rely on children for financial support and care. The female oldest old in China are also seriously disadvantaged in activities of daily living, physical performance, cognitive function, and self-reported health, as compared with their male counterparts; these gender differences are more marked with advancing age. The large gender differentials among the Chinese oldest old need serious attention from society and government, and any old-age insurance and service programs to be developed or reformed must benefit older women and men equally.

Assessment of Activities of Daily Living, Self-Care, and Independence

Activities of daily living (ADL) comprise the basic actions that involve caring for one's self and body, including personal care, mobility, and eating. In this review article, we (1) review useful clinical tools including a discussion on ways to approach ADL assessment across settings, (2) highlight relevant literature evaluating the relationship between cognitive functioning and ADLs, (3) discuss other biopsychosocial factors affecting ADL performance, (4) provide clinical recommendations for enhancing ADL capacity with an emphasis on self-care tasks (eating, grooming, dressing, bathing and toileting), and (5) identify interventions that treatment providers can implement to reduce the burden of ADL care.

Longitudinal Relationships Between Productive Activities and Functional Health in Later Years

This study examined the longitudinal relationships between functional health in later years and three types of productive activities: volunteering, full-time, and part-time work. Using the data from five waves (2000–2008) of the Health and Retirement Study, we applied multivariate latent growth curve modeling to examine the longitudinal relationships among individuals 50 or over. Functional health was measured by limitations in activities of daily living. Individuals who volunteered, worked either full time or part time exhibited a slower decline in functional health than nonparticipants. Significant associations were also found between initial functional health and longitudinal changes in productive activity participation. This study provides additional support for the benefits of productive activities later in life; engagement in volunteering and employment are indeed associated with better functional health in middle and old age.

Determinant Factors Contributing to Variations in Memory Performance in Centenarians

The role of environmental markers in memory performance among centenarians was examined in a study comparing non-cognitive factors to various aspects of memory performance. The centenarian group participating in the study consisted of 100 individuals (82 females and 18 males). Selected as non-cognitive factors were Quality of Life, Life-Habits, Health, Personality, and Autonomy. These factors were later compared to memory performance in short-term memory, semantic memory, and episodic memory. Using a structural equation model, results showed that performance in short-term memory was best predicted by life-habits and personality, while performance in semantic and episodic memory were best predicted by autonomy and life-habits. Implementation of the result from a life-span perspective includes a closer monitoring of environmental markers in the future. In effect, this could preserve memory function and optimum health through old age, thus making interventions easier to realize.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Economic downturns during the life-course and late-life health: an analysis of 11 European countries

BACKGROUND

Research has shown that individual socio-economic circumstances throughout life affect health in older ages. However, little attention has been paid to the broad economic context affecting individual's life-chances. This paper examines whether economic downturns experienced during young and mid-adulthood have long-run effects on physical health.

METHODS

We exploit data on economic fluctuations in the period 1945-2010 in 11 European countries, linked to longitudinal data from three waves of the Survey of Health, Ageing and Retirement in Europe. We estimate a country fixed effect model assessing whether downturns experienced at 5-year intervals between ages 25 and 54 are associated with levels and onset of new limitations with Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) in older age (55-80).

RESULTS

Experiencing an economic downturn at ages 45-59 is associated with increased risk of having at least one disability limitation in later-life (odds ratio [OR] for ADL = 1.66, 95% CI [Confidence Interval] 1.24, 2.22; OR for IADL = 1.46, 95% CI 1.10, 1.94). Economic downturns at ages 40-44 and 45-49 also increase the risk of a new functional limitation in later-life (OR for IADL ages 40-44 = 1.20, 95% CI 1.03, 1.40; OR for IADL ages 45-49 = 1.44, CI 1.10-1.88). Economic downturns experienced around these ages are also associated with significantly greater risks of smoking and excessive alcohol consumption as well as lower incomes in older age.

CONCLUSIONS

Exposure to an economic downturn at ages 40-49 is associated with poorer health in older ages, possibly by increasing risk of unhealthy behaviours and low incomes persisting into older age.

Estimating the Co-Development of Cognitive Decline and Physical Mobility Limitations in Older U.S. Adults

This study examines the co-development of cognitive and physical function in older Americans using an age-heterogeneous sample drawn from the Health and Retirement Study (1998–2008). We used multiple-group parallel process latent growth models to estimate the association between trajectories of cognitive function as measured by immediate word recall scores, and limitations in physical function as measured as an index of functional mobility limitations. Nested model fit testing was used to assess model fit for the separate trajectories followed by estimation of an unconditional parallel process model. Controls for demographic characteristics, socioeconomic status, and chronic health conditions were added to the best-fitting parallel process model. Pattern mixture models were used to assess the sensitivity of the parameter estimates to the effect of selective attrition. Results indicated that favorable cognitive health and mobility at initial measurement were associated with faster decline in the alternate functional domain. The cross-process associations remained significant when we adjusted estimates for the influence of covariates and selective attrition. Demographic and socioeconomic characteristics were consistently associated with initial cognitive and physical health but had few relations with change in these measures.

Degree of cognitive impairment and mortality: a 17-year follow-up in a community study

BACKGROUND

To test the hypothesis that cognitive impairment in older adults is associated with all-cause mortality risk and the risk increases when the degree of cognitive impairment augments; and then, if this association is confirmed, to report the population-attributable fraction (PAF) of mortality due to cognitive impairment.

METHOD

A representative random community sample of individuals aged over 55 was interviewed, and 4557 subjects remaining alive at the end of the first year of follow-up were included in the analysis. Instruments used in the assessment included the Mini-Mental Status Examination (MMSE), the History and Aetiology Schedule (HAS) and the Geriatric Mental State (GMS)-AGECAT. For the standardised degree of cognitive impairment Perneczky et al's MMSE criteria were applied. Mortality information was obtained from the official population registry. Multivariate Cox proportional hazard models were used to test the association between MMSE degrees of cognitive impairment and mortality risk. We also estimated the PAF of mortality due to specific MMSE stages.

RESULTS

Cognitive impairment was associated with mortality risk, the risk increasing in parallel with the degree of cognitive impairment (Hazard ratio, HR: 1.18 in the 'mild' degree of impairment; HR: 1.29 in the 'moderate' degree; and HR: 2.08 in the 'severe' degree). The PAF of mortality due to severe cognitive impairment was 3.49%.

CONCLUSIONS

A gradient of increased mortality-risk associated with severity of cognitive impairment was observed. The results support the claim that routine assessment of cognitive function in older adults should be considered in clinical practice.

Predictors of 49-month mortality in Chinese nonagenarians and centenarians in PLAD study

OBJECTIVE

To examine whether a set of well-known predictors of mortality in younger elderly also maintain their importance in Chinese oldest old group.

DESIGN

A cross-sectional study of 1401 inhabitants aged 90 and older were conducted in the area of Dujiangyan, China. 825 subjects participated and were followed up for vital status after 49 months. Professional interviewers collected baseline data concerning socio-demographic characteristics, lifestyle habits, physical factors and geriatric assessment. Bivariate analysis was conducted between survivors and deceased. Cox regression models were used to evaluate predictors of mortality.

RESULTS

Four hundred and thirty-six (52.8%) of 825 participants eligible for the analysis died during the 49 months of follow-up period. Older age, comorbidity, lower MMSE score, lower ADL and IADL scores increased the risk of mortality in the study group. Multivariate analyses showed older age (HR = 1.03, 95% CI 1.01-1.07) and comorbidity (HR = 1.09, 95% CI 1.02-1.17) were associated with mortality while female gender (HR = 0.61, 95% CI 0.43-0.86), taking exercise (HR = 0.80, 95% CI 0.64-1.01) and higher MMSE scores (HR = 0.96, 95% CI 0.94-0.99) showed a positive effect on survival.

CONCLUSION

In Chinese nonagenarians and centenarians, age, gender, taking exercise, cognitive impairment and comorbidity at baseline show predictive power of oldest old mortality.

The Health of India's Elderly Population: A Comparative Assessment Using Subjective and Objective Health Outcomes

This study examined relationships between and predictors of objective and subjective health measures among 766 individuals aged ≥ 45 years in India using the 2010 pilot wave of the Longitudinal Aging Study in India (LASI). Correlations between and gender differences in objective [grip strength, lung function] and subjective [self-rated health (SRH), dependence in activities of daily living (dADL)] health measures were examined. Multivariate logistic regression analyses, accounting for sample design, were conducted to identify predictors of poor health. Fewer individuals were classified as at risk according to subjective (SRH, 9 %; dADL, 12 %) than objective (lung function, 57 %; grip strength, 77 % women, 87 % men) indicators. Poor SRH was only weakly correlated with dADL (r = 0.103, p ≤ 0.05) and grip strength (r = −0.138, p ≤ 0.001). From this study we conclude that older Indians tend to report more positive perception of health than the objective measures of health indicates, and that subjective and objective health indicators capture different aspects of health and only weakly correlated.

Disability status, mortality, and leading causes of death in the United States community population

OBJECTIVE

We examined the effect of functional disability on all-cause mortality and cause-specific deaths among community-dwelling US adults.

METHODS

We used data from 142,636 adults who participated in the 1994-1995 National Health Interview Survey-Disability Supplement eligible for linkage to National Death Index records from 1994 to 2006 to estimate the effects of disability on mortality and leading causes of death.

RESULTS

Adults with any disability were more likely to die than adults without disability (19.92% vs. 10.94%; hazard ratio=1.51, 95% confidence interval, 1.45-1.57). This association was statistically significant for most causes of death and for most types of disability studied. The leading cause of death for adults with and without disability differed (heart disease and malignant neoplasms, respectively).

CONCLUSIONS

Our results suggest that all-cause mortality rates are higher among adults with disabilities than among adults without disabilities and that significant associations exist between several types of disability and cause-specific mortality. Interventions are needed that effectively address the poorer health status of people with disabilities and reduce the risk of death.

Comparing the Relationship Between Stature and Later Life Health in Six Low and Middle Income Countries

This paper examines the relationship between stature and later life health in 6 emerging economies, each of which are expected to experience significant increases in the mean age of their populations over the coming decades. Using data from the WHO Study on Global Ageing and Adult Health (SAGE) and pilot data from the Longitudinal Ageing Study in India (LASI), I show that various measures of health are associated with height, a commonly used proxy for childhood environment. In the pooled sample, an additional 10cm increase in height is associated with between a 2 and 3 percentage point increase in the probability of being in very good or good self-reported health, a 3 percentage point increase in the probability of reporting no difficulties with activities of daily living or instrumental activities of daily living, and between a fifth and a quarter of a standard deviation increase in grip strength and lung function. Adopting a methodology previously used in the research on inequality, I also summarise the height-grip strength gradient for each country using the concentration index, and provide a decomposition analysis.

The disability burden associated with stroke emerges before stroke onset and differentially affects blacks: results from the health and retirement study cohort

BACKGROUND

Few longitudinal studies compare changes in instrumental activities of daily living (IADLs) among stroke-free adults to prospectively document IADL changes among adults who experience stroke. We contrast annual declines in IADL independence for older individuals who remain stroke free to those for individuals who experienced stroke. We also assess whether these patterns differ by sex, race, or Southern birthplace.

METHODS

Health and Retirement Study participants who were stroke free in 1998 (n = 17,741) were followed through 2010 (average follow-up = 8.9 years) for self- or proxy-reported stroke. We used logistic regressions to compare annual changes in odds of self-reported independence in six IADLs among those who remained stroke free throughout follow-up (n = 15,888), those who survived a stroke (n = 1,412), and those who had a stroke and did not survive to participate in another interview (n = 442). We present models adjusted for demographic and socioeconomic covariates and also stratified on sex, race, and Southern birthplace.

RESULTS

Compared with similar cohort members who remained stroke free, participants who developed stroke had faster declines in IADL independence and lower probability of IADL independence prior to stroke. After stroke, independence declined at an annual rate similar to those who did not have stroke. The black-white disparity in IADL independence narrowed poststroke.

CONCLUSION

Racial differences in IADL independence are apparent long before stroke onset. Poststroke differences in IADL independence largely reflect prestroke disparities.

Long-term outcomes among African-American and white women with breast cancer: what is the impact of comorbidity?

OBJECTIVES

We examined the association between comorbidity and long-term mortality from breast cancer and other causes among African-American and white women with breast cancer.

METHODS

A total of 170 African-American and 829 white women aged 40-84years were followed for up to 28years with median follow-up of 11.3years in the Health and Functioning in Women (HFW) study. The impact of the Charlson Comorbidity Score (CCS) in the first few months following breast cancer diagnosis on the risk of mortality from breast cancer and other causes was examined using extended Cox models.

RESULTS

Median follow-up was significantly shorter for African-American women than their white counterparts (median 8.5years vs. 12.3years). Compared to white women, African-American women had significantly fewer years of education, greater body mass index, were more likely to have functional limitations and later stage at breast cancer diagnosis, and fewer had adequate financial resources (all P<0.05). Proportionately more African-American women died of breast cancer than white women (37.1% vs. 31.4%, P=0.15). A positive and statistically significant time-varying effect of the Charlson Comorbidity Score (CCS) on other-cause mortality persisted throughout the first 5years of follow-up (P<0.001) but not for its remainder.

CONCLUSIONS

Higher CCS was associated with increased risk of other-cause mortality, but not breast cancer specific mortality; the association did not differ among African-American and white women.

Effects of Medicare payment reform: evidence from the home health interim and prospective payment systems

Medicare continues to implement payment reforms that shift reimbursement from fee-for-service toward episode-based payment, affecting average and marginal payment. We contrast the effects of two reforms for home health agencies. The home health interim payment system in 1997 lowered both types of payment; our conceptual model predicts a decline in the likelihood of use and costs, both of which we find. The home health prospective payment system in 2000 raised average but lowered marginal payment with theoretically ambiguous effects; we find a modest increase in use and costs. We find little substantive effect of either policy on readmissions or mortality.